Effectiveness of spiritual care training to enhance spiritual health and spiritual care competency among oncology nurses

doi:10.21203/rs.2.16979/v1

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Effectiveness of spiritual care training to enhance spiritual health and spiritual care competency among oncology nurses

https://doi.org/10.21203/rs.2.16979/v1

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published 26 Nov, 2019

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Background: Although spiritual care is a basic element of holistic nursing, nurses' spiritual care knowledge and abilities are often unable to satisfy patients' spiritual care needs. Therefore, nurses are in urgent need of relevant training to enhance their abilities to provide patients with spiritual care. Design: A non-randomized controlled trial. Objective : To establish a spiritual care training protocol and verify its effectiveness. Methods: This study recruited 92 nurses at a cancer-treatment hospital in a certain province via voluntary sign-up. The nurses were divided into two groups: the experimental group (45 people) and the control (wait-listed) group (47 people) using a coin-toss method. The experimental group received one spiritual care group training session each six months based on their routine nursing education; this training chiefly consisted of lectures by experts, group interventions, clinical practice, and case sharing. The control group participated in monthly nursing education sessions organized by the hospital for 12 continuous months. Results : After 12 months of intervention, the nurses in the experimental group had significantly higher overall spiritual health and spiritual care competency scores as well as significantly higher scores on all individual dimensions compared with those in the control group ( P <0.01). Conclusions: A spiritual care training protocol for nurses based on the concept of mutual growth with patients enhances nurses' spiritual well-being, spiritual care competencies.Trial registration: ChiCTR1900020930. Registered 22 January 2019.

Anesthesiology & Pain Medicine

nurses

spiritual care

spiritual health

spiritual care competency

Although the debate on 'defining' spirituality [1, 2] is long-standing, spiritual health (also known as spiritual well-being: in the Chinese cultural context, the construct of spiritual well-being is the same as spiritual health [3, 4], and this is also consistent with the general view that "spiritual health is considered as one of the important dimensions of wellness [5]") in the present study refers to "the state of an individual's affirmation of the meaning of his or her own life; understanding and affirmation of the value of oneself, others, and the environment; the ability to connect harmoniously with others and the environment; the possession of inner resources and strength; and ability to adapt to adversity." [1-6]. This definition represents the existential meaning of spiritual health. Spiritual health often includes six aspects [7-9]: an individual's relationship with him or herself, with others, and with the environment; his or her beliefs; the ability to overcome adversity; and the meaning of life. As one of the core elements of quality of life, spiritual health is of great importance [10,11]. Research has shown that the enhancement of nurses' spiritual health not only boosts their personal satisfaction with life [12, 13] but also reduces job burnout [14] and assists them with providing spiritual care to patients in their clinical work. Nurses are the chief providers of spiritual care to patients [15-17], and a close relationship exists between nurses' attitude and ability to provide spiritual care to patients and their perceptions of spirituality and spiritual health [18-21].

Spiritual care encompasses an attitude and behaviour shaped by nurses' spiritual nursing values [22, 23] (especially the affirmation of attributes such as human dignity, goodness, benevolence, peace of mind, warmth, self-care, and care for others) and consists of care that reflects individuals' cultures and beliefs provided after assessing their spiritual needs and challenges [24]. Spiritual care also consists of nursing methods or activities that rely on the provision of company or care, listening, or religious activities that correspond to patients' beliefs to help them to achieve better physical, mental, social, and spiritual health and comfort [17, 25] The purpose of spiritual care is to ease patients' difficulties at the spiritual level and help them find the meaning of life, self-actualization, hope, creativity, faith, trust, peace, comfort, prayer, and the ability to love and forgive in the midst of suffering and disease [17, 26]. Additionally, spiritual care seeks to help patients to face their fears of death, mitigate the uncertainty and discomfort of the treatment process, and regain their inner peace [27-29]. In clinical work, spiritual care education and training helps nurses to understand patients' senses of honour, values, and experience to express kind concern for their patients, ease patients' stress and tension, provide them with spiritual well-being and serenity [30] and let them find meaning and purpose amidst adversity [17, 31]. Under this care, patients can explore strategies to overcome their illnesses as well as strengthen their physical, social, and psychological health, thereby improving their quality of life and state of health [17, 23, 31, 32]. Spiritual care is a core element of holistic nursing and has already been incorporated into nursing education and practice [33-36]. In addition, the ability to provide spiritual care to patients is increasingly considered a major occupational skill for nurses [19, 23].

In clinical work, however, nurses have insufficient knowledge and understanding of spiritual care and inadequate spiritual care competencies, which has led to patients' spiritual needs often remaining unmet [37-39]. Research has shown that medical personnel who have undergone spiritual care training are more likely to meet patients' spiritual needs when providing spiritual care [39, 40-44]. Currently, research on nurses' spiritual health and spiritual care competencies remains at a preliminary stage [34, 45], and little relevant interventional research has been conducted. As a consequence, scientifically based and effective intervention protocols must be drafted to boost nurses' levels of spiritual care. The aim of this study was to evaluate the effects of a spiritual care programme for oncology nurses. We investigated whether nurses gain benefits from this training such as positive changes in their spiritual health and higher levels of spiritual care competencies.

This was a nonrandomized study, and nurses were recruited by voluntary participation. Participants were incompletely randomly assigned to an intervention group or a control group.

2.1. Participants

From September 2017 to October 2018, 92 clinical nurses at a cancer treatment hospital in Henan Province were selected based on a survey of existing conditions. These nurses were assigned to a study or a control group via a coin-toss method. The following inclusion criteria were considered for the current study: registered nurses who had been engaged in clinical work for ≥5 years (The present study is part of a series of research projects. The majority of nurses with more than five working years are mostly clinical teachers in China, which will facilitate the training of other nurses and nursing students in the later period and can create an environment to foster the provision of spiritual care.), signed an informed consent form and voluntarily participated in the study. The exclusion criteria were as follows: nurses receiving other advanced training; individuals who might be expected to drop out of the study due to pregnancy, retirement, or transfers; and individuals joining part way through the intervention. No significant differences were found with regard to age, work seniority, occupation, religious beliefs, etc. between the two groups. The baseline data for the nurses were uniform across the two groups (see Additional file 1: Table 1).

2.2. Procedure

2.2.1 Establishment of an intervention team

The members of the intervention team consisted of two palliative nursing education experts from Hong Kong and three clinical head nurses who specialize in spiritual care. In addition, one statistical expert with statistical analysis skills was recruited who participated in the analysis of the data but not in the intervention process.

2.2.2. Drafting of the intervention protocol

The intervention methods included lectures and instruction, case sharing, group discussion, and individual psychological counselling. Yao Jianan et al. [46] suggest that spiritual care education should include life-and-death education as well as hospice care education. Some scholars [47] have incorporated religious and communication skills into teaching. Timmins et al. [48] concluded that spiritual content education includes personal understanding of spirituality and spiritual concepts and identification of patients' spiritual needs. Ross et al. [23] showed that nurses' personal beliefs and values and their spirituality and sensitivity levels can affect spiritual care outcomes. Baldacchino [49] proposed self-reflection, case studies, and small-group discussions to promote nurses' spirituality and the understanding of spiritual care to improve their competencies' in spiritual care.

The spiritual care training protocol was drafted based on a literature review, expert recommendations, and the results of a current status survey. This study's preliminary examination of the literature [43, 45, 50,51] with clinical nurses revealed that nurses have great need for spiritual care training, which was reflected in the fact that the nurses realized that their spiritual health and self-perceptions of spirituality must be improved and that the long-term clinical care of patients with cancer had made the nurses aware that although these patients tend to have high spiritual care needs, the nurses' own spiritual care competencies and experience were insufficient, which was (importantly) due to inadequate training. Using the nurses' spiritual health and growth as a point of entry, we designed a spiritual care training protocol that focused on nurses' spiritual health and spiritual care competencies. This protocol used strategies such as "spiritual care education fosters spiritual practice"[52], "in order to convey the mystery of life to others, people need to perceive the paradox within themselves" [53], and "spiritual growth occurs among people participating in service-learning" [54] to guide the nurses to view themselves more clearly, explore the mysteries of life, and learn about the operating rules of the spiritual world in detail. In addition to providing the nurses with positive professional knowledge and attitude, the protocol sought to encourage the nurses to uncover their full potential through a "focus on the establishment of a positive mood and sense of happiness, an emphasis on holistic development, and the goal of uncovering, cultivating, and realizing individuals' strengths and potential" [55] while boosting their spiritual health and promoting better spiritual care skills.

This study design included a 12-month spiritual care training protocol for nurses based on the hospital's general nursing education; this protocol, which was implemented from September 14, 2017, to October 15, 2018, consisted of spiritual care training classes for two weeks every six months, two case sharing sessions each month, and one personal growth book discussion session each month. The spiritual health, spiritual care competencies, emotional regulation, and level of psychological resilience of the nurses in the two groups were tested before and after training. The members of the control group participated in one intensive nursing service training session each month during the training period.

(1) Study group protocol. The intervention group participated in the one session/month concentrated study organized by the hospital in the same period as the control group. In addition, all members of the study group concentrated on the training for two sessions, once every six months, five days/session, eight hours/day. The lecturers were senior teaching supervisors of clinical spiritual care education and pastoral counselling in Hong Kong. After the centralized training, organized activities occurred twice a month, including one case sharing, three hours; personal growth reading activities, one session, two hours each session, including two books in the training period: "You Can Heal Your Life"(Louise Hay, US) and "Being Mortal: Medicine and What Matters in the End"(Atul Gawande, US ). The time and place of the event were fixed. The "spiritual care training classes" of this training were incorporated into the workday and approved by the hospital nursing manager for continuing education. The team members participating in the training attended two weeks of special spiritual care group study every year. The time of "case sharing sessions" was the time used for the monthly seminar. The "the personal growth book discussion" time was after dinner every Wednesday, and this session was the only one of the training programme that was outside the workday. Each activity was led by a spiritual care training team leader responsible for organizing and implementation. The team leader had three deputy senior titles and a clinical head nurse who had obtained the qualification of a national second-level counsellor. This protocol included life-and-death education, suicide prevention strategies, end-of-life care, spiritual growth, spiritual care cognition and practice, etc. (see Additional file 1: Table 2).

(2) Control group protocol. The control group only participated in the centralized study of the hospital for one session/month during this period. Each session was two hours. The training received by the control group included nursing research training and the care of commonly observed psychological problems among patients with cancer. To ensure equal treatment, if the effectiveness of this study's spiritual care training protocol was verified after the 12^th month, then the intervention would be continued to provide the control group nurses and the other nurses in the hospital with the same specialized spiritual care training.

2.2.3. The content of the intervention

The content of the spiritual care education curriculum included a group pledge and the sharing of feelings, empathy training, positive spiritual education fostering personal growth, reflective logs, the law of attraction (the law of attraction means that when thoughts are concentrated in a certain field, people and things related to this field will be attracted to a person with certain qualities [56]; this conception helps one to find stability and security in a changing and challenging world [57] and shows how one person can use spiritual tools to change one's mindset from a fearful one into a more confident positive approach to the world [58, 59]), suicide prevention, end-of-life care, and life-and-death education.

2.3. Implementation of the intervention protocol

2.3.1 Assessment period

Prior to the start of the intervention, the members of the intervention team performed a baseline survey of all of the participating nurses. The intervention protocol arrangements and the amounts of time required were explained to the nurses before the intervention, and their informed consent was obtained. The nurses' baseline data were then analysed. Authorization of use of all questionnaires was obtained from the authors of the original questionnaires.

2.3.2 Intervention period

The nurses received spiritual care training chiefly in accordance with the intervention protocol developed for this study during the intervention period. During the two-week intensive training periods that focused on three topics each period, the intervention format chiefly consisted of experts' lectures and interactive classroom discussion. Prior to the conclusion of the intensive intervention, the trainees were asked to receive a one-month reinforcement training session and were informed about enhanced training assignments and completion requirements. After each intervention period concluded, the nurses completed a training class feedback questionnaire to assess their training results.

2.3.3. Evaluation period

After the spiritual care training concluded, the Spiritual Well-being Scale and the Spiritual Care Competency Scale were administered to both groups, and one-on-one interviews were conducted to assess the degree to which the goals of the intervention protocol had been realized.

2.4. Assessment instruments

2.4.1 General background survey form

The general background survey form included items regarding gender, age, work seniority, department, level of education, title, monthly income, assessment of one's own work, willingness to share, and sharing behaviour.

2.4.2 Spiritual Well-being Scale

The Spiritual Well-being Scale is a spiritual health scale developed by the Taiwanese scholars Ya-chu Hsiao et al. [60] based on a sample consisting of nurses. This scale comprises 24 questions across five dimensions: bonding with others, searching for meaning, overcoming adversity, religious faith, and self-knowledge. This scale has a Cronbach α coefficient of 0.93, with subscale values ranging from 0.77 to 0.89 [61]. The scale's use has reached a level of maturity, and it has been steadily optimized.

2.4.3. Spiritual Care Competency Scale

Leeuwen et al. drafted this scale [47]; it contains 27 items across six dimensions, is scored using a five-point Likert scale, and has excellent validity and reliability [47]. The Chinese version was translated and culturally localized by the study team with the permission of Dr. Leeuwen. It was evaluated using the EFA and CFA method [34] and was divided into three dimensions using factor analysis based on the conceptual framework of the original scale: assessment, implementation, professionalization, and quality improvement of spiritual care (AIPI); personal and team support (PTS); and attitudes towards patient spirituality and communication (ATPSC). The Cronbach α coefficients of these dimensions were 0.93, 0.92, and 0.89, respectively [34].

2.5. Statistical methods

IBM SPSS 23.0 was used for data analysis. We employed independent samples testing to compare the two groups' preintervention test scores. The paired-samples t-test was used to compare the preintervention and postintervention scores of the two groups, and the independent samples t-test was used to compare the postintervention scores of the two groups; P<0.05 was considered significant, and the eta squared () was used to evaluate the effect sizes of the intervention.

3.2 Sample characteristics

Additional file 1: Table 1 shows the comparison of demographic characteristics between nurses in the two groups. A total of 92 nurses completed the experiment. All returned questionnaires were suitable for this study. All nurses were female. The average length of employment in the study group was 18 years, and that in the control group was 16 years. The basic characteristics of the participants are summarized in Additional file 1: Table 1.

3.2 Between-group comparisons of the spiritual health and spiritual care competency before and after intervention

The results indicated that the study group had higher total spiritual health and spiritual care competency scores as well as higher scores for their individual dimensions than the control group (P<0.05). However, the score of the "Self-understanding" dimension of the spiritual health scale was not higher in the study group than in the control group (P>0.05). The effect sizes of sub-scales of the two scales after intervention ranged from 0.04 to 0.28. See Additional file 2: Table 3.

3.2 Comparison between the preintervention and postintervention spiritual health and spiritual care competency scores of the nurses in the study group and control group.

The results indicated that the overall spiritual health and spiritual care competency scores and their subscale scores in the study group were higher after the intervention (P<0.05), and the effect values of the study group before and after the intervention ranged from 0.23 to 0.88 (see Additional file 2: Table 4).

4.1. Spiritual care training enhances nurses' spiritual health and spiritual care competencies

The above study results indicate that the nurses in the study group had significantly higher total spiritual health and spiritual care competency scores as well as significantly higher individual dimension scores after the intervention with a moderate to intensity effect. In addition, compared with the control group, the study group showed significantly better spiritual health and spiritual care competency scores as well as significantly better individual dimension scores following the intervention. Although the control group had higher spiritual care competency scores prior to the intervention (this result is likely because the nurses in the control group were slightly younger than those in the study group and therefore had less exposure to the spiritual care concept), the nurses in the study group displayed greater spiritual care competency than the nurses in the control group after the 12-month intervention. Based on the results of a survey of the prevailing state of affairs and using spiritual growth as a point of entry, this study designed a spiritual care training protocol for clinical nurses to address their perceptions of spirituality and spiritual care competencies. The results of this study indicated that this protocol supported specific achievements.

The goal of spiritual care training for nurses is to help them understand the methods and techniques that they can use to provide spiritual care to their patients. During this process, nurses' self-perceptions of spirituality are inevitably raised, and true spiritual clinical nursing practice will have a major, albeit intangible, effect on nurses' own spiritual health and their cognition of additional psychological aspects [41, 43, 49, 61]. Through the group intervention, the nurses expressed their feelings, which gave them an opportunity to review their own spiritual needs. When nurses transform the knowledge and skills that they learn in training into active, conscious clinical practice (e.g., life-and-death education and the end-of-life care process of patients with terminal cancer), the nurses' own perspectives of life and death as well as their attitudes towards the things around them will also change.

Furthermore, the group pledge and sharing of feelings provide an appropriate setting and environment for the sharing and expression of the nurses' spiritual experiences. After being in contact with each other for a certain period of time, the team members formed a cooperative learning team that enjoyed mutual growth. This study's effort to employ a "spiritual education fostering personal growth" to increase the nurses' spiritual awakening and use of personal growth methods to inspire awareness of and search for positive life goals as well as realize the concept of a spiritually and behaviourally healthy person significantly enhanced the nurses' level of spiritual well-being, including such aspects as living a meaningful life and understanding oneself.

4.3. Clinical relevance

Motivated by the growing importance placed on the provision of spiritual care to patients, research on spiritual care has recently increased [34]. However, although previous research has shown that both patients and their family members have great spiritual needs and that medical personnel must show concern for and satisfy these needs, this issue has not received sufficient attention in nursing practice [37, 62]. One obstacle to spiritual care practice is that nurses—the chief healthcare providers—are insufficiently prepared to take on this role because of their inadequate education in this area [28-31, 43, 45]. To provide more effective spiritual care to patients, it is urgent that nurses receive education or training to improve their spiritual care knowledge and skills. The current work verified that the training protocol designed in this study to enhance nurses' spiritual health and spiritual care competencies is feasible and effective. Clinical nursing managers should use this protocol as a reference to help clinical nurses improve their spiritual health. Therefore, the results of this study have great relevance at a time when a worldwide shortage of nurses exists. The protocol developed in this study should also be used to improve nurses' spiritual care knowledge and skills to enable them to better satisfy patients' spiritual needs and improve their nursing quality.

4.4. Research limitations and future research

All participants in this study included nurses in various departments of a single cancer hospital. Furthermore, to facilitate the continued provision of spiritual care training to all nurses, a considerable portion of these participants consisted of head nurses or nursing staff members in their respective departments. As a consequence, most of the nurses in this study were senior personnel with over seven years of experience. Although these individuals had a certain degree of representativeness, some uncertainty remains concerning the effectiveness of the intervention protocol when applied to nurses with less seniority. Subsequent research should therefore examine the effectiveness of the training protocol in the case of less experienced nurses. In addition, certain contents of the intervention (such as "Illness comes from the mind: Anxiety and fear will cause the functioning of qi in our bodies to shut down, thereby impeding circulation of life force, whereas joy and serenity cause the qi to function freely, enabling our life force to flow freely and create an energy field, preventing illnesses from drawing near") is a combination of the unique elements of Chinese culture and the content of intervention with Chinese cultural characteristics. The transcultural validity of the intervention requires further consideration and verification.

Future research may focus on the following aspects: First, through the spiritual care training programme, expert instruction may boost the nurses' perceptions of spirituality. Moreover, nurses who were originally unfamiliar with spiritual concepts became conscious that everyone has a spiritual nature and uncovered their own spiritual nature. Second, in this case, it was easier for the trainees to reveal their inner thoughts in front of trusted team members, and this process also might strengthen their ties with their colleagues and help them find positive resources and strength that they may use to cope with problems, thereby facilitating their spiritual growth while providing a platform for ongoing learning that benefited the nurses' spiritual care competencies. Third, nurses with spiritual care experience will value the opportunity for a healthy life even more and will show greater tolerance for the challenges that they encounter. During the process of helping patients find meaning in life and overcoming adversity, nurses will also gain a greater ability to make their lives meaningful and overcome adversity, which will make this process mutually influencing and mutually reinforcing. As a consequence of the practical experience needed to assess patients' spiritual needs in a real-world environment and provide spiritual care to patients, in addition to the positive feedback that the results of spiritual nursing brings nurses, nurses' spiritual care competencies and personal spiritual well-being will continue to improve. Future research may evaluate these potential benefits for nurses.

Nurses with spiritual health have a better ability to recognize and respond to patients' spiritual needs and are more likely to proactively provide spiritual care to patients. Using the enhancement of nurses' spiritual health as a point of entry, this study developed and implemented a spiritual care training protocol to improve nurses' spiritual care. The results showed that this protocol can boost nurses' spiritual health and spiritual care competencies. This spiritual care training protocol might be worth additional promotion and application among nurses.

Ethics approval and consent to participate

Informed written consent was obtained from all participants. The present study has been reviewed and approved by the Institutional Review Board of the School of Nursing, Jilin University (access number: 2017082301).

Consent to publish

Not applicable.

Availability of data and materials

The data of this study can be obtained by any reasonable request. If needed, please contact the author of this article.

Competing interests

The authors declare that they have no competing interests to disclose.

Funding

This work was supported by grants from the National Natural Science Foundation of China [grant numbers #81320108025, #81672109] and the Graduate Innovation Fund of Jilin University [grant number 101832018C088]. The funding agencies did not have any role in the design of the study or in the collection, analysis, and interpretation of the data or the writing of the manuscript.

Authors' contributions

YLH led the analysis plan, conducted the data analysis, interpreted the findings, drafted the manuscript, and revised the manuscript critically for important intellectual content. FL was responsible for the study design, supervised the study, led the data collection, and revised the manuscript. MRJ modified the training plan and performed the training programme. All authors read and approved the final manuscript.

Acknowledgements

The authors thank all participants. We are grateful to the AJE team of experts for their efficient language revisions, which have helped us to clearly convey the contributions of our study.

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Table 1 Comparison of demographic characteristics between nurses in the two groups

Characteristic	Study group （n＝45）	Control group （n＝47）	or c²value	p-value
Age（year, ）	38.076.52	36.087.15	1.39	0.17
Working years (year, )	18.167.71	16.277.94	1.09	0.28
Educational level
Junior college or below	0	2	5.06	0.08
Undergraduate	42	45
Postgraduate or above	3	0
Income/month（￥）
＜6000	0	6	8.33	0.04^*
6000～	17	22
8000～	28	19
Technical titles
Nurse Practitioner	2	12	9.06	0.03^*
Supervisor nurse	30	27
Associate professor of nursing and above	13	8
Position
Nurse	21	27	3.07	0.38
Ward head nurse	20	19
Chief nurse and above	4	1
Religion
Yes (Christianity, 6; Buddhism,1)	7	5	0.49	0.48
No	38	42
Self-work ability evaluation
Excellent	19	18	1.02	0.60
Good	21	26
Qualified	5	3
Spiritual health
Total score	90.2913.12	91.5712.05	-0.49	0.63
Connection to others	16.512.19	17.062.93	-1.02	0.31
Meaning derived from living	24.223.89	24.214.77	0.01	0.99
Transcendence	21.825.04	23.724.41	1.93	0.06
Religious attachment	12.623.82	10.094.35	2.97	R<0.05
Self-understanding	15.113.00	16.492.58	-2.37	R<0.05
Spiritual care competency score
Total score	79.2420.70	91.8115.68	-3.27	R<0.05
AIPI	34.4210.43	39.498.87	-2.51	R<0.05
PTS	24.137.18	28.685.38	-3.43	R<0.05
ATPSC	20.695.32	23.643.99	-3.00	R<0.05

R<0.05，the difference was statistically significant.

AIPI: assessment, implementation, professionalization and quality improvement of spiritual care (SCCS 1); PTS: personal and team support (SCCS 2); ATPSC: attitude toward patient spirituality and communication (SCCS 3)

Table 2 Nurses' clinical spiritual care training protocol

Intervention unit and time

Intervention training topic

Content

Unit 1

Form a group

1. Group pledge and sharing of feelings: Trainees should have a sense of psychological security when speaking. Participants should respect others' speech with prudence and patience.

2. Moderator's most important tasks during the group pledge are to understand the speakers' exact implied meanings and help speakers reorganize their ideas by mentioning their main points.

3. Methods for handling differences of opinion among trainees

4. Helps everyone to relax, creates a pleasant atmosphere, and ensures that all the trainees are willing to express themselves.

5. Reflective logs

(a) Goal: To help the trainees to assess their important clinical spiritual care learning experiences and achieve the instructional goals in conjunction with the trainees

(b) Reflection: Trainees submit reflective logs as directed by the supervisors and use formal methods to reflect on their learning and growth in training.

(c) Recommended content of reflective logs: Relationships with patients, family members, colleagues, household members, and other important people; expression of attitudes; factors impeding or facilitating the implementation of clinical spiritual care. et al.

Unit 2

Personal spiritual growth

1. Construction of a personal world

(a) Knowing oneself: The ideas of Freud, the hierarchy of consciousness, and theory of personality structure; the Christian belief that people are composed of a physical body, mind, responses, responsibilities, and spirit.

(b) Concept of a healthy person:

(1) A healthy person has the ability to perform everyday tasks; maintains harmonious relationships with others and appreciates others; and possesses the ability to get out of a bad mood.

(2) Five stages of mental health: normal adaptive behavior, stress-response behavior, neurotic coping behavior, abnormal psychoneurotic behavior, and psychotic behavior

(3) How to shape a person who is psychologically and behaviorally healthy. Interior methods: Self-awareness (reflection on strengths and weaknesses); self-opening (open communication with others); self-identification and acceptance; and self-respect. External methods: Leading a disciplined life; setting goals in life; handling tasks in an orderly fashion; time management; learning methods for relaxation; learning methods for preparation; being a grateful person

2. Mysteries of life

(a) True meaning of life. The reason that some people are optimistic is their ability to look at problems from the correct angle; the reason that some people are pessimistic is their restricted thinking and looking at problems from a single angle.

(b) Human beings have a collective subconsciousness. We have a natural tendency to draw close to greater and more powerful life and security and connect with spiritual power.

(c) Rules of the operation of spiritual power. Human beings possess a spirit (linking all eternities), soul (linking individuals through relationships), and body (linking human beings with the material world).

(d) Rules of interaction between the material and spiritual worlds. The internal determines the external, and we must listen to the voice of the spirit. Illness comes from the mind: Anxiety and fear will cause the functioning of qi in our bodies to shut down, thereby impeding circulation of life force, whereas joy and serenity cause the qi to function freely, enabling our life force to flow freely and create an energy field, preventing illnesses from drawing near. Fear is the murderer of human life. Human beings should retain positive energy and joyful emotions such as kindness, love, compassion, and harmony, embrace honesty and goodness, and maintain serenity, happiness, and hope, which will improve their physical and mental health.

(e) Spiritual integration. Following short-term treatment, many ill patients can obtain a complete cure by adjusting their inner power. If people cannot improve their illnesses due to emotional inhibition, them they should search for spiritual caregivers who know how to listen to help them find their potential inner power and achieve spiritual integration to counteract illness. Both health and illness can be transmitted. Heaven helps those who help themselves.

(f) Relationship between thinking and attitude. Fear is in inverse proportion to self-confidence. Aesop provided the following example: 45,000 people who encounter an epidemic die from fear. A joyful heart is good medicine. The highest state of helping others is to enable those seeking help to help themselves. The five secrets of helping others are self-knowledge, self-acceptance, self-mastery, self-liberation, and self-integration.

3. Positive life education:

(a) Positive psychology is the study of an individual character’s strengths that focuses on the establishment of a positive mood and a sense of happiness as well as emphasizes holistic development and the goal of uncovering, cultivating, and realizing individuals' strengths and potential. The positive factors promoting human development include optimism, joy, and mutual love. Actively facing life's stresses and challenges can enable us to lead fuller lives.

(b) The "happy Ferris wheel". The subject of positive psychology is well-being. Well-being includes five measurable elements: positive emotions, wholehearted commitment, interpersonal relationships, meaning, and a sense of accomplishment.

(c) Virtue and character strengths. According to the "Father of American Psychology", "If an individual can use his or her personal strengths in work, leisure, and family life, [then] that individual can easily appreciate authentic happiness and a sense of well-being". The six Chinese virtues are intelligence and knowledge, courage, spirit and transcendence, benevolence and compassion, righteousness, and moderation.

Unit 3

Spiritual care cognition and practice

1. Discussion on the concept of spiritual care

2. Spiritual care methods: birth, body, mind, society, spirit

3. Teaching spiritual care according to the content of the spiritual care cognitive scale and the spiritual care ability assessment scale

4. Spiritual Care Practice: Patients are assessed with a psychological pain thermometer when they are admitted to the hospital, and one-on-one mind care intervention is given to patients with a psychological distress greater than 4 points. On the other hand, if the patient assesses the degree of psychological distress greater than 6 points, there is a spiritual care group to conduct spiritual counseling for the patient after the discussion.

Unit 4

Life-and-death education

1. Origin of life-and-death education

2. The concepts of death of the Egyptians, Tibetans, Babylonians, Persians, Greeks, and communists

3. The relationship between death and life. Death is a continuation of life. Death helps people reflect on their lives. Death explains life. Death helps us cherish life. Death causes us to undergo an awakening. Life and death are fundamentally one entity.

4. Reasons that the Chinese fear death: fear of the unknown, fear of separation and loss, fear of the form and process of death, media reports, attachment to continuity, and unfulfilled wishes and regrets concerning the fear of being unable to make amends.

5. Methods of resolution: turning the unknown into the known; learning to accept unavoidable loss and tragedy in life; learning, accepting, and understanding human fragility and the restrictions of life; clearly understanding the meaning of eternity, and adjusting the priority of one's values on this basis; knowing gratitude for what one has and living without regret

6. Modern people's discussion of death. Influences on modern people's perception of life and death (Confucianism, Daoism, Buddhism, folk beliefs, Islam, Judaism, Christianity, and others)

7. Death education

(a) Discussion of end-of-life care and death. Case analysis: The regrettable consequences of when family members refuse to discuss death

(b) Discussing Life and Death with Equanimity (Center of Behavioral Health, University of Hong Kong). The correct preparation for death, including recollection of past details and preparing for the end of life

(c) Unloading sorrows: A manual for helpers and self-help (Ng and Yim). Five sentences to leave the world without regret: “I love you.” “Please forgive me.” “I forgive you.” “Thank you.” “Goodbye.”

(d) Twenty-three Ways to Practice Saying Goodbye (Hori). In the last moments, there are 23 practices to say goodbye, including finding the strength to live on (eight practice methods), going down the final road together in happiness (nine practice methods), and a message written from you to who will be left in the world (six practice methods). Let children participate in death education.

8. The "life" in life-and-death education. The Universal Declaration of Human Rights; nutrition and physical/mental health; health information on diet and mood; healthy and happy living equals emotional health+social health+psychological health+spiritual health

9. The "death" in life-and-death education. Discussing death with equanimity: having a good life plan

Unit 5

Suicide prevention

1. Definition and forms of suicidal behavior. Causes of suicidal behavior: Physiological and mental problems (e.g., physiological illnesses, psychological problems, and drug/alcohol abuse); social causes (family, work, school, interpersonal, social changes, and psychic contagion); and spiritual reasons (guilt and deviant beliefs).

2. Warning signs of possible suicide: withdrawal, excessively emotional reactions, aggressiveness, abuse of medication, promiscuity, abnormal diet, giving treasured items as gifts, pain, personality changes, intimidation, and fear

3. Key preventive measures: Early discovery of suicide risk factors; aggressive treatment of mental illness; maintaining contact with people with suicidal tendencies; not making discussion of suicide a taboo; asking people with suicidal tendencies whether they have suicidal ideations, suicidal impulses, or concrete suicide plans; immediately arranging referral for diagnosis by a specialist as soon as it is discovered that someone is at risk of suicide

4. Handling suicide crises: confirming that the person involved is actually committing or planning suicide; assessing the danger of the person's suicidal behavior, understanding the person's behavioral motivations; drafting an assistance plan

5. Correcting misunderstandings about suicide and understanding the true face of suicide. Most people who talk often about suicide will try to commit suicide. Signs of possible suicide: Suicidal individuals might accept guidance, although risk remains even after the immediate risk of suicide is past. Suicidal individuals include the rich and poor, men and women, and people of all ages. Suicidal individuals do not necessarily have mental illnesses or psychological problems. The suicide rate is highest among youth. The frequent mention of suicide facilitates suicide prevention.

6. How to face crises in life

(a) Crises include dangers and opportunities

(b) Common elements of crises. Crises are composed of a cumulative series of events, situations of high risk, and unexpected/sudden factors.

(c) Handling methods: establishing balancing factors such as the correct understanding and analysis of the case; ensuring an adequate support network, a dependable response system, and limited handling time

(d) Characteristics of middle-aged people and crisis handling. The establishment of a sense of safety and a support network among friends; long-term psychological preparation; economic arrangements; social support

Unit 6

End-of-life care

1. The meaning of palliative end-of-life care. A team who have received special training to provide physical, mental, social, and spiritual care and support to terminal patients help patients ease their suffering and discomfort while respecting their dignity and values and enabling them to pass their remaining time in comfort and dignity

2. Promoting ethics bills concerning end-of-life care work: death education and mourning assistance; the provision of adequate consulting and referral resources

3. The ability of people engaged in end-of-life care work. Understanding of one's own feelings about death and the ability to forthrightly describe and express those feelings; the ability to understand service recipients’ ideas about death and their emotional response development stage; the ability to discern and understand society's viewpoints and discussion of death; a full knowledge of the science of death and life-and-death education; an understanding of one's own viewpoint concerning different death events and the ability to maintain a neutral position; skill at employing empathy; excellent communication skills and ability

4. Taiwan's "Five Alls" model: All subdistricts, all team members, all people, full-course, and the whole household

5. Holistic care: life, body, mind, society, spirit

6. Needs of patients receiving end-of-life care: a clear understanding of their illness; the alleviation of one's suffering; companionship; maintenance of autonomy; the maintenance of effective communication; emotional relief and support; the preservation of dignity; the recollection and integration of life experiences

7. What is a good death? No need for prolonged suffering before death; the reduction of suffering as much as possible before death; the chance to reconcile with family members and friends before death; the knowledge that one does not need to worry about family members' lives after one's death; the completion of one's family responsibilities before death; the ability to take a load off one's mind

8. End-of-life care model: past, present, future; individual, family, social relationships, and spiritual aspects

Table 3 Comparison of spiritual health and spiritual care competency scores of the two groups of nurses before/after intervention (points，S)

Content		Before intervention				After intervention
Content		Study group (n=45)	Control group(n=47)	value		Study group (n=45)	Control group (n=47)	value
Spiritual health	Total score	90.2913.12	91.5712.05	-0.49^b	.00	106.498.31	95.0011.91	5.38^*	.24
	Connection to others	16.512.19	17.062.93	-1.02^b	.01	18.671.58	17.682.68	3.05^*	.09
	Meaning derived from living	24.223.89	24.214.77	0.01^b	.00	27.692.66	25.434.44	2.98^*	.09
	Transcendence	21.825.04	23.724.41	1.93^b	.04	27.183.21	24.574.58	3.15^*	.10
	Religious attachment	12.623.82	10.094.35	2.97^*	.09	15.073.95	10.914.80	4.54^*	.19
	Self-understanding	15.113.00	16.492.58	-2.37^*	.06	17.891.90	16.813.03	2.06^*	.04
Spiritual care competency	Total score	79.2420.70	91.8115.68	-3.27^*	.11	110.849.40	95.6015.22	5.81^*	.27
	AIPI	34.4210.43	39.498.87	-2.51^*	.07	47.736.12	41.027.89	4.57^*	.19
	PTS	24.137.18	28.685.38	-3.43^*	.12	36.643.78	30.915.41	5.90^*	.28
	ATPSC	20.695.32	23.643.99	-3.00^*	.09	26.472.62	23.664.02	3.95^*	.15

^* P＜0.05；^bP＞0.05；^aP=0.05; : Eta Squared (Effect size); AIPI: assessment, implementation, professionalization and quality improvement of spiritual care (SCCS 1); PTS: personal and team support (SCCS 2); ATPSC: attitude toward patient spirituality and communication (SCCS 3)

Table 4 Comparison of spiritual health and spiritual care competency scores of the study and control group before and after intervention (points，S)

Content		Study group (n=45)					Control group (n=47)
Content		Before intervention	After intervention	value	value		Before intervention	After intervention	值	value
Spiritual health	Total score	90.2913.12	106.498.31	-16.20	-8.37^*	0.23	91.5712.05	95.0011.91	-3.43	-2.06^a	0.02
	Connection to others	16.512.19	18.671.58	-2.16	-8.91^*	0.87	17.062.93	17.682.68	-0.21	-0.52^b	0.09
	Meaning derived from living	24.223.89	27.692.66	-3.47	-5.85^*	0.49	24.214.77	25.434.44	-1.21	-2.02^a	0.06
	Transcendence	21.825.04	27.183.21	-5.36	-6.97^*	0.52	23.724.41	24.574.58	-0.85	-1.20^b	0.04
	Religious attachment	12.623.82	15.073.95	-2.44	-5.49^*	0.17	10.094.35	10.914.80	-0.83	-1.46^b	0.04
	Self-understanding	15.113.00	17.891.90	-2.78	-5.91^*	0.77	16.492.58	16.813.03	-0.32	-0.74^b	0.03
Spiritual care competency	Total score	79.2420.70	110.849.40	-31.60	-9.74^*	0.36	91.8115.68	95.6015.22	-3.79	-2.33^a	0.01
	AIPI	34.4210.43	47.736.12	-13.31	-7.94^*	0.36	39.498.87	41.027.89	-1.53	-1.49^b	0.02
	PTS	24.137.18	36.643.78	-12.51	-11.51^*	0.88	28.685.38	30.915.41	-2.23	-3.22^a	0.08
	ATPSC	20.695.32	26.472.62	-5.78	-7.66^*	0.30	23.643.99	23.664.02	-0.02	-0.04^b	0.00

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Effectiveness of spiritual care training to enhance spiritual health and spiritual care competency among oncology nurses

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