Principal findings
The McSCTP-HPCT was developed to allow HPCT members to maximize the patient’s spiritual resources. It addressed itself to human spirituality rather than religious aspects [20–22]. The theoretical background was rooted in the spiritual care model presented by ISPEC’s guidelines and the logotherapy approach which is a meaning-centered approach rather than a pathos-centered approach [20, 21]. In previous studies, meaning in life was reported as a stable intrapersonal resource that can be used to maintain the spiritual well-being of patients with chronic or life-threatening illness [36, 37]. The main characteristics of McSCTP-HPCT are as follows: First, it is linked to spiritual needs with expressions, spiritual issues, and meaning-centered interventions based on the attributes of spirituality. Second, it is designed to meet the existential needs of terminally ill patients and promote spiritual well-being. Finally, it was based on the spirituality concept presented by ISPEC and an interdisciplinary approach to spiritual assessment, implementation model, and spiritual issues. Researchers have shown that personnel who undergo spiritual care training are more likely to meet patients’ spiritual needs [38–40]. Through the spiritual care training program, the HPCTs can more effectively assist patients to find meaning in life and overcome the spiritual suffering experienced during their illness.
Development of McSCTP-HPCT
A feature of Module I was that the medical personnel’s own spirituality and compassion skills were dealt with for spiritual care. Their spirituality affects health care outcomes including QoL [18]. Compassion is a spiritual practice, a way of being, a way of service to others, and an act of love. Thus, spirituality is intrinsically linked to compassion [7, 41]. HPCT members’ compassion and SCC were assessed before providing spiritual care, and compassion training was also emphasized. In order to effectively provide spiritual care, the compassion of HPCT has been reported as an important factor [41] In addition, the self-reflection process of HPCT enabled the HPCT members to discover meaning in their own profession as a prior education for spiritual care [6]. Riahi et al. [42] also emphasized the importance of the nurses’ own professional meaning and commitment to spiritual care.
The differentiation of modules II, III, IV is the linking of spiritual needs based on the attributes of spirituality, spiritual issues, meaning-centered intervention, and objectives of intervention with evaluation using patient-reported outcomes (Supplementary 2). In addition, the implementation result was evaluated with one item (5-point scale) per initial issue, and finally, the effects of the meaning-centered spiritual care was evaluated with spiritual well-being (8 items, 5-point scale). Spiritual well-being is an important outcome criterion and is a core component of quality in oncology and palliative care [37].
For the composition of the main contents of meaning-centered intervention, systematic reviews, meta-analyses, and clinical trial literature published in the last five years were analyzed [8, 10, 12–13, 23–25, 42]. The common purpose of MCI identified through analysis was to improve spiritual well-being by finding meaning in life even in painful situations including incurable diseases. The major contents of intervention were confirmed to be the essential characteristics of human existence (meaning of life, will to meaning, freedom of will, choice and responsibility, self-transcendence), and how to find meaning (creativity, experience, attitude). Based on previous studies, the McSCTP-HPCT was composed to help patients find the meaning of life through their own strengths, creativity, positive experiences, and attitude modification based on four main theoretical concepts (finding meaning, attitudinal modification, awareness of responsibility, self-transcendence) proposed in logotherapy
Most previous studies which applied MCI to patients with an advanced or terminal illness or in an unavoidable suffering situation were designed as group interventions, with eight sessions lasting 90–120 minutes per session with lectures, discussion, reading and self-reflection as individual tasks [23–25] Two studies, which applied MCI to improve job satisfaction and QoL among palliative care nurses [12–13], were designed with four sessions of group intervention, lasting 120180 minutes per session. The teaching methods were didactic presentations, discussions, experiential exercises, and home exercises, similar to those of McSCTP-HPCT in this study. The educational methods of these previous studies were planned around five sessions, 240 minutes per session, and group intervention.
In Module V, the overall implementation process of meaning-centered care by HPCTs was presented. Puchalski et al. [18] pointed out the importance of spiritual care in palliative care settings and provided clarification about who should provide spiritual care and the role of health care team providers in spiritual caring. To date, although the importance of spiritual care was emphasized by some researchers, spiritual care was not provided systematically especially for the patients with life threatening conditions because of the insufficient preparedness of the HPCT [7]. The spiritual assessment, the third stage of spiritual assessment presented by ISPEC, included a question that could confirm the spiritual resources of patients (Supplementary 1) [29]. These are questions that can lead to spiritual resources shown in the Medicine Chest, one of the logotherapy counseling techniques [29]. Therefore, HPCTs must pay attention to and care for their patients’ spirituality carefully. Part of their role is to safeguard patients’ spirituality. Accordingly, they are able to help patients cope with their terminal illness and treatment using the defiant power in spirituality [10]. Lewis et al [43] also reported that patients’ spirituality helps them make sense of their lives and feel whole, hopeful, and peaceful even in the midst of a serious illness. In addition, it also helps clinicians to conceptualize and plan subsequent treatment.
Furthermore, the 12 spiritual issues presented in the ISPEC guidelines [5] were adjusted as follows to nine issues suitable for Korean culture: meaning (“despair/hopelessness” and “lack of meaning and purpose [existential]”), interconnectedness (“anger at God or others”, “guilt/shame”, “grief/loss”, “reconciliation”, and “abandonment by God or others/isolation”), transcendence (“concerns about relationship with deity” and “conflicted or challenged belief systems”). This imply that the frameworks and contents of spiritual care training should consider variations according to cultural differences, although still following the global standard guideline [44–46].
Preliminary Evaluation
In the preliminary evaluation, three outcomes (CF, SCC, and SCT) were chosen to measure the changes in the spiritual care competencies of HPCTs. CF was tested to identify HPCTs’ own self-preparedness, SCC was used to evaluate their ability [27], and SCT was used to measure the frequencies of HPCT-provided spiritual care [33]. In Iran, a study regarding the effects of spiritual intelligence training for critical care nurses showed no significant effects on SCC until four weeks after the intervention [42]. On the other hand, in this study, in the first post-measurement, all three variables (CF, SCC, and SCT ) showed significant differences compared to the pretest scores, but in the measurements after four weeks, only SCC was maintained significantly. The reason that the maintenance effect in CF and SCT was short-lived may be speculatively attributed to the fact that it was difficult to apply the contents of McSCTP-HPCT continuously after training because only one or two people per institution participated. Therefore, we recommend that all HPCTs at the institution participate in the McSCTP-HPCT, and continuous application and evaluation should be established at the same time [42, 47].
Clinical Implications
Spiritual care education is one of the core categories of interprofessional team training in hospice/palliative care settings [18, 42–47]. We, the authors, expect that the spiritual training program will help HPCTs understand the techniques they can use to provide effective spiritual care for their patients. Therefore, McSCTP-HPCT may facilitate the development and improvement of HPCT members’ competence at providing spiritual care to diverse patients and their families with life-limiting illnesses or conditions.
In addition, we expect this study will highlight the importance of spiritual care training which can impact on spiritual well-being in patients with life-threatening illness. Considering that the purpose of spiritual care is to ease patients’ difficulties and help them to find meaning in life and to improve their spiritual well-being [8], the McSCTP-HPCT developed in this study will help patients’ understand their own sense of value, find meaning in their life, and provide them with spiritual well-being.
Limitations
The limitations of this study should be acknowledged. First, the McSCTP-HPCT is a training program to help HPCTs provide spiritual care with a focus on meeting the existential needs of patients. Communication, ethics, and religious care were not included in the educational content. Regarding communication, only the part of compassion training through reflective listening was dealt with, and the overall concept and domain of communication were not included. Second, McSCTP-HPCT was developed with a focus on the inpatient spiritual care implementation model of ISPEC, and, when considering the outpatient situation, program modification and further testing are required. Finally, a tool used to measure the CF of HPCT is necessary to verify objective validity for conceptualization. This tool should consist of themes (e.g., belief and attitudes around spirituality, knowledge, ability, and frequency about spiritual care) suggested by Harrad et al. [11] as an early sign of CF.