SPIRITUALITY IN SELF-CARE FOR INTENSIVE CARE NURSING PROFESSIONALS

This study aimed to understand how spirituality permeates the process of caring for oneself and for others in the intensive care scenario from nursing professionals’ point of view. This study used the qualitative approach of Cabral’s Creative-Sensitive Method to guide information production and analysis in nine art and experience workshops. Nine nursing caregivers from the Intensive Care Unit (ICU) of a university hospital participated in the study. This article presents one of the topics that emerged during this process: spirituality in self-care, which is evidenced in the daily practices that take place through prayers, close contact with nature, as well as in the sense of connection with a Higher Power that provides peace, welfare, and greater strength to ICU caregivers’ life and work. Self-knowledge emerged as an essential practice in caring for oneself, in order to deliver better care to others.


LA ESPIRITUALIDAD EN EL CUIDADO DE SI PARA PROFESIONALES DE ENFERMERÍA EN TERAPIA INTENSIVA
Este estudio tuvo por objetivo comprender como la espiritualidad envuelve al proceso de cuidar de sí mismo y de otros, en el mundo de la terapia intensiva, bajo la perspectiva de los profesionales de enfermería.

A ESPIRITUALIDADE NO CUIDADO DE SI PARA PROFISSIONAIS DE ENFERMAGEM EM TERAPIA INTENSIVA
Este estudo teve por objetivo compreender como a espiritualidade permeia o processo de cuidar de si e do outro, no mundo da terapia intensiva, sob o olhar das profissionais de enfermagem.A pesquisa caracterizou-se por abordagem qualitativa do método criativo-sensível de  showing how this subject appears in this environment (1) .
Intensive care was chosen based on the fact that it is the authors' field of research.Through a critical look at the intensive care context, the researchers perceived how this scenario is still rooted in practices that privilege knowledge about external, physical and measurable realities, rejecting internal knowledge, such as subjectivity and the human spiritual dimension (2) .
Hence, spirituality still remained far from discussions, and was relegated to individual experiences that did not appear in the professionals' reports and records.Only the casualness of daily dialogues showed the presence of distinct comprehensions about spirituality in the lives of the nursing professionals.This meant they could permeate the caring for oneself process, at the same time as the professionals looked after other people.However, one question remained unanswered, about how care and spirituality were associated, leaving a veil of invisibility over this theme in the intensive care scenario.
The return to spirituality and the great interest it arouses are related to the holistic notion of care.
This notion comprehends all human dimensions (3) and the great efforts to include new approaches that meet not only technological, but also ontological competences, which are essential for the maturity of nursing and its survival as a profession (4) .Therefore, education, research and nursing practice emerge in this discussion, with a view to understanding how human spirituality permeates the care scenarios, as well as its implications for contemporary nursing.
Although there is no definition of spirituality that captures the entire essence of the concept, each definition is as if it were a sense of direction of our attention to understand it in the care process (5) .One of the great challenges to integrate spirituality and spiritual care in nursing curricula and practice has been the evolutionary understanding of the spirituality concept, which starts to be understood as something broader than religion, without excluding the latter (6) .
In this research, spirituality is understood as an encounter of one's self-knowledge with the most loyal and beautiful dimension -the spiritual -that enables the connection to oneself and the cosmos, and in which unequalled resources that influence the human life and its relations to the whole are reached (1) .It is the essence; the center of the being, that permeates all aspects of life in a unifying way (3) .
A growing number of studies on spirituality have been carried out in different health areas, demonstrating a clear wish to seek new rejuvenating sources that increase its possibilities to solve human pain, as well as to explain a large part of the mysteries and complexities in the cosmos.This paradigm change movement is evident in nursing.Besides articles on spirituality, there is research on the philosophical meaning of the concept (3)(4)(5)7) , methods to evaluate spiritual needs (8) and practical aspects of its implications in nursing care (9)(10)(11) . Ths study was performed in this sense, and has the clear purpose to contribute to the universe of possibilities that the dialogue about spirituality in education, research and nursing care may provide, as well as to contribute with the construction of this profession of love and care.
Therefore, this research aimed to understand how spirituality permeates the process of caring for oneself and for others in the intensive care scenario from nursing professionals' point of view.

METHODOLOGY
In order to dare transform care scenarios, it is essential that the experiences and diversity of knowledge built until that moment be used as the lever for this process.Therefore, in the diversity of qualitative research, the Creative and Sensitive Method (CSM) (12) approach was chosen, because it values human creativity and sensitivity as essential elements in research production.Moreover, it foresees the active participation of everyone involved in the process.
The combinations between "science and art, spontaneity and introspection, creativity and sensitivity, reality and creative expression" unquestionably differentiate the CSM from other methods, which are already consolidated in research, mainly in terms of data collection.This method joins collective semi-structured interview, group dialogue and participative observation in the space created during the creativity and sensitivity dynamics, which are based on the artistic productions.In this aspect, corporeality and emotiveness are also brought into the creation process, confirming its innovative capacity in qualitative research (12) .In this study, the creativity and sensitivity dynamics were named art and experience workshops.
The starting point of the CSM is artistic production, which becomes the synthesis of the individuals' creativity and sensitivity, representing their cultural universe, beliefs, values and experiences.The harmonious combination between the artistic production and group dialogues is essential when dealing with certain research problems, particularly those aiming to bring up latent issues (12) .Based on this idea, it can be guaranteed that the CSM was capable of immersing in the universe of nursing although the initial idea of the study had been to join a group with 12 people.In the information production period, the proportion was one nurse for every four technicians, so that nursing technicians naturally participated more.In order to comply with the ethical guidelines of resolution 196/96 (13) , subjects' anonymity was assured through fictitious names.This study was developed after approval by the Institution's Research Ethics Committee.
. This article is about the second research theme.The statements evidence that intimate contact with nature, which humans are also part of, represents a relation of care for oneself, by taking distance from busy environments and reflecting about life, in peace.

SPIRITUALITY IN CARE FOR ONESELF
This experience broadens the caregiver's awareness, increasing the understanding of how care for oneself can be improved.This practice provides the nursing caregivers with tranquility and welfare for, contemplating spiritual welfare, which comprehends the belief in a Higher Being, the need for meaningful relationships, interior harmony, a good support system, as well as the appreciation of nature, in a sense of connection with others and the universe (14) .
In addition, the statements also show that water symbolizes a practice of cleaning and renovation, evidencing human beings' potential to cure their own bitterness and diseases.The Sun symbolizes something that lights up the caregiver's life, contemplating the reverence to life as an expression of spirituality in these practices.
In this sense, it could also be observed that the subjects linked up to a Higher Power, in their care practices for themselves, while they also delivered care to others, as the following dialogue denotes: ... The statements evidence a close and intimate relation with a Higher Power, which represents a wider conception of the external and distant God, also to understand an inner God, a divine power inside oneself.
The Higher Power emerging here is revealed as a sacred dimension of the human being, as a power that motivates the nursing caregivers in their lives.
Spirituality provides support and assurance and is represented in care for oneself (15) .
Spirituality refers to the awareness of an inner self and the tendency to build meaning by being connected to dimensions that transcend the ego.These experiences can occur in an intrapersonal (connecting oneself), interpersonal (in the context of the other and the natural environment) and transpersonal level (in connection with what it not visible, God or a Higher Power) (16) .Among the practices that involve religious beliefs, integrated in the comprehension of spirituality, the subjects confirmed prayers as the way they take care of themselves: Most subjects turn to prayers in care for themselves.This way of relating to a Higher Power creates a care environment that provides welfare to the caregiver.
The dialogues also expressed the experience of other people's death and pain, as well as the caregivers' feelings and emotions.These experiences evidenced spirituality as the way to seek the strength they need to face the difficulties of work at the ICU, as shown in the dialogue below: . During the discussion, it is observed that the ICU scenario may be a source of suffering for these nursing caregivers as well.The statements showed the importance of spirituality when dealing with death, in order to find meanings for the existential questions that pervade daily life in the intensive care area.In addition, it was recognized that the intensive care environment may be a source of tension, due to the characteristics of working with patients in critical conditions and their families, for the use of the technology and the relations between human beings, which sums up to daily extrahospital problems, generating imbalance and, possibly, sickening due to stress.
Emotional stress and tension due to intensive nursing care often contribute to the development of the Burnout syndrome (17) .In fact, intensive care probably does not cause burnout, but the lack of care by the caregivers.This situation was also presented in another study at an ICU, as the nursing professionals focused on their emotions and feelings and stressed how much of the world is pervaded by suffering experiences, which they generally do not think about together (18)   .Sharing these situations with colleagues is a way to mitigate the suffering and find solutions, as the following statement mentions: As they become more aware of themselves, they recognize the need to receive care from their colleagues.Mutual help is perceived as care.Thus, a support network is needed which favors and contemplates communication.This way, it is possible to think that nursing will only reach the objective of taking care of other persons in their wholeness when a network of supportive care is established (19)   in the community, society and in their relationships with nature and the universe (20) .
In this sense, relaxation, meditation and reflection practices during the workshops confirmed that, by thinking of the experiences and finding time for themselves, the participants associated spirituality in this process.These practices provided the caregivers with the opportunity to find themselves, turning toward their inner world, in a movement to learn about the complexity of the deep Self and search for resources that bring more awareness and welfare.
The caregivers, when thinking about their practices, stressed the relevance of self-knowledge and the need to care for themselves.Therefore, it is likely that caregivers who develop a positive attitude towards their spirituality are sensitive to the spirituality of the patient/family (9) , providing space for it to pervade intensive care.

CONCLUSIONS
Daily practices were evidenced in the synthesis of the alliance knowledge on the theme: spirituality in care for oneself.They happened through prayers, intimate contact with nature, as well as through the connection to a Higher Power, in an encounter that provided tranquility, welfare and strengthening for life and, therefore, for ICU work.The caregivers and disclose the way spirituality pervades the care process for oneself and for others in the intensive care scenario.This study was developed at the Intensive Care Unit (ICU) of the University Hospital of Porto Alegre (HCPA).The ICU is located on the thirteenth floor and has 34 beds; it is considered a closed unit, attending adult patients who require intensive care.The beds are distributed in three areas: cardiac -six surgical beds and three coronary beds; area I -12 General ICU beds; area II -12 General ICU beds and one bed for transplants.Subjects were selected intentionally, through invitations, and with the criterion of having a minimal experience of one year at the ICU-HCPA.The group consisted of two nurses and seven nursing technicians, Nine art and experience workshops were held to produce the information.The workshops happened once a week, and lasted an average of 2 hours.Each workshop was structured to respond to the research purpose, with four guiding topics.Each topic was developed in two workshops.The first workshop aimed to announce and investigate the topic, using guiding questions that should be answered through the artistic production and group dialogue.This manuscript translates the results of the two workshops on caregiver spirituality, using the guiding question: what is spirituality for you and how does it influence your life?All workshops were recorded on cassette tape.At the end of each workshop, the tapes were transcribed and the information was returned for the group, The second workshop deepened the reflection on the subject, and also extended and promoted the alliance and negotiation space of knowledge Hence, information production and analysis, as planned by the CSM, followed a number of stages: coding, which comprehended the elaboration of the artistic production as a moment of introspection and self-dialog, in order to recover past experiences and reflections about the study subject; decoding, which was put in practice through the expression of the artistic production meanings, a stage when group dialog was established, including critical and collective analysis of the artistic productions and ideas that emerged in this space.Therefore, this stage also comprised knowledge negotiation, considered as the act of sharing experiences and ideas in the collective space, exchanging knowledge, feelings, and emotions.Substantial statements emerged from this dialogue, which showed the world lived by the participants.The following stage was re-coding or knowledge alliance, which included the moments of approximation and convergence of ideas, as well as the acquisition of new knowledge, involving respect for different thoughts.After all data had been compiled and the researcher had elaborated an in-depth analysis according to theoretical frameworks, the ninth workshop was held to validate the analysis of the information.This methodology led to the emergence of meanings and constructs of three themes: meanings of spirituality, spirituality in care for oneself and spirituality in care delivery to others in human beings.From the deep internal change, spirituality unchains transformations .. we deal with death very closely [...].And those ... ... you have to be careful not to neglect.[...] And if you do not care for yourself, you cannot search for spirituality...
... you just have to stop and think, even at this moment, that we are meeting in this group.All of us should do it sometime.Stop.What are we?What are we doing?(Lavender) ... actually, we should start by ourselves.We have to find harmony [...].I think what we are doing now is a way to care for ourselves