Introduction

Integrating spirituality into health care is still a challenge for health care professionals. Nursing science has evolved over time in the search to improve care by making it more humane and holistic¹. “Informal care” is a practice that has increased greatly in recent years along with an aging population and an increase in non-communicable diseases and multi-morbidity, which is reflected in the increase in the percentage of disabled population and the need for another person to provide care for the continuity of life.

An informal caregiver is a person who is responsible for providing care and satisfying the basic needs of another person who, given his situation of vulnerability, illness, or disability, he cannot satisfy; all of this without receiving any financial compensation. Being female, caring for long hours without a set schedule, having a relationship of consanguinity or affinity, and lack of professional training in the health area are among the most common characteristics of these caregivers².

The aging of the population is closely linked to informal care since it predisposes to situations of vulnerability, illness and/or disability (sometimes one or even all three simultaneously). Older people, considered by the World Health Organization as those aged 60 or more, are at greater risk of acquiring a disability due to the decline of vital functions and the prevalence of non-communicable diseases³.

European countries have been facing this phenomenon for years and have developed care strategies for both the elderly and the informal caregivers, unlike Latin American countries where this panorama is relatively recent. Unlike Latin America, the Spanish health system recognizes informal care and combines it with formal care to enhance the health of its vulnerable and dependent population⁴.

Jean Watson, in her Theory of Human Care, proposes avant-garde ideas aimed at nurses in order to achieve loving, humane, and quality care, translated into the 10 caritas processes. However, these proposals are based on seven basic premises and a conception of the being as a unit comprised by mind, body, and spirit in close relationship with nature and the universe. The basic premises address important characteristics of the soul or spirit which are highlighted below^5,6:

One of Jean Watson's reiterative ideas is the capacity of the spirit to transcend time and space and to reflect itself on other people through ideas or emotions^6,7. Pamela Reed supports this thought in a unipersonal way in her Theory of Self-transcendence and affirming that the process of self-transcendence is an expansion of personal limits that implies maturity and greater awareness of the environment⁸. However, Watson emphasizes the impact that one person's spirit can have on another through spiritual transcendence.

She also believes that spirituality is built on experience, therefore the older the person the more experience and the greater the importance and role that spirituality plays in people's lives. This has been demonstrated in repeated studies that conclude that the accompaniment of the family and spirituality constitute an important support both for the caregivers and the elderly in their care and are considered a protective factor for the development of resilient behaviors^9,10).

Although these ideas and assumptions or premises were key to the development of the Theory of Human Care (which is specifically oriented to nursing), they do not necessarily describe the characteristics of the nurse, but rather of the person capable of providing care regardless of her professional training; therefore, taking into account that the need and impulse to provide and/or receive love and care is a primitive force that identifies the human being, these basic premises can be adapted to the reality of any person.

As previously mentioned, the nursing profession constantly requires strategies to improve the quality of care and incorporating spirituality is a successful step towards achieving wholeness; informal caregivers are part and parcel of the professional care process, however, their needs and health often are considered secondary, similar to the great potential they have to contribute to the health of their loved one.

The present article is an integrative review of the literature with the objective of identifying areas of opportunity and knowledge gaps, which can propitiate the understanding and strengthening of the spiritual transcendence of informal caregivers towards the elderly they care, as well as the benefits of such spiritual transcendence in their health, both of the caregiver and of the elderly, taking into account the basic premises of Jean Watson's philosophy and considering only literature regarding Ibero-American population in order that the Spanish trajectory and experience guide the emerging care strategies of Latin American countries.

Methods

In order to achieve this objective, the Evidence-Based Nursing methodology described by Alonso et al was used, consisting of five phases¹¹. Each one is described below:

1. Preparation of clinical questions:

Spirituality imbued in health care is a crucial element in the health of the population, often forgotten by a biomedical system focused on disease. Informal caregivers contribute greatly to professional nursing care and represent a latent opportunity for comprehensive care planning, even more so when the global sociodemographic and epidemiological panorama reveals an increase in the number of older people as well as a high rate of dependency mainly due to multi-morbidities. Therefore, taking into account the principles and values of Jean Watson's philosophy of humanized care, the following questions were stated:

What is the importance of the spirituality of the informal caregivers of older people in Latin America?

What are the elements or characteristics of the transcendence of the spirit described in Jean Watson's philosophy?

Do some elements or characteristics of spiritual transcendence agree with the reality of informal caregivers in Ibero-America?

Based on the above, the theme “Spiritual transcendence as an opportunity for informal caregivers of the elderly in Ibero-America: An integrative review from Watson's philosophy” was selected. Subsequently, the elements of the PICOT format were delimited where the Patient (P) is the informal caregiver of the elderly in Ibero-America, the Intervention (I) is the spirituality in the healthcare, since there is no point of Comparison (C), the Outcome (O) is the opportunity for spiritual transcendence and, since it is a review of literature, there is no specific Time (T) for the intervention.

Taking into account these elements, the following question was prepared, which guides the systematized review of the literature:

Is there an opportunity for the spiritual transcendence of informal caregivers of the elderly in Latin America according to Watson's philosophy?

2. Literature search:

The databases PubMed, Biblioteca Virtual en Salud (BVS), Cochrane, Lilacs, Scielo, CUIDEN, and EBSCO Host were selected for their high concentration of literature of Hispanic and Portuguese origin using the Descriptors in Health Sciences (DeCs), caregivers, spirituality, and aged in English as well as the boleano operator AND. It should be noted that the descriptors were searched in Spanish in the CUIDEN database since this is the main language of the database. The selection criteria used were:

Inclusion criteria:

Articles that address the spirituality of informal caregivers of the elderly even if it is not the central theme.

Studies performed in Spanish and Portuguese speaking population between the years 2010 and 2019.

Literature in English, Spanish, and Portuguese.

Exclusion criteria:

Articles with text or summary not available on the web. Validation of instruments.

Repeated articles. Initially, 353 articles were found, 13 of which were selected. Afterwards, exclusion criteria were applied to end up with a total of 6 articles that answered the research question. The eligibility of the articles is described in more detail in Table 1.

Table 1: Search and eligibility of scientific literature / Source: Own development (2019). 

3. Critical reading:

In the selected literature, the validity, reliability, relevance, and pertinence of the articles were evaluated based on their approach to the spirituality of informal caregivers of older people, which translates into the ability to respond to the research question presented.

4. Implementation:

The results were grouped based on the several findings found by the authors.

5. Evaluation:

Finally, the findings of this literature review that may allow nursing professionals to incorporate spirituality into the healthcare of the elderly with the support of their informal caregivers were highlighted.

Results

Six scientific articles were selected from the PubMed⁵ and Virtual Health Library¹ databases; the rest was eliminated mainly due to repetition.

Publication years ranged from 2013 to 2019, with 2018 being the year with the highest number of publications³, and 2013, 2017, and 2019 reporting only one published article each. The main language of the articles was English⁴ followed by Spanish¹ and Portuguese¹. Brazil is the country with the highest scientific productivity in relation to the spirituality of informal caregivers of the elderly ³ followed by Colombia¹, Mexico¹ and the United States¹; although the United States has worked repeatedly on this topic, only those studies with Latin American population were taken into account.

The predominant type of study was qualitative ³, same that descriptive designs³ followed by cross-sectional studies². In 4 of the 6 studies convenience sampling was used, while in the remaining two studies simple random sampling was used.

The characterization of the participants followed a similar pattern in all cases despite the fact that the only condition to be included in the review was that their care was addressed to the elderly. The caregivers were in an age range between 18 and 90 years of age, with an average age of 60 years and a female predominance of 73.28%; in 37.37% of the cases there is a marital relationship with the older person being cared for and Catholic religion stands out as religious practice, followed by Evangelical or Protestant religions.

The measurement of spirituality was done through interviews given the qualitative nature of the studies; only in one article a quantitative measurement of spirituality was performed, using the Pamela Reed's Spiritual Perspective Scale developed in 1986, which has been widely applied and has a Cronbach alpha of 0.92 - 0.95. It is important to note that not all studies have spirituality as a central theme. One study focused on the quality of life of the informal caregiver and another one on the patterns of care; nevertheless, all evidence considered it an important element for the health and well-being of caregivers.

In all cases there is a strong spiritual attachment on the part of the informal caregivers who claim that spirituality is a way of coping with difficult times they go through with respect to the health of the older person in their care. Studies reveal that spiritual work in conjunction with family and social support provides caregivers accompaniment, reassurance, strength, and companionship to overcome obstacles and even financial support; furthermore, they often view illness as a divine plan and thus it represent an opportunity for personal growth and the purification and redemption of the spirit^9,12-16).

Religiosity is an important part of spirituality and the most visible. Arias et al reported a negative association between the religious support of the informal caregiver and the uncertainty related to family support, which means that the greater the religious support the less the uncertainty regarding the illness⁹. Likewise, Vitorino et al report that negative spiritual and religious coping strategies such as religious apathy, the feeling of divine punishment, and vengeance and anger toward God are associated with depression in informal caregivers ¹⁶.

One of the most recurrent religious practices of informal caregivers is prayer, which is considered a form of communication to a higher power and a way to feel close to Him, followed by frequent participation in religious services and events ¹⁵. Da Silva et al listed some of the main religious and spiritual practices of older people who are informal caregivers of other older people: the most common were establishing a connection with God by praying for their own well-being and others’ well-being, seeking God's love and protection in the belief that He always cares and accompanies them, seeking strength, support, and encouragement from God, have a space at the home for worship, reading the Bible and other spiritual books, watching religious films and performing religious rites such as praying the rosary, making the sign of the cross, going to confession, fasting, and chanting mantras. Other slightly less frequent practices among the participants of the study were attending temple and religious and/or spiritual events and listening to and chanting praises¹⁵.

Informal caregivers from every Latin American culture have a unique and specific way of expressing their spirituality; however, regardless of culture, spiritual practices play an important role in the well-being and resilience of caregivers of older people^12,13.

Discussion

Spirituality is an essential element in alleviating fear, uncertainty, and stress of the informal caregivers of older people, given the high rate of multi-morbidity and proximity to the end of life^9,13-15. Likewise, the bond with older people needs that spiritual strength takes into account that the experience they have acquired throughout their lives has allowed them a spiritual growth and development⁶.

The relationship that an informal caregiver establishes with the older person being cared for can be compared to that established by nursing professionals during healthcare and can even be more intimate and stronger. According to Jean Watson's philosophy, intense human relationships produce a bonding of the spirit of the participants, a bond through which it is possible to reflect one's own spirit in that of the other person^5,6). Based on this, a door of opportunity is opened for nursing to diagnose and participate in the spiritual needs of the informal caregiver and directly impact the health of the older persons they care for¹⁶.

Promotion of spiritual practices in caregivers, in addition to being an opportunity for spiritual transcendence, is also a highly fruitful effort capable of reducing the levels of overload, risk of depression, and uncertainty with respect to the illness of their loved ones ^9,16.

Contrary to what was expected, no scientific evidence was found regarding the topic of interest in Spanish literature, which shows that very little has been studied about the capacity for spiritual transcendence (and spirituality in general) in Latin American countries, despite the fact that their cultures, and above all, health management, have a great religious influence^13,16.

Conclusion

Scientific evidence positions spirituality as a key piece that the nursing profession needs to understand and incorporate into its daily practice in order to achieve wholeness in healthcare. Various studies have demonstrated the benefits of its inclusion in nursing interventions and the significant changes it produces in the health of the subjects of care ¹⁷. However, very few studies have addressed spirituality as a central theme, or that have performed a deep study on it, which limits its potential.

Nursing, simply because of its object of study, becomes a spiritual practice that consists not only in the development of techniques and procedures but also in the “being” for the other person, for which the dominion of the spiritual sphere is fundamental. Nevertheless, the study of the benefits of the spirituality in health, but mainly, its application into the practice, continues being a challenge for the discipline.

Jean Watson’s philosophy is one of the most current and promising in the nursing profession, since its focus is human care, the discipline’s subject of study. In it, the author is emphatic in the qualities of the human spirit specifically that of “transcendence”, which suggests that strength of spirit increases the possibility that it crosses the limits of time and space and remains reflected in the memory, thoughts, emotions, and feelings of the others. Informal caregivers establish such an intimate relationship with the person in their care that they facilitate a path of spiritual transcendence through such relationship. Specifically, when it comes to caring for the elderly, spirituality becomes more relevant to both, especially when, in addition to aging, the reason for care is illness. In these cases, spirituality serves as a support that helps the individual being cared for and to the caring human being to give meaning to the illness and to develop resilient behaviors to face it with a positive attitude and even resignation when the end of life is imminent.

The development of spiritual and religious practices in the nursing work strengthens the spirituality of informal caregivers and increases the opportunity for transcendence. Latin American countries have a culture highly influenced by religion and it is the elderly who are the main exponents and who preserve this spiritual wealth due to their life experience and because they feel shaped by their culture, which makes them sensitive to this type of stimuli, however, these opportunities have not been able to be integrated when planning the healthcare.

Similarly, nursing professionals in charge of the professional care of the elderly should also welcome their caregivers, considering their physical and spiritual well-being as a way to impact the health of the older person in their care given the characteristic of transcendence of the spirit, as proposed by Jean Watson in her Theory of Human Care.

This integrative review of the literature demonstrates that informal caregivers of older persons constantly implement strategies to strengthen the spirit as a way to cope with difficult moments related to the health of their loved one, who is respected and cared for, as well as to give them a sense. However, it is evident that there is a gap in knowledge regarding spirituality in health that needs to be filled, and nursing is one of the disciplines that is the most qualified to do so taking into account its closeness to the subject of this study.

Likewise, as a way of contributing to the strengthening of Jean Watson's philosophy, it is necessary to carry out quantitative research that demonstrates that, effectively, the transcendence of the spirit is possible and that it can be reflected in an improvement of the health of the elderly. Regarding the ideal population for the development of this type of study, it is suggested to work with Latin American population because of their great potential and spiritual and religious development.