Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
Short report
The spiritual environment in New Zealand hospice care: identifying organisational commitment to spiritual care Richard Egan,1 Rod MacLeod,2 Chrystal Jaye,3 Rob McGee,4 Joanne Baxter,5 Peter Herbison6
For numbered affiliations see end of article. Correspondence to Dr Richard Egan, Cancer Society Social & Behavioural Research Unit, Te Hunga Rangahau Arai Mate Pukupuku, Department of Preventive & Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand; [email protected] Received 26 November 2013 Revised 8 April 2014 Accepted 30 April 2014 Published Online First 20 May 2014
To cite: Egan R, MacLeod R, Jaye C, et al. BMJ Supportive & Palliative Care 2014;4: 299–302.
ABSTRACT Objectives Spiritual matters naturally arise in many people who have either a serious illness or are nearing end-of-life. The literature shows many examples of spiritual assessments, interventions and care; however, there is a lack of focus on organisational support for spiritual care. We aimed to ascertain the structural and operational capacity of New Zealand’s hospices to attend to the spiritual needs and concerns of patients, families and staff. Methods As part of a larger study, a mail out cross-sectional survey was distributed to 25 New Zealand hospices and asked details from staff about facilities, practices and organisational aspects of spiritual care. Data were collated by creating a ‘hospice setting spiritual score’ based on an aggregate of eight items from the survey. Results There was a 66% response rate. Summary scores ranged from 2 to 7 indicating that while sites delivered a range of spiritual services, all could improve the level of spiritual care they provide. The two most common items missing were ‘spiritual professional development’ and ‘formal spiritual assessment.’ Conclusions This simple setting spiritual score provides a snapshot of a hospice’s commitment to spiritual care. It could be used as a preliminary auditing tool to assist hospices in identifying organisational and operational aspects that could be improved to enhance spiritual care delivery.
INTRODUCTION There is almost universal agreement that ‘spiritual concerns are important to many patients, particularly at the end of life.’1 It is therefore not surprising that the hospice palliative care field examines, researches and attends to spirituality more than other areas of healthcare.2 Hospices guide the way in mandating
spiritual care while hospice based research and publications often dominate and lead Western spirituality and health literature.3 Exact numbers for end of life care provision by New Zealand hospices are difficult to ascertain. The best estimate is approximately half of those who died had some contact with a hospice based on 2012 figures that note New Zealand hospices cared for 14 400 people,4 while 30 099 people died that year.5 The literature provides many examples of spiritual assessments, interventions and care.6 However, there is a lack of focus on organisational support for spiritual care, including governance, management, policy, professional development and resources. For instance, a recent audit of hospice services in New Zealand reported gaps in access to spiritual care staff.7 As part of a larger project,8 we attempted to ascertain the structural and operational capacity of New Zealand’s hospices to attend to the spiritual needs and concerns of patients, families and staff by means of a survey addressing a number of areas related to spiritual care. METHODS Perceptions of spiritual care in hospices were obtained from a mail out crosssectional national survey. In lieu of the lack of existing tools to measure the spiritual care environment in this setting, the lead researcher developed the questions based on a literature review9–11 and the expert opinion of fellow project members. Face validity was based on a pilot survey at Otago community Hospice and with the Otago Southland
Egan R, et al. BMJ Supportive & Palliative Care 2014;4:299–302. doi:10.1136/bmjspcare-2013-000632
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Short report Cancer Society Supportive Care staff. The primary investigator called each CEO of the then available 32 hospices in New Zealand and 25 hospices agreed to participate. The non-participating hospices were largely small hospices with few or no beds with the exception of one large hospice that did not participate as it was experiencing significant staff management issues. In introducing this survey to participants, we reiterated that spirituality means different things to different people and included our working definition of spirituality: ‘Spirituality includes beliefs, values, sense of meaning and purpose, identity, and for some people religion.’ The advantage of providing this definition was that from the outset it was clear that the survey was looking at more than religious issues and would follow best practice as used by the WHO Quality of Life instrument.12 Staff inclusion criteria were all eligible staff including paid clinical staff ( plus all chaplains), and nurses who work 0.5 FTE (full time equivalent) or more. Due to resource capacity, it was decided not to survey all staff and given the largest profession in hospice care is nursing many were naturally excluded because they worked less than half time. The ‘hospice setting spiritual score’ is based on an aggregate of survey questions that relate to the whole hospice spiritual environment. The score is made up of eight items from the survey. Questions used to formulate the hospice setting spirituality score included: did the hospice have a paid chaplain/spiritual carer (yes/no)? Was there a chapel/quiet room available (yes/no)? Was there staff spiritual support (yes/no)? Did the hospice have a spiritual care policy (yes/no)? Were there opportunities for spiritual professional
Figure 1
300
development (Annual/no/occasionally)? Were there spiritual resources (10 options)? Was a formal spiritual assessment routinely undertaken (5-option Likert scale)? And, finally, how important is spirituality in your hospice (5-option Likert scale)? A binary score for each item was developed and then summed to create the score. A higher value indicated a greater structural commitment to spirituality. RESULTS Participation was predominantly from female responders (men 11%, women 89%). The responders were dominated by the nursing population, which explains the gender difference. Of the 600 surveys sent to hospices, 550 were successfully distributed to staff, and of these 365 were completed giving a 66% response rate. The results for each component item for the 25 hospices was that 19 had paid chaplains, 19 had a chapel/quiet room, 22 had adequate staff spiritual support, 20 had a spiritual care policy, one had adequate spiritual care professional development, 13 had four or more spiritual resources, nine always or often did formal spiritual assessments, and all the hospices thought spirituality was important. More specifically, for professional development, 35% (CI 30% to 41%) of staff reported not having spirituality professional development, 11% (CI 8% to 14%) reported having it annually, while 54% reported having it ‘occasionally’ (CI 48% to 59%). Of the sites surveyed, 50% (95% CI 45% to 55%) had a spiritual care policy. However, 34% (CI 29% to 39%) of the respondents did not know if they had a policy or not, so the percentage could be higher. Formal spiritual assessments were performed by 40% (95% CI 35% to 45%) of staff
The total score for each hospice surveyed.
Egan R, et al. BMJ Supportive & Palliative Care 2014;4:299–302. doi:10.1136/bmjspcare-2013-000632
Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
Short report regularly (‘Always’, ‘Mostly’ and ‘Often’), which means that most of the time, 60% (CI 55% to 65%) of staff do not undertake spiritual assessments. The hospice setting spiritual scores in this survey show that all sites could improve overall spiritual care provisions based on these criteria (figure 1). The two most common items missing were ‘spiritual professional development’ and ‘formal spiritual assessment.’ While it is a subjective assessment based on the survey responses of staff in each hospice, combining eight items for each hospice does give an overall sense of how ‘spirituality-nurturing’ or attentive a hospice is to spiritual matters. DISCUSSION The results of the hospice setting spirituality score included five hospice care settings that do not have an inpatient option where it may be unreasonable to expect a chapel/quiet room (one of the eight criteria). The other seven items are relevant for any site independent of size. The limitations of this score include the subjective nature of choosing how to weight each binary choice, but it is understood to be a ‘crude’ or ‘broad brush’ indicator, which hospices could use as a preliminary tool to audit their own spiritual care environment. Maori, the indigenous people of New Zealand, are underserved by palliative and hospice care.13 One omission from the survey was a set of questions related to cultural competency, particularly the degree to which each hospice meets the spiritual needs of Maori. Future development of this tool might include an additional item to measure a hospice’s commitment to cultural spirituality and Maori ‘Tikanga (Generally taken to mean "the Maori way of doing things," it is derived from the Maori word tika meaning ‘right’ or ‘correct’) guidelines of care and recommended ways to honour Maori values and beliefs into frontline service delivery.’14 Further measures of cultural competency could also be applied to Pacific peoples, another group to encounter significant barriers in accessing appropriate palliative services.15 CONCLUSIONS This hospice setting spiritual score was developed by collating eight items that reflect an institution’s commitment to spiritual care. All sites surveyed in New Zealand, based on this measurement, could improve their spiritual care. This relatively simple setting spiritual score provides a snapshot of a hospice’s commitment to providing spiritual care. It can be used as an auditing tool to help hospice groups identify organisational and operational aspects that need to be improved to enhance spiritual care delivery.
Author affiliations Cancer Society Social & Behavioural Research Unit, Te Hunga Rangahau Arai Mate Pukupuku, 1
Department of Preventive & Social Medicine, Dunedin School of Medicine, University of Otago, Medical School, Dunedin, New Zealand 2 HammondCare and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia 3 Department of General Practice and Rural Health, Dunedin School of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand 4 Department of Preventive & Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand 5 Health Sciences Division, Maori Health Workforce Development Unit, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand 6 Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand Acknowledgements We acknowledge the support of the University of Otago departments of General Practice and Preventive and Social Medicine. Funding This work was supported by grants from the Genesis Oncology Trust (PhD scholarship) and the Canterbury West Coast Cancer Society. Grant number GOT-0401-PGS. Competing interests None. Ethics approval Ethics approval was obtained from the Multi-region Ethics Committee, New Zealand (9MEC/06/04/ 042). Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 Sulmasy D. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist 2002;42(Special Issues III):24–33. 2 Byock IR. To Life! Reflections on spirituality, palliative practice, and politics. Am J Hosp Pall Med 2007;23:436–8. 3 Speck P, Higginson I, Addington-Hall J. Spiritual needs in health care. BMJ 2004;329:123–4. 4 Hospice New Zealand. Hospice New Zealand: 2012 Annual Report. Wellington: Hospice New Zealand, 2013. 5 Statistics New Zealand Tatauranga Aotearoa. Births and deaths: year ended December 2012. Wellington: Statistics New Zealand Tatauranga Aotearoa, 2013. 6 McSherry D, Ross L, eds. Spiritual assessment in healthcare practice. Keswick: M & K Publishing, 2010. 7 Cancer Control New Zealand. National Health Needs Assessment for Palliative Care Phase 2 Report: Palliative Care Capacity and Capability in New Zealand. Wellington: Cancer Control Council, 2013. 8 Egan R, MacLeod RD, Jaye C, et al. What is spirituality? Evidence from a New Zealand hospice study. Mortality 2011;16:307–24. 9 Puchalski C. A time for listening and caring: spirituality and the care of the chronically ill and dying. New York: Oxford University Press, 2006. 10 Rumbold B. A review of spiritual assessment in health care practice. Med J Aust 2007;186(10 Suppl):S60–2.
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Short report 11 Ross L. Spiritual care in nursing: an overview of the research to date. J Clin Nurs 2006;15:852–62. 12 WHOQOL-SRPB Group. A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life. Soc Sci Med 2006;62:1486–97. 13 Cancer Control New Zealand. National Health Needs Assessment for Palliative Care. Phase 2 Report: Palliative Care
302
Capacity and Capability in New Zealand. Wellington: Cancer Control New Zealand, 2013. 14 Hospice New Zealand. Hospice New Zealand Standards for Palliative Care quality review programme and guide 2012. Wellington, New Zealand, 2012. 15 Ministry of Health. The New Zealand Palliative Care Strategy. Wellington Ministry of Health, 2001.
Egan R, et al. BMJ Supportive & Palliative Care 2014;4:299–302. doi:10.1136/bmjspcare-2013-000632
Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
The spiritual environment in New Zealand hospice care: identifying organisational commitment to spiritual care Richard Egan, Rod MacLeod, Chrystal Jaye, Rob McGee, Joanne Baxter and Peter Herbison BMJ Support Palliat Care 2014 4: 299-302 originally published online May 20, 2014
doi: 10.1136/bmjspcare-2013-000632 Updated information and services can be found at: http://spcare.bmj.com/content/4/3/299
These include:
References Email alerting service
This article cites 7 articles, 3 of which you can access for free at: http://spcare.bmj.com/content/4/3/299#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Short report
The spiritual environment in New Zealand hospice care: identifying organisational commitment to spiritual care Richard Egan,1 Rod MacLeod,2 Chrystal Jaye,3 Rob McGee,4 Joanne Baxter,5 Peter Herbison6
For numbered affiliations see end of article. Correspondence to Dr Richard Egan, Cancer Society Social & Behavioural Research Unit, Te Hunga Rangahau Arai Mate Pukupuku, Department of Preventive & Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand; [email protected] Received 26 November 2013 Revised 8 April 2014 Accepted 30 April 2014 Published Online First 20 May 2014
To cite: Egan R, MacLeod R, Jaye C, et al. BMJ Supportive & Palliative Care 2014;4: 299–302.
ABSTRACT Objectives Spiritual matters naturally arise in many people who have either a serious illness or are nearing end-of-life. The literature shows many examples of spiritual assessments, interventions and care; however, there is a lack of focus on organisational support for spiritual care. We aimed to ascertain the structural and operational capacity of New Zealand’s hospices to attend to the spiritual needs and concerns of patients, families and staff. Methods As part of a larger study, a mail out cross-sectional survey was distributed to 25 New Zealand hospices and asked details from staff about facilities, practices and organisational aspects of spiritual care. Data were collated by creating a ‘hospice setting spiritual score’ based on an aggregate of eight items from the survey. Results There was a 66% response rate. Summary scores ranged from 2 to 7 indicating that while sites delivered a range of spiritual services, all could improve the level of spiritual care they provide. The two most common items missing were ‘spiritual professional development’ and ‘formal spiritual assessment.’ Conclusions This simple setting spiritual score provides a snapshot of a hospice’s commitment to spiritual care. It could be used as a preliminary auditing tool to assist hospices in identifying organisational and operational aspects that could be improved to enhance spiritual care delivery.
INTRODUCTION There is almost universal agreement that ‘spiritual concerns are important to many patients, particularly at the end of life.’1 It is therefore not surprising that the hospice palliative care field examines, researches and attends to spirituality more than other areas of healthcare.2 Hospices guide the way in mandating
spiritual care while hospice based research and publications often dominate and lead Western spirituality and health literature.3 Exact numbers for end of life care provision by New Zealand hospices are difficult to ascertain. The best estimate is approximately half of those who died had some contact with a hospice based on 2012 figures that note New Zealand hospices cared for 14 400 people,4 while 30 099 people died that year.5 The literature provides many examples of spiritual assessments, interventions and care.6 However, there is a lack of focus on organisational support for spiritual care, including governance, management, policy, professional development and resources. For instance, a recent audit of hospice services in New Zealand reported gaps in access to spiritual care staff.7 As part of a larger project,8 we attempted to ascertain the structural and operational capacity of New Zealand’s hospices to attend to the spiritual needs and concerns of patients, families and staff by means of a survey addressing a number of areas related to spiritual care. METHODS Perceptions of spiritual care in hospices were obtained from a mail out crosssectional national survey. In lieu of the lack of existing tools to measure the spiritual care environment in this setting, the lead researcher developed the questions based on a literature review9–11 and the expert opinion of fellow project members. Face validity was based on a pilot survey at Otago community Hospice and with the Otago Southland
Egan R, et al. BMJ Supportive & Palliative Care 2014;4:299–302. doi:10.1136/bmjspcare-2013-000632
299
Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
Short report Cancer Society Supportive Care staff. The primary investigator called each CEO of the then available 32 hospices in New Zealand and 25 hospices agreed to participate. The non-participating hospices were largely small hospices with few or no beds with the exception of one large hospice that did not participate as it was experiencing significant staff management issues. In introducing this survey to participants, we reiterated that spirituality means different things to different people and included our working definition of spirituality: ‘Spirituality includes beliefs, values, sense of meaning and purpose, identity, and for some people religion.’ The advantage of providing this definition was that from the outset it was clear that the survey was looking at more than religious issues and would follow best practice as used by the WHO Quality of Life instrument.12 Staff inclusion criteria were all eligible staff including paid clinical staff ( plus all chaplains), and nurses who work 0.5 FTE (full time equivalent) or more. Due to resource capacity, it was decided not to survey all staff and given the largest profession in hospice care is nursing many were naturally excluded because they worked less than half time. The ‘hospice setting spiritual score’ is based on an aggregate of survey questions that relate to the whole hospice spiritual environment. The score is made up of eight items from the survey. Questions used to formulate the hospice setting spirituality score included: did the hospice have a paid chaplain/spiritual carer (yes/no)? Was there a chapel/quiet room available (yes/no)? Was there staff spiritual support (yes/no)? Did the hospice have a spiritual care policy (yes/no)? Were there opportunities for spiritual professional
Figure 1
300
development (Annual/no/occasionally)? Were there spiritual resources (10 options)? Was a formal spiritual assessment routinely undertaken (5-option Likert scale)? And, finally, how important is spirituality in your hospice (5-option Likert scale)? A binary score for each item was developed and then summed to create the score. A higher value indicated a greater structural commitment to spirituality. RESULTS Participation was predominantly from female responders (men 11%, women 89%). The responders were dominated by the nursing population, which explains the gender difference. Of the 600 surveys sent to hospices, 550 were successfully distributed to staff, and of these 365 were completed giving a 66% response rate. The results for each component item for the 25 hospices was that 19 had paid chaplains, 19 had a chapel/quiet room, 22 had adequate staff spiritual support, 20 had a spiritual care policy, one had adequate spiritual care professional development, 13 had four or more spiritual resources, nine always or often did formal spiritual assessments, and all the hospices thought spirituality was important. More specifically, for professional development, 35% (CI 30% to 41%) of staff reported not having spirituality professional development, 11% (CI 8% to 14%) reported having it annually, while 54% reported having it ‘occasionally’ (CI 48% to 59%). Of the sites surveyed, 50% (95% CI 45% to 55%) had a spiritual care policy. However, 34% (CI 29% to 39%) of the respondents did not know if they had a policy or not, so the percentage could be higher. Formal spiritual assessments were performed by 40% (95% CI 35% to 45%) of staff
The total score for each hospice surveyed.
Egan R, et al. BMJ Supportive & Palliative Care 2014;4:299–302. doi:10.1136/bmjspcare-2013-000632
Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
Short report regularly (‘Always’, ‘Mostly’ and ‘Often’), which means that most of the time, 60% (CI 55% to 65%) of staff do not undertake spiritual assessments. The hospice setting spiritual scores in this survey show that all sites could improve overall spiritual care provisions based on these criteria (figure 1). The two most common items missing were ‘spiritual professional development’ and ‘formal spiritual assessment.’ While it is a subjective assessment based on the survey responses of staff in each hospice, combining eight items for each hospice does give an overall sense of how ‘spirituality-nurturing’ or attentive a hospice is to spiritual matters. DISCUSSION The results of the hospice setting spirituality score included five hospice care settings that do not have an inpatient option where it may be unreasonable to expect a chapel/quiet room (one of the eight criteria). The other seven items are relevant for any site independent of size. The limitations of this score include the subjective nature of choosing how to weight each binary choice, but it is understood to be a ‘crude’ or ‘broad brush’ indicator, which hospices could use as a preliminary tool to audit their own spiritual care environment. Maori, the indigenous people of New Zealand, are underserved by palliative and hospice care.13 One omission from the survey was a set of questions related to cultural competency, particularly the degree to which each hospice meets the spiritual needs of Maori. Future development of this tool might include an additional item to measure a hospice’s commitment to cultural spirituality and Maori ‘Tikanga (Generally taken to mean "the Maori way of doing things," it is derived from the Maori word tika meaning ‘right’ or ‘correct’) guidelines of care and recommended ways to honour Maori values and beliefs into frontline service delivery.’14 Further measures of cultural competency could also be applied to Pacific peoples, another group to encounter significant barriers in accessing appropriate palliative services.15 CONCLUSIONS This hospice setting spiritual score was developed by collating eight items that reflect an institution’s commitment to spiritual care. All sites surveyed in New Zealand, based on this measurement, could improve their spiritual care. This relatively simple setting spiritual score provides a snapshot of a hospice’s commitment to providing spiritual care. It can be used as an auditing tool to help hospice groups identify organisational and operational aspects that need to be improved to enhance spiritual care delivery.
Author affiliations Cancer Society Social & Behavioural Research Unit, Te Hunga Rangahau Arai Mate Pukupuku, 1
Department of Preventive & Social Medicine, Dunedin School of Medicine, University of Otago, Medical School, Dunedin, New Zealand 2 HammondCare and Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia 3 Department of General Practice and Rural Health, Dunedin School of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand 4 Department of Preventive & Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand 5 Health Sciences Division, Maori Health Workforce Development Unit, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand 6 Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand Acknowledgements We acknowledge the support of the University of Otago departments of General Practice and Preventive and Social Medicine. Funding This work was supported by grants from the Genesis Oncology Trust (PhD scholarship) and the Canterbury West Coast Cancer Society. Grant number GOT-0401-PGS. Competing interests None. Ethics approval Ethics approval was obtained from the Multi-region Ethics Committee, New Zealand (9MEC/06/04/ 042). Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 Sulmasy D. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist 2002;42(Special Issues III):24–33. 2 Byock IR. To Life! Reflections on spirituality, palliative practice, and politics. Am J Hosp Pall Med 2007;23:436–8. 3 Speck P, Higginson I, Addington-Hall J. Spiritual needs in health care. BMJ 2004;329:123–4. 4 Hospice New Zealand. Hospice New Zealand: 2012 Annual Report. Wellington: Hospice New Zealand, 2013. 5 Statistics New Zealand Tatauranga Aotearoa. Births and deaths: year ended December 2012. Wellington: Statistics New Zealand Tatauranga Aotearoa, 2013. 6 McSherry D, Ross L, eds. Spiritual assessment in healthcare practice. Keswick: M & K Publishing, 2010. 7 Cancer Control New Zealand. National Health Needs Assessment for Palliative Care Phase 2 Report: Palliative Care Capacity and Capability in New Zealand. Wellington: Cancer Control Council, 2013. 8 Egan R, MacLeod RD, Jaye C, et al. What is spirituality? Evidence from a New Zealand hospice study. Mortality 2011;16:307–24. 9 Puchalski C. A time for listening and caring: spirituality and the care of the chronically ill and dying. New York: Oxford University Press, 2006. 10 Rumbold B. A review of spiritual assessment in health care practice. Med J Aust 2007;186(10 Suppl):S60–2.
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Short report 11 Ross L. Spiritual care in nursing: an overview of the research to date. J Clin Nurs 2006;15:852–62. 12 WHOQOL-SRPB Group. A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life. Soc Sci Med 2006;62:1486–97. 13 Cancer Control New Zealand. National Health Needs Assessment for Palliative Care. Phase 2 Report: Palliative Care
302
Capacity and Capability in New Zealand. Wellington: Cancer Control New Zealand, 2013. 14 Hospice New Zealand. Hospice New Zealand Standards for Palliative Care quality review programme and guide 2012. Wellington, New Zealand, 2012. 15 Ministry of Health. The New Zealand Palliative Care Strategy. Wellington Ministry of Health, 2001.
Egan R, et al. BMJ Supportive & Palliative Care 2014;4:299–302. doi:10.1136/bmjspcare-2013-000632
Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
The spiritual environment in New Zealand hospice care: identifying organisational commitment to spiritual care Richard Egan, Rod MacLeod, Chrystal Jaye, Rob McGee, Joanne Baxter and Peter Herbison BMJ Support Palliat Care 2014 4: 299-302 originally published online May 20, 2014
doi: 10.1136/bmjspcare-2013-000632 Updated information and services can be found at: http://spcare.bmj.com/content/4/3/299
These include:
References Email alerting service
This article cites 7 articles, 3 of which you can access for free at: http://spcare.bmj.com/content/4/3/299#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
