1. bookVolume 9 (2022): Edizione 1 (January 2022)
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License
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Rivista
eISSN
2296-990X
Prima pubblicazione
19 Nov 2014
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1 volta all'anno
Lingue
Inglese, Tedesco
Open Access

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

Pubblicato online: 14 Oct 2022
Volume & Edizione: Volume 9 (2022) - Edizione 1 (January 2022)
Pagine: 127 - 138
Ricevuto: 24 Sep 2021
Accettato: 05 Aug 2022
Dettagli della rivista
License
Formato
Rivista
eISSN
2296-990X
Prima pubblicazione
19 Nov 2014
Frequenza di pubblicazione
1 volta all'anno
Lingue
Inglese, Tedesco
INTRODUCTION
Background

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.

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

Outcome variables.

Course content and theoretical framework

We implemented an interdisciplinary online spiritual care course named Spiritual CareEmergency CarePalliative 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.

Study aim

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.

METHODS
Study design

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

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).

Procedure

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

) before (T0) and after (T1) course participation. The survey is subdivided into six parts: demographic data, and five self-assessments, for knowledge, skills, and attitudes concerning spiritual care, facets of spiritual care competency, empathy, spiritual sensitivity, and self-efficacy. CG subjects filled out a paper-pencil version of the same questionnaire before and after an interim interval of one semester. The questionnaire took about 15 minutes to complete. Data was gathered from April 2019 (start of summer semester 2019) through February 2021 (end of winter semester 2020/21). IG data were collected through EvaSys® and downloaded directly into statistics software (Excel, SPSS). CG data were manually collected. Pre- and post-data matching was achieved through an individually generated code. As an incentive, on completion of data gathering at two time points, all subjects went into a draw to win a 15€ online voucher by e-mail.

Measures
Demographic data.

At baseline (T0), respondents provided information regarding their age, gender, nationality, marital status, religious preference, self-identification as a religious or spiritual person, study field, years of studying, previous vocational training, and familiarity with the concept of spiritual care. At T1, IG participants were asked about their course participation behaviour, including frequency and duration of online sessions, and number of modules worked on in the course. To control for other intervention variables, CG subjects were asked about any spiritual care–related input they got during interim interval.

Spiritual care competency areas, knowledge, skills, and attitudes.

Based on Wasner et al. (2008), we used twelve items measuring knowledge, skills, and attitudes concerning spiritual care (12-ksa) listing the following topics covered by the online course SEPCare: (1) spirituality/spiritual support, (2) dealing with limit situations/crisis, (3) palliative and pain care, and (4) self-care. According to Wasner's format and in order to allow comparability, respondents were asked to self-assess their competency on a 11-point Likert scale (1 = extremely low to 11 = extremely high) concerning (a) knowledge on, (b) skills in, and (c) attitudes towards these four topics.

Spiritual care competency facets.

The German assessment tool Spiritual Care Competence Questionnaire (SCCQ; Frick et al. 2019) is a self-administered questionnaire using a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree) for measuring seven facets of spiritual care competency: (1) perceptual competence; (2) team spirit; (3) documentation competence; (4) self-awareness and proactive opening; (5) knowledge about other religions; (6) competence in conversation technique; (7) proactive empowerment competence. Cronbach's alpha of these SCCQ-scales reaches from .73 to .86. While the original SCCQ consists of 26 items and addresses professionals, we used a 19 item student version, leaving those items out that asked for actual clinical practice (for example, ‘In the team, we have rituals [for example farewell and interruption rituals] to deal with problematic situations’). Additionally, we slightly adapted some item formulations in order to suit our student focus group, and the future perspective on their care work (for example, instead of ‘I am confident I can perceive the spiritual needs of patients’ and ‘In our team, we regularly exchange about our own spirituality’, we used ‘For my future work, I am confident I can perceive the spiritual needs of patients’ and ‘Among us students, we regularly exchange about our own spirituality’). The adapted items of the SCCQ were reviewed and content validated by the authors of the original version, Frick and Büssing. The retesting of the validity and reliability of the SCCQ-student is in progress (unpublished manuscript).

Spirituality-based component, spiritual sensitivity.

To explore participants' sensitivity for the spiritual dimension, the Spiritual Sensitivity Scale (SSS; Tirri & Nokelainen, 2011) was used, a 11-item 5-point Likert-type self-assessment instrument (1 = totally disagree to 5 = totally agree) consisting of the following four dimensions: (1) awareness sensing, (2) mystery sensing, (3) value sensing, and (4) community sensing. Reliabilities reach from .62 to .75.

Care-based component, empathy.

Based on Davis's Interpersonal Reactivity Index (IRI; Davis 1980, 1983), the German Saarbrücker Persönlichkeitsfragebogen (SPF; Paulus, 2009, 2019) measures respondents' self-assessed empathy with 16 items on 4 subscales – perspective taking (PT, α = .79), fantasy (FS, α = .79), empathic concern (EC, α = .75), and personal distress (PD, α = .76) – on a 5-point Likert scale (1 = never to 5 = always). The empathy score is a sum of the three subscales EC+PT+FS (Paulus, 2012). The IRI, resp. the German SPF, is widely used to measure health care students' empathy.

Competence-based component, self-efficacy.

The General Self-Efficacy Scale (GSES) is a self-administered questionnaire based on Bandura's concept of perceived self-efficacy (Bandura, 1997). In this study, the German version by Jerusalem and Schwarzer (2018) was used. For analysis, the ten items employing a 4-point Likert-type scale (1 = not at all true to 4 = exactly true) are summed to a total score of perceived self-efficacy (Schwarzer & Jerusalem, 1999). Cronbach's alpha of the GSES ranges from .80 to .90.

Statistical Analysis

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.

RESULTS
Study population

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.

Description of study population.

Variables IG, n = 78 CG, n = 67 p
Age in years, mean (SD; range) 26.6 (8.2; 19–56) 25.0 (6.9; 19–52) .90 (t = .90) 2
Nationality*: German, % 92% 96% .54 (χ2 = 1,24)1
Gender*: female, n (%) 63 (81%) 50 (75%) .13 (χ2 = 4.04) 1
Marital status*, % .85 (χ2 = 1.38) 1
single 68% 69%
married 16% 15%
Study subject*, n (%) .00 (χ2 = 66.67) 1
medicine 12 (15%)
nursing science 5 (6%)
theology/religious education 14 (18%)
healthcare sciences 6 (8%)
social work 31 (39%) 67 (100%)
others (psychology, philosophy/medical ethics) 6 (8%)
Semesters studied, mean (SD) 5.5 (2.7) 4.7 (2.0) 1.82 (t = .07)2
Previous vocational trainingIn healthcare sector, % 31% 27% .32 (χ2 = 2.27) 1
Self-assessed religiosity/spirituality (1 = not at all, 6 = completely true), mean (SD)
spiritual 4.6 (1.3) 3.7 (1.3) .00 (t = 4.35)2
religious 4.2 (1.4) 3.4 (1.4) .00 (t = 3.10)2
Religious preference, % .25 (χ2 = 6.67) 1
Catholic 64% 48%
Protestant 15% 28%
Muslim 3% 2%
other 3% 3%
none 12% 18%
Familiarity with spiritual care, % 27% 7% .00 (χ2 = 9.38) 1

IG = Intervention Group; CG = Comparison Group; SD = standard deviation

Note. Beyond the presented options, individuals could choose the option “no reply” or “other”, rarely or not selected options (e.g., marital status: divorced, widowed; nationality: other – please specify; religious preference: Jewish)

Chi-square test,

independent-sample t-test.

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.

Reliability of scales

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.

Reliability of scales.

Measures Pre-test (Cronbach's α) Post-test (Cronbach's α)
IG CG IG CG
Spiritual care competency areas (12-ksa) .63 – .68 .57 – .75 .60 – .71 .57 – .72
Spiritual care competency facets (SCCQ) .45 – .93 .46 – .78 .55 – .93 .31 – .79
Spiritual sensitivity (SSS) .42 – .74 .30 – .72 .56 – .77 .50 – .72
Empathy (SPF) .60 – .81 .59 – .77 .59 – .80 .70 – .79
General self-efficacy (GSES) .88 .88 .87 .86

12-ksa= 12 items measuring knowledge, skills, attitudes concerning spiritual care; SCCQ= Spiritual Care Competence Questionnaire; SSS= Spiritual Sensitivity Scale; SPF= Saarbrücker Persönlichkeitsfragebogen; GSES= General Self-Efficacy Scale; IG = Intervention Group; CG = Comparison Group

Effects on the outcome variables
Comparison at baseline.

At baseline (T0), means of IG and CG scores in general self-efficacy and empathy showed no significant differences. The spiritual sensitivity subscale awareness sensing, and the spiritual care competency subscales team spirit, knowledge about other religions, and competence in conversation technique varied similarly in IG and CG, too. Scores on the three other subscales in spiritual sensitivity, scores on knowledge, skills, and attitudes concerning spiritual care, as well as scores on four subscales in spiritual care competency differed significantly at T0 (p < .05). In these scales, CG subjects started on a lower level than IG subjects.

Repeated measures ANOVA.

The time by intervention analysis showed the following effects on the primary outcome measures: there were significant interactions in each of knowledge, skills, and attitudes concerning spiritual care (p < .001) and significant main effects for both time and group (p ≤ .001). Three of the seven spiritual care competency facets showed statistically significant time-by-group interactions: team spirit (p = .04), documentation competence (p < .001), and knowledge about other religions (p < .001). For team spirit and for documentation competence, main effects for time as well as for group were statistically significant (p < .001), for knowledge about other religions, the main effect for time was non-significant, yet the main effect for group was significant (p < .001). For perceptual competence, there was a significant main effect for group (p < .001), but not for time, and a nonsignificant interaction. For self-awareness and proactive opening, the main effect for time was significant at p = .001, the main effect for group was significant at p < .001. The interaction, however, was nonsignificant. There was a nonsignificant main effect for time and a significant main effect for group (p < .01) for competence in conversation technique, and a nonsignificant interaction. For proactive empowerment competence, the main effect for time was significant (p = .02) and the main effect for group, too (p < .001), the interaction of time by group, however, was nonsignificant.

Results for the secondary outcome measures were as follows: for spiritual sensitivity, the subscale awareness sensing showed a significant interaction (p = .01), the main effects for time and group were nonsignificant. The subscales mystery sensing, value sensing, and community sensing showed no significant interaction, the main effects for time were nonsignificant, but the main effects for group were significant (p < .001). For empathy, there was no significant main effect for time, but a significant main effect for group (p = .04). The interaction was nonsignificant. For general self-efficacy, the main effect for time was significant (p = .01), the main effect for group was nonsignificant, yet the interaction of time and group was significant at p = .02. The results are presented in Table 3. Each of the graphical analyses of the statistically significant interactions suggest the existence of hybrid interaction effects.

Mean, standard deviations, and repeated measures analyses of variances (ANOVA) in spiritual care competency measures at baseline (T0) and after (T1) intervention (Intervention Group) or interim interval (Comparison Group).

Measures IG (n = 78) CG (n = 67) Time by intervention Effecta Partial η2
M (T0) SD (T0) M (T1) SD (T1) M (T0) SD (T0) M (T1) SD (T1)
Primary outcomes
Spiritual care competency areas (12-ksa)
Knowledge 6.08 1.70 7.96 1.14 5.39 1.67 5.66 1.64 F (1, 142) = 28.95*** 0.17
Skills 6.23 1.57 7.56 1.33 5.56 1.69 5.84 1.57 F (1, 142) = 15.53*** 0.10
Attitudes 7.77 1.34 8.84 1.01 6.88 1.98 7.02 1.74 F (1, 142) = 11.13*** 0.07
Spiritual care competency facets (SCCQ)
Perceptual competence 3.09 0.49 3.26 0.41 2.81 0.59 2.79 0.59 F (1, 143) = 3.61 0.03
Team-spirit 1.75 0.63 2.09 0.70 1.56 0.58 1.66 0.60 F (1, 142) = 4.38* 0.03
Documentation competence 1.40 0.62 2.84 0.85 1.22 0.40 1.37 0.46 F (1, 143) = 87.45*** 0.38
Self-awareness and proactive opening 2.71 0.61 2.93 0.53 2.18 0.67 2.24 0.63 F (1, 141) = 3.29 0.02
Knowledge about other religions 2.79 0.55 3.05 0.61 2.80 0.70 2.60 0.58 F (1, 140) = 17.46*** 0.11
Competence in conversation technique 3.45 0.60 3.53 0.47 3.27 0.62 3.22 0.61 F (1, 140) = 1.71 0.01
Proactive empowerment competence 2.75 0.67 3.03 0.58 2.27 0.79 2.30 0.72 F (1, 141) = 3.46 0.02
Secondary outcomes
Spirituality-based component: Spiritual sensitivity (SSS)
Awareness sensing 3.90 0.85 4.04 0.72 3.75 0.75 3.66 0.80 F (1, 142) = 6.27* 0.04
Mystery sensing 4.06 0.57 4.12 0.61 3.79 0.59 3.75 0.65 F (1, 142) = 1.10 0.01
Value sensing 4.40 0.67 3.75 0.65 3.76 0.88 3.76 0.77 F (1, 141) = 3.26 0.02
Community sensing 3.94 0.84 3.85 0.84 3.34 0.90 3.39 0.94 F (1, 141) = 1.30 0.01
Care-based component: Empathy (SPF) 3.79 0.36 3.80 0.39 3.67 0.38 3.67 0.44 F (1, 143) = 0.03 0.00
Competence-based component: General self-efficacy (GSES) 2.88 0.45 3.00 0.39 2.90 0.44 2.91 0.37 F (1, 143) = 5.71* 0.04

12-ksa= 12 items measuring knowledge, skills, attitudes concerning spiritual care; SCCQ= Spiritual Care Competence Questionnaire; SSS= Spiritual Sensitivity Scale; SPF= Saarbrücker Persönlichkeitsfragebogen; GSES= General Self-Efficacy Scale; IG = Intervention Group; CG = Comparison Group

Note.

p < .05,

p < .001.

Greenhouse-Geisser.

DISCUSSION

The study's purpose was to determine the impact of an online spiritual care course on perceived spiritual care competency of students in social and health care professions. The primary outcomes relate to the three coarse spiritual care competency areas knowledge, skills, and attitudes concerning spiritual care, as well as seven differentiated facets of spiritual care competency. Secondary outcomes cover spirituality, care, and competency components, in particular spiritual sensitivity, empathy, and general self-efficacy. Results show a particular impact on spiritual care competency areas and facets, as well as on spiritual awareness and general self-efficacy. More precisely, after course completion, and compared to a control group without spiritual care–related input, students in social and health care professions perceived themselves as having more knowledge and more skills and rated their attitudes concerning spiritual care higher than before. They rated themselves higher on knowledge about other religions and documentation competence, and their perception of team spirit increased from pre- to post-training. Additionally, participation in the online spiritual care course made students sense a higher spiritual awareness and a heightened self-efficacy.

These findings demonstrate the effectiveness and suitability of the examined online spiritual care educational strategy to increase aspects of spiritual care competency among students in social and health care professions. The most relevant aspect is the positive impact on cognitive parts of spiritual care competency, namely the increase in participants' knowledge concerning different spiritual care related topics (e.g. concerning spirituality/spiritual support), in documentation (e.g. knowing instruments to document a spiritual history), and in knowledge about other religions (e.g. being well aware of the religious characteristics of patients from other religious communities). Another relevant impact is the change in skills concerning different spiritual care–related topics (e.g. in palliative/pain care), and least but still significantly, the change in attitudes concerning spiritual care (e.g. in self-care). Whereas awareness sensing in spiritual sensitivity was positively impacted by the course, other dimensions of spiritual sensitivity were not. The lack of impact in mystery, value, and community sensing shows that the online course did not aim at deepening one's own spirituality, which is also reflected by the nonsignificance of the facet self-awareness and proactive opening. The significant increase in post-test awareness sensing, however, leads to the assumption that one of the aims of the course—sensitising for the spiritual dimension—was met. Scores in the two spiritual care competency facets, perceptual competence and self-awareness and proactive opening, however, did not increase significantly. This indicates that a differentiation is required between general awareness sensing (e.g. contemplating in busy everyday life, as measured by the Spiritual Sensitivity Scale), and the perception competence in the specific, clinical context (e.g. perceiving patients' spiritual needs, as measured by the Spiritual Care Competence Questionnaire). Nonetheless, as the interaction between group and time in scores of perceptual competence was close to being significant (p = .06), a positive trend could be observed. Another small but statistically significant difference (p = .04) was noted in the spiritual care competency facet of team spirit. This supports the assumption that the spiritual care course positively influenced students' willingness and readiness to discuss spiritual care (e.g. about their own or about patients' spirituality). This is a promising effect, as the use of an online intervention might have led to the assumption of lower impact on (direct) exchange with others and on the feeling of team spirit than nonvirtual education would do. Two other competency facets that are close to clinical practice, namely competence in conversation technique, and proactive empowerment competence, were not impacted by the online spiritual care course. Interestingly, empathy—as the care-related component of spiritual care competency—was not impacted, but students' general self-efficacy increased significantly after participation. This demonstrates students' general perception of being prepared to perform and supports the hypothesis that the online spiritual care course impacted the cognitive and motivational aspects, but barely the affective aspects, of spiritual care competency. It must be considered, though, that course participants in this study tended to score high in empathy subscales at baseline so that a ceiling effect cannot be excluded.

The findings are congruent with those of earlier studies. For example, a comparative intervention-control group study among nursing students in the Netherlands showed that some aspects of spiritual care competency improved after participating in a spiritual care course (van Leeuwen et al., 2008). More recently, Hu et al. showed the effectiveness of spiritual care training on spiritual care competency scores among oncology nurses in China (2019). Like Wasner et al. who found a highly significant impact of a palliative care training for medical students on all self-assessed skills and attitudes (Wasner et al., 2008), we found highly significant changes on both knowledge, skills, and attitudes concerning spiritual care. Moreover, a meta-analysis of RCT studies that examined comparable palliative care education showed that such intervention is effective in improving health professional students' knowledge and attitudes towards palliative care. In contrast to our findings, however, attitudes improved only under possibly biased conditions, namely when studies at high risk of bias were excluded, and skills did not increase (Donne et al., 2019). Our results for general self-efficacy can be compared with other similar studies that showed that spiritual care interventions can enhance participants' perceived self-efficacy (Salamizadeh et al., 2017; Dehghani et al., 2020). Overall, our study is in line with other evaluation studies that show a positive impact of online spiritual care training on competencies in health care (Petersen et al., 2017; Pearce et al., 2020).

Limitations

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.

Implications and future directions

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.

CONCLUSION

The present findings provided empirical evidence for the effectiveness of an online spiritual care training on social and health care students' perception of spiritual care competency. Participation in an online course increased their knowledge, skills, and attitudes concerning spiritual care, cognitive and motivational facets of spiritual care competency, their spiritual awareness and general self-efficacy. This study has the potential to inform educators with insights into the impact of interdisciplinary spiritual care education via e-learning environments and helps prepare future caregivers in providing spirituality-informed patient care.

Figure 1

Outcome variables.
Outcome variables.

Mean, standard deviations, and repeated measures analyses of variances (ANOVA) in spiritual care competency measures at baseline (T0) and after (T1) intervention (Intervention Group) or interim interval (Comparison Group).

Measures IG (n = 78) CG (n = 67) Time by intervention Effecta Partial η2
M (T0) SD (T0) M (T1) SD (T1) M (T0) SD (T0) M (T1) SD (T1)
Primary outcomes
Spiritual care competency areas (12-ksa)
Knowledge 6.08 1.70 7.96 1.14 5.39 1.67 5.66 1.64 F (1, 142) = 28.95*** 0.17
Skills 6.23 1.57 7.56 1.33 5.56 1.69 5.84 1.57 F (1, 142) = 15.53*** 0.10
Attitudes 7.77 1.34 8.84 1.01 6.88 1.98 7.02 1.74 F (1, 142) = 11.13*** 0.07
Spiritual care competency facets (SCCQ)
Perceptual competence 3.09 0.49 3.26 0.41 2.81 0.59 2.79 0.59 F (1, 143) = 3.61 0.03
Team-spirit 1.75 0.63 2.09 0.70 1.56 0.58 1.66 0.60 F (1, 142) = 4.38* 0.03
Documentation competence 1.40 0.62 2.84 0.85 1.22 0.40 1.37 0.46 F (1, 143) = 87.45*** 0.38
Self-awareness and proactive opening 2.71 0.61 2.93 0.53 2.18 0.67 2.24 0.63 F (1, 141) = 3.29 0.02
Knowledge about other religions 2.79 0.55 3.05 0.61 2.80 0.70 2.60 0.58 F (1, 140) = 17.46*** 0.11
Competence in conversation technique 3.45 0.60 3.53 0.47 3.27 0.62 3.22 0.61 F (1, 140) = 1.71 0.01
Proactive empowerment competence 2.75 0.67 3.03 0.58 2.27 0.79 2.30 0.72 F (1, 141) = 3.46 0.02
Secondary outcomes
Spirituality-based component: Spiritual sensitivity (SSS)
Awareness sensing 3.90 0.85 4.04 0.72 3.75 0.75 3.66 0.80 F (1, 142) = 6.27* 0.04
Mystery sensing 4.06 0.57 4.12 0.61 3.79 0.59 3.75 0.65 F (1, 142) = 1.10 0.01
Value sensing 4.40 0.67 3.75 0.65 3.76 0.88 3.76 0.77 F (1, 141) = 3.26 0.02
Community sensing 3.94 0.84 3.85 0.84 3.34 0.90 3.39 0.94 F (1, 141) = 1.30 0.01
Care-based component: Empathy (SPF) 3.79 0.36 3.80 0.39 3.67 0.38 3.67 0.44 F (1, 143) = 0.03 0.00
Competence-based component: General self-efficacy (GSES) 2.88 0.45 3.00 0.39 2.90 0.44 2.91 0.37 F (1, 143) = 5.71* 0.04

Reliability of scales.

Measures Pre-test (Cronbach's α) Post-test (Cronbach's α)
IG CG IG CG
Spiritual care competency areas (12-ksa) .63 – .68 .57 – .75 .60 – .71 .57 – .72
Spiritual care competency facets (SCCQ) .45 – .93 .46 – .78 .55 – .93 .31 – .79
Spiritual sensitivity (SSS) .42 – .74 .30 – .72 .56 – .77 .50 – .72
Empathy (SPF) .60 – .81 .59 – .77 .59 – .80 .70 – .79
General self-efficacy (GSES) .88 .88 .87 .86

Description of study population.

Variables IG, n = 78 CG, n = 67 p
Age in years, mean (SD; range) 26.6 (8.2; 19–56) 25.0 (6.9; 19–52) .90 (t = .90) 2
Nationality*: German, % 92% 96% .54 (χ2 = 1,24)1
Gender*: female, n (%) 63 (81%) 50 (75%) .13 (χ2 = 4.04) 1
Marital status*, % .85 (χ2 = 1.38) 1
single 68% 69%
married 16% 15%
Study subject*, n (%) .00 (χ2 = 66.67) 1
medicine 12 (15%)
nursing science 5 (6%)
theology/religious education 14 (18%)
healthcare sciences 6 (8%)
social work 31 (39%) 67 (100%)
others (psychology, philosophy/medical ethics) 6 (8%)
Semesters studied, mean (SD) 5.5 (2.7) 4.7 (2.0) 1.82 (t = .07)2
Previous vocational trainingIn healthcare sector, % 31% 27% .32 (χ2 = 2.27) 1
Self-assessed religiosity/spirituality (1 = not at all, 6 = completely true), mean (SD)
spiritual 4.6 (1.3) 3.7 (1.3) .00 (t = 4.35)2
religious 4.2 (1.4) 3.4 (1.4) .00 (t = 3.10)2
Religious preference, % .25 (χ2 = 6.67) 1
Catholic 64% 48%
Protestant 15% 28%
Muslim 3% 2%
other 3% 3%
none 12% 18%
Familiarity with spiritual care, % 27% 7% .00 (χ2 = 9.38) 1

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