1. Background
Spirituality is a universal phenomenon experienced by each individual. It encompasses a set of values, attitudes, and beliefs connected to the transcendent aspect of a person and is associated with experiences that guide one toward excellence. However, it is important to note that spirituality, in the context of healthcare, should not be mistaken for theology and does not seek to provide answers to personal and intricate questions (1).
Spirituality should be practical, realistic, broad, and focused, allowing for its transmissibility. It should also be distinguishable from other aspects of health, easily accessible to all individuals, and have a scientific foundation that is widely accepted (2). Within medical education literature, spirituality is regarded as a fundamental and essential aspect of human existence (3) that aligns with a holistic approach to medicine (4).
While religious and spiritual guidance primarily falls within the purview of religious individuals, it is the responsibility of academic experts in their respective fields to employ a scientific and spiritually-informed approach to treating and fostering healthy behaviors (4).
Certain physicians and faculty members in the field of medical sciences recognize the significance of spirituality in healthcare and emphasize the importance of incorporating spiritual communication into patient care. However, in practice, the integration of spirituality has not been widely implemented. Various texts highlight the barriers to implementing spirituality, including constraints such as lack of time, knowledge, and education (5).
The curriculum serves as a crucial instrument for realizing the objectives and missions of higher education. It should be designed to address the current and future needs of the community while actively contributing to problem-solving and fostering the development of learners (6). A documented curriculum, often referred to as a declared curriculum, is a written guide that outlines educational objectives, content, teaching methodologies, and assessment strategies, effectively organizing the teaching and learning processes within the educational system (7).
In medical schools, the predominant focus is on disease treatment using a biomedical approach. This approach, centered around knowledge and disease, often overlooks various individual and social factors. However, it is essential to acknowledge that the field of medicine aims to preserve and enhance human health, which encompasses both the physical and spiritual aspects of individuals. Consequently, any medical intervention will impact both the body and soul of a person. Neglecting the holistic nature of human beings, as both body and soul, can reduce a doctor's role to that of a computer program merely interpreting patient test results (8). In recent decades, there has been substantial growth in the number of conceptual and empirical articles exploring the concept and significance of spirituality in healthcare (9). A study by Barnett and Fortin (2006) revealed that inadequate training in spirituality was among the reasons for the limited attention given to spirituality in the realm of health services (10). Consequently, in order to address this matter and incorporate spirituality effectively in healthcare provision, it becomes crucial to provide the necessary training (11).
Education offers the optimal platform for exploring and understanding the spirituality of individuals, and spirituality inherently holds significance within the realm of pedagogy (3). The necessity of spirituality in education and culture surpasses that of other domains. Consequently, prominent institutions such as the American Association of Medical Schools, the World Health Organization, and the Accreditation Commission of Health Organizations have advocated for the incorporation of spiritual considerations into clinical care and medical education (5).
In 1993, merely three medical schools in the United States offered spiritual education to their medical students. However, by 2011, this number had risen significantly to include 100 medical schools (12). Consequently, the topic of spirituality sparked extensive debates within scientific circles. Research indicates that 59% of UK medical schools and 90% of American medical schools have incorporated spiritual health content into their curriculum. However, limited information is currently available regarding the integration of spirituality within the curriculum of medical schools in Latin America, Asia, Australia, and Africa (13). In the past decade, significant emphasis has been placed on advancing the concept of spirituality within the literature of various medical disciplines, particularly nursing. Fawcett (2000) asserts that individuals' worldviews play a crucial role in shaping the development of conceptual models and theories. Therefore, the inclusion of the concept of spirituality within each model and conceptual theory is a reflection of the theorist's worldview(14). Considerable evidence and studies advocate for the implementation of comprehensive training in spirituality within medical and educational institutions across different countries, aiming to enhance the provision of care and spiritual counseling (15, 16).
2. Objectives
Given the current absence of collaboration between the care team and spiritual and mental health programs in Iran, there is a need for specialized spiritual care services within healthcare systems. Consequently, there is a requirement to establish and implement a specialized spiritual health education program within the field of medical sciences. This program aims to train healthcare professionals who can effectively contribute to the provision of comprehensive and standardized care for patients as integral members of the healthcare team. As such a curriculum has not been developed in Iranian Medical Universities, this study was conducted to formulate a master's degree curriculum in spiritual health.
3. Methods
This study aimed to design a master's degree curriculum in spiritual health, following Tyler's model, through a three-phase approach (17).
In the initial phase, the primary objective is to assess the existing state of spiritual health education programs and examine the historical and practical aspects through an extensive literature review. A comprehensive search was conducted across relevant international databases, including Google, Google Scholar, PsycINFO, ERIC, PubMed, CINAHL, EBSCO, ProQuest, Elsevier, Medline, SCOPUS, and Science Direct. The search terms utilized were (spiritual health OR spirituality) AND (program OR curriculum) AND (education OR training).
The gathered articles underwent an initial screening process by two researchers (the first and second authors) to evaluate the relevance of their titles and content. Any articles deemed irrelevant were excluded. The remaining articles, focusing on the experiences of individuals in the realm of spiritual health education in Iran and other countries, were then reviewed by two additional researchers (the third and fourth authors). These researchers were responsible for extracting relevant content pertaining to spiritual health education from the articles and evaluating them in accordance with the research objectives and the cultural and religious context of Iran. In the event of any challenges or disagreements during the content extraction process, a final discussion and consultation were conducted with another researcher (the sixth author).
In the second phase, a focus group discussion on the spiritual health curriculum was conducted, involving eight experts and scholars with extensive experience in spiritual health and curriculum development. All participants held Ph.D. degrees in medical education and had practical knowledge of integrating spirituality into education. The focus group meeting (as outlined in Table 1) was organized in consideration of the time constraints, resulting in a productive session lasting three hours with two half-hour breaks interspersed. Initially, the focus group session was led by the proficient moderator (the first author), who holds a Ph.D. and possesses a decade of experience in conducting research in the field of spirituality. Drawing upon available resources and the insights gained from the focus group discussion, the initial draft of the program titled "Master's Degree in Spiritual Health Curriculum" was developed. This curriculum was designed in accordance with Tyler's curriculum development model (17), encompassing four essential steps: Defining the educational objectives, identifying relevant educational experiences, organizing the experiences, and evaluating the achievement of the objectives. Tyler's model is considered one of the oldest, simplest, and most extensively utilized models in curriculum design. Its user-friendly nature, grounded in four distinct stages, has contributed to its popularity and widespread adoption (18). Upon extracting relevant content pertaining to spirituality, the contents were subsequently designed following Tyler's model, encompassing four key steps, namely:
● Part one: Objectives of the spiritual health curriculum
● Part two: Content of the spiritual health curriculum
● Part three: Teaching and learning opportunities for the spiritual health curriculum
● Part four: Evaluation of the spiritual health curriculum
Table 1.Demographic Characteristics of Focus Group Experts
| Number | Field of Study | Academic Ranking | Age (y) | Male/Female | Job Experience (y) |
|---|---|---|---|---|---|
| 1 | Medical education | Professor | 62 | Male | 28 |
| 2 | Nursing education | Associate professor | 52 | Female | 21 |
| 3 | Islamic sciences and theology | Professor | 54 | Male | 25 |
| 4 | Health policy | Associate professor | 51 | Male | 20 |
| 5 | Social medicine | Associate professor | 49 | Female | 18 |
| 6 | Curriculum planning | Professor | 55 | Male | 25 |
| 7 | Health psychology | Associate professor | 48 | Female | 19 |
| 8 | Medical ethics | Associate professor | 43 | Female | 15 |
In the final phase, the nominal group process was employed to facilitate consensus among the experts. The initial draft of the curriculum was presented to 15 experts in a face-to-face setting to gather their consensus ideas. Experts were encouraged to provide feedback on any existing items. The selected experts for this stage formed an interdisciplinary team comprising specialists in areas such as spirituality, spiritual well-being, medical ethics, psychology, social medicine, medical education, nursing, and clergy. Table 2 presents the demographic characteristics of these experts. The draft underwent revisions based on the experts' feedback to ensure agreement on each item and was subsequently returned for a final vote. This iterative process continued until an 80 percent agreement was reached. The nominal group process is particularly useful when designing programs or services that are being introduced for the first time or when the consensus among experts is lacking (19, 20).
Table 2.Demographic Characteristics of Nominal Group Experts
| Number | Field of Study | Academic Ranking | Age (y) | Male/Female | Job Experience (y) |
|---|---|---|---|---|---|
| 1 | Medical education | Professor | 62 | Male | 28 |
| 2 | Medical education | Assistant professor | 35 | Female | 8 |
| 3 | Medical education | Assistant professor | 37 | Female | 9 |
| 4 | Nursing education | Associate professor | 52 | Female | 21 |
| 5 | Islamic sciences and theology | Professor | 54 | Male | 25 |
| 6 | Health policy | Associate professor | 51 | Male | 20 |
| 7 | Social medicine | Associate professor | 49 | Female | 18 |
| 8 | Curriculum planning | Professor | 55 | Male | 25 |
| 9 | Health psychology | Associate professor | 48 | Female | 19 |
| 10 | Medical ethics | Associate professor | 43 | Female | 15 |
| 11 | Islamic sciences | Associate professor | 52 | Male | 21 |
| 12 | Islamic sciences | Assistant professor | 48 | Male | 19 |
| 13 | Islamic sciences | Professor | 60 | Male | 24 |
| 14 | Psychiatrist | Professor | 65 | Female | 27 |
| 15 | Health in disaster | Assistant professor | 40 | Female | 12 |
4. Results
The spiritual health education curriculum was designed based on Tyler's curriculum planning, consisting of four parts.
4.1. Part One: Objectives of the Spiritual Health Curriculum
4.1.1. Discipline Definition
A master's degree in spiritual health aims to equip graduates with the skills necessary to provide spiritual counseling in the medical sciences, aligned with the principles of spiritual health. Spiritual health encompasses both theoretical and practical aspects. In the theoretical aspect, it delves into the foundations and concepts of this discipline, explores existing theories, and examines its connection with various cultures, religions, and societal customs. On the other hand, the practical aspect draws upon the theoretical foundations to address issues, problems, and topics relevant to healthcare and medical care, thereby providing a framework for informed decision-making.
4.1.2. Vision
In the current critical era, there is a growing call from academics, activists, leaders, and thinkers for a prompt reassessment of our educational and cultural environment. To achieve progress, development, and a sustainable and equitable future, it is crucial to engage in critical thinking about our connections with the natural world, other societies, and the beliefs and values that shape our individual and collective actions. The inclusion of a spiritual health education program is being advocated as a potential solution to address health crises.
4.1.3. Expected Outcomes for Graduates
● Training competent professionals capable of teaching spiritual education courses at various levels of medical sciences.
● Training skilled researchers in the field of spiritual well-being, leveraging the rich cultural and religious education of Islamic society and the existing scientific knowledge in this field worldwide.
● Offering consultative expertise to physicians, researchers, managers, and other stakeholders in the healthcare system on critical health-related matters.
4.1.4. Professional Responsibility
● In the teaching role: Delivering courses, conducting workshops
● In the counseling role: Conducting research, organizing conferences
● In the prevention role: Raising awareness, generating preventive content
● In the remedy role: Implementing spiritual interventions
● In the caring role: Providing diverse spiritual care services
4.2. Part Two: Content of the Spiritual Health Curriculum
The content in the spiritual health curriculum is organized into three categories: Prerequisite, required, and elective courses.
(1) Prerequisite: Certain prerequisites are necessary for entering the field, and students have the flexibility to choose them based on group discretion (Table 3).
Table 3.Remedial Courses
| Lesson Code | Name | Number of Course Units | Comment About Lesson | |
|---|---|---|---|---|
| Theory | Total | |||
| 01 | Medical information systems | 5 | 1 | Students should develop the ability to utilize various search methods in relevant databases within their field of study and become acquainted with the library services offered by their university. Additionally, they should be familiar with popular internet browsers and proficient in conducting searches using search engines and accessing reputable and valuable information sources within their field. |
| 02 | General English | 2 | 2 | Students should be familiar with the structure of academic writing, adhere to English grammar rules, and possess the ability to comprehend the meaning of texts and translate them accurately. |
(2) Required courses: These courses are mandatory for all students, and successful completion is a requirement. The following lessons are included in this category (Table 4).
Table 4.Core Courses
| Lesson Code | Name | Number of Course Units | Comment About Lesson | |
|---|---|---|---|---|
| Theory | Total | |||
| 03 | English language | 2 | 2 | Proficiency in English: Students should have a strong command of the English language. They should be able to identify and rectify errors in texts written by their peers. |
| 07 | Theoretical principles of spiritual health | 2 | 2 | Students become familiar with concepts related to spiritual health, with a particular emphasis on Islam. |
| 08 | Principles of psychological health | 2 | 2 | Students become familiar with the principles of psychology and their relationship to other aspects of human existence. |
| 09 | Psychology of religion | 2 | 2 | Students become familiar with the theories and foundations of religious psychology and also conduct research in the psychology of religiosity. |
| 10 | Ethics in medical sciences | 2 | 2 | Students learn the principles of professionalism and effective communication with patients. |
| 11 | Lifestyle and risky behaviors | 2 | 2 | Students learn behavioral change programs aimed at improving lifestyles. |
| 13 | Spiritual assessment | 1 | 2 | Students become familiar with the goals of Spiritual Assessment and practice various assessment techniques. |
| 14 | Spirituality therapy and spiritual counseling | 1 | 2 | Students learn counseling interviewing techniques and practice them. |
| 15 | Internship | - | 2 | Students practice spiritual interventions and learn how to provide spiritual services to patients. |
| 16 | Apprenticeship | - | 2 | Students can provide spiritual services independently under the supervision of a professor in outpatient clinics and hospital departments. |
(3) Elective courses: These courses can be selected based on the student's dissertation topic (Table 5).
Table 5.Noncore Courses
| Lesson Code | Name | Number of Course Units | Comment About Lesson | |
|---|---|---|---|---|
| Theory | Total | |||
| 04 | Education in medical sciences | 2 | 2 | Students learn the concept of medical education and other educational terminology, such as teaching techniques. |
| 05 | Advanced study methods and statistics | 1 | 2 | Students should be proficient in utilizing various research methods in their field of study. Additionally, they should be capable of applying statistical principles, conducting statistical inference tests, interpreting the results of statistical tests, and appropriately reporting their findings. |
| 06 | Principles of epidemiology | 1 | 2 | Students learn how to calculate health and disease indicators and become familiar with various types of epidemiological studies, including their characteristics and applications. They develop the ability to critically analyze and evaluate epidemiological literature pertaining to community health. |
| 12 | Principles and techniques of counseling in health sciences | 1 | 2 | Students become familiar with the general concepts of counseling in health sciences. |
4.3. Part Three: Teaching and Learning Opportunities for the Spiritual Health Curriculum
At least three faculty members are needed, including a Ph.D. in psychology and two with expertise in medical education, medical ethics, or social medicine. It is required that at least one of them holds the position of associate professor.
4.3.1. Educational Setting
● General educational environment: This includes classrooms, internship rooms, reliable and high-speed internet access, a conference hall, and an education archive file.
● Specific educational environment: This pertains to hospitals and healthcare networks.
● Target population: This includes patients visiting health centers, patients admitted to hospitals, and all community members, in line with the primary prevention and health promotion approach.
4.3.2. Materials and Techniques
● Various types of conferences: These include cross-departmental conferences, interdisciplinary conferences, inter-hospital conferences, inter-university conferences, and seminars.
● Small group discussions: This involves workshops, book clubs, and case presentations.
● Clinical activities: These include morning reports, educational and practice rounds, outpatient education, and education in the operating theater.
● Utilization of distance learning techniques: This allows for the use of facilities and simulations in distance learning.
● Situated learning approach: This involves the use of role-play and practical applications in learning.
4.4. Part Four: Evaluation of the Spiritual Health Curriculum
Conducting formative evaluation: This involves conducting interviews with program designers involved in its implementation, as well as focused group discussions with the participation of professors, key informants, students, and graduates from the field.
Conducting summative evaluation: The program will be evaluated based on the following conditions:
● Three years after the program implementation
● Major technological changes that may require revisions
● Decisions made by key policymakers associated with the program
4.4.1. Evaluation Program Indication
Satisfaction of faculty members and students with the program: 80%
Satisfaction of health system managers with the program results: 70%
Assessment of meeting the needs and addressing health problems of graduate students: As determined by the evaluation group
Quantity and quality of intellectual and research outputs by graduate students: As determined by the evaluation group
5. Discussion
This study aims to develop a curriculum for a master's degree in spiritual health education. Currently, there is a lack of comprehensive educational programs for spiritual health in Iran, despite the integration of spirituality into the curricula of many medical schools worldwide. This highlights the growing importance of spirituality in medical education (21-23) In several medical education programs and related disciplines, optional courses are available for medical students to explore spirituality (24-26). Spirituality is a significant and multidimensional aspect of mental well-being and healthcare systems. Its recognition and enhancement are increasingly acknowledged as crucial for overall health globally (10). Studies have indicated that insufficient training in spirituality is one reason for its limited integration into healthcare services (9). This research focuses on the development of a master's degree curriculum in spiritual health, utilizing Tyler's curriculum planning framework comprising four essential elements (17). This program has been designed to empower students in the field of spiritual health, spiritual interventions, and spiritual care, with a focus on establishing goals, developing curriculum content, identifying teaching opportunities, and implementing effective learning and assessment methods. The curriculum was developed based on a comprehensive review of articles and texts related to spiritual health education programs and incorporating expert opinions. Following Tyler's curriculum model, a spiritual health curriculum was formulated.
In the initial section of the spiritual health curriculum, key aspects such as defining the discipline, establishing the mission statement and vision, setting curriculum objectives, determining expected outcomes, and outlining roles and professional tasks are addressed. This study aligns with Puchalski's research on the development of a spirituality and health curriculum. The study, conducted in collaboration with seven medical schools in the United States, explores the competencies necessary for integrating spirituality into healthcare. The findings of this study identified six domains of competence in this field, namely: healthcare systems, knowledge, patient care, humanitarian presence, personal and professional development, and communication (27).
The proposed course aims to prepare mental health professionals for real-world scenarios they may encounter after graduation. By combining subject matter and content, these lessons create a sustainable learning experience, enabling students to bridge the gap between theory and practice. The program's ultimate goal is to train professionals who can effectively fulfill their responsibilities and contribute to the enhancement of patients' spiritual health. Unlike existing spirituality programs in medical schools, this program specifically focuses on training spiritual health professionals. Many studies have treated the teaching of spirituality as an elective or optional component in the curriculum (9, 21, 28, 29). However, this curriculum aims to educate specialists who are integral members of healthcare and treatment teams. They will acquire the necessary knowledge and skills, stay updated with new technologies, and be capable of providing comprehensive and standardized patient care.
The developed curriculum in this study fully integrates the establishment of courses, ensuring that each lesson prepares students for tasks related to care, treatment, and counseling. The integration of the program fosters a deeper understanding for students and promotes the synthesis of theoretical and practical aspects. This curriculum is entirely based on the training needs and existing spiritual capacity within the Iranian context, aligning with a research study titled "Interests of Participants in Integrating Spirituality in the Curriculum of the Medical Group in Iran." This research categorizes the key components necessary for designing a spirituality curriculum in medical education into educational needs, integration capacities, and challenges (13).
In the section on teaching and learning opportunities, the curriculum has emphasized meeting human and environmental needs and utilizing effective teaching and learning strategies. These strategies align with the principles of accountability in healthcare, promoting the integration of spirituality in health education. This study aligns with Laccheti's research on "Methods for Teaching Spirituality in Health." Laccheti identified various teaching methods, including lectures, small group activities, spiritual history taking, clinical experiences, national conferences, workshops, role play, the use of standardized patients, and problem-based learning (21).
The concluding section of the spiritual health curriculum incorporates evaluation programs, encompassing both formative and summative assessments. The evaluation of the program encompasses various indicators, including the program's effectiveness in meeting the societal, faculty members', and students' needs, as well as the employment rate of graduates (30).
One of the limitations of the current study is the challenge of coordinating the participation of experts in the expert panel and nominal group. It is recommended that future studies address this limitation by arranging video conferences for experts who are unable to attend in person and conducting expert panel meetings in multiple sessions. Furthermore, it is suggested to include students, who are the primary beneficiaries of such studies, in future research and consider their opinions in the study and curriculum development process.
5.1. Conclusions
The spiritual health curriculum is designed to incorporate spirituality into the curriculum planning process, encompassing goals, content, education implementation, and evaluation. It aims to guide individuals toward achieving spiritual well-being by addressing various dimensions of spiritual health through interventions and therapies. Students in the spiritual health curriculum acquire the necessary skills to respond to the needs of patients in collaboration with the healthcare team.
