SPIRITUALITY AND RELIGIOSITY IN THE PERSPECTIVES OF NURSES

Considering the human being as a unit composed of body, mind and spirit, it is important that nurses evaluate the need for spiritual intervention. This study aims to describe the understanding of nurses about the meaning of spirituality and religiosity at a hospital. This is an exploratory and qualitative research that was carried out with 17 nurses. Data were collected through semistructured interview and analyzed using content analysis. Results show that nurses identify the particularities involved in the concepts of spirituality and religiosity and recognize the link between them. The applicability of these terms in nurses’ clinical practice is directly influenced by their own spirituality and religiosity, by their academic training and their fear of negative repercussions resulting from the direct approach of these issues with patients. DESCRIPTORS: Spirituality. Religion. Nursing. Professional-patient relations. ESPIRITUALIDAD Y RELIGIOSIDAD EN LA PERSPECTIVA DE LOS ENFERMEROS RESUMEN: Al considerar el ser humano como una unidad formada por cuerpo, mente y espíritu, es importante que los enfermeros evalúen la necesidad de intervención en el campo espiritual. Este estudio describe la comprensión del significado de la espiritualidad y la religiosidad de los enfermeros que actúan en hospitales. Esta es una investigación exploratoria y cualitativa y fue desarrollada con 17 enfermeros. La recolección de datos fue realizada con entrevistas semiestructuradas y analizadas a través de análisis de contenido. Los resultados muestran que los enfermeros identifican las particularidades involucradas en los conceptos de espiritualidad y religiosidad, así como reconocen el vínculo entre ellos. La aplicabilidad de estos términos en la práctica clínica de los enfermeros es influenciada directamente por su propia espiritualidad y religiosidad, su formación académica y el miedo de las repercusiones negativas derivadas de la aproximación directa de estas cuestiones con los pacientes. DESCRIPTORES: Espiritualidad. Religión. Enfermería. Relaciones profesional-paciente. 52


INTRODUCTION
The increasing number of studies on spirituality in different fields of health sciences have demonstrated the clear desire to find revitalizing sources that broaden the possibilities of finding solutions for human suffering. 1In the last decade, an important movement has been observed among researchers in psychology, education, sociology and health, investigating about the influence of religiosity and spirituality in people's life. 2 This movement is evident in nursing, which has also contributed to knowledge production in the area, despite disagreements on nurses' roles in spiritual care. 3Recently, it has been demonstrated in the literature that these professionals are more sensitive to the spiritual care dimension.Nurses' skills to identify and assess this care need to be enhanced though, besides the need for further clarifications and knowledge on concepts and scientific foundations through research in the area. 4nding a definition for spirituality is challenging, as no existing definition is able to cover the full range of its meaning.One may say that it comprises different interconnected concepts though. 1 Spirituality is a universal experience that covers the existential domain and the essence of being human; it is not synonymous with a religious doctrine, but can be considered a philosophy of the individual, of values and meaning in life. 1 It is an inborn attribute of human beings, which promotes wellbeing, health and stability.It is related to the essence of life and associated to spiritual issues, distinct from any material means; it produces behaviors and feelings of hope, love and faith, providing a meaning for life. 4Religiosity, then, is a way for individuals to express their spirituality through the adoption of values, beliefs and ritual practices that give answers to essential questions about life and death. 5It involves the systemization of a group-shared cult and doctrine. 6This apparently subtle distinction between spirituality and religiosity has an important meaning, as people who do not follow a religion can find an important support source in spirituality, which strengthens their coping and, on the opposite, people who follow religions do not always find strengthening in their doctrines.
Nurses should know about patients' sources of strengthening, encouraging them and reinforcing their faith, so that it can promote the comfort and security spirituality or religion offers.Care that involves the spiritual dimension is an incentive towards life and needs to be provided by people who are prepared, based on the premise that both workers and users need to receive care that covers the physical, emotional, intellectual, professional, social, cultural and spiritual dimensions. 7It is reinforced in the literature that spirituality and religion integrate and influence the behaviors of chronically-ill children's family members. 8Also, the need for a holistic understanding of patients is underlined, including religious and spiritual issues, which can positively influence their treatment and coping with the situation they experience. 9sed on the understanding that the spiritual dimension is a full part of individual, we inquire about how nurses understand religiosity and spirituality and its applicability in professional practices.We depart from the premise that, when necessary, it is important for nurses to assess intervention needs in this area. 10In that context, the aim in this research was to describe the meaning of spirituality and religiosity according to nurses at a hospital in the interior of São Paulo State, as well as its applicability in professional practice.

METHOD
An exploratory study with a qualitative methodological approach was conducted at a state-owned teaching hospital in the interior of São Paulo State, which prioritizes secondarycare delivery in different specialties.Approval was obtained from the IRB at the University of São Paulo at Ribeirão Preto College of Nursing (Process 1018/2009) and the guidelines for research involving human beings were followed.In compliance with ethical care in research involving human beings and the researchers' caution, we elaborated the Informed Consent Form, which served as a guide to inform all participants about the research procedures and their rights before starting the study.Each participant received a signed copy of that form, which contained the researchers' contact information in case of any need.
Twenty-six nurses were working at the institution selected for the study at the time of data collection.As selection criteria, we invited Spirituality and religiosity in the perspectives of nurses all researchers who worked at that institution during data collection, independently of their time since graduation and professional experience at the hospital.Data were collected in the second semester of 2009, at a private room in the institution, according to the participants' availability, and without interrupting their work routine.To reach the study objective, semistructured interview was used as the data collection technique, which was audio-recorded with the nurses' authorization and took between 20 and 60 minutes.Initially, the particularities of the spirituality and religiosity concepts were explored separately, so as to permit a detailed understanding, valuing the participants' subjectivity.Then, the interviewees discussed their perceptions about these concepts, motivated by the request to describe how they understand and articulate these concepts in their clinical practice.
After interviewing 17 out of 26 potential participants, we observed that no new information was being provided and certified that the research objective had been reached, and therefore terminated data collection.For the sake of anonymity, the nurses were identified by the letter N, followed by a number that represented the order of their inclusion in the study.Hence, N1 was the first interviewee and N17 the last.
The interviews were fully transcribed.Empirical data analysis was undertaken in phases, following orientations for content analysis. 11The first phase was coding, a process that allowed us to identify the words, phrases, themes or concepts inside the data, so that the underlying patterns could be identified and analyzed.All data were read, underlining significant words or phrases in the text, and we commented on anything that stood out in the margin.In the next phase, called categorization, we got familiar with the data and started organizing the information.The final phase was the integration of the categories into broader themes, which describe spirituality and religiosity in the nurses' perspective.

RESULTS AND DISCUSSION
Study participants were 17 nurses, mainly women (16 women and one man), between 24 and 29 years of age, with an equivalent time since graduation and professional experience, ranging between three and 12 years.At the time of data collection, the interviewed nurses were working in different settings at the institution, which are not described here to preserve their identities.
The data analysis process permitted the identification of four themes: religiosity and spirituality in nurses' perspective: approximation with the concepts; spirituality according to nurses; religiosity according to nurses; and spirituality and religiosity in nurses' clinical practice, which describes the recognition and application, or not, of these concepts in their daily work.

Religiosity and spirituality in nurses' perspective: approximation with the concepts
Since the start of nursing history, all professional actions have been linked with religious and spiritual aspects and, until today, nurses do not know the true meanings of religiosity and spirituality, which directly influences care delivery. 12n this study, the analysis process allowed us to identify each nurse's difficulty to express his/her understanding about spirituality and religiosity.Although they are routinely used as synonyms, these concepts are distinct.4] Despite mutual differences, 15 the testimony below illustrate the lack of clarity about the concepts and the participants' attempt to express their understanding: I think that spirituality and religiosity are different but related things (N10).
Most interviewees used religion or religiosity to express their spirituality conception, demonstrating the hard task of distinguishing between the two concepts: spirituality is not just religion, because there are people who are not religious, but have a great internal strength (N7).
We also identified that, when reflecting on these concepts, the nurses try to define the limits between these definitions, appointing the thin line between both: so, like, I can't tell them apart, but I believe there is close proximity and a very thin line between the two.Now, establish a concept, I don't know that (N8).The same result was appointed in an earlier study. 16According to the participants in this research, the similarities between religion and spirituality were highlighted.
Next, the concepts of spirituality and religiosity are presented and explored separately, with a view to disclosing their articulations, even distinguished from one another.

Spirituality according to nurses
For the group of nurses in this research, spirituality was described in different ways.Despite each participant's difficulty to express his/her understanding of the term, the definitions presented reveal a conceptual approximation with the literature, 17 in which spirituality appears as something subjective, but nevertheless intrinsic in human beings: spirituality is subjective (N9); [...] I see it as something natural, as a part of him [the human being] (N17).
Like in N17's testimony, authors 13 consider spirituality as a natural characteristic of human beings, and some interviewees added the existence of a kind of force or energy that goes beyond the biological, sometimes related to a higher being, in accordance with the literature. 1,18fferent views exist on the same theme, and these perceptions are directly related with individual experiences, connected or not with professional activities, in view of values and beliefs.In addition, it is crucial for each individual to know his/her own spiritual language, premises and experiences, 19 mainly for nurses who, aware of their own religiosity and spirituality, can promote distinguished care. 4The understanding about spirituality in this group of nurses was complemented by N2, evidencing the valuation of individuals' beliefs: [...] spirituality means having a belief and holding onto that belief for everything (N2).
When discussing spirituality, four interviewees presented an association with Spiritism, due to both words' similar roots.Consequently, there may be a mistaken understanding about spirituality and Spiritism: [...] I have a Catholic background, but I accept Spiritism well.So, there is no way to talk about spirituality and not remember Spiritism [...].Spirituality, they talk about Spiritism, for example.But I think it has nothing to do with it, it has nothing to do with religion.Spiritism is a religion like all others.I think many people mix that up (N17).The definition of Spiritism is due here, a doctrine based on the belief in the survival of the soul and the existence of communication through mediumship between the live and the dead. 20Thus, Spiritism fits better into the definition of religiosity.

Religiosity according to nurses
The participants attributed different concepts to religiosity, but five of them used the term "religion" to present their understanding, also mentioning a religious institution that represented it and which the nurses attended since their childhood.It is through religion that each individual's personal values are manifested.Religiosity was understood as follows: [...] it is related to the person's religion, it is related, mainly in the way of speaking, what to bring or what one believes in (N15).
Among the religiosity concepts presented, the nurses used words like force, support and faith in a God to describe the term, underlining literature findings, 1,21 in which religiosity is seen as a connection with one's God, besides entailing the idea of faith: religiosity means strength for me [...] and faith is what gives me strength (N7).
In the nurses' presentation about their understanding of the term religiosity, the participants appointed that different kinds of religion exist, associating them with the use of certain words, the following of teachings and doctrines, and religious higher beings who are worshipped.Thus, social groups were characterized, constituted by the same values and opinions, in accordance with the literature in the area: 21 religion will provide you with some assertions about this and that according to that book, according to that bible, according to that gospel, whatever [...].I think that, if you believe and have faith in something, you will look for something more concrete to affirm these questions you believe in [...].I think that, if you want to realize it, if you want to know more and put this in practice or even study something about it, you will look for a religion (N15).
The above testimony suggests that individuals' beliefs are put in practice through religiosity.Hence, the analysis of empirical data in this research and scientific knowledge on theme 22 demonstrate that religiosity can also comprise the practice of religious rituals as a means to achieve a spiritually advanced degree.
Thus, for the nurses in this study, having a religion implies having spirituality, but the opposite is not true.The same fact is appointed in the literature 14 , mentioning that spirituality is broad and comprises religiosity.N1 illustrates that: [...] I may have spirituality without being religious.But, if I follow a religion, I have spirituality and a religion, which is commanded by a person or group (N1).

Spirituality and religiosity in nurses' clinical practice
All research participants acknowledged spirituality and religiosity as a part of nursing care.Not all nurses reported that they apply these concepts in their daily clinical practice though.Although the results demonstrate positive perceptions on the theme, the participants reported that they rarely incorporated this care in their daily activities.Next, two subcategories are presented, which result from the analysis and interpretation of the empirical data and summarize the nurses' recognition of the concepts, including their applicability or not in clinical practice.

Nurses who recognize and apply the concepts in clinical practice
According to the professionals who recognize and apply the two concepts in clinical practice, we observed that the nurses' own spirituality seems to influence the decisions they make, that is, on whether to include spiritual care delivery to patients.Depending on their view of spirituality, nurses find it difficult or easy to deal with the situation they experience.The following example describes how a nurse naturally attended to a patient's spiritual need: one patient was very agitated, extremely agitated, and the daughter understood what he wanted to say.It was praying, and I was there in the room.Then we held hands and prayed and he said all words of the Our Father correctly, and he was talking all mixed up until then, he was able to say it completely and then he really calmed down (N7).
Most interviewed professionals acknowledged and described a situation in which spirituality and religiosity were present in their daily activities, and even mentioned that nursing practice is totally linked with spirituality.In that sense, when considering spirituality as inborn in human beings, 13 it is present in nurses' personal and professional life.When dealing with people, it is desirable for nurses to offer care that integrates body, mind and spirit 10 and, in most cases, they are able to contribute to further research in the area. 23The participants reinforced that aspects by trying to describe their views on spirituality: to work in nursing, we need empathy, because I think we have to assume a commitment, in a way, you have to feel the other, not just the external part.You just have to look him in the eye, you really see his spirit, you see what he is feeling (N9).
In daily nursing practice, the nurses attend to people in different phases of the lifecycle, in situations of weakness for example, when it is natural for them or their relatives to turn to spirituality as a means to cope with difficult situations and find answers. 1 Various authors 10,16,18,21 picture that aspects when discussing spirituality and religiosity in nursing practice.In this study, the nurses described feelings the patients displayed, like anguish, suffering and fear, and underlined situations like severe illnesses and the finiteness of life, like cancer, which make it easier for nurses to approach spirituality and religiosity in their work routine.The following testimony demonstrates that patients' moments of weakness represent opportunities when nurses feel secure to address spirituality and religiosity aspects of the patient they are taking care of: [.

..] I do not talk about God or spirituality every day. But, when I see that it's necessary, at a moment of severe illness or when the person is in great anguish, when we've already done the prescription and things don't get better and it's no use to call the doctor, when I don't know what to do anymore, I propose a prayer (N1).
On the opposite, the study participants are obviously afraid of addressing spirituality and religiosity aspects with patients in situations of clinical weakness.In this respect, they fear that patients will interpret them wrongly, that is, the participants demonstrated fear that their actions covering spirituality or religiosity will not be met reciprocally: [...] so, it doesn't really work to pray or talk about [spirituality and religiosity] with patients who are good.Sometimes, some patients will think that: 'I'm getting worse!She came to pray with me' (N12).
We found that it was easier to describe work situations involving the theme among professionals who reported preliminary professional experience in specific contexts, like intensive care units, surgery, oncology or bone marrow transplantation units.In this respect, considerable knowledge on the theme has been developed in care contexts for severe and terminal patients. 1,24 Cnsequently, this knowledge facilitates the discussion on and dissemination about the importance of this approach to patients and, at the same time, reaffirms the need for further research on the theme at all health care levels, like in a study 25 that identified spirituality as an element in the care practice of family caregivers to chronic patients in the home hospitalization context.One participant's testimony illustrates that aspect: I work in bone marrow transplantation.The patient often prays then, the patient often thanks God [...] (N8).Also, it should be reminded, as highlighted in an earlier study, 26 that spirituality often includes religion and the practice of rituals.In that perspective, spirituality was present, for example, when one of the nurses offered the possibility of holding a mass for the patient or receiving visits from religious people.In the following example, nurses' roles are perceived, as facilitators of actions that, according to the interviewees, attended to the patient's spiritual needs: they also ask us that when we spend the weekend at the nursing ward.We're the ones who permit visits by ministers (N1).
In some situations, however, the nurses act as mediators of actions that incorporate patients' spirituality and religiosity, provided that they do not feel threatened by institutional standards.Health institutions should acknowledge spiritual care as a part of comprehensive patient care and value nurses as essential nursing team members to put this care in practice.The following testimony suggests that the situations the nurses are confronted with are not always considered as spiritual care delivery to patients: [...] some relative suddenly informs us or requests authorization, saying that he would like to bring a minister, a priest, an adult from his church, from the center, from his community [...].I support situations I was confronted with as intermediary, provided that they do not interfere in all of the hospitals' organizational protocol issues (N15).
In the context of justifications to apply spirituality and religiosity concepts in nursing care, the nurses gave different examples of benefits, which often justified their use not only in clinical practice, but also in their personal life.In the testimonies analyzed, motivations were observed that were similar to another study, 18 in which benefits for patients and their families were reported, particularly better acceptance of the disease, calmness, peace, optimism, security, overcoming and hope of care: spirituality offers tranquility, the search for that peace, less fear at a delicate time (N12).Specifically religiosity can benefit patients, manifested by force and perseverance in treatment, also exemplified in an earlier study 21 : [...] when the person believes and has faith, it's easier not to give up, to want to live.So, I think that, in that situation, religiosity helps a lot (N8).
The participants interpreted some values linked with religiosity as potentially capable of causing damage for patients themselves, when they interfere in the therapeutic plan: Jehovah's witness for example.I've already had a case of a patient who was a Jehovah's witness who, in which the family did not give authorization until the doctor said: 'she's going to die if she does not get a transfusion'.And I've had patients who died because they did not authorize transfusions and die because of this religious belief (N16).
Although the nurses acknowledge the influence of religiosity in their daily work, one participant reminded that, in practice, the patient's religion generally is not considered in care planning.In this study, this consideration was present only in cases of patients who were Jehovah's witnesses, due to its implications for blood transfusion needs.Hence, the patient's spirituality and religiosity only emerge during care when they interfere directly in therapeutic practices, that is, they are not part of care planning: [...] the person has been here for that long, he's abandoned, and abandons this issue of this religiosity too.To what extent is that interfering in the patient's mood, in her acceptance of treatment?[...] when thinking about the practical side, this issue of Jehovah's witnesses not being allowed to get transfusions is not relevant in people's daily attitude to help in care, in patient care (N2).
Beyond this participant's consideration, it should be reminded that nurses need to be sensitive to premises linked with other religious doctrines, which should equally be respected and valued throughout nursing care planning.
The nurses also valued the mutual benefits, i.e. for professionals as well as for patients.According to them, even if some spirituality or religiosity-related action or thought is only directed at the patient, in the end, both fall back on themselves, nourishing them in their needs to get comfort as well: our work is to do good to the patient, to take care of the patient and, if that [referring to addressing spirituality and religiosity with the patient] is good to the patient than it's definitely good for us too (N13).
The interviewed nurses considered it was essential to address spirituality and religiosity in nursing care, as both exert direct influence on the quality of care delivery and on the professional's wellbeing.According to the literature, 24 nurses who use spirituality in their profession report on the benefits offered for their daily life, like comfort to calm down patients who are suffering.Particularly in this study, the importance of spirituality and religiosity for nurses was demonstrated through the security that is transmitted to them, based on the request for protection on the way to work, and on the request for support when undertaking procedures and attending to problems, in accordance with E5: [...] you're gonna perform a procedure and say: 'oh my God, help me' (N5).

Nurses who acknowledge but do not apply the concepts in clinical practice
Among the interviewees, four nurses mentioned recognizing the spirituality and religiosity concepts, but denied their use in clinical practice or acknowledged their sporadic use.During the interviews, when we asked one of the participants about that, he said: sometimes, only in punctual circumstances, like deaths, among others.Not as a part of routine (N3).
Although they do not use them, the participants manifested their desire to enhance the spirituality and religiosity concepts' applicability in their clinical practice: I use them less than I would like to! (N12).Two professionals did not believe that spirituality and religiosity were areas that deserved to be addressed in nurses' work, one of whom affirmed that nursing interventions are not possible in the area.The other professional preferred not to address the issue, due to lack of professional experience according to him.As appointed in the literature, 7 this disbelief in a higher force is reflected in the fearful attitudes towards patients and this theme.N13 told us: so, I also have little experience and that ends up interfering (N13).
Two other professionals reported difficulties to confront their beliefs and values with the patient's.As nurses' practice is influenced by these experiences and values, they are frequently confronted with this barrier in their daily work: 27 I try not to influence [...].Some of them have their beliefs or not, and that's often not the same as mine (N11).
The lack of understanding about spirituality and fear of confronting one's own ideas who those of other people can be considered one of the difficulties to introduce this theme in un-dergraduate nursing curricula and professional practice. 1There is an obvious need to reconsider nursing education, in the attempt to complete the knowledge gaps in that area.N13's testimony evidences the need to offer nurses with moments of reflection on the theme: I've got no idea, I've never stopped to think about how I could address this spirituality issue (N13).
The successful applicability of spirituality and religiosity concepts in nurses' clinical practice is directly linked with the construction of knowledge to support care, through further research development on the theme, and with skills development to address patients in the different contexts of professional practice.

FINAL CONSIDERATIONS
Nursing has stood out as an important profession that stands close to patients and, therefore, are responsible for a holistic perspective that covers the biological, mental, emotional and spiritual dimensions of human beings in the care process.In that perspective, the understanding of terms like spirituality and religiosity is fundamental to offer nursing care, ranging from health promotion to rehabilitation.
We acknowledge that the use of the interview as the sole data collection strategy during one meeting represents a limitation, as the analysis of nurses' practices in their natural work environment could have furthered the understanding of the research problem.
The present study results demonstrate that the nurses identify the particularities involves in the spirituality and religiosity concepts, and also recognize the articulation between both.The applicability of these concepts in nurses' clinical practice is directly influenced by their own spirituality and religiosity, by their professional education and the fear of how the direct approach of these aspects will affect the patients.Offering opportunities do discuss the role of spirituality and religiosity since the start of nursing professionals' education and in permanent education can contribute to recover the essence of comprehensive care delivery.
We have also learned that nurses' greater or lesser involvement with the patients' spirituality and religiosity seems to be favored in contexts in which these people's weakness is evidenced.
In those cases, nurses feel strengthened to offer comprehensive care, which addresses human beings in all of their dimensions.Future studies on religiosity and spirituality perspectives and their applicability to care, in the voice of other nursing team members, can contribute to enhance knowledge on the theme.