Creating an interprofessional education package on patients’ spiritual needs

As a healthcare chaplain completing a master of science degree in advanced healthcare practice, I (the first author) undertook an elective course in ‘Education for professional practice’ led by the second author, who contributed to preparing this article. This involved designing, delivering and reflecting on an education session relevant to my practice, and the subsequent review of the session based on learner feedback. This allowed me to share the education package with others in my team at work, while learning more of the education theory involved in creating learning spaces during clinical placements.

My role includes building relationships with the staff and students on the wards to support them when needed. While discussing their placement with a student nurse, I ended by indicating they could always refer patients that they thought might need to speak to a healthcare chaplain. The student replied: ‘We have nobody religious on the ward!’. I did not reply immediately, but when reflecting on this I realised, despite being a newly qualified practitioner myself, it was my role to challenge this view. Healthcare chaplains are the people who should be promoting their role and the work they do. I remembered that the previous year, when I was a student chaplain, the first time I met other students on placement was when I provided a spiritual care learning session, and it felt wrong somehow. I realised I wanted to create a space for students of all disciplines to come together on placement, to share experiences and support each other, and decided to do something about it.

This article outlines the development of an interprofessional learning (IPL) session on spiritual care for nursing, midwifery and allied health profession (NMAHP) students on clinical placement. As a registered professional within health care, the healthcare chaplain's role includes education in spiritual and religious care (UK Board of Healthcare Chaplains, 2020). Although the role of healthcare chaplain in Scotland has changed from primarily religious care to ‘generic’ spiritual care over the past 15 years (NHS Education for Scotland (NES), 2021a), I find many NMAHP students on placement still perceive the chaplain's role as limited to religious care. In practice, I spend my time equally between supporting patients and supporting staff; religious care taking up the minority of my time.

Using a ‘Plan Do Study Act’ model (NES, 2021b), the session can be planned and reviewed to improve the learning experience of students. Creation of an education session requires understanding of education and learning theories, preferences and styles (Redmond et al, 2016). A learning needs assessment then informs the creation of an education package, and appropriate assessment methods. After implementation, the session is evaluated by students, and feedback used to improve the session. This provides an opportunity to reflect and develop practice.

Developing understanding of education

When providing education around spiritual care, educationalists might share evolving knowledge or ideas that cannot be objectively measured. This ‘cognitive pedagogy’ approach (Mackintosh-Franklin, 2016) presents knowledge to the student to integrate within their worldview, perhaps in a non-logical way, focusing on student-centred learning. For example, the educator may share several theories defining a ‘person’ with the students so individuals can adopt the method most suited to their values. This learning theory of constructivism (Dent et al, 2017: 189) allows the learner to build on previous learning using their own independent learning process. Whereas theories may help the educator prepare, the most effective learning in adults (Lethaby, 2017) builds on prior knowledge, relates to their experience, and encourages the learner to learn how they learn. For adults, education must be relevant to what students need to know, based on their experience. IPL increases understanding and awareness across professions, potentially removing cultural barriers to workplace collaboration, and enhances patient safety and care (Visser et al, 2017). For example, in one study, nursing and physiotherapy students found peer learning advantageous to practical problem-solving (Fogstad and Christiansen, 2011). Students may share, reflect, critique and support each other through peer learning. Combining Gagné’s theory of instruction (Akdeniz, 2016) with learning needs assessments, the session can be formed using theory applied with clinical knowledge in IPL and spiritual care.

Learning needs assessment

When creating an education session, it is important to consider what a participant needs to learn, and what they might already know. NMAHP students on placement vary in educational levels, between 7 and 11 (Scottish Credit and Qualifications Framework Partnership, 2017), and life experience (recent school leavers to mature career changers). They may be studying with any university or college in Scotland, with varying experience of spiritual care through these academic programmes. Some students may be religious, spiritual, both or neither. Since ‘religion or belief’ is a protected characteristic under the Equality Act 2010, the session should not require students to disclose any particular religious affiliation, as this would void the non-judgemental discussion of spiritual care.

Students need to understand the relevance of spiritual care to engage with learning. Since spiritual care is delivered in a one-to-one therapeutic non-judgemental relationship, it is necessarily person-centred as defined by the Royal College of Nursing (2019). The Nursing and Midwifery Council's (NMC) Standards (NMC, 2018a) require that all registered nurses include spiritual assessment in practice relating to decision-making competencies. Physiotherapists, occupational therapists, dietitians and speech and language therapists are expected to be aware of how spiritual or religious beliefs impact on care (Health and Care Professions Council (HCPC), 2013a; 2013b; 2013c; 2013d). Therefore there was a strong rationale for the education session.

Aim and learning outcomes

The aim of the session was to encourage student awareness of spiritual and religious care, when planning high-quality person-centred care.

The learning outcomes for the session were as follows:

• Appreciate the difference between spiritual care and religious care
• Appreciate that meeting spiritual needs is an important part of person-centred care
• Value our own spiritual support and identify our own spiritual needs
• Appreciate that by understanding our own spirituality we are better equipped to discuss spirituality with others.

The education package

Learning in spiritual care is not driven by learning new facts, but by self-reflection and realisation as one gains awareness of one's own spirituality. Since many health professionals are required to reflect on their role and practice to ensure that, as registrants, they live by their professional code of practice (NMC, 2018b), or to engage in career-long learning (HCPC, 2021), this style of learning will be familiar to students.

The concept of spiritual care may be challenging in practice if students do not accept there is a ‘spirit’. Many models describe a person in medical, health or wellbeing terms. Some models include spirituality, such as the ‘mind-body-spirit’ model (McGrady and Moss, 2018), and the ‘mental, emotional, physical and spiritual’ model (Chilton and Bain, 2018) whereas some, such as the World Health Organization's (2006) ‘physical, mental and social’ approach, do not. Students should be encouraged to explore a variety of models until they find one with which they are comfortable. This will integrate the question of ‘what makes us human?’ within the student's worldview, not that of the educator. Since a worldview is a core part of a person's identity, the educator must be careful to make no judgements of whether a model is ‘right’ or ‘wrong’; the model used is a ‘preference’. In the midst of this complexity, national guidelines (Scottish Government Healthcare Policy and Strategy Directorate, 2008) should be used to clarify the definitions of spiritual care and religious care. Box 1 provides one definition of spiritual and religious care.

Box 1.Definitions of spiritual and religious care

• ‘Spiritual care is usually given in a one-to-one relationship, is completely person-centred and makes no assumptions about personal conviction or life orientation
• ‘Religious care is given in the context of shared religious beliefs, values, liturgies and lifestyle of a faith community
• ‘Spiritual care is not necessarily religious. Religious care should always be spiritual’

Source: Scottish Government Healthcare Policy and Strategy Directorate, 2008

After discussing theory, learning has to be applied to practice. Case studies are advised for constructivism education, particularly in IPL (Dent et al, 2017: 195) and in multi-generational classes (Oermann, 2015), which may be a possibility in this situation. Through careful design of a case study, students from all disciplines receive the stimulus to apply learning to clinical practice (Akdeniz, 2016), setting the patient's spiritual needs contextually in person-centred care. Group discussion of cases allows students to feed back to each other, and receive feedback from the educator, on how learning is applied. By the end of the session, students should realise that understanding their own spirituality helps them to relate to spirituality in others. This leads to the final aspect of spiritual care that students need to know: how the healthcare chaplain can support staff and students. This leads to the lesson overview (Figure 1).

Small group discussion (Dent et al, 2017: 241) presents an opportunity for all students to engage, and the educator to listen to the students. An ice-breaker activity such as the use of Envision cards (NES, 2012) draws everyone's attention to a discussion of visual stimuli using social questions (Hughes and Quinn, 2013). Each participant selects an image from the pack that represents how they feel about the placement. The image is presented to the group for others to use the ‘three ways of seeing’ to reflect what the image represents: ‘I notice, I wonder, I realise’ (Paterson, 2013). For example, Student 1 might select a picture of a forest in autumn. Student 2 might say: ‘I notice some trees have colourful leaves and some have bare branches; I wonder which means most to you?’ Student 1 might then reflect: ‘I realise the different colours of the leaves represent the different talents of all the staff on my placement.’ This allows students to provide reflective, non-judgemental feedback to each other without getting involved in debates that might start ‘If it were me, I would …’. It also serves to demonstrate how we each make meaning from our experiences in different ways. This combines Gagné’s theory of instruction (Akdeniz, 2016) and the ‘visual learning’ channel (Utley et al, 2018).

Sitting around a table, the educator and students appear equal in the group dynamics. The educator can encourage participation and reflection through appropriate questions, essential components of constructivism learning theory. This develops the overview into a question-driven lesson plan (Table 1).

Assessing learning

Learning may be assessed to evaluate student engagement with the subject, note progress and identify gaps in knowledge. The educator can also gauge the effectiveness of the session and the accuracy of the learning needs assessment (Oermann, 2015). Preparation for practice is fundamental for students (Kalogirou et al, 2021). If students disagree that learning outcomes have been met, then the session has not embedded spiritual care in person-centred care. Learning will be assessed throughout the session by applying what is learned. Three case studies are used in the session – an example is provided in Box 2. Students should be able to identify spiritual needs by the end of the third case study, after being guided through the first two (Oermann, 2015). This will be apparent by the reduction in educator input. The differences between spiritual and religious care may be assessed by asking students to define them.

Box 2.Case studyMr Graham, a 58-year-old bariatric patient, is on the ward following a fall at home. He lives alone, his mobility is poor, he experiences shortness of breath when attending to personal care, and he has type 2 diabetes. After 3 months as an inpatient, the fall injury has healed, yet he sits at the bedside all day. The only thing he says he looks forward to, is not being watched by staff when he goes home. The patient complains of generalised pain when mobilising. When you try to encourage him, he says: ‘You don't understand. I can't. You don't know what it's like.’QuestionHow might Mr Graham's situation impact on his care and recovery?Potential issues

• Loss of: hope; self-esteem; purpose; motivation; independence
• Fear of: isolation, falling, dependence on others
• Feelings: angry, anxious, overwhelmed, ignored, judged

Questions staff might ask Mr Graham

• ‘Tell me about your pain’
• ‘Tell me what this is like for you’

Other questions students have considered

• What does the patient's home life look like?
• Has the patient become ‘institutionalised’?
• Does he want to go home to be alone/isolated?
• Does the patient feel judged somehow?

This is an illustrative case study with a fictitious patient name

Reflective evaluation of the education session

This session was developed and delivered in a regional general hospital over a 6-month period. The department's evaluation form was returned by all 52 students who attended, optionally disclosing their discipline. When evaluating the session, it is important to determine whether learning needs were identified accurately, whether learners’ needs were met, and whether education methods facilitated student learning (Hagler, 2019). Feedback was reflected on after each session, refining the session outline where needed. Students mostly agreed or strongly agreed (85%) that the session met their learning needs. One area of possible improvement concerned the case studies.

One student commented:

‘As a dietetic student the case study scenarios were not very applicable. Still enjoyed hearing nursing/physio student input.’

Student 1

New case studies were developed and a dietetics student who attended a later session, responded:

‘I really enjoyed the case studies as I could see how I would apply spiritual care during my placement to benefit patient experience.’

Student 36

Interactive group discussion was initially daunting for the first author, who is more familiar with larger group lectures and one-to-one tutoring. Students appreciated the delivery method, where they were able to interact with the educator and each other to discuss concepts. Unlike medicine, not all spiritual questions have answers (Roberts et al, 2012), and many answers are personal to the individual. This allowed the group to learn from each other (Williams et al, 2015). As a consequence of this session, those who support NMAHP students in clinical practice have reported students initiating discussions of patients’ spiritual needs. This is in line with Gagné’s final step of ‘enhancing retention and transfer’ (Akdeniz, 2016). This is arguably the best indicator of effective education, as the student demonstrates reflection and knowledge application to clinical practice.

Conclusion

This article has documented the creation, implementation and evaluation of a spiritual care IPL session for NMAHP students that can now be shared with others. Considering the application of educational theories, the understanding of adult learning, and modes of delivery allowed the educator to structure an education session. By assessing the learning needs of NMAHP students, the aims and objectives were expanded into an outline education package, assessed in a method appropriate to the material. After implementation, reflection on student feedback drove case study enhancements. The reflection, feedback and lessons learned contributed to developing this work further, highlighting the advantages of using educational theory in clinical practice to create effective learning environments. The session could be further developed into a series, taking themes from the education session and dealing with them in more depth.

KEY POINTS

• Despite Scotland's healthcare chaplains moving from ‘religious care’ to ‘generic’ spiritual care during recent years, the perception of some nursing and other healthcare students is still that the healthcare chaplain is there for ‘religious care’ and only speaks to people who are religious
• Developing a safe space on clinical placement for students to come together to discuss spiritual care of patients, and of themselves, means students can support each other, while discovering how spiritual care supports patients
• The first author developed an educational session that allowed students to understand their own spiritual needs and identify sources of spiritual support. As part of the session, the role of the healthcare chaplain in supporting staff and students was explored

CPD reflective questions

• How would you discuss spiritual care with a student you were supporting in practice?
• How can the healthcare chaplains in your area support you to provide spiritual care?
• In what ways can healthcare chaplains provide support to staff?
• How could you adapt this teaching package for use in your clinical area?