IntroductionAlthough there is no consensus, spirituality is usually considered the “dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant, and/or the sacred” (Nolan et al., 2011Nolan S. Saltmarsh P. Leget C. Spiritual care in palliative care: Working towards an EAPC Task Force.; p.88). This dimension is different and a broader concept as compared to the term “religion”, which involves “beliefs, practices, and rituals related to the transcendent” (Koenig, 2012Religion, Spirituality, and Health: The Research and Clinical Implications.; p.2).In the last decades, there has been a remarkable increase in this field of knowledge (Lucchetti and Lucchetti, 2014

Lucchetti, G., & Lucchetti, A. L. (2014). Spirituality, religion, and health: over the last 15 years of field research (1999-2013). International journal of psychiatry in medicine, 48(3), 199–215. 10.2190/PM.48.3.e

) and the current evidence shows that spiritual well-being plays a fundamental role in both physical and mental health (Heidari et al., 2016Heidari H. Karimollahi M. Mehrnoush N. Evaluation of the perception of Iranian nurses towards spirituality in NICUs.), providing peace and harmony that can lead to healthier lifestyles (Azarsa et al., 2015Azarsa T. Davoodi A. Khorami Markani A. Gahramanian A. Vargaeei A. Spiritual wellbeing, Attitude toward Spiritual Care and its Relationship with Spiritual Care Competence among Critical Care Nurses.). Likewise, these beliefs seem to have an important influence on the decision-making of patients and their families (Nascimento et al., 2016Nascimento L.C. Alvarenga W.A. Caldeira S. Mica T.M. Oliveira F.C.S. Pan R. Vieira M. Spiritual care: The nurses’ experiences in the pediatric intensive care unit.).In this context, spiritual care (i.e. meeting the spiritual needs of patients and family) is especially important in intensive care units (ICUs) and emergency services, where the complexity and severity of the diseases and the critically ill situations of patients create an environment of unexpected changes that causes loss of hope, anxiety, fear and stress (Abu-El-Noor, 2016ICU nurses’ perceptions and practice of spiritual care at the end of life: Implications for policy change.; Azarsa et al., 2015Azarsa T. Davoodi A. Khorami Markani A. Gahramanian A. Vargaeei A. Spiritual wellbeing, Attitude toward Spiritual Care and its Relationship with Spiritual Care Competence among Critical Care Nurses.; Pierce et al., 2020Pierce A. Hoffer M. Marcinkowski B. Manfredi R.A. Pourmand A. Emergency department approach to spirituality care in the era of COVID-19.). Some studies have already confirmed the importance of spiritual care in these settings, showing an improvement in stress, self-esteem and depression, a decrease in hospitalization time, and a reduction in healthcare costs (Riahi et al., 2018Riahi S. Goudarzi F. Hasanvand S. Abdollahzadeh H. Ebrahimzadeh F. Dadvari Z. Assessing the Effect of Spiritual Intelligence Training on Spiritual Care Competency in Critical Care Nurses.; Abu-El-Noor, 2016ICU nurses’ perceptions and practice of spiritual care at the end of life: Implications for policy change.).However, healthcare professionals seldom include spiritual care in their routine clinical practice. Several reasons are pointed as barriers to include this care such as a lack of understanding of the concept of spirituality, fear of imposing own beliefs or offending patients, preference for biological issues and lack of training (Choi et al., 2019Choi P.J. Curlin F.A. Cox C.E. Addressing religion and spirituality in the intensive care unit: A survey of clinicians.; Cordero et al., 2018Cordero R.D. Romero B.B. de Matos F.A. Costa E. Espinha D.C.M. Tomasso C.S. Lucchetti G. Opinions and attitudes on the relationship between spirituality, religiosity and health: A comparison between nursing students from Brazil and Portugal.; Gallison et al., 2013Gallison B.S. Xu Y. Jurgens C.Y. Boyle S.M. Acute care nurses spiritual care practices.; Kim et al., 2017Kim K. Bauck A. Monroe A. Mallory M. Aslakson R. Critical care nurses’ perceptions of and experiences with chaplains.; Koukouli et al., 2018

Koukouli, S., Lambraki, M., Sigala, E., Alevizaki, A., & Stavropoulou, A. (2018). The experience of Greek families of critically ill patients: Exploring their needs and coping strategies. Intensive and Critical Care Nursing, 45, 44–51. 10.1016/j.iccn.2017.12.001

; Vasconcelos et al., 2020Vasconcelos A. Lucchetti A. Cavalcanti A. da Silva Conde S. Gonçalves L.M. do Nascimento F.R. Chazan A. Tavares R. da Silva Ezequiel O. Lucchetti G. Religiosity and Spirituality of Resident Physicians and Implications for Clinical Practice-the SBRAMER Multicenter Study.). These barriers result in a late addressing of the spiritual needs, which are commonly limited to the last 24 to 48 hours of the patient's life (Choi et al., 2019Choi P.J. Curlin F.A. Cox C.E. Addressing religion and spirituality in the intensive care unit: A survey of clinicians.).All these problems seem to be increased during moments of crisis, when time and resources are limited, such as during the COVID-19 pandemic. COVID-19 has affected millions of individuals worldwide and Europe has seen a very delicate situation, where the number of deaths and hospitalizations in ICUs were alarming (Shah and Farrow, 2020A commentary on “World Health Organization declares global emergency: A review of the 2019 novel Coronavirus (COVID-19).). In the specific case of Spain, the number of infected people has reached more than 400,000 cases, and more than 28,500 people have died (). Regarding ICU hospitalizations, the figures have exceeded 12,000 cases. Currently, nurses are constantly subjected to the stress of critically ill patients, something that has intensified even more during this pandemic (). In addition, although the family is one of the main pillars for providing spiritual care, family visits have been limited in all healthcare units due to restrictions.Therefore, during the COVID-19 pandemic, patients needed to overcome the feeling of isolation in different ways. Among several coping strategies, spiritual and religious beliefs were important to these patients as noted by some studies (Lucchetti et al., 2020Lucchetti G. Góes L.G. Amaral S.G. Ganadjian G.T. Andrade I. Almeida P.O. de A. Manso M.E.G. Spirituality, religiosity and the mental health consequences of social isolation during Covid-19 pandemic.). However, the support of religious services and religious leaders during the pandemic were not fully available (Kowalczyk et al., 2020Kowalczyk O. Roszkowski K. Montane X. Pawliszak W. Tylkowski B. Bajek A. Religion and Faith Perception in a Pandemic of COVID-19.; Roman et al., 2020

Roman, N. V, Mthembu, T. G., & Roman, N. (2020). Spiritual care – ‘A deeper immunity’ – A response to Covid-19 pandemic Spiritual care in the South African. African journal of primary health care & family medicine, 12(1), 1–3. 10.4102/phcfm.v12i1.2456

). Some hospitals tried provide technological means for communication between patients and their families (video calls or telephone conversations), in an attempt to alleviate the lack of spiritual support from their loved ones ().Although the number of publications has drastically increased during the pandemic, most of the studies have focused on the treatment, care planning and epidemiology of COVID-19 disease (; Dawood et al., 2020Dawood F.S. Ricks P. Njie G.J. Daugherty M. Davis W. Fuller J.A. Bennett S.D. Observations of the global epidemiology of COVID-19 from the prepandemic period using web-based surveillance: a cross-sectional analysis.). In this context, more studies are needed to understand the qualitative experiences of critical care health professionals towards spiritual care and, to our knowledge, no study has investigated this aspect in Spain, one of the most affected countries.

In order to bridge this gap, this study aims to investigate the perceptions, knowledge and attitudes of nurses working at critical care units (ICUs) and emergency services in Spain concerning the spiritual needs of patients and families and the spiritual care provided during their clinical practice during the COVID-19 pandemic.

Findings Participant's characteristicsThe sample consisted of 19 nursing professionals working at Spanish ICU and emergency services, being 78.9% women with a mean age of 30.0 (SD:8.9) years old (ranging from 22 to 52 years). In the total sample, six participants sent a photograph that symbolized some aspect of spiritual or religious care during the pandemic. Most participants work in emergency departments (57.9%), in public health institutions (78.9%) and the most common cities were in Barcelona (47.3%), Madrid (15.8%), and Seville (36.9%). Regarding their spiritual and religious beliefs, 47.3% had no religious affiliation and did not believe in God and 42.1% were Catholics. Only 36.9% of the sample defined themselves as spiritual and religious beings. The characteristics of the sample are shown in Table 1.

Table 1Sociodemographic characteristics of the participants

The analysis yielded five main themes which reflect all of the categories: “The definition of Spirituality”, “Addressing spirituality in clinical practice and its influence on health”, “Spiritual care during the COVID pandemic”, “Barriers to provide Spiritual Care and possibilities for improvement”, and “Spiritual care training for health professionals”. These themes are described below.

 Theme 1: The definition of Spirituality

It was clear that there was no consensus on the definition of spirituality by nurses. In fact, spirituality was related to a series of different factors such as: meaning and searching for answers, religious beliefs; the essence of really fundamental things, such as love, family, friends; and the exchange of energy between people. Some participants also have acknowledge the differences between spirituality and religion, describing that they have beliefs but were not religious persons.

“I like to think about the meaning of things, searching for answers that cannot be explained in a scientific way” (P-2, man, 32 years); “I consider myself spiritual and integrate it into my life to relieve stress. For example, I do meditation and it helps me relax, something essential in these hard times” [referred to COVID-19 pandemic] (P-7, woman, 22 years); “I am not a member of any religion, but I have beliefs and values of my own” (P-9, woman, 23 years).

 Theme 2: Addressing spirituality in clinical practice and its influence on health

Nurses used the words faith, support, or beliefs to explain the term spirituality. Most participants (n=17) agreed that there was a positive and direct relationship between patient's spirituality and health, that spirituality may help in coping with a disease and that could improve the nurse-patient relationship. Some nurses shared their experiences as shown below:

“Some patients have coped better with their illness by clinging to God through prayers, images, and promises”; (P-1, woman, 25 years) “I think it influences both the patient's attitude and the nurse-patient relationship. I have dealt with patients who have accepted their treatments better thanks to their beliefs and with other ones who have rejected them due to the same reason” (P-5, woman, 25 years).

Although two people preferred to talk about emotion management as the way to achieve success in coping with health problems, most participants believe spirituality and/or religiosity help the patient to cope and adapt to a new situation of illness, providing hope, energy, and strength to overcome health problems.

Nurses were aware that the spiritual needs of their patients are an important part of care. However, some nurses believe the care should focus predominantly on biological dimensions, especially in high technology and stressful environments such as the ICU and the emergency services: “In critical and emergency situations, I think the issue spiritual care should be left aside since we must prioritize serious care” (P-13, woman, 29 year). Likewise, some participants considered that other professionals have more competencies to carry out this spiritual approach: “As in hospitals there are Catholic chaplains, we let them provide that care. We, in the emergency room or in the ICU, respond quickly to the physiological state of people, that is the priority” (P-10, woman, 33 years).

Nurses also emphasized that healthcare professionals need to respect every aspect that may positively influence patients’ health, and this should be done regardless of the religiosity of the healthcare worker: “I consider that Professionals' beliefs should not interfere. I am not a religious believer and I have supported the beliefs of those who were religious because it made them feel better” (P-8, woman, 24 years); “Religious / spiritual patients who practice their faith, carry images and they pray during their illness process ... respecting it is synonymous with professionalism” (P-2, man, 32 years old).

Despite the respect for the spiritual beliefs, most nurses did not address these issues in clinical practice: “By not considering myself a spiritual / faith person, I have never noticed this need in my patients, possibly in an erroneous on my part” (P-4, man, 31 years), and tend to have little experience with the spiritual issues: “I have not had experience on spiritual care. Once, they [patients] have asked us for the chaplain to come so they can speak, confess or ask for extreme unction. Other than that, nothing” (P-2, man, 32 years).

 Theme 3: Spiritual care during the COVID pandemicCOVID-19 pandemic was a special moment in which, according to the participants, emotions and spirituality are necessary as a support for the patient: “A woman began to pray when the doctors confirmed the diagnosis of COVID-19 positive and it did not seem strange to us. I remained silent as a sign of respect and support for her” (P-17, man, 25 years). Likewise, they understand spirituality as a moral support to those who suffer the most, in many cases, the relatives of the most serious patients: “More than to the patient, the support is often offered to families when we have had to prepare them for the loss of a loved one, when we can only limit ourselves to comfort and advise them (...), when everything is lost, the only thing we can do is pray because it will make us feel better” (P-11, man, 46 years). In fact, in several occasions, religious and spiritual symbols were given to patients as noted in figure 1.

Figure 1It incorporates two photos of ICU rooms: (a) The daughter of a patient brought a handmade canvas made by the villagers. Since she couldn't be with her father, she asked the nurse to hang it up. The nurse one afternoon hung it in the place where the patient could see it and he told her about "his Virgin”; (b) A nurse found an image of the Virgin next to a patient's respirator, understanding it as a symbol of protection that the patient and her family trusted.

Nursing professionals were responsible for providing psychological and spiritual support to patients during the pandemic, since family visits were not allowed and religious leaders were not fully available. However, some participants reported that they did not have the appropriate training to handle this situation: “I think that no one was prepared for this situation. Some patients have faced it by taking refuge in their religion or spirituality, and others have needed psychological attention, but I do not know if everyone has had this help. Sometimes the family has that function, but it has not been possible on this occasion, so we do what we can” (P-7, woman, 22 years).

Although some professionals acknowledged that religious beliefs influenced the acceptance of the prognosis of COVID-19 by patients: “I believe that patient's religious beliefs have been useful in coping with the disease and the uncertainty of its evolution, and move forward with more force” (P-7, woman, 22 years), other participants considered that the only factors relevant to the prognosis of this condition were the immune status of the patients and a good ventilatory support, supporting that the biomedical science is the only appropriate method for caring their patients.

Although spirituality was not important to most of our participants, they tended to agree that their work was characterized by empathy, compassion, solidarity, patience, resilience, and companionship: “Few colleagues express their religious thoughts to patients” (P-2, man, 32 years); “I have seen many aspects of professional resilience in many moments, psychological messages of support and encouragement, but I have not seen professionals attending to the spirituality of patients or of themselves” (P-9, woman, 23 years). On the other hand, some nurses have tried to cope with the stressful situation and the suffering of patients and relatives through mental disconnection (e.g. yoga or relaxation techniques) and by religious practices (e.g. prayer). This has been expressed through Figure 2.

Figure 2A nurse and an emergency technician enter a Catholic church. They work for 12 hours, providing home care, where people affected by COVID-19 remain alone, sad and desperate. When they get a break or finish their workday, they remain silent with their thoughts and with God in this church, seeking answers and hope to overcome the pandemic.

 Theme 4: Barriers to provide Spiritual Care and possibilities for improvement

During the interviews, most of the nurses (n=15) reported the barriers and reflected on the possibility of improving spiritual care in critical and emergency care units. The most common barriers cited were, work overload during the pandemic (e.g. absence of breaks), insufficient time, a high professional-patient ratio and the lack of training.

Other difficulties were not feeling prepared to answer “transcendental” or personal questions, the lack of social and professional recognition of spiritual care, difficulty in identifying the presence of religious symbols that accompany the patient and restrictions on family visits to reduce the spread of the COVID-19 virus: “I believe that it is one of the greatest handicaps of this pandemic since the accompaniment of family members is very comforting to both; and the restriction of visits generates anguish and uncertainty; although we must understand that it is the best for everyone” (P-8, woman, 24 years) and the patient's critical condition: “In ICUs we have worked with patients who are totally sedated and when we have been able to extubate him/her, we have provided him/her mainly moral support” (P-11, man, 46 years).

Some participants have also underscored the differences of beliefs as an important barrier in order to provide a more integrative care: “It can be difficult for a religious professional to understand a patient with different beliefs and vice versa” (P-6, woman, 22 years); “My religious or spiritual beliefs influence, in my case, I declare myself an atheist and I think that a religious belief that indoctrinates a person can lead him/her to reject a treatment that would probably save his/her life ...” (P-9, woman, 23 years). However, sharing beliefs could bring the patient closer to the nurse as noted by one participant: “From my experience, if a patient and the health worker are religious, the relationship is more open to talk about it” (P-7, woman, 22 years).

Despite these remarkable barriers, in order to promote a better spiritual care, professionals reported that they need a silent moment without interruptions in order to provide such care: “It would be necessary to mark a moment where there is no interruption so that there is connection between patient and nurse and build trust” (P-5, woman, 25 years), better guidelines and protocols for the inclusion of spiritual care in these settings: “Setting objectives for nurses and doctors regarding care psychological and spiritual, interviewing the patient, using quality scales” (P-9, woman, 23 years), appropriate spaces for contemplative practices: “From spaces for meditation, yoga to others where religious practices of any kind are carried out” (P-5, woman, 25 years), improving training on spiritual care, the creation of support groups, the incorporation of specialized personnel (chaplain, priest or priest) of different religions in the ICU or emergency services and a coordinated work with them within the interdisciplinary team.

 Theme 5: Spiritual care training for health professionals

“We must be prepared to provide spiritual care” is a common statement shared by nurses, being the increase in cultural diversity in large Spanish cities the main reason: “It is necessary [having competencies to provide spiritual care] because we are dealing with patients with a multitude of beliefs and we are not being able to take care of the patient in that regard” (P-11, man, 46 years).

However, most of the participants state that they have not received any training concerning spirituality (n = 17) and did not feel prepared to provide this care (n = 15). Therefore, nurses consider that training in spirituality should be offered to professionals from any health discipline (n = 14): “In Barcelona it is important because there are many people from other countries, with different religious beliefs and spirituality. If the healthcare professional is not trained, the patient will not trust you” (P-9, woman, 23 years).

While some nurses only associate training in spiritual health with the acquisition of competencies to care for patients in near-death situations: “I miss the university training in spiritual care for situations of grief or coping with a serious illness” (P-15, woman, 26 years), others believe this issue is personal and training should not be addressed as mandatory: “Classes on spiritual care should be optional, since religion and spirituality are very personal things and diverse, and it can hurt sensibilities” (P-2, man, 32 years); “I do not think this type of training is adequate, at least not in a scientific career like nursing” (P-16, woman, 31 years).

A graphic summary of the results is shown in the following figure:

Figure3.Discussion and recommendations

This study showed that, during the COVID-19 pandemic in Spain, nurses were responsible for providing spiritual care for their patients. Although they generally believe that spirituality is important to treatment and help patients to cope with the disease, they do not have a consensual definition of spirituality and were not trained to handle this care. Several barriers are cited as limitations of the spiritual care such as the work overload, insufficient time and lack of training.

The diversity of our findings stems from the terminological confusion about spirituality itself (Nascimento et al., 2016Nascimento L.C. Alvarenga W.A. Caldeira S. Mica T.M. Oliveira F.C.S. Pan R. Vieira M. Spiritual care: The nurses’ experiences in the pediatric intensive care unit.). Although the World Health Organization proposed the spiritual aspect as a component of health in 1983 (), there is still no universal and clear definition of spirituality (Canfield et al., 2016Canfield C. Taylor D. Nagy K. Strauser C. VanKerkhove K. Wills S. Sorrell J. Critical Care Nurses Perceived Need for Guidance in Addressing Spirituality in Critically Ill Patients.). This explains why some nurses use spirituality and religiosity as synonyms, or even erroneously exclude spirituality as part of religiosity (Sonemanghkara et al., 2019

Sonemanghkara, R., Rozo, J. A., & Stutsman, S. (2019). The Nurse-Chaplain-Family Spiritual Care Triad: A Qualitative Study. Journal of Christian Nursing : A Quarterly Publication of Nurses Christian Fellowship, 36(2), 112–118. 10.1097/CNJ.0000000000000592

). Also coinciding with our study, nurses also include compassion and empathy as related to spirituality, as shown in a previous study investigating Thai ICU nurses ().Although the nurses in our study perceive the influence of Spirituality/Religiosity (S/R) on patient's health and on the way they cope with the disease, there is a clear confusion concerning the role that nurses should play towards spiritual care. One of the reasons for this confusion is the presence of religious personnel such as chaplains, who are considered the professionals with greater competence for spiritual care and, in the perception of the family, are the most important figures to address spiritual beliefs in critically ill patients (Gallison et al., 2013Gallison B.S. Xu Y. Jurgens C.Y. Boyle S.M. Acute care nurses spiritual care practices.).In the same direction, most of the spiritual care is provided by the family as seen in previous studies. Previous authors have reported that family accompaniment is “something spiritual”, helping patients to seek meaning and protection from God in order to cope with tragedies (). In this context, nurses are responsible for making this connection between family and the patient and providing a safer and confortable environment (Nascimento et al., 2016Nascimento L.C. Alvarenga W.A. Caldeira S. Mica T.M. Oliveira F.C.S. Pan R. Vieira M. Spiritual care: The nurses’ experiences in the pediatric intensive care unit.). However, the restrictions on family visits during the pandemic, increased the tension between nurses, since, although they professionally respect the spiritual needs of their patients, they fear facing them alone and without training (Kowalczyk et al., 2020Kowalczyk O. Roszkowski K. Montane X. Pawliszak W. Tylkowski B. Bajek A. Religion and Faith Perception in a Pandemic of COVID-19.).In Spain, some institutions have made efforts to incorporate the spiritual and religious approaches in health care. Taking as a framework the Spanish legislation that recognizes the right to religious freedom; spiritual and religious assistance in hospital centers is considered as a right of the patient and the family. The Observatory of Religious Pluralism (OPR, 2011) in Spain, published a guideline for health personnel on recommendations about how to address spiritual and religious assistance in hospitals. However, we observed that the inclusion of the S/R as part of the comprehensive care of critically ill patients is yet uncommon. On the one hand, critical care units and emergencies are characterized by a biomedical care approach (De Brito et al., 2013De Brito F.M. Costa Pinto I. C. Andrade Garrido de C. Oliveira de Lima K. F. Costa da S. F.G. Lopes Limeira M. E Spirituality in iminent death: Strategy utilized to humanize care in nursing.; Huijer et al., 2019Huijer H.A.-S. Bejjani R. Fares S. Quality of care, spirituality, relationships and finances in older adult palliative care patients in Lebanon.; Ferrell et al., 2020Ferrell B.R. Handzo G. Picchi T. Puchalski C. Rosa W.E. The urgency of spiritual care: COVID-19 and the critical need for whole-person palliation.). On the other hand, the nurses state that their own beliefs can constitute a handicap to provide spiritual care (), and other barriers as well. Lack of time, the high patient / nurse ratio, the fear of making the patient uncomfortable and the belief that spirituality is something private are also shared by other authors (Gallison et al., 2013Gallison B.S. Xu Y. Jurgens C.Y. Boyle S.M. Acute care nurses spiritual care practices.).Finally, the nurses in this study share with other nursing professionals and students the need to improve their competence to provide spiritual care to patients (Cordero et al., 2018Cordero R.D. Romero B.B. de Matos F.A. Costa E. Espinha D.C.M. Tomasso C.S. Lucchetti G. Opinions and attitudes on the relationship between spirituality, religiosity and health: A comparison between nursing students from Brazil and Portugal.; Riahi et al., 2018Riahi S. Goudarzi F. Hasanvand S. Abdollahzadeh H. Ebrahimzadeh F. Dadvari Z. Assessing the Effect of Spiritual Intelligence Training on Spiritual Care Competency in Critical Care Nurses.). According to the International Council of Nurses and the Commission on the Rights of Patients, nurses must have the knowledge and skills to be able to promote and assess the satisfaction of the spiritual needs of their patients (De Brito et al., 2013De Brito F.M. Costa Pinto I. C. Andrade Garrido de C. Oliveira de Lima K. F. Costa da S. F.G. Lopes Limeira M. E Spirituality in iminent death: Strategy utilized to humanize care in nursing.) and, for this reason, institutions should be able to provide education to these professionals concerning spiritual care. However, the application of the biomedical science to nursing, as well as the consideration that there are professionals with better skills to deliver this care to patients (e.g. chaplains, psychologists) seem to reduce the willingness to provide such care.Study limitations and strengths

The present study has some limitations that should take into account while interpreting our findings. First, this study was carried out in Spain and it reflects the experiences of health professionals from Spanish health care facilities. It is difficult to guarantee that the same results would be observed in other countries, since the cultural and religious backgrounds are different. Second, we used a purposive sample and generalizability should be made with caution. Third, Spain was one of the most affected countries in the COVID pandemic and, for this reason, nurses were burned out and with work overload, which may have impacted our findings. Finally, since nurses have been one of the largest healthcare forces with patients affected by COVID, feminization has resulted in a higher proportion of women.

Based on this study, we suggest a few directions for future research. Future research should include new care contexts, religious personnel (if this hospital resource exists), as well as other health professionals as members of the health team. In addition, interventions aimed at clarifying terms of S/R would be the first step so that health professionals can internalize them and take it into account as part of holistic care. Multicenter studies and cross-cultural comparisons are suggested between countries, to know the experiences of health professionals (especially nurses) in secular countries or where different religious practices predominate.

Finally, this study showed spiritual needs are commonly expressed during life-threatening situations, such as those experienced in ICUs. Because our results highlight that most nurses are open to this subject, a valuable strategy would be training to handle these situations. Therefore, health managers are commended to organize training for ICU health care professionals in order to provide a more holistic care.

Credit statements

Rocío De Diego-Cordero: Conceptualization, Methodology, Formal analysis and interpretation, Software, Writing- Reviewing and Editing, Supervision, Project administration, Lorena López-Gómez: Investigation, Formal analysis and interpretation, Data curation, Software, Giancarlo Lucchetti: Formal analysis and interpretation, Writing- Original draft preparation, Validation, Visualization, Bárbara Badanta: Conceptualization, Writing-Reviewing and Editing, Supervision, Project administration.