Contributor: Vanessa Silva (Portugal)*
Over the centuries, human history has experienced numerous challenges in the area of health and disease, namely through the experience of pandemic realities, such as the Black Death in the 19th century and the Spanish Influenza in the 20th century, in which there was a high mortality and morbidity rate associated not only to the lack of adequate medical equipment, but also to the limited scientific knowledge in the area of health and pharmacology.
During the 21st century, we have witnessed a revolution in health care through scientific, biochemical, and pharmaceutical advances, the design of increasingly specialized medical equipment, and the training of increasingly competent health professionals in technical-scientific, communicational, and relational terms. However, and despite all the evolution that we have been witnessing, in 2020 the world was once again unprepared to face the colossal challenge posed by the SARS-CoV-2 infection, which was called the COVID-19 Pandemic.
The evolution of science and technology in health and other areas has allowed for a significant decrease in the mortality and morbidity rate associated with this pandemic. However, it is not enough to look at morbidity in terms of a person’s physical component, since I believe that this pandemic also brought highly damaging emotional, psychological, and spiritual consequences for humanity, particularly for health professionals, users, informal caregivers, and families, leaving a legacy of anguish, fear, despair, and deep spiritual suffering.
Jean Watson (2002) defines caring as a transpersonal artistic process, which is characterized by a human interaction so profound that it allows touching the other’s soul and feeling his/her emotions. According to the author, this process will be more artistic and true the more the nurse is able to join the other person and allow the release of emotions, the transcendence of the physical, and the appreciation of the condition of his/her soul, so as to enable the person to move towards greater harmony and spiritual evolution (Watson, 2002, p. 119-124)
In this sense, and based on the great influence of Jean Watson’s Caring Science Institute (1999) in nursing care, over the past few years there has been a growing concern of nurses with the humanization of care and the respect for all dimensions of the human person, his/her principles, values, culture, dignity and what is important to him/her throughout the life cycle, particularly in death, ensuring, also in this phase, the respect for the dignity of the end-of-life patient as a human person.
However, and along with the respect for the dignity of the patient at the end of life, another concern arises related to those who care, those who give up caring for themselves to care for the other.
According to Jean Watson (2002) the humanization of care presupposes leaving aside traditional care focused only on the physical dimension of the person and on curing the disease, focusing on the indispensability of an approach to the person as a whole, by attending to their spiritual and existential questions, valuing love and respect for the sacred, and thus contributing to the person reaching a higher level of harmony between mind, body, and soul.
As a nurse working in primary health care, namely in the follow-up of users, informal caregivers, and families in integrated continuous care and palliative care, I have witnessed a reality that is often not very in line with the humanization of care. Thus, I dare say that one of the greatest challenges in my clinical practice during this pandemic has been to witness the “spiritual morbidity” experienced by informal caregivers and families of those who, due to being at the end-of-life stage (due to terminal illness or acute illness), were hospitalized. Spiritual suffering has also been noted as an anticipatory factor to the need for hospitalization of the person who needs it, which has often translated into the postponement of this decision by the informal caregiver and family.
According to Jean Watson and Barbara Brewer (2015), despite the evolution of nursing as a profession and discipline, the nursing care provided to patients is still often clouded by a biomedical vision. However, we are facing an awakening to a caring approach to the person as a whole, placing the emphasis of care on inner healing and emotional and mental health, by addressing human suffering.
When I referred earlier to “spiritual morbidity”, I meant the legacy of anguish, fear, despair, guilt, deep spiritual suffering, and loss of meaning in life, left by this pandemic to those who saw their family member leave home, in the uncertainty of the future and the certainty that that look and touch could be their last.
During this pandemic, I have also witnessed the deprivation of the right to visit your hospitalized family member and be visited, which is a violation of human dignity. This deprivation was imposed by the emergency in compliance with all the measures that would allow the spread of the SARS-CoV-2 infection to be controlled as much as possible. However, this measure culminated in the impossibility of death being experienced as a family and of farewells taking place, instilling not only the patients, but also the informal caregivers and families, with a spiritual suffering that will be difficult to overcome.
In the last 2 years, with the focus of health in the areas of prevention and treatment of the infection by COVID-19, much has been said about the collateral damage of this pandemic (undiagnosed, under-diagnosed and even diagnosed diseases, but without the proper follow-up), and the impact of these on the costs charged to the National Health Service. However, I believe that spiritual suffering can also lead to the emergence of complex human responses, such as impaired social interaction, social isolation, self-care deficit, sadness, loneliness, among others (NANDA 2021-2023) that, when not properly valued, diagnosed, and treated may lead not only to the loss of meaning in life, but also to the onset of physical illness, often disabling, and even death, thus also imputing costs to the National Health Service.
Jean Watson focuses on the spiritual aspects of the person and the relationship of human consciousness with the universe, the sense of the divine and the mystery surrounding life, recognizing the importance of spirituality in the non-physical and spiritual dimensions of the person’s existence as central (Tomey, A., Aligood, M., 2002). Thus, and according to Jean Watson’s Theory of Caring, which defines malaise as (…) “a restlessness or disharmony in a person’s inner self or soul (…) or disharmony within the person’s spheres; (…) in mind, body and soul” (…) and health as (…) “harmony in mind, body and soul.” (Watson, 2002, p.86), it seems to me the emergence of a bifocal vision in health care is urgently needed, in that, alongside the areas of prevention and treatment of COVID-19 infection, there is also an urgent investment in multidisciplinary care for the spiritual suffering of those who care.
I also consider it fundamental to open the field of vision of health professionals and their leaders, in order to lead to a paradigm shift. To this end, there is an urgent need to adopt a humanistic and holistic approach with a focus on love, respect for dignity, and spirituality (not only of the patient, but also of those who care for him or her), as well as care strategies directed at the caregivers, in order to restore to these informal caregivers and to these families their spiritual well-being and the meaning of life that is often lost.
An example of a caregiving strategy is the COVID-19 project: An Organizational-theory-guided Holistic Self_Caring and Resilience Project, based on the Caritas Program created by Jean Watson and the Faculty of Watson Caring Science Institute. This project, implemented in 2021 in a hospital in North Carolina (USA), focuses on the importance of nurses’ physical and psychological well-being, and their impact on the quality of care and relationship with the patient and family. It consisted in adopting a holistic approach with attention not only to the physical, but also to the psychological and spiritual well-being of nurses, through a continuous and close intervention with them, and the adoption of strategies (positive reinforcement, gratitude) and non-pharmacological measures (aromatherapy, relaxation sessions), which allowed the deconstruction of negative feelings and emotions, such as fear, anxiety, stress and burnout, left as a legacy of the COVID-19 pandemic. The concepts of healing through love and caring science were also integrated into their practice, which led to increased resilience and an authentic holistic experience, not only for nurses, but also for patients and their families (Barnett, P., Barnett, M., Borgueta, E., Watson, J., 2021).
In this sense, and taking into account that, according to Jean Watson (2002), nursing is the science of care based on love and on the totalitarian vision of the person, who is understood as a being-in-the-world, spiritual, magnificent, who is part of nature, not being only matter and having three dimensions: mind, body and soul, and the nurse who is understood as a coparticipant in the transpersonal process of caring who helps the person to find meaning, in the face of situations causing disharmony and suffering, the previously mentioned project presents itself as an excellent example of the path to follow for the deconstruction of the negative emotions and feelings of those who care, thus contributing to their spiritual well-being. However, for this, it is also essential to ensure the physical and emotional well-being of nurses, who are also tired and worn out by the ordeal of caring during this pandemic, as well as the allocation of responses and resources in the community capable of responding to this increasingly emerging problem.
Barnett, P., Barnett, M.,Borgueta, E.. Watson, J. (2021). COVID-19: a Organizational-theory-guided holistic self-caring and resilience project. Journal of Holistic Nursing, 39 (4), 325-335. https://journals.sagepub.com/doi/10.1177/08980101211007007
Brewer, B., Watson, J. (2015). Evaluation of Authentic Human Caring Professional Practices. JOURNAL OF NURSING ADMINISTRATION, 45 (12), 1-6. DOI: 10.1097/NNA.0000000000000275, accessed at https://www.watsoncaringscience.org/files/PDF/measurement/brewerwatson2015jona.pdf
Evangelista, C. B., Lopes, M. E., Nóbrega, M. M., Vasconcelos, M. F., & Viana, A. C. (2020). An analysis of Jean Watson’s theory according to Chinn and Kramer’s model. Nursing Journal Referência, 5(4), e20045. doi: 10.12707/RV20045
NANDA International – NURSING DIAGNOSES Definitions and Classification 2021–2023 [electronic book]; (12ª ed.) – New York: Thieme Medical Publishers, Inc.DOI 10.1055/b000000515
Tomey, A,. Alligood, M. (2002). Nursing Theorists and their work (5ª ed.). Lusociência
Watson, J. (2002). Nursing: Science and Human Care. A Theory of Nursing.em. Lusociência
*About Vanessa Silva
I graduated in Nursing in 2007 by the São Vicente de Paulo School of Nursing. I worked in the Pontinha Health Centre from 2007 to 2010, and now work in the Community Care Unit Nostra Pontinha-ACES Loures-Odivelas, since 2010 to date. I have been working for 14 years in the areas of community intervention, long-term care, and palliative care, accompanying the population throughout the various stages of their life cycle. I am a student in Master’s course in Nursing in the area of Community Nursing and Public Health at the Institute of Health Sciences of the Portuguese Catholic University of Lisbon. This post was made in the curricular unit of nursing theories of the Master Course in Nursing of the Institute of Health Sciences of the Portuguese Catholic University (Lisbon), with the pedagogical supervision of Professor Zaida Charepe (PhD, Associate Professor).