Perception of spirituality, religiosity, and euphemia in the light of hospitalized patients

Objective: to apprehend patients’ perception of spirituality, religiosity, and the practice of euphemia throughout hospitalization. Methods: qualitative research, conducted with 12 hospitalized patients. Data collection took place through individual interviews. The speeches were transcribed in full, submitted to thematic content analysis, and the discussion was based on the Transpersonal Care theory. Results: from the speeches, three categories emerged: Spirituality and religiosity: meaning and balm to human life; Benefits of the practice of euphemia in the hospital environment; Spirituality, religiosity, and euphemia in the art of nursing care: biopsychosocial triad in the patient’s perception. Conclusion: spirituality, religiosity, and euphemia were configured as a biopsychosocial triad capable of attributing meaning, foundation, and balm to human life. Also, it may encourage patients and nursing professionals to face the adversities of the hospital environment. Descriptors: Spirituality; Religion; Hospitalization; Patients; Nursing Care. 1Universidade Estadual de Maringá. Maringá, PR, Brasil. 2Universidade Estadual do Paraná. Paranavaí, PR, Brasil. Autor correspondente: Nadia Raquel Suzini Camillo Rua José Ferreira de Castilho, 1411 Centro. São Jorge do Ivaí. CEP: 87.190-000. Maringá, PR, Brasil. E-mail: nadiasuzinicamillo@hotmail.com EDITOR CHEFE: Ana Fatima Carvalho Fernandes EDITOR ASSOCIADO: Francisca Diana da Silva Negreiros Nadia Raquel Suzini Camillo1 Laura Misue Matsuda1 Edilaine Maran2 Jéssica dos Santos Pini2 Hellen Emília Peruzzo Aveiro2 Célia Maria Gomes Labegalini2 Yasmin Pereira Blanco2 Como citar este artigo: Camillo NRS, Matsuda LM, Maran E, Pini JS, Aveiro HEP, Labegalini CMG, et al. Perception of spirituality, religiosity, and euphemia in the light of hospitalized patients. Rev Rene. 2021;22:e62502. DOI: https://doi.org/10.15253/2175-6783.20212262502 Camillo NRS, Matsuda LM, Maran E, Pini JS, Aveiro HEP, Labegalini CMG, et al Rev Rene. 2021;22:e62502. 2 Introdução A ocorrência de uma enfermidade que aflige e ameaça o prosseguimento da vida é capaz de ocasionar diversos fenômenos emocionais nos indivíduos acometidos e em seus familiares(1). A imprescindibilidade de assistência médica aflora no indivíduo a divergência entre estar saudável e estar doente, o que pode gerar pesares e confrontos emocionais, os quais acarretam desafios à equipe de saúde, paciente e familiares(1). Nestes casos, tende-se a ampliar a constatação subjetiva do sofrimento humano e dos interesses de cuidados com a saúde porque o cuidar transcende o corpo físico e deve ser desprovido de olhar reducionista, atribuído ao contexto biomédico e curativista(2). A perspectiva da abordagem espiritual, inserida no olhar ampliado e holístico em saúde, consiste em importante ferramenta de encorajamento emocional, haja vista que, ao lidarem com acontecimentos indesejáveis, os indivíduos tendem a voltar-se às crenças e valores que proporcionam alívio às aflições e possíveis perdas(2). Diante disso, fornecem mecanismos como força, tranquilidade e fé, para enfrentar as enfermidades, inclusive àquelas com elevado potencial de morte(3). A espiritualidade e religiosidade, apesar de associadas e, por vezes, interpretadas com a mesma semântica, não são sinônimas. Por religiosidade, entende-se o conjunto de cultos e doutrinas compartilhadas por um grupo ou comunidade, com traços culturais sociais, doutrinários e valorais próprios. Já a espiritualidade, se relaciona com a metafísica e com o divino como algo individual, universal, dinâmico, multidimensional e integrador, que atribui sentido à vida e ao julgamento de que há algo além daquilo que é capaz de ser visualizado ou compreendido(3-4). A prática de orar, rezar ou executar preces é caracterizada como eufemia e pode ser classificada em dois tipos: petição, quando pede-se a Deus algo para si e; intercessão, quando pede-se a Deus algo para o outro(5). A eufemia, portanto, assumida neste estudo como sinônimo de oração/reza/prece, decorre da experiência religiosa e espiritual. Por outro lado, apesar de a espiritualidade buscar respostas individuais para questões existenciais humanas que envolvem a compreensão dos propósitos da vida e possível conexão com a transcendência, não está necessariamente vinculada à prática da eufemia ou doutrina religiosa(5). No que tange à espiritualidade e à religiosidade dos profissionais de enfermagem, quando estas práticas se fazem presentes na assistência ao paciente, interferências nas dimensões físicas e psíquicas destes podem ser percebidas, de modo a impulsionar a fé, a psique humana e assim, ampliar o cuidado para além do biológico(4-5). Atrelado a esse contexto, a prática da eufemia é considerada estratégia importante no atendimento à saúde, pois favorece o bem-estar, a redução da ansiedade, o desenvolvimento da cura e a reabilitação de enfermidades(4,6). Embora a espiritualidade, religiosidade e eufemia, apreendidas como parte da prática assistencial da enfermagem sejam importantes, ainda são pífias como estratégias de cuidado no Brasil(5,7). Neste sentido, lacunas inerentes aos conteúdos sobre espiritualidade, religiosidade e eufemia na formação acadêmica, atreladas à escassez de informações técnico-científicas sobre o tema, podem contribuir para o despreparo do profissional à adoção de tais práticas no cuidado ao paciente(7). Ante o entendimento de que a espiritualidade, religiosidade e eufemia são práticas relevantes para qualificar a assistência integral ao indivíduo hospitalizado, questionou-se: qual a percepção de pacientes acerca da espiritualidade, religiosidade e prática da eufemia, durante a internação hospitalar? Em resposta a essa questão, o presente estudo objetivou apreender a percepção de pacientes acerca da espiritualidade, religiosidade e prática da eufemia durante a


Introduction
The manifestation of a disease that affects and threatens the continuation of life may cause several emotional phenomena in the individuals involved and their families (1) . The indispensability of medical assistance shows in the individual the discrepancy between being healthy and being sick, which may cause regrets and emotional confrontations, which create challenges to the health team, patient, and family (1) . In these cases, there is an attempt to expand the subjective observation of human suffering and health care interests because care goes beyond the physical body and must be devoid of a reductionist view, attributed to the biomedical and curative context (2) .
The perspective of the spiritual approach, introduced in the expanded and holistic view of health, consists of an important tool of emotional encouragement, since, when dealing with undesirable events, individuals tend to appeal to the beliefs and values that offer relief from afflictions and possible losses (2) . Consequently, they provide mechanisms such as strength, tranquility, and faith, to face illnesses, including those with a high potential for death (3) .
Spirituality and religiosity, although related and sometimes understood with the same semantics, are not synonymous. By religiosity, it is understood the set of rituals and doctrines shared by a group or community, with their own cultural, social, doctrinal, and morals characteristics. Spirituality, on the other hand, is related to metaphysics and the divine as something individual, universal, dynamic, multidimensional, and integrating, which gives meaning to life and the judgment that there is something beyond what is capable of being visualized or understood (3)(4) .
The practice of praying, pleading, or calling upon for help is characterized as euphemia and can be grouped into two types: petition when you ask God for something for yourself and; intercession when you ask God something for the other (5) . Euphemia, therefore, adopted in this study as a synonym for prayer/ plead, comes from religious and spiritual experience.
On the other hand, although spirituality pursues individual answers to human existential questions that involve understanding the purposes of life and possible connection with transcendence, it is not necessarily related to the practice of euphemia or religious doctrine (5) .
Regarding the spirituality and religiosity of nursing professionals, when these practices are present in patient care, interferences in their physical and psychological dimensions can be observed, to enhance faith, the human psyche and, therefore, expand the care beyond the biological (4)(5) . Linked to this context, the practice of euphemia is considered an important strategy in health care, as it promotes well-being, reducing anxiety, developing the cure, and rehabilitating illnesses (4,6) .
Although spirituality, religiosity, and euphemia, understood as part of nursing care practice are important, they are still poor as care strategies in Brazil (5,7) . In this sense, gaps inherent in the contents on spirituality, religiosity, and euphemia in academic education, linked to the scarcity of technical-scientific information on the subject, may contribute to the professional's unpreparedness to adopt such practices in patient care (7) .
Given the understanding that spirituality, religiosity, and euphemia are relevant practices to qualify comprehensive care for hospitalized individuals, we questioned: what is the perception of patients about spirituality, religiosity, and the practice of euphemia, during hospitalization? To answer this question, the present study aimed to apprehend patients' perception of spirituality, religiosity, and the practice of euphemia throughout hospitalization.

Methods
Qualitative research, based mainly on the theoretical framework of Transpersonal Human Care (8) .
The study was conducted with 12 patients hospitalized in a clinical-surgical inpatient unit of a philanthropic hospital, located in southern Brazil. This setting was chosen because, in previous research conducted by one of the authors (5) , it was found that the nursing professionals of this institution practiced euphemia in the workplace, which incited the interest in interviewing patients admitted to the unit where the practice of praying was common. It should be stated that nursing professionals did not participate in the present investigation.
The eligibility criteria for the participants were patients admitted to a clinical-surgical unit, age ≥ 18 years. About the established exclusion criterion, the patient's cognitive impairment was considered and assessed using the Mini-Mental State Examination test (9) . Through this test, no patient invited to participate in the study showed cognitive impairment.
The sampling process for participants started with the identification of the patient's age recorded the medical records in the clinical-surgical hospitalization unit. Of the 23 eligible patients, the recruitment of participants took place by individual invitation. There was no refusal, and the inclusion of participants was completed when they realized the saturation of the data and achievement of the objective when reached interview number 12.
Data collection was conducted in June and July 2019, on a day and time previously scheduled through a semi-structured, recorded interview, in a private room, with questions regarding sociodemographic and spiritual variables (age, sex, education, marital status, length of stay, health/biopsychospiritual care, religion), plus the following guiding questions: Tell me how you understand/perceive your spirituality, religiosity and prayer practice at this time of hospitalization, and what is the relevance of these practices at this moment and; Tell me how you perceive the spirituality, religiosity and prayer practice of nursing professionals for self-care and care for patients.
To differentiate the terms spirituality, religiosity and euphemia, in this study, it was considered that the spiritual care offered by nursing professionals is a set of practices that improves reflection on the dimension of human existence and connection with the Divine/Transcendent, whether through prayer, detached from religious/dogmatic doctrine; while religious care refers to practices that refer to the rituals of a certain belief, such as reading a religious/Sacred book/Bible, praises and also prayer and; euphemia is the individual or collective prayer strategy associated with spiritual and/or religious care.
The recordings were fully transcribed, if possible, on the same day they were recorded, preserving the participants' style, with orthographic correction and suppression of sway and/or repetitions. The corpus was analyzed using the thematic content analysis (10) and discussed mainly in the light of the theoretical framework of Transpersonal Human Care (8) .
To guarantee the participants' anonymity, they were identified by the letter "P" for a patient followed by sequential Arabic numerals. Moreover

Results
Twelve patients participated in the study. Of these, nine were female, aged between 30 and 66 years old, with the level of education ranging from illiterate to complete higher education, most were married and the average length of hospital stay, at the time of the interview, was six days.
Regarding the religiosity and spirituality profile, seven patients declared themselves practicing Catholics, two practicing Evangelicals, two Spiritualists and; one stated having no religion, but that he was spiritual. Regarding the frequency with which the interviewees pray/plead, eight informed that they practice this action once a day, three reported two or more times a day, and one said that only a few times a year.
All participants reported believing in God and that they feel the presence of Him or something divine when they pray, plead, or read the Bible. Regarding the dimension of comprehensive human care, nine respondents reported that they appreciated and cared about their biopsychospiritual health.
From the speeches, three thematic categories emerged: Spirituality and religiosity: meaning and balm to human life; Benefits of the practice of euphemia in the hospital environment; Spirituality, religiosity, and euphemia in the art of nursing care: biopsychosocial triad in the patient's perception.

Spirituality and religiosity: meaning and balm for human life
Spirituality translates the awareness of the existential dimension itself. In this sense, each participant nurtures this awareness in the perception that God is considered a Being/Entity responsible for human existence and essential for the existence of man in the universe. Thus, the care provided by nursing professionals to patients seems to reflect the Creator's protective care that brings real meaning to life, as can be evidenced in the excerpts below: ... Because  Among different religious activities/rituals, the practice of prayer/plead or meditation is pointed out by the participants as beneficial for the management of life's stresses, positive for mental health to the healing process, and for the spiritual strengthening itself. Furthermore, these practices are also perceived as useful for dealing with experiences involving stress, fear, and suffering, as shown in the extracts below: ...

Benefits of the practice of euphemia in the hospital environment
In the opinion of the interviewed patients, if the individual or collective euphemia is practiced by the nursing professionals during the working day, the nursing team may increase the desire to gather strength to face the difficulties at work, motivation to care, and better relationship between patients and professionals: I believe that the prayer of nurses brings people,

Spirituality, religiosity, and euphemia in the art of nursing care: biopsychosocial triad in the patient's perception
Participants stated that spirituality, religion, and euphemia positively influence the health/disease coping process and therefore, it is important to have the spiritual and religious needs met by nursing during health care: ... People  During the interviews, P1 and P2 were indifferent to the importance of religious, spiritual, and euphemia practices as part of nursing care and this indifference could also be noted in the facial expressions and in the tone of voice with which they expressed the statements.

Discussion
The peculiar perception of spirituality, religio-sity, and the practice of euphemia by some patients declared to be Christian and/or spiritualized, in a specific hospital context in Southern Brazil, may be a limiting factor in this study. This homogeneous group does not necessarily translate opinions from other locations and different cultures. However, the findings of this study are in line with other investigations (8,11) and contribute to the advancement and promotion of this relevant theme. The results unveiled work as subsidies for an approach that holistically contemplates the individual and supports nursing professionals to include patients' religious and spiritual beliefs in their respective care plans, in line with ethical and legal principles. The study may also contribute to improving the faith of patients and health professionals who support the belief in God, divine intervention, and the multidimensionality of the human being.
When discussing faith, individual characteristics seem to affect the perception of religiosity. This is because studies show that women approach spirituality and religion and that the search behavior for the spiritual dimension can be increased as the individual grows older (12) . Although the sample of the current study consists mostly of females and middle-aged adults, the speeches of the interviewees and the research design itself were not sufficient to consolidate these surveys.
In the hospital setting, spirituality can be understood as a subjective coping strategy that provides relief from stressful events such as pain, stress, fear, anxiety, and even death. Despite the complexity of care, the benefits of spiritual practice can reverberate both for health professionals involved in care, as well as for hospitalized patients and their families. In this way, spirituality may be introduced in the management of care with a view to the well-being of those who care and those who are cared for (8,13) .
Most of the interviewed patients recognize the importance of spiritual and religious practice for the reestablishment of health, to promote the therapeutic plan performed by nursing. In this sense, other investigations are consistent with the results of this rese-arch and point out that spirituality and religiosity are relevant to clinical practice because they provide relief and well-being to the patient and the team, in the social, physiological, and emotional aspects. Furthermore, spirituality may provide balance to the social, psychological, and biological dimensions of the human being, because it promotes personal satisfaction, mental health, and the high sense of Being (8) .
From the perspective of keeping the biopsychosocial balance (8) , the participants reported that spirituality, religiosity, and euphemia can be a "strong" ally of the nursing team, as they have the potential to relieve stress, fear, and suffering resulting from work. A recent investigation (11) , conducted throughout the COVID-19 pandemic, is consistent with the studies of this research about the practice of spirituality and religiosity as a strategy for the humanization of nursing care in a hospital setting. Thus, when considering the possible benefits of spiritual and religious practices for the health-disease process and the quality of life of professionals, it is suggested that nursing professionals experience them in the organizational environment.
About the insertion of euphemia as an ally to the practice of nursing care, the interviewees showed dual perceptions. This is because of the acceptance of the prayer/plead/prayer inserted in the care for patients. Although to a lesser extent, some considered it as something private and personal, without the need to be approached by professionals in a hospital environment. Thus, it is highlighted that religious practices are considered healthy, but can become iatrogenic, if they do not respect the perceptions of those involved who need professional evaluation for their implementation.
In the context that involves comprehensive health care, researchers (14)(15) show the clients' desire to receive religious and spiritual care by health professionals, as they do not feel uncomfortable, or even offended by these interventions. Other research (6,8) reveals that spirituality is a complex human dimension, surrounded by different phenomena, such as spiritual fear whose responsibility to diagnose and treat it is the health team, independently, so that comprehensive care and holistic is achieved. Nevertheless, the authors of this study assume that a patient's relationship with their religiosity and spirituality requires the nursing professional to take a careful, humane, and scientific view, to verify the possibility of these care strategies.
An investigation (16) similar to this one, conducted in a teaching hospital in southern Brazil, found a dichotomy between the practice of care provided by the nursing team and that conceived by patients. According to the patients, the nurse appreciated spiritual and religious care with prayer/plead, moments of encouragement, strength, and liveliness, but the professional was limited to acting according to the biomedical and technicist model of health care, with distance from the biopsychosocial dimensions.
Religious and spiritual activities as care strategies by nursing professionals to patients were not observed in this study. These data corroborate other investigations (2,17) and may be related to professional unpreparedness in dealing with the spirituality of patients in the hospital environment; absence of religious themes in the curriculum of most Brazilian training schools; and not approaching the patient by health professionals in a biopsychosocial and spiritual way. On the other hand, researchers (8,18) point out that health professionals who recognize and adopt spiritual practices have a greater tendency to perform humanistic care, surrounded by sensitivity, respect, and understanding.
The participants reported the experience of the spiritual dimension in the health/disease process and considered that they felt comfortable receiving religious and spiritual support during the institutionalization period. It is worth noting, therefore, that it is the role of the health professional to promote or act as a facilitator of this assistance so that the principles of autonomy and beneficence are respected (19) . This makes it essential that all nursing care practices are guided by the ethical context and that the spiritual experience, lived in the workplace, contributes intending to expand the compassion and solidarity that are configured as humanistic moral acts (5,8) .
Paradoxically, the contradiction concerning the desire for spiritual support for the affected health needs was also manifested. Therefore, it is important to consider that spiritual care starts based on ethical precepts and behaviors on the part of the professional who assists the patient and his/her family, especially because he/she is experiencing together all the difficult moments and coping inherent in the hospitalization process (20) .
Given the above, it is understood that spirituality, religiosity, and euphemia are designed as a biopsychosocial triad, capable of positively impacting the health and well-being of hospitalized patients and nursing professionals. Furthermore, it is observed that these care strategies can be implemented ethically by the nursing team, to provide relief to their suffering, especially when therapeutic measures do not favor a good prognosis (3) .
It is evident, therefore, the favorable influence of this biopsychosocial triad in the assistance scope, and for that reason, it is expected that managers and leaders of health institutions constantly support comprehensive humanistic care, so that the patients themselves realize that they are protagonists of this model of health care that results in better health outcomes.
For those who do not see the inclusion of spiritual and religious practices in nursing care, this study may provide reflections on the benefits of this biopsychosocial triad in the work environment, for the caregiver and patient and stimulate the interest in experiencing, or not, the connection with the transcendent and the supernatural, even in the face of doubt, or the impossibility, of proving the existence of a Higher Being.
It is suggested that further studies be conducted emphasizing the spiritual and religious approach of the health professional with the hospitalized patient through prayer, a brief meditation, praise/singing, reading small texts from the Bible/books, and other actions, to broaden the understanding of the benefits of spiritual and religious care to human life, given the difficulty in differentiating the experience of spirituality and religiosity, which expresses limitations for these practices in the hospitalization context.

Conclusion
This study allowed to reveal the perception of hospitalized patients regarding the spirituality, religiosity, and euphemia experienced by them. According to the results, it is considered that the interviewees understand spirituality, religiosity, and euphemia as a biopsychosocial triad, capable of attributing meaning, foundation, and balm to human life.
Regarding the approach of spiritual and religious practices through euphemia, as a health care strategy carried out by the nursing team, the participants show contributions to the physical, mental, and social well-being for those in charge of care, as well as of those who are taken care of. Thus, although atypical, some do not imagine including these practices in nursing care.

Acknowledgments
To the Fundação Araucária, notice 010/2018, and the Pro-rectory of Research and Graduate Studies at the State University of Paraná.

Collaborations
Camillo NRS, Maran E, and Blanco YP contributed to the conception and design, analysis, and interpretation of data, writing of the article, and relevant critical review of the intellectual content. Pini JS, Aveiro HEP, and Labegalini CMG contributed to the writing of the article, and relevant critical review of the intellectual content. Matsuda LM contributed to the conception and design, analysis, and interpretation of data, writing of the article, and relevant critical review of the intellectual content and final approval of the version to be published.