Nursing and spirituality

Objectives: To evaluate the spiritual well-being of nurses; to appraise their opinions as to the importance of offering patients spiritual assistance, and to verify whether nurses received any specific type of preparation during their professional training for giving spiritual assistance to patients. Methods: This is an exploratory and descriptive study, carried out with a sample of 30 nurses who worked at the Stepdown Unit and Oncology Unit of Hospital Israelita Albert Einstein, using the application of the Spiritual Well-Being Scale (SWS) and a questionnaire prepared by the authors. results: On the Spiritual Well-Being Scale, 76.6% of nurses produced positive scores. On the Existential Well-Being subscale, 80% had positive scores, and on the Religious Well-Being subscale, 76.6% had positive scores. On the SWBS, the general average score was 107.26, and for the Existential and Religious ones, the average scores were 54.4 and 53.2, respectively. Most nurses responded affirmatively as to the importance of offering patients spiritual assistance, and 40% of nurses offered as rationale “to provide well-being and comfort to the patient”. Most nurses reported not having received professional training for giving spiritual assistance to patients in any of the nursing courses they had done. conclusions: The results indicate the need for professional training and/or continued education courses in nursing to extend the reflection and discussion on spirituality and spiritual assistance to patients.

Descritores: Terapias espirituais/enfermagem; Terapias espirituais/ educação; Religião; Enfermagem holística; Enfermagem holística/ educação; Enfermagem holística/ética; Assistência ao paciente/ métodos intrODUctiOn Over the last few years, scientific research in the area of health has been carried out with the objective of studying the possible influences of spirituality on health status of human beings.In parallel, spirituality has been increasingly considered as a dimension that should be included in global patient care.
In 1988, the World Health Organization (WHO) initiated a deepening of its investigations on spirituality, including the spiritual aspect in the multidimensional concept of health.Currently, spiritual well-being has been considered one more dimension of the health status, along with the physical, psychological, and social dimensions (1) .
Religiosity and spirituality are not synonyms, as religiosity involves systematization of the services and doctrines shared by a group.Spirituality is associated with issues related to the significance and purpose of life, with the belief in spiritualistic aspects in order to justify one's existence and significance (2)(3) .
Spirituality may be defined as the human propensity to seek significance for life by means of concepts that transcend the tangible: a feeling of connection with something greater than oneself, which may or may not include formal religious participation (2)(3)(4) .
The issue of spirituality is very extensive and its measurement is very complex, in which spiritual wellbeing, i.e., the subjective perception of the subject's well-being related to his/her belief is one of the evaluable aspects.The instruments of measurement of spiritual well-being are based on the concept of spirituality that involves a vertical, religious component (a feeling of well-being in relation to God), and an existential, horizontal component (a feeling of purpose and satisfaction in life) (5) .
In Nursing, spirituality is a question that has appeared since Florence Nightingale and, in Brazil, the first scientific publication on the theme dates from 1947.Over time, the attitude of Nursing as to the spiritual dimension suffered modifications, and became more of a tendency to see spirituality linked to religion for reflections of an ethical, bioethical, and philosophical character, as well as an attempt to comprehend the phenomena of spirituality of patients and those of nurses themselves (6) .
In a study performed with Nursing teachers as to spirituality and spiritual assistance in undergraduate courses, it was concluded that there is a lack of clarity in Nursing as to the meaning of what spirituality, religiosity and spiritual assistance are, and that this theme leads to personal questioning in nurses.Therefore, the formal discussion of this topic is necessary in undergraduate teaching (7) .
In another study, which had the objective of identifying the perception of undergraduate nursing students about care given to the spiritual dimension in fields of internship, it was noted that the majority of students did not perceive care given to the spiritual dimension of patients.The students that affirmed having perceived spiritual assistance being given, named the Chaplain as the main caregiver of this type of assistance, but most stated that Nursing should attend to the spiritual dimension of patients (8) .
The present research had as its focus the evaluation of the spiritual well-being of nurses, the verification of their opinions about the importance of offering patients spiritual assistance, and the assessment to know if they had received some form of preparation for giving spiritual assistance to the patient.

OBJectiVeS
To evaluate the spiritual well-being of nurses, to verify their opinions as to the importance of offering patients spiritual assistance and to check whether the nurses had received any type of preparation during their formal professional training for giving patients spiritual assistance.

Study design
This is a quantitative, level I, exploratory and descriptive study.Exploratory and descriptive studies seek more accurate information on groups, institutions, subjects, or situations, characterizing them and outlining a profile (9) .A quantitative study is conducted within the context of prior knowledge from an initial point of a study (posing a question) to the final point (obtaining an answer) in a logical sequence of steps, which typically involve activities with a strong conceptual or intellectual element that includes, reading, thinking, rethinking, and appraising ideas with creativity (9) .
A cross-sectional study was performed on a sample of 30 nurses working at the Step-down Unit and Oncology Unit of Hospital Israelita Albert Einstein.The Spiritual Well-Being Scale (SWS) (Appendix A) (10) and a questionnaire drawn up by the authors of the present study (Appendix B) were applied.
The Step-down Unit has 41 beds and 32 nurses, and the Oncology Unit of Hospital Israelita Albert Einstein has 32 beds and 33 nurses.

Population and sample
The sample of the present study was composed of 30 nurses: 15 working at the Step-down Unit and 15 at the Oncology Unit of Hospital Israelita Albert Einstein.
The inclusion criterion was the nurse's agreement to participate in the study, by signing the informed consent form.

instrument The Spiritual Well-Being Scale
The SWS has the objective of assessing the patient's general spiritual well-being; it was developed by Poulotizan and Ellison, in 1982 (11) , and was adapted for the Brazilian population by Marques et al. (SWS) (10) .The SWS is made up of 20 items, 10 of which evaluate the religious well-being (RWB), and the others, the existential well-being (EWB).Each one of the 20 items is answered according to a six-point scale, varying from "I strongly agree" to "I strongly disagree" (Appendix A).The subject should grade statements such as "I believe that God is concerned with my problems" for the RWB, and such as "I feel fulfilled and satisfied with life" for the EWB.The scores of the two subscales are added in order to obtain the general measurement of the SWS.Spiritual well-being is understood as a feeling of wellbeing experienced when there is a purpose that justifies our commitment to something in life, and this purpose involves an ultimate meaning/significance for life.RWB is considered as one in reference to communion and intimate personal relationship with God or a Superior Force (12) .
Paloutzian and Ellison suggested as cutoff points for the general Spiritual Well-Being Scale score, the intervals from 20 to 40, 41 to 99, and 100 to 120, equivalent to low, moderate, and high scores, respectively (11) .In both subscales, the intervals are from 10 to 20, 21 to 49, and 50 to 60 points (13) .In the analysis of this study, the Spiritual Well-Being Scale results were denominated positive for the high score and negative for the moderate and low scores (11) .

Questionnaire
A questionnaire was applied with open-ended and closed questions that covered the following items: socialdemographic data, opinions of the nurses as to the importance of offering patients spiritual assistance, and the preparation of nurses for giving this spiritual assistance.
The questionnaire was prepared by the authors of the present study (Appendix B).

Data collection
The collection of data was performed after approval of the research project by the Scientific Committee of Faculdade de Enfermagem of Hospital Israelita Albert Einstein [Nursing School] and by the Research Ethics Committee of Hospital Israelita Albert Einstein, as well as the authorization of the institution.Posteriorly, the nurses who worked at the Step-down Unit and Oncology Unit were invited to participate in the study, and those who accepted, signed the informed consent form and answered the SWS and the questionnaire designed by the authors.

Data analysis
The results were analyzed by descriptive statistics (mean, standard deviation, median, and percentages) and presented in tables.

Sociodemographic characteristics
In the group of 30 nurses studied, 70% were female.Ages varied from 23 to 59 years, with a mean age of 32.8 years, a median of 33 years, and standard deviation of 9.7 years.As to the marital status, 46.6% of nurses were single.In reference to religion, the majority (60%) of nurses reported following the Roman Catholic religion, and most of them (80%) stated that they were practicing Catholics.As to the year of conclusion of their studies, 57% of nurses had graduated between the years of 2000 and 2007 (Table 1).

assessment of spiritual well-being of nurses
As to their performance on the SWS, it was noted that 76.6% of the nurses had positive SWS scores.For the EWB subscale, 80% of nurses had positive scores, and for the RWB subscale, 76.6% of them had positive scores (Table 2).
As to performance on the SWS, the general average was 107.26, and for the EWB and RWB subscales, it was 54.4 and 53.2, respectively.

nurses' opinions on the importance of offering patients spiritual assistance
As to the nurses' opinions on the importance of offering the patient spiritual assistance, the majority (83%) answered affirmatively.
Of the total, 25 nurses who answered affirmatively about the importance of offering patients spiritual assistance, 40% of them gave as rationale "to provide well-being and comfort to the patient" (Table 3).performed with Psychology students of Faculdade de Psicologia of PUC-RS.These results were also higher than the means of the study conducted by Volcan et al., in a research project with 464 university students in the areas of Medicine and Law, in which the average Spiritual Well-Being Score was 90.4, with 45.6 and 45.1, respectively, for the Existential and Religious subscales (13) .
As to the opinions of the nurses on the importance of offering the patient spiritual assistance, most responded affirmatively.This result is similar to that of a survey conducted with graduating Nursing school students, in which most reported that it is important for nurses to be involved in the patient's spiritual dimension (8) .
The fact that most nurses mentioned considering it important to give the patient spiritual assistance may be related to a current tendency in Nursing to view the human being within a holistic perspective, in which the basic precept of holism is that the entire individual (body, mind, and spirit) is more than the sum of its parts.These dimensions interact, and therefore, in treating one of them, the others will be affected.In this way, the spiritual dimension is considered an integral part of the individual, and it is necessary for nurses to evaluate the spiritual dimension of the patient and intervene when necessary (7) .
Of the total number of nurses who responded affirmatively as to the importance of offering patients spiritual assistance, less than half of them offered as a reason "to provide well-being and comfort to the patient".This opinion is congruent with the multidimensional concept of health recommended by the WHO, in which spiritual well-being has been increasingly considered one more dimension of health, along with the physical, psychological, and social dimensions (1) .
Most of the nurses reported not having received professional training for giving patients spiritual assistance in any of the following courses: undergraduate Nursing school, graduate Nursing school, and other Nursing courses.
In a study carried out with graduating Nursing students as to knowledge and perception of the importance of tending to the spiritual dimension of the patient, it was concluded that it is important to observe the way in which the theme has been treated in academic circles, since, in this study, the lack of theory on this topic related to interventions for the spiritual needs of the patients was noted in the students (8) .
A formal discussion of spirituality during undergraduate training is necessary, since the object of Nursing is the human being from the holistic perspective -the comprehension of man as a bio-psycho-socialspiritual being.Thus, one way of initiating this discussion could be by using the definitions of North American Nursing Diagnosis Association (NANDA) and testing the indicators it proposes for detecting "Spiritual Distress" (7) .Of the five nurses who responded negatively as to the importance of offering the patient spiritual assistance, 60% justified their answer with "it is not the responsibility of the nurses to interfere in this subject." Most (67%) nurses reported not having received professional training during their undergraduate Nursing course, 93% of them received no training during their graduate course, and 87% responded that they had received no professional training in other Nursing courses for giving spiritual assistance to patients.

DiScUSSiOn
In the present study, we verified that the majority of nurses had positive scores on the SWS, while in another study carried out with Psychology students of Universidade Católica de Pelotas, 84.6% of the students obtained negative scores.Likewise, in the EWB and RWB subscales, the scores for nurses were higher than the scores obtained by Psychology students (10) .
The performance of the nurses on the SWS showed higher means than the results obtained in a survey cOnclUSiOnS The assessment of the spiritual well-being of nurses showed that the majority presented positive scores, i.e., considered that it is important to offer the patient spiritual assistance.
Most of the nurses reported not having received professional training for providing the patient with spiritual assistance in any of the courses they had concluded.
The results point to the need for professional training and/or continued education courses in Nursing, in order to expand the space given to the reflection and discussion of spirituality and spiritual assistance to the patient.

table 1 .
Distribution of the social-demographic characteristics of nurses

table 2 .
Distribution of nurses as to the Spiritual Well-Being Scale (SWS) and its subscalesThe results were considered positive for high score and negative for moderate and low scores.

table 3 .
rationales offered by nurses as to the importance of offering spiritual assistance to patients