| Original Full Text | Citation: Casaleiro, T.; Martins, H.;Caldeira, S. Promoting SpiritualCoping of Family Caregivers of anAdult Relative with Severe MentalIllness: Development and Test of aNursing Intervention. Healthcare 2024,12, 1247. https://doi.org/10.3390/healthcare12131247Academic Editor: EvridikiE. PatelarouReceived: 10 April 2024Revised: 4 June 2024Accepted: 17 June 2024Published: 22 June 2024Copyright: © 2024 by the authors.Licensee MDPI, Basel, Switzerland.This article is an open access articledistributed under the terms andconditions of the Creative CommonsAttribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).healthcareArticlePromoting Spiritual Coping of Family Caregivers of an AdultRelative with Severe Mental Illness: Development and Test of aNursing InterventionTiago Casaleiro 1,2,* , Helga Martins 1,3,4 and Sílvia Caldeira 11 Faculty of Health Sciences and Nursing, Centre for Interdisciplinary Research in Health, UniversidadeCatólica Portuguesa,1649-023 Lisbon, Portugal; hemartins@ucp.pt (H.M.); scaldeira@ucp.pt (S.C.)2 Escola Superior de Enfermagem São Francisco das Misericórdias, Grupo Autónoma, 1169-023 Lisbon,Portugal3 Escola Superior de Saúde, Instituto Politécnico de Beja, 7800-111 Beja, Portugal4 Postdoctoral Program Integral Human Development, Católica Doctoral School, 1649-023 Lisbon, Portugal* Correspondence: tcasaleiro@esesfm.ptAbstract: Severe mental illness disrupts daily functioning, burdening family caregivers, who oftenadopt spiritual coping strategies. With comprehensive skills, mental health nurses can promotewell-being and mental health. The aim is to develop and test the nursing intervention “promotingspiritual coping” in the family caregivers of home-dwelling people with mental illness. This studywas conducted in two distinct stages. Initially, the intervention was developed according to thefirst phase of the Framework for Developing and Evaluating Complex Interventions. Secondly,the intervention protocol was tested in a mixed-method pilot study. An intervention protocol wasdeveloped and tested on ten family caregivers. The intervention comprised three sessions, andbefore-and-after assessments were conducted. Significant improvements were observed in theoutcomes, with caregivers expressing that discussing spirituality and religiosity benefited them.This intervention prioritized the therapeutic relationship of the nurses and family caregivers. Theintervention “promoting spiritual coping” was created and evaluated as a suitable approach formental health nurses to use in a psychotherapeutic context with family caregivers of individuals withmental illness.Keywords: caregivers; coping holistic nursing; nurses; nursing care; psychiatric nursing; spirituality;spiritual coping1. IntroductionPolicymakers and healthcare providers have addressed mental health challengesin recent decades but are not always effective and successful [1]. The World HealthOrganization has revealed that an estimated 13% of the world’s population has a mentalhealth disorder [1]. The impact and severity of mental illnesses vary, and some conditionsare categorized as severe or serious mental illnesses [2]. In 2019, approximately 4% ofthe population had a severe mental illness, including schizophrenia, conduct disorder,bipolar disorder, and major depression [3]. These numbers may be higher globally due tounderreporting for various reasons [1].The recovery-oriented approach to mental health is based on an integrated and compre-hensive approach that considers the holistic perspective of the individuals [4]. In addition,the recovery-oriented approach in mental health care also advocates for community-basedcare, with both formal and informal care [1]. Mental health nurses are specialized healthcareprofessionals who promote the mental health of individuals and groups and provide care,support, and treatment for individuals with mental health issues.Caregiving is a challenge for family caregivers who must adapt to the needs of theirrelatives [5]. These caregivers face a higher probability of developing emotional stressHealthcare 2024, 12, 1247. https://doi.org/10.3390/healthcare12131247 https://www.mdpi.com/journal/healthcareHealthcare 2024, 12, 1247 2 of 15and depressive symptoms [6]. Different coping strategies are used by caregivers, suchas cognitive strategies, problem- and/or emotion-focused coping, and religious/spiritualcoping [7]. Gall and colleagues proposed a Spiritual Framework of Coping [8]. This seminalwork suggests that when facing a stressor, a person appraises the situation influenced bypersonal factors, meaning in life, spiritual connections, and spiritual coping behaviors [8].A systematic review explored the spiritual aspects of family caregivers of relatives withsevere mental illness, identifying both spiritual needs and spiritual coping strategies usedby caregivers [9]. This review revealed that caregivers facing stressful situations turn to thesacred, conduct spiritual/religious practices/rituals, and adhere to a formal religion [9].Recent research shows that positive spiritual/religious coping strategies positively impactmental health and quality of life [10].Mental health nurses regularly contact family caregivers, supporting their role andpromoting coping behaviors. However, a qualitative study revealed that few mental healthnurses provide spiritual care [10]. These professionals acknowledge the lack of trainingand time required to adequately address spirituality [11].Moreover, the debate about spirituality in psychiatric and mental health nursing isgrowing, and a recent study revealed that the attention to spirituality in mental healthpractice by mental health nurses was influenced by their religiosity, spiritual perspectives,and years of experience [12]. These factors should be taken into account in researchconducted in this field.Since evidence shows the impact of positive spiritual coping, mental health nursesare urged to address spiritual needs and promote coping. This path has challenges andopportunities [13]. There may persist some resistance regarding spiritual care. Nevertheless,there is still a moral and ethical mandate to promote personal resources that impact thewell-being, burden, and satisfaction of family caregivers of adults with severe mentalillness.The existence of an intervention to promote spiritual coping would help nurses supporttheir practice and assess the impact of the intervention. Therefore, this study aims todevelop and test the nursing intervention ‘promoting spiritual coping’ for family caregiversof a community-dwelling adult relative with severe mental illness.2. Materials and MethodsThis study was conducted in two stages. In the first stage, the main goal was todevelop an intervention, and a two-step exploratory, descriptive, mixed-methods studywas conducted, corresponding to the first phase of the Framework for Developing andEvaluating Complex Interventions [14]. The intervention protocol was tested in a mixed-method pilot study embedded in the framework’s feasibility phase in the second stage. Thetests were conducted in Lisbon, Portugal.2.1. Part 1: Development of the InterventionThe guidelines for developing interventions, according to O’Cathain et al. [15], wereconsidered to operationalize the development stage. A spiritual intervention in the On-cologist Assisted Spiritual Intervention Study (OASIS), implemented by oncologists, wasfound [16]. This intervention consisted of a spiritual inquiry into how people cope withcancer. The current study modified the intervention in OASIS to suit a different contextand population.We engaged with various stakeholders to evaluate how this intervention could betailored to the specific context. The initial version of the intervention was developed andpresented to two separate online focus groups: one comprised family caregivers and theother consisted of professionals, including mental health nurses and researchers in thefield. Due to the geographical spread of the participants and COVID-19-related restrictions,online focus groups were deemed appropriate for this study. The first group was composedof a non-probabilistic sample of four family caregivers of adults with severe mental illnesses,and a caregivers’ association facilitated recruitment. The second group included six nursesHealthcare 2024, 12, 1247 3 of 15with extensive experience in practice, teaching, and research who were invited by e-mail.The groups met separately, completing one session each. The sessions took place online inJuly 2021 and took around 90 min. The groups were asked for their opinion about essentialaspects regarding the suitability and pertinence of the intervention, participants, place,procedure, and content of sessions (Figure 1). Both groups received previously, by e-mail,the first version of the intervention protocol, and the interview followed its structure forassessment of the participants.Healthcare 2024, 12, x FOR PEER REVIEW 3 of 15 presented to two separate online focus groups: one comprised family caregivers and the other consisted of professionals, including mental health nurses and researchers in the field. Due to the geographical spread of the participants and COVID-19-related restrictions, online focus groups were deemed appropriate for this study. The first group was composed of a non-probabilistic sample of four family caregivers of adults with severe mental illnesses, and a caregivers’ association facilitated recruitment. The second group included six nurses with extensive experience in practice, teaching, and research who were invited by e-mail. The groups met separately, completing one session each. The sessions took place online in July 2021 and took around 90 min. The groups were asked for their opinion about essential aspects regarding the suitability and pertinence of the intervention, participants, place, procedure, and content of sessions (Figure 1). Both groups received previously, by e-mail, the first version of the intervention protocol, and the interview followed its structure for assessment of the participants. Figure 1. Session plans of the first version of the intervention. Deductive content analysis was performed according to Kyngäs and Kaakinen [17]. According to this method, a structured analysis matrix can be defined beforehand. The sessions followed the intervention protocol and allowed the participants to give further comments. The matrix included participants, place, procedure, and session content. The session audio was recorded and transcribed by the lead researcher, then reviewed and validated by an observer, as two researchers were involved in conducting the interviews. The units of analysis were highlighted. The units were then coded using NVivo 13 software [18]. The units were inserted in the predefined categories of the matrix. When needed, subcategories were defined. After analysis, changes were performed in the intervention protocol. The second version was presented to a panel of nurses, aiming for consensus. Following the TIDieR-PHP checklist [19], a modified e-Delphi was conducted, considering the nurses’ focus group as the first round and one round of questionnaires sent to the participants’ e-mails [20]. They were asked if they agreed with the elements of the intervention: title, pertinence, participants, local, content of session, number and time of sessions, feasibility, and modifiability of the intervention. The answer was on a 4-item Likert scale ranging from totally disagree to totally agree. Participants were offered an open space to comment on each question. The criteria for consensus were adapted from Fink et al. [21]: only those topics that received a mean rating of two or higher were accepted. Additionally, only the issues supported by at least 75% of the participants were adopted, and if more than 65% totally agreed with the item (rate four), it was considered a higher consensus. 2.2. Part 2: The Test of the Intervention A pilot study was conducted to assess the intervention’s results in a small group and test the processes [22]. The hypothesis that the intervention ‘promoting spiritual coping’ Figure 1. Session plans of the first version of the intervention.Deductive content analysis was performed according to Kyngäs and Kaakinen [17].According to this method, a structured analysis matrix can be defined beforehand. Thesessions followed the intervention protocol and allowed the participants to give furthercomments. The matrix included participants, place, procedure, and session content. Thesession audio was recorded and transcribed by the lead researcher, then reviewed andvalidated by an observer, as two researchers were involved in conducting the interviews.The units of analysis were highlighted. The units were then coded using NVivo 13 soft-ware [18]. The units were inserted in the predefined categories of the matrix. When needed,subcategories were defined. After analysis, changes were performed in the interventionprotocol.The second version was presented to a panel of nurses, aiming for consensus. Fol-lowing the TIDieR-PHP checklist [19], a modified e-Delphi was conducted, consideringthe nurses’ focus group as the first round and one round of questionnaires sent to theparticipants’ e-mails [20]. They were asked if they agreed with the elements of the interven-tion: title, pertinence, participants, local, content of session, number and time of sessions,feasibility, and modifiability of the intervention. The answer was on a 4-item Likert scaleranging from totally disagree to totally agree. Participants were offered an open space tocomment on each question. The criteria for consensus were adapted from Fink et al. [21]:only those topics that received a mean rating of two or higher were accepted. Additionally,only the issues supported by at least 75% of the participants were adopted, and if morethan 65% totally agreed with the item (rate four), it was considered a higher consensus.2.2. Part 2: The Test of the InterventionA pilot study was conducted to assess the intervention’s results in a small group andtest the processes [22]. The hypothesis that the intervention ‘promoting spiritual coping’does not affect spiritual coping, quality of lif related to physical and mental health, orthe burden of caregivers of relatives with severe m ntal illness living at home was tested.The intervention consists of three sessions, one-to-one, delivered across six weeks. Theintervention in the current study took into account both the Spiritual Framework of Copingby Gall and colleagues [8] and the Nursing Theory of Self-Transcendence by Reed [23].Healthcare 2024, 12, 1247 4 of 152.2.1. ParticipantsA non-probability convenience sampling method was used to select ten participants.The number of participants is minimal when the aim is to test the process and assess itsacceptance [24]. The inclusion criteria were defined as adult family caregivers of an adultwith severe mental illness living at home. A family member is considered to have a first-or second-degree kinship. All individuals who wished to participate in this study anddemonstrated their capacity to consent were included. Family caregivers of adults withthe following mental illnesses and comorbidities were excluded: substance use disorder,dementia, and neurodevelopmental disorders, along with family caregivers who obtaineda score of 0 on the Brief RCOPE-PT instrument when completing the questionnaire.The mental health community team provides care to around 75 persons with severemental illness. The participant’s enrollment process started with a mental health nursefrom the mental health community team making the first contact with the family caregivers.Consent was obtained to provide their contact information to the principal investigator.After this step, the principal investigator (first author) made an initial phone call to eachparticipant and initiated the intervention following the protocol.2.2.2. InstrumentsIn this study, four instruments were used for data collection. Firstly, a sociodemo-graphic questionnaire was developed for this phase of the study. Then, the Brief RCOPE-PTscale (13 items), already validated in European Portuguese for family caregivers of peoplewith health problems [25]—Brief RCOPE-PT—was used. This is a two-dimension instru-ment. The positive spiritual coping subscale’s score ranges from 7 to 28, and the negativespiritual coping ranges from 6 to 24. The highest value represents the frequent use ofthe coping strategy. The second version of the 12-item Short Form Health Survey—SF-12v2 [26]—was used to assess the health-related quality of life. This instrument assesses notonly physical but also mental health. The scores range from 0 to 100. A score of 0 indicatesthe lowest level, and 100 is the highest. The brief version of the Informal Caregiver BurdenAssessment Questionnaire (QASCI) [27] was used to assess the burden. In this instrument,higher scores represent a higher burden, and scores range from 0 to 100.2.2.3. Data CollectionThe researcher who conducted the intervention applied the four instruments beforethe intervention and immediately after the intervention.After the intervention, an open-ended question was aimed at obtaining participants’experiences during the intervention. The use of the mixed methodology in the feasibilitytest is based on the philosophical perspective of critical realism, which allows for a positivistapproach, evident in the quantitative study, with the constructivist approach that collectsparticipants’ experiences throughout the intervention [28].2.2.4. Statistical AnalysisIBM SPSS Statistics 28 software was used to analyze the quantitative data. A de-scriptive analysis was performed, and the internal validity of each scale, both pre- andpost-intervention, was calculated using Cronbach’s alpha homogeneity test. Additionally,the median and 25–75 percentiles for each instrument’s pre- and post-intervention resultswere calculated. Individual changes in the scores of each instrument were also calculated.A non-parametric Wilcoxon test for two paired samples was used to test the hypothe-ses, and the significance level was set at p ≤ 0.05. A non-parametric test was chosenbecause the conditions for parametric tests were not met as the sample size was less than30 participants [29].Healthcare 2024, 12, 1247 5 of 152.2.5. Content AnalysisRecordings were transcribed, and inductive content analysis was performed followingthe guidelines of Kyngäs [28] to analyze qualitative data obtained through an open-endedquestion.First, units of analysis were defined as words or phrases. Categories were then createdby combining two or more units of analysis [30]. The text was coded using NVivo 13software (QSR International Pty Ltd., Doncaster, Australia).2.3. Ethical ConsiderationsAll procedures were performed according to ethical standards, and the institutionalethics committee approved this study. All participants provided written informed consentfor participation in this study, the recording of the audio of the focus groups, and the open-ended questions in the pilot test. In addition, measures were taken to preserve participants’anonymity and confidentiality through the attribution of codes to each participant and theremoval of aspects that could identify the participants.The researchers and nurses involved in the research have their own religious andspiritual beliefs. Efforts were made to ensure that the research team’s spiritual or religiousbackgrounds or beliefs did not put respondents under pressure to engage in the research inparticular ways. This was achieved through regular meetings and supervision after contactwith the participants.3. Results3.1. Part 1: Development of the InterventionThe focus groups included ten participants: four family caregivers (P1–P4) and sixnurses and researchers (P5–P10).After coding the transcripts with NVivo, the analysis matrix was completed [17] withinformation from both focus groups. The pre-established categories were participants inthe intervention, place, procedure, and content. The item “Procedure” was divided intotwo subcategories: the number of sessions and follow-up sessions. The item “Content” wassplit into two subcategories: introduction and the concepts of spirituality vs. religiosity. InTable 1, it is possible to identify some units of analysis that were categorized, including theprocedure category, with more comments.Table 1. Categorization of findings in focus groups.Categories Number of Codes ExamplesParticipants in the intervention 8“[it was important that] this theme was part of the standardintervention attributed to the healthcare team, and it could beattributed to nurses” (P2)“This intervention could be part of nursing care as a complement ofthe relationship established with the persons” (P3)Place 5 “in what concerns with the place, I think it depends on theparticipants, the place where they feel comfortable” (P2)ProcedureNumber of sessions 16 “if the aim is to capacitate for spiritual coping, then it is neededmore [sessions]” (P7)Follow up 7“I think that two sessions may be enough, but there is a risk thatthe caregivers feel a connection with the nurse and look for furthersupport” (P2)“It feels that we look at the persons, we raise a bunch of questions,talk with him or her once again, and then we vanish” (P7)ContentIntroduction 10“[in the beginning] to open more, to ask a broader question (. . .)how the person is dealing with the experience . . . so . . . don’t directimmediately to spiritual coping” (P7)Spirituality vs.religiosity 6“not focus that much in the interventions directed to religiosity butalso give caregivers some suggestions regarding spirituality” (P6)Healthcare 2024, 12, 1247 6 of 15Through a deductive content analysis, it was possible to confirm the aspects regardingthe participants in the intervention and the place of intervention in the first version of theprotocol. Nevertheless, comments and suggestions regarding the number of sessions andtheir content made the need for changes in the intervention evident. The focus group offamily caregivers considered the intervention pertinent and useful, and their commentswere in line with the intervention’s characteristics. The focus group of experts raisedmore questions regarding the procedure and the content. The research team considered itimportant to obtain consensus on the new version of the intervention.A new version of the intervention has been developed (Figure 2). The second versionconsisted of three sessions. Some questions regarding experience as a caregiver were added.The terms “spirituality” and “religion/religiosity” were also clarified.Healthcare 2024, 12, x FOR PEER REVIEW 6 of 15 “It feels that we look at the persons, we raise a bunch of questions, talk with him or her once again, and then we vanish” (P7) Content Introduction 10 “[in the beginning] to open more, to ask a broader question (…) how the person is dealing with the experience … so … don’t direct immediately to spiritual coping” (P7) Spirituality vs. religiosity 6 “not focus that much in the interventions directed to religiosity but also give caregivers some suggestions regarding spirituality” (P6) a deductive co tent analysis, it was possible to confirm he aspects regarding the participa ts in the intervention and the place of i tervention in the first version of the protocol. Nevertheless, comments and suggestions regarding the number of sessions and th ir co tent made the need for changes n the ntervention evident. The ocus group of family caregivers considered the intervention pertine t and useful, a d th ir comm nts wer i line with the interv ntion’s characteristics. The focus group of experts raised more questions regar ing the procedur and the content. The research t am considered it important to obtain consensus on the new version of the intervention. i f t i t ti l ( i ). i c siste of three sessions. Some questions regarding experience s a caregiver were added. The terms “spirituality” and “religion/religiosity” were also clarified. Figure 2. Session plans of the second version of the intervention. The six experts were then invited to respond to a modified e-Delphi. All the participants answered positively. The questionnaire included ten closed-ended questions with a four-item Likert scale. The criteria for consensus were obtained during the first round. All the topics were accepted; more than 75% of the participants rated each item 3 or 4. Five out of ten received higher accordance, as more than 65% of the experts rated them as 4. In addition to the closed question, it provided an open space for the experts’ comments. The consensus was generally high concerning the relevance of the intervention, but a noteworthy comment questioned its applicability to individuals who do not use spiritual coping strategies. A stipulation was incorporated into the protocol to address this concern, specifying that the intervention ends if an individual responds defensively or declines to engage with this spiritual aspect. Additionally, one expert emphasized the importance of caregivers’ prior interactions with psychiatric and mental health nurses, as a pre-existing therapeutic rapport is deemed essential. Consequently, it was included in the protocol that caregivers should already have some level of contact with the mental health team. Regarding the intervention’s dosage, there was a consensus recommending a minimum session length of 45 min, and one expert suggested incorporating a follow-up session. Concerns also arose regarding session closure, prompting the addition of a directive in each session and at the intervention’s conclusion, emphasizing the nurse’s role in reviewing the session and procedure to enhance the caregiver’s autonomy. Fig re 2. Session lans of the secon version of the intervention.si experts were then i vited to respond to a modified e-Delphi. All the par ici-nts answered positively. Th questionnaire i cluded ten clos d-ende questions w th afour-item Lik rt scal .i i i i fi . ll it ; r t f t rti i ts r t it r . i t f t r ii er cc r ce, s re t f t e e erts r te t e s . I iti t t eclose estio , it ro i e a o e s ace for t e ex erts’ co e ts.The consensus as generally high concerning the relevance of the intervention, but anoteworthy comment questioned its applicability to individuals ho do not use spiritualcoping strategies. A stipulation as incorporated into the protocol to address this concern,specifying that the intervention ends if an individual responds defensively or declines toengage with this spiritual aspect. Additionally, one expert emphasized the importance ofcaregivers’ prior interactions with psychiatric and mental health nurses, as a pre-existingtherapeutic rapport is deemed essential. Consequently, it was included in the protocolthat caregivers should already have some level of contact with the mental health team.Regarding the intervention’s dosage, there was a consensus recommending a minimumsession length of 45 min, and one expert suggested incorporating a follow-up session.Concerns also arose regarding session closure, prompting the addition of a directive in eachsession and at the intervention’s conclusion, emphasizing the nurse’s role in reviewing thesession and procedure to enhance the caregiver’s autonomy.At the end, the intervention consisted of three sessions, conducted by one mentalhealth nurse, the first two spaced two weeks apart, with the final session scheduled onemonth later. Each session lasted between 45 and 60 min. An interview guide was designedto assist the nurse, but modifications to the topics could occur depending on the caregiver’sneeds (Appendix A). The interview included questions about the experience of caring for arelative with mental illness and the use of spirituality as a way to cope with stress.Healthcare 2024, 12, 1247 7 of 15This modified e-Delphi assessed the validity of the intervention ‘promoting spiritualcoping of family caregivers of a relative with severe mental illness’.3.2. Part 2: The Test of the InterventionThe pilot study was conducted between June and October 2022 with a sample of 10family caregivers of individuals with severe mental illness living at home. The mentalhealth nurse from the community mental health center referred the family caregivers andmade the first contact. The three intervention sessions occurred at the caregivers’ chosenlocations: at home and in other public spaces. The protocol was followed throughout theintervention with all participants.Table 2 provides an overview of the sociodemographic characteristics of the partici-pants. The average age of the individuals being cared for in this sample was 48.6 years, witha standard deviation of ±10.56. The majority (6 out of 10) of them had a mood disorder,while psychotic disorders (2 out of 10) and personality disorders (2 out of 10) were alsoidentified.Table 2. Characteristics of the pilot test’s participants.NGenderFemale 9Male 1Caregiver’s age (µ = 61.8)Under 45 1Between 45 and 54 years 1Between 55 and 64 years 3Over 65 years 5Marital statusSingle 2Married/Civil partnership 6Widower 1Divorced 1Education1st cycle of primary education (4th year) 3Secondary education (12th grade) 6Higher education (bachelor’s, bachelor’s,master’s, or doctorate) 1Degree of kinshipFather/mother 5Son/Daughter 1Sibling 3Partner 1Level of carePermanent 6Regular, but not permanent 4CohabitationYes 6No 4Religiosity/spiritualitySpiritual and religious 8Spiritual but not religious 2ReligionNo religion 2Christianity (Roman Catholic church) 6Jehovah’s witnesses 2Healthcare 2024, 12, 1247 8 of 15During the intervention, it was possible to identify those caregivers engaged in privateand communitarian religious or spiritual practices, such as individual prayer, contact withnature, and participation in religious services and sacraments.The instruments used in the pilot study revealed a good internal consistency in boththe pre- and post-intervention: Brief RCOPE (T0 α = 0.71; T1 α = 0.76); Brief RCOPE positivereligious coping subscale (T0 α = 0.94; T1 α = 0.94); Brief RCOPE negative religious copingsubscale (T0 α = 0.77; T1 α = 0.72); QASCI (T0 α = 0.66; T1 α = 0.70); SF-12v2 Physical HealthSummary (T0 α = 0.93; T1 α = 0.95); and SF12v2 Mental Health Summary (T0 α = 0.89; T1α = 0.90). The individual changes in the scores (see Supplementary Information) revealthat 8 out of 10 participants had positive changes, and 2 out of 10 had no change in theBrief RCOPE positive religious coping subscale; 6 out of 10 had positive changes, and 4 outof 10 with no change in the Brief RCOPE negative religious coping subscale. Regardingthe burden, 8 out of 10 participants changed positively, whereas two remained with thesame score. In the Physical Health Summary of SF-12v2, seven participants had a negativechange, and three improved. Inversely, eight participants had a positive change in themental health summary and two had a negative change.Table 3 contains the summary of the 25th percentile (Q1), median, and 75th percentile(Q3). In the subscale of Positive Spiritual Coping of Brief RCOPE and in the Mental HealthSummary of SF-12v2, the median increased, showing an enhancement in these outcomes.The median of the QASCI reveals a decrease in burden. The results regarding the PhysicalHealth Summary of SF-12v2 show slight changes in all quartiles. The Negative SpiritualCoping subscale results show that the median did not vary but there was a change inboth Q1 and Q3. In all the outcomes, there were changes in both Q1 and Q3, suggestinga widespread impact, affecting both the lower and higher ends of the score distribution.The interquartile range showed mixed results, with a small increase in the variabilityof the scores in the Positive Spiritual Coping subscale and the Mental Health Summary,and a small decrease in the other outcomes. Additionally, a summary of Wilcoxon’ssigned rank test results is provided as a supplement. The results also demonstrate thatthe intervention enhances the quality of life related to mental health in these participants(p = 0.047, Z = −1.988 a). However, the hypothesis that the intervention improves thequality of life related to physical health was rejected (p = 0.285, Z = −1.070 b).Table 3. Summary of median and percentiles pre- and post-intervention.Pre-InterventionQ1, Mdn, Q3Post-InterventionQ1, Mdn, Q3StatisticspBrief RCOPE-PT—PositiveSpiritual Coping 13.00, 16.5, 23.75 14.75, 18.5, 26.25 0.011 *Brief RCOPE-PT—NegativeSpiritual Coping 7.00, 8.00, 10.25 6.75, 8.00, 9.25 0.024 *SF-12v2—Physical HealthSummary 55.84, 58.5, 59.88 55.68, 57.92, 59.18 0.285SF-12v2—Mental HealthSummary 52.04, 53.55, 54.62 53.27, 54.39, 56.54 0.047 *QASCI 38.84, 49.11, 54.46 36.61, 45.54, 50.45 0.011 *Legend: Q1—25th percentile; Q3—75th percentile; Mdn—median; * Indicates a statistically significant change.Regarding the outcome of positive spiritual coping, the findings show that the inter-vention increases positive spiritual coping (p = 0.011, Z = −2.539 a). Similarly, the resultsshow that negative spiritual coping decreases after the intervention (p = 0.024, Z = −2.264 b).Furthermore, the family caregiver burden decreased with the intervention (p = 0.011,Z = −2.536 b).Healthcare 2024, 12, 1247 9 of 15In the third session, an open question was posed regarding experience during theintervention. After a careful review of the documents, 21 units were identified. Consideringthese similarities, five categories have emerged (Table 4).Table 4. Inductive content analysis.Examples of Analysis Units Number of Units of Analysis Category“[These issues] are not always talked about by nurses and otherhealth professionals” (P2)“Normally, these subjects are not spoken” (P4)“Initially, I thought it was strange for a nurse to talk about thesethings” (P9)3 Taboo“For me, it was positive to talk about this topic but also to be able tovent about my concerns” (P5)“What I am now talking to you also helps me in other aspects, in myday-to-day life” (P6)“But I keep thinking I miss support in other aspects of my life.” (P10)4Interconnectionspirituality with caringexperience“At first I didn’t realize what spirituality was, but now I know it’smore than going to church because I’m away” (P2)“I end up knowing other things, and spirituality is what also movesme to have more strength in the day-to-day, to help me in theday-to-day, which is not easy...” (P3)“I realized how good this can be to take care of me... Being in nature,helping others, having moments for myself. I need to take care ofmyself” (P9)3 Increase of knowledgeand strategies“To talk about it, it is always good; it always does us much goodspiritually in our life” (P1)“It is quite useful” (P3)“It is important for nurses to talk about this topic from the moment ithelps us” (P6)3 Relevance of theintervention“It is very important to me, I enjoyed talking, talking to you” (P1)“I enjoyed talking about these topics” (P2)“It was nice to know they cared about that... I felt moreunderstood.” (P7)“Talking about it does me good” (P8)8 Satisfaction with theintervention4. DiscussionIn this study, a specialized nursing intervention was developed that engaged stake-holders and focused on the essential aspect: the therapeutic relationship between thenurse and the person, in this case, the family caregiver. The research was centered onnursing practice, contributing an additional intervention that can address the needs of anoften-neglected population.In the development phase of the current study, the caregivers considered the interven-tion relevant and important as part of the attention given to the caregivers. Additionally,they reinforced that this intervention needs to target family caregivers with prior contactwith a mental health team. Given all the above, this population is overloaded at differentlevels and needs a complex response from several areas [31]. Thus, addressing spiritualissues cannot be disconnected from other needs and challenges associated with the caregiv-ing experience. Embracing this holistic perspective is a step further in delivering care inthe mental health field [4].The development of this intervention considered the different stakeholders involvedin the care delivery. This iterative process changed a two-session intervention stronglyfocused on the spiritual dimension into a three-session intervention with broader questions.The sample characteristics closely resemble the findings from a European study [32]:predominantly female caregivers over 45, with a notable proportion being elderly (5 outof 10). One aspect that was most evident in this sample was the aging of the caregivers,Healthcare 2024, 12, 1247 10 of 15which we highlight is a public health concern due to the associated vulnerabilities [33].Regarding the caregivers’ spirituality and religiosity, the majority are Roman Catholics,which is similar to what was found in a survey on religion in the geographical area ofLisbon, Portugal [34].Conducting a pilot study with a small sample allows for the identification of aspects ofthe intervention to be changed. Data collection is assumed to be preliminary and allows forestimating the effectiveness of the intervention in a future randomized study. Hypotheseswere tested with pre- and post-intervention evaluations. This initial data collection isconsidered one of the elements of the guidelines for the development of interventions [15].Regarding the quality of life related to health, it was established that the interventionin this sample does not increase the quality of life related to physical health. However,effectiveness was observed regarding the quality of life related to mental health. In theintervention protocol, some issues are linked to the caregiving experience and the use ofother coping strategies in addition to those related to spirituality. Relating the contentanalysis results to caregivers’ experience in this intervention, this was demonstrated inthe “interconnection of spirituality with caregiving experience” category. In this category,caregivers reveal that the intervention is linked with spirituality and other aspects of theirlives.The findings of the positive spiritual coping, measured through the positive religiouscoping subscale of Brief RCOPE-PT, show that the intervention increased the spiritual cop-ing values. In addition, the intervention decreased the negative spiritual coping assessedthrough the instrument. The caregivers revealed that the intervention allowed for an in-crease in knowledge and spiritual coping strategies, as evidenced through content analysis.Furthermore, it was possible to verify a decrease in caregiver overload, considering thetotal value of the scale.The positive spiritual coping subscale results point to the use of spirituality to a greateror lesser degree. If spirituality is a vital resource, the intervention can help maintain thisresource. In a qualitative study on elderly spirituality, it was identified that the best way toprovide spiritual support depends on how the older person expresses that same spirituality,which is the starting point [35].Now, focusing our attention on the content analysis of the responses to the open-endedquestion at the end of the intervention, we can still find some reservations in talking aboutspirituality issues because family caregivers do not feel an openness to talk about the subjector consider that this is a field of nurse intervention. This finding aligns with what wasidentified in Cone and Giske’s [36] study, where mental health professionals themselvesidentify difficulty in addressing the subject.In general, the caregivers showed satisfaction with the intervention and considered itrelevant, although with the caveat that exploring this topic should not be isolated from otheraspects of caregiving. This aspect had already emerged previously in the caregiver focusgroup. These findings support the value of addressing the physical, emotional, social, andspiritual aspects of a person’s life in the context of their mental health recovery-orientatedplan [4].When analyzing the procedure, a psychoeducational dimension became evident,which involves teaching coping strategies to deal with emotions resulting from role perfor-mance. However, this psychoeducational dimension is based on an established relationshipwith psychotherapeutic foundations. In a recent systematic review and meta-analysis ofstudies conducted with family caregivers, the effect of different mental health interventionson their mental health was widely identified [37]. Therefore, the efficacy was recognizedin studies with psychoeducation, psychosocial interventions, multicomponent cognitivebehavioral therapy, mindfulness, and interventions with support groups [37].We align with a perspective advocating that mental health and psychiatric special-ist nurses are competent enough to conduct psychotherapeutic interventions in mentalhealth [38]. The latest statement is reinforced by authors who proposed a model of psy-chotherapeutic intervention in nursing with an integrative approach of brief or intermediateHealthcare 2024, 12, 1247 11 of 15duration, based on the therapeutic relationship in different settings and with a sessionduration between 45 and 60 min [39].5. Conclusions5.1. LimitationsIn the first part of this study, the stakeholders were invited to provide feedback on thepertinence and suitability of the intervention. The intervention protocol received insightfulcomments from the focus groups, but the number of participants was restricted. Theparticipation of a larger and more diverse group would enrich the discussion and notesome aspects that may have been neglected. For instance, spiritual support workers orchaplains could have been part of the focus group.The pilot test was the first step towards a future randomized clinical trial to assessthe intervention’s effectiveness with control and experimental groups. Apart from thesmall sample, it is also identified as a limitation of the assessment immediately after theintervention. Nevertheless, the impact of the intervention over time is unknown.It is possible to identify not only a predominance of Christian denominations in thissample but also an aging group of participants. This represents a limitation as the impact ofthe intervention on caregivers with other characteristics, such as being from other cultures,backgrounds, and ages, is unknown. Nurses must acknowledge spiritual and religiousdiversity with increased migration across countries [40].Concerning the intervention, a significant limitation is the difficulty in isolating theindependent variable. When delivering the intervention, the mental health nurse developsa therapeutic relationship with the person so that other factors may confound the results.Another challenge is the difficulty in standardizing the intervention, as it depends on thetherapeutic relationship established. Still, one of the strategies to reduce this limitationcould be a training activity for professionals who implement this intervention in clinicalpractice.5.2. Implication for PracticeThe intervention ‘promoting spiritual coping’ for family caregivers of people withsevere mental illness can be considered a brief psychotherapeutic intervention in clinicalpractice carried out by a mental health nurse.Throughout this intervention in clinical practice, nurses can facilitate caregivers ofpeople with severe mental illness to reframe their experiences and find meaning. Throughself-transcendence, caregivers acknowledge vulnerability and boundaries, with nursesleading the self-transcendence process. This fosters connections with self, others, nature,and the transcendent, aligned with caregivers’ beliefs. Given the risk of isolation, nursesmust attentively identify and provide therapeutic support to help the caregivers. Theassistance for family caregivers is often neglected and overlooked, as the health systemsfocus on the person with mental illness. If they were less burdened and had a better qualityof life, family caregivers would be more able to maintain the role of caregiver.Supplementary Materials: The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/healthcare12131247/s1, Table S1: Individual changes in scores—Brief RCOPE positive religious/spiritual coping; Table S2: Individual changes in scores—BriefRCOPE negative religious/spiritual coping; Table S3: Individual changes in scores—QASCI; Table S4:Individual changes in scores—SF-12—Physical Health Summary; Table S5: Individual changes inscores—SF-12—Mental Health Summary; Table S6: Summary of Wilcoxon’s signed rank test resultscomparing baseline (T0) with post-intervention assessment (T1).Author Contributions: Conceptualization, T.C. and S.C.; methodology, T.C., H.M. and S.C.; software,T.C.; validation, H.M. and S.C.; formal analysis, T.C., H.M. and S.C.; investigation, T.C. and S.C.;resources, T.C. and S.C.; data curation, T.C. and S.C.; writing—original draft preparation, T.C.;writing—review and editing, H.M. and S.C.; visualization, T.C., H.M. and S.C.; supervision, S.C.;funding acquisition, S.C. All authors have read and agreed to the published version of the manuscript.Healthcare 2024, 12, 1247 12 of 15Funding: National Funds financially supported this work through FCT—Fundação para a Ciência ea Tecnologia, I.P., under the project UIDB/04279/2020.Institutional Review Board Statement: This study was approved by the institutional ethics committee(Comissão de Ética para a Saúde—Centro Hospitalar Psiquiátrico de Lisboa on 4 November 2020.Approval numbers 08/2020 and 09/2020).Informed Consent Statement: Informed consent was obtained from all subjects involved in thisstudy.Data Availability Statement: Dataset available on request from the authors.Acknowledgments: This review contributes to author T.C.’s Ph.D. The authors acknowledge andthank the participants involved in the different stages of this study.Conflicts of Interest: The authors declare no conflicts of interest.Appendix AIntervention: Promoting Spiritual Coping in Family Caregivers of Individuals withSevere Mental IllnessParticipants• Mental health nurse specialist.• Family caregiver of an individual with severe mental illness who has had previouscontact with the mental health team.Location• Chosen by the family caregiver.Intervention Procedure• Three in-person sessions with interviews (45 to 60 min each).• The intervention concludes at any point when the individual refuses to discuss thetopic, exhibits a defensive response, or shows discomfort. For example, throughverbal language (expressing unwillingness to continue, changing the subject, or re-maining silent) or body language (avoiding eye contact, adopting a withdrawn ortense posture).Session 1• Inquiry about the caregiving experience—How has your experience been caring foryour family member with a mental illness?• Inquiry about coping strategies utilized—Caregiving is a challenging condition. Peoplefacing such challenges often use various strategies to cope. How have you beenmanaging the challenges of caregiving?• Identification of spiritual/religious coping strategies used by caregivers of individualswith mental illness—“Some caregivers have mentioned that the following have beenhelpful for them, for example, meditation; Prayer; Attending church/temple; Belong-ing to a religious group; Speaking with a spiritual leader (e.g., a priest); Feeling closeto the divine (e.g., God); Being in contact with nature; Writing; Expressing gratitude.”• Inquiry about religious/spiritual coping—Spirituality is how each person seeks andexpresses meaning and purpose, how they experience their connection with the presentmoment, with others, with nature, with something significant, or with the sacred.Religion is related to an organized entity, with rituals and practices focusing on ahigher power or God. Some people live their spirituality even if they are not part ofa religion. “Some people caring for a family member with mental illness often usespirituality or religion as a resource/support to better cope with the challenges ofcaregiving. How has it been for you?”• Tailoring the interview according to the response: If the response points to positivespiritual/religious coping, inquire about religious/spiritual coping strategies. “Whatdo you consider most helpful regarding spirituality or religion?”; If the response isHealthcare 2024, 12, 1247 13 of 15neutral but receptive to the topic—“Do you think you could turn to spirituality orreligion to better deal with caregiving challenges? How?”; If the response points tonegative spiritual/religious coping—“Some people feel that way... what could helpyou in that regard?”; If defensive response/refusal to discuss the topic—“I understandthat addressing spirituality and religiosity may not be convenient at the moment. Tobetter help you, I would like to ask how you are coping with caring for your familymember with mental illness... could you tell me more about that?”• Conclusion of the interview by summarizing and reinforcing coping strategies alreadyused. If the person does not use them, suggest addressing the issue in the next session.• Validate receptivity for subsequent sessions: “Would you like to discuss this again?Are you interested?”Session 2• Inquiry about the caregiving experience since the last conversation.• Inquiry about spirituality-related aspects: “Since our last conversation, have youthought about any aspect related to spirituality or religion?”• Inquiry about meaning in life and hope: “Some people caring for a family memberwith mental illness find it difficult to find a sense of life and lack hope. Has thishappened to you?”• Inquiry about spiritual/religious coping strategies—If the person did not use spiri-tual/religious coping strategies: “You told me in the previous session that you werenot in the habit of using spiritual/religious coping strategies. Has this situation re-mained the same or changed?”; If the person already used spiritual/religious copingstrategies: “You told me in the previous session that you used to use spiritual/religiouscoping strategies. Has this situation remained the same or changed?”• Inquiry about resources: Have you used resources to experience your spiritual-ity/religiosity, such as prayer groups, religious participation, contact with spiri-tual/religious leaders, computer resources, readings, radio programs, and televisionprograms?• Offering support if necessary.• Conclusion of the intervention and providing contacts for referral.• Validating receptivity for subsequent sessions: “Would you like to discuss this again?Are you interested?”Session 3• Inquiry about spirituality-related aspects: “Since our last conversation, have youthought about any aspect related to spirituality or religion?”• Inquiry about the impact of religious/spiritual coping strategies: “Do you think thatreligious/spiritual coping strategies have helped you?”• Inquiry about other caregiving needs: “Besides what we have discussed regardingspirituality, is there any other aspect you feel is missing?”• Offering support if necessary.• Conclusion of the intervention and providing contacts for referral.Procedure Modifications• The mental health nurse considers the family caregiver’s needs and adapts the inter-views accordingly.References1. 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