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Foundations of Spiritual Care –

professional development programme

Evaluation Report 2015

Professor Rod MacLeod, Dr Tess Moeke-Maxwell, Dr Richard Egan and Rachael Crombie

Foundations of Spiritual Care / 3

Hospice New Zealand (HNZ) identified a need to increase the capacity for spiritual care within Hospice. They highlighted the need for the sector to provide staff with spiritual care training across all workforce domains to build spiritual health literacy and competency to support the idea that spiritual care is shared by all within the team (Paal et al, 2015).

ResultsPositive experiences and outcomes for staff and volunteersThe Foundations of Spiritual Care (FOSC) programme positively influenced participants in two key areas; personal and professional influence.

Personal Influence:

• Increased personal awareness and understanding of spirituality and spiritual care

• Refreshed, affirmed and validated prior spiritual knowledge

• Increased confidence

“ I feel more comfortable with what spirituality might mean for myself and others. I am able to raise questions with patients to find out more about their spirituality”

Professional Influence:

• Increased collegiality

• Increased health literacy

• Development of new skills

“ Helped me to find some spiritual assessment tools and reflect on appropriate language and terminology”

Some questions were raised by participants on the sustainability of experiences and outcomes and mixed feelings were reported on the relevance of the entire programme for non-clinical participants.

Positive experiences and outcomes for hospice organisations100% of hospices involved to date reported benefits in undertaking the programme, but they also recognised that there were challenges involved (96%). Only one of the 21 hospices that undertook the programme, rated their experience below average. Some organisations reported difficulties in measuring impact and outcomes or it was too soon to report on these. However 78% of key informants responded that there were changes in the way the organisation addresses spiritual care needs following the programme (n= 27).

There was evidence that hospice organisations experienced:

• Positive team building and relationships

• Development of a common language/increased literacy

“ As all our staff have completed the programme, we have a common springboard from which to move forward. It provided an opportunity for us to meet together as a team, share our understanding of spirituality and spiritual care”

EVALUATION EXECUTIVE SUMMARY

Evaluation Report – Executive Summary

4 / Foundations of Spiritual Care

Hospice organisations recognised the following when delivering the programme:

• Importance of organisational support

• Importance of the facilitator roles

As with participants, there were mixed feelings from organisations on whether the programme met the needs of all team members – particularly the needs of volunteers and board members.

Critical success factors and barriers to improving spiritual careThe willingness of hospice boards, management, facilitators and clinical and non-clinical staff to support and participate in the FOSC programme was pivotal to increasing the opportunity to develop a spiritual culture within Hospice. The FOSC programme influenced improvements to hospice spiritual care culture leading to improved spiritual care in the following key areas:

• Staff empowerment

• Increased spiritual care practice

• Increased spiritual health literacy

“ Spirituality remains present and integral rather than coincidental and optional”

Barriers included time, discomfort or disinterest in engaging in spiritual care, lack of spiritual health care literacy and structural barriers.

RefinementsThe following refinements were suggested for the programme by participants and hospices:

• Improve the balance of programme time and content

• Enhance the Wairuatanga component of programme

• Increase support for facilitators

• Provide a follow up or next level programme

Conclusion and RecommendationsThe development of an enhanced culture of spiritual care was evident within hospices that participated in the evaluation. The Foundation of Spiritual Care programme has the potential to improve connectedness and relationships between staff and to help facilitate an environment where spiritual care within hospice is improved. It has provided a potentially transformative educational experience. By this we mean that it has created opportunities to stimulate diverse, alternative and multiple perspectives on spirituality and spiritual care through reflection either individually or in groups and hence incorporated into practice.

This programme provides an opportunity to increase spiritual health literacy. It also influences a sense of responsibility among the workforce to give expression to spirituality at both a personal and at an organisational level. When staff confidence grows this is likely to influence the development of a spirit of care towards patients, families and whanau. Hospices are well placed to resource and support these people to champion FOSC and to further develop spiritual care education.

The evaluation has provided evidence that the FOSC programme has the potential to increase and strengthen the spiritual health domain within hospice. However, a culture of spiritual care has to be prioritised, resourced and sustained to contribute towards upholding and strengthening the spiritual care domain, which positively benefit its recipients: staff, patients, family and whanau.

Some minor changes to the FOSC programme are recommended to enhance outcomes and delivery of the programme.


EVALUATION REPORT 2015

The authors recommend consideration of the following:

• Continue support and investment into delivery of FOSC programme across all hospices

• Investigate follow-up or an advanced level programme to sustain and build on new knowledge and provide opportunities for deeper learning. Gains made from the FOSC programme need to be embedded and built on. There was a call for a next level programme that goes deeper into spirituality, spiritual needs and care. Hospices are well placed to develop the culture of spiritual care by supporting those with a “natural interest or inclination” to progress this health domain within Hospice.

• Improve the balance of time and content of programme. Clarify expectations of content to be covered and consider time available to met learning outcomes, especially session 3 and 4.

• Relevancy of some programme elements for non-patient facing members of hospice team

• Consider requirements for attendance. Compulsory attendance would mean all clinical and non-clinical staff would have equitable access to spiritual care training.

• Provide an enhanced segway/introduction into the wairuatanga component of programme. To help participants prepare for Wairuatanga content throughout the programme a segway could be developed to introduce staff to a Maori cultural spiritual worldview, why it’s included and the benefits to staff, patients, family and whanau.

• Increase structural support for programme and its outcomes. This may include extra training or support mechanisms for facilitators, increase staff knowledge of the existing spiritual policies and resources within the organisation and provide time, space and resources to progress spiritual care within Hospice. The programme content inspired some staff to continue to develop the spiritual care culture within hospice following the course but no formal mechanism, pathway or resources were put in place to ensure the continuation of spiritual care gains. Hospices could be encouraged to identify spiritual care champions alongside the chaplain/spiritual carer and support them to further develop a culture of spiritual care and lead the development of the spiritual care domain within hospice.

• Consider offering programme to other organisations. The FOSC programme is a useful, well developed and evaluated programme that with some refinement could be useful for other organisations such aged residential care, mental health contexts or even mainstream primary/secondary/tertiary healthcare. Some adjustments would be necessary with each context being unique, therefore a pilot – evaluation process is recommended.

• Plan evaluation of ongoing and long term outcomes of the programme


Spiritual care is integral to palliative care (Rumbold, 2003, Morgan et al, 2015). New Zealand research highlighted that there were gaps in spiritual care provision by hospices and a lack of professional development opportunities in this area (Egan et al, 2011). This evidence, a literature review (Egan & Blank, 2012) and consultation with hospices, informed the development of the Foundations of Spiritual Care professional development programme. The programme was developed by Hospice New Zealand to target the spiritual care needs of NZ hospice teams (all staff and volunteers). The programme aims to improve the understanding and knowledge of spirituality with and for the wider hospice team; thereby improving the spiritual wellbeing of their organisations and spiritual care for patients, families and whanau.

The expected benefits of the programme are:

• Patients, families and whanau having their spiritual needs consistently recognised and met in New Zealand

• A common language and shared understanding of spirituality and spiritual care within and across hospices in New Zealand

• Guardianship of the unique hospice values and philosophy that sets hospice apart in New Zealand

• Alignment to national strategies and standards.

The guiding principles of the programme are stated as:

• It is a foundation course – “starting the conversation”

• It is available to all team members (clinical, non-clinical, governance, volunteers)

• It is a professional development resource with reflective components and not spiritual counselling sessions

• It is non-sectarian and participants’ own spiritual practices are respected

• The programme is not about instilling but rather uncovering what people already know, experience and do – it is drawing out what’s within – “what do I bring to my work?”

• It will provide hospices with the ability to shape sessions appropriate to local organisation and team needs and allow identification of spiritual care within our own organisations and acknowledge the challenges

The programme is structured as four sessions and the resources include a selection of activities for facilitators to choose from to meet the needs of the audience and to meet the learning outcomes.

Programme Learning Outcomes:

Session One: Exploring Spirituality

1. Clarify what spirituality may mean

2. Differentiate between spirituality and religion

3. Explain the importance of spiritual care in palliative care and end of life care

4. Develop a deeper awareness of your own spirit

5. Describe some attributes required to respond appropriately to spiritual need

6. Describe existential suffering/spiritual distress/spiritual wellness

Session Two: Wairuatanga – Spirituality in Te Ao Maori

You will know, or be reminded of, some of the fundamentals of Te Ao Maori

1. Karakia – (prayer, incantation, blessing) the practice and its importance

2. Whanaungatanga – (acknowledgement of our relationships and connections) holistic connectedness to everything around us

1. Background and Programme Purpose



Session Three: Spirituality at the End of Life

1. Identify sources of spiritual distress

2. Acknowledge the importance of therapeutic relationships

3. Discuss likely spiritual needs/issues at the end of life

4. Outline why assessment of spiritual need is important

5. Differentiate between screening/assessment/taking a spiritual history

6. Discuss the importance of accurate documentation and care planning

7. Identify when a person may need to be referred to a specialist spiritual carer

Session Four: Spiritual Care at the End of Life & Caring for ourselves

1. Discuss the role of self in developing a therapeutic relationship

2. Demonstrate good communication skills

3. Identify sources of burnout/compassion fatigue

4. Describe strategies for self care

Programme guidelines suggested that participant groups were made up of a cross section of the wider hospice team, with no more than 15 in a group to allow for the interactive style and sharing involved with the programme.

Programme guidelines suggested that the programme was facilitated by two people and that these two people would best be a spiritual care team member and a Maori liaison team member. These two facilitators were expected to attend every session. The programme outline also recommended guidance from local kaumatua and hospice educators for aspects of the programme.

After a pilot with four hospices, the programme was launched in October 2013 and offered to hospices around the country. The programme is voluntary and hospices choose to first register for facilitator study days and then begin delivery of the programme when they feel the timing is right for their organisation.

At the time of evaluation (May 2015), 28 hospices (out of 33 members) had facilitators who had attended study days and 21 hospices had delivered one or more courses to their staff/volunteers. One hospice choose to deliver the programme to staff via a neighbouring hospice. Via these courses, a total of 525 participants had completed the programme across a wide range of disciplines including clinical and non-clinical staff, volunteers, management and governance representatives. The timing of the evaluation was chosen to determine what had been successful and challenging with the delivery of the programme to date and explore what refinements could enhance the programme.


The programme evaluation considered the following:

1. Hospice staff and volunteer experiences and outcomes from participating in this professional development programme

2. Experiences and outcomes for hospice organisations as a whole

3. To identify critical success factors, common strategies and barriers to improving spiritual care for patients, families and whanau in hospice care

4. To inform further refinements of this resource and inform use outside of the hospice sector

2. Programme Evaluation Aims



This project used a mixed methods approach to evaluate the FOSC programme. The evaluation included cross-sectional surveys of programme participants and key informants (facilitators and senior management) within hospices and focus groups (n=3 hospices) of programme participants. It also included information from participants’ post programme reflection forms. Ethics approval was obtained from the Department of Preventive and Social Medicine, University of Otago (reference D15/027).

Focus Groups Two small focus groups were undertaken with programme participants representing three hospices. Following the focus groups, two interviews were also undertaken with programme facilitators from two of the participating focus group hospices. The focus groups were held in one North and one South Island hospice; there was a total of 5 and 7 participants respectively. Generic focus group techniques were used in both the process and analysis (Patton, 2002). Two researchers (RE & TMM) independently coded the focus group transcripts and then merged their analysis.

SurveysKey Informant Survey

21 hospice organisations in New Zealand had completed one or more courses of the FOSC programme by May 2015. For hospices who had completed at least one programme we invited those who had facilitated the programme (both cultural and spiritual advisors) and a senior management representative to complete the online key informant survey. All 21 hospices provided one or more responses to the key informant survey, with a total of 28 responses.

Characteristics of participating hospices:

Inpatient Facility 90% 19/21

Chapel/Quiet Room 90% 19/21

Spiritual Carer/Chaplain 95% 20/21

Paid Spiritual Carer/Chaplain role 85% 17/20

Average hours per week of paid spiritual carer/chaplain 23 hours n=16

Participant Survey

We asked programme facilitators to forward an email invitation to an online participant survey to all those in their organisation who had completed the programme. There were 131 survey responses from 405 invitations sent to participants, a 32% response rate. All participants were either hospice employees or trained volunteers and were from a wide variety of hospice roles, clinical and non-clinical; 12% were from volunteer roles. Most respondents work part-time at the hospice (68%) and over half of the respondents had worked five years or more in hospice (52%).

The participant survey included both quantitative and qualitative components.

Post programme Reflections

Following the completion of the programme, participants are asked to fill in a self-reported reflection, 4-6 weeks after completing the programme. This reflection form includes Likert scales and open ended questions. These forms were collected by programme facilitators and entered into a Hospice NZ online database. Anonymous data was then collated and key themes analysed (RC and RM).

215 participant post programme reflection forms were available and were analysed from 525 who had completed the course (41%).

3. Method


Thematic Analysis

A thematic analysis was undertaken for all the responses in the surveys and programme reflections that required free text qualitative responses. Thematic coding is a form of qualitative analysis which involves recording or identifying passages of text or images that are linked by a common theme or idea allowing you to index the text into categories and therefore establish a “framework of thematic ideas about it” (Gibbs 2007).

Whilst there are a variety of different approaches to thematic analysis each option is still a form of thematic coding.

The approach to thematic analysis we utilised follows that outlined by (Braun & Clarke, 2006). It involves a six-phase process:

1. Familiarisation with the data: This phase involves two researchers (RC and RM) reading and re-reading the free text data, to become immersed and intimately familiar with its content.

2. Coding: This phase involves generating succinct labels (codes) that identify important features of the data that might be relevant to our exploration of the outcomes of this evaluation. It involves coding all the texts, and after that, collating all the codes and all relevant data extracts, together for later stages of analysis.

3. Searching for themes: This phase involves examining the codes to identify significant broader patterns of meaning (potential themes).

4. Reviewing themes: This phase involves checking the potential themes against the dataset, to determine that they tell a convincing story of the data (does it make sense), and one that gives us useful information about our evaluation questions. In this phase, themes are typically refined, we found that we only needed to refine some wordings and create some sub-themes. Some original themes were discarded.

5. Defining and naming themes: This phase involves developing a detailed analysis of each theme, working out the scope and focus of each theme, determining the ‘story’ of each. It also involves deciding on an informative name for each theme.

6. Writing up: This final phase involves weaving together the analytic narrative and data extracts, and contextualising the analysis in relation to existing literature.

Limitations

The reported response rates could mean that non-responder programme participants may effect evaluation results. However all hospices that have completed the programme have provided input into the evaluation in some way. There is also a significant number of participants represented throughout the combined arms of the research. The results represent recurring and strong themes across the different methods. Member checking also took place for the vignettes represented.



The following results indicate the recurring and common themes across all arms of the evaluation. They are divided into hospice staff and volunteer experiences and outcomes, experiences and outcomes for hospice organisations as a whole, critical success factors and barriers and suggested refinements.

4.1 Hospice staff and volunteer experiences and outcomes The responses from the participant survey and programme reflections showed that the FOSC programme was a positive experience for attendees and the majority rated programme impact and usefulness above average or excellent.

Graph 1: Self-Reported participant experiences from online participant survey

(Content n=106, Delivery n=101, Wairuatanga n=107)

Graph 2: Participant ratings of programme impact and usefulness

(Programme reflection responses n=215, Participant responses n=93)

The FOSC programme positively influenced two key areas for staff, summarised below as, “personal influence” and “professional influence”.

4. Results


4.1.2 Personal influenceThe evaluation revealed that the FOSC programme personally influenced staff in the following key areas:

Increased personal awareness and understanding of spirituality and spiritual care; Participants reported that the programme had provided time and space for personal reflection on their own spirituality and its impact on work and personal life. Participants appreciated the opportunity to reflect on their personal experiences and beliefs about spirituality and their spiritual care role within the organisation. Many participants noted a greater awareness of the importance of self care. As one facilitator reported “by learning more about themselves they could see how this impacted on their care of patients.”

“ I wasn’t quite sure where this would take me personally and I was thinking very focussed on the Hospice palliative care side of things but I found it quite interesting and rewarding in a lot of ways personally” (Focus Group participant).

This theme was reflected throughout participant responses in the surveys and reflection forms:

“ Huge impact, loved the reconnecting with my spirituality. The awareness of all that happens at Hospice is eye opening to a lot of people. I learnt a lot from this programme”

“ Opportunity to take time to look at this important topic away from the busyness of work.”

Participants reported a new understanding and recognition of diversity across patients, families and colleagues. The areas of diversity recognised were in spiritual and cultural areas.

“ Spirituality remains present and integral rather than coincidental and optional”

“ It has made me mindful of my own spirituality which has made me understand more what spirituality can mean to different people”

“ (The programme) Made me more conscious of how I interact, not to rush and move and listen and ask questions at their pace. To be more open, given me a lot more confidence in how I articulate and pose my questions. Feeling more comfortable around the area of spirituality”

“ Heightened respect for differences and unique needs of patient. More respect for difference between staff”



Refreshed, affirmed and validated prior spiritual knowledge: the programme allowed “space” to share personal views about spirituality confirming and normalising it as an important dimension of health care. As spiritual care is a mandated aspect of hospice care it was clear for some participants the programme affirmed what they knew and were doing,

“ I found it confirmation, what I’d done years ago, I s’pose I was a little bit stale and just needed that refreshment” (Focus Group participant).

The theme was also reflected throughout participant responses in the surveys and reflection forms:

“ I realised after attending that the way I think and the way I live my life and conduct my work contains a spirituality which I wasn’t really aware of before but has always been a part of who I am”

“ I feel very comfortable with speaking to patients about their spirituality and this was a good confirmation about what I do and I certainly learned new things.”

Some participants noted that as the programme provided affirmation and confirmation of practices they were already doing, the programme hadn’t provided a change to their practice as such.

“ I don’t believe my practice has changed as a result of attending this programme. I am very comfortable talking to patients about their spirituality and refer on if appropriate or outside my scope of practice.”

Another personal influence was reflected in the evaluation was Increased confidence to engage with spiritual care and to work safely with patients, family and whanau. Participants reported a variety of very positive outcomes that related to new knowledge about their own and others’ spirituality and a heightened awareness of spiritual care needs. Participants reported that they placed more emphasis on and had more confidence in discussing spirituality and spiritual care with patients and families.

“ Has really made me more aware of how I interact with patients and families, to slow down, be more conscious of being present”

“ I think I have a better understanding of what conversations can be like in EOL care and have more confidence in sharing in them if a patient brings up a delicate or difficult topic and also knowing what is appropriate to be discussed”

“ I feel more comfortable with what spirituality might mean for myself and others. I am able to raise questions with patients to find out more about their spirituality”


4.1.3 Professional influence

The FOSC programme professionally influenced hospice staff in the following key areas:

Collegiality was increased among hospice teams, as one focus group participant said, “the highlight of it was to get to know other people in my group”. Survey participants reported:

“ Good for diverse team members to participate together – breaks down barriers across services”

“ I enjoyed doing the course with colleagues and learning what they think about spirituality”

“ Brought many of us who have attended closer, and deep and growing respect for colleagues.”

Health Literacy was increased. Understanding of spirituality and spiritual wellbeing grew. Participants recognised the breadth of meaning attached to the term “spirituality” (different meanings for people) and conversations about spirituality became more “established and normal” among staff.

One focus group hospice noted that in MDT meetings staff had more freedom to speak about spiritual health care:

“I noticed really soon after this, the language of multidisciplinary team meetings including spiritual care, it included spiritual health, spiritual care” (Focus Group participant).

Participant’s programme reflections really highlighted these influences on literacy:

“ Always giving patients the opportunity to discuss spiritual issues... Listening more, talking less”

“ Use Te Whare tapa wha to help regulate my own wellness... manage my clinical time to allow more space to engage in compassionate care... widen my professional lens to include spirituality and spiritual issues”

“ Seek better MDT framework on this aspect of care... seek to improve listening skills... make a bigger effort to encourage the medical team to record and think about psychospiritual and social aspects of a patient’s health.”



As shown above, the FOSC programme contributed to the development of new skills that assisted staff to work effectively with patients, family and whanau. There was evidence of relating new knowledge to practices in screening, assessment, documentation, planning and frameworks.

“ Helped me to find some spiritual assessment tools and reflect on appropriate language and terminology”

“ It has shown me empathetic skills to talk and listen to the patients and how to take a spiritual history”

“ Draw on Maori health models of care as a base for spiritual assessment and spiritual care in my practice”

“ Knowing when to talk and when to just listen. Recognising body signs and language”

However the sustainability of changes to practice and the organisation were queried by some participants.

Graph 2 (above), shows a decrease in programme impact ratings from post programme reflections to the participant survey. The qualitative themes also reflected this difference, with practice themes of making time, listening and being present with patients and families featuring more in the reflection forms compared to the survey.

With programme reflections finalized soon after completion of the course and the participant survey completed many months later, this may signal a difference in short and longer term outcomes of the programme. As one participant reported “Impact is good, but proves difficult to sustain.”

There were also queries on whether the programme learnings were transferred into organisational change. 46% felt the programme hadn’t changed the organisation (n= 107).

“ We talk about spirituality a lot more – but I am not sure that it has changed practice”

“ (The programme has changed the organisation) maybe a little as to the awareness of spirituality but in the day to day business I don’t believe it has changed much”

“I think there is more awareness and need to develop policy around this”


4.1.4 Mixed feelings on the relevance of content for “non-clinical” participants

Some of the participants in non-patient facing roles felt areas of the programme were not relevant to their roles. However some noted that they had gained a new understanding of how their roles impact on the spiritual care being provided to patients and families.

“ As I work in a non-clinical setting the content was not directed at my work. The team did their best to try and make it applicable but the content didn’t particularly allow for this”

“ Having no patient contact in my role, (the programme) opened my eyes to what spirituality is and how my role does impact in the wider multidisciplinary team, especially employees”

“ As shop manager I deal with volunteers who have been touched by hospice in some way. This has helped me deal with their feelings and also customers donating goods for the shop that have had dealings with hospice”

“ I do not have a clinical load – however my awareness has been re-ignited when talking with the patients and families/whanau within the inpatient unit and colleagues and health partners”

4.2 Experiences and outcomes for hospice organisations as a wholeThe following summarises the impact the FOSC programme had at an organisational level and their experiences of delivering the programme. A very positive programme experience was reported by programme facilitators and hospice senior management (key informants). All reported benefits in undertaking the programme (100% of respondents) but they also recognised that there were challenges involved (96%, n =27).

Only one of the 21 hospices that had undertaken the programme rated their experience below average. This hospice identified facilitator recruitment and facilitator training as barriers to success and did not continue after the initial course.

“ In my opinion the facilitators need more training (also mentioned by the facilitators) in the delivery of the programme. I think they felt that they had a great resource... very comprehensive and weren’t sure what to use and when. Staff were very critical and this was targeted at the facilitators that resulted in me not going on with the programme after the trial.”



Graph 3: Key informant experiences of programme components

(Key informant online survey responses Content n=27, Delivery n=23, Wairuatanga n=27)

Graph 4: Changes to the way the organisation addresses spiritual care needs

(Key informant online survey responses n= 27)

The FOSC programme provided hospices with benefits and outcomes in two key areas; positive team building and relationships and improved health literacy.


4.2.1 Positive team building and relationshipsA consistent outcome for management, facilitators and participants was increased perception of a team spirit among hospice staff as collegiality was increased. This directly relates to the programme aim of improving spiritual wellbeing of the organisation.

“ Overall I think the FOSC programme made a promising impact with whanaungatanga/ connecting people across organisations as one of its strengths”

“ The main benefit was in the area of staff wellness, team building, value and respect for each other”

“ As all our staff have completed the programme, we have common springboard from which to move forward. It provided an opportunity for us to meet together as a team, share our understanding of spirituality and spiritual care”

Links with the wider health sector (wider health team) were also fostered. For example, a non-hospice based Maori cultural expert provided training thereby improving connections with local iwi (through the wairuatanga session):

“I can’t emphasis enough the importance of getting local Maori involved in the delivery of this component. The significance of having (them) involved has been the single most commented on aspect of the programme.”

4.2.2 Development of a common language/increased literacyThe second improvement was the increase in health literacy within the organisations (spiritual language became more accessible). Key informants reported that staff had developed a common language about spirituality and spiritual care which increased the likelihood of staff discussing spiritual distress and seeking help. This directly relates to the programme aim of creating shared understanding.

“ Questions still arise from the participants and I notice spirituality discussions which all different members of our team and discussions are introduced to patients and families with ease”

“ Staff doing the programme have spoken of being helped in the understanding of spirituality as an important part of overall hospice care”

“ Has stimulated discussion in the workplace. A ‘common language’ beginning to be articulated”



Focus group participants at one hospice reported that there was an increase in conversations about the need for the development of spiritual assessment tool and an increased written presence of spiritual health literacy in documentation,

“ ... in our (data system) assessments, there’s a section that says “Spiritual Assessment” – blank normally or... it’s pretty much blank and we’re starting to see a little bit more and more [being filled in]... that’s, people are having a go at addressing that...” (Focus Group participant).

4.2.3 Uncertainty on measuring organisational impact and confirming long term outcomes Some organisations reported it was difficult to measure some of the changes that had taken place or it was too early to determine impact. Others questioned the sustainability of changes that had taken place. 61% of key informants rated their experience of the programme impact above average or excellent (n=14/23).

“ At the time of delivery and participation this created a way for staff and volunteers to interact outside their areas of subject matter expertise, the opportunities of sharing and diversity was great but it challenging to keep this alive as people go back to their key responsibilities and tasks, none the less the enriched understanding across participants can only enhance our professional service delivery and personal practice/reflection”

“ There is a growing awareness that we need to develop spirituality as an organisation. Has prompted a lot of discussion on how this can happen”

“ Some of the more practical ideas and details about what you might say or how you might do something is discussed but not nearly enough time. We have decided to have some ongoing monthly groups to keep the conversations going”

“ I cannot say with certainty that (spiritual care in the organisation) has changed, however that is not automatically a negative as (our hospice) does make a decent effort at incorporating spiritual care into its care anyway”


4.2.4 Organisation commitment and support Key informants identified that the benefits and outcomes of the programme had resulted from commitment and investment from their organisations to the programme, especially in the preparation phase. Some of the reported barriers to overcome included resourcing, rostering and administration. One hospice has chosen to make this programme mandatory for all staff.

“The time given for preparation needs to be acknowledged”

“ We ran with it too early – only a two week window after orientation to the package... More time with a more planned approach would have better captured some of the targeted “how to” moments”.

“ Resourcing, rostering staff out and being able to access appropriate Maori facilitators (were challenges in undertaking the programme) – none that were insurmountable though”

4.2.5 Importance of Facilitator RoleA strong theme throughout the participant and key informant survey was the importance of the facilitator role. The evidence highlighted the time and effort facilitators had provided in ensuring the needs of participants were met and learning outcomes covered.

Key informants reported benefits from the co-facilitation model of delivery and sharing this responsibility. As expected, some hospices were unable to identify suitable facilitators from within current staff. These hospices reported that significant time and effort was required to identify and build relationships with these facilitators from outside the organisation. Key informants also reported turnover of facilitators delivering the programme for various reasons.

“ Good development of our relationship as co-facilitators – group members commented on the way our relationship added to their good experience in the group”

“ We were able to share the load and compliment each other’s skill sets. The cultural component delivered by our Maori facilitator was especially well received”

“ I was the sole facilitator…I have been used to a co-facilitation model which shares the energetic ‘holding’ of the group and I found the responsibility demanding”

“ a lot of effort going in from the CEO and the senior management team to get Maori participation at different levels in the service so that’s been a direct result of not just the programme but the relationship that we’re building” (Focus Group participant).



The programme guidelines ask facilitators to select activities to meet the needs of the audience and the learning outcomes. It is not an expectation for all the information and resources provided to be used in every course. Facilitators felt they required dedicated preparation time to review and familiarise to the material and plan delivery. Facilitators reported a strong sense of responsibility for the programme and an increased workload outside of their usual roles. Many facilitators reported that their confidence and learning grew with delivery of successive courses.

“ At times it was a difficult tension holding together the worlds of nurses and doctors with volunteer gardeners and shop helpers”

“ Our first course I found quite stressful as it was the first time a spirituality course had been attempted at (our hospice) and you are never quite sure how the group will gel. The next time we were more relaxed & as a result the delivery went very well”

“ It works well now that I have a facilitator with similar way of working and is keen to be involved. Previous facilitator was quite nervous about it and didn’t enjoy doing it”

“ Challenge was, particularly for the first time through the programme, finding time as co-ordinators to get together and prepare well. Successes were that participants got a variety of angles and personality types to relate and connect with”

Though they reported a positive experience with the programme content, many facilitators commented there was tension between programme content and time available. They reported they “felt rushed” to complete learning outcomes in the time.

“Much material provided, which met the purpose of the course beautifully”

“ Good content but not always presented in the programme booklet and facilitator’s guide in an easily understood manner.”

“ I feel the programme content is very good, although I did find it difficult to pull together.” There’s a huge amount which is great, and the workbook is very good, but it does mean there’s an expectation from participants that everything will be covered. In future I’ll make it very clear that this may not be possible and will choose the things I feel are most relevant to the particular group.”


4.2.6 Mixed feelings on meeting the needs of all team membersKey informants were very positive about the benefits of having a cross section of the team present, however 48% of key informants reported that the programme did not meet the needs of all members of the hospice teams. Qualitative themes specifically highlighted their concern at meeting the needs of volunteers and board members particularly. Session 3 was highlighted by facilitators as the most difficult to adapt for non-patient facing roles.

“ We decided that the programme in its entirety would not be worthwhile to our shop staff, all our volunteers or our Board. We still want them to attend module 1 and 2 but the modules that are very practice based are not relevant to them”

“ Volunteers were keen participants, however most of them expressed at varying points through the programme that they don’t really meet with dying patients much, if at all, therefore that felt out of place being in those conversations”

“Non clinical people found parts difficult to relate to”

4.3 Critical success factors, common strategies and barriers to improving spiritual care for patients, families and whanau in hospice care

4.3.1 Critical success factors – Improving spiritual careThe willingness of hospice boards, management, facilitators and clinical and non-clinical staff to support and participate in the FOSC programme was pivotal to increasing the opportunity to develop a spiritual culture within Hospice. The programme was designed to support all health professionals to incorporate spirituality in their work. The following section identifies three key areas where the FOSC programme influenced improvements to hospice spiritual care culture leading to improved spiritual care. Each key area is reflected in a vignette from a focus group participant.

Staff were empowered: staff began to define and discuss spiritual care as well as recognise spiritual distress. As the confidence of both clinical and non-clinical staff grew they could identify appropriate spiritual care for patients, family and whanau. This vignette illustrates how FOSC was effective in building confidence among non-clinical staff.

Sally felt a sense of purpose when she was employed as a “cook.” However, she felt she lacked confidence to communicate with whanau/family and patients. She attributed this to not having a clinical background, “I’m not this professional person that’s qualified... I was always quite nervous, not very confident on how to approach patients; they would ask me questions about things and I had a feeling of great responsibility [to respond to] a person’s dying wish.”

However, after completing FOSC Sally stated “It gave me confidence and made me realise there was no right or wrong answers on that... it gave me the ability to walk into... the aura of that [patient’s] room and take a deep breath and face with confidence what I needed to face.”



Increased spiritual care practice: FOSC programme attendance was vital for increasing personal growth and lifting spiritual care across all staffing domains. Spiritual care was viewed as “everyone’s responsibility”. Interest in developing a spiritual assessment tool and an increase in written content in assessment forms was also evident in some hospices. A sense of collegiality developed among staff and through reflection, personal awareness and understanding of spirituality and spiritual care practice increased. This vignette illustrates how FOSC was effective in helping a new staff member to engage with bereaved families by supporting her to integrate spiritual awareness into everyday practice.

Lisa became comfortable with terms such as “death” and dying”. She said “I haven’t got a history or experience with dying or even thinking about dying much.” The programme helped her to identify “feelings of sadness and grief and then identification with other people’s sadness and grief.” She said “it gave me a confidence to say “dying” and “death”... and to realise that I didn’t need to know anything or say anything in particular but to be there as a presence.” This was useful in helping her to successfully engage with bereaved families:

“[Bereaved wife] was just talking about him, and I was able to say ‘oh when did he die?’ Like it was just a passing comment but it opened up a conversation for her, gave her permission to talk...”

Spiritual health literacy: Some participants suggested a common spiritual language developed and was introduced into Hospice dialogue through the programme. The normalisation of the use of the language of spirituality provides evidence that spiritual health literacy increased as a result of participation in the FOSC programme. This vignette illustrates how FOSC was effective in building spiritual collegiality among hospice staff and communication on spirituality and health.

Anita, a spiritual care coordinator, expressed her appreciation that FOSC influenced a culture of spiritual care within hospice. She commented “so people did open up and people listened and talked... I felt the whole awareness lift, you know and some huge spinoffs; it just went well out of the room of awareness of people.” The “spinoff” was evidenced in conversations that developed among staff:

“[Y]ou know we got a common language... recognising just exactly what is spiritual care because, although obviously it’s pretty hard to define, at least there were efforts... it was brought up as a conversation and we were talking about it…” When referring to new spiritual developments in the hospice remembrance service structure the spiritual care coordinator stated “that change – that has coincided with the Foundations of Spiritual Care.”

She also commented on regular reminders for the “spiritual side of care”:“[Y]ou know any change that’s instituted, any new movement or anything in any organisation falls away unless you know, it’s like a pot plant isn’t it, if you don’t water it, it dies…”


4.3.2 Critical barriers to improving spiritual care:A number of critical factors were identified that acted as barriers to improving spiritual care in hospice:

Personal barriers: some participants were uncomfortable or disinterested in engaging in spiritual care as it can be viewed as a contentious subject. It was suggested there was a tendency for some people to guard their personal beliefs. Not all clinical staff choose to attend the FOSC programme (i.e. where it was not compulsory) highlighting that spiritual care may not be attractive or appear relevant to everyone. Conversely, some staff had great personal investment in the training, highlighting a desire for personal spiritual self-awareness and development. A distinction should be made however, that FOSC is concerned with preparing staff to practice spiritual safety and is not designed as a personal therapy tool.

Lack of spiritual health care literacy within Hospice: several participants were unaware of the spiritual care policies, practices (rituals; room blessing) and resources available at hospice. Further, Hospice lacks a definable pathway to advance spiritual care training, with some participants suggesting the need for ongoing (after the FOSC programme) spiritual care training and support for staff.

Organisation level: Lack of time and skill to work with spiritually distressed patients was identified as a potential issue (i.e. staff did not wish to open up “Pandora’s box” when they had little time to support the patient). Some noted there was a lack of spiritual carers/chaplains to deal with identified needs or those staff worked part-time. This raises the issue: is it ethical to ask a patient or family members about their spiritual needs if there are not the trained staff to deal with the identified need?

The following key informant comments reflect some of these barriers:

“ The same pressure exists for staff on the ground in that time limits a more in depth conversation around this with patients – this varies of course according to confidence levels”

“ Some groups were more “head” orientated rather than “heart”. This always kept us from becoming complacent”

“ Some participants found programme gave food for thought, some gained insights for themselves and practice – others simply used as a tick box.”

4.4 To inform further refinements of this resource and inform use outside of the hospice sectorThe findings suggest that the continuation of the FOSC programme would benefit staff to support patients, family and whanau and improve the wider hospice environment. There were however some suggestions about how the programme might be improved.



4.4.1 Improve the balance of programme time and content It was reported that there was not enough time to explore all content and meet the expectations of completing all content in the participant guide. The FOSC programme was considered to be ‘jam packed’ with information which staff generally enjoyed, however two sessions were identified as requiring refinement (session 3 and 4). Participant responses were split on the duration of the course – some wanted a longer course, some wanted less time commitment involved.

“ ... however the discussion was limited due to “moving on” to complete the agenda and outcomes for the day”

“ Personal inquiry and discussion was limited as the focus was on the content coverage”

“It seems the workbooks were too extensive for the time available”

4.4.2 Wairuatanga component The Wairuatanga component received mixed responses. Key informants reported a very positive experience of this component of the programme (see Graph 3), however there were mixed perceptions from participants. Some participants thought that there needed to be more in this session, while others thought there was too much focus on taha Maori. Participant ratings of their experiences of the Wairuatanga component were 25% less than key informants experience ratings. Some participants wanted more ‘practice based’ content and the session prompted discussion and debate over biculturalism versus multi-culturalism. Some preferred to have a more general cultural reference to spirituality while others agreed that Maori culture had something unique to offer palliative care in New Zealand. Some staff felt FOSC privileged Maori spirituality and that the content should focus more on the “humanness” of people.

“ We are lucky to have [an] alternative holistic voice to [the] biophysical model… it really helps”

“ Develop (the Wairuatanga component) more to cater at looking from a nursing or hospice caregiver perspective to caring for patients and families in need of spiritual help”

“Needs to be multicultural not just focused on Maori perspective”

“ I believe (the wairuatanga component) is good as it is – maybe an advanced module for those who want more education or more depth”

“ I guess what was missing (from the Wairuatanga component) for me was the purpose of doing it. I’m one of those people who likes to understand the ‘why’ so although I enjoyed it, I wasn’t quite clear of what the intention was”


4.4.3 Increase support for facilitatorsParticipant feedback aligned to key informant feedback in this area and stressed the importance of facilitators and their influence on the experience of the programme. Requests from key informants for more in depth training or an opportunity to experience the programme fully before delivery. Practical support, such as help preparing and sending emails to participants before and between sessions may improve participants’ preparation and reduce nervousness for sessions. Hospices also flagged ongoing movement in programme facilitators and a request for ongoing opportunities to share successes/challenges from those facilitating the programme.

“ I believe that the facilitators and a balanced delivery are the main components as to whether the programme will be advantageous to staff and patients”

“ I felt the delivery was very good, however the receptiveness by a lot of the hospice staff was poor which made the delivery very difficult”

“Beautifully delivered, peaceful environment, very supportive”

“ The facilitators were new to the content and might have been helpful if they spoke from personal experience as opposed to trying to cover the content of the programme”

4.4.5 Follow up/ next level programmeKey informants and some participants requested a ‘refresher’ course or an opportunity to explore some content in more depth. Some participants reported they would like to build on the momentum gained by the programme and limit a “one off” perception of the programme. There were several suggestions for further exploration and time to develop and discuss assessment tools. There were also requests for more time role-playing difficult conversations with patients, families and whanau.

“ Spend more time working on the aspects that relate spirituality to practice working with patients, families and other staff members”

“ Would like more on recognising and understanding spiritual agitations and how to be helpful when dealing with spiritual fear, anxiety, anger”

“ It is such a relevant/important aspect of a patient’s journey that I feel this course only touched the surface and there is room for ongoing follow up education on this subject”

“ A bit more training in good questions to ask to open up patients’ thoughts, fears and feelings”



“ Not really changed my practice, I am perhaps a little more aware of the family concept when introducing myself to patients and families looking at where I have come from. Otherwise not really. Need more opportunity to learn good ways of communication and helping others to deal with difficult things”

A focus group participant highlighted the need for spiritual champions by suggesting FOSC could be used to:

“ [M]aybe even identify during that meeting or during the training or after the training that there are people who are more interested in this who could get another level of training but they could be a resource to other people, either identified or pre-identified before we go into those meetings.”

Another area that might be further explored by groups of staff is Spiritual care responsibility. There was a feeling amongst some focus group participants that because of the programme they now had to ‘do’ spiritual care. This was obviously not the intent of the programme, but was expressed by some participants as below. Thus care needs to be taken to make clear that no-one should work outside of their comfort zone or scope of practice.

“ We all have capacity to give spiritual care and I think that’s very enabling and permission giving and all that kind of thing but I also, the flip side of that could be that it could be a bit intimidating” (Focus group participant).

“ I have 15+ years in this field and already provide the spiritual care I am comfortable with providing. I hope the programme gave permission to others to provide spiritual care when appropriate, but I do not think this programme is a replacement for clergy and chaplains doing specialized spiritual care”


This innovative programme has achieved much of what it set out to achieve. In particular, there is evidence from feedback of positive team building and relationships and the development of a common language and increased literacy in the area of spirituality and spiritual care. Hospices recognised, when delivering the programme, the importance of organisational support and the importance of the role of the facilitator. However, there were mixed feelings from organisations as a whole on whether the programme met the needs of all team members – particularly the needs of volunteers and board members. Evaluations suggested that there are critical success factors and barriers to improving spiritual care. The willingness of hospice boards, management, facilitators and clinical and non-clinical staff to support and participate in the FOSC programme was pivotal to increasing the opportunity to develop a spiritual culture within Hospice. This programme appears to have influenced improvements to hospice spiritual care culture leading to improved spiritual care in the areas of staff empowerment, increased spiritual care practice and increased spiritual health literacy. The barriers that have been identified included time, discomfort or disinterest in engaging in spiritual care, lack of spiritual health care literacy and structural barriers.

Spiritual care is “grounded in core principles of service, compassion, dignity and the interconnectedness of all people, the field is a commitment to making patients’ search for meaning and relationship an essential focus of medical education, patient care and the health system” (Puchalski et al 2014). It is person-centred care that “seeks to help people (re)discover hope, resilience and inner strength in times of illness, injury, transition and loss” (Kelly, 2012). This programme was developed as an introduction to the provision of spiritual care and to provide guidance on what might be expected of staff working in New Zealand hospices. As such, it appears to have been a key indicator of success. The development of this programme went through a number of stages with expert advisory groups convening to refine the end product. A majority of New Zealand hospices have now undertaken the programme and have had the opportunity to evaluate and reflect on the content and delivery.

The findings identified here bear out much of what has been written previously on this subject. Spiritual care training helps to raise awareness and encourage discussion of aspects of spiritual care not just with patients and families but also within the team (Paal et al 2015). Raising confidence, awareness and understanding of spiritual care was a significant aim of the teaching that appears to have been met, as illustrated by the comments around staff empowerment, increased spiritual health literacy and overall improved spiritual care. It has previously been noted that improved awareness of behaviour enables more effective spiritual care (Wallace et al 2008, Attar et al 2010) along with the themes of making time, listening and being present with patients. Combined with these attributes are improved confidence and competence in screening, assessment, documentation, planning and frameworks. All of these characteristics of practice lead towards a greater awareness overall of the dimensions of spiritual care and emphasise the importance of relationships over meaning-making which has previously been identified as a key component of high quality spiritual care (Edwards et al 2010). Personal reflection and sensitivity towards one’s own spirituality (spiritual awareness) have also been acknowledged as significant components of the ability to deliver effective spiritual care (Edwards et al 2010; Holland & Neimeyer 2005; Paal et al 2015; Puchalski et al 2014; Lewinson et al 2015). A further aspect facilitating these components here was an affirmation of current practice, leading some to see less tangible changes in their practice than they may have expected or hoped for.

Barriers to success in this evaluation were similar to those identified by others, namely, time, lack of knowledge and awareness, overcoming longstanding models of care and a reluctance by some to share their personal beliefs (Edwards et al 2010).

Spirituality is affected by one’s own beliefs, culture, social background and history. Recent Ministry of Health research has highlighted the importance of whanaungatanga (acknowledgement of our relationships and connections) and wairuatanga for effective communication and enhancing palliative care for Maori (Ministry of Health, 2014). Edwards et al, in their meta-study also identified language, culture and religion as potential barriers to providing spiritual care (2010) hence the inclusion here of a specific component on wairuatanga or Maori spiritual health. The knowledge and resources developed and shared in this component of the programme were highly valued by facilitators. The authors acknowledged the difficulty in examining

5. Discussion



wairuatanga, as a health dimension in isolation, acknowledging its core essence and connection to everything in and around us (Moon, 2004). This component was viewed by some participants as ‘outstanding’ but for others, less so. However, it is essential in New Zealand, as part of our obligations to the Treaty of Waitangi, that this health dimension is easily understood to enable us to respond to the needs of Maori. The wairuatanga component is an important dimension of end of life care and will be further enhanced. Some participants would prefer more discussion about different cultures and their spiritual belief systems, a suggestion which has been acknowledged by the authors.

As was identified for nursing, (Timmins & McSherry 2012) spirituality is ‘embedded within the core values’ of palliative care practice. Consequently we believe that spiritual care education needs to be addressed effectively in order for this essential component of health to be addressed. In their European Association for Palliative Care (EAPC) survey of spiritual care education Paal et al (2015) recommend that “teaching spiritual care requires creativity and attention, just like providing spiritual care does.” This programme appears to have done just that. It was designed for all health care professionals and volunteers, was taught in small groups and developed core competencies in self-reflection, theory and integration – all recommended by the EAPC Task Force on Spiritual Care in Palliative Care as key factors for success.

Mezirow and associates (2009) have suggested that there is growing interest in transformative learning in adult education, “an approach to teaching based on promoting change, where educators challenge learners to critically question and assess the integrity of their deeply held assumptions about how they relate to the world around them” (p xi). MacLeod (2001) has pointed out that the ability of doctors to care is influenced by the socialization process they undergo in training; a similar situation is seen in hospice education. People can be changed by the culture of the hospice they are working in. “In order to provide effective care for people who are dying, some degree of personal or social transformation is needed…and we as educators must be able to create the conditions where this may take place” (MacLeod and Egan, 2009, p 119). It is our belief that this programme has the potential to encourage participants to reflect in and on their practice through this potentially transforming experience. This course is designed for all those working and volunteering in hospices in New Zealand and as such acknowledges the suggestions of the EAPC Taskforce (Paal et al, 2015) that courses be designed for all healthcare professionals because “spiritual care is a task to be shared by all within the team.” It is our belief that this programme encourages each member of the hospice team to “employ their spiritual care skills in different ways and at different times.”

As with other programmes identified in the literature, the Foundations of Spiritual Care was evaluated both qualitatively and quantitatively but so far no on-going evaluations are available. Measuring long term effects will be essential. This is planned for the future.


The development of an enhanced culture of spiritual care was evident within Hospices that participated in the evaluation. The Foundation of Spiritual Care programme has the potential to improve connectedness and relationships between staff and to help facilitate an environment where spiritual care within Hospice is improved. It has provided a potentially transformative educational experience. By this we mean that it has created opportunities to stimulate diverse, alternative and multiple perspectives on spirituality and spiritual care through reflection either individually or in groups and hence incorporated into practice.

This programme provides an opportunity to increase spiritual health literacy. It also influences a sense of responsibility among the workforce to give expression to spirituality at both a personal and at an organisational level. When staff confidence grows this is likely to influence the development of a spirit of care towards patients, families and whanau. Hospices are well placed to resource and support these people to champion FOSC and to further develop spiritual care education.

The evaluation has provided evidence that the FOSC has the potential to increase and strengthen the spiritual health domain within Hospice. However, a culture of spiritual care has to be prioritised, resourced and sustained to contribute towards upholding and strengthening the spiritual care domain, which positively benefit its recipients: staff, patients, family and whanau.

Some minor changes to the FOSC programme are recommended to enhance outcomes and delivery of the programme.

Recommendations The authors recommend consideration of the following:

• Continue support and investment into delivery of FOSC programme across all hospices

• Investigate follow-up or an advanced level programme to sustain and build on new knowledge and provide opportunities for deeper learning. Gains made from the FOSC programme need to be embedded and built on. There was a call for a next level programme that goes deeper into spirituality, spiritual needs and care. Hospices are well placed to develop the culture of spiritual care by supporting those with a “natural interest or inclination” to progress this health domain within Hospice.

• Improve the balance of time and content of programme. Clarify expectations of content to be covered and consider time available to meet learning outcomes, especially session 3 and 4.

• Relevancy of some programme elements for non-patient facing members of hospice team

• Consider requirements for attendance. Compulsory attendance would mean all clinical and non-clinical staff would have equitable access to spiritual care training.

• Provide an enhanced segway/introduction into the wairuatanga component of programme. To help participants prepare for wairuatanga content throughout the programme a segway could be developed to introduce staff to a Maori cultural spiritual worldview, why it’s included and the benefits to staff, patients, family and whanau.

• Increase structural support for programme and its outcomes. This may include extra training or support mechanisms for facilitators, increase staff knowledge of the existing spiritual policies and resources within the organisation and provide time, space and resources to progress spiritual care within Hospice. The programme content inspired some staff to continue to develop the spiritual care culture within Hospice following the course but no formal mechanism, pathway or resources were put in place to ensure the continuation of spiritual care gains. Hospices could be encouraged to identify spiritual care champions alongside the chaplain/spiritual carer and support them to further develop a culture of spiritual care and lead the development of the spiritual care domain within Hospice.

• Consider offering programme to other organisations. The FOSC programme is a useful, well developed and evaluated programme that with some refinement could be useful for other organisations such aged residential care, mental health contexts or even mainstream primary/secondary/tertiary healthcare. Some adjustments would be necessary with each context being unique, therefore a pilot – evaluation process is recommended.

• Plan evaluation of ongoing and long term outcomes of the programme

6. Conclusion and Recommendations



Paal P, Leget C, Goodhead A 2015 Spiritual care education: results from an EAPC survey. European Journal of Palliative Care 22(2) 91-5

Rumbold B.D 2003 Caring for the spirit: lessons from working with the dying. Medical Journal of Australia 179 (6): S11-S13

Morgan A, MacLeod RD, Schumacher M, Egan R 2015 Delivering spiritual care: a resource to train hospice staff in New Zealand. European Journal of Palliative Care 22(3); 130-132

Egan R, MacLeod R, Jaye R, McGee R, Baxter J & Herbison P. 2011 What is spirituality? Evidence from a New Zealand hospice study, Mortality, 16:4,307-324

Egan R, Blank M 2012 Hospice New Zealand, Spirituality Professional Development Project: Literature Review, University of Otago: 1-41.

Patton M 2002 Qualitative Research and Evaluation Methods. Thousand Oaks, Sage.

Gibbs, G 2007 Thematic coding and categorizing. Analyzing Qualitative Data. London: SAGE Publications, Ltd

Braun V, Clarke V, 2006 Using thematic analysis in psychology Qualitative Research in Psychology 3(2); 77-101

Puchalski CM, Blatt B, Kogan M, Butler A 2014 Spirituality and Health: the development of a field. Academic Medicine doi 10.1097/ACM.0000000000000083

Kelly E 2012 Competencies in spiritual care education and training. In M. Cobb, C. Puchalski & B. Rumbold (eds) Oxford textbook of spirituality in healthcare, Oxford: Oxford University Press

Paal P, Helo Y, Frick E 2015 Spiritual care training provided to healthcare professionals: a systematic review Journal of Pastoral Care & Counseling 69(1) 19-30

Wallace M, Campbell SH, Grossman S, Shea JY, Lange JW 2008 Integrating spirituality into undergraduate nursing curricula. International Journal of Nursing Education Scholarship 5(1)

Attar MA, Hernandez ME, Mullan PB, Tang TS & Haftel H et al 2010 Pediatric residents’ competency in communicating bad news and eliciting spiritual needs: development and evaluation of a skills-based curriculum. Journal of Neonatal-Perinatal Medicine 3(3): 177-185

Edwards A, Pang N, Shiu V, Chan C 2010 The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research. Palliative Medicine 24(8): 753-770

Holland JM, Neimeyer RA 2005 Reducing the risk of burnout in end-of-life care settings: the role of daily spiritual experiences and training. Palliative and Supportive Care 3, 173-181

Lewinson LP, McSherry W, Kevern P 2015 Spirituality in pre-registration nurse education: a review of the literature Nurse Education Today 35: 806-814

Ministry of Health 2014. Palliative care and Maori from a health literacy perspective. Wellington, Ministry of Health.

Moon, P 2004. Tohunga: Hohepa Kereopa. Auckland, David Lang Publishing Ltd.

Timmins F, McSherry W 2012 Spirituality: the Holy Grail of contemporary nursing practice. Journal of Nursing Management 20: 951-7

Mezirow J, Taylor EW and associates 2009 Transformative Learning in Practice; insights from community, workplace and higher education. San Francisco CA, Jossey-Bass

MacLeod RD 2001 On reflection: Doctors’ learning to care for people who are dying. Social Science & Medicine, 52, 1719-1727

MacLeod RD, Egan T 2009 Transformative Palliative Care Education in Mezirow J, Taylor EW (Eds) Transformative Learning in Practice; insights from community, workplace and higher education. San Francisco CA, Jossey-Bass (p119)

7. References

foundations of spiritual care - hospice.org.nz€¦ · foundations of spiritual care / 7 evaluatio...

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