Professional skills on the spiritual dimension. A mixed methods evaluation of a multicomponent intervention for nursing home teams

Professional skills on the spiritual dimension. 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A mixed methods evaluation of a multicomponent intervention for nursing home teams Niecky Fruneaux, Anke Persoon, Ewald Bronkhorst, Yvonne Engels This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5241737/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Dec, 2025 Read the published version in BMC Nursing → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Moving to a nursing home has a major existential impact on the lives of residents and their relatives. In particular, healthcare professionals who have daily contact with residents have many opportunities to pay attention to existential and spiritual issues. We aimed to increase awareness of the spiritual dimension to understand how healthcare professionals evaluate their spiritual competencies, which coaching questions they have and which spiritual skills can be observed in daily practice after a multicomponent intervention, comprising training, team intervision and individual coaching on the job. Methods: To implement the intervention in two nursing home teams, we performed action research. The participants were mainly certified nurse assistants and client support workers. The training was evaluated with the Spiritual Care Competency Scale (SCCS). Paired-samples t-tests were used to compare the sum scores of the scales of the pre- and posttests of the SCCS (n=24 participants). Thematic analysis was used to analyse the different coaching questions. Observations during individual coaching-on-the-job were analysed via deductive content analysis. Results: The sum scores of the scales and subscales significantly increased between the pre- and posttests. The awareness of participants’ own role in contact with residents was mentioned frequently in the coaching questions. Increased awareness of one’s role in contacts was also reported. Additionally, participants without specific coaching questions appreciated the feedback. [NF1] These observations provide valuable insight into the application of different spiritual skills: aligning, connecting and deepening. Many different actions in response to residents’ needs are observed when healthcare professionals pay attention to what is particularly important. Conclusions: Increasing SCCS scores indicate that the intervention improved spiritual competencies. Trainingand individual coaching were helpful for increasingawareness and translating theories and tools during the daily work of healthcare professionals in a nursing home. [NF1]Even iets over toevoegen in discussie en conclusie Background Moving to a nursing home has a major existential impact on the lives of residents and their relatives. (van der Leer 2023) People who move to a nursing home leave their familiar surroundings behind. Everything changes in relationships and the wider social network. In a nursing home, the resident is confronted with constantly changing healthcare professionals and fellow residents that they have not chosen themselves. Furthermore, people must deal with one or more conditions that put their mobility and autonomy to the test. People realize that the nursing home will be their last place to live. In addition, especially the most fragile elderly go to a nursing home, often in the last stage of life. (ten Koppel 2023, van der Priem 2024) This means that one must learn to live with increasing dependence and imminent death. Even excellent care cannot take away this existential upheaval. It requires a lot of sensitivity of healthcare professionals to attune to it. Moreover, it requires the awareness that care on the spiritual dimension is more about being (present with attention) than about doing (problem solving). (van der Leer 2023) Many existential questions and themes arise that require attention, a sympathetic ear and thinking along. Although a spiritual caregiver can offer support and guidance during one or more contact moments, healthcare professionals who have daily contact with residents have many opportunities to pay attention to the spiritual dimension. However, as someone usually does not directly say what concerns him/her most, it can be difficult for healthcare professionals to recognize this. (van Meurs, Smeets et al. 2018) Many healthcare professionals feel insufficiently competent in this area. (van Meurs, Smeets et al. 2018) At the same time, it is worth exploring where healthcare professionals are unconsciously competent on the dimension of spirituality, as they already encounter the existential impact of living in a nursing home for residents and their relatives in their daily work. Indeed, the initial educational programs for healthcare professionals pay very little or no attention to the spiritual dimension or how to recognize and respond to issues and questions that may concern someone. For these reasons, the Dutch Existential and Spiritual Aspects of Palliative Care multidisciplinary guideline was developed to provide support for healthcare professionals in integrating the spiritual dimension in healthcare. (IKNL 2018) The guideline offers guidance in identifying and exploring spiritual issues during daily practice. Integrating attention to meaning in life and spirituality during daily contact means that healthcare professionals can recognize and explore cues that residents and their relatives show, referring to what matters most to them. However, very little is known about the daily practice of healthcare professionals and what they need to translate the theory and tools of this guideline into their work. The aim of this study is to increase awareness of the spiritual dimension to understand how healthcare professionals evaluate their spiritual competencies, which coaching questions they have and which spiritual skills can be observed in daily practice after a multicomponent intervention. Methods Design This study was part of the action research ‘Insight into meaning’ (Zicht op zingeving) to implement an intervention focused on the integration of the spiritual dimension in the daily practice of healthcare professionals of two teams working in a nursing home. The study consisted of two action research cycles, each with preparation, action, evaluation and reflection. (Munten, Legius et al. 2012, van Lieshoud, Jabcobs and Cardiff 2017) Both cycles lasted 3.5 months. Intervention The spiritual dimension was defined as "a dynamic dimension of human life relating to the way individuals (individually and in community) experience, express, and seek meaning, purpose, and transcendence, and the way they connect to the moment, to self, to others, to nature, and to the significant and/or sacred" (Nolan, Saltmarsh and Leget 2011). This definition encompasses the meaning and purpose that life has for someone. It can vary from person to person and changes over the course of life. The attention that healthcare professionals have for the spiritual dimension was operationalized as follows: seeing, hearing and adequately responding to what is particularly on someone's mind. The practical intervention Insight into meaning consisted of three components: training, coaching and team intervision (see Table 1). The theoretical basis of the training was based on four concepts: the inner space of the professional, listening, being present with attention, and the layers of meaning of a statement (see Table 2). Setting and inclusion of participants The study was conducted in two wards: one ward with residents with mainly somatic diseases (18 residents) and one ward with residents with psychogeriatric diseases (36 residents) in a medium-sized nursing home institution (469 beds) in the eastern part of the Netherlands. This institution employs healthcare professionals ranging from client support workers to nurses, with the majority (44--56%) being certified nurse assistants. In addition, there are other healthcare professionals working in the department: doctors, physiotherapists, occupational therapists, logo therapists, psychologists, social workers and spiritual caregivers. Women make up a vast majority (91%) of healthcare professionals in the nursing home. All healthcare professionals from the two wards were invited to participate in the intervention and received financial compensation for the invested time outside working hours. The inclusion criteria were employment in one of these wards and providing informed consent. We aimed for the participation of approximately 2/3 of the healthcare professionals in the wards, but only 1/3 of them registered to participate (n=44). Especially after the first cycle, more healthcare professionals became interested and enthusiastic after the participants in this first cycle shared their experiences and stories. Data collection Data collection took place between October 2022 and March 2024. Information and informed consent forms were provided and obtained beforehand. Two sources of data were administered: the Spiritual Care Competence Scale (SCCS) for self-evaluating spiritual competencies and a registration form filled out by the five coaches for investigating the coaching questions and the observed competencies. Before and after the training, the participants completed the SCCS. The SCCS contains 27 questions with 5-point Likert scales ranging from 1 (totally disagree) to 5 (totally agree) with the following subscales: assessment and implementation of spiritual care; professionalization and improvement of the quality of spiritual care; personal support and patient counselling; referral to professionals; and attitudes towards patients’ spirituality and communication. (Leeuwen 2008) As the SCCS was developed for the hospital context, the questions were adjusted according to the situation in the nursing home. Four questions were excluded to make the questionnaire more suitable for healthcare professionals in nursing homes; these questions somewhat overlapped or were not applicable. Only the data of the participants in the second action research cycle (n=24) were used, as the practical intervention was adjusted after the evaluation phase of the first action research cycle. After each individual coaching session on the job (a maximum of two per participant), the coaches filled out a form with the participant’s coaching question and the observed competencies in relation to the content of the training: inner space, listening, being present with attention, layers of meaning) and applied skills (see Table 2). For practical reasons, 13 participants (54%) were included for analysis of the coaching; purposeful sampling was applied on the basis of the clarity of the registration forms and an even representation of the five coaches and participants of both wards. Data analysis Paired t-tests were used to compare the sum scores of the scales of the pre- and posttests of the SCCS (n= 24) before and after training, and t-tests for differences between nurses, nurse assistants and other healthcare professionals were performed via SPSS version 29. Qualitative data were coded line-by-line via Atlas.ti version 9. Thematic analysis was used to analyse the different coaching questions of the participants. (Braun and Clarke 2006) Observations of spiritual skills during individual coaching-on-the-job (n=13) were analysed via deductive content analysis. (Elo 2008) Observations were categorized on the basis of a previous study on skills on the spiritual dimension that emerged from reflexive thematic analysis of interviews with residents and relatives, namely, three themes and eight categories: aligning (being present with attention and recognizing individuality), connecting (attuning approach, attuning communication and building a care relationship) and deepening (deepening contacts and recognizing life-questions). (Fruneaux - van Amerongen 2024; submitted). 1) Aligning revolves around the skills of tuning in as a process and attitude of searching in contact: who is this person? What does he/she want or find important? An important aspect of alignment is the inner space of healthcare professionals. 2) Connecting is about seeking mutual involvement on the part of healthcare professionals in contact with residents and their loved ones. Something happens between two people in the (care)relationship. 3) Deepening revolves around the ability to explore the deeper meaning of an expression when signalling aspects of the spiritual dimension. Deepening entails that healthcare professionals dare to open up for and are curious about the spiritual dimension, different layers of meaning, and can ask inviting questions and name their observations in their contact with residents. In instances where observations do not conform to the current structure, new themes and categories can be introduced. However, any attempt to capture the complex reality of human contact into discrete categories will fall short in some way. Importantly, this categorization describes different skills and actions in practice that can be observed simultaneously. Ethical considerations This study was performed within Dutch law and good clinical practice guidelines. Since the study concerned the observation of routine care and participants were not subject to treatment or were required to behave in a certain way, the Medical Research Ethics Committee Oost-Nederland concluded that this study was not subject to the Medical Research Involving Human Subject Act (2022-13622). Written informed consent was obtained from all participants. To guarantee the anonymity of participants and clients, client characteristics, including quotes, were adjusted to prevent recognition that all participants were mentioned or quoted alike and as women. Clinical trial number: not applicable. Competing interests: The authors declare no competing interests. Funding This study was supported by Liemerije, Zevenaar and Radboudumc Nijmegen, the Netherlands. Funding was provided by ZonMW (project number 6390039261 ) . The funding agency had no role in the study design and procedures, participant recruitment, data collection and analysis and the preparation of the paper. Results Twenty-four healthcare professionals participated in the second research action phase of the practice intervention (see Table 3). Self-evaluation of spiritual competencies The response rate was 100% for the pretest and 79% for the posttest (n=24). Table 4 shows the outcomes of the pre- and posttests for self-evaluations with the SCCS. Nineteen self-evaluations were included in the analysis of differences between the pre- and posttests. The sum scores of the scales and subscales all significantly increased, indicating that the intervention improved spiritual competencies in these aspects. We found no significant differences between the outcomes of nurses plus certified nurse assistants (n=15) and those of other healthcare professionals (n=4) (p=>0.05). Individual coaching questions Most of the observed participants had one or more coaching questions. Most of the coaching questions were about the healthcare professionals’ own role in the conversation: giving more space (20%), deepening contacts (30%) and being present in the moment instead of focused on problem solving (30%). The questions about layers of meaning (20%) were about becoming aware of a theoretical framework in daily practice. Finally, balancing attention for the group and the individual shows the inner struggle of a healthcare professional to practice more space in contacts, while several other residents also need and/or ask attention. After the coaching session, the coaches reflected on what the participants had learned from the training and what might have helped them further develop their skills. The observations showed that individual coaching was useful for healthcare professionals to gain more awareness of a) their own role, b) questions about meaning in life and c) their own communication. Additionally, in many forms, the coaches mentioned statements of participants, showing d) their appreciation of receiving individual feedback for their development, whether they had a specific coaching question or not. The following quotes, written in the forms by the coaches, represented the skills that the participants were working on: a) How a participant became more aware of her own role in contacts: ‘When a colleague asked if the participant could stay longer, she took care of her own inner space by asking some time to think about this decision. When we talked about how to take care of your own inner space, she recognized that she made a more conscious choice that affected her inner space positively, even in the hustle and bustle.’ (Coach C, participant 22) b) Participants’ awareness of life questions and how these questions are also part of their personal daily life: ‘The participant gained more awareness that there are almost always 'hidden' questions of meaning during a conversation. Not only with a resident but also with themselves (calling with your own child before bedtime during your shift, like she does, for example) [as they discussed the hidden life-question this call had for the participant]. ’ (Coach B, participant 8) c) Participants’ awareness of their own communication: ‘The participant was not aware that she was indeed already naming emotions [which was her coaching question] . She was happy to hear it!’ (Coach C, participant 14) d) appreciation of individual feedback: 'It provides recognition but also space to reflect on how you do your work. I think it is nice to hear positive points and receive constructive comments'. (Coach C, participant 11) Observed spiritual skills The observations of spiritual skills during individual coaching-on-the-job fit well into the three preformulated themes, on the basis of a previous study. In each theme, one or two categories were added, resulting in the following: 1) aligning; (managing inner space, being present with attention, recognizing individuality and listening), connecting (attuning approach, attuning communication and building a care relationship) and deepening (deepening contact, recognizing life-questions and layers of meaning). (Fruneaux - van Amerongen, submitted 2024). The three themes are described and discussed below. Importantly, we included the actions that participants took in response to residents or relatives as a part of these three themes. Aligning Aligning is about the attitudes and states of mind of healthcare professionals. Within the theme alignment, four categories of skills were observed: a) managing inner space, b) being present with attention, c) recognizing individuality and d) listening, of which managing inner space and listening were new categories added to the original theme Aligning. a) Managing inner space influences the ability to align and attune to the person with whom one is in contact. In three forms, the participants were reported to have a certain effusion of calmness and composure. Additionally, twelve examples of ways to expand inner space were reported that could be captured in three underlying actions: sharing experiences, taking a moment for oneself and realizing that one is not alone. Lessened inner space was reported in three forms. In one case, the participant faced challenging situations in her private life that also affected her state of mind at work. In the second case, a workday with control tasks under a certain time pressure clearly affected the ability of a vocational trained nurse to remain open and empathic. In the third case, a colleague of the participant called in sick at the last minute. The stress and time pressure to provide the same care with fewer people lessened the inner space. ‘ A number of things that happened gave the participant recognition about her own She did not take over the conversation with her own story, but she did share what this is like for herself. In a careful, calm way. In this way , she also shows parts of herself and manages her inner space. It helped her to connect with the resident’ (Coach B, participant 8) b) Being presen t with attention was reported very frequently. To experience attention in the spiritual dimension, a certain attentive attitude that is inviting is an important condition.(Fruneaux - van Amerongen 2024) The observations provided more insight into struggles and examples of ways healthcare professionals try to remain present with attention during contact moments. Struggles especially occur in situations where several tasks are urgent and draw attention away from the resident. We observed remaining present with attention as follows: staying close, applying important information about the resident and remaining resident-oriented. ‘The participant sits in such a way that the residents can see they receive full The participant allows silence so that the residents have time to process. The participant also provides an opening for another topic that is also happening at the moment. Residents seem to feel at ease with this participant (they show their emotions and share memories”). (Coach A, participant 4) c) Acknowledging individuality was found in the data as follows: alignment with individual needs; sensing someone is different from usual; alignment with (im)possibilities; space for one’s own personality; and showing one’s individuality as a healthcare professional. A new insight is this last category, with examples of how healthcare professionals can use their own individuality to connect from person to person. An example of alignment with individual needs was a reported situation of a resident who needed to use the bathroom: ‘The resident is restless and keeps pacing around the living room. She wants to say something but cannot express herself. The resident is seated at the table by a colleague: “You must eat first”. The resident repeatedly gets up and walks towards the participant. The participant knows this resident well, as is clearly visible in the interaction. The participant immediately realizes that the resident needs to go to the toilet. The relief is visibly great when she notices that she is understood’. (Coach A, participant 4) d) Listening was analysed to gain more insight into how healthcare professionals try to listen to residents. The results provide many examples of the listening attitudes of healthcare professionals in their daily work, resulting in the addition of a separate category of theme connections. The participants were observed to have an attentive listening posture, have the same eye level, apply silence, use nonverbal communication, show genuine interest, take a seat and let the resident lead the conversation. For example, ‘ When the resident is talking, the participant is silent, she has an attentive listening posture and allows silences to occur, so that the resident has space to talk. She hums in between, to confirm that she hears and understands, the resident. She also briefly summarizes what the resident said every now and then.’ (Coach A, participant 1) Connecting The theme Connecting is about a certain focus on another person and mutual involvement in contacts. Within the theme Connecting, three categories were observed: a) attuning communication; b) attuning approach; and c) building a care relationship. There is room for connection when the approach and (non)verbal communication are attuned to the resident and/or relative. Several ways were observed to building the care relationship. Based on the observations no new categories were added. For all categories, we found new information and examples of the actions participants took in practice that helped them connect with residents. a) By attuning communication, we mean (non)verbal exchange between people. We observed actions such as asking confirmation someone understood you; articulating clearly; engaging in nonverbal communication; summarizing; returning to topics; setting limits; consciously not responding to statements; and indicating what you are doing with each action and stating the purpose of a conversation. ‘She is there to congratulate him on his wins in a game he played. She quickly sees that these stimuli are becoming too much for him. However, she remains present , and if he resident does want something, she is there to pick up those signals. “I see you have a dry mouth, would you like some juice?” “Yes, please” he answers while at the same time making a dismissive gesture.’ (Coach C, participant 5) b) By attuning approach, we mean the way in which someone is treated. The action of healthcare professionals is appropriate in approach to the resident when they can adjust their approach. We found examples such as taking the necessary time, physical contact and adjusting tempo. ‘While dispensing medication, she always took time to pay attention to individual Sometimes with a joke, sometimes with an arm around someone of a compliment.’ (Coach C, participant 14) c) To build a care relationship, we observed building trust and reciprocity in daily practice. This quote gives an example of reciprocity we observed: ‘Did you see that? I was done , and I wanted to walk away , but then she said something else. Did you hear what she said? “I wish you all the health and happiness in your life.” All by herself. That is truly the greatest compliment I can receive from her.’ (Coach C, participant 5) Deepening Deepening revolves around interactive practices to further explore meaning. We identified three categories within the theme of Deepening: a) deepening contact; b) acknowledging life-questions; and c) layers of meaning. The last category is added on the basis of observations, mainly because this was also an important part of the practice intervention. a) Many examples were found of deepening contact in daily practice by asking further questions, providing space for one’s story, exploring meanings and naming emotions. Exploring meanings and naming emotions are new to this category, which is based on observations. It improves the understanding of what healthcare professionals can do to deepen their contacts. This quote shows deepening by exploring meaning : ‘What is that like for you, if you have always been able to do everything yourself with a busy job and then suddenly you have to leave everything to others?’ “Yes, I find it truly difficult. I truly cannot do anything myself anymore, you need someone else for everything” (…) “Powerless... is that how you feel?” “Yes, powerless yes.... (...) But you have no choice. We have nothing more to want.”’ (Coach C, participant 8) b) Recognizing life-questions was not observed very often. This is a specific skill that contributes to deepening. It is about seeing and naming questions that are complex and far-reaching for residents, relatives and colleagues. This example shows how some healthcare professionals can have an impact on their colleagues in the ward by increasing their awareness of life questions in practice: 'I am much more aware of it. Therefore, I truly focus much less on solutions. In addition, what also helps: I'm saying it out loud now. Like that gentleman. He suddenly became very ill, completely yellow. We are not going to send him to the hospital for treatment anymore. However, that is quite a thing here. Now I said out loud to colleagues: can this man die too? Later, a colleague came up to me and said, “I had not thought about it that way.”' (Coach C, participant 24) c) We found many examples of using the layers of meaning, helping healthcare professionals to deepen contacts, as a single statement can have different meanings that can be explored. As healthcare professionals were observed to explore different meanings in their contacts, the spiritual layer was least reported: ‘ She started the conversation with the “difficult resident” with a comment about the air conditioning (it was a hot day!) and it quickly became clear that something was bothering the client. She asked, “What exactly is going on?” After the resident responded, she first asked factual questions, and during the conversation, she also mentioned the residents’ emotions: “Why are you so angry?” and “it is okay to be sad about that.” She also asked further: “What makes you so sad?” (Coach C, participant 14) Discussion This study explored the awareness and self-evaluation of the spiritual competencies of healthcare professionals in a nursing home, their coaching questions and observed spiritual skills in daily practice. After an intervention consisting of training, team intervision and individual coaching on the job, the spiritual competence of the participants increased significantly. Awareness of the spiritual dimension was frequently mentioned throughout the intervention. The coaching questions of the participants focused on the role of the professional in the conversation, and many examples of practicing the three needed spiritual skills, alignment, connecting and deepening, were observed. Furthermore, different actions to pay attention to the spiritual dimension in daily practice were observed. The intervention and observations focused on the ability of healthcare professionals to pay attention to what is particularly on someone's mind. Our findings suggest how healthcare professionals are able to address the spiritual dimension. Not as a separate subject, but as truly integrated in their daily work by being open and aware. The data revealed the nature of the contacts and how they pay attention to what is truly important for residents and their relatives. The skills of healthcare professionals appeared to be crucial in paying attention to the daily meaning in life of residents in a nursing home. This finding supports the notion of a difference between daily meaning in life and existential meaning in life. Daily meaning in life is about the meaning of personal life, whereas existential meaning in life concerns the question of the meaning of life in general (Reker, 2000). In psychological theories, existential meaning is often distinguished from daily meaning in life. (Westerhof and Bohlmeijer 2010) Religion, the philosophy of life and spirituality are then seen as possible sources from which people can derive meaning. In today's secularized society, religion and spirituality have become complex sources of meaning. People have come to see the meaning of life in more mundane terms. Work, relationships and one's own personal development have become more prominent (Westerhof and Bohlmeijer 2010). We found many examples of unconsciously competent, empathic and sensitive participants who pay attention to daily meaning in life of residents. The study increased our own understanding of and appreciation for the complex and mostly undervalued work of healthcare professionals in a nursing home, especially vocational trained nurses, certified nurse assistants and client support workers. These findings may lead to a re-evaluation of the importance of ‘daily meaning in life’ and the important role healthcare professionals must pay attention to the spiritual dimension. We suggest paying more attention to and appreciating the impact of healthcare professionals on the daily meaning in life of residents. Contrary to our expectations, the role of the coaches turned out to be less focused on applying new knowledge and skills from the training. Many participants wanted to reflect and receive more general feedback on communication. The coaches needed to attune themselves to the participants and what was happening in that moment of observation, resulting in many examples of skills, attitudes and behavior put into practice that helped participants align, connect and deepen their communication. These results are in line with insights into effective workplace learning, closely tailoring learning to the situation and learning preferences of individual healthcare professionals. (Clus 2011, Hager 2011, Ruijters and Simons 2020, Goedmakers 2021) We recommend ensuring some kind of workplace learning, as healthcare professionals may greatly benefit from it. Most participants mentioned the personal and professional impact of the practice intervention. It is important to reflect on the consequences and impact of expecting spiritual competency of healthcare professionals. Because in our study, we noticed that healthcare professionals became more open and receptive to their own existential issues, pain, sadness and disappointment in life and that of others. Although it is known that healthcare professionals experience great job satisfaction when they see that they can mean something to someone, this is commonly used as an argument for integrating spiritual care in daily practice. (Vlasblom, van der Steen et al. 2011, van de Geer, Veeger et al. 2018), we simultaneously observed that it demands a lot of healthcare professionals to be confronted with existential pain. We need to pay attention to the impact on individual healthcare professionals. This finding was also reported by other studies with coaching-on-the-job on the spiritual dimension. (Hupkens, Goumans et al. 2019, Modderkolk, van Meurs et al. 2023) We recommend attuning healthcare professionals’ individual needs, abilities and motivation when further integrating the spiritual dimension in daily practice instead of generally striving for increased spiritual competence after an intervention. Increased attention to the spiritual dimension generally makes healthcare professionals more aware of dilemmas. They frequently face situations where they have to make difficult choices between two or more undesirable alternatives for or about residents. Dealing with issues that arise in practice and being able to discuss them with colleagues in an accessible way, such as a collective intervision meeting or a moral deliberation, is needed to support professionals in these situations. This finding is consistent with observations of recent research on integrating attention for meaning in life and spirituality in home care. (Lectoraat Zorg en Zingeving 2023) We suggest that the increased personal and collective awareness and skills of professionals on the spiritual dimension can be supported by work processes and organizational structures. The qualitative observations overlapped with aspects of the SCCS subscales ‘Personal support and patient counselling’ and ‘Attitudes’. However, the current study suggests that ‘personal support and patient counselling’ entails much more than being able to have conversations about the spirituality of residents, as is the focus of the questionnaire. As the SCCS was initially developed for measuring competency in nurses working in hospitals, the categorization of the questionnaire does not fully cover the daily practice of healthcare professionals in long-term care. The observations in this study may indicate the need for a questionnaire that measures underlying attention, skills, attitudes and behavior in these competencies in the daily practice of healthcare professionals in long-term care. Importantly, the combination of a training duo, a spiritual caregiver and a vocational trained nurse or certified nurse assistant was fruitful and promising for continuation. It helps balance theory and practice in terms of the spiritual dimension. We suggest developing a train-the-trainer for duos and further elaborating the role of the spiritual caregiver and other healthcare professionals, who can combine their experiences and knowledge to help translate tools and theories on the spiritual dimension into daily practice. Strengths and limitations To our knowledge, this is the first study to provide insight into specific competencies and ways healthcare professionals can open up to the spiritual dimension of residents in a nursing home in daily practice. The study was conducted after a thorough process of cocreation with different stakeholders, which strengthened the commitment and support within the organization. However, our study also has limitations. First, the main researcher combined this study with performing a practical intervention, which might have caused bias. We minimized this risk by working together with different coaches and analysing the data with two researchers who were not involved in the practice intervention. Second, health records were outside the scope of this study. Very few examples of conversations and written reports between healthcare professionals about the spiritual dimension were found. Consequently, the current study does not provide much information about how spiritual care is addressed between healthcare professionals. Finally, the practice intervention was carried out in one nursing home in the Netherlands, and generalizability to other healthcare settings is unknown. Conclusion Training, intervision meetings and coaching on the job significantly increased the spiritual care competence of the participating healthcare professionals in a nursing home, especially certified nurse assistants and client support workers. Individual coaching on the job helped participants answer their personal coaching questions and become more aware of their spiritual skills in daily practice and their own role in contact with residents. The observations in this study revealed skills in aligning, connecting and deepening the conversation and may lead to a re-evaluation of the importance of ‘daily spirituality’ and the role of healthcare professionals on the spiritual dimension. This study provides insight into the daily practices of healthcare professionals, showing how daily actions are, in fact, very important for making use of the many opportunities to pay attention to the existential and spiritual issues of residents in a nursing home. This study also revealed the importance of addressing the impact of integrating the spiritual dimension into practice instead of only striving for increased spiritual competencies. Furthermore, theories and tools could be translated into the daily work of healthcare professionals in a nursing home by balancing theory and practice through training in duos of a spiritual caregiver and other healthcare professionals. When considering the existing structures in the organization, we are positive that practice interventions that combine collective and individual learning help embed the spiritual dimension in the daily practice of healthcare organizations. Abbreviations Spiritual Care Competency Scale (SCCS). Declarations Funding This study was supported by Liemerije, Zevenaar and Radboudumc Nijmegen, the Netherlands. Funding was provided by ZonMW (project number 6390039261). The funding agency had no role in the study design and procedures, participant recruitment, data collection and analysis and the preparation of the paper. Author Contribution N. A. and Y. wrote the manuscript text.E. performed the statistical analysis.Alle authors reviewed the manuscript. Acknowledgement We like to thank all healthcare professionals, relatives and residents who were involved in the practice intervention of 'Insight into meaning' on Tesma 3 and de Meridiaan of Liemerije. Special thanks to the coaches-on-the-job and supervisors: Anne Slöetjes, Kathleen Beihsner, Crista Hoeksma, Janique van Schaijk, Nicolette Hijweege and Wim Smeets. Data Availability https://doi.org/10.17026/LS/S6KTS References Baart, A. (2005). Aandacht, Etudes in presentie. (Attention, Etudes in presence) Utrecht, Uitgeverij Lemma. Baart, A. and M. Grypdonck (2008). Verpleegkunde en presentie. Een zoektocht in dialoog naar de betekenis van presentie voor verpleegkundige zorg. (Nursing and presence. A search in dialogue for the meaning of presence for nursing care) Den Haag, Uitgeverij Lemma. Braun, V. and V. Clarke (2006). "Using thematic analysis in psychology." Qualitative Research in Psychology 3 : 77-101. Clus, M. (2011). "Informal learning in the workplace: A review of the literature." Australian Journal of Adult Learning 51 : 355-373. Elo, S., Kyngäs, H. (2008). "The qualitative content analysis process." Journal of Advanced Nursing 61 (1): 107-115. Fruneaux - van Amerongen, N. P., A. Engels, Y. (2024). "[Attention to what is really important: residents of a nursing home and their loved ones about spiritual skills of healthcare workers.]" Tijdschrift voor Geriatrie en Gerontologie (in press) . Goedmakers, G. W., Burger, Y., & Ruijters, M. (2021). "Professional Identity Development of Executive Coaches." Amsterdam in Science, Business and Society 3 : 57-58. Hager, P. (2011). The SAGE Handbook of Workplace Learning. London, SAGE Publications Ltd. Hijweege, N. e. S., W (2024). Luisteren met ruimte (Listening with space), Uitgeverij van Warven. Hupkens, S., et al. (2019). "Meaning in life of older adults in daily care: A qualitative analysis of participant observations of home nursing visits." J Adv Nurs 75 (8): 1732-1740. IKNL (2018). Existential and Spiritual Aspects of Palliative Care. National guideline : 96. Lectoraat Zorg en Zingeving, A. H. C., Hogeschool Viaa (2023). Rapportage leernetwerk 3. Participatief Actieonderzoek 'Verbinden werken tussen geestelijke verzorging en zorg thuis'. (Learning network report 3. Participatory Action Research 'Connecting spiritual care and care at home) Leeuwen, R. v. (2008). Towards nursing competencies in spiritual care. Groningen - Ede, SHARE eigen beheer. Leget, C. (2003). Ruimte om te sterven. Een weg voor zieken, naasten en zorgverleners. (Space to die. A path for the sick, loved ones and healthcare providers) Tiel, Uitgeverij Lannoo. Modderkolk, L., et al. (2023). "Effectiveness of Meaning-Centered Coaching on the Job of Oncology Nurses on Spiritual Care Competences: A Participatory Action Research Approach." Cancer Nurs. Mohammed Javeed, A. (2024). Healing the Body and Soul: A Comprehensive Review of Spiritual Nursing Care. Munten, G., et al. (2012). Practice Development. Naar duurzame verandering van zorg- en onderwijspraktijken. (Towards sustainable change in healthcare and education practices) Den Haag, Boom Lemma uitgevers. Nolan, S., et al. (2011). "Spiritual care in palliative care : Working towards an EAPC task force." European Journal of Palliative Care: 86-89. Pesut, B. (2006). "Fundamental or foundational obligation? Problematizing the ethical call to spiritual care in nursing." ANS Adv Nurs Sci 29 (2): 125-133. Reker, G.T. (2000). Theoretical perspective, dimensions, and measurement of existential meaning. In Reker, G.T. & Chamberlain, K. (Eds.) Exploring existential meaning: optimizing human development across the life span (pp.39-58). Thousand Oaks, CA: Sage. Ruijters, M. and P. R. J. Simons (2020). "Connecting professionalism, learning and identity." Eesti Haridusteaduste Ajakiri. Estonian Journal of Education 8 : 32-56. ten Koppel, M. G., J. J. van Dijk, C. (2023). Monitor Verblijfsduur van verpleeghuisbewoners met een Wlz indicatie Verpleging en Verzorging, Zorginstituut Nederland. (Length of stay monitor of nursing home residents with a Wlz indication for Nursing and Care, Zorginstituut Nederland.) van de Geer, J., et al. (2018). "Multidisciplinary Training on Spiritual Care for Patients in Palliative Care Trajectories Improves the Attitudes and Competencies of Hospital Medical Staff: Results of a Quasi-Experimental Study." American Journal of Hospice and Palliative Medicine® 35 (2): 218-228. van der Leer, N. (2023). "Zingeving in het verpleeghuis." (Meaning in the nursing home) Nurse Academy O&T 4 : 4. van der Priem, M. (2024). Verblijfsduur verpleeghuis vaak langer dan twee jaar. (Length of stay in a nursing home is often longer than two years.) https://www.actiz.nl/verblijfsduur-verpleeghuis-vaak-langer-dan-twee-jaar, Actiz. van Lieshoud, F., et al. (2017). Actieonderzoek. Principes en onderzoeksmethoden voor participatief veranderen. (Action research. Principles and research methods for participatory change.) Assen, Uitgeverij Koninklijke Van Gorcum. van Meurs, J., et al. (2018). "Nurses Exploring the Spirituality of Their Patients With Cancer: Participant Observation on a Medical Oncology Ward." Cancer Nurs 41 (4): E39-e45. Vlasblom, J. P., et al. (2011). "Effects of a spiritual care training for nurses." Nurse Educ Today 31 (8): 790-796. Weiher, E. (2011). Das Geheimnis des Lebens berühren - Spiritualität bei Krankheit, Sterben, Tod. Eine Grammatik für Helfende. (Touching the mystery of life - spirituality in illness, dying, death. A grammar for helpers.) Stuttgart, Kohlhammer. Westerhof, G. and E. Bohlmeijer (2010). Psychologie van de levenskunst. (Psychology of the art of living.) Amsterdam, Boom. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tabel1.docx Tabel2.docx Tabel3.docx Tabel4.docx Cite Share Download PDF Status: Published Journal Publication published 12 Dec, 2025 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 22 Oct, 2024 Editor assigned by journal 22 Oct, 2024 Submission checks completed at journal 21 Oct, 2024 First submitted to journal 10 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5241737","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":368946943,"identity":"60ec84d0-430f-4f2a-87ad-974cfeff7f0c","order_by":0,"name":"Niecky Fruneaux","email":"data:image/png;base64,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","orcid":"","institution":"Liemerije","correspondingAuthor":true,"prefix":"","firstName":"Niecky","middleName":"","lastName":"Fruneaux","suffix":""},{"id":368946944,"identity":"eb8af5b3-3fec-4f0b-8037-e1eb3b211d0e","order_by":1,"name":"Anke Persoon","email":"","orcid":"","institution":"Radboud University Nijmegen Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Anke","middleName":"","lastName":"Persoon","suffix":""},{"id":368946946,"identity":"eea0e369-20a1-44bc-8a7c-71410fad8fa1","order_by":2,"name":"Ewald Bronkhorst","email":"","orcid":"","institution":"Radboud University Nijmegen Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ewald","middleName":"","lastName":"Bronkhorst","suffix":""},{"id":368946947,"identity":"df39e815-277b-44ac-b16e-9e842c74a367","order_by":3,"name":"Yvonne Engels","email":"","orcid":"","institution":"Radboud University Nijmegen Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Yvonne","middleName":"","lastName":"Engels","suffix":""}],"badges":[],"createdAt":"2024-10-10 18:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5241737/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5241737/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-04089-3","type":"published","date":"2025-12-12T15:57:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":98243498,"identity":"93eedd7c-944a-4e92-a733-2c2e20c4f78d","added_by":"auto","created_at":"2025-12-15 16:07:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":518667,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5241737/v1/e9c812c2-1007-4990-aa64-f90017adfaea.pdf"},{"id":68281397,"identity":"7fc83173-2702-4dec-ae97-8db537a42f0f","added_by":"auto","created_at":"2024-11-05 15:24:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16780,"visible":true,"origin":"","legend":"","description":"","filename":"Tabel1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5241737/v1/cc92a83305900d04f3009f8f.docx"},{"id":68281395,"identity":"5bbd693f-0220-47d8-929d-d319af996dfe","added_by":"auto","created_at":"2024-11-05 15:24:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21724,"visible":true,"origin":"","legend":"","description":"","filename":"Tabel2.docx","url":"https://assets-eu.researchsquare.com/files/rs-5241737/v1/930b6c188e363ab5c045eb6b.docx"},{"id":68281396,"identity":"8491378a-b464-4f6e-85b5-71e319a07bb9","added_by":"auto","created_at":"2024-11-05 15:24:14","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20805,"visible":true,"origin":"","legend":"","description":"","filename":"Tabel3.docx","url":"https://assets-eu.researchsquare.com/files/rs-5241737/v1/01ced59e3f51a5bbf108ceae.docx"},{"id":68281398,"identity":"acf32a6a-4288-4f7d-ab75-3bcd233eef86","added_by":"auto","created_at":"2024-11-05 15:24:15","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":13254,"visible":true,"origin":"","legend":"","description":"","filename":"Tabel4.docx","url":"https://assets-eu.researchsquare.com/files/rs-5241737/v1/cb01bcbb3956ad4632e8d52e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Professional skills on the spiritual dimension. A mixed methods evaluation of a multicomponent intervention for nursing home teams","fulltext":[{"header":"Background","content":"\u003cp\u003eMoving to a nursing home has a major existential impact on the lives of residents and their relatives.\u0026nbsp;(van der Leer 2023)\u0026nbsp;People who move to a nursing home leave their familiar surroundings behind. Everything changes in relationships and the wider social network. In a nursing home, the resident is confronted with constantly changing healthcare professionals and fellow residents that they have not chosen themselves. Furthermore, people must deal with one or more conditions that put their mobility and autonomy to the test. People realize that the nursing home will be their last place to live. In addition, especially the most fragile elderly go to a nursing home, often in the last stage of life.\u0026nbsp;(ten Koppel 2023, van der Priem 2024)\u0026nbsp;This means that one must learn to live with increasing dependence and imminent death. Even excellent care cannot take away this existential upheaval. It requires a lot of sensitivity of healthcare professionals to attune to it. Moreover, it requires the awareness that care on the spiritual dimension is more about being (present with attention) than\u0026nbsp;about\u0026nbsp;doing (problem solving).\u0026nbsp;(van der Leer 2023)\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Many\u0026nbsp;existential questions and themes arise that\u0026nbsp;require\u0026nbsp;attention, a sympathetic ear and thinking along.\u0026nbsp;Although a spiritual caregiver can offer support and guidance during one or more contact moments, healthcare professionals who have daily contact with residents have many opportunities to pay attention to the spiritual dimension. However, as someone usually does not directly say what concerns him/her most, it can be difficult for healthcare professionals to recognize this.\u0026nbsp;(van Meurs, Smeets et al. 2018)\u0026nbsp;Many healthcare professionals feel insufficiently competent in this area.\u0026nbsp;(van Meurs, Smeets et al. 2018)\u0026nbsp;At the same time, it is worth exploring where healthcare professionals are unconsciously competent on the dimension of spirituality, as they already encounter the existential impact of living in a nursing home for residents and their relatives in their daily work. Indeed, the initial educational programs for healthcare professionals pay very little or no attention to the spiritual dimension or how to recognize and respond to issues and questions that may concern someone.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; For these reasons, the Dutch Existential and Spiritual Aspects of Palliative Care multidisciplinary guideline was developed to provide support for healthcare professionals in integrating the spiritual dimension in healthcare. (IKNL 2018) The guideline offers guidance in identifying and exploring spiritual issues during daily practice. Integrating attention to meaning in life and spirituality during daily contact means that healthcare professionals can recognize and explore cues that residents and their relatives show, referring to what matters most to them. However, very little is known about the daily practice of healthcare professionals and what they need to translate the theory and tools of this guideline into their work. The aim of this study is to increase awareness of the spiritual dimension to understand how healthcare professionals evaluate their spiritual competencies, which coaching questions they have and which spiritual skills can be observed in daily practice after a multicomponent intervention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eDesign\u003c/em\u003e\u003cbr /\u003e This study was part of the action research \u0026lsquo;Insight into meaning\u0026rsquo; (Zicht op zingeving) to implement an intervention focused on the integration of the spiritual dimension in the daily practice of healthcare professionals of two teams working in a nursing home. The study consisted of two action research cycles, each with preparation, action, evaluation and reflection. (Munten, Legius et al. 2012, van Lieshoud, Jabcobs and Cardiff 2017) Both cycles lasted 3.5 months.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe spiritual dimension was defined as \u003cem\u003e\"a dynamic dimension of human life relating to the way individuals (individually and in community) experience, express, and seek meaning, purpose, and transcendence, and the way they connect to the moment, to self, to others, to nature, and to the significant and/or sacred\"\u003c/em\u003e (Nolan, Saltmarsh and Leget 2011). This definition encompasses the meaning and purpose that life has for someone. It can vary from person to person and changes over the course of life. The attention that healthcare professionals have for the spiritual dimension was operationalized as follows: seeing, hearing and adequately responding to what is particularly on someone's mind. The practical intervention Insight into meaning consisted of three components: training, coaching and team intervision (see Table 1). The theoretical basis of the training was based on four concepts: the inner space of the professional, listening, being present with attention, and the layers of meaning of a statement (see Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSetting and inclusion of participants\u003c/em\u003e\u003cbr /\u003e The study was conducted in two wards: one ward with residents with mainly somatic diseases (18 residents) and one ward with residents with psychogeriatric diseases (36 residents) in a medium-sized nursing home institution (469 beds) in the eastern part of the Netherlands. This institution employs healthcare professionals ranging from client support workers to nurses, with the majority (44--56%) being certified nurse assistants. In addition, there are other healthcare professionals working in the department: doctors, physiotherapists, occupational therapists, logo therapists, psychologists, social workers and spiritual caregivers. Women make up a vast majority (91%) of healthcare professionals in the nursing home.\u003c/p\u003e\n\u003cp\u003eAll healthcare professionals from the two wards were invited to participate in the intervention and received financial compensation for the invested time outside working hours. The inclusion criteria were employment\u0026nbsp;in one of these wards and providing informed consent. We aimed for the participation of approximately 2/3 of the healthcare professionals in the wards, but only 1/3 of them registered to participate (n=44). Especially after the first cycle, more healthcare professionals became interested and enthusiastic after the participants in this first cycle shared their experiences and stories.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData collection took place between October 2022 and March 2024. Information and informed consent forms were provided and obtained beforehand. Two sources of data were administered: the Spiritual Care Competence Scale (SCCS) for self-evaluating spiritual competencies and a registration form filled out by the five coaches for investigating the coaching questions and the observed competencies.\u003c/p\u003e\n\u003cp\u003eBefore and after the training, the participants completed the SCCS. The SCCS contains 27 questions with 5-point Likert scales ranging from 1 (totally disagree) to 5 (totally agree) with the following subscales: assessment and implementation of spiritual care; professionalization and improvement of the quality of spiritual care; personal support and patient counselling; referral to professionals; and attitudes towards patients\u0026rsquo; spirituality and communication. (Leeuwen 2008) As the SCCS was developed for the hospital context, the questions were adjusted according to the situation in the nursing home. Four questions were excluded to make the questionnaire more suitable for healthcare professionals in nursing homes; these questions somewhat overlapped or were not applicable. Only the data of the participants in the second action research cycle (n=24) were used, as the practical intervention was adjusted after the evaluation phase of the first action research cycle.\u003c/p\u003e\n\u003cp\u003eAfter each individual coaching session on the job (a maximum of two per participant), the coaches filled out a form with the participant\u0026rsquo;s coaching question and the observed competencies in relation to the content of the training: inner space, listening, being present with attention, layers of meaning) and applied skills (see Table 2). For practical reasons, 13 participants (54%) were included for analysis of the coaching; purposeful sampling was applied on the basis of the clarity of the registration forms and an even representation of the five coaches and participants of both wards.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePaired t-tests were used to compare the sum scores of the scales of the pre- and posttests of the SCCS (n= 24) before and after training, and t-tests for differences between nurses, nurse assistants and other healthcare professionals were performed via SPSS version 29. Qualitative data were coded line-by-line via Atlas.ti version 9. Thematic analysis was used to analyse the different coaching questions of the participants. (Braun and Clarke 2006) Observations of spiritual skills during individual coaching-on-the-job (n=13) were analysed via deductive content analysis. (Elo 2008) Observations were categorized on the basis of a previous study on skills on the spiritual dimension that emerged from reflexive thematic analysis of interviews with residents and relatives, namely, three themes and eight categories: aligning (being present with attention and recognizing individuality), connecting (attuning approach, attuning communication and building a care relationship) and deepening (deepening contacts and recognizing life-questions). (Fruneaux - van Amerongen 2024; submitted).\u003c/p\u003e\n\u003cp\u003e1) \u003cem\u003eAligning\u003c/em\u003e revolves around the skills of tuning in as a process and attitude of searching in contact: who is this person? What does he/she want or find important? An important aspect of alignment is the inner space of healthcare professionals. 2) \u003cem\u003eConnecting\u003c/em\u003e is about seeking mutual involvement on the part of healthcare professionals in contact with residents and their loved ones. Something happens between two people in the (care)relationship. 3) \u003cem\u003eDeepening\u003c/em\u003e revolves around the ability to explore the deeper meaning of an expression when signalling aspects of the spiritual dimension. Deepening entails that healthcare professionals dare to open up for and are curious about the spiritual dimension, different layers of meaning, and can ask inviting questions and name their observations in their contact with residents. In instances where observations do not conform to the current structure, new themes and categories can be introduced. However, any attempt to capture the complex reality of human contact into discrete categories will fall short in some way. Importantly, this categorization describes different skills and actions in practice that can be observed simultaneously.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical considerations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed within Dutch law and good clinical practice guidelines. Since the study concerned the observation of routine care and participants were not subject to treatment or were required to behave in a certain way, the Medical Research Ethics Committee Oost-Nederland concluded that this study was not subject to the Medical Research Involving Human Subject Act (2022-13622). Written informed consent was obtained from all participants. To guarantee the anonymity of participants and clients, client characteristics, including quotes, were adjusted to prevent recognition that all participants were mentioned or quoted alike and as women. Clinical trial number: not applicable. Competing interests: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was supported by Liemerije, Zevenaar and Radboudumc Nijmegen, the Netherlands. Funding was provided by ZonMW (project number \u003cstrong\u003e6390039261\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e. The funding agency had no role in the study design and procedures, participant recruitment, data collection and analysis and the preparation of the paper.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-four healthcare professionals participated in the second research action phase of the practice intervention (see Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-evaluation of spiritual competencies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe response rate was 100% for the pretest and 79% for the posttest (n=24). Table 4 shows the outcomes of the pre- and posttests for self-evaluations with the SCCS. Nineteen self-evaluations were included in the analysis of differences between the pre- and posttests. The sum scores of the scales and subscales all significantly increased, indicating that the intervention improved spiritual competencies in these aspects. We found no significant differences between the outcomes of nurses plus certified nurse assistants (n=15) and those of other healthcare professionals (n=4) (p=\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndividual coaching questions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost of the observed participants had one or more coaching questions. Most of the coaching questions were about the healthcare professionals\u0026rsquo; own role in the conversation: giving more space (20%), deepening contacts (30%) and being present in the moment instead of focused on problem solving (30%). The questions about layers of meaning (20%) were about becoming aware of a theoretical framework in daily practice. Finally, balancing attention for the group and the individual shows the inner struggle of a healthcare professional to practice more space in contacts, while several other residents also need and/or ask attention.\u003c/p\u003e\n\u003cp\u003eAfter the coaching session, the coaches reflected on what the participants had learned from the training and what might have helped them further develop their skills. The observations showed that individual coaching was useful for healthcare professionals to gain more awareness of a) their own role, b) questions about meaning in life and c) their own communication. Additionally, in many forms, the coaches mentioned statements of participants, showing d) their appreciation of receiving individual feedback for their development, whether they had a specific coaching question or not.\u003c/p\u003e\n\u003cp\u003eThe following quotes, written in the forms by the coaches, represented the skills that the participants were working on:\u003c/p\u003e\n\u003cp\u003ea) How a participant became more aware of her own role in contacts:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;When a colleague asked if the participant could stay longer, she took care of her own inner space by asking some time to think about this decision. When we talked about how to take care of your own inner space, she recognized that she made a more conscious choice that affected her inner space positively, even in the hustle and bustle.\u0026rsquo; \u003c/em\u003e(Coach C, participant 22)\u003c/p\u003e\n\u003cp\u003eb) Participants\u0026rsquo; awareness of life questions and how these questions are also part of their personal daily life:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;The participant gained more awareness that there are almost always 'hidden' questions of meaning during a conversation. Not only with a resident but also with themselves (calling with your own child before bedtime during your shift, like she does, for example) \u003c/em\u003e[as they discussed the hidden life-question this call had for the participant].\u003cem\u003e\u0026rsquo; \u003c/em\u003e(Coach B, participant 8)\u003c/p\u003e\n\u003cp\u003ec) Participants\u0026rsquo; awareness of their own communication:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;The participant was not aware that she was indeed already naming emotions \u003c/em\u003e[which was her coaching question]\u003cem\u003e. She was happy to hear it!\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e(Coach C, participant 14)\u003c/p\u003e\n\u003cp\u003ed) appreciation of individual feedback:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e'It provides recognition but also space to reflect on how you do your work. I think it is nice to hear positive points and receive constructive comments'.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e(Coach C, participant 11) \u003cstrong\u003e\u003cbr /\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObserved spiritual skills\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe observations of spiritual skills during individual coaching-on-the-job fit well into the three preformulated themes, on the basis of a previous study. In each theme, one or two categories were added, resulting in the following: 1) aligning; (managing inner space, being present with attention, recognizing individuality and listening), connecting (attuning approach, attuning communication and building a care relationship) and deepening (deepening contact, recognizing life-questions and layers of meaning). (Fruneaux - van Amerongen, submitted 2024). The three themes are described and discussed below. Importantly, we included the actions that participants took in response to residents or relatives as a part of these three themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAligning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAligning is about the attitudes and states of mind of healthcare professionals. Within the theme alignment, four categories of skills were observed: a) managing inner space, b) being present with attention, c) recognizing individuality and d) listening, of which managing inner space and listening were new categories added to the original theme Aligning.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ea) Managing inner space \u003c/em\u003einfluences the ability to align and attune to the person with whom one is in contact. In three forms, the participants were reported to have a certain effusion of calmness and composure. Additionally, twelve examples of ways to expand inner space were reported that could be captured in three underlying actions: sharing experiences, taking a moment for oneself and realizing that one is not alone. Lessened inner space was reported in three forms. In one case, the participant faced challenging situations in her private life that also affected her state of mind at work. In the second case, a workday with control tasks under a certain time pressure clearly affected the ability of a vocational trained nurse to remain open and empathic. In the third case, a colleague of the participant called in sick at the last minute. The stress and time pressure to provide the same care with fewer people lessened the inner space. \u003cbr /\u003e\u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003cem\u003eA number of things that happened gave the participant recognition about her own \u003c/em\u003e\u003cbr /\u003e \u003cem\u003e She did not take over the conversation with her own story, but she did \u003c/em\u003e\u003cbr /\u003e \u003cem\u003eshare what this is like for herself. In a careful, calm way. In this way\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e she also shows\u003c/em\u003e\u003cbr /\u003e \u003cem\u003eparts of herself and \u003c/em\u003e\u003cem\u003emanages\u003c/em\u003e\u003cem\u003e her inner space. It helped her to connect with the \u003c/em\u003e\u003cbr /\u003e \u003cem\u003eresident\u0026rsquo; \u003c/em\u003e(Coach B, participant 8)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb) Being presen\u003c/em\u003et with attention was reported very frequently. To experience attention in the spiritual dimension, a certain attentive attitude that is inviting is an important condition.(Fruneaux - van Amerongen 2024) The observations provided more insight into struggles and examples of ways healthcare professionals try to remain present with attention during contact moments. Struggles especially occur in situations where several tasks are urgent and draw attention away from the resident. We observed remaining present with attention as follows: staying close, applying important information about the resident and remaining resident-oriented. \u003cbr /\u003e\u003cem\u003e\u0026lsquo;The participant sits in such a way that the residents can see they receive full \u003c/em\u003e\u003cbr /\u003e \u003cem\u003e The participant allows silence so that the residents have time to \u003c/em\u003e\u003cbr /\u003e \u003cem\u003eprocess. The participant also provides an opening for another topic that is also happening at the moment. Residents seem to feel at ease with this participant \u003c/em\u003e\u003cbr /\u003e \u003cem\u003e(they show their emotions and share memories\u0026rdquo;). \u003c/em\u003e(Coach A, participant 4)\u003cbr /\u003e\u003cbr /\u003e\u003cem\u003ec) Acknowledging individuality\u003c/em\u003e was found in the data as follows: alignment with individual needs; sensing someone is different from usual; alignment with (im)possibilities; space for one\u0026rsquo;s own personality; and showing one\u0026rsquo;s individuality as a healthcare professional. A new insight is this last category, with examples of how healthcare professionals can use their own individuality to connect from person to person. An example of alignment with individual needs was a reported situation of a resident who needed to use the bathroom:\u003cbr /\u003e \u003cem\u003e\u0026lsquo;The resident is restless and keeps pacing around the living room. She wants to say \u003c/em\u003e\u003cbr /\u003e \u003cem\u003esomething but cannot express herself. The resident is seated at the table by a \u003c/em\u003e\u003cbr /\u003e \u003cem\u003ecolleague: \u0026ldquo;You must eat first\u0026rdquo;. The resident repeatedly gets up and walks towards \u003c/em\u003e\u003cbr /\u003e \u003cem\u003ethe participant. The participant knows this resident well, as is clearly visible in the \u003c/em\u003e\u003cbr /\u003e \u003cem\u003einteraction. The participant immediately realizes that the resident needs to go to the \u003c/em\u003e\u003cbr /\u003e \u003cem\u003etoilet. The relief is visibly great when she notices that she is understood\u0026rsquo;. \u003c/em\u003e(Coach A, \u003cbr /\u003e participant 4)\u003c/p\u003e\n\u003cp\u003ed) \u003cem\u003eListening \u003c/em\u003ewas analysed to gain more insight into how healthcare professionals try to listen to residents. The results provide many examples of the listening attitudes of healthcare professionals in their daily work, resulting in the addition of a separate category of theme connections. The participants were observed to have an attentive listening posture, have the same eye level, apply silence, use nonverbal communication, show genuine interest, take a seat and let the resident lead the conversation. For example,\u003cbr /\u003e\u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003cem\u003eWhen the resident is talking, the participant is silent, she has an attentive listening \u003c/em\u003e\u003cbr /\u003e \u003cem\u003eposture and allows silences to occur, so that the resident has space to talk. She hums \u003c/em\u003e \u003cem\u003ein between, to confirm that she hears and understands, the resident. She also briefly \u003c/em\u003e\u003cbr /\u003e \u003cem\u003esummarizes what the resident said every now and then.\u0026rsquo; \u003c/em\u003e(Coach A, participant 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConnecting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe theme Connecting is about a certain focus on another person and mutual involvement in contacts. Within the theme Connecting, three categories were observed: a) attuning communication; b) attuning approach; and c) building a care relationship. There is room for connection when the approach and (non)verbal communication are attuned to the resident and/or relative. Several ways were observed to building the care relationship. Based on the observations no new categories were added. For all categories, we found new information and examples of the actions participants took in practice that helped them connect with residents.\u003c/p\u003e\n\u003cp\u003ea) By attuning communication, we mean (non)verbal exchange between people. We observed actions such as asking confirmation someone understood you; articulating clearly; engaging in nonverbal communication; summarizing; returning to topics; setting limits; consciously not responding to statements; and indicating what you are doing with each action and stating the purpose of a conversation. \u003cbr /\u003e\u003cem\u003e\u0026lsquo;She is there to congratulate him on his wins in a game he played. She quickly sees \u003c/em\u003e\u003cbr /\u003e \u003cem\u003ethat these stimuli are becoming too much for him. \u003c/em\u003e\u003cem\u003eHowever,\u003c/em\u003e\u003cem\u003e she remains present\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e and \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eif he resident does want something, she is there to pick up those signals. \u0026ldquo;I see you have a dry mouth, would you like some juice?\u0026rdquo; \u0026ldquo;Yes, please\u0026rdquo; he answers while at the same time making a dismissive gesture.\u0026rsquo;\u003c/em\u003e (Coach C, participant 5)\u003c/p\u003e\n\u003cp\u003eb) By attuning approach, we mean the way in which someone is treated. The action of healthcare professionals is appropriate in approach to the resident when they can adjust their approach. We found examples such as taking the necessary time, physical contact and adjusting tempo. \u003cbr /\u003e\u003cem\u003e\u0026lsquo;While dispensing medication, she always took time to pay attention to individual \u003c/em\u003e\u003cbr /\u003e \u003cem\u003e Sometimes with a joke, sometimes with an arm around someone of a \u003c/em\u003e\u003cbr /\u003e \u003cem\u003ecompliment.\u0026rsquo; \u003c/em\u003e(Coach C, participant 14)\u003c/p\u003e\n\u003cp\u003ec) To build a care relationship, we observed building trust and reciprocity in daily practice. This quote gives an example of reciprocity we observed: \u003cbr /\u003e\u003cem\u003e\u0026lsquo;Did you see that? I was done\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e and I wanted to walk away\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e but then she said \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003esomething else. Did you hear what she said? \u0026ldquo;I wish you all the health and happiness in your life.\u0026rdquo; All by herself. That is truly the greatest compliment I can receive from her.\u0026rsquo; \u003c/em\u003e(Coach C, participant 5)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeepening\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeepening revolves around interactive practices to further explore meaning. We identified three categories within the theme of Deepening: a) deepening contact; b) acknowledging life-questions; and c) layers of meaning. The last category is added on the basis of observations, mainly because this was also an important part of the practice intervention.\u003cbr /\u003e\u003cbr /\u003e a) Many examples were found of deepening contact in daily practice by asking further questions, providing space for one\u0026rsquo;s story, exploring meanings and naming emotions. Exploring meanings and naming emotions are new to this category, which is based on observations. It improves the understanding of what healthcare professionals can do to deepen their contacts. This quote shows deepening by exploring meaning\u003cem\u003e:\u003c/em\u003e\u003cbr /\u003e \u003cem\u003e\u0026nbsp;\u0026lsquo;What is that like for you, if you have always been able to do everything yourself \u003c/em\u003e\u003cem\u003ewith a busy job and then suddenly you have to leave everything to others?\u0026rsquo; \u0026ldquo;Yes, I \u003c/em\u003e \u003cem\u003efind it truly difficult. I truly cannot do anything myself anymore, you need someone \u003c/em\u003e \u003cem\u003eelse for everything\u0026rdquo; (\u0026hellip;) \u0026ldquo;Powerless... is that how you feel?\u0026rdquo; \u0026ldquo;Yes, powerless yes.... \u003c/em\u003e\u003cem\u003e(...) But you have no choice. We have nothing more to want.\u0026rdquo;\u0026rsquo; \u003c/em\u003e(Coach C, participant 8)\u003c/p\u003e\n\u003cp\u003eb) Recognizing life-questions was not observed very often. This is a specific skill that contributes to deepening. It is about seeing and naming questions that are complex and far-reaching for residents, relatives and colleagues. This example shows how some healthcare professionals can have an impact on their colleagues in the ward by increasing their awareness of life questions in practice: \u003cbr /\u003e \u003cem\u003e'I am much more aware of it. Therefore, I truly focus much less on solutions. In \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e addition, what also helps: I'm saying it out loud now. Like that gentleman. He \u003cbr /\u003e suddenly became very ill,\u003c/em\u003e\u003cem\u003ecompletely yellow. We are not going to send him to the \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e hospital for treatment anymore. However, that is quite a thing here. Now I said out \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e loud to colleagues: can this man die too? Later, a colleague came up to me and said, \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e \u0026ldquo;I had not thought about it that way.\u0026rdquo;'\u003c/em\u003e (Coach C, participant 24)\u003c/p\u003e\n\u003cp\u003ec) We found many examples of using the layers of meaning, helping healthcare professionals to deepen contacts, as a single statement can have different meanings that can be explored. As healthcare professionals were observed to explore different meanings in their contacts, the spiritual layer was least reported: \u003cbr /\u003e\u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003cem\u003eShe started the conversation with the \u0026ldquo;difficult resident\u0026rdquo; with a comment about the \u003c/em\u003e\u003cbr /\u003e \u003cem\u003eair conditioning (it was a hot day!) and it quickly became clear that something was \u003c/em\u003e\u003cbr /\u003e \u003cem\u003ebothering the client. She asked, \u0026ldquo;What exactly is going on?\u0026rdquo; After the resident \u003c/em\u003e\u003cbr /\u003e \u003cem\u003eresponded, she first asked factual questions, and during the conversation, she \u003c/em\u003e\u003cbr /\u003e \u003cem\u003ealso mentioned the residents\u0026rsquo; emotions: \u0026ldquo;Why are you so angry?\u0026rdquo; and \u0026ldquo;it is okay to \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e be sad about that.\u0026rdquo; She also asked further: \u0026ldquo;What makes you so sad?\u0026rdquo; \u003c/em\u003e(Coach C, \u003cbr /\u003e participant 14)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the awareness and self-evaluation of the spiritual competencies of healthcare professionals in a nursing home, their coaching questions and observed spiritual skills in daily practice. After an intervention consisting of training, team intervision and individual coaching on the job, the spiritual competence of the participants increased significantly. Awareness of the spiritual dimension was frequently mentioned throughout the intervention. The coaching questions of the participants focused on the role of the professional in the conversation, and many examples of practicing the three needed spiritual skills, alignment, connecting and deepening, were observed. Furthermore, different actions to pay attention to the spiritual dimension in daily practice were observed. The intervention and observations focused on the ability of healthcare professionals to pay attention to what is particularly on someone's mind.\u003c/p\u003e\n\u003cp\u003eOur findings suggest how healthcare professionals are able to address the spiritual dimension. Not as a separate subject, but as truly integrated in their daily work by being open and aware. The data revealed the nature of the contacts and how they pay attention to what is truly important for residents and their relatives. The skills of healthcare professionals appeared to be crucial in paying attention to the daily meaning in life of residents in a nursing home. This finding supports the notion of a difference between daily meaning in life and existential meaning in life. Daily meaning in life is about the meaning of personal life, whereas existential meaning in life concerns the question of the meaning of life in general (Reker, 2000). In psychological theories, existential meaning is often distinguished from daily meaning in life. (Westerhof and Bohlmeijer 2010) Religion, the philosophy of life and spirituality are then seen as possible sources from which people can derive meaning. In today's secularized society, religion and spirituality have become complex sources of meaning. People have come to see the meaning of life in more mundane terms. Work, relationships and one's own personal development have become more prominent (Westerhof and Bohlmeijer 2010). We found many examples of unconsciously competent, empathic and sensitive participants who pay attention to daily meaning in life of residents. The study increased our own understanding of and appreciation for the complex and mostly undervalued work of healthcare professionals in a nursing home, especially vocational trained nurses, certified nurse assistants and client support workers. These findings may lead to a re-evaluation of the importance of \u0026lsquo;daily meaning in life\u0026rsquo; and the important role healthcare professionals must pay attention to the spiritual dimension. We suggest paying more attention to and appreciating the impact of healthcare professionals on the daily meaning in life of residents.\u003c/p\u003e\n\u003cp\u003eContrary to our expectations, the role of the coaches turned out to be less focused on applying new knowledge and skills from the training. Many participants wanted to reflect and receive more general feedback on communication. The coaches needed to attune themselves to the participants and what was happening in that moment of observation, resulting in many examples of skills, attitudes and behavior put into practice that helped participants align, connect and deepen their communication. These results are in line with insights into effective workplace learning, closely tailoring learning to the situation and learning preferences of individual healthcare professionals. (Clus 2011, Hager 2011, Ruijters and Simons 2020, Goedmakers 2021) We recommend ensuring some kind of workplace learning, as healthcare professionals may greatly benefit from it.\u003cbr /\u003e Most participants mentioned the personal and professional impact of the practice intervention. It is important to reflect on the consequences and impact of expecting spiritual competency of healthcare professionals. Because in our study, we noticed that healthcare professionals became more open and receptive to their own existential issues, pain, sadness and disappointment in life and that of others. Although it is known that healthcare professionals experience great job satisfaction when they see that they can mean something to someone, this is commonly used as an argument for integrating spiritual care in daily practice. (Vlasblom, van der Steen et al. 2011, van de Geer, Veeger et al. 2018), we simultaneously observed that it demands a lot of healthcare professionals to be confronted with existential pain. We need to pay attention to the impact on individual healthcare professionals. This finding was also reported by other studies with coaching-on-the-job on the spiritual dimension. (Hupkens, Goumans et al. 2019, Modderkolk, van Meurs et al. 2023) We recommend attuning healthcare professionals\u0026rsquo; individual needs, abilities and motivation when further integrating the spiritual dimension in daily practice instead of generally striving for increased spiritual competence after an intervention. \u003cbr /\u003e Increased attention to the spiritual dimension generally makes healthcare professionals more aware of dilemmas. They frequently face situations where they have to make difficult choices between two or more undesirable alternatives for or about residents. Dealing with issues that arise in practice and being able to discuss them with colleagues in an accessible way, such as a collective intervision meeting or a moral deliberation, is needed to support professionals in these situations. This finding is consistent with observations of recent research on integrating attention for meaning in life and spirituality in home care. (Lectoraat Zorg en Zingeving 2023) We suggest that the increased personal and collective awareness and skills of professionals on the spiritual dimension can be supported by work processes and organizational structures.\u003c/p\u003e\n\u003cp\u003eThe qualitative observations overlapped with aspects of the SCCS subscales \u0026lsquo;Personal support and patient counselling\u0026rsquo; and \u0026lsquo;Attitudes\u0026rsquo;. However, the current study suggests that \u0026lsquo;personal support and patient counselling\u0026rsquo; entails much more than being able to have conversations about the spirituality of residents, as is the focus of the questionnaire. As the SCCS was initially developed for measuring competency in nurses working in hospitals, the categorization of the questionnaire does not fully cover the daily practice of healthcare professionals in long-term care. The observations in this study may indicate the need for a questionnaire that measures underlying attention, skills, attitudes and behavior in these competencies in the daily practice of healthcare professionals in long-term care.\u003c/p\u003e\n\u003cp\u003eImportantly, the combination of a training duo, a spiritual caregiver and a vocational trained nurse or certified nurse assistant was fruitful and promising for continuation. It helps balance theory and practice in terms of the spiritual dimension. We suggest developing a train-the-trainer for duos and further elaborating the role of the spiritual caregiver and other healthcare professionals, who can combine their experiences and knowledge to help translate tools and theories on the spiritual dimension into daily practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo our knowledge, this is the first study to provide insight into specific competencies and ways healthcare professionals can open up to the spiritual dimension of residents in a nursing home in daily practice. The study was conducted after a thorough process of cocreation with different stakeholders, which strengthened the commitment and support within the organization. However, our study also has limitations. First, the main researcher combined this study with performing a practical intervention, which might have caused bias. We minimized this risk by working together with different coaches and analysing the data with two researchers who were not involved in the practice intervention. Second, health records were outside the scope of this study. Very few examples of conversations and written reports between healthcare professionals about the spiritual dimension were found. Consequently, the current study does not provide much information about how spiritual care is addressed between healthcare professionals. Finally, the practice intervention was carried out in one nursing home in the Netherlands, and generalizability to other healthcare settings is unknown.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTraining, intervision meetings and coaching on the job significantly increased the spiritual care competence of the participating healthcare professionals in a nursing home, especially certified nurse assistants and client support workers. Individual coaching on the job helped participants answer their personal coaching questions and become more aware of their spiritual skills in daily practice and their own role in contact with residents. The observations in this study revealed skills in aligning, connecting and deepening the conversation and may lead to a re-evaluation of the importance of \u0026lsquo;daily spirituality\u0026rsquo; and the role of healthcare professionals on the spiritual dimension. This study provides insight into the daily practices of healthcare professionals, showing how daily actions are, in fact, very important for making use of the many opportunities to pay attention to the existential and spiritual issues of residents in a nursing home. This study also revealed the importance of addressing the impact of integrating the spiritual dimension into practice instead of only striving for increased spiritual competencies. Furthermore, theories and tools could be translated into the daily work of healthcare professionals in a nursing home by balancing theory and practice through training in duos of a spiritual caregiver and other healthcare professionals. When considering the existing structures in the organization, we are positive that practice interventions that combine collective and individual learning help embed the spiritual dimension in the daily practice of healthcare organizations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSpiritual Care Competency Scale (SCCS).\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by Liemerije, Zevenaar and Radboudumc Nijmegen, the Netherlands. Funding was provided by ZonMW (project number 6390039261). The funding agency had no role in the study design and procedures, participant recruitment, data collection and analysis and the preparation of the paper.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN. A. and Y. wrote the manuscript text.E. performed the statistical analysis.Alle authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe like to thank all healthcare professionals, relatives and residents who were involved in the practice intervention of 'Insight into meaning' on Tesma 3 and de Meridiaan of Liemerije. Special thanks to the coaches-on-the-job and supervisors: Anne Sl\u0026ouml;etjes, Kathleen Beihsner, Crista Hoeksma, Janique van Schaijk, Nicolette Hijweege and Wim Smeets.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003ehttps://doi.org/10.17026/LS/S6KTS\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBaart, A. (2005). 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Bohlmeijer (2010). Psychologie van de levenskunst. (Psychology of the art of living.) Amsterdam, Boom.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5241737/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5241737/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Moving to a nursing home has a major existential impact on the lives of residents and their relatives. In particular, healthcare professionals who have daily contact with residents have many opportunities to pay attention to existential and spiritual issues. We aimed to increase awareness of the spiritual dimension to understand how healthcare professionals evaluate their spiritual competencies, which coaching questions they have and which spiritual skills can be observed in daily practice after a multicomponent intervention, comprising training, team intervision and individual coaching on the job.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e To implement the intervention in two nursing home teams, we performed action research. The participants were mainly certified nurse assistants and client support workers. The training was evaluated with the Spiritual Care Competency Scale (SCCS). Paired-samples t-tests were used to compare the sum scores of the scales of the pre- and posttests of the SCCS (n=24 participants). Thematic analysis was used to analyse the different coaching questions. Observations during individual coaching-on-the-job were analysed via deductive content analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The sum scores of the scales and subscales significantly increased between the pre- and posttests. The awareness of participants’ own role in contact with residents was mentioned frequently in the coaching questions. Increased awareness of one’s role in contacts was also reported. Additionally, participants without specific coaching questions appreciated the feedback. [NF1] These observations provide valuable insight into the application of different spiritual skills: aligning, connecting and deepening. Many different actions in response to residents’ needs are observed when healthcare professionals pay attention to what is particularly important.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eIncreasing SCCS scores indicate that the intervention improved spiritual competencies. Trainingand individual coaching were helpful for increasingawareness and translating theories and tools during the daily work of healthcare professionals in a nursing home.\u003c/p\u003e\n\u003cp\u003e[NF1]Even iets over toevoegen in discussie en conclusie\u003c/p\u003e","manuscriptTitle":"Professional skills on the spiritual dimension. A mixed methods evaluation of a multicomponent intervention for nursing home teams","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-05 15:23:56","doi":"10.21203/rs.3.rs-5241737/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-22T08:30:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-22T07:05:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-21T08:45:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2024-10-10T18:41:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3157b6f3-2969-456e-ad90-31bdd228264b","owner":[],"postedDate":"November 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:00:45+00:00","versionOfRecord":{"articleIdentity":"rs-5241737","link":"https://doi.org/10.1186/s12912-025-04089-3","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-12-12 15:57:02","publishedOnDateReadable":"December 12th, 2025"},"versionCreatedAt":"2024-11-05 15:23:56","video":"","vorDoi":"10.1186/s12912-025-04089-3","vorDoiUrl":"https://doi.org/10.1186/s12912-025-04089-3","workflowStages":[]},"version":"v1","identity":"rs-5241737","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5241737","identity":"rs-5241737","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}