INTRODUCTION

Religion is an important cultural asset that affects the thoughts, behaviors, and lifestyles of individuals and can positively impact the life of the human beings, as it directs them to have healthy life habits (Chiang et al., 2020). The terms spirituality and religiosity, although sometimes considered synonymous, constitute distinct nursing diagnoses.

Spirituality has several definitions, since its attributes are considered difficult to define and with a subjective, individual, and complex dimension (Mosque et al., 2017). In the nursing literature, the concept was determined as the search for meaning in life, connection, and transcendence, which is broader than religion, being an important dimension for believers or non-believers (Cabaço et al., 2017). The concept of religiosity refers to religious practices in which the individual seeks to express his spirituality through rituals, symbols, beliefs, cults, and doctrines that bring the individual closer to the sacred or transcendent (Tavares et al., 2018).

Even if closely related to spirituality, religiosity is a subject poorly described by authors, and until recently, a dimension sometimes forgotten and even neglected (Mosque et al., 2017). Philosophers stated that religion would disappear as societies modernized, a fact that did not happen, since it is clear how religion is strengthening in some societies (Bentzen, 2020). The world was more religious in the year 2000 (87.0%) than in 1970 (80.8%), with this trend continuing in 2017 (88.9%), projecting the estimated value of 90.2% for the year 2030 (Grim et al., 2018).

In the study of nursing, it is understood that for some people the involvement in their community of faith, their rituals, and their ministries feeds the spirit; for others, spiritual well-being does not necessarily revolve around participation in a specific religion (Bentzen, 2020; Taylor, 2020). Nurses, in this regard, must provide assistance to their patient, so that they can provide comfort and safety, which spirituality or religion offers (Tavares et al., 2018). For this, the professional needs to recognize the needs of individuals, as well as to observe the implications in the use of standardized nursing language systems to document cares that may involve spiritual and religious aspects (Burkhart & Solari-Twadell, 2008; Tavares et al., 2018).

Since the beginning of 2020, due to the emergence of SARS-CoV-2, countries have decreed a quarantine period for the population, aimed at maintaining social distancing. COVID-19 spread rapidly around the world and was declared a pandemic by the World Health Organization (WHO) in March 2020. Social distancing was one of the measures recommended by the WHO, because there is no established treatment and medication for the control and cure of the disease (World Health Organization, 2020).

Based on the assumption that religiosity implies religious practices of worship and rituals, the social distancing factor harms such practices, since religiosity is directly linked to the idea of gathering in an environment of its own, usually in temples.

The COVID-19 pandemic affected traditions and festivities related to religion and the maintenance of religious practices in Brazil and the world, as well as pilgrimages and religious tourism resulting from them, where high-visibility religious mass meetings are held (Yezli & Khan, 2020).

Even with the restrictions imposed by distancing, the literature points out that disasters and tragedies lead individuals to connect with some higher being in whom they place their faith. A study pointed to a substantial increase in the search term “prayer” in the pandemic period, reaching unprecedented numbers from mid-March 2020 worldwide, doubling its results for every 80,000 new cases of COVID-19 (Bentzen, 2020).

In the pandemic of COVID-19 it is understood that there was the emergence of new health demands, as well as social, psychological, and spiritual. Investigating nursing diagnoses involving religiosity during the pandemic became relevant, considering the individual as a biopsychosocial-spiritual being.

Purpose

Given the importance of religiosity in human experience, including the search for balance and hope, and the change of this experience due to social distancing, this study sought to identify the elements (defining characteristics—DC, related factors—ReF, and risk factors—RiF) of the diagnoses of NANDA International (NANDA-I) impaired religiosity (00169), risk for impaired religiosity (00170), and readiness for enhanced religiosity (00171) (Herdman et al., 2021), in a period of social distancing in the pandemic of COVID-19, and associate them with the behavior of individual and collective religious practice, before and during the pandemic.

METHODS

A survey study was conducted by online questionnaire, in a convenience sample. The research was disseminated via social media (Facebook, Instagram, and WhatsApp), shared in pages and profiles of religious communities in Brazil. A promotional material was posted in social media websites with information about the research and instructions on how to participate. Participants answered the questionnaire via Google Forms. In the electronic questionnaire, the second page had all information about the research, the purpose, the ethical aspects considerations, and the informed consent to participate in the study. To have access and answer the questions, all participants needed to give consent in the electronic questionnaire.

The inclusion criteria were >18 years old and declared to be a member of a religious community. Only participants who answered the questionnaire in full were included. Data collection took place in June 2020.

The theoretical framework of Jean Watson was used, with the presupposition of care practice the integration between biophysical knowledge and human behavior, to generate or promote health. The faith-hope is one of the care factors presented by Watson as essential for the healing process (George, 2011).

Individual and collective religious practices were variables of interest to the study, considering the period before and during the pandemic of COVID-19, also the elements (DC, ReF, and RiF) of the diagnoses impaired religiosity (00169), risk for impaired religiosity (00170), and readiness for enhanced religiosity (00171) (Herdman et al., 2021).

The diagnosis “impaired religiosity,” approved in 2004, revised in 2017, with evidence level 2.1 is defined as “impaired ability to exercise reliance on beliefs and/or participate in rituals of a particular faith tradition” (Herdman et al., 2021).

The diagnosis “risk of impaired religiosity” was approved in 2004, revised in 2013 and 2017 with evidence level 2, and is defined as “susceptible to an impaired ability to exercise reliance on religious beliefs and/or participate in rituals of a particular faith tradition, which may compromise health” (Herdman et al., 2021).

The diagnosis “Readiness for Enhanced Religiosity” approved in 2004, revised in 2013, level of evidence 2.1, is defined as “a pattern of reliance on religious beliefs and/or participation in rituals of a particular faith tradition, which can be strengthened” (Herdman et al., 2021).

The measures of central tendency were analyzed, and tests of association between the diagnoses studied and the behavior of the population in individual and collective religious practice were performed. Cox regression models were adjusted to explain the occurrence of individual and collective changes. In the models, associations were considered statistically significant if p < 0.05. The analyses were performed with Software SPSS 22.

Assuming simple random sampling, type I and II errors equal to 0.05 and 0.20, respectively, allocation ratio of 1:5:1 between reduction, maintenance and increase levels of individual religious practices, allocation ratio of 15:10:1 between reduction, maintenance, and increase in the levels of collective religious practices, assuming a scenario of uncertainty where the prevalence of diagnostic elements oscillates around 33%, and assuming a minimum difference between the levels of individual religious practices of 20%, it is estimated that at least 62 subjects are needed at each level of individual religious practices and at least 62 subjects at each level of collective religious practice.

The research was approved by the Research Ethics Committee in Brazil (Approval Number: 4.059.323) and ethical aspects involving research with human beings were respected. The study followed the STROBE checklist as a recommendation for observational studies.

Findings

The study included 719 people, 563 (78.3%) were women, with a median age of 39 years (min 18–max 73), of Catholic religion (64.7%), with a median of 29 years of religious practice (min 0–max 70). The participants were from Southeast 652 (90.68%), South 49 (6.82%), Northeast 13 (1.82%), Midwest 4 (0.56%), and North 01 (0.14%) of Brazil.

Participants predominantly declared to perform daily individual religious practice before the pandemic (48.7%) and daily practice during the pandemic (55.5%); they indicated maintaining the frequency of individual religious practice during the pandemic (70.8%).

Regarding collective religious practice, predominantly before the pandemic, they performed one to two times a week (53.7%), and during the pandemic they did not perform regular religious practice (69.9%); they indicated a reduction in collective religious practice (55.9%).

The characterization of the participants and the profile of religious practice is presented in Table 1.

Table 1. Characterization of participants and profile of individual and collective religious practice before and during the COVID-19 pandemic (n = 719). Brazil, 2020 N % Median (min–max) Gender Male 156 21.7 Female 563 78.3 Age (years) 39 (18–73) Years of religious practice 29 (0–70) Individual religious practice before the pandemic Without regular practice 64 8.9 1–2 days/week 162 22.5 3 or more days/week 143 19.9 Every day 350 48.7 Individual religious practice during the pandemic Without regular practice 85 11.8 1–2 days/week 131 18.2 3 or more days/week 104 14.5 Every day 399 55.5 Changing individual religious practice in the pandemic Decreased 93 12.9 Maintained 509 70.8 Increased 117 16.3 Collective religious practice before the pandemic Without regular practice 157 21.8 1–2 days/week 386 53.7 3 or more days/week 128 17.8 Every day 48 6.7 Collective religious practice during the pandemic Without regular practice 496 69.0 1–2 days/week 146 20.3 3 or more days/week 26 3.6 Every day 51 7.1 Changing collective religious practice in the pandemic Decreased 402 55.9 Maintained 291 40.5 Increased 26 3.6

The reduction in individual religious practice during the pandemic was associated with the following elements: expresses distress about separation from faith community (DC 00169), desires to reconnect with belief pattern (DC 00169), environmental constraints (ReF 00169, RiF 00170), ineffective caregiving (ReF 00169, RiF 00170), depressive symptoms (ReF 00169, RiF 00170), ineffective coping strategies (ReF 00169, RiF 00170), spiritual distress (ReF 00169, RiF 00170), inadequate transportation (ReF 00169, RiF 00170), and expresses desire to enhance participation in religious experiences (DC 00171).

The increase in individual religious practice was associated with the following elements: anxiety (ReF 00169, RiF 00170) and expresses desire to enhance religious options (DC 00171).

The reduction in collective religious practice was associated with the following elements: expresses distress about separation from faith community (DC 00169), desires to reconnect with customs (DC 00169), desires to reconnect with belief pattern (DC 00169), anxiety (ReF 00169, RiF 00170), ineffective caregiving (ReF 00169, RiF 00170), ineffective coping strategies (ReF 00169, RiF 00170), and expresses desire to enhance participation in religious practices (DC 00171).

The maintenance of collective religious practice was associated with the following elements: difficulty adhering to prescribed religious beliefs (DC 00169), difficulty adhering to prescribed religious rituals (DC 00169), questions religious customs (DC 00169), questions religious beliefs (DC 00169), expresses desire to enhance religious options (DC 00171).

The increase in collective religious practice was associated with the following elements: spiritual distress (ReF 00169, RiF 00170), inadequate transportation (ReF 00169, RiF 00170), expresses desire to enhance forgiveness (DC 00171), expresses desire to enhance use of religious material (DC 00171), and expresses desire to reestablish religious customs (DC 00171).

Table 2 shows the association among the diagnoses impaired religiosity (00169), risk for impaired religiosity (00170), and readiness for enhanced religiosity (00171) and changes in individual and collective religious practice during the pandemic.

Table 2. Association between diagnosis elements of impaired religiosity (00169), risk for impaired religiosity (00170), and readiness for enhanced religiosity (00171) and the change in individual and religious practice during the COVID-19 pandemic (n = 719). Brazil, 2020 Individual religious practice Collective religious practice Decreased (n = 93) Maintained (n = 509) Increased (n = 117) Decreased (n = 402) Maintained (n = 291) Increased (n = 26) Diagnosis elements N % N % N % p N % N % N % p Expresses distress about separation from faith community (DC 00169) 46 49.5 142 27.9 28 23.9 < 0.001 157 39.1 51 17.5 8 30.8 < 0.001 Desires to reconnect with customs (DC 00169) 51 54.8 227 44.6 63 53.8 0.060 244 60.7 82 28.2 15 57.7 < 0.001 Desires to reconnect with belief pattern (DC 00169) 25 26.9 48 9.4 15 12.8 < 0.001 69 17.2 18 6.2 1 3.8 < 0.001 Difficulty adhering to prescribed religious beliefs (DC 00169) 3 3.2 20 3.9 5 4.3 0.924 6 1.5 22 7.6 0 0.0 < 0.001 Difficulty adhering to prescribed religious rituals (DC 00169) 1 1.1 25 4.9 4 3.4 0.213 9 2.2 20 6.9 1 3.8 0.011 Questions religious customs (DC 00169) 9 9.7 63 12.4 15 12.8 0.738 28 7.0 59 20.3 0 0.0 < 0.001 Questions religious beliefs (DC 00169) 12 12.9 57 11.2 14 12.0 0.883 34 8.5 48 16.5 1 3.8 0.002 Anxiety (ReF 00169, RiF 00170) 35 37.6 135 26.5 52 44.4 < 0.001 141 35.1 74 25.4 7 26.9 0.023 Inadequate social support (ReF 00169, RiF 00170) 3 3.2 14 2.8 6 5.1 0.420 14 3.5 9 3.1 0 0.0 0.614 Environmental constraints (ReF 00169, RiF 00170) 11 11.8 15 2.9 7 6.0 0.001 20 5.0 12 4.1 1 3.8 0.855 Cultural barrier to practicing religion (ReF 00169, RiF 00170) 1 1.1 10 2.0 1 0.9 0.624 5 1.2 7 2.4 0 0.0 0.397 Ineffective caregiving (ReF 00169, RiF 00170) 26 28.0 80 15.7 15 12.8 0.007 80 19.9 39 13.4 2 7.7 0.035 Depressive symptoms (ReF 00169, RiF 00170) 24 25.8 59 11.6 20 17.1 0.001 65 16.2 35 12.0 3 11.5 0.282 Pain (ReF 00169, RiF 00170) 11 11.8 40 7.9 9 7.7 0.428 37 9.2 22 7.6 1 3.8 0.519 Ineffective coping strategies (ReF 00169, RiF 00170) 16 17.2 38 7.5 15 12.8 0.006 48 11.9 19 6.5 2 7.7 0.055 Insecurity (ReF 00169, RiF 00170) 21 22.6 91 17.9 30 25.6 0.125 82 20.4 53 18.2 7 26.9 0.501 Inadequate sociocultural interaction (ReF 00169, RiF 00170) 2 2.2 19 3.7 5 4.3 0.691 15 3.7 8 2.7 3 11.5 0.07 Fear of death (ReF 00169, RiF 00170) 14 15.1 49 9.6 19 16.2 0.063 46 11.4 32 11.0 4 15.4 0.796 Spiritual distress (ReF 00169, RiF 00170) 20 21.5 29 5.7 11 9.4 < 0.001 40 10.0 16 5.5 4 15.4 0.047 Inadequate transportation (ReF 00169, RiF 00170) 10 10.8 21 4.1 10 8.5 0.014 31 7.7 6 2.1 4 15.4 0.001 Expresses desire to enhance connection with a religious leader (DC 00171) 8 8.6 33 6.5 9 7.7 0.718 32 8.0 16 5.5 2 7.7 0.448 Expresses desire to enhance participation in religious experiences (DC 00171) 26 28.0 99 19.4 32