emotional upset, occupational duty, quality of life, scotland, specialised care hospice staff, spirituality policies
C Caddell. Specialised Care Staff Attitude to Hospice Policy, Spirituality, and Occupational Quality Of Life. The Internet Journal of Law, Healthcare and Ethics. 2005 Volume 4 Number 1.
Using the Coping with Palliative Care Duties questionnaire (CPCD, Caddell, 2002), this study measured spirituality orientation among hospice staff (N = 100) within two specialised care hospices within the west of Scotland (Hospice A & Hospice B). The principle aim was to investigate whether staff with "High", "spirituality measurement scores" (SMS) were more favourable towards the introduction or maintenance of spirituality issues within hospice policy programmes than staff with "Low" SMS. The study also investigated staff depression concerning occupational duties and overall quality of life (QOL) levels. Two-way Between-Groups ANOVA tests indicated non-significant results intimating that staff with Low SMS were as favourable as staff with High SMS towards the introduction of spirituality policies within hospice regime. Findings also suggested however, that although QOL scores were evenly matched between both hospices, Hospice B staff with "High" SMS experienced higher emotional upset regarding occupational duties than the same staff grouping within Hospice A.
An individual's belief system is rarely taken into account when assessments are being considered concerning coping ability or quality of life of palliative care patients. Recent research has highlighted that when spirituality / religious belief orientation is recognised and integrated into hospice policy programmes, the quality of life (QOL) of spirituality / religiously orientated, end-of-life patients can be significantly increased due to the psychological bolstering effect of the hospice ethos.  All patients however, within a hospice setting, whether religious or non-religious experience increased physical and psychological stress when confronted with terminal illness and as such, frequently adopt coping strategies in order to come to terms with the physical discomfort and mental anguish of the trauma. These conscious or unconscious manoeuvres help maintain emotional stability.  Central to the philosophy of palliative medicine is the concept of holistic care, concentrating not only on the physical needs of the patient, but also on emotional, spiritual and social needs. . Hospice staff have become increasingly aware of the great variety of new stressors with which a hospitalised patient is subjected and the strong effects of psychological stress caused by the physical constraints of their illness. Observing the status of patient's thinking ability, feelings and behaviour during the admission process and ongoing nursing care is an important element of a nurse's responsibility.  But the pressures of palliative care often limit medical staff to the primary objective of physical comfort and pain relief aspects of patient management rather than the more idealistic agendas of interpersonal communication and counselling. Indeed, they may consider any inquisition into the patient's mental, psychological or spiritual needs as an additional work task to an already busy work schedule. What is also sometimes overlooked is the emotional impact of the demands of palliative care upon hospice staff. Earlier research listed several sources of stress as,
“Difficulty in accepting the fact that the patient's physical and psychological problems cannot always be controlled.Frustration at being involved with a patient's family only after their emotional resources have been drained by the illness.Disappointment if expectations for patients to die “a good death” (however this may be defined) are not met.Frustration at having invested large amounts of energy in caring for people who then die, taking this investment with them.Anger at being subjected to higher than standard performance expectations in prototypal facilities exposed to considerable scrutiny and publicity.Difficulty in establishing a sense of realistic limitations on what the hospice service, which is expected to be all-encompassing, can provide”. 
Traditionally, medical staff have had difficulty with spirituality as it interrelates with their patients and have considered it best left to the hospice chaplains. Yet research has indicated that the key to emotional coping with serious illness is often to be found within the matrix of patient spirituality.  A recent study revealed that most patients were not offended by inquiries into religious beliefs and attitudes. Forty per cent of the respondents, who denied having religious beliefs, agreed to an initial inquiry on the subject and only sixteen per cent of all respondents refused a discussion on the subject. The remainder described themselves as religious and welcomed the idea of having care-staff discuss spirituality issues with them. 
These results raise questions as to whether health care workers devoid of spirituality / religious belief would find it difficult to respect the beliefs of their spirituality / religiously orientated patients. Would they resent any introduction of spirituality policies within hospice agenda? Would misunderstandings occur because neither could fully comprehend the other's opinions in the area of communication about spirituality or religious belief? Would they resent any inquiry into their personal spirituality / religious beliefs and attitudes as an unwarranted intrusion into their personal space?
This research sought to address these issues by investigating the attitude of staff within 2 West of Scotland specialised care hospice units to spirituality policy, quality of life (QOL) and emotional response to occupational duty.
This “between-subjects” quasi-experimental study was “questionnaire” in structure. The research population comprised 100 hospice staff members from 2 West of Scotland Palliative Care units consisting of males and females ranging in age from 22 – 62 years. This research with staff took place within the same hospices (Hospice A and Hospice B) as did the patient research discussed within the Introduction section of this article (1).
During a three week period, all participating volunteers were measured using the Coping With Palliative Care Duties questionnaire (CPCD, Caddell, 2002), which was self-administering in design. The self-rated scores were assessed using a Likert-type scale. The Staff Questionnaire contained 20 questions. The objective was to establish whether palliative care staff acknowledged their own belief system as a possible aid to caring for the terminally ill and for coping with the occupational stresses involved in end-of-life care. In addition, the “CPCD Questionnaire” had been devised by the researcher in order to investigate attitudes towards spirituality issues within hospice policy, coping strategies and quality of life levels among staff within Hospices A & B. All volunteer staff participants answered exactly the same questions. Although the CPCD is not yet a validated or reliable measuring instrument, it nonetheless received approval and consent from the “collaborative team” within both hospices who were anxious to detect differences in hospice staff score totals. The CPCD questionnaire was modeled on the MQOL-SV (McGill Quality of Life - Scottish Version) measuring instrument which was used in the Patient Research programme within Hospice A & Hospice B and had been designed for use only in the event of significant differences occuring within the Patient Research programme. As the latter did in fact occur, Staff research using the CPCD questionnaire was instigated.
Hospice staff were given the opportunity to take part in the study by means of Information, Questionnaire and Consent Sheets placed within routine “staff mailngs” distributed by the hospice chaplain in Hospice A and the spiritual director in Hospice B. Participating volunteers were asked to place the completed questionnaires and consent forms into a box situated within a secure part of each hospice. Following the allotted time period, 100 questionnaires had been returned (50 from each hospice). The participants, although predominantly female consisted of people with a diverse attitude to spirituality and religious issues. Hospice A was staffed with 8 doctors, 65 nurses and 77 “others” (auxiliary/administrative staff). Hospice B was staffed with 6 doctors, 70 nurses and 32 “others”. Data from the returned questionnaires revealed that from Hospice A, 100% of doctors, 32% of nurses and 27% of other workers chose to take part in the study. Hospice B participants numbered, 67% doctors, 35% nurses and 34% others.The treatment of all staff involved in the research was in accordance with the ethical standards of the British Psychological Society.
Frequencies and percentages were recorded for the 20 scored variables included within the sub-scales of,
Spiritual Measurement Scores (SMS).
Spiritual Attitude Scores (SAS).
Coping Category Inclusion (CCI).
Coping with Depression (CD).
Coping with Occupation (CO).
Quality of Life (QOL).
Religiosity and Ritual Scores (RRS).
Score totals for the variables, SMS & RRS were combined to form the dependent variable “Personal Spirituality Measurement Scores” (PSMS). T-Tests for Independent Samples were performed in order to establish mean differences between the dependent variable PSMS (specifically defined as High Score and Low Score Totals), and the interval score totals of,
Spiritual Attitude Scores
Coping Category Inclusion
Coping with Depression
Coping with Occupational Stress
Coping Strategy Development
Quality of Life
Investigation of this particular IV helped establish whether staff with lower PSMS recorded similar or different attitudes towards aspects of spirituality (e.g. SAS & CCI) within the hospice in which they were employed. It also helped establish whether staff with lower PSMS scores tended to be represented in staff with higher / lower indicators of occupational coping, quality of life and low depression levels.
“Two Way Between Groups” ANOVA were employed (utilising a 3 x 2 factorial design), in order to assess the statistical significance of the relationship between,
Attitude to Spirituality Issues (ASI)
Coping Category Inclusion (CCI)
Coping with Occupational Depression (COD)
Quality of Life (QOL)
and the 2 participating hospices categorised as,
The use of the independent variable (SMS) helped establish which category (as represented by “High”, “Medium” or “Low”) attained the highest mean score totals for the sub-scales of ASI, CCI, COD & QOL.
“Occupation” incorporated 3 levels,
The first 20 questions were designed to measure –
Personal spirituality – Numbers 1 – 4 (producing score range 0 – 8)
Attitude to spirituality issues as hospice policy – Numbers 6 – 8 (producing score range 0 - 10)
Attitude towards spirituality/religion as a coping mechanism – Number 9 (producing score range 0 – 4)
Coping with depression - Number 10 & 13 (producing score range 0 – 4)
Quality of Life measurement – Question 14 & 16 (producing score range 0 – 4)
Personal religiosity & ritual assessment – Questions 17 – 20 (producing score range 0 – 8)
Personal spirituality was assessed in questions 1 – 4 while the opinions of staff with no religious / spirituality beliefs were provided for in the open-ended question number 5 - “During your lifetime, what has helped sustain you during times of crisis?” Question 6 (a) and (b) assessed staff attitudes towards working with hospice chaplains and visiting clergy and questions 7 (a) & (b) & 8 explored staff attitudes towards the discussion of spirituality and religious issues and praying with patients. Whether spirituality and religious issues were assessed as worthy of being included as coping strategies for the terminally was assessed in question 9 (a) and (b). Questions 10 and 11 were inserted to gauge levels of depression or emotional upset and question 12 provided an opportunity to gain insight into staff attitude towards “meaningful existence”. Questions 13 & 15 investigated the subject of coping strategies and question number 16 provided a Quality of Life assessment score. Lastly questions 17 - 20 assessed personal religiosity.
Questions numbered 1 – 4 were scored as follows,Yes = 2; No = 0; Not sure =1; Not appropriate = 0 (score range 0 – 8).Question number 5 was an open-ended question. Questions numbered 6 (a & b), 7(a & b) & 8 were scored as follows,Yes = 2; No = 0; Sometimes = 1: Unsure = 1 (score range 0 –10)Question number 9 (a & b) was scored as follows,Yes = 2; No = 1; Unsure = 0 (score range 0 – 4).Question numbered 10 was scored as,Yes = 0; Occasionally = 1; No = 2 (score range 0 – 2).Question number 11 was an open-ended question.Question number 12 was also open-ended and will be compared to question C in the Patient's Questionnaire.Question 13 and 14 were scored as follows,Yes = 2; No = 0; Unsure =1 Not appropriate = 0 (score range 0 –4). Question 15 was open-ended.Question 16 was scored as,Good = 2; Fair = 1; Poor = 0 (score range 0 – 2).Questions 17 – 18 were scored as follows,Yes = 1; No = 0 (score range 0 – 2)Questions 19 – 20 were scored as,Daily = 3; Weekly = 2; Monthly = 1; Never = 0 (score range 0 – 6).Total overall score for staff participants ranged from 2– 38.
The “Two Way Between Groups” ANOVA investigated -
Attitude to Spirituality Issues (ASI) -
Coping Category Inclusion (CCI) -
Coping with Occupational Depression (COD) -
Quality of Life (QOL) -
“Two Way Between Groups factorial ANOVA” were employed (utilising a 6 x 2 factorial design). Since all 100 staff had previously been measured on each of the 4 CPCD sub-scales variables of “Spirituality Issues Attitude”, “Coping Category Inclusion”, “Coping with Occupational Depression” and “Quality of Life”, the latter now served as 4 separate dependent variables (DV's). The factorial design incorporated “Spirituality Measurement Scores” (SMS) and “Occupation” with 3 levels and “Hospice” with 2 levels. In common with the “Patient Research”(1) a Bonferroni adjustment was applied and as the Staff Questionnaire (CPCD) contained 4 tests, a p level of 0.012 was set for all statistically significant results.
Since “Staff Research” took place within 2 separate hospices, Descriptive Statistics results are initially displayed in order to illustrate resulting differences.
Two Way Between Groups factorial ANOVA (Profile plots 1- 4)
Attitude to Spirituality Issues (ASI)
Descriptive Statistics had revealed little score differences within the categories of “Hospice Chaplain”, “Discussing spirituality / religious issues” and “Praying with patients”. It was only within the “Comfortable with visiting clergy” category that some discrepancies arose. Interestingly, it was staff in Hospice B that claimed to be slightly less favourable towards visiting clergy. 36% of staff claimed to be “uncomfortable” or “sometimes uncomfortable” in their attitude towards visiting clergy in Hospice B, in contrast to 22% in Hospice A.
A, 6 (Spiritual Measurement Score: High vs. Medium vs. Low x Occupations: Nurse vs. Doctor vs. Other) x 2 (Hospice: A vs. B) between groups factorial ANOVA was conducted to explore the impact of “SMS,” “Hospice” and “Occupation” on levels of “Spirituality Issues Attitude” as measured by the CPCD
Tests of Between Subjects Effects showed no significant results. - “SMS”
Subsequent one-way ANOVA did not identify significant results in either hospice - [Hospice A – Spirituality (
Coping Category Inclusion (CCI) - Profile 2
Inspection of “Descriptive Statistics”(Table 1) reveal only a slight difference in score totals between Hospices A & B regarding this issue. Interestingly, it was Hospice A staff who attained slightly higher scores in both categories. However the differences were so slight that Inferential Statistics recorded no significant results.
A, 6 (Spiritual Measurement Score: High vs. Medium vs. Low x Occupations: Nurse vs. Doctor vs. Other) x 2 (Hospice: A vs. B) between groups factorial ANOVA was conducted in order to explore the impact of “SMS,” “Hospice” and “Occupation” on levels of “Category Inclusion” as measured by the CPCD. Tests of Between Subjects Effects showed that there were no significant results within the main effects of “SMS”
Subsequent one-way ANOVA did not identify significant results in either hospice -[Hospice A – Spirituality (
Coping with Occupational Depression (COD) - Profile 3
“Descriptive Statistics” revealed differences in score totals between Hospices A & B regarding the emotional impact experienced by staff due to the stresses involved in day to day caring of patients with life-threatening illnesses. 88% of staff in Hospice B compared to 56% in Hospice A declared that they were always or occasionally subject to emotional distress when caring for their terminally ill patients. Interestingly, only 12% in Hospice B claimed that they did not struggle emotionally compared to 44% in Hospice A. With regard to “Cope with Job” (Qu.13) 24% of Hospice B staff felt that they struggled to cope compared to only 6% in Hospice A.
Turning to inferential statistics, A, 6 (Spiritual Measurement Score: High vs. Medium vs. Low x Occupations: Nurse vs. Doctor vs. Other) x 2 (Hospice: A vs. B) between groups factorial ANOVA was conducted in order to explore the impact of “SMS,” “Hospice” and “Occupation” on levels of “Coping with Occupational Depression” as measured by the CPCD. Tests of Between Subjects Effects showed that there were no significant results within the main effects of “SMS”
Subsequent one-way ANOVA did not identify significant results in either hospice -[Hospice A - Spirituality – (
Quality of Life (QOL) - Profile 4
“Descriptive Statistics” revealed that there were no differences in score totals between Hospices A & B regarding “Quality of Life” score totals. Staff QOL personal assessment scores were identical in both hospices. Overall, “Descriptive Statistics” indicated that 66% of staff in both hospices assessed their quality of life to be “Good”, while 26% described it as “Fair”. As “Coping Strategy” was the main area of research within the “Patient Research”, it was also considered of prime importance to the “Staff Research” programme and was included within QOL assessments. “Descriptive Statistics” revealed a slight difference in score totals between Hospices A & B. Interesting, while 60% in Hospice A and 66% in Hospice B declared that they had developed a coping strategy, 28% in each hospice declared that they had not developed a coping strategy.
Turning to inferential statistics, A, 6 (Spiritual Measurement Score: High vs. Medium vs. Low x Occupations: Nurse vs. Doctor vs. Other) x 2 (Hospice: A vs. B) between groups factorial ANOVA was conducted in order to explore the impact of “SMS,” “Hospice” and “Occupation” on levels of “Quality of Life” as measured by the CPCD. Tests of Between Subjects Effects showed that there were no significant results within the main effects of “SMS”
Subsequent one-way ANOVA did not identify significant results in either hospice -[Hospice A - Spirituality – (
Attitude to Spirituality Issues
It had been thought that hospice staff with “High” SMS, would probably feel more comfortable working with hospice chaplains / visiting clergy, discussing spirituality / religious issues and praying with patients than those staff with lower SMS”. One of the most surprising results (Descriptive Statistics) was that more than half of the staff in each hospice were willing to discuss spirituality and religious issues with patients and even pray with them. Perhaps the most surprising overall finding was that 96% of staff in Hospice A and 88% of staff in Hospice B considered spirituality issues worthy of inclusion within a category entitled, “Coping Strategies in Terminal Illness” while slightly less considered religiosity issues worthy of inclusion. These results are noteworthy for 2 reasons. Firstly the researcher did not expect such a high percentage of staff members within both hospices to be so favourable towards spirituality and religiosity issues. Secondly, staff members within Hospice A (where spirituality and religiosity issues were not incorporated into the care regime policies to the same extent as they were in Hospice B), in fact recorded a higher score for discussing spirituality issues with patients. This result opens the way for spirituality / holistic policies to be introduced more fully into the palliative care policies of Hospice A. Descriptive statistics (Table 1) also revealed a noticeable discrepancy in scores for “Comfortable with visiting clergy” and it is interesting to speculate why nurses in Hospice B with “High” SMS scored lower than “High” SMS nurses in Hospice A (Profile Plot 1). Is it possible that nurses in Hospice B may have had unresolved personal grudges or grievances arising from more frequent contact with clergy than nurses in Hospice A? Interestingly doctors within Hospice B with medium to low SMS were slightly more favourable to the discussion of spirituality and religious issues with patients than the nursing staff (Profile Plot 1a). Overall however, staff with “Low” SMS (in both hospices) appeared to be slightly less unfavourable towards spirituality policies but as previously stated, no statistical differences were found. Findings such as these concur with the ethos of the 1991 survey by Maugans and Wadland and research such as Ehman et al (1999) (7) and Kellehear (2000).
Coping Category Inclusion
It had been proposed that staff in both hospices with “High” SMS would record higher scores in judging spirituality and religious issues worthy of inclusion into hospice policy than staff with lower SMS”. Descriptive Statistics refuted this proposal by revealing that 90% of staff who took part in the study were favourable to the introduction of these issues (Table 1). Reference to Profile 2 revealed that nursing staff in Hospice A appeared to be slightly more favourable than nurses in Hospice B and that doctors in Hospice A within all 3 categories of “spirituality measurement” together with doctors in Hospice B with “low SMS” recorded the same score. These are surprising results since it revealed that within both hospices, a high number of participating volunteers (irrespective of SMS) considered spirituality / religiosity issues to be suitable for inclusion as possible “coping strategy” aids for patients. This finding gives support to Koenig's 1994 research (10).
Coping with Occupational Stress
The research proposed that hospice staff with “High” SMS would be less depressed (struggle emotionally) with duties connected to their work than those respondents with lower SMS”. Some discrepancies began to emerge between the scores of Hospices A and B in connection with occupational stress and emotional upset (Table 1) although ultimately, score differences were statistically non-significant. Profile Plots 3 and 3a do reveal however that both nursing and doctor staff within Hospice A appeared to experiance less occupational stress than nurses and doctors in Hospice B. The latter had a large amount of staff who admitted experiencing emotional upset with regard to their occupational duties in comparison to those who did not. The numbers who experienced emotional upset in Hospice A was smaller than Hospice B but nonetheless constituted more than half. The most noted difference in results was for Hospice A staff who claimed not to experience emotional upset. This result was more than four times that of Hospice B (Table 1).
The question must therefore be asked why Hospice A staff recorded less emotional upset when assessing occupational duties. Was it feasible that almost half of the staff in Hospice A declared no emotional ties with any of their patients because they genuinely had no feelings for them? Or could it be that the constant witnessing of dying and death had resulted in this particular portionof the sample populating adoption (consciously or unconsciously) a type of denial of reality. There is of course no way of specifically knowing why 44% of staff in Hospice A distanced themselves emotionally from both duties and patients. Perhaps they felt more comfortable concentrating solely on physical care responsibilities or perhaps they were comprised of less experienced or younger members of palliative care staff. Inevitably, some explanations may be found in the Vachon's 1979 study (5). Also, because a larger proportion of Hospice B staff gained higher overall SMS, it is possible that they regarded their work as a vocation and as such may have been more motivated to truth telling in the sense of confessing their innermost emotions.
Ultimately the findings indicated that for the most part, occupational duty carried a heavy burden of moral decision making. Whether the latter was linked to religious / spirituality orientation or not, staff were presented with the dilemma of either succumbing continually to the emotional distress associated with end-of-life care or of completely closing down their emotional reactions to the more distasteful and frightening aspects of terminal illness. Since death was a regular occurrence, staff repeatedly experienced the loss of an individual in whom large amounts of effort had been invested. It was not surprising therefore that some staff chose (consciously or unconsciously) to adopt coping strategies which would protect their emotional and psychological well-being from continual distress. An indication of the necessity of coping strategy adoption was revealed in results to question 13 (Table 1 - Coping with Job). Staff in Hospice A were much more confident in their evaluation of how well they coped with occupational stress, in comparison to staff in Hospice B. This provided strong indications that staff within both hospices were aware of the potentially disastrous consequences of becoming too closely entangled in their patient' plight. For some staff (particularly in Hospice B) emotional closeness with patients was judged to be the correct decision even although it resulted in a degree of uncertainty concerning the efficiency of occupational capability. For other staff members (mainly within Hospice A), emotional distancing was judged to be the correct procedure in order to obtain maximum occupational efficiency.
The design of the “Staff Research” had allowed for the inclusion of some qualitative research. The question concerning “emotional upset”, (Question 11 Table 1) gave participants who did experience emotional distress, an opportunity to write down on their questionnaire sheet anything in their lives which helped them cope with this distress. The findings are recorded below -
Quality of Life
The last area of research inquired into whether hospice staff with “High” “SMS” would attain a higher “Quality of Life” assessment than staff with lower SMS”.
Once again, although no statistically significant results emerged, finding nonetheless produced interesting and unexpected findings considering the differing policies operating within both hospices regarding spirituality issues. Results to questions 14 & 16 (Table 1 ) assessing “Development of Coping Strategy” and “Quality of Life” produced almost identical scoring for staff in both hospices. The high scores attained in both of these areas indicated that for most staff members, individual coping strategy choice regarding involvement with or distancing from patients appeared to fulfil its desired function – i.e. the alleviation of emotional and psychological distress relating to occupational duty.
As in Coping Category Inclusion, “Staff Research” design had allowed for the inclusion of some qualitative research with regard to “Developed a coping strategy”. Staff participants who had developed coping strategies were encouraged to record what they were. Examples of the findings are detailed below.
Only 4% of staff in both hospices rated their QOL as “Poor” despite the emotional distress aspect previously discussed. The occurrence of such high “Quality of Life” scores may have been due to the fact that, as well as assessing their working environment, participants also included life outside the hospice environment in their evaluations. This is an interesting finding especially since 56% in Hospice A and 88% in Hospice B reported having “struggled” or “occasionally struggled” with emotional upset. Thus 22% of staff in Hospice B and 4% in Hospice A were struggling emotionally with the duties connected to their occupation, but had not thought to develop a coping strategy.
That CPCD results were non-significant is a surprising result, indicating that despite the fact that staff in Hospice B had higher overall SMS than staff in Hospice A, no statistical differences occurred in staff attitude towards the introduction of spirituality centred hospice policies. This finding may encourage hospice administrators to consider spirituality issues when introducing new policy agenda. American opinion polls consistently show that although approximately 60% of patients would like their medical practitioners to talk to them about faith or spirituality as a factor in health prognosis, only 10% have in fact reported this happening - Maugans and Wadland, (8 ) Ehman, (7 ) Delbanco, (11).
CPCD findings nonetheless indicated that Hospice B staff with “High” SMS experienced higher emotional distress regarding occupational duties and that it was this factor which contributed to their lower scores concerning occupational capability. However, as was stated at the outset, although scoring differences were not robust enough to produce statistically significant results, they are interesting to note since they highlight areas for future research. To date, little investigation has been conducted into the adoption of coping strategies by hospice staff as a means of alleviating occupational stress.
Finally, results for “Staff Research” highlighted the fact that both participating hospices in the West of Scotland were staffed with predominantly young, dedicated professionals, committed to palliative care who carried out their stressful tasks in a conscientious manner, designed specifically to ameliorate the anguish of their vulnerable end-of-life patients. Results also indicated that both hospices were receptive to the introduction of spirituality policies but that staff with “High” SMS in Hospice B seemed to suffer greater emotional distress due to occupational duty.
All concerned with the care and medical treatment of hospice patients should recognise spirituality / religiosity to be a normal part of work with end-of-life patients. Thus nurses, doctors, social workers, chaplains, psychologists and medical directors would share equal responsibility in this undertaking.
The opinions and concerns of hospice staff members should be further explored and investigated. Consideration should be given to their mental health status, particularly in areas of anxiety and emotional distress related to occupational duties.
Future research should investigate whether staff who are attracted to palliative medicine are more spirituality / religiosity orientated than other sections of the medical community and what implications results may have for future palliative care spirituality / holistic policies.
The CPCD questionnaire should be repeated in other similarly matched specialised care hospice units in order to test reliability.
Grateful acknowledgement is given to the staff of both hospices who gave up their time to participated in the CPCD questionnaire thus enabling the operation and reporting of this research. Particular gratitude is given to,
Hospice A - End of Life, Specialised Hospice, Glasgow. Scotland: (D.M.)Hospice B - End of Life, Specialised Hospice, Lanarkshire. Scotland: (G.B.)