The Role of Spirituality and Religiosity in Healthcare During the COVID-19 Pandemic: An Integrative Review of the Scientific Literature

In recent decades, the field of spirituality, religiosity, and health research has increasingly consolidated in the scientific community (Lucchetti & Lucchetti, 2014), presenting an increase of 600% in the number of publications between 1993 and 2002 (Valiente-Barroso & García-García, 2010) and gaining even more attention of researchers particularly over the last 35 years (Koenig et al., 2021).

In the field of nursing, the relationship between spirituality and healthcare has been considered one of the pillars of modern nursing. According to Florence Nightingale, spirituality is considered an intrinsic component of human nature and 'the most profound resource and powerful healing power available to the person.' In fact, previous studies have shown that including spiritual care in nursing practice not only provides benefits for patients but also for nurses, since the practice of their profession brings greater satisfaction (Vlasblom et al., 2011). Despite this importance, few nurses feel prepared to handle these issues in clinical practice (Cordero et al., 2018) and there is a clear gap to address spiritual needs despite the fact that most patients want their healthcare professionals to discuss these issues (Sager, 2020).

In case of others health professionals such us physicians, they pointed out obstacles such us lack of training, lack of time, and fear in addressing this dimension in their care practice to provide adequate care in this regard (López-Tarrida et al., 2021).

Spirituality is considered a crucial resource during disaster situations. As an example, during World War I, chaplains were assigned to military units as a resource for moral support, and, during times of battle, they went to the front to give absolution to outgoing soldiers (Chirico & Nucera, 2020). Another example was the Asian highly pathogenic avian influenza HPAI A/H5N1 pandemic. In this period, a study found that spirituality was associated with higher levels of positive emotions and helping behavior and lower levels of illegal behavior (Smith et al., 2009). Likewise, in 2014, the largest Ebola epidemic in history caused 10,000 deaths and more than 26,000 people were infected in Africa. During this crisis, religiosity was also an important aspect of the provision of care (Marshall & Smith, 2015).

These aforementioned crises were followed by one of the most unprecedented infectious diseases that the world has ever faced, the COVID 19 pandemic. According to data recorded by John Hopkins University, the total number of cases of infections worldwide at the beginning of October 2021 was 237,668,106 and the total number of deaths was close to 5 million people (Center for Systems Science & Engineering at Johns Hopkins University, 2021). Likewise, the World Health Organization (WHO) reported an increase in mental health problems due to the disease itself, as well as the social distancing and confinement imposed to stop the contagion (Pan American Health Organization, 2020). In this context, spirituality and religiosity have emerged as important coping mechanisms to overcome mental and physical health problems, promoting positive emotions that could strengthen the immune system and minimize suffering (Bhaskar & Mishra, 2019).

During the COVID 19 pandemic, spiritual support has in fact become evident and due to the limited number of chaplains or due to the avoidance of contact with patients, healthcare professionals were instructed to give blessings to those who were dying from loved ones, highlighting the role of spiritual care in disaster scenarios such as the COVID-19 pandemic, to alleviate stress and psychological suffering (Chirico & Nucera, 2020).

Despite these initiatives, few studies have collected evidence on the role of spiritual and religious beliefs on care during the COVID-19 pandemic. This is particularly important to understand how spirituality is addressed and what are the challenges to address it, helping healthcare managers plan better interventions in future pandemics.

The spiritual approach in disaster situations includes holistically assessing the patient, recognizing values and beliefs, detecting spiritual needs, and offering appropriate care. The main objective of this study was to provide a comprehensive analysis of the role of spirituality and religiosity on health care for the general population during the COVID-19 pandemic.

Our review questions were as follows:

A flow chart was prepared according to the Prisma Declaration (Page et al., 2021). First, 1,338 articles were retrieved after applying the database search strategy. No results were extracted from the gray literature search. After removing duplicate records and reviewing the titles and abstracts of 1,143 records, a total of 123 studies were selected for full text reading (Fig. 1).

Finally, a total of 25 articles have been included in the review, of which 22 were descriptive observational studies, 2 were qualitative studies, and 1 was a randomized controlled study. A total of 88% of the studies included in this review adopted a descriptive cross-sectional design, 8% qualitative designs, and 4% clinical trials. The included studies are presented in Table 3.

The purpose of this review was to analyze the role of spirituality and religiosity on health care during the COVID-19 pandemic. Most studies investigated the effect of spiritual/religious beliefs on people's health during the COVID-19 pandemic. Other studies have focused on spiritual interventions and on the use of coping strategies by healthcare professionals. Our findings denote the importance of addressing spiritual needs in clinical practice due to its benefits, as well as highlight the need for training health professionals to be able to carry out interventions that take into account the spiritual and religious aspects.

First, in studies that evaluate healthcare professionals, our findings revealed that spiritual and religious issues are important aspects for these professionals and can influence their health and clinical practice. Some articles have emphasized that the mental health of professionals has been affected by the pandemic and identified spirituality and good family functioning (Kim et al., 2021), as well as religious or spiritual beliefs and practices (Sierra Leguía & Montalvo Prieto, 2012) and faith (Matheson et al., 2020) as coping strategies. This is fully supported by previous studies before the pandemic, which have also found that religiosity and spirituality were significantly associated with a reduction in anxiety levels and an improvement in depressive symptoms (Gonçalves et al., 2015; Hook et al., 2010; Peselow et al., 2014).

In relation to the resilience of nurses during the pandemic, religious values, morality, self-awareness, patience and hope, wisdom, voluntary activities and belief in the afterlife have been identified as important components of being resilient (Rajabipoor Meybodi & Mohammadi, 2021; Wei et al., 2019). Together with resilience, spiritual practices appeared to provide a sense of security and inner peace that prevent the appearance of other negative emotions such as fear, anxiety, or insecurity (Prazeres et al., 2020), although some studies also suggest that nurses with greater spiritual perception present high levels of anxiety before death (Rahman et al., 2021).

It is interesting to note that some interventions designed to promote spiritual and religious beliefs (e.g. mantra repetition programs (Kostovich et al., 2021)) appeared to be effective for nurses during the pandemic, as this was in line with the interventions offered before the pandemic for those professionals such as the creation of a good spiritual work environment (Wu et al., 2020), prayer (Ibrahim et al., 2020) or spirituality training programs on well-being and spiritual integrity (Yong et al., 2011). In this regard, previous studies have pointed to the need to include religiosity and spirituality education programs for undergraduate and graduate students, providing relevant training courses for nurses that allow them to learn the skills necessary to provide spiritual care and to handle their spiritual needs (de Diego Cordero et al., 2019; Moreira-Almeida et al., 2014).

Although the literature highlights the unpreparedness and burnout of health professionals while addressing spiritual needs in the hospitals due to the risks of contagion of chaplains (Chirico & Nucera, 2020), it is important to highlight that chaplains were and are very important figures in the COVID-19 pandemic as well. According to the different communities and contexts, chaplains have responded in different ways, providing emotional, religious, spiritual support during this challenging moment where gathering have been prohibited in many places (Carey et al., 2020). These risks have lead chaplains to provide spiritual care at a distance, trying to maintain contact with the believers, shifting towards online-based services, spiritual recollections and retreats, community prayers and sacraments (Domaradzki, 2022). Likewise, religious leaders were allowed to use online devices to provide spiritual care during the hospitalization to alleviate the suffering of patients. These strategies were essential to minimize the problems arising from the uncertainty of the disease (Badanta et al., 2021).

Second, several studies have assessed the role of spirituality and religiosity in different health outcomes for the general population during the COVID 19 pandemic. These studies have revealed that spiritual and religious beliefs could be associated with greater coping, less mental health problems (stress, anxiety, depression) and better well-being. According to previous studies, the most prevalent negative emotional symptoms during the pandemic were anguish, fear, and suffering. In this context, spirituality appears to be an important tool for overcoming suffering among individuals. These results found during the pandemic were also observed before the pandemic by several studies. Individuals tend to use religiosity and spirituality to face problems, with actions such as greater participation in religious activities, trust in God for their protection against fear and isolation; find joy and courage when listening to gospel music and reading scriptures (Hamilton et al., 2021), using positive religious coping strategies (Fatima et al., 2020; Mahamid & Bdier, 2021; Thomas & Barbato, 2020), trusting in God (Pirutinsky et al., 2021), supporting their closest loved ones, using spiritual intelligence, subjective vitality and mindfulness (Saini & Seema, 2021). All these strategies were associated with decreased fear, relief from suffering and increased well-being (Durmuş & Durar, 2021; Lucchetti et al., 2020; Rababa et al., 2021), experiencing 'spiritual renewal' (Kowalczyk et al., 2020). These results could serve to make healthcare professionals and healthcare managers aware of the spiritual and religious needs of their patients, to promote integrative and person-centered care. They should ensure the continuity of religiosity and spirituality activities during the pandemic (Lucchetti et al., 2020) and consider these factors when planning interventions to address health problems in times of crisis in the treatment of mental health (Mahmood et al., 2021; Moreira-Almeida et al., 2014).

In conclusion, our findings revealed that spirituality could be considered a good coping strategy used by healthcare professionals to deal with mental health problems during the COVID-19 pandemic, providing greater inner strength, resilience and well-being, as well as greater patient satisfaction with the care given. In relation to the general population, evidence shows that meeting the spiritual needs of individuals leads to a reduction in stress, anxiety, depression, and other negative emotional symptoms that have appeared in people during the COVID-19 pandemic, thus achieving an increase in psychological well-being and providing resilience and hope.

For both healthcare professionals and the general population, spirituality has helped reduce negative emotional symptoms related to the COVID-19 pandemic, providing psychological well-being, resilience, and hope. Our results support the need for adequate spirituality training for health professionals, aiming to promote integrative care that takes into account the spiritual and religious aspects of people.