Developing an Educational Course in Spiritual Care: An Action Research Study at Two Danish Hospices

Round 1

Reviewer 1 Report

Overall, this is a good piece of work that can be of importance for practice. To strengthen this potential impact, I have some suggestions:

some major revisions that I recommend:

• explain what 'spiritual care' is to you as authors or at least how it was asked at the interviewees and/or interpreted by them. It seems to me that you took a broad definition whereby also existential themes were seen as spiritual care; spiritual care was not only seen as care for religious questions/practices and care for all issues regarding to a higher power.
• I liked your introduction where you refer to other authors and what is already known in the field. The barriers to give spiritual care are researched oftentimes as you describe yourself (lack of self-reflection, inadequate knowledge, lack of language,....). I do miss this reflection in the discussion. Are there any new findings? What is similar to other research? If there are new findings, do you think its related to your own Danish context or can they potentially be seen in other contexts as well? It's touched upon but can be more nuanced and elaborated in the discussion section that now most of the time only replicates the 'results' section.
• It was surprised that the research of for example Van Leeuwen is not mentioned. It's logical that a lot of Danish researchers are cited but reflections and research from other secularized contexts can be interesting as well. Results from for example the EAPC survey are mentioned but are not reflected upon in the discussion in relation to your own findings.

some minor revisions:

• line 485 ''own vulnerability' instead of one vulnerability
• line 171: rewrite sentence to make sure that authors are not mentioned three times
• line 245: hours instead of houra
• '2.2 participants': I understand that you wanted to add this paragraph but it repeats much of the information already given in '2.1 data generation'. This is confusing as a reader. Try to restructure this paragraphs.

other: I do appreciate the fact that it's action research and the focus was on making a good educational course. Too much of our research is limited to articles and books. I wonder whether it is possible to make the content of the course accessible to the readers (website, booklet) and referred to in your article? As such your findings can actually be used in practice.

Author Response

Response to Reviewer 1 Comments

Point 1: Explain what 'spiritual care' is to you as authors or at least how it was asked at the interviewees and/or interpreted by them. It seems to me that you took a broad definition whereby also existential themes were seen as spiritual care; spiritual care was not only seen as care for religious questions/practices and care for all issues regarding to a higher power.

Response 1: We have defined “Spirituality” in the manuscript and emphasized our definition of “spiritual care”. We have also added a table on the interview topics and examples of questions to the manuscript (table 2).

Point 2: I liked your introduction where you refer to other authors and what is already known in the field. The barriers to give spiritual care are researched oftentimes as you describe yourself (lack of self-reflection, inadequate knowledge, lack of language,....). I do miss this reflection in the discussion. Are there any new findings? What is similar to other research? If there are new findings, do you think its related to your own Danish context or can they potentially be seen in other contexts as well? It's touched upon but can be more nuanced and elaborated in the discussion section that now most of the time only replicates the 'results' section.

Response 2: We have added this in the discussion section, where we also broadens the discussion to international research and contexts, and particularly elaborate on HCPs competencies and education for providing Spiritual Care.

Point 3: It was surprised that the research of for example Van Leeuwen is not mentioned. It's logical that a lot of Danish researchers are cited but reflections and research from other secularized contexts can be interesting as well. Results from for example the EAPC survey are mentioned but are not reflected upon in the discussion in relation to your own findings.

Response 3: We have tended to focus too much on the Danish hospice context, and therefore have overseen several international studies and key authors. We have added several international studies in the introduction (including Leeuven) and these as well as the results from the EAPC survey are being addressed in the discussion.

Point 4 - some minor revisions:

• line 485 ''own vulnerability' instead of one vulnerability
• line 171: rewrite sentence to make sure that authors are not mentioned three times
• line 245: hours instead of houra
• '2.2 participants': I understand that you wanted to add this paragraph but it repeats much of the information already given in '2.1 data generation'. This is confusing as a reader. Try to restructure this paragraphs.

Response 4: Thank you for these comments – they have all been corrected in the manuscript. The validity section has been re-written, and the paragraph of 2.2 has been reorganized.

Point 5: I do appreciate the fact that it's action research and the focus was on making a good educational course. Too much of our research is limited to articles and books. I wonder whether it is possible to make the content of the course accessible to the readers (website, booklet) and referred to in your article? As such your findings can actually be used in practice.

Response 5: Thank you for your interest in our work. We are currently working on making the content available for Danish hospices and palliative care units through the websites of the Danish Hospice Association, and we will then translate this presentation to English and make it available internationally.

Reviewer 2 Report

Dear authors,

Thank you for this interesting paper on a relevant topic, using an innovative action research methodology. Your research methodology provides interesting results, and it seems to me that your emphasis on the need for (training of) vulnerability, reflexiveness, and a common spiritual language for hospice staff, is an important one. 

I have a few questions/suggestions, mostly concerning the presentation and organisation of your method and result section.

Methods:

105 – 115: could you be more specific on the reflection on practice phase by adding a table specifying the interview topics; and a table specifying the focusgroup topics

145 – 154: could you provide a table with characteristics of participants (eg: patients age & illness;  and staffs disciplines)

199 - 207 could you provide a table with initial themes as presented to the staff; and could you be more specific as to how you got from these initial themes to the three topics? A table with focusgroup topics could help here as well

Results:

In general:

- Please consider switching 3.1 framework for a flexible course design and the three topics (3.2 – 3.4). As a reader, I would like to first be introduced to the content of the training, before I am introduced to the format in which it is presented

- Could you be more specific on the perspective of the patients? The results seem to be written primarily from the perspective of the staff?

- Would it be possible to separate the different phases of the project (reflection in practice; action in practice (is this the same as the developing the curriculum?) and evaluation of the training) in the result section? This would help to understand the (status of) the results better. It is now sometimes confusing what a phrase like … is expected to… (346-348) or ….will improve … (375 – 378) means. Is this referring to literature? Or to the needs identified in the reflection in action phase?   

385 please provide a table with an overview of the curriculum

Discussion:

Please consider switching the framework for a flexible course design and the three topics here as well

Conclusions

514 – 515 can you make this claim re. improvement of spiritual care? This is no effect study, and it seems to me you have to be careful with these types of claims…   

Author Response

Response to Reviewer 2 Comments

Thank you for your comments and feedback.

Point 1: Methods:

105 – 115: could you be more specific on the reflection on practice phase by adding a table specifying the interview topics; and a table specifying the focusgroup topics

145 – 154: could you provide a table with characteristics of participants (eg: patients age & illness;  and staffs disciplines)

199 - 207 could you provide a table with initial themes as presented to the staff; and could you be more specific as to how you got from these initial themes to the three topics? A table with focusgroup topics could help here as well

Response 1: We have added a table on the interviews topics and examples of questions asked (table 2), as well as a table of the patients’ characteristics (table 1). However, we have not added a table on staff, as they we all female (except from one doctor) and they were all specialized within palliative care – we have clarified that in in the text. We also added a table on the action research process presented the process from initial themes to the three topics (table 3).  

Point  2: Results:

- Please consider switching 3.1 framework for a flexible course design and the three topics (3.2 – 3.4). As a reader, I would like to first be introduced to the content of the training, before I am introduced to the format in which it is presented

- Could you be more specific on the perspective of the patients? The results seem to be written primarily from the perspective of the staff?

- Would it be possible to separate the different phases of the project (reflection in practice; action in practice (is this the same as the developing the curriculum?) and evaluation of the training) in the result section? This would help to understand the (status of) the results better. It is now sometimes confusing what a phrase like … is expected to… (346-348) or ….will improve … (375 – 378) means. Is this referring to literature? Or to the needs identified in the reflection in action phase?   

385 please provide a table with an overview of the curriculum

Response 2: We have switched section 3.1. to 3.4 as suggested. Thank you for this suggestion.

The perspectives of the patients have been emphasized in the manuscripts, however, as they all died short time after the interviews, their involvement in the action research process was centered on the initial phases and to inform and be the starting point for the staff's reflections and process.

 We have clarified the different phase of the action research process in the results section by relating it to the structure of the action research process presented in table 3.

We have also added a table (table 4) presenting an overview of the flexible curriculum.

Point 3: Discussion: Please consider switching the framework for a flexible course design and the three topics here as well

Response 3: In the discussion we now apply the same structure as 3.1-3.4 as presented in the results section.

Point 4: Conclusions

514 – 515 can you make this claim re. improvement of spiritual care? This is no effect study, and it seems to me you have to be careful with these types of claims… 

Response 4: Thank you for this comment. You are right, and we have changed it in the manuscript.

Reviewer 3 Report

Thank you for this submission and for your work in the field.

The paper, while largely well written, has several issues that need addressing before the paper could be considered for publication. This is an outline of the issues identified [this is not exhaustive]:

1. The literature is surprisingly out of date an is over reliance on papers from the country of origin of the research [without any clear justification for this].
2.  There is a surprising omission of key authors in the field of spirituality and healthcare - the literature cited seems to be very selective and arbitrary [not systematic].
3. Competencies required for health care professionals have not been addressed [see EPICC for example:Enhancing Nurses and Midwives' Competence in Providing Spiritual Care through Innovation, Education and Compassionate Care (EPICC) (2019) http://epiccproject.wixsite.com/epicc
4. The literature ought to cite other approaches to health care worker education e.g: Timmins, F., Neill, F., Quinn-Griffin, M., Kelly, J. & DeLa Cruz, E. (2014) Spiritual Dimensions of Care: Developing an Educational Package for Nurses in the Republic of Ireland Holistic Nursing Practice 28(2): 106–123.
5. Spirituality needs definition.
6. Validity is not the correct terminology for rigour in qualitative research. This section needs to address transferability, auditability, confirmability etc
7. The discussion is simply a repeat of the findings, even so far as the themes frame the discussion. This is not appropriate. The discussion should compare the findings with international literature.
8. The limitations ought to be more specific and provide a balanced and honest account of the weaknesses of the study and the approach. Action research is by its nature subjective, and this must be drawn out. The language and wording of the limitations section needs attention. This statement is not correct: " This means that the results of this study cannot be generalized to all clinical se tings and that further research in other areas of the health sector will be needed" - the study cannot be generalised in any case given the approach taken.  These sentences dont make sense:"Secondly, the action-based method is vitiated by a quite large consumption of resources. Therefore,  economy is always a significant factor in action-based research. Thirdly, and significantly,  the dying patients' statements cannot, for good reasons, be evaluated over time, as is the case, for example, with hip and knee patients".

The changes required to this paper are substantive and the manuscript requires a full rewrite and restructuring. A systematic search of the literature to include uptodate and relevant research is key and this needs to be reflected in a robust discussion that provides clear advice for practitioners internationally.

Author Response

Response to Reviewer 3 Comments

Thank you for your review. Thanks to you, we believe, the manuscript has been improved.

Point 1:The literature is surprisingly out of date an is over reliance on papers from the country of origin of the research [without any clear justification for this].

Response 1: We have broadened the use of literature to include up-to-date and international research in the field.

Point 2: There is a surprising omission of key authors in the field of spirituality and healthcare - the literature cited seems to be very selective and arbitrary [not systematic].

Response 2: Thank you for these comments. We have definitely focused too much on the Danish hospice context, and therefore have overseen several studies and key authors. We have search the literature more thorough and broadened the literature of the introduction.

Point 3: Competencies required for health care professionals have not been addressed [see EPICC for example:Enhancing Nurses and Midwives' Competence in Providing Spiritual Care through Innovation, Education and Compassionate Care (EPICC) (2019) http://epiccproject.wixsite.com/epicc

Response 3: Thank you for this comment and recommendation. We have added several studies on HCPs competencies and education for providing Spiritual Care (Including the EPICC network), which we also discuss in relation to the findings of the study.

Point 4: The literature ought to cite other approaches to health care worker education e.g: Timmins, F., Neill, F., Quinn-Griffin, M., Kelly, J. & DeLa Cruz, E. (2014) Spiritual Dimensions of Care: Developing an Educational Package for Nurses in the Republic of Ireland Holistic Nursing Practice 28(2): 106–123.

Response 4: Thank you for these comment and recommendations. We have added several studies on HCPs competencies and education for providing Spiritual Care.

Point 5: Spirituality needs definition.

Response 5: We have added clear definitions of “Spiritual needs” and “spirituality” in the introduction.

Point 6:Validity is not the correct terminology for rigour in qualitative research. This section needs to address transferability, auditability, confirmability etc

Response 6: We have elaborated on the section and we have named it “Rigour and trustworthiness”.

Point 7: The discussion is simply a repeat of the findings, even so far as the themes frame the discussion. This is not appropriate. The discussion should compare the findings with international literature.

Response 7: We have re-written the introduction and discussion, where we focus on discussing the findings of the study in relation to both more international studies and HCPs competencies and education for providing Spiritual Care.

Point 8: The limitations ought to be more specific and provide a balanced and honest account of the weaknesses of the study and the approach. Action research is by its nature subjective, and this must be drawn out. The language and wording of the limitations section needs attention. This statement is not correct: " This means that the results of this study cannot be generalized to all clinical se tings and that further research in other areas of the health sector will be needed" - the study cannot be generalised in any case given the approach taken.  These sentences dont make sense:"Secondly, the action-based method is vitiated by a quite large consumption of resources. Therefore,  economy is always a significant factor in action-based research. Thirdly, and significantly,  the dying patients' statements cannot, for good reasons, be evaluated over time, as is the case, for example, with hip and knee patients".

Response 8: Thank you for your specific and thorough comments. We have rewritten the limitation section.