Materials and Method

This is an integrative review of the scientific literature carried out from January 1, 2009 to December 31, 2019. The following steps were carried out: (a) identification of the research problem; (b) literature search; (c) evaluation of studies; (d) data analysis; (e) interpretation (^{Hopia et al., 2016}; ^{Whittemore & Knafl, 2005}).

The review considered the recommendations established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyse Protocols ((PRISMA); ^{Moher et al., 2010}) for performing searches, analysis and systematic description. The question that guided this study was developed through the PICO strategy, often considered in the reviews that are based on evidence-based practice, such as that of an integrative nature. The question to be answered from the review received the following wording: How has the scientific literature evidenced R/S in the experiences of health professionals in pediatric oncology?

Data collection was carried out in the databases/libraries Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (Lilacs), Cumulative Index to Nursing and Allied Health Literature (CINAHL), National Library of Medicine of the USA (Pubmed) and Psychology Information (PsycINFO). Such databases/libraries were defined based on the literature that was intended to be collated, notably that of the field of health sciences and as they encompass scientific productions at an international and regional level (Latin America and the Caribbean). Thus, it was expected that the results would show how the scientific literature has approached this topic at a global level, but also in the social context in which the authors develop the research. The search criteria adopted considered the objectives of the review and descriptors that could evidence the state of scientific production on the target theme.

The keywords used and their combinations were: religiosity OR religion OR spirituality OR spiritual OR faith AND health personnel OR pediatric oncologist OR pediatric oncologists OR pediatric oncology OR oncologists OR oncologist AND neoplasms OR childhood cancer OR child with cancer OR adolescent with cancer and their respective terms in English and Spanish. In the Pubmed and PsycINFO databases, the keywords used were inserted only in English, given that they do not accept Portuguese at the time of the search.

As inclusion criteria, the following were selected: articles published within 10 years (January 2009-December 2019), written in English, Portuguese or Spanish, that focused on R/S in the work of health professionals and in personal experiences and that were fully available. The attention in pediatric oncology considered in the present review encompassed the different professional categories. Productions that were not articles (such as thesis, dissertations, chapters and books, for example), articles that escaped the theme, that had a population other than health professionals as a basis, repeated, in languages other than Portuguese, English and Spanish theoretical articles and the ones not found in full were excluded. The time period adopted sought to encompass the most recent productions found at the time the article was produced. It has been usual for reviews to adopt a period of 10 years in data retrieval, due to covering an adequate number of studies and current ones on the investigated themes.

For the discussion of the results, chaplains and religious/spiritual advisors were considered as members of the health team in this review for the work they develop with patients, family caregivers and other professionals who work in the context of child and adolescent cancer care. It is known that, in many situations, chaplains are considered spiritual professionals in the hospital environment, helping in decision-making, pain control, in the resolution of bioethical conflicts, in moments of patients’ spiritual crisis, among other aspects (^{Choi et al., 2015}).

After carrying out the searches, the results were entered into the Rayyan Software (^{Ouzzani et al., 2016}) for systematic organization and selection. The analysis of the evidence was carried out by two independent judges with experience with the subject and the disagreements analyzed and resolved by a third judge. The information collected was previously defined by two of the authors considering the objectives of the study and the PRISMA checklist and a standardized form were established to enter the information of the selected articles.

In order to answer the guiding question, the ways in which health professionals experienced R/S in cancer illness were presented and discussed in two categories produced later, that is, after reading and analyzing the material collected.

Results

Figure 1 presents the flowchart of the process of selection of articles that were included in the study. After selecting and filtering the material, the final sample consisted of 12 articles, nine of which were qualitative and three were quantitative. Table 1 shows the articles in the final sample, authorship, year of production, nationality of authors, place of study, type of study, data collection method used and participants. After the final selection, the full reading was carried out to select the contents that would answer the guiding question.

Figure 1: Flowchart of survey and selection of articles 

Table 1: Articles according to authorship, year and nationality of authors, place of study, type of study and data collection method used 

From the analysis of the contents of these articles that made up the corpus, two thematic categories were produced for data presentation: 1) R/S as an element that permeates situations experienced at work; 2) R/S as a dimension present in the lives of patients and families. The categories were created after analyzing all the material and focusing on the objectives of the study and synthesizing the main results observed. This way, the results that stood out the most and were similar were grouped, summarizing the two categories described here.

Discussion

The present review has shown a gap in the production of scientific knowledge regarding the study of religious and spiritual aspects in the personal and professional experiences of the pediatric oncology health team. During the selection of material, it was observed that there is a significant number of publications that consider R/S in the practices of pediatric professionals. However, when the focus turns to pediatric oncology, the results are considerably restricted. In addition to this, in some cases, it is observed that R/S is approached tangentially, being only mentioned as a dimension that influences the lives of subjects, an important resource for coping with personal and work situations or as a component of comprehensive health care, without it being possible to analyze it in more detail.

Based on this finding, it can be questioned that R/S, even if it is scientifically recognized and as an index encompassed by evidence-based practices, ends up being compared as a dimension of lesser value when we analyze the experiences of these professionals. As a resource, it is thus shown to be underused or under investigated. Added to this, R/S is more mentioned in studies with patients and their families, as if this were a powerful resource in coping with cancer and not in the development of a more humanized and reflective care by health professionals.

Another aspect that deserves attention in relation to the scientific production found refers to the fact that most publications do not focus on how health professionals are impacted by R/S in their personal experiences. That is, there is a significant portion of these studies that are aimed at describing how professionals perceive R/S in the lives of patients and family members, without describing in detail how R/S permeates personal experiences or how it interferes with their subjectivity and its emotional aspects (^{Cadge & Ecklund, 2009}; ^{Guedes et al., 2019}; ^{Lion et al., 2019}).

This movement reveals that R/S is still a resource little explored in the experiences of these professionals, who have difficulty in positioning themselves in relation to their own R/S and the use of this dimension in care, in a possible effect of a biomedical tradition that emphasizes the search for neutrality and the distance between patient and professional (^{Cunha & Scorsolini-Comin, 2020}). This difficulty of insertion of R/S on the part of professionals in the area may be based on the understanding spread by the biomedical model that science and spirituality are, in fact, irreconcilable, promoting the following paradox: R/S can be used by the patient, but not by the professional, as it is based on science (^{Dal-Farra & Geremia, 2010}).

Thus, the meaning of the professionals’ R/S itself, the understanding of it as a facilitator in the face of stressful situations and that should be integrated into the practice of care (^{Arrieira et al., 2018}) ends up not being embodied in practice or being understood as something that cannot be offered due to other care needs that are considered more priority in the interventions they carry out (^{Nascimento et al., 2016}). In practice, neutrality positions tend to operate in the sense that R/S is a dimension that can be evoked and developed only by those who receive care, which can promote a fragmented and inauthentic health practice precisely because of non-involvement of the professionals in this field. This aspect can promote what ^{Neubern (2013}) calls unwelcoming reception, with important repercussions for the humanization of care.

When analyzing the studies, the need to consider chaplaincy professionals as team members was perceived, even without necessarily having an academic background in health courses. These professionals have been included as an important category for the care provided, mainly due to the fact that R/S has gained more space to be considered in the contexts of people’s illness. The chaplains often have a religious/spiritual training/path from different religious denominations and in care contexts they work in an integrated way with multidisciplinary teams and health facilities, being considered as members of the care process provided to patients, family members and to other team members who work in the services (^{Lion et al., 2019}; ^{Proserpio et al., 2016}).

Among the study participants, medical and nursing professionals stand out as being the ones that were most evident. This data reflects an aspect that is remarkable in the contexts of child and adolescent cancer care, as these two professional categories end up being the ones that have the most contact with patients and family members. This finding can be justified by considering that nurses, for example, are the largest group in the health system and provide full-time care, being more likely to find patients with spiritual needs (^{Chiang et al., 2016}) and, therefore, studies focusing on these professionals can be prioritized.

Regarding the ways in which R/S is described in the personal and professional experiences of the pediatric oncology health team, it is clear that the subsidies offered by this dimension are important to be considered, as this work environment is demarcated for being potentially stressor. Faced with the suffering condition of the patient and their families, the health team ends up expressing feelings and emotions such as pity, compassion and love, guilt and anxiety, anger and hurt (^{Oliveira & Firmes, 2012}). In this way, R/S can be a support mechanism for the conditions they experience in work practices.

R/S can also be important for health professionals when they realize that this dimension can be a complementary therapy to treatment. A study by ^{Sampaio and Siqueira (2016}) showed, for example, that nurses recognize R/S as an element that influences the way patients will experience conditions of suffering, recovery, and the meaning of life. ^{King et al. (2013}), when investigating the perception of physicians about the R/S of patients in pediatric and oncology environments, showed that these professionals believe that this dimension is relevant because it provides a support system in times of crisis, has repercussions on behaviors and decisions related to health, positively affect health and help in the therapeutic relationship between the professional, the patient and the family.

R/S was also observed when health professionals needed to deal with situations that involved the possibility of death or death of patients. It is observed that R/S supports them in a delicate moment of being faced and created conditions for them to believe that death would not be the final limit of existence. ^{Silva Junior et al. (2016}), when describing the use of R/S in oncology, mention that professionals perceive the process of death contained in their personal religious conceptions, defining it on some occasions as a passage, leading to the symbolic representation of a path to well-being and relief from suffering. However, it is important to emphasize that it should not be considered as a resource to be used only at the time of the patient’s death or when there is no other alternative for treatment, as it is present throughout people’s development and not only at the end of life.

Another aspect worth mentioning is that, during the selection of articles that would enter the sample, it was possible to observe an association between R/S, palliative care and people hospitalized in the Intensive Care Unit (ICU). This aspect raised questions about the emphasis that is given to R/S in these phases of treatment and why investigations specifically focus on these moments. These questions are in line with the data presented by ^{Choi et al. (2015}), when they describe that most meetings of patients with chaplains occur in the last day or two of life, meaning that visits to chaplains are usually requested for patients who are actively dying, and not with the aim of proactive spiritual support for families and patients. Chaplain involvement in the ICU is also not frequent, but appears to become more frequent in critically ill patients, and becomes the norm for dying patients (^{Choi et al., 2015}). That is, R/S seems to be used more at the time of death than during the entire illness process.

In the articles selected, R/S was considered by health professionals as an element of care provided to family caregivers and that provided conditions for coping with all stages of child and adolescent cancer care. A review study published by ^{Robert et al. (2019}) analyzing the importance of spiritual care in pediatric oncology shows that spiritual support is a supportive and useful resource for patients and family caregivers in coping with the disease.

The interferences of the R/S of family members in professional practices were also evidenced and are important to be considered. It is known that in certain situations people’s beliefs conflict with procedures that need to be performed, leading to complex bioethical conflicts. These emerging bioethical conflicts remind us that not every relationship between spirituality/religion/religiosity and health is balanced, and it is evident that in the processes that involve dialogue between these fields, confrontation and discussion arise in the face of existential issues (^{Tavares et al., 2016}).

Final Remarks

The review presented here evidenced the scarcity of scientific productions that focus on the influence of R/S in the work and personal experiences of pediatric oncology professionals. The results presented indicate that there is a difference in the way R/S is described in the experiences of patients and family members in relation to how it is presented in the daily lives of health professionals. When used by patients and family members, this dimension is described as a resource in facing the difficult situations that are experienced in the diagnosis, the treatment course, cure or end of life. However, when evidenced and related to health professionals, it becomes another protocol to be followed, it focuses on the perception of the health team in relation to the R/S of the sick person and its caregiver, without actually being seen as a potential and experiential resource that could provide reception and support for the practices they develop and which are difficult to face.

The data revealed that health professionals have considered R/S in their practices and its importance has gained more emphasis over the years, with the search for comprehensive care through the actions developed. Nursing and medical professionals are the most mentioned when dealing with the R/S aspects of sick children/adolescents. The chaplaincy, on the other hand, stood out as part of the care team for people that are sick with cancer and has offered some of the main care related to the religious and spiritual aspects that emerge in this context.

The bioethical conflicts related to R/S that permeate work practices in pediatric oncology showed a relevant component that can emerge as a result of the opposition between people’s beliefs and the methods that are to be used in health care. This data showed that there will not always be a friendly and harmonious relationship between R/S and health practices, so that the work of several professionals from different backgrounds will be important in conducting dialogues between the sick person, his or her family and the health team.

The implications for practice reinforce the need to evoke with these professionals their own experiences in relation to R/S, as well as this element can emerge in their practices. It is necessary that empirical studies focus on the production of this evidence, which can be useful both for promoting a more comprehensive and humanized care and for a better understanding of the Intersubjective aspects of these professionals. The results found demonstrate the need to consider R/S in health contexts, as this dimension is present in the lives of patients, family members, and the health team and can help in the experiences of illness or being a factor that will be challenging for the patient care provided when it causes conflicts between people’s beliefs and the procedures that will need to be developed. All of these elements converge so that R/S is a component to be incorporated into the training curricula of the different professions in the health area that may have to deal with this dimension in the professional practices they develop, such as care in pediatric oncology.

As limitations of this study, the fact that the studies, although aiming to investigate R/S in health professionals, end up focusing on how they observe this dimension in patients or family members is evidenced. Thus, the results show only a little of how R/S is experienced by these professionals in their personal lives or how it can interfere, for example, with subjectivity and mental health conditions and, consequently, with how they deal with aspects of the work context, especially those who mobilize feelings in relation to what is experienced. It is also observed that there are few studies in the national reality whose objective was to investigate R/S specifically in pediatric oncology. Thus, it is relevant that further investigations be carried out, mainly with a focus on understanding how R/S can be a coping resource and its implications/associations with levels of mental health in this population.