Impact of an online spiritual care course on perceived competency in spiritual care of students in social and health care professions / Wirksamkeit eines Online-Spiritual Care-Seminars auf die wahrgenommene Spiritual Care-Kompetenz bei Studierenden in Sozial- und Gesundheitsberufen

Spiritual Care—which refers to the spiritual dimension in the caring process—is an integral part of high-quality health care and a shared responsibility of all social and health care professionals. It takes patients' needs, options, resources, and limits in the field of spirituality into account (Frick, 2017). According to Nolan et al., spirituality can be understood as ‘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., p. 88). Spiritual Care understands spirituality as one of four dimensions of human health needs: physical, psychological, social, and spiritual. These dimensions affect one another and overlap but are also distinct dimensions. Each dimension plays a significant role in contributing to people's well-being and health.

In this paper, we argue that education related to the spiritual dimension of health is as important as the skills and competencies related to the physical, psychological, or social dimensions of health. Research consistently shows that health professionals are aware of spirituality in patient care, yet do not offer spiritual care. This is not only because of lack of money, time, or personnel resources but because of a lack of competency (Abdulla et al., 2019; O'Brien et al., 2019; van der Vis-Sietsma et al., 2019). Poor integration of spiritual care into caregivers' education is a reason for health professionals' lack of competency in providing spiritual care (Balboni & Balboni, 2019). In particular, newly graduated, less experienced health professionals do not feel confident in their spiritual care competency and believe that universities are not providing enough information on this topic (Giezendanner et al., 2017; de Diego Cordero et al., 2019; Esperandio et al., 2021). Relevant training can enhance the quality of spiritual care delivery and helps to prepare students in social and health care professions for this area (Moosavi et al., 2019). Reported outcomes of spiritual care training include increased levels of competency (Jones et al., 2021). Internationally, a great variety of educational strategies has been developed with a focus on teaching knowledge, skills and attitudes required to administer spiritual care (Paal et al., 2015; Helo, 2017; Jones et al., 2021). A majority of studies address nurses and midwives (Attard et al., 2019; McSherry et al., 2020; Vargas-Escobar & Guarnizo-Tole, 2020; van Leeuwen et al., 2021). In German-speaking countries, specific spiritual care trainings have been developed (Gratz & Roser, 2016; Prenner, 2016; Peng-Keller & Argiro, 2017; Gratz & Roser, 2019; Kunsmann-Leutiger et al., 2021). These trainings are mostly offered for health professionals in the context of palliative care. There is little interdisciplinary spiritual care education for students in diverse disciplines of the social and health care sector, and literature on their effectiveness is limited. Online spiritual care training is a growing topic of interest (Best et al., 2020; Pearce et al., 2020). Previous studies have demonstrated the efficacy of online education for spiritual care programs (Ellman et al., 2012; Petersen et al., 2017) and reported benefits of e-learning in terms of increased accessibility, improved self-efficacy, cost effectiveness, learner flexibility, and interactivity (Sinclair et al., 2016; Campbell et al., 2019; Mazanec et al., 2019). This study contributes to the existing body of knowledge by investigating the effectiveness of an interdisciplinary online spiritual care training. It addresses students from different social and health care disciplines, the future caregivers, namely students in social work and allied health care professions, for instance, nursing, medicine, pastoral care/theology, psychology, and so on.

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Outcome variables and rationale

In the literature, a variety of definitions and measurements of spiritual care competency exist (McSherry et al., 2002; van Leeuwen et al., 2009; Iranmanesh et al., 2012; Ross et al., 2014; Frick et al., 2019). Following van Leeuwen et al., we define spiritual care competency as the knowledge, skills, and attitudes required for spiritual care delivery (van Leeuwen et al., 2009). It includes cognitive, behavioural, and affective components, such as knowledge of religions, being spiritually aware, and feeling prepared to talk about spiritual needs (Ross et al., 2014; Frick et al., 2019). Based on a sample of nursing students, van Leeuwen et al. developed the Spiritual Care Competence Scale (SCCS), an instrument to measure spiritual care competency (van Leeuwen et al., 2009). Similarly, Frick et al. (2019) developed the Spiritual Care Competence Questionnaire (SCCQ), a German spiritual care competency instrument that addresses the linguistic and cultural situation of continental Europe and specifically the German-speaking context. It is validated with different health professions, such as nurses, physicians, and chaplains. The SCCQ considers the following ten topics of spiritual care competency: perception and recording of spiritual needs of patients, implementation of spirituality in team processes, one's own reactions to the topic and possibilities of intervention, impact of perceptions on one's own activities, development of one's own actions, development of one's own spirituality, proactive competence (empowerment), creating time/space, knowledge about other religions (‘foreignness competence’), discharge and transition management, and implementation barriers (Frick et al., 2019). These topics have been incorporated into seven different competency facets with different weightings. The seven facets can be understood as a differentiation of the three areas—knowledge, skills, and attitudes—required for spiritual care delivery. While the SCCS is used widely internationally, it is tailored for nursing students and uses English items. In this study, we decided to use the SCCQ to measure spiritual care competency. The rationale behind selecting the SCCQ over the SCCS is both its development in the German language and its alignment with diverse health professionals and allied disciplines.

In order to evaluate spiritual care competency on both a coarse level and a fine level, we decided to differentiate the construct in two primary outcome variables. On the one hand, we examined the coarser spiritual care competency areas of knowledge, skills, and attitudes concerning spiritual care. On the other hand, we examined the differentiated facets of spiritual care competency. According to Wasner et al. (2008) who evaluated the knowledge, skills, and attitudes of medicine students after participating in a palliative care course, we assessed competency levels in spiritual care. Because of the complex nature of spiritual care competency, and its multifactorial acquisition and application, we further evaluated the following secondary outcomes: empathy, spiritual sensitivity, and self-efficacy. The rationale behind selecting these outcome variables is that they help in gaining insights into the quality of future health care delivery and competence-based spiritual care. Empathy is expected to reflect care-related skills and attitudes and relates to the care-based component of spiritual care competency. Spiritual sensitivity—the spirituality-based component—is expected to raise awareness of the importance of spiritual competency. Self-efficacy reflects individuals' perception of their own abilities to cope with different needs and situations and is required for competence-based performance. The relationship between spiritual care competency and empathy (Kim & Choi, 2015), spiritual sensitivity (Callahan & Benner, 2018), and self-efficacy (Cheng et al., 2021) has been shown. Furthermore, these constructs cover cognitive, affective, and motivational aspects of perceived spiritual care competency. This selection is in accordance with other course evaluation studies in health care examining changes in knowledge, skills, and attitudes (Pereira et al., 2008; Wasner et al., 2008), empathy (Yamada et al., 2018; Spatoula et al., 2019), spiritual sensitivity (Catanzaro & McMullen, 2001; Callahan & Benner, 2018), and self-efficacy (Egenberg et al., 2017; Saslaw et al., 2017). The outcome variables are presented in Figure 1.

Figure 1

We implemented an interdisciplinary online spiritual care course named Spiritual Care – Emergency Care – Palliative Care, SEPCare (Maidl et al., 2019; Magin et al., 2020). This course is designed for students in social and health care professions, with the aim of sensitising participants to the spiritual dimension in health care and making participants realise the importance of their own spiritual and existential dimensions. These help to integrate them into professional practice. SEPCare is rated as a course with a workload of three ECTS points, and consists of the following five modules: three thematic modules concern getting to know the concept of spirituality in health care, learning about religiosity/spirituality, and developing basic competency in spiritual care; one optional module—called the ‘spiritual break’— includes music, lyrics, and inspirations to provide a timeout during studying; the final module links the content with a graduation essay task. SEPCare is implemented via the learning platform Moodle and is offered by the Virtuelle Hochschule Bayern (vhb; network of 33 universities and universities of applied sciences in Bavaria). While the course is open for all Bavarian students, most students study at the three host universities of the SEPCare course—the Technical University of Munich, the Katholische Stiftungshochschule München University of Applied Sciences, and the Legendary Institute of Technology. Using methodologically diverse educational strategies (such as lectures, videos, audio recordings, case studies), we ensured that participants had opportunities to actively engage with the material (using, for example, self-knowledge checks, reflection questions). Additionally, we provided numerous examples to show how the content can be applied in clinical contexts. An evaluation form can be used by the students to evaluate the course once it is completed. Additionally, an evaluation was completed by experts in this field using criteria from a catalogue with respect to content and technical usability.

Kirkpatrick's conceptual model provides a useful theoretical framework to consider course effectiveness (Kirkpatrick, 1996). The model identifies four levels of evaluation that can be transmitted to health care interventions (Pereira et al., 2008). The second level focuses on learners' changes in knowledge, skills, and attitudes. Accordingly, this study focuses on learners' pre- versus post-course changes in self-perceived knowledge, skills, and attitudes concerning spiritual care as well as changes in facets of spiritual care competency, and related outcome variables.

The aim of this study was to examine to what extent the online spiritual care course is suitable and effective in increasing perceived spiritual care competency among students in social and health care professions. Derived from that, our hypothesis was as follows: scores in spiritual competency and in spiritual care competency related constructs (empathy, spiritual sensitivity, and self-efficacy), will increase from pre- to post-training and will be higher than those of a comparison group without training. Specifically, we expected a hybrid interaction between group and time in scores on individual measures.

This study used a two-group pre-post-test quasi-experimental design with a time-by intervention analysis. The course's effects on students' self-reported spiritual care competency were assessed with quantitative methods using questionnaires.

Subjects were N = 145 students in social and health care professions from Bavaria, Southern Germany. Of these, 78 students participated in the online spiritual care course (Intervention Group, IG); 67 students did not receive spiritual care training (Comparison Group, CG).

For IG recruitment, students that were enrolled in the online spiritual care course SEPCare were presented an invitation to the study at the beginning of the course and could optionally follow the link to the survey or start the course without study participation. Students that were studying a major in social and health care professions, such as nursing science, medicine, healthcare sciences, social work, theology/pastoral care, and so on, at a Bavarian university were admitted to the study. Guest participants in SEPCare (not students) or participants majoring in other fields were excluded, as well as course participants who did not engage with the course or who did not complete the questionnaire at two time points (dropout). CG students had not (yet) participated in SEPCare and were students from the Katholische Stiftungshochschule München University of Applied Sciences, majoring in social work. The online survey for IG subjects was presented in an electronic format by Electric Paper Evaluationssysteme (EvaSys® V7.1

https://www.evasys.de/evasys-education.html

Descriptive statistics were run on demographic factors. Cronbach alpha coefficients were calculated to examine the internal reliability in all pre- and post-test scores (Cronbach, 1951). A repeated measures ANOVA was performed on all scores with time (within) and group (between) as factors. The statistical significance level was set at α < .05. All analyses were conducted using IBM® SPSS Statistics version 26.

The N = 145 subjects ranged from 19 to 56 years old (IG M = 26.6, CG M = 25.0). Female subjects constituted 81% of those who completed the course (IG), and 75% of those who did not (CG). The majority of the sample were Germans (IG: 92%, CG: 96%), single (IG: 68%, CG: 69%), and identified with a Christian religious community (IG: 64% Catholic, 15% Protestant; CG: 48% Catholic, 28% Protestant). On a 6-point Likert scale, subjects' average spirituality was 4.6 (SD = 1.3) in the IG and 3.7 (SD = 1.3) in the CG, the average religiosity was 4.2 (SD = 1.4) in the IG and 3.4 (SD = 1.4) in the CG. While all CG students studied social work, 39% of IG students did. The other IG students studied theology/religious education (18%), medicine (15%), healthcare sciences (8%), nursing science (6%), or other allied disciplines. Students were on average in their fifth semester (IG M =5.5, CG M = 4.7). Approximately a third of the study population had previous vocational training in the health care sector and/or practical experience in clinical settings (IG: 31%, CG 27%). Subjects familiar with the spiritual care concept constituted 27% of IG subjects and 7% of CG subjects. The description of the study population separated into Intervention and Comparison Group is presented in Table 1.

Independent T-tests and chi-square analyses revealed significant differences between IG and CG by study subject, religious/spiritual self-assessment, and familiarity with the concept of spiritual care (p < .05). Other relevant characteristics (e.g. age, gender, religious preference, semesters studied, etc.) varied similarly. IG subjects completed on average 83% of the online spiritual care course (SD = 17.3) and most worked three times a month for 129 minutes (SD = 76.0) on the five course modules.

Cronbach alpha coefficients were calculated for each measurement and subscale. For most of the measures, reliability was moderate. The lowest alpha coefficient (α = .30) was found in the CG pre-test in the subscale mystery sensing of the Spiritual Sensitivity Scale. The highest reliabilities in both the IG pre- and post-tests were α = .93 in the spiritual care competency facet documentation competence of the SCCQ. Table 2 shows the reliabilities of all measures.

These findings should be interpreted with several limitations in mind. First, the choice of study population and its compilation. The sample was self-selected, and results might be affected by social desirability. There was no randomised assignment to intervention or control group and an influence of selection bias on the results must be considered. While all respondents in the comparison group studied social work, only 39% of IG students were students in social work. In terms of clinical practice, it is worth considering that social workers must meet different care requirements than medical health professionals such as physicians or nurses. So comparability of health care students to social work students is limited. However, all social and health care professions need a similar basic competency in spiritual care and can profit from interdisciplinary education. Another difference that might have affected the results and/or data quality is the collection of data (online vs. paper-pencil based). Additionally, data showed that IG students were more open to religiosity/spirituality and more familiar with the concept of spiritual care than CG students. Consequently, course participants were already spiritually committed and were thus more likely to experience (or report experiencing) a change in competency scores. Since most of the study population were female, single, and Catholic, generalisability to the overall population of social and health care students may be limited. However, gender distribution in this sample is close to the one in the overall social and health care sector. Another point that must be reflected on is the choice of measurements. The relatively low reliability coefficients (α < .60) for some subscales might have affected the validity of the results. Furthermore, the validation of the SCCQ-student version is about to be conducted. Additional research that builds on these findings is needed to better classify its results. Finally, this study focused on self-reported instruments and students' perceptions were assessed once after the online spiritual care course, without a follow-up assessment. As such, we are unable to determine whether the identified changes were temporary or long-lasting, nor whether there will be a translation of learning into actual behaviour change. Longitudinal studies with behavioural measures of effect would provide evaluation of the stability of these changes over a longer period and of the impact on client outcomes. Overall, this was a first step in improving spiritual care competency in future social and health care providers through online spiritual care training. Further educational strategies and a more sophisticated design would be the next step in providing stronger support for the effectiveness of spiritual care interventions on competency changes and their translation into clinical practice. Moreover, future variations of the course with varying technologies would be interesting for further research, e.g. efficiency of virtual reality learning scenarios or serious games in terms of role models or testing of individual spiritual care scenarios.

The online spiritual care course is an innovative interdisciplinary educational strategy that has the potential to impact competency in spiritual care. The study provides insights into whether and how online training can enhance knowledge, skills, and attitudes related to spiritual care and may contribute to the literature by evaluating current spiritual integration training of graduate students in the social work, medicine, and nursing science fields. Thereby, it supports educators in the development of similar programs and can help practitioners to select personnel that may profit from more specified training. It is through first educating social and health care students about what spiritual care is, and how to deliver it, that future caregivers can integrate it into clinical practice. Effective spiritual care educational initiatives are crucial if the spiritual domain is to be adequately incorporated into daily patient care. Online spiritual care interventions for students might be the first step to decrease the existing perception of a lack of competency regarding spiritual care.