This study, conducted at the Arcispedale Santa Maria Nuova Hospital in Reggio Emilia, Italy, from November 2021 to November 2022, explores the implementation of A Multidisciplinary Training Program For Spiritual Care In Palliative Care. The hospital, a 900-bed research institution recognized as a Comprehensive Cancer Centre by the Organization of European Cancer Institutes (OECI), provided the setting for this initiative within its specialist hospital-based Palliative Care Unit (PCU). This PCU, while lacking inpatient beds, plays a crucial role in clinical practice, education, and research in palliative care, offering specialist consultations both within the hospital and in outpatient settings for oncology patients and their families.
Established in 2013, the PCU is staffed by three senior physicians and three advanced practice nurses. Crucially, it collaborates with five psychologists from the hospital’s Psycho-Oncology Unit, who contribute to clinical consultations and are responsible for the training of PCU staff, as well as engaging in palliative care research and education. Further enriching the multidisciplinary approach is the Bioethics Unit (BU), comprised of two bioethicists. The BU’s mandate is to enhance the quality of patient care, family support, and healthcare professional well-being through research, educational programs, and ethical consultations.
All professionals from the PCU, Psycho-Oncology Unit, and BU were invited to participate in this study, and all accepted, demonstrating a strong commitment to advancing spiritual care competencies.
The training program was delivered by two experienced spiritual care professionals (SCPs). F.L., active in hospice care and a member of the Scientific Committee of the Italian Journal of Palliative Care (Rivista Italiana di Cure Palliative), and M.C., with experience in both hospice and general hospital settings (including acute and intensive care units) and co-author of the Core Curriculum for Spiritual Care by the Italian Society for Palliative Care (Società Italiana di Cure Palliative) [22], led the training. Their combined expertise ensured a comprehensive and practical approach to spiritual care education.
Methods: Designing a Complex Intervention
This study adopted a Phase 0-I design to develop and assess the feasibility of a complex intervention – the multidisciplinary training program for spiritual care. Drawing upon the Medical Research Council (MRC) framework for complex interventions [21], the program was structured to address the identified gap in spiritual care training for hospital-based healthcare professionals in Italy. COVID-19 restrictions necessitated online delivery by the SCPs, while healthcare professionals (HPs) participated in person.
The training program was carefully structured in two key phases:
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Foundational Theory and Introduction: This initial 4-hour session combined a theoretical lecture with interactive elements, designed to introduce HPs to the concept of spirituality within the clinical context. The format incorporated both didactic teaching and group work to facilitate engagement and understanding. SCPs were online, and HPs attended in a classroom setting.
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Paired Meetings and Individual Follow-up: The core of the program involved paired meetings between SCPs and HPs. Each pair of HPs participated in three structured meetings, followed by two individual online follow-up sessions at 3 and 6 months post-training initiation. Each meeting had a specific focus, building upon the previous session:
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Meeting 1: Defining Personal Spirituality (45 minutes): The first meeting aimed to encourage participants to explore and articulate their own understanding of spirituality. Beginning with a warm-up activity where each pair shared “what spirituality means to me,” the session utilized guiding questions inspired by Christina Puchalski’s FICA tool [23]. Questions such as “Do you feel spiritual?”, “What is the importance of spirituality in your life?”, and “What importance does it have to you in terms of community?” were used to prompt reflection and discussion. This initial exploration of personal spirituality is crucial for healthcare professionals to effectively address the spiritual needs of their patients.
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Meeting 2: Developing Spirituality (30 minutes): The second meeting shifted focus to the factors that contribute to the development of personal spirituality. Questions explored participants’ spiritual journeys from childhood and adolescence, prompting reflection on enduring influences and potential areas for renewed focus. For instance, “What form did your spirituality take as a child/teenager?” and “Is there anything from that time that has not occupied time and space in your life since then?” This introspective process aimed to identify personal resources and experiences that could foster spiritual growth.
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Meeting 3: Maintaining and Growing Spirituality (30 minutes): The final paired meeting centered on practical strategies for maintaining and nurturing personal spirituality. SCPs posed questions like “How do you intend to take care of your spirituality from now on?” and “What is empty and what is full in your spiritual life?” This future-oriented discussion aimed to equip participants with actionable steps for ongoing spiritual self-care.
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Follow-up Meetings (Online): Two online follow-up meetings incorporated guided meditation and open discussion, revisiting themes from the paired meetings. The first follow-up focused on personal spirituality, while the second extended the reflection to interpersonal spirituality in professional interactions with patients and colleagues. These sessions provided continued support and reinforcement of the training’s principles.
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Fig. 1: Diagram illustrating the multidisciplinary training program for spiritual care in palliative care, detailing the sequence of theory lecture, paired meetings, and follow-up sessions.
The educational model employed by the SCPs was grounded in established guidelines and core curricula [6, 22]; https://www.aamc.org/media/24236/download, https://advancingexpertcare.org/position-statements/spiritualcare, emphasizing personal self-reflection and spiritual growth as integral components.
To foster a conducive learning environment, all training activities were conducted outside the participants’ usual workplace. A quiet and reflective atmosphere was encouraged throughout, with background music used to promote relaxation and concentration. A designated music room provided space for trainees during waiting periods or for reflective writing exercises. Virtual platforms facilitated meetings with online SCP instructors and in-person participant gatherings.
The training program was evaluated as a complex intervention with a concurrent triangulation mixed-method assessment [25], incorporating qualitative and quantitative data collection, separate analyses, and integrated interpretation to enhance study validity through data triangulation.
The evaluation framework adopted a before-during-after approach, inspired by Moore et al.’s expanded outcomes framework [20], focusing on Level 3B, Procedural Knowledge, to assess impact on personal performance. The evaluation encompassed:
- Participation (Level 1): Measured by the number of HPs participating.
- Satisfaction (Level 2): Assessed the extent to which participant expectations were met.
- Learning (Level 3A & 3B): Evaluated declarative knowledge (Know) and procedural knowledge (Know-how), reflecting understanding and application of spiritual care principles.
Feasibility was determined by assessing whether training components were appropriately identified as active intervention elements and whether the program was completed as planned across all three hospital units with full participant engagement.
Data Collection and Analysis: A Mixed-Methods Approach
Longitudinal qualitative interviews were employed to gauge participant satisfaction and knowledge acquisition, supplemented by reflective journals completed by participants throughout the training. A total of thirty-six interviews were conducted, and thirty-five journals were analyzed.
The research team comprised one male (LG) and several female researchers. Interviews averaged 58 minutes in duration (ranging from 21 to 92 minutes). A convenience sample of all HPs from the participating units was utilized, with no refusals to participate.
Initial interviews (T0, before training, see Additional file 1) gathered information on perceived training needs in spirituality to inform program development (Table 2). Follow-up interviews were conducted at three months (T1, Additional file 2) and six months (T2, Additional file 3) after training commencement.
A simple, pre-planned interview guide was used for T0 (Additional file 1), which was not piloted. All interviews were audio-recorded and transcribed verbatim. Consistent topics across interviews facilitated the evaluation of changes, with T1 and T2 interviews including questions on training feedback and program adjustments (Additional file 2, Additional file 3). Participant codes are available in Additional file 4.
Two female researchers, GA (expert research nurse) and GLB (anthropologist and qualitative research expert), both hospital-based researchers, conducted the interviews. Participation was quantitatively assessed through attendance records, with a 75% attendance threshold.
T0 interviews were transcribed and analyzed to identify training expectations. Subsequent interviews were similarly processed. A participant feedback meeting with SCPs validated the results. The final dataset comprised interviews, journals, and participant validation. Data collection occurred in the workplace without additional personnel present, and no field notes were taken during interviews.
Interview data were analyzed using an inductive approach with the framework method (FM) [24]; https://www.aamc.org/media/24236/download, facilitating theme emergence and inter-coder agreement. Researchers immersed themselves in the data (familiarization), developed initial codes, and grouped them into themes, creating a working framework matrix.
ST, EB, and SS independently analyzed transcripts, iteratively coding interview segments and grouping them into themes and macro-themes. Disagreements were resolved through discussion, and LG provided supervision. Data saturation was discussed and confirmed. The FM was applied to remaining interviews, tracking thematic changes across T0, T1, and T2, providing a longitudinal perspective on evolving meanings and perspectives. No software was used for data management. GLB also analyzed reflective journals using FM, triangulating data and consolidating findings.
Rigor and Reflexivity in the Research Process
Reflexivity was carefully considered. GA had no prior contact with participants. Palliative care physicians [ST, SS] and palliative care nurses [EB], involved in data analysis, had professional contact with participants from the bioethics and psycho-oncology units, acknowledging potential influence due to their belief in the importance of spirituality and high motivation for the training program. External researchers (LG, AG, GLB) ensured methodological rigor. Positive relationships with participating colleagues were acknowledged as a potential facilitating factor. GLB (anthropologist) and LG (qualitative research expert), external to the training program, provided expertise throughout the research process, with LG leading the Qualitative Research Unit and having no prior contact with trainees.
We believe a lot in the importance of the spiritual dimension and our involvement in the course was very high, we were very motivated.
The fact that three of us (ST, SS, EB) analyzed the results may influence positive interpretations.
Three external researchers (LG, AG, GLB) ensured the rigor (as expressed in the method, see Methods section).
The good relations with the colleagues participating in the training certainly helped.
This multidisciplinary training program for spiritual care in palliative care demonstrates a structured and rigorously evaluated approach to enhancing the spiritual competencies of healthcare professionals. The study’s mixed-methods design and attention to reflexivity strengthen the credibility of its findings, offering valuable insights for the development and implementation of similar programs in other palliative care settings.
