Spiritual care in patients hospitalized with COVID-19: scoping review

Objective: to map existing evidence on spiritual care for patients hospitalized with COVID-19. Methods: scoping review developed in accordance with methodological processes developed by the Joanna Briggs Institute, carried out through a search in the data bases SCOPUS, Science Direct, MEDLINE, Web of Science, CINAHL, and Google Scholar ® , in addition to a reverse search in the works selected. The review included studies with evidence on the topic at hand, which had been published in any language, in any time frame. Results: 19 studies were analyzed, and 8 different spiritual care interventions were mapped, which were: listening to the spiritual pain of the patient; grief support; on-line video tools with content on faith and resilience; on-line calls with relatives; availability of religious representatives; spiritual triage; training professionals to provide spiritual care; and music therapy as an instrument of spirituality. Conclusion: this review allowed map- ping the evidence about spiritual care in patients hospitalized with a diagnosis of COVID-19, addressing strategies to bring spir- ituality into health care. Contributions to practice: this study contributes for the advancement of the practice of nursing regarding spirituality and patients with COVID-19, providing subsidies to use spirituality as a tool to support care and facilitate dealing with difficult situations. Descriptors: mapear


Introduction
The pandemic of the new coronavirus (CO-VID-19) started in 2020 and quickly spread through many countries. The disease can cause several symptoms, such as dry cough, fever, shortness of breath, and pulmonary infections. Up to May 2021, the pandemic caused more than three million deaths and infected more than 170 million people around the globe (1) .
Due to the growing number of cases and deaths caused by the virus, the situation can be alarming. The feeling of uncertainty and unpredictability affects the anxiety mechanisms associated with threats. Hospitalized patients are in an even higher degree of isolation, solitude, and vulnerability, facing spiritual needs due to the complex settings of life of death caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) (2) .
Humanized and integral care can be essential for the evolution of the framework of the patient, Current research has shown that spiritual practices and beliefs are related to the ability to cope with diseases and harsh situations, as well as with post-discharge recovery. Thus, the relevance of bringing spirituality into clinical practice has been clearly demonstrated (3) .
Spirituality is defined as a set of abstract convictions and experiences, which presume to determine the meaning of life beyond our understanding. It can be connected to religious practices and beliefs or not (4) . Spiritual care is widely understood as a type of care that addresses and tries to understand existential and spiritual challenges associated with diseases and crises (5) .
The NANDA-International taxonomy includes the nursing diagnoses "Spiritual Distress" (00066) and "Risk for spiritual distress" (00067), which highlight that nursing workers must consider humane responses in regard to spirituality. Therefore, it is necessary for health care, especially in the case of patients diagnosed with COVID-19, to encompass social aspects, and systems of values and beliefs that are part of the lives of individuals (6) .
It is valid to recognize the growing cases of spiritual suffering among patients with a COVID-19 diagnosis. Nonetheless, spiritual care is often delayed under the pretext that the multidisciplinary and nursing teams have little knowledge about spirituality and about which type of care can be implemented to avoid patient spiritual suffering (7) .
Thus, studies regarding spiritual care and its practical application during assistance are essential, since spirituality is an intrinsic factor for the integral care of individuals, as well as an essential dimension of nursing practice (5) . Therefore, the development of studies about the topic is justified in order to provide subsidies to address a type of health care that recognizes the spiritual dimension of the human being, and to guide assertive actions based on scientific evidence.
As a result, our goal was to map the evidence on spiritual care in hospitalized patients diagnosed with COVID-19.

Methods
This study is a scoping review developed in accordance with the methodological processes from the Joanna Briggs Institute (JBI) and elaborated according with the criteria determined in the extension for Scoping Reviews of the checklist Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA-ScR) (8)(9) . The protocol of the study was registered in the platform Open Science Framework (OSF), receiving a sequential identifier from the Uniform Resource Locator (https://osf.io/2yg6a/) (10) .
With the guidance of a research protocol elaborated earlier, the five proposed methodological stages were developed: identification of the guiding question of the research; identification of relevant studies in the research; study selection; mapping and extraction of the results found; and narrative synthesis of the results (8) .
To identify the guiding question of the review, the mnemonic strategy PCC was used (P: population -patients with COVID-19; C: concept -spiritual care; and C: context -hospital care). Based on this strate-gy, the following guiding question was defined: What forms of spiritual care are offered to patients hospitalized with a COVID-19 diagnosis?
To identify primary studies published or not (gray literature) about the topic at hand, we conducted, in August 2022, a search in the following databases: SCOPUS; Web of Science; Science Direct; Medical Literature Analysis and Retrieval System Online (MEDLINE), through the National Library of Medicine National Institutes of Health (PUBMED); Cumulative Index to Nursing and Allied Heath Literature (CINAHL); and Google Scholar ® . There were also advanced searches in each database, and in the portal of journals from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES -Coordination for the Improving of Higher Education Personnel), through the Comunidade Acadêmica Federada (caféthe Federated Academic Community).
The following ordered descriptors were used in the search strategy, all of which are present in the Health Science Descriptors (DeCS) and in the Medical Subject Headings (MeSH): (Infecções por Coronavirus; Coronavirus Infections), 2# (Terapias Espirituais; Spiritual Therapies), 3# (Espiritualidade; Spirituality). Boolean operators AND and OR were used to cross the descriptors.
The search in Google Scholar ® was carried out to identify the gray literature. As a result, it was possible to find works that were relevant to the topic of this study but had not been identified during the search in the databases. The search strategies in the databases is presented in Figure 1.

Databases
Search strategy SCOPUS ALL("Coronavirus Infections") AND ("Spiritual Therapies") OR ("Spirituality") Web of Science ALL=("Coronavirus Infections") AND ("Spiritual Therapies" OR "Spirituality") Science Direct "Coronavirus Infections" AND ("Spiritual Therapies" OR "Spirituality") MEDLINE/PUBMED ("Coronavirus Infections") AND ("Spiritual Therapies") OR ("Spirituality") CINAHL "Coronavirus Infections" AND ("Spiritual Therapies" OR "Spirituality") Google Scholar® "Coronavirus Infections" AND ("Spiritual Therapies" OR "Spirituality") The following inclusion criteria were adopted to select the studies: studies that included evidence on the spiritual care provided to patients hospitalized with a COVID-19 diagnosis, available in any language, in full, present in the databases analyzed. There was no specific time frame, in order to identify the highest number of studies available. Letters to the editor, abstracts, and studies whose topic was not relevant to our goals were not included in the sample.
Two reviewers carried out independently a pre-selection of the studies, by skimming their titles and abstracts. After this stage, the studies selected for the final sample were read in full. Still in this stage, a search was carried out in the bibliography included in the list of references of the articles selected, in an attempt to find additional studies that had not been found during the previous search. Any disagreements were decided by consensus between the reviewers. Duplicate studies were only accounted for once.
An instrument to map and extract the data was created in Microsoft Excel 2019 ® , including the following items: identification of the publication (title, authors, year of publication, country, type of study, and source of data); methodological aspects (objective/research question, methodology used, level of evidence and approach -quantitative/qualitative); main recommendations about the spiritual care for COVID-19 patients, target audience of the spiritual care; and workers responsible for implementing said care.
The studies were classified according with the following levels of evidence: Level 1. Evidence from systematic reviews or meta-analyses of controlled randomized clinical trials; Level II. Evidence from well-designed controlled randomized clinical trials; Level III. Evidence from non-randomized well-designed clinical trials; Level IV. Evidence from well-designed case-control cohort studies; Level V. Evidence from systematic reviews of descriptive and qualitative studies; Level VI. Evidence from descriptive or qualitative studies; and Level VII. Opinion from authorities and/or reports (11) .
The organization of the works mentioned and the list of references for this review were managed by Mendeley Desktop, a software for the management of references. The critical analysis and synthesis of the studies selected were descriptive, using figures and a table.

Results
The searches in the databases and in Google Scholar found 697 works. The reverse search using Regarding their year of publication, the studies were published in 2020 and 2021, with most (15 -78.9%) being published in 2020 Most studies 8 (42.1%) were found in the database SCOPUS. The United States (US) were responsible for 5 (26.3%) of the studies selected. Most studies were (17 -89.4%) written in English. Regarding the level of evidence of the references of the studies selected previously led to the inclusion of five other articles After the removal of 15 duplicates and 602 works that were not in accordance with the eligibility criteria, 85 studies were selected to be read in full. After this stage, 66 investigations were excluded as they were not congruent with our research question. As a result, the final sample of this review was formed by 19 studies. Figure 2 presents the process of search and selection of studies according with recommendations from the PRISMA-ScR (9) . the studies, most were of level VII, a total of 5 (33.3%). Figure 3 describes the authors, year, country of publication, type of study/level of evidence, target audience of the spiritual care, workers responsible for implementing the care, and main recommendations for the spiritual care provided by the studies selected. Keeping contact between patient/family and a spiritual representative.

Type of study/level of evidence
Making possible for relatives to use on-line video calls.
Providing grief support.

Health and social workers
Helping patients cope with fears, overcome them, and find hope.
Caring for existential distress.
Addressing feelings of punishment, guilt, injustice, and remorse.
Providing grief support in the preparation for death Sharing the decision making process with the family and discussing post-COVID-19 exit strategies.

Patients in general Nurses
Providing training to change the attitudes of the nurses and the role of the spiritual care.
Reducing the workload and improving the planning of management to provide high-quality assistance to the patient.
Ferrell et al. 2020/USA (2) Qualitative study/VI Children and adults Nurses and physicians Carrying out spiritual triages for all patients at admission.
Using tools for routine spiritual triage, such as the tools faith, import or influence, community, address (FICA), and belief system, ethics or values, lifestyle, involvement in spiritual community, education, near future events of spiritual significance for which to prepare the child (BELIEF).
Providing opportunities for the patient to express themselves spiritually.
Active listening and showing acceptance of the spiritual pain of the patient with no judgment. (the Figure 3 continue in the next page...) Bringing up discussions about rituals or spiritual needs the patient desires.

Type of study/level of evidence
Providing additional support to grief through telehealth services.

Figura 3 -Apresentação dos estudos incluídos na revisão. Natal, RN, Brasil, 2022
Regarding the target audience of the spiritual care in the studies, we found children, adults, elders, and patients in general (people whose age group was not defined). Patients in general were the most common target audience (12 studies -63.1%). The professionals responsible for the implementation of the care, as represented in the studies, were mostly nurses and members of the nursing team (11 -57.8%).

Discussion
Our search found that there are few studies on the topic, highlighting the need for further investigation on the topic. Below, the works identified will be explained according with the findings in literature.
For most studies, it is important for health professionals to provide opportunities for patients to express themselves spiritually when their health is being assessed. These workers must be prepared to carefully listen to the spiritual of the patient and show understanding without judgment. A part of providing spiritual care during the COVID-19 is to help patients face and overcome fears and find hope and meaning, in attention to their existential distress. Through listen-ing, plans of care that involve the individual spiritual needs of each patient should be elaborated (2,(17)(18)23,25,27) .
Regarding grief support, studies recommend that it should be targeted both for the patient and their family, and can be implemented by nurses, psychologists, and social assistants (16)(17)21,27,29) . It is necessary to provide spiritual care in the preparation for death of critical patients, considering the imminent risk presented by these patients (16)(17) .
Hospitals that have religious representatives should ask them to talk with patients or relatives about imminent death and provide comfort and wellbeing at this time (15)(16)21,25) . The relevance of providing grief support has also been made clear. The decision making process should have the participation of the family, including the discussion of post-COVID-19 exit strategies, whether the outcome is discharge or death (19) .
The studies also recommend the use of technology to provide spiritual care to patients hospitalized with COVID-19. On-line video calls between patients, family, and health workers are a way to soften spiritual pain and increase the connection with the family, especially due to the social isolation needed as a part of the COVID-19 treatment, due to which the family cannot visit (16,19,21,24) .
When the family cannot use virtual options, health professionals can encourage other ways to stay in touch, such as writing cards/letters, painting pictures, or sending photos of the patient to remind them of the time they spent together. Even if the patient cannot read, the health workers can, for example, read the cards or letters, in order to establish a connection between the patient and their family (21) .
Other digital tools were also recommended, such as psychoeducational interventions carried out through on-line tools, using techniques to manage stress, mindfulness, and positive psychotherapy about faith and resilience developed by nurses and psychologists (12) . One study also made available a television as a part of its spiritual care, so clients could watch religious representatives or other content that addressed subjects related with faith and hope (24) . Furthermore, the guided imagery used in digital tools is also a method that induces the patient into a calm and positive condition, reducing anxiety and promoting wellbeing. Nurses can use a script to adequately guide the imagination of the patient in such a way as to increase their comfort. Despite the fact that guided imagery is easy to implement, the nurse has a fundamental role in the implementation of their use, so the patients will not misunderstand the lines of thought during its implementation (12,19) .
Regarding the spiritual triage, it became clear how important it is for nurses, physicians, and psychologists to carry out, in the admission to health services, the triage and a routine spiritual evaluation for all patients. The spiritual triage is a moment to verify the spiritual needs of the patient, where the patient can be asked about their religion or their spiritual strategies (2,24) .
There are tools available to carry out this triage, which can be adapted for the context of general CO-VID-19 patients. These include the instruments Faith, Import or Influence, Community, Address (FICA), and Belief System, Ethics or values, Lifestyle, Involvement in spiritual community, Education, near Future events of spiritual significance for which to prepare the child (BELIEF). The latter can be an option for pediatric care (24) .
The studies also recommend the presence of a religious representative from all religions. If that is not possible, one must consider that the patient or family is likely to have a representative that can contact the patient on-line to provide comfort. The spiritual needs of those who are not represented by the religions available or are not religious must also be considered, meaning there should be attempts to implement other strategies regarding spirituality (16,25) .
Regarding professional training, studies suggest the need to train health workers so they can deal with the spiritual aspects of patients in general (26) . It is also essential to train workers to change the attitudes of nurses and the teachings about the role of spirituality in health care. In addition, it is necessary to re-duce the workload of these professionals and manage the plans towards providing high-quality assistance to the patient (20) . It could also be noted that most health workers feel unprepared to deal with situations that involve health and spirituality, showing that the implementation of spiritual dimension in care is not relatively easy and should not be delayed (26) .
Music therapy as an instrument of spirituality in the environment of intensive care in COVID-19 patients was found to be an effective type of care presented by the nursing team, emphasizing that this care should not be merely its biological scope, but include all aspects of the patient by humanizing through music (14) .
Nursing was the most mentioned category of professionals in the study, since the nursing team tends to spend more time in patient care and, as a result, has more opportunities to implement interventions for spiritual care. Nonetheless, it should be highlighted that the multiprofessional team as a whole is essential to provide quality care to all patients (20,26) .
In summation, although the research question is targeted at patients hospitalized with COVID-19, this study can contribute to aid patients with other types of infection, who may need social isolation. Most forms of care identified can also be used in patients hospitalized due to other health issues.
It is plausible to reiterate the need to carry out studies in this topic, even those with stronger levels of evidence. We strongly recommend that the management of institutions implement interventions and tools to prevent spiritual distress in patients, providing adequate training for their health workers in order to correctly implement spiritual care.

Study limitations
The main limitation of this study was the scarcity of publications on the topic, which made it impossible to analyze a broader sample. In addition, most studies found had a low level of evidence, which is another limitation of this study.

Contributions to practice
This study contributed for the advancement of nursing in regard to spirituality and patients with COVID-19, providing subsidies to use spirituality as a support in care, to facilitate coping with difficult situations.

Conclusion
Among the findings in this review, the main recommendations related to spiritual care were: listening to the spiritual pain of the patient and offering grief support to both patients and their families. Furthermore, the studies also propose the use of technology as a strategy to soften spiritual pain, including video calls to family, online video tools, and music therapy with faith and resilience content to the patients. In addition, patients should undergo spiritual triages at admission and health workers should receive training regarding spiritual care.
Studies have shown that the presence of spirituality in health brings care closer to integral attention, leading to a more humane health care. Considering the role that spirituality can have in the improvement of disease and of the quality of life of the patient, nursing workers must be able to explore this facet of health care.