ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

Spirituality and humanization according to nursing undergraduates: an action research

La espiritualidad y la humanización según los graduandos de enfermería. Una investigación-acción

A espiritualidade e a humanização segundo graduandos de enfermagem. Uma pesquisa-ação

¹RN, Ph.D. University of São Paulo at Ribeirão Preto College of Nursing - EERP-USP-, Brazil. email: gcoscrato@yahoo.com.br.

²Pedagogue, Ph.D. EERP-USP, Brazil. email: smvbueno@eerp.usp.br.

Receipt date: February 4, 2014. Approval date: July 25, 2014.

Article linked to research: Conceptions of nursing undergraduates about humanization and spirituality: an action research. Doctoral Dissertation, 2013. University of São Paulo at Ribeirão Preto College of Nursing.

Subventions: none.

Conflicts of interest: none.

ABSTRACT

Objective. To know the conceptions of undergraduates from the Teaching Diploma Program with Bachelor degree in Nursing at a public state-owned higher education institution in an interior city in the State of São Paulo about spirituality and humanization, as well as to propose educative action in that sense. Methodoly. A qualitative study was undertaken, using the action research method. The data were collected in the second semester of 2012 through participant observation, registered in a field diary, and interviews with the help of questionnaires. For the interpretative data analysis, categorization was used. Results. The implicit predominance of the technical-procedure care discourse was observed, to the detriment of the educational care discourse, as complementary constructs, according to the participant' statements. Nevertheless, the educational action permitted constructivism and the problematization of knowledge. Conclusion. Although the results may not reflect the reality at the investigated institution, it is concluded that the academic education of nurse educators is a moment of possibilities to include spirituality and humanization, regarding the development of competences that grant individual support to patients and families, in health promotion and coping with disease situations.

Key words: nursing; spirituality; humanization of assistance; nursing education research; education, higher.

RESUMEN

Objetivo. Conocer las concepciones sobre la espiritualidad y la humanización de los graduandos de la Licenciatura en Enfermería de una institución pública estatal de enseñanza superior de un municipio del interior paulista,  con el fin de proponer acciones educativas en este sentido. Metodología. Estudio cualitativo en el que se utilizó la metodología de investigación-acción. Los datos se recolectaron en el segundo semestre de 2012, mediante de observación participante que fue registrada en un diario de campo, y de entrevistas utilizando cuestionarios. En el análisis interpretativo de los datos se empleó la categorización. Resultados. Se observó que está implícita la predominancia del discurso de cuidado/asistencia técnico-procedimental en detrimento del educativo, además de no ser evidente la asociación de los temas de humanización y de espiritualidad, a pesar de que son constructos que se complementan, según los testimonios de los participantes. Con todo, la acción educativa viabilizó el constructivismo y la problematización de conocimientos. Conclusión. La formación académica de los enfermeros educadores se encuentra en un momento en el que es posible la inserción de la espiritualidad y de la humanización en el desarrollo de competencias para el apoyo individualizado al paciente y a su familia, en la promoción de la salud y en el enfrentamiento de las situaciones de enfermedad.

Palabras clave: enfermería; espiritualidad; humanización de la atención; investigación en educación en enfermería; educación superior.

RESUMO

Objetivo. Conhecer as concepções dos graduandos do curso de Licenciatura com Bacharelado em Enfermagem, de uma instituição pública estadual de ensino superior, de um município do interior paulista, sobre espiritualidade e humanização, bem como propor ação educativa neste sentido. Metodologia. Trata-se de estudo qualitativo que utilizou-se da metodologia da pesquisa-ação. Coletaram-se os dados no segundo semestre de 2012, através da observação participante, registrada em diário de campo, e de entrevistas, apropriando-se de questionários. A análise interpretativa dos dados foi feita por categorização. Resultados. Observou-se estar implícita a predominância do discurso do cuidado/assistência técnico-procedimental em detrimento do educativo, além de não estar evidente a associação dos temas da humanização e da espiritualidade, enquanto constructos que se complementam, segundo as falas dos participantes. Contudo, a ação educativa viabilizou o construtivismo e a problematização de conhecimentos. Conclusão. Ainda, com a ressalva de que os resultados podem não refletir a realidade da instituição pesquisada, conclui-se que a formação acadêmica de enfermeiros educadores configura-se em momento de possibilidades de inserção da espiritualidade e da humanização, no que diz respeito ao desenvolvimento de competências que proporcionem suporte individualizado ao paciente e família, na promoção de saúde e no enfrentamento de situações de adoecimento.

INTRODUCTION

For the purpose of scientific production that is sensitive to the aspects intrinsically associated with the integrality and complexity of life, and with regard to the innovative and humanizing aspects of health care, the relevance of consolidating more reflexive, critical and humanizing curricula in the education of health professionals and, therefore, nurses is highlighted. There is an urgent need for competence building that provides individual and spiritual support to patients and families, in health promotion as well as in coping with disease situations. This justifies the improvement of health care towards new approaches that consider the technical knowledge produced but also permit overcoming modern paradigms of traditional positivist and biological medicine and the traditional, uncritical and vertical teaching model, based on knowledge transmission to the students, towards pedagogical approaches that prioritize the exercise of interdisciplinarity in the mental, collective and hospital areas.^1-4

The health promotion approach requires appropriate and harmonious academic education in the articulation with the work reality, in line with the proposal of the World Health Organization (WHO) about the Primary Health Care (PHC) concept, whose guiding axis is the support to the autonomy and control of individuals and social groups over life and health, moving beyond the organic context.¹ On the other side, in hospitalization situations, nurses are often confronted with disease and death risk, leading the patients to depression, isolation, despair and, therefore, mental and spiritual suffering, knowing that the family also shares this suffering. In addition, nursing care for patients with mental disorders and/or users of alcohol and other drugs demands remodeling, in view of the global scenario of the psychosocial rehabilitation proposal.³ Therefore, the scientific paradigms that permeate the modern health care modes and their transitions to the post-modern ones encompass laws, theories, applications and instruments, which give rise to models that lead to coherent research traditions. When crisis points emerge, scientific revolutions are triggered, which question and aim to move beyond the knowledge that is constructed.⁵

Within this logic, it is observed that spirituality can constitute a cross-sectional construct, at the interface of the actions towards humanization and Education for Health.^6-8 The spiritual and religious dimensions can be present in the personal and professional life of health workers and researchers and, therefore, of nurses, as this health work process can lead to mental suffering, causing negative consequences for the productivity of work and influencing the humanization of care.^9-11 Hence, it is fundamental that these professionals pay attention to themselves, as well as to the facilitators in the maintenance process of health and life.^11-14 We use Paulo Freire’s theoretical-methodological universe to support the structuring axis of Education for Health and humanization, at the interface between the individuals and familie' search for autonomy and awareness in health.^2,12 Therefore, sensitivity and dialogue need to be developed between nurses and patients, moving towards the internal mobilization and the attribution of meaning to life, inducing and aggregating a new side to nursing care, that is, spiritual care.^2,12,13 In view of spiritual care in nursing, the theorist Joyce Travelbee, a North American psychiatric nurse, who passed away in 1973, already drew attention to self-knowledge, as well as to the understanding of the nurse' own spiritual values and feelings, communication, love for other people and the self, as elements of the therapeutic relationship.¹⁵

In view of the above, the educational and humanizing premises of Freire’s approach Travelbee’s theory of interpersonal relationship, also revealing humbleness, dialogue, cooperation and partnership in this process. The increased scientific production about spiritual care in nursing in recent years should also be highlighted, as verified in different studies, mainly at the international level.^11,16,17 In view of the proposed revision of nursing education, aiming to envisage the humanities with a view to comprehensive health care, the objective in this study was to know how nursing undergraduates perceive spirituality and humanization, proposing educational action.

METHODOLOGY

Action research, a method that started with group research in the 1940’s, in the attempt to approach the dynamics of social practice with a societal theory, emphasizes the need for self-knowledge and relational technologies. Lewin and Corey, Noth American authors, who are the precursors of the line of thinking in social psychology, proposed that the detailed observation of the different processes that lead to social change would permit reflection and scientific production, which would give rise to social action, and not only to the production of books and/or material restricted to the academy.²² In the fields of education and health, Bueno (2001, 2009) combines and adapts the molds of this research, based on the theoretical-methodological framework of Freire and Thiollent (theoretical precepts about the action research methodology) and of Minayo (theoretical precepts about qualitative research in health).^12,18-21 This action research modality is constituted in two phases: the survey of sociodemographic data and the thematic universe, which originates the generating themes, representing the first phase; while the second phase involves the educational action. The separation between both phases is done didactically, and the researcher’s immersion in the research context permits the movement (and not the reflection or mirror) towards the complexity demanded to apprehend the reality, which is dynamic.²⁰

Hence, the research subject by itself mobilizes the participants towards reflection, whether in the conceptions, values, beliefs and academic knowledge, corresponding to the theoretical-methodological terms chosen for this research, in line with the problematizing proposal and rejecting the watertight criteria of neutrality towards the research problem, as scientific validation elements of the positivist paradigms.^19,20 Characterized as idiographic, this research is concerned with studying a specific and particular situation in a broad, in-depth and interpretative sense, focusing on the process, not only on the outcomes, and without nomothetic intentions, i.e. it does not intend to apprehend and generalize the results and general laws.²² In that sense, there was no intent to reflect the reality of the research institution in this research.

In this study, the following data collection techniques were used: participant observation, using the field diary as an instrument to write down the observed infrastructure data; and individual interviews, in which the participants answered a questionnaire with questions about the participant' identification data and guiding questions about the research theme (spirituality and humanization), which started approximately 10 minutes before the start of classes and went another 10 minutes into the classes without the teacher’s presence, inside the classroom, as previously agreed upon with the participants. The researcher invited the nursing undergraduates from the one-but last (fourth) year of the Teaching Diploma with Bachelor Degree in Nursing, offered at a public higher education institution in the interior of the State of São Paulo, Brazil. The public institution was chosen because it develops a lot of research that contributes to nursing in Brazil and internationally. Therefore, the intent was to consider the reality of future professionals who can serve not only as caregivers and educators, but also as researchers.

The inclusion criteria were: the free and spontaneous acceptance to participate; being a student in the one-but-last course year in 2012; having signed the free and informed consent form; having handed in the answers to the script within the deadline; having participated in the entire educational actions described in Phase 2 of this study. The exclusion criteria were: being a student in other course years or in the Bachelor program; not having handed in the script answers; and not having participated in the educational activities.

Out of 49 undergraduates, the participants consisted of nine students who corresponded to the inclusion criteria described earlier, as the others alleged that they did not want to participate due to fatigue and the countless academic commitments at the end of the school year. Most of the subjects are women (6), between 21 and 30 years of age (8), all single, with unfinished higher education. The ranking of religious beliefs started with the Catholic religion, followed by Spiritualism, one protestant and one did not have a religion. The majority (7) had a single occupation: being a student. The research complied with the scientific rigor and ethical premises required by the National Council for Research Ethics involving human beings and received approval from the institutional Ethics Committee under opinion number: 169174. The data were collected in 2012.

RESULTS

The participant' answers were allocated in three categories, according to their understanding of spirituality, and in four categories depending on their understanding of humanization. These results are associated with the other data collected for the action research, which the researcher registered in the context of the reality in order to apprehend it, like the subject' facial and/or bodily expressions, which were written down in the field diary.

Next, the categories are presented.

1st Category: Spirituality is belief in something that rules life/goes beyond the biological and religious. It means that you believe in something higher than our existence, something that rules your life without you seeing it (PA); (...) it means believing that there is something beyond the biological (PC); (...)  it is the personal belief, it is the being’s fine-tuning with the self and with his ''god'', his faith (PD); (...) it is a set of factors that involves the psychological wellbeing, the belief in something that is not necessarily linked to religion and also to a state of internal tranquility that cooperates to coping with some situation (PE); (...) it means being well or bad with oneself and with others, feeling what one things, likes and wants (PG); It means believing and experiencing a higher power that sustains and balances life (PH); (...) it is what moves us, what makes our body function, what allows us to participate in life and interact in it. It is what lies beyond the physical, the mental and the psychological – a link among these three dimensions that permits the dynamical existence of each being (PI).

2nd Category: Spirituality seen as a positive or negative context of life. It is a state, a subjective condition of being that, depending on the person’s context, can take a positive or negative form (PB).

3rd Category: Spirituality seen as respect for each person’s values. It means you working with the patient’s belief, you respecting his values, and not wanting to impose our combined values on him (PF).

Categories of understanding about humanization

1st Category: Humanization means doing good. It means you doing good to any person, no matter who and how she is (PA).

2nd Category: Humanization is the guarantee of human rights. It means treating the other to guarantee all rights a human being has (PB).

3rd Category: Humanization is the consideration of the person as a biopsychosocial being. It means treating people knowing that they are biopsychosocial beings (PC).

4th Category: Humanization means being respectful, not exceeding the person’s limits. – it is mainly the respectful form of treatment (PB); (...) it is the act of looking at each person individually and understanding that people have their own need and characteristics (PD); (...) it refers to care for individuals as unique beings, with their particularities and life context (PE);(...) it means that you attend to the patient with the best weapon that can exist, respect. (...) it means treating people with respect, attention and trying to do what we consider best, without exceeding the family’s and the patient’s own values (PF);(...) it means being respectful and doing the best possible for the other, thinking about their feelings, the individual and the people involved in that situation; not harming them and not making them suffer (PG).

Phase 1. Investigation: categories. In phase 1, in which the research survey was done, the categories presented earlier could be elaborated.

Categories of understanding about spirituality

1^st Category: Spirituality is belief in something that rules life/goes beyond the biological and religious. According to the data presented about this category, it was verified that these participant' understanding is linked to something higher, that is, it rests on the religious and mythical conception, but goes beyond the purely biological view. WHO⁶ and Chan et al.⁷ distinguish between spirituality and religiosity, although the latter can serve as a spiritual expression channel. Hence, spirituality means an individual philosophy, that is, the values and meaning attributed to life, and therefore is not defined as a religious doctrine, but comprises the existential domain and the essence of what a human being is, aiming to respond to existential issues.^6-8 Religiosity is therefore translated as a relation between a group of people and some kind of divine or supernatural force, linked to the sacred and to a doctrine. It can serve as a vehicle for the expression of spirituality, based on beliefs, values and ritual, leading to the search for answers about matters of life and death^6-8. The modern scientific paradigm seems to be present in almost all answers. It is interesting to note that the post-modern scientific paradigm, not linked to religion, is present in the answer of (PE), reminding that this participant has no religion. It can be inferred that the other participant' concepts receive interference form individual religious beliefs.

2^nd Category: Spirituality seen as a positive or negative context of life. This statement reveals the post-modern paradigm, in which spirituality is a state that is manifested positive or negatively in people’s life, according to the beliefs and life context. Travelbee considers that that would be the starting point of the determinant factors to help the patient, with a view to finding the meaning of life during a situation of disease and mainly mental suffering, so that they do not negatively influence the therapeutic relationship and the quality of the care offered.¹⁵

3^rd Category: Spirituality seen as respect for each person’s values. In the care situation, a relation exists between the caregiver and the person receiving care, in which the research participant reports that the professional should not impose values. This assertion converges with Freire’s theoretical precepts of humanization.¹² The pedagogical post-modern scientific paradigm is predominant in this answer. In line with Freire’s view, authors like MacDonald and Warren¹³ cite that Paulo Freire’s theory is directly applicable to Primary Health Care. His educational method would serve as a solid base to fully achieve it. Despite acknowledging the importance of the body/mind/spirit relation to put in practice humanization and integral health care, nurses rarely establish diagnoses and implement actions that involve the patient' spirituality, due to different factors, including: incipient approach in academic education; difficulties to interpret the patient’s spiritual behavior; lack of consensus in the related literature; so that this practice is still conquering space as scientific professionalism.^11,14 Therefore, it was observed that, despite containing post-modern specifications, most participants maintained an important focus on the religious aspect.

Categories of understanding about humanization

1^st Category: Humanization means doing good.  According to Benevides and Passos,²³ the meaning of humanization should neither be linked to the charitable meaning of health actions, nor purely associated with the sense of treating people well. This understanding is indicated in the expression that humanization means ''you doing well'', characterizing the presence of the modern mythical or even religious paradigm in this statement. In a way, this is even justified by the history of nursing as a profession, permeated by the influence of religion. Nevertheless, the feeling, respect and solidarity are part of the differences between the professionals and patients, in a movement that converges towards the post-modern scientific paradigm.

2^nd Category: Humanization is the guarantee of human rights. Participant (PB)’s statement converges towards humanization in health, guaranteeing people’s freedom to come and go and their choices, according to certain life forms and contexts.^3,12,23 This reflects the post-modern scientific paradigm, as it directs the trends of global and Brazilian public policies, like the National Humanization Policy for example, which guarantees health as a human right that should be guaranteed by the State.²

3^rd Category: Humanization is the consideration of the person as a biopsychosocial being. Here, the participant (PC) reveals human being' multiple dimensions, which should be fully considered in health care, remitting to the post-modern scientific paradigm.² WHO (2001) refers to the different factors of human being' health, highlighting their interdependences with a view to effective disease prevention, psychosocial rehabilitation and health promotion, mainly regarding mental health.³

Phase 2. Educational action

The educational action took place in a meeting between the researcher and the subjects, in a discussion and cultural circle that took approximately two hours, in a classroom at the research institution, but beyond class hours; as well as by e-mail, as agreed upon in the group. The educational action involved different steps: in the first, the problems and experiences in academic internships were discussed with regard to the research theme. Next, some bibliography on the theme was read.

In addition, the balloon activity was used. Balloons and pins were distributed among the participants. They were all asked to inflate the balloons, representing good things and dreams. All participants wanted to burst their colleague’s balloon. The researcher then asked them to reflect that, in line with the activity, the nurses deal with people and that dreams and ways of life, demanding care and respect for the other as, on the opposite, this could result in dehumanizing and non-spiritual action. The particular and educational research process of the action research caused surprise in the group, and the researcher tried to move beyond the unique procedure that marked the data collection, which occurs in other types of scientific research, as well as punctual assessment (based on pre and post or comparative tests), which do not fit in the action research method. Then, the summative assessment was used, permitting qualitative interaction between researcher and subjects.^12,18 They informally and casually indicated the educational characteristic and rapid return of the research’s scientific contributions as an opportunity for expressions and problematization of real-life contexts. Regarding this perspective of the teaching-learning process based on group strategies, Bleger²⁴ highlights the educational action movement, which ends up being therapeutic and vice-versa. Hence, in line with that research, nursing, as an art, science and profession that deals with people as a process and product of their actions, should develop and enhance self-knowledge and interpersonal relations, and that group strategies can offer this space, also reminding that group workshops, in psychosocial rehabilitation cases, have been used and widely disseminated in health services.

Paulo Freire highlights the religious communicative dimension as an epistemological characteristic of pedagogy, not as a sense of affirmation of the religious nature, but as a channel that permits the educational action: ''faith in man is the premise of dialogue'', and ''as the foundation of dialogue, love is also dialogue''.^11,12 Hence, the theoretical-methodological choice in this study culminates in Freire’s proposal, in the thematic association among Education for Health, humanization and spirituality. The action research, as a research and educational proposal, raised challenges for the researcher, as: a) the study limitation was dealing with many student' lack of motivation to participate in the research, as it was the end of the school year, and the students were already physical and mentally tired. This characteristic (condition sine qua non) of qualitative research, however, represents the insertion in the participant' real-life historical context, without the need for an ideal sample, which would be analogue to quantitative research terms.²⁰ b) the complexity of the theme (humanization and spirituality), and the relation with nursing education, demands the communicational aspect in the preparation of educational action, an element that drives greater flexibility, listening and proposed adjustments, besides lesser preliminary control of actions/discussions during the meeting; and c) the assessment as an element of the process is peculiar to the action research and not punctual and quantifiable, present in the modern scientific paradigm.

Therefore, it is highlighted that the enriching aspect of this research was the problematization, revealing different questions and perspectives, that is, the research did not remain in the inductive/deductive thinking, in the immediacy and punctuality of changed conceptions or behaviors, nor even in the pejorative criticism against the research institution, also because that would not be the educational goal proposed by Freire and Bueno. Nevertheless, the knowledge exchange, which certainly permits more respectful and horizontal relations, gives rise to the constructive factor knowledge and constitutes one of the different steps to be taken towards the post-modern scientific paradigm, in line with theorists on the subject.^11,12,18-20

In conclusion, as a study limitation, few students participated, as the composition of the participants depends on their availability and interest in participating in the study, as discussed earlier. In addition, the pedagogical project of the course was not analyzed, which is a gap that entails other research possibilities on the study theme. Hence, the findings are not closed, concluded or definitive, but grant an unfinished aspect to this study, in line with Freire’s ideals, proposing the investigation of the reality with regard to humanization and spirituality in nursing education, as a continuous movement for the purpose of putting the obtained results in practice as well as deepening and expanding other elements that can interfere in the nurse' teaching-learning process. The implicit predominance of the technical-procedure care discourse was observed, to the detriment of the educational care discourse, besides the lack of clarity on the association between humanization and spirituality as complementary constructs, according to the participant' viewpoints, who will be clinical professionals and faculty members in health programs, demonstrating the need for investments in academic education. Nevertheless, the educational action permitted constructivism and the problematization of knowledge.

Conclusion. Although the results may not reflect the reality at the investigated institution, it is concluded that the academic education of nurse educators is a moment of possibilities to include spirituality and humanization, regarding the development of competences that grant individual support to patients and families, in health promotion and coping with disease situations.

The group strategies, as part of the action research method, can grant spaces for the development of communication and negotiation skills, contributing to a more spiritualized and therefore more comprehensive and humanized therapeutic relationship. This research indicates the emerging possibility of nurse educator' academic education as a moment to insert spirituality and humanization, using strategies that take into account the complexity of human nature, considering the intersection among the integrated curriculum that problematizes the reality, the humanizing principles of PHC, spirituality and Education for Health. With a view to the building of competences that grant individual support to patients and families, in health promotion and in coping with disease situations, the importance of health care and teaching is emphasized as technical, scientific and political fields. In methodological terms, moving beyond punctual actions in education was proposed, using new post-modern perspectives, aiming for new ways to produce science.

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