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Journal of Religion and Health ISSN 0022-4197Volume 51Number 3 J Relig Health (2012) 51:879-889DOI 10.1007/s10943-010-9399-7

Can Spirituality be Taught to Health CareProfessionals?

Pamela Meredith, Judith Murray, TrishWilson, Geoff Mitchell & Richard Hutch

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ORI GIN AL PA PER

Can Spirituality be Taught to Health Care Professionals?

Pamela Meredith • Judith Murray • Trish Wilson •

Geoff Mitchell • Richard Hutch

Published online: 1 October 2010� Springer Science+Business Media, LLC 2010

Abstract Although people with life-limiting conditions report a desire to have spiritual

concerns addressed, there is evidence that these issues are often avoided by health care

professionals in palliative care. This study reports on the longitudinal outcomes of four

workshops purpose-designed to improve the spiritual knowledge and confidence of 120

palliative care staff in Australia. Findings revealed significant increases in Spirituality,

Spiritual Care, Personalised Care, and Confidence in this field immediately following the

workshops. Improvements in Spiritual Care and Confidence were maintained 3 month

later, with Confidence continuing to grow. These findings suggest that attendance at

a custom-designed workshop can significantly improve knowledge and confidence to

provide spiritual care.

Keywords Spirituality � Health care professionals � Palliative care

Introduction

Spirituality is a delicate and complex topic that is receiving increasing attention in aca-

demic and medical circles (Sulmasy 2002), with evidence of the importance of spirituality

P. Meredith (&)School of Health and Rehabilitation Sciences, The University of Queensland,St Lucia, QLD 4072, Australiae-mail: p.meredith@uq.edu.au

J. MurraySchool of Psychology, The University of Queensland, St Lucia, QLD, Australia

T. WilsonMater Health Services, South Brisbane, QLD, Australia

G. MitchellSchool of Medicine, The University of Queensland, Ipswich, QLD, Australia

R. HutchSchool of Religion, The University of Queensland, St Lucia, QLD, Australia

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to both physical and emotional health (Larson and Larson 2003). Within a holistic

approach to health, there is recognition of the need to address existential or spiritual issues

(Sulmasy 2002), and this particularly exists in the field of palliative care (Murphy et al.

2000; Mytko and Knight 1999). Further, the need for spiritual concerns to be taken up by

all disciplines, rather than just those of a religious orientation, has been recognised

(Hermann 2001; Rumbold 2003). Nevertheless, there is also evidence that these issues are

often not broached or addressed by practitioners working with those facing serious health

challenges, even though patients report a desire to address them (Farber et al. 2004; Hart

et al. 2003).

Reasons for failure of health care professionals to address these issues include a lack of

knowledge of the issues, a lack of confidence in broaching spiritual topics, and a lack of

shared language of spirituality outside the confines of traditional religious terminologies

(Kellehear 2000). Illustrating the challenge of providing this care, and indicative of the need

for training, a survey of Australian nurses revealed that, although 97% of registered nurses

believe that they should address patient’s spiritual needs, only 66% felt able to do so

(Barletta and Thompson 2001). Some of the reasons identified within the literature for such

discrepancies include the nurses’ perceived inability to communicate on spiritual matters

(Greasley et al. 2001), pluralism resulting in nurses encountering a wide variety of ideol-

ogies, philosophies and creeds (Laukhuf and Werner 1998), and deficits in nursing edu-

cation in relation to spiritual care (Catanzaro and McMullen 2001). Similar difficulties have

been expressed in other professions: ‘‘Spirituality is not well understood by occupational

therapists and neither do we seem to educate ourselves about it.’’ (Wilding 2002, p. 47).

These difficulties are exacerbated by the multidisciplinary nature of palliative care and

lack of easily defined competencies in spiritual care across disciplines (Gordon and

Mitchell 2004). In addition, issues arise in the perception of spiritual needs as of lesser

priority, the extent of contrasting belief systems, limited staff resources, and training that

fails to enhance knowledge, insight, and confidence (Culliford 2002). However, there is

some evidence that training in spiritual care that focuses on spirituality as a broad concept,

as opposed to religious interpretations, can improve staff attitudes to patients and families,

reduce stress, and build the confidence of staff (Abrams et al. 2005; Wasner et al. 2005), as

well as enhance multidisciplinary collaboration in palliative care (Oppenheimer et al.

2004).

A Training Option

In response to a perceived need, a multidisciplinary team of health and religious profes-

sionals at the University of Queensland, Australia, in consultation with people with life-

limiting illness, their family members, and those employed in the clinical field, developed a

set of training resources. These resources were designed to increase the knowledge and

confidence of staff in the field of palliative care in terms of overcoming hesitancy and/or

difficulty in knowing how to address issues of existential and spiritual care with patients.

The nature of the resources was to ensure the accessibility of the information by health care

practitioners regardless of geographic location or religious affiliation. The resources were

designed to appeal equally to health professionals and pastoral care givers with religious

and non-religious orientations. They were designed to be used as either a self-paced

independent learning package or a workshop that could be delivered by a member of any

profession. The Spirituality in Palliative Care training resource is available, free of charge,

from Palliative Care Australia on their national website at: www.pallcare.org.au. Having

undertaken this developmental task, the next aim was to evaluate the training resources.

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Study Expectations

In this paper, the outcomes of four pilot workshops using the Spirituality in Palliative Care

package are described. It was anticipated that participation in the workshops would result

in significant gains in measures of spiritual care, spirituality, and confidence to provide

spiritual care in palliative care. Furthermore, it was expected that these gains would be

maintained up to 3 months after workshop attendance. Religiosity, workplace concerns,

stress, anxiety, and depression, although not expected to change in response to the

workshop, were also measured as control variables. In anticipation of these objectives

being met, it is suggested that this training package will prove to be a valuable educational

tool for health care professionals.

Methods

Participants

Participants were a self-selected sample of employees and volunteers in the field of pal-

liative care. Approximately 120 people attended one of four workshops. Pre-workshop

questionnaires were collected for 113 (94.2%) of these (23 ? 26 ? 28 ? 36 at each of the

four workshops, respectively). At the post-workshop stage, 109 questionnaires (96.5%)

were returned, and 69 of the 113 participants (61.1%) completed follow-up questionnaires.

As can be seen from Table 1, participants were predominantly Australian women, older

than 40 years of age, who were employed permanently in the field of palliative care. A

wide range of professions was represented.

Procedure

Following the development of the workshop content by the authors, promotions for the

Queensland pilots were undertaken in three locations: one provincial town (Cairns), one

rural town (Roma), and one metropolitan town (Brisbane). Due to the high numbers of

registrants, two workshops were provided in Brisbane. Promotional material was distrib-

uted through hospital, hospice and palliative care facilities, church groups, and aged care

facilities in the various locations. Participants enrolling in the workshops were sent the pre-

workshop questionnaire as part of their confirmation of registration package. The majority

of participants completed these measures before attendance on the day of the workshop.

Those who forgot to complete their questionnaire prior to the workshop, or who neglected

to bring it with them on the day, were provided with an additional questionnaire to

complete prior to the commencement of the workshop. Workshops were delivered jointly

by a psychologist and a nurse counsellor on the program development team. Participants

completed the post-workshop questionnaire prior to leaving the workshop venue on that

day. Three months following the workshop, participants were sent the follow-up ques-

tionnaire by mail and asked to return the completed questionnaire in a postage-paid

envelope. Ethical clearance for this project was obtained from The University of

Queensland’s Behavioral and Social Science Ethical Review Committee. Confidentiality of

participants was maintained through the use of a confidentiality code—a unique six letter

code generated by the participants from personal information known only to them. This

code was required in order to link pre-, post- and follow-up questionnaires.

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Measures

Demographic Details

Participants were invited to provide information regarding their gender, age, country of

origin, employment status, and profession.

The Spirituality and Spiritual Care Rating Scale (SSCRS) (McSherry et al. 2002)

The SSCRS is a 17-item measure employing a five-point Likert scale (1 = strongly dis-

agree, to 5 = strongly agree) that seeks to determine an individual’s understanding of

Table 1 Demographic detailsfor the workshop participants

Demographic variable (N = 113) n (%)

Gender

Male 12 (11)

Female 97 (86)

Missing 4 (3)

Age

\19 years 1 (1)

20–29 4 (3)

30–39 11 (10)

40–49 33 (29)

50–59 42 (37)

[60 18 (16)

Missing 4 (3)

Country of origin

Australia 84 (74)

Other 26 (23)

Missing 3 (3)

Employment status

Permanent 68 (60)

Casual 7 (6)

Volunteer 11 (10)

Missing 27 (24)

Profession

Chaplain/clergy/pastoral care 25 (22)

Nursing 32 (28)

Allied Health (psychology, occupationaltherapy, social work, physiotherapy)

8 (7)

Doctor 6 (5)

Counsellor 6 (5)

Other (e.g., volunteers, recreation officer,diversional therapist, liaison officer,personal carers)

21 (19)

Administrative (e.g., project co-ordinators,reception, CEO)

12 (11)

Missing 3 (3)

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spiritual care. It produces four subscales: (1) ‘‘Spirituality’’, (2) ‘‘Spiritual Care’’, (3)

‘‘Religiosity’’, and (4) ‘‘Personalised Care’’. The Spirituality subscale reflects participants’

beliefs about what constitutes personal spirituality. An example is: ‘‘I believe spirituality is

about finding meaning in the good and bad events of life’’. The Spiritual Care subscale taps

into the beliefs of participants with respect to who is responsible for providing spiritual

care and how spiritual care can be offered e.g., ‘‘I believe we can provide spiritual care by

showing kindness, concern and cheerfulness when giving care’’. Religiosity reflects beliefs

concerning the centrality of religious beliefs to spiritual care, as in the following example:

‘‘I believe spirituality involves only going to Church/Place of Worship’’. Finally, Per-

sonalised Care reflects staff beliefs concerning the interactional nature of spiritual care,

such as: ‘‘I believe spirituality involves personal friendships, relationships’’.

Perception of Workplace Change Schedule (POWCS)(Nolan et al. 1998; Schofield et al. 2005)

The POWCS is a 16-item measure employing a 5-point Likert scale (1 = decreased a lot,

to 5 = increased a lot) that seeks to measure the perceptions of staff with respect to their

workplace. It provides three subscales that measure: (1) perceived ‘‘Strengths’’ of the

workplace (e.g., ‘‘My feelings of being a valued employee have…’’), (2) ‘‘Concerns’’ held

about the workplace (e.g., ‘‘The levels of stress I feel have…’’), and (3) ‘‘Pressures’’ in

terms of workplace demands (e.g., ‘‘My workload has…’’). This measure was included at

only the pre-workshop and follow-up phases to determine if there had been any perceived

changes in the workplace that could account for any changes in outcome measures.

Knowledge and Confidence Scale (KCS) (Murray and Chan, manuscript in preparation)

This is a 15-item measure employing a seven-point Likert scale (1 = very strongly dis-

agree, to 7 = very strongly agree) that was developed by one of the researchers in previous

research looking at provision of care in bereavement and other adverse life events. It

provides two subscales: (1) participant ‘‘Confidence’’ in their ability to provide spiritual

support and (2) participant ‘‘Compassion’’, reflecting the willingness on the part of staff to

view providing support as their role or responsibility. A sample confidence item is: ‘‘I have

skills that I can use to help a person facing death’’, while a sample compassion item is:

‘‘People facing death need to talk about their situation.’’ Because the Cronbach’s alpha for

the Compassion subscale fell below 0.7 at all three data collection stages, the Compassion

scale was not utilised in this study.

Depression Anxiety Stress Scale-21 (DASS-21) (Lovibond and Lovibond 1995;Clara et al. 2001)

The DASS is a 21-item scale that comprises three scales: (1) ‘‘Stress’’, (2) ‘‘Depression’’,

and (3) ‘‘Anxiety’’, each with seven items. Questions are scored on a four-point scale

(0 = did not apply to me at all, to 3 = applied to me very much or most of the time) based

on the previous week. Adequate reliability, convergent and discriminant validity have been

reported, internal consistency, temporal stability, and convergent and discriminant validity

are excellent, and a consistent factor structure has been found (Brown et al. 1997; Clara

et al. 2001; Crawford and Henry 2003; Lovibond and Lovibond 1993). Sample items

include: ‘‘I found it hard to wind down’’ (stress), ‘‘I experienced trembling’’ (anxiety), and

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‘‘I couldn’t seem to experience any positive feeling at all’’ (depression). The scale was

employed only at pre-workshop and follow-up phases of the project.

Statistical Analyses

Results were analysed using SPSS Version 15.0. Participants with missing data were

excluded from some analyses, resulting in smaller numbers in some analyses. No outliers

were detected. Each variable was analysed with the Kolmogorov-Sminov statistic, and

results confirmed that data were normally distributed. Descriptive data for categorical

demographic variables are provided in Table 1, and descriptive data for continuous vari-

ables are provided in Table 2. Due to the high number of t-tests employed in this study, a

conservative level of significance was adopted (P = 0.01) in order to minimise the family

wise error rate.

Table 2 Descriptive data for each of the subscales at three stages of measurement

Measure N = 124 Stage ofevaluation

Valid N Mean Standarddeviation

Range

Spirituality Pre- 108 20.79 2.80 12–25

Post- 109 22.09 2.33 16–25

Follow-up 69 21.12 2.65 12–25

Spiritual care Pre- 108 21.69 2.93 10–25

Post- 109 22.59 2.56 9–25

Follow-up 69 22.55 2.40 13–25

Religiosity Pre- 108 4.61 1.54 3–10

Post- 109 4.62 1.75 3–11

Follow-up 68 4.43 1.60 3–10

Personalised care Pre- 107 12.44 1.83 7–15

Post- 109 12.91 1.53 7–15

Follow-up 69 12.68 1.70 8–15

Confidence Pre- 106 31.13 7.68 15–57

Post- 102 35.72 4.66 25–49

Follow-up 69 47.81 4.36 37–60

Perception of workplace strengths Pre- 104 24.49 5.48 7–35

Follow-up 67 24.60 5.41 11–35

Perception of workplace concerns Pre- 97 23.82 5.48 11–35

Follow-up 63 23.43 5.41 13–35

Perception of workplace pressures Pre- 101 14.28 2.37 8–19

Follow-up 67 13.60 2.64 7–20

Stress Pre- 109 4.55 3.34 0–15

Follow-up 68 4.03 2.66 0–11

Depression Pre- 109 1.96 2.40 0–11

Follow-up 67 1.52 2.54 0–13

Anxiety Pre- 108 1.48 2.15 0–14

Follow-up 65 1.62 2.05 0–8

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Results

Comparisons Between Pre-Workshop, Post-Workshop, and Follow-Up Measures

A series of paired sample t-tests were conducted in order to compare changes on each of

the scales between three time frames: (1) pre-workshop to post-workshop, (2) pre-work-

shop to follow-up, and (3) post-workshop to follow-up. The results of these analyses are

summarised in Table 3.

Pre- to Post-Workshop Comparison

Immediately following the workshop, there was a significant increase in four of the sub-

scales: Spirituality, Spiritual Care, Personalised Care, and Confidence. A significant

change was not detected for the Spiritual Care-Religiosity subscale.

Pre-Workshop to Follow-Up Comparison

There was a significant change in two subscales between the pre-workshop and follow-up

stages of the study: Spiritual Care and Confidence. There was no significant change

between the pre-workshop and follow-up measures for Spirituality, Religiosity, Persona-

lised Care, the Strengths, Concerns and Pressures subscales of the Perceptions of Work-

place Changes measure, or Stress, Anxiety or Depression.

Table 3 Summary of paired sample t-tests for each subscale

Measure/subscale Pre- to post-workshopcomparison

Pre-workshop tofollow-up comparison

Post-workshop tofollow-up comparison

Spirituality t(103) = -5.97,P \ 0.001

t(57) = -1.48,P = 0.14

t(57) = 2.13,P = 0.04

Spiritual care t(103) = -4.71,P \ 0.001

t(57) = -3.00,P = 0.004

t(57) = -0.58,P = 0.56

Religiosity t(103) = 0.24,P = 0.81

t(57) = 0.76,P = 0.45

t(57) = -0.18,P = 0.86

Personalised care t(102) = -2.96,P = 0.004

t(56) = -1.00,P = 0.32

t(57) = 0.62,P = 0.54

Confidence t(95) = -7.08,P \ 0.001

t(56) = -19.15,P \ 0.001

t(54) = -17.31,P \ 0.001

Perception of workplacestrengths

Not measured t(54) = -1.27,P = 0.21

Not measured

Perception of workplaceconcerns

Not measured t(49) = -0.88,P = 0.38

Not measured

Perception of workplacepressures

Not measured t(52) = 1.07,P = 0.29

Not measured

Stress Not measured t(56) = 0.00,P = 1.00

Not measured

Depression Not measured t(55) = 0.88,P = .38

Not measured

Anxiety Not measured t(53) = -0.73,P = .47

Not measured

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Post-Workshop to Follow-Up Comparison

The only significant change between post-workshop and follow-up was an increase in

Confidence scores. There was no significant change in the other four subscales: Spiritual

Care, Spirituality, Religiosity, and Personalised Care subscales of the SSCRS.

Discussion

As identified in the literature, there is a need for health care professionals to increase their

knowledge and confidence in addressing spiritual issues as part of our health care services.

The overall aim of the Spiritual Care in Palliative Care Project was to develop a training

program that would improve the confidence and ability of staff to provide spiritual care in a

palliative care setting. The results of this study suggest that the workshops were successful

in achieving this aim. Immediately following the workshop, participants significantly

increased their Spiritual Care (Spirituality, Spiritual Care, and Personalised Care) and

Confidence in this field. The improvement in the Spiritual care subscale was maintained at

3 months, while the Confidence subscale continued to improve beyond the post-workshop

scores. Thus, over a 3-month period, the workshops contributed to ongoing improvements

in the confidence of staff in providing spiritual care. As anticipated, there was no change in

participants’ level of religiosity: the workshop clearly distinguished between spirituality

and religiosity, and appeared to have no impact on religiosity.

At the same time as participants reported improvements in staff confidence to provide

spiritual support, there were no perceived alterations to workplace demands or to staff levels

of personal stress, anxiety or depression. That is, improvements in spiritual care and con-

fidence cannot be attributed to decreases in workplace concerns or pressures, increases in

workplace strengths, or to positive changes in staff mood or stress levels. Thus, it appears that

identified changes are related more to the self-perceived ability of individual staff members

to provide spiritual care in their everyday encounters with patients and their families.

In addition, workshop participants showed significant improvements in personal spiritu-

ality at the post-workshop phase, as indicated by the Spirituality subscale of the Spirituality

and Spiritual Care Rating Scale (SSCRS). This aspect of personal spirituality enhancement

appears to have had its own effects on the individual, separate from mental health, which, as

previously noted, did not differ significantly over time. That both Spiritual Care and personal

Spirituality improved is consistent with Toomey’s (1999, p. 198) notion that: ‘‘…by seeing

our own spirituality we become better equipped to recognise spiritual things in others’’.

The initial improvements in personal Spirituality and Personalised Care present

immediately post-workshop decreased 3 months post-workshop to be non-significant,

however. While the opportunity for staff in this field to gather together, reflect on clinical

practice, and discuss spiritual matters may nurture one’s spirituality and refuel one’s

capacity to provide personalised care, it appears that this effect does not last. Thus, hosting

gatherings such as these workshops intermittently for staff in palliative care may confer a

significant benefit. Notably, while scores in these personal aspects of spirituality returned

to pre-workshop levels, improvements in spiritual care and confidence in providing support

were maintained at the follow-up stage and, as noted earlier, confidence continued to

improve. This is apparently not the result of the participant’s innate spirituality.

It is possible only to speculate upon the mechanisms behind the apparent success of

these workshops. The positive outcomes could potentially be attributed to a combination or

interaction of a range of factors, including: (a) the nature of the presenters of the

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workshops, (b) the content and format of the program itself, and/or (c) the emotional and

intellectual benefits of a group of like-minded people gathering collectively. The program

team was comprised of professionals with a range of relevant backgrounds (medical,

nursing, psychology, religion, occupational therapy) and clinical experience. Hence,

potentially ethereal topics were able to be clearly presented in language relevant to

everyday clinicians and situations. For example, core concepts were couched in terms of

‘‘love and fear’’ for clarity and acceptability by all participants, regardless of religious

affiliation. Further, processes guiding workshop development included an extensive liter-

ature review (including recommendations for teaching health professionals), consultation

with an expert reference group drawn from a range of professions, and wide consultation

with key stakeholders. This ensured that the workshops were both comprehensive and

relevant, while also informing a range of design decisions. For example, the teaching and

learning concept of ‘‘different ways of knowing’’ was adopted by using a diversity of

learning resources (poems, music, quotes, movie clips, interviews with people experi-

encing life-limiting illnesses and their families, a reflection journal, and photo montages).

In this way, the team demonstrated that spirituality is more than a cognitive experience—

the workshops engaged sensory, emotional and experiential aspects of the participant in

addition to the cognitive element. Finally, although the workshops were designed to be

delivered by any health professional, training at all four of the evaluated workshops was

provided by people on the project team. While each of these aspects may have contributed

to the observed success, only further tailored research considering the many potential

influencing factors (workshop development, content, personnel, method of delivery, group

processes, and dynamics) could shed further light on this question.

There are a number of considerations that indicate a need for caution in interpreting the

results. Firstly, a self-selection bias may have been introduced in several ways. The par-

ticipants attending each workshop were voluntary registrants, suggesting that those

interested in and open to exploring spiritual elements presented in the workshops may have

been more likely to attend. In addition, although the sample of individuals attending the

workshops was over 120, the rate of questionnaire return at the 3-month follow-up stage

was only 61% of the initial sample. Secondly, the sessions were conducted in English, as

were the evaluations. People whose primary language is not English and who may have a

non-European cultural background may be under-represented, and the study is not appli-

cable to non-European cultures. Thirdly, although workshops were delivered in a range of

settings throughout Queensland, results may not be generalisable to staff and volunteers in

other states of Australia, or in other countries. Finally, there was no control group, so the

observed changes cannot be categorically attributed to the intervention itself. Further

research would help to address these issues.

Although it is a strength of this study that longitudinal measures were obtained, time

constraints on the project made only a 3-month follow-up possible. This may have been

insufficient to determine long-term changes to care offered by staff or any subsequent

changes to the workplace as the result of staff changes. It would be advantageous to review

outcomes about 1 year after the workshop to determine longevity of change.

The measurements in this project relied on the self-report of participants. While this

may have been appropriate given the goal of improving participants’ spiritual care and

confidence, it may have also been valuable to consider more behavioral measures of the

impact of the workshops. For example, the absence of objective measures of actual change

in staff behaviors and care (as determined by colleagues or patients and their families, for

example) meant that reports of change were restricted to subjective perceptions on the part

of staff.

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Future Directions

There is still much research to be done in relation to this training package. Replications of

this training and outcome study using various samples and altering outcome measures will

strengthen confidence in these findings. While there is now evidence that the workshop,

delivered by the experts who were part of the program development team, has an apparent

beneficial outcome for participants, it remains to be seen whether the content of the

workshop will be similarly helpful for those who elect to take a self-directed study

approach to the online package. Finally, there is a need to measure outcomes for partic-

ipants of workshops delivered by trainers not previously involved in the development of

the package.

Conclusion

As noted by Toomey (1999), the growth of one’s own spirituality involves a complex

journey, yet embarking on this journey equips us to recognise the spiritual lives of those

with whom we work. The aim of the Spiritual Care in Palliative Care Project was to

develop and evaluate a set of staff training resources aimed at encouraging a multidisci-

plinary approach to spirituality and health in palliative care. In order to achieve this aim,

the workshops were focused on improving the awareness, confidence, and ability of the

multidisciplinary group of staff and volunteers to provide spiritual care in palliative care

settings. The evidence reported in this paper suggests that this aim has been met, and that

spirituality can indeed be taught to health care professionals.

Acknowledgments The authors would like to acknowledge the financial support of The AustralianDepartment of Health and Ageing Local Palliative Care Grants—Pastoral Care Counselling and SupportSub-Program. We would also like to express our appreciation to the participants of the workshops whocompleted several questionnaires and to the people with terminal illnesses, their families, and palliative careworkers, who agreed to be interviewed and videoed for the purpose of developing this training package.

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