Nurses' training and teaching-learning strategies on the theme of spirituality

ABSTRACT

Objective

to investigate whether and how the theme of spirituality was addressed in the training of nurses working in palliative care.

Method

a qualitative study, carried out with 34 nurses from a cancer treatment hospital in Rio de Janeiro. Data was collected in 2019, through semi-structured interviews. Analysis was of the lexical type using the Alceste software.

Results

the nurses recognize the need to approach spirituality in care, but the gaps or insufficiency of approach in training hinder its application in the practice. To bridge these gaps, strategies are applied in permanent education in the services.

Conclusion and implications for the practice

the lack of formal and technical preparation for approaching and offering care to the patients' spiritual dimension compromises the performance of comprehensive care. Permanent education proved to be the only possibility to prepare nurses to care for such dimension. It reveals the importance of addressing spirituality and the impacts on health and care, especially in the field of palliative care, which makes it transversal and necessary in professional training.

Keywords:
Nursing; Spirituality; Education in Nursing; Continuing Education; Nursing Care

RESUMO

Objetivo

investigar se e como o tema da espiritualidade foi abordado na formação de enfermeiros que atuam em cuidados paliativos.

Método

estudo qualitativo, realizado com 34 enfermeiros de um hospital de tratamento de câncer do Rio de Janeiro. Os dados foram coletados em 2019, por meio de entrevista semiestruturada. A análise foi lexical por meio do software Alceste.

Resultados

os enfermeiros reconhecem a necessidade de abordagem da espiritualidade no cuidado, mas as lacunas ou insuficiência de abordagem na formação dificultam sua aplicação na prática. Para supri-las, estratégias são aplicadas na educação permanente nos serviços.

Conclusão e implicações para a prática

o não preparo formal e técnico para a abordagem e oferta de cuidados à dimensão espiritual dos pacientes comprometem a realização do cuidado integral. A educação permanente mostrou ser a única possibilidade de preparar os enfermeiros para o cuidado a esta dimensão. Desvela-se a importância da abordagem da espiritualidade e os impactos para a saúde e o cuidado, mormente no campo dos cuidados paliativos, o que a torna transversal e necessária na formação profissional.

Palavras-chave:
Enfermagem; Espiritualidade; Educação em Enfermagem; Educação Continuada; Cuidados de Enfermagem

RESUMEN

Objetivo

investigar si y cómo se abordó el tema de la espiritualidad en la formación de enfermeros que se desempeñan en cuidados paliativos.

Método

estudio cualitativo, realizado con 34 enfermeros de un hospital especializado en el tratamiento de cáncer en Rio de Janeiro. Los datos se recolectaron en 2019, a través de entrevistas semiestructuradas. Se llevó a cabo un análisis lexical mediante el software Alceste.

Resultados

los enfermeros reconocen la necesidad de abordar la espiritualidad en el cuidado, pero las brechas o insuficiencias de abordaje en la formación dificultan su aplicación en la práctica. Para suplirlas, se aplican estrategias de formación continua en los servicios.

Conclusión e implicaciones para la práctica

la falta de preparación formal y técnica para abordar y ofrecer atención a la dimensión espiritual del paciente compromete la realización de la atención integral. La educación permanente resultó ser la única posibilidad de preparar enfermeros para atender esta dimensión. Se revela la importancia de abordar la espiritualidad y los impactos en la salud y en la atención, especialmente en el ámbito de los cuidados paliativos, lo que la hace transversal y necesaria en la formación profesional.

Palabras clave:
Enfermería; Espiritualidad; Educación en Enfermería; Educación Continua; Atención de Enfermería

INTRODUCTION

In the last two decades, the number of studies and surveys with spirituality and religiousness as a theme articulated towards health to human care has been increasing. This is evident in the researchers' interest to investigate the theme in the scientific literature, through review studies showing the importance of spirituality and religiousness both in people's physical and mental health, to face disease situations, stress, health promotion, adherence to therapy and rehabilitation^1-3. Empirical research studies investigating the theme with different participants and in the most varied fields are also added^4-6.

Understanding spirituality and its role in human life can enhance the health care conception, in addition to favoring a holistic view of the person⁷. It is observed that many studies address spirituality and religiousness together; however, it is necessary to make the proper conceptual differences between them. Religiousness can be understood as a set of practices of a particular religion, which in turn encompasses a structured way of beliefs that leads to behavioral rules that define their association and prescribed rituals.⁷ Spirituality has a broader concept that encompasses the meaning of existence, being-in-the-world, with interconnection and inner peace experiences, with or without religious affiliation⁷. There is also a definition that corroborates the understanding that the human spirituality dimension is not directly related with religion, but with an approach to the sacred or transcendental through a personal quest to understand life issues⁸.

Spirituality and religiousness are also factors that influence the anxiety caused by death/dying, which can affect people's mental health. Such relationship is evidenced in a review study conducted with 93 publications aiming, among other results, at the fact that increased spiritual well-being reduces death anxiety in cancer patients. This review concludes that the use of religious spiritual approaches can reduce death anxiety and improve people's mental health⁹. Similarly, a research study conducted in Brazil with aged cancer patients concluded that both - spirituality and religiousness - understood as coping strategies, are applied in the unstable life routine of these individuals by providing them with comfort and resilience¹⁰.

In the field of studies about palliative care, it is emphasized that most of the patients who experience risk to life do not have their spiritual needs adequately met by health professionals¹¹. Palliative care implies understanding the person as a whole, reflected in the multidimensional approach to the biopsychosocial model, in which spirituality must be recognized and the barriers to the provision of care in attention to such dimension must be addressed¹¹.

Attention to the human spirituality dimension is formally recognized in the definition of palliative care as an approach aimed at improving the quality of life of patients and their families, in the prevention and relief of suffering by identifying and evaluating their physical, psychosocial and spiritual problems¹².

Considering the care provided to human beings, understanding them as integral beings, refers us to the Nursing science, which is based on the holistic approach, involving the physical, mental, emotional and spiritual dimensions. And to meet them, nurses need to address the patient's needs, perceiving and anticipating them in their own life contexts¹³.

In this sense, appropriating the concept of spirituality and assigning meanings can contribute for nurses to build a new reality in the practice of spiritual care, since such practice must develop in the caregiver sensitivity and empathy, regardless of the treatment outcomes¹⁴.

Spirituality is contemplated in the taxonomic classification system proposed by the North American Nursing Diagnosis Association International (NANDA-I) to the Nursing diagnoses, recognizing the human spiritual nature and that nurses must be prepared to offer care related to that dimension¹⁵.

Inclusion in the NANDA diagnosis list corroborates the need to prepare the nurse for systematic care based on a comprehensive clinical perspective, on interventions and results aimed at the spiritual well-being of the patient and the family respecting their particularities. Nevertheless, the literature indicates that nurses do not feel prepared to offer spiritual assistance to patients¹⁶. A research study conducted with 10 nurses working in palliative care evidences that the professionals recognize the spiritual dimension in patient care, but communicate lack of preparation to deal with that dimension¹⁷; and that there are barriers in the professional practice they need to overcome so that comprehensive care is provided, recommending the incorporation of spirituality in the curricula of health courses¹⁸.

Not only in Brazil there is evidence of problems for the provision of care by nurses, in order to meet the patients' spiritual dimension. Researchers from the United Kingdom and Italy conducted a literature review and found that assessment and provision of spiritual care by nurses do not occur so frequently. In addition, students and nurses are aware of the importance of such care, but are hampered by lack of training and permanent education on the best way to implement it¹⁹.

This article discusses spiritual care in the field of palliative care provided to people with cancer, in order to investigate whether and how the theme of spirituality was approached in the training of nurses working in palliative care.

METHOD

A qualitative, descriptive and exploratory study, conducted in the sectors of Hospitalization, Home Care and Outpatient Clinic of the Palliative Care Unit of a public hospital belonging to a cancer treatment Institute, located in the municipality of Rio de Janeiro.

All 38 nurses, belonging to the hospital staff and allocated to the aforementioned sectors, were invited to participate in the study. The inclusion criterion was to be active (working) in one of the sectors in the data production period, regardless of training time or performance time in the sectors, and professing any creed or religion or not. The exclusion criterion was being away from work for any reason in the period defined for data production. Four licensed nurses were excluded from the study. Therefore, the qualitative sample consisted of 34 participants (89.47%).

Data collection took place between October 05 and December 15, 2019, and consisted in applying a semi-structured interview technique, with anticipated scheduling with the participants, on a day and time being compatible with the work dynamics. All were held in the hospital's Continuing Education room, individually, through the application of an instrument with two parts: the first was used to obtain data on the participants' identification and professional and socio-demographic profile in order to characterize them; and the second part consisted of the following open questions: Did the training course (undergraduate/graduate) meet the professional's need for taking care of people who require care in the spiritual dimension? How? What content (theoretical and practical) did it have in relation to this theme? Which suggestion(s) would you give to the Colleges/Courses in relation the theme? At work, is there or has there already been any activity on the theme? Would you have any suggestions for the universities and care institutions?

Before the interviews, the participants were informed about the research details and were handed in the free and informed consent form, with signing of such document being a condition for their participation. The records were made by means of electronic equipment, being faithfully transcribed at the end of each interview.

The data on the participants' identification and professional and socio-demographic profile were analyzed by means of simple statistics and, in the open questions, lexical-type analysis was applied using the Alceste 2012 software (Lexical Analysis through Context of a Set of Text Segments). This software is an ancillary data analysis instrument, which does not fail to consider the quality of the phenomenon under study, even providing criteria from the material itself, for its consideration as an indicator of a phenomenon of scientific interest²⁰.

For processing the textual data, the stages in accordance with the criteria determined by Alceste software were followed, namely: preparation of the corpus, where each interview is called Initial Context Unit (ICU) and was preceded by command lines made up by the following variables for each participant [Gender (Sex), Religion (Rel), Workplace (Ltr) and Experience in palliative care (Excp)]. Submission of the corpus to Alceste and text processing in four stages: reading the text and calculating the dictionaries; calculating the data arrays and classifying the elementary context units (ECUs); description of the ECU classes and complementary calculations.

After deploying the data in the software, a pre-analysis of the results was made and it was considered that saturation was reached with delineation of the empirical study framework and prospection for meeting the study objective, which requires deepening, scope and diversity in the understanding process²¹.

The analysis applied is of the lexical type, considering the descending hierarchical classification (DHC), the hierarchical ascending classification (AHC) and the ECUs, which constitute speech fragments expressing the meanings from the words analyzed. These are the ECUs that allow understand the lexical classes made up by Alceste, based on the words with greater statistical association (Phi).

The ethical principles were followed as provided in Resolution No. 466, of December 12^th, 2012, by the National Health Council of the Ministry of Health and the rules applicable to research studies in Human and Social Sciences set forth in Resolution No. 510/2016. Identity was preserved by means of alphanumeric codes inherent to the command lines required by Alceste, and waiver to take part in the research at any time was ensured, even after consent, with no harms to their inclusion in the institution. The participants were duly informed about the research purpose and received all the necessary information so that they could issue their free and informed consent by signing such a form (FICF). Only after signature did they actually participate in the research. The study was approved by the Research Ethics Committee of the proposing and co-participating institutions, according to opinion No. 3,296,145 and 3,452,306, respectively, through Plataforma Brasil, with approval confirmed on July 12^th, 2019.

RESULTS

Most of the participants are female (31 - 91.18%); with prevalence of the age group from 36 to 50 years old (18 - 52.94%); predominantly professing the Catholic religion (13 - 38.23%), although there are also Kardecists (8 - 23.53%); Evangelicals (7 - 20.59%); non-religious (4 - 11.76%) and Umbanda believers (2 - 5.89%). Training in private institutions prevailed (19 - 55.88%); the participants predominantly have some specialization (27 - 79%) and have between 6 and 10 years of experience in palliative care (16 - 47.06%). Most of the participants reported no proximity to the theme (33 - 97.06%).

The process generated a lexical class (Class 1) characterized by the need for nurses’ training and teaching-learning strategies on the theme of spirituality, care and health and the need for formal discussion spaces with participation, conferences, lectures, classes and debates. The most significant speeches produced in this class emerged from participants numbers 31, 08 and 16, male, with ample experience in Palliative Care, from 6 to 10 years, and professing no religion.

Considering the words with greatest statistical association (Phi), as seen in the DHC (Table 1), and the proximity relationships between them in the AHC (Figure 1), it is identified that the professionals communicate the importance of discussing the theme in the professional training, so as to approach the concepts and practices related to it. They cited strategies such as lectures, academic subjects and classes, elucidated the information contained in the ECUs.

Table 1
- Descending Hierarchical Classification (DHC) of Class 1. Rio de Janeiro, 2020.

Presence	Phi
Graduation	0.40
Theme	0.36
Lecture (lecturing; speakers)	0.34
Has	0.33
College	0.27
Academic subject; Course	0.26
Participation; participate; participated; participate	0.24
Class	0.24
Approximation; approximate; approached	0.23
Concept	0.22
Congress	0.19
Graduate course	0.19
Duty (I should, they should)	0.19
Health	0.19
Discussion	0.19
Academy; academic	0.19
Debate	0.19
Practice; practices; practical	0.18
Approached (f); approached (m); approach; they approach; we approach	0.17

• Source: Summary report of the Alceste results

Figure 1
- Ascending Hierarchical Classification (AHC).

The ECUs which comprise this Class more clearly inform the meanings attributed to the theme by the participants, alluding to the lack of approach to spirituality in the professional training both in undergraduate and in graduate studies, among other issues that contribute to its non-implementation in the practice.

In addition to the absence of academic subjects, the theme is not addressed or it is addressed in a very subtle way, in an incipient manner. They evidence that, in the professional academic training, there is lack of approach on the theme of spirituality, but point out what should be done and value the theme in training.

The lack of approach in the formal spaces of the training courses causes the professionals to not feel being prepared and with sufficient knowledge to deal with the topic and address it in the professional practice, constituting a barrier in meeting the spiritual needs of the patient during the care provided.

Spirituality was not worked on and studied in my undergraduate training, and so little in the graduate oncology studies. Perhaps it's lack of knowledge on the theme and its confusion with religiousness that hinder its approach (ICU No. 12).

[...] it's certainly that undergraduate training doesn't prepare the nurse to these practices in care. There's a lot of theory that needs to be transferred and built up because I see that there's a lot of difference and in fact knowledge is something that needs to be constructed by the professor with the students, but there's a lot of knowledge transfer (ICU No. 31).

No contact with the theme in my undergraduate training, also none in my graduate studies (ICU No. 11).

[...] I had no practical or theoretical content in my undergraduate studies, not that I remember. (ICU No. 14).

[...] then, specifically an academic subject, no. I didn't have any formal academic subject. But, I remember that in the undergraduate course, we approached the theme in isolated classes in other academic subjects, not as a formal subject on spirituality (ICU No. 8).

Lack of training is configured as an element that hinders meeting the patient's spiritual demand. The results show the need to broaden the discussions on the theme in different scenarios: in the academic and professional life in the health institutions, deepening the professionals'/nurses' knowledge so that they may be able to identify the patients' needs and improve their quality of life.

The participants value the theme in the professional training/qualification and consider its inclusion as extremely relevant.

At work, there was a class that I attended and found it very valid and which added many values. I find extremely important the issue of a chair, an academic subject on spirituality in the academic area (ICU No. 28).

The university should explore the topic in the classrooms, even in academic life, whether in the area of natural sciences, humanities, as well as in the health institutions (ICU No. 25).

[...] I also extend the suggestion of lectures by the undergraduate and graduate programs themselves in the context of spirituality, making an association of spirituality as care. I even believe in bringing it, in the academic subjects, or in a subject with a lower hour load, even if optional, so as to humanize and spiritualize the students (ICU No. 31).

Despite the existing gap in the professional training on the theme of spirituality, the nurses were able to express in the ECUs where the knowledge came from and where the approach to the theme of spirituality took place, showing that inclusion in the palliative care narrowed their relationship with this knowledge, through conferences and lectures, as well as their own experience at work.

The nurses expressed that the experience in palliative care causes them to resume that dimension of care for human beings:

What I understand about spirituality came just from insertion in palliative care, where you're directly linked to this theme. Considering that this is one of the dimensions of care to human beings. Especially in palliative care when you're confronted with the finitude of life, those issues become more apparent, so to say, in the clinical practice (ICU No. 8).

In a specific spirituality event, neither, but in the events where that I took part, yes, it's always found in all palliative care, almost always addressing the theme (ICU No. 11).

In the professional field I've had the opportunity of sometimes, through palliative care, attending lectures where the theme was that issue of grief, of spirituality. Yes, I've already had an experience in palliative care and how you apprehend the issue in a more relaxed manner ends up facilitating and improving interest (ICU No. 31).

Faced with the need to broaden the professionals' knowledge in the palliative care unit, the participants cite the in-service training and learning strategies in the practice, that is, the permanent education strategy proves to be effective according to the participants.

Here in my work I had a lecture, I participated and found it very interesting, I think it's a theme that must be addressed more often (ICU No. 14).

For the institutions, the suggestion is the same, working this issue in lectures, discussions, I believe that discussions groups on that theme of spirituality, bringing speakers and experts of this universe to build up, to arouse interest (ICU No. 31).

DISCUSSION

It is evidenced that the theme is not formally addressed in the professional training courses, and this leads to lack of preparation for approaching the users/patients in the care practices. Lack of approach in the formal spaces of the training courses makes the professionals not feeling prepared, and without enough knowledge to deal with the theme and address it in the professional practice.

Lack of approach to the theme in the professional training period was pointed out as an aspect that hinders meeting the patient's spiritual demand, corroborating with several studies conducted with nurses that also evidence absence or unsatisfactory approach in academic/university training. The training courses do not prepare and/or qualify the professional to develop different competences, skills, behaviors, attitudes and sensitivity to address and integrate spirituality to the Nursing/health care actions²². Lack of training emerges as one of the barriers to providing spiritual care^3,23-24, which generates insecurity, lack of training and difficulty implementing that care dimension by the health professionals²⁵.

Lack of knowledge can be minimized through additional education²⁶ and the movement to create the Academic Leagues has been increasing in order to overcome the lack and absence of academic subjects and broaden the discussions on various topics. This is configured as an extracurricular strategy, consisting of undergraduate and graduate students under the guidance of a professor, with mutual interest on any theme whose role is to discuss and disseminate it among the members, future professionals, and also the lay population. In the Academic Leagues Association and Study Groups in Spirituality and Health there are 61 spirituality leagues, encompassing public universities and private universities, and they also include palliative care²⁷.

The entire analysis above points out to the need for progress in the nurses' training courses on spirituality in order to improve understanding and the care provided to the patients and family members in the palliative care context. Knowing about spiritual care is an essential element for the nurse's training in providing this care¹⁶. Spirituality is an essential construct in the health-disease care process actions aimed at the needs of human beings, in view of its multidimensionality²².

The need to expand discussions on the various scenarios became evident: in the academic and professional life and in the health institutions, so that the professionals/nurses deepen their knowledge so that they can identify the patients' needs and improve their quality of life.

The nurses have expressed their support for the inclusion of spirituality in the training courses, evidencing a fertile field for them to be better prepared, adding values and reverberating for a change of attitude in the professional practice in palliative care. A study conducted with Nursing professionals about the nurses' perception concerning spirituality in end-of-life care concluded that including the theme in the undergraduate course would be one of the strategies to fill that knowledge gap, as a way to raise awareness and train the professionals^28,29.

Nurses who in palliative care daily deal with suffering, with finitude of life and with the individual's vulnerabilities, which makes it a challenge to work with human beings and requires that they understand spirituality issues²⁹.

There are people in palliative care who state that life does not end with physical death, and who, when feeling the weakening of the biological body, feel the strengthening of the spirit, understanding death as a passage to another place³⁰. In this sense, spirituality provides a them sense of continuity, preparing them to face death naturally, therefore being important to keep active this relationship with a thought that refers them to spirituality. In this context, caring for the spiritual dimension of the being helps a person to make sense of the experience and, in a reciprocal relationship, this is also important for the nurses themselves. From cultivating this value and from the understanding aspect, end-of-life can be understood as only physical death, with something beyond human life²². Such understanding may mean comfort and serenity when facing death, with minimum pain.

Given the need to broaden the professionals' knowledge in the palliative care unit, the permanent education strategy proves to be effective according to the nurses, as Permanent Education in Health offers the proposal for improvement in a participatory manner, respecting the professionals' knowledge and expanding learning in the workplace, which is very important for a critical reflection, building up strategies collectively.

The concept of Permanent Education in Health (PEH) was initially worked on in the health area by the Pan American Health Organization (PAHO) in the mid 1980s. In 2004, in Brazil, it was instituted as a public policy, which is understood as learning at work, where the learning and teaching actions are incorporated into the organizations' routine and also at work³¹.

PEH focuses on meaningful learning and not only based on linear knowledge transmission. This method seeks autonomy of the subjects involved in learning to innovate, change practices with creative solutions regarding work and management, not individually, but collectively³². Nevertheless, it is observed that the research participants report specific educational intervention strategies such as lectures, without properly alluding to experiences based on problematizing education or applying a reflection-action-reflection method.

PEH advocates articulation between theory and practice in order to attain transformation, with support from the institutional policies, transcending the traditional educational methods. With the purpose of having a transformative praxis, the stimulus is for knowledge grounded on individual and collective freedom is constructed, so that the individual transformation can impact on social transformations³³.

The National Humanization Policy (Política Nacional de Humanização, PNH) recommends that the health units must ensure permanent education to their workers. Knowledge translation must be ensured with the expansion of the strategies indicated by the research participants, since one of the specific guidelines of the PNH in hospital care is that it has a permanent education plan for workers with humanization-related themes³⁴.

There are gaps in the knowledge about the theme of spirituality due to lack of or insufficient approach in undergraduate studies and, although not the only possibility, it is acknowledged that permanent education offers good response potential to assist nurses in their work routines in palliative care, encouraging them to study to better deal with the topic in the health care practice. Lectures and discussions are strategies that arouse the interest of the group and facilitate articulation between the Nursing professionals and the other members of the multidisciplinary team. The discussion groups enable sharing experiences and improve communication between the Nursing team and the other professionals involved in the assistance provided to palliative care patients. In addition, they also enhance listening to the patient and the family.

The professionals' experience portrays the movement that the institution which conducted the study has been developing for years now, in order to provide the approach of such subjective aspects in the in-service training courses. It is therefore noteworthy to highlight the importance of management in stimulating the approach of subjective themes and spirituality in the institution.

The nurses' attitude involving the affective-appreciation component, of showing to be favorable to the theme and considering the importance of approaching the theme of spirituality in training, arises from the practical experience, that is, as they are faced with the patients' demands. Regarding where they need support to care, they perceive that there is a gap in training. The practice-related demands lead them to reflect on the gaps and the quality of professional training.

As in the undergraduate course, they report about the absence of specific academic subjects, with the educational activities applied in the services and permanent education appearing as important strategies to bridge that gap.

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE

Absence or insufficiency in the approach to the theme of spirituality and its application in care in the scope of the professional training courses was evidenced, with implications for the quality of Nursing care since, as they do not feel formally and technically prepared, the patients' demands cannot be adequately met and comprehensive care cannot be contemplated. Given the absence or insufficiency of training, permanent education emerges as the only possibility to prepare nurses to care for the patients' spiritual dimension, when they are faced with such situations in their professional practice.

The study limitations are methodological, since it was limited to one institution. Expansion of the research to other care fields may contribute to the scope of the debate and to a broader perspective about spirituality.

The implications of the results for the practice are evident, as they reveal the importance of approaching the theme of spirituality in human life, with impacts on health and care, especially in the field of palliative care, which makes makes it transversal and necessary in professional training, especially in the Nursing education field. It is noteworthy that identifying the theme given the practice articulated to the professionals' difficulties handling it indicates that the institution can, perhaps, think about applying strategies through collective and dynamic activities so that, jointly, the team may seek solutions applicable to their care practice.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  06 Sept 2021
• Date of issue
  2021

History

• Received
  15 Mar 2021
• Accepted
  16 July 2021