ORIGINAL ARTICLE

Spiritual therapies in nursing care: an integrative review

Terapias espirituais no cuidado de enfermagem: uma revisão integrativa

Terapias espirituales en la atención de enfermería: una revisión integradora

Santos, Camila Santana dos[1]; Souza, Rozemere Cardoso de[2]; Silva, Thiago Nogueira;[3] Santos, Vanessa Thamyris Carvalho dos[4]; Santos, Josenaide Engracia dos[5]

ABSTRACT

Objective: analyze the scientific production in Nursing about spiritual therapies. Method: integrative review with 41 articles, selected from the Virtual Health Library, between January 9 and February 3, 2020, with the descriptors “Spiritual Therapies” and “Nursing” and the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols methodology. Data were collected through a synoptic chart and critical analysis. Results: increasing studies were identified, especially in the United States and Brazil and in a hospital context, in addition to identifying modalities of spiritual therapies and their contexts of use, training and essential role to Nursing care are described. Conclusions: spiritual therapies promote promote benefits in comprehensive nursing care, in chronic health conditions, in disaster situations, such as the coronavirus disease 2019 pandemic, in the daily lives of different clinics and in promoting well-being.

Descriptors: Nursing care; Spiritual therapies; Spirituality; Complementary therapies

RESUMO

Objetivo: analisar a produção científica em Assistência de Enfermagem em Terapias Espirituais. Método: revisão integrativa com 41 artigos, selecionados na Biblioteca Virtual da Saúde, entre 09 de janeiro e 03 de fevereiro de 2020, com os descritores “Spiritual Therapies” e “Nursing” e a metodologia Preferred Reporting Items for Systematic review and Meta-Analysis Protocols. Fez-se coleta dos dados por meio de quadro sinóptico e análise crítica. Resultados: identificaram-se estudos crescentes, especialmente, nos Estados Unidos e Brasil e em contexto hospitalar, além de identificar terapias e seus contextos de uso, formação e papel essencial ao cuidado de Enfermagem. Conclusão: terapias espirituais promovem benefícios na assistência integral de enfermagem, em condições crônicas de saúde, em situações de desastre, como a pandemia do coronavírus, no cotidiano de diferentes clínicas e na promoção do bem-estar.

Descritores: Cuidados de enfermagem; Terapias espirituais; Espiritualidade; Terapias complementares

RESUMEN

Objetivo: analizar la producción científica en Asistencia de Enfermería en Terapias Espirituales. Método: revisión integradora, que siguió las pautas de Preferred Reporting Items for Systematic review and Meta-Analysis Protocols. Se seleccionaron 41 artículos en la Biblioteca Virtual en Salud, entre el 9 de enero y el 3 de febrero de 2020, con los descriptores “Spiritual Therapies” y “Nursing”. Los datos se recogieron a través de un cuadro sinóptico y análisis crítico. Resultados: se identificaron estudios crecientes, especialmente en los Estados Unidos y Brasil y en contexto hospitalario, además de identificar las terapias espirituales y sus contextos de uso, formación y función esencial a los cuidados de enfermería. Conclusiones: las terapias espirituales promueven beneficios en la atención integral de enfermería, en condiciones crónicas de salud, en situaciones de desastre, como la pandemia de coronavírus, en la vida diaria de diferentes clínicas y en la promoción del bienestar.

Descriptores: Atención de enfermería; Terapias espirituales; Espiritualidad; Terapias complementarias

INTRODUCTION

Despite the history between religion, spirituality, and medical practice, only in recent decades, scientific literature has portrayed religiosity/spirituality as having a role in the physical and mental health of patients.¹ Religiosity/Spirituality is considered to be a dimension of human existence that directs people towards practices and searches for meanings and purposes in life² and is stimulated and/or expressed more distinctly in situations of adversity.^3-4

The terms religiosity and spirituality have close meanings but keep their particularities. Spirituality can be conceptualized as a personal perspective and behaviors that express a sense of belonging to a transcendent dimension or something greater than it.⁵ It is defined primarily as an essence and a way of seeing events in a new perspective, capable of making individuals experience inner peace, increase connectivity with a higher power and have interconnections with nature and other human beings.^6-7 With it, we develop the ability to transcend oneself, to face suffering, pain, create values, and find meaning and intention for the various circumstances of existence.^8-9

Religiosity, as its name suggests, corresponds to “a specific expression of spirituality that involves a doctrine, a sacred narrative, rules of conduct, organized rituals, and an institution such as a church or a synagogue”.^10:36 In religiosity, spirituality is expressed in its organizational form, which makes up an important dimension in measuring instruments applicable to different religions.¹¹

This lack of consensus hinders comparing results among studies.¹² However, review study has show correlations between religiosity/ spirituality and the prevention of various diseases, with evidence of improvement in life quality and rise in the afterlife.¹³

There is a correlation between higher religious frequency and increased immunity.¹⁴ Regarding mental health, some studies have shown a direct relationship with psychological well-being, such as satisfaction, happiness, and moral values.^15-16 In randomized clinical trials on religiosity and spirituality, showed additional benefits, including reduction of clinical symptoms, mainly, anxiety.¹⁷

The approach of spiritual needs in Nursing Care is also expressed in different contexts. At the time of patient admission, as well as in daily need, this approach would help in the evaluation, dissemination, and practice of Spiritual Care with the patient,¹⁸ and promote well-being.¹⁹ However, there is still a reduced focus on spirituality in care and barriers, even with research revealing its impact on health.^20-21  

This study is following to know how is the use of spiritual therapies by nurses based on the analysis of the scientific production on the subject by nurses. Spiritual Therapies include “mystical, religious, or spiritual practices, made to benefit health^”.²² Therefore, in this study, no distinction is made between the use of the term’s spiritual practices and religious practices.

Only the growth in research on spirituality will enable, through evidence-based practice, professionals to adopt ideal measures against the detection of spiritual distress due to the subjectivity and complexity of this Nursing diagnosis.²³

The study may contribute to reflect on the permanent need to overcome the biomedical model of illness; to address social, psychological, or behavioral aspects and resources in the management of the disease; the wholeness of care; and the possibility of patients taking part in the healing process.

The theme is relevant for the pandemic’s global context, caused by the New Coronavirus and COVID-19 disease, and the consequent adoption by many countries of social isolation as a measure to reduce the spread of the pathogen,²⁴ which has had repercussions on psychological impacts to the population.^25-26 This scenario requires the development of efficient and low-cost interventions that help in reducing the psychological suffering of people,²⁷ such as spiritual therapies that can be increasingly used for this purpose.

With the exposed, from the perspective of contributing to reflect on Nursing practice, with spiritual therapies as potential care resources, this study aimed to analyze the scientific production in Nursing on the use of spiritual therapies.

METHOD

This is an integrative literature review, which is a method that proposes the synthesis of scientific research results related to an issue or theme, in a comprehensive, systematic, and orderly manner, providing broader information on a subject/problem, thus constituting a body of knowledge.²⁸

For the elaboration of the guiding question, we used the PICO strategy, an acronym in English that means “Patient, Intervention, Comparison and Outcome”, as fundamental elements of the research matter and the elaboration of the question for the search for evidence in the literature.²⁹ Thus, P – Population, represented by patients taken care of by nurses, I - is the application of spiritual therapy actions, Co – Context, healthcare units, and O - is the identification of evidence in the literature on the application of spiritual therapies with Nursing Care. Thus, the main question was: What are the modalities, contexts and importance of spiritual therapies used by nurses in patient care practices?

The inclusion criteria for the selection of the studies were: to be a complete article, available electronically, in Portuguese, English, or Spanish; to portray the theme of the study as one of the main subjects of the article, and to have been written by nurses or to be published in nursing journals. We did not use the timeline as a filter so that we could have access to the publications available so far. The following materials were excluded: repeated studies, editorials, literature review articles, document analysis, theoretical reflections, experience reports, and articles that did not answer the guiding question proposed by this study. A total of 146 articles were excluded.

To answer the guiding question, we searched for publications available on-line, on the portal of the Virtual Health Library (VHL), from January 09 to February 03, 2020. Therefore, the descriptors “spiritual therapies” and “nursing” were used. 

The term “Spiritual Therapies” in this study, as described in the Health Sciences Descriptors (DeCS), does not distinguish between spiritual and religious practices. Thus, spiritual therapies include “mystical, religious or spiritual practices made to benefit health”. ²²

The PRISMA guidelines for review studies were followed.³⁰ The selection of the articles of the review followed the steps described in the flowchart (Figure 1), which were: pre-selection of the articles; application of the filter “completed works”; reading of the pre-textual data (title and type of study); careful reading of the abstracts and, when necessary, dynamic reading of the complete article, to verify whether the manuscript met the inclusion criteria. In total, 41 articles were selected to compose the study sample.

Figure 1: Flowchart of identification, selection and inclusion of articles, for the development of Research, following the PRISMA. ³⁰

Source: prepared by the authors, 2021.

The participants in the initial stages of the study, survey and selection of materials were a researcher and a student from the Nursing course, and then three more researchers were invited, being two nurses and a psychologist and occupational therapist part of the study group in the area of mental health, who gave significant contributions to the study design, scientific writing and critical analysis, as to the results and discussion.

For data collection and organization, a synoptic chart was constructed and allowed visualizing the material contents, from the following categories: author/year/country/ institution, study title, objective, method(s), therapies used or indicated for use, main results, journal and complete reference.

For data analysis, we initially made exhaustive readings of the selected materials, followed by the production of records and systematization of information in panels and tables, with specific contents of the works converging with the objectives of the study. Subsequently, the selected studies were characterized and thematic categories were defined to highlight content related to the therapies addressed, to the contexts and audiences involved, and to the relevance described in the set of articles.

Thus, the contents of the works were grouped under empirical categories and a thematic synthesis was described, consisting of three categories of analysis: Techniques and handling of spiritual therapies conducted by nurses; Context of performance and training of nurses in Spiritual Therapies; Spiritual Therapies as essential to Nursing Care.

RESULTS AND DISCUSSION

Out of 41 selected articles^31-71, 31 (78.0%) were published in nursing journals,^{31-33,35-36;38-44,47,49-51,55-62,63-66,68,70-71} all were published internationally. There was a wide variety of journals but a higher frequency of publications in two journals entitled: Journal of Holistic Nursing and Holistic Nursing Practice. The list of journals is following shown (Table 1).

Table 1: Distribution of articles on spiritual therapies and nursing, according to journal of publication

Journal	N	%
Journal of Holistic Nursing	5	12.2
Holistic Nursing Practice	3	7.3
Journal of Clinical Nursing	2	4.9
Scandinavian Journal of Caring Sciences	1	2.4
Creative Nursing	1	2.4
Enfermería Clínica (Ed. impresa.)	1	2.4
Journal of Religion and Health	1	2.4
Index de Enfermería	1	2.4
Enfermería Global	1	2.4
Journal of Pediatric Oncology Nursing	1	2.4
Nurse Educator	1	2.4
Revista de Enfermería del Instituto Mexicano del Seguro Social	1	2.4
Aquichan	1	2.4
Saude e Pesquisa (Impr.)	1	2.4
International Nursing Review	1	2.4
BMC Palliative Care	1	2.4
Nursing & Health Sciences	1	2.4
Advances Nursing Science	1	2.4
Cultura del Cuidado Enfermería	1	2.4
Curationis	1	2.4
Nephrology (Carlton)	1	2.4
Revista Enfermagem UERJ	1	2.4
Home Healthcare Nurse	1	2.4
Nursing Research	1	2.4
Nursing in Critical Care	1	2.4
Journal of Nursing Research	1	2.4
International Journal of Nursing Education Scholarship	1	2.4
Applied Nursing Research	1	2.4
Einstein (São Paulo)	1	2.4
Oncology Nursing Forum	1	2.4
Qualitative Health Research	1	2.4
Revista Mineira de Enfermagem	1	2.4
Cancer Nursing	1	2.4

Source: prepared by the authors, 2021.

Regarding language, 32 (78.0%) articles were published in English,^{31-37,40-43,47-51,53-57,59-66,68-71} five (12.2%) in Portuguese,^45-46,58,67 and four (9.8%) in Spanish.^38-39,44,52 As for the country of affiliation of the articles, Brazil was the country with the highest frequency of publications; second only the United States of America (USA).

As for the year of publication of the articles, the period ranged from 2008 to 2019. There was a growing interest in the study of the subject in question, especially in the last six years, except for 2019; the largest number of articles published was in 2015, with seven (17.1%) articles;^47-53 with a possibility of increasing the number for 2019, taking into account the period of data collection of this study and new publications.

The articles are classified according to the context in which the studies were conducted. The great majority, 21 (51.2%), were performed in the hospital context.^{24,31,34,37-38,42,44-49,51,56-58,60,62,66-67,71} Among them, 6 (51.3%) were school hospitals.^{37,42,45,60,67,71} After the hospital, the nurse training institutions (colleges) and the community was the most frequent settings for the study of spiritual therapies. Two of the works only identified the region of the study^{40, 43} (Table 2).

Table 2: Articles on spiritual therapies and nursing, according to the context of the studies.

Care Units	N	%
Hospital (06 School hospitals – 51,3%)	21	51.2
Clinics and specialized health centers	3	7.3
Community (01 AA Program - 16.7%)	6	14.6
Formation/ Faculties	8	19.5
Clinics, hospitals, and community	1	2.4
Not disclosed	2	4.9

Source: prepared by the authors, 2021.

Regarding the study methods of the articles investigated, there were no major differences in the frequencies of qualitative and quantitative approaches, with numbers and percentages respectively of 20 (48.8%)^{31-32,34,42,45-46,48,50,52-55,58-61,64,66,70-71} and 16 (39.0%),^{37-40,43-44,47,49,55-57,62-63,65,67-68} demonstrating the feasibility of the subject’s study, from several methodological outlines. Some studies stood out in the relative experimental modality, with tests before and after some educational intervention (Table 3).

Table 3: Articles according to the methodology used for the studies on spiritual therapies and nursing.

Study Method	N	%
Qualitative Quantitative (transversal, exploratory, descriptive) Quasi-experimental Quali-quantitative	20	48.8
	16	39.0
	4	9.8
	1	2.4

Source: prepared by the authors, 2021.

Regarding the contents of the work concerning the main objectives and results (Figure 2), converging to the objectives of this study, and the interest of the researchers, the following themes are described, which facilitated the analysis.

Figure 2: Characterization of the modalities and main results of spiritual therapies used by nurses in the analyzed studies.

Spiritual therapies identified	Main effects
Services of chaplains31,45,47,54	Well-being; understanding of the chaplains in the interprofessional health team; learning about assistance tools used by him/her.
Prayers36,38,45,50- 51,54,57,60- 61,66,69-70	Spiritual well-being; feeling of power to deal with the illness and eventually death; physical comfort; pain relief and relaxation.
Embracement, listening, empathy and other interpersonal abilities45,47-49,51,55	Interconnectivity, adaptation to the environment, inner harmony, peace with oneself, with others and with the world, the cosmos and eternity; recognition of spiritual suffering. For the nurse, he/she develops courage and competence to provide spiritual assistance.
Readings of the Bible, leaflets and/ or materials50,53-54,61	Mental health promotion during stressful life events; development of acceptable and sensitive approaches.
Appropriate touch, holding hands and hugging41,45	Better situation, resignification of the disease, comfort, acceptance, calm and optimism. For the professional, positive emotions.
Reflective diary; gratitude journal; visual diary – art33,35,37,41,71	Comfort; end-of-life help in palliative care; relief from pain and suffering; self-care; self-reflection; encouraging patients to see themselves as strong, handsome/beautiful, powerful or healed. For students, learning and security in the provision of spiritual care.
Positive attitudes or sentences36-37	It qualifies the care provided to the patient. Associated with Yoga, they can stimulate the nervous system and improve the circulatory system.
Encouragement and/or exercise of faith and hope in God or higher something37 43 46 51-52 57	It qualifies care; improves quality of life; promotes resilience; hope for healing or, when not possible, spiritual healing with the forgiveness necessary for passage; generosity; strengthens relationships, provides opportunities for worship and prayer, emotional peace received by those who give and receive, besides support, care, and healing.
Music offers38,45,50-51,57,68,71	Compassion, relaxation, calm and joy; essential congruence of oneself and the spirit, culminating in a level or degree of healing.
Radio or television programs38	Emotional well-being; adaptation to the environment; self-reflection.
Religious rituals47 51-52 54 69	It promotes meaning in life and death and strengthens faith.
Relaxation and Meditation Methods50,65,69	Positive emotions – feeling of happiness – or negative emotions – feeling of failure or sadness; meeting the needs of affection and affiliation; promoting a sense of spiritual healing.
Forgiveness practice39,46-47,51	Assistance in decision-making; feeling of being too close to God or to a “greater power”; resilience; strength, backup, and generosity.
Use of the nurse’s humor and/or health experiences42-43	It promotes patient-centered care that reflects not only specialized and safe care, but also care that is aligned with the patient’s needs, i.e., significant care.
Thanatological visits44	Spiritual well-being; inner peace, faith and capacity for encounter
Blessing70	Care/cure of diseases; life promotion; allows the individual to pass and overcome the different crises of life.
Pedagogical strategies32,40,48,53,55,56,64	Positive changes in understanding spirituality and spiritual care; support in coping with existing barriers in supply and teaching; responsibility to respect other beliefs and reflection on the lives of students.
Development and/or validation of instruments34,43,49,56,58,62,67	Instruments that can be used to identify spiritual needs and to measure frequencies of nurses’ interventions; instruments for specific cultures.

Source: prepared by the authors, 2021.

Modalities and management of spiritual therapies used by nurses

The spiritual therapies applied by nurses have been gaining notoriety concerning the care given to patients. This kind of care can include a variety of activities, such as listening to the concerns and anxieties of patients; a practical knowledge of various beliefs and religions; providing hope and comfort; recognizing the importance of spiritual concerns in acutely ill and dying clients; and processes necessary to refer clients to the clergy or other spiritual counselors.^{30-31,37-38,43,45-49,51-52,54-55,57,59.}

Knowing and understanding the importance of spirituality is the first step in providing spiritual care. ³⁷ Nurses also need to take into account their own beliefs about major life issues in order to develop effective care.⁵⁵ The use of humor and the sharing of experiences that can benefit the patient and produce long-term spiritual memories through encounters, rituals of faith, remembrance of past spiritual experiences throughout life that generated growth.⁶⁹ For those who do not believe in God or a supreme being, spiritual care can be linked to vital transcendence, art, creativity, free expression and ethics and morals. ⁴⁰ In a trusting relationship, the opportunities for meaningful spiritual connections seem endless.⁵⁵

Reported in a descriptive study of 54 African-American adults, living in the southeastern United States, that the religious practice of reading the Bible is a strategy to promote mental health. Participants use Bible passages to provide guidance, strength, peace, and comfort during nights when they could not sleep with depressive symptoms, and the scriptures bring promises of healing and protection from disease. For some participants, reading the Bible was unique as a strategy that helped them overcome traumatic situations.⁶¹

In addition to these experiences, the following modalities of spiritual therapies applied by nurses were frequent in the studies: grateful practices,³⁵ yoga;³⁶ positive words, and prayers;^36,42 help from chaplains (spiritual/religious counselor);^31,38 environment adaptation to provide self-reflection of patients; active listening of expressions of spiritual suffering, use of other communication techniques to help them clarify their values, beliefs and reasons for hope, encouragement of interpersonal relationships, teaching the practice of relaxation methods and guided imagination; music, literature or radio or TV programs to the taste of customers, ensuring the practice of religious and/or spiritual traditions and rituals.^38,58

Besides, studies point out that providing assistance to the patient’s family, touching, like taking the patient’s hand or giving them a hug^45,58 facial expression, body attitude, and religious symbols also constitute modalities of spiritual therapies.⁴⁵

Spiritual therapies could also be identified in studies on the development and validation of psychometric scales, such as the (Spirituality and Spiritual Care Rating Scale - SSCRS), whose list of items was included in the list: Active listening; facilitation of religious practices; prayers for or with the patient; reading scriptures; meditation; being present with the patient; holding hands; facilitating the visit of family members and close friends; respect; giving comfort and security; maintaining hope, meaning and purpose; laughter and good humor; demonstration of kindness.^33,43

A study conducted in Brazil found that verbal and nonverbal communication, including family, are used by nurses to identify spiritual needs, such as touch, facial expression, body attitude, and religious symbols.⁵⁸

Factors leading to effective spiritual care by nurses include their personal belief system, perception of spiritual needs and care, life experience, and disposition and sensitivity to spirituality;⁴⁰ care provided from a multi-professional team approach.³¹

Barriers to spiritual nursing care are reported in a phenomenological study referring to the culture of health, which often discourages interaction with patients on a spiritual level. Insufficient knowledge and resources lead to the understanding that offering spiritual care would increase nurses' workload. Another cultural factor refers to the environment. For example, the Chinese avoid talking about spirituality and death. In similar contexts, the implications of spiritual care for patients and nurses may differ from case to case.⁶⁶

Other studies have reported failures to provide spiritual care related to the following difficulties: nurses not feeling comfortable providing this care;³⁴ lack of knowledge about the effect of quality spiritual care health outcomes, failure to recognize the spiritual needs of patients and lack of understanding the best ways to provide spiritual care; fear of prejudice by the patient and other professionals,⁴⁵ busy working hours, insufficient knowledge of spiritual care, low motivation, diversity of patients’ spiritual needs and sense of “disqualification” to provide spiritual care.⁴⁷

Contexts of performance and training of nurses in spiritual therapies

This topic describes the contexts and commonplaces of spiritual therapies in the studies investigated, with emphasis on the training of nurses in spiritual therapies. In this sense, the Nascimento⁴⁵ study reports that the need for spiritual care provided by nurses was related to situations of patient fragility, which are seen as conducive to the provision of care directed to the needs related to the condition of human existence, the search for explanations about the nature of life, its meaning and terminality.

Besides, stages such as birth and death are also permeated by encounters with nurses and are also associated throughout history with religious traditions. In this sense, multiculturalism puts on the scene diverse spiritual issues and religious needs. Such understandings may explain why, in clinical practice, the hospital context was the one where nurses frequently applied spiritual therapies in the studies, present in more than half of the articles^{31,34,37-38,42,44-49,51,56-58,60,62,66-67,71}, and exemplified in the following studies.

A study conducted with nurses and patients in burned-out clinics using an internationally recognized measuring instrument, the Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being (FACIT-Sp 12), used to assess the relationship between spiritual well-being and state of health of patients living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and cancer because of the long hospitalization period, evaluated the spiritual well-being at the beginning and end of the patients’ stay in the hospital where they received thanatological attention — including spiritual during the whole period of hospitalization. There has been a significant increase in the welfare score, with implications for greater inner peace, faith, and the ability to find oneself despite the situation they face.⁴⁴

A study identified the importance of spirituality in the resilience of 20 oncologic patients hospitalized in a large and highly complex hospital oncologic unit.⁴⁶ All reported the great change that occurred with the diagnosis, the family’s despair, and the changes that occurred in its structure, in addition to the fear of suffering in the face of illness, and it was also unanimous that there is an influence of spirituality on the resilience to face this situation.

Other research pointed out that the spiritual assistance offered by other components of the multidisciplinary team, in association with nursing, is seen as a necessary part for spiritual assessments, identification of spiritual distress, and provision of spiritual support to patients.³¹ Because of this, it can be seen as a component to achieve better results in the patient’s treatment, as well as a cost-effective provision of Health Services.

In a New Zealand study with specialists from renal centers, there was also recognition by a doctor, from a total of five, and a nurse, from the nine that were recruited, that spiritual care is valid in helping to meet patient’s needs with improvement in their quality of life in general and adherence to therapy. ⁵⁴

The study conducted in members of the Alcoholics Anonymous program (AA) exemplifies those performed in the community. The research, which was carried out in Mexico with 35 AA members, has the intention of determining their spiritual perspectives, the time for filling out the Scale of Spiritual Perspective (SPS), as well as the reliability coefficient of this scale, and the frequencies and proportions of practices and beliefs as spiritual members of AA who, in the majority, stated that at least once a day they share the problems and joys of living according to their religious and spiritual beliefs, read spiritual materials at least once a day, and pray (alone or in groups) or meditate at least once a day. They also strongly agree that their beliefs have influenced their lives and that their religious and spiritual beliefs are especially important because they answer many of the questions on how they feel about the meaning of life.³⁹

From the studies conducted in training/faculty spaces, which represent 1/3 of the studied sample, some relative experimental researches, with pre and post-test, involved qualification processes for the use of spiritual therapies by nurses. In general, convergent ideas are described as an educator’s need to promote and support students' self-awareness before taking care of parents’ spiritual needs; rather than ignoring nurses’ spiritual heritage, it is necessary to embrace it inside a modern paradigm; nurses and nursing students need preparatory programs to be guided towards the best approaches.^56:505

A study conducted with nurses that work in intensive care units in Turkey showed that most professionals disagreed on the inclusion of patients’ spiritual needs in a nursing care plan as a tool to offer them a holistic approach and they have not recorded data regarding their patients’ spiritual care as well. The results of the research showed that most nurses are confused about the nature of spiritual care in practice and that the way they understand this modality of care influences on how they perform because those who ignore their spiritual health find it more difficult to deal with patients’ spiritual needs.⁶²

There are reports of nurses who have received guidance on spiritual dimension at university but it was in a timely and not comprehensive manner ⁴⁵, and also that undergraduate and postgraduate students in the medical/healthcare field consider that spiritual care could be applied to their current or future practice, being that they pointed out suggestions and potential benefits of spiritual interventions for patients and health professionals when incorporating spiritually into their health practice.³³ 

Innovative teaching methods include undergraduate nursing programs to improve competence and confidence in the provision of care that address the spiritual dimension of nursing care. A significant increase in their perceived confidence and feeling of readiness to provide spiritual care were reported by students after participation in a program, in simulation scenarios, to meet physical care needs and listen to the patient. ⁴¹

Similarly, it was identified that the patients' beliefs also affected nurses, leaving them calmer in the handling of care, closer to their religiosity, and being an important aid in communication with patients, contributing to a therapeutic environment. Thus, spiritual care requires a relationship characterized by mutuality, trust, continuous dialogue (talking and listening), and lasting presence, which is essential to the training of nurses.⁶⁰

Spiritual therapies would be essential to nursing care

The offer of spiritual therapies is a quality requirement of Nursing Care,^32,37,64 and is also associated with greater well-being,^38,44,57 a better quality of life,^44,54 improved mental health, including lower rates of depression, stress and anxiety^42,51-52,61, and relief from spiritual pain and suffering.^60-61

Spiritual care means a new field of alternative possibilities of nursing care. This was perceived concerning the experience with chaplains, who improve communication serving as a “bridge” between patient and professional.³¹

Although recognized internationally as relevant for patients and their clinical outcomes^32,62,50 spiritual cares have been insufficiently provided.^47,66 For such care to be included in professional practice, efforts such as reformulation of nursing theories, bringing spirituality as a need to be met, must be undertaken.

A study observed the development of spiritual and existential care competence of health professionals matters, however, the quality of spiritual and existential care is also based on other variables, such as the general culture of the workplace, philosophy, leadership, and organization of care.⁴⁸

Considering the nursing skills practices for spiritual and religious care, diagnoses of spiritual distress, or at risk of spiritual distress are accepted ³⁴. Care often takes place informally^37,54,59. Based on the nursing processes, there are steps of assessment, diagnosis, planning, implementation and assessment⁵¹ and can take place from the beginning to the end of life.⁴⁰

To identify spiritual distress, verbal and non-verbal communication are important. With patients and family members, emotions, beliefs, prayers and the sharing of some spiritual experience can be observed, which may indicate an openness to receive spiritual care. The non-verbal expression also expresses the need for this support, sometimes with tears, anxious behaviour, furrowed brows and altered heart rate. However, some nurses either choose not to enter in spiritual encounters or feel a barrier in providing spiritual care.⁶⁹

Pilot study for the development of an evidence-based educational package for hospital nurses in the Republic of Ireland, found out that nurses provided spiritual assistance and, in many cases, lacked instruction.⁵⁶ Many nurses reported their inexperience with various religions and demonstrated awareness of the role that the pastoral care team has in supporting patients. They denoted frustration with the lack of knowledge around meetings related to the patients’ health and spiritual needs, confirming the need for education in spiritual care for nurses.

Therefore, it should be emphasized that empirical studies with professionals in the field are also essential to base reflections on practical experiences of nurses in the attention to the spiritual needs of their patients because, from these experiences, their knowledge is built and can be consolidated.

Holistic care speaks of spirituality.^32,58,60,64 Spiritual care should be targeted by nurses in caring for all needs, objective, individual, or socially constructed, perceived in the intersubjectivity of caregivers and patients, hence the importance of building spaces for their manifestations.⁴⁵

Finally, we remember the times lived and still ongoing of the COVID-19 pandemic state about the nurses’ need to explore the spiritual and religious needs of their clients and plan their care properly at the end of life.³² In this sense, questions are suggested for possible studies on the theme: in pandemic times, considering high levels of morbidity and mortality, what would be the place of spiritual therapies? Would they be the “central metaphors” of care to answer questions of human existence, producing meaning, resilience, comfort, and hope, both for nurses and clients? And by thinking like so, would spiritual therapies be complementary or essential to nursing care?

Thus, the study presents limitations regarding the discussion of the theme in relation to the COVID-19 pandemic, the instruments for evaluating the use of spiritual therapies by nurses, and a comparative analysis of the use of spiritual therapies in the contexts of teaching, research and the production of care in health services.

FINAL CONSIDERATIONS

In this integrative review, the investigated production was characterized by articles, among other aspects, mostly published in international nursing journals and indicated a topic of increasing and progressive interest in the area. An expressive set of modalities of spiritual therapies was identified, being frequent, among others, the use of chaplains’ services, prayers, meditation, gratitude practices, interpersonal skills and music offering.

The contexts of studies focused on practices, teaching and research point to a tendency of Nursing to promote continuous and permanent training and to incorporate into curricula theoretical and practical contents that develop competencies of nurses to identify the spiritual needs of patients and to elaborate intervention plans, including reducing the distance between these two acts of care – planning/acting.

The study indicates the relevance of this training process, as well as points to possible ways of coping with Nursing challenges, in the care of the spiritual needs of patients, as well as the professionals themselves and the multidisciplinary team, important conditions for the effectiveness of this management.

Reflecting on the theme, in the light of this review, invites us, therefore, to think of subjects in graduate courses as an optional and / or mandatory component, as well as other pedagogical acts that instrumentalize professionals to use spiritual therapies. Thus, new studies are necessary, as well as efforts to reformulate theories and training processes of nursing, which include spirituality as a need for human health care.

REFERENCES

1 Koenig HG, King DE, Carson VB. A history of religion medicine and healthcare. In Koenig HG, King DE, Carson VB (Eds.). Handbook of religion and health. Oxford: Oxford University Press; 2012. p.15–34.

2 Hermann CP. Development and testing of the spiritual needs inventory for patients near the end of life. Oncol. nurs. forum. [Internet]. 2006[cited 2020 June 15];33(4):737–43. Available from: https://doi.org/10.1188/06.ONF.737-744

3 Maftum MA, Souza JR, & Bais DDH. Nursing care facing the recognition of patients’ belief or religion: undergraduates’ perceptions. Online braz. j. nurs. (Online). [Internet]. 2008[cited 2021 Feb 15];7(2). Available from: https://doi.org/10.5935/1676-4285.20081525

4 Brewer-Smyth K, & Koenig HG. Could spirituality and religion promote stress resilience in survivors of childhood trauma? Issues mental health nurs. [Internet]. 2014[cited 2020 May 20]; 35(4):251-6. Available from: https://doi.org/10.3109/01612840.2013.873101

5 Reed PG. Spirituality and well-being in terminally ill hospitalized adults. Res nurs health. [Internet]. 1987[cited 2020 Sept 20];10(5):335-44. Available from: https://doi.org/10.1002/nur.4770100507

6 Reginato V, Benedetto MAC, Gallian DMC. Spirituality and health: an experience in undergraduate schools of medicine and nursing. Trab. educ. saúde. [Internet]. 2016[cited 2020 Jul 10]; 14(1):237-55. Available from: https://doi.org/10.1590/1981-7746-sip00100

7 Jim HS, Pustejovsky JE, Park CL et al. Religion, spirituality, and physical health in cancer patients: a meta‐ analysis. Cancer. [Internet].  2015[cited 2020 Nov 20];121(21):3760-8. Available from: https://doi.org/10.1002/cncr.29353

8 Giovanetti JP. Psicologia e espiritualidade. In: Amatuzzi, M M (org.) Psicologia e espiritualidade. São Paulo: Paulus; 2005. p.129-45.

9 Frankl, V. Em busca de sentido: um psicólogo no campo de concentração. Petrópolis: Vozes; 1991.

10 Saad M, Medeiros R. Alignment between patient’s religious beliefs and hospital treatment. Continuing Education in Health Einstein. [Internet]. 2012[cited 2020 Oct 10];10(1):36-7. Available from: http://apps.einstein.br/revista/arquivos/PDF/2300-36-37.pdf

11 Moreira-Almeida A, Koenig HG, Lucchetti G. Clinical implications of spirituality to mental health: Review of evidence and practical guidelines.        Braz. J. Psychiatry. [Internet]. 2014[cited 2020 Oct 10];36(2):176–82. Available from: https://doi.org/10.1590/1516-4446-2013-1255

12 Gonçalves JP, Lucchetti G, Menezes PR, Vallada H. Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials. Psychol. med. [Internet]. 2015[cited 2020 Dec 10];45(14):2937-49. Available from: https://doi.org/10.1017/S0033291715001166

13 Sawatzky R, Ratner PA, Chiu L. A meta-analysis of the relationship between spirituality and quality of life. Social Indicators Research. [Internet]. 2005[cited 2020 Dec 15]72:153-88. Available from: https://doi.org/10.1007/s11205-004-5577-x

14 Bormann JE, Aschbacher K, Wetherell JL, Roesch S, Redwine, L. Effects of        faith/assurance on cortisol levels are enhanced by a spiritual mantram intervention in adults with HIV: A randomized trial.   J. psychosom. res. [Internet]. 2009[cited 2020 Dec 15]; 66(2):161-71. Available from: https://doi.org/10.1016/j.jpsychores.2008.09.017

15 Bonelli R, Dew RE, Koenig HG, Rosmarin DH, Vasegh S. Religious and spiritual factors in depression: integration and review of the research. Depression research and treatment. [Internet]. 2012[cited 2021 mar 20];962860. Available from: https://doi.org/10.1155/2012/962860

16- Moreira-Almeida, Alexander, Koenig, Harold G,Lucchetti, Giancarlo. Clinical implications of spirituality to mental health: review of evidence and practical guidelines. Braz. J. Psychiatry. [Internet].  2014[cited 2021 Mar 20]36(2):176-82. Available from: https://dx.doi.org/10.1590/1516-4446-2013-1255

17 Gonçalves JPB, Lucchetti G, Menezes PR, Vallada H. Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials. Psychol Med. [Internet]. 2015[cited 2020 Dec 15];45(14):2937-49. Available from: https://doi.org/10.1017/s0033291715001166

18 Silva TCV, De Mazzi NR. A espiritualidade no cuidado perioperatório: a perspectiva do paciente. J. nurs. health. [Internet]. 2019[acesso em 2020 dec 15];9(2):e199205. Disponível em: https://doi.org/10.15210/jonah.v9i2.14752

19 Singh DK, Ajinkya S. Spirituality and religion in modern medicine. Indian journal of psychological medicine. [Internet]. 2012[cited 2020 Dec 15];34:399–402. Available from: https://doi.org/10.4103/0253-7176.108234

20 Luengo CML, Mendonça ARA. Spirituality and quality of life in diabetic patients. Rev. bioét. [Internet]. 2014 [cited 2020 Oct 10];22(2):380–7. Available from: https://doi.org/10.1590/1983-80422014222020

21 Carr TJ. Facing existential realities: Exploring barriers and challenges in spiritual nursing care. Qual. health res. [Internet].  2010[cited 2021 Mar 20]; 20(10):1379–92. Available from: https://doi.org/10.1177%2F1049732310372377

22- Organização Pan-Americana de Saúde (OPAS). Centro Latino Americano e do Caribe de Informação em Ciências da Saúde (BIREME). Biblioteca Virtual em Saúde (BVS). Descritores em Ciências da Saúde (DeCS). [Internet]. 2020[acesso em 202o dec 15]. Disponível em :  http://decs.bvsalud.org

23 Simão TP, Chaves ECL, Iunes DH. Spiritual distress: the search for new evidence.            Rev. Pesqui. (Univ. Fed. Estado Rio J., Online). [Internet]. 2015 [cited 2020 Oct 10];7(2):2591-602. Available from: https://doi.org/10.9789/2175-5361.2015.v7i2.2591-2602

24 World Health Organization (WHO). Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020. [Internet]. 2020[cited 2021 Aug 06]. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020

25 Jeong H, Yim HW, Song YJ, Ki M, Min JA, Cho J, et al. Mental health status of people isolateddue to Middle East Respiratory Syndrome. Epidemiol. health. [Internet]. 2016;[cited 2020 Oct 10];38:e2016048. Available from: https://doi.org/10.4178/epih.e2016048

26 Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain behav. immun. [Internet]. 2020[cited 2021 mar 20]; 87:40–8. Available from: http://doi.org/10.1016/j.bbi.2020.04.028

27 Zanon C, Dellazzana-Zanon LL, Wechsler SM, Fabretti RR, Rocha KN. COVID-19: Implicações e aplicações da psicologia positiva em tempos de pandemia [COVID-19: Implications and applications of positive psychology in times of pandemic]. Estud. Psicol. (Campinas). [Internet]. 2020[cited 2020 Oct 10];37:e200072. Available from: https://doi.org/10.1590/1982-0275202037e200072

28 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & contexto enferm. [Internet]. 2008[acesso em 2021 ago 06];17(4):758-64. Disponível em: https://doi.org/10.1590/S0104-07072008000400018

29 Santos CMC, Pimenta CAM, Nobre MRC. The PICO strategy for the research question construction and evidence search. Rev. latinoam. enferm. (Online). [Internet]. 2007[cited 2020 Oct 05];15(3):508-11. Available from: https://doi.org/10.1590/S0104-11692007000300023

30 Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA group preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. PloS med. [Internet]. 2009;[cited 2020 Oct 05];6(7):e1000097. Available from: https://doi.org/10.1371/journal.pmed.1000097

31 Huehn SL, Kuehn MB, Fick KE. Integrating spiritual care during interprofessional simulation for baccalaureate nursing students. J. holist. nurs. [Internet].  2019[cited 2021 Feb 20];37(1):949. Available from: https://doi.org/10.1177/0898010118765203

32 O’Brien MR, Kinloch K, Groves K E, Jack BA. Meeting patients’ spiritual needs during end of life care: A qualitative study of nurses’ and healthcare professionals’ perceptions of spiritual care training. J. clin. nurs. [Internet]. 2018[cited Aug 06];28(1-2):182-9. Available from: https://doi.org/10.1111/jocn.14648

33 Hovland C, Niederriter J, Thoman J. Spirituality and interprofessional healthcare education. J. Christ. nurs. [Internet].  2018[cited 2021 Mar 20];35(4):47–52. Available from: https://doi.org/10.1097/cnj.0000000000000543

34 Vogel A, Schep-Akkerman AE. Competence and frequency of provision of spiritual care by nurses in the Netherlands. Scand. j. caring sci. [Internet]. 2018[cited 2020 Jun 20];32(4):1314-21. Available from: https://doi.org/10.1111/scs.12575

35 Beese RJ, Ringdahl DR. Enhancing spiritually based care through gratitude practices: a health-care improvement project. Creat. nurs. [Internet]. 2018[cited 2021 Mar 20];24(1):42-51. Available from: https://doi.org/10.1891/1078-4535.24.1.42

36 Kertapati Y, Sahar J, Nursasi AY. The effects of chair yoga with spiritual intervention on the functional status of older adults. Enferm. clín. [Internet]. 2018[cited 2021 Jan 20];28:70–3. Available from: https://doi.org/10.1016/S1130-8621(18)30040-8

37 Babamohamad H, Ahmadpanah, M-S, Ghorbani, R. Attitudes towards spirituality and spiritual care among Iranian nurses and nursing students. J Relig Health. 2018[cited 2021 Aug 06] 57(4):1304-14. Available from: https://doi: 10.1007/s10943-017-0485-y

38 Martín MSM, Serna JMJJ, Peña FL. Actitudes de las Enfermeras ante los Cuidados Espirituales y Religiosos en un Hospital General. Index enferm. [Internet]. 2017[acceso en 2021 fev 20];26(3):152-6. Disponible en: https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1132-12962017000200007

39 Rodríguez Puente LA, Alonso Castillo MM, Álvarez Bermudes J, Gómez Meza MV, Arméndariz García NA, Hernández Martínez EK. Perspectiva espiritualidad en integrantes de alcohólicos anónimos: estudio piloto. Enferm. glob. [Internet]. 2017[cited 2020 Oct 20];16(3):496-511. Available from: https://doi.org/10.6018/eglobal.16.3.260831

40 Petersen JA, Rasmussen LS, Rydahl-Hansen S. Barriers and facilitating factors related to use of early warning score among acute care nurses: a qualitative study. BMC emerg. med. [Internet]. 2017[cited 2020 Jun 20];17(36). Available from: http://doi.org/10.1186/s12873-017-0147-0

41 Connors J, Good P, Gollery, T. Using innovative teaching strategies to improve nursing student competence and confidence in providing spiritual care. Nurse educ. [Internet]. 2017[cited 2021 Mar 20];42(2):62-4. Available from: https://doi.org/10.1097/NNE.0000000000000301

42 Costello M. Nurses' self-identified characteristics and behaviors contributing to patients' positive perceptions of their nursing care: a qualitative study. J Holist Nurs. [Internet]. 2017[cited 2021 Feb 20]; 35(1): 62-66. Available from: https://doi.org/10.1177/0898010116643835

43 Musa AS, Pevalin DJ, Shahin FI. Impact of spiritual well-being, spiritual perspective, and religiosity on the self-rated health of Jordanian Arab Christians. J. transcult. nurs. [Internet]. 2016[cited 2021 mar 20]27(6):550–7. Available from: https://doi.org/10.1177/1043659615587590

44 Fajardo-Gámez ML, Molina-Prado MT, Korkowski-Zepeda IR, Ambriz-Orozco LM, Zavala-Díaz R, Luna-Pizarro D, et al. Atención tanatológica para mejorar el bienestar espiritual de los pacientes hospitalizados con quemaduras. Rev. enferm. Inst. Mex. Seguro Soc. [Internet]. 2016[acceso en 2020 jun 20];24(2):99-108. Disponible en https://www.medigraphic.com/cgi-bin/new/resumen.cgi?IDARTICULO=65609

45 Nascimento LC, Oliveira FCS, Santos TFM, Pan RS, Milena FA, Willyane A, Rocha, SMM. Attention to spiritual needs in clinical nursing practice. Aquichan. [Internet]. 2016[cited 2021 mar 20];16(2):179-92. Available from: https://doi.org/10.5294/aqui.2016.16.2.6

46 Soratto MT, Silva DM, Zugno PI, Daniel R. Spirituality and resilience in patients suffering from cancer. Saude e pesqui. [Internet]. 2016[cited 2021 Mar 20];9(1):53-63. Available from: http://doi.org/10.17765/1983-1870.2016v9n1p53-63

47 Kiaei, MZ et al. Spirituality and spiritual care in Iran: nurses’ perceptions and barriers. Int. nurs. rev. [Internet]. 2015[cited 2021 Mar 20]; 62(4):584–92. Available from: https://doi.org/10.1111/inr.12222

48 Tornøe K, Danbolt LJ, Kvigne K, Sørlie, V. A mobile hospice nurse teaching team’s experience: Training care workers in spiritual and existential care for the dying: a qualitative study. BMC palliat. care. [Internet]. 2015[cited 2021 Mar 20];14:43. Available from: https://doi.org/10.1186/s12904-015-0042-y

49 Wu L-F, Koo M, Tseng H-C, Liao Y-C, Chen Y-M. Concordance between nurses’ perception of their ability to provide spiritual care and the identified spiritual needs of hospitalized patients: a cross-sectional observational study. Nurs. health sci. [Internet]. 2015[cited 2021 Mar 20];17(4):426–33. Available from: https://doi:10.1111/nhs.12210

50 Willis DG, DeSanto-Madeya S, Ross R, Sheehan DL, Fawcett J. Spiritual healing in the aftermath of childhood maltreatment. Adv. nurs. sci. [Internet]. 2015[cited 2021 Mar 20];38(3):162–74. Available from: https://doi.org/10.1097/ans.0000000000000075

51 Elham H, Hazrati M, Momennasab M, Sareh K. The effect of need-based spiritual/religious intervention on spiritual well-being and anxiety of elderly people. Holist. nurs. pract. [Internet]. 2015[cited 2021 Mar 20];29(3):136–43. Available from: https://doi.org/10.1097/hnp.0000000000000083

52 García Piña E, Cardoso Gómez MA, Serrano Sánchez C, Ostiguín Meléndez Mª. Prácticas de cuidado tradicional y espiritual en una comunidad indígena nahua. Cult. cuid. [Internet]. 2015[acceso en 2021 mar 20];19(41):34-43. Disponible en: http://dx.doi.org/10.14198/cuid.2015.41.06

53 Linda NS, Klopper HC, Phetlhu DR. Students’ voices on spiritual care at a Higher Education Institution in the Western Cape. Curationis. 2015[cited 2021 Mar 20];38(2):1520. Available from: https://doi.org/10.4102/curationis.v38i2.1520

54 Egan R, Macleod R, Tiatia R, Wood S, Mountier J, Walker R. Spiritual care and kidney disease in NZ: A qualitative study with New Zealand renal specialists. Nephrology. [Internet]. 2014[cited 2021 Mar 20]19(11):708–13. Available from: https://doi.org/10.1111/nep.12323

55 Briggs CL, Lovan SR. Nursing students’ feedback to a spiritual health reflection. J. holist. nurs. [Internet]. 2014[cited 2021 Mar 20];32(3):183–88. Available from: https://doi.org/10.1177/0898010113519288

56 Timmins F, Neill F, Griffin MQ, Kelly J, De La Cruz E.  Spiritual dimensions of care. Holist. nurs. pract. [Internet].2014[cited 2020 Oct 200];28(2):106–23. Available from: https://doi.org/10.1097/hnp.0000000000000015

57 Abu-El-Noor M K, Abu-El-Noor NI. Importance of spiritual care for cardiac patients admitted to coronary care units in the gaza strip: patients' perception. J. holist. nurs. [Internet]. 2013[cited 2020 Oct 20];32(2):104–15. Available from: https://doi.org/10.1177/0898010113503905

58 Brito FM, Costa ICP, Andrade CG, Lima KFO, Costa SFG, Lopes MEL. Spirituality in iminent death: strategy utilized to humanize care in nursing. Rev. enferm. UERJ. [Internet]. 2014[cited 2020 Oct 20];21(4):483-9. Available from: https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/10013

59 Ruder S. Spirituality in nursing: nurses' perceptions about providing spiritual care. Home healthc. nurse. [Internet]. 2013[cited 2020 Oct 200];31(7):356–67. Available from: https://doi.org/10.1097/nhh.0b013e3182976135

60 Tirgari B, Iranmanesh S, Ali Cheraghi M, Arefi A. Meaning of spiritual care: iranian nurses experiences. Holist. nurs. pract. [Internet]. 2013[cited 2020 Nov 20];27(4):199–206. Available from: https://doi.org/10.1097/hnp.0b013e318294e774

61 Hamilton JB, Moore AD, Johnson KA, Koenig HG.Reading the bible for guidance, comfort, and strength during stressful life events. Nurs. res. [Internet]. 2013[cited 2020 Oct 02];62(3):178–84. Available from: https://doi.org/10.1097/nnr.0b013e31828fc816

62 Turan T, Yavuz Karamanoğlu A. Determining intensive care unit nurses’ perceptions and practice levels of spiritual care in Turkey. Nurs. crit. care. [Internet]. 2012[cited 2021 Mar 20];18(2):70–8. Available from: https://doi.org/10.1111/j.1478-5153.2012.00538.x

63 Wu L-F, Liao Y-C, Yeh D-C. Nursing student perceptions of spirituality and spiritual care. J. res. nurs. [Internet]. 2012[cited 2021 Mar 20];20(3):219–27. Available from: https://doi:10.1097/jnr.0b013e318263d956

64 Scott Barss K. Building bridges: an interpretive phenomenological analysis of nurse educators' clinical experience using the T.R.U.S.T. Model for inclusive spiritual care. Int J Nurs Educ Scholarsh. [Internet]. 2012[cited 2021 Mar 20];30(9):1-17. Available from: https://doi: 10.1515/1548-923X.2389.

65 Johnson M. A randomized study of a novel Zen dialogue method for producing spiritual and well-being enhancement: implications for end-of-life care. J Holist Nurs. [Internet]. 2011[cited 2021 Mar 20]; 29(3):201-10. Available from: https://doi: 10.1177/0898010110391265

66 Wong KF, Yau SY. Nurses' experiences in spirituality and spiritual care in Hong Kong. Appl Nurs Res. [Internet]. 2010[cited 2021 Mar 20];23(4):242-4. Available from: https://doi:10.1016/j.apnr.2008.10.002.

67 Pedrão RB, Beresin R. Nursing and spirituality. Einstein (São Paulo). [Internet]. 2010[cited 2021 Aug 06];8(1):86-91. Available from:  https://doi.org/10.1590/S1679-45082010AO1208

68 López AJ, McCaffrey R, Quinn Griffin MT, Fitzpatrick JJ. Spiritual well-being and practices among women with gynecologic cancer. Oncol Nurs Forum. [Internet]. 2009[cited 2021 Mar 20];36(3):300-5. Available from: https://doi: 10.1188/09.ONF.300-305.

69 Burkhart L, Hogan N. An Experiential theory of spiritual care in nursing practice. Qual. health res. [Internet]. 2008[cited 2021 Mar 20];18(7):928–38. Available from: https://doi:10.1177/1049732308318027

70 Borges MS, Shimizu HE, Pinho DL M, Almeida AMO. O modo de cuidar na benzeção: saber popular e racionalidade divina. REME rev. min. enferm. [Internet]. 2008[acesso em 2021 ago 06];12(2):241-248. Available from: https://cdn.publisher.gn1.link/reme.org.br/pdf/v12n2a15.pdf

71 Lane MR. Spirit-body healing II: a nursing intervention model for spiritual/creative healing. Cancer nurs. [Internet]. 2008[cited 2021 Aug 06]; 31(3):E24–31. Available from: https://doi.org/10.1097/01.ncc.0000305719.90894.e9

Submission date: 23/02/2021

Acceptance date: 09/07/2021

Publication date: 13/08/2021