Faculty of Medicine and Health A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Jason Mills, RN FACN FHEA BN (Hons I) GCertHlthPromPall (La Trobe) GradDipMHN (RMIT) ProfCertPosEd (Melb) MCHMed (ANU) April, 2018 Self-care, Self-compassion, and Compassion for Others Jason Mills
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Self-care, Self-compassion, and Compassion for Others
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Faculty of Medicine and Health
A thesis submitted in fulfilment of the requirements for the degree of
The wellbeing of health care professionals is a key antecedent of patient care, and self-care
practice plays an important role in promoting health and wellbeing. Despite the importance of
self-care for palliative care professionals, there is scant research evidence to guide it.
In the same way, positive emotions such as self-compassion and compassion for others
appear to represent essential, yet poorly understood aspects of palliative care. As a physician,
Cassel (2009) argued that the promotion of compassion, as an essential emotion for health
care professionals, falls under the remit of positive psychology.
Together, compassion, self-compassion, and self-care have been the subject of growing
discussion in the recent nursing and medical literature (Chambers & Ryder, 2009; Mills, et
al., 2015; Nyima & Shlim, 2015; Mills & Chapman, 2016); however, an empirical
understanding of these phenomena in palliative care contexts is limited. The research
reported in this thesis aimed to address these gaps.
Based on the literature discussed above, the aims of the study reported in this thesis were thus
twofold:
1. To explore self-care practice in palliative care nurses and doctors; and
2. To examine levels of and relationships between self-care ability, self-compassion and
compassion for others.
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Thesis overview
This thesis is presented in nine chapters. Following this introductory chapter, Chapter 2
provides a review of the literature to situate the study within the context of the current body
of knowledge. It also summarises the gaps identified in the literature review.
Chapter 3 outlines the research questions, research design, and methods used in the
study. Philosophical and ethical considerations are also discussed. Chapter 4 reports and
discusses the quantitative results of the study.
Chapter 5 reports and discusses the qualitative findings from the study. Chapter 6
presents answers to the research questions through integration of both quantitative results and
qualitative findings from the study.
Chapter 7 provides a discussion of the overall results of the study in the context of this
thesis. It discusses the key study findings and their implications for practice, as well as
recommendations for future research. It also outlines the study’s contribution to the literature,
noting its relative strengths and limitations. Chapter 8 discusses the role and development of
middle range theory in relation to the study findings and other relevant theoretical literature.
Chapter 9 provides a conclusion to the thesis.
Chapter Conclusion
This chapter has introduced the study as well its aims and background, in the context of
current theory and practice. An orientation to key terms informing the research has been
provided, followed by a chapter overview of the thesis.
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CHAPTER 2
LITERATURE REVIEW
Chapter Introduction
This chapter provides a review of the literature to situate the study within the context of the
field. This chapter includes one journal article published in the International Journal of
Palliative Nursing. Details of this publication are outlined below. More recent studies
published since this paper was accepted for publication are then considered before the chapter
concludes with a summary of what was known at the commencement of this study.
Palliative care professionals' care and compassion for self and others
Published Article:
Mills, J., Wand, T., & Fraser, J. A. (2017). Palliative care professionals' care and compassion
for self and others: A narrative review. International Journal of Palliative Nursing,
23(5), 219-229.
Author Contributions:
JM developed the review objective, formulated the search strategy and conducted the
screening and review of the literature, under the guidance of JF and TW. As the
corresponding author, JM drafted the initial manuscript and revised it with important input
from JF and TW.
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International Journal of Palliative Nursing 2017, Vol 23, No 5 219
AbstractIntroduction: Compassion is arguably central to palliative care. However, calls for the restoring of compassionate care suggest a need for greater understanding and promotion of compassion in practice. Drawing upon the Foucauldian concept ‘Care of the Self’, this review explored the literature relating to palliative care professionals’ self-care, self-compassion, and compassion for others. Methods: Three electronic databases were searched using identified key words. A thematic approach was used to synthesise and critically discuss the literature in the form of a narrative review. Results: Four themes were identified: (1) importance of self-care; (2) awareness, expression, and planning; (3) dimensions of self-care; and (4) balanced compassion. Approaches to self-care practice and research focused mainly on compassion fatigue or a coping paradigm. Conclusions: This review highlights both the importance and multifaceted nature of palliative care professionals’ self-care, in relation to self-compassion and compassion for others. Despite widespread discussion, empirical knowledge of these variables is limited. Future research could usefully explore health promotion interventions in self-care practice, or a positive psychology paradigm that encompasses compassion and self-compassion as positive emotions associated with wellbeing.Key words: l Compassion l Self-care l Self-compassion l Palliative care
This article has been subject to double-blind peer review
Compassion has traditionally been a hallmark of care for the dying (Saunders et al, 1981), but there is increasing
concern that the expression of compassion as a value in palliative care is being compromised (Kellehear, 2005). There is now growing clinical and research interest in the nature and place of compassion in palliative care internationally (Larkin, 2015). This, coupled with outside developments in the scientific study of compassion as expressed towards others and oneself (Singer and Bolz, 2013), presents a valuable opportunity for members of the palliative care profession to better understand and promote compassionate care. The Foucauldian concept ‘care of the self’ provides a pertinent perspective from which to understand care and compassion for others:
‘Care for others should not be put before the care of oneself. The care of the self is ethically prior, in that the relationship with oneself is ontologically prior.’ (Foucault, 2003)
According to Foucault, in order to take care of others, one must first learn to take care of oneself. This has been increasingly discussed in the health professions generally (Mills et al, 2015; Mills and
Chapman, 2016) and is now appearing in the palliative care discourse. For example, Vachon and colleagues (2015) have highlighted a link between self-care and self-compassion, and argued that self-compassion is a prerequisite to compassion for others. These perspectives suggest that more research is needed to examine the relationship between compassionate care for others, self-compassion and self-care.
In the context of health care professionals, self-care has been defined as ‘the self-initiated behaviour that people choose to incorporate to promote good health and general well-being’ (Sherman, 2004). Within the caring professions self-care is associated with resilience and burnout prevention, while a lack of self-care has been linked to compassion fatigue (Skovholt, 2001; Figley, 2002). As an ethical imperative, the Oxford Textbook of Palliative Social Work describes self-care as best practice in palliative care (Clark, 2011); and the relevance of self-care to quality patient care is also echoed in related disciplines of nursing, medicine, and allied health professions working in palliative care (Watson et al, 2009; Cherny et al, 2015; Vachon et al, 2015).
Self-care practice has even been mandated nationally and internationally through discipline-specific professional standards
Palliative care professionals’ care and compassion for self and others:
a narrative review
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(Canning et al, 2005; American Academy of Hospice and Palliative Medicine, 2009; Palliative Care Nurses New Zealand, 2014), and also within palliative care quality standards at the health service level (Palliative Care Australia, 2005; Hospice New Zealand, 2012). Despite this, there has yet to be a comprehensive review of self-care in the palliative care literature. Moreover, self-care has not yet been examined in relation to compassion for self and others. The objective of this review was to critically examine the literature relating to palliative care professionals’ self-care, self-compassion, and compassion for others; identifying implications for practice and future research.
MethodsA narrative review of the peer-reviewed literature was undertaken. This method was chosen in consideration of both the review objective and the emergent area of investigation, less suited to protocol-driven reviews that include empirical evidence only (Coughlan et al, 2013).
Search strategyFirst, a systematic search of the peer-reviewed literature was conducted. MEDLINE Complete, CINAHL Complete, and PsycINFO electronic databases were searched using the key words: compassion; self-compassion; self-care; palliative care; hospice. This search was then supplemented with an electronic search of key palliative care journals. Finally, bibliographies from articles were hand searched to identify any additional papers relevant to the literature review.
Criteria for inclusion and exclusionAll searches were limited to full-text articles published between 2000 and 2016 in English-language peer-reviewed journals. Articles were included where content directly informed the focus and objective of the literature review, including discursive papers as well as scientific papers reporting qualitative and or quantitative research. Papers were excluded if their focus was not directly relevant to one of the search terms, or where they focused on populations outside of the palliative care workforce. Editorials and conference abstracts were also excluded. For the purposes of this review, the term ‘hospice’ was used to accommodate variance throughout international terminology in relation to hospice and palliative care. A date restriction was not applied, considering the absence of any prior published reviews of the topic area.
Article management and reviewThe initial categorisation and storage of articles was managed using Thomson Reuters’ EndNote X7 bibliographic software. Full-text articles for inclusion were then imported to a dedicated database using QSR NVivo 10 data management software. Articles were read and re-read with annotations made to inform the review, and subsequent coding was performed to aid identification of patterns and common themes throughout the articles. As noted by Coughlan et al (2013), this is an effective approach to facilitate the integration of both theoretical and empirical literature. Further synthesis of the literature was then organised into themes for critical discussion.
Table 1. Summary of theoretical articlesYear Authors Country Population Review themes
2014 Doka USA Palliative care (PC)
Workforce
Importance of self-care
2014 Fernando and
Consedine
New
Zealand
PC workforce Balanced compassion
2013 Sanchez-Reilly et al. USA PC physicians Importance of self-care; dimensions of self-care; awareness, expression, and planning
2012 Radwany et al. USA PC workforce Awareness, expression and planning
2012 Halifax USA PC workforce Balanced compassion
2011 Halifax USA PC workforce Balanced compassion
2010 Showalter USA PC workforce Importance of self-care
2009 Kearney et al. USA PC physicians Importance of self-care; awareness, expression and planning; balanced compassion
2009 Morgan USA Paediatric PC nurses Importance of self-care
2005 Coulehan and Clary USA PC physicians Awareness, expression and planning; balanced compassion
2005 Jones USA Hospice workforce Awareness, expression and planning; dimensions of self-care
2005 Rokach Canada PC workforce Importance of sc; dimensions of self-care
2002 Katz and Genevay USA PC workforce Awareness, expression and planning
2002 Keidel USA Hospice workforce Importance of self-care
2000 Wakefield UK PC nurses Importance of self-care
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ResultsA total of 38 articles were included in the review, comprising 15 theoretical papers and 23 empirical reports. Table 1 and Table 2 provide an overall summary of these articles. Four themes were identified from the literature: (1) importance of self-care; (2) awareness, expression and planning; (3) dimensions of self-care; and (4) balanced compassion (Figure 1).
Importance of self-careThe holistic promotion of health and the maintenance of personal wellbeing are defining characteristics of self-care within the palliative care literature (Sanchez-Reilly et al, 2013). Self-care is further defined as a process of maintaining one’s wholeness (Radwany et al, 2012). In this context, the importance of self-care in the palliative care workforce is well established in the literature. This is evident through widespread discussion and research into coping with occupational stressors such as grief, as well as burnout, and compassion fatigue (see for example: Keidel, 2002; Alkema
et al, 2008; Showalter, 2010; Harris, 2013; Kamal et al, 2016).
In his paper exploring the experiences of carer grief, Doka (2014) identified the ongoing exposure to loss and suffering as a danger to both the wellbeing of palliative care professionals as well as their capacity for effective care provision. This, he argued, is the risk when the experience of grief is either unexpressed, or otherwise disenfranchised through the professional context of the caring role. Doka further suggested that coping with grief relies on a variety of individual strategies such as acknowledgement, acceptance, and sharing of one’s grief. By way of an informal case study discussion, Wakefield (2000) argued for ‘relentless self-care’, meaning an enduring commitment to self-care practice as an important component of practice for palliative care nurses.
Citing unprocessed grief from ongoing exposure to loss, Sanchez-Reilly and colleagues (2013) highlighted self-care as a means to mitigate the harmful effects of burnout and compassion fatigue. Similarly, Kearney et al
Table 2. Summary of empirical articlesAuthor (Year) Country Design Population Review themes
Kamal et al (2016) USA Quantitative Hospice/PC workforce Importance of self-care
Beng et al (2015) Malaysia Qualitative PC doctors and nurses Importance of self-care; balanced compassion
Edmonds et al (2015) Canada Case Report PC workforce Awareness, expression and planning; importance of self-care
Forster and Hafiz (2015) Australia Qualitative Paediatric PC workforce Importance of self-care
Perez et al (2015) USA Qualitative PC workforce Importance of self-care
Shimoinaba et al (2015) Japan Qualitative PC nurses Importance of self-care; awareness, expression and planning
Sansó et al (2015) Spain Quantitative PC workforce Importance of self-care; dimensions of self-care; awareness,
expression and planning
Harris (2013) USA Qualitative Hospice nurses Importance of self-care
Kim et al (2013) Canada Quantitative PC medical trainees Awareness, expression and planning
Slocum-Gori et al (2013) Canada Quantitative Hospice/PC workforce Importance of self-care
Whitebird et al (2013) USA Quantitative Hospice workforce Importance of self-care
Breiddal (2012) USA Qualitative PC workforce Importance of self-care; balanced compassion
Melvin (2012) USA Qualitative Hospice/PC nurses Importance of self-care
Way and Tracy (2012) USA Qualitative Hospice workforce Balanced compassion
Lobb et al (2010) Australia Quantitative PC nurses Importance of self-care
Rushton et al (2009) USA Mixed methods PC workforce Balanced compassion; importance of self-care; awareness,
expression and planning
Swetz et al (2009) USA Qualitative PC physicians Importance of self-care; dimensions of self-care
Alkema et al (2008) USA Quantitative Hospice workforce Importance of self-care; dimensions of self-care
Rose and Glass (2008) Australia Qualitative PC nurses Importance of self-care; balanced compassion
Desbiens and Fillion (2007) Canada Quantitative PC nurses Importance of self-care
Abendroth and Flannery (2006)
USA Quantitative Hospice nurses Importance of self-care
Feld and Heyse-Moore (2006)
UK Quantitative PC junior doctors Awareness, expression and planning
Wasner et al (2005) GER Quantitative Hospice/PC workforce Importance of self-care; balanced compassion
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(2009) outlined various stresses that can lead to burnout and compassion fatigue, while emphasising self-care as an imperative when providing end-of-life care. In another review paper, Rokach (2005) suggested that each member of the palliative care team can and should attend to their own needs through self-care to cope with burnout. This was in recognition that palliative care professionals also experience suffering, just as patients and their families do. The cost of caring can significantly impact on the health and wellbeing of physicians, nurses, social workers, chaplains and volunteers in palliative care (Showalter, 2010). Keidel (2002) suggested that too many palliative care professionals have left their role because they were unable to continue as they had little capacity to care for others. However, capacity for self-care is also important, as many professionals in caring roles neglect self-care despite its importance (Showalter, 2010).
A range of research designs have been employed to examine self-care in relation to coping with occupational stress, burnout, and compassion fatigue. A qualitative study by Melvin (2012) explored compassion fatigue and coping strategies used among hospice and palliative care nurses in northeast USA. Through content analysis of interview data, the study concluded that physical and emotional health
consequences exist for nurses working in hospice and palliative care; and while some general strategies were reported, further research into coping strategies was recommended.
Abendroth and Flannery (2006) investigated burnout and compassion fatigue in a cross-sectional survey of 216 nurses across 22 hospices in Florida. In their study, burnout was related to physical and emotional exhaustion caused by exposure to emotionally demanding situations, while compassion fatigue was conceptualised as a secondary traumatic stress reaction from helping others. Hospice nurses in their study were deemed to be at moderate to high risk for both burnout and compassion fatigue. Additionally, these nurses were identified as at greater risk of compassion fatigue if they did not report self-care practice.
Beng and colleagues (2015) developed the total care model of occupational stress in palliative care, with total care conceived as an approach that integrates self-care into caring for others. Through focus group discussions with American hospice nurses, Harris (2013) found that social support, humour, and prayer/meditation were reported as the most effective ways of coping. Commonly used coping methods in a study by Perez and colleagues (2015) included ‘engaging in healthy behaviours and hobbies’ and ‘seeking emotional support from colleagues and friends’. Taken together, the vast majority of discussion and research reflects the discourse of self-care as a way of coping. There are, however, other ways in which self-care is viewed as important.
Research by Breiddal (2012) suggests that self-care is also understood and practised by the palliative care workforce as a way of being. Breiddal argued that historically self-care has been socially constructed as a series of disconnected activities in response to stress rather than as an agent of prevention, or early intervention for stress and burnout. Through her discourse analysis, Breiddal interpreted self-care to mean an active and responsive way of being, in relation to personal and organisational values, responsibilities and resources.
Apart from a way of coping or a way of being, self-care can also be understood as a way of promoting health and maintaining wellbeing. From their qualitative study of Australian nurses, Rose and Glass (2008) highlighted the importance of self-care in enhancing emotional wellbeing when providing palliative care. As the only study to allude to barriers to self-care, this research also found that stigma prevented some nurses from prioritising self-care, highlighting influence of peers. Apart from this, it is evident Figure 1. Themes identified from the literature
The importance of self-care
Way of coping (stress, grief, burnout, compassion fatigue)Way of beingPromotion of health and maintenance of wellbeing
Awareness, expression, planning
Mindfulness and meditationDebriefing, clinical supervision, poetryIndividual self-care plans
Balanced compassion
Self-compassionCompassion for others
Dimensions of self-care
Physical, psychological, emotional, spiritual, professional, balance Physical, inner, socialPersonal, professional
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that very little research into self-care has explicitly focused on health promotion and the fostering of wellbeing, outside of a paradigm of coping with stressors. Nonetheless, the peer-reviewed literature is unequivocal in both its volume and emphasis with regards to the importance of self-care. In addition to this, it also highlights key aspects of self-care.
Awareness, expression, and planningAwareness, expression, and planning, together represent significant aspects of self-care. This is evident through widespread discussion and research into associated activities such as debriefing, clinical supervision, reflective writing, poetry, mindfulness and other meditative or planning techniques (see for example: Katz and Genevay, 2002; Jones, 2005; Rushton et al, 2009; Edmonds et al, 2015; Sansó et al, 2015).
Awareness relates both to the suffering of others as well as ones’ own emotional responses and suffering. Katz and Genevay (2002) outlined the complexity and potential impact of counter-transference issues that may arise in emotional responses when providing end-of-life care. Self-awareness is therefore considered to be central to self-care. To this end, the use of mindfulness meditation and reflective writing has been discussed as an effective means to foster self-awareness and facilitate self-care (Sanchez-Reilly et al, 2013; Kearney et al, 2009). For Kearney et al (2009) self-awareness is essential to maximising individual wellness. Others have reported the use of clinical supervision as an effective self-care strategy to promote the expression of thoughts and feelings (Edmonds et al, 2015). Expression, in this way, represents an important aspect of self-care; although it is not limited to clinical supervision or debriefing. For instance, writing poetry has also been discussed as an effective self-care strategy, and has been used in team activities as a creative and effective outlet for personal expression (Radwany, 2012; Coulehan and Clary, 2005).
Planning for self-care is also considered important for palliative care professionals. In the same way that dedicated care plans contribute to optimal care for patients, there is a view that self-care should be systematic rather than haphazard. According to Jones (2005), to relieve stress and prevent burnout an individualised self-care plan should be developed and used to balance ones’ own needs with the needs of patients. Sanchez-Reilly et al (2013) go further, to recommend self-awareness plans in addition to a self-care plan. Despite this recommendation, there appears to have been no research to date
into the uptake or utility of self-care planning in the palliative care workforce.
There has, however, been research involving awareness and expression as key aspects of self-care. Findings from a qualitative study of Japanese palliative care nurses highlighted the importance of self-awareness and expression of emotions, in relation to self-care (Shimoinaba et al, 2015). These findings are supported in part by other research (Sansó et al, 2015) that investigated awareness and coping in a large multidisciplinary sample of Spanish palliative care professionals. Results from this study indicated that greater awareness positively predicted compassion satisfaction and negatively predicted both compassion fatigue and burnout. Participants with higher levels of self-awareness were also those with greater scores in competence in coping with death.
As a targeted educational intervention for Canadian doctors training in palliative care, Kim and colleagues (2013) developed and evaluated a structured self-care learning module that involved participation in a facilitated group discussion. Evaluation revealed that most participants gained an appreciation for the importance of self-reflection and self-awareness as a component of self-care. While the majority of participants described this training as a valuable learning experience, some were uncertain or did not consider it to be valuable. Other research by Feld and Heyse-Moore (2006) evaluated the implementation of support groups in the UK, for junior doctors working in palliative care. Similarly, most participants reported this to be helpful, particularly in sharing clinical experiences for confidential discussion. However, some reported barriers such as trust among peers and difficulties raising issues within the support groups. This was identified in relation to traditional medical training, leaving doctors either unaccustomed or reluctant to express feelings, fearful of being judged, or concerned that issues expressed would be perceived as weakness. Consideration of these challenges is therefore necessary in team-based self-care initiatives that foster awareness and expression.
Awareness also featured prominently in the evaluation of a contemplative end-of-life training program by Rushton and her colleagues (2009) in the USA. Mindfulness and self-care formed core components of this training, and its evaluation was informed by 95 online survey responses and 40 telephone interviews. The majority of participants indicated that mindfulness practices enabled them to better recognise and express their own grief through
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self-awareness, leading to a heightened focus on patient care as well as self-care. Some also expressed the importance of having a self-care plan. In summary, the literature reviewed highlights awareness, expression and planning as key aspects of self-care. At the same time, it is also important to appreciate that self-care practice is multifaceted.
Dimensions of self-careAs a holistic concept, self-care is multi-dimensional in the way it is understood and practised by palliative care professionals. Within the theoretical literature three authors have discussed different dimensions of self-care. Jones (2005) incorporated physical, emotional/ cognitive, relational, and spiritual self-care into a proposed self-care plan; while Rokach (2005) focused more broadly on either personal or professional dimensions of self-care. Sanchez-Reilly et al (2013) discussed these two dimensions, adding further distinction between individual or team-based self-care strategies within the professional dimension. Self-care dimensions have been discussed in the literature more extensively than they have been studied. Within the research literature, only two studies have explicitly examined dimensions of self-care (Figure 2).
First, in their study of hospice workers Alkema (2008) investigated the relationship between six different self-care dimensions as well as compassion fatigue, burnout, and compassion satisfaction. The most common dimensions of self-care reported for this sample were spiritual self-care, physical self-care, and psychological self-care. Results further indicated that compassion fatigue was significantly negatively correlated to five dimensions of self-care (all except for physical self-care); while compassion satisfaction was significantly positively correlated with only emotional, spiritual, and balance self-care dimensions. As previously noted, this study was limited by a very small convenience sample
of 37 hospice professionals from two hospices in Midwest America. It should also be noted that the instrument used in this study was an informal self-report rating tool, not a validated scale to measure self-care psychometrically as a construct.
Second, Sansó and her colleagues (2015) studied three dimensions of self-care in a cross-sectional survey of nearly 400 palliative care professionals in Spain. Development of these dimensions was informed by both theoretical and empirical work; focusing specifically on physical, inner, and social wellbeing. In contrast to the Alkema et al study, results from this research indicated that self-care was practised predominantly through a social dimension, followed by dimensions of physical and then inner self-care. All dimensions of self-care were significantly positively correlated with compassion satisfaction, and significantly negatively associated with compassion fatigue and burnout. Inner and social self-care dimensions were also positively correlated with respondents’ ability to cope with death.
While several dimensions of self-care have been discussed in the theoretical literature for over a decade, research has been limited. Taken together, the studies suggest that while individual uptake may vary, practising self-care across a range of dimensions may be positively associated with compassion satisfaction and inversely related to burnout and compassion fatigue.
Balanced compassionCompassion is defined in the literature as an emotion one experiences when feeling concern for others’ suffering and wanting to alleviate that suffering (Halifax, 2012). For palliative care professionals, the cultivation of compassion for oneself is considered equally important as compassion for others. The relevance of balanced compassion to self-care is evident across the theoretical and empirical literature, with compassion conceptualised in multiple ways (see for example: Halifax, 2011; Way and Tracy, 2012; Fernando and Consedine, 2014).
Way and Tracy (2012) conceptualised compassion as ‘recognising’, ‘relating’, and ‘(re)acting’. In their study of communication among hospice staff, it was found that compassion was exemplified when staff were able to recognise suffering, relate to others, and react in a meaningful way to alleviate suffering. Fernando and Consedine (2014) proposed a theoretical model of physician compassion, highlighting compassion as transactional in nature, rather than being a finite quality that becomes depleted as it is used. Within this model it was suggested Figure 2. Dimensions of Self-Care
Alkema et al (2008)
1. Physical
2. Psychological
3. Emotional
4. Spiritual
5. Workplace
6. Balance
Sansó et al (2015)
1. Physical
2. Inner
3. Social
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that physician compassion arises from interrelated influences between physician, patient and family, clinical situation, and environmental factors. For Halifax (2011), compassion is necessary not only for patients, but also for clinicians themselves.
Similarly, from her self-care discourse analysis, Breiddal (2012) concluded that having compassion for oneself is mutually beneficial for self and others. This is supported by Rose and Glass (2008) who argued that compassionate care for oneself can enhance wellbeing for palliative care professionals in the same way as with patients. Further, it has been suggested that those neglecting self-care and experiencing burnout or compassion fatigue tend to display a lack of compassion toward themselves and others (Kearney et al, 2009). However, these claims have not been supported through research to date.
Given that the psychometric constructs of compassion fatigue and compassion satisfaction do not directly relate to compassion itself, very little research has investigated compassion or self-compassion in the palliative care workforce. Of those studies that have investigated these direct ly, none have used a val idated psychometric instrument.
Wasner and col leagues (2005) used standardised scales to measure religiosity, self-transcendence, and aspects of spirituality, in their evaluation of spiritual care training for palliative care professionals in Germany. Self-compassion and compassion for others were examined as general attitudes on a self-rated numeric scale from 0 (not at all) to 10 (very much). The mean levels of self-rated compassion and self-compassion reported at baseline were found to increase significantly after spiritual care training, although the concepts were tested as general attitudes rather than tested as constructs using validated instruments.
In summary, compassion and self-compassion are considered important for palliative care professionals. Research suggests there may be a relationship with self-care, and can be increased through contemplative practices. However, these studies are few and have limitations Current empirical knowledge of these variables in palliative care practice is limited.
DiscussionThe objective of this review was to examine the literature relating to palliative care professionals’ self-care, self-compassion, and compassion for others; identifying implications for practice and future research. Key areas of consideration for current practice and future research include the
importance of self-care; awareness, expression and planning; dimensions of self-care; and ba lanced compass ion. Pa l l ia t ive care professionals’ self-care may be supported firstly by prioritising it, and subsequently by employing a variety of self-care strategies that promote awareness, expression and planning. The provision of staff support in the workplace may help promote professional self-care activities, but this alone is not sufficient (Showalter, 2010). It is also clear that compassion for self and others is important.
The notion that compassion should be a practice imperative is not new to the field of palliative care. Kellehear (1999; 2005) had previously argued for compassion to become a priority, declaring that the expression of compassion should not be idiosyncratic, nor its analysis impressionistic. Yet, approaches to research, education and practice in palliative care have, to date, been less than systematic or thorough in their exploration of compassionate care. Much of the attention towards compassion has been in the context of so-called compassion fatigue or, to a lesser extent, compassion satisfaction. However, these terms appear somewhat misleading in that these psychometric constructs do not measure levels of compassion. It is evident from this review that compassion, itself, is yet to be measured in this population.
Compassion and self-compassion can be investigated empirically, either through functional magnetic resonance imaging or as psychometric constructs (Singer and Bolz, 2013). In the context of positive emotions, compassion and self-compassion are increasingly examined within the field of positive psychology, with its strengths-based emphasis on wellbeing (Cassel, 2009; Neff and Lamb, 2009). Despite this, empirical knowledge of these is lacking in palliative care practice. While this may also be the case in health care generally, the literature is unequivocal about the need for palliative care professionals to practise compassion for oneself and for others. There is also a premise that self-compassion is a prerequisite to compassion for others.
This is increasingly discussed within general medical and nursing literature, in which self-compassion is understood as a mindful practice oriented toward the emergence of compassion and holistic care for all who experience suffering (Mills and Wand, 2015; Mills and Chapman, 2016). In palliative care, the apparent theoretical association between compassion and self-compassion is best encapsulated by Vachon’s (2015) assertion that one cannot practise compassion for others if one does not practise
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self-compassion. However, this has yet to be established empirically, and there is no evidence that compassion is in fact lacking in the palliative care workforce. Understanding of an apparent association between self-compassion and compassion for others is thus limited to theoretical discussion, as is also the case with the relationship between these variables and self-care.
There is a lack of evidence in relation to the Foucauldian perspective that one must first learn to take care of oneself in order to take care of others. The literature suggests a dominant and more reactive paradigm of self-care as a way of coping with various occupational stressors. The dominance of this paradigm seemingly shifts focus away from self-care itself, and more onto coping. While professional and quality standards require that palliative care professionals implement and maintain effective self-care strategies, the large majority of literature instead reflects an explicit focus on coping strategies.
This is perhaps because occupational stress has featured prominently in the palliative care literature over time, stemming from perceptions that caring for the dying is particularly stressful (Vachon, 2011). Yet, the literature is inconclusive as to whether clinicians working in palliative care experience higher levels of stress or burnout than other specialty areas of practice. Systematic reviews of stress and burnout in the palliative care workforce have found that studies indicate prevalence of these is comparable to that of other clinical specialties (see for example: Peters et al, 2012). That is not to suggest palliative care practice is not stressful per se, or that self-care as a way of coping is not important; in the same way that understanding of palliative care practice is not confined to negative factors such as stress, coping represents an important aspect of self-care, but not its entirety. This is highlighted through Breidall’s (2012) conceptualisation of self-care as a way of being, and also in the distinction between surviving and thriving made by Peters and McDermott (2012).
It is evident from the literature that occupational stressors and associated coping strategies are themselves discrete subjects of research. Moreover, coping strategies may not necessarily be constructive. For example, drinking alcohol is reported as a strategy used by hospice workers to cope with stress (Whitebird et al, 2013). Further, there is research to suggest that palliative care professionals who use avoidant coping strategies are at higher risk for post-traumatic stress disorder symptoms (O'Mahony et al, 2016). Coping is understood in the literature as pertaining to ones’ cognitive or
behavioural efforts to manage internal and external demands appraised to be taxing or exceeding ones’ resources (Lambert and Lambert, 2008), whereas self-care is much broader in its focus on the promotion of health and maintenance of wellbeing.
Health promotion is intrinsic to self-care, however, health promotion approaches to self-care in palliative care professionals appear largely unexplored. While self-care as a way of coping may be viewed through a narrow lens of harm-minimisation, there is merit in considering other health promotion principles such as prevention or reorientation to more supportive work environments (Kellehear, 2005). Given that exploration of these areas appears largely neglected, a greater focus toward understanding self-care outside of a coping paradigm is indicated.
Future researchThis review highlights a number of gaps to be addressed. Although self-care is considered important, the utility and general uptake of self-care practice among palliative care professionals remains largely unknown. For example, the concept of self-care planning was introduced over a decade ago, yet this review did not identify any research investigating whether palliative care professionals actually use individual self-care plans; and if so, the extent to which they are found to be effective. Ascertaining the level of awareness around use of self-care plans, or engagement with self-care training in general, would further contribute to this.
Understanding of the meaning of self-care within the palliative care workforce also remains limited. Beyond theoretical definitions or analyses of textbooks, a greater understanding of how self-care is perceived across the broader palliative care profession might serve to inform education and training initiatives. This knowledge would also build from the conceptualisation of self-care as a way of being. At the same time, it will be important to identify barriers and enablers to effective self-care practice experienced by palliative care professionals. To date these areas remain largely unexplored. Further, if as Wakefield (2000) recommended, self-care is to be relentless, then investigating the regularity of self-care practice among palliative care professionals is another priority.
Other opportunities for future research into self-care include foci such as resilience, health promotion, or positive psychology approaches to health and wellbeing. For example, correlational studies might usefully examine self-care practice in relation to resilience as a dependant variable.
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Given the relevance of health promotion to self-care, fruitful explorations may be undertaken in this area. While most interest in health promoting palliative care has to date focused on the general community, it is clear from its public health context, that health promotion practice and research should also consider palliative care professionals. Specific health promotion areas for research might include uptake of health promoting behaviours and the evaluation of prevention campaigns implemented in workplaces. But self-care research more relevant to compassion and self-compassion will likely encompass the positive psychology elements of wellbeing, or flourishing.
Flourishing is the stated goal of positive psychology, and to this end positive emotions form the foundation of wellbeing (Seligman, 2012). Cassel (2009) argued that development of education programmes and interventions to instil compassion, as a vital emotion for health care professionals, falls under the remit of positive psychology. Compassion and self-compassion both represent positive emotions that may foster personal wellbeing and, more broadly, contribute to one’s flourishing as a palliative care professional (Neff et al, 2007; Cassel, 2009; Neff and Lamb, 2009; Vachon, 2012). Specifically, compassion and self-compassion have been linked with positive factors in health professionals such as improved sleep and resilience (Kemper et al, 2015). Further investigation of this area within palliative care practice would contribute to the nascent field of positive health, as proposed by Seligman (2012). Moreover, it would add to a growing body of literature that suggests interventions to promote these positive emotions in health care professionals offer not only the potential for positive health and wellbeing, but also improved patient care.
LimitationsAs this literature review was limited to full text articles published in the English language, there may be other literature outside the scope of this paper.
ConclusionThis review has highlighted the importance and multi-faceted nature of self-care to palliative care professionals’ practice, in relation to compassion and self-compassion. Despite growing interest and widespread discussion, current empirical knowledge of these variables remains limited. Future directions for research include health promotion and positive psychology approaches to self-care in the context of health and wellbeing. Through exploration of these areas, palliative care professionals’ understanding and practice of self-care can progress beyond a paradigm of coping, and toward a more positive paradigm of flourishing. ●IJPN
Declaration of interests
The author have no conflict of interest to declare
Acknowledgements:
JM is supported by an Australian Postgraduate Award from
the University of Sydney.
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Professional Self-Care Scale developed for Spanish palliative care professionals
A newly developed self-care scale for Spanish palliative care professionals was published
online towards the end of 2015 in the Spanish Journal of Psychology, (Galiana, Oliver,
Sansó, & Benito, 2015), that is, several months after quantitative data collection had ceased
for the present study. A feature of this scale is its focus on the physical, social, and inner
domains of self-care – consistent with the definitions of health and self-care (see Appendix A
for scale items); however, problems with item-level reliability were identified by the scale
authors in the reporting of the scale’s psychometric properties. This issue, combined with
item linguistics and other potential cultural considerations, may prove a barrier to the
application of this scale outside of Spain. Nonetheless, the theoretical basis of this scale
appears sound and, in the future, it might usefully be adapted and validated for reliable use in
non-Spanish populations.
Mindful self-care, compassion satisfaction and burnout among hospice professionals
A study of hospice professionals using a newly developed mindful self-care scale (Cook-
Cottone & Guyker, 2018) was published online in late February 2018 (Hotchkiss, 2018). See
Appendix B for full details of this 33-item scale. Analyses of data from a cross-sectional
survey of 324 hospice care professionals in the USA indicated that participants who engaged
in multiple and frequent self-care strategies experienced higher levels of professional quality
of life. The construct of mindful self-care was positively correlated with compassion
satisfaction and negatively correlated with compassion fatigue. However, this study did not
measure compassion itself, and its findings are consistent with past research already
reviewed.
39
Summary
Four themes were identified from the literature: (1) The importance of self-care; (2)
Awareness, expression and planning; (3) Dimensions of self-care; and (4) Balanced
compassion. In reviewing the literature, several key knowledge gaps became apparent.
Despite widespread discussion of their importance, the evidence base from empirical
knowledge of self-care, self-compassion, and compassion for others is limited. Compassion
and self-compassion are positive emotions that may contribute to the health, wellbeing and
flourishing of palliative care professionals. However, these variables have not been measured
together in this population, meaning that balanced compassion is difficult to discern.
Moreover, assertions that one cannot practise compassion for others if one does not practise
self-compassion are yet to be established empirically.
The uptake, regularity, and specific nature of self-care practices among palliative care
professionals is largely unknown. The ways and the extent to which palliative care
professionals are able to implement or maintain effective self-care strategies remains unclear.
Moreover, it is not known whether any self-care training is provided by palliative care
services to support effective self-care practice. An understanding of factors that facilitate or
impede self-care practice is important, yet these have been neglected in the literature so far.
Qualitative perspectives from palliative care practitioners are also lacking, leaving expert
accounts of the meaning and practice of self-care from the field relatively limited.
Palliative care research has typically focused on coping strategies in the context of
occupational stressors. Accordingly, there has been relatively little research into self-care as a
discrete practice. Given that effective self-care practice has been an explicit professional
practice requirement in Australia since 2005, further research in this area is warranted.
Positive psychology offers a valuable perspective from which to investigate self-care,
particularly in the context of positive emotions and their relationship to health and wellbeing.
40
Chapter Conclusion
This chapter has provided a review of the literature to situate the study and thesis within a
context of the current body of knowledge. In addition to the narrative review published in the
International Journal of Palliative Nursing, a further update of relevant literature was
discussed in relation to the 5th edition of Palliative Care Australia’s (2018) National
Palliative Care Standards, and two other studies published after the initial review. The next
chapter will outline the specific research questions addressed by the study, as well as the
research design and methods used.
41
CHAPTER 3
RESEARCH DESIGN AND METHODS
Chapter Introduction
The purpose of this chapter is to outline the research design and methods used in the study.
Philosophical and ethical considerations relating to the research will also be discussed. The
chapter begins by outlining the research questions to be addressed.
Research questions
The following research questions (RQ) were formulated from the literature review presented:
RQ1: Which self-care strategies are most commonly used by palliative care nurses
and doctors?
RQ2: How important is self-care considered to be in palliative care practice?
RQ3: How regularly is self-care practised?
RQ:4 How many in this group have received self-care education or training?
RQ:5 To what extent and affect are self-care plans used as part of self-care practice?
RQ:6 What levels of self-care ability, self-compassion, and compassion for others
are reported by palliative care nurses and doctors?
RQ7: What is the relationship between self-compassion and self-care ability?
42
RQ8: What is the relationship between self-compassion and compassion for others?
RQ:9 What it is the meaning of self-care, as described by palliative care nurses and
doctors?
RQ10: How do palliative care nurses and doctors describe effective self-care
practice?
RQ11: What inhibits effective self-care practice?
RQ12: What promotes effective self-care practice?
Mixed Methods Research
The decision to use mixed methods in this study was guided by the research questions being
guide was piloted and refined in response to feedback received from a small group of
palliative care professionals not involved in this study (Payne, 2007). As outlined by
Musselwhite et al. (2007), telephone interviewing is an effective method of data collection
when the interviewer understands the benefits as well as its inherent challenges
(Musselwhite, Cuff, McGregor, & King, 2007). Thus, considerable effort was made to
minimise communication barriers such as the absence of non-verbal cues. Clarification was
frequently sought to confirm that the interviewer had correctly heard and understood the
content and meaning of what participants had conveyed verbally. Conducting interviews in
this way was considered more efficient and cost-effective than interstate travel and other
logistics associated with face-to-face interviews; ultimately, the use of telephone interviews
provided a broader geographical sample for the qualitative strand of the study.
Field notes were taken to inform iterative analysis, and audio recordings of all
interviews were transcribed verbatim for inductive qualitative content analysis (Liamputtong
& Serry, 2013; Welch & Jirojwong, 2011). This began with the reading, re-reading, and
52
initial coding of raw data, and progressed with the identification of categories and
interpretation of emerging themes (Elo & Kyngas, 2008; Hsieh & Shannon, 2005). Given the
relatively large data set, all qualitative data management was assisted by QSR NVivo
software (Serry & Liamputtong, 2013). To minimise unnecessary duplication, further details
of research methods used in both strands of the study are presented in the Methods section of
each journal article either published or in press.
Middle range theory. The integration of quantitative and qualitative data is a
preliminary step towards further theory development. In turn, middle range theory statements
then inform practice and future research. The development of middle range theory represents
a practical yet underutilised research strategy, providing the potential to combine the strands
of research and practice to form a synthesised and more meaningful thread (Liehr & Smith
(1999).
Rigour and Reflexivity. The demonstration of rigour and researcher reflexivity
throughout the research process is of great importance to nursing research (Freshwater, 2005;
Welch, 2011). Despite a lack of clarity regarding methods for demonstrating rigour in mixed
methods designs (Halcomb & Hickman, 2015) this research has demonstrated
methodological rigour in both qualitative and quantitative strands of the study, as advocated
by Creswell and Plano Clark (2011). For example, sound internal and external validity have
been shown in the quantitative strand. Rigour is also supported by peer-review and
publication of study findings in high-quality journals. Similarly, trustworthiness, credibility
and potential for transferability have been demonstrated within the qualitative strand (Elo et
al., 2014; Graneheim & Lundman, 2004); although, as noted by Elo and colleagues (2014),
transferability to other settings or contexts, ultimately, can only be discerned by others.
To ensure trustworthiness in the research process, the researcher undertook
specialised training in underdeveloped areas, such as quantitative data analysis and software
53
packages, so that requisite knowledge and practical skills were obtained to conduct the study
(Halcomb & Hickman, 2015). Expert statistical guidance was sought before and after data
collection to ensure quality and rigour in quantitative data analysis. Authenticity and
confirmability were established through the reporting of participant quotations and careful
synthesis of perspectives to support the qualitative findings and ensure that conclusions were
well grounded in the data (Welch, 2011).
According to Halcomb and Hickman (2015), ‘rigour in mixed methods research
involves providing the reader with a clear audit trail and with well-considered, justified
rationales for the decisions made throughout the research process’ (p.46). Thus, to ensure
rigour and trustworthiness, a decision-making trail was reported throughout the study with
clear rationales justified where key decisions were made, for example, to guide data analysis
(Liamputtong & Serry, 2013; Welch & Jirojwong, 2011). Credibility and confirmability have
also been supported through the presentation and publication of study findings to national and
international nursing, medical, and palliative care audiences.
Finally, reflexivity was documented to situate the researcher within the context of the
research conducted. Reflexivity refers to an ‘ongoing analysis of personal involvement’
throughout the research process (Jootun, McGhee & Marland, 2009, p.45). According to
Jootun and colleagues (2009), ‘reflecting on the process of one’s research and trying to
understand how one’s own values and views may influence findings adds credibility to the
research and should be part of any method of qualitative enquiry’ (p.42).
It has been argued that reflexive studies are only valid ‘if the researcher’s bias is fully
incorporated and becomes transparent throughout the study’ (Mantzoukas, 2005, p.311).
However, Freshwater (2005) asserts that a researcher’s bias can never be known fully and
only that which is conscious can be articulated. Bracketing, as a cognitive process of
detaching from one’s own thoughts and beliefs, is discussed in the nursing research literature;
54
however, nurses’ ability to fully achieve this separation within an interpretive process is
contested (Jootun et al., 2009). Given that self-awareness and transparency are key factors for
promoting rigour, the task of the researcher is thus to engage in reflective practices
throughout the research process to promote self-awareness and provide transparency (Jasper,
2005; Clarke, 2009).
Having previously realised the benefits of reflective writing to support the research
process (Mills, 2012), a reflexive research journal was kept by the researcher throughout the
present study. For example, personal values and beliefs about the phenomena under
investigation were documented in a prior reflective account to enable awareness and analysis
of the researcher’s potential influence on the collection or analysis of data. Appendix D
outlines this reflective account, as an excerpt from the reflexive journal used to support the
research process.
Ethical considerations
Consideration of ethical principles that guide and govern research practice is important for
nurse researchers (Ingham-Broomfield, 2017). A number of ethical considerations were
relevant to the conduct of this study, in accordance with the National Statement on Ethical
Conduct in Human Research (National Health and Medical Research Council, Australian
Research Council, & Australian Vice-Chancellors’ Committee, 2015). As detailed in
Appendix E, the research protocol was subjected to ethical review and revised prior to
approval (2015/013) being granted by the University of Sydney Human Research Ethics
Committee (USYD HREC).
In accordance with this approval, participant recruitment and collection of data did
not commence until this approval had been obtained. For survey participants, informed
consent was implied after navigating through the participant information and completing the
55
online survey (see Appendix F for Survey Participant Information Statement). Informed
written consent was obtained from all who participated in an interview (see Appendix G for
Survey Participant Information Statement and Consent Form). Considerable care was taken in
the survey design and development, ensuring that anonymity of individual survey response
data was protected, whilst also facilitating means for survey participants to provide their
name and contact details securely and separately to the survey data provided. Care was also
applied to data management processes, including the de-identification of interview participant
data and allocation of pseudonyms for the reporting of qualitative data. All necessary
reporting to the USYD HREC was completed.
Chapter Conclusion
This chapter has outlined the research questions, research design, and methods used in the
study. Philosophical and ethical considerations relating to the research were also discussed.
The next chapter will present results from the quantitative strand of the study.
56
CHAPTER 4
QUANTITATIVE STRAND RESULTS
Chapter Introduction
The purpose of this chapter is to report results from the quantitative strand of the study. This
chapter presents two journal articles published in the Journal of Palliative Medicine and the
International Journal of Palliative Nursing.
Self-care in palliative care nursing and medical professionals
Published Article:
Mills, J., Wand, T., & Fraser, J. A. (2017b). Self-care in palliative care nursing and medical
professionals: A cross-sectional survey. Journal of Palliative Medicine, 20(6), 625-
630.
Author Contributions:
JM, JF, and TW contributed to the conception and development of the study design. JM
drafted the initial questionnaire and refined it in response to feedback from JF and TW. JM
developed the REDCap survey and tested online functionality with input from JF and TW.
JM managed participant recruitment and administered the open and closing of survey
responses. JM performed data analysis with guidance from JF. As the first named author, JM
drafted and revised the manuscript, with input from JF and TW.
57
Self-Care in Palliative Care Nursingand Medical Professionals:A Cross-Sectional Survey
Jason Mills, RN, BN (Hons), MCHMed, FACN,Timothy Wand, NP, RN, MN (Hons), PhD, and Jennifer A. Fraser, RN, RM, PhD
Abstract
Background: Self-care is an important consideration for palliative care professionals. To date, few details havebeen recorded about the nature or uptake of self-care practices in the palliative care workforce. As part of abroader mixed methods study, this article reports findings from a national survey of nurses and doctors.Objective: The objective of this study was to examine perceptions, education, and practices relating to self-careamong palliative care nursing and medical professionals.Design: A cross-sectional survey using REDCap software was conducted between April and May 2015.Perceived importance of self-care, self-care education and planning, and self-care strategies most utilized wereexplored. Descriptive statistics were calculated and content analysis used to identify domains of self-care.Setting/Subjects: Three hundred seventy-two palliative care nursing and medical professionals practicing inAustralia.Results: Most respondents regarded self-care as very important (86%). Some rarely practised self-care and lessthan half (39%) had received training in self-care. Physical self-care strategies were most commonly reported,followed closely by social self-care and inner self-care. Self-care plans had been used by a small proportion ofrespondents (6%) and over two-thirds (70%) would consider using self-care plans if training could be provided.Conclusions: Self-care is practised across multiple health related domains, with physical self-care strategiesused most frequently. Australian palliative care nurses and doctors recognize the importance of self-carepractice, but further education and training are needed to increase their understanding of, and consis-tency in, using effective self-care strategies. These findings carry implications for professional practice andfuture research.
Palliative care professionals are highly trained incaring for others, but they may receive little to no
training in caring for themselves. In palliative care, a clini-cians’ expertise is rightly directed toward the care needs ofpatients and their families accessing palliative care. From aworkforce perspective, however, due consideration must alsobe given to the individual’s needs with regard to health andwell-being. Concerns about increasing demands on the pal-liative care workforce have featured on the palliative careagenda for some time,1,2 but related workforce issues such as
self-care, while espoused through professional practice andquality standards, have received relatively little researchattention.
Self-care encompasses the caring behaviors used to pro-mote health and well-being3 and is increasingly discussed inthe nursing and medical literature.4,5 The palliative care lit-erature does highlight the importance of self-care for pallia-tive care professionals in supporting their caring role. It isapparent, however, that self-care is discussed in the palliativecare literature more than it is researched, with most studiesfocused on strategies used to cope with burnout or other workrelated stressors rather than self-care strategies used to
Faculty of Nursing and Midwifery, The University of Sydney, New South Wales, Australia.Accepted December 19, 2016.
JOURNAL OF PALLIATIVE MEDICINEVolume 20, Number 6, 2017ª Mary Ann Liebert, Inc.DOI: 10.1089/jpm.2016.0470
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promote health and well-being. Key gaps in the palliativecare literature include a lack of evidence to inform self-carepractice and limited knowledge relating to the uptake of self-care practices such as the utilization of self-care plans. InAustralia, for example, therapeutic guidelines developed by apalliative care expert group6 highlight a need for palliativecare professionals to consider their own health needs; yetthere is scant research to support the specific self-care strat-egies recommended.
Given that the use of effective self-care strategies is man-dated in national quality and practice standards across multiplecountries,7–11 further research into palliative care profession-als’ self-care is warranted. Within the context of a broadermixed methods study, the objective of this study was to ex-amine perceptions, education, and practices relating to self-care among palliative care nursing and medical professionals.
Materials and Methods
Design and participants
This study was conducted in Australia using a cross-sectional survey design and administered through REDCap(Research Electronic Data Capture). REDCap is a secureweb-based application designed to support data capture forresearch studies.12
A brief questionnaire was developed from a review of therelevant literature and refined in response to feedback re-ceived from a small cohort of palliative care nurses anddoctors. From this process, a clear definition of self-care wasadded to the survey for respondents’ reference. No errors orfurther ambiguity was identified.
Participant invitations were sent to members of PalliativeCare Nurses Australia, the Australian and New ZealandSociety of Palliative Medicine, and to palliative care serviceswith contact details listed on Palliative Care Australia’snational service directory. Participants were eligible for thisstudy if they were a registered nursing or medical profes-sional practicing in Australia, with palliative care as theirmain area of practice. This study population was chosenbecause the nursing and medical health workforce representsa large majority of the palliative care workforce and unlikeother allied health professions in Australia are accessiblenationally through survey distribution from their respectivemember organizations.
Questionnaire
The questionnaire included 13 items relating to profes-sional role and sociodemographic variables, as well asparticipant perceptions, education, and practices relating toself-care. Most items were multiple choice questions allow-ing single answer responses, with subsequent questions pre-sented, where relevant, using the branching logic providedthrough REDCap. One open question was included to elicitfree text qualitative data describing specific self-care strate-gies most used by respondents. An electronic link to thesurvey was distributed to 609 eligible palliative care nursingand medical professionals in April 2015, through e-mail. Thesurvey remained open for a total of six weeks, with twofollow-up reminders sent during this period. While no in-centive to participate was provided, a number of consider-ations were factored into the survey design to help maximize
the survey response rate.13 These included the provision ofreminder e-mails, participant anonymity, and ensuring thesurvey was brief and easily accessible online for completionby participants at a time of convenience.
Data analysis
All survey data were collected and managed using RED-Cap electronic data capture tools hosted at the University ofSydney. Quantitative data were exported directly to IBMSPSS Statistics 22 for descriptive analysis of frequencies andpercentages. Qualitative data were exported into QSR NVivo10 for coding and content analysis.
Content analysis is a systematic method of describing andquantifying phenomena, as a means to distil words or phrasesinto representative categories based upon related content.14 Inthis way, qualitative content analysis was performed deduc-tively, drawing upon a recently published framework that de-lineates categories of physical self-care, inner self-care, andsocial self-care.15 This framework is consistent with the WorldHealth Organization’s definition of health,16 with each self-care domain corresponding to physical, mental, and socialwell-being, respectively. In addition, the inner self-care domainencompasses spiritual well-being and, therefore, includes but isnot confined to mental well-being. Thus, self-care strategies,including exercise activities or nutritional intake, were coded asphysical self-care; strategies involving relationships or inter-action with friends, family, or colleagues were coded as socialself-care; and strategies relating to psychological, emotional, orspiritual dimensions were coded as inner self-care. The analysiswas conducted to identify the use of self-care domains at anindividual level and across the sample as a whole.
Ethical considerations
Ethical approval for this study was received from theUniversity of Sydney Human Research Ethics Committee(2015/013). Detailed information about the study was pro-vided in recruitment e-mails to participants, as well as theinitial online page viewed before accessing the survey. Par-ticipation was voluntary and anonymous, with consent im-plied through commencement of the survey.
Results
A total of 372 palliative care nursing and medical profes-sionals completed the survey, giving a response rate of 61%.In addition, 11 incomplete responses were excluded fromanalysis. With respondents from all Australian States andTerritories, the overall demographic profile of the sample wasconsistent with recent palliative care workforce data and,therefore, considered representative of the palliative carenursing and medical workforce in Australia (totalling 3560based on 2014 data).17
Respondents from each profession were mostly female,and approximately two-thirds of all respondents were nurses.While most were based in metropolitan areas, the proportionof respondents working in full-time or part-time roles wasrelatively similar. The majority was aged over 50 and morethan half had worked in palliative care for more than a de-cade, with nearly one-third having worked in this specialtyfor 16 years or more. Detailed demographics and professionalrole characteristics are presented in Table 1.
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Participant responses to the self-care questionnaire aredetailed in Table 2. A majority of respondents consideredself-care to be very important for nurses and doctors workingin palliative care. While others thought it was important, onlya few considered self-care not important. The regularity ofrespondents’ self-care practice was mostly either frequent orintermittent; however, a considerable proportion rarely en-gaged in self-care strategies. Less than half of respondentshad received any workplace training or education about ef-fective self-care strategies.
The utilization of self-care plans was also low, with only6% of respondents reporting they used a self-care plan.However, of these, 100% reported that they found the use of aself-care plan to be an effective self-care strategy. Of thosenot using a self-care plan, 70% indicated they would considerdeveloping a self-care plan if they were supported to do sowith training.
A total of 1501 self-care strategies were reported by par-ticipants when asked to describe examples of self-carestrategies they used most, with self-care defined as ‘‘the self-initiated behavior that people choose to incorporate topromote good health and general well-being.’’3 Several re-sponses were not included as they were not entirely consistentwith this definition and did not correspond directly with theself-care framework used for content analysis. For example,without further contextual data, it was considered that re-sponses such as ‘‘watching television’’ or ‘‘providing directpatient care’’ did not directly correspond to the health related
domains of physical self-care, inner self-care, or social self-care. This was subsequently confirmed by advice receivedthrough electronic correspondence with the researchers whodeveloped this framework (Dr. Amparo Oliver, personalcommunication, September 19, 2016); therefore data such asthese were excluded from content analysis.
On average, respondents could identify 4 self-care strate-gies, and a total of 1476 were coded for analysis. Physicalself-care strategies were used most frequently, followed bysocial self-care and inner self-care strategies, although therewas a relatively even distribution across all three domains.These results were comparable between both professions androles. Examples of physical self-care strategies includedjogging, hydrotherapy, and yoga. Common social self-carestrategies included group debrief or clinical supervision withcolleagues and spending time with friends or family. Ex-amples of inner self-care strategies included meditation,mindfulness, and spiritual practice. See Table 3 for self-caredomain frequencies and percentages derived from the contentanalysis of all self-care strategies reported. At the individuallevel, 11% of respondents used only one self-care domain,while 89% used either two or three domains.
Table 1. Participant Demographics (N = 372)
Demographic/professional role n (%)
GenderFemale 306 (82)Male 66 (18)
Age group18–29 years 6 (2)30–39 years 62 (17)40–49 years 95 (25)50–59 years 154 (41)‡60 years 55 (15)
ProfessionPalliative care nurse 252 (68)Palliative care doctor 120 (32)
Main roleClinician 300 (81)Educator 44 (12)Manager 17 (4)Researcher 11 (3)
Work statusFull time 178 (48)Part time 194 (52)
Population focusAdult palliative care 341 (92)Pediatric palliative care 16 (4)Aged palliative care 15 (4)
Years worked in palliative care0–5 years 82 (22)6–10 years 96 (26)11–15 years 76 (20)‡16 years 118 (32)
Table 2. Characteristics of Participants’
Perceptions and Practice of Self-Care (N = 372)
Questionnaire n (%)
How important do you think self-care is for nursesand doctors working in palliative care?Not very important 4 (1)Important 50 (13)Very important 318 (86)
How regularly do you practice self-care strategies duringa working week?Rarely 41 (11)Intermittently 165 (44)Frequently 166 (45)
Have you received specific training/education or resourcesin your workplace about effective self-care strategies?No 226 (61)Yes 146 (39)
Do you use a self-care plan?No 349 (94)Yes 23 (6)
(Yes) Do you find it to be effective?No 0 (0)Yes 23 (100)
(No) Would you consider developing a self-care planif you were provided with training to do it?No 106 (30)Yes 243 (70)
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Figure 1 illustrates a word cloud generated from thequalitative survey data using the word frequency queryfunction within NVivo, as described by Glasper and Rees.18
While limited if used alone, visual representation throughword clouds has been shown to be an effective tool to in-crease comprehension of qualitative survey data when used tocomplement other qualitative analysis methods such ascontent analysis.19 This word cloud contains the 50 wordsmost commonly used by respondents when describing theirself-care strategies in the survey. The words vary in size andcolor density according to their frequency. ‘‘Time’’ was themost commonly used word (frequency = 145) and was relevantto the context of all self-care domains. Beyond this, the nextmost frequently used words were consistent with the contentanalysis ranging in frequency from the physical self-care do-main down to social and inner self-care domains: ‘‘exercise’’(124); ‘‘walking’’ (87); ‘‘family’’ (86); ‘‘friends’’ (80); ‘‘col-leagues’’ (75); ‘‘meditation’’ (63); and ‘‘reading’’ (55).
Discussion
This study examined the perceptions, education, andpractices relating to self-care among palliative care nursingand medical professionals in Australia. The study findingsaddress key gaps in the palliative care literature relating toprovision of self-care education, as well as the nature anduptake of self-care practices such as the use of self-care plans.While past research has largely focused on self-care as a wayof coping with occupational stressors, this study examinedself-care in the context of promoting health and well-being.
Perceptions within the palliative care workforce are con-sistent with discussion in the literature, with regard to theimportance of self-care. Although it had been argued thatself-care is important,20,21 there are now empirical data toshow that a majority of the workforce shares this position.With this knowledge, palliative care services should considerprioritizing resources to support self-care practice, especiallywith regard to training.
Adequate education and training are important for self-care.6 That only 39% of nurses and doctors had receivededucation about self-care is alarming. Especially given that inAustralia, since 2005, palliative care professionals have beenrequired to initiate and maintain effective self-care strategiesin accordance with Palliative Care Australia’s nationalquality standards.10 This professional expectation is sharedinternationally,7–11 yet many staff may not have received the
necessary training to do so. This finding supports other na-tional data suggesting that the provision of self-care educa-tion across palliative care services may be limited.22 Takentogether, they indicate that addressing self-care learningneeds is a priority. Given that self-care is a professional ex-pectation, equipping palliative care professionals with themeans to understand and engage in effective self-care prac-tices should be prioritized. Content and pedagogical ap-proaches to self-care training could be drawn from programsalready piloted. These have so far focused on mindfulness,poetry, clinical supervision, and other structured reflectivepractice.23–27 The broader development and provision of self-care education can usefully inform emerging palliative careworkforce development frameworks.28
The use of self-care plans has been promoted in the liter-ature for more than a decade,20,21 yet before this study noresearch had investigated the utility or uptake of self-careplans in the palliative care workforce. In the current study, allof the nurses and doctors who used a self-care plan reported itto be an effective self-care strategy. However, the uptake ofself-care planning was very low. Further qualitative researchcould usefully explore the context of this finding. This may berelated to the lack of self-care education reported, as a con-siderable majority of those not using a self-care plan indi-cated they would consider doing so if provided with trainingand resources. The reported lack of self-care planning mayalso relate to the infrequent nature of some participants’ self-care practice. That 11% of nurses and doctors rarely practiceself-care is a concern and suggests a need for education andfurther exploratory research.
As with a previous study of hospice professionals in NorthAmerica,29 the nurses and doctors in this study most fre-quently practised physical self-care. The use of physical self-care strategies such as engaging in regular physical activity,following dietary guidelines, and getting adequate sleep isconsistent with the healthy lifestyle behaviors observed in acohort study of Australian and New Zealand nurses andmidwives.30 While physical self-care was most common inthe current study, the self-care strategies described by re-spondents were spread relatively evenly across the domainsof physical, social, and inner self-care. This is consistent withother research15 that investigated these self-care domains in asample of Spanish palliative care professionals and indicatesthat a variety of strategies are important to self-care practicein palliative care. Thus palliative care professionals shouldconsider broadening their self-care practice where it is
FIG. 1. Word cloud from reported self-care strategies.
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currently limited to one self-care domain. The findings fromthis study also add empirical support to the palliative caretherapeutic guidelines’ recommendation for self-care prac-tice to encompass broad development areas such as educationand peer and professional support.6
Future research
From the results of this study, a number of areas for futureresearch become apparent.
First, further qualitative inquiry into the personal or pro-fessional contexts of infrequent self-care practice and lowuptake of self-care planning could assist educators and pal-liative care services in promoting effective self-care practice.Future research should also focus on the development andevaluation of innovative self-care education programs im-plemented by palliative care services. Studies could usefullycompare baseline knowledge and understanding of self-care instaff, as well as the uptake of self-care planning and regularityof self-care practice. While the current study explored the self-care strategies most used by participants, it would be useful forfuture research to examine the strategies reported as most ef-fective. Since strategies found to be most effective may notnecessarily be the most commonly utilized, the identificationof barriers and enablers to effective self-care practice is alsoimportant. This broader context of self-care practice could beinvestigated through in-depth exploration of relevant personaland professional factors.
It will also be important for future research to better un-derstand the subjective meaning of self-care, from the per-spective of those working in palliative care. In the currentstudy, nurses and doctors were provided with a definition ofself-care from the literature to guide their understanding inreporting the self-care strategies they used most. Despite this,a considerable proportion of responses reported the use ofself-care strategies that, without further context, did not ap-pear consistent with the promotion of an individual’s healthand well-being.
In the case of ‘‘watching television,’’ for example, longi-tudinal data from a large cohort study of female nurses haveshown that the sedentary nature of television watching isassociated with higher risk of becoming obese and develop-ing diabetes mellitus.31 A more recent meta-analysis oftelevision viewing data also identified a higher risk for car-diovascular disease and all-cause mortality.32 Ensuring thatpalliative care professionals understand effective self-carestrategies will be important if palliative care services are tosupport self-care practice and, thus, promote the provision forquality palliative care.
Strengths and limitations
To the best of the authors’ knowledge, this is the first studyof its kind to explore the perceptions, education, and practicesrelating to self-care among palliative care nursing and med-ical professionals. While this study has a number of strengths,it is somewhat limited by its self-report and cross-sectionalresearch design. There is also potential for nonresponse biaswithin the study population; however, this is mitigated tosome extent by the representative nature of the sample andresponse rate achieved.33
The survey response rate of 61% in this study is consideredsatisfactory.33 As a national survey, this response rate is rela-
tively high compared to past surveys of palliative care pro-fessionals in Australia. Doctors in particular have beenassociated with response rates of 29% and 35%, depending onthe survey methods and questionnaire content.34,35 The re-sponse rate in the current study may have been maximized by avariety of factors such as a high level of participant interest inthe survey subject matter or the survey design considerationsundertaken to achieve a satisfactory response rate. As no par-ticipation incentive was offered, it is likely that participants’intrinsic motivation influenced their completion of the survey.
Conclusion
Physical self-care strategies are most commonly used bypalliative care professionals among a variety of health relatedself-care practices. Most palliative care nurses and doctorsrecognize the importance of self-care and engage in effectiveself-care practice either frequently or intermittently.
However, a considerable proportion rarely engage in self-care, or do so only through one domain, and a majority have notreceived education or training in the use of effective self-carestrategies. The use of self-care plans is reported to be an effectiveself-care strategy; however, there is very low uptake amongpalliative care nurses and doctors. These limitations to self-carepractice should be addressed through targeted training and self-care education, as most indicated they would be receptive to this.
Given that self-care practice is a professional expectationin palliative care, requisite education is necessary to supporteffective self-care in the palliative care workforce. Suchinitiatives could promote greater understanding of self-care,awareness of domains, and uptake of self-care plans. Furtherresearch is needed to understand the broader context of self-care practice and to develop and evaluate the effectiveness ofself-care education programs.
The findings of this study can inform current practice andemerging palliative care workforce development frameworks.
Acknowledgments
J.M.’s PhD candidature is supported by an AustralianPostgraduate Award from the University of Sydney. Theauthors gratefully acknowledge all nurses and doctors fortheir participation in this study, as well as Palliative CareNurses Australia and the Australian and New Zealand So-ciety of Palliative Medicine for their generous support of thisresearch. The authors also thank the anonymous reviewersfor their valuable feedback.
Author Disclosure Statement
No competing financial interests exist.
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Examining self-care, self-compassion, and compassion for others
Published Article:
Mills, J., Wand, T., & Fraser, J. A. (2018). Examining self-care, self-compassion, and
compassion for others: A cross-sectional survey of palliative care nurses and doctors.
International Journal of Palliative Nursing, 24(1), 112-119.
Author Contributions:
JM, JF, and TW contributed to the conception and development of the study design. JM
drafted the initial questionnaire and refined it in response to feedback from JF and TW. JM
developed the REDCap survey and tested online functionality with input from JF and TW.
JM managed participant recruitment and administered the open and closing of survey
responses. JM performed data analysis with expert assistance from Faculty Biostatistician,
and under the guidance of JF. As the first named author, JM drafted and revised the
manuscript, with input from JF and TW.
6464
4 International Journal of Palliative Nursing 2018, Vol 24, No 1
AbstractThis study examined levels of, and relationships between, self-care ability, self-compassion, and compassion among palliative care nurses and doctors. Methods: A total of 369 participants across Australia completed a cross-sectional survey comprising a demographic questionnaire and outcome measures for each variable. Descriptive and inferential statistics were analysed, controlling for potential social-desirability bias. Results: Levels of compassion, self-compassion and self-care ability varied, with some individuals scoring high or low in each. Self-compassion and self-care ability were positively correlated (r = .412, p<.001), whereas a negative correlation was observed between compassion and self-compassion (r = -.122, p<.05). Linear regression further indicated that: increased compassion was associated with a decrease in self-compassion, and increased self-care ability was associated with an increase in self-compassion. Conclusion: These results suggest important implications for self-care in the palliative care workforce. Moreover, this study contributes an empirical basis to inform future research and education to promote balanced compassion and compassion literacy in palliative care practice.Key words: l Compassion l Compassion literacy l Palliative care l Self care l Self-compassion l Survey
This article has been subject to double-blind peer review
Compassion is considered the essence of palliative care (Larkin, 2015). To sup-port this compassionate care, self-care
for palliative care professionals is also viewed as essential. Despite their importance, however, there is little evidence to inform self-care strate-gies or enhance compassionate care in palliative care practice. Research to-date has primarily focused on a coping paradigm, and constructs of burnout or compassion fatigue, rather than a positive paradigm that examines compassion itself (Mills et al, 2017a).
Balanced compassion was identified as a key theme in a recent review of the palliative care literature, proposing the relevance of a positive psychology approach to research into self-care and compassion (Mills et al, 2017a). In this context, compassion and self-compassion represent positive emotions that contribute to psychological flexibility and emotional resilience to support one’s own health and wellbeing as well as that of others (Neff et al, 2007; Cassel, 2009; Neff and Tirch, 2013; Seppala et al, 2013; Stellar and Keltner, 2014; Tugade et al, 2014; Kemper et al, 2015; Warren et al, 2016). This approach is informed by Fredrickson’s (2001) seminal broaden-and-build theory of positive emotions, as well as Seligman’s (2008; 2012) work on positive
health and flourishing. While many definitions exist, compassion can be understood as a positive emotion involved in the recognition of—and therapeutic response to—others’ needs and suffering (Cassel, 2009; Stellar and Keltner, 2014). Thus compassion, according to Perez-Bret et al (2016), is intrinsic to the daily clinical practice of health-care professionals. Compassion is most commonly understood in the context of feeling compassion for others; however, the practice of self-compassion is less familiar.
Self-compassion involves directing this same compassion inwards to oneself with self-kindness, and it is therefore commonly discussed as important to self-care (Mills et al, 2015). Self-care involves a variety of strategies to promote one’s own health and holistic wellbeing and ensure that personal needs are not neglected while caring for others (Mills and Chapman, 2016). Research has shown that palliative care professionals consider self-care very important to their practice, and this importance is reflected internationally within professional and quality standards for palliative care practice (Mills et al, 2017a; 2017b). In countries such as Australia, palliative care professionals have, for more than a decade, practised under national quality standards requiring that they initiate and
Research
Jason Mills, Timothy Wand and Jennifer A Fraser
Jason Mills,Registered Nurse; Lecturer/Unit Coordinator, School of Nursing, Faculty of Health, Queensland University of Technology, Queensland, Australia
Timothy Wand,Nurse Practitioner; Registered Nurse;Associate Professor,Faculty of Nursing and Midwifery, the University of Sydney, New South Wales, Australia
Jennifer A Fraser,Registered Nurse; Associate Professor, Faculty of Nursing and Midwifery, the University of Sydney, New South Wales, Australia
Examining self-care, self-compassion and compassion for others:
a cross-sectional survey of palliative care nurses and doctors
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maintain effective self-care strategies as part of their palliative care practice (Palliative Care Australia, 2005). However, only a minority of this workforce reports having received self-care education or training, and research has yet to investigate palliative care professionals’ ability to implement and maintain effective self-care strategies (Mills et al, 2017b).
In the same way that theoretical links between self-compassion and self-care are discussed in the literature, it is also argued that self-compassion is associated with compassion for others; however, supporting evidence is limited (Mills et al, 2017a). Given their importance, there is surprisingly little research to inform palliative care professionals’ understanding of self-care or compassion in practice. To address these gaps in the literature, and as part of a broader mixed-methods study, this research aimed to examine relationships between self-care ability, self-compassion and compassion for others. Specifically, the present study addressed the following research questions:
●What levels of self-compassion, self-care abilityand compassion for others are reported bypalliative care nurses and doctors? ●What is the relationship between self-compassion and self-care ability? ●What is the relationship between self-compassion and compassion for others?
MethodsEthical approval was first obtained from the relevant human research ethics committee. As part of a cross-sectional survey design, a 28-item questionnaire was administered over a 6-week period, using Research Electronic Data Capture (REDCap) software. REDCap is increasingly used internationally as a secure, web-based survey platform, designed to support data collection in academic research (Harris et al, 2009).
MeasuresCompassion and self-compassion were measured using validated self-report instruments available in short form. A validated measure of social desirability was also administered to control for social desirability bias. These measures are discussed below.
CompassionConsistent with similar research in other populations (Neff and Pommier, 2013), compassion was measured using the Santa Clara Brief Compassion Scale (SC-BCS) (Hwang et al, 2008). In this study, participants were scored from zero (not at all true of me) to five (very true
of me) in responses to item questions such as: ‘When I hear about someone going through a difficult time, I feel a great deal of compassion for him or her.’ This scale has shown sound psychometric properties over time as a valid and reliable measure of compassion (Plante and Mejia, 2016).
Self-compassionSelf-compassion was measured using the Self-Compassion Scale-Short Form (SCS-SF) (Raes et al, 2011). This 12-item Likert scale was developed as a brief version of the widely used 26-item Self-Compassion Scale, which has been shown to be a valid and reliable measure of self-compassion (Neff, 2003; 2016). Participants are scored from zero (almost never) to five (almost always) in responses to item questions such as: ‘When I’m going through a very hard time, I give myself the caring and tenderness I need.’ Within this scale, self-compassion is operationalised as a six-factor structure: (1) self-kindness, (2) mindfulness, (3) common humanity, (4) self-judgement, (5) isolation and (6) over-identification. Self-judgement, isolation, andover-identification subscale items are reverse-scored and then combined with the othersubscale scores to measure a total self-compassion score. The SCS-SF has a strongcorrelation with the longer form scale and hasdemonstrated sound psychometric propertieswhen measuring a total self-compassion score(Raes et al, 2011).
Self-care abilityGiven the absence of any validated measure of self-care ability at the time of this study, respondents were provided with a definition of self-care from the literature (Mills et al, 2017a) and asked to rate their ability to implement and maintain effective self-care strategies via sliding visual analogue scale (VAS). This metric was administered as a customised survey tool in REDCap, ranging from zero (not able) to one hundred (fully able), with ‘somewhat’ midway between. A numeric value was visible to respondents as they moved the slider bar across a horizontal axis. This was not intended to measure self-care ability as a construct, but rather to quantify individual self-care ability as perceived by respondents.
The wording of the VAS prompt ‘Rate your ability to initiate and maintain effective self-care strategies’ was developed and refined in response to feedback received from a small cohort of palliative care nurses and doctors prior to finalising the survey. As this wording mapped directly to
❛Compassion isintrinsic to thedaily clinicalpractice ofhealth careprofessionals❜
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Standard 13 of Palliative Care Australia’s (2005) quality standards, requiring an ability to initiate and maintain effective self-care strategies, this approach was viewed as an appropriate way to investigate self-care ability in this study.
Social desirabilityAlthough the provision of anonymity in this survey represents a key strategy to minimise socially desirable responding, a short form of the seminal Marlowe-Crowne Social Desirability Scale (MC-SDS-SF) (Strahan and Gerbasi, 1972) was also used as a control measure. This is consistent both with recommendations made in the literature (van de Mortel, 2008) and other research using the same scale to examine compassion and self-compassion in other populations (Neff and Pommier, 2013). This 10-item dichotomous scale has demonstratedgood psychometric properties (Fischer and Fick,1993) and comprises ‘true’ or ‘false’ responsestatements, such as ‘I have never been irked whenpeople expressed ideas very different from myown.’ Socially desirable response scores rangefrom zero–ten for each participant.
Participants and procedurePalliative care nurses and doctors practicing in Australia were eligible to participate in this study. A total of 609 participant invitations were sent to members of Palliative Care Nurses Australia and the Australian and New Zealand Society of Palliative Medicine, as well as palliative care services with contact details listed on Palliative Care Australia’s national service directory. The survey link remained open for a period of 6 weeks, with two follow-up reminders sent. Detailed information about the research was provided in the recruitment email, in addition to the initial page viewed prior to accessing the study survey. Participants were informed that responses were voluntary and would remain anonymous, with participant consent implied through completion of the survey.
A total of 369 usable survey responses were received and included for analysis in the present study (60% response rate). All survey data were collected and managed using the REDCap survey platform. These data were exported directly from REDCap to IBM SPSS Statistics version 22 for descriptive and inferential statistical analysis. An SPSS missing values analysis indicated that data imputation was not required, as missing data were minimal (less than 5%), thus list-wise deletion of cases was employed during statistical testing. All relevant assumptions were met for statistical tests undertaken. Confidence intervals
were set at .95, and tests of significance were two-tailed with p values (probability) <.05 considered statistically significant.
ResultsThe sample comprised 67% palliative care nurses and 33% palliative care doctors across each state and territory in Australia. Most participants were female (82%), worked as clinicians (81%) and were based in metropolitan areas (68%), compared with those in regional (29%) or remote (3%) areas of Australia. Participants came from the following age groups: 60+ years (15%), 50–59 years (41%), 40–49 years (25%), 30–39 years (17%) and 18–29 (2%). Over half of the sample had been working in palliative care for more than a decade, and approximately one third had worked in this specialty for 16 years or more.
The SC-BCS and SCS-SF were found to be reliable measures of compassion and self-compassion in the present study. Internal reliability as measured by Cronbach’s Alpha was .86 and .85 respectively. Table 1 reports descriptive statistics for study variables, including self-compassion sub-scales.
Based on past research, in which gender was observed as a main effect on compassion and self-compassion in the general community, an independent samples T-Test was performed for comparison in this study sample. While the difference in self-compassion between males (mean (M) = 3.39, standard deviation (SD) = .64) and females (M = 3.23, SD = .63) was marginally significant (p = .054), the difference in compassion between males (M = 3.67, SD = .64) and females (M = 3.81, SD = .72) was far from statistically significant (p = .2).
Next, Pearson’s r coefficients were calculated to examine associations between compassion and self-compassion, and between self-compassion and self-care ability. Partial correlations controlling for social desirability are shown in Table 2. A significant positive association was observed between self-compassion and self-care ability in females (r = .387, p = <.001), males (r = .499, p = <.001) and the sample as a whole (r = .412, p = <.001).
A significant negative association was found between compassion and self-compassion in females (r = -.158, p = <.05) and the sample as a whole (r = -.122, p = .019).
A hierarchical linear regression analysis was then conducted to further examine the relationship between self-compassion as a dependent variable and self-care ability and compassion for others as independent variables. Based on past research, social desirability and
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gender were entered consecutively into the first two steps of the model to control for any effect of these variables. Self-care ability and compassion for others were then entered separately in the third and fourth steps of the model respectively. Table 3 shows the four steps in this model, indicating that as self-care ability increased, self-compassion also increased, and as compassion for others increased, there was a decrease in self-compassion.
Lastly, exploratory factor analysis (EFA) was conducted to better understand the compassion data in relation to self-compassion data. Although EFA is commonly used to guide development of psychometric scales, here it was employed in a descriptive manner to explore underlying dimensions of these data by observing where they cluster together across multiple dimensions. This method is particularly useful in illustrating individual participant placement across multiple factors (Hershberger, 2005). First, all scale items from the SCS-SF and SCBCS were loaded for EFA. This initial analysis resulted in a three-factor structure. A two-factor structure was then specified using maximum likelihood extraction and varimax rotation methods. From this analysis, all scale item data from the SCS-SF loaded onto Factor 1, and all scale item data from the SCBCS loaded onto Factor 2, indicating that these data had clustered together.
Factor 1 was interpreted as ‘Compassion for self ’, and Factor 2 was interpreted as ‘Compassion for others’. As outlined by Grice (2001), value loadings from both factors were then computed as Anderson-Rubin scores, and these were saved as a new variable in SPSS to allow for descriptive analysis of both factors as a standardised composite (M = 0, SD = 1). These data are illustrated in Figure 1 (scatter plot) by gender, with Factor 1 on the horizontal axis, and
Factor 2 on the vertical axis. Cross-tabulation indicated that 23% of females and 28% of males scored positive on both Factor 1 and Factor 2. In total, 29% of females and 20% of males scored negative on Factor 1, but positive on Factor 2.26% of females and 22% of males scored negative on both Factor 1 and Factor 2.
Table 2. Partial correlations between self-compassion, self- care ability and compassion for others (controlling for social desirability)
Sample Females Males
Self-care ability .412** .387** .499**
Compassion for Others -.122* -.158* .126***
* p = < .05 ** p = < .001 (two-tailed) *** p = .32
Note: P value relates to statistical significance
Table 3. Hierarchical linear regression modelSelf-compassion b SE b 95% CI ß ΔR2
Step 1 .032***
Social desirability .059 .017 .026, .092 .186***
Step 2 .046*
Social desirability .067 .017 .033, .100 .210***
Gender .214 .087 .044, .385 .132*
Step 3 .204***
Social desirability .048 .016 .017, .079 .152***
Gender .186 .079 .030, .342 .115
Self-care ability .013 .002 .010, .017 .403***
Step 4 .211*
Social desirability .051 .016 .020, .082 160***
Gender .178 .079 .023, .334 .110*
Self-care ability .013 .002 .010, .016 .400***
Compassion for
others
-.085 .043 -.171, .000 -.095*
Note: Gender is coded 0 = females and 1= males; * p ≤ .05; ** p ≤ .005; *** p ≤ .001;
R2 = .220; b = unstandardised beta; SE b = standard error for unstandardised beta; CI = confidence intervals; β = standardised beta; ΔR2 = adjusted R-squared
Table 1. Descriptive statistics for study variables and subscalesSample Females Males
Variable M (SD) Min Max M (SD) Min Max M (SD) Min Max
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DiscussionThis study aimed to examine levels of—and associations between—self-care ability, self-compassion and compassion for others. While these variables are increasingly discussed in nursing and medicine generally (Mills et al, 2015; Mills and Chapman, 2016), to the authors’ knowledge this is the first study to examine them together in the palliative care workforce.
These findings provide new insight into palliative care nurses’ and doctors’ perceived ability to implement and maintain effective self-care strategies. The importance of self-care is explicit in international palliative care practice standards, yet understanding of the complexities of self-care ability is, to-date, limited. While nurses and doctors in this study rated their abil ity reasonably high on average, a considerable number reported very low levels of self-care ability. This finding may have been influenced by a lack of self-care education and training, and it supports a recommendation for more educational initiatives to support self-care practice (Mills et al, 2017b).
Given the l imited understanding of compassion in health care, this study has extended empirical knowledge of compassion
beyond the coping paradigm of compassion fatigue and compassion satisfaction commonly found in the literature. Through the lens of positive psychology, it has identified varying levels of compassion and self-compassion as positive emotions reported by palliative care nurses and doctors. This line of inquiry is highly valuable to self-care, as these positive emotions form part of a foundation for emotional resilience, health and wellbeing (Fredrickson, 1998; Seligman, 2008; Seppala et al, 2013; Stellar and Keltner, 2014; Tugade et al, 2014; Kemper et al, 2015; Warren et al, 2016).
While concerns have been raised in the literature that compassion is lacking, findings from this study suggest that palliative care nurses and doctors have generally higher levels of compassion and self-compassion than other populations, such as undergraduate students or the general community (Neff and Pommier, 2013). This is perhaps not surprising, given these nurses and doctors work in a profession where compassionate care is essential. Nevertheless, in light of the discourse on coping with compassion fatigue and burnout, this finding is, on the whole, encouraging.
However, it must be noted that these levels varied at the individual level, as indicated by EFA and corresponding Anderson-Rubin scores, with some respondents scoring low in either compassion, self-compassion, or both. This finding suggests that nurses, doctors and pall iative care services should not be complacent in viewing compassion as a constant that does not require considered and ongoing attention. Although some argue that compassion cannot be taught, there is increasing evidence that it can be cultivated, and those low in compassion and/or self-compassion may therefore benefit from training to cultivate compassion (Mills et al, 2015; Mills and Chapman, 2016). The need for compassion training in health-care professionals has also been voiced by patients (Sinclair et al, 2016).
This study provides preliminary evidence to support the theoretical discussion in the literature regarding a positive relationship between self-compassion and self-care. This knowledge can support self-care planning and practice as well as informing training or education initiatives. However, further research incorporating a validated self-care scale is needed to build from this initial evidence-base. That self-compassion was negatively associated with compassion was somewhat surprising. In contrast, significant positive associations have been observed in samples of the general community and
Figure 1. Scatter plot of individual Anderson-Rubin (A-R) factor scores
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FemaleMale
A-R Score for Factor 1: Compassion for self
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-2.00000 -1.00000 1.00000 2.00000 3.00000.00000
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meditators (Neff and Pommier, 2013). This finding might be explained by clinical or environmental barriers to compassion in practice, or other factors unique to a health-care provider context (Fernando and Consedine, 2017). While compassion for others is a social and professional expectation, the expression of compassion for oneself is subject to a stigma of being selfish (Mills et al, 2015). Moreover, specific education or training in compassion is largely absent in nursing, medicine and palliative care curricula (Mills et al, 2015; Mills and Chapman, 2016; Mills et al, 2017a).
These results are suggestive of limited compassion literacy. As described by Burridge et al (2017), compassion literacy is characterised by an understanding that self-care is not selfish, as well as an ability to balance compassion for patients with compassion for oneself . Interestingly, both orientations of compassion can be subject to fear. That is, for some people, feelings of compassion for others may be inhibited due to fear of being taken advantage of, or perceived as weak. Similarly, feelings of compassion for oneself can be inhibited due to performance-related fears of underachievement (Jazaieri et al, 2013). The development of compassion l i teracy in pall iat ive care professionals may therefore be critical to provide an understanding of balanced compassion, as well as the ability to enact this in the context of p rac t i s ing s e l f - ca re wh i l e p rov id ing compassionate care for patients.
This study highlights several other avenues for future research. As identified in a recent systematic review (Hill et al, 2016), there is an urgent need for targeted psychosocial interventions to improve the wellbeing of pal l ia t ive care profess ionals . Further interventional research into the role of positive emotions in this context is therefore recommended. Future research could usefully draw upon Fredrickson’s (2001) broaden-and-build theory of positive emotions to establish a sound theoretical base for compassion literacy.
A growing body of literature suggests potential benefit in the use of psychological interventions, such as loving-kindness meditation and compassion training, to cultivate positive emotions and benefit health and wellbeing in both community and health professional populations (Hofmann et al, 2011; Boellinghaus et al, 2014). Consistent with the broaden-and-build theory of positive emotions, loving-kindness meditation results in increased positive emotions and personal resources that predict increased life satisfaction and reduced depressive
symptoms (Fredrickson et al, 2008). It has been identified as an effective approach to enhance compassion, self-compassion and self-care in trainee psychotherapists (Boellinghaus et al, 2013). Loving-kindness meditation has also produced improvements in compassion, self-compassion and wellbeing in a range of health professionals, with research positing it to be a practical and viable tool to promote resilience and the quality of patient care (Seppala et al, 2014; Rao and Kemper, 2017).
An alternative to this is compassion training, with several formal protocols developed and found to enhance compassion, self-compassion and self-care in the general community. These include the Compassion Cultivation Training programme developed at Stanford University (Jazaieri et al, 2013), Neff and Germer’s (2013) Mindful Self-compassion Program and the Cognitively-based Compassion Training programme developed at Emory University (Ozawa-de Silva et al, 2012). In health care workers, there is growing evidence that programmes such as these can enhance compassion and resilience, and may be helpful in improving patient care and preventing burnout (Mascaro et al, 2016; Scarlet et al, 2017).
Other emerging approaches can also be found in the nursing literature. For example, the novel use of a ‘clinical compassion café’ has been reported to improve compassion literacy in nurses (Winch et al, 2014), and online learning modules have also been developed to teach compassionate care to nursing students (Hofmeyer et al, 2017). Surprisingly, none of the above approaches appear to have been used in palliative care research to date. Taken together, there appears sufficient evidence to warrant investigation of these approaches in a palliative care workforce context. Specifically, research should examine the role of compassion literacy in the context of compassionate care for patients as well as self-care. Future studies could also extend knowledge of self-care ability through qualitative designs to explore barriers and enablers to effective self-care.
LimitationsLimitations to this study are acknowledged. A cross-sectional design provides a snapshot, but does not address variability over time. Also, self-report instruments can be prone to participant response bias. This potential bias was addressed through provision of participant anonymity and use of a control measure. Notwithstanding these limitations, this study serves to advance knowledge and inform future research in an area of significance to palliative care practice.
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ConclusionTo the authors’ knowledge this is the first published study to examine compassion, self-compassion and self-care together in palliative care nurses and doctors. These results suggest that the promotion of individual compassion literacy within palliative care teams may be important to self-care practice and support compassionate care for patients. Moreover, they contribute an empirical basis to inform future research and education to promote compassion literacy in the palliative care workforce. Given the international focus on promoting compassion in practice, this new knowledge can serve to maintain the imperative of compassion as the essence of palliative care.
Declaration of interests:
The authors declare that no conflicts of interest exist.
Acknowledgements:
The authors gratefully acknowledge the palliative care
nurses and doctors who participated in this study. Thanks
also go to Judith Fethney, Biostatistician at the University
of Sydney, for assistance with data analysis.
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Continuing professional development: reflective questions l How would you rate your current ability for self-care practice?
l How would you rate your current level of compassion for others?
l How self-compassionate are you? Dr Kristin Neff’s full self-compassion scale is available online at
https://tinyurl.com/ky9bx5x
Key pointsl Levels of self-care ability, self-compassion, and
compassion for others varied greatly, with some
individuals scoring quite low or very high
l Self-care ability was linked to higher levels of self-
compassion
l Compassion for others was associated with lower
levels of self-compassion, suggesting limited compassion
literacy
l Compassion literacy involves a healthy balance of
compassion for others with compassion for oneself;
these findings suggest that some palliative care nurses
may benefit from compassion cultivation training to
support self-care and compassionate care for patients
and their families●IJPN
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Call for papersIs there a subject you would like to see covered in the International Journal of Palliative Nursing?
The journal invites submissions on all aspects of palliative nursing care. We would particularly welcome reviews of clinical management issues, non-cancer diagnoses, and commentary or discussion pieces.
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Chapter Conclusion
This chapter has presented results from the quantitative strand of the study, as published in
the Journal of Palliative Medicine and the International Journal of Palliative Nursing.
Chapter five will present findings from the qualitative strand of the study.
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CHAPTER 5
QUALITATIVE STRAND FINDINGS
Chapter Introduction
The purpose of this chapter is to report findings from the qualitative strand of the study. The
chapter presents an accepted journal article in press at BMC Palliative Care. This paper was
formatted and referenced according to the requirements of this journal. Bibliographic details
for this accepted article, in press, are below.
Exploring the meaning and practice of self-care
Mills, J., Wand, T., & Fraser, J. A. (2018). Exploring the meaning and practice of self-care
among palliative care professionals: A qualitative study. BMC Palliative Care
(In Press).
Author Contributions:
JM and JF contributed to the initial conception and design of the study, whilst TW
contributed to its refinement and finalisation. JM recruited participants, conducted the data
collection, data management, and qualitative content analysis with guidance from JF and TW.
As the corresponding author, JM drafted and revised the manuscript with important input
from JF and TW.
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ABSTRACT
Background: Self-care practice within the palliative care workforce is often discussed,
yet seemingly under-researched. While palliative care professionals are required to
implement and maintain effective self-care strategies, there appears little evidence to guide
them. Moreover, there is an apparent need to clarify the meaning of self-care in palliative
care practice. This paper reports qualitative findings within the context of a broader mixed-
methods study. The aim of the present study was to explore the meaning and practice of self-
care as described by palliative care nurses and doctors.
Methods: A purposive sample of twenty-four palliative care nurses and doctors across
Australia participated in semi-structured, in-depth interviews. Interviews were digitally
recorded and transcribed prior to inductive qualitative content analysis, supported by QSR
NVivo data management software.
Results: Three overarching themes emerged from the analysis: (1) A proactive and
holistic approach to promoting personal health and wellbeing to support professional care of
others; (2) Personalised self-care strategies within professional and non-professional
contexts; and (3) Barriers and enablers to self-care practice.
Conclusions: The findings of this study provide a detailed account of the context and
complexity of effective self-care practice previously lacking in the literature. Self-care is a
proactive, holistic, and personalised approach to the promotion of health and wellbeing
through a variety of strategies, in both personal and professional settings, to enhance capacity
for compassionate care of patients and their families. This research adds an important
qualitative perspective and serves to advance knowledge of both the context and effective
practice of self-care in the palliative care workforce.
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BACKGROUND The concept of relentless self-care is well known to those in the field of palliative social work
[1]. Interest in self-care is growing within the nursing and medical disciplines [2, 3], and its
importance to all palliative care professionals is evident internationally through a suite of
quality standards, core competencies, and practice standards in which self-care practice is
mandated [4-10]. But what does self-care mean?
Self-care is broadly defined by Sherman [11] as ‘the self-initiated behaviour that
people choose to incorporate to promote good health and general well-being’. Despite this
health-promoting emphasis on good health and wellbeing, the palliative care literature
focuses largely on coping strategies in the context of occupational stressors such as burnout
or compassion fatigue [12]. Clearly, management of stress is very important; however, there
are other important aspects of promoting good health and wellbeing that extend beyond the
scope of coping with stress. In many cases there also appears to be conflation between the
terms coping strategy and self-care strategy. Further confusion about the meaning of self-care
was highlighted in an Australian survey of palliative care professionals [13]. Beyond
academic definitions, there is a need to understand and articulate the meaning of self-care in a
palliative care practice context. Given that some palliative care professionals have reported
low levels of self-care ability, there is also an urgent need to explore barriers and enablers to
self-care, and identify examples of effective self-care strategies used in practice. In reviewing
the literature [12], significant gaps are apparent in the current evidence base for self-care
practice and education.
To advance knowledge in these areas, this study aimed to explore the meaning and
practice of self-care as described by palliative care nurses and doctors. Specifically, the
following research questions were addressed:
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1. What it is the meaning of self-care, as described by palliative care nurses and
doctors?
2. How do palliative care nurses and doctors describe effective self-care practice? METHODS Research Design
Given the nature of the research questions, a qualitative research design was employed [14].
An interview guide (see Table 1) was developed to address the study aim in consideration of
gaps identified from the literature. The initial guide was refined in response to feedback
received from a small group of palliative care professionals not involved in this study. Open
questions were used to elicit deeper exploration of meaning and experience within a flexible
yet focused discussion about participants’ self-care practice [15].
Table 1. Interview Guide
• In the context of palliative care practice, what does self-care mean to you?
• From your experience, how would you describe effective self-care practice?
• Tell me about the self-care strategies you find to be most effective
• What supports your self-care practice?
• What, if anything, gets in the way of your self-care practice?
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A purposive sample was recruited into this qualitative research from a pool of palliative care
nurses and doctors who had completed a self-care survey as part of a broader mixed-methods
study [13]. Consistent with the purpose of obtaining relevant and rich data from an
appropriate source, eligible participants were nurses and doctors practising in Australia with
palliative care as their main area of practice. Informed written consent was obtained from all
participants through initial email contact prior to being interviewed via telephone. A total of
24 semi-structured, in-depth interviews were conducted over a six-month period in 2015,
with recruitment ending once data saturation was reached. That is, when the collection of
additional data served only to repeat existing rather than generate new content, as identified
from the use of field notes and iterative analysis. The first author, an experienced qualitative
researcher, conducted all interviews and recorded field notes to support a process of iterative
analysis throughout the data collection period. The average duration of interviews was
approximately 50 minutes, with audio content digitally recorded, transcribed verbatim, and
de-identified. Gender-appropriate pseudonyms were randomly allocated to each respondent.
Data Analysis
Interview transcripts were initially read and re-read to make note of key words and phrases
before importing them into QSR NVivo 11 data management software for open coding and
qualitative content analysis. Qualitative content analysis is a widely used method for
interpreting the content of textual data through a process of systematic classification, coding,
and identification of patterns or themes [16]. As recommended by Graneheim and Lundman
[17], a number of decisions were made to guide content analysis and ensure trustworthiness.
First, it was decided that a conventional approach to content analysis would be adopted
[16]. That is to say, the analysis was inductive and focused on latent content, or words and
sentences that required an interpretation of underlying meaning. Second, whole participant
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interviews were discerned to be the most appropriate unit of analysis in terms of providing a
context for meaning units during the analytical process [17]. Finally, it was decided that these
meaning units would comprise interrelated words, sentences and paragraphs from interview
transcripts. In this way, interview data were analysed inductively through the generation of
codes, grouping and collapsing of codes into common categories, and subsequent abstraction
to identify overall themes that represent the raw data in an aggregated form [18, 19]. Figure 1
outlines the thematic coding and category content generated from the content analysis.
Sample
The sample of 24 participants comprised 12 nurses and 12 doctors working in community,
inpatient, or consult palliative care services located in both metropolitan and regional/rural
settings across six of the eight States and Territories in Australia. These were clinical nurse
specialists, nurse educators, clinical nurse consultants, nurse practitioners, nurse unit
managers, senior medical officers, consultant physicians, and heads of department. They had
an average of 15 years’ experience working in either adult, aged, or paediatric palliative care
settings. Most were female, aged between 40 and 49, and worked in full-time roles. See Table
2 for detailed participant demographics.
RESULTS Three overarching themes emerged from the analysis in relation to the meaning and practice
of self-care: (1) A proactive and holistic approach to promoting personal health and
wellbeing to support professional care of others; (2) Personalised self-care strategies within
professional and non-professional contexts; and (3) Barriers and enablers to self-care
practice. Figure 2 illustrates these themes as the meaning and practice of self-care. Thematic
data from these themes are reported in Tables 3, 4, and 5, in the form of participant
quotations to ensure trustworthiness [20].
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Demographic n (%)
Gender
Female 15 (63)
Male 9 (37)
Age Group
30-39 years 4 (17)
40-49 years 11 (46)
50-59 years 7 (29)
≥ 60 years 2 (8)
Population Focus
Adult Palliative Care 19 (79)
Paediatric Palliative Care 2 (8)
Aged Palliative Care 3 (13)
Work Status
Full-time 14 (58)
Part-time 10 (42) Years Worked in Palliative Care
1-5 years 1 (4)
6-10 years 3 (13)
11-15 years 12 (50)
≥ 16 years 8 (33)
Table 2. Participant Demographics and Professional Characteristics (N = 24)
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Figure 1. Coding Categories and Thematic Content
• Meaning• Relational context• Balancing care for others with care for self• Promotion of health and wellbeing• More than just a tick-box checklist
A proactive and holistic approach to promoting personal health and wellbeing to support professional care of others
• Self-care strategies used inside the workplace setting• Reflective practice• Accessing other staff support• Boundaries• Regulation of workload• Work-life harmony• Team-care/healthy team• Laughter and use of humour
• Self-care strategies used outside the workplace setting• Separating work from home• Meditation• Spiritual practice• Positive social relationships• Rest and relaxation• Preventative health behaviours• Accessing support from health care professionals
• Shared responsibility• Individual self-care practice• Staff support from employer
• Self-care as a personalised and ongoing practice• Practised according to the individual and context• Ongoing nature
A range of personalised self-care strategies within professional and non-professional contexts
• Facilitators of self-care• Recognising importance of self-care• Planning and prioritising self-care in a preventative approach• Self-awareness• Supportive work culture and leadership• Leadership/role models to normalise self-care• Positive emotions and relationships• Character strengths
• Impediments to self-care• Unsupportive work culture and environment• Stigma• Busyness• Lack of planning/prioritising self-care• Inadequate boundaries between work and home• Self-criticism and low self-worth
Barriers and enablers to self-care practice
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Theme 1: A proactive and holistic approach to promoting personal health and wellbeing
to support professional care of others
The meaning of self-care was described in terms of its positive relational context with self
and others. Although self-care was focused primarily on individual needs, it was informed by
the broader clinical context of capacity to engage in positive and therapeutic relationships to
provide patient care. Self-care meant fulfilling a fundamental part of palliative care practice,
with one participant commenting that self-care is intrinsic to the work itself.
Self-care also meant balancing care for others with care for self, with the promotion
of personal health and wellbeing central to its meaning. Self-care was described as a
conscious and deliberate practice that meant much more than just a ‘tick-box’ checklist to be
completed within a set of allocated tasks.
Table 3. Theme 1
A proactive and holistic approach to promoting personal health and wellbeing to support professional care of others
Prudence Gwendolen Darrell Felicity Patrick Merilyn Winston Prudence Mason
Through self-care, what we are doing is developing a relationship with ourselves – which actually supports us in developing relationships with everybody else. Self-care - it’s looking after me to look after patients, so to speak; if I’m not of a good healthy physical state or emotional state, I’m hardly likely to be able to support someone. You can’t look after dying patients without looking after yourself, really, can you? And do a good job of that, in a compassionate way? Balancing care for yourself and others is essential. It’s part of a holistic approach… if you’re not caring for yourself then you’re less able to care for others. [It’s about] maintaining a good balance between body and mind… being able to stay fit and healthy. You look after your own health so that you can deliver patient-centred care. That’s what self-care is; it’s a way of living, it’s a way of living every moment. The thing is, [self-care] is not a tick-box commodity.
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Figure 2. The meaning and practice of self-care
Theme 2: Personalised self-care strategies within professional and non-professional
contexts
Effective self-care practice was described as a personalised and ongoing endeavour. In the
words of one participant, it’s a constant work in progress. Participant descriptions of
effective self-care practices were consistently characterised by a variety of self-care strategies
that were maintained both within, and external to, workplace settings.
Self-care in Personal Settings. Effective self-care strategies used outside of the
workplace settings included a range of health behaviours, meditation and spiritual practice. A
healthy diet, adequate sleep, and moderation of alcohol intake were considered important. In
addition to exercising for fitness, other physical activities such as yoga and massage were
found to be effective self-care strategies. Rest and relaxation at home in a bath were
described as effective self-care strategies when feeling overwhelmed or needing to wash
away (metaphorically) thoughts of the workplace. Socialising and maintaining positive
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relationships with friends and family was both supportive and meaningful. Meditation
practice was also an effective self-care used within both personal and professional contexts.
A variety of meditation practices were used by participants, including loving kindness
meditation. Spiritual practice was also considered an effective self-care strategy.
Finding harmony between personal and professional roles was consistently described
as an effective self-care strategy. Some described this harmony in terms of work-life balance.
Interestingly, others found the concept of work-life balance to be problematic in practice.
Given the elusive nature and individual context of what constitutes a balance between work
and life, most considered it more important to acknowledge that different life-domains
require varying degrees of attention at any given time; and that finding individual harmony
between personal and professional roles was a key strategy towards flourishing in life. One
participant explained:
It’s never like you’ve got this nice balance - where work finishes, then
you’ve got an hour to sort of wind down before the rest of life begins…
[it’s more about] just trying to keep all the different areas of life
flourishing (Darrell).
Establishing and maintaining boundaries between home and the workplace was
considered an effective self-care strategy. Some boundaries involved commuting to the
workplace via modes of transport that prevented over-working, while for others the commute
time itself constituted a process of unwinding from work so as to separate from it when
arriving home.
Self-care in Workplace Settings. Boundaries were also relevant to effective self-care
within the workplace. Awareness of boundaries in this context was supportive in terms of not
over-working due to resource limitations, whilst also ensuring clarity of expectations for
multiple stakeholders. In the words of one participant:
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The amount of resources [allocated to the] palliative care service - that
actually creates a certain set of boundaries within which I can work -
I’m not going to step over those boundaries; if they want additional
work, they need to increase the resourcing… It’s about managing
expectations around what I will do and what I won’t do - and being
able to be very upfront in relation to that… with management… with
staff that I work with, so [they] are aware of what we can do, and what
we can’t; but more importantly, with patients and their families, so
there’s a very clear set of expectations around what can reasonably be
done for them (Gordon).
Self-regulation of workload was important, but often difficult to achieve. It involved being
assertive about one’s capacity in relation to workload and wellbeing. Taking meal breaks,
taking recreation leave for regular holidays, and taking personal leave during illness were
also considered effective self-care strategies. For some, choosing to work part-time was an
effective self-care strategy that provided ongoing regulation of workload in relation to other
competing demands.
Self-regulation as a self-care strategy was often supported by other members of the
team. In this way, team-care was considered an aspect of effective self-care that contributed
to a healthy team. One participant described an example of team-care in terms of checking in
with colleagues about how they are feeling, as a reminder and invitation to attend to self-care.
Having a cohesive team was important and this contributed to a supportive working
environment. Mindfulness exercises were an effective self-care strategy in the workplace,
both in individual and group contexts. A sense of allowing oneself to be human, in the
context of displaying emotion in the clinical setting, was also part of effective self-care
practice.
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Table 4. Theme 2: Personalised self-care strategies within professional and nonprofessional contexts Philis Carmel Felicity Gwendolen Abbie Larissa Doreen Abbie Lucas Reece Deanna Sandra
It’s really not formulaic; it’s really quite individual, and so everybody has to find their own way of doing it. You not only need self-care strategies in the workplace - but also in your personal life. I do try and exercise a reasonable amount and I try and get to bed on time because I have to get up at a reasonable time… and diet’s important. I regularly exercise, do yoga and have a regular massage as well. [Having] a bath; it’s almost like I’m washing the hospital off me. I have an extremely supportive, very good husband and I have an extremely good network of friends, so… spending time with family and friends. Maintaining relationships with family; making sure I’m spending a reasonable amount of time with my children makes me feel that all is right in the world. Meditate for half an hour a day; that’s all I actually need to do to function well - I’m great at work, I’m calm with [son]. But if I don’t do that, then I get irritable [and] I don’t have as much to give at work. With just half an hour of meditation a day as my top priority for the day, I’m just better all round. I’m quite involved in my Church, and faith is actually a big anchor [that keeps me grounded]. …my spiritual practice which, for me, is a very reliable tool; Buddhist practices… to do with strengthening my connection with compassion or loving kindness for self and others. Work-life balance is really important. There's no such thing as work-life balance, it's rubbish.
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Cathi Felicity Deanna Winston Cathi Larissa Scott Doreen Carmel Darrell Deanna Abbie
If it’s after five o’clock: (a) I won’t be [at work]; and (b) my diary will be sitting on my desk with my mobile phone on it turned off, with my name tag sitting on it. My computer will be off. [It’s] about making certain that work is at work, so I don’t take my mobile phone home. I don’t take my diary home [to follow up on things]; no, sorry that’s work, and it will wait… work stays at work. I take the train… I can only arrive at a certain time and leave at a certain time – those boundaries are actually very helpful. I’ve never been very good at placing boundaries, so I actually have to do this physical boundary of ‘Right, the train’s leaving, and I have to go’ - and that’s worked quite well. My de-escalating time is driving home and when I walk in the door at home, work stays at work… and I find that something to be really important to me actually – that the two don’t intermix. It’s not sustainable to give out more than you really can on an ongoing basis… absolutely [regulating work demands is important]. I take regular holidays. I’m not somebody who’s got an annual leave balance; I always take my meal breaks, take my days off, and sick leave when ill. I chose [to work] part-time. It’s very difficult to do self-care without [team] support, and so you support each other in doing self-care at work, definitely. A mindful activity, just grounding yourself …this conscious thing of ‘Okay, what can I see? What can I feel? What am I touching? Supervision [provides] a safe and guided reflective space that allows you to talk about your practice; to think about what is meaningful to you, about a time, something you did, something you’ve been experiencing recently… allow yourself to really drill into - not just the story - but how did it make you feel… how did you behave… what would you change? [informal debriefing] is a sign of a healthy team because that’s… self-initiated, as opposed to organised or imposed. It’s Friday, I’m tired. A lot has gone on, and I’m giving a handover. I get half-way through the ward and then I start wrapping up. And they go, ‘What are you doing? There’s still the other half of the ward to go yet’, and I’m like, ‘Oh, damn’! So, being able to [make a mistake] and be able to laugh about it was important. Being kind and being compassionate about that. Being able to accept that you are human. We’ve all got a very black sense of humour, so it works really well.
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Reflective practice, especially through participation in clinical supervision, was described by
many as an effective self-care strategy, although formal supervision was not available in all
participants’ workplace. Importantly, respect and confidentiality were important components
for clinical supervision to be effective. But formal supervision was not necessarily helpful for
everyone, with many finding informal debriefing with peers to be effective. However, this
also required trust among colleagues. While the use of informal debriefing among colleagues
was considered a sign of a healthy team, formal, structured debriefing was also common in
some workplaces to support self-care. Use of humour and laughter was also an effective self-
care strategy used in the workplace, with laughter often expressing a sense of acceptance,
kindness and compassion for oneself rather than self-judgement during times when feelings
of inadequacy arise.
Participants reported accessing a variety of professional supports as part of effective
self-care practice. These ranged from Employee Assistance Programs and private counsellors
to psychologists, general practitioners and other medical specialists. For doctors, it was
considered especially helpful to seek objective medical advice from a general practitioner.
Interestingly, choice of employer was a self-care consideration in terms of gauging
organisational commitment to support staff with workplace self-care activities such as
clinical supervision. Finally, effective self-care practice was described as a shared
responsibility between palliative care professionals and the health services in which they
practised. However, there can be a lack of clarity with regards to this shared responsibility.
Theme 3: Barriers and enablers to self-care practice
Participants described the ongoing need to manage self-care barriers and enablers as part of
maintaining self-care strategies in both personal and professional contexts.
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Self-care barriers. Multiple impediments to self-care were identified in the workplace
including busyness. For some, this workload was compounded by limited opportunity to take
holidays from work. Workplace culture was also identified as problematic, where it was not
conducive to self-care. In some workplace cultures there was a stigma associated with self-
care, making it difficult for individuals to engage in self-care practice without feeling judged
as being selfish. Bringing work home was described as a barrier to self-care, and related to
workplace culture and expectations. Self-worth was also discussed as a common concern for
effective self-care, where self-criticism and a lack of self-worth undermined self-care as an
important priority. Finally, a lack of planning for self-care, or otherwise adopting a solely ad
hoc approach was considered a barrier to effective self-care.
Self-care enablers. Several factors were described as facilitators of effective self-care.
Recognising the importance of self-care was considered an important enabler by all. Some
became conscious of this through previous experiences of illness or being unwell after having
initially neglected self-care. Prioritising self-care was an important enabler which correlated
with noticeable benefits. Adopting a preventative approach to self-care was important, whilst
recognising that additional strategies may need to be implemented, as required, according to
context. While formal self-care plans were used by some, for most participants it was more
important to engage in reflection and self-assessment as part of an ongoing planning process,
rather than have a static document.
Positive workplace cultures supportive of self-care were described as vital to effective
self-care practice. Where a supportive culture was absent, the normalisation of self-care within
workplaces was considered a key enabler, requiring leadership from the top-down to effect
positive change towards a culture more supportive of self-care. One participant explained:
Normalisation… the reason I bang on about [self-care] is because I
think, yes, you do need to normalise it. I think the key thing is the ethos
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of the unit, and I think that’s set firstly through the medical head but
then also the administrative or hierarchal structure [helps] - if it’s
normalised and supported from the top then I think that flows down
through the service… [from my observation] it is the leadership group
of the team, and unfortunately that is still medical, who set the ethos
of the unit. So, if you want to change the culture of the place, my
approach would be to get the most senior consultants on board,
(Winston).
Leadership and positive role models were considered key enablers to effective self-care. This
also related to the allocation of reasonable workloads. Other facilitators of effective self-care
were more intrapersonal. These included having a positive outlook, self-awareness and positive
emotions. Self-awareness was described as central to effective self-care practice. Gratitude and
taking a positive perspective, even in the face of negative circumstances, enabled self-care.
Self-compassion was considered essential to self-care, and relational to compassion for others
- as expressed through patient care. One participant explained:
Self-care is built on self-compassion. If your compassion does not
include yourself, it is not complete; it extends to yourself and to your
clients equally. And if you’re not doing that, then something’s not
working (Carmel).
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Table 5. Theme 3: Barriers and enablers to self-care practice Cathi Patrick Scott Merilyn Gordon Larissa Winston Peggie Prudence Sandra Philis Carmel
There’s too many patients and you can’t get enough done… busyness contributes to poor self-care because you actually don’t stop to go ‘How has this affected me? What can I do? What do I need to make me ‘okay’ about it?’ There is an expectation that people won’t take holidays, but how are people supposed to recharge so they can keep working? There’s this… culture sometimes where you just sort of ‘soldier on’ and do what’s expected – take work home. It just follows you home and it can really impact on your home life and your health, because you’re just… stressing about things The biggest hindrance to self-care is organisational culture. There’s a big culture shift that needs to happen in order for people to be able to look after themselves properly. There is still a lot of stigma around having feelings or accepting feeling or being vulnerable… we do see confronting things but there is still that superhero, you know, not letting it affect you. People are considered to be selfish if they do something for themselves… you know, if you take a day off because you’re on a mental health day people think ‘Oh, she’s so selfish because she’s let her team down’ Lack of self-worth and self-value is a bit of an issue… I can see that in how my colleagues - how people treat themselves, and that’s not a judgment - it’s an observation coming from someone doing pretty much the same kind of thing. Self-care always get shoved down to the bottom… that self-worth thing of… you know, something else always being much more important. I certainly used to be quite critical about myself… which isn’t a particularly helpful thing to do really… [most of us] just beat ourselves up emotionally and physically… and then eventually work out why you can't keep doing that for the rest of your life. Self-care goes down the toilet when it’s random… there’s no effective random self-care.
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Peggie Gordon Abbie Winston Reece Carmel Kaleb Cathi Doreen Reece Gordon Lucas
I’m very conscious of [self-care] because I’ve been a in bad spot before with palliative care… I really didn’t cope very well, so I’m [now] highly vigilant about self-care. I was ‘young and bullet-proof’… and I found [that] to be a fairly unpleasant experience; ‘young and bullet-proof’ didn’t work very well. But it took me about seven years to work that out, and I became significantly burnt out… So, having burnt out… taken time off, and readjusted… I’m now very conscious of how important self-care is. When I do [prioritise self-care] I’m calm and I’m more compassionate. Preventative maintenance… Yeah, well it is [like having a regular check-up and a tune-up] I have written self-care plans for myself… but I don’t approach that in a sense of, you know, at six months – ‘now I need to redo my self-care plan’. An ongoing planning process is the critical element rather than just the piece of paper. Leadership. It’s got to come from the top. You can’t have someone at the top who thinks that people who need to go for counselling are 'poor little things'. Seriously, it’s not going to work Having a reasonable degree of self-awareness is hugely important [for effective self-care], particularly in our line of work. Finding the positive in situations… also taking account of things that have negatively impacted me [but still finding] something positive. …intentionally choose how I want to be each morning, and how I want to leave work, and respond to events; having a mindset of gratitude. Practising self-compassion is a really important enabler – without that I’m not really sure how authentic my self-care would be. Being realistic about your limitations is central to self-care… self-care involves being honest about a whole host of things, and it’s primarily being honest with yourself - and being prepared to take that up with other people where you need to - but it’s about being honest with yourself in relation to your limitations. Contemplating my own mortality is very important in terms of self-care. I have to have confronted that; there but for the Grace of God go I… and this could be me [dying]… Really puts things into perspective and helps you to live and enjoy your life to the full.
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Importantly, self-compassion did not necessarily come naturally, and in many cases had to be
learned. For some, self-compassion was viewed as an emotion that became more apparent
later in life, when career achievement was less of a priority. Authenticity and courage were
also described as self-care enablers. These encompassed self-advocacy and self-acceptance –
in terms of being realistic about limitations; and being, in the words of one participant,
authentically human. Lastly, reflecting on and having an appreciation of one’s own mortality
was considered important and enabling for self-care practice.
DISCUSSION This study explored the meaning and practice of self-care as described by palliative care
nurses and doctors. These findings contribute new knowledge in several ways, with
implications for clinical practice, research and education.
A proactive and holistic approach to promoting personal health and wellbeing to
support professional care of others. The holistic nature of self-care as revealed in this study
is consistent with the discourse analysis conducted by Breiddal [21]. Findings from the
present study extend this existing knowledge by providing new insight into the meaning of
self-care, and also through further evidence of the relational context in which self-care is
practised, as voiced by practitioners in the field. For palliative care professionals, self-care is
not a selfish endeavour apathetic to the needs of others; rather, it is a proactive and relational
practice cognisant of practitioners’ health and human needs, and motivated by the
professional context of sustaining compassionate care in therapeutic relationship with patients
and their families. This was especially evident in the words of one participant: …if you don’t
feed yourself, you’ve got nothing to give; much of what we do in palliative care is about
human connectedness. It also supports Kearney and colleagues’ [22] assertion that self-care is
not a selfish luxury, but is instead essential to clinicians’ therapeutic relationship with
patients.
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Personalised self-care strategies within professional and non-professional contexts.
While most research has to date focused on strategies used to cope with occupational
stressors [12]; these findings, situated in the broader context of self-care, reveal not only the
variety of effective strategies employed, but also the challenges and complexities involved
with maintaining effective self-care strategies in practice. The need for reflective practice to
build self-awareness, as well as the management of multiple barriers and enablers to self-care
practice, clearly demand ongoing attention from practitioners and palliative care services.
That mindfulness exercises were used spontaneously by participants in practice
settings suggests that the benefits of formal mindfulness training initiatives extend beyond the
training room and into the clinical milieu [23, 24]. Clinical supervision was effective for
many, but not for others; and in many instances, it was not available at all. This seems to
reflect, in part, a different attitude to clinical supervision within the nursing and medical
disciplines; when compared to other disciplines such as social work, in which supervision has
long been a cornerstone. As a social worker, Firth [25] explains that many nurses may feel
threatened by supervision, whilst doctors have traditionally avoided it. Given the potential
benefits to self-awareness and staff wellbeing, the provision of supervision should
nonetheless be considered; perhaps with an emphasis on the restorative aspects of clinical
supervision [25-27].
Formal and informal debriefing was consistently described as an effective self-care
strategy, and thus should be encouraged. Similarly, laughter and the use of humour formed a
fundamental part of self-care, and should be fostered as appropriate. Laughter has long been
considered a coping strategy to manage stress in palliative care settings [28]; however, this
finding extends a new context in terms of self-care behaviours to support health and
wellbeing. Indeed, there is evidence to suggest not only psychological, but also physiological
health benefits from laughter, including enhanced cardiac and immune function [29-31].
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Establishing and maintaining effective boundaries within and outside of the
workplace was an effective self-care strategy for participants in this study, as was work-life
harmony. Whilst so-called work-life balance was discussed by some, and has also featured in
other palliative care research into coping mechanisms [32]; this concept was incongruous to
the experience of others. Overall, it was important to acknowledge that different life-domains
require varying degrees of attention at any given time, and finding one’s individual harmony
between personal and professional roles was thus a key strategy towards flourishing in life.
This is consistent with McMillan and colleagues’ [33] definition of work-life harmony as ‘an
individually pleasing, congruent arrangement of work and life roles that is interwoven into a
single narrative of life’. It also corresponds with recent research findings that work-life
interference, or conflict, is associated with higher levels of burnout in nurses and predicts
intention to leave an organisation or the nursing profession [34]. Thus, work-life harmony is
an important aspect of effective self-care. Given this finding, future self-care education might
usefully incorporate this new emphasis on work-life harmony over the common parlance of
‘work-life balance’ which is ill-defined and otherwise problematic in practice for some [33].
Another interesting finding related to participants electing to work part-time as a self-
care strategy. While only 42% of participants worked part-time in the present study, the
majority of participants who had earlier completed a survey worked part-time. Given these
and earlier research findings [32], working a part-time load appears to be a common self-care
strategy for palliative care professionals. Indeed, one participant suggested that part-time
roles should perhaps be encouraged in favour of a full-time load, given the emotionally
demanding nature of palliative care. However, this would need to be weighed up by the
individual in relation to feasibility of lower income and potentially limited opportunities for
career advancement in roles where full-time work is required.
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Barriers and enablers to self-care practice. While positive workplace cultures were
discussed as enablers of self-care, there were many who described their current workplace
culture as a barrier to effective self-care, in that it was not supportive of self-care practice.
This finding is alarming, yet not altogether surprising when taken in the context of self-care
being highly stigmatised – as either selfish or weak – in some participants’ workplaces.
Perhaps more concerning, is that this stigma may serve to not only impede effective self-care
practice in the workplace; it could also discourage palliative care professionals from taking
personal leave or seeking professional support when they become unwell. As described by
Hill [35], a paediatric palliative care physician, showing vulnerability or seeking help is often
viewed as a sign of weakness; and acknowledging one’s shared humanity and vulnerability
through self-compassion is vital to self-care behaviours. Understanding factors that contribute
to supportive workplace cultures and facilitate self-care is therefore essential. Some palliative
care services in Australia might benefit from the experience of their counterparts in Canada
and the United Kingdom, who have focused on leadership to foster workplace cultures of
self-awareness, self-care, and staff support [36, 37].
Several enabling factors to self-care practice were identified in this study, both
interpersonal and environmental. Authenticity, courage, and leadership were highlighted by
participants. Being authentically human in acknowledging one’s own vulnerability; having
the courage to challenge stigma or be assertive in saying ‘no’, when acquiescing to additional
workload may compromise one’s own wellbeing; and leading by example in supporting and
normalising self-care as an essential aspect of palliative care practice. Authenticity, courage,
and leadership have been recognised as character strengths that can be measured and
cultivated [38]. Development of these character strengths in palliative care teams should
therefore be encouraged to assist in transforming any unsupportive workplace cultures.
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In this study, positive emotions such as gratitude and self-compassion enabled self-
care. This is consistent with a growing field of positive psychology research, in which
positive emotions not only have a biological basis for physiological health benefits; but have
also been shown to broaden repertoires of positive thoughts and actions which, in turn, help
to build personal and social resources that lead to wellbeing and flourishing [39-43]. Whilst,
in the context of psychological flexibility, negative emotions are not necessarily to be
avoided [44]; awareness of, and capacity for the cultivation of, positive emotions should thus
be fostered as part of self-care practice. This may serve to promote resilience and emotional
intelligence both individually and across the palliative care team [45, 46].
That self-compassion was considered enabling to self-care, corresponds with findings
from a recent correlational study [47] in which perceived self-care ability was significantly
associated with increased self-compassion in palliative care nurses and doctors. Indeed, as
highlighted by Vachon [48], self-compassion entails knowing and caring for oneself.
The self-care barriers identified in the present study provide a valuable context which may
also explain the low levels of self-care ability identified in some doctors and nurses from the
previous study. Building from emerging evidence to support compassion-oriented training
interventions in palliative care teams [24], future research should therefore investigate any
causal relationship between these variables longitudinally. Potential studies could incorporate
interventions that draw upon loving kindness meditation or other compassion training
programs which have been shown to enhance compassion for self and others, and may
therefore contribute positively to both self-care and compassionate care of others [49-53].
In other research [13, 54], palliative care professionals’ reported self-care practices
have corresponded with physical, social, and inner domains of self-care. Importantly,
findings from the present study underscore the imperative that strategies from these self-care
domains are implemented and maintained in both personal and workplace settings. Findings
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from this study can thus inform the self-care education and training interventions recently
called for [55], especially in relation to self-care planning, work-life harmony, and
management of identified barriers and enablers to effective self-care practice. Educational
resources might usefully draw upon this qualitative evidence previously lacking in the
literature, to articulate and foster the meaning and practice of effective self-care in the
palliative care workforce. For example, clarifying staff confusion about the shared
responsibility for self-care practice – as identified in this study.
The issue of balance between individual and organisational responsibility is multi-
faceted and requires careful consideration by palliative care services. Clearly, an organisation
cannot practise self-care on behalf of its workforce; however, it can enable and enhance self-
care through corporate leadership and a variety of structural supports to foster positive
workplace cultures that are conducive to effective self-care practice [36, 37]. At the same
time, individual practitioners carry a personal responsibility for self-care to maintain their
health and capacity for professional practice. This was highlighted by one participant, who
stated: It’s the responsibility of every team member to look after themselves, but having
management or organisational strategies in place to support someone doing self-care is
incredibly important… it’s a dual process. This collaborative approach to promoting health
and wellbeing in workplace contexts is reflected in the World Health Organisation’s (WHO)
[56] Healthy Workplace Framework.
While individual responsibility relates to implementing and maintaining self-care
strategies, organisational responsibility is thus oriented towards supporting staff in effective
self-care practice to promote health and wellbeing. This support represents an investment,
with a host of potential organisational benefits including increased patient and family
satisfaction, increased staff retention and reduced absenteeism, improved staff morale and job
satisfaction [27]. Conflict between colleagues can be a common source of staff stress, and is
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an important workplace concern where all parties must take some responsibility. While the
degree of responsibility will vary according to context, the use of employee assistance
programs and adoption of the WHO Healthy Workplace Framework can provide support and
guidance in this area.
Clarity may also be lacking with regards to shared responsibility for self-care practice
where clinicians experience chronic illness and or disability. Health services, as institutions,
have the potential to promote health and wellbeing not only for health care consumers; but
also for health care professionals [57]. Indeed, some argue that hospitals should serve as
exemplars of healthy workplaces [58]. Given this context, a collaborative approach
encompassing individual self-management and organisational support would be consistent
with the WHO Healthy Workplace Framework, which recommends that workplaces be
supportive of employees living with chronic disease and disability [56]. Palliative care
services might usefully draw upon this or similar approaches.
Given the highly personalised nature of self-care, palliative care services should also
consider ways in which a variety of self-care strategies can be supported. For example,
providing opportunities for both informal debriefing and formal clinical supervision –
depending on individual preference; as well as scope for the supported development of
individual self-care plans for those who feel they would benefit from them.
A novel finding from this study was the concept of team-care to promote a healthy
team. As an encouraging sign of positive workplace cultures, this highlights an additional
dimension to the relational context of self-care practice, whilst underscoring the importance
of supporting interdisciplinary teamwork as an integral part of the philosophy of palliative
care. It also contributes to the literature on positive relationships and workplace wellbeing in
the context of self-care and positive health [59]. Taken together, the practice of team-care as
an antecedent to a healthy team in palliative care represents a potential avenue of qualitative
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inquiry for future research. This would be enhanced with the inclusion of participant
observation and patient-reported outcomes on any perceived benefits to the quality of care
provided.
Limitations. Limitations to this study should be noted. Socio-cultural considerations
were not represented in the demographic data collected or subsequent analysis. Whilst, to our
knowledge, any significant impact of culture on self-care has not featured in the literature to
date, we acknowledge that palliative care professionals from culturally and linguistically
diverse backgrounds may understand and approach self-care practice in ways other than as
described in this study sample. Additionally, the sample was somewhat limited in terms of
participants’ geographical location. While the study recruited participants from metropolitan
and inner or outer (rural) regional locations of nearly all Australian States and Territories,
remote area locations were not represented. The meaning and practice of self-care may have
unique characteristics in remote area practice, thus transferability of findings from this study
should be gauged by remote area practitioners. Despite these limitations, which may be
addressed in the future by discrete population-specific studies, this research has generated
new knowledge in line with the study aim.
CONCLUSIONS
The findings of this study reveal a context and complexity of effective self-care practice
previously lacking in the literature. Taken together, the findings of this research provide new
insight to support palliative care practice and education. Self-care is a proactive and
personalised approach to the promotion of health and wellbeing through a variety of
strategies, in both personal and professional settings, to support capacity for compassionate
care of patients and their families. Importantly, it is a shared responsibility between palliative
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care professionals and the palliative care services in which they work, with staff support and
positive workplace cultures required to manage various barriers and enablers to effective self-
care practice. This research adds an important qualitative perspective and serves to advance
knowledge of both the context and effective practice of self-care in the palliative care
workforce.
Chapter Conclusion
This chapter has presented findings from the qualitative strand of the study. The next chapter
will provide overall results of the study, answering the research questions via the integration
of both quantitative results and qualitative findings.
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