Interprofessional Spiritual Care Education Curriculum: A Milestone toward the Provision of Spiritual Care

Abstract

Background:

Spiritual care is a key domain of quality palliative care. Spiritual distress is highly prevalent in patients and their families facing serious illness. Guidelines support the ethical obligation of health care providers to attend to spiritual distress as part of total distress. All clinicians require education and support to provide this care to patients and their families facing serious illness.

Objective:

This project focused on the development of a curriculum for education of health care professionals in spiritual care. It was based on a consensus-derived generalist–specialist model of spiritual care, with all clinicians providing generalist–spiritual care and trained chaplains providing specialist spiritual care.

Design:

The curriculum was designed for classroom and online learning.

Setting:

The curriculum is appropriate for all clinical settings in the United States and internationally.

Measurements:

Needs assessment surveys and course evaluation data have provided a basis on which to develop and refine the curriculum. This curriculum is built on a pilot Interprofessional Spiritual Care Education Curriculum (ISPEC) course held at the Veterans Administration, DC.

Results:

Needs assessment and course evaluation data support the ISPEC course content.

Conclusions:

The ISPEC curricula serve as a much-needed training resource to improve spiritual care for all people with serious illness.

Introduction

Over the past decade, evidence has demonstrated the importance of spirituality in health care. Addressing patients' spirituality and providing spiritual care has been shown to improve patients' physical health and quality of life: how patients experience pain and suffering, cope with stress associated with illness, view wellness, and approach the end of life.^1–7 Evidence shows that spiritual distress is associated with worse physical, social, and emotional distress.^4,8

Spiritual care has emerged as an essential component of quality care for patients facing serious illnesses.^9,10 Consensus-derived recommendations developed in a 2009 conference, “Improving the Quality of Spiritual Care in Palliative Care,” define a generalist–specialist spiritual care model where all clinicians address spiritual issues and work with trained chaplains who are spiritual care specialists.¹² The National Consensus Project (NCP) spiritual domain is based on the consensus conference.¹²

Despite evidence and guidelines supporting spiritual care, many patients continue to report unmet spiritual needs.^4,13,14 Although health care providers acknowledge the importance of addressing patients' spiritual needs, they report time limitations, discomfort in discussing spirituality, and cultural differences as barriers to providing quality spiritual care.^1,15,16 Health care professionals require spiritual care education, yet there is a lack of such training offered globally.

Background

Interprofessional Spiritual Care Education Curriculum (ISPEC) for health care professionals is a new multiyear, outcomes-based, education initiative to improve spiritual care for seriously or chronically ill patients in the United States and internationally. The ISPEC trains interdisciplinary teams of clinicians, physicians, nurses, social workers, psychologists, physical and occupational therapists, and spiritual care providers to recognize, address, and attend to the spiritual needs and suffering of seriously or chronically ill patients and that of their families. Critical to achieving these outcomes is a culture change where dignity, respect, and compassion form the foundation of care.

Based on the generalist–specialist model of care and the NCP guidelines,¹² all team members are responsible for addressing patient suffering and providing support to patients and their families.

The ISPEC curriculum includes three components:

Online Training program: This training focuses on knowledge-building, using case-based learning, virtual presentations, videos, and reading materials.

Train-the-Trainer Program: A 2.5-day program focuses on leadership skills, effecting institutional culture change, goal development, integration of spiritual care into clinical practice and education, and assessment and care planning. Participants receive one year of mentoring postcourse. Formal program evaluation occurs at 6 and 12 months postcourse.

ISPEC for institutions: The program offers training within a single institution to equip clinicians and chaplains with leadership skills to advance uniform implementation of spiritual care.

Curriculum development

Phase one: Curriculum development in spirituality and medicine

In 2009, George Washington Institute for Spirituality and Health (GWish) led the National Initiative to Develop Competencies in Spirituality in Medical Education (NIDCSME) for medical students, including teaching methods and assessment tools required to demonstrate student attainment of the competency behaviors.¹⁷ Based on the Accreditation Council for Graduate Medical Education (ACGME) framework, competency behaviors were identified as inpatient care, communication, personal/professional development, health care systems, and knowledge. The one competency that was unique to the NIDCSME, not present in ACGME, was compassionate presence.

To develop an interprofessional pilot spiritual care training program for clinicians, GWish created an online needs assessment survey in 2011 and collected input from 441 physicians, nurses, and chaplains. The most highly ranked educational needs by percentage were defining spiritual care outcome measures (67%); developing quality programs that sustain healthy interdisciplinary teams (57%); and differentiating between simple and complex spiritual distress (56%) (Table 1).

Table 1.

Top-Ranked Educational Needs in Provision of Interprofessional Spiritual Care—GWish Online Needs Assessment, 2011

	All respondents (n = 441), %	Physicians (n = 155), %	Nurses and nurse practitioners (n = 121), %	Chaplains (n = 165), %
1. Defining spiritual care outcome measures	67	69	65	67
2. Developing quality programs that sustain healthy interdisciplinary teams	57	56	60	55
3. Differentiating between simple and complex spiritual distress	56	54	63	52
4. Integrating the Biopsychosocial–Spiritual care model	54	49	51	61
5. Understanding how spiritual distress impacts other domains of care (physical, psychological, and social) for cancer patients	53	55	59	46
6. Defining leadership skills needed to stimulate culture change within the clinical setting	51	49	51	53
7. Understanding practices and rituals that might relate to the spiritual issues of cancer patients	50	51	56	43
8. Differentiating between a spiritual history, spiritual screening, and spiritual assessment	49	49	60	37
9. Facilitating communication among chaplains and health care professionals	49	47	41	58
10. Understanding how to bill for spiritual care	49	47	45	54
11. Recognizing spirituality-related concerns of cancer patients	49	53	60	34
12. Doing a spiritual screening	46	48	61	29
13. Understanding the health care economics that influence providing interprofessional spiritual care for cancer patients	46	40	44	54
14. Finding time to integrate spirituality discussions during cancer patient visits	45	51	51	32
15. Following up with cancer patients at future visits to assess whether their spiritual needs changed	44	48	43	41
16. Addressing the cancer patient's spirituality in the context of his/her culture traditions	43	46	50	34
17. Taking a spiritual history	40	43	52	25

GWish, George Washington Institute for Spirituality and Health.

The needs assessment informed the course content of the first ISPEC in 2011 at the District of Columbia's Veterans Administration (VA) Medical Center. Interprofessional health care providers participated in a one and a half-day training program based on the generalist–specialist model. The four curriculum modules were (1) Introduction to Spirituality and Health Care Model; (2) Spiritual Assessment; (3) Developing a Treatment Plan; and (4) Professional Development: Ethical Issues and Dilemmas, Compassionate Presence and the Role of Clinician's Spirituality. The training was offered three times in 2011 to 38 clinicians.

The clinician training evaluation was a pre–post retrospective format. Results demonstrated a significant increase in providers' self-reported ability to perform a spiritual screening, identify and chart a patient's spiritual distress and strengths, identify interventions, develop care plans, establish boundaries, practice compassionate presence, understand the role of spirituality, and identify ethical issues.¹⁰

In 2014, another needs assessment was completed through an online survey in a national sample by 119 clinicians from National Cancer Institute (NCI)-affiliated cancer centers and chaplains. Taking a patient's spiritual history was reported as an important educational priority by 59% of chaplains, 79% of nurses, and 62% of physicians. Identifying patients' spiritual distress was rated an important educational need by 63% of chaplains, 84% of nurses, and 89% of physicians. The preferred mode of training by all disciplines was a blended training, a combination of online and in-person training, favored by 62% of chaplains, 65% of nurses, and 53% of physicians (Table 2).

Table 2.

2014 Interprofessional Spiritual Care Education Curriculum Needs Assessment

Frequency of the important educational needs of participants and preferred mode of training (n = 119, participants include clinicians from National Cancer Institute [NCI]-affiliated cancer centers and chaplains)
Topics	Chaplains, %	Nurses, %	Physicians, %
Taking a spiritual history	59	79	62
Identifying patients' spiritual resources	60	84	88
Identifying patients' spiritual distress	63	84	89
Practicing compassionate presence	58	52	65
Differentiating between spiritual and psychological factors	73	74	90
Developing a spiritual care plan	72	89	84
Identifying appropriate spiritual interventions	74	83	84
Addressing ethical issues and dilemmas	82	98	85
Impact of spiritual care on quality of patient care	77	79	77
Developing leadership skills in spirituality and health	79	84	87
Frequency of preferred mode of training for different disciplines
Online	12	10	15
In-person training	25	25.0	30
Blended training (combination of online and in-person training)	62	65	53

Curriculum development

Phase two: ISPEC curriculum content development

The ISPEC modules and Train-the-Trainer course are based on the previous curriculum development, needs assessments, and the VA-DC course described earlier. This training demonstrated that interprofessional education could build leaders, advocates, and knowledgeable clinicians to educate, empower, and guide other health care professionals to integrate spiritual care. Interprofessional teams from Medicine, Nursing, Social Work, Psychology, Physical and Occupational Therapy, and others who work with seriously and chronically ill patients at hospitals, hospices, nursing homes, and outpatient clinics are the target audience. The curriculum merges two delivery platforms, face-to-face and online learning, to provide a comprehensive and flexible learning environment¹⁸ (Table 3).

Table 3.

Interprofessional Spiritual Care Education Curriculum Learning Objectives

1. Recognize the role of spirituality as an essential component of patient-centered care

2. Review spiritual care guidelines and identify the basics of implementation of these guidelines.

3. Define spiritual distress in adults and children and distinguish the difference between spiritual distress and other types of distress.

4. Recognize skills for practicing compassionate presence.

5. Identify communication strategies for eliciting spiritual issues.

6. Develop a whole-person assessment and treatment or care plan.

7. Recognize the clinician's spirituality as an integral component of professional development.

ISPEC modules

Module 1: introduction and background

Module 1 emphasizes the theoretical, ethical, and evidence base for the role of spirituality in clinical care of seriously and chronically ill patients. The NCP guidelines describe spiritual care as “an essential component of quality palliative care.”¹² This module reviews the broad definition of spirituality as “a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.”¹⁹ The module summarizes the state of the science, current spiritual care models, and spirituality's role in improving patient outcomes: coping with disease, quality of life, and improved physical, psychological, and social well-being. It also reviews patients' spiritual needs—connection, seeking peace, meaning/purpose, and transcendence²⁰; barriers to spiritual care provision²¹; and the consensus-based spiritual care guidelines and recommendations in the United States and internationally.^22–24

Module 2: Spiritual distress

Palliative care is defined by the World Health Organization (WHO) as “an approach that improves the quality of life of patients through the prevention and relief of suffering by means of early identification and correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.”²⁵ Module 2 describes spiritual distress in adults and children and demonstrates the critical need for addressing and treating it. Studies have documented the prevalence of spiritual distress ranging from 16% to 78% across illnesses and countries; 96% of patients reported having experienced spiritual pain at some point in their lives.⁵ This module discusses how spiritual distress is associated with worse physical, social, and emotional distress,^4,9 how it can negatively impact physical pain,²⁶ cause poor emotional well-being,²⁷ lower satisfaction with life,²⁸ and increase risk for suicidal ideation.²⁹

Module 2 discusses how spiritual issues may manifest differently at different stages of spiritual development.³⁰ Understanding differences between spiritual distress and other types of distress helps the health care provider recognize the “pain in the soul”³¹ as part of an overall distress screening. Participants learn to identify signs of spiritual distress in adult and pediatric patients.

Module 3: Compassionate presence: a contemplative approach

Module 3 defines the elements of compassionate presence, identifies clinical models, and describes contemplative listening. It explores the nature and causes of suffering and attending to patients' and families' spiritual suffering. “Suffering occurs when an individual feels voiceless. This may occur when the person is mute to give words to their experience or when their ‘screams' are unheard.”³² Deep listening and presence are essential communication interventions with people who are suffering.^33–37 This module helps students understand different modalities of caring for people who are suffering. Participants review two models for compassionate presence and practice the skills.³⁵ Key to these models is the notion of “unknowing” or being open to information and experiences that we do not know.⁴⁰ In mystical traditions, this is described as being present to the divine with neither a cognitive nor an emotional awareness of the divine's presence.^37–39

Module 4: Communicating about spiritual issues and doing spiritual assessments

Module 4 presents communication strategies for eliciting spiritual issues and diagnosing spiritual distress; exploring spiritual screening, spiritual history, and spiritual assessment and the tools to use. It teaches participants to chart and report information and how to use the information in developing a treatment plan. Through cases and role play, participants learn to utilize the FICA spiritual history tool.⁴⁰

Module 5: Whole person assessment and treatment plans

Module 5 addresses whole person assessment and treatment plans based on the biopsychosocial and spiritual model.⁴¹ Through case-based presentation, clinicians formulate a spiritual care plan, discuss how to document spiritual issues in the medical chart, and apply spiritual care interventions, including (1) therapeutic communication techniques (compassionate presence, reflective listening, inquiry about spiritual beliefs, values, and practices); (2) referral to spiritual care professionals⁴² and other referrals for meaning-oriented therapy,⁴³ dignity therapy,⁴⁴ Mindfulness-Based Stress Reduction,⁴⁵ life review, forgiveness therapy,⁴⁶ and art therapy; (3) self-care spiritual practices (e.g., meditation, yoga, tai chi, massage, spiritual support groups, and sacred spiritual readings or rituals); and (4) interdisciplinary interventions.^47,48 Case studies provide an opportunity to practice spiritual care interventions to provide meaningful, compassionate care that addresses patients' spiritual needs.

Module 6: Ethics and professional development

Module 6 focuses on ethical standards in providing spiritual care and reflective or spiritual practice in clinician self-care. It helps participants identify ethical standards and how they relate to spiritual care, cultivate professional development, and recognize cultural competence as an essential skill. Participants explore boundary issues that may arise in spiritual care, for example, praying with patients, and the concept of spiritual countertransference.⁴⁹ Participants reflect on how to implement spiritual care guidelines to honor the diversity of patient beliefs and customs, while also honoring the clinician's own beliefs and values. Learners reflect on their own spirituality in practicing compassionate presence, their professional call to serve, and their spiritual beliefs and self-care practices.

ISPEC Train-the-Trainer course

The first ISPEC Train-the-Trainer was held on July 10–12, 2018, in Washington, DC.

Participants were selected through a competitive Request for Applications. Health care providers from different clinical professions were paired with chaplains and required to propose two to three goals. A selection committee reviewed applications based on: (1) clinician–chaplain pairing, (2) strength and feasibility of institutional goals, and (3) institutional support letters.

Of the 51 teams selected, 48 teams attended the ISPEC program, from 19 U.S. states and territories and 10 different countries. Forty-one teams had a chaplain–clinician or clinician–spiritual care provider pair; 7 did not—some attendees did not have professional spiritual care providers in their country's hospitals. In some cases, the designated “spiritual care professional” had training in theology or pastoral counseling. Some pairs consisted of a clinician–psychologist/social worker, with the psychologist/social worker specializing in spiritual care. Most participants (76%) were female, and the majority were either physicians or nurses.

The 2.5-day course had didactic presentations, discussions, and labs sessions for each module (Table 4). Both didactic and online modules include video clips and demonstrations of skills in spiritual assessment and care. In a skills-building session for communication and treatment planning, participant teams interviewed standardized patients to identify their physical, emotional, social, and spiritual needs; diagnose distress; make referrals; and suggest treatment. The last day focused on improving participant leadership skills to cultivate institutional organizational changes to integrate interprofessional spiritual care. Networking was encouraged throughout the course to facilitate learning among team members at the different health care settings. All participants were given one-year free access to the online course, available on the Relias Academy website https://reliasacademy.com/rls/ispec.

Table 4.

Interprofessional Spiritual Care Education Curriculum Train-the-Trainer Agenda

Day 1
8:00–8:15	Welcome
8:15–9:15	Module 1: Overview and Background
9:15–9:45	Module 1: Overview and Background Discussion
9:45–10:00	Break
10:00–11:00	Module 1: Overview and Background Lab Session
11:00–12:00	Module 2: Spiritual Distress
12:00–12:45	Lunch
12:45–1:15	Module 2: Spiritual Distress Discussion
1:15–2:15	Module 2: Spiritual Distress Lab Session
2:15–2:30	Break
2:30–3:30	Module 3: Compassionate Presence
3:30–4:00	Module 3: Compassionate Presence Discussion
4:00–4:15	Break
4:15–5:15	Module 3: Compassionate Presence Lab Session
5:15–5:30	Evaluation and Dismiss
Day 2
7:00–8:00	Registration and Breakfast
8:00–8:15	Recap
8:15–9:15	Module 4: Spiritual Assessment
9:15–9:45	Module 4: Spiritual Assessment Discussion
9:45–10:00	Break
10:00–11:00	Module 4: Spiritual Assessment Lab Session
11:00–12:00	Module 5: Whole Person Treatment Plan
12:00–12:45	Lunch
12:45–1:15	Module 5: Whole Person Treatment Plan Discussion
1:15–1:30	Break
1:30–3:45	Standardized Patient Lab
3:45–4:00	Break
4:00–5:00	Module 6: Ethics and Professional Development
5:00–5:15	Evaluation and Dismiss
Day 3
7:00–8:00	Registration and Breakfast
8:00–8:15	Recap
8:15–8:45	Module 6: Ethics and Professional Development Discussion
8:45–9:45	Module 6: Ethics and Professional Development Lab Session
9:45–10:00	Break
10:00–11:00	Implementing in your Setting and Debrief/Networking
11:00–12:00	Conclusion, Evaluation, and Dismissal

Evaluation of the ISPEC Course

Course evaluation

Participants rated presentation quality and content, teaching methods, and venue on a scale of 1 (lowest) to 5 (highest), including presentation clarity, content quality, value to their practice, and overall opinion. Participants were asked to rate whether the course met their objectives and how conducive the environment was for learning. They were asked to provide overall strengths and weaknesses, suggestions for improvement, and what additional material they would have liked. The rating for presentation clarity, content clarity, and value to their practice ranged from 4.3 to 4.6 out of 5 (Table 5).

Table 5.

Overall 2018 Interprofessional Spiritual Care Education Curriculum Course Evaluation (N = 98)

What was your overall opinion of this course?	4.6/5
To what extent did the course meet the objectives and your expectations?	4.5/5
Was the environment conducive to learning (i.e., room, space, lighting, AV, handouts, etc.)	4.3/5

The qualitative data included comments describing the course as “professional, engaging, and interactive.” In open-ended questions about the benefits of ISPEC, participants cited “professional” faculty, the “wealth of resources” including different team perspectives, “great” labs (especially Standardized Patient Simulation) and discussion sessions, and the opportunity to network with other clinicians and chaplains. Participants noted being able to discuss spiritual care topics with both faculty and other participants. Physicians from Kenya discussed with social workers from Florida ways to identify spiritual distress inpatients. Chaplains from Korea were able to brainstorm with nurses from New Mexico on developing a spiritual care plan in an interdisciplinary team. Some participants suggested adding evening social events to maximize networking.

Postcourse evaluation

Participants were followed for one year postcourse. Regular conference calls addressed goal progress, successes and challenges, and goal evaluation. This systems-based evaluation approach focuses on the utility and quality of the training from the participants' perspective and participants' goals in integrating spiritual care in their institutions.

Goal Evaluation: In the course application, participants were required to submit three realistic and practical goals to improve spiritual care in their institutions. Participants were guided in goal development, refinement, and implementation. During the one-year postcourse mentorship, GWish held six calls with participants to share successes and resources, explore challenges, and build community. Teams were asked to complete goal progress forms at 3-, 6-, and 12 months postcourse, using the goal evaluation tool. They provided narrative descriptions of goal progress and a percentage of completion for each goal.

Team Evaluation: A survey was developed to assess the facilitators and barriers to a productive partnership between disciplines in institutional contexts. The team evaluation will be conducted at the end of the one-year mentorship period.

ISPEC participants' activities

ISPEC participants developed goals for implementing course content in their clinical setting reflecting the values of spiritual care—dignity, respect, and compassion. Since the July 2018 ISPEC training, participants report having made significant progress toward goal achievement. For example, the ISPEC curriculum was delivered to more than 300 medical students and faculty members at Western University of Health Sciences. The associate dean of the university acknowledged this training, stating: “I am pleased to say this curriculum was extremely well received by not only our students, but even comments from our faculty and staff have been extremely positive.” Kenya Hospices and Palliative Care Association recently hosted a national palliative care conference bringing together 280 physicians, nurses, and community volunteers, reported to be very well received by participants. The ISPEC participants frequently received invitations from local universities, hospitals, and conferences to present the ISPEC materials. Two different groups of ISPEC participants presented at national conferences within six months postcourse.

The ISPEC supports quality improvement efforts to integrate interprofessional spiritual care in all aspects of patient care. Two participating sites are working on quality improvement projects in their universities—one in a pediatric oncology setting, another with medical residents taking a spiritual history.

One of the ISPEC's objectives is to foster increased clinician awareness of their own spirituality as part of their professional call to serve others. The leadership group from Chile felt that clinicians' exploration of their own spirituality was essential before beginning spiritual care training. They integrated spirituality into the ethics course for second year medical students and began training volunteers in spiritual accompaniment, while exploring opportunities to develop a more formal chaplaincy program.

A recurrent theme was the recognition of the importance of providing spiritual care to patients and of working closely with trained chaplains. The team from Chile spent time at Virginia Commonwealth University's CPE (Clinical Pastoral Education program), noting that although their country's spiritual care volunteers were important to the team, trained chaplains functioned in the capacity of a health care professional. Clinicians noted that the ISPEC training helped them engage chaplains more readily; chaplains felt they could function more effectively as spiritual care experts rather than feeling they were forcing their way onto teams, thus resulting in more holistic patient care.

Perhaps the most powerful demonstration of the program's impact was from participants who spoke about the privilege of witnessing patients' spiritual stories. One participant described the opportunity as a “a privilege to get to see and hear these things.”

Conclusion

Patient suffering, particularly spiritual distress, is pervasive in clinical care. Guidelines mandate that all clinicians address spiritual distress, yet studies have shown that this does not happen routinely. One of the major reasons cited is clinicians' lack of training. Chaplains are trained to attend to spiritual distress but unless clinicians refer patients, chaplains may not evaluate patients. Although there are other interprofessional education programs, the ISPEC contributes to this area not only by providing clinician–chaplain pairs with skills training but also by training them how to be leaders in their own institutions in implementing interprofessional spiritual care.^50,51 The ISPEC program builds on this partnership to develop clinician–chaplain leaders in the United States and internationally. Initial evaluation data from the first ISPEC course demonstrates the effectiveness of the training and this partnership. The ISPEC's goal is to train clinicians–chaplains in all clinical settings, so that interprofessional spiritual care can be fully integrated and patients' spiritual distress attended to by all members of the team. The ISPEC has been used in 16 countries. Although the international dissemination has been continually evaluated to assure that it is appropriate across various settings and cultures, we recognize that this training needs to be carefully tailored for each specific use.

Footnotes

Acknowledgments

The authors are grateful to the Fetzer Institute for their generous financial support that made this project possible. They thank all ISPEC participants, partner institutes, and faculty members, including Tracy Balboni, MD, MPH; Marvin Delgado, MD; Kathleen Ennis-Durstine, MDiv; Noreen Chan, MD; Paul Galchutt, MDiv, MPH; Trace Haythorn, PhD, MDiv; Carolyn Jacobs, PhD, MSW; Elisha Waldman, MD; and Anne Vandenhoeck, PhD, MA.

Funding Information

Fetzer Institute, Kalamazzo, Michigan, Collaboration Agreement #3852.00.

Author Disclosure Statement

No competing financial interests exist.

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