THE DESCRIPTION OF NURSES’ SPIRITUAL SUPPORT FOR PATIENTS OF DIFFERENT RELIGIONS IN HOSPITALS

The term spiritual is an inseparable part of the meaning of religion. In the health service, providing spiritual support is a duty of health workers, especially nurses. Social conflicts that lead to religious conflict, may affect to nurses' performance, especially to fulfill patients' spiritual needs with different religions or beliefs. This is makes studies related to nursing and religion are impressive. This study aimed to describe nurses' spiritual support for patients of other religions in hospitals. The research used qualitative method with phenomenology study approach. The data collection was performed using interviews. The informant selection technique used the purposive sampling technique and resulted in 5 informants. According to Creswell, the trustworthiness used triangulation, while the data analysis method used a method. Six themes emerged from this study, including the meaning of God, the meaning and the purpose of life, source of happiness, the meaning of the tragic event, assessment of good and bad things, and the interaction between nurses and patient with same or different religions. The conclusion of this study is the spiritual support provided by nurses as an informant is focus on two things, namely the meaning of God's existence and relationships with others. Received: 19 August 2019 Revised: 4 September 2019 Accepted: 24 february 2021


INTRODUCTION
In some areas in Indonesia, issues concerning religion are sensitive. This is proven by the conflict that occurred in Ambon in 1999, which has a dark history related to the religious issue. Not only were the victims killed in this conflict, but other losses in the form of houses also being burned down, and property that was lost resulted in residents being forced to flee to safer places (Nainggolan, 2012).
The impact arising from this conflict is the occurrence of a rift in relations between community groups and personality changes among individuals (Rudiansyah, 2015). According to (Latipun (2014), the problems that occur in post-conflict and displaced areas are both psychological and social, namely strong suspicion of other groups, hatred, and tendency to blame other groups for the occurring problems. Besides, physical violence during conflicts, loss of property, and loss of loved ones can be a stressor for psychological disorders (post-conflict trauma). The trauma experienced by a person after a conflict, known as post-traumatic stress disorder (PTSD), can be in the form of repetitive nightmares and memories of conflicts (Ranimpi, 2003). This disorder is a psychological manifestation of traumatic experiences or life-threatening conditions such as war/conflict, violence and abuse, natural disasters, and serious accidents (Iribarren et al., 2005).
In the context of the Ambonese society, one of the peace solutions adopted is to segregate settlements. Residential segregation is an effort to prevent conflict by placing homogeneous populations together based on religious groups. The act creates separation barriers and creates a negative stigma against people outside the group. Initially, segregation of existing settlements further strengthened the existing trauma. The segregation of religious-based settlements shows that religious solidarity is stronger than cultural solidarity (Latipun, 2014). Pela-gandong culture as a form of the covenant of brotherhood (blood relations), that has existed for hundreds of years, has been shaken by religious conflicts (Bakri, 2015). This shows the dominance of religion in influencing people, especially in Ambon today. This understanding is not much different from Ajawaila's opinion (2000) that said that the development of religion not only affects the pattern of community order that has been fostered long ago but also affects the strengthening of group sentiment and solidarity. Segregation can cause social distance between groups, both because of religious and cultural differences.
The meaning of religion cannot be separated from the term spirituality. According to Yafie, et al. in Hasnani (2012), religion is spiritual nourishment (spiritual nutrition), which can be a preventive part of an illness. Spiritual emptiness or religious sense that occurs can cause problems in the health sector. Meanwhile, according to Triyanta (2002), spirituality is part of religion. Spirituality is an effort to cultivate sensitivity to self, others, creatures other than humans and God. Spirituality is something abstract and intrinsic.
In the context of health, spirituality is one of the human needs that is required to be fulfilled. According to the World Health Organization (WHO) cited by Madadeta and Widyaningsih (2015), there are four elements of health namely physical, psychological, social, and spiritual. Health services are considered holistic if they cover these four elements. Holistic health services must be able to be provided by health workers including nurses.
According to Yanto (2013), nurses are the first person who has the longest contact with patients because of their 24hour service. In carrying out their duties, nurses are required to be able to care for and help patients by paying attention to their needs holistically including meeting spiritual needs or providing spiritual support (Tricahyono et al., 2015). According to Kinasih & Wahyuningsih in Madadeta & Widyaningsih (2015), the spiritual support that the patients get is not only from themselves but also from the participation of the nurses and the patients' families. This is certainly not an easy task for nurses to perform. Nurses need to be professional and have a strategy in dealing with patients, especially in providing services to patients who are of a different faith from the nurses themselves.
According to Sianturi (2016), one obstacle in the implementation of spiritual care is ambiguity, which arises when nurses have different beliefs to the patients they care for. Ambiguity includes the confusion of nurses, fear of being wrong, and assuming that spirituality is too sensitive and a personal matter of the patients. This may result in insecurity for the nurses. RSUD Dr. M. Haulussy Ambon is one of the regional public hospitals in Ambon which of course accepts patients from different religious backgrounds. Ideally, in-hospital service must provide holistic health services including in the aspect of spirituality. This is increasingly interesting, seeing a variety of different backgrounds, especially the religious backgrounds of nurses and patients treated at RSUD Dr. M. Haulussy Ambon. Also, the impact of conflicts in the past has also influenced social life, in this case it has also affected the interaction of nurses and patients in Ambon. Therefore, the authors are interested to know how nurses spiritually support patients with different religions in RSUD dr. Haulussy Ambon.

Study Design
This research used the qualitative method with a descriptive phenomenology approach. In phenomenology studies, researchers focus on describing the general meanings of some individuals regarding their life experiences related to concepts or phenomena (Creswell, 2015). According to Moustakas in Creswell (2015), the type used is transcendental phenomenology that focuses less on interpretations from researchers but rather a description of the experiences of the informants.

Study Informants
The informant selection technique used a purposive sampling technique. The researchers choose the informants and places because it can specifically provide an understanding of the research problem or phenomenon in the study (Creswell, 2015). The criteria for informants were nurses who had work experience of at least 5 years and had a direct role in caring for patients, especially patients of different religions at the hospital. Based on the above criteria and the willingness of informants, the sampling technique obtained 5 nurses.

Data Collection
Data collection techniques used were interviews -both indepth interviews and semi-structured interviews. This technique was performed because researchers needed to obtain data widely and in-depth but also directed (Sugiyono, 2012).

Data Analysis
The data analysis method used is a method according to Creswell. The data analysis started with organizing data in the form of interviews, observational notes, and converting data in the form of files into appropriate units of text (a word, a sentence, or a complete story). Next, the researcher reads and makes a memo containing the main ideas in the form of short phrases. Then, the data is described, classified, and interpreted into codes and themes. In the coding process, text or visual data is grouped into smaller categories of information. Furthermore, some existing codes are compiled into a general idea called a theme. This is the stage of classification or sorting of texts. The next step is data interpretation. In this stage, the existing code is developed and a theme is formed based on these codes, followed by organizing the theme into a broad picture to interpret the data (Creswell, 2015).

Trustworthiness
Trustworthiness in this study used triangulation. Triangulation is a data testing technique by checking data from various sources. Data checking is carried out using a variety of ways and times, which is why triangulation is divided into source triangulation, triangulation of data collection techniques, and time (Sugiyono, 2012). In this study, the triangulation data technique used triangulation of data and time, in which researchers interviewed informants from different departments, different religions, and a different time.

Ethical Consideration
The study was approved by the ethics committees of the Faculty of Medicine and Health Science, Universitas Kristen Satya Wacana, and in accordance with the Nuremberg Code and Helsinki Declaration. This study also obtained informants' approval using informed consent.

RESULT
Data collection was conducted at RSUD Dr. M. Haulussy Ambon, the regional hospital, which receives a variety of patient backgrounds. Most of the nurses who work in this hospital are Muslim and Christian. Out of the 5 informants, 2 of them were Muslim and 3 were Christians. The following characteristics of informants are as follows: Based on interviews with the informants, there were 6 themes of forms of spiritual support given by informants to patients, namely the meaning of God, the meaning and the purpose of life, source of happiness, the meaning of the tragic event, assessment of good and bad things, and the interaction between nurses and patient with same or different religions.
1. The meaning of God God was interpreted by informants as a creator and an owner who has power over this world, including being able to provide comfort, strength and health, and healing. "…Usually, I illustrated the existence of God like when patients ask about when he/she gets well… We as a nurse can only convince patients that we are just tools, healing is only from God…" (P3) God is depicted as invisible but real, proven by His care/inclusion in daily life. An understanding of God has to do with sacredness and also leads to religious/spiritual activities such as prayer. According to informants, sacredness is something that is holy and that cannot be disturbed. In addition, sacred also has a white meaning, clean, something very important, and must not be damaged with bad things. Moreover, a sacred life is interpreted as being able to protect themselves from something worldly and not pleasing to God. According to informants, the existence of God has a very big influence on life. One informant said, one of the differentiators in explaining to patients of the same religion and a different religion was the difference in understanding the shape or the figure of God. Talking about the meaning of life with patients is considered beneficial in the recovery process because it can provide enthusiasm and strength of patients to deal with all conditions. The way informants communicate about the meaning of life to their patients, that is, motivating patients and directing patients to be able to accept the situation and receive treatment even though sometimes they cannot cure the patients. "...for example, a terminal patient that will get a hemodialysis procedure. We, as nurses, must give the support that hemodialysis is not curing but will prolong life... we as nurses must convince patients that the hemodialysis procedure is usual and must be done to survive..." (P2) Furthermore, the informants also directed patients of the same or different religion that healing was the primary goal of life. Surrendering to God and focusing on healing are steps that can be taken to achieve that life goal.

The Source of Happiness
On average and overall, informants said their source of happiness was family. Informants directed patients of different religions to realize the same source of happiness, which was prioritizing family. "… I directed patients that one of the sources of happiness is family... without family we are nothing, and everything we have done all this time, everything is for the family..." (P4) Informants motivated the patient to be more enthusiastic in the treatment process in order to meet with his family. "... I directed for patients that they should always keep strong so she/he can back home and meet loved ones, such as their children or parents..." (P5) Besides, informants also made patients aware of other sources of happiness, namely, happiness that comes from the heart, such as not having envy or jealousy, no anger, being able to laugh out loud, and not having conflicts. Informants considered that differences of opinion should not to be questioned, instead, they must be respected. One informant assumed that everyone has their understanding and source of happiness.

Meaning of a tragic event
The tragic event is interpreted and perceived as a disaster, reprimand, lesson, or experience for someone to be more aware of in the future. The informants gave an understanding to the patient and the patients' family that bad events are God's way to make humans be more introspective/careful. All that can be done is to surrender and pray to God. "… that I convince the patients to keep praying because every event, good or bad is a part of God's plan, so God will give better for us… the point is if we keep doing good, we will get good things too..." (P4) This understanding influences patients to understand the intent of bad events that occur as well as reinforcement for patients. However, some patients feel unable to accept the explanation and some feel worse because they feel the disease they have suffered has been for a long time and they have not experienced healing.
5. Assessment of good and bad things Some informants said that there were no differences in perceptions concerning judgments about good and bad. Both the patient and the informant did not dispute the differences in religion/belief. Contrary to this opinion, one informant said that it was difficult to direct the patient to believe/have the same understanding as himself. Informants only pointed out that true things are all from God Almighty and chose not to try to influence their patients too much. "…sometimes, directing patients for something other than what they believe is difficult, we only directed patients that all of the good things have come from God, we cannot influence them further…"(P2) 6. The interaction between nurses and patients with the same or different religion Some informants assessed religious differences as not affecting the process of interaction with patients. Others said that the differences in belief greatly affected the interaction of informants with patients of different faiths. One example of an action that cannot be taken because of privacy that is related to a patients' belief is the prohibition of long beards for health reasons. Facial hair hygiene cannot be applied to some patients because the patients' belief does not allow shaving his beard. One informant realized the religious conflict that had previously occurred in Ambon was the basis for why religious and spiritual matters were sensitive and had to be carefully discussed. "We live in Ambon where there was conflict about religion before, so we have to keep our mouth, don't offend others... yes, don't make them who have different religion feel offended..." (P5) However, religious sensitivity did not affect the service of informants to patients who are of the same religion or who have different religions; all were treated equally.

DISCUSSION
Based on all themes in this study, the identity of patient religion does not affect the provision of spiritual meaning by nurses.
Some informants tried to rule out religious differences. The informants' understanding of spirituality is not limited to certain religions. According to Burkhardt in Yusniarita et al. (2016), the aspects of spirituality include uncertainty in life or something unknown, finding meaning and purpose in life, being aware of abilities that can become strengths in oneself, having a sense of attachment to self and with God the Highest. This was also illustrated by the informants by communicating several aspects such as the meaning and the purpose of life, the understanding of God, and things that were the source of happiness in life.
The informants understood the figure of God as one who can provide strength and healing, and have a major influence in life. This understanding is also instilled by the informant in the patient. This statement is in line with Ambarwati's opinion in Rosyadi et al. (2019), where belief in God is seen as a transcendental force in the face of every test in life. God has a major role in providing strength in facing the challenges of everyday life (Ardian, 2016). In addition, informants said that a holy life is meant as being able to protect themselves from something worldly and not pleasing to God. This indirectly illustrates that things that are holy or sacred are something that comes from God. This opinion is in line with Achlami (2015) who stated that the rules of religion are upheld more than the rules made by humans. This is because religion is defined as a rule that comes from God and it is sacred, absolute, and universal.
The meaning of life and the purpose of life is something important that must be owned by everyone, including patients and nurses as providers of spiritual support. According to Wijayanti and Lailatushifah (2012), someone who has a meaningful life will feel satisfied with his life because he feels he has become a whole person. This feeling of satisfaction will eliminate the anxiety that can arise because the individual feels that he has done the best things in his life. The above opinions are in line with this study where the meaning and the purpose of life can impact positively on a person/patient.
The meaning and the purpose of life also have to do with one's happiness. According to Shaeful (2016), happiness is the goal of every human. He further said that happiness was divided into two, namely, temporary happiness which is worldly happiness, and ultimate happiness that comes from God, including heaven that is obtained after life ends. According to Aristotle in Bakar (2018), something that is considered happiness by others, is not necessarily the same as for other people, because happiness is a pleasure that is achieved by each person based on individual wishes. This finding is in line with the results of this study, where one informant said that everyone has their understanding and source of happiness respectively. Various things can be a source of happiness such as attention and love from others, feelings of being useful to others, hobbies and activities in nature (Nur'aeni et al., 2013). Even people with HIV/AIDS (PLWHA) interpreted their happiness by helping fellow PLWHA and meeting their material needs (Arriza et al., 2011). Thus, the source of happiness and meaningful life extends from things that are material/physical, social relations, and the actualization of affection and empathy for others.
This finding is similar to the findings of Nur'aeni (2013) who explained that a bad/tragic trial or event that occurred was interpreted as a reprimand from God or a manifestation of God's love -this is a positive religious statement (Nur'aeni et al., 2013). Positive religious coping is a safe condition with God, where there is a belief that something more meaningful is found in life and in the spiritual sense of dealing with others (Utami, 2012). Submission to God and prayer is a form of positive religious coping, which is a collaborative religious coping mechanism where individuals will establish cooperative relationships with God in problemsolving and will feel accompanied by God when facing problems (Utami, 2012).
In the theme of judging about good and bad things, informants explained to patients that things that were true were all from God Almighty. This is in line with the opinion of Hill and Pargament in Kurniawati (2015) where spiritual wellbeing has a relationship with well-being to God, which is keeping a religious lifestyle according to God's command. Good things that come from God can be interpreted as commands that God gives.
In the previous theme, it was described how nurses understood the meaning of God, the meaning of life, and the meaning of God's existence in life. In addition to understanding it, nurses must be able to convey to patients what they understand. God's understanding and the meaning of life are part of spiritual needs that have to be considered. According to Sarbini in Aryanto (2017), spiritual necessity is the harmonization of life dimensions including finding meaning, purpose, suffering, and death; the need for hope and belief in life; the need for confidence in oneself; and God. Furthermore, Aryanto (2017) mentioned 5 basic human spiritual needs, namely the meaning and the purpose of life, feelings of mystery, devotion, trust, and hope in times of distress. As far as this research went, there were no differences regarding this matter.
Another study found that 63.5 per cent of respondents, who are nurses, provided spiritual care with care to patients regardless of their different beliefs (Naibaho et al., 2015). This study also showed that religious sensitivity does not affect patient care. Moreover, nurses respected what a patient believed, which was not shaving his beard for religious reasons. These results are consistent with Gunarsa's in Tawale, et al. (2011) who stated that one of the qualities that nurses must have is to respect existing relationships. The service of a nurse is considered successful if it can make adjustments, namely, concerning the relationships and humanitarian ties needed in dealing with both healthy and sick people (Tawale et al., 2011).

Limitation of The Study
The limitation of this study is this study was conducted with a small number of informants, this is affected result not too diverse. This is because there is limitation of informant criteria and nurses' willingness to be a informants. However, the selected informants come from several different wards, so it is expected to reduce the possibility of bias.

CONCLUSION AND RECOMMENDATION
In facilitating the spiritual needs of patients with different beliefs, informants showed no difference between patients of the same or different religion. Religious identity is not used as a benchmark in meeting the spiritual needs of patients. Meeting the spiritual needs of patients by informants in the form of spiritual support is focused on two things, namely the existence of God and relationships with others. The existence of God means when a informant gives an understanding to the patient that God is the source of good things, namely strength, healing, and other good things. In addition, belief in the existence of God also has a great influence on life, which determines whatever happens in life, even for bad events. Informants always advised their patients to always pray and rely on God. The second part, namely relationships with others, can be seen from the way informants interpret life as something that can benefit others. This is also confirmed by the informants' statement that the family is a life goal, a source of motivation, and a source of happiness to patients.
Further research on spiritual support in patients has to do with patients who have different religions. Subsequent studies require sources from various hospitals so that the data obtained is more diverse.