Received: 16 November 2021  | Revised: 31 January 2022  | Accepted: 3 February 2022 DOI: 10.1111/jocn.16261 O R I G I N A L A R T I C L E Developing and testing the EPICC Spiritual Care Competency Self- Assessment Tool for student nurses and midwives Tove Giske1  | Annemiek Schep- Akkerman2  | Bodil Bø3  | Pamela H. Cone4  | Britt Moene Kuven1,5  | Wilfred Mcsherry1,6  | Benson Owusu7  | Venke Ueland3  | Joanne Lassche- Scheffer2  | Rene van Leeuwen8  | Linda Ross9 1Faculty of Health Studies, VID Specialized University, Bergen, Norway Abstract 2Viaa Christian University of Applied Aims and objectives: To develop and psychometrically test a self-a ssessment tool that Sciences, Zwolle, The Netherlands measures undergraduate nursing and midwifery students’ perceptions of spiritual 3Faculty of Health Sciences, University of Stavanger, Stavanger, Norway care competence in health care practice. 4School of Nursing, Azusa Pacific Background: Spiritual care is part of nurses/midwives’ responsibility. There is a need University, Greater Los Angeles, California, USA to better benchmark students’ competency development in spiritual care through 5Western Norway University of Applied their education. The EPICC Spiritual Care Education Standard served as groundwork Sciences, Bergen, Norway for the development of the EPICC Spiritual Care Competency Self-A ssessment Tool. 6Department of Nursing, School of Health, Design: Cross sectional, mixed methods design. A STROBE checklist was used. Science and Wellbeing, Staffordshire University Stoke-o n- Trent, University Methods: The Tool (available in English, Dutch and Norwegian) was developed by an Hospitals of North Midlands NHS Trust, international group. It was tested between July–O ctober 2020 with a convenience Stoke- on-T rent/Stafford, UK 7School of Public Health, College of sample of 323 nursing/midwifery students at eight universities in five countries. The Health Sciences, University of Ghana, Tool was tested for validity using Kaiser– Meyer– Olkin (KMO) test, exploratory and Accra, Ghana confirmatory factor analysis, one- way ANOVA and independent samples t test. The 8Viaa Christian University of Applied Sciences, Zwolle, The Netherlands reliability was tested by Cronbach's alpha coefficient. Qualitative data were analysed 9School of Care Sciences, Faculty of Life using thematic analysis. Sciences & Education, University of South Wales, Wales, UK Results: The KMO test for sampling adequacy was 0.90. All, but two, items were re- lated to the same factor. Cronbach's alpha coefficient for the Tool was 0.91. Students Correspondence Tove Giske, Faculty of Health Studies, VID found the Tool easy to use, and they gained new insights by completing it. However, Specialized University, Bergen, Norway. students felt that some questions were repetitive and took time to complete. Email: tove.giske@vid.no Conclusions: The Tool has construct and discriminant validity, and high internal con- Funding information sistency (is reliable). In addition, students found the Tool useful, especially in early All authors used their time for research in preparing this article. No other funding stages of education. was received. Relevance to clinical practice: The Tool affords student nurses and midwives the op- portunity to self-e valuate their knowledge, skills and attitudes about spirituality and spiritual care. The Tool offers students, educators and preceptors in clinical practice a tangible way of discussing and evaluating spiritual care competency. This is an open access article under the terms of the Creative Commons Attribution- NonCommercial- NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non- commercial and no modifications or adaptations are made. © 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd. J Clin Nurs. 2022;00:1–15. wileyonlinelibrary.com/journal/jocn  | 1 2  |    GISKE Et al. K E Y W O R D S instrument development, nursing/midwifery competences, nursing/midwifery students, psychometric testing, spiritual care, spiritual care competency 1  |  INTRODUC TION What does this paper contribute to the wider It is widely acknowledged that spiritual care is a part of the nurse global clinical community? and midwives’ (N/M) responsibility (International Council of Nursing, 2021), and is embedded in many nursing theories such as Henderson, • This paper presents a newly developed valid and reliable Travelbee, Martinsen and Neuman (Alligood, 2018). Moreover, it is a self- assessment tool that nursing and midwifery stu- part of the documentation system used in some healthcare systems dents can use to rate their competency in spiritual care. (Giske et al., 2021). Some countries use the International Council • The Tool, called the EPICC Spiritual Care Competency of Nurses’ International Classification for Nursing Practice (ICNP), Self- Assessment Tool, is provided within the manuscript while others utilise NANDA I (North American Nursing Diagnosis and reference for using it for own personal and profes- Association and NIC Nursing Interventions Classification) (Herdman sional development is provided. & Kamitsuru, 2018) in their documentation systems. However, N/M • The Tool is written in accessible language (English, continue to report that they are unsure about what spirituality is and Dutch, Norwegian) making it easy to use. that they are poorly prepared for spiritual care in clinical practice (Egan et al., 2017; McSherry & Jamieson, 2013). Internationally, many researchers have published on spiritual care education, and multiple strategies have been suggested (Rykkje from 21 countries developed a consensus- based spiritual care edu- et al., 2021). These include development of spiritual care competen- cation standard between 2016 and 2019. The ‘EPICC Spiritual Care cies (Attard et al., 2019a, 2019b; van Leeuwen & Cusveller, 2004; Education Standard’ (McSherry et al., 2020; van Leeuwen et al., Van Leeuwen et al., 2009), creation of unique clinical experiences 2020; www.epicc -n etwor k.org) comprises four core spiritual care for students (Huehn et al., 2019), and efforts to justify a consis- competencies for undergraduate nursing and midwifery students. tent inclusion across curricula (Cone & Giske, 2018; Giske & Cone, The EPICC work builds upon earlier work of European researchers 2012; Lewinson et al., 2015). A prospective, longitudinal correla- seeking to develop competency frameworks for nurses and mid- tional study in eight European countries at 21 universities found wives. van Leeuwen and Cusveller (2004) developed a literature- that students’ perceived competence increased significantly during based competency framework of six spiritual care competences, their education, which they attributed to caring for patients, own which later was developed and validated into a tool to assess life events, education at the university and reflecting on practice. spiritual care competence (Van Leeuwen et al. (2009). Attard's Perceived competency was significantly correlated with the stu- PhD (Attard et al., 2019a, 2019b) build on this work providing a dents’ own spirituality and perception of spirituality/spiritual care framework of 58 competences for nurses and midwives, and was (Ross et al., 2018). A study by Kuven and Giske (2019) underlined used as a starting point for the consensus-b ased EPICC Spiritual the importance of mandatory participation in spiritual care educa- Care Educational Standard/‘EPICC Standard’) (van Leeuwen et al., tion because students found the subject to be private and personal, 2020). The EPICC Standard consists of four subscales (compe- taboo. Studies around the world reveal the importance of intentional tences), each with 5– 8 items (total 28 items) as shown in Table 1. spiritual care education for professional’s health care (Australia— The four subscales/competences are (a) intrapersonal spirituality, Jones et al., 2020; China— Hu et al., 2019; Iran— Babamohamadi (b) interpersonal spirituality, (c) assessment and planning of spir- et al., 2018; Sweden— Henoch et al., 2013; Turkey— Yilmaz & Gurler, itual care and (d) intervention and evaluation of spiritual care. The 2014; USA – Kincheloe et al., 2018) to benefit patients and/or their four subscales set out the knowledge, skills and attitudes relevant families (Denmark— Hvidt et al., 2018; USA— Koenig et al., 2017). A to each competency. study from Iran (Yousefzadeh, 2017) points to the importance of To provide context, the EPICC Standard also includes defini- self- assessment for continuous improvement in education in nursing tions of spirituality and spiritual care based upon the European and midwifery. Association for Palliative Care's (EAPC) (Nolan et al., 2011) and NHS Education for Scotland (2010) definitions, respectively (Van Leeuwen et al., 2020). 1.1  |  Background Spirituality: ‘The dynamic dimension of human life To contribute to a more common understanding of what knowl- that relates to the way persons (individual and com- edge, skills and attitudes in spiritual care N/M should acquire at munity) experience, express and/or seek meaning, their graduation, a group of European researchers and teachers purpose and transcendence and the way they connect GISKE Et al.     |  3 TA B L E 1  The four competences with knowledge, skills and attitudes of the EPICC Spiritual Care Education Standard Competencies Knowledge (cognitive) Skills (functional) Attitude (behavioural) INTRAPERSONAL SPIRITUALITY - Understands the concept - Reflects meaningfully - Willing to explore one's own and Is aware of the importance of spirituality of spirituality upon one's own individuals’ personal, religious, and on health and well-b eing - Can explain the impact of values and beliefs and spiritual beliefs spirituality on a person's recognises that these - Is open and respectful to persons’ health and well- being may be different from diverse expressions of spirituality across the lifespan for other persons’ oneself and others - Takes care of oneself - Understands the impact of one's own values and beliefs in providing spiritual care INTERPERSONAL SPIRITUALITY - Understands the ways that - Recognises the - Is trustworthy, approachable and Engages with persons’ spirituality, persons’ express their uniqueness of persons’ respectful of persons’ expressions acknowledging their unique spiritual spirituality spirituality of spirituality and different world/ and cultural worldviews, beliefs and - Is aware of the different - Interacts with and religious views practices world/religious views responds sensitively to and how these may the person's spirituality impact upon persons’ responses to key life events SPIRITUAL CARE: ASSESSMENT - Understands the concept - Conducts and documents - Is open, approachable and AND PLANNING of spiritual care a spiritual assessment non- judgemental Assesses spiritual needs and resources - Is aware of different to identify spiritual -H as a willingness to deal with using appropriate formal or informal approaches to spiritual needs and resources emotions approaches, assessment - Collaborates with other and plans spiritual care, maintaining - Understands other professionals confidentiality and obtaining professionals’ roles in - Be able to appropriately informed consent providing spiritual care contain and deal with emotions SPIRITUAL CARE: - Understands the concept - Recognises personal - Shows compassion and presence INTERVENTION AND EVALUATION of compassion and limitations in spiritual - Shows willingness to collaborate with Responds to spiritual needs and presence and its care giving and refers and refer to others (professional/ resources within a caring, importance in spiritual to others as appropriate nonprofessional) compassionate relationship care - Evaluates and documents - Is welcoming and accepting and - Knows how to respond personal, professional shows empathy, openness, appropriately to and organisational professional humility and identified spiritual needs aspects of spiritual care trustworthiness in seeking and resources giving, and reassess additional spiritual support Knows how to evaluate appropriately whether spiritual needs have been met to the moment, to self, to others, to nature, to the Spiritual care: ‘Care which recognises and responds to significant and/or the sacred. The spiritual field is the human spirit when faced with life- changing events multidimensional: (such as birth, trauma, ill health, loss) or sadness, and can include the need for meaning, for self-w orth, to express oneself, for faith support, perhaps for rites or prayer or 1. Existential challenges (e.g. questions concerning identity, meaning, sacrament, or simply for a sensitive listener. Spiritual care suffering and death, guilt and shame, reconciliation and forgiveness, begins with encouraging human contact in compassion- freedom and responsibility, hope and despair, love and joy). ate relationship and moves in whatever direction need 2. Value- based considerations and attitudes (e.g. what is most impor- requires’ (Van eeuwen et al., 2020). tant for each person, such as relations to oneself, family, friends, work, aspects of nature, art and culture, ethics and morals, and life The EPICC Standard has influenced nursing and midwifery educa- itself). tion in over 26 universities across 16 countries (https://blogs.staffs. 3. Religious considerations and foundations (e.g. faith, beliefs and prac- ac.uk/epicc/ files/ 2021/01/Use-a nd-V alue - of- the- EPICC - Outpu ts- tices, the relationship with God or the ultimate).’ final.pdf) to better prepare newly qualified nurses and midwives to 4  |    GISKE Et al. provide spiritual care in practice. Clinicians and educators from as (STROBE) checklist was used for this project (STROBE, 2022, see far afield as Brazil, China, Venezuela, Canada, USA and Kenya have Supplementary checklist). joined the EPICC Network (June 2020), and the Network has over 200 ResearchGate followers from Asia, Africa, North/South America and Australia, suggesting that the EPICC Standard may have utility 2.3  |  Sample/participants beyond Europe (McSherry et al., 2020; van Leeuwen et al., 2020). This article focuses on further development of the EPICC A convenience sample of undergraduate nursing/midwifery students Standard (Table 1 and https://blogs.staffs.ac.uk/epicc/ files/ (n = 4479) from eight universities in five countries (California, USA; 2020/08/EPICC - Spirit ual- Care-E ducat ion- Standa rd.pdf) into a self- England, UK; Ghana; the Netherlands; Norway; Wales, UK) where assessment tool (from now on referred to as the Tool) by members the authors worked were invited to take part in the study. Four uni- of the ‘Spiritual Care and Practice Development’ (SEP) project. This versities were secular and four were Christian (Table 2). Students is a group of Norwegian and international researchers who obtained received an email from their university explaining the project and funding (from VID University Norway) for this purpose (https:// inviting them to take part, and it contained an information sheet and www.vid.no/en/resea rch/vids-f remr agend e-f orsk nings miljo er/ the link to the Tool. Two or three reminders were sent in the weeks sep/). thereafter. Additionally, an open invitation to complete the Tool was placed on some students’ university learning platforms. For each country, we aimed to have a minimum of 60 fully com- 2  |  METHODS pleted Tools to achieve a minimum total of 300 fully completed. This was to enable data analysis per country as well as overall. Power 2.1  |  Aim analysis was based on literature: using the rule of a minimum ratio of 10 respondents to 1 item for scale development, we needed The aim of this study was to develop and then test and validate the 10 × 28 = 280 respondents (Morgado et al., 2017), and using the psychometric properties of the Tool. sample size rules of thumb from Wilson VanVoorhis and Morgan (2007), we needed around 300 respondents for factor analysis. 2.2  |  Design 2.4  |  Development of the tool A cross- sectional, mixed methods research design was adopted, involving the collection of quantitative and qualitative data. The original EPICC Standard (Table 1) was changed to make it suit- Quantitative data enabled calculation of construct validity, cross- able for self- assessment. Self- assessment tools usually have state- cultural validity, discriminant validity and reliability of the Tool. ments with ‘I’, because people then can easily identify themselves Qualitative data provided reflections from respondents on their with the content of the sentence. So, the 28 statements were re- perceived competence, offering an avenue for examining content phrased to begin with ‘I’… Next, a 4- point Likert scale was added validity of the Tool and providing feedback about its usefulness. The to each statement to enable students to score themselves (range: Strengthening the Report of Observational Studies in Epidemiology 1 = ‘not very’ to 4 = ‘very’). TA B L E 2  Number of students (invited and responded) per country, course and year of study, plus KMO test California, England, Wales, The Country Norway USA UK UK Ghana Netherlands Total Culture Secular (2) and Christian (1) Christian Secular Secular Christian Christian university Course Nursing 65 33 36 32 72 56 294 Midwifery — — 20 6 3 — 29 Year of study 1 — — 8 12 3 5 28 2 34 12 35 14 2 19 116 3 31 7 13 12 14 15 92 4 — 14 — — 56 17 87 Total response 65 33 56 38 75 56 323 Total invited 1262 330 656 1400 131 700 4479 KMO 0.65 0.38 0.65 0.57 0.75 0.67 0.9 Abbreviation: KMO, Kaiser– Meyer– Olkin test for sampling adequacy. GISKE Et al.     |  5 Some questions about personal information were added to the saved per country (in Excel and Word) and sent to the relevant au- start of the Tool: course of study (nursing or midwifery), country, thor/lead researcher in each country for separate analysis. year of study (range: 1 to 4). Age and gender were not requested, because previous research showed these characteristics were not significantly correlated with perceived spiritual care competency 2.5  |  Ethical considerations (Ross et al., 2018) and we aimed to keep the questionnaire as short as possible. Open response sections were added after each of the Prior to the commencement of the study, ethical approval was ob- 4 competences so students could write their reflections relating to tained from *ethics committees within participating universities or the following questions: (a) ‘What is your strength?’ and (b) ‘Which countries as required by each country. Participation was voluntary, areas do you need to develop?’. A final open response section was and no identifiable data were gathered, so anonymity and confiden- added enquiring about the usefulness of the Tool: (a) ‘How useful tiality were assured. No pressure was put on students to complete was the Tool? In which ways?’, (b) ‘How clear was it?’, (c) ‘How likely the Tool. The invitation stated that answering the questions implied is it that you will use it again?’ and (d) ‘How would you improve it?’. consent. 2.4.1  |  Translation of the tool 2.6  |  Data analysis The Tool (originally in English) was translated by forward– backward Only fully completed Tools were included in the analysis. These translation into Norwegian and Dutch based on Martins et al. (2015) were merged into one database using IBM SPSS statistics version stepwise protocol: 27. Item names were abbreviated using the name of the subscale, a shorter version of ‘knowledge’, ‘skills’ and ‘attitude’ and a number - Step 1— Two separate translators familiar with both languages (see Table S1). and the objectives of the Tool translate the Tool from English to the new language - Step 2— Project Leader examines the translation 2.6.1  |  Quantitative analyses - Step 3— Two separate translators familiar with both languages but not with the Tool translate it back to English (two versions) Descriptives - Step 4—A n Expert Panel examines both the translation and the First, descriptive analyses of the student characteristics were per- original version to finalise the document in the new language. formed. After that, we analysed range, mean, standard deviation, The Expert Panel is made up of 6 members, including nurses, re- skewness (measure of asymmetry; should be below 1), kurtosis (de- searchers, educators, subject area experts and a tool validation scription of tailedness; should be below 1) and item- total correlation expert. per item of the Tool. Skewness and kurtosis were analysed to see whether the answers were according to a normal distribution. Item- In this study, we used English, Norwegian and Dutch versions of total correlation was analysed to check inconsistency: items with a the Tool. correlation value less than 0.3 are inconsistent with the average be- haviour of the other items. The score of the subscales for the Tool as a whole is the sum of all scores on the statements divided by the 2.4.2  |  Data collection number of statements in the subscale or total Tool (so, it is the mean score). Between July and October 2020, university teachers or course ad- ministrators sent an email to students inviting them to complete the Validity Tool. The invitation was also placed on some student online learn- To test discriminant validity of the Tool, to see whether the Tool ing platforms during this time. By clicking on the link in the email could be used to detect differences between groups, all student and or on the website, the students were directed to the online Tool on school characteristics (course of study, year of study, country, cul- the Enalyzer platform which was used to build and administer the ture of school) were used. The mean score for the Tool as a whole Tool and provided anonymity. Students in England, Wales, Ghana was calculated by the sum of all scores on the statements divided by and the USA were sent the English version of the Tool; Norwegian the number of statements in the total Tool. Scores from subgroups students were sent the Norwegian version; and students from the from the student and school characteristics were tested by one- Netherlands were sent the Dutch version. Following the comple- way ANOVA (for differences between more than two groups) or the tion deadline (30 October 2020), answers were downloaded from independent samples t test (for differences between two groups). the website and saved per country. The Tools from individuals who After a significant ANOVA, t tests were performed to check which did not rate all the statements were excluded. Qualitative data were group had an extraordinary score. 6  |    GISKE Et al. The Kaiser– Meyer– Olkin (KMO) sampling adequacy test was 3  |  RESULTS performed to establish whether underlying factors may explain the variance in scale responses. A KMO value equal to or more than 3.1  |  Respondents 0.6 was considered just significant (Anthoine et al., 2014); however, >0.8 is more typical. It was calculated for the database as a whole A total of 4479 students were invited to take part in the study; and per country. To find out whether there was cross-c ultural valid- 866 students started to fill in the Tool, and 323 completed it fully. ity, exploratory factor analysis was executed for all countries with a Two hundred and fourteen (n = 214) students stopped answering the KMO value >0.8, to verify if the same statements loaded on the first questions after the first competency, another 211 stopped after the factor in the different countries. second competency, and a further 118 after competency 3. There To check the construct validity and uncover an underlying were no differences in mean scores between the students who fully structure of this set of variables, Bartlett's sphericity test for fac- and partially completed the Tool. The response rate was 7% of all in- tor analysis compatibility was performed (if significant, than fac- vited and 37% of those who started to fill in the Tool. Table 2 shows tor analysis is compatible) and an exploratory factor analysis was the number of students who fully completed the Tool per course, executed (with and without items with an item- total correlation country and year of study. We were aiming for 60 completions per below 0.3). The next setting was used: extraction of principal com- country, which was achieved for Norway and Ghana but not for the ponents, based on Eigenvalue greater than 1 and no rotation ma- other countries, England and the Netherlands had just below 60, and trix. Evidence that the items could be aggregated into a single scale USA (California) and Wales between 30–4 0 responses. score was tested by examining whether the test indicated a unifac- torial solution and whether items loaded significantly (>0.35) on the first factor (Streiner, 1994). If items load on one factor, they are 3.2  |  Validity of the tool related to the same latent variable, concept or construct, despite apparent differences in content. Factors should have at least three 3.2.1  |  Descriptive analyses of items items with a loading greater than 0.4 (Streiner, 1994). To confirm the construct validity, confirmatory factor analysis was performed For most items, the whole range of scores was used (1–4 ), only for two with IBM SPSS AMOS 26 graphics (with and without items with an items just 2– 4 were used. The lowest mean score of the items was 2.23 item-t otal correlation below 0.3). Standardised estimates/regres- and the highest 3.80. There are quite a few items with a high skewness sion weights were calculated (have to be >0.7) next to (default) and kurtosis (9 items), which means that the answers of these items model fit: CMIN/df (have to be below 5), chi- squared test (CMIN are skewed (mostly negative, seeing the minus before the 1) and too have to be non- significant, otherwise poor fit [or a big sample size]), peaked (value above +1). Two items had an item- total correlation value comparative fit index (CFI has to be >0.95), root mean square error below 0.3 (IntraSkil1 and IntraSkil2), which means that they are incon- of approximation (RMSEA <0.08 is acceptable, <0.06 is better) sistent with the average behaviour of the other items. However, the (Hu & Bentler, 1999). other ones were acceptable (For all numbers see Table S2). Reliability To check reliability with the internal consistency, Cronbach's alpha 3.2.2  |  Discriminant validity coefficient was calculated for the Tool as a whole and for the 4 sub- scales. A value over 0.7 was considered acceptable, over 0.8 good There is a significant difference in mean scores between the years of or fair, and over 0.9 excellent (DeVellis, 2012). For Cronbach's alpha study of the students (year 1: mean 3.0, year 2–4 : mean 3.2 or 3.3), coefficients >0.9 inter-i tem correlations were analysed, to identify between countries (California, USA, has a mean score of 3.5, while potential redundancies among the items. This may be the case if a the other countries have scores of 3.1 to 3.3) and between secular correlation between two items is >0.8. (mean score 3.1) or Christian schools (mean score 3.3). There is no statistically significant difference between nursing and midwifery Qualitative analysis students (both had a score of 3.2). This means that the Tool has dis- Thematic analysis (Braun & Clarke, 2006) was used for qualitative criminant validity (for all number see Table S3.) responses to the following questions: (a) ‘How useful was the Tool? In which ways?’, (b) ‘How clear was it?’, (c) ‘How likely is it that you will use it again?’ and (d) ‘How would you improve it?’. Researchers 3.2.3  |  Cross-c ultural validity from each country analysed their own data by open coding and searched for themes. They met virtually to present, compare and The KMO sampling adequacy test was performed for each country discuss the initial themes. After that each country continued to separately (last row Table 2). The KMO test for the whole database analyse their data before we met again to discuss the main- and was 0.90, but the KMOs per countries were below 0.8, so we only sub- themes until consensus was reached and we could write up our performed analyses with the whole dataset (This means that the findings together. cross- cultural validity analysis was not possible). GISKE Et al.     |  7 TA B L E 3  Exploratory factor analysis Factor Item Factor 1 Factor 2 Factor 3 Factor 4 5 IntraKnow1 0.621 −0.264 −0.156 −0.104 0.424 IntraKnow2 0.653 −0.264 −0.284 −0.042 0.338 IntraKnow3 0.571 −0.031 −0.434 0.007 0.271 IntraSkil1 0.327 0.149 −0.371 0.394 0.126 IntraSkil2 0.216 0.034 0.092 0.606 0.250 IntraAttid1 0.476 0.352 −0.126 0.208 0.035 IntraAttid2 0.409 0.504 0.016 0.130 −0.131 InterKnow1 0.607 −0.142 −0.389 0.076 −0.136 InterKnow2 0.511 −0.077 −0.342 0.265 −0.243 InterSkil1 0.512 0.211 −0.435 −0.109 −0.184 InterSkil2 0.602 0.218 −0.155 −0.095 −0.262 InterAttid1 0.442 0.545 0.108 0.156 −0.186 AssPlKnow1 0.726 −0.310 −0.040 −0.093 0.081 AssPlKnow2 0.642 −0.415 0.097 0.060 −0.189 AssPlKnow3 0.584 −0.322 0.109 −0.123 −0.214 AssPlSkil1 0.613 −0.327 0.297 0.126 −0.252 AssPlSkil2 0.482 −0.102 0.362 0.200 −0.251 AssPlSkil3 0.472 0.148 0.468 0.083 0.366 AssPlAttid1 0.370 0.506 0.151 0.082 −0.107 AssPlAttid2 0.440 0.477 0.303 −0.016 0.343 IntEvalKnow1 0.593 0.084 −0.053 −0.424 −0.040 IntEvalKnow2 0.678 −0.241 0.112 0.060 0.071 IntEvalKnow3 0.664 −0.412 0.192 0.015 0.008 IntEvalSkil1 0.627 −0.090 0.130 −0.365 0.016 IntEvalSkil2 0.649 −0.333 0.258 0.140 −0.069 IntEvalAttid1 0.528 0.427 0.143 −0.166 0.162 IntEvalAttid2 0.486 0.446 0.055 −0.344 −0.008 IntEvalAttid3 0.470 0.531 −0.050 −0.002 −0.115 Eigenvalue 8.38 2.97 1.69 1.30 1.21 % of Total variance 30 11 6 5 4 explained Cumulative. % 30 41 47 51 55 3.2.4  |  Construct validity second factor (see Table S4) (Barlett's test of sphericity significant, X2 = 3508.527, df = 325, p- value = 0.000). The items in the first 2 Bartlett's test of sphericity for factor analysis compatibility was sig- factors accounted for 41% of the variance. nificant (X2 = 3630.304, df = 378, p-v alue = .000). Table 3 shows Figure 1 shows the result of the confirmatory factor analysis of which items loaded significantly on the first five factors in explora- the whole Tool, with all items. Not all standardised estimates/regres- tory factor analysis. All items, except two (the skills statements of sion weights (the numbers in the figure) are below 0.7, which means the first competency: IntraSkil1 and IntraSkil2), loaded (>0.35) on that the correlations of these items with the latent factor are not factor 1, so these items are related to the same latent variable, con- that high. The correlations between the competencies/subscales are cept or construct (spirituality). On the second factor, all items with acceptable (>0.7). This confirmatory factor analysis shows the same respect to attitude loaded, so these items are related to the same as the exploratory factor analysis: the items IntraSkil1 and IntraSkil2 concept (attitude). On Factors 3 to 5, there were only one or two have a low estimate/correlation with the subscale and the items items with a loading factor over 0.4. If we leave out the two items with respect to attitude also have a relative low estimate/correlation with a low item- total correlation (IntraSkil1 and IntraSkil2) and run with the subscales (below 0.5): which shows: they are different from the exploratory factor analysis again, the result is quite the same: the other ones. Just as seen in in the exploratory factor analysis: all items load on the first factor and the attitude items load on the IntraSkil1 and 2 are extraordinary and loaded together on Factor 4 8  |    GISKE Et al. F I G U R E 1  Confirmatory factor analysis GISKE Et al.     |  9 and the items with respect to attitude were loading on the second 3.4  |  Student reflections on the factor (next to on the first). usefulness of the tool The fit indices for the model were not below or above the thresh- olds, except: CMIN/df = 4.09 [below 5 was ok]. Other indices: p- Students reflected on the usefulness of the Tool by answering an value CMIN = 0.000 [is significant instead of non-s ignificant; but open question. They reflected on awareness of spirituality and spir- this can be caused by the sample size], CFI =0.688 [is not above itual care, on insight gained into their personal learning process and 0.9], RMSEA = 0.098 [is not below 0.08]. Each item (except one on the content and the structure of the Tool. Reflections ranged (IntraSkil2)) loaded significantly onto its corresponding first- order from ‘very useful’ to ‘difficulty in usefulness’, though the majority factor. If the model is run without the two items IntraSkil1 and indicated it was useful. Students also offered suggestions for im- IntraSkil2 (see Figure S1), the standardised estimates and the fit proving the Tool. Table 4 provides an overview of the outcomes that indices for the model do not change in the right direction (CMIN/ were derived from the open comments of students from the partici- df = 4.47 [not lower (=better fit), but higher], p-v alue CMIN = 0.000 pating countries. Most of the students found the Tool very useful for [still significant], CFI = 0.694 [still not above 0.9], RMSEA = 0.104 gaining insight on the concept of spirituality and for gaining insight [still not below 0.08])). on their personal growth and learning process. The Tool generated (new) insights in spirituality and spiritual care and helped to identify elements of spiritual care competences for self- improvement. 3.3  |  Reliability and internal consistency of the tool Some students reported difficulty in using of the Tool, regard- ing lack of conceptual clarity about spirituality and spiritual care, Cronbach's alpha coefficient of the Tool as a whole was 0.91. The seemingly due to lack of education and/or because of their missed value above 0.7 indicates that it is excellent. The Tool is highly experiences from healthcare practice. This seemed especially rel- reliable. If the two items (IntraSkil1 and IntraSkil2) are excluded, evant for students in the early stage of their education. Students Cronbach's alpha is the same: 0.91. Cronbach's alpha for the sub- who were close to graduation commented that the Tool did not scales/competencies was between 0.7–0 .8. Cronbach's alpha add much to their competence development. Most of the students for all items with respect to attitude was 0.8, for all items with were positive about the content and structure of the Tool, in terms respect to skills 0.7 and for all items with respect to knowledge of clear item description and the method of scoring and manage- 0.9. Therefore, the internal consistency of the subscales is also ability of the Tool. Some students had difficulty understanding acceptable. some items in the Tool, and some felt the instructions could have Because of the high Cronbach's alpha coefficient, inter- item cor- been clearer. Students at the start of their education seemed to re- relations are analysed, to identify potential redundancies among the quire more clarification and explanation. Almost all students com- items: there were not correlations >0.8 (See Table S5). mented that it was unnecessary to have reflective questions after TA B L E 4  Student reflections on the usefulness of the tool Usefulness Difficulties Suggestions for improvement Insight in spirituality Reflection on different aspects of Lack of teaching Use tool together with and spiritual care spirituality and spiritual care promotes Unclear what spiritual care means teaching gaining new insights Difficult to connect with personal Add insight on the goals of Identification of gaps in patient care competence spiritual care Insight in personal Assessment of knowledge, skills and Little (or no) experience in healthcare Repeated assessment during learning processes attitude for self- improvement practice education Highlight and reminder of strengths and Insufficient insight in self Add question about limitations in spiritual care Experience no added value to learning experience as point of process reference Add more specific questions to improve answers Content of the tool Clear, coherent, and easy to use Difficult to understand Formulate clear, concise Confirms awareness Some repetitive or similar questions questions Add introduction and instruction Add examples or cases Structure of the tool Ticking questions are clear Confusing, unclear structure Technical improvements by Numbering scores 1– 4 with explanation Takes too much time to complete online measurement Subdivision in competences Missing overview of the tool because Likert scale with introduction of questions on different pages Only one open reflection at the end 10  |    GISKE Et al. TA B L E 5  Final version of the EPICC Spiritual Care Competency Self- Assessment Tool This self- assessment tool allows you to evaluate your level of knowledge, skills, and attitudes in four key areas of competencies for spiritual care. Spirituality and spiritual care are understood as: Spirituality: The dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant and/or the sacred The spiritual field is multidimensional: Existential challenges (e.g., questions concerning identity, meaning, suffering and death, guilt and shame, reconciliation and forgiveness, freedom, and responsibility, hope and despair, love and joy) Value- based considerations and attitudes (e.g., what is most important for each person, such as relations to oneself, family, friends, work, aspects of nature, art and culture, ethics and morals, and life itself) Religious considerations and foundations (e.g., faith, beliefs and practices, the relationship with God or the ultimate) EAPC (n.d.). EAPC Task Force on Spiritual Care in Palliative Care. Retrieved from: https://www.eapcn et.eu/eapc- group s/task- force s/spirit ual- care. Last accessed 18/02/19 Spiritual care: Care which recognises and responds to the human spirit when faced with life- changing events (such as birth, trauma, ill health, loss) or sadness, and can include the need for meaning, for self- worth, to express oneself, for faith support, perhaps for rites or prayer or sacrament, or simply for a sensitive listener. Spiritual care begins with encouraging human contact in compassionate relationship and moves in whatever direction need requires van Leeuwen, R., Attard, J., Ross, L., Boughey, A., Giske, T., Kleiven, T., & McSherry, W. (2020). The development of a consensus- based spiritual care education standard for undergraduate nursing and midwifery students: An educational mixed methods study. Journal of Advanced Nursing. 00, 1- 14. https://doi.org/10.1111/jan.14613 Please score yourself from 1 – 5 on each of the competencies, where 1 = Completely disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, 5 = Completely agree Please write a short reflection at the end about your own competence in spiritual care Competency 1. INTRApersonal (within you) spirituality Knowledge I understand the concept of spirituality 1 2 3 4 5 I can explain the impact of spirituality on a person’s health and well-b eing 1 2 3 4 5 across the lifespan for myself and others I understand the impact of my own values and beliefs in providing spiritual 1 2 3 4 5 care Skills I reflect meaningfully upon my own values and beliefs and recognise that 1 2 3 4 5 these may be different from other people’s values and beliefs 1 2 3 4 5 I take care of my own well-b eing Attitude I am willing to explore my own personal, religious, and spiritual beliefs 1 2 3 4 5 I am open and respectful to people’s diverse expressions of spirituality 1 2 3 4 5 Competency 2. INTERpersonal (related to others) spirituality Knowledge I understand the ways that people express their spirituality 1 2 3 4 5 I am aware of the different world/religious views and how these may impact 1 2 3 4 5 upon people’s responses to key life events Skills I recognise the uniqueness of people’s spirituality 1 2 3 4 5 I interact with, and respond sensitively to people’s spirituality 1 2 3 4 5 Attitude I am trustworthy, approachable, and respectful of people’s expressions of 1 2 3 4 5 spirituality and different world/religious views Competency 3. Spiritual care: assessment and planning Knowledge I understand the concept of spiritual care 1 2 3 4 5 I am aware of different approaches to spiritual assessment 1 2 3 4 5 I understand other professionals’ roles in providing spiritual care 1 2 3 4 5 Skills I can conduct and document a spiritual assessment to identify spiritual needs 1 2 3 4 5 and resources 1 2 3 4 5 I can collaborate with other professionals in the provision of spiritual care I can appropriately contain and deal with emotions 1 2 3 4 5 Attitude I am open, approachable, and non- judgmental 1 2 3 4 5 I am willing to deal with emotions 1 2 3 4 5 Competency 4. Spiritual care: intervention and evaluation Knowledge I understand the concept of compassion and presence and its importance in 1 2 3 4 5 spiritual care 1 2 3 4 5 I know how to respond appropriately to identified spiritual needs and resources 1 2 3 4 5 I know how to evaluate whether spiritual needs have been met GISKE Et al.     |  11 TA B L E 5  (Continued) Skills I recognise my personal limitations in spiritual care giving and refer to others 1 2 3 4 5 as appropriate 1 2 3 4 5 I evaluate and document personal, professional, and organisational aspects of spiritual care, and reassess appropriately Attitude I show compassion and presence 1 2 3 4 5 I am willing to collaborate with and refer to others (professional/non- 1 2 3 4 5 professional) in providing spiritual care I am welcoming and accepting and show empathy, openness, professional 1 2 3 4 5 humility, and trustworthiness in seeking additional spiritual support This section is for you to reflect on your own competencies in spiritual care A. What are your strengths? B. Which areas do you need to develop further? C. How might you do that? © Copyright EPICC Network 2021 This self- assessment tool was developed from the EPICC Spiritual Care Education Standard which you can find on the EPICC Network website www.epicc - networ k.org each competency, suggesting that it would be better to include discussed them in the whole group and the final analysis was con- these only at the end. ducted by two researchers (RvL, JL-S ) working together. Overall, the statistical findings of the Tool reveal that it is a valid tool for self- assessment and that for almost all items the item-t otal 3.5  |  The final version of the tool correlation is within acceptable limits, and discriminant validity is shown. Next to this, all but two items load on one factor, next to that After reviewing the statistics and the open comments from students, all attitude items load on another factor, and Cronbach's alpha are we made some changes to the Tool (highlighted in italics in Table 5). high. This is not surprising since we built the Tool from the already The preamble from the EPICC Standard (van Leeuwen et al., 2020) established EPICC Spiritual Care Educational Standard, developed was added, providing definitions of spirituality and spiritual care, to by educators and researchers from 21 European countries over give the student some background and reference. We adjusted two three years. The rigour with which the original researchers devel- points concerning the text: a further explanation of ‘intrapersonal’ oped the four competencies of the EPICC Standard (van Leeuwen and ‘interpersonal’ was provided by adding ‘(within you)’ and ‘(re- et al., 2020) created a smooth pathway for the development of this lated to others)’, respectively, to headings of Competences 1 and 2, self- assessment Tool. Why the confirmatory factor analysis did not and ‘person’ was changed to ‘people’. The 4-p oint Likert scale was fully confirm this, require further investigations. changed to a 5-p oint Likert scale, as used by Leeuwen et al. (2009) The statement with the lowest item-t otal correlation and load- and to reduce skewness and kurtosis. ing lowest on the first factor in the exploratory factor analysis Because the students said the reflective questions were too re- (IntraSkil2) was revised, as can often be the case in tool develop- petitive, they were removed from the end of each competency. The ment. It may be that this factor is not seen as a skill and needs to only reflective section was at the very end of the Tool where the be stated in a different way to be clearly related to the concept/ wording was changed to: ‘A What are your strengths? B. Which areas construct in the Tool. In nursing, self- care is often taught to patients do you need to develop further? And C. How might you do that?’. and their families, but nurses may neglect self- care of themselves. Table 5 shows the final version of the Tool. Some nurses may feel that it is selfish or self-c entred to focus on self- care and their own well-b eing. However, Schwartz et al. (2021) remind us that nurses are vulnerable to stress overload and need to 4  |  DISCUSSION develop good networks, identify resources to stay healthy and prac- tice healthy self- care by managing of stress and utilising healthy cop- The aim of this study was to develop and test the psychometrics ing strategies. This is something that needs to be explored further. of the EPICC Spiritual Care Self-A ssessment Tool, which we did The EPICC Standard was developed within Europe, which is di- through statistical and qualitative analysis of the students’ feed- verse in relation to languages and how history has shaped cultures back. We assume that the students who took part in this study gave and life views in the various countries. The Tool was translated into honest answers since it was an anonymous online survey. By using Dutch and Norwegian and was thus tested in three languages. In open questions for reflections and an invitation to provide feedback addition, we worked with researchers from California and Ghana, on the tool at the end, respondents were not forced in a particular which provided us with the opportunity to test the Tool in two other direction; they could fill in what they felt was important to them. continents outside of Europe. The nursing school in California is a We therefore consider the students’ responses as valid and reliable. private Christian University where integration of the Christian faith We also consider the reliability of the analysis of the open questions is embedded in all courses across the university. This might be the as strong because we first analysed them country by country, then reason why the students from California scored on average higher 12  |    GISKE Et al. than the other students. In Ghana, they do not teach spiritual care as professional knowledge into practice (Balgopal & Montplaisir, 2011; part of their nursing education since spiritual care is seen as a way of Kuven & Giske, 2019; Ross et al., 2018). The Tool provides students life rather than a nursing procedure. The testing of the Tool has thus with an opportunity to assess themselves on the four spiritual care been conducted in different countries to ensure that concepts and competences considered as core to undergraduate nursing/mid- constructs are understood by people from different cultures, and we wifery education in Europe. The final Tool has 28 items for self- hope to continue that effort and invite scholars around the world to assessment using a 5- point Likert scale and just one final question further test the newly developed Tool. In the future, it is particularly inviting students to write a reflection about their strengths, areas for important to determine how the key concepts used in the Tool are development with actions. In this way, we make it less time consum- understood outside the Judeo-C hristian world view. ing to use the Tool, but still invite the student to complete a summary It is interesting to note that there were no statistically signifi- reflection. cant differences in overall findings across the languages used in this We see the self-a ssessment Tool as a valuable trigger for stu- study. The evidence of acceptable reliability and validity found in dents to reflect on their level of knowledge and skills, together with all three languages is reassuring as the SEP team considers ongo- the core attitudes outlined in the Tool. The score from 1– 5 pro- ing work of translation into other languages. Moreover, the quali- vides a visual pattern of their knowledge, skills and attitudes scored tative data paralleled the quantitative results, which reinforces the across the four competences at a certain point in time. The visual strength and quality of the Tool. pattern can challenge students to reflect around questions, such as if their attitudes score higher than their skills and knowledge, and what it means for their clinical practice if their scores are higher 4.1  |  Understanding of spirituality and for Competency 1 (Intrapersonal spirituality) than Competency 4 spiritual care (Spiritual care: intervention and evaluation). However, as much as self- reflection through self- assessment can be very helpful for stu- One of the areas some students commented on was that they were dents in their learning process, we acknowledge the limitation it can unclear what spirituality and spiritual care meant because the terms have and the importance of external assessment of students’ spiri- were not defined in the Tool. Some students commented that they tual care competences in clinical placements. had not had any teaching or training about the subject. Uncertainty related to how to understand spirituality and thus spiritual care is a well- known challenge within nursing (McSherry et al., 2020; 4.3  |  Limitations Weathers et al., 2016). This was also something we worked on in the EPICC project (van Leeuwen et al., 2020) and where we, through a The response rate was probably not that high in this study because of consensus process, agreed on the EACP’s definition of spirituality the special circumstances due to the COVID-1 9 pandemic. Students (Nolan et al., 2011) and the revised definition about spiritual care were busy with providing care and/or with managing education at from NHS Education for Scotland (van Leeuwen et al., 2020). These home, causing extra stress. With so much online education, an ad- are definitions that hold a broad view of spirituality and spiritual ditional request to complete a survey with reflective questions may care, which is found to correlate with higher self- reported spiritual have been too much for them. Additionally, the invitation was only care competences in the only longitudinal-, multinational- and large- announced online, without an explanation from a teacher, so stu- scale study conducted in the area of spiritual care education with dents might not have felt the solidarity with their school or with their N/M students (Ross et al., 2018). Therefore, we added the defini- teachers, making them less inclined to take part. Many students tions of spirituality and spiritual care from the EPICC Standard to the started to fill in the questionnaire but did not finish it. Students new Tool to bring clarity for students. may have been put off by the repetitive reflective questions after What this research also showed, was that knowledge and skills each competence or there may have been too many items. However, are connected and differ from attitude. All items with respect to at- when all data were combined, there were enough responses to an- titude loaded on the second factor in exploratory factor analysis, alyse and validate the self-a ssessment Tool with statistical signifi- and all those items also had a low correlation in confirmatory factor cance. Therefore, the results of this study may be generalisable to analysis. So, attitude in spiritual care is different from knowledge nursing and midwifery students in Europe and beyond, but it is not and skills in spiritual care and is unique. This was also seen in the clear if this applies to qualified nurses and midwives. higher scores for attitude items, as also shown in our previous study The students who participated may be more interested in spiri- (Ross et al., 2018). tuality and spiritual care than those who did not; however, that did not influence the results of this validation study. Unfortunately, the number of completed questionnaires per country was not enough 4.2  |  Importance of reflection to conduct exploratory factor analyses per country or to estab- lish cross- cultural validity. In our future work, we aim to add more Self- reflection is widely used in healthcare education because it countries to improve the generalisability of the tool and to explore is seen as an important pedagogical tool to develop and integrate whether spirituality as defined in the Tool is a global concept. GISKE Et al.     |  13 4.4  |  Considerations for ongoing development in clinical practice to evaluate the effectiveness of teaching and learning strategies designed to enhance healthcare professional's Spiritual issues touch what is deeply important to people, so it is development in knowledge, skills and attitudes about spirituality best whether these phenomena are addressed in your mother (na- and spiritual care. Globally, nurses report that they do not have tive) tongue. That is why the students from Norway received the adequate preparation and training for spiritual care in their bache- tool in Norwegian and those from the Netherlands read it in Dutch. lors’ education programmes. We recommend the use of the EPICC To minimise conceptual differences during translation, a standard- Spiritual Care Education Standard along with the newly developed ised protocol was used (Martins et al., 2015). However, challenges EPICC Spiritual Care Self- Assessment Tool to raise awareness of the in translation of spirituality and spiritual care materials into different spiritual domain and to provide opportunities for personal and pro- languages and cultures require more than word- for- word translation fessional growth in this area for both N/M students and healthcare to develop concepts and language that is meaningful to students professionals. within their nursing/midwifery tradition. It is important to use local experts not only in language but also CONFLIC T OF INTERE S T in culture and in the subjects of nursing/midwifery and spirituality, The authors declare no conflict of interest. so that the end product becomes culturally sensitive. Translation teams will need to be formed with various experts who are fluent in AUTHOR CONTRIBUTIONS both English and the new language. Being familiar with the language Study plan: TG, AS- A, PHC, WM, RvL and LR; data collection: TG, and culture and knowing nursing and midwifery practice in a specific AS- A, BB, PHC, BMK, WM, BO, VU, RvL and LR; data analysis: TG, country will ensure that the spiritual concepts and constructs are AS-A , BB, PHC, BMK, WM, BO, VU, JL- S, RvL and LR; manuscript understood in the new language and/or culture. Every time the Tool and revision of the article and agreed on the final version: TG, AS- A, is translated into another language, researchers must test it using BB, PHC, BMK, WM, BO, VU, JL- S, RvL and LR. the same protocol presented by Martins et al. (2015) to ensure it is true to the original Tool while demonstrating relevance in the new E THIC AL APPROVAL language and/or culture. We welcome people to translate the EPICC Norway: Norwegian Centre for Research Data # 847359, granted Standard and the EPICC Tool; however, it should only be done with April 4th 2020. Wales: University of South Wales, Faculty of Life written permission from the EPICC Steering group. Sciences & Education Ethics Sub Group Ref 200501HR, granted 18th June 2020. England: Staffordshire University, School of Health and Social Care (now School of Health, Science and Wellbeing) Ref 5  |  CONCLUSION No. SU_19_151. California: Azusa Pacific University, IRB, # 20-1 88, granted July 22, 2020. The Netherlands—C hristian University of While tools exist for assessment of patient spirituality and spiritual Applied Sciences, department of Health Care/Nursing (no refer- needs, few self-e valuation tools are available for N/M students in ence number). Ghana Central University, IRB # 20/001, granted this area. Therefore, an instrument for self-a ssessment was needed July 1st 2020. to increase awareness and knowledge and to improve skills and at- titudes in the domain of spirituality and spiritual care. This EPICC DATA AVAIL ABILIT Y S TATEMENT Spiritual Care Self-A ssessment Tool is a valid and reliable tool that Data supporting these findings are available with the authors. The N/M students can use to evaluate their own competences. data would be made available by authors upon reasonable request. Students who responded to the call to test the new self- assessment Tool found it beneficial with some minor changes. The ORCID tool has good psychometrics in three languages, so it may be use- Tove Giske https://orcid.org/0000-0002-6018-4468 ful across many areas of the world. Moreover, qualitative data rein- Annemiek Schep- Akkerman https://orcid. forced the quantitative findings and statistical analyses. org/0000-0002-3068-3821 Bodil Bø https://orcid.org/0000-0002-4232-7277 Pamela H. Cone https://orcid.org/0000-0003-4127-289X 6  |  RELE VANCE TO CLINIC AL PR AC TICE Britt Moene Kuven https://orcid.org/0000-0003-0080-2655 Wilfred Mcsherry https://orcid.org/0000-0003-0932-5875 Students noted that they have few role models in clinical practice, Benson Owusu https://orcid.org/0000-0002-4061-490X and we think the use of the Tool in continued education for working Venke Ueland https://orcid.org/0000-0001-5600-3348 nurses and midwives will enhance their ability to act as role models Joanne Lassche- Scheffer https://orcid. in spiritual care for students. org/0000-0003-4108-9534 This newly developed Tool can be used by students and work- Rene van Leeuwen https://orcid.org/0000-0002-2136-6509 ing professionals in nursing and midwifery. It could also be useful Linda Ross https://orcid.org/0000-0003-3978-5952 14  |    GISKE Et al. nursing students. Journal of Holistic Nursing, 37(1), 94–9 9. https:// R E FE R E N C E S doi.org/10.1177/08980 10119 835616 Alligood, M. R. (Ed.). 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