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Nurses’ performance in palliative care: spiritual care in the light of Theory of Human Caring

Rev Bras Enferm. 2022;75(1): e20210029 https://doi.org/10.1590/0034-7167-2021-0029 8 of ABSTRACT Objectives: to analyze nurses’ role in assisting patients in palliative care, with emphasis on the spiritual dimension, in the light of Theory of Human Caring. Methods: this is an exploratory, qualitative study, carried out in a hospital in João Pessoa, Paraíba, between August and December 2019, with 10 nurses. For data collection, semi-structured interviews were used. For analysis, we opted for content analysis. Results: the spiritual dimension of care is contemplated by several religious and spiritual practices. These are respected and encouraged by nurses, although there is difficulty in providing care for the spiritual dimension. Final Considerations: nurses have attitudes consistent with Jean Watson’s Theory and apply the Caritas Process elements during assistance to patients’ spiritual dimension in palliative care. Descriptors: Nursing; Patients; Palliative Care; Spirituality; Nursing Theory.


INTRODUCTION
Chronic diseases are increasing worldwide as well as the life expectancy of individuals affected by them (1)(2) . Thus, it becomes necessary to establish a care model that contemplates the entire process of patients' illness, death and dying so that it is possible to promote an improvement in the quality of life during illness and finitude, as proposed by palliative care (2) .
Palliative care refers to holistic care directed at individuals with potentially fatal diseases, including those at the end of their lives. This care aims to improve the quality of life of patients, with life threatening diseases, and their families/caregivers (3)(4)(5) . Palliative care must be offered by a multidisciplinary team so that there is excellent care, highlighting nurses' role (6) , who must pay attention to patients' real needs, be they physical, psychological, social and spiritual, although it is not always easy to attend to all of them, in their completeness (2) .
Regarding the spiritual dimension, nurses' recognition of the importance of attending this dimension stands out. They understand spirituality as something that strengthens, promotes comfort and faith, helping patients to cope with the problem and enabling them to improve their health, even in the face of a life-threatening illness. However, there is still a lack of preparation of these professionals in addressing issues of a spiritual nature (7) , although there are nursing theories that contribute greatly to support nurses' practice and that address spiritual issues.
Among the nursing theories that address the spiritual dimension in patient care, the Theory of Human Caring stands out. This theory emphasizes care as opposed to healing, values the mysteries of life, recognizing the spiritual dimension and the inner power in the care process, in which nurses are co-participants (8) .
That said, this study is justified by the need for nurses to contemplate the spiritual dimension in assisting patients who are affected by a life-threatening disease, aiming at the relief of their spiritual suffering (7,9) , and the possibility for nurses to base their care practice with a theory like that of Jean Watson, which can assist them in patient physical and non-physical care, since he considers the connection between the mind, body and spirit.
Thus, this study sought to seek answers to the following guiding question: How do nurses perform in the care provided to patients in palliative care, with emphasis on the spiritual dimension, in the light of Theory of Human Caring?

OBJECTIVES
To analyze nurses' role in assisting patients in palliative care, with emphasis on the spiritual dimension, in the light of Theory of Human Caring.

Ethical aspects
The research was initiated after approval by an Institutional Review Board and met the recommendations contained in Resolution 466/2012 (10) , which provides for research with human beings, including the guarantee of anonymity of participants and their consent to participate in the study, by signing the Informed Consent Form (ICF).

Theoretical framework
For the theoretical framework, we chose to use Theory of Human Caring, developed by Jean Watson (8) , and the 10 Caritas Process elements, described below: practicing loving-kindness, compassion and equanimity with oneself and with each other; being authentically present, enabling, sustaining and honoring faith and hope; cultivate one's own spiritual practices, beyond the ego to the transpersonal presence; developing and maintaining relationships of love, trust and affection; allowing the expression of positive and negative feelings, authentically listening to the other's story; using creativity to solve problems, seeking the solution through the care process; engaging in a genuine transpersonal teaching and learning experience; creating a healing environment at all levels (physical and non-physical); sustaining human dignity and respecting assistance for basic human needs; allowing miracles and open the spiritual, mysteries and the unknown (8,(11)(12) .

Type of study
This is a qualitative exploratory research, excerpted from the main author's thesis, which followed the criteria present in the Consolidated criteria for reporting qualitative research (COREQ) checklist, in order to improve the quality of qualitative research and assist in the performance of this research (13) .

Methodological procedures
Initially, the first contact with nurses was made. On that occasion, the main researcher presented the research proposal, addressing the theme, the objectives and the way in which data collection would be carried out. The interviews were carried out on a day and time scheduled with each participant, always seeking to ensure privacy and a calm and reserved environment, in addition to clarifying any doubts of participants regarding the research process.

Study setting
The study was conducted at a large public hospital in the city of João Pessoa, Paraíba, chosen for treating patients with a variety of life-threatening diseases, for having a qualified team to assist these patients and for involving the palliative care theme in professional training processes.
This hospital has a multidisciplinary team composed of doctors, nurses, nutritionists, psychologists, social workers, dentists, nursing technicians and occupational therapists. The hospital has an outpatient sector, medical, surgical, obstetric, pediatric and infectious diseases, surgical block, Intensive Care Unit, among others.

Data source
The population involved nurses from that institution and the sample consisted of 10 nurses working in the selected hospital during the data collection period, with at least six months of experience in the institution selected for the study. Professionals removed from their activities, due to vacation or leave, and those who did not work with a patient in palliative care, were excluded. Among the participating nurses, 9 were female and 1 male, aged between 33 and 60 years. It should be noted that the sample quantum was given for convenience and was completed in view of the saturation of the interviews. Saturation identification is a relevant criterion for interrupting data collection and, consequently, for determining the final sample size in qualitative research (14) . In saturation, the completion of data collection occurs when the empirical material begins to show redundancy and repetition from the point of view of the interviewer (15) .

Data collection and organization
Data collection took place between August and December 2019 through semi-structured interviews and included questions about the nursing care provided to patients in palliative care; strategies to meet the dimensions of patients who are in palliative care; the relationship between nurses and patients in palliative care; meeting of spiritual needs of patients in palliative care; encouragement of religious and spiritual practices.
The interviews were recorded and transcribed in full. To maintain the anonymity of the participants, they were identified using the letter N (nurse), followed by the ordinal number, according to the sequence of the interviews (e.g., N1, N2, N3 and so on).

Data analysis
The analysis of the empirical material from the interviews was carried out through content analysis, proposed by Laurence Bardin. For this, the stages of pre-analysis, exploration of the material, treatment and interpretation of results were carried out (16) , which allowed the formation of the categories: The spiritual dimension of care is contemplated through religious and spiritual practices; The spiritual dimension of care is carried out with respect and encouragement to patients' religious and spiritual beliefs and practices; The spiritual dimension of care is carried out with personal, structural and professional training difficulties.

Category I -The spiritual dimension of care is contemplated through religious and spiritual practices
In this category, religious and spiritual practices performed by nurses stood out. These professionals considered prayer, reading the Bible, listening, talking, comforting words, presence, being together and providing for the arrival of a religious leader as expressions of the spiritual dimension of nursing care, with patients in palliative care. [ N5 and N9 highlight the importance of contemplating the spiritual dimension during care, for the relief of symptoms that the patient in palliative care may present, considering that, in life-threatening situations, it is possible that only medication does not promote the relief of the manifestations felt by patients. [...]. We know that there will be no medication that will revert, there will be no analgesia that will work, but there will be a support word that will comfort [...] and it will be that word that will, many times, make a painkiller it stops being done, because he will be comfortable there with himself, and with a greater strength that he has [...]. (N9) It is noteworthy that N1 and N7 report the need to prepare to be able to offer spiritual support to patients:

Category III -The spiritual dimension of care is carried out with personal, structural and professional training difficulties
In category III, most nurses express numerous difficulties in offering spiritual care to patients in palliative care, which are related to personal issues, professional training and the service structure. They mentioned as personal difficulties the fear that a patient will die on duty, as shown below: [ Regarding the service structure, the routine of the service stands out with the high demand from patients and the lack of a specialized clinic to assist patients in palliative care. Participants recognize that patients are neglected, with spiritual assistance being the responsibility of each professional, i.e., nurses end up improving the development of this competence in practice. [

DISCUSSION
Considering the suffering of patients with serious and fatal illness and the suffering of their family, it is necessary to develop human care based on scientific evidence, to enable more effective responses to the problems faced by the disease. Theory of Human Caring can be an approach used in these cases, as it is equivalent to what palliative care proposes, including attention to spiritual aspects (17) .
Among the religious and spiritual practices carried out by the nurses in this research, prayer, Bible reading, listening, conversation, words of comfort, presence and providence of a religious leader stood out. These practices, characterize the spiritual care they perform, since they are understood by them as a support, a strength, a comfort to meet the health needs of patients in palliative care, at the moment, and may even avoid the use of medication.
A qualitative study, based on Theory of Human Caring, carried out at a geriatric center in Salvador, with 17 nurses, showed that they also perform and encourage prayer, the reading of biblical words and respond to requests from religious representatives to assist the spiritual dimension of hospitalized elderly people (18) .
These actions denote nurses' idea being authentically present, allowing the belief system and the subjective world of themselves and the other, so that it affirms faith and hope, as well as develops and maintains a relationship of help, trust, love and affection present, respectively, to the second and fourth Caritas Process elements (8,12) .
Nursing care should open up the spiritual aspects, mysteries of life, death, pain, joy and changes, allowing for miracles, as evidenced in the tenth element Caritas Process element (8,12) . Emphasis is placed on the relevance of the role that faith and hope play in people's lives, especially when faced with the unknown, mysteries and diseases, pain, stress, despair, sadness, fear, and death (19) .
In the face of a life-threatening situation, with medication no longer having the desired effect, spiritual care emerges as a therapeutic option, providing basic needs as sacred acts, sustaining human dignity and creating a healing environment in all aspects, physical and non-physical, both present in the ninth and eighth Caritas Process elements, respectively (8,(11)(12) .
Nurses' acknowledgment of a threatening environment for patients, the development of an empathic relationship, a modifying attitude, allied with the use of technical procedures, all this forms the basis for restoring health and meeting basic human needs. Considering the human complexity and its biopsychoemotional and spiritual dimensions, it is necessary to reflect on the implementation of nursing care that contemplates not only the physical, but the other dimensions of the human being (20) . To promote the well-being of individuals, it is necessary to have an environment that allows healing through care, providing comfort, peace and harmony (21) .
Listening and talking with patients, performed by nurses, must be authentic and allow the expression of feelings, whether positive or negative, as proposed by Watson, in his fifth element (8,12) . Many problems can arise in nursing, such as failure to build an empathic relationship with the other. However, it is necessary to understand that nurses, when engaging with patients, at the moment of care, and really listening to their story, may be offering the greatest healing gift and may allow patients to feel more comfortable talking about issues delicate things that are really affecting them (19) .
It was found that encouragement and respect for spiritual and religious beliefs and practices were referred to as adopting an attitude of not imposing professionals' opinion, but of motivating, encouraging dialogue, praising, identifying a spiritual need, looking for an alternative, another way of intervene and help. These statements represent the third Caritas Process element. This element concerns the cultivation of spiritual beliefs and practices (8,12) .
This can facilitate the construction of a trustworthy relationship, which helps care. In order to develop sensitivity, oneself need to pay attention to their own feelings and thoughts. By adopting a spiritual practice to connect with the inner self, individuals extrapolate the physical dimension and seeks a deeper source of inner wisdom and the truths themselves. The practice of selfreflection, through registration, prayer, meditation and artistic expression, demonstrates the willingness to explore the feelings, beliefs and values of others for personal growth (19) .
Furthermore, it was possible to perceive the cultivation of practices of loving kindness, compassion and equanimity with oneself and with others, the first Caritas Process element (8,12) , considering that this element can be represented by help acceptance and offer and for being authentically present (21) .
It was evidenced that the majority of nurses participating in this research encourage, respect and perform spiritual care for patients in palliative care. Respect for patients' religious practice was strongly emphasized in nurses' statements. The varied beliefs, and the willingness of nurses to attend to patients' spiritual dimension, show respect for the other, an understanding of the other's subjective world and the relevance of this dimension (18) .
Teaching and learning relationships within the context of care, the seventh element of the process (8,12) were highlighted by N4, when he reported that he likes to learn about patients' religions. It is known that in nursing, patient education is very present. However, little is mentioned about the learning that one has with patients and that is encouraged by Theory of Human Caring.
The Caritas teaching and learning process does not allow the authoritarian approach of nurses due to their professional position. On the contrary, it is a relational, confident, engaging and liberating process, resulting in possibilities of self-knowledge, self-care, self-control and even self-healing (19) .
Among the problems related to the lack of incentive to spiritual and religious practices and beliefs, there was a lack of time among nursing professionals, since, in view of other care attributions, they may not be able to provide assistance that contemplates body-mind-soul. A qualitative study, carried out with 27 nursing assistants, showed that this lack of time, associated with the exhaustive work routine, the lack of knowledge about the spiritual dimension, care centered on the biological dimension and the absence of emotional support to the team, all of this contributes to hinder the spiritual dimension in palliative care (22) .
Nurses also reported personal difficulties, professional training, and related to the structure of the service to meet the spiritual dimension of patients in palliative care. Among the personal difficulties, the lack of preparation to deal with death and the lack of skills to attend to the spiritual dimension stood out, including, for associating this only with religious issues. Bearing in mind that spirituality is based on sacred values that transcend the physical world and the reality that can be seen, its understanding becomes difficult and, consequently, its incorporation in care directed to patients in palliative care is difficult (23) .
It should be noted that sacred acts and transcendence are present in Theory of Human Caring. The administration of sacred acts of care and healing in order to provide holistic care; also, attention to spiritual aspects is part of the ninth Caritas Process element (11) , as mentioned. As nurses perform these functions, they bring the spirit to the physical dimension, which promotes new connections between basic and evolving spiritual needs. In this way, each act of the physical dimension connects with the spirit dimension and changes individuals' lives. Nurses help others, as a sacred act, and recognize that, with this act, they connect and contribute to the spirit of themselves and that of the other (19) .
Transcendence is part of the concept of transpersonal care, understood by Watson as intersubjectivity in the relationship between humans, in which there is the influence of those involved in the process. This transpersonal relationship denotes the idea of union with another person. It starts when nurses enter patients' phenomenological field, being able to identify in their hearts the spirit of patients (8) . Thus, performing transpersonal care is of great importance to know what is not possible to see in the assisted patient. However, this is not always easy to do.
This makes it possible to understand the importance of attending the spiritual dimension in patient care and carrying out the Caritas Process, especially in the face of a patient weakened by his health condition, although there are difficulties in performing this service in clinical practice.
Some nurses in this research stated that they were unable to meet the spiritual dimension of their patients in palliative care. They reported resorting to other professionals with competence to perform this type of care, also found in other studies (7,24) . The collaboration of several professionals is a great way to offer excellent service. This interprofessional human care must be attentive to the mysteries of life and spiritual (21) . Furthermore, professional training and a specialized care environment for patients with life-threatening diseases could facilitate meeting this need, as evidenced in the statements.
Nurses recognize the need for spiritual support of patients in palliative care as legitimate and attribute the unpreparedness to lack of knowledge, since in training they only knew about drug therapy and as a result, they are not prepared to deal with finitude. They claim the need for training to assist patients with life-threatening diseases. They understand that all of this leads to a loss in patient care. Even due to the high demand for work, this assistance is neglected.
In this context, Resolution 41 of the Ministry of Health of Brazil addresses the guidelines for the organization of palliative care services in the Unified Health System (SUS -Sistema Único de Saúde). Among its objectives are the provision of permanent education for health professionals, the encouragement of multidisciplinary work and the promotion of curricular components on palliative care in lato sensu (Master of the Arts) undergraduate and graduate teaching in Brazil (4) , which will assist in assisting patients with life-threatening diseases and meeting their biopsychosocial and spiritual needs. The Caritas Process itself can be used as part of the programmatic content of training in palliative care in health services to promote patient care and care for spiritual aspects (17) .
Searching for alternatives that help patients in the care of their spiritual dimension is reflected in the sixth Caritas Process, which deals with the use of creative methods for problem solving and in decision-making about care (25) ; including, nurses' reports about the moments when they were able to provide spiritual assistance highlight this element of care. In human care for patients, professionals need to use their creativity, which requires all forms of combined knowledge (science, art, ethics and personal experiences) so that the manifestation of the science of care is enhanced (21) .
Considering the above, it is emphasized that the spiritual dimension needs to be ensured in the assistance of nurses to patients, for their holistic care. Assistance directed to the spiritual dimension, in addition to considering humanistic aspects in care, allows the improvement of well-being and quality of life of patients (18) , being congruent with what advocates palliative care.

Study limitations
Among the study limitations, it is worth mentioning that it was carried out at only one hospital that assists patients in palliative care. Another limitation concerns the non-use of the systematic observation technique, which could help to verify the application of the Caritas Process elements during nurses' care practice and contribute to strengthening the findings found in this research.

Contributions to nursing, health, and public policy
This research has important contributions in nursing and health, considering that it may encourage the production of studies on Jean Watson's Theory of Human Caring and, consequently, the application of the Caritas Process in the care of the spiritual dimension of patients who have a life-threatening disease, whose spiritual aspects need to be attended to and may have greater relevance than physical care considering the finitude of life and the impossibility of a cure.
The dissemination of this study may alert nurses about the knowledge of nursing theories, with emphasis on Jean Watson's Theory and its important application in the practice of patientoriented care. In this case, patients in palliative care. It is also noteworthy that nurses will be able, from this study, to realize that they empirically use the theory in question, thus, it will also be able to encourage them to seek more scientific basis for their practice.

FINAL CONSIDERATIONS
In this study, it was possible to verify that most nurses understand spirituality as an important resource for caring for patients in palliative care; they even respect and offer religious and spiritual practices during their care, despite finding difficulties in their application, with emphasis on unpreparedness and lack of time.
It is also evident that nurses have attitudes consistent with Jean Watson's Theory of Human Caring and apply the Caritas Process elements, even empirically. However, it is understood that a qualification aimed at professionals who care for patients in palliative care, focused on this theory and the care of the spiritual dimension, can offer higher quality care, seeking to care for patients as a sacred being that must be fully respected.
It is suggested that further studies be carried out to assess the care of the nursing team, through systematic observation, in order to verify the Caritas Process elements present in nurses' actions. Moreover, studies are needed that contemplate the conduct of nursing professionals, before and after conducting training that addresses Theory of Human Caring and the Caritas Process elements, applied to the hospital context. Such studies may enable the growth of these professionals, contributing to significant changes in their clinical practice.