A Multidisciplinary Training Program for Spiritual Care in Palliative Care Settings

Context and Participants

This study, conducted at the Arcispedale Santa Maria Nuova Hospital in Reggio Emilia, Italy, between November 2021 and November 2022, explored a vital aspect of healthcare: spiritual care within palliative settings. This 900-bed research hospital, recognized as a Comprehensive Cancer Centre by the Organization of European Cancer Institutes (OECI), served as the location for this important investigation. The hospital’s Palliative Care Unit (PCU), while not possessing inpatient beds, plays a crucial role in delivering specialized hospital-based palliative care services. Its mission encompasses clinical practice, education, and research in palliative care, offering expert consultations both within the hospital and in its outpatient clinic, primarily catering to oncology patients and their families.

Established in 2013, the PCU is staffed by a dedicated multidisciplinary team. Currently, this includes three experienced physicians and three advanced practice nurses. Recognizing the holistic needs of patients, the PCU also collaborates closely with five psychologists from the hospital’s Psycho-Oncology Unit. These psychologists contribute through clinical consultations and are integral to the training of PCU staff, alongside their involvement in palliative care research and education. Furthermore, the hospital’s Bioethics Unit (BU), comprising two bioethicists, is involved. The BU’s focus is on enhancing the quality of care for patients, their families, and healthcare professionals through research initiatives, educational programs, and ethical consultation services.

All professionals from the PCU, Psycho-Oncology Unit, and BU were invited to participate in this study focusing on spiritual care. Importantly, all approached professionals agreed to participate, highlighting the commitment to advancing spiritual care within this multidisciplinary healthcare environment.

Methods: Developing and Implementing a Spiritual Care Training Program

This research adopted a Phase 0-I study design, guided by the Medical Research Council (MRC) framework for complex interventions. The program’s development was informed by a recognized gap in existing literature concerning spiritual care training for hospital-based specialists in palliative care in Italy. Acknowledging the limitations, this study aimed to create and assess a multidisciplinary training program for spiritual care in palliative care.

Due to COVID-related restrictions, the spiritual care professionals (SCPs) delivered the training online, while the healthcare professionals (HPs) participated in person. This blended approach allowed for flexibility and safety while maintaining interactive engagement.

Program Layout: A Step-by-Step Approach to Spiritual Care Education

The training program was structured in a phased manner, incorporating theoretical knowledge, personal reflection, and practical application:

1. Initial Theory and Interactive Session (4 hours): This introductory session combined a theory-based lecture with interactive components. Healthcare professionals were physically present in the classroom, while spiritual assistants joined online. The primary goal was to introduce the concept of spirituality, specifically within the context of a clinical setting. The teaching approach was deliberately mixed, incorporating both lecture-style delivery for foundational knowledge and group work to encourage engagement and shared learning.

2. Paired Meetings Between SCPs and HPs: The core of the training involved a series of meetings designed to foster personal and professional growth in spiritual care. Each pair of healthcare professionals participated in three structured meetings with the SCPs, followed by two individual follow-up meetings at 3 and 6 months post-training initiation.

   • Meeting 1: Defining Personal Spirituality (45 minutes): The first meeting, conducted with HPs in the classroom and SCPs online, centered on personal reflection. Participants were prompted to explore and articulate their own understanding and experience of spirituality. As a warm-up activity, each pair of HPs shared “what spirituality means to me.” Guiding questions, inspired by Christina Puchalski’s FICA tool, facilitated this exploration, including: “Do you feel spiritual?”, “What is the importance of spirituality in your life?”, and “What importance does it hold for you in terms of community?”.

   • Meeting 2: Exploring the Development of Spirituality (30 minutes): The second paired meeting, again with HPs present and SCPs online, focused on the developmental aspects of spirituality. Participants were encouraged to reflect on factors that have contributed to the evolution of their spiritual perspectives. Questions included: “What form did your spirituality take as a child/teenager?”, “Is there anything from that time that has not occupied time and space in your life since then?”, and “Thinking about significant people in your life, what comes to mind concerning spirituality?”.

   • Meeting 3: Maintaining and Growing Spirituality (30 minutes): The third meeting in the pair series, with the same online/in-person setup, shifted the focus to practical strategies for nurturing ongoing spiritual growth. SCPs posed questions such as: “How do you intend to take care of your spirituality from now on?” and “What feels empty and what feels full in your spiritual life?”.

   • Follow-up Meetings (Online): Two online follow-up meetings were conducted with HPs in the classroom and SCPs online to reinforce learning and encourage continued reflection. These sessions incorporated guided meditation and provided a space for open discussion about the preceding meetings. The first follow-up specifically focused on participants’ personal spirituality, while the second addressed interpersonal spirituality, particularly in interactions with patients and colleagues.

Fig. 1 The training program

A visual representation of the multidisciplinary training program for spiritual care, outlining the structured approach and components designed to enhance healthcare professionals’ skills in palliative care settings.

The educational model employed by the SCPs drew upon established guidelines and recognized core curricula in spiritual care (including resources from the AAMC and Advancing Expert Care), integrated with an emphasis on personal self-reflection and spiritual growth. This comprehensive approach aimed to provide a robust and well-rounded training experience.

To further enhance the learning environment, all training activities were intentionally conducted outside the participants’ usual workplace. Throughout the sessions, an atmosphere of silence and reflection was encouraged, with background music played to facilitate relaxation and personal focus. A designated music room was available for trainees before and after their meetings or reflective writing exercises, promoting a calm and contemplative space. The paired meetings with SCP instructors were facilitated via a virtual platform, maintaining the SCPs’ online presence while the training participants gathered in person.

This multidisciplinary training program for spiritual care was considered a complex intervention, necessitating thorough assessment. The evaluation strategy employed a mixed-method approach with concurrent triangulation. This involved the simultaneous collection of qualitative and quantitative data, followed by separate analyses and subsequent integration of findings during the interpretation phase. Data triangulation was specifically utilized to strengthen the validity and reliability of the study’s results.

The program evaluation followed a before-during-after design, inspired by Moore et al.’s expanded outcomes framework. Moore’s framework comprises seven progressive levels of practitioner learning outcomes. This study concentrated on Moore’s Level 3B, focusing on evaluating the impact of the training on personal performance, deemed most relevant to the program’s objectives.

The specific levels of Moore’s framework assessed were:

• Participation—Level 1: Measured by the number of healthcare professionals who participated in the training program.
• Satisfaction—Level 2: Assessed the extent to which the participants’ expectations regarding the training were met.
• Learning—Level 3A (Declarative Knowledge): Evaluated the degree of knowledge participants reported gaining from the training.
• Learning—Level 3B (Procedural Knowledge): Examined the degree to which participants demonstrated an understanding of knowing how to do spiritual care practices.

Information regarding the achievement of program objectives was collected for each training component. Semi-structured interviews at the T1 time point were conducted to gather detailed feedback on the individual components of the training program (as detailed in Table 1). Program feasibility was defined by two key criteria: (a) the appropriate identification of active components within the training course, and (b) the successful completion of the program as planned across the three hospital units and by all participating professionals.

Table 1 Feasibility table; evaluation of training components

Full size table

A detailed table outlining the components of the multidisciplinary spiritual care training program and their respective feasibility evaluations, providing insights into the practical implementation of the program.

Data Collection and Analysis: Gathering Insights into Program Effectiveness

Longitudinal qualitative interviews were the primary method for assessing participant satisfaction and knowledge acquisition. These were complemented by reflective journals maintained by participants throughout the training program.

A total of thirty-six interviews were conducted, and thirty-five reflective journals were produced and analyzed, providing a rich dataset for evaluation. The research team included both male and female researchers. The median interview duration was 58 minutes, with a range from 21 to 92 minutes, indicating varied depths of engagement and discussion.

A convenience sample, encompassing all healthcare professionals from the three participating units, was utilized, and notably, no one declined to participate, demonstrating strong engagement with the multidisciplinary training program for spiritual care.

Participants were interviewed at three time points: before the training commenced (T0), and then three months (T1) and six months (T2) after the training began. The initial interviews (T0) aimed to understand participants’ perceived training needs in spirituality to tailor the program effectively. Subsequent interviews at T1 and T2 included questions about the training experience, suggestions for program adjustments, participant perspectives, and recommendations for future program redesign.

A pre-planned, simple interview guide was used for T0 interviews. While not pilot-tested, this guide, along with topics identified from T0 interviews, informed the structure of subsequent interview guides (T1 and T2) to ensure consistency and track changes over time. All interviews were audio-recorded and transcribed verbatim for detailed analysis.

A meeting was organized at the participants’ request to share feedback with the SCPs and validate the preliminary findings, ensuring participant involvement in the research process. The final dataset comprised interview transcripts, reflective journals, and participant validation of results.

Data collection took place in the workplace, with only the participant and researcher present to maintain confidentiality and minimize distractions. No field notes were taken during interviews.

Interview data from each time point were analyzed using an inductive approach, employing the framework method (FM). This method was chosen for its suitability in allowing themes to emerge organically from the data and facilitating inter-coder agreement. Researchers immersed themselves in the data through familiarization to gain a deep understanding of the content. Initial codes were developed by systematically labeling data segments relevant to the research question. These codes were then grouped into categories or themes, creating a working framework – a matrix with cases/participants as rows and themes/codes as columns.

Three researchers (ST, EB, and SS) independently analyzed transcripts, repeatedly reading texts, labeling segments with codes, and grouping codes into themes and macro-themes. Disagreements were discussed to reach a consensus on data allocation, with supervision provided by LG throughout the process. Data saturation was also discussed among researchers.

This refined framework method was then applied to the remaining interviews. The FM application considered how meanings evolved across T0, T1, and T2 within macro-themes, providing a longitudinal perspective. This highlighted recurrent and evolving themes and identified shifts in meanings or perspectives over time. No specialized software was used for data management during the analysis process.

Furthermore, GLB analyzed the reflective journals for each participant using the FM, allowing for data triangulation and consolidation of findings across different data sources.

Rigor and Reflexivity: Ensuring Research Quality and Transparency

To ensure rigor and reflexivity, several measures were implemented. GA, one of the interviewers, had no prior contact with participants, minimizing potential bias. Two palliative care physicians (ST, SS) and a palliative care nurse (EB), all trainees themselves, analyzed the interviews. While they had contact with colleagues from the bioethics and psycho-oncology units in their daily work, their involvement as analysts brought valuable clinical perspective. Their experience in conducting and analyzing training programs in palliative care, a core function of the palliative care unit, further strengthened the analytical process.

The researchers acknowledged their strong belief in the importance of the spiritual dimension in care and high motivation for the training program, recognizing the potential for positive interpretation bias. To mitigate this, three external researchers (LG, AG, GLB) were involved to ensure methodological rigor. GLB, with an anthropology background, and LG, an expert in qualitative research and head of the Qualitative Research Unit, provided external expertise and had no prior contact with trainees, enhancing objectivity. The researchers also noted that good relationships with participating colleagues facilitated the research process.