Article

Spiritual Care Training Provided to Healthcare Professionals: A Systematic Review

Pastoral Care and Counseling 2015, Vol. 69(1) 19–30 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1542305015572955 pcc.sagepub.com

Piret Paal Ludwig Maximilian University, Germany

Yousef Helo Ludwig Maximilian University, Germany

Eckhard Frick Ludwig Maximilian University, Germany

Abstract This systematic review was conducted to assess the outcomes of spiritual care training. It outlines the training outcomes based on participants’ oral/written feedback, course evaluation and performance assessment. Intervention was defined as any form of spiritual care training provided to healthcare professionals studying/working in an academic and/or clinical setting. An online search was conducted in MEDLINE, EMBASE, CINAHL, Web of Science, ERIC, PsycINFO, ASSIA, CSA, ATLA and CENTRAL up to Week 27 of 2013 by two independent investigators to reduce errors in inclusion. Only peer-reviewed journal articles reporting on training outcomes were included. A primary keyword-driven search found 4912 articles; 46 articles were identified as relevant for final analysis. The narrative synthesis of findings outlines the following outcomes: (1) acknowledging spirituality on an individual level, (2) success in integrating spirituality in clinical practice, (3) positive changes in communication with patients. This study examines primarily pre/post-effects within a single cohort. Due to an average study quality, the reported findings in this review are to be seen as indicators at most. Nevertheless, this review makes evident that without attending to one’the repeliefs and needs, addressing spirituality in patients will not be forthcoming. It also demonstrates that spiritual care training may help to challenge the spiritual vacuum in healthcare institutions. Keywords healthcare professionals, medical education, professional development, spiritual care training, spirituality, undergraduate education

Introduction Spiritual care is person-centered care which seeks to help people (re)discover hope, resilience and inner strength in times of illness, injury, transition and loss (Kelly, 2012). The central aim of spiritual care is “to offer a framework for healthcare professionals to connect with their patients, listen to their fears, dreams and pain; collaborate with their patients as partners in their care; and provide, through the therapeutic relationship, an opportunity for healing” (Puchalski & Romer, 2000, p. 135). Several studies have pointed out that, despite some “uncertainty and fear surrounding the boundaries between personal belief and

professional practice” (McSherry & Jamieson, 2013, p. 3170), healthcare professionals have genuine interest in providing spiritual care and building a relationship with their patients (Balboni et al., 2014; Kuczewski et al., 2014; Ross et al., 2014; Zamanzadeh et al., 2014). However, it is also known that the hidden curriculum still carries the message that a comprehensive patient care is not the domain of a healthcare professional and thus Corresponding author: Piret Paal, Professorship of Spiritual Care, Department for Palliative Medicine, University Clinic, Munich, Germany. Email: [email protected]

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spiritual care competencies “are not valued like the curing and technical imperatives” (Tait & Hodges, 2013, p. 727). In this systematic review, the notion of spirituality is approached as encompassing religious and existential domains that combine theistic and secular world-views in an individual’s belief system (La Cour & Hvidt, 2010; Breitbart, 2007). Consequently, “by virtue of being human. . . everyone is spiritual” (Burkhardt & NagaiJacobson, 2009, p. 618), meaning that once spirituality is discovered and defined at an individual level it can be activated to expand the professional scope, and thus improve the connection and collaboration between professional caretakers and their patients. Numerous writings have stressed the importance of educating healthcare professionals in screening and assessing spirituality in patients and their relatives. Suggestions on a national and international level are made for curriculum development in this important field (Kelly, 2012; Burkhardt & Nagai-Jacobson, 2009; Lucchetti et al., 2012; Puchalski et al., 2012; Paal et al., 2014; Balboni et al., 2014). Since the 1980s, when publications focusing on the meaning, definition and assessment of spirituality began to emerge in health-related literature (Sessanna et al., 2007), there has been a significant rise in spiritual care training provided to healthcare professionals (Paal et al., 2014). Nevertheless, it remains a burning topic: how, when, to whom, and to what extent should spiritual care training be provided? This systematic review aims to systematically identify, summarize and appraise the evidence on outcomes of spiritual care training in order to support the spiritual care curriculum development in an academic and clinical setting. As a meta-analysis this study does not review any single spiritual care training, but contrasts and combines the results from different studies in order to identify common challenges and advantages. Consequently, this review addresses the following research question: Which training outcomes based on participants’ feedback, course evaluation or performance assessment can be outlined?

medical care, including hospitals, healthcare centers, private practices, ambulatory services, nursing and care homes for elderly people, mental health, rehabilitation and end-of-life care facilities. Non-professional healthcare providers, such as voluntary workers, general public, families, parents and ethnic/traditional healers, were excluded. However, any training provided to a multidisciplinary team was automatically included as relevant in terms of team working and covering the grey areas in institutional practice (Kelly, 2012). The intervention was defined as any form of spiritual care training provided to healthcare professionals in an academic and/or clinical setting, excluding, however, the tertiary sector, such as community and parish-based educational services. Complementary and alternative therapy trainings were equally excluded as principally concentrating on different care competencies. Likewise, changes in work life atmosphere or any implementation of a spiritual care program without training were not included as relevant interventions. Based on previous publications it was assumed that the available data regarding spiritual care training is heterogeneous. The collaborators writing about spiritual care training programs represent different academic disciplines and administer different styles of collecting data and presenting research findings. It was anticipated that the majority of studies would not provide evidence-based outcomes involving control groups, thus we concentrated on before and after outcomes within a single cohort. As the primary outcomes of the studies, changes in participants’ awareness, advantages in knowledge, attitudes or practical skills and improvements in incorporating spirituality in clinical practice were defined as relevant training outcomes. To assess these findings the course evaluation, performance assessment, and participants’ feedback (oral comments, written responses, critical appraisals) were considered. Also, changes in clinical practice and in communication with patients were addressed.

Methods

Literature search

This systematic literature review follows the standard review procedures.

A search strategy was developed, tested and refined. The final search algorithm is presented in Figure 1. The search strategy was adapted where necessary. The selection of databases followed the guidelines for systematic reviews in medical education (Cook & West, 2012). The electronic search was conducted in MEDLINE (Medical Literature Analysis and Retrieval System Online) (1950 up to 2013, Week 27), EMBASE (Excerpta Medica Database) (1974 up to 2013, Week 27), CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1950 up to 2013, Week 27), Web of Science (1950 up to 2013, Week 27), ERIC (Education Resource Information Center) (1966 up to 2013, Week 27), PsycINFO (American Psychological Association) (1950 up

Defining the review question The PICO (population, intervention, comparison, outcome) mnemonic (Cook & West, 2012) was followed to define the research question. The inclusion criteria regarding the population were undergraduate and postgraduate healthcare professionals (nurses, social workers, art/music therapists, psychologists, physicians, residents, physical/ occupational therapists, chaplains/pastoral counsellors/spiritual directors, pharmacists, paramedics, decision-makers/ leaders) who provide their services within the field of

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1 educat$ 2 train$ 3 teach$ 4 coach$ 5 supervision$ 6 seminar$ 7 lectur$ 8 workshop$ 9 curricul$ 10 round$ 11 school$ 12 tutor$ 13 or/1-12

Key $ = Truncation function Adj2 = Adjacent terms OR/AND = Boolean search terms pt = Publication type af = All fields

Search algorithm EMBASE

AND

Spiritual$ Adj2 14 care 15 healing 16 guidance 17 therapy 18 treatment 19 supervision 20 history 21 care in medicine 22 future 23 needs 24 councel$ 25 or/15-24

Religio$ Adj2 26 care 27 healing 28 guidance 29 therapy 30 treatment 31 supervision 32 history 33 care in medicine 34 future 35 needs 36 councel$ 37 or/25-36

13 and 25: (educat$ OR train$ OR teach$ OR coach$ OR supervision$ OR seminar$ OR lecture$ OR workshop$ OR curricul$ OR round$ OR school$ OR tutor$) AND ((spiritual$ adj2 care) OR (spiritual$ adj2 healing) OR (spiritual$ adj2 needs) OR (spiritual$ adj2 guidance) OR (spiritual$ adj2 therapy) OR (spiritual$ adj2 treatment) OR (spiritual$ adj2 supervision) OR (spiritual$ adj2 history) OR (spiritual$ adj2 care in medicine) OR (spiritual$ future) OR (spiritual$ adj2 councel$)) 13 and 37: (educat$ OR train$ OR teach$ OR coach$ OR supervision$ OR seminar$ OR lecture$ OR workshop$ OR curricul$ OR round$ OR school$ OR tutor$) AND ((religio$ care) OR (religio$ healing) OR (religio$ guidance) OR (religio$ therapy) OR (religio$ treatment) OR (religio$ supervision) OR (religio$ history) OR (religio$ cace in medicine) OR (religio$ future) OR (religio$ needs) OR (religio$ councel))

Figure 1. The final search algorithm.

to 2013, Week 27), ASSIA (Applied Social Sciences Index and Abstracts) (1987 up to 2013, Week 27), CSA (Social Service Abstracts) (1979 up to 2013, Week 27), ATLA (Religion database) (1950 up to 2013, Week 27) and CENTRAL (Cochrane Central Register of Controlled Trials) (1950 up to 2013, Week 27).

Inclusion and exclusion criteria In addition to the decisions regarding the study population and social setting, the following inclusion criterion was considered: original peer-reviewed journal papers in English or German language. Other publication types, such as letters to the editors and editorials, reviews, conference abstracts, brief communications, books and theses, were excluded.

Study selection The electronic search was conducted by two independent investigators to reduce error in inclusion. At this point two articles in the German language (Elhardt et al., 2013; Wasner et al., 2008) as hand search results were added to gained data. Irrelevant articles based on title were removed independently by both reviewers, who identified the clear and unclear titles at the same time. This step was followed by discussing the unclear titles between the reviewers. Close examination of selected abstracts resulted in retrieval of 62 articles. Based on established inclusion and exclusion criteria and consensus discussions between two reviewers, 46 articles were selected for the final review (see Figure 2.).

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Data extraction A two-step data extraction process was applied to synthesize the evidence-based data for the final discussion. Firstly, available data was systematically identified and documented. Extracted data was collected in an Excel spreadsheet. Each article was assessed thoroughly in order to extract the following information: target group, number of participants, program title, format, and the availability of course details. This data was used to generate a table

12529 records identified through database searching

2 records identified through other sources

4912 records after duplicates removed

752 records screened

690 records excluded

62 full-text articles assessed for eligibility

16 articles excluded based on consensus

46 studies included in final synthesis

Figure 2. The trial flow.

containing information on the key features of single studies. Additional variables were used to indicate if any performance assessment had taken place, if any application of learned competencies in patient care had taken place and if any changes in patients’ responsiveness were reported. This information was mainly used for quantitative data pooling. In addition, the training objectives, teaching methods, evaluation techniques and outcomes were outlined. The latter variable was used for further analyses. As a second step, thematic content analysis was applied (Anderson, 2007) to extract available qualitative data from the variable ‘outcomes’. The data was analysed separately by two independent researchers, who defined the meaning units or nodes essential to disambiguate the meaning within the (con)text. The meaning units were paraphrased to accord the review question. Finally, the themes emerging from the data were discussed and categorized deductively to link premises with conclusions. This resulted in initial descriptions of the outcomes of included studies. Finally, narrative synthesis was selected as an appropriate method to systematically and critically appraise the outcomes of spiritual care training. Narrative synthesis allows description of patterns, further interrogation and exploring relationships (with)in the data. Furthermore, it allows application of theory to the findings. To increase the credibility of the synthesis, product references to original studies are provided when summarizing and explaining the findings in words (Popay et al., 2006). The step-by-step data extraction process leading to narrative synthesis is described in Figure 3.

I. Preliminary Data Extraction

II. Thematic Content Analysis

III. Narrative Synthesis

Identifying and documenting the relevant quote into a predefined variable, for example, results and outcomes

Identifying the meaning units and paraphrasing

Summarising and explaining the findings in words, adding references to original studies

The learning effects as indicated by students may be summarized using these dimensions: (i) gaining awareness, (ii) developing self-confidence with respect to aspects of spiritual care provision and (iii) developing a change-directed attitude toward spiritual care

[gaining awareness] [developing self-confidence in providing spiritual care] [change in attitude toward spiritual care] Categorisation of identified themes, for example, gaining awareness

Spiritual care trainings help to raise awareness and broaden the scope by drawing attention to caregivers’ difference making and clarifying the importance of spiritual dimension in providing care

A subcategory? A new category? Fit in more than one category?

Figure 3. The step-by-step data extraction process.

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Results

full-text articles were assessed for eligibility and 46 articles were selected for the final review (see Figure 4). Reasons for excluding 14 articles at the final stage were the following: (1) articles did not include any clearly-stated student evaluation; (2) articles tackled end-of-life or

Study appraisal The outcomes were merged in Endnote and duplicates removed prior to trial. From 4912 preliminary hits, 62

Ref. number

Author and year

Group size1

Course details pp.

Reported outcomes Course evaluation

Performance assessment

Written/Oral feedback

Applied in practise

Patient feedback

Clinical pastoral education [37]

Lucas 2001a

n.a.

138-141

+

+

+

+

-

[64]

Lucas 2001b

n.a.

6-7

-

+

-

+

+

[52]

Rodriquez 2001

****

375

+

-

+

-

-

[75]

Wilson 2004

*

95

+

-

+

-

-

[47]

Kraus 2008

n.a.

333-334

+

+

+

-

-

[77]

Bentur 2010

***

n.a.

-

-

+

+

-

Medical students / residents / physicians [62]

Musick 2003

*****

68

+

+

-

+

-

[63]

King 2004

*****

65

+

+

-

-

-

[46]

Tordes 2005

*

2734-2735

-

+

+

+

-

[72]

Barnett 2006

****

482

+

-

+

-

-

[69]

Thompson 2006

***

533

-

-

+

-

-

[61]

Grabovac 2008

****

333-334

+

-

+

-

-

[19]

Wasner 2008

*****

674

+

-

-

-

-

RCT

[50]

Attar 2010

***

179

+

+

-

+

-

[43]

Bell 2010

****

1205

+

+

+

-

-

[79]

Nicol 2012

n.a.

131-132

-

-

+

-

-

Multidisciplinary healthcare team [45]

Sierpina 2001

*****

149-153

-

-

+

-

-

[54]

Wasner 2005

****

100

+

-

-

-

-

[67]

Hall 2006

**

55

-

-

+

-

-

[68]

Price 2006

**

538

+

-

+

-

-

[40]

Smith 2009

***

90

+

+

+

-

-

[73]

Bushfield 2010

n.a.

n.a.

-

-

+

-

-

[71]

Ellman 2012

n.a.

1241-1242

+

-

+

-

-

[18]

Elhardt 2013

*****

29

+

-

-

-

-

[51]

Piotrowski 2013

*****

187-189

-

-

+

+

-

Figure 4. The overview of identified studies alienated by target group and reported outcomes.

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Pastoral Care and Counseling 69(1) Nursing Students and Registered Nurses [36]

Emmer1984

***

65-66

+

+

+

+

-

[80]

Groer 1996

n.a

276

-

+

+

-

-

[49]

Shih 1999

****

86

-

+

+

-

-

[44]

Shih 2001

***

336-337

+

+

+

+

-

[70]

Lovanio 2007

**

44-45

+

-

-

-

-

[38]

Morita 2007

*****

164

+

-

-

-

-

[76]

Robinson 2007

****

175-177

+

+

+

-

-

[58]

Leeuwen 2008

****

2775

+

+

-

-

-

[39]

Wallace 2008

*****

4

+

+

+

-

-

[74]

Taylor 2009

*****

1134-1135

+

-

+

-

-

[41]

Leeuwen 2009

****

415

+

-

+

-

-

[48]

Bay 2010

****

120

+

-

+

-

-

[42]

Lemmer 2010

**

147

-

-

+

-

-

[53]

Baldacchino 2011

*****

45

+

+

-

-

-

[55]

Jinsun 2011RCT

****

283

+

+

-

-

-

[66]

Lind 2011

****

88

+

-

-

+

-

[56]

O’Shea 2011

****

83

+

-

-

-

-

[65]

Vlasblom 2011

****

792

+

-

-

+

+

[60]

Burkhart 2012

*****

317

+

+

+

-

-

[59]

Costello 2012

****

278-279

+

-

+

-

-

****

284

+

-

+

+

-

[57] 1

RCT

Ya-Chu 2012

Group size: *100 participants.

Figure 4. Continued.

palliative care with the main focus on suffering, pain management or ethical decision-making; (3) articles did not evaluate any specific course. The first exclusion criterion was problematic in a number of articles included in the final investigation due to a vague distinction between student, instructor and investigator appraisal (Hodge & Bushfield, 2006; Beckman et al., 2007; Baldacchino, 2008; Feldstein et al., 2008). The second exclusion criterion made evident that in a palliative and end-of-life care setting spirituality is declared as an important theme, but eventually disregarded (Adriaansen et al., 2005; Wessel & Garon, 2005; Cadell et al., 2007; McGuigan, 2009; Kumar et al., 2011; Browning, 2012; Johnston, 2013; Kell et al., 2008). The third exclusion criterion was that no specific course/training was presented (Kemper et al., 2011; Price, 2013).

Study characteristics Spiritual care training was provided in multiprofessional (19%, n ¼ 9), nursing (46%, n ¼ 21), pastoral care (13%, n ¼ 6), medical professional and student (22%, n ¼ 10) settings. Overall, 26 (57%) of the studies originated from North America, 14 (30%) from Europe, five (11%) from Asian countries and one (2%) from the Middle East. The training sessions were quite equally provided to smaller study groups with less than five participants (4%, n ¼ 2), 6 to 10 participants (9%, n ¼ 4), or 11 to 30 participants (13%, n ¼ 6), medium groups from 30 to 100 participants (35%, n ¼ 16) and large groups with more than 100 trainees (24%, n ¼ 11). Seven studies (15%) did not report the number of participants. According to available data, performance assessment was conducted in

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19 (14%) cases, written evaluations or surveys in 34 (74%) and oral/written feedback in 31 (67%) cases. Twelve studies (26%) reported that the gained competencies were applied in clinical practice. Only two studies (4%) used the patient satisfaction sheets to evaluate the training outcomes.

Participants’ feedback Based on participants’ appraisal and criticism the following aspects became evident. Spiritual care training helped to raise awareness and broaden the scope by drawing attention to the importance of the spiritual dimension in providing care (Wasner et al., 2008; Emmer & Browne, 1984; Lucas, 2001; Morita et al., 2007; Wallace et al., 2008; Smith & Gordon, 2009; van Leeuwen et al., 2009; Lemmer, 2010). Accordingly, one participant argued: “To wholly heal a person, you need to look beyond the physical body” (Bell et al., 2010, p. 1206). Discussing spirituality led to recognition of individual spirituality: “It has helped me to be more comfortable with my own spirituality and therefore easier to integrate into my own practice” (Lemmer, 2010, p. 148). Above all, this meant disclosing personal value systems and spiritual needs (Shih et al., 2001), addressing own beliefs and judgement as factor in communication with patients in matters of spirituality, developing self-confidence with respect to aspects of spiritual care provision, and recognising spiritual distress in self (van Leeuwen et al., 2009; Sierpina & Boisaubin, 2001; Todres et al., 2005; Kraus, 2008; Bay et al., 2010). Explaining the demographics of spirituality and differences between religious groups led to understanding the need for sensitivity towards the diversity of beliefs of the patients and families as well as the impact and meaning of rituals (Bell et al., 2010; Sierpina & Boisaubin, 2001; Shih et al., 1999). One participant reported: “It has given me a greater appreciation of each person’s individual spirituality and how wide a spectrum that covers. Even if someone is not religious, their spirit should be tended” (Lemmer, 2010, p. 148). Another participant said: “I never thought of spirituality this way, but it makes sense. We all have a need to be in relationship with God and other. Spirituality is how that gets expressed by different people” (Lemmer, 2010, p. 148). Participants acknowledged that listening allows patients time to discuss and explore their fears, anxieties and troubles (Wallace et al., 2008; Attar et al., 2010). After the training, taking a spiritual history did not appear an impossible task anymore: “You’ve demystified the realm of the spiritual screening for me. I’m not afraid to try it now” (Piotrowski, 2013, p. 189). Regarding communication with patients, a simple “How do you cope?” question may be a powerful entry into the patient’s inner world related to illness and healing (Todres et al., 2005, p. 2735). Participants agreed

that communicating with patients and family helps them to relate more meaningfully (Todres et al., 2005). Furthermore, such training gave confidence: “I feel more comfortable being at the bedside of a patient” (Rodriguez et al., 2011, p. 376). Participants altered their coping strategies (Baldacchino, 2011) and adapted their approach: “I felt my approach was subtly different, I think it was something about me not having to have all the answers every time” (Smith & Gordon, 2009, p. 86). The participants understood that developing comprehensive patient care competencies is an ongoing process: “After watching myself on the video I realized I need to keep practicing” (Kraus, 2008, p. 334).

The measured outcomes Different validated measurement tools were used to monitor the changes in participants. Some measures, such as the FACIT-Sp (Wasner et al., 2005), Spiritual Transcendence Scale (Elhardt et al., 2013; Wasner et al., 2005), Spiritual Well-Being Scale (Burkhardt & Nagai-Jacobson, 2009; Jinsun et al., 2011) or Spiritual Perspective Scale (O’Shea et al., 2011) were used to observe changes in individual spirituality, integrity and health (Ya-Chu et al., 2012). Other studies measured the attitudes and skills of participants using the Spiritual Care Competence Scale (van Leeuwen et al., 2008; Costello et al., 2012), Spiritual Care Inventory or the Spiritual Care in Practice measures (Burkhart & Schmidt, 2012). More frequently, the rise in competencies was assessed via numerical self-assessment scales. The measured outcomes provided evidence on rise in spiritual care competencies (Emmer & Browne, 1984; van Leeuwen et al., 2008), in particular improvement in attitudes, knowledge and confidence (Elhardt et al., 2013; Wasner et al., 2008; Morita et al., 2007; van Leeuwen et al., 2008, 2009; Costello et al., 2012; Grabovac et al., 2008). Above all, the theoretical aspects became clearer (Elhardt et al., 2013). The trainees recognized explicit spiritual content (containing religious vocabulary) over implicit spiritual content (van Leeuwen et al., 2009), but demonstrated poor performance in taking spiritual history (Musick et al., 2003), which indicates a gap between confidence and actual performance skills (van Leeuwen et al., 2009). The further outcomes pointed out advantages in integrating spirituality and spiritual care in different care and assessment models. Evidence demonstrated that spiritual aspects can be successfully integrated in medical history-taking (King et al., 2004), communication (Attar et al., 2010), as well as in the care plan (Piotrowski, 2013). The data at hand showed that spiritual care training improved (short-term) spiritual health (Ya-Chu et al., 2012) and reduced work-related stress and burn-out (Wasner et al., 2005; Jinsun et al., 2011). Furthermore, participants received higher scores in spiritual well-being

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and spiritual integrity than those in the control group (Jinsun et al., 2011). Two studies examined the changes in patients (Lucas, 2001; Vlasblom et al., 2011). The results indicated that patients were more likely to take the initiative/pick up a conversation after their spirituality was addressed.

The outcomes in clinical practice The outcomes in clinical care practices demonstrated a rise in pastoral care calls (Vlasblom et al., 2011), and the emergency calls became regular calls (Lucas, 2001). Reporting spiritual distress increased and became part of planned documentation during shifts rather than occurring due to unplanned reporting (Lucas, 2001; Vlasblom et al., 2011). Further evidence demonstrated that spiritual screening tools were routinely used by all team members (Piotrowski, 2013). The training motivated (palliative) care teams to take further steps toward multidisciplinary care through the utilization of spiritual screening tool and data collection associated with spirituality (Piotrowski, 2013). The studies also reported improvements in providing multidisciplinary spiritual care (Hall et al., 2006). For example, nurses taking over pastoral care responsibilities (Lucas, 2001) understood that a patient could ask for the administration of the anointing of the sick or a sacrament (Vlasblom et al., 2011). All in all, the spiritual care training also improved the working atmosphere (Wasner et al., 2005).

Discussion This systematic review of spiritual care training outcomes revealed that the primary aim of spiritual care training was to broaden the scope of professional responsibility. This involves presenting the benefits of multidisciplinary teamwork and defining the role of different professionals. Another task was to provide information about comprehensive care planning by introducing the importance of integrating spiritual health needs into the philosophy and management of patient and family care. The review revealed that the main objectives of spiritual care training may be divided into three groups: firstly, developing trainees’ sensitivity towards their own spirituality; secondly, clarifying the role of spirituality in healthcare; and thirdly, preparing trainees for spiritual encounters. The first step in developing sensitivity towards spiritual care was to increase the awareness about personal spirituality and spiritual needs (Baldacchino, 2011; King et al., 2004; Vlasblom et al., 2011). Special retreats (Bay et al., 2010) or meditation sessions (Jinsun et al., 2011) aimed to improve participants increase the awareness about personal spirituality and spiritual needs spiritual care training may be divided into three-to-day work (Baldacchino, 2011;

Hall et al., 2006). The evidence at hand demonstrated that when professional caregivers recognize and appreciate their individual spirituality, their judgments towards attending to spirituality in patients and their families changes. Clarifying the role of spirituality in medicine and the importance of spiritual care (Lemmer, 2010; Sierpina & Boisaubin, 2001; Shih et al., 1999; Musick et al., 2003; Lucas, 2001; Price & McNeilly, 2006; Grudzen et al., 2007) meant explaining the main concepts, such as spirituality, spiritual care, spiritual well-being or spiritual distress. It also involved drawing the line between religious (Lemmer, 2010), cultural and ethical concerns and dilemmas (Ellman et al., 2012). Work with relevant definitions and clarifying the connections to peripheral themes, such as end-of-life care (Smith & Gordon, 2009; Hall et al., 2006; Grudzen et al., 2007), ethical decision-making (Todres et al., 2005; Barnett & Fortin, 2006), clinical features of imminent death (Rodriguez et al., 2011; Ellman et al., 2012), cultural correctness (Bell et al., 2010) or the facets of suffering in the dying person (Wasner et al., 2005; Hall et al., 2006) were equally essential. One aim of spiritual care training was to support healthcare professionals in perceiving adequately the spiritual needs in patients and their families (Vlasblom et al., 2011; Ellman et al., 2012) Furthermore, to help healthcare professionals recognize the cues (Burkhart Schmidt, 2012) and decide when an inclusion of religious practices, such as participation in rituals or prayer, or creativity, is needed (Lemmer, 2010; Vlasblom et al., 2011). A third group of objectives was preparing trainees for spiritual encounters or showing how to provide spiritual care (Shih et al., 2001; Sierpina & Boisaubin, 2001). This part of training aimed to encourage the exploration of patients’ and family’s needs for spiritual support (Emmer & Browne, 1984; Shih et al., 2001; Hall et al., 2006). Introducing spiritual screening tools, such as FICA (Elhardt et al., 2013; Barnett & Fortin, 2006), HOPE (King et al., 2004) or Spiritual Life Map (Thompson & MacNeil, 2006; Bushfield, 2010), was part of the process (Wallace et al., 2008; Sierpina & Boisaubin, 2001; Todres et al., 2005; Musick et al., 2003; King et al., 2004). However, it became evident that integration of spiritual assessment to record a comprehensive health history (King et al., 2004) or practicing delivering bad news incorporating spiritual assessment tools (Attar et al., 2010) may be equally significant. The findings indicated that interaction with patients and their families was one of the crucial components of spiritual care training (Attar et al., 2010; Costello et al., 2012; Taylor et al., 2009). Providing spiritual care is not only about posing the right questions, but is as much about listening (Wilson, 2004), being present and available (Lucas, 2001; Robinson, 2007) and free from stereotypes towards different cultures and religions (Todres et al., 2005). Providers of spiritual care were expected to discuss

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spiritual or theological issues (Wilson, 2004) and create empathic responses (Wasner et al., 2005; Taylor et al., 2009). Learning to initiate and end spiritual encounters meaningfully was highlighted as an imperative part of spiritual care training (Burkhart & Schmidt, 2012).

Facilitators and barriers The majority of studies reported that the spiritual care training was perceived as a positive, awakening, conscious, enlightening, and eye-opening intervention. The trainees enjoyed the holistic nature of the course (Robinson, 2007) and found that the training content dealt with real issues in a way the rest of the medical curriculum failed to do (Bell et al., 2010). The participants welcomed the opportunity to humanize medicine and medical practice. Studying in multidisciplinary groups was seen as particularly beneficial (Baldacchino, 2011; Ya-Chu et al., 2012). Undergraduate participants liked the early exposure to other professionals, which helped to eliminate power hierarchies (Hall et al., 2006). Furthermore, they appreciated the richness of having multiple perspectives and demonstrated willingness to explore professional boundaries (Hall et al., 2006). In several studies participants claimed that they gained clarity about the pastoral care role and help provided (Lucas, 2001; Vlasblom et al., 2011; Barnett & Fortin, 2006). Many of them wished for more education in spiritual care and pointed out the need for regular meetings (Shih et al., 2001; Wasner et al., 2005). Negative and hesitant resonance was mainly gained due to practical experiences. The focal critique was that the clinical environment did not support the inclusion of a spiritual dimension in an assessment and treatment of spiritual issues (Grabovac et al., 2008), and spiritual care was neglected in favor of physical care (Bushfield, 2010). Participants also sensed some degree of antagonism towards assessing spirituality during their placement in clinical settings. Hostility affected the transference of personal attitudes towards spirituality into the professional context (Bentur & Resnizky, 2010). Going into uncharted territories made it even clearer that the lack of practical application leaves many questions still unsolved: is it okay to address spirituality in practice, is it my role to assess spirituality, when do I take a spiritual history and how do I make the situation comfortable? Participants also pointed out the lack of vocabulary to discuss spiritual care comfortably (Barnett & Fortin, 2006). Therefore, individual mentoring and supervision, in particular in clinical practice, was seen as significant (Bentur & Resnizky, 2010), playing a key role in reflecting on own work and progress.

Bias reported in reviewed studies The content analysis revealed a number of limitations reported in the studies. Regarding the outcomes the

investigators noted the social desirability to please the investigator (Barnett & Fortin, 2006) and the questionnaire fatigue among the participants (Price & McNeilly 2006). Two studies pointed out the need for specific evaluation tools (van Leeuwen et al., 2008; Price & McNeilly, 2006). Further bias was reported due to the small homogeneous group as a limitation to the generalizations of the findings (Grudzen et al., 2007) and high interest in spiritual issues among the participants (Elhardt et al., 2013; Grudzen et al., 2007).

Reviewers’ comments on study quality The findings indicate that the importance of well-aimed performance assessment is disregarded. Clear statements about what are the training objectives and what is expected from participants after the training is central in order to find an accurate form for performance assessment. If participants are expected to demonstrate their sensitivity towards spiritual matters or theoretical knowledge, a written assignment, such as an essay, could be adequate. If a rise in practical skills is hoped for, the performance assessment should include practical assignments, encompassing opportunities for self-reflection and feedback. The evaluations placed high value on outcomes based on trainees’ self-assessment. Probably the most important question regarding the outcomes concerns the self-perceived rise in spiritual care competencies. Only few studies took the question further and tested whether the participants really are as competent as they perceive themselves to be. The use of validated tools was equally problematic. Measures that serve the research purpose need to meet the research criteria by being validated and suited for healthy populations (Arndt, 2012). This argument would, for example, deny using the FACIT-Sp (Wasner et al., 2005) to measure spirituality in healthcare professionals. The reviewed studies on spiritual care training seldom involved a control group (Attar et al., 2010; Jinsun et al., 2011; Ya-Chu et al., 2012). Only two articles (Lucas, 2001; Vlasblom et al., 2011) reported that the learned competencies were tested in patient care and evaluated in situ. Accordingly, the reported findings in this review are to be seen as indicators at most.

Limitations to the study This systematic review has the following limitations to report. Firstly, the review considered original papers in English or German only, excluding publication in other languages. Secondly, publications other than peer-reviewed journal articles reporting on training outcomes were excluded.

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Conclusions This systematic review complements previous literature on spiritual care training for healthcare professionals. It identifies and summarizes published research on outcomes in spiritual care training. The outcomes demonstrate effects in acknowledging spirituality on an individual level, success in integrating spirituality in clinical practice, and improvements in incorporating spirituality in communication with patients. Providing training in spiritual care to healthcare professionals is one way to integrate the aspect of spirituality in comprehensive patient care. The reviewed literature indicates that personal values, emotions, bodily and spiritual distress are some of the most common aspects that healthcare professionals perceive as barriers in integrating spirituality in daily work. Therefore, participants need time and space to assess their beliefs and the overall situation before integrating spirituality into their professional scope. At this stage the preliminary task of training is to deliver “words” that help to define individual spirituality. The findings in this review make evident that without attending to one’s own beliefs and needs, addressing spirituality in patients will not be forthcoming. This review points out the importance of hands-on training. Healthcare professionals are not explicitly trained in communication, thus, short screening and assessment tools may be helpful for the beginners. However, before entering the field, healthcare professionals have to be prepared to meet vulnerability, emotions, and rejection. It must be clear that, unlike many bodily concerns, the spiritual concerns do not have a fix. Spiritual care is much more about attending the patient by being present and listening than “delivering the message”. Implementation of spiritual care helps to challenge the hidden values of healthcare institutions. Besides personal stressors, such as lack of time and work load, problems within the team, such as mistrust and different value systems, are perceived as highly problematic. It is a common mistake to leave people alone with their newly gained ideas and changed attitudes. A successful integration process needs role models and clearly identified mentors who accompany the integration process. Their primary role is to provide feedback and help to reflect on human errors. The findings of this review indicate that in order to overcome the spiritual vacuum a spiritual care training involving the whole team may be helpful to reset the institutional agenda.

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Piret Paal is a researcher at the Ludwig Maximilian University, Munich, Germany.

Yousef Helo is a medical student at the Ludwig Maximilian University, Munich, Germany. Eckhard Frick is a professor for spiritual care at the Ludwig Maximilian University, Munich, Germany.

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