The influence of spirituality and religion on critical carenursing: An integrative review

RESEARCH The influence of spirituality and religion on critical care nursing: An integrative review B arbara Badanta PhD 1 | Estefanía Rivilla-García RN 2 | Giancarlo Lucchetti MD, PhD 3 | Rocío de Diego-Cordero PhD 4 1 Research Group under the Andalusian Research CTS 1050 “Complex Care, Chronic and Health Outcomes”, Department of Nursing, Faculty of Nursing, Physiotherapy, and Podiatry, University of Seville, Seville, Spain 2 University of Seville, Seville, Spain 3 Department of Medicine, School of Medicine, Federal University of Juiz de Fora, Brazil 4 Research Group CTS 969 “Innovation in HealthCare and Social Determinants of Health”, School of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain Correspondence Rocío de Diego-Cordero, Faculty of Nursing, Physiotherapy, and Podiatry, University of Seville, Spain. Email: [email protected] Abstract Background: Spiritual care could help family members and critically ill patients to cope with anxiety, stress and depression. However, health care professionals are poorly prepared and health managers are not allocating all the resources needed. Aims and objectives: To critically review the empirical evidence concerning the influence of spirituality and religion (S-R) on critical care nursing. Methods: An integrative review of the literature published in the last 10 years (2010-2019) was conducted in PubMed, Scopus, CINHAL, PsycINFO, Web of Science, Cochrane and LILACS. In addition, searches were performed in the System for Information on Grey Literature in Europe and the Grey Literature Report. Quantitative and/or qualitative studies, assessing S-R and including health care professionals caring for critically ill patients (i.e. adults or children), were included. Results: Forty articles were included in the final analysis (20 qualitative, 19 quantitative and 1 with a mixed methodology). The studies embraced the following themes: S-R importance and the use of coping among critical care patients and families; spiritual needs of patients and families; health care professionals' awareness of spiritual needs; ways to address spiritual care in the intensive care unit (ICU); definition of S-R by health care professionals; perceptions and barriers of addressing spiritual needs; and influence of S-R on health care professionals' outcomes and decisions. Our results indicate that patients and their families use S-R coping strategies to alleviate stressful situations in the ICU and that respecting patients' spiritual beliefs is an essential component of critical care. Although nurses consider spiritual care to be very important, they do not feel prepared to address S-R and report lack of time as the main barrier. Conclusion and implications for practice: Critical care professionals should be aware about the needs of their patients and should be trained to handle S-R in clinical practice. Nurses are encouraged to increase their knowledge and awareness towards spiritual issues. KEYWORDS adult, critical care, intensive care, nursing, paediatric, religious, spirituality Received: 20 August 2020 Revised: 21 March 2021 Accepted: 20 April 2021 DOI: 10.1111/nicc.12645 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2021 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses. Nurs Crit Care. 2021;1–19. wileyonlinelibrary.com/journal/nicc 1 1|INTRODUCTION Spirituality and religiosity (S-R)havebeendiscussedinhealthcare for years and research in this area has been constantly growing and consolidating. 1 Religion is defined as “the set of beliefs, practices, rituals and ceremonies that are normally acquired by tradition within a group or community.” 2 On the other hand, spirituality is a broader concept, defined as “the personal quest for understanding answers to ultimate questions about life, about meaning and about relationship to the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community.” 2 Although these are clearly overlapping concepts, they could have different implications. However, it is important to consider that there is no consensus on the definition of S-R 3 and a great number of authors use these terms as synonyms. Another important observation while investigating this field of knowledge is the fact that cultural backgrounds have an important influence on the relationship between S-R and health care. Population from European countries (e.g. Sweden, Denmark) are usually more secular and S-R tend to be lessincorporatedinhealthcare, whereas population from Asiatic and Middle East cultural backgrounds are more open to this issue and tend to include it more frequently in health care. 4-6 In clinical practice, there has been increased consideration and recognition of S-R as part of the holistic model of care. Recent studies have shown that most patients want to discuss S-R with health care professionals in a routine basis, and indeed this willingness increases at the time of crisis. 7,8 Likewise, S-R can promote a better mental and physical health. 9 Other findings show that individuals use S-R beliefs to cope and accept their illnesses and that spiritual care is an important factor in improving patients' quality of life during end-of-life care. 10 However, Badanta et al 11 found that S-R has a negative effect in terms of treatment adherence for patients with HIV and chronic conditions. Within the critical care context, S-R needs of patients seem to increase when experiencing high levels of anxiety, stress and depression. 12 However, studies concerning critically ill patients are relatively scarce, both in the intensive care units (ICUs), but also in other environments (e.g. emergency rooms) where these patients are becoming more common. 13 In the context of critical care, life-threatening situations and unexpected changes are common, causing loss of hope and great anguish to the adult or child patient, family members and health care professional. 3,14 Although paediatric is different from adult critical care in several aspects, they share similarities such as the suffering of the family, the burn out levels of the critical care team, the stressful environment, and the end-of-life care. 15 In the context of critical, understanding factors such as S-R beliefs that might influence health outcomes in care patients (adults or children) are needed. Previous studies revealed that spiritual care could help both patients and their families to cope better with the intensive care situation, generating beneficial effects for both patients and their family. 16 Likewise, family members tend to use positive and negative coping strategies* during their relatives' hospitalization in the ICU, seeking support in spirituality and religious beliefs, such as hoping that God would resolve and control the situation. 12 Despite the importance of S-R for critically ill patients and their families, ICU health care professionals recognize that they do not have appropriate resources to deal with spiritual care. 16,17 In a recent research on S-R in the intensive care setting carried out in United States, four basic recommendations for ICU patients concerning spiritual care were proposed: evaluation and incorporation of spiritual needs in the ICU care plan; training in spiritual care for doctors and nurses; medical review of interdisciplinary assessments of spiritual needs; and attention to patients' requests to pray with them. 18 Therefore, paying attention to this dimension is essential to provide quality holistic care to patients, particularly in the ICU environment. Although there are recent reviews concerning this topic, they were based on narrative reviews 17 or clinical practice guidelines 18 and not relying on a systematic approach. Another integrative review did not include other critical care patients (such as paediatric critical care patients), had limited the language of the studies (English, Dutch) and had included opinion articles. 16 Our review has a different approach, aiming to include a comprehensive update of this field of research, not restricting the language of the studies, assessing the quality of these studies and including original research, both quantitative and qualitative, providing a panorama of the current evidence. What is known about this topic •Considering S-R needs and providing spiritual care is an important part of a holistic care for critically ill patients and should be considered by nurses. Studies have shown that S-R training could enhance the awareness and identification of S-R needs of the patients and family members, as well as could help improving the care of the patient. What this paper adds •This integrative review has shown that, although S-R needs are very common in the ICU environment, health care professionals are still little prepared to address these issues. From a research perspective, there are few studies and little empirical evidence of the influence of S-R on critical care nursing as well. Our results could stimulate future training concerning this topic and make these professionals more aware of this component of care. 2BADANTA ET AL. 2|AIMS AND OBJECTIVES OF REVIEW/ REVIEW QUESTIONS The main objective of this study is to provide a comprehensive analysis of the evidence around the spiritual care for critically ill patients, especially in order to understand the opinions and attitudes of health care professionals towards S-R care, and to identify the S-R needs of patients and their family members. The findings could help health managers to develop strategies to incorporate spiritual care in clinical practice, providing a more holistic care. Therefore, this review aims to critically analyse the empirical evidence concerning the influence of S-R on critical care nursing. Our review questions are: What are the needs and experiences of critically ill patients and their families towards S-R, and what kind of nursing care is provided to them? What are the perceptions, knowledge, experiences and attitudes of nurses towards S-R care for critically ill patients and their families? 3|DESIGN AND METHODS 3.1 |Search strategy An integrative review was conducted between May and October 2019. First, we discussed the most appropriate methodology and developed a protocol based on Whittemore et al 19 guidelines for integrative reviews. It was decided that the eligibility criteria, search strategies, data extraction, data synthesis and quality assessment would be predefined in order to reduce the possibility of a researcher bias. Whittemore et al 19 identify five stages in conducting an integrative review: (a) Problem identification; (b) Literature search; (c) Data evaluation; (d) Data analysis and; (e) Presentation. A brief version of these guidelines adapted to our review can be visualized in Table S1. Three reviewers (Reviewer 1, Reviewer 2 and Reviewer 4) carried out stage 1 (problem identification) from a theoretical perspective in order to provide focus and boundaries for the integrative review. Then, two reviewers (Reviewer 1 and Reviewer 2) independently carried out the literature search on seven electronic databases in the last 10 years: PubMed, Scopus, CINHAL, PsycINFO, Web of Science, Cochrane and LILACS. We also looked at the reference lists of the included papers we may have missed. The keywords and Boolean expressions used for the search were combined as follows: (religio* OR “religious beliefs”OR spiritual* OR “spiritual care”)AND (“critical care” OR “intensive care”OR ICU)AND (nurs*). In addition, one author (Author 3) conducted a search in the grey literature, which consists of any scientific material not gathered by conventional databases, such as doctoral theses and scientific communications. Searches were performed in the System for Information on Grey Literature in Europe (OpenGrey) and the Grey Literature Report. The proceedings of national and international conferences held over the past 5 years by scientific societies related to this topic were also consulted. The grey literature search was intended to find valid articles cited by the authors of the reports, but finally, they did not strictly match our search parameters and did not provide valuable context for the integrative review. All retrieved references were entered in Mendeley software (version 1.19.4) to create and organize a bibliography of all the references we have cited. 3.2 |Inclusion and exclusion criteria for selected articles Articles were included if they investigated spiritual care in critically ill patients and their families and were: (a) peer-reviewed articles with original data published in the last 10 years, (b) quantitative, qualitative or mixed studies, and (c) met the PICOTS criteria (Table 1). In addition, no language limit was set. This integrative literature review excluded any opinion pieces, such as editorials or other forms of popular media. In addition, studies where spirituality is addressed by a non-health care provider or a non-nursing care provider were also excluded, as well as those in which patients were not critically ill/did not receive critical care. Studies aiming to evaluate a specific S-R measurement tool were also excluded. 3.3 |Study selection The screening procedure was carried out by two reviewers (Reviewer 1and Reviewer 2) independently in order to identify relevant studies based on the inclusion and exclusion criteria. First, duplicate publications were removed and then the reviewers were screened by title and abstract. If there was a disagreement, another reviewer (Reviewer 4) was consulted. Then, full text articles were screened by three reviewers (Reviewer 1, Reviewer 2 and Reviewer 4) who evaluated the general information in order to include only those studies that analysed S-R care in both adults and children critically ill patients. Any discrepancies in this process were solved by a fourth investigator (Reviewer 3). TABLE 1 Population, intervention/exposure, comparator, outcome, time and study design (PICOTS) criteria PICOTS criteria Population Health care provider, patients and families in intensive care units (ICUs)/neonatal and paediatric intensive care units (NICU/PICU) Intervention/exposure Spiritual and/or religious Comparator Not applicable Outcome Spiritual care in patients treated in intensive and critical care services and their families Time Published in the last 10 years Study design Quantitative, qualitative studies and mixed methods BADANTA ET AL.3 3.4 |Data extraction One reviewer (Reviewer 1) was in charge of extracting and analysed the data from the papers, which was subsequently verified by another reviewer (Reviewer 3). Once the data had been extracted, a table was drawn up including authors, year, country, purpose of the study, research design, sample characteristics, data collection, instruments, and a summary of the major findings. The summary tables were thoroughly reviewed by three reviewers (Reviewer 1, Reviewer 3 and Reviewer 4) independently, with critical discussions of the extracted data. 3.5 |Assessment of methodological quality The studies that met the inclusion criteria were assessed by two reviewers independently for methodological validity prior to inclusion in the review (Author 1 and Author 4). Any disagreements that arose between the reviewers were resolved through discussion or by a third reviewer (Reviewer 3). The methodological quality was assessed using tools that ensure high-quality presentation of observational studies (i.e. STROBE), 20 clinical trials (i.e. CONSORT) 21 and of qualitative studies (i.e. SRQR guidelines) 22 in order to determinate a sound methodology within the retrieved studies. Studies scoring low on the appraisals would be excluded. For the SRQR, despite the fact that this score does not rate items, the following categorization was used based on the percentage of items meeting the appraisal criteria (Excellent: 80-100% of the items, Good: 50-80%, Regular: 30-50% and Poor: <30%). 3.6 |Development of themes In order to develop the themes for this integrative review, a thematic analysis approach was taken. 23 The reviewers participating in the searches, screening, articles assessment and data extraction (Reviewer 1and Reviewer 3) organized descriptive labels, focusing on emerging or persistent concepts and similarities or differences in S-R behaviours or practices, spirituality perceptions, and statements of nurses and family members. The coded data from each paper were examined and compared with the data from all the other studies. Finally, the different categories were gathered (grouped) into different themes. 4|RESULTS/FINDINGS A total of 1097 articles were initially retrieved from the databases and 6 articles were identified via secondary searches from other sources, FIGURE 1 Flowchart for the selection of articles for the integrative review 4BADANTA ET AL. TABLE 2 Results References, Country Purpose of the study Research design and sample characteristics Data collection and instruments Major findings Quality Abu-El-Noor, 43 Palestine To explore how Palestinian ICU nurses understand spirituality and the provision of spiritual care at the end of life Qualitative study (interpretivedescriptive approach) (n =13 ICU nurses) Semi-structured interviews Spirituality and spiritual care were very difficult to define for the ICU nurses and most of them made it in the context of religion. The majority of ICU nurses offered spiritual attention, especially when they felt that the treatment was useless and did not improve the condition of the patients, changing the goal of healing for being more attentive to the psychological and spiritual needs of others patients and their families SRQR Excellent Alimohammadi et al, 33 Iran To explore the clinical care needs of patients in the ICU with severe traumatic brain injuries (TBI), based on the nurses' perspectives Qualitative study Purposive sampling (n =14 ICU nurses) Semi-structured, in-depth interviews The nurses considered paying attention to the religious beliefs and considering the patients as human beings and respecting the patients and their privacy as part of spiritual needs. They also expressed that providing spiritual care is one of the factors of patients' mental and physical comfort SRQR Excellent Al-Mutair et al, 30 Saudi Arabia To identify the perceived needs of Saudi families of patients in Intensive Care in relation to their culture and religion Qualitative, exploratory study Purposive sampling (n =12 family members) Semi-structured in-depth interviews Saudi families have cultural and spiritual healing beliefs and practices including faith in God and that God is the ultimate healer, reading of the Qur'an, prayer, Shahadatain before the commencement of intubation and charity. These lessen their stress and connect them to hold on to hope In addition, maintaining proximity to their ill family member was considered of the greatest importance to the families SRQR Excellent Al-Mutair et al, 38 Saudi Arabia To identify the needs of ICU patients' families in Saudi Arabia as perceived by family members and ICU health care providers Quantitative, crosssectional design Convenience sampling (n =673, 176 family members and 497 intensive health care providers) Critical Care Family Need Inventory (CCFNI) According to the cultural and spiritual needs, having the health care providers handle the body of the dead Muslim with extreme caution and respect, was perceived as the most important need by family members and the fifth most important need by the health care providers STROBE 17/22 Al-Mutair et al, 36 Saudi Arabia To explore the perceived impact and influence of cultural diversity on how neonatal and paediatric intensive care nurses (NICU/ PICU) care for Muslim families before and after the death of children Qualitative descriptive study Convenience sampling (n =13 NICU/PICU nurses) Semi-structured interviews Nurses described that the practices preferred by Muslim families when the baby/child was seriously ill or near the end of life were knowing that a copy of the Koran or an audio recording of the Koran was used for the dying baby/child, the use of Zamzam water (holy water recovered from the well of Zamzam in Mecca) and Muslim rituals regarding the orientation of the body looking at SRQR/Good (Continues) BADANTA ET AL.5 TABLE 2 (Continued) References, Country Purpose of the study Research design and sample characteristics Data collection and instruments Major findings Quality Mecca once the baby has passed away or securing his hands for prayer Azarsa et al, 14 Iran To evaluate spiritual wellbeing, attitude toward spiritual care and its relationship with the spiritual care competence among ICUs nurses Quantitative, correlational, crosssectional, descriptive study (n =109 ICU nurses) Spiritual Wellbeing Scale, Spirituality and Spiritual Care Rating Scale (SSCRS) and Spiritual Care Competence Scale (SCCS) The nurses' attitude towards spirituality and spiritual care influences the provision of spiritual care. The mean score of the spiritual well-being was 94.45, the spiritual care perspective was 58.77, and the spiritual care competence was 98.5, meaning that there was a positive relationship between the spiritual care competence with spiritual well-being and the way of providing these cares STROBE 18/22 Bakir et al, 3 Turkey To determine the experiences and perceptions of Muslim ICUs nurses about spirituality and spiritual care Quantitative, crosssectional, descriptive study (n =145 ICU nurses) SSCRS Among the nurses, 44.8% received spiritual care training and 64.1% provided spiritual care to their patients. About their spiritual care practices, 28.3% stated that they used the therapeutic touch on patients. Barriers to provide spiritual care to patients were the “insufficient number of nurses (47.6%), excessive workload (28.3%), and fatigue (24.1%). The nurses being knowledgeable with spirituality and spiritual care were found to have a significantly higher spiritual care perception” STROBE 17/22 Bone et al, 40 Canada To explore the effect of spiritual care on nurses and how nurses understand the role of spiritual care in the ICU Qualitative descriptive study Purposive sampling (n =25 ICU nurses) Semi-structured interviews Nurses often disclosed being unaware of when they were providing spiritual care, and they also described how the presence of a chaplain supported caring for dying patients. They feel a sense of relief after calling chaplains, knowing they will jointly help support the patient and the patient's family SRQR Good Brelsford et al, 27 USA To determine whether secular and religious coping strategies were related to family functioning in the NICU Quantitative, crosssectional, descriptive study Parents of preterm infants (admitted to the NICU) (n =52) Brief COPE (secular coping), the Brief RCOPE (religious coping), and the Family Environment Scale Greater use of negative religious coping strategies, like feeling abandoned or punished by God, was significantly related to higher levels of denial and lower levels of family cohesion STROBE 19/22 Canfield et al, 52 USA To examine critical care nurses' definition of spirituality, their comfort in providing spiritual care to patients, and their perceived need for education in providing this care Qualitative study (Phenomenological method) Purposive sampling (n =30 ICU nurses) Interviews The spirituality as a belief in a higher power, higher being, or God was described by 47% of nurses. They did not feel a person had to be religious to be spiritual; however, the majority of the nurses then referenced religion as a means to express spirituality SRQR Excellent 6BADANTA ET AL. TABLE 2 (Continued) References, Country Purpose of the study Research design and sample characteristics Data collection and instruments Major findings Quality 75% expressed some degree of comfort providing spiritual care to critically ill patients. However, they mentioned the need of formal classes in different religions, cultures, or spiritual values Choi et al, 34 USA To determine how ICU clinicians address the religious and spiritual needs of patients and families Quantitative, crosssectional design n=219 clinicians (63 physicians, 138 nurses and 18 Advance Practice Providers) Questionnaires ad hoc Levels of religiosity and spirituality correlated with how clinicians view their responsibility in addressing religious and spiritual concerns of patients A majority of clinicians (79% of attending, 74% of fellows, 89% of nurses and 83% of APPs) expressed that it is their responsibility to address the religious/ spiritual needs of patients but in the practice, only 14% of attending, 3% of fellows, 26% of nurses, and 17% of APPs asked patients about these questions STROBE 20/22 de Brito et al, 46 Brazil To investigate the comprehension of nurses of concepts of spirituality and spiritual necessities of patients without therapeutics possibilities Qualitative, exploratory study (n =7 ICU nurses) Interviews It is evidenced the binding between S-R. Nurses consider the verbal communication and non-verbal communication (a tear, having a Bible) as instruments that can be used in identifying spiritual needs in patients and their family SRQR Good Ehsani et al, 53 Iran To explore the viewpoints of nurses working in ICUs about the concept of spiritual well-being Quantitative, crosssectional study Random sample (n =62 ICU nurses) Questionnaire about spiritual well-being ad hoc Among nurses, 53.2% had a positive attitude towards spiritual health, 27.4% had a moderate to somewhat favourable attitude, and 19.3% had a negative attitude. There was a positive significant correlation between spiritual care, age and work experience STROBE 16/22 Ernecoff et al, 59 USA To determine the frequency and characteristics of treatments on religiosity/spirituality among health care professionals and surrogate decision makers during visits to the ICU Mixed design (qualiquanti) (n =546 surrogate decision makers and 150 health care professionals) 249 goals-of-care conversations in 13 ICUs Religion or spirituality were very important for surrogate decision maker's life (77.6%) and this is demonstrated in how religiosity or spirituality was raised in 40 of the family meetings (16.1%) where the most common belief was that God is ultimately responsible for health and that the physician is his instrument to promote healing. To face the surrogates' spiritual statements, health care professionals mainly redirected the conversation to medical considerations and offered to involve hospital spiritual care providers SRQR Good STROBE 18/ 22 Ghaljaei et al, 48 Iran To explain the spiritual challenges experienced by nurses in neonatal end of life in the NICU Qualitative content analysis method Purposive sampling (n =24 NICU nurses) Semi-structured in-depth interviews The spiritual challenges experienced by nurses include challenge of psychological/spiritual support of family and spiritual distress of the SRQR Excellent (Continues) BADANTA ET AL.7 TABLE 2 (Continued) References, Country Purpose of the study Research design and sample characteristics Data collection and instruments Major findings Quality nurse. Most of the nurses stated that spiritual/religious beliefs of families are an important factor to calm the family, however, a number of nurses believed that if the families are allowed for such actions, then the treatment procedure of newborns would be disrupted Green, 39 Australia To describe how neonatal nurses manage the situation of medical futility when the parents are hoping for divine intervention and a miracle Qualitative study (Phenomenological method) Purposive sampling (n =24 NICU nurses). Self-completed questionnaire and semistructured interviews The nurses all knew that religion played an important role in the lives of many families in the NICU. However, they did not know how to respond to the mother's belief in a miracle despite a dismal prognosis for the baby. They understood that praying for a miracle was about hope and parents who expected a miracle were unlikely to be swayed by medical science. The nurses acknowledged that parents needed time to spend with their baby and to be able to hope for a positive outcome or divine intervention; however, whenever the baby was on a dying trajectory, the nurses experienced moral distress SRQR Good Heidari et al, 28 Iran To determine the perception of Iranian nurses towards spirituality in NICUs Qualitative study Purposive sampling (n =9 NICU staff: 8 nurses and 1 physician) Semi-structured interviews Most of the participants stated that spirituality leads to peace of mind and helps resolve their problems and they have recourse to God while doing routine daily activities. Recoursing to God and Ahl-al Bayt is considered as an appropriate approach to enhance spirituality SRQR Good Hlahatsi et al, 31 South Africa To determine if critically ill patients' needs were met in 11 intensive care units of four private hospitals in Gauteng Quantitative, descriptive, cross-sectional design (n =112 family patients) Questionnaire ad hoc Only 46% of the patients indicated that their spiritual needs were met in the intensive care unit (related to doubts and questions, to be informed when their relative's condition changed or to have a place close to the ICU to be with him) and 21% said the spiritual need was not applicable to them STROBE 14/22 Ibrahim et al, 55 Brunei To explore the spiritual coping with stress among the nurses in the Emergency Department and Critical Care Services in Brunei Darussalam Quantitative, crosssectional, descriptive study (n =113 nurses) Spiritual Coping Questionnaire (SCQ) Majority of nurses perceived spiritual stress coping as religious (46.9%), personal (30.1%) achieving inner peace or strength and having a positive attitudeand social (6.19%) such as gaining support or advice from others such as family or friends. Those who have been working more than 15 years were using significantly lower negative religious coping STROBE 18/22 8BADANTA ET AL. TABLE 2 (Continued) References, Country Purpose of the study Research design and sample characteristics Data collection and instruments Major findings Quality Kim and Yeom, 54 South Korea To describe the relationship between spiritual well-being and burnout of ICU nurses Quantitative, crosssectional, descriptive study (n =318 ICU nurses) Questionnaire ad hoc and the Spiritual WellBeing Scale and Burnout Questionnaire Burnout was negatively correlated with spiritual well-being (r=0.48, P< .001). Higher levels of spiritual well-being were associated with lower levels of burnout STROBE 20/22 Kim et al, 42 USA To explore ICU nurses' experiences with providing spiritual care to critical patients and their families, perceptions about chaplains and the duties best performed by chaplains, and suggestions to meet the spiritual needs of critically ill patients, their families, and the ICU staff Qualitative study Purposive sampling (n =31 ICU nurses) In-depth interviews (n =19) and 2 focus groups (n =5 and n=7) Most nurses did not feel prepared to meet the spiritual needs of critical patients and their families, so they invited a member of the spiritual care department, emphasized the supportive role of the chaplain. Nurses felt that their own spiritual needs should be met in order to offer spiritually based nursing care among patients and their families SRQR Good Kisorio and Langley, 29 South Africa To elicit critically ill patients' experiences of nursing care in the adult ICU Qualitative descriptive study Purposive sampling (n =16 patients). Semi-structured interviews Some patients had negative experiences regarding nursing care for the bad communication and for feeling that the presence of the nurses was scarce and they only saw them when they had to perform some procedure SRQR Excellent Kisvetrov a et al, 35 Czech Republic To assess the practice of registered nurses (RNs) with respect to dying care and spiritual support interventions in ICUs Quantitative, crosssectional, descriptive study Convenience sampling (n =277 ICU nurses) Questionnaire ad hoc Activities focused on the spiritual needs of the patient like treating him with dignity and respect, biological dimension activities like “monitor pain”or “assist with basic care”were the most often provided activities in the care. Less frequently used activities were “communicate willingness to discuss death”,“offer culturally appropriate foods”, and “facilitate discussion of funeral arrangements” STROBE 18/22 Koukouli et al, 24 Greece To explore the experiences, needs and coping strategies of families of patients admitted to adult ICU of three hospitals in the island of Crete, Greece Qualitative study Non-random purposeful sampling (n =14 ICU patient's family members) Semi-structured, face to face interviews The main coping mechanisms used were optimism, support from their family networks and spirituality. Spirituality as a means to deal with a difficult situation emerged as an original and significant finding in this particular cultural context underscoring the importance of recognizing, respecting and meeting families' spiritual needs SRQR Excellent Küçük et al, 37 Turkey To identify the effect of spiritual care given to mothers with infants in NICU on their levels of stress Randomized controlled trial Random sample (n =62 mothers, randomly divided into a spiritual care group (n =30) and a control group The Mother–Baby Introductory Information Form and the Parental Stressor Scale: Neonatal Intensive Care Following spiritual care, there was a significant difference between the PSS:NICU scores of the mothers, for the Infant's Appearance and Behaviours subscale, in favour of the spiritual care group (P< .05) The mothers stated that they cope their children´s health problems CONSORT 21/25 (Continues) BADANTA ET AL.9 heterogeneity is observed within religions in palliative care practices such as advanced directives, euthanasia and physicianassisted suicide, physical requirements (artificial nutrition, hydration, and pain management) and autopsy practices. 67 Recent studies showed a positive correlation between the competence of spiritual care with the spiritual well-being of nurses and their attitude towards spirituality. 68 Wu et al 66 also revealed that positive spiritual climate supports transformational leadership as means to reduce nursing burnout. In addition, previous studies have showed that the attitude of spiritual care was rooted in faith and spiritual beliefs 69 according to which nurses considered spiritual care as a professional responsibility that must be treated with the same level of attention as physical needs. 70 All this evidence could help in the development of training and in the improvementofspiritualcareincriticalpatients. 6|LIMITATIONS The present review has some limitations that should be acknowledged. It is possible that our search strategy has not included all possible keywords and, as a result, failed to retrieve and include some important articles. The inclusion and exclusion criteria could be not exhaustive or fully comprehensive. On the one hand, future studies on this topic should indicate specific characteristics of S-R care to identify those articles that meet these criteria. However, this could be complicated because of the lack of consensus on the definition of concepts such as S-R. On the other hand, the date limits used in this study have excluded older studies. Although this is a limitation, we decided to include the most up-to-date evidence in this review, since guidelines, clinical practices and evidence change in a rapid pace. Most studies included in this review were from Asian countries, which are usually more open to spiritual needs as compared with some secular societies. This could have influenced our findings. Finally, as previously mentioned, although we recognize that paediatric and adult critical care are different in some aspects, they carry important similarities and, for this reason, we decided to include all studies with critically ill patients in the review, broadening its scope and adding to the literature. Future studies should deepen the knowledge on how spiritual care is addressed by nurses worldwide, the differences in cultural backgrounds and the mechanism by which S-R issues may influence the physical and mental health of critical patients and their families. 7|IMPLICATIONS AND RECOMMENDATION FOR PRACTICE This review indicated spiritual needs are commonly expressed during life-threatening situations, such as those experienced in ICUs, lifethreatening conditions and health care professionals should be aware of them. Because our results highlight that most nurses are open to this subject and would like to be trained to handle these situations, ICU managers are commended to organize training for ICU health care professionals in order to provide a more holistic care. 8|CONCLUSIONS In conclusion, this review has demonstrated that spirituality is an important issue for critical care patients, family members and health care professionals. Critical care professionals should be aware about the needs of their patients and should be trained to handle S-R in clinical practice. 8.1 |Impacts 8.2 |Ethics practices During this review, ethical practices were applied. The authors have aimed for transparency, accuracy and the avoidance of plagiarism. The review followed a structured guideline provided by Whittemore et al. 19 AUTHOR CONTRIBUTION Study conception and design: B arbara Badanta, Rocío de DiegoCordero. Data collection: B arbara Badanta, Estefanía Rivilla-García. Data analysis and interpretation: B arbara Badanta, Estefanía RivillaGarcía, Rocío de Diego-Cordero. Drafting of the article: B arbara Badanta, Giancarlo Lucchetti, Rocío de Diego-Cordero. Critical revision of the article: B arbara Badanta, Giancarlo Lucchetti, Rocío de Diego-Cordero. ORCID Rocío de Diego-Cordero https://orcid.org/0000-0002-3453-003X ENDNOTE * A positive spiritual/religious coping includes a spiritual relationship connection with God and with others. Negative spiritual/religious coping involves questioning the existence or love of God, considering stress factors as divine punishment or evil forces, delegating to God the resolution of the health problems, feeling dissatisfaction towards God or members of religious institution. According to Schleder et al, 12 the first one is directly resulting in better quality of life. REFERENCES 1. Lucchetti G, Lucchetti ALG. Spirituality, religion, and health: over the last 15 years of field research (1999–2013). Int J Psychiatry Med. 2014;48(3):199-215. https://doi.org/10.2190/pm.48.3.e. 2. Koenig HG, ME MC, Larson DB. Handbook of Religion and Health. Oxford: Oxford University Press; 2001:712. 3. Bakir E, Samancioglu S, Kilic SP. Spiritual experiences of Muslim critical care nurses. 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Accessed April 20, 2021 SUPPORTING INFORMATION Additional supporting information may be found online in the Supporting Information section at the end of this article. How to cite this article: Badanta B, Rivilla-García E, Lucchetti G, de Diego-Cordero R. The influence of spirituality and religion on critical care nursing: An integrative review. Nurs Crit Care. 2021;1–19. https://doi.org/10.1111/nicc. 12645 BADANTA ET AL.19