Counseling and Spiritual Assistance to Chemotherapy Patients: A Reflection in the Light of Jean Watson's Theory

Orientación y asistencia espiritual a pacientes en quimioterapia: una reflexión a la luz de la Teoría de Jean Watson

Abstract

Aim:

To reflect on the use of spiritual interventions and methods of psychological, theological and psychotherapeutic counseling applicable to nursing.

Method:

Theoretical reflection article, used to identify approximations and distances of counseling methods and spiritual interventions with Jean Watson's Theory of Human Care.

Results:

The critical analysis of methods of psychological, theological and psychotherapeutic counseling indicates approximations with the Theory of Human Care, promoting the improvement of spiritual interventions directed to patients in chemotherapy.

Conclusion:

From Jean Watson's Theory emerged a creative, original and unique advice in nursing.

Implications for practice:

Understanding counseling methods and spiritual interventions are important tools for the practice of oncological nursing, as well as enhancing the resources available to integrate spirituality and health.

Keywords:
Counseling; Spirituality; Neoplasms; Nursing

Resumen

Objetivo:

Reflexionar sobre la utilización de intervenciones espirituales y métodos de orientación psicológica, teológica y psicoterápica aplicables a la enfermería.

Método:

Artículo de reflexión teórica, identificando las aproximaciones y los distanciamientos de los métodos de orientación e intervenciones espirituales a la Teoría del Cuidado Humano, de Jean Watson.

Resultados:

El análisis crítico de los métodos de orientación psicológica, teológica y psicoterápica indica aproximaciones a la Teoría del Cuidado Humano, lo que promueve el perfeccionamiento de las intervenciones espirituales direccionadas a los pacientes en quimioterapia.

Conclusión:

A partir de la Teoría de Jean Watson emergió una orientación creativa, original y única en enfermería.

Implicaciones para la práctica:

La comprensión de los métodos de orientación e intervenciones espirituales constituyen importantes herramientas para la práctica de enfermería oncológica, y potencializan los recursos disponibles para integrar espiritualidad y salud.

Palabras clave:
Orientación; Espiritualidad; Neoplasias; Enfermería

Resumo

Objetivo:

Refletir sobre o emprego de intervenções espirituais e métodos de aconselhamento psicológico, teológico e psicoterápico aplicáveis à enfermagem.

Método:

Artigo de reflexão teórica, identificando aproximações e distanciamentos de métodos de aconselhamento e intervenções espirituais com a Teoria do Cuidado Humano, de Jean Watson.

Resultados:

A análise crítica de métodos de aconselhamento psicológico, teológico e pscioterápico indica aproximações com a Teoria do Cuidado Humano, promovendo o aprimoramento de intervenções espirituais direcionadas a pacientes em quimioterapia.

Conclusão:

A partir da Teoria de Jean Watson emergiu um aconselhamento criativo, original e único na enfermagem.

Implicações para a prática:

A compreensão acerca de métodos de aconselhamento e intervenções espirituais constituem importantes ferramentas para a prática de enfermagem oncológica, bem como potencializam os recursos de que dispõe para integrar espiritualidade e saúde.

Palavras-chave:
Aconselhamento; Espiritualidade; Neoplasias; Enfermagem

INTRODUCTION

Spiritual suffering is very prevalent among cancer patients, affecting 42% of the elderly population with this diagnosis, revealing the importance of the implementation of spiritual care by nurses who assist this clientele.¹ Scientific research has shown that faith and religious practice show positive results in mental health,² and can no longer be ignored or excluded from the scope of studies, nor be taxed as irrelevant components of the nursing praxis.

Despite the difficulties in clearly defining and measuring spirituality, recent studies have demonstrated its importance in the care of cancer patients, validating the beneficial effects in the coping process and psychological adjustment to the disease, quality of life and survival.^3-5

A meta-analysis published in 2014, which analyzed the effect of spiritual interventions on cancer patients, presented moderate results on depression and meaning of life, but had significant results on anxiety. According to the study, spiritual interventions, when provided by nurses using an individual approach, may be effective in improving the spiritual and psychological well-being of patients.⁶

These data point to the need to find strategies that facilitate not only the identification of spiritual suffering by nurses, but also the knowledge necessary for the planning of adequate interventions. Among these interventions, we explored counseling more deeply, an intervention defined by the Nursing Interventions Classification (NIC) as "the use of an interactive process of help focused on the needs, problems or feelings of patients and significant people to improve or support coping, problem solving and interpersonal relationships".^7:4798

In spite of its benefits in the scope of spiritual interventions, there is a lack of intellectual production that clearly describes how counseling sessions can be conducted during nurses' care. In this perspective, methods of counseling and spiritual interventions that can be inserted in the care of patients with antineoplastic chemotherapy will be discussed, specifying the limits and possibilities of this intervention in contemporary nursing.

When we think of spiritual support, health institutions can count on a chaplain or religious counselor; however, nurses are able to offer a systematized spiritual care, through specific research methods and evaluation of human responses in the spiritual dimension. Thus, reflecting the counseling as an intervention means to seek enrichment of the clinical practice of nurses who administer antineoplastic therapy, identifying skills for the exercise of this action, requirements for those who intend to dedicate themselves to this task and suggestions of methodological approaches to increase their level of effectiveness.

Part of the problems faced by patients in the chemotherapy outpatient clinic indicates a veiled quest for spiritual care, and it is up to nurses to realize this need, often hidden in the client's complaints and symptoms. Although nurses are not religious practitioners, they need to be present and understand when the patient's cause of suffering is associated with feelings of divine punishment, for understanding cancer as the cause of mistakes and faults committed in the past. The quest for spiritual assistance may also come from ethical conflicts or dilemmas, demanding counseling in the face of confrontation between religious beliefs and health care.

In this way, this article aims to reflect theoretically on the use of spiritual interventions and methods of psychological, theological and psychotherapeutic counseling applicable to nursing, using Jean Watson's Theory of Human Care for this transposition of elements. To achieve positive results on the spiritual suffering presented by patients undergoing chemotherapy, the requirements and qualities of the counselor were explored.

METHOD

This is a theoretical-reflective study that proposes a discussion on counseling methods and spiritual interventions from the perspective of Jean Watson's Theory of Human Care. It is based on a review of the scientific literature and on the authors' perception and experience about the researched topic.

The review of the literature was done in the databases PUBMED, Portal of Electronic Journals in Psychology (PePSIC), Virtual Health Library Portal (VHL) and PsycINFO, from the terms Counseling, Pastoral Care, Psychotherapy, Spirituality, Religion and its correspondents in English. For inclusion, publications should meet at least three of the following requirements: Present the concept of counseling, which is the purpose of this intervention, its principles/guidelines, methods and techniques employed, qualities of a counselor and suggestions to optimize this practice. We excluded studies that dealt with the subject in specific contexts and those that did not have affinity with the proposal of the article, such as genetic, professional, career, educational and sexual counseling.

The selection was made, in the first stage, by the reading of titles and abstracts, and, in a second stage, by the complete reading of the published articles, highlighting the points of interest for this reflection. The final review sample consisted of 17 articles.

Transposition of elements of psychoanalysis, psychology and theology in the light of the theoretical reference of Jean Watson

Nursing is a science in constant interaction with other areas of knowledge.⁸ Knowing, producing and using knowledge from other disciplines in interface with nursing, meeting their purposes before society, requires that the professional in this area be interactive and reflective.⁹

The knowledge produced on counseling in the theological, psychological and psychotherapeutic aspects precedes nursing and can provide basis for the execution of this action in nurses' practice. Traditionally considered psychological intervention, counseling supports a plurality of theoretical practices and perspectives that can be articulated with nursing.

For the nurse, it is a challenge to reflect and, mainly, to use standards of knowledge produced in these areas, in order to maintain scientificity, sensitivity, humanization, ethics and respect in their care. Therefore, the approach of this interdisciplinary integration has innovative potential.

For the development of this reflection, which seeks to integrate methodical elements from other disciplines, it was necessary to base a theory that would provide support for the transposition of scientific foundations. In order to avoid paradoxes, ambiguities and lack of clarity in the limits of performance, it became necessary to use a systematically constructed conceptual model in order to size the field of possibilities that can be explored by nurses. Jean Watson's Theory of Human Care was chosen and made possible the analysis, assimilation and synergistic union of interventions and methods of counseling of the aspects under study with nursing.

Watson, in his theory, attaches great importance to training in human sciences - a very forgotten aspect in the training of nurses - because it is able to provide essential tools for understanding the social, cultural and psychological dynamics of individuals.¹⁰ The author proposes in the Caritas Process the use of Self, and other knowledge recognized as part of the caring process, in order to provide an engagement in the process of health recovery through art.¹¹

For the integration of methodological approaches and spiritual interventions in nursing counseling provided by the disciplines under study, the Caritas Process (or Clinical Caritas), which is an extension of the Carative Factors of Human Care Theory, was analyzed.¹¹ These postulates provide attributes for access to the spiritual dimension and guide the practice of care in the conscience Caritas.

The expression Caritas is of Latin origin and means to treat with affection, to love, to nourish, to give special attention, to appreciate and to be sensitive. In evolving with the Carative Factors, Jean Watson expanded concepts such as the sacredness of the human being, the connection with more genuine sources of love, and the proposition of Healing as a reconstitution of being. With the process of reformulation and improvement of theory in 2005, new concepts emerged, core concepts were reinforced and some points were changed.¹¹

Table 1 presents qualities/requirements that are recommended by nurses, applicable to the practice of oncological nursing, counseling methods and spiritual interventions, articulated with Watson's theoretical principles proposed in the Carative Factors and in the Clinical Caritas Process.

Table 1
Qualities/requirements and spiritual interventions for counseling in accordance with the theoretical principles of Jean Watson. Rio de Janeiro, 2018

Qualities/requirements for counseling	Methods and spiritual counseling interventions	Caritas Processes
Empathy; spiritual self-care; compassion		Formation of a system of altruistic-humanistic values: practice of love/kindness, equity for oneself and for the other.
- need to recognize the impact of cultural and religious differences between therapist and client on counseling13-15 - multicultural competences13 - authenticity16	- reading of biblical and/or religious texts13-15 - prayer15,17-19 - application of elements of ethno-psychological advice16 - application of elements of multicultural counseling13 - therapy of hope20	Instillation of faith and hope: to be authentically present; enable, sustain and deeply honor the belief system of self and other.
- active clinical listening - practical experience and training - awareness of one's limitations	- centralization techniques to establish spiritual connections with counseling15	Cultivation of the sensibility of self and of the other: cultivation of one's own spiritual practice and a transpersonal "Self" that goes beyond one's own ego.
- congruence16	- strategic counseling21 - non-directive procedures21	Development of a relationship of help and confidence: development and permanence of an authentic relationship of care.
	- meditation15,17 - mindfulness20 - use of transference and countertransference as therapeutic elements in counseling22	Promoting acceptance of negative and positive feelings: being present to support the manifestation of positive and negative feelings as a means of deep connection with yourself and with individuals for care.
- know cultures and religious practices13,14,16		Systematic use of the scientific method of problem solving for decision making: use of the Self and all other knowledge recognized as part of the process of caring for engagement in a health recovery process through art.
- specialization in mental health - masters in the area of spiritual care		Promoting an interpersonal teaching-learning process: engage truly in teaching-learning experiences within the context of caring; assist another person fully and in the subjective sense of experience.
		Provision of a supportive, protective and/or corrective mental, physical, sociocultural and spiritual environment: creation of a healthy environment at all levels, both physical and non-physical, conscientious and energetically refined, whereby totality, beauty, comfort, dignity and peace are strengthened.
		Assistance from the gratification of human needs: with reverence and respect, meet basic human needs; maintain the consciential intentionality of care by touching and dealing with the embodied spirit of the other, honoring the connection of the being; allow spiritual connection.
	- application of strategies proposed by Gestalt-Therapy14,23	Recognition of existential phenomenological forces: openness and attention to the spiritual, mysterious, unknown and existential dimension inherent in life, death and suffering.

From the Carative Factors and the Clinical Caritas Process, more connection points were identified than the distance from the methods and spiritual care in pastoral counseling, as discussed below.

Methods and spiritual interventions in nursing counseling: approaches to the theory of human care

Techniques of centralization (spiritual connection with the patient), meditation, and prayer can be absorbed by the Theory of Transpersonal Care. Research on prayer and its healing power, phenomena of faith and hope, unexplained by current medicine, take on new meanings in the Caritas Consciousness. Pastoral counseling involves prayer, reading sacred texts and healing words,¹⁵ and is consistent with Caritas practices of caring. In this area, creating healing-care rituals and turning traditional tasks in nursing into intentional healing acts allows the advancement of the profession. The author cites practical examples of psychic cleansing, purification, and blessing the patient while preparing for the moment of caring.¹¹

Praying is a nursing intervention, recognized and classified in the Nursing Interventions Classification (NIC).^7,24 It is associated with benefits during chemotherapy treatment,^25,26 correlating with higher overall functioning scores. Nurses can find in this intervention an autonomy that allows them to obtain gains in health,²⁴ contributing to alleviate anxiety during the antineoplastic treatment.²⁶

It is recommended, however, to request permission to perform this nursing action, assessing the needs and opinions of the patient. Therapists cannot assume that religious clients will be open to any intervention of this nature and should ask them to evaluate the relationship of clinical complaints with their spiritual experiences.^14,24 In order for prayer to be authentic in the Caritas Consciousness, it is advocated for a congruence between the religious values of the therapist and the advised, in order to employ this intervention successfully.²⁴

Spiritual solidarity, the method of centralization (spiritual connection) described in the theological section,¹⁵ presents levels of therapist-advised interaction that approach the transpersonal relationship sought by Watson. It occurs when the counselor acts empathetically and focuses his attention on the counselor. In this technique, there is a sharing of spiritual experiences: therapist and clients can see, feel and think about certain issues in tune. By transferring his state of attention to the person in crisis, the counselor can achieve, with this method, a greater understanding of the stories narrated in counseling from the perspective of those who experience it.

In Watson, at the moment of the nurse-patient interaction, the potential for establishing what the author calls Caring Occasion arises. This moment, when not explored, becomes a care relationship. On the other hand, when explored in depth, it evolves into a transpersonal relationship, which gives rise to the Actual Caring Occasion. At this moment, the past and the present of the patient are added to the past and present of the nurse, forming a field greater than the very occasion of care.¹¹

With this contact of consciousness, nurses can open access to more subtle fields, among them the spiritual dimension. When they are able to see and connect with the spirit of the other, therapists make counseling become transpersonal. After this connection, it is possible to unveil the meaning of the spiritual experiences, capturing the Gestalt of the present moment.¹¹ At this point, the nurse is able to read the phenomenological field (of perception) beyond appearances and behaviors, comprising unique life histories in spiritual counseling.

The use of this methodological approach in counseling implies a more intense concentration in patients. It is recommended to listen not only physically, but also spiritually. The literary encounter with stories narrated, proposed in this method, leads to an understanding of the gaps in the dialogues, perceiving forgetfulness, redundancies and preteritions in the discourse of clients.

In this movement, therapists may receive "revelations" that may be unavailable to those who perform non-meditative logical analysis.¹⁵ This reading is a metaphysical experience of care and surpasses the scientific evidence on which the current nursing is based.¹¹ At this point, the method of pastoral counseling understands, as Watson does, that it is not the logic of counseling itself that makes it curative, but the nature of intimacy and the quality of relationships established between therapists and counselors.

The multicultural counseling model, widely adopted in psychotherapeutic care, advocates culture as an essential part of interventions.¹³ The elements of this method can go through and integrate the advice framed by Jean Watson, in that it provides for abstaining from judgments in terms of how different cultures of the therapist behave or organize themselves.^11,13 These two approaches have in common the understanding that the suspension of value judgments (whether or not to agree with what is reported) and reality (if facts fit only the imaginary) should guide the practice of therapists in dealing with spiritual matters.¹¹ In this understanding, this model finds assumptions in the Carative Factor "Formation of an altruistic-humanist value system", which leads us to tolerate differences and see the other through the way he sees the world.

Watson, in the Caritas Process, allows openness to phenomenological-existential forces and harmonizes with the appreciation of cultural aspects of human experience and psychic phenomena of multicultural counseling. From this principle, respect for belief in cures and spiritual practices not explained by traditional Western medicine is reaffirmed. The need for interventions in this field arises only when there is a manifest desire to abandon conventional treatment.

Within the so-called multicultural competences, the knowledge of different cultures, their characteristics and regularities allows the therapist to reflect on these practices and to be more fluent in the dialogues, bringing them closer to the cultural universe they face.¹³ By this means, the identification of ethnic and racial minorities is perceived as essential, allowing the recognition of clients in situations of greater vulnerability and risk for the diagnosis of spiritual suffering.

In multicultural counseling, as in Watson's Theory, the individual's ability to recognize himself is critical to recognizing the other. The individual's awareness of himself, as a being carrying a cultural baggage and his own spiritual experiences, allows an evaluation of his limits^11,27 and influences of personal values in counseling.¹³ This method has close theoretical links with the Clinical Caritas Process and Carative Factors 1 and 2, and can instrumentalize therapists in the practice of counseling.

In fact, studies have considered that the scientific future of psychological counseling depends on the ability to conduct culturally sensitive research that may have practical application in promoting the well-being of individuals, groups and systems around the world. This work must be consistent and theoretically based according to experts,^28,29 finding in the Human Care Theory a fertile field for its development.

Similar to the method of multicultural counseling, the attitude of otherness and respect for the other guide the use of ethno-psychological interventions in counseling, allowing the execution of care aligned with the spiritual needs of clients. The use of ethno psychology in counseling takes into account social contexts, having as a principle the valuation of individuals, their beliefs and worldview. This approach leads to the reflection in terms of how religious conceptions can give meaning to experiences, offering a meaning for cancer suffering. It opens up considerations on how these elements can relate to the way individuals are advised and understand their life paths.¹⁶ Thus, there are points of common interest between multicultural, ethno-psychological and Watsonian assumptions.

According to the Caritas Process, it is necessary to enable individuals to cultivate their belief system and perform their rituals, helping to maintain faith in themselves for healing.³⁰ The openness to the expression of spirituality in its purest form, proposed by ethnopsychology,¹⁶ relates not only to the theoretical principle of maintaining the person's belief system, but also to the principle of developing a relationship of trust, recognizing the capacity of each individual to exercise full freedom and autonomy. In other words, patients - or users - do not belong to us; regardless of our congruence with our secular values, we do not own their suffering, nor can we restrict their spirituality. Allowing patients to report pain in the face of death and incurability and proceeding with religious rituals without feeling trapped promotes the success of spiritual interventions.

The application of Gestalt-Therapy-guided interventions can be assimilated by the Transpersonal Theory, since both have a holistic view of the patient, highlight spirituality as a dimension of the human totality to be explored in the therapist-client relationship and converge to an existential phenomenological positioning.^11,31 In this perspective, spirituality presents itself as a relevant topic for gestaltists and cannot be subtracted from the assistance in the theoretical reference of Watson.

The immediate here-and-now experience in Gestalt-Therapy is enclosed in parentheses; and offers the advised individuals the possibility to explore the problems on their own, finding more creative solutions. In this sense, Gestalt-Therapy, as well as the Human Care Theory, is phenomenological and focuses on the description of the patient's feelings.^11,31 Both favor decision-making from an "intersubjective" consciousness, involving therapists and advised individuals, and help in the search for meaning for suffering, revealing the ways of a past time and a present time. In other words, it means carefully focusing intentional and conscious expressions of experience - which arise during counseling - in their irreducible uniqueness.³¹

Transference and countertransference as elements of the therapeutic method fit the transpersonal attribute, considered to be the most described in Watson's theory.³² Transpersonal refers to an intersubjectivity present in the human to human relationship, in which the nurse influences and is influenced by the personality of the other: both are fully present in the moment "Caritas Caring" and experience a sense of union that is mutual. By sharing the same phenomenological field, they become part of one another's life history, acting as coparticipants in the present and future tense.³³

In this look, the analyst can maintain a responsible role of "free floating" in counseling, with his own thoughts, feelings, attitudes and behaviors. The therapist becomes part of the analytic situation, not only as a spectator, but as an active part, allowing the action of his subjectivity in counseling.^11,22,32 The analyst's position is not simply to observe and interpret behaviors of the advised, but of proactive involvement, in which he becomes a co-author in the therapeutic process; in this way he can modify intolerable and mismatched aspects of the patients expressed in the transference. The therapist can return them in an attenuated and detoxified form in countertransference.²²

The method of strategic counseling works according to the postulates of Theory of Transpersonal Care. This method does not explain the situation in terms of parameters, but of the actions involved and levels of competence to achieve it, with progressive delegation of responsibility. It highlights the costs of an action, its effects, goals and meanings within a problem. In short: what is happening and what the subject can do to solve. Once the analysis is understood and the way in which the variables work, the subject gains the means to face the conflict effectively.²¹

The acquisition of technical skills to analyze the dispositions of the person advised to perform these actions requires the learning of ontological skills of care, to be cultivated through the practice of sensitivity to oneself and to the other. Watson emphasizes that this sensitivity is reinforced by the formation of an altruistic-humanist value system.

Strategic counseling integrated with Watson's Theory considers that nurses have the role of providing support and protection for decision making, and patients have to choose their own experiences, which are responsible for positive changes in behavior. The Caritas Process indicates that the care environment offered by nurses should be one that fosters personal development and enables people to choose the best action for themselves.³³

Non-directive procedures, represented by psychological counselors, are about an explicit, more or less directive orientation by an expert, about how to approach a problem, or manage one's own emotions, behaviors, and actions.²⁰ Counseling differs from advice and assumes not doing something to the patient, but doing something with the patient. Consisting of science and art, it aims to improve the clinical prowess of therapists, proposing, as in the Watsonian theory, a change in the patterns of unideretional communication, centered in the figure of the therapist. Counseling, from a perspective of transpersonal care relationships, involves exploring the patient's beliefs, attributions, and expectations on an equal footing in the decision-making process. In non-directive procedures, one seeks to listen more than to speak, to understand more than to judge, to ask more than to suppose and persuade more than to impose.³⁴ It implies, therefore, an action aimed at clarifying a problem, without necessarily imposing which action should be undertaken or the best option to be considered.²¹

Qualitative studies in women with relapsed cancer reported a multiplicity of thoughts and feelings related to the physical symptoms of the disease, numerous chemotherapy sessions, past memories and concerns about the future.³⁵ The practice of Mindfulness in this context presents itself as an effective psychological intervention in improving oncological coping patterns²⁰ and for relieving suffering in other conditions.¹¹

Mindfulness is explored in the Human Care Theory as a lifelong preparatory practice to sustain and expand Caritas awareness for oneself and for the other. It is not tied to any particular religion.¹¹ It has been successfully used to reduce depression and anxiety, improving the mood and quality of life of cancer patients.³⁶ It is capable of reducing the negative effects of stress and anxiety by increasing the positive effects on mental health.²⁰ Both approaches work by harmonizing with the principle of equanimity in Caritas Consciousness, reducing pain and suffering by applying goodness to oneself and to another.¹¹

Allowing the free flow of energy, accepting anger, pain and despair, forms a kind of spiritual purification of feelings, leading to healing and wholeness.¹¹ When clients are able to observe the details of each breath, they can train their mind to develop a metacognitive vision, understanding how their thoughts and feelings arise and dissolve. In this reasoning, meditation is an important practice that can be integrated into counseling. Teaching clients that negative thoughts and feelings can disappear, if they do not cling to them, is an intervention that can substantially reduce suffering.³⁷

According to the theoretical framework of Jean Watson, spiritual interventions can be developed and coupled with counseling, improving the results of oncological nursing treatment.

The Clinical Caritas Process indicates the creative use of self as a participant in the art of care and of all ways of knowing as part of the care process.¹¹ Watson made explicit, with this theoretical foundation, that excessive systematization of regulations in care is an impediment to the creative development of the profession.³¹ Developing the practice of religious/spiritual counseling according to the Transpersonal Theory requires the ontological skills of human care. It is not about strictly following prescribed steps and methods, restricting a practice that must be original and unique as each experience of interpersonal relationship. In this understanding, counseling is about an intervention that is not strictly scientific, nor totally empirical, but reflective and exploratory.¹¹

Distances and points of conflict between the spiritual counseling of nursing and the analyzed aspects

In the follow-up of patients in antineoplastic therapy, we emphasize that the role of the nurse in counseling also extends to other levels of complexity and competence. In addition to the interpretation of client's spiritual responses, there should be a correlation with the diagnosis presented and the toxicity of the chemotherapeutic treatment, since the client's choices regarding the health care implemented are directly interfered with religious precepts and dogmas. In the decision-making process, the nurse should assess how individuals stand in the face of medical/nursing interventions, and how they are affected by the choices made.

Patients who are Jehovah's Witnesses may refuse to receive blood transfusion and therapy with blood components, which may be indicated for the treatment of myelosuppression, secondary to the use of antineoplastics. In guiding the patient, the nurse should be aware and inform all accessible therapeutic options and how they will reflect on the health outcomes. Support and sensitivity are fundamental in this decision-making process, as bioethical dilemmas can create clashes and constitute a source of spiritual suffering. In this way, it is important to be attentive and able to deal with complex issues involving health and religion. Skills at this level may require professional experience, extensive knowledge in bioethics and religious culture.

Notwithstanding the skills to conduct such situations, it is considered that patients may choose someone from the same religious denomination to receive policy guidance in ethical conflicts involving medical treatment. In this case, pastors and spiritual leaders of the same religious denomination as the advised individual may be required for counseling.

Nursing counseling distances itself from pastoral counseling regarding religious morality and the ethical convictions associated with it. In the oncological context, this intervention does not bring a message of salvation and cannot evaluate conduct of life as sinful according to well defined concepts and dogmas in religion; it aims to work in congruence with the client's beliefs. In pastoral counseling, not offering religious guidance when these values are in question is considered a serious omission.³⁸

When counseling in psychotherapy aims at deeper changes in the personality structure of the advised person, with a focus on uncovering the dynamics that explain particular existential crises,³⁹ it moves away from the counseling provided by nurses. In the presence of psychic disorders, which require a more intense self-understanding of the individual, specific psychological or psychotherapeutic counseling techniques should be employed. The limits between the slopes should not, however, disprove the transdisciplinary importance in caring for suffering. The problem of the individual, destiny and pain, for which we often do not have answers, can be better dealt with with unique counseling approaches that integrate different perspectives of listening and receiving the problems, not only of the psyche, but also of the human soul. In this sense, technical ignorance can be a cause of failure in nursing care, because in some way, the idea that suffering, fear and anxiety are conditions exclusively treated in psychology and psychotherapy practices is perpetuated.

Therefore, the proposed counseling takes different paths, aiming to alleviate the patients' suffering by allowing them to understand the difficulties they face, favoring their greater autonomy in terms of solving problems, and exploring personal coping mechanisms, generating empowerment for decision making. It is understood, in this process, the integration of the individual with his own spirituality as a major end.

CONCLUSIONS

Postponing or responding to religious questions without proper preparation and technical competence can aggravate the spiritual suffering of patients. On the other hand, meeting the demand when it happens generates confidence and strengthens the link with the nursing team. In the analysis of spiritual interventions and counseling methods, psychology, theology and psychotherapy can contribute to the nurse who knows how to position himself critically, distinguishing between points of conflict and common interests, without discarding these methods of therapy from his professional practice. From this perspective, this article presents approximations, distances and points of integration that must be evaluated by the advising nurse.

By appropriating the knowledge obtained with the disciplines studied, the nurse can provide support and theoretical contribution to his professional practice for the application of spiritual interventions and counseling, adding greater scientific value to the decision-making process during the conduction of these interventions.

Future studies will be needed to measure the efficacy of spiritual counseling in relieving or healing the suffering of oncology patients on anticancer therapy. The suffering experienced by them has multiple dimensions and requires the nurse to know scientific methods to conduct counseling, finding important tools for practice in psychology, theology and psychotherapy. It is considered that all areas of action complement each other and are indispensable, being vital in the assistance.

ACKNWOLEDGMENTS

We would like to express our thanks to the Fundação CAPES (Coordination for Higher Education Staff Development), CAPES-COFEN letter for your contribution to the financing of this study.

REFERENCES

• ¹
  Caldeira S, Carvalho EC, Vieira M. Between spiritual wellbeing and spiritual distress: possible related factors in elderly patients with cancer. Rev Latino Am Enferm [Internet]. 2014 Jan/Feb; [cited 2018 Abr 19]; 23(1):28-34. Available from: http://dx.doi.org/10.1590/0104-1169.3073.2382
  » http://dx.doi.org/10.1590/0104-1169.3073.2382
• ²
  Bonelli RM, Koenig HG. Mental Disorders, Religion and Spirituality 1990 to 2010: A Systematic Evidence-Based Review. J Relig Health [Internet]. 2013 Jun; [cited 2018 Mar 8]; 52(2):657-73. Available from: http://dx.doi.org/10.1007/s10943-013-9691-4
  » http://dx.doi.org/10.1007/s10943-013-9691-4
• ³
  Peteet JR, Balboni MJ. Spirituality and religion in oncology. CA Cancer J Clin [Internet]. 2013 Jul/Aug; [cited 2018 Mar 1]; 63(4):280-9. Available from: http://doi.wiley.com/10.3322/caac.21187
  » http://doi.wiley.com/10.3322/caac.21187
• ⁴
  Sousa FFPR, Freitas SMFM, Farias AGS, Cunha MCSO, Araújo MFM, Veras VS. Religious/Spiritual Coping by People with Cancer Undergoing Chemotherapy: Integrative Literature Review. SMAD Rev Eletr Saúde Ment Álcool Drog [Internet]. 2017 Jan/Mar; [cited 2018 Mar 2]; 13(1):45-51. Available from: http://dx.doi.org/10.11606/issn.1806-6976.v13i1p45-51
  » http://dx.doi.org/10.11606/issn.1806-6976.v13i1p45-51
• ⁵
  Freire MEM, Vasconcelos MF, Silva TN, Oliveira KLO. Spiritual and religious assistance to cancer patients in the hospital context. J Res Fundam Care Online [Internet]. 2017 Apr/Jun; [cited 2018 Mar 10]; 9(2):356-62. Available from: http://dx.doi.org/10.9789/2175-5361.2017.v9i2.356-362
  » http://dx.doi.org/10.9789/2175-5361.2017.v9i2.356-362
• ⁶
  Oh P, Kim SH. The Effects of Spiritual Interventions in Patients With Cancer: A Meta-Analysis. Oncol Nurse Forum [Internet]. 2014; [cited 2018 Mar 8]; 41(5):E290-301. Available from: http://dx.doi.org/10.1188/14.ONF.E290-E301
  » http://dx.doi.org/10.1188/14.ONF.E290-E301
• ⁷
  Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. NIC - Classificação das Intervenções de Enfermagem. 6ª ed. Tradução de Denise Costa Rodrigues. Rio de Janeiro: Elsevier; 2016.
• ⁸
  Ribeiro M, Santos SL, Meira TGBM. Refletindo sobre liderança em Enfermagem. Esc Anna Nery [Internet]. 2006;10(1):109-15. Available from: http://www.scielo.br/scielo.php?pid=S1414-81452006000100014&script=sci_abstract&tlng=pt
  » http://www.scielo.br/scielo.php?pid=S1414-81452006000100014&script=sci_abstract&tlng=pt
• ⁹
  Lacerda MR, Zagonel IPS, Martins SK. Padrões do conhecimento de enfermagem e sua interface ao atendimento domiciliar à saúde. Online Bras J Nurs [Internet]. 2006; [cited 2018 Feb 21]; 5(2):206-15. Available from: http://www.redalyc.org/pdf/3614/361453972024.pdf
  » http://www.redalyc.org/pdf/3614/361453972024.pdf
• ¹⁰
  Gomes IM, Silva DI, Lacerda MR, Mazza VA, Méier MJ, Mercês NNA. Jean Watson's theory of transpersonal caring in nursing home care to children: a reflection. Esc Anna Nery [Internet]. 2013 Jul/Aug; [cited 2018 Mar 10]; 17(3):555-61. Available from: http://dx.doi.org/10.1590/S1414-81452013000300021
  » http://dx.doi.org/10.1590/S1414-81452013000300021
• ¹¹
  Watson J. Nursing: The Philosophy and Science of Caring. Boulder: University Press of Colorado Boulde; 2008.
• ¹²
  Watson J. Watson's theory of human caring and subjective living experiences: carative factors/caritas processes as a disciplinary guide to the professional nursing practice. Texto Context Enferm [Internet]. 2007 Jan/Mar; [cited 2018 Mar 1]; 16(1):129-35. Available from: http://dx.doi.org/10.1590/S0104-07072007000100016
  » http://dx.doi.org/10.1590/S0104-07072007000100016
• ¹³
  Scorsolini-Comin F. Elementos do aconselhamento multicultural aplicados à psicoterapia em contexto etnopsicológico. Estud Pesqui Psicol [Internet]. 2015; [cited 2018 Mar 10]; 15(2):587-607. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1808-42812015000200009
  » http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1808-42812015000200009
• ¹⁴
  Campos AF, Ribeiro JP. Psicoterapia e espiritualidade: da gestalt-terapia à pesquisa contemporânea. Rev abordagem gestalt [Internet]. 2017;23(2):211-8. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_abstract&pid=S1809-68672017000200009
  » http://pepsic.bvsalud.org/scielo.php?script=sci_abstract&pid=S1809-68672017000200009
• ¹⁵
  Miller AJ. The Spiral Staircase: A Narrative Approach to Pastoral Conversation. J Pastor Care Couns [Internet]. 2016 Dec; [cited 2018 Mar 03]; 70(1):26-33. Available from: http://journals.sagepub.com/doi/10.1177/1542305015619884
  » http://journals.sagepub.com/doi/10.1177/1542305015619884
• ¹⁶
  Scorsolini-Comin F. Plantão Psicológico centrado na pessoa: intervenção etnopsicológica em terreiro de umbanda. Temas Psicol [Internet]. 2014;22(4):885-99. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1413-389X2014000400016
  » http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1413-389X2014000400016
• ¹⁷
  Sharma V, Marin DB, Sosunov E, Ozbay F, Goldstein R, Handzo GF. The Differential Effects of Chaplain Interventions on Patient Satisfaction. J Health Care Chaplain [Internet]. 2016; [cited 2018 Mar 1]; 22(3):85-101. Available from: http://dx.doi.org/10.1080/08854726.2015.1133203
  » http://dx.doi.org/10.1080/08854726.2015.1133203
• ¹⁸
  Brown O, Elkonin D, Naicker S. The use of religion and spirituality in psychotherapy: enablers and barriers. J Relig Health [Internet]. 2013 Dec; 52(4):1131-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=The+Use+of+Religion+and+Spirituality+in+Psychotherapy%3A+Enablers+and+Barriers.+J+Relig+Health.+2013%3B52(4)%3A1131-46
  » https://www.ncbi.nlm.nih.gov/pubmed/?term=The+Use+of+Religion+and+Spirituality+in+Psychotherapy%3A+Enablers+and+Barriers.+J+Relig+Health.+2013%3B52(4)%3A1131-46
• ¹⁹
  Memaryan N, Ghaempanah Z, Saeedi MM, Aryankhesal A, Ansarinejad N, Seddigh R. Content of Spiritual Counselling for Cancer Patients Undergoing Chemotherapy in Iran: A Qualitative Content Analysis. Asian Pac J Cancer Prev [Internet]. 2017 Jul; [cited 2018 Mar 1]; 18(7):1791-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28749107
  » http://www.ncbi.nlm.nih.gov/pubmed/28749107
• ²⁰
  Thornton LM, Cheavens JS, Heitzmann CA, Dorfman CS, Wu SM, Andersen BL. Test of mindfulness and hope components in a psychological intervention for women with cancer recurrence. J Consult Clin Psychol [Internet]. 2014 Dec; [cited 2018 Mar 3]; 82(6):1087-100. Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/a0036959
  » http://doi.apa.org/getdoi.cfm?doi=10.1037/a0036959
• ²¹
  Manjón González J. La Autoayuda y el Consejo como Procedimientos Psicoterapéuticos. Rev Asoc Esp Neuropsiq [Internet]. 2014 Apr/Jun;34(122):283-300. Available from: http://dx.doi.org/10.4321/S0211-57352014000200004
  » http://dx.doi.org/10.4321/S0211-57352014000200004
• ²²
  Jang JE. The Interactive Play and a Persuasive God: A Psychoanalytic Approach to Re-envisioning Pastoral Care and Counseling. J Pastor Care Couns [Internet]. 2016; [cited 2018 Mar 3]; 70(2):136-42. Available from: http://dx.doi.org/10.1177/1542305016643057
  » http://dx.doi.org/10.1177/1542305016643057
• ²³
  Henning-Geronasso MC, More CLOO. Influência da Religiosidade/Espiritualidade no Contexto Psicoterapêutico. Psicol Cienc Prof [Internet]. 2015;35(3):711-25. Available from: http://www.scielo.br/scielo.php?pid=S1414-98932015000300711&script=sci_abstract&tlng=pt
  » http://www.scielo.br/scielo.php?pid=S1414-98932015000300711&script=sci_abstract&tlng=pt
• ²⁴
  Caldeira S. Cuidado Espiritual - rezar como intervenção de enfermagem. CuidArte Enferm. 2009 Jul/Dec; 3(2):157-64. Available from: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=BDENF&lang=p&nextAction=lnk&exprSearch=20554&indexSearch=ID
  » http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=BDENF&lang=p&nextAction=lnk&exprSearch=20554&indexSearch=ID
• ²⁵
  Paiva CE, Paiva BS, Yennurajalingam S, Hui D. The impact of religiosity and individual prayer activities on advanced cancer patients' health: is there any difference in function of whether or not receiving palliative anti-neoplastic therapy? J Relig Health [Internet]. 2014 Dec; [cited 2018 Mar 10]; 53(6):1717-27. Available from: http://dx.doi.org/10.1007/s10943-013-9770-6
  » http://dx.doi.org/10.1007/s10943-013-9770-6
• ²⁶
  Carvalho CC, Chaves ECL, Iunes DH, Simão TP, Grasseli CSM, Braga CG. Effectiveness of prayer in reducing anxiety in cancer patients. Rev Esc Enferm USP [Internet]. 2014 Aug; [cited 2018 Jan 24]; 48(4):684-90. Available from: http://dx.doi.org/10.1590/S0080-623420140000400016
  » http://dx.doi.org/10.1590/S0080-623420140000400016
• ²⁷
  Machín EI. Enfermería: Teoría de Jean Watson y la inteligencia emocional, una visión humana. Rev Cuba Enferm [Internet]. 2015; [cited 2018 Jan 27]; 31(3). Available from: http://www.revenfermeria.sld.cu/index.php/enf/article/view/686/131
  » http://www.revenfermeria.sld.cu/index.php/enf/article/view/686/131
• ²⁸
  Hardin EE, Robitschek C, Flores LY, Navarro RL, Ashton MW. The cultural lens approach to evaluating cultural validity of psychological theory. Am Psychol [Internet]. 2014; [cited 2018 Jan 18]; 69(7):656-68. Available from: http://dx.doi.org/10.1037/a0036532
  » http://dx.doi.org/10.1037/a0036532
• ²⁹
  Robitschek C, Hardin EE. The future of counseling psychology research viewed through the cultural lens approach. J Couns Psychol [Internet]. 2017; [cited 2018 Jan 18]; 64(4):359-68. Available from: http://dx.doi.org/10.1037/cou0000207
  » http://dx.doi.org/10.1037/cou0000207
• ³⁰
  Urra ME, Jana AA, García VM. Algunos Aspectos Esenciales del Pensamiento de Jean Watson y su Teoría de Cuidados Transpersonales. Cienc Enferm [Internet]. 2011 Dec; [cited 2018 Jan 12]; 17(3):11-22. Available from: http://dx.doi.org/10.4067/S0717-95532011000300002
  » http://dx.doi.org/10.4067/S0717-95532011000300002
• ³¹
  Boris GDJB, Melo AK, Moreira V. Influence of phenomenology and existentialism on Gestalt therapy. Estud Psicol (Campinas) [Internet]. 2017 Oct/Dec; [cited 2018 Mar 3]; 34(4):476-86. Available from: http://dx.doi.org/10.1590/1982-02752017000400004
  » http://dx.doi.org/10.1590/1982-02752017000400004
• ³²
  Favero L, Pagliuca LMF, Lacerda MR. Transpersonal caring in nursing: an analysis grounded in a conceptual model. Rev Esc Enferm USP [Internet]. 2013 Apr; [cited 2018 Jan 10]; 47(2):500-5. Available from: http://www.scielo.br/scielo.php?pid=s0080-62342013000200032&script=sci_arttext&tlng=en
  » http://www.scielo.br/scielo.php?pid=s0080-62342013000200032&script=sci_arttext&tlng=en
• ³³
  Watson J. Human caring science: a theory of nursing. Ontario: Jones & Bartlett Learning; 2012.
• ³⁴
  Cancio H, Serrano R. El counselling: un arte, una técnica, un modo de vivir la relación con los pacientes. Cuad Psiquiatr Comunit [Internet]. 2007;7(1):7-13. Available from: https://dialnet.unirioja.es/servlet/articulo?codigo=2660993
  » https://dialnet.unirioja.es/servlet/articulo?codigo=2660993
• ³⁵
  Thornton LM, Levin AO, Dorfman CS, Godiwala N, Heitzmann C, Andersen BL. Emotions and social relationships for breast and gynecologic patients: A qualitative study of coping with recurrence. Psychooncology [Internet]. 2014 Apr; [cited 2018 Mar 9]; 23(4):382-9. Available from: http://dx.doi.org/10.1002/pon.3429
  » http://dx.doi.org/10.1002/pon.3429
• ³⁶
  Carlson LE, Tamagawa R, Stephen J, Drysdale E, Zhong L, Speca M. Randomized-controlled trial of mindfulness-based cancer recovery versus supportive expressive group therapy among distressed breast cancer survivors (MINDSET): long-term follow-up results. Psychooncology [Internet]. 2016 Jul; [cited 2018 Mar 10]; 25(7):750-9. Available from: http://dx.doi.org/10.1002/pon.4150
  » http://dx.doi.org/10.1002/pon.4150
• ³⁷
  Cheung KC, Oh A, Zhao Q, Wu F, Chen S, Diaz T, et al. Buddhist Counseling: Implications for Mental Health Professionals. Spiritual Clin Pract [Internet]. 2017; [cited 2018 Jan 14]; 4(2):113-28. Available from: http://dx.doi.org/10.1037/scp0000124
  » http://dx.doi.org/10.1037/scp0000124
• ³⁸
  Woldemichael MT, Broesterhuizen M, Liégeois A. Christian pastoral care and psychotherapy: a need for theoretical clarity. J Pastoral Care Counsel [Internet]. 2013 [cited 2018 Mar 2]; 67(4):1-13. Available from: http://dx.doi.org/10.1177/154230501306700406
  » http://dx.doi.org/10.1177/154230501306700406
• ³⁹
  Bond T. The nature and outcomes of counseling. In: Keithley J, Marsh G, editors. Counseling in primary health care. Oxford: Oxford University Press; 1995. p. 3-26.

Publication Dates

• Publication in this collection
  02 July 2018
• Date of issue
  2018

History

• Received
  12 Mar 2018
• Accepted
  25 May 2018