Community Mental Health Nursing Consultation in a Public Bathhouse: A Spiritual Coping Resource

: (1) Background: The spiritual dimension’s importance in health / disease processes is widely recognized, also being demonstrated by scientiﬁc evidence. Hence, its study is crucial, particularly with respect to a Mental health nursing consultation occurring in a community resource, such as a public bathhouse. This study aims to identify the nursing interventions of spiritual nature developed over 5 years in the abovementioned setting, thus characterizing the Portuguese reality; (2) Methods: Observational, cross-sectional and quantitative study, based on a sample comprising all users who attended a community Mental health nursing consultation, from March 2015, to 31 December 2019; (3) Results: A total of 205 nursing appointments were performed, from which emerged a set of 346 diagnoses, resulting in 455 nursing interventions. Of the latter, some deserve to be highlighted, due to a greater prevalence: “listening” (61; 13%), “supporting” (38; 8%), “promoting self-esteem” (37; 8%), “monitoring vital signs” (31; 7%), and “identifying attitude towards care” (25; 5%); (4) Conclusions: even though some of the interventions performed during the consultations were associated with the spiritual dimension, the collected data points towards a need for new diagnoses and nursing interventions, namely, those which may help mitigate spiritual distress.


Introduction
Public bathhouses (PB) have been available in Lisbon since the 1830s. They are community resources managed by the parish councils and aimed at offering bathing services to the vulnerable population. For many, the public bathhouse represents the last redoubt to satisfy a dignifying basic need. We were able to characterize PB users in previous studies. The typical user is a male (78.6%), single (66.2%), active (87.5%), residing in Alcântara (25.5%) and of Portuguese nationality. At the time, the main reasons to use the PB comprised the following: sanitary and economic conditions, solitude and being homeless (29.7%).
With respect to socio-economic status, most users did not possess an income source (57.2%), were homeless and used the PB frequently. Regarding the health status, the majority had no family physician (51%) and had not performed any checkups during the previous year (36.6%). They often presented morbidities, namely, mental pathologies (24.8%) (Seabra et al. 2017), as well as cardiovascular (19.3%) and infectious (15.9%) diseases (Figueiredo et al. 2016). The results of these diagnoses drew attention to the fact that PB lacked community intervention strategies capable of promoting and managing the health/disease processes of their users.
"Public Bathhouse Nursing" is a university extension project which proposes, as one of its objectives and within the scope of the nursing consultation, a contribution to the empowerment of PB users, aiming at a better self-management of the respective health/disease processes. This project has been integrated, since 2013, in the Nursing Research Platform (Lisbon) of the Centre for Interdisciplinary Research in Health of Universidade Católica Portuguesa, aggregating three major dimensions: education, research and service provision.
Regarding service provision, a Community mental health nursing consultation initiative has been implemented since 2015, in a PB context (Figueiredo et al. 2018), with the following objectives: contributing to the promotion of healthy lifestyles; identifying health problems and referring the affected individuals, whenever necessary, to national health system resources; identifying psychosocial risk factors; identifying mental health problems that require intervention; contributing to the minimization of psychic suffering, while empowering users to manage their health/disease processes.
This consultation presents unique characteristics, including: "walk-in" participation, freedom of choice to participate, and the possibility of participating anonymously. It is not uncommon to find desperate people, who wander in life and hardly recognize themselves in such a precarious existence. The nursing interventions identified during a 3 year time span (Figueiredo et al. 2018), in addition to the present study, conducted after 5 years, allow us to direct the consultation towards a nursing response centered on the spiritual needs of those who resort to it.
Furthermore, based on the identified nursing diagnoses and needs, we consider important highlighting the performed interventions, which gave voice to the participants, through active listening and emotional support, thus responding to specific needs, while permitting the participants' referral to adequate social and healthcare resources, when required.
In previous studies developed in this context, it was found that a considerable portion of PB users are homeless (FEANTSA 2017). Additionally, among PB users, there is a high percentage of individuals with mental health problems. These characteristics reflect a vulnerable population (Figueiredo et al. 2016;Seabra et al. 2017).
The spiritual dimension's importance in health/disease processes is recognized by national and international nursing associations, also being demonstrated by scientific evidence (Caldeira et al. 2011).
In this sense, the present study's objective is to identify the nursing interventions of spiritual nature which were carried out, over 5 years, in the PB's community mental health nursing consultation.
Spirituality and spiritual care are viewed, by nurses, as an important dimension of the nursing practice (Egan et al. 2017). However, it seems necessary to continue to discriminate the corresponding professional interventions. In the field of healthcare, there has been an evident growth of interest with respect to the spirituality phenomenon. Nonetheless, the progression of Portuguese research on this subject continues to be slow, especially when compared with international efforts (Romeiro et al. 2018).
When analyzing the concept of spirituality, the following definition emerges: "Spirituality is a way of being in the world in which a person feels a sense of connectedness to self, others, and/or a higher power or nature; a sense of meaning in life; and transcendence beyond self, everyday living, and suffering" (Weathers et al. 2015, p. 15).
Regardless of the aforesaid concept's complexity, spiritual care is acknowledged as an integrating dimension of nursing care (Ramezani et al. 2014), because it is associated with support and therapeutic effect, both in adverse health conditions and unexpected life events (Caldeira and Timmins 2017).
The conclusions of a study conducted by Ramezani et al. (2014) contain guidelines for educational policies to be applied in the field of Nursing, in an attempt to develop a curriculum focused on spirituality. Likewise, a comparative study which analyzed the presence of spirituality in the undergraduate curricula of Portuguese and Brazilian (São Paulo) Nursing Schools, carried out by Caldeira et al. (2016), concludes that such curricula should include specific theoretical and clinical knowledge.
The use of the consultation experience as a coping resource suggested the inclusion of a diagnosis related to the spiritual dimension. Through the described interventions, we comprehended apparently meaningless life stories, which reflected a deep anguish and were in accordance with the definition of spiritual distress. In this context, "[ . . . ] spiritual distress is an intimate, deep and suffering experience in life, which requires coping strategies and involves spiritual values and beliefs" (Romeiro et al. 2018, p. 13).

Materials and Methods
The present work corresponds to an observational, cross-sectional and quantitative study, based on a sample comprising all users who attended a community mental health nursing consultation, from March 2015 to 31 December 2019, resulting in a total of 205 appointments. Regarding the characterization of the consultation's user profile, the average age is 53 years, 63% are female, 12% are married, 38% are single, 40% are unemployed and 18% are retired.
The consultation was conducted employing an assessment instrument available in a digital file. All relevant information was saved in the Catholic University Nursing Center's database, by means of Microsoft Access (Amado et al. 2011). During the assessment procedure, several indicators were gathered, namely: structure indicators (users' socio-demographic characterization and clinical profile); process indicators (number and type of healthcare centers, as well as number and type of performed nursing interventions, according to the International Classification for Nursing Practice) and outcome indicators (number of appointments and number of referrals). All the collected data were saved, coded and analyzed. Descriptive statistics were used for that purpose. Anonymity and confidentiality were safeguarded throughout the process.
To assure the data's protection, an adequate registration was made at the Portuguese Data Protection Authority which resulted in database authorization No. 9673/2014. In this context, a Microsoft Access database was specifically created for the studied consultation. Its use was authorized for the recording of health-related information, being integrated in the university's activities. Only the professionals who performed the consultation had access to the database, in order to record the collected information, namely, the performed interventions, in accordance with the current international classification for the nursing practice.
The information's analysis and processing were conducted by researchers who did not deal directly with the participants, so as to guarantee the independence of the information which was reported and transferred to this analysis.
The facilities where the consultation took place provided the necessary privacy for the practice of nursing care. Furthermore, given the nature of the initiative-which required a progressive approach to the participants-in some cases, the nurses were not able to collect all the relevant data, because they favored the establishment of trust. Data were obtained according to an established protocol, but always respecting the circumstances of each participant, in order to favor a relationship of trust with the users during the continued care provision.

Results
In order to assist PB users, a total of 205 nursing appointments were carried out, from which emerged a set of 346 nursing diagnoses, resulting in 455 nursing interventions, as shown in Figure 1.

Results
In order to assist PB users, a total of 205 nursing appointments were carried out, from which emerged a set of 346 nursing diagnoses, resulting in 455 nursing interventions, as shown in Figure 1.

Nursing Interventions
Regarding the number and type of performed nursing interventions, the obtained data were recorded in the aforementioned database, following the 2013's version of the International Classification for Nursing Practice (ICNP) (International Council of Nurses 2019). To produce the findings presented within this document, all the information was analyzed, being also recoded in accordance with the 2019's version of the ICNP (International Council of Nurses 2019).
The nursing interventions' analysis revealed that the 15 most registered ones concentrated 69% of the total number of registers, as seen in Figure 2.

Nursing Interventions
Regarding the number and type of performed nursing interventions, the obtained data were recorded in the aforementioned database, following the 2013's version of the International Classification for Nursing Practice (ICNP) (International Council of Nurses 2019). To produce the findings presented within this document, all the information was analyzed, being also recoded in accordance with the 2019's version of the ICNP (International Council of Nurses 2019).
The nursing interventions' analysis revealed that the 15 most registered ones concentrated 69% of the total number of registers, as seen in Figure 2.

Results
In order to assist PB users, a total of 205 nursing appointments were carried out, from which emerged a set of 346 nursing diagnoses, resulting in 455 nursing interventions, as shown in Figure 1.

Nursing Interventions
Regarding the number and type of performed nursing interventions, the obtained data were recorded in the aforementioned database, following the 2013's version of the International Classification for Nursing Practice (ICNP) (International Council of Nurses 2019). To produce the findings presented within this document, all the information was analyzed, being also recoded in accordance with the 2019's version of the ICNP (International Council of Nurses 2019).

Discussion
In the context of clinical care, spirituality is often perceived as a tangential aspect, unless the patient is on the threshold of life. Nevertheless, evidence shows that, in the particular case of end-oflife care, spirituality is regarded as a priority. Most patients expect nurses to provide some form of spiritual care, through nursing interventions, such as active and empathetic listening, proactive communication, and expressing compassion (Hughes et al. 2017).

Discussion
In the context of clinical care, spirituality is often perceived as a tangential aspect, unless the patient is on the threshold of life. Nevertheless, evidence shows that, in the particular case of end-of-life care, spirituality is regarded as a priority. Most patients expect nurses to provide some form of spiritual care, through nursing interventions, such as active and empathetic listening, proactive communication, and expressing compassion (Hughes et al. 2017).
In the field of nursing, the available knowledge's evolution is essential to construct concepts, theories and models that allow a humanized and comprehensive care practice (Muñoz et al. 2013). This study supports the abovementioned perspective, based on the physical, mental, emotional and spiritual needs associated with care relationships according to Jean Watson's Theory of Human Caring-communication, empathy, harmony and trust (Tonin et al. 2017;Savieto and Leão 2016).
By analyzing the obtained results, it was found that the most frequent nursing interventions were: "listening", "supporting", "promoting self-esteem", "monitoring vital signs" and "identifying attitude towards care".
During the appointments, a person-centered approach was employed, in which active listening allowed a better knowledge of the individual, as well as of his/her spiritual resources and concerns. In this sense, the interventions that involve support and the promotion of self-esteem seem to enable the attribution of meaning to human existence and to one's life. A study by Egan et al. (2017), developed in New Zealand, demonstrates the importance of spirituality as a crucial aspect of holistic nursing care. Furthermore, according to Guilherme et al. (2016), the inclusion of spirituality in nursing care is pertinent, even when the goal is improving the patient's physical parameters.
The assessment of vital signs is primarily associated with the gathering of objective data. Nonetheless, it is often a mediating intervention, which facilitates other interventions that carry a greater significance for the individual's spirituality.
In the present study, the less frequent nursing interventions of the top 15 list were "assessing environmental conditions", "counseling about hope" and "establishing rapport". These interventions usually require more than one appointment and a continuity of care, which are often difficult to achieve in the studied context. This is a consequence, not only of the community resource's nature (Figueiredo et al. 2016), but also of the characteristics of its users and respective families, who are in a vulnerable situation (Figueiredo et al. 2018(Figueiredo et al. , 2019Figueiredo et al. 2020;Andrade et al. 2020).
The reflection derived from the consultation experience led us to consider the need to include, in the established protocol, a diagnosis related to the spiritual dimension, in addition to others related to the mental health dimension, which had been previously considered. We justify this need by identifying the following aspects in the participants' discourse: the central theme present in the definition of spiritual distress; the expression of the participants' suffering associated with lack of meaning, lack of work, lack of family support, social isolation, extreme loneliness, hopelessness and uncertainty regarding the future (Romeiro et al. 2018).
The obtained results reveal the researchers' necessity to identify spiritual suffering, through catalogued nursing interventions, in order to satisfy the patients' spiritual needs, while keeping in mind that the nurse is a spiritual being as well. Consequently, he/she has to achieve a high level of self-knowledge in the spiritual domain, given its extreme importance during care provision (Caldeira and Timmins 2017).
For the participants who were facing difficult situations, an increased spiritual coping enabled the development of strategies to better handle and solve the existent problems (Miranda et al. 2020).
Regarding the nurse's training, it is essential to safeguard the consolidation of empathic and affective links, as well as of communication skills. This will give the nurse the ability to gather qualities capable of improving the interpersonal human relationship between caregiver and care recipient (Savieto and Leão 2016).
By means of their active involvement, healthcare professionals have a key role to play in the acknowledgement of methods destined to enable and manage the patients' spirituality, and also in evidence-based research pertaining to that particular field (Keenan 2017).
After analyzing all these findings, the authors who participated in the "Public Bathhouse Nursing" initiative were lead to rethink the existent diagnostic classification system, contemplating the introduction of new nursing diagnoses related to the spiritual realm, when providing assistance in the studied community resource.
This research had some limitations: the dimension of the sample are not representative.

Conclusions
This study evaluated 5 years of care provision within the context of the community Mental health nursing consultation initiative. During that period, we were confronted with the participants' difficult life conditions, evidenced by their suffering and distress. Consequently, the most frequently registered nursing interventions were related to the participants' spiritual needs, namely: "listening", "supporting", "promoting self-esteem", "monitoring vital signs" and "identifying attitude towards care".
The collected data suggests the pertinence of introducing new diagnoses and nursing interventions in the aforesaid consultation, meant to contribute to the safeguard of humanity, dignity and life's meaning, amongst the vulnerable population that uses the consultation and the community resource itself.
The inclusion of an additional diagnosis will allow establishing strategies and interventions that are more directed towards spiritual care. Here, we refer specifically to strategies and interventions aimed at mitigating spiritual distress, often expressed by the participants through loose words, either during their final trips to the PB or during their elusive participation in the consultation, where they frequently avoid identifying themselves, so as not to express verbally their existence.