ARTIGO ORIGINAL
Contributions for teaching religiosity/spirituality in undergraduate nursing programs: a qualitative study with Brazilian nurses*
Contribui��es para o ensino de religiosidade/espiritualidade na gradua��o em enfermagem: estudo qualitativo com enfermeiros brasileiros
Contribuciones para ense�anza de religiosidad/espiritualidad en la graduaci�n en enfermer�a: estudio cualitativo con enfermeros brasile�os
Cunha, Vivian Fukumasu da;[1] Coimbra, Susana;[2] Fontaine, Anne Marie;[3] Neubern, Maur�cio da Silva;[4] Scorsolini-Comin, Fabio[5]
ABSTRACT
Objective: to identify and collect recommendations for teaching religiosity/spirituality in undergraduate Nursing courses of nurses working in a Hospital. Method: this is a qualitative study, with 34 nurses interviewed. The research corpus was fully transcribed and submitted to content analysis. Results: the religiosity/spirituality theme was absent in the graduation of most of professionals. They mentioned the restricted preparation to deal with human issues and for being a dimension that offers a resource to face the challenges of the daily life of the profession. What mitigated this gap was that some professionals have their own religious/spiritual beliefs, which have often guided how this religious/spiritual support is provided in health care. Conclusions: participants suggest the presence of religiosity/spirituality teaching in nursing graduation effectively and practically, not only theoretically reinforce its importance. Taking religiosity/spirituality content to undergraduate courses can be sensitive to the holistic needs of patients/users and even the professionals themselves.
Descriptors: Spirituality; Religion; Nurses; Education, nursing; Professional practice
RESUMO
Objetivo: identificar e coletar recomenda��es para o ensino da religiosidade/espiritualidade na gradua��o em Enfermagem a partir de enfermeiros de um Hospital. M�todo: estudo qualitativo, com 34 enfermeiros(as) entrevistados(as). O corpus de pesquisa foi transcrito na �ntegra e submetido � an�lise conte�do. Resultados: a religiosidade/espiritualidade esteve ausente na gradua��o da maioria dos profissionais e � referida em termos da restrita prepara��o para lidar com quest�es humanas e por ser uma dimens�o que oferece enfrentamento para os desafios do cotidiano da profiss�o. O que tenuou essa lacuna foi a presen�a da pr�pria cren�a religiosa/espiritual, o que tem balizado, muitas vezes, como o apoio religioso/espiritual � oferecido no cuidado. Conclus�es: os participantes sugerem o ensino da religiosidade/espiritualidade na gradua��o em enfermagem de maneira efetiva e pr�tica, n�o apenas refor�ar sua import�ncia. Levar esse conte�do para a gradua��o pode se mostrar sens�vel �s necessidades hol�sticas dos pacientes/usu�rios e at� mesmo dos pr�prios profissionais.
Descritores: Espiritualidade; Religi�o; Enfermeiras e enfermeiros; Educa��o em enfermagem; Pr�ctica profissional
RESUMEN
Objetivo: identificar y recoger recomendaciones para la ense�anza de la religiosidad/espiritualidad en la graduaci�n de enfermer�a de enfermeros de un hospital. M�todo: estudio cualitativo, con 34 enfermeros entrevistados. El corpus de investigaci�n fue transcrito en su totalidad y sometido a an�lisis de contenido. Resultados: la religiosidad/espiritualidad estuvo ausente en la formaci�n de la mayor�a de estos profesionales y es se�alada por su falta de preparaci�n para enfrentar los problemas humanos y porque es una dimensi�n que ofrece recursos para enfrentar del d�a a d�a. Las creencias religiosas/espirituales de los profesionales paliaron esta brecha, que muchas veces ha marcado c�mo se ofrece el apoyo religioso/espiritual en el cuidado. Conclusiones: la religiosidad/espiritualidad en la graduaci�n de enfermer�a se sugiere de manera pr�ctica, no solo reforzando su importancia. Contenidos de religiosidad/espiritualidad a los cursos de pregrado puede ser sensible a las necesidades hol�sticas de los pacientes/usuarios e incluso de los propios profesionales.
Descriptores: Espiritualidad; Religi�n; Enfermeras y enfermeros; Educaci�n en enfermer�a; Pr�ctica profesional
INTRODUCTION
Since 1998, the World Health Organization declared that health is multidimensional, composed of bio-psycho-socio-spiritual aspects. With this, the interest in the spiritual dimension has been standing out as a growing theme in the health literature of recent years. Evidence suggests positive and negative impacts of religiosity/spirituality (R/S) on physical and mental health outcomes1 and the interest of nursing is it's about the promotion of health care that goes beyond the physical, which comprehends the patient/user in their entirety and from their needs.
Although religiosity and spirituality are phenomena understood as conceptually different, we opted to adopt the combined term of R/S, assuming that differences exist but following a trend found in the health.1-2 It suggests a broader understanding of the phenomenon, including more institutionalized aspects linked to specific religions and beliefs but also related to the subjectivity evoked when we look at these phenomena. In addition, there is the possibility that this differentiation is not distinct and goes through the perspective of the other, both the patient/user and the health professional.2
Because they occupy a leading place in health care, nurses can articulate and integrate expanding, systematized, and involving care. This corresponds to understanding the human being in its uniqueness and multidimensionality.3 Thus, the nurse is in a privileged position due to the close contact with the patient/user, having the opportunity to evaluate and intervene on religious/spiritual aspects of their routines.4 Also, patients/users report that they would like to have religious/spiritual care and prefer that nurses or assistants do it because of the place of proximity they occupy.5
Despite the growth of investigations about a spiritual dimension, national and international research has listed many difficulties and challenges for nurses in that topic, such as the difficulty in understanding the phenomena of religion, religiosity, and spirituality, often confusing limits and possibilities of action; the professional's own religious/spiritual beliefs (or absence thereof) as a bias in understanding the world, which guides behavior that may not be compatible or comprehensive to allow the expression of the other; fears of impositions and unethical occurrences; lack of training, giving more emphasis on the technical performance; lack of well-trained professionals for teaching; distance between theory and practice; professional overload and, consequently, lack of time for this type of assistance.4,6
However, this data also points out a positive perception of the influence of R/S on health and a willingness of nurses to include this assistance in practice. But the assistance health care that consists of these aspects still seems to be far from the practice and systematic discussions in the training of these professionals,4,6 suggesting a field of attention that involves the articulation among the advances in the research, education, and performance in nursing.
In Brazil, a large part of the population identifies itself as religious/spiritual. It is common to find different beliefs and creeds with roots in the colonization and miscegenation of cultures that make up the country. The interest in the issue of R/S lies in its cultural composition, which is not always the same if we consider the international reality. Therefore, we believed that professionals who already work in practice could contribute to thinking about the teaching and training of R/S, both nationally and internationally.
Considering the challenges faced by the nurse professional, the following questions arise. How can the experience of working professionals contribute to the education of new nurses? How do professionals in practice understand (or not) the need for training that addresses the religiosity/spirituality (R/S) theme? Based on the practice experiences, this study aimed to identify and collect recommendations for teaching religiosity/spirituality in undergraduate Nursing courses of nurses working in a Hospital.
METHOD
The aim of this study was to explore the experiences and perceptions of nurses� professionals about training and preparing them for work with R/S. In addition, collect suggestions regarding how R/S may be present in the education of future nurses.
This is a qualitative, exploratory, descriptive, cross-sectional study conducted with nurses from a public General Hospital in the state of S�o Paulo, Brazil. Considering these professionals are already active in nursing, their opinions and representations are necessary to improve knowledge. Also, implementing a qualitative approach of listening to professionals already engaged in the profession about enhancing the expression of R/S was the appropriate methodological to deepen the sensibility of the issue. For the presentation of the results, the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed.
Thirty-four nurses participated in the study, 30 women and four men with an average age of 39.97 years ranging from 27 to 67 years. The average length of professional experience was 14.85 years. The participants were selected using the snowball technique, in which each interviewed participant indicated another nurse to participate in the study until reaching the saturation criterion.7 The number of participants followed the recommendations of saturation sampling, so data collection was closed when exhaustive repetitions in the responses of different participants were found.
The activity sectors of the nurses were Pediatric Outpatient Clinic (n=1), Surgical Clinic (n = 2), Dermatology (n=1), Child and Adolescent Infirmary (n=2), Oncological Gynecology (n=3), Hematology and Chemotherapy (n=3), Immunotherapy (n=3), Nuclear Medicine (n=2), Neurology (n=3), Psychiatry (n=4), Radiology/Radiotherapy (n=4), Mental Health (n=1), Organ Transplantation (n=4), and Coronary Unit (n=1). The religious/spiritual beliefs declared by them were Catholicism (n=13), Spiritism (Kardecist) (n=5), being raised Catholic but currently linked to Spiritism (n=7), Protestantism (n=2), Presbyterianism (n=1), belonging to a Christian Congregation (n=1), and Eclectic (various beliefs) (n=5).
Data were collected from February to December 2019. The collected was through in-person semi-structured interviews based on an interview script developed for this study that presented sociodemographic questions, which identified the characteristics of the subjects, and questions about the presence or absence of R/S in their training, suggestions, and experiences concerning teaching-education about this dimension (Figure 1).
Figure 1: Interview prompts
|
Introduction stage: Question about sociodemographic data |
Gender Age Sector that is currently allocated How long have you been graduated in Nursing? How long have you been active? How was the choice of this practice? Do you have any religion? (If the answer is yes: Which is it? And how do you get involved with her? If the answer is negative: Are you involved in any religious or spiritual practices in your life?) |
|
Development stage: Questions about R/S |
Did your training education include any references regarding R/E? (If the answer is negative: Did you miss (or not) to talk about it? If the answer is positive: Do you believe what you learned was enough for the current job?) How do you imagine that these issues related to R/S can be addressed with undergraduate nursing students to contribute to the profession? |
|
Closing stage |
About the topic discussed, would you like to add anything else that I didn't ask? How was it for you to talk about this subject? |
Font: autors, 2019.
The research only began with the consent of the chief nurse of the sector. After that, the nurses were approached during the work period, in different shifts and days. The interviews were carried out when the professional was not busy and could take this moment to participate. The interviews took place at the hospital, such as in exam rooms or break rooms. Each interview took place in a single meeting from the reading and consent to the Free and Informed Consent Form (FICF). The interviews were recorded on audio equipment and transcribed in full for the composition of the analytical corpus.
The study was carried out following the ethical standards of the recommendations of the Brazilian National Health Council Resolution No. 466 of December 12, 2012. It was submitted to and approved by the Research Ethics Committees of the university of origin of the first author (process number 3026622) and the co-participating institution (process number 3027861). We assured all participants of their right to withdraw their consent at any stage of the research. Also, we guarantee to preserve the identity and secrecy at all moments. We provide a copy of the FICF to all participants.
Data analysis was based on the procedures proposed by Bardin8 for content analysis. All three phases proposed by the author were applied: pre-analysis, exploration of the material and treatment, and interpretation of the results. The transcribed material was organized to identify the ideas in recording units, listing the points of similarity and differences among the speeches of the participants, allowing to portray the views shared and non-shared among them, identifying thematic categories. The interpretation of the data was based on literature that covers the subject of R/S in its interface with health. To ensure confidentiality and anonymity, the participants were identified by the letter P followed by numbers from 1 to 34.
The assumptions to maintain rigor and credibility are applied. The research adopted the following criteria: data collection was performed by a researcher with experience in the theme and the qualitative research design; excerpts from the participants' statements were used to illustrate and highlight the thematic categories; the construction of thematic categories was discussed with the researchers involved; the research steps were presented to enable replication with other professionals and audiences.
According to the participants, R/S was either completely absent in their training (n=19), approached slightly or superficially (n=7), or they did not remember having contact with this theme in their undergraduate education (n=4). Four participants reported the topic having been addressed during their undergraduate training. Based on the recurrences in the responses, the corpus built a posteriori showed two major categories: Reasons to miss the R/S (or not) in undergraduate education and Suggestions for teaching R/S in nursing training.
Reasons to miss the R/S (or not) in undergraduate education
In this category, it was made evident that, among the 30 participants who had the topic absent, addressed slightly/superficially, or did not remember, half (50%) expressed feeling they had missed out on having the topic addressed or addressed at a greater depth in their academic education, and the other half did not. Two main reasons were identified for feeling they missed out on the R/S in their academic education, presented in two subcategories:� Weak preparation for human issues, Aid resource to face the professional challenges. One reason stood out for not feeling as if they missed out on the R/S in their academic education: Having their own religious/spiritual beliefs.
Weak preparation for human issues
In this subcategory, it was highlighted how the nursing training is centered on the biological field. It requires technical and human preparation to deal with organic processes and the implementation of care ranging from the individual to the community levels. For some interviewees, the absence of the R/S theme or the lack of depth in their training is a good example of the overvaluation of the technical content compared to the little preparation provided to deal better with human issues, as may be observed in the following reports:
We ended up not thinking about R/S because the nurse is very practical, the nurse looks at care-related things and ends up forgetting about this psychological, spiritual side, but we needed to have addressed it a little bit more. I think that this theme could be present in academic education a little more. (P10)
At the time, I think so because there are many issues related to spirituality concerning our field. We work a lot with the direct, physical part and, this part is missing a little. (P27)
We are very prepared for techniques and leadership, but I think there could be a more intense preparation for the psychological and religious part to help us work with this. (P30)
Aid resource to face the professional challenges
In this subcategory, the interviewees highlighted that the profession involves many aspects, be they technical, relational, or emotional, for example, and R/S is a resource that may help face the difficulties of the profession, as illustrated in the following excerpts:
In the beginning, when we are trained, everything is very new. We have to learn techniques, we have to learn to work together, and, over time, we lose other things, which is what helps us to go through the challenges. So it was much harder to go through everything without having any support [...]. If we had the religious and psychological training, if we had treated this topic better, it would have been much easier. (P11)
I think it should be addressed more. I always had an experience with spirituality because I was raised in a Christian home, so I always had religiosity, but when I was in college, I missed it a lot. I think it needs to be discussed to strengthen ourselves and strengthen the patients, who are going through a difficult moment. (P18)
Having their own religious/spiritual beliefs
In this subcategory, the main reason highlighted for not feeling as if they had missed out on the topic in their undergraduate education was having an R/S reference from home. According to the participants, having R/S in the family and growing up within R/S supported them in having resources to deal with these issues in the professional context, with the religious/spiritual belief itself being a way to understand aspects of the profession, as illustrated in the following speeches:
It was always very clear to me this issue of religion. So that is why I did not miss it because I have always had this a lot. Do you know when everything is very well resolved? So I did not miss it. (P20)
I am a Spiritist and, because of that, I already entered the hospital environment knowing that it was a charged environment, bringing many problems for patients. It is an environment that, at the same time that you have the joy of birth, you have the sadness of death from the loss of a loved one. Because of that, I feel that it needs to have R/S, but, as I come from this Spiritist background, there were not so many problems. However, I think people have to study to know how to deal because it is a place where you have joy, sadness, losses, achievements, and good and bad news all the time. So if we don't get attached to God, I think we end up not having mental balance. (P23)
I always had my R/S, so I did not miss it. However, sometimes some people do not have any beliefs; in that case, it would be more interesting. I think it depends a lot on the person's beliefs too. (P32)
In my family, my father is very religious, and we are Catholic, so I had this support from home. I did not miss it so much in college, but when you start doing an internship, you start to see other realities; I think that would be important, but it is very little discussed. (P33)
Suggestions for teaching R/S in nursing training
According to the participants, the majority (n = 29) believed that the subject of R/S may and should be present during academic education. Given their professional experiences, they suggested that R/S may be present in the curricular unit and that some specific content should be discussed and presented, with two subcategories standing out: Course and teaching strategies and Essential content. One participant spoke out against the presence of the R/S in undergraduate training, and four others did not know whether this was a viable possibility, forming subcategory Opposition and challenges for the field.
Course and teaching strategies
The participants' speeches suggest that R/S may be present in undergraduate nursing training through a specific course or as part of a course. In these classes, it is valuable to have teaching-learning strategies that bring the subjectivity of the theme closer to the possibility of experiences that can support the professional in their practice.
With students, I think it would be possible to include some classes or a course about it, like in psychology, pedagogy, or even psychiatric nursing classes, sometimes add a part in this course or even have a course focused on that. But there are means and space for classes about R/S because we have this Psychology part; at least I had it. (P2)
I hope, I don't know what it is like today, but I hope there is a course in that regard. When I was pursuing my master's degree, I participated in classes that addressed this theme, so I believe it must be included. It does not occur to me that I do not have a course that teaches students to be more human and incorporate religiosity and spirituality into practice. I believe that it has to exist. (P21)
I think that it should be taught bringing experiences because the theoretical part is important, but I think that bringing experiences, sometimes working in groups, experiencing cases. It's a complicated subject. It is very introspective, right? So, I think it has to be experienced. Experiencing a clinical case example, group dynamics, so they end up feeling, not in the same intensity, but to some extent, what that person could be feeling. (P5)
I think the trainers are still not prepared to deal with the practical context. Today, after a while, I can realize that there is a lot in theory, and we bring up the technical issue but forget about the psychological part. Undergraduate training has to have a better approach because the practice has to be together with the theory. And there is no practice without theory. There is psychology, there is religiosity, but in theory. I realized that, in practice, teachers are not able to experience what happens. The teacher needs to stay here more (at the hospital) to give a better testimony to the student. You see what the texts have, they speak, but you don�t see what happens here. (P11)
Essential content
The respondents pointed out that some content should guide teaching-learning, such as knowledge of religions and related concepts, respect, as an aspect of human need and humanization, as a condition for coping with difficult situations such as death and dying, and how to use this dimension with the patient/user:
For the undergraduate student, I think that a gateway would be the humanization of care. Within this theme, I would approach religiosity. Because, if I am going to provide humanized care, if I have to worry about the patient's well-being, religion is within that topic. So, I would approach in that sense, presenting the various religions, some terminologies to facilitate and try to seek a form of prayer that is communal, something in that sense. It is easy to practice, but it is hard to think about how to teach it (laughs). (P7)
I think maybe through discussion groups. Maybe each one presents a religion, the characteristics, the benefits, finding common ground among all because we have to be able to understand and respect all religions, regardless of ours, [...] but I think it would be a part that would help understand that it is even part of the patient's treatment. (P23)
Oh, I think that the issue of respecting the religion of others, to discuss, and, first, before you approach anything, we have a notion if the person has a religion, what religion, if they believe, if they do not believe. [�] because sometimes we have our beliefs, and you go there and want to impose yours. We have to know their belief before we say anything. If they have a belief or not. If they do not like it. Some people do not like to talk, right? So, I think that could be worked with students. (P16)
I think there should be a subject as they have in religious schools, they have Portuguese, Mathematics and there is a subject of religiosity. There should be themes about God, death because we are not prepared. Sometimes the patient dies, and we don't know what to say to comfort; I�m not talking about religion, but it would be spirituality; I think there should be. It should be part of the curriculum since undergraduate education to show professionals the importance of this theme. This includes the physicians too. The medical class should value it more. (P18)
I think it is important from the beginning to bring the subject up to have the knowledge and respect. (P27)
Opposition and challenges for the field
This subcategory points out that the R/S theme also raises challenges and oppositions among health professionals. According to some participants, R/S is a private and specific dimension. The variety of creeds and beliefs may be a divergence and difficulty factor for the teaching-learning processes. It is also questionable if it is a competence that nurses should perform. The following excerpts illustrate these ideas:
I don't think it has to be curricular. If you put it in the curriculum, you invade the professional space too, which I think it has to have. I work with people who have different religions, who provide quality assistance regardless of the religion they have. So I think that this does not have to be discussed. I think that the discussion has to be while respecting the patient's space and period. I don't believe in a discussion of how to include it, how to approach it, because the approach is to respect the patient�s space, I think that is the approach. The person is under no obligation as a professional to give religious support to a person, not least because they may not believe in anything, so there is no way to demand that from the professional. It is not our job; I think that it is beyond our competencies. (P24)
I don't know, it is personal. There are atheists here, there is everything, it is so hard! So, I think this type of guidance may be with a psychologist, sociologist; they know how to approach these issues. (P15)
DISCUSSION
Brazilian and international health agencies such as the International Council of Nurses (ICN)9 and the Brazilian Society of Cardiology10 have already emphasized the spiritual dimension as a vertex of care that is the responsibility of health professionals. Nevertheless, the R/S issue was absent or little/superficially present in the training of 26 nurses in this study.
According to Reasons to miss the R/S (or not) in undergraduate education, specifically subcategories Weak preparation for human issues and Aid resource to face the professional challenges, the training of nurses still focuses on teaching that emphasizes the biological and technical dimensions, with a gap in the R/S subjective. This gap also highlights the importance of the debate on the Brazilian National Humanization Policy (PNH), created in 2003. The policy indicates that the incentives of respectful models of care established by the Unified Health System (SUS), highlighting humanization as central, may not be strongly consolidated in the nursing education curriculum.11
In addition, R/S is understood as a source to deal with the challenges of the profession. It is manifested as a positive bias, where R/S may produce better health effects and greater job satisfaction. The promotion of R/S in the workplace is a factor that favors the institutional spiritual climate and is associated with greater job satisfaction and lower rates of burnout or stress.12 Thus, what is observed is that the issue of R/S in training would be beneficial so that nurses themselves may evoke this dimension to reflect their professional role and its challenges and limitations.
According to subcategory Having their own religious/spiritual beliefs, the nurses' own R/S would be a way to understand these subjective aspects of their practice, and the scientific approach of this learning would not be necessary. Two essential points of the presence of R/S in nurses are discussed here. First, a nurse who has R/S may be favored and have a greater openness to recognize the R/S of the patient/user and include it in their practice because they also recognize their need.13 On the other hand, the presence of the professional's R/S may hinder the interaction with the patient/user if the beliefs are different. It may impact the degree of impairment in the care, with the nurse being milder when they choose not to talk about the subject to prevent conflicts, ending up neglecting the benefits of using this dimension. Alternatively, in more serious situations, the nurse may try to impose their own R/S, configuring an unethical attitude of the profession.4
Concerning these meanings, it is also argued that having R/S was presented by professionals as the best way to produce some repertoire on the subject. Thus, in the absence of academic training on this theme - or preparation to conduct this discussion -, R/S was raised to the condition of personal content of an intimate nature, and only some professionals would be able to work with such a dimension. This promotes the reinforcement of R/S as less of a scientific aspect and more linked to what could be understood as human subjectivity. Thus, whoever has experience related to R/S will be better prepared to deal with the issue. This misunderstanding may relegate R/S to a less academic discursive field, which will unequivocally produce the withdrawal of some professionals from this discussion and, consequently, the possibility of evoking or considering this dimension in health care.
This does not mean that the professional has no right or should deprive themselves of having R/S. However, having R/S should not be understood as having sufficient knowledge to consider and include professional care based on this dimension. To study this dimension in health care, it is essential that we can approach this theme and our way of perceiving it. Also, to include the R/S in assistance the patient/user perspective must be considered, suspending the professional's convictions to make room for the other's need to emerge.13-14
Another point is that R/S is strongly embedded in cultural values. Thus, it is essential that nurses be able to expand and deepen this repertoire in order to become more competent from a cultural point of view and make their approaches and practices more inclusive and respectful of diversity. Studies have demonstrated that more culturally-sensitive people are more empathic, open, and less judgmental; characteristics that indicate this intercultural sensitivity may and should be developed.15 To create intercultural competence in professional practice, there must be sensitivity that, in turn, depends on the existence of intercultural knowledge capable of providing reflections and actions closer to reality.16
The discussion on the subject of R/S in the academic education and training of professionals must prioritize knowledge based on scientific evidence that, at the same time, allows the applicability and inclusion of the R/S dimension as a health resource. The systematization of learning and incorporation of R/S in practice should no longer be a task to be performed, but it must be made possible for this type of care to be undertaken by any professional, regardless of their own religious/spiritual beliefs, ensuring the patient/user the same conditions and fulfilling the multidimensional health care proposal. Furthermore, this comprehensiveness must unequivocally be part of the reflection around the human dimension of those who care, that is, the R/S of health professionals.
In category Suggestions for teaching R/S in nursing training, specifically subcategories Course and teaching strategies and Essential content, the participants discussed what should be approached concerning R/S and how. A point to highlight was the expression of learning about religions. In the experience of Cunha and Scorsolini-Comin17 on an R/S course offered to undergraduate Psychology students, they expressed unmet expectations of knowing more about religions in general. The authors argued that the role of the professional is not to become an expert in religion but to understand how religious/spiritual beliefs influence subjectivity. It should be a careful point because, even when sharing the same beliefs, one may have different behaviors and interpretations; thus, an individual assessment is fundamental, not the knowledge of the religion itself. It would not fall upon a teacher of this type of content the task of building basic knowledge about religions, but rather to arouse curiosity, openness, and respect for the culture, and for the different R/S to be known by the subject to the extent in which they present themselves to the subject throughout their care promotion itinerary. In this way, the training must prepare the professional to understand, accept, respect, and be sensitive to enter the perspective of the other.
The experience of Cunha and Scorsolini-Comin17 also shows that the gap in teaching-learning may be filled with voluntary adherence and the interest of students. It was observed that this gap in undergraduate programs not only generates professionals who do not have the knowledge and skills to approach R/S in practice but also reveals other problems such as the lack of teachers who have mastery over the topic to teach it.18 In fact, the experience of the authors was only possible because they were R/S researchers. Thus, initiatives to discuss this theme are still only supported by specific projects led by professionals interested in this dimension, making it difficult for these elements to be understood as part of the entire care process and not in just a few steps or areas of expertise.
In Subcategory Opposition and challenges for the field, the criticism raised by the interviewees in this study involved whether the teaching of R/S should exist at the undergraduate level. According to the ethics code of the ICN, nurses are responsible for promoting an environment in which the values, customs, and religious/spiritual beliefs of patients are respected.9 The nurse is professionally and ethically responsible for providing spiritual care and, therefore, there must be education and adequate preparation during their undergraduate education.18 It is unclear whether this responsibility would only fall upon the nurses, given that other health professionals also have conditions and opportunities to offer it in their daily routines.9-10
If teaching about R/S is not mandatory in the training of nurses, those who have difficulty in the subject and, possibly, those who most need to learn about it will probably not do so.19 Evidence indicates that nurses and nursing students would like to have the R/S addressed and in greater depth in their training curricula so that they may feel better prepared to access this dimension,19-20 with suggestions of how this may take place.18 The suggestions presented in the literature are similar to those suggested by the interviewees of the present study: to design a specific course or a part of already available courses in which the theme is appropriate; to present specific contents related to R/S; to use teaching strategies that can better elucidate the practice; to promote more comprehensive education supporting the professionals on the needs of the patient/user throughout their life.
The opinions of the professionals must be considered in the assistance, enabling articulations and dialogue between what is taught and professional reality. This study contributes to the evidence that including the R/S dimension in health education is essential for equal access and opportunities for health care as recommended in the current health system. In addition, the field shows that the possibilities of incorporating R/S in teaching and practice are dynamic and must take into account aspects of the patient/user, of the professional, of the opportunities present in the institution, and the sector of hospital assistances. Some situations may evoke a closer approximation to the religious/spiritual need. The academic training must enable the emergence of competence to employ R/S in the treatment/prevention, starting from the patient/user.10 The teaching-learning of R/S sensitizes health care to a more humanized and whole way, considering the individual needs.
It is understood as a limitation of this study the fact that the professionals came from specific sectors of the General Hospital, which may have influenced the greater or lesser degree of appreciation of this dimension in their professional experiences. The fact that there were no atheist or agnostic participants may also have favored points of view on understanding the highlighted issues. Furthermore, the fact that the data collection took place at the workplace may have reinforced social desirability. Despite all the efforts to avoid it, it may have caused discomfort and fear of being evaluated according to their responses, inhibiting their expressions. It is suggested to investigate differences among the sectors of the hospital institution, seeking to understand if there are significant differences in the field of activity among areas that may more frequently evoke the greater or lesser appreciation of the R/S dimension in these spaces. Areas with proximity to death, dying, or chronic commitment may indicate a greater need for support about the R/S.
FINAL CONSIDERATIONS
This research showed that the R/S subject was deficient in the training of participants, being an important resource to learn to deal with human aspects and the difficulties of the profession. However, professionals who had R/S did not seem to feel as if they missed out on the topic in their academic education, as they used their own beliefs to interpret the challenges of the profession or when this dimension emerges in the line of care. Also, they considered that the R/S theme is welcome to be addressed in undergraduate education. They expressed the importance of theory being linked to practice, considering the need for care protocols that can effectively include this dimension and not just theoretically reinforce its importance.
The research field points out that the R/S theme is consolidated in the scientific literature. However, in health practice, it still seems to reveal difficulties and distances, still prevailing a view that contents on R/S are neither scientific nor the responsibility of health professionals. Taking the R/S content to the education and training of professionals seems essential to change a position that, in practice, shows significant results in the treatment and prevention of diseases. This presence may prove to be sensitive to the needs of patients/users and even of the professionals themselves, making up the health guidelines. In addition, one must pay attention to the culture, given that, considering that Brazil is a highly religious/spiritual country, this may increase the chances and/or the need of its population. However, the globalization process increasingly introduces exchanges with other cultures, which also increasingly requires intercultural sensitivity.
� Approaching and including R/S in health care should not be just another task or function of the professional, as a sum of the parts, but an understanding of the need for human aspects presents in culture/society and the formation of people for thousands of years, driving sense and meaning that guide subjectivity, providing behaviors and beliefs capable of influencing health outcomes. It meets the PNH and other world guidelines, not in an authoritarian way, but as a recognition of its essentiality. To make it present, it is urgent to provide new leadership in training that evokes teaching considering this dimension. It will represent innovation, not only in terms of the nursing curricula but also to guide changes in areas that, possibly, are still more distant from this debate on screen.
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Aceito em: 26/07/2023
Publicado em: 09/08/2023
*The research was supported by the Coordination for the Improvement of Higher Education Personnel (CAPES) through a doctoral scholarship and a scholarship from the Internationalization Program (CAPES-PrInt) for the first author. It also received support from the National Council for Scientific and Technological Development (CNPq) for the last author.
[1] Universidade de S�o Paulo (USP). Ribeir�o Preto, S�o Paulo (SP). Brasil (BR). E-mail: vivianfcunha@gmail.com ORCID: http://orcid.org/0000-0002-0963-956X
[2] Universidade do Porto (UP). Porto. Portugal (PT). E-mail: susana@fpce.up.pt ORCID: http://orcid.org/0000-0002-7738-4757
[3]� Universidade do Porto (UP). Porto. Portugal (PT). E-mail: fontaine@fpce.up.pt ORCID: http://orcid.org/0000-0001-9232-8692
[4] Universidade de Bras�lia (UnB). Bras�lia, Distrito Federal (DF). Brasil (BR). E-mail: mauricio.neubern@gmail.com ORCID: http://orcid.org/0000-0002-6971-0655
[5] Universidade de S�o Paulo (USP). Ribeir�o Preto, S�o Paulo (SP). Brasil (BR). E-mail: fabio.scorsolini@usp.br ORCID: http://orcid.org/0000-0001-6281-3371
How to cite: Cunha VF, Coimbra S, Fontaine AM, Neubern MS, Scorsolini-Comin F. Contributions for teaching religiosity/spirituality in undergraduate nursing programs: a qualitative study with Brazilian nurses. J. nurs. health. 2023;13(2):e1323312. DOI: https://doi.org/10.15210/jonah.v13i2.23312