A Meaning-centered spiritual care training program for hospice palliative care team in South Korea: development and preliminary evaluation


 Background

Spirituality is a fundamental and intrinsic aspect of human beings and should be a core component of quality palliative care. There is an urgent need for training of hospice palliative care teams (HPCTs) to enhance their competency to provide spiritual care. The purpose of this study was to develop and evaluate a meaning-centered spiritual care training program for hospice palliative care teams (McSCTP-HPCT).
Methods

In this methodological study we developed a training program for HPCTs, using the ADDIE educational content developmental model. The final training program comprised five modules. The modules’ content was informed by Viktor Frankl’s meaning-centered logotherapy with its emphasis on spiritual resources as well as the spiritual care model of ISPEC (Interprofessional Spiritual Care Education Curriculum). Following development, a pilot test was conducted with four nurses. The results of the pilot were used to inform the final program. The final program was tested in an intervention involving 13 hospice palliative care nurses. Measurements using self-administered questionnaires were taken at three points before and after the intervention. Participants’ demographic and career-related characteristics and the degree of variance between outcome variables (compassion fatigue [CF], spiritual care competency [SCC], and spiritual care therapeutics [SCT]) were analyzed using descriptive statistics, t-test, and one-way ANOVA.
Results

The MCTP-HPCT was developed into five modules. Module I: The HPCT’s SCC evaluation, understanding the major concepts of spiritual care and logotherapy, Module II-IV: Meaning-centered intervention related to the spiritual needs (existential, relational, and transcendental/religious), Module V: The process of meaning-centered spiritual care. The preliminary evaluation showed a significant differences in all three outcome variables at the first measure point (CF, p = 0.037; SCC, p = 0.005; SCT, p = 0.002). At the second measure point statistical significance was found only with SCC (p = 0.006).
Conclusions

The MCTP-HPCT developed in this study is suitable for use in clinical settings and provides evidence for evaluating the spiritual care competency of HPCTs.

satisfaction and QoL, and another study that developed the spiritual care training protocol for oncology nurses as a comprehensive concept of spiritual care was conducted in China [8]. However, a training program to enhance the spiritual care competency of HPCT members in Korea has not yet been done.
Currently, there are 87 hospice palliative care institutions that have formal approval by the Korean government in 2020 [14], but hospice palliative care services provided in Korea are still focused on physical symptom management, and no systematic training programs have been developed for the spiritual well-being of terminal patients. Moreover, there is no speci ed curriculum for spiritual care training for HPCT members. In order to promote the QoL of patients with life-threatening disease, spiritual care interventions grounded in human spirituality need to be established. In addition, in order to establish spiritual care as a core component of hospice palliative care and quality control service not limited to religious support, education and training of HPCT members should be implemented as a priority. The purpose of this study was to develop and evaluate a spiritual care training program for HPCTs using Victor Frankl's meaning-centered logotherapy approach to addressing the resources of spirituality. The training program will from here on be referred to as McSCTP-HPCT (meaningcentered spiritual care training program for hospice palliative care teams).

Study Design
This is a methodological study employing a one-group pretest posttest design. The developmental process used follows the ADDIE model of Seels and Richey [15] (Fig. 1).

Theoretical Foundation
A McSCTP-HPCT was developed incorporating the spiritual care guideline formulated by ISPEC [5], and concepts from Viktor Frankl's logotherapy conceived by experiences in the concentration camps in World War 2 and established as the meaning centered theory were used to focus on and enhance the resources of spirituality (Fig. 2).
"Spirituality" refers to a dynamic and intrinsic aspect of humanity that has an important in uence on the status of body and mind [7]. The main attributes of spirituality are meaning, interconnectedness, and transcendence [16][17][18]. That the attitude of patients in the terminal stage of their illness developed from "pain" to "meaning" (such as the meaning of suffering, life, and death) con rms that the attributes of spirituality are related to meaning in life. In addition, 12 primary spiritual issues (e.g., despair/hopelessness, grief/loss, guilt/shame, reconciliation, isolation etc.) suggested by the National Consensus Project for Quality Palliative Care in the United States are related to the nature of spirituality [18]. Therefore, spiritual care should be focused on recognizing and responding to the needs of the human spirit including the attributes of spirituality with compassionate relationship [19]. ISPEC suggested an Interprofessional Special Care Model to improve the quality of spiritual care in the hospice palliative care area, and, in this model, the need for a multidisciplinary team approach was proposed as well as three levels for spiritual assessment (spiritual screening, history-taking, and assessment).
Viktor Frankl described the spiritual dimension of human beings as a "healthy core" or "the de ant power of human spirit" that affects the body and mind. In addition, the will to meaning in human spirituality is a motivating force to overcome the inevitable pain and live actively [20]. He developed "logotherapy", a theoretical system and psychotherapeutic intervention that advocates using spiritual resources to overcome unavoidable suffering. The main assumptions of logotherapy are that awareness of responsibility (being responsible for one's own existence), nding meaning (as the motivational and driving force of relieving suffering), and self-transcendence (dedication to something beyond themselves) within an authentic encounter are the essence of human existence. Recovery from suffering and spiritual well-being can be achieved through attitudinal modi cation towards optimism in situations where pain is inevitable [20][21][22].

Procedure
The ow of the McSCTP-HPCT development process is presented in Fig. 2 [23] and two meta-analyses [24,25]. Besides the MCI study, which was designed to prevent burnout among and provide support for nurses who provide palliative care [12,13], only one study on spiritual care training protocols was conducted regarding the general educational contents of spiritual care training for oncology nurses [8]. To the best of our knowledge, no meaning-centered spiritual care training program for hospice palliative care teams has been developed yet.
Identi cation of spiritual care guidelines. Through searching for protocols or guidelines regarding spiritual care, we identi ed the ISPEC guideline [5] which have been developed by the National Consensus Project as an evidence-based training program for multidisciplinary teams [18], and which includes speci c models regarding the process of spiritual care. Therefore, it is appropriate as a guideline to develop a training program suitable for Korean culture.
Needs assessment. A needs assessment was conducted as follows. First, we identi ed the spiritual care needs of patients with lifethreatening illness and their families who were admitted to hospice palliative care institutions in Korea [26]. Among their spiritual care needs, the desire for love and connection, nding meaning, and hope and peace were found to be higher than religious beliefs. As a result, we understand that spirituality (rather than religion) is a universal, intrinsic aspects of being human. Second, 282 nurses working at hospice palliative care institutions (n = 282) were surveyed on the meaning of spiritual care and their capacity for spiritual care. In response to the open question "What do you think special care is?", 33.7% recognized spiritual care as "Helping prepare for a digni ed death including religious support." On the other hand, a survey conducted using the spiritual care competency (SCC) tool [27] showed that the lowest-scored SCC items were "assessment and evaluation of special care" and "professionalization and impacting the quality of special care". Finally, the researchers collected opinions regarding spiritual care needs from a panel comprising seven experts on hospice palliative care practice, education, and o cials responsible for hospice policy.
The analysis process con rmed the necessity that the McSCTP-HPCT be developed with due regard to the attributes of spirituality.

Design
Speci cation of contents, sessions, and modules. The major contents of the McSCTP-HPCT, composed through previous research analysis, are the SCC evaluation of HPCT, the concepts of spiritual care and logotherapy, and meaning-centered care linked to the three attributes of spirituality (meaning, interconnectedness, and transcendence). The program consists of ve sessions, and a total of 20 hours.
Educational methods. As main educational methods for meaning-centered intervention, logotherapy counseling technique were applied, with logo-analysis and Socratic dialogue as the main techniques, and Medicine Chest and Appealing Technique as complementary methods. Logo-analysis [28] is the process of discovering potential spiritual resources in one's spirit and analyzing them to nd the meaning and purpose of life. The speci c analytic processes are as follows: Self-evaluation, Acting as if…, Establishing an encounter, Finding values in creativity, experience, attitude, and commitment (Table 1). Socratic dialogue is a way of helping people recognize the latent "logohints" in their minds through an authentic conversation with a counselor. Medicine Chest is a way of helping patients recognize that there is a healthy core (the de ant power of the human spirit) in their spiritual dimension. Appealing Technique is a selftraining meditation method that consists of positive content to help strengthen the use of one's spiritual resources. Development of initial program. To ensure effective outcomes for both patients and health care professionals, the program had to address both the importance of spiritual care based on the attributes of spirituality and the hospice palliative care provider's compassion [7,[29][30][31][32]. These issues were re ected in the evaluation of compassion fatigue (CF) and SCC of HPCTs. The initial program also addressed the spirituality of ISPEC guideline, the meaning and standard of spirituality care, spiritual assessment and diagnosis based on the three attributes of spirituality, and basic concepts of spirituality implementation. To facilitate the e cient progress of education, McSCTP was organized as a group intervention. It included a mix of didactic presentations, case sharing, experiential exercises with main logotherapeutic counselling techniques including logo-analysis, Socratic dialogue, group discussions with re ection, and home exercises.
Critical review by professionals and modi cation process. At a workshop with spiritual care experts in the HPC eld, it was agreed that ve sessions, ve hours per week, for four weeks, and a total of 20 hours of training programs would be appropriate for the education component of the McSCTP-HPCT. In addition, it was agreed that in order to strengthen case-oriented education, the 12 spiritual issues presented in the ISPEC guideline have been adjusted to nine issues that are suitable for Korean culture. The McSCTP-HPCT is an approach based on the universal spiritual attributes of human beings, and the three levels of spiritual assessment were modi ed to be appropriate for the Korean situation. It was agreed that religious needs expressed by the subject should be referred to the clergy.
Establishment of an intervention team. To ensure consistency of education, the rst author of this study and one of the coauthors, who is an expert (a trained chaplain) in the eld of HPC, were designated as both educator and facilitator.
Pilot test. To check the suitability of the MCTP-HPCT, the problem and satisfaction level of the progress procedure and the content validity were tested by four nurses working in the tumor and HPC area. The content validity index score showed over 80% in all 10 items tested. These results were used to complete the nal McSCTP-HPCT.
Stage II: Preliminary evaluation Implementation Participants. Participants for the preliminary evaluation were HPCT members who works at a nationally administered hospice care institution. The inclusion criterion was that HPCT members must have been engaged in a hospice palliative care unit or center for more than ve years. Initially, 15 people participated in the study, but two dropped out, leaving a total of 13 (eight nurses, two social workers, and three related professions).
Intervention procedure. The McSCTP-HPCT was presented at four weekly training sessions (a total of ve hours per week, 20 hours in total) by two educators who acted as facilitators for lectures and discussions. Application and group discussion were conducted with real cases, and tasks for re ection were given to prepare for the next session.  [34,35] It was measured by means of 16 items using a 5-point Likert scale (1 = never, 2 = rarely, 3 = occasionally, 4 = often, 5 = very often). The scale exhibits internal reliability with an alpha coe cient of 0.85. After the translation-reverse translation process, both SCT and CF were validated by ve experts, and content validity index showed more than 80% over all items.
Data analysis. Data were analyzed using the Statistical Package for Social Sciences (IBM SPSS, version 25.0). Participants' demographic and career-related characteristics and the degree of variance between outcome variables were analyzed using descriptive statistics, t-test, and one-way ANOVA. The preliminary effects of McSCTP were tested with paired t-test to determine the change in the score between the measurement points.

Development of McSCTP-HPCT
The MCTP-HPCT was developed into ve modules as described brie y below and in more detail in Table 1. Each module consists of learning objectives, key training contents, and workbooks and consists of case-based discussions and exercises for effective practical application.
Module I. This module consists of the HPCT's SCC evaluation, understanding the major concepts of spiritual care and logotherapy, and the application of meaning-centered intervention directly to HPCT. In particular, to enhance the competency of HPCT members to provide meaning-centered intervention, they practiced self-evaluation to nd meaning in their own job.
Module II. This module consists of a meaning-centered intervention process that presents two spiritual issues ("despair/hopelessness" and "lack of meaning and purpose") related to the existential needs of patients.
Module III. Module III contains a meaning-centered intervention process that presents ve spiritual issues ("anger at God or others", "guilt/shame", "grief/loss", "abandonment by God or others/isolation", and "reconciliation") related to the relational needs experienced by patients and their families.
Module IV. The contents of this module are related to the transcendental/religious needs, with two spiritual issues focused on ("concerns about relationship with deity", "con icted or challenged belief systems").
Module V. This nal module reconstructs the process of meaning-centered spiritual care in the context of the Spiritual Care Implementation Model presented by ISPEC and consists of two parts. The rst part comprises a meaning-centered spiritual care model including a) spiritual implementation model, b) decision pathways, and c) caring principle for spiritual well-being. In the second part, we presented a spiritual care matrix (spiritual assessment with three levels: screening, history, and assessment/spiritual resources, and needs based on spiritual attributes, spiritual issues, and meaning-centered intervention evaluation).
The workbooks for modules II, III, and IV presented practical exercises to identify spiritual needs (existential, relational, and transcendental) and how to satisfy these with spiritual resources, and other spiritual issues based on actual cases.

Preliminary Evaluation
Participants' Background Characteristics and Differences in Outcome Variables. The characteristics of the participants are presented in Table 2. The item that differed most in the outcome variables according to the characteristics of the participants was religious status (p = .041) in CF. In the results of a post-hoc Scheffe test, none of the items showed signi cant differences in the mean scores of the three outcome variables.   (27)

Principal ndings
The McSCTP-HPCT was developed to allow HPCT members to maximize the patient's spiritual resources. It addressed itself to human spirituality rather than religious aspects [20][21][22]. The theoretical background was rooted in the spiritual care model presented by ISPEC's guidelines and the logotherapy approach which is a meaning-centered approach rather than a pathos-centered approach [20,21]. In previous studies, meaning in life was reported as a stable intrapersonal resource that can be used to maintain the spiritual well-being of patients with chronic or life-threatening illness [36,37]. The main characteristics of McSCTP-HPCT are as follows: First, it is linked to spiritual needs with expressions, spiritual issues, and meaning-centered interventions based on the attributes of spirituality. Second, it is designed to meet the existential needs of terminally ill patients and promote spiritual well-being. Finally, it was based on the spirituality concept presented by ISPEC and an interdisciplinary approach to spiritual assessment, implementation model, and spiritual issues.
Researchers have shown that personnel who undergo spiritual care training are more likely to meet patients' spiritual needs [38][39][40]. Through the spiritual care training program, the HPCTs can more effectively assist patients to nd meaning in life and overcome the spiritual suffering experienced during their illness.

Development of McSCTP-HPCT
A feature of Module I was that the medical personnel's own spirituality and compassion skills were dealt with for spiritual care. Their spirituality affects health care outcomes including QoL [18]. Compassion is a spiritual practice, a way of being, a way of service to others, and an act of love. Thus, spirituality is intrinsically linked to compassion [7,41]. HPCT members' compassion and SCC were assessed before providing spiritual care, and compassion training was also emphasized. In order to effectively provide spiritual care, the compassion of HPCT has been reported as an important factor [41] In addition, the self-re ection process of HPCT enabled the HPCT members to discover meaning in their own profession as a prior education for spiritual care [6]. Riahi et al. [42] also emphasized the importance of the nurses' own professional meaning and commitment to spiritual care.
The differentiation of modules II, III, IV is the linking of spiritual needs based on the attributes of spirituality, spiritual issues, meaningcentered intervention, and objectives of intervention with evaluation using patient-reported outcomes (Supplementary 2). In addition, the implementation result was evaluated with one item (5-point scale) per initial issue, and nally, the effects of the meaning-centered spiritual care was evaluated with spiritual well-being (8 items, 5-point scale). Spiritual well-being is an important outcome criterion and is a core component of quality in oncology and palliative care [37].
For the composition of the main contents of meaning-centered intervention, systematic reviews, meta-analyses, and clinical trial literature published in the last ve years were analyzed [8, 10, 12-13, 23-25, 42]. The common purpose of MCI identi ed through analysis was to improve spiritual well-being by nding meaning in life even in painful situations including incurable diseases. The major contents of intervention were con rmed to be the essential characteristics of human existence (meaning of life, will to meaning, freedom of will, choice and responsibility, self-transcendence), and how to nd meaning (creativity, experience, attitude). Based on previous studies, the McSCTP-HPCT was composed to help patients nd the meaning of life through their own strengths, creativity, positive experiences, and attitude modi cation based on four main theoretical concepts ( nding meaning, attitudinal modi cation, awareness of responsibility, selftranscendence) proposed in logotherapy Most previous studies which applied MCI to patients with an advanced or terminal illness or in an unavoidable suffering situation were designed as group interventions, with eight sessions lasting 90-120 minutes per session with lectures, discussion, reading and selfre ection as individual tasks [23][24][25] Two studies, which applied MCI to improve job satisfaction and QoL among palliative care nurses [12][13], were designed with four sessions of group intervention, lasting 120180 minutes per session. The teaching methods were didactic presentations, discussions, experiential exercises, and home exercises, similar to those of McSCTP-HPCT in this study. The educational methods of these previous studies were planned around ve sessions, 240 minutes per session, and group intervention.
In Module V, the overall implementation process of meaning-centered care by HPCTs was presented. Puchalski et al. [18] pointed out the importance of spiritual care in palliative care settings and provided clari cation about who should provide spiritual care and the role of health care team providers in spiritual caring. To date, although the importance of spiritual care was emphasized by some researchers, spiritual care was not provided systematically especially for the patients with life threatening conditions because of the insu cient preparedness of the HPCT [7]. The spiritual assessment, the third stage of spiritual assessment presented by ISPEC, included a question that could con rm the spiritual resources of patients (Supplementary 1) [29]. These are questions that can lead to spiritual resources shown in the Medicine Chest, one of the logotherapy counseling techniques [29]. Therefore, HPCTs must pay attention to and care for their patients' spirituality carefully. Part of their role is to safeguard patients' spirituality. Accordingly, they are able to help patients cope with their terminal illness and treatment using the de ant power in spirituality [10]. Lewis et al [43] also reported that patients' spirituality helps them make sense of their lives and feel whole, hopeful, and peaceful even in the midst of a serious illness. In addition, it also helps clinicians to conceptualize and plan subsequent treatment.
Furthermore, the 12 spiritual issues presented in the ISPEC guidelines [5] were adjusted as follows to nine issues suitable for Korean culture: meaning ("despair/hopelessness" and "lack of meaning and purpose [existential]"), interconnectedness ("anger at God or others", "guilt/shame", "grief/loss", "reconciliation", and "abandonment by God or others/isolation"), transcendence ("concerns about relationship with deity" and "con icted or challenged belief systems"). This imply that the frameworks and contents of spiritual care training should consider variations according to cultural differences, although still following the global standard guideline [44][45][46].

Preliminary Evaluation
In the preliminary evaluation, three outcomes (CF, SCC, and SCT) were chosen to measure the changes in the spiritual care competencies of HPCTs. CF was tested to identify HPCTs' own self-preparedness, SCC was used to evaluate their ability [27], and SCT was used to measure the frequencies of HPCT-provided spiritual care [33]. In Iran, a study regarding the effects of spiritual intelligence training for critical care nurses showed no signi cant effects on SCC until four weeks after the intervention [42]. On the other hand, in this study, in the rst postmeasurement, all three variables (CF, SCC, and SCT ) showed signi cant differences compared to the pretest scores, but in the measurements after four weeks, only SCC was maintained signi cantly. The reason that the maintenance effect in CF and SCT was shortlived may be speculatively attributed to the fact that it was di cult to apply the contents of McSCTP-HPCT continuously after training because only one or two people per institution participated. Therefore, we recommend that all HPCTs at the institution participate in the McSCTP-HPCT, and continuous application and evaluation should be established at the same time [42,47].

Clinical Implications
Spiritual care education is one of the core categories of interprofessional team training in hospice/palliative care settings [18,[42][43][44][45][46][47]. We, the authors, expect that the spiritual training program will help HPCTs understand the techniques they can use to provide effective spiritual care for their patients. Therefore, McSCTP-HPCT may facilitate the development and improvement of HPCT members' competence at providing spiritual care to diverse patients and their families with life-limiting illnesses or conditions.
In addition, we expect this study will highlight the importance of spiritual care training which can impact on spiritual well-being in patients with life-threatening illness. Considering that the purpose of spiritual care is to ease patients' di culties and help them to nd meaning in life and to improve their spiritual well-being [8], the McSCTP-HPCT developed in this study will help patients' understand their own sense of value, nd meaning in their life, and provide them with spiritual well-being.

Limitations
The limitations of this study should be acknowledged. First, the McSCTP-HPCT is a training program to help HPCTs provide spiritual care with a focus on meeting the existential needs of patients. Communication, ethics, and religious care were not included in the educational content. Regarding communication, only the part of compassion training through re ective listening was dealt with, and the overall concept and domain of communication were not included. Second, McSCTP-HPCT was developed with a focus on the inpatient spiritual care implementation model of ISPEC, and, when considering the outpatient situation, program modi cation and further testing are required. Finally, a tool used to measure the CF of HPCT is necessary to verify objective validity for conceptualization. This tool should consist of themes (e.g., belief and attitudes around spirituality, knowledge, ability, and frequency about spiritual care) suggested by Harrad et al. [11] as an early sign of CF.

Conclusions
To better integrate spiritual care in clinical practice, it is necessary to create and increase the importance of spiritual care among HPCTs through effective training programs. For this study, a research proposal with the purpose, content, scope, method, and data analysis was submitted to the Research Ethics Committee. The ethical aspects were considered in the entire research process. IRB approval was obtained from Sahmyook University (2019017HR). The purpose and procedure of this study were fully explained to the team members working in the hospice palliative care eld who participated in the pilot test. The consent form was signed by the subjects who voluntarily agreed after it was explained that anonymity was guaranteed and participation could be withdrawn at any time according to the person's intention, and the surveyed data would never be used for any purpose other than research.

Consent for publication
Not applicable

Availability of Data and Materials
The data of this study can be obtained by any reasonable request from authors with permission of the National Research Foundation of Korea. If needed, please contact the author of this article.

Figure 1
The process of this study Figure 2