Improving training in spiritual care: a qualitative study

exploring patient perceptions of professional

educational requirements
SJ Yardley North Western Deanery, Manchester, CE Walshe The School of Nursing, Midwifery and Social
Work, The University of Manchester, Manchester and A Parr St. Catherines Hospice, Preston
Healthcare professionals express difficulties in delivering spiritual care, despite it
being a core component of palliative care national policies. The patient perspective
on professional training to address difficulties has not previously been sought. The
aim of this study is to describe patient suggestions for development of training to
deliver spiritual care. Qualitative semi-structured in-depth palliative patient inter-
views (n = 20) were analysed thematically. Training suggestions encompassed practi-
cal care delivery. Patients supported staff who introduced questions about spiritual
needs, and they expected opportunities to engage in spiritual care discussions. The
right attitude for spiritual care delivery was defined as being non-judgemental, pro-
viding integrated care and showing interest in individuals. Training issues included
patient perspectives of boundaries between personal and professional roles. This
study provides palliative patient perspectives to strengthen recommended models
of spiritual care delivery. It shows that user opinions on training can be helpful not
only in deciding objectives but also how to achieve them.
Key words: continuing education; delivery of health care; needs assessment; palliative care;
qualitative; spirituality
Introduction
Spiritual care is integral to palliative care,
1
and meeting
spiritual needs appears to improve the ability to cope
with ill health.
26
Although spirituality, spiritual care
and spiritual needs have been difficult to define, key ele-
ments are likely to include exploring a sense of meaning
and purpose in life.
3,7,8
Despite the recognised importance to patients,
911
there are difficulties encountered in delivering optimal
spiritual care: first, uncertainty about who should deliver
spiritual care
3
; second, lack of confidence and competence
in delivering spiritual care in palliative settings
12
and
third, difficulty identifying specific spiritual needs.
13,14
National Institute of Clinical Excellence (NICE) guidance
on spirituality is clear that spiritual care is the responsibil-
ity of all health professionals, although some patients may
have specialised needs.
12
Increased education to enhance
spiritual care delivery
15,16
is called for in healthcare
training.
17
The NICE guidelines for supportive and palli-
ative care incorporate Marie Curies competency levels
for spiritual care.
12,16
The competencies cover all health-
care professionals in contact with patients who have palli-
ative care needs. There are four levels of expertise defined,
and each associated with competencies for knowledge,
skills and actions (see Box 1). Specialised groups such as
the clergy are working at level 4, which includes the edu-
cation and training of others in spiritual care. The Marie
Curie competency levels were developed by the consensus
because there have been fewempirical works in the United
Kingdomon who should deliver spiritual care and at what
level within specialist palliative care settings. There is a
need for practical interventions to emerge from described
theories of spirituality,
18
as some research relates to prac-
tical evidence-based training in spiritual care provision.
3
It may be that a critical step in developing spiritual
interventions that both meet patient needs and are deliv-
erable within palliative care is to involve patients in spiri-
tual care education and training. Increasingly, there are
policy drives for service users to be more involved in
research and service development particularly when
needs are difficult to define.
20,21
Research is needed to determine the best ways of iden-
tifying spiritual needs and providing support to patients in
different settings and at different stages of disease.
2224
Smith and Gordon
23
have highlighted the dangers of a
Current address: SJ Yardley, Medical Education, Keele Medical
School, Keele University, Staffordshire, UK.
Current address: A Parr, St Catherines Hospice, Lostock Lane,
Lostock Hall, Preston, Lancashire, UK.
Correspondence to: SJ Yardley, Medical Education, Keele
Medical School, Keele University, Staffordshire, ST5 5BG, UK.
Email: syardley@doctors.org.uk
2009 SAGE Publications, Los Angeles, London, New Delhi and Singapore 10.1177/0269216309105726
Palliative Medicine 2009; 23: 601607
culture of specialisation of spiritual care, which could
lead to deskilling of multidisciplinary teams. The theory
behind our study was that gaining the perspective of
patients could be used to facilitate professional
development.
2527
The key message of this study is to
report hospice patients views on how hospice staff (in
any role or capacity) should be trained to deliver good
spiritual care. It has been previously established that
patients agree with the principle of spiritual care being
available to those who want it.
8
Methods
Methodological approach
This is a qualitative study of hospice patients using semi-
structured in-depth interviews with an explicit focus on
professional training for spiritual care delivery. A qualita-
tive interview approach is an appropriate method to
obtain patient perspectives.
28
One-to-one interviews were
chosen in recognition of this area often being viewed as
belonging to the personal sphere.
22,29
Objectives
The objectives of this study are to understand hospice
patient(s) perspectives on the challenges of meeting spiri-
tual needs and to describe patient suggestions for the
development of professional training to deliver spiritual
care.
Setting
This study took place within a hospice in the north of
England. The setting was chosen as it represents a key pop-
ulation targeted by guidelines
12
and end of life policies
30
for
spiritual care. During the study period, there was one
whole time equivalent chaplain post at the hospice (with
two sequential incumbents during the data collection
period). There were also several volunteers who worked
with the chaplain. However, the hospice supports the
view that spiritual care is the responsibility of all staff and
it is included in the admission pro forma.
Participants
Patients were invited to participate if receiving inpatient,
outpatient or day care at the hospice. Staff identified
patients who met the inclusion criteria (physically able
and willing to participate in an interview) and then
selected them sequentially from these lists. Additionally,
arbitrary samples of patients throughout the hospice were
invited to consider participation. The information leaflet
explicitly stated this study was about spirituality (not con-
fined to religion) but avoided offering definitions of what
this might include to avoid prejudicing patients personal
views. Patients could opt into the study by responding and
providing written consent. Exclusion criteria were a
preference not to participate at any stage, being unable
to provide informed consent or being physically unable
to participate in an interview in any format. Patients
were offered additional support if the interview raised
concerns.
Data collection
Ethical approval was obtained. A topic guide (Box 2) was
prepared for each interview, reflecting iterative changes
from previous interviews. All interviews were conducted
in private rooms. Interviews were semi-structured, allow-
ing patients flexibility to determine content and direction.
Interviews (30105 min) were recorded and fully tran-
scribed, supported by detailed field notes. Data were col-
lected over 3 months in 2007 by one author (SY) who is a
doctor training in palliative medicine.
31
Three patients
had communication difficulties necessitating the use of
Box 1 Overarching components of the Marie Curie
model
15
1. Competency development according to depth of
patient contact (see levels below)
2. Guide to achieving competency objectives
3. Suggested tools: training and education, case-based
and personal development reviews and (self) assess-
ment documents
4. Suggested items for competency portfolio
5. Examples of audit tools for organisations
6. Pilot study
19
describes delivery of the model
through seminar training sessions with positive
outcomes and improvements
Level 1
All staff and volunteers who have casual contact with
patients and their families
Level 2
Staff and volunteers whose duties require contact with
patients and their families/carers
Level 3
Staff and volunteers who are members of the multidis-
ciplinary team
Level 4
Staff or volunteers whose primary responsibility is for
the spiritual and religious care of patients, visitors and
staff
SJ Yardley et al. 602
alternative materials in addition to audio recording
interviews.
Data analysis
The transcribed interviews, with accompanying field notes,
were entered into NVivo 7(QSR International, Doncas-
ter, Victoria, Australia).
32
Following familiarisation with
initial data, a thematic coding scheme was developed and
constantly amended until data saturation occurred. Text
was read as a whole and reread code by code before devel-
oping themes. Similarities and differences across subgroups
were looked for in the data.
29,33
Techniques to enhance rigour included independent
analysis of data by CWand use of data extracts to support
developing themes.
3335
Patients were given the opportu-
nity to provide feedback on the emerging results. Atten-
tion was paid during the data collection and analysis
phases of the study to the fact that interviews are socially
constructed encounters.
31,36
Results
Participation and feedback
A total of 41 patients were invited to take part in this
study by hospice staff. Twelve declined participation for
no reason or being uninterested. One patient declined
as he or she was given the information on the day he or she
was being discharged from the hospice. Four patients lost
the capacity to consent and conduct an interview, and
another four became otherwise too physically unwell to
participate after accepting information about the study.
The remaining 20 patients participated, constituting
13.8% of the hospice patient population (n = 145) during
the study period.
Two interviews were transcribed by SY; the others
were done by a professional transcriber and then checked
by SY. Eight of the interviewed patients died after their
interview but before study completion. Fourteen patients
requested the opportunity to provide feedback on emerg-
ing results. Ten patients returned comments, all of which
supported the emerging analysis. Details of all patients
characteristics are summarised in Table 1. This sample is
consistent with the hospice population during the recruit-
ment period and hospice demography within England.
37
Findings
This article focuses on suggestions generated for training
to deliver spiritual care. Patients were clear that spiritual
care should be integral to hospice services. Their defini-
tions of spirituality focused around meaning and purpose
in life, and answers to questions regarding spiritual care
were often referenced to feelings:
I think it would be good if you could always get to talk to
someone when you are feeling really down or not well
even if they only talk to you to put your mind at rest
(I2 discussing how spiritual care should be available)
Patients thought it is better to have opportunities to refuse
care than not to be offered it. Training suggestions emerg-
ing from the analysis divide into four interrelated themes
of knowledge, attitudes, skills and actions.
Knowledge about barriers and facilitators of spiritual care
Patients described barriers to spiritual care delivery relat-
ing to reluctance to engage in spiritual talk and the need
for it to be provided outside explicit religious roles:
spirituality in general I think people dont readily talk
about it, I think it is something they wonder about it,
private butthat they dont easily voice, maybe
becauseit is quite an emotional subject
(I18)
I just dont believe that someone who is actually try-
ing to offer a spiritual comfort to dying patients should
be clergy, they can be but I dont think it is necessary
for them to be at that level
(I15)
Box 2 Interview themes
1. Understanding of spirituality
2. Difficulties in discussing spirituality
3. Experience of spiritual need
4. Definition and remit of spiritual care
5. Barriers and facilitators
6. Expectations
7. Suggestions for training
8. Interaction between spirituality and illness
9. Sample questions about spiritual needs
Table 1 Participant demographic data
Characteristic Study patients (n = 20)
Gender 13 female, 7 male
Diagnosis 15 malignant disease,
5 non-malignant disease
Ethnicity 20 Caucasian
Age range 3486 years
Religious background 10 no declared religion, 7 Christian,
3 non-religious but clearly
defined belief systems
Care setting 6 inpatient, 6 outpatient, 8 day care
Best predicted prognosis
(by patients
consultant)
Range from days to years with
11 patients expected to live
some months, 5 less than that
and 4 more
Improving training in spiritual care 603
There was an expectation that any healthcare professionals
could deal with initial care to meet spiritual needs alongside
a recognition that those with more experience or training
were needed to support both their colleagues and patients.
Ageneral knowledge of differing world views was desirable
amongst professionals, but these patients were looking for
professionals with whomthey could personally identify and
open up to rather than expertise.
Attitudes towards spiritual care
Patients were clear that attitudes were the most important
area for training. They felt able to establish who was will-
ing to identify with them without falseness and who took
an interest in them as a person:
I think you can have someone who is caring and
good at their job and you can have people who are
good at their job but not as caring
(I6)
Training was thought necessary to teach people to elicit,
recognise and meet individual needs:
he [staff member] validated what I was thinking, he
didnt make any judgmentsand at my pace we were
allowed to explore that in a little bit more detail and
I have a good enough relationshipto feel I could
discuss it again with him
(I1)
No participant felt they would mind being asked ques-
tions about spirituality, and several thought it would be
a positive step if done with a caring and professional
attitude:
someone could chat with you and ask you those ques-
tions in an informal way to get the background really
I would want to know more about what they were
searching for but I wouldnt mind answering any ques-
tions like that
(I11)
Several patients expressed an interest in knowing what
professionals thought about spiritual issues and described
circumstances in which this was acceptable:
If I was sitting talking to a member of staffthen I
wouldnt mind in the slightest if they were giving their
own opinions of things because we are not talking
preaching we are talking about something we are
both interested in
(I14)
It seems fromthis data the right attitude that patients are
looking for is one of caring, interest in the individual, will-
ingness for staff to share of themselves and engagement
with the patient that is non-judgmental, on an equal
basis and unhurried.
Skills in meeting spiritual needs
Patients wanted to share in care planning and delivery and
thought that they should have control over the prioritisa-
tion of care issues, spiritual or otherwise:
everybody has different needs recognising the core of
that students needs which is a similar thing to being
patient centred isnt itthat is what I would be looking at
(I12, a teacher)
They valued professionals who were comfortable with
uncertainty and who built relationships where concerns
could be addressed sensitively:
I think that [staff developing skills via training] is very
importantits a huge step. I guess it would be okay to
turn around and say do you know I have often thought
about that myself and I dont have an answer, but if
you talk to this member of staff she might be able to
help you a little bit more than I
(I13)
Professionals should practice asking questions about spir-
itual care to find natural ways of engaging with patients:
what kind of training, well first of all a new patient
comes in and you get to know the patientFirst of
all you would have to ask, you wouldnt impose it on
themyou would ask them first
(I20)
and show active listening and empathy:
all you can do is train somebody to recognise the individ-
ual, that they have needs whether they are nine or ninety
they need to be listened to and they need to be valued
(I12)
It was seen as legitimate for professionals to facilitate con-
versations and to offer spiritual care in a way that implied
no obligation but gave opportunity to patients who did
not feel confident to raise the issue:
I think its attitude, and if they approach you rather
than you approaching them, you can do if you want
to but what I have noticed is they make sure that they
SJ Yardley et al. 604
come round and speak to you individuallyif you
dont want to that is fine as well
(I6)
The skills required to do this reflect those of communica-
tion in general a respect for others and developing a way
to interact sensitively with individual patients.
38
Actions for assessment and practical delivery of
spiritual care
Training programmes for spiritual care need to address
the hurdle of moving from theory to practice. At the
time of this study, there was no formal spiritual care train-
ing programme per se in the hospice, although this topic
was included on the in-service training topic list. Partici-
pants did not specify who should deliver training beyond
suggesting that more experienced professionals should
mentor newer members of staff:
I suppose as a team everybody must meet together and
talk about these issues
(I13)
Some suggested that real patients could be used in train-
ing to provide feedback and that staff might draw on their
previous interactions with patients to make suggestions or
prompt thought around issues with current patients.
I also think in terms of training that its useful some-
times to have real patients and I think it is really impor-
tant that people, staff are open and listening to criticism
constructively
(I1)
In regard to sample questions (to initiate spiritual care
discussions) that were shown to patients, they felt that
three might be particularly useful:

What principles do you live by?

Do you have a personal faith?

Have you ever prayed about your situation?

Surprisingly, these were not interpreted as being confined
to religious needs. Actions which patients felt would
facilitate conversations are those used in communication
skills training: considering atmosphere and environment,
explaining motivation, asking questions naturally and
giving permission to patients to share without risking
judgement.
3840
Participants were also keen to learn
from others experiences and felt these could be a source
of ideas which they could evaluate the usefulness of for
themselves.
Discussion
Individualised patient choice is current policy
21,30
as is
spiritual care regardless of diagnosis or prognosis.
41
The
patients in this study affirmed that meeting spiritual need
was integral to palliative care, regardless of diagnosis and
extent of hospice involvement. Spiritual need is also
recognised but unmet in other healthcare settings.
19
Evi-
dence
42
suggests recognition of professional uncertainty
regarding spiritual care has not lead to changes in train-
ing. Current guidelines recommend using the Marie Curie
model of reflective practice and competency frameworks
to train healthcare professionals in spiritual care
(Box 1).
12,43
The uptake of this model is unknown, and
training is not currently standardised.
This study provides patient validation to support
increased use of the Marie Curie model and can contrib-
ute to training development by providing evidence of
patient expectations, and it addresses identified difficulties
in delivering optimal spiritual care. The patient perspec-
tive on uncertainty about who should deliver spiritual care
is that it is a legitimate activity for all healthcare
professionals.
Professionals working at higher levels of competency
within the Marie Curie model should act as a resource
for knowledge, support, training and education for
healthcare; interpersonal and communication skills; spiri-
tual and religious care.
16
Some patients in this study sug-
gested they would also be interested in participating in
training professionals.
Questions of confidence and competence can be
addressed by incorporation of this studys findings into
reflective experience-based training. The expectation that
training should be given by those whose primary respon-
sibility is for the spiritual care of patients, visitors and
staff has been traditionally accepted in practice although
there is a lack of evidence to support this. Questions
remain about competencies and qualifications to deliver
spiritual care training which are similar to the longstand-
ing debate in spiritual care delivery.
13
This later question
has been partly set aside in practice by the requirement to
follow the NICE guidance and work within the Marie
Curie competencies. Marie Curie has piloted training
models
23,43
in 2004 and 2009 both of which were delivered
by level 4 professional, in the latter case alongside a prac-
tice educator. The evaluation of these pilots shows a pos-
itive response to the training as a whole.
These patients felt that identifying specific spiritual
needs could be facilitated simply by professionals raising
the subject, asking questions as outlined above and engag-
ing in individual discussions over time. Patients did not
want spiritual assessment to be a tick box exercise but
flexible, allowing them to set the pace and agenda of con-
versations. This is a challenge to professionals, as the use
Improving training in spiritual care 605
of national assessment tools
4345
may only superficially
meet what patients really expect. The importance placed
on time and relationships provides patient perspectives on
the value of knowing the patient,
46
the ability to under-
stand an individual and the ability to select appropriate
interventions for them.
4648
A change in training that
might facilitate this is involving volunteer patients to dis-
cuss and practise spiritual care assessment and delivery
before developing skills as part of everyday practice. The
patients in this study supported staff introducing ques-
tions about spiritual needs into conversation, which they
could choose to answer or not. These results show that
patients want to engage in two-way relationships and nei-
ther expect nor think it appropriate for healthcare profes-
sionals to consider themselves expert before attempting
spiritual care. Religion was considered independent of
spiritual need; not only those without religious affiliation
did express spiritual needs but also those with recognisa-
ble religious beliefs drew distinctions between ritual reli-
gious needs and spiritual needs. This has not been clearly
documented before.
Training should include practice to develop coherent
ways of explaining why questions are asked to avoid con-
cerns about a hidden agenda. Professionals must be aware
of boundaries they set between personal and professional
roles and to consider whose benefit these are for and
whether the boundaries are necessary. The findings of this
data have been shared informally with professionals by
delivering educational sessions based on questions recom-
mended by patients to open conversations regarding spiri-
tual care, identified barriers and facilitators and sugges-
tions for professional development. The work has been
well received with positive engagement and feedback.
Strengths and weaknesses of this study
This study sought user ideas to advance spiritual care
training. As one researcher was based within the hospice,
the data collection process was flexible, which contributed
to uptake. A weakness of this study is that patients
were from a limited demographic background. Although
reflecting the hospice population from which recruitment
occurred, this limits transferability of findings into differ-
ent settings without further work.
Conclusions
Spiritual care is important to hospice patients. Healthcare
professionals should be competent in spiritual care deliv-
ery via an individualised two-way process. Attitude and
willingness to engage are more important than the right
words. Training should incorporate the sharing of patient
perspectives to support learning through experience and
reflection. Consideration of spiritual questions deemed
useful by these patients, alongside their perspectives on
professional boundaries and expertise, could improve pro-
fessional engagement in spiritual care delivery. Delivery
of training with formal evaluation is required to further
assess the practical application of these recommendations
to palliative care practice. This study has potential to
inform the development of standards for organisational
audit of spiritual care provision, but further research is
required to address the question of who should be training
the providers of spiritual care education and training
themselves.
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