Soul care in the hospital nursing context: an analysis based on Transpersonal Caring

1 Universidade Federal da Bahia, Campus Anísio Teixeira, Vitória da Conquista, BA, Brazil. 2 Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação Interunidades, São Paulo, SP, Brazil. 3 Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Materno-Infantil e Psiquiátrica, São Paulo, SP, Brazil. ABSTRACT Objective: To unveil spirituality in the care process of nursing professionals in the hospital context under the lens of Transpersonal Caring. Method: A descriptive-exploratory study implementing a qualitative approach conducted with professionals from the nursing team in a general hospital in Bahia, using a semi-structured interview submitted to the content analysis technique and analyzed from the perspective of the Theory of Transpersonal Caring theoretical framework. Results: There were 16 professionals who participated. It was found that the nursing team perceives the patient and family’s demand for spiritual care, and sometimes even has experiences and suggestions for interventions, especially those which cultivate faith and spirituality, but this does not happen with most of these professionals who demonstrate difficulties, unpreparedness and fear of taking on such care responsibility. Conclusion: There is a need to develop better interaction/spiritual care skills by nursing professionals in the challenging context of the search for meaning, faith and hope mobilized by the disease experience. The Systematization of Spiritual Nursing Care and Transpersonal Caring stand out as appropriate devices, which provide consistent subsidies for undertaking spiritual care.


INTRODUCTION
This study has spirituality in the hospital nursing care context as its theme. It emerged from the concerns experienced in the "Welcoming Multidisciplinary Grouping (MGW): action of teaching-research-extension in proving care of the family facing the risk of hospital death" and developed from the perspective of Watson's Theory of Transpersonal Caring, which is based on 10 Carative factors: humanistic-altruistic value system; faith-hope; cultivation of sensitivity for one's self and for the other; development of helping-trust relationship; promotion/acceptance of the expression of positive and negative feelings; systematic and creative use of science; promotion of transpersonal teaching-learning; the provision of a mental, social, spiritual support environment; assistance with gratification of human needs; and allowance for existential--phenomenological spiritual forces (1) .
For Watson, nursing care must reach the other in its total body-mind-soul. In this framework it is the soul which defines itself as spirit, inner self, the essence of the person -which is accessed by self-knowledge through a higher degree of awareness of inner strength. Its understanding is illustrated by the Sacred Mirrors by Gray, resulting from studies of human anatomy and body-mind-spirit interconnection, which show successive images changing from the physical body, evolving to the spiritual level. These images allow the viewer to 'mirror' their own image, experiencing a resonance between their being and the image of the sacred mirrors, creating the sense of self-introspection (2) .
Spirituality communicates the human desire for a sense of meaning, purpose, connection and fulfillment through relationships/experiences. When a serious illness or suffering affect the individual, it usually awakens the spiritual domain and triggers questions about life. In this way, spirituality is defined as something which gives meaning and purpose to existence and invites particular ways of being in the world in relation to others, to oneself and to the universe. Some also adopt a religion, which is distinct from spirituality, but it converges with this. Religion is affiliation with a particular faith community that shares beliefs, rituals, morals, and at times a health code centered on a transcendent higher power, often called God (3) .
However, spirituality is considered a philosophical reference which transcends the dimension of religion and refers to the living encounter with the divine, which mobilizes an inner 'numinous' state capable of enlivening and (re)signifying human experience in directing the meaning of life regarding the difficulties which arise in daily life (4) .
Spiritual care is understood as an interprofessional process, as it interdisciplinarily mobilizes organizational procedures and personal attitudes capable of promoting spiritual well-being converging with the health of the person being cared for; it is also bidirectional due to its ability to trigger a reflexive emotional response in the caregiver or nurse who accepts to interact with others in the universal dimension of human spiritualities (5) . Therefore, the literature highlights nurses as beings who are professionally and ethically responsible for providing spiritual care directed to health through practical appropriation of the evidence produced by research in the area, and which point out the relevance of an adequate curriculum formation to identify, evaluate and intervene in the patients' spiritual needs (6) .
Faith and spirituality increase courage, tranquility and confidence for self-care, in addition to developing serenity, authentic happiness and resilience in the individual, and is therefore capable of increasing the quality of life, even in the course of a disease. However, spiritual care has often been neglected or overlooked by nurses and other health professionals, which is related to the fact that there are still few publications on its application in health care practice (3,(7)(8) .
In this sense, this study aims to add knowledge to the state of the art about this theme which is presenting a revival movement in the health scenario, and which still needs more investment and investigation in the search to be better understood as an interface of professional nursing care, even though it has research around its theme. Thus, one sought to explore the problem: "How does spirituality develop in the care process of nursing professionals in the hospital context?" Thus, this study aimed to unveil spirituality in the care process of nursing professionals in the hospital context under the lens of Transpersonal Caring.

Study deSign
This is a descriptive-exploratory study with a qualitative approach.

Scenario
The study was developed in a general hospital in the countryside of Bahia in the break during the shift of each subject in private rooms in the Intensive Care (Adult), Internal Medicine and Clinical Surgery sectors, which have 19, 37 and 44 beds, respectively. The participants were 16 nursing professionals (6 with a university degree and 10 with a technical degree) who work in the hospital care area.
At least one year of experience in hospital care was observed as inclusion criterion, aiming at a more solid experience among the participants.
The sample definition was delimited by theoretical data saturation (9) . data collection Data collection involved using multi-techniques: a dynamic technique with the use of a mirror and a simple semi--structured interview containing discursive questions on the theme, both applied by two authors in pairs (a psychologist and a nurse), both with knowledge/experience in Transpersonal Caring. The dynamics were chosen from the framework of a study called the Theory of Human Caring (2) . Its use aimed to provide better access for the participant to their inner self, enabling more reflective revelations than those from the semi-structured interview. The collection took place individually in private rooms in each professional's work sector in order to safeguard the privacy of the participants. The dynamics consisted of offering the participant a flat mirror so that they could report what they were seeing in the mirror beyond the physical when looking at their image. Thus, professionals were able to evoke their hospital experiences, expressing feelings arising from reflecting on themselves.
In the second stage there was a semi-structured interview containing questions prepared by the authors, with the answers being recorded and later transcribed to enable the analysis. They are: "What is the relationship between spirituality and health, in your opinion?"; "How do you usually cultivate your own spirituality?"; "Have you noticed any spiritual need in patients or families in your daily work?"; "Can you tell us about any form of spiritual care you have provided?"; "What suggestion can you give so that nursing care better contemplates spiritual needs, even foreseen in the scope of possible nursing diagnoses?" data analySiS and proceSSing The implemented data analysis technique was the interactive content model which follows three steps: data reduction, mediated by exhaustive reading and identification of key passages to answer the objective (coding); data processing, converging the organization of explanatory categories and subcategories of the phenomenon to be unveiled (structuring information); and interpreting and verifying conclusions, attributing meaning to reduced data through formulating relationships (discussion) (10) .

ethical aSpectS
The cultural, social, moral, religious and ethical values of the participants were respected as per Resolution 466/2012. They agreed to the study by signing the Informed Consent Form, which happened after approval by the Ethics and Research Committee of the da Universidade Federal da Bahia, Anísio Teixeira campus (Opinion no. 1.978.943, of March 3, 2017). Participants were given codenames of birds to ensure their anonymity, chosen for referring to spirituality (11) .

RESULTS
The analysis generated convergent results in 4 categories, as presented in Figure 1: The first category is subdivided into the subcategories: Spirituality as an element of the human dimension; and Spirituality as an element which promotes health.
In the Spirituality as an element of the human dimension subcategory, it is evident that there is recognition of the human spiritual dimension with their specific care needs on the part of professionals, challenging the professional to offer expanded care when meeting such demands.
In reality, we look and within us there are several things (...) the mother side, the friend side, the woman side, the religious side too (...). Mirror dynamic (Eagle).
(...) he's going through an illness process, some problem, be it psychological or physical, the first part that we seek, that we seek refuge, is the spiritual part (...) if he is an atheist he will still look for something there to take refuge (Cowbird).
When the patient is serious condition, we see that all family members appeal to God, regardless of which religion (...), they make a bargain, seek a miracle, a pastor comes, a priest comes and the family appeals to the health team and to God (Great kiskadee).
In the Spirituality as an element which promotes health subcategory, nursing professionals express the understanding that spiritual care promotes health improvement and recovery, admitting the great influence and interdependence which exist between the spiritual, physical and emotional dimensions. This category is subdivided into the subcategories: Religious practices of cultivating one's own spirituality; and Personal faith reflecting hope for the sick individual.
The Religious practices of cultivating one's own spirituality subcategory shows that professionals identify the particularities involved in the concepts of spirituality and religiosity in the same way that they recognize the articulation between them. On the other hand, the applicability of this understanding in practice comes up against the direct influence of their own spirituality and religiosity in fear of negative repercussions, resulting from the direct approach of these aspects to patients, and also in their academic education.
[ This category is divided into subcategories: Needs of spiritual care perceived in the individual and Strategies suggested for spiritual nursing care. The first subcategory, Needs of spiritual care perceived in the individual, expresses the specific demands perceived by the nursing team related to spiritual care, and shares experiences from daily professional life.
I perceive a need in patients, of receiving a word that comes from God, and also from the family, wanting to hold on to something bigger. (...) I pray during the baths, give advice on hope (Dove).
(...) I said the prayer for her and then she said she felt better, she said she felt better out of nowhere, because I didn't tell her, you know? (...) I always prayed for her. And my family too (...). When you want God to bless someone, you're taking care of that person spiritually (Sparrow).
In this sense, the Strategies suggested for spiritual hospital nursing care subcategory meets the alternatives and possibilities chosen by professionals as viable and opportune for spiritual care.
The use of words of comfort and the reading of short texts, prayers and music were mentioned as interventions capable of healing anguish present inside each patientstrategies which not only represent support for families and patients, but also for the professionals themselves in the midst of the exhaustion of their daily work.  This last category, which addresses the difficulties mentioned by the interviewees for spiritual nursing care in the hospital environment, brought together the subcategories: personal difficulties and professional unpreparedness.
The Personal Difficulties subcategory reveals the professional's fear of offending or imposing their own beliefs on patients and families during the attempt to provide spiritual care, in addition to fear in not knowing how to deal with religions other than their own, expressing their own suffering in facing the painful and sad atmosphere which is typical of the hospital environment. In addition to personal difficulties, there is an insufficiency in training and professional preparation. The sub-category Professional unpreparedness is about the interviewees' finding that the category is unprepared for developing spiritual care; after all, even if the nurse personally does not have the facility to deal with the spirituality of the other, as they act in the context of suffering, certainly this professional will face care needs of this order, which calls for professional preparation for such situations. In order to be able to pass spirituality on to others, you have to be prepared spiritually and I don't see that nursing is very prepared. Then it gets hard (Rufous hornero). The World Health Organization defines health as a state of complete physical, mental and social well-being and not only the absence of affections and illnesses, in addition to including spiritual well-being (12) . Spirituality translates into the fact that man is spiritual and temporarily has a physical body. Research carried out by the natural sciences (physics and biology) has endorsed this claim. The physical body is only a reflection of the spirit, a place where the person symbolically builds the meaning of their life and seeks refuge from the vulnerability triggered by crisis situations (3,13) .
A German study with professional and volunteer caregivers defined spirituality as an attitude which governs the way people interact with each other, which for them determines a spirit of compassion in the care setting, which in turn can be expressed through small nursing gestures involving touch, sensitivity and kindness, which are so special in crisis situations such as illness and finitude, constituting care which is able to fill the spiritual needs and desires of suffering patients (14) .
Regarding this, Watson points to the need to resacralize human existence, which means rescuing the spiritual dimension of being in a movement through antagonistic unity to fragmentation which restricts the care focus to only the body. This view incorporates a scientific care model which integrates an evolved caritas nursing (2) . The Human Caring Theory, later called the Caritas Process, has 10 carative factors in its basic concepts, among which two allude to the importance of professional faith: Factor 2: "The stimulation of faith and hope", represents the possibility that the nurse maintains and honors the faith and hope of their patient and the family; and Factor 10: "Permission for existential-phenomenological spiritual forces", or the acceptance of miracles which requires professionals to be open to spiritual aspects, unknown to the existential dimension (1) .
Therefore, nursing professionals recognize the importance of Spiritual Care in Category I of this study and understand that their personal investment in approach and management strategies with the spiritual dimension is relevant, which is then expressed in Category II directed to spiritual self-knowledge of these professionals.
category ii -perceiving their own Spirituality in the profeSSional context Spiritual life is not learned, it is already within the human being. However, even though spiritualities are not in the domain of religions, both can establish a good relationship. The spirit, born with the human being, may also be manifested by religious practices. In this context, religion has the function of generating conditions so that each adept human being can put their inner immersion into practice and be with the divine (4) .
Therefore, training and encouraging nurses to provide spiritual care of sick people and their families becomes easier when the professional is connected with their own spirituality. The more inner self-knowledge and spiritual development nurses have, the better integrated and better equipped they are to help and support those who suffer. Spirituality generates reflection in professionals, capable of stimulating feelings and behaviors of competence, confidence and understanding of their roles in a more complete way through self-awareness and the meaning of their actions (3,15) .
In turn, religiosity has been demonstrated as positive for the health team. Studies prove that its practice provides better physical well-being to the professional, increases the quality of life at work and favors the ability of interpersonal relationships. It is intensely reflected in the understanding of the health-disease process and in the empathic relationship with the patient, significantly differentiating their care (16) .
In this sense, Watson highlights the inner transformation of being as a requirement for Transpersonal/Spiritual Caring. It suggests that the professional's human heart is linked to the spiritual 'Source' for maintaining the human spirit, in the perspective that it is always filling with care, seeking the spirit of compassion, wisdom, truth and faith from the 'Source'. And this thinking converges in the Carative Factor 3: "The cultivation of sensitivity to one's self and to others", which highlights the need for nurses to cultivate their own spiritual practices to deepen self-awareness and transpersonal/spiritual caring, and the Carative Factor 1: "The formation of a humanistic-altruistic system of values", which means practicing love and kindness for oneself and for others in directing the connection of the totality mind-body-soul between humans and with the Source which unites all (1) .
category iii -undertaking Spiritual care for the hoSpitalized individual Spirituality in the context of health-disease increases the reserves of individuals and helps them to endure the difficulties of becoming ill. It can be experienced through positive emotion, reverence and the longing for the sacred, expressed from (for example) the attitude of each nursing professional towards patients (17) .
This spiritual care attitude is detailed in other studies and ranges from general interventions to more specific ones. The use of listening, communication, valuing silence, bonding and music are observed to minimize feelings and emotions related to the process of illness and finitude. It is also distinguished in the offer of prayer, in religious support and in access to leaders, literature, significant objects for each patient, as well as a physical space to confide and express their faith (14,(18)(19) .
In this sense, Watson ensures that any action motivated by love and zeal to care contributes to the spiritual well-being of others. It points out dialogue, self-knowledge, the cultivation of the beauty and human warmth in relationships, intuition, compassion and bonding as a foundation for promoting inner peace and hope in the Transpersonal/Spiritual Caring process. Strategies which converge to Carative Factor 4: "Development of a helping-trust relationship", which refers to relational congruence and empathy; and Factor 5: "The promotion and acceptance of the expression of positive and negative feelings", which provides for a professional being attentive to the patient's feelings in order to individually intervene to alleviate physical-mental-spiritual suffering (1)(2) .
NANDA-I defines the nursing diagnosis of spiritual suffering as a state of suffering that is related to the impaired ability to experience meaning in life through a connection with oneself, with others, with the world or with a divine being. This very relevant tool in the systematization of nursing care endorses the capacity that nursing professionals have to diagnose, intervene and promote positive outcomes through spiritual care (20) . Spiritual distress constituted a nursing diagnosis which was identified in 42% of a sample of a study with older adults; a prevalence that alerts to the need for spiritual nursing care (21) .
A study which validated the nursing diagnosis of spiritual distress in cancer patients undergoing chemotherapy found that they presented an expression of suffering and a lack of meaning in life as the most important defining characteristics, enabling nursing to develop a clinical reasoning for care centered on spiritual needs. But in order for this to be effective, it is first necessary for the nurse to recognize patients as spiritual beings, and that in this condition they are susceptible to suffering associated with the meaning of their life, their relationship with the other, with the world or with a divinity (19,22) .
Another study defines that the collection of the patient's spiritual history must be assumed by all nursing as a starting point for planning spiritual care -which certainly can be multiprofessional. Thus, it recognizes limitations that nursing may have for such care, but does not exempt it from minimally systematizing the spiritual demands of its patients to improve its performance in this area (23) .
category iv -identifying the knotS of the relationShip between Spirituality and care The last category of the present study deals with the difficulties experienced by nursing in handling spirituality in the context of their care practices.
There are convergent findings in the literature leading to an insecure posture on the topic, justified by the concerns of the nursing team about stumbling on the topic of religion with patients who come from a different formation/belief than theirs, while trying to address spirituality. The fear of generating conflicts or negative interactions is common, which leads the professional to erroneously omit the subject. Training programs and other efforts can help the team personally connect with the idea of spirituality; after all, a significant part of the nursing staff says that they would like to provide spiritual care more often than they actually do (24) .
In addition, it appears that patients with spiritual suffering require more attention and time from nursing in care practice, when they are willing to perform this type of care. Therefore, attention on the part of management is necessary in order to not only organize the physical resources, but also sufficient human resources for this care (19) .
In this sense, the importance of addressing the spiritual aspects of patients while undergoing academic training is emphasized in order to better prepare these future professionals to manage and provide this care. Research among teachers concluded that there is a strong need to not only develop the competence of caring for the physical body in health students, but also the competence to care for the spirit. Therefore, this affirms that it is essential to incorporate spirituality in the undergraduate health curricula (25) .
Such expectation of more attentive training to this demand is also evidenced in a study carried out with freshmen in the undergraduate course of a health area in which the importance attributed to religiosity and spirituality was verified, and the expectation that the chosen course curriculum contemplates the comprehensiveness of health care (26) . In line with this finding, another study addresses this perception in nurses, but they report an obstacle in the fact that they feel poorly prepared by their training to provide such care (27) .
Therefore, incorporating spiritual care in nursing curricula is a challenge which can implement strategies such as: readings, role-plays, discussion groups and tasks for building spiritual concepts from simple to complex based on experiences with patients/families over the course period (27) .
Regarding this, Watson expresses her concern in the "use of scientific knowledge in a systematic and creative way", for solving problems in the care process (Carative Factor 6), which outlines the creative use of their own being and all forms of care knowledge as part of the care process. Moreover, through the Carative Factor 7, it encourages the "promotion of transpersonal teaching-learning", which means the construction of an educational process which serves the person/student, considering their subjective meaning and spirituality, so that it can reflect such behavior in its practice (1)(2) .
The limitations of this study comprise the restriction to a specific context. Thus, the development of more studies in the area is encouraged, as well as more investments on the part of schools and teaching professors, and further still of managers and hospital institutions which need to undertake

CONCLUSION
It is evident that spirituality, as part of human beings, emerges in the intersubjective encounter between the caregiver-nurse and being-patient as a place of mobilization and inner strength capable of generating resilience through faith in times of illness. Spiritual care is recognized by the nursing team as opportune, especially in the hospitalization context where human vulnerability strikes people in a marked way, favoring the bond and exchange of positive experiences in the healthcare process.
However, it was observed that the "spirituality" theme and its practices in the daily work of nursing professionals are still a challenge which need to be better assumed and worked on in the process of continuing education for these professionals, so that they develop skills and confidence to welcome this demand.
The Systematization of Spiritual Nursing Care stands out as opportune devices, using spiritual anamnesis, specific NANDA diagnoses and planned and evaluated interventions which may include listening and welcoming, music, prayer, accessibility to religious leaders/practices, among others in directing the mobilization of faith and hope in the patient-family. Transpersonal Caring also proved to be a relevant device capable of subsidizing spiritual care by offering a care model to the whole body-mind-soul via undertaking actions organized from the Caritas Process, in its carative factors explicitly converging to provide spiritual care.