Spi i ual ca e in c i ically ill pa ien s du ing
COVID-19 pandemic
Roc
ıo de Diego-co de o, PhD
a
, Lo ena L
opez-G
omez, RN
b
,
Gianca lo Lucche i, MD, PhD
c
,B
a ba a Badan a, PhD
d,
*
a
Facul y o Nu sing, Physio he apy and Podia y. Uni e si y o Se ille, Spain. Resea ch G oup CTS 969 “Inno a ion in Heal hCa e and Social
De e minan s o Heal h”. School o Nu sing, Physio he apy and Podia y. Uni e si y o Se ille
b
Facul y o Nu sing, Physio he apy and Podia y. Uni e si y o Se ille, Spain
c
Depa men o Medicine, School o Medicine, Fede al Uni e si y o Juiz de Fo a, B azil
d
Depa men o Nu sing; Facul y o Nu sing, Physio he apy, and Podia y, Uni e si y o Se ille, Spain. Resea ch G oup unde he Andalusian
Resea ch CTS 1050 “Complex Ca e, Ch onic and Heal h Ou comes”
ABSTRACT
In oduc ion: Spi i ual ca e has a posi i e in luence when pa ien s a e subjec ed o
se ious illnesses, and c i ically ill si ua ions such as he case o he COVID-19
pandemic.
Pu pose: The pu pose o his s udy was o in es iga e he pe cep ions and a i udes o
nu ses wo king a c i ical ca e uni s and eme gency se ices in Spain conce ning
he spi i ual ca e p o iding o pa ien s and amilies du ing he COVID-19 pandemic.
Me hods: A quali a i e in es iga ion was ca ied ou using in-dep h in e iews
wi h 19 ICU nu sing p o essionals.
Findings: Du ing he pandemic, nu ses p o ided spi i ual ca e o hei pa ien s.
Al hough hey belie ed ha spi i uali y was impo an o help pa ien s o cope
wi h he disease, hey do no had a consensual de ini ion o spi i uali y. Wo k
o e load, insu icien ime and lack o aining we e pe cei ed as ba ie s o
p o iding spi i ual heal hca e.
Discussion: These esul s suppo he ole o spi i uali y in momen s o c isis and
should be conside ed by heal h p o essionals wo king in c i ical ca e se ings.
Ci e his a icle: de Diego-co de o, R., L
opez-G
omez, L., Lucche i, G., & Badan a, B. (2021, xxx). Spi i ual
ca e in c i ically ill pa ien s du ing
COVID-19 pandemic. Nu s Ou look, 00(00), 114. h ps://doi.o g/10.1016/j.ou look.2021.06.017.
ARTICLE INFO
A icle his o y:
Recei ed 21 Decembe 2020
Recei ed in e ised o m
13 June 2021
Accep ed 17 June 2021
Keywo ds:
C i ical ca e
COVID-19
Eme gency
Heal h p o essionals
Quali a i e esea ch
Spi i ual ca e
Spi i uali y
In oduc ion
Al hough he e is no consensus, spi i uali y is usually
conside ed he “dynamic dimension o human li e
ha ela es o he way pe sons (indi idual and
communi y) expe ience, exp ess and/o seek meaning,
pu pose and anscendence, and he way hey connec
o he momen , o sel , o o he s, o na u e, o he sig-
ni ican , and/o he sac ed” (Nolan, Sal ma sh, & Lege ,
2011; p.88). This dimension is di e en and a b oade
concep as compa ed o he e m “ eligion”, which
Con lic o In e es : No con lic o in e es has been decla ed by he au ho s.
*Co esponding au ho : B
a ba a Badan a, Nu sing depa men , Uni e si y o Se ille: Uni e sidad de Se illa, A enzoa , 6, 41009, Se illa
(Spain).
E-mail add ess: [email p o ec ed] (B. Badan a).
0029-6554/$ -see on ma e Ó2021 The Au ho (s). Published by Else ie Inc. This is an open access a icle unde he CC BY-NC-ND
license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/)
h ps://doi.o g/10.1016/j.ou look.2021.06.017
ARTICLE IN PRESS
A ailable online a www.sciencedi ec .com
Nu s Ou look 000 (2021) 114 www.nu singou look.o g
in ol es “belie s, p ac ices, and i uals ela ed o he
anscenden ”(Koenig, 2012; p.2).
In he las decades, he e has been a ema kable
inc ease in his ield o knowledge (Lucche i & Luc-
che i, 2014) and he cu en e idence shows ha spi i-
ual well-being plays a undamen al ole in bo h
physical and men al heal h (Heida i, Ka imollahi, &
Meh noush, 2016), p o iding peace and ha mony ha
can lead o heal hie li es yles (Aza sa, Da oodi,
Kho ami Ma kani, Gah amanian, & Va gaeei, 2015).
Likewise, hese belie s seem o ha e an impo an
in luence on he decision-making o pa ien s and hei
amilies (Nascimen o e al., 2016).
In his con ex , spi i ual ca e (i.e. mee ing he spi i-
ual needs o pa ien s and amily) is especially impo -
an in in ensi e ca e uni s (ICUs) and eme gency
se ices, whe e he complexi y and se e i y o he dis-
eases and he c i ically ill si ua ions o pa ien s c ea e
an en i onmen o unexpec ed changes ha causes
loss o hope, anxie y, ea and s ess (Abu-El-
Noo , 2016;Aza sa e al., 2015;Pie ce, Ho e , Ma cin-
kowski, Man edi & Pou mand, 2020). Some s udies
ha e al eady con i med he impo ance o spi i ual
ca e in hese se ings, showing an imp o emen in
s ess, sel -es eem and dep ession, a dec ease in hos-
pi aliza ion ime, and a educ ion in heal hca e cos s
(Riahi e al., 2018;Abu-El-Noo , 2016).
Howe e , heal hca e p o essionals seldom include
spi i ual ca e in hei ou ine clinical p ac ice. Se e al
easons a e poin ed as ba ie s o include his ca e such
as a lack o unde s anding o he concep o spi i uali y,
ea o imposing own belie s o o ending pa ien s, p e -
e ence o biological issues and lack o aining
(Choi, Cu lin & Cox, 2019;Co de o e al., 2018;
Gallison, Xu, Ju gens, & Boyle, 2013;Kim, Bauck, Mon oe,
Mallo y & Aslakson, 2017;Koukouli, Lamb aki, Sigala,
Ale izaki, & S a opoulou, 2018;Vasconcelos e al., 2020).
These ba ie s esul in a la e add essing o he spi i ual
needs, which a e commonly limi ed o he las 24 o
48 hou s o he pa ien 's li e (Choi e al., 2019).
All hese p oblems seem o be inc eased du ing
momen s o c isis, when ime and esou ces a e lim-
i ed, such as du ing he COVID-19 pandemic. COVID-19
has a ec ed millions o indi iduals wo ldwide and
Eu ope has seen a e y delica e si ua ion, whe e he
numbe o dea hs and hospi aliza ions in ICUs we e
ala ming (Shah & Fa ow, 2020). In he speci ic case o
Spain, he numbe o in ec ed people has eached mo e
han 400,000 cases, and mo e han 28,500 people ha e
died (Minis y o Heal h, Consump ion and Social Wel-
a e MHCSW, 2020). Rega ding ICU hospi aliza ions, he
igu es ha e exceeded 12,000 cases. Cu en ly, nu ses
a e cons an ly subjec ed o he s ess o c i ically ill
pa ien s, some hing ha has in ensi ied e en mo e du -
ing his pandemic (Gab iel & Webb, 2013). In addi ion,
al hough he amily is one o he main pilla s o p o-
iding spi i ual ca e, amily isi s ha e been limi ed in
all heal hca e uni s due o es ic ions.
The e o e, du ing he COVID-19 pandemic, pa ien s
needed o o e come he eeling o isola ion in di e en
ways. Among se e al coping s a egies, spi i ual and
eligious belie s we e impo an o hese pa ien s as
no ed by some s udies (Lucche i e al, 2020). Howe e ,
he suppo o eligious se ices and eligious leade s
du ing he pandemic we e no ully a ailable
(Kowalczyk, e al., 2020;Roman, M hembu & Roman,
2020). Some hospi als ied p o ide echnological
means o communica ion be ween pa ien s and hei
amilies ( ideo calls o elephone con e sa ions), in an
a emp o alle ia e he lack o spi i ual suppo om
hei lo ed ones (And ews & Benken, 2020).
Al hough he numbe o publica ions has d as ically
inc eased du ing he pandemic, mos o he s udies
ha e ocused on he ea men , ca e planning and epi-
demiology o COVID-19 disease (Del Cas illo, 2020;
Dawood e al., 2020). In his con ex , mo e s udies a e
needed o unde s and he quali a i e expe iences o
c i ical ca e heal h p o essionals owa ds spi i ual ca e
and, o ou knowledge, no s udy has in es iga ed his
aspec in Spain, one o he mos a ec ed coun ies.
In o de o b idge his gap, his s udy aims o in es i-
ga e he pe cep ions, knowledge and a i udes o nu ses
wo king a c i ical ca e uni s (ICUs) and eme gency se -
ices in Spain conce ning he spi i ual needs o pa ien s
and amilies and he spi i ual ca e p o ided du ing hei
clinical p ac ice du ing he COVID-19 pandemic.
Me hods
Design
A quali a i e, explo a o y and desc ip i e design s udy
using an e hnog aphic-phenomenological app oach
has been ca ied ou . This app oach is cha ac e ized
by (a) a concep ual o ien a ion p o ided by a
esea che eam; (b) a ocus on a disc e e communi y;
(c) a ocus on a p oblem wi hin a speci ic con ex ; (d) a
limi ed numbe o pa icipan s; (e) he use o pa ici-
pan s who may hold speci ic knowledge; and ( ) he
use o selec ed episodes o pa icipan obse a ion
(Muecke, 1994). Da a collec ion consis ed o in-dep h
in e iews conduc ed by a quali ied in es iga o om
Janua y o June 2020 (6 mon hs o da a collec ion).
Sample and Se ing
Pa icipan s we e included p o ided hey we e nu sing
p o essionals wo king a in ensi e ca e uni s (ICUs) o
eme gency se ices om public o p i a e hospi als in
Spain and ea ing c i ically ill pa ien s wi h COVID-19.
Religious pe sonnel om hospi al cen e s, heal h p o-
essionals who we e wo king ou side ICUs o eme -
gency se ices, as well as hose no ca ing o pa ien s
(e.g. academic o managemen le el) we e excluded.
Da a Collec ion
A Wha sApp blas including a pos e desc ibing he s udy
was dis ibu ed widely using esea che s’ p o essional
ARTICLE IN PRESS
2Nu s Ou look 00 (2021) 114
and pe sonal con ac s. In o de o inc ease he numbe o
pa icipan s, a snowball sampling p ocedu e was used,
aiming o ha e a di e se ange o ages and expe iences
(Higginbo om, 2004). In e es ed pa icipan s con ac ed
he esea che s (Re iewe 1, Re iewe 4)di ec ly and eligi-
bili y c i e ia we e applied. Eligible pa icipan s we e
in i ed by he main esea che (Re iewe 1), who is a
nu se and an h opologis wi h expe ise in spi i ual ca e
and ha has published se e al a icles in he ield o
“Spi i uali y and Heal h”.
Since Spain was acing he implemen a ion o a
“S a e o Eme gency” du ing his pe iod, no ace- o-
ace mee ings wi h heal h p o essionals we e allowed.
The e o e, in e iews occu ed a a ime o con e-
nience o he pa icipan , using elephone calls, e-mail
o o he web mee ings. The in e iews we e ca ied
ou by one esea che (Re iewe 2) in he Spanish lan-
guage, las ed app oxima ely 50 o 60 minu es and
we e audio aped by he main esea che , ansc ibed
e ba im by wo esea che s (Re iewe 1, Re iewe 2),
and hen, ansla ed in o English by a ansla ion com-
pany. Da a collec ion con inued un il da a sa u a ion
was eached (U a, Mu~
noz, & Pe~
na, 2013).
In addi ion, as pa o he in e iews, pa icipan s we e
asked o send images cap u ed by hem du ing he
COVID-19 pandemic. These images we e impo an o
co obo a e pa icipan s’ s a emen s and o show hei
expe iences wi h spi i uali y and spi i ual ca e. In he
las decades, he e is a end o in e es in using quali a-
i e echniques such as pho o oice, as a esea ch me hod
in heal hca e esea ch in o de o ully examine he s ud-
ied con ex (Oos e b oek, Yonge, & My ick, 2020). The
pa icipan s we e o ien ed o p oduce pho og aphs and
hey we e asked o epo wha each pho o ep esen ed
o hem. The esea che eam analyzed hese images,
which we e inco po a ed in o he analysis.
Ins umen
An in e iew sc ip was used. An expe panel using
he Delphi me hod (Boulkedid, Abdoul, Lous au, Sib-
ony, & Albe i, 2011) ca ied ou an analysis o he
sc ip ’s con en be ween Janua y and Feb ua y 2020.
The con ac and con ibu ions o assess his ini ial
sc ip we e made online in wo ounds, whe e 17
expe s in spi i ual heal h and/o c i ical ca e we e
in i ed o pa icipa e ia email, o which 10 ag eed o
pa icipa e. The cha ac e is ics o he expe s’ panel
a e shown as a Supplemen a y ma e ial (Table A1).
The in e iew sc ip was based on p e ious quan i a-
i e ins umen s and on he expe ience o he mem-
be s o he Delphi panel (e.g. spi i uali y and i s
in e ace wi h COVID-19). These ins umen s we e
adap ed and used as open-ques ions in a quali a i e
way. The ollowing ins umen s se ed as a heo e ical
amewo k o he de elopmen o he in e iew:
Sociodemog aphic cha ac e is ics: gende , age, e h-
nici y, eligion and yea o unde g adua e nu sing
aining;
Religiosi y: using he Duke Uni e si y Religion
Index (DUREL) (Koenig, Pa ke son, & Meado , 1997),
which is an ins umen wi h i e ques ions con-
ce ning he eligious aspec s o a pe son, including
o ganiza ional eligiosi y ( eligious a endance),
non-o ganiza ional eligiosi y (p i a e eligious
p ac ices) and in insic eligiosi y ( eligion as an
impo an pa o li e).
A i udes and opinions abou spi i uali y and
heal h: using he Cu lin’s ins umen , “Religion and
Spi i uali y in Medicine, Pe spec i es o Physi-
cians—RSMPP” (Cu lin, Law ence, Chin, & Lan os,
2007). This ins umen has wo sec ions: (a) The
i s sec ion deals wi h eligion, spi i uali y and
clinical p ac ice (spi i uali y’s in luence on heal h,
a i udes and ba ie s o add ess hese ques ions
wi h pa ien s and he in luence o hese on he p o-
essionalpa ien ela ionship), (b) The second sec-
ion e alua es p o essional’ opinions abou
academic aining and eaching.
Ques ions ela ed o he clinical ca e du ing COVID
19 pandemic: de eloped du ing he Delphi panel, i
includes he in luence o spi i ual and eligious
belie s on COVID pa ien s, he challenges o p o id-
ing spi i ual ca e du ing he pandemic and he cop-
ing s a egies hese p o essionals use.
The comple e in e iew is a ailable as a Supplemen-
a y ma e ial (Table B1).
Da a analysis
T ansc ip ion, li e al eading, and heo e ical manual
ca ego iza ion we e pe o med, and MAXQDA so -
wa e was used. Da a analysis s a ed wi h indi idual
eadings and looking a he pho os o ge an o e iew
o esponden s’ expe iences. Two esea che s ead all
in e iew ansc ip ions and looked a he pho os se -
e al imes, o gain an o e all unde s anding o he con-
en . The analysis con inued by o ganizing desc ip i e
labels, ocusing on eme ging o pe sis en concep s
and simila i ies/di e ences in pa icipan s’ beha io s,
s a emen s and pic u es. The coded da a om each
pa icipan we e examined and compa ed wi h he
da a om all he o he pa icipan s o de elop ca ego-
ies o meanings. Finally, he analysis and ea men
o quali a i e da a MAXQDA was used and a inal
epo was de eloped (B aun, Cla ke, Hay ield, & Te y,
2019), wi h he s a emen s o he pa icipan s (P- pa -
icipan numbe , sex, age).
T us wo hy
This esea ch ollowed he c i e ia o The Consolida ed
C i e ia o Repo ing Quali a i e S udies (COREQ)
(Tong, Sainsbu y, & C aig, 2007) (See he Supplemen-
a y ma e ial Table C1). The me hods used o
gua an eeing quali y we e da a iangula ion, includ-
ing pa icipan s wi h di e en sociodemog aphic
ARTICLE IN PRESS
Nu s Ou look 00 (2021) 114 3
cha ac e is ics, and iangula ion o da a analysis ia
di e en esea che s.
E hical conside a ions
The s udy ecei ed app o al om he [BLINDED FOR
PEER REVIEW]. Pa icipan s we e in i ed h ough he
main esea che o pa icipa e olun a ily, so hey
we e inco po a ed in o he s udy a e accep ing and
signing he in o med consen sen by email.
Findings
Desc ip ion o Sample Cha ac e is ics
The sample consis ed o 19 nu sing p o essionals
wo king a Spanish ICU and eme gency se ices, being
78.9% women wi h a mean age o 30.0 (SD:8.9) yea s
old ( anging om 22 o 52 yea s). In he o al sample,
six pa icipan s sen a pho og aph ha symbolized
some aspec o spi i ual o eligious ca e du ing he
pandemic. Mos pa icipan s wo k in eme gency
depa men s (57.9%), in public heal h ins i u ions
(78.9%) and he mos common ci ies we e in Ba celona
(47.3%), Mad id (15.8%), and Se ille (36.9%). Rega ding
hei spi i ual and eligious belie s, 47.3% had no eli-
gious a ilia ion and did no belie e in God and 42.1%
we e Ca holics. Only 36.9% o he sample de ined
hemsel es as spi i ual and eligious beings. The cha -
ac e is ics o he sample a e shown in Table 1.
The analysis yielded i e main hemes which e lec
all o he ca ego ies: “The de ini ion o Spi i uali y”,
“Add essing spi i uali y in clinical p ac ice and i s
in luence on heal h”, “Spi i ual ca e du ing he COVID
pandemic”, “Ba ie s o p o ide Spi i ual Ca e and pos-
sibili ies o imp o emen ”, and “Spi i ual ca e ain-
ing o heal h p o essionals”. These hemes a e
desc ibed below.
Theme 1: The de ini ion o Spi i uali y
I was clea ha he e was no consensus on he de ini-
ion o spi i uali y by nu ses. In ac , spi i uali y was
ela ed o a se ies o di e en ac o s such as: meaning
and sea ching o answe s, eligious belie s; he
essence o eally undamen al hings, such as lo e,
amily, iends; and he exchange o ene gy be ween
people.Some pa icipan s also ha e acknowledge he
di e ences be ween spi i uali y and eligion, desc ib-
ing ha hey ha e belie s bu we e no eligious pe -
sons.
“I like o hink abou he meaning o hings, sea ching o
answe s ha canno be explained in a scien i ic way” (P-2,
man, 32 yea s); “I conside mysel spi i ual and in eg a e i
in o my li e o elie e s ess. Fo example, I do medi a ion
and i helps me elax, some hing essen ial in hese ha d
imes” [ e e ed o COVID-19 pandemic] (P-7, woman,
22 yea s); “I am no a membe o any eligion, bu I ha e
belie s and alues o my own” (P-9, woman, 23 yea s).
Theme 2: Add essing spi i uali y in clinical p ac ice and
i s in luence on heal h
Nu ses used he wo ds ai h, suppo , o belie s o
explain he e m spi i uali y. Mos pa icipan s (n= 17)
ag eed ha he e was a posi i e and di ec ela ionship
be ween pa ien 's spi i uali y and heal h, ha spi i u-
ali y may help in coping wi h a disease and ha could
imp o e he nu se-pa ien ela ionship. Some nu ses
sha ed hei expe iences as shown below:
“Some pa ien s ha e coped be e wi h hei illness by
clinging o God h ough p aye s, images, and p omises”;
(P-1, woman, 25 yea s) “I hink i in luences bo h he
pa ien 's a i ude and he nu se-pa ien ela ionship. I ha e
deal wi h pa ien s who ha e accep ed hei ea men s be -
e hanks o hei belie s and wi h o he ones who ha e
ejec ed hem due o he same eason” (P-5, woman, 25
yea s).
Al hough wo people p e e ed o alk abou emo ion
managemen as he way o achie e success in coping
wi h heal h p oblems, mos pa icipan s belie e
Table 1 – Sociodemog aphic Cha ac e is ics o he
Pa icipan s
Va iables Pa icipan s (n= 19)
Gende n(%)
Woman 15 (78.9)
Man 4 (21.1)
Age (yea s) M(SD) 30 (8.09)
E hnici y
Eu opean (whi e) 18 (94.7)
Asian 1 (5.3)
Incomes
500-1,499€2 (10.5)
1,500-2,999€13 (68.4)
3,000-4,999€3 (15.8)
5,000€1 (5.3)
Ci y o esidence and wo k
Ba celona 9 (47.3)
Mad id 3 (15.8)
Se ille 7 (36.9)
Hospi al se ice
In ensi e C i ical Uni (ICU) 8 (42.1)
Eme gency se ices 11 (57.9)
Type o hospi al acco ding o inancing
Public 15 (78.9)
P i a e 1 (5.3)
Mixed 3 (15.8)
Religious a ilia ion
None and I don' belie e in God 9 (47.3)
Ca holic 8 (42.1)
Buddhis 1 (5.3)
Belie in ene gies 1 (5.3)
Do you conside you sel a spi i ual /
eligious pe son?
Spi i ual and Religious 7 (36.9)
Spi i ual, bu no Religious 1 (5.3)
Religious, bu no Spi i ual 2 (10.5)
Nei he Spi i ual no Religious 9 (47.3)
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4Nu s Ou look 00 (2021) 114
spi i uali y and/o eligiosi y help he pa ien o cope
and adap o a new si ua ion o illness, p o iding hope,
ene gy, and s eng h o o e come heal h p oblems.
Nu ses we e awa e ha he spi i ual needs o hei
pa ien s a e an impo an pa o ca e. Howe e , some
nu ses belie e he ca e should ocus p edominan ly on
biological dimensions, especially in high echnology
and s ess ul en i onmen s such as he ICU and he
eme gency se ices: “In c i ical and eme gency si ua ions,
I hink he issue spi i ual ca e should be le aside since we
mus p io i ize se ious ca e” (P-13, woman, 29 yea ). Like-
wise, some pa icipan s conside ed ha o he p o es-
sionals ha e mo e compe encies o ca y ou his
spi i ual app oach: “As in hospi als he e a e Ca holic
chaplains, we le hem p o ide ha ca e. We, in he eme -
gency oom o in he ICU, espond quickly o he physiologi-
cal s a e o people, ha is he p io i y” (P-10, woman, 33
yea s).
Nu ses also emphasized ha heal hca e p o essio-
nals need o espec e e y aspec ha may posi i ely
in luence pa ien s’ heal h, and his should be done
ega dless o he eligiosi y o he heal hca e wo ke :“I
conside ha P o essionals'belie s should no in e e e. I am
no a eligious belie e and I ha e suppo ed he belie s o
hose who we e eligious because i made hem eel be e ”
(P-8, woman, 24 yea s); “Religious / spi i ual pa ien s who
p ac ice hei ai h, ca y images and hey p ay du ing hei
illness p ocess ... espec ing i is synonymous wi h p o es-
sionalism” (P-2, man, 32 yea s old).
Despi e he espec o he spi i ual belie s, mos
nu ses did no add ess hese issues in clinical p ac ice:
“By no conside ing mysel a spi i ual / ai h pe son, I ha e
ne e no iced his need in my pa ien s, possibly in an e one-
ous on my pa ” (P-4, man, 31 yea s), and end o ha e
li le expe ience wi h he spi i ual issues: “I ha e no
had expe ience on spi i ual ca e. Once, hey [pa ien s] ha e
asked us o he chaplain o come so hey can speak, con ess
o ask o ex eme unc ion. O he han ha , no hing” (P-2,
man, 32 yea s).
Theme 3: Spi i ual ca e du ing he COVID pandemic
COVID-19 pandemic was a special momen in which,
acco ding o he pa icipan s, emo ions and spi i ual-
i y a e necessa y as a suppo o he pa ien :“A
woman began o p ay when he doc o s con i med he diag-
nosis o COVID-19 posi i e and i did no seem s ange o
us. I emained silen as a sign o espec and suppo o
he ” (P-17, man, 25 yea s). Likewise, hey unde s and
spi i uali y as a mo al suppo o hose who su e he
mos , in many cases, he ela i es o he mos se ious
pa ien s: “Mo e han o he pa ien , he suppo is o en
o e ed o amilies when we ha e had o p epa e hem o
he loss o a lo ed one, when we can only limi ou sel es o
com o and ad ise hem (...), when e e y hing is los , he
only hing we can do is p ay because i will make us eel
be e ” (P-11, man, 46 yea s). In ac , in se e al occa-
sions, eligious and spi i ual symbols we e gi en o
pa ien s as no ed in Figu e 1.
Nu sing p o essionals we e esponsible o p o iding
psychological and spi i ual suppo o pa ien s du ing
he pandemic, since amily isi s we e no allowed and
eligious leade s we e no ully a ailable. Howe e ,
some pa icipan s epo ed ha hey did no ha e he
app op ia e aining o handle his si ua ion: “I hink
ha no one was p epa ed o his si ua ion. Some pa ien s
ha e aced i by aking e uge in hei eligion o spi i uali y,
and o he s ha e needed psychological a en ion, bu I do no
know i e e yone has had his help. Some imes he amily has
ha unc ion, bu i has no been possible on his occasion, so
we do wha we can” (P-7, woman, 22 yea s).
Al hough some p o essionals acknowledged ha
eligious belie s in luenced he accep ance o he p og-
nosis o COVID-19 by pa ien s: “I belie e ha pa ien 's
eligious belie s ha e been use ul in coping wi h he disease
and he unce ain y o i s e olu ion, and mo e o wa d wi h
mo e o ce” (P-7, woman, 22 yea s), o he pa icipan s
conside ed ha he only ac o s ele an o he p og-
nosis o his condi ion we e he immune s a us o he
pa ien s and a good en ila o y suppo , suppo ing
ha he biomedical science is he only app op ia e
me hod o ca ing hei pa ien s.
Al hough spi i uali y was no impo an o mos o
ou pa icipan s, hey ended o ag ee ha hei wo k
was cha ac e ized by empa hy, compassion, solida i y,
pa ience, esilience, and companionship: “Few col-
leagues exp ess hei eligious hough s o pa ien s” (P-2,
man, 32 yea s); “I ha e seen many aspec s o p o essional
esilience in many momen s, psychological messages o sup-
po and encou agemen , bu I ha e no seen p o essionals
a ending o he spi i uali y o pa ien s o o hemsel es” (P-
9, woman, 23 yea s). On he o he hand, some nu ses
ha e ied o cope wi h he s ess ul si ua ion and he
su e ing o pa ien s and ela i es h ough men al dis-
connec ion (e.g. yoga o elaxa ion echniques) and by
eligious p ac ices (e.g. p aye ). This has been
exp essed h ough Figu e 2.
Theme 4: Ba ie s o p o ide Spi i ual Ca e and
possibili ies o imp o emen
Du ing he in e iews, mos o he nu ses (n= 15)
epo ed he ba ie s and e lec ed on he possibili y o
imp o ing spi i ual ca e in c i ical and eme gency ca e
uni s. The mos common ba ie s ci ed we e, wo k
o e load du ing he pandemic (e.g. absence o b eaks),
insu icien ime, a high p o essional-pa ien a io and
he lack o aining.
O he di icul ies we e no eeling p epa ed o answe
“ anscenden al” o pe sonal ques ions, he lack o
social and p o essional ecogni ion o spi i ual ca e, di -
icul y in iden i ying he p esence o eligious symbols
ha accompany he pa ien and es ic ions on amily
isi s o educe he sp ead o he COVID-19 i us:“I
belie e ha i is one o he g ea es handicaps o his pan-
demic since he accompanimen o amily membe s is e y
com o ing o bo h; and he es ic ion o isi s gene a es
anguish and unce ain y; al hough we mus unde s and ha
i is he bes o e e yone” (P-8, woman, 24 yea s) and he
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pa ien 'sc i icalcondi ion: “In ICUs we ha e wo ked wi h
pa ien s who a e o ally seda ed and when we ha e been able
o ex uba e him/he , we ha e p o ided him/he mainly mo al
suppo ” (P-11, man, 46 yea s).
Some pa icipan s ha e also unde sco ed he di e -
ences o belie s as an impo an ba ie in o de o
p o ide a mo e in eg a i e ca e: “I can be di icul o a
eligious p o essional o unde s and a pa ien wi h di e en
belie s and ice e sa” (P-6, woman, 22 yea s); “My eli-
gious o spi i ual belie s in luence, in my case, I decla e
mysel an a heis and I hink ha a eligious belie ha
indoc ina es a pe son can lead him/he o ejec a ea men
Figu e 1 – I inco po a es wo pho os o ICU ooms: (a) The daugh e o a pa ien b ough a handmade can as
made by he illage s. Since she couldn' be wi h he a he , she asked he nu se o hang i up. The nu se one
a e noon hung i in he place whe e he pa ien could see i and he old he abou "his Vi gin”; (b) A nu se
ound an image o he Vi gin nex o a pa ien 's espi a o , unde s anding i as a symbol o p o ec ion ha he
pa ien and he amily us ed.
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6Nu s Ou look 00 (2021) 114
ha would p obably sa e his/he li e ...” (P-9, woman, 23
yea s). Howe e , sha ing belie s could b ing he
pa ien close o he nu se as no ed by one pa icipan :
“F om my expe ience, i a pa ien and he heal h wo ke a e
eligious, he ela ionship is mo e open o alk abou i ” (P-7,
woman, 22 yea s).
Despi e hese ema kable ba ie s, in o de o p o-
mo e a be e spi i ual ca e, p o essionals epo ed
ha hey need a silen momen wi hou in e up ions
in o de o p o ide such ca e: “I would be necessa y o
ma k a momen whe e he e is no in e up ion so ha he e
is connec ion be ween pa ien and nu se and build us ” (P-
5, woman, 25 yea s), be e guidelines and p o ocols
o he inclusion o spi i ual ca e in hese se ings:
“Se ing objec i es o nu ses and doc o s ega ding ca e
psychological and spi i ual, in e iewing he pa ien , using
Figu e 2 – A nu se and an eme gency echnician en e a Ca holic chu ch. They wo k o 12 hou s, p o iding
home ca e, whe e people a ec ed by COVID-19 emain alone, sad and despe a e. When hey ge a b eak o in-
ish hei wo kday, hey emain silen wi h hei hough s and wi h God in his chu ch, seeking answe s and
hope o o e come he pandemic.
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Nu s Ou look 00 (2021) 114 7
quali y scales” (P-9, woman, 23 yea s), app op ia e
spaces o con empla i e p ac ices: “F om spaces o
medi a ion, yoga o o he s whe e eligious p ac ices o any
kind a e ca ied ou ” (P-5, woman, 25 yea s), imp o ing
aining on spi i ual ca e, he c ea ion o suppo
g oups, he inco po a ion o specialized pe sonnel
(chaplain, p ies o p ies ) o di e en eligions in he
ICU o eme gency se ices and a coo dina ed wo k
wi h hem wi hin he in e disciplina y eam.
Theme 5: Spi i ual ca e aining o heal h
p o essionals
“We mus be p epa ed o p o ide spi i ual ca e” is a
common s a emen sha ed by nu ses, being he
inc ease in cul u al di e si y in la ge Spanish ci ies he
main eason: “I is necessa y [ha ing compe encies o
p o ide spi i ual ca e] because we a e dealing wi h
pa ien s wi h a mul i ude o belie s and we a e no being
able o ake ca e o he pa ien in ha ega d” (P-11, man,
46 yea s).
Howe e , mos o he pa icipan s s a e ha hey
ha e no ecei ed any aining conce ning spi i uali y
(n= 17) and did no eel p epa ed o p o ide his ca e
(n= 15). The e o e, nu ses conside ha aining in
spi i uali y should be o e ed o p o essionals om
any heal h discipline (n= 14): “In Ba celona i is impo an
because he e a e many people om o he coun ies, wi h
di e en eligious belie s and spi i uali y. I he heal hca e
p o essional is no ained, he pa ien will no us you” (P-
9, woman, 23 yea s).
While some nu ses only associa e aining in spi -
i ual heal h wi h he acquisi ion o compe encies o
ca e o pa ien s in nea -dea h si ua ions:“Imiss he
uni e si y aining in spi i ual ca e o si ua ions o g ie
o coping wi h a se ious illness” (P-15, woman, 26
yea s), o he s belie e his issue is pe sonal and
aining should no be add essed as manda o y:
“Classes on spi i ual ca e should be op ional, since eli-
gion and spi i uali y a e e y pe sonal hings and
di e se, and i can hu sensibili ies” (P-2,man,32
yea s); “I do no hink his ype o aining is adequa e,
a leas no in a scien i ic ca ee like nu sing” (P-16,
woman, 31 yea s) Figu e 3.
Discussion
This s udy showed ha , du ing he COVID-19 pan-
demic in Spain, nu ses we e esponsible o p o iding
spi i ual ca e o hei pa ien s. Al hough hey gene -
ally belie e ha spi i uali y is impo an o ea men
and help pa ien s o cope wi h he disease, hey do no
ha e a consensual de ini ion o spi i uali y and we e
no ained o handle his ca e. Se e al ba ie s a e
ci ed as limi a ions o he spi i ual ca e such as he
wo k o e load, insu icien ime and lack o aining.
The di e si y o ou indings s ems om he e mi-
nological con usion abou spi i uali y i sel (Nasci-
men o e al., 2016). Al hough he Wo ld Heal h
O ganiza ion p oposed he spi i ual aspec as a com-
ponen o heal h in 1983 (WHO, 1998), he e is s ill no
uni e sal and clea de ini ion o spi i uali y
(Can ield e al., 2016). This explains why some nu ses
use spi i uali y and eligiosi y as synonyms, o e en
e oneously exclude spi i uali y as pa o eligiosi y
(Sonemanghka a, Rozo, & S u sman, 2019). Also
Figu e 3 – G aphic summa y o he eul s.
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8Nu s Ou look 00 (2021) 114
coinciding wi h ou s udy, nu ses also include com-
passion and empa hy as ela ed o spi i uali y, as
shown in a p e ious s udy in es iga ing Thai ICU
nu ses (Lundbe g & Ke don ag, 2010).
Al hough he nu ses in ou s udy pe cei e he in lu-
ence o Spi i uali y and/o Religiosi y (S/R) on pa ien 's
heal h and on he way hey cope wi h he disease,
he e is a clea con usion conce ning he ole ha
nu ses should play owa ds spi i ual ca e. One o he
easons o his con usion is he p esence o eligious
pe sonnel such as chaplains, who a e conside ed he
p o essionals wi h g ea e compe ence o spi i ual
ca e and, in he pe cep ion o he amily, a e he mos
impo an igu es o add ess spi i ual belie s in c i i-
cally ill pa ien s (Gallison e al., 2013).
In he same di ec ion, mos o he spi i ual ca e is
p o ided by he amily as seen in p e ious s udies. P e-
ious au ho s ha e epo ed ha amily accompani-
men is “some hing spi i ual”, helping pa ien s o seek
meaning and p o ec ion om God in o de o cope
wi h agedies (Ch
a ez-Co ea, 2014). In his con ex ,
nu ses a e esponsible o making his connec ion
be ween amily and he pa ien and p o iding a sa e
and com o able en i onmen (Nascimen o e al.,
2016). Howe e , he es ic ions on amily isi s du ing
he pandemic, inc eased he ension be ween nu ses,
since, al hough hey p o essionally espec he spi i-
ual needs o hei pa ien s, hey ea acing hem
alone and wi hou aining (Kowalczyk e al., 2020).
In Spain, some ins i u ions ha e made e o s o
inco po a e he spi i ual and eligious app oaches in
heal h ca e. Taking as a amewo k he Spanish legis-
la ion ha ecognizes he igh o eligious eedom;
spi i ual and eligious assis ance in hospi al cen e s is
conside ed as a igh o he pa ien and he amily. The
Obse a o y o Religious Plu alism (OPR, 2011)in
Spain, published a guideline o heal h pe sonnel on
ecommenda ions abou how o add ess spi i ual and
eligious assis ance in hospi als. Howe e , we
obse ed ha he inclusion o he S/R as pa o he
comp ehensi e ca e o c i ically ill pa ien s is ye
uncommon. On he one hand, c i ical ca e uni s and
eme gencies a e cha ac e ized by a biomedical ca e
app oach (De B i o e al., 2013;Huije , Bejjani, & Fa es,
2019;Fe ell, Handzo, Picchi, Puchalski, & Rosa, 2020).
On he o he hand, he nu ses s a e ha hei own
belie s can cons i u e a handicap o p o ide spi i ual
ca e (Tu an & Ya uz Ka amano
glu, 2013), and o he
ba ie s as well. Lack o ime, he high pa ien and/o
nu se a io, he ea o making he pa ien uncom o -
able and he belie ha spi i uali y is some hing p i-
a e a e also sha ed by o he au ho s (Gallison e al.,
2013).
Finally, he nu ses in his s udy sha e wi h o he
nu sing p o essionals and s uden s he need o
imp o e hei compe ence o p o ide spi i ual ca e o
pa ien s (Co de o e al., 2018;Riahi e al., 2018). Acco d-
ing o he In e na ional Council o Nu ses and he
Commission on he Righ s o Pa ien s, nu ses mus
ha e he knowledge and skills o be able o p omo e
and assess he sa is ac ion o he spi i ual needs o
hei pa ien s (De B i o e al., 2013) and, o his eason,
ins i u ions should be able o p o ide educa ion o
hese p o essionals conce ning spi i ual ca e. How-
e e , he applica ion o he biomedical science o nu s-
ing, as well as he conside a ion ha he e a e
p o essionals wi h be e skills o deli e his ca e o
pa ien s (e.g. chaplains, psychologis s) seem o educe
he willingness o p o ide such ca e.
Limi a ions and S eng hs
The p esen s udy has some limi a ions ha should
ake in o accoun while in e p e ing ou indings. Fi s ,
his s udy was ca ied ou in Spain and i e lec s he
expe iences o heal h p o essionals om Spanish
heal h ca e acili ies. I is di icul o gua an ee ha
he same esul s would be obse ed in o he coun ies,
since he cul u al and eligious backg ounds a e di e -
en . Second, we used a pu posi e sample and gene -
alizabili y should be made wi h cau ion. Thi d, Spain
was one o he mos a ec ed coun ies in he COVID
pandemic and, o his eason, nu ses we e bu ned ou
and wi h wo k o e load, which may ha e impac ed
ou indings. Finally, since nu ses ha e been one o he
la ges heal hca e o ces wi h pa ien s a ec ed by
COVID, eminiza ion has esul ed in a highe p opo -
ion o women.
Based on his s udy, we sugges a ew di ec ions o
u u e esea ch. Fu u e esea ch should include new
ca e con ex s, eligious pe sonnel (i his hospi al
esou ce exis s), as well as o he heal h p o essionals
as membe s o he heal h eam. In addi ion, in e en-
ions aimed a cla i ying e ms o S/R would be he i s
s ep so ha heal h p o essionals can in e nalize hem
and ake i in o accoun as pa o holis ic ca e. Mul i-
cen e s udies and c oss-cul u al compa isons a e sug-
ges ed be ween coun ies, o know he expe iences o
heal h p o essionals (especially nu ses) in secula
coun ies o whe e di e en eligious p ac ices p e-
domina e.
Finally, his s udy showed spi i ual needs a e com-
monly exp essed du ing li e- h ea ening si ua ions,
such as hose expe ienced in ICUs. Because ou esul s
highligh ha mos nu ses a e open o his subjec , a
aluable s a egy would be aining o handle hese si -
ua ions. The e o e, heal h manage s a e commended
o o ganize aining o ICU heal h ca e p o essionals
in o de o p o ide a mo e holis ic ca e.
Conclusions
Spi i uali y was conside ed an essen ial dimension o
ca e du ing he COVID-19 pandemic as obse ed in he
opinions and pe cep ions o he Spanish nu ses
included in his s udy. These esul s suppo he ole
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