Self-care, Self-compassion, and Compassion for Others
Transcript of Self-care, Self-compassion, and Compassion for Others
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
ABSTRACT
Introduction: This study of self-care arose through increasing interest in the relationship between the
quality of health care, and the health and wellbeing of health professionals providing that care.
Self-care practice is especially relevant for palliative care professionals, with the use of effective self-
care strategies mandated as a vital part of palliative care practice in Australia since 2005. Yet, there has
been little research to inform education and guide practice. The aim of this study was to explore
palliative care professionals’ self-care practice, and examine levels of, and relationships between, self-
care ability, self-compassion and compassion for others.
Methods: Using a mixed methods research design, a national survey of palliative care nurses and
doctors was conducted. The survey comprised a questionnaire about self-care practice, and validated
outcome measures of self-compassion and compassion for others, as well as a control measure of social
desirability. From the 372 respondents who completed the survey, 24 nurses and doctors participated in
semi-structured interviews. Quantitative and qualitative data were analysed separately using IBM SPSS
and QSR NVivo software.
Results: Self-care was practised across multiple health-related domains, with physical self-care
strategies used most frequently. Palliative care nurses and doctors recognised the importance of self-
care practice, but most participants had not received any self-care education or training. Levels of self-
care ability, self-compassion, and compassion for others varied. Self-compassion and self-care ability
were positively correlated; at the same time, a negative correlation was observed between compassion
for others and self-compassion, raising concerns about compassion literacy. Qualitative findings
revealed three themes relating 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. From a synthesis of the combined results, middle range theory
statements were generated for further testing and refinement in practice and future research.
Discussion: Self-care is a proactive approach to promoting personal health and wellbeing to support
professional care of others. Effective self-care practice involves maintaining a variety of personalised
self-care strategies within personal and professional settings, and across physical, social, and inner
health domains. Consistent with the broaden-and-build theory of positive emotions, self-compassion
supports effective self-care practice. However, further research and intervention is recommended to
support individual capacity for self-compassion. Self-care training programs should be evaluated to test
whether compassion training and education enhance compassion literacy and promote health and
wellbeing in palliative care professionals.
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ACKNOWLEDGEMENTS
To my supervisory team, Associate Professors Jennifer Fraser and Timothy Wand, thank you.
I am deeply grateful for your unfailing patience, encouragement and expert guidance. Beyond
what I have learned, I also have a greater appreciation of all that is still to be learned.
My thanks go to the palliative care nurses and doctors who gave their time and careful
consideration as participants in this research. I found their courage, candour and commitment
as health care professionals to be deeply inspiring. I also acknowledge the generous support
of Palliative Care Nurses Australia and the Australian and New Zealand Society of Palliative
Medicine with recruitment during the survey component of this study. This research would
not have been possible without the support of an Australian Postgraduate Award from the
University of Sydney. I also thank Judith Fethney for her expert statistical guidance.
To my family, thank you for your love and support that has carried me through the
many twists and turns of this learning journey. Kristoff and Emely, Margie, Pete and Sue;
each of you have encouraged and supported me in so many ways that words cannot begin to
express how grateful I am. Jasper and Felix, this is the book that I promised to include your
names in. It’s also the reason for all those late nights and early mornings when you would
wake and find me at my desk. I now look forward to more walks and playing in the park with
you and Chai, rather than late nights at my desk.
Shyla, I could not have completed this work without your tireless support. Whether it
was taking the kids away for the weekend so that I could write at home, or sending me off on
a writing retreat to Boudhanath, Kathmandu. You always seemed to know just when and
what I needed to keep me going and on track. Thank you for believing in me and this work.
This belief proved infectious because I too, eventually, began to believe. You’ve been so
thoughtful and generous in many ways, but it is this gift that I will always treasure most.
Thank you.
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CANDIDATE’S STATEMENT
This is to certify that, to the best of my knowledge, the content of this thesis is my own work.
This thesis has not been submitted for any degree or other purposes. I certify that the
intellectual content of this thesis is the product of my own work and that all the assistance
received in preparing this thesis and sources have been acknowledged.
Jason Mills
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AUTHORSHIP ATTRIBUTION
This thesis contains published journal articles for which authorship attribution is provided by
the candidate below.
Chapter Two of this thesis is published as:
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.
As the first named author, I developed the review objective and formulated the search
strategy, conducted the screening and review of the literature, and prepared the manuscript
for publication.
Chapter Four of this thesis is published as:
Mills, J., Wand, T., & Fraser, J. A. (2017). Self-care in palliative care nursing and
medical professionals: A cross-sectional survey. Journal of Palliative
Medicine, 20(6), 625-630.
AND
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), 4-11.
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As the first named and lead author, I led the conception and development of the study design;
drafted the initial questionnaire and refined it in response to feedback; developed the
REDCap survey and tested online functionality; managed participant recruitment and
administered the open and closing of survey responses; performed data analysis with
guidance; and prepared the final manuscript for publication.
Chapter Five of this thesis is a journal article currently in press for publication as:
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).
As the first named and lead author, I led the conception and design of the study, recruited
participants, performed data collection, data management and analysis, and prepared the final
manuscript for submission.
I understand that if I am awarded a higher degree for my thesis entitled Self-care, Self-
compassion, and Compassion for Others being lodged herewith for examination, the thesis
will be lodged with the Director of University Libraries and made available for immediate
use.
Jason Mills
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SUPERVISOR’S STATEMENT
As supervisor of Jason Mills’ higher degree research, I certify that the thesis entitled
Self-care, Self-compassion, and Compassion for Others is in a form suitable for examination.
As supervisor for the candidature upon which this thesis is based, I can confirm that the
authorship attribution statements above are correct.
Associate Professor Jennifer Fraser
Susan Wakil School Nursing and Midwifery
The University of Sydney
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PUBLICATIONS
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.
Mills, J., Wand, T., & Fraser, J. A. (2017). Self-care in palliative care nursing and medical
professionals: A cross-sectional survey. Journal of Palliative Medicine, 20(6), 625-
630.
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), 4-11.
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).
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PRESENTATIONS
2014 Do nurses care about self-care? Research priorities
and implications for practice. Oral paper presented at the
Australian College of Nursing ‘National Nursing Forum’,
Adelaide, SA.
2015 Are we fit for the future? Self-care strategies to future-proof
compassionate palliative care. Oral paper presented at the
13th Australian Palliative Care Conference: ‘Fit for the Future’,
Melbourne, VIC.
2017 The primacy of compassion: An essential connection with
community. Oral paper presented at the 14th Australian
Palliative Care Conference: ‘Connection with Community’,
Adelaide, SA.
2018 Understanding the Meaning and Practice of Self-care:
Fundamental to Fostering the Workforce. Oral paper
presentation at the 7th Biennial Palliative Care Nurses Australia
Conference: ‘Fostering Excellence in Palliative Care’,
Brisbane, QLD.
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TABLE OF CONTENTS
Preliminaries………………………………………………………………………………….ii
Abstract………………………………………………………………………………..….ii
Acknowledgements……………………………………………………………………....iii
Candidate’s Statement.………………………………………………………….………..iv
Authorship Attribution……………………………………………………………….…...v
Supervisors’ Statement………………………………………………………….………vii
Publications……………………………………………………………….…………….viii
Presentations……………………………………………………………….…………….ix
Table of Contents………………………………………………………….……………...x
List of Tables……………………………………………………………….…………...xii
List of Figures………………………………………………………….……………….xiii
Chapter One: Introduction and overview of the thesis…………………………………...14
Chapter Introduction………………………………………………………………….…14
Background….……..……………………………………………………………………14
Key Terms………..……………………………………………………………………...21
Study Aims………..……………………………………………………………….…….25
Thesis Overview………..………………………………………………………….…….26
Chapter Conclusion………..……………………………………………………….……26
Chapter Two: Literature review………..…………………………………………….……27
Chapter Introduction………..…………………………………………………………...27
Palliative care professionals’ care and compassion for self and others………….……...28
Professional Self-Care Scale developed for Spanish palliative care professionals…..….39
Mindful self-care, compassion satisfaction and burnout among hospice professionals...39
Summary………..……………………………………………………………………… 40
Chapter Conclusion………..………………………………………………………….…41
Chapter Three: Research design and methods…………………………………………...42
Chapter Introduction………..……………………………………………………….…..42
Research Questions………..……………………………………………………….……42
Mixed Methods Research..………………………………………………………….…..43
Philosophy of Pragmatism………………………………………………………….…...45
Research Methods………………………………………………………………….…....47
Ethical considerations……………………………………………………………….......55
Chapter Conclusion………………………………………………………………….......56
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Chapter Four: Quantitative Strand Results………………………………………………57
Chapter Introduction………..…………………………………………………….……..57
Self-care in palliative care nursing and medical professionals…………………….……58
Examining self-care, self-compassion, and compassion for others……………….…….64
Chapter Conclusion………..……………………………………………………….……73
Chapter Five: Qualitative Strand Findings……………………………………………….74
Chapter Introduction………………………………………………………………….…74
Exploring the meaning and practice of self care...............................................................74
Chapter Conclusion……….……………………………………………………………101
Chapter Six: Study Results………………………………………………………………..109
Chapter Introduction…………………………………………………………….……..109
Answering the research questions………………………………………………….…..109
Chapter Conclusion………………………………………………………………...…..114
Chapter Seven: Discussion………………………………………………………………..115
Chapter Introduction…………………………………………………………………...115
Discussion of Key Findings…………………………………….………………….…..115
Contribution of the Study…………………………………………….………….……..140
Strengths and Limitations………………………………………….…………….……..141
Recommendations……………………………………………………………………...142
Chapter Conclusion…………………………………………………………...….….....143
Chapter Eight: Generating Middle Range Theory……………………………………...144
Chapter Introduction……………………………………………………………….…..144
Middle range theory……………………………………………………….…………...144
Chapter Conclusion……………………………………………………………….…....147
Chapter Nine: Conclusion…………………………………………………………...…....148
Thesis conclusion……………………………………………………………….……...148
References…………………………………………………………………….…………....150
Appendices………………………………………………………………………………....195
Appendix A: Professional Self-care Scale……………………………………...……...196
Appendix B: Mindful Self-care Scale………………………………………….............197
Appendix C: Survey Questionnaire………………………………………………….....200
Appendix D: Reflexive Journal Extract……………………………………...………...205
Appendix E: Human Research Ethics Approval……………………...………..……....207
Appendix F: Survey Participant Information Statement………………………..……...210
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Appendix G: Interview Participant Information Statement and Consent Form…….….214
Appendix H: Self-Compassion Scale – Short Form……………………………………220
Appendix I: Santa Barbara Brief Compassion Scale…………………………….…….221
Appendix J: Marlowe-Crowne Social Desirability Scale – Short Form…………...…..222
LIST OF TABLES
Chapter 2
Summary of theoretical articles………………………………………………………………29
Summary of empirical articles………….……………………………………………………30
Chapter 4
Participant demographics…………………………………………………………….………60
Characteristics of participants’ perceptions and practice of self-care…………………..……60
Content analysis of self-care strategies………………………………………..………..……60
Descriptive statistics for study variables and subscales……………………………….……..68
Partial correlations between self-compassion, self-care ability and compassion for others…68
Hierarchical linear regression model…………………………………….………….….…….68
Chapter 5
Interview guide…………………………………………….…………….………….….…….77
Participant demographics and professional characteristics………….…………….....…...….80
Theme 1: A proactive and holistic approach to promoting personal health and wellbeing
to support professional care of others……………….....................................................….….82
Theme 2: Personalised self-care strategies in professional and nonprofessional contexts…..86
Theme 3: Barriers and enablers to self-care practice ………….…………….....…...……….91
Chapter 7
Areas of Key Findings………………………………………………….………….….…….116
Chapter 8
Middle range theory statements………………………….…………….………….….…….145
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LIST OF FIGURES
Chapter 2
Themes identified from the literature…………………………………………………...……31
Dimensions of self-care…………………………………………………........................……33
Chapter 3
Parallel convergent study design…………………………………………...…………...……45
Chapter 4
Word cloud from reported self-care strategies………………………………………….……61
Scatter plot of individual Anderson-Rubin factor scores…………………………………….69
Chapter 5
Coding categories and thematic content………………………………………………..….....81
The meaning and practice of self-care……………………………………………………….83
Chapter 6
Self-compassion supports self-care……………………………………………………...….111
Self-care domains and contexts……………………………………………………………..112
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CHAPTER 1
INTRODUCTION AND OVERVIEW
Chapter Introduction
The purpose of this chapter is to introduce the study and present an overview of this thesis.
The chapter begins with background to situate the study within the context of current theory
and practice. An orientation to key terms informing the research is then provided, followed
by the study aims. Finally, a stepwise description of each chapter is provided as an overview
to this thesis.
Background
The capacity of health care professionals to provide high quality, compassionate care to
patients is influenced, in part, by their own health status and level of wellbeing. The
importance of workforce wellbeing to both care performance and patient experience of care
has been established through large-scale studies of national health services’ staff (Boorman,
2009; Maben, Adams, Peccei, Murrells & Robert, 2012). The wellbeing of health
professionals is an important antecedent of patient care performance (Maben et al., 2012).
For example, in a multi-site mixed methods study using 498 patient experience surveys, 106
patient interviews, 427 staff wellbeing surveys, 86 staff interviews and 206 hours of
observation, Maben et al. (2012) concluded that efforts to enhance the wellbeing of staff were
not only important in their own right, but also for the quality of patients’ experience of health
care. The relationship between the quality of health care and the health and wellbeing of staff
providing that care is therefore significant.
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In recent years, there has been increasing evidence of chronic illness and growing
concern about poor physical health and psychological wellbeing in the Australian health care
workforce, particularly in the nursing and medical professions (Beyond Blue, 2013;
Bogossian et al., 2012; Lamont et al., 2017; Perry, Gallagher & Duffield, 2015; Perry,
Lamont, Brunero, Gallagher & Duffield, 2015; Ross & Barr, 2013; Ross, 2014; Schluter,
Turner & Benefer, 2012). Indeed, age-standardised rates of suicide in Australian nurses and
doctors between 2001 and 2012 were higher than those in other occupations outside of health
care (Milner, Maheen, Bismark, & Spittal, 2016). Given these concerns and the potential
implications for compromised patient care, more thorough investigation of health promoting
practices such as self-care is warranted.
Although caring is central to nursing practice, many nurses neglect self-care
(McAllister & McKinnon, 2009). Similarly, in medicine, self-sacrificing behaviours have
traditionally been viewed as noble (Rowe & Kidd, 2009). But self-care practice is an
important factor in preventing burnout and building resilience (Newell, 2017; Skovholt &
Trotter-Mathison, 2011). This is highlighted in Newell’s (2017), competency-based model
for professional resilience in human service professionals, which features self-care as one of
its key components.
Physician wellness was identified as a missing health care quality indicator in The
Lancet nearly 10 years ago (Wallace, Lemaire & Ghali, 2009), yet there appears to have been
little progress in prioritising the health and wellbeing of clinicians as an antecedent to optimal
patient care. Discussion of a ‘clinician-burnout crisis’ featured in a recent issue of the New
England Journal of Medicine, reminding health care professionals that they too are human,
and thus vulnerable to illness which may compromise clinical care (Dzau, Kirch & Nasca,
2018). In the same journal, Hill (2017), a palliative care physician, provided a poignant
account of human vulnerability in the context of addiction, depression, suicidal ideation and
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stigma, followed by recovery, self-awareness and self-care. Indeed, Hills noted his first
lesson in recovery was to prioritise self-care and wellbeing, instead of abusing alcohol to
cope with the demands of modern health care practice. While self-care is increasingly
discussed in the general nursing and medical literature (Mills, Wand & Fraser, 2015; Mills &
Chapman, 2016), it is especially relevant to those working in the specialty practice area of
palliative care.
Palliative care professionals represent a relatively small yet essential part of the health
care system, with nurses and doctors forming the majority of palliative care teams across
Australia (Australian Institute of Health and Welfare, 2017). As a specialty area of clinical
practice, the palliative care workforce is characterised by its holistic and team-based
approach, as well as a central focus on therapeutic relationships with patients and their
families to provide ‘total care’ (Clark, 1999; Canning, Rosenberg & Yates, 2007). This total
care requires an ongoing and, at times, intensive therapeutic use of self that demands constant
attention to self-care (Beng et al., 2015; Wakefield, 2000). This practice reality has been
reflected in professional and competency standards for more than a decade now, with the use
of effective self-care strategies mandated in Australia (Palliative Care Australia, 2005;
Canning, Yates & Rosenberg, 2005). However, the uptake and utility of self-care practices
appears largely unknown.
Chiarella and Duffield (2007) had previously identified concerns about the Australian
palliative care workforce that, in their view, warranted greater attention to ensure sufficient
staff would be available to meet the increasing demand for palliative care provision over
time. These concerns are further compounded by significant workforce shortages projected in
both nursing (Health Workforce Australia, 2014a) and medical professions (Health
Workforce Australia, 2014b) in the coming years. Given that nurses and doctors provide a
large majority of direct care work; these issues, coupled with concerns about health and
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wellbeing in the nursing and medical disciplines, raise important implications for the
sustainability of high quality palliative care in Australia.
Despite some evidence to suggest that palliative care professionals do not experience
higher levels of burnout or psychiatric morbidity than those working in other specialty areas
(Dunwoodie & Auret, 2007), Vachon (2011) outlines a broad variety of occupational
stressors that have featured over the past four decades. While suggesting that early
recognition of the important role of self-care in the palliative care field may have gone some
way towards alleviating the extent of stress experienced, Vachon cautioned that occupational
stressors appear to be increasing and thus complacency must be avoided. This position is
supported by research in Australian and international contexts of stress and burnout reported
in studies of palliative care nurses (Peters, Lee & O'Connor, 2013; Peters et al., 2012). While
much of the literature focuses on the prevalence of negative emotion and its relation to ill
health, positive emotions such as compassion represent an important yet under-researched
phenomena that may help palliative care professionals to thrive rather than just survive
(Vachon, 2011).
Studies have investigated positive emotions in relation to wellbeing among palliative
care patients (Beng et al., 2014), but positive emotions in this context have yet to be
examined in palliative care professionals. While a cursory discussion of positive emotions
such as compassion and self-compassion exists in relation to coping with occupational
stressors (Beng et al., 2015; Vachon, 2011), empirical research into positive emotion is more
broadly oriented towards flourishing and the promotion of health and wellbeing. Recent
concerns that compassion is lacking in care of the dying (Vachon, 2016a) highlight a further
need for investigation of positive emotions among palliative care professionals.
As understood through the interface of emotion science and evolutionary theory,
positive emotions have served an important adaptive function and are linked to increased
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social support and physical health (Shiota, 2014). Past research has established multiple links
between positive emotions, physical health, psychological wellbeing, and prosocial
behaviour. For example, the Nova Scotia Study (Davidson, Mostofsky, & Whang, 2010)
found that increased positive affect was protective against coronary heart disease over a 10-
year period. In studies led by Carnegie Mellon University in the USA, positive emotions were
associated with greater resistance to viral illnesses such as Rhinovirus (Cohen, Doyle, Turner,
Alper & Skoner, 2003), and Influenza A (Cohen, Alper, Doyle, Treanor & Turner, 2006). In
other research, Richman and colleagues (2005) found that higher levels of hope were
associated with decreased likelihood of having or developing hypertension, diabetes mellitus,
or respiratory tract infections; and similarly, higher levels of curiosity were associated with
decreased likelihood of hypertension and diabetes mellitus. Gratitude, as a positive emotion,
is also linked with a variety of benefits including improved sleep, cardiac function, and other
biomarkers of physical health (Emmons & McCullough, 2003; McCraty, Atkinson, Tiller,
Rein, & Watkins, 1995; Mills et al., 2015; Jackowska, Brown, Ronaldson, & Steptoe, 2015;
Redwine et al., 2016; Wood, Joseph, Lloyd & Atkins, 2009; Wood, Froh & Geraghty, 2010).
A meta-analysis of data from 35 studies found that positive psychological wellbeing
was significantly correlated with reduced cardiovascular mortality in healthy populations, as
well as reduced mortality rates in patients with renal failure or human immunodeficiency
virus (Chida & Steptoe, 2008). In addition to these links with wellbeing, positive emotions
also drive prosocial behaviour. There is evidence to suggest this occurs through a positive
feedback loop between positive emotions, prosocial behaviours and wellbeing (Layous,
Nelson, Kurtz & Lyubomirsky, 2017). Positive psychological wellbeing is thus an important
consideration for overall health and wellbeing in the context of caring for others.
The study of positive emotions in relation to psychological wellbeing, prosocial
behaviour, and physical health is largely informed by the field of positive psychology.
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Pioneered by Martin Seligman, positive psychology aims to focus equal attention on positive
affect and human flourishing to redress the traditional emphasis placed on negative affect and
human pathology (Seligman, 2012; Seligman, 2008; Seligman & Csikszentmihalyi, 2000).
The following quote illustrates the importance of this approach to workforce applications:
The field of positive psychology at the subjective level is about valued
subjective experiences: wellbeing, contentment, and satisfaction (in the past);
hope and optimism (for the future); and flow and happiness (in the present).
At the individual level, it is about positive individual traits: the capacity for
love and vocation, courage, interpersonal skill, aesthetic sensibility,
perseverance, forgiveness, originality, future mindedness, spirituality, high
talent, and wisdom. At the group level, it is about the civic virtues and the
institutions that move individuals toward better citizenship: responsibility,
nurturance, altruism, civility, moderation, tolerance, and work ethic
(Seligman & Csikszentmihalyi, 2000, p.5).
Seligman later developed a model for human flourishing (2012) and positive health (2008)
based on Positive emotion; Engagement; Relationships; Meaning; and Accomplishment
(PERMA). Positive emotions are significant in forming the foundation of the PERMA model,
yet this area has been neglected in studies of wellbeing in the workplace. The health and
wellbeing of health care professionals, in particular, might usefully be examined in this way
(Wiesmann, 2016); especially as the benefits of positive emotion and positive health may
potentially extend beyond health care professionals to their patients as care recipients
(Gudmundsdottir, 2011). Joseph (2015, p.5) explains that:
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As human beings, we are motivated to fulfil our potential, function at optimal
levels, and achieve a pleasurable and meaningful life; positive psychology is
concerned with how best to support these aspirations in us—in ways that are
both good for us, and those around us.
Two main approaches to wellbeing research are evident in the social sciences, adopting either
hedonic or eudaimonic perspectives to wellbeing (Deci & Ryan, 2008). Hedonia is associated
with the experience of short-term pleasure, positive affect, and enjoyment of material
comfort; whereas eudaimonia is characterised by a longer-term pursuit of meaning, purpose,
authenticity, and growth towards self-actualisation (Ryff, 2013; Ryff & Singer, 2008).
Eudaimonic wellbeing, in particular, is yet to be fully applied in health care settings.
(Weismann, 2016). While the experience of positive emotions represents a core aspect of
hedonic wellbeing, there is empirical evidence to suggest that positive emotions forecast and
induce increases in eudaimonic wellbeing, with both contributing to physical wellbeing
(Fredrickson, 2013). Thus, hedonia and eudaimonia are interrelated and complementary
facets of wellbeing, which together play a key role in human flourishing (Fredrickson, 2016;
Huta, 2015). This is consistent with the broaden-and-build theory of positive emotions.
According to Fredrickson’s (2001) broaden-and-build theory of positive emotions, the
experience of positive emotions broaden the individual’s mindset, leading to greater
behavioural and psychological flexibility. This then builds personal and social resources that
promote resilience and support physical health (Cohn & Fredrickson, 2009; Fredrickson,
2004; Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008; Fredrickson, Tugade, & Waugh,
2003). In this way, although the experience of positive emotions may be transient, the
supportive resources accrued are lasting (Fredrickson, 2008). Taken together, this body of
work indicates that the study of positive emotions represents an important avenue of inquiry
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in the context of health, wellbeing, and self-care. This thesis views health and wellbeing
through the lens of positive psychology, with positive emotions forming the foundation of
flourishing.
Key terms
Self-care. The term self-care came to prominence with Dorothea Orem’s Self-care Theory in
Nursing (Renpenning & Taylor, 2003). Self-care, in this context, relates to the identification
of a patient’s self-care deficit, and requires nurses’ appreciation of the agency, capacity and
responsibilities of patients in promoting their own health and wellbeing. Perhaps more
importantly, Orem stressed that self-care was fundamentally a human endeavour.
It is in this broader context that self-care is situated within this thesis, given that
health professionals are themselves human. In his seminal work The Nature of Suffering and
the Goals of Medicine, Cassell (1991) described nature and causes of suffering in medical
patients. In a corresponding text The Nature of Suffering and the Goals of Nursing, Ferrell
(2008) drew attention to the shared humanity and suffering of nurses, declaring that caring
for others without caring for oneself was unsustainable. Thus, self-care is not only a matter of
personal survival or optimal wellbeing; it also represents an important consideration for
sustaining clinicians’ capacity for patient care. This is reflected in Watson’s (2008) Theory of
Human Caring and the Foucauldian (2003) concept known as care of the self. Whilst noting
that Foucault’s philosophy of the self was not confined to the physical body, Perron (2013)
introduced the primacy of the self-self relationship as central to nursing and argued that care
of the self was a fundamental condition for nurses to care for others.
Self-care is not limited to coping with stress, and there may be merit in moving
beyond the confines of traditional stress and coping paradigms (Frydenberg, 2002) towards a
more positive paradigm of understanding how people flourish and thrive in their work, rather
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than merely survive (Moore, 2002). For the purpose of this thesis, self-care has been defined
as the self-initiated behaviour consciously adopted to promote health and wellbeing. Whilst
the capacity to cope with stress is important to resilience, coping strategies are not within the
scope of this thesis, in the same way that health is not merely the absence of disease or
infirmity (Gudmundsdottir, 2011; World Health Organisation, 1946).
Compassion for others. The origin of the term ‘compassion’ can be traced to its Latin
root: compati, meaning ‘suffer with’ and denoting a shared sense of human vulnerability
(Larkin, 2016a). As Nelson Mandela (2000) once observed, ‘…our human compassion binds
us the one to the other; not in pity or patronisingly, but as human beings who have learnt how
to turn our common suffering into hope for the future’. Common humanity is thus an intrinsic
element of compassion. Described by Nussbaum (1996) as the basic social emotion,
compassion and its cultivation have been the subject of considerable thought across
interdisciplinary discourse in philosophy, medical ethics, and the health humanities (Gelhaus,
2012, 2013; Leget & Olthuis, 2007; Nussbaum, 1996; Ozawa-de Silva, Dodson-Lavelle,
Raison & Negi, 2012; Vachon, 2012).
While much of the literature on compassion and its cultivation incorporates
perspectives from various Buddhist traditions (Gilbert & Choden, 2014; Halifax, 2011;
Hopkins, 2001; Jinpa, 2015; Masel, Schur & Watzke, 2012), compassion is universal to many
religions and wisdom traditions (Larkin, 2016a). Indeed, Larkin (2016a) argues that Dame
Cicely Saunders, widely acknowledged as the founder of the modern hospice movement,
established the philosophy and practice of palliative care as an expression of compassion
informed by her ‘profound Christian belief’ (p.169). According to the Dalai Lama (2003), a
noted scholar of compassion, the human capacity for compassion does not come from
religion; it comes from biology, but in this form, it is limited and biased towards kin - unless
it is consciously cultivated and expanded to include others in broader prosocial contexts.
22
This is consistent with evolutionary theories of compassion (Gilbert, 2015; Shiota, 2014) and
is reflected in the thoughts of scientists such as Albert Einstein who had earlier theorised
about the importance of broadening one’s compassion to embrace those outside of personal
and familial networks (Ricard & Thuan, 2001).
Compassion is a virtue informed by diverse philosophical, religious and scientific
traditions, yet it finds common expression in palliative care practice. According to Larkin
(2016b) compassion requires resilience, fortitude, tenacity and determination. On the need for
courage, Jinpa (2015) argued that compassion requires a fearless heart. These qualities were
reflected in Saunders’ leadership and advocacy to reduce unnecessary suffering through the
provision of more compassionate end-of-life care (Larkin, 2016a). Indeed, Peterson and
Seligman (2004, p.325) cited Saunders as an exemplar of compassion in their handbook of
character strengths and virtues; a seminal text in the field of positive psychology.
Goetz, Keltner and Simon-Thomas (2010) defined compassion as ‘the feeling that
arises in witnessing another’s suffering and that motivates a subsequent desire to help’
(p.351). While there has been conflation between compassion and empathy in the health care
literature, compassion is different from empathy. From their evolutionary analysis and
empirical review of the literature, Goetz and colleagues (2010) concluded that compassion is
a discrete emotion associated with prosocial behaviour, but distinct from other emotions such
as empathy. This conclusion was later supported by further evidence from the neuroscientific
work of Singer and Klimecki (2014) using functional magnetic resonance imaging.
Importantly, in the context of health care practice patients can distinguish between
compassion and empathy, identifying compassion as most preferred and impactful (Sinclair et
al. (2017). From their grounded theory study of cancer patients, Sinclair et al. (2016) defined
compassion as ‘a virtuous response that seeks to address the suffering and needs of a person
through relational understanding and action’ (p.195). Compassion can be understood not only
23
as the recognition and awareness of suffering, but also the desire to alleviate it. For the
purpose of this thesis, compassion for others is considered a positive emotion involving the
recognition of, and therapeutic response to, the needs and suffering of others. It is important
to note, however, that compassion can be oriented to others or to oneself.
Self-compassion. Self-compassion involves directing compassion inwards to oneself
with self-kindness, understanding, and positive regard (Germer, 2009). It is therefore
commonly thought of as important to self-care in nursing and medicine (Mills, Wand &
Fraser, 2015; Mills & Chapman, 2016; Skovholt & Trotter-Mathison, 2011). As a pioneer in
self-compassion research, Neff (2003) conceptualised self-compassion as a six-factor
construct comprising three positive sub-scales: (1) Self-kindness, (2) Common humanity, (3)
Mindfulness; and three corresponding negative sub-scales: (4) Self-judgement, (5) Isolation,
and (6) Over-identification.
For the purpose of this thesis, self-compassion was defined as a positive emotion
involved in (a) extending kindness and understanding to oneself rather than harsh self-
criticism and judgment; (b) seeing one’s experiences as part of the larger human experience
rather than as separating and isolating; and (c) holding one’s painful thoughts and feelings in
balanced awareness rather than over-identifying with them (Neff, 2003, p.224).
Self-compassion is associated with prosocial behaviour (Lindsay & Creswell, 2014),
emotional intelligence in nurses (Heffernan, Griffin, McNulty, & Fitzpatrick, 2010), and a
broad range of benefits to health and wellbeing (Arch et al., 2014; Hall, Row, Wuensch &
Godley, 2013; Homan & Sirois, 2017; Neff & Dahm, 2015; Neff, 2003; Svendsen, et al.,
2016; Neff, Rude & Kirkpatrick, 2007).
24
Study Aims
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.
25
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.
26
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
Review
Jason Mills, Timothy Wand and Jennifer A Fraser
Jason Mills, RN, BN(Hons), MCHMed,
FACN, PhD Candidate. Lecturer, School of
Nursing, Queensland University of Technology,
QLD Australia
Timothy Wand, NP, RN, MN(Hons), PhD.
Associate Professor, Faculty of Nursing and
Midwifery, The University of Sydney,
NSW Australia
Jennifer A Fraser, RN, PhD. Associate Professor,
Faculty of Nursing and Midwifery, The
University of Sydney, NSW Australia
Corresponding author:[email protected]
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
investigated (Gelling, 2014; Halcomb & Hickman, 2015; Hesse-Biber, 2010). By combining
the strengths of both quantitative and qualitative research methods, a more detailed
understanding of relevant phenomena can be obtained than otherwise through the use of one
method alone (Creswell & Plano Clark, 2011; Halcomb, Andrew, & Brannen, 2009; Östlund,
Kidd, Wengström, & Rowa-Dewar, 2011; Shannon-Baker, 2016). Mixed methods research
systematically combines the collection and analysis of qualitative and quantitative data within
the same study (Johnson, Onwuegbuzie, & Turner, 2007; Lewis, 2011; Taket, 2013). It is
increasingly used in palliative care research because it resonates with the complexity of
palliative care practice (Farquhar, Ewing & Booth, 2011; Seymour, 2012).
Within mixed methods research, careful consideration of the study design is required.
For example, clarity regarding the prioritisation, timing and systematic integration of
43
methods and data is necessary (Grbich, 2013; Halcomb & Hickman, 2015; Morgan, 2014a).
A parallel convergent mixed methods design was used in this study. This design involved the
collection and analysis of both quantitative and qualitative data during the same phase of the
study, followed by the triangulation of results from each strand of the study into an overall
interpretation (Creswell & Plano Clark, 2011; Grbich, 2013). Triangulation, in this context,
refers to the combining of multiple methods and data sources (Grbich, 2013), with
quantitative and qualitative methods prioritised equally. As explained by Creswell and Plano
Clark (2011, p.77), the purpose of the parallel convergent design is to ‘obtain different but
complementary data’ to best understand the phenomena of interest and answer the research
questions. In this way, the study design provides a structure and systematic process in which
findings from the qualitative strand may extend or complement results from the quantitative
strand (Creswell & Plano Clark, 2011; Grbich, 2013; Morgan, 2014a). Figure 1 illustrates the
triangulation of these strands within the parallel convergent design, as adapted from Creswell
and Plano Clark, 2011, p.78).
Figure 1. Parallel convergent study design
44
Philosophy of Pragmatism
While philosophy is neither a solely theoretical endeavour, nor a branch of empirical inquiry
(Rescher, 2013), it is a central pillar which underpins research design (Baldwin, 2014). The
research design for this study was underpinned by the philosophy of pragmatism. Pragmatism
was initially developed as a philosophical position through the work of Charles Sanders
Pierce, and was later informed by William James and John Dewey (Levi, 2012). Some
diversity of thought is evident within the writing of pragmatists; however, it is clear that
functional efficacy is the common and fundamental concern of pragmatism (Rescher, 2013).
That is, in the context of mixed methods research, pragmatism prioritises, as an outcome, the
function of methods to answer research questions in a way that is both appropriate and
meaningful; thus functional efficacy takes priority over adherence to other methodological or
paradigmatic doctrines (Feilzer, 2010; Grbich, 2013; Muncey, 2009; Nowell, 2015; Shannon-
Baker, 2016).
It is important, however, to consider the strengths and limitations of adopting a
pragmatic approach to research. As a relatively new research paradigm, pragmatism has been
considered disruptive to the philosophical assumptions of older paradigms (Morgan, 2014).
As a philosophy, it has thus been subjected to ongoing critique for more than a century
(Moore, 1905). Limitations to the use of a pragmatic approach include issues relating to both
the researcher and the research process. For example, pragmatism would not be considered an
appropriate research paradigm where it is incongruent with a researcher's personal worldview
relating to assumptions of epistemology or ontology (Grbich, 2013; Nowell, 2015). During
the research process, careful consideration is required when analysing or integrating
quantitative and qualitative data, given that a lack of methodological rigour can weaken the
credibility of the research (Feilzer, 2010; Shannon-Baker, 2016). One of the most significant
limitations of adopting a pragmatic approach relates to misconceptions about the credible use
45
of pragmatism as a research paradigm. Being 'pragmatic', for example, can be interpreted, in
the everyday vernacular, as being 'expedient'; or as otherwise synonymous with the phrase
'anything goes' (Morgan, 2014). Indeed, Morgan (2014, p.1046) concedes that a 'crude
summary of pragmatism as merely asking about “what works” has been a perennial problem'.
However, it has been argued that the strengths and potential benefits of adopting a
pragmatic approach outweigh these limitations, particularly when they have been addressed
through careful consideration (Feilzer, 2010; Margolis, 2003; Nowell, 2015). The key
strengths of a pragmatic approach relate to its middle-ground positioning, between
traditionally polarised approaches, which effectively supports the use of mixed methods to
gain a broader and more in-depth understanding of phenomena to answer research questions
and better inform practical concerns (Feilzer, 2010; Morgan, 2007, 2014a, 2014b; Shannon-
Baker, 2016). While the combining of quantitative and qualitative methods is problematic
when viewed from either positivist or constructivist paradigms, pragmatism represents a lens
through which ‘reality exists not only as natural and physical realities, but also as
psychological and social realities which include subjective experience and thought, language
and culture’ (Grbich, 2013, p.313). In this way, a pragmatic use of mixed methods brings
with it an intersubjectivity that is situated between the dichotomous extremes of complete
objectivity or complete subjectivity (Shannon-Baker, 2016). This is further reflected in the
pragmatist process of abduction that is favoured over approaches that use either induction or
deduction (Feilzer, 2010; Grbich, 2013; Shannon-Baker, 2016). Consistent with
intersubjectivity, abductive reasoning cycles between inductive and deductive processes
(Feilzer, 2010; Grbich, 2013; Morgan, 2007; Shannon-Baker, 2016). The mixed methods
research design employed in this study is thus supported by the philosophy of pragmatism.
46
Research Methods
Sampling. The use of mixed methods in this study encompassed both probability and non-
probability sampling (Grbich, 2013). Thus a parametric, representative sample was obtained
for the quantitative strand of the study, whereas a non-parametric, purposive sample was
obtained for the qualitative strand. Recruitment of the study sample was guided by specific
inclusion criteria.
Recruitment and Inclusion Criteria. Participant invitations were sent to members of
Palliative Care Nurses Australia (PCNA) and the Australian and New Zealand Society of
Palliative Medicine (ANZSPM) via email from the secretariat of each respective professional
association. In addition to this, invitations were sent to palliative care services whose contact
details were listed on Palliative Care Australia’s national service directory. Participants were
eligible for this study if they were a nurse or doctor practising in Australia, with palliative
care as their main area of practice. This population was chosen because the nursing and
medical disciplines represent a large majority of the palliative care workforce (Australian
Institute of Health and Welfare, 2017) and, unlike other Australian allied health professions
in palliative care, are accessible nationally through survey distribution from their respective
member organisations (PCNA and ANZSPM).
Quantitative strand. In this strand of the study, a cross-sectional survey was
administered to collect quantitative data from research participants for the purpose of
generalising results (Fowler, 2014; Schofield & Forrester-Knauss, 2013). The survey was
developed using Research electronic data capture (REDCap) software, and was administered
online over a period of approximately six weeks between April and May, 2015. REDCap is a
secure and widely used web-based survey platform that was designed to support data
collection in academic research (Harris, 2009). While survey research is an effective method
for nursing and palliative care research (Addington-Hall, 2007a; Keough & Tanabe, 2011), it
47
is important to discern the most appropriate mode of survey in relation to the study aims and
population (Addington-Hall, 2007b). Web-based surveys are an efficient and cost-effective
alternative to telephone or hardcopy paper-based surveys (Schleyer & Forrest, 2000), but
response rates can vary significantly (Schofield & Forrester-Knauss, 2013). A web-based
mode of survey was chosen for this study because of its advantages in relation to
geographical reach as well as both time and cost-efficiency. However, this decision brought
with it a need for considered strategies to achieve a satisfactory response rate.
Unique factors must be taken into account when conducting surveys in the health
professions compared to the general population. For example, survey response rates are
typically lower due to clinical work demands and time scarcity, especially in physicians and
other medical professionals (Flanigan, McFarlane & Cook, 2008). Careful consideration
regarding the design and delivery of a survey is therefore required to enhance participation
and overall response rate when surveying people working in these disciplines.
Strategies to improve survey participation have been explored in both nurses (Cooper
& Brown , 2017; VanGeest & Johnson, 2011) and physicians (Cunningham et al., 2015;
Flanigan, et al., 2008), emphasising brevity and content relevance. From their systematic
review, VanGeest, Johnson and Welch (2007) concluded that surveys designed to be concise
and personalised were more likely to be successful, particularly where they had been endorsed by
relevant professional associations. This strategic approach was thus adopted in designing the
cross-sectional survey of palliative care nurses and doctors.
Apart from designing a brief questionnaire structure, a number of web-based design
strategies were implemented. For example, the use of embedded data and adaptive
questioning (Helms, Gardner & McInnes, 2017) drawing upon the branching logic function in
REDCap. That is to say, the questionnaire was designed to be efficient and responsive to
individual participants by only asking them questions that are relevant, as determined by their
48
previous responses. After being asked: Do you use a self-care plan? only those participants
who responded affirmatively were next asked: Do you find it effective? In contrast, those who
responded in the negative were asked: Would you consider developing a self-care plan if you
were provided with the time and resources to do it? Rather than frustrating participants with
irrelevant questions, these advanced aspects of web-based survey design serve to enhance the
individual participant experience and improve the overall response rate (Helms, Gardner &
McInnes, 2017).
Other strategic design features were also incorporated. Manual programming of
Hypertext Markup Language (HTML) in REDCap was used to customise the presentation of
questionnaire content, and thus present a more visually appealing user interface for
participants accessing the survey. Moreover, the inclusion of a visual progress indicator made
participants aware of how close they were to completion of the survey at any given stage. The
REDCap platform also accommodated mobile data entry, making the survey widely
accessible. For example, participants could view and respond to the survey in any location
with internet connectivity, via multiple devices such as smartphones, tablets, or
laptop/desktop computer; with the display size and functionality automatically optimised to
each device by REDCap. The survey content and accessibility was piloted among a small
group of palliative care nurses and refined prior to being finalised (Addington-Hall, 2007a).
The survey comprised a brief questionnaire including demographics and a
combination of open and closed questions about self-care practices. All numeric
questionnaire fields were coded appropriately as either categorical or continuous data
variables (Field, 2013; Schofield & Forrester-Knauss, 2013). Three validated measures of
self-compassion, compassion for others, and social desirability were also included: (1) Self-
Compassion Scale - Short-form (SCS-SF) (Raes Pommier, Neff & Van Gucht, 2011); (2)
Santa Clara Brief Compassion Scale (SCBCS) (Hwang, Plante, & Lackey, 2008); and (3)
49
Marlowe-Crowne Social Desirability Scale - Short-form (MC-SDS-SF) (Reynolds, 1982).
Sound validity and reliability of these scales has been reported within the psychometric
properties published across a number of studies (Fischer & Fick, 1993; Hwang et al., 2008;
Neff, 2016; Plante & Mejia, 2016; Raes et al., 2011; Reynolds, 1982).
While the SCS-SF and SCBCS were used as outcome measures, the MC-SDS-SF was
employed as a control measure to minimise the potential for social desirability response bias.
The importance of controlling for socially desirable responding in self-report research is
highlighted in the nursing literature (van de Mortel, 2008). Together, these measures are
identical to those used in other research by Neff and Pommier (2013). Given the absence of
any validated self-care measures at the time of this study, participants were asked to rate their
ability to implement and maintain effective self-care strategies using a horizontal sliding
visual analogue scale (VAS). This metric was administered using the REDCap survey VAS
tool, ranging from zero (not able) to one hundred (fully able), with ‘somewhat’ midway
between these. Electronic versions of a single-item VAS have been recognised as valid and
reliable survey instruments when measuring other phenomena such as pain and quality of life
(Bird et al., 2016; de Boer et al., 2004). Appendix C details the survey questionnaire in its
entirety, generated as a print report in REDCap.
All survey data were managed using REDCap software hosted at the University of
Sydney. Numeric data were exported directly to IBM SPSS Statistics 22 for descriptive
analysis of frequencies, means and percentages; or as appropriate, inferential statistical testing
(Field, 2013; O'Halloran, 2013). After performing Little’s (1988) Missing Completely at
Random Test in SPSS, it was determined that missing data were minimal and data imputation
was therefore not necessary (Field, 2013). All relevant assumptions such as normal
distribution of data and homogeneity of variance were met for parametric statistical tests
undertaken (Field, 2013). Confidence intervals were set at .95 and tests of significance were
50
two-tailed with p values < .05 considered statistically significant (Buettner, Muller & Buhrer-
Skinner, 2011). Inferential statistical analyses included hierarchical linear regression and
Pearson’s partial correlation coefficients using the widely accepted effect sizes of r =.1
[small], r = .3 [medium], and r = .5 [large] (Cohen, 1988; Field, 2013; Pierson, 2013).
Exploratory factor analysis was performed to provide a more detailed understanding
in relation to the self-compassion (SCS-SF) and compassion for others (SCBCS) scale data.
While exploratory factor analysis is most frequently used in the development and validation
of psychometric scales, in this study it was employed in a descriptive manner to explore
underlying dimensions of quantitative data by observing where they cluster together across
multiple dimensions. This method of analysis is particularly useful in illustrating individual
participant placement across multiple factors (Hershberger, 2005).
This exploratory analysis proceeded with all scale items from the SCS-SF and SCBCS
being loaded for factor analysis using maximum likelihood extraction and varimax rotation
methods (Field, 2013; Hershberger, 2005). From the resultant factors obtained, value
loadings were then computed as Anderson-Rubin scores and saved as a new variable in SPSS
to allow for descriptive analysis of both factors as a standardised composite (Field, 2013;
Grice, 2001).
Textual survey data from open question responses were exported into QSR NVivo 10
for coding and content analysis (Serry & Liamputtong, 2013; Liamputtong & Serry, 2013).
Content analysis is a systematic method of describing and quantifying phenomena, as a means
to distil words or phrases into representative categories based upon related content (Elo &
Kyngas, 2008). In this way, the content analysis deductively drew upon a framework of
physical self-care, inner self-care, and social self-care. This is consistent with the World
Health Organization’s (1946) definition of health with each self-care domain corresponding
to physical, mental, and social wellbeing, respectively. The use of content analysis was well
51
suited to this mixed methods study, as it can be performed either deductively or inductively.
Qualitative strand. In this strand of the study, in-depth interviews were conducted to
collect equally important qualitative data to extend or complement the quantitative data
(Payne, 2007; Serry & Liamputtong, 2013; Welch, 2011). After completing the survey,
participants were offered the opportunity to provide contact details—in an online form
separate to the survey—if they were interested in participating in a telephone interview.
These participants were contacted and interviewed by the researcher over a period of several
months until data saturation was reached (Payne, 2007; Welch & Jirojwong, 2011).
In-depth interviews were conducted via telephone using a semi-structured interview
guide. This was developed from the research questions after reviewing the literature
(Musselwhite, Cuff, McGregor, & King, 2007; Serry & Liamputtong, 2013). The interview
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.
Keywords: doctors; nurses; palliative care; self-care; survey; workforce
Introduction
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
625
58
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.
626 MILLS ET AL.
59
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)
Table 3. Content Analysis of All
Self-Care Strategies
Self-care domain Frequency (%)
1. Physical self-care 570 (38.7)2. Social self-care 455 (30.8)3. Inner self-care 451 (30.5)
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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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Address correspondence to:Jason Mills, RN, BN (Hons), MCHMed, FACN, PhD (c)
Faculty of Nursing and MidwiferyThe University of Sydney
M02 Mallett StreetNew South Wales 2050
Australia
E-mail: [email protected]
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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.
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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
Corresponding author:[email protected]
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
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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
Self-care ability 71.0 (19.1) 8.0 100 70.8 (18.8) 8.0 100 72.0 (20.5) 15.0 100
Compassion for others 3.79 (.70) 1.80 5.00 3.81 (.72) 1.80 5.00 3.67 (.64) 2.00 4.80
Self-compassion 3.26 (.63) 1.25 4.92 3.23 (.63) 1.25 4.92 3.39 (.64) 1.92 4.58
Self-kindness 3.11 (.79) 1.00 5.00 3.08 (.79) 1.00 5.00 3.26 (.79) 1.50 4.50
Self-judgement 2.80 (.95) 1.00 5.00 2.85 (.96) 1.00 5.00 2.57 (.91) 1.00 4.50
Common humanity 3.43 (.80) 1.00 5.00 3.40 (.82) 1.00 5.00 3.60 (.72) 1.00 5.00
Isolation 2.81 (.96) 1.00 5.00 2.82 (.95) 1.00 5.00 2.78 (.98) 1.00 5.00
Mindfulness 3.67 (.73) 1.00 5.00 3.65 (.74) 1.00 5.00 3.75 (.69) 2.00 5.00
Over-identification 3.07 (1.0) 1.00 5.00 3.10 (1.0) 1.00 5.00 2.90 (1.0) 1.00 5.00
Note: M = mean; SD = standard deviation.
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8 International Journal of Palliative Nursing 2018, Vol 24, No 1
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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
3.00000
2.00000
1.00000
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-1.00000
-2.00000
-3.00000
-3.00000
FemaleMale
A-R Score for Factor 1: Compassion for self
A-R
Sco
re fo
r Fa
ctor
2: C
ompa
ssio
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hers
-2.00000 -1.00000 1.00000 2.00000 3.00000.00000
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International Journal of Palliative Nursing 2018, Vol 24, No 1 9
Research
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.
If you have any queries or questions regarding submitting an article to the journal, please contact the Editor: [email protected] www.ijpn.co.uk
72
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.
73
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.
74
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.
75
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:
76
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
97
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
98
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
99
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
100
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.
101
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CHAPTER 6
STUDY RESULTS
Chapter Introduction
The purpose of this chapter is to present answers to the research questions through integration
of findings from the quantitative and qualitative strands of the study. Each of the study
research questions are addressed in turn, drawing upon either or both strands of the study as
appropriate.
Answering the research questions
RQ1. Participants practised self-care strategies across all three health-related domains of self-
care: (1) Physical; (2) Social; and (3) Inner-self-care. Physical self-care strategies were most
commonly used (39%), followed by social (31%) and inner self-care strategies (30%). The
most commonly used physical self-care strategies related to exercise and walking. The most
commonly used social self-care strategies involved spending time with family and friends.
Finally, the most common inner self-care strategies related to meditation and reading.
RQ2. Most participants (86%) considered self-care to be very important for nurses
and doctors working in palliative care. Others (13%) thought it was important, whilst some
(1%) considered self-care not very important to palliative care practice. Participants
commented that self-care was important in the context of longevity of being able to keep
caring for others.
RQ3. The regularity of participants’ self-care practice was mostly either frequent
(45%) or intermittent (44%), however, a considerable proportion (11%) rarely engaged in
self-care strategies.
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RQ4. Less than half of all participants (39%) had received specific training, education
or resources in their workplace about effective self-care strategies.
RQ5. Self-care plans were used by a small proportion of participants (6%); however,
more than two-thirds (70%) of participants reported they would consider using self-care plans
if training was provided. All participants who used self-care plans reported they were an
effective self-care strategy. Qualitative findings revealed that an ongoing process of planning
was considered an enabler to effective self-care practice.
RQ6. On average, the level of reported self-care ability in this sample was moderate
(M = 71, SD = 19; however, individual scores ranged as low as 8 from a maximum of 100.
The average level of participants’ reported self-compassion was also moderate (M = 3.26, SD
=.63), with some individual scores as low as 1.25 from a maximum of 5. Compassion for
others was, on average, reported at levels in the upper range of moderate (M = 3.79, SD
=.70); however, individual scores were reported at levels as low as 1.8 from a maximum of 5
RQ7. A positive and statistically significant relationship existed between self-
compassion and self-care ability in this sample, as indicated by a medium effect size
Pearson’s partial correlation coefficient, controlling for socially desirable responding (r =
.412, p = <.001). This association was further supported by hierarchical linear regression
indicating that self-care ability increased with higher levels of self-compassion. Qualitative
findings revealed that self-compassion was a key enabler to effective self-care practice.
Together, the quantitative and qualitative strands of this study suggest that self-compassion
supports self-care in this population (see Figure 1).
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Figure 1. Self-compassion supports self-care
RQ8. A modest, but negative, and statistically significant relationship was found
between self-compassion and compassion for others, as indicated by Pearsons’ partial
correlation coefficient, controlling for socially desirable responding (r = -.122, p = .019).
Hierarchical linear regression further indicated that as compassion for others increased, there
was a decrease in self-compassion. Exploratory factor analysis performed using composite
Anderson-Rubin scores suggests that a considerable proportion of participants scored either
low in both compassion for self and others, or high in compassion for others but low in
compassion for self. These results contrast with qualitative findings suggesting a contextual
connection between self-compassion and compassion for others, as enabling positive
emotions in the context of self-care practice. Self-compassion and compassion for others are
considered relational and enabling to self-care practice; however, there is an apparent
discrepancy in this population where increased compassion for others is associated with
decreased compassion for self. Taken together, the relationship between self-compassion and
compassion for others appears to vary.
RQ9. The meaning of self-care was described by palliative care nurses and doctors as
a proactive and holistic approach to promoting personal health and wellbeing to support
111
professional care of others. Self-care was further described as a relational and fundamental
part of palliative care practice – in the words of one participant, intrinsic to the work itself.
RQ10. Effective self-care practice was described as the implementation and
maintenance of personalised self-care strategies within professional and non-professional
contexts and the ongoing management of barriers and enablers to self-care practice.
Effective self-care practice encompasses a variety of strategies—both within and outside the
workplace—to enhance capacity for compassionate care provided through therapeutic
relationships. It is a shared responsibility between palliative care professionals practising self-
care, and the palliative care services in which they work. Positive workplace cultures and the
provision of staff support can assist staff to manage barriers and enablers to effective self-
care practice. Taken together, the self-care domains identified from the quantitative results
combined with the qualitative findings relating to the need for self-care across settings,
suggest that effective self-care practice involves the application of physical, social, and inner
self-care strategies in both personal and professional contexts (see Figure 2).
Figure 2. Self-care Domains and Contexts
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RQ11. A lack of planning for self-care, or otherwise adopting a solely ad hoc approach to
self-care practice was considered a barrier to effective self-care. Self-criticism and lack of
self-worth were discussed as common barriers to effective self-care. Multiple impediments to
self-care were identified in the workplace including busyness, workload, and limited
opportunities to take leave for holidays. 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 also described as a
barrier to self-care, and this was identified in relation to workplace culture and workload
expectations.
RQ12. Recognising the importance of self-care and prioritising it was considered an
important enabler of effective self-care practice. For some, this recognition arose through
previous experiences of illness or being unwell after having initially neglected self-care.
Reflecting on and having an appreciation of one’s own mortality was considered important
and enabling for self-care practice. Adopting a preventative approach to self-care was
important, whilst recognising that additional strategies may need to be implemented, as
required, according to context. Self-awareness was described as central to effective self-care
practice. Having a positive outlook, positive relationships, and positive emotions such as
gratitude or compassion for self and others were also considered enabling.
Planning for self-care was a key enabler of effective self-care practice. Participants
who used formal self-care plans found them enabling, while others who did not have formal
self-care plans considered an ongoing planning process to be more enabling than having a
static document. Positive workplace cultures conducive to 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
113
to effect positive change towards a culture more supportive of self-care. Positive role models
and leadership were also considered key enablers to effective self-care.
Chapter Conclusion
This chapter presented the integrated results of the study. It has addressed the research
questions by drawing upon both quantitative and qualitative strand data as appropriate. The
next chapter will discuss the overall results of the study in the context of this thesis.
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CHAPTER 7
DISCUSSION
Chapter Introduction
The purpose of this chapter is to discuss the overall results of the study in the context of this
thesis. The chapter begins with discussion of key findings and their implications for practice,
as well as recommendations for future research. It then proceeds by outlining the contribution
of the study to the literature. The chapter concludes with discussion of strengths and
limitations of the study.
Discussion of Key Findings
The key findings of this study add new knowledge and extend current understanding across
several areas, particularly in the Australian context of palliative care practice (see Table 1).
These findings are now discussed in relation to the existing literature. Whilst the study
findings related to all four themes identified from the literature review, the most significant
findings were those that address the fourth theme, balanced compassion.
Self-care strategies most commonly used. The self-care activities most frequently
practised by participants were physical. This is consistent with previous research involving
hospice professionals in North America (Alkema, Linton, & Davies, 2008). The use of
physical strategies such as regular physical activity, healthy dietary intake, and adequate
sleep also correspond with the healthy lifestyle behaviours observed in a cohort study of
Australian and New Zealand nurses and midwives (Tuckett & Henwood, 2015).
115
Table 1. Areas of Key Findings
Self-care strategies most commonly used
Perceived importance of self-care in
palliative care practice
Regularity of self-care practice
Provision of self-care education and
training
Uptake and utility of self-care planning
Ability to implement and maintain effective
self-care strategies
Levels of compassion for others
Levels of self-compassion
Relationship between self-compassion and
self-care ability
Relationship between self-compassion and
compassion for others
Compassion literacy The meaning and practice of self-care
Barriers and enablers to self-care practice
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While physical self-care was most common in the present study, the self-care strategies
described by participants were spread relatively evenly across the health-related
domains of physical, social, and inner self-care. This is consistent with other research that
investigated these domains in a sample of Spanish palliative care professionals (Sanso´ et al.,
2015), and suggests that employing a variety of strategies is important to palliative care
professionals’ self-care practice. Thus, palliative care professionals should consider
broadening their self-care practice where it is limited to one or two self-care domains.
Perceived importance of self-care in palliative care practice. Perceptions of
palliative care nurses and doctors in Australia are consistent with discussion in the literature
with regard to the importance of self-care. Whilst scholars have argued that self-care is
important (Jones, 2005; Kearney et al., Sanchez-Reilly et al., 2013; Kearney, Weininger,
Vachon, Harrison, & Mount, 2009), the perception of those in the broader field of palliative
care practice was to date largely unknown. This study provides empirical data to suggest that
a majority of the Australian palliative care workforce may share this position. Palliative care
services in Australia can use this knowledge to prioritise resources to support self-care
practice, especially with regards to targeted education and training for those receptive to it.
Moreover, education can be tailored to the small proportion of people who do not
consider self-care to be important to palliative care practice. These initiatives might usefully
draw upon these and other findings from this study to manage barriers and enablers to self-
care practice. For example, demonstration that a large majority of the study sample consider
self-care to be important might serve to break down stigma and help to normalise self-care in
workplace cultures where it is stigmatised as selfish.
Regularity of self-care practice. Renzenbrink (2004) argues the need for ‘relentless
self-care’, but the regularity of palliative care professionals’ self-care practice has not
featured in previous research. This knowledge could be useful in situations where
117
palliative care professionals might appreciate the importance of self-care but not engage
with self-care in practice. The finding that less than half of the participants practised self-
care frequently and more than 10 per cent rarely engaged in self-care practice is cause for
concern; this suggests a need for greater attention towards self-care education and
training. As alluded to previously, understanding the barriers and enablers to self-care
practice may be pivotal in improving the regularity of self-care practice so that it is more
consistent.
Provision of self-care education and training. Although adequate education and
training is important in supporting self-care (Palliative Care Australia, 2018; Palliative
Care Expert Group, 2016), only 39 per cent of nurses and doctors in this study had
received self-care education or training. This is concerning, especially given that in
Australia, for more than a decade now, palliative care professionals have been required to
initiate and maintain effective self-care strategies in accordance with Palliative Care
Australia’s (2005) national quality standards. This finding suggests that many staff may
not have received the necessary training to promote effective self-care practice. It also
supports the previous recommendations for increased self-care training (Palliative Care
Australia, 2016). More importantly, this finding underscores the importance of the recent
changes to the national standards (Palliative Care Australia, 2018) which, in effect, now
mandate the provision of self-care training for health care professionals working in palliative
care services in Australia. Indeed, the relevant survey paper was published during the
standards review consultation period, and this key finding helped to inform the changes
made.
This shift is significant in that there is now more emphasis on the responsibility of
palliative care services to provide adequate training to support self-care practice. Given
that self-care is a professional expectation, equipping palliative care professionals with
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the necessary means to understand and engage in effective self-care practices represents
a priority for palliative care services in Australia. While content and pedagogical
approaches to self-care training might usefully be drawn from programs already piloted
(Edmonds et al., 2015; Kerr, 2016; Kim, Rapp, Gill, & Myers, 2013; O’Connor &
Peyton, 2015; Radwany et al., 2012), findings from the present study suggest merit in the
consideration of compassion-based interventions to enhance self-care in the context of
promoting positive emotions. However, these interventions should be evaluated to test
for their effect on compassion levels, as well as health and wellbeing in palliative care
professionals.
Uptake and utility of self-care planning. The use of self-care plans has long been
promoted in the literature (Jones, 2005; Sanchez-Reilly et al., 2013); yet, prior to the
present study, data to indicate the utility and uptake of self-care plans in the palliative
care workforce was not available in the published research literature. In the current
study, all nurses and doctors who used a self-care plan reported it to be an effective self-
care strategy. However, the uptake of self-care plans in this sample was very low.
This might relate to the infrequent nature of some participants’ self-care practice,
or indeed, the lack of self-care education provided; as a considerable majority of those
who did not use a self-care plan indicated that they would be receptive to doing so, if
provided with requisite training and resources. This finding was further clarified by the
qualitative findings from this study. The low uptake of formal self-care plans was
contextualised by participants who described an ongoing process of planning as an enabler
to effective self-care practice, and more important than having a formal self-care plan that
represented a static document. Taken together, the study findings suggest that ongoing
planning for self-care practice is important, and that for some, formalising this process
through individual self-care plans is effective. Future education and training initiatives should
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therefore offer flexibility around the use of either formal or informal methods of self-care
planning.
Ability to implement and maintain effective self-care strategies. Despite an
international mandate for self-care in palliative care practice, palliative care professionals’
ability to implement and maintain effective self-care strategies had not been investigated in
the published research literature prior to this study. Collectively, participants in this study
reported a moderate level of ability to implement and maintain effective self-care strategies.
Individually, however, a proportion of very low ratings indicate that some palliative care
professionals feel limited in their capacity for self-care practice. This may be associated with
the previous finding relating to infrequent self-care practice.
Traditionally, self-care has not featured in general nursing or medical training, and the
findings herein suggest this is also the case for most nurses and doctors specialising in
palliative care. It is perhaps not surprising then, that some clinicians may find it challenging
to balance care of others with care for self. Indeed, in writing about self-care, Rogers (1980)
claimed it was more difficult than caring for others, and that it took time to learn. Rogers
(1980, p.80) conceded ‘I have always been better at caring for and looking after others than I
have in caring for myself. But in these later years I have made progress’. Elaborating further,
Rogers (1980, p.81) recounted a period when he felt particularly challenged in relation to
self-care whilst caring for his wife:
I was close to breaking point from being on call as a 24-hour nurse,
a housekeeper, a professional person in much demand, and a writer...
I explored and tried to meet my own needs. I explored the strain that
this period was putting on our marriage. I realised that it was
necessary for my survival to live my life, and that this must come
first, even though Helen was so ill.
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This realisation is consistent with the Foucauldian philosophy of the care of self, in which
people must first take care of themselves in order to better take care of others (Foucault,
2003). Individual results from the present study relating to self-care ability suggest that some
palliative care nurses and doctors may benefit from targeted education and training in this
area. Given the apparent importance of effective self-care practice, these findings suggest
room for improvement towards building capacity among palliative care professionals to
implement and maintain effective self-care strategies.
Levels of compassion for others. Despite growing concern that compassion is lacking
in care of the dying (Vachon, 2016a), there was very limited empirical understanding of
compassion for others in the palliative care literature prior to the present study. Overall,
participants in this sample reported a moderate level of compassion for others, with a mean
score of 3.79 as measured by the Santa Clara Brief Compassion Scale. Perhaps not
surprisingly, this sample of palliative care nurses and doctors scored higher in compassion for
others than did college students from Santa Clara University in North America, with mean
scores ranging from 3.09 in Engineering graduates to 3.69 in social science graduates, using
the same scale (Plante & Halman, 2016).
In other research using the Santa Clara Brief Compassion Scale, Neff and Pommier
(2013) compared undergraduate students with general community members. Palliative care
professionals in the present study scored higher than both, with the mean score of 3.22 in
undergraduate students and 3.31 in the general community. Whilst health professionals may
be expected to have higher levels of compassion than student and general community
populations, this finding is highly encouraging given that the literature is replete with
discussion of compassion fatigue. Nonetheless, on an individual level, there appears to be
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some cause for concern, with participants in the present study scoring as low as 1.8 on the
Santa Clara Brief Compassion Scale.
Lower levels of compassion for others might be explained by specific barriers to
compassion experienced in the clinical setting. While barriers to so-called medical
compassion have been investigated in physicians (Fernando & Consedine, 2017), future
research might usefully examine associations between identified barriers and levels of
individual compassion for others among broader health professional populations including
nurses. Other factors that may block compassion include coping and communication styles.
In conceptualising non-violent communication as a language of compassion,
Rosenberg (1999) argues that life-alienating communication involving moral judgement,
comparison, and denial of responsibility represent significant barriers to compassion. To this
end, preliminary work has been undertaken to examine and catalogue various characteristics
of compassionate communication in physician-patient dialogues (Cameron, Mazer, DeLuca,
Mohile, & Epstein, 2015); building on earlier work that established the mutual benefits of
non-verbal communication of compassion (Kemper & Shaltout, 2011). Although human-
centeredness lay at the heart of health care practice, there is also evidence to suggest that the
dehumanising of patients is a coping strategy for some nurses and doctors (Schulman-Green,
2003; Trifiletti, Di Bernardo, Falvo, & Capozza, 2014), and this may inhibit their expression
of compassion. Gilbert (2014) explains that many psychological difficulties relate to social
relational problems with feeling a caring, affiliative orientation towards others and oneself.
For example, self-criticism and negative emotions such as anger, disgust, or anxiety can
restrict feelings of compassion for oneself or others (Gilbert, 2014; Jinpa, 2015; Gilbert &
Choden, 2014).
Additionally, the phenomena of compassion fade (Västfjäll, Slovic, Mayorga &
Peters, 2014) and compassion collapse (Cameron (2017) may reveal insights into the
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experience of palliative and other health care professionals. Based on his research into
motivated regulation of affect (Cameron & Payne, 2011), Cameron (2017) explains that
compassion collapse – or the strategic avoidance of compassion – can occur as a protective
response where individuals feel overwhelmed by the magnitude of suffering they encounter.
The form of emotion regulation apparent in this compassion collapse is distinct from the
construct of compassion fatigue commonly discussed within the health care literature.
Another phenomenon described in the psychological literature is that of pseudoinefficacy.
Associated with psychic and psychophysical numbing, a sense of pseudoinefficacy is said to
occur when one feels non-rationally deterred or ineffective at engaging in compassionate
behaviours, based upon the scale of suffering that is apparent (Västfjäll, Slovic, & Mayorga,
2015).
These phenomena warrant further investigation within palliative care settings, given
the ongoing exposure to death, loss and grief. As explained by Remen (2002), ‘the
expectation that we can be immersed in suffering and loss daily and not be touched by it, is as
unrealistic as expecting to be able to walk through water without getting wet’ (p.52). As a
physician, Remen (2002) cautions, however, that protecting oneself from loss rather than
grieving and healing it, is a major cause of burnout. Taken together, the results of the present
study point to a need for further investigation of potential barriers to compassion, as well as
targeted interventions to help palliative care professionals better engage with suffering in
clinical practice - in a way that is both compassionate and sustainable. Indeed, sustainable
compassion is an important theme highlighted by Larkin (2016b).
Levels of self-compassion. Increasing attention has been paid to self-compassion in
the palliative care literature however, a lack of research has meant that empirical knowledge
is limited. This study found a moderate mean level of self-compassion among participants
(3.26). This is higher than was found in other research involving community nurses (Durkin,
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Beaumont, Hollins Martin, & Carson, 2016) and student midwives (Beaumont, Durkin,
Hollins Martin, & Carson, 2016) in the United Kingdom, with mean self-compassion scores
of 2.8 and 2.89 respectively. Limitations of these studies included an absence of control
measure for social desirability bias, and small sample size. Therefore, direct comparison with
these results may not be reliable.
Neff and Pommier’s (2013) study comparing undergraduate students with general
community members found mean self-compassion scores of 3.01 and 2.95 respectively. This
suggests that, on average, palliative care nurses and doctors have higher levels of self-
compassion than students and members of the general community. However, on an individual
level, self-compassion scores in this study ranged as low as 1.25. That some participants
reported very low levels of self-compassion is concerning and may impact on individual
capacity for self-care practice.
Lower levels of individual self-compassion may be explained by environmental
factors. For example, the health care system, itself, can be experienced as dehumanising to
the health care professionals working within it (Youngson & Blennerhassett, 2016); and this
experience, in turn, can lead to self-dehumanisation (Bastian et al., 2013l; Yang, Jin, He, Fan,
& Zhu, 2015). Given that appreciation of common humanity is a key component of self-
compassion, a diminished sense of one’s own humanity, in this context, may inhibit capacity
for self-compassion. Personal factors such as fear of positive emotion might also be involved.
A fear of giving or receiving compassion, for example, could contribute to the
variance in levels of compassion for self and others. As explained by Gilbert (2014), it is not
uncommon for self-compassion or compassion for others to be inhibited by fear. For
example, a nurse may fear being actively compassionate to patients whilst simultaneously
feeling in a state of emotional exhaustion; or a doctor may avoid feeling self-compassion
from a fear of it being perceived as weak, or otherwise antithetical to performance and
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achievement. Considering this, the expression of compassion for oneself or others is not
weak; it requires great courage not only to overcome these potentials fears, but to actively
engage with suffering with compassionate presence and action (Gilbert & Choden, 2014;
Jinpa, 2015). The requisite courage to engage in compassionate action in work settings is also
highlighted in the organisational literature (Kanov, Powley, & Walshe, 2017).
Self-criticism is correlated with a range of psychopathologies, such as depression and
anxiety (Longe et al., 2010), and people who are highly self-critical can find it especially
challenging to develop self-compassion (Gilbert, 2009, 2011; Jinpa, 2015; Neff & Tirch,
2013). Indeed, a study by Gilbert and colleagues (2012), found that self-criticism was
significantly correlated with a fear of compassion for self. This was evident in the qualitative
findings of the present study, with perceptions that achievements are largely accomplished by
beating yourself up a bit – to get a bit further and get better. This perception contrasts with
evidence that self-improvement motivation, personal improvement, and mastery achievement
goals are positively associated with a self-compassionate approach of accepting personal
failures (Breines & Chen, 2012; Neff, Hsieh, & Dejitterat, 2005; Zhang & Chen, 2016). The
fear of positive emotions may thus represent a considerable challenge to effective self-care
practice. Future research could advance knowledge in this area by investigating this
relationship using the fears of compassion scales (Gilbert, McEwan, Matos & Rivis, 2011).
According to Gilbert and his colleagues (2011), ‘it is not just the absence of compassion that
is important, but also the fear of compassion. This means that people may actively resist
engaging in compassionate experiences or behaviour’ (p.252).
Nonetheless, a number of benefits may be realised for those who embrace self-
compassion. For example, in a study of 213 health professionals and trainees, self-
compassion was strongly and significantly associated with resilience, mindfulness, improved
sleep, and reduced stress (Kemper, Mo & Khayat, 2015). It is also associated with physical
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health (Arch et al., 2014), psychological flexibility and emotional wellbeing (Marshall &
Brockman, 2016). This association is also supported by findings of a randomised controlled
trial of Acceptance and Commitment Therapy (ACT), in which the ACT intervention led to
large increases in self-compassion, mediated by psychological flexibility, with combined
reductions in psychological distress (Yadavaia, Hayes, & Vilardaga, 2014). Given that self-
compassion and its components of self-kindness, mindfulness, and common humanity are all
significantly correlated with emotional intelligence (EI) in nurses (Heffernan, Griffin,
McNulty, & Fitzpatrick, 2010; Şenyuva, Kaya, Işik, & Bodur, 2014), it may be that
differences in self-compassion in the present study can be explained by varying levels of EI
in this population of nurses and doctors. EI is fundamentally characterised by a capacity to
combine cognition and emotion towards achievement of a desired outcome (Hurley &
Linsley, 2012). In positive psychology, this capacity, or intelligence, is highly relevant in
relation to the utility and judicious use of positive emotions (Salovey, Mayer, Caruso, & Yoo,
2009; Bar-On, 2010). Tugade and Fredrickson (2002) speak to the intelligent use of positive
emotions as an ability to discern when they are appropriate, or not; and how best to use them
according to situational context. That self-compassion was negatively correlated with
compassion for others, in the case of the present study, may reflect limited EI in this self-care
context of positive emotion. Future research and education should therefore consider the
potentially mediating roles of EI and psychological flexibility when developing self-care
training programs. While the importance of EI to self-care among palliative care
professionals has been recognised, there is a need for future research in this area (Codier,
Muneno, & Freitas, 2011).
The relationship between self-compassion and self-care ability. Prior to this study,
the relationship between self-compassion and self-care ability had not featured in the research
literature. That self-compassion was strongly and positively associated with self-care ability
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is perhaps not surprising; however, this finding serves to establish an empirical basis to
support the theoretical literature positing a relationship between self-care and self-
compassion (Ajimol, 2011; Ozan, Okumuş & Lash, 2015; Vachon, 2016b; Watson, 2008,
2009; Youngson and Blennerhassett, 2016). According to Watson’s (2012) nursing theory of
human caring, loving-kindness, self-compassion and self-care are the building blocks of an
authentic, compassionate care for others. This finding also builds upon Fredrickson’s (2004)
broaden-and-build theory of positive emotions, in that self-compassion was significantly
associated with self-care ability, and participants considered self-compassion as enabling to
their self-care practice. In line with previous evidence to support the broaden-and-build
theory, self-compassion as a positive emotion may help to broaden one’s scope of attention,
cognition and action, whilst building and mobilising a range of personal resources and social
supports within an upward spiral to enhance physical health and psychological wellbeing
(Cohn & Fredrickson, 2010; Fredrickson, 2016; Fredrickson, 2013; Fredrickson et al., 2013;
Fredrickson, Cohn, Coffey, Pek & Finkel, 2008; Fredrickson & Branigan, 2005; Garland et
al., 2010; Hall, Row, Wuensch, & Godley, 2013; Odou & Brinker, 2015).
While a correlation does not indicate a causal relationship, the additional hierarchical
linear regression analyses, coupled with contextual qualitative findings identifying self-
compassion as an enabler to self-care practice, are suggestive of this. Thus, the fostering of
self-compassion as a positive emotion in the palliative care workforce may support and
enhance self-care practice. However, further research is needed to test this longitudinally,
through evaluation of self-compassion interventions in the palliative care workforce.
The relationship between self-compassion and compassion for others. A surprising
result from this study was that self-compassion was negatively correlated to compassion for
others. Yet these were described by participants as related positive emotions that enable self-
care. That these same variables were positively associated in a study of non-health care
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professionals with identical outcome and control measures as used in the present study, raises
questions about potentially unique factors inhibiting self-compassion in these nurses and
doctors. Given the association between self-compassion and self-care ability, this relationship
may be influenced by contextual factors such as barriers and enablers to self-care practice in
the workplace. Indeed, Chambers and Ryder (2009) suggested the culture of the practice area
is key to enabling compassionate care.
Vachon (2016b) wrote that self-compassion is necessary for compassion for others.
But the findings from the present study have indicated that palliative care nurses and doctors
report being capable of high levels of compassion for others, despite a lack of self-
compassion. As balanced compassion was an important theme identified in the literature, this
issue warrants further consideration, especially given that compassion for others was
negatively correlated with self-compassion in this study. According to the Dalai Lama
(2003), a respected scholar of compassion, ‘caring for others requires caring for oneself’
(p.125). This position is consistent with that espoused by Watson’s (2012) nursing theory of
human caring. Taken together, it may be that compassion for others, as a positive emotion, is
strengthened or more sustainable over time, when coupled with self-compassion; but since
these variables were negatively associated in this sample, further research is needed to test for
a causal relationship. The apparent discrepancy in balanced compassion raises implications
for compassion literacy (Burridge, Winch, Kay & Henderson, 2017).
Compassion literacy. As described by Burridge and colleagues (2017), compassion
literacy encompasses the capacity to balance compassion for patients with compassion for
oneself. That the present study found a negative correlation between compassion for others
and self-compassion raises concern that compassion literacy may be lacking in this
population. Thus, there is a need for further research to investigate this as well as factors that
might inhibit or promote compassion literacy. This line of inquiry may be particularly
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fruitful, given there is, in the psychological literature, a compelling body of evidence to
suggest the cultivation of self-compassion and compassion for others is beneficial to physical
health and psychological wellbeing (MacBeth & Gumley, 2012; Klimecki, Leiberg, Lamm,
& Singer, 2013; Klimecki, Leiberg, Ricard, & Singer, 2014; Kemper, Mo & Khayat, 2015;
Kok et al., 2013; Lutz, Brefczynski-Lewis, Johnstone, & Davidson, 2008; Lutz, Greischar,
Perlman & Davidson, 2009; Neff, Rude, & Kirkpatrick, 2007; Pace et al., 2009; Petrocchi,
Ottaviani & Couyoumdjian, 2017; Stellar, Cohen, Oveis & Keltner, 2015; Stellar & Keltner,
2014; Svendsen et al., 2016; Thayer, Ahs, Fredrikson, Sollers & Wager, 2012; Weng et al.,
2013).
However, further work should be undertaken to strengthen the theoretical basis and
inform future assessment of compassion literacy. While strategies for enabling compassion
literacy are discussed in the nursing literature, there is a lack of high quality evidence for
interventions to increase it as an outcome variable. This could be addressed through the
development and validation of an instrument to measure compassion literacy.
Given its relation to the important theme of balanced compassion, compassion literacy
and its measurement as a psychometric construct represents a priority for further study.
Future research should therefore undertake scale development and validation to enable the
reliable measurement of compassion literacy in the context of training interventions.
The research literature within the health professions is mixed in terms of articulating a
sound theoretical basis and methodological rigour where curricula or training interventions
designed to enhance compassion in health care professionals have been evaluated (Halifax,
2014; Hofmeyer et al., 2017; Lown, 2016; Rao & Kemper, 2017; Rushton et al., 2009; Winch
et al., 2014). Cullen (2016) argues that Schwartz Rounds represent an intervention that can
promote compassionate care and healthy organisations. Schwartz Rounds have been
implemented extensively across the USA (Lown & Manning, 2010) and increasingly in the
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UK, (Robert et al., 2017), including community, mental health (Farr & Barker, 2017), and
hospice settings (Reed, Cullen, Gannon, Knight & Todd, 2015). Given its broad uptake, the
acceptability and utility of this staff support intervention appears promising. However, a
stronger case for the implementation of Schwartz Rounds could be made with evidence that it
increased compassion in participants, which is to date lacking in the published literature.
Taken together, there is a lack of high-level evidence to support the effectiveness of
compassion-based interventions developed for health care professionals.
Given that contemplative emotion training can reduce negative emotional behaviour
and promote prosocial responses (Kemeny et al., 2012), future training interventions and
research could draw upon a number of compassion-based training programs that were
developed outside of the health care professions, but have been shown to enhance self-
compassion and or compassion for others (Brito-Pons, Campos & Cebolla, 2018; Jazaieri et
al., 2013; Kirby, 2017; Neff & Germer, 2013; Ozawa-de Silva et al., 2012), in addition to
promoting wellbeing (Jazaieri et al., 2014; Jazaieri et al., 2016; Jazaieri et al., 2017). A recent
systematic review by Kirby, Tellegen and Steindl (2017) conducted a meta-analysis of the
effects of compassion-based interventions from 21 randomised controlled trials involving
more than 1,000 participants. They found significant between-group differences in change
scores of compassion, self-compassion, mindfulness, depression, anxiety, psychological
distress, and well-being; concluding that the current evidence base indicates the potential
benefit of compassion-based interventions on a range of outcomes (Kirby et al., 2017). A
notable finding from research into the compassion cultivation training (CCT) protocol
developed at the Stanford University School of Medicine (Jinpa, 2013), is that caring
behaviours for oneself and others were significantly increased; from being negatively
associated at baseline, to being positively and strongly correlated post intervention (Jazaieri
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et al., 2016). In light of the present study, such change in caring behaviours may prove
significant if it can be replicated in the palliative care workforce.
Another strength of the CCT protocol is that it incorporates multiple foci including
mindfulness meditation, loving kindness meditation, and compassion-based contemplative
practices oriented towards oneself and others. Informed by both Buddhist and Western
psychology, the CCT program not only supports participants to generate loving kindness and
compassion for close companions; it also trains for compassionate responding towards
strangers and other people perceived to be difficult or challenging, by embracing a shared
sense of common humanity (Jinpa, 2015). As explained by Chodron (2002), ‘compassion is
not a relationship between the healer and the wounded. It’s a relationship between equals…
Compassion becomes real when we recognise our shared humanity’ (p.67). Thus, this
capacity may be particularly useful in the context of clinical practice. Indeed, a recent study
into the effects of CCT on health care professionals in North America found significant
improvements in mindfulness, interpersonal conflict, self-compassion, and compassion for
others (Scarlet, Altmeyer, Knier & Harpin, 2017). The authors of this study concluded that
CCT may be helpful in improving health and promoting resilience in health care
professionals.
Resilience, defined as ‘the ability of an individual to positively adjust to adversity’, is
an essential quality for health professionals that can be strengthened through self-care
(Jackson, Firtko & Edenborough, 2007, p.1). The present study has addressed previous calls
for exploratory qualitative research into different ways that resilience can be developed, and
strategies to promote self-care (Jackson et al., 2007). Qualitative findings relating to positive
emotion, positive relationships, character strengths, and self-awareness as enabling to self-
care, are entirely consistent with strategies identified for building resilience to survive and
thrive in the workplace (Jackson et al., 2007; McAllister & McKinnon, 2009). Moreover,
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there is growing theory and evidence linking positive emotions and character strengths to
resilience (Fredrickson, Tugade & Waugh, 2003; Tugade & Fredrickson, 2004; Tugade,
Fredrickson & Barrett 2004; Tugade, Devlin, & Fredrickson, 2014; Martínez-Martí & Ruch,
2017). Whilst negative emotions are considered a short-term evolutionary technique for
coping and survival, positive emotions are more durable and contribute to a reserve of
personal resources that can be drawn upon when resilience is required (Luthans, Vogelgesang
& Lester, 2006). Thus, effective self-care practice incorporating the development of positive
emotions may enhance resilience in palliative care professionals. Given that there has been
limited research into resiliency among palliative care professionals, these findings may serve
to inform tailored interventions to build resilience (Perez et al., 2015; Back et al., 2016).
Research involving the cultivation of positive emotions among healthcare
professionals may benefit through insights gained from new and emerging fields such as
positive neuroscience (Ashar, Andrews-Hanna, Dimidjian, & Wager, 2016) or more
specifically, compassion science (Seppala et al., 2017). Recent findings from these fields
highlight key associations between compassion, the amygdala, and activity in the vagus nerve
which connects the brain with visceral organs throughout the body (Man, Ames, Todorov &
Cunningham, 2016; Porges, 2017). One example of potential implications for research in the
health professions is the newly proposed role of heart rate variability for training and
assessing compassion (Kirby, Doty, Petrocchi & Gilbert, 2017).
Organisational perspectives. Having identified positive emotions, positive
relationships and character strengths as facilitators of effective self-care practice, this study
reveals the relevance of other research fields from which palliative services may stand to
learn in their efforts to promote health and wellbeing through self-care. For example, insights
from the field of positive organisational scholarship may help understand and implement
workplace interventions that impact beyond individuals, and within an organisational context,
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build more supportive cultures that promote self-care, positive emotions, and health and
wellbeing through the development of positive institutions (Cameron, Dutton, & Quinn,
2003; Cote, 2014; Garcea, Harrington & Linley, 2010; Peterson & Park, 2006).
The broaden-and-build theory of positive emotions has been applied to the context of
positive organisational scholarship (Vacharkulksemsuk & Fredrickson, 2013), and research
into compassion within organisations has been building for several years (Atkins & Parker,
2012; Dutton, Workman, & Hardin, 2014; Dutton & Workman, 2012; Frost, 1999; Kanov et
al., 2004; Lilius et al., 2008; Rynes, Bartunek, Dutton, & Margolis, 2012). A positive
example of this outside of palliative care, is the use of Appreciative Inquiry as a method to
develop a compassion awareness training program within a group of hospitals, mental health,
and primary care services in the United Kingdom (Curtis et al., 2017). Indeed, health services
research has demonstrated that explicit organisational measures to provide and support
compassion in the workplace are associated with positive patient experience ratings and
wellbeing in nurses (McLelland, Gabriel & DePuccio, 2018; McLelland & Vogus, 2014).
A key construct in positive organisational scholarship is that of psychological capital.
Luthans et al. (2007, p.542) define psychological capital as:
an individual’s positive psychological state of development characterised
by: (1) having confidence (self-efficacy) to take on and put in the necessary
effort to succeed at challenging tasks; (2) making a positive contribution
(optimism) about succeeding now and in the future; (3) persevering towards
the goals, and when necessary, redirecting paths to goals (hope) in order to
succeed; and (4) when beset by problems and adversity, sustaining and
bouncing back and even beyond (resilience) to attain success.
Building psychological capital in the workplace is said to be beneficial to the
individual, their colleagues, and the organisation; given that psychological capital
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comprises self-efficacy, hope, optimism, and resilience (Luthans, Vogelgesang, &
Lester, 2006; Youssef & Luthans, 2010). Psychological capital in nurses is
associated with greater work engagement (Bonner, 2016); however, it does not
appear to have been researched in the palliative care workforce.
Building from the concept of ‘healthy hospitals’, as discussed by Baum (2002) and
later by McAllister and McKinnon (2009), the findings from this study serve to advance the
field of healthy workplaces through the contribution of new knowledge. The World Health
Organisation (2010) provide the following definition:
A healthy workplace is one in which workers and managers collaborate to use
a continual improvement process to protect and promote the health, safety, and
wellbeing of all workers and the sustainability of the workplace (p.16).
The WHO (2010) further qualify this definition, stating that it is intended to primarily address
primary prevention aspects of health promotion, that is, to prevent illness happening in the
first instance; whilst at the same time, not precluding secondary or tertiary prevention. In a
health promotion context, this may help to clarify some apparent conflation in the literature to
date, by situating self-care strategies as most relevant to the primary prevention domain of
health promotion, as distinct from coping strategies and self-management, which may be
more relevant to secondary and tertiary domains of health promotion.
As highlighted by McAllister and McKinnon (2009), working in the health
professions is not without challenge or adversity; to the contrary, the complexities of
contemporary nursing and medical practice can at times be overwhelming from the ethical
challenges and emotional adversity encountered. Given that many nurses and doctors in
Australia are either experiencing or at risk of chronic illness, further intervention and research
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into self-care as part of health promotion would be beneficial. Indeed, nurses are commonly
viewed by patients as role models for health promotion (Mills et al., 2015), and it has been
argued in the Medical Journal of Australia, that hospitals should be exemplars of healthy
workplaces (Russell, Anstey, & Wells, 2015).
Such an achievement would require a reorientation of foci from those of treating
pathology or coping with stress and illness, to broader foci associated with promoting health
and wellbeing. Clearly, this kind of aspiration may represent a significant challenge for
hospitals or palliative care services, if undertaken in isolation and without support. However,
advances in effective self-care, workplace culture, and indeed, the health and wellbeing of
palliative care teams, may be more achievable if hospitals or palliative care services were to
join and actively participate in initiatives such as the World Health Organisation’s (2007)
International Network of Health Promoting Hospitals and Health Services. This network
was created with a purpose to promote and support the concept of health promotion in
hospitals and health services internationally. Active participation in this network would
go some way towards challenging the perceived conceptual dissonance between health
promotion and palliative care services, as well as demonstrating congruence with the growing
field of health promoting palliative care as a public health approach relevant to whole
communities (Rosenberg, Mills, & Rumbold, 2016; Mills, Rosenberg & McInerney, 2015;
Rosenberg & Yates, 2010).
The meaning and practice of self-care. The meaning of self-care, described by
participants as a proactive and holistic approach to promoting personal health and wellbeing
to support professional care of others, is consistent with the Foucauldian philosophy of the
care of self, in which people must first take care of themselves in order to better take care of
others. Thus, the meaning of self-care was described in a relational context that was
supportive and caring of others, rather than one that is solely self-serving. For palliative care
135
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,
motivated by the professional context of sustaining compassionate care in therapeutic
relationship with patients and their families. This finding reflects the following practice
sentiment captured in the Oxford Handbook of Palliative Care:
It is your responsibility to your patients, and your human right for yourself,
to nurture and maintain your physical, emotional, intellectual, and spiritual
being (Brigid Proctor, cited in Watson, Lucas, Hoy & Wells, 2009, p.965).
Moreover, it is consistent with the mandate for effective self-care practice as part of
maintaining a therapeutic relationship with patients and their families (Canning et al., 2005);
whilst supporting assertions from Kearney and colleagues (2009), that self-care is not a
selfish luxury, but is instead essential to clinicians’ therapeutic relationship with patients.
The practice of self-care was described as a process of maintaining a range of
personalised self-care strategies within both professional and non-professional settings. While
most research has to date focused on strategies used to cope with occupational stressors, this
finding, situated in the broader context of self-care, reveals not only the variety of effective
strategies employed; but also the challenges and complexities involved with maintaining
effective self-care strategies in practice. While palliative care professionals’ reported self-
care practices have previously corresponded with physical, social, and inner domains of self-
care (Sansó et al., 2015), findings from the present study underscore the imperative that
strategies from these self-care domains are implemented and maintained in both workplace
and personal settings. This recognition is important, as there can be a tendency to frame self-
care solely within organisational contexts, which leads to the neglect of other significant self-
care needs outside the workplace (Newell, 2017). Moreover, this finding underscores the dual
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importance of sustaining the professional self, whilst nurturing the personal self (Skovholt &
Trotter-Mathison, 2011).
Clinical supervision was an effective self-care strategy for many, but not for others;
and in some instances, was not available. Given the potential benefits to self-awareness and
staff wellbeing, the provision of supervision should be considered where it has not already
been made available with a focus on the restorative aspects of clinical supervision (Edmonds
Yeung, Onderdonk, Mitchell & Thornberry, 2015; Firth, 2011; Kearney & Weininger, 2011).
Mindfulness exercises were used spontaneously by participants in practice settings,
suggesting that the benefits of formal mindfulness training initiatives impact beyond training
rooms and into the clinical milieu (O'Connor & Peyton, 2015; Orellana-Rios et al., 2017).
Formal clinical supervision and informal debriefing were effective self-care strategies, 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 (Dean, 1998); however, this
finding extends a new context in terms of self-care behaviours to support health and
wellbeing. Indeed, there is evidence to suggest psychological and physiological health
benefits from laughter, including enhanced cardiac and immune function (Bennett &
Lengacher, 2009; Berk, Felten, Tan, Bittman & Westengard, 2001; Miller & Fry, 2009).
Establishing and maintaining effective boundaries within and outside of the
workplace was also an effective self-care strategy, and was related to work-life harmony.
While so-called work-life balance was discussed by some, and has also featured in other
palliative care research into coping mechanisms (Zambrano, Chur-Hansen & Crawford,
2014); this concept was incongruous to the experience of others. Overall for participants, 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
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roles was therefore a key strategy towards flourishing in life. 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 rather than using the term
‘work-life balance’ which is ill-defined and otherwise problematic in practice for some
palliative care professionals. For participants in this study, the practice of self-care also
involved managing barriers and enablers to self-care practice.
Barriers and enablers to self-care practice. The identification of specific barriers and
enablers to self-care practice has to date been lacking in the literature. Participants in this
study identified a number of barriers to effective self-care including stigma, busyness,
inadequate boundaries, self-criticism, low self-worth, and a lack of planning or prioritising
self-care. The barriers identified provide a valuable context which may also explain the low
levels of self-care ability identified in some doctors and nurses from the quantitative strand of
this study.
Perhaps the most prominent barrier discussed was that of unsupportive team cultures
or workplace environments that were not conducive to effective self-care practice. This
finding is highly alarming, yet not surprising, when considering that self-care was stigmatised
as either selfish or weak in some participants’ workplaces. Perhaps more concerning, is that
this stigma may serve not only to impede effective self-care practice in the workplace; but it
might also discourage palliative care professionals from taking personal leave or seeking
professional support when they require it. Compassionate organisations are vital to the
enactment of compassionate care for palliative patients and their families (Renzenbrink,
2016). In the words of Larkin (2016b) ‘compassion is not just about individual responses but
rather how practitioners are enabled by systems to sustain and support themselves in the
complex and challenging work that they do’ (p.204). Therefore, understanding the factors
that contribute to supportive workplace cultures and facilitate self-care is essential (Speck,
138
2006; Thompson, 2011). Palliative care services in Australia may benefit from the experience
of counterparts in the United Kingdom and Canada, who have focused on effective leadership
to foster workplace environments and team cultures of self-awareness, self-care, and staff
support (Dechamps, 2011; Wainwright & Breiddal, 2011).
Several enablers to self-care practice were identified in this study, both environmental
and interpersonal. Courage, authenticity and leadership were highlighted by participants:
being authentic in acknowledging one’s own human vulnerability; having the courage to
challenge stigma or be assertive in saying ‘no’, if acquiescing to additional workload might
compromise one’s own wellbeing; and leading by example in normalising and supporting
self-care as an essential aspect of palliative care practice. Courage, authenticity and
leadership have been recognised as character strengths that can be measured and cultivated
(Peterson & Park, 2009). Development of these strengths in palliative care teams should thus
be encouraged to help transform any unsupportive workplace cultures.
In this study, positive emotions such as self-compassion enabled self-care. This is
consistent with a burgeoning field of positive psychology research, in which positive
emotions not only have a biological basis for physiological health benefits; but also broaden
repertoires of positive thoughts and actions which, in turn, help to build personal and social
resources that lead to psychological wellbeing and flourishing (Cohn & Fredrickson, 2009;
Fredrickson, 1998, 2001; Kreibig, 2014; McCraty & Rees, 2009). While, in the context of
psychological flexibility, negative emotions are not necessarily to be avoided (Kashdan &
Ciarrochi, 2013); an awareness of and capacity to cultivate positive emotions should thus be
fostered as part of self-care practice. This might serve to promote resilience and emotional
intelligence both individually and across the palliative care team (Tugade & Fredrickson,
2002, 2004). Self-care planning was also enabling to self-care practice, but this process did
not necessarily require documentation of a formal plan.
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The finding that self-compassion was considered enabling to self-care corresponds
with the results from the quantitative strand of this study, in which self-care ability was
significantly associated with increased self-compassion in palliative care nurses and doctors.
Building from emerging evidence to support compassion-oriented training interventions in
palliative care teams (Orellana-Rios et al., 2017), future research should investigate any
causal relationship between these variables longitudinally. Studies could potentially
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
(Fredrickson et al., 2008; Jazaieri et al., 2013, Neff & Germer, 2013).
The ongoing need for reflective practice to build self-awareness, as well as the
management of multiple barriers and enablers to self-care practice, clearly demand increased
attention from practitioners and palliative care services. Given the personalised nature of self-
care practice, palliative care services should also consider ways in which a variety of self-
care strategies can be supported. For example, providing opportunities for formal clinical
supervision and informal debriefing, depending on individual choice; as well as supported
opportunities for the development of individual self-care plans for those who would benefit
from them.
Contribution of the study
The results from this study address key gaps in the palliative care literature relating to
provision of self-care education, as well as the nature and uptake of self-care practices such
as the use of self-care plans. The findings provide new insight into palliative care nurses’ and
doctors’ perceived ability to implement and maintain effective self-care strategies.
140
Furthermore, this study contributes an important qualitative perspective and serves to
advance knowledge of both the context and effective practice of self-care in the palliative
care workforce. In elucidating the meaning and practice of self-care through the voice of
palliative care professionals, this study extends current knowledge through a detailed account
of the context and complexity of effective self-care practice previously lacking in the
literature. In highlighting a shared responsibility for self-care practice, between palliative care
professionals and the palliative care services in which they work; key barriers and enablers to
self-care practice have also been identified, especially in relation to workplace culture.
While past studies have largely focused on self-care as a way of coping with
occupational stressors, this original research examined self-care in the context of promoting
health and wellbeing – firstly, by identifying the use of self-care domains that directly
correspond with health through physical, social, and emotional wellbeing; and secondly,
through the measurement and analysis of self-compassion and compassion for others, as
positive emotions associated with health and wellbeing. In addition to the development of
new education and training resources to support individual self-care practice, the uptake and
integration of findings from this study would be beneficial to existing resources such as the
Therapeutic Guidelines (Palliative Care Expert Group, 2016), and the national Palliative
Care Curriculum for Undergraduates (Australian Government Department of Health, 2017),
both of which include explicit content relating to self-care practice. The results of this study
might also be of use to other health professionals working outside of palliative care.
Strengths and Limitations
The use of a mixed methods research design represents a strength of this study, in combining
the strengths of quantitative and qualitative research. The representativeness and survey
response rate achieved in a national sample was also a strength. The use of a validated
141
measure to control for social desirability added further strength to the findings. Given that
reflexivity is not always addressed in mixed methods research, a final strength of this study is
the demonstrated rigour and trustworthiness achieved with regards to qualitative content
analysis, and ensuring transparency in relation to researcher reflexivity.
Nevertheless, a number of limitations to this study must also be acknowledged. First,
there were no validated scales available at the time of this study to measure self-care. The
visual analogue scale used in the survey therefore captured participant perceived self-ratings
of their own self-care ability. Future research should confirm the results of this study using
validated scales to measure self-care as a psychometric construct. Subsequent studies should
consider using the scales developed by Galiana and colleagues (2015) or Cook-Cottone and
Guyker (2018).
Second, the cross-sectional survey design was limited in its ability to only explain one
time point. Finally, consideration of potential cultural diversity in the expression of
compassion for self or others did not form part of this study. While this limitation is
consistent with other studies and scales developed to measure compassion, it is
acknowledged that potential differences may exist in the way that compassion is expressed.
This should be investigated through a discrete program of research testing the universality of
compassionate behaviours across cultures. Notwithstanding these limitations; as the first
study of its kind, this original research serves to advance knowledge and inform future
research in an area of significance to palliative care practice.
Recommendations
Having discussed the study findings in the context of current research literature, the following
key recommendations are made from this thesis to inform practice and future
research:
142
1. Increased self-care education and training for palliative care professionals.
2. Longitudinal research to investigate for any causal relationship between self-
compassion, self-care, and other variables such as resilience, measuring self-care as a
psychometric construct using validated scales.
3. Evaluation of compassion-based education and training interventions to test for
effect on compassion levels, as well as health and wellbeing in palliative care
professionals.
4. Further empirical investigation to strengthen the theoretical basis of compassion
literacy and inform the assessment of it through a validated measure.
Chapter Conclusion
This chapter has discussed the overall findings of the study, implications for practice, and
recommendations for future research. It has also outlined the strengths, limitations, and
contribution of this study to the literature. The next chapter will discuss the role and
development of middle range theory in the context of this thesis.
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CHAPTER 8
GENERATING MIDDLE RANGE THEORY
Chapter Introduction
Having answered the research questions and discussed the study findings in detail, this
chapter discusses the generation of middle range theory. From the empirical basis established
in this study, as well as consideration of the existing theory and research already discussed,
middle range theory statements are generated as a preliminary step towards further theory
development to inform practice and future research.
Middle range Theory
While the development and application of theory is evident in palliative care discourse
through the use of research methodologies such as grounded theory (Kuziemsky, Downing,
Black & Lau, 2007; Stiel et al., 2010; Shimoinaba et al., 2015), it is limited in the broader
context of practice. In describing the practitioner as theorist, Ellis (2012) argues that
theorising is an essential, but often neglected aspect of contemporary nursing practice. Given
that further theory development can serve to extend current theoretical knowledge and
advance practice in palliative care (Dobrina, Tenze & Palese, 2014; Desbiens, Gagnon &
Fillion, 2012), attention is now directed towards the generation of middle range theory.
Middle range theory is recognised as a meaningful organising structure within a
growing body of nursing knowledge that can be applied to both research (Lenz, 1998a) and
practice (Lenz, 1998b). Indeed, Liehr and Smith (1999) used the analogy of a wool spinner to
liken the impact of middle range theory, to the spinning of research and practice strands
together to form a synthesised and more meaningful thread. The origin of middle range
theory can be traced to sociologist, Robert Merton, who described middle range theory as
144
theories situated between everyday minor hypotheses, and theories that are systematically
developed and unified (Merton, 1968). In further conceptualising middle range theory, Smith
and Liehr (2003) refer to a ladder of abstraction comprising three distinct levels of discourse:
(1) philosophical; (2) theoretical; and (3) empirical, with middle range theory represented by
the middle rung – above the lower concrete level of empirical discourse, yet underneath the
higher level of philosophical discourse. Others situate middle range theory in between
practice or micro-range theory, grand theory, and meta-theory; with meta-theory representing
the most abstract and universal of four levels of theoretical thinking (Higgins & Moore, 2012;
McEwen, 2011a). Middle range theories function to describe, explain, or predict phenomena,
whilst being both specific and testable (McEwen, 2011b). While grand theory has
traditionally been the focus of much nursing research (Smith, 2014), middle range theory
serves greater practical utility through the development of generalisable theories that can
easily be applied, tested and refined in both practice and research (Higgins & Moore, 2012).
Moreover, the development of middle range theory is an effective approach to integrating
qualitative and quantitative findings into a synthesised thread (Liehr & Smith, 1999). As a
preliminary step towards the development of a formally named middle range theory as
described by Liehr and Smith (2017), middle range theory statements were developed under
the relevant domains of context, meaning, and practice (see Table 1).
This approach is consistent with other nursing research involving the generation of
similar middle range theory statements (Wand, White & Patching, 2011). The generation of
middle range theory is best achieved via multiple approaches (Liehr & Smith, 1999),
therefore the following middle range theory statements were developed through combination
of: (1) inductive theory building from the present study; (2) deductive theory building from
grand theory; and (3) synthesis of other theoretical literature (Liehr & Smith, 2017), as
discussed in chapter seven.
145
Table 1. Middle range theory statements
Domain Middle range theory statement
Context Self-care is a relational aspect of palliative care practice.
Meaning Self-care means adopting a proactive and holistic approach to
promoting personal health and wellbeing to support capacity for
the professional care of others.
Practice Effective self-care practice involves maintaining a variety of
personalised self-care strategies across physical, social, and
inner health domains, within both personal and professional
settings.
Self-compassion is a positive emotion that supports effective
self-care practice in health care professionals.
The relationship between self-compassion and compassion for
others varies according to individual compassion literacy.
146
While these are intended as generalisable statements for further application outside the scope
of this thesis, an important next task will be to test and refine them in practice, education, and
further research (Liehr & Smith, 2017).
Chapter Conclusion
This chapter has discussed the role of middle range theory and outlined preliminary middle
range theory statements generated to inform practice and future research through further
theory development. The next and final chapter will conclude the thesis.
147
CHAPTER 9
CONCLUSION
Thesis Conclusion
Through the reporting and discussion of a mixed methods study, this thesis has explored self-
care practice in palliative care nurses and doctors, and examined levels of and relationships
between self-care ability, self-compassion and compassion for others.
As noted in the review of the literature, there has been much discussion about self-
care, self-compassion, and compassion, yet relatively little research or empirical evidence.
This is despite the insistence of Kellehear (1999) that, in palliative care contexts, the
expression of compassion should not be idiosyncratic, nor its analysis impressionistic. While
positive emotions and wellbeing have been investigated in palliative care patients, similar
research has been lacking in workforce studies.
This thesis makes an original contribution towards the development of a more robust
body of knowledge to guide self-care education and thus support palliative care practice. It
has revealed the meaning and complexity of self-care practice as described by palliative care
nurses and doctors. It has also contextualised self-care strategies within the health-oriented
domains of physical, social, and mental wellbeing. In identifying a lack of self-care training
around Australia, the findings of this research have been of influence to the National
Palliative Care Standards (Palliative Care Australia, 2018). Increased education and more
widespread training is required to support palliative care professionals’ self-care practice.
This thesis also calls for greater compassion literacy and training to enhance it. The levels of
self-compassion and compassion for others measured in this study suggest a need for further
investigation into compassion literacy, and targeted interventions to promote it.
148
A preliminary middle range theory arising from this thesis posits that self-compassion
is a positive emotion that supports effective self-care practice. This along with other middle
range theory statements generated as part of this thesis should be tested in practice and
refined through further investigation. As the first mixed methods study of the palliative care
workforce to have examined self-care in relation to the positive emotions of self-compassion
and compassion for others, this research serves to establish the foundation of an empirical
evidence base for the relationship between positive emotions and self-care practice to
promote health and wellbeing in palliative and other health care professionals.
A sound basis for the scientific study of compassion—for self and others—is already
established outside of the palliative care literature. Future research should draw
methodological insights from the nascent field of compassion science (Seppala et al., 2017)
to establish a credible evidence base to support and guide the promotion of positive emotions
in palliative care practice. While the direct examination of health and wellbeing was outside
the scope of the present study, there is a significant body of evidence in support of the
broaden-and-build theory of positive emotions, suggesting that self-compassion and
compassion for others also contribute to the health, wellbeing, and flourishing of those who
experience and cultivate these positive emotions. However, further research involving direct
measures of health and wellbeing is required. Future studies should evaluate self-care training
programs to test whether compassion-based training and education enhance compassion
literacy and promote health and wellbeing in palliative care professionals. Given the
relationship between staff wellbeing and patients’ experience of care, this line of inquiry is
important, and may also serve to benefit health professionals working outside of palliative
care.
149
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