'You've got to give a part of yourself to do the job well': an exploration of occupational stress, wellbeing and psychological flexibility in palliative care professionals.
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Date
27/07/2020Author
Fisher, Shaun
Metadata
Abstract
Background: Palliative care professionals work with ongoing emotionally
and practically challenging situations. These challenges may include dealing
with complex symptomology, being unable to relieve suffering, patient
deaths, and having to have difficult end-of-life conversations with patients
and their family members. Despite these challenges, palliative care
professionals appear to have similar or lower levels of occupational stress or
burnout compared to other medical professional groups (e.g. oncology,
medical-surgical, etc.). The current thesis had three main aims. Firstly, it was
hoped that this research could lead to better decisions around measuring
occupational stress in palliative care professionals. Second, this research
aimed to describe and understand the experiences of palliative care
professionals and the helpful and unhelpful ways they respond to stress or
challenges at work. Thirdly, this thesis hoped to explore the role of
psychological flexibility (i.e. ability to contact the present moment without
judgment while persisting or changing behaviour in accordance with chosen
values) in the wellbeing of palliative care and other healthcare professional
wellbeing. Fourthly, this thesis also aimed at further investigating the
psychometric properties of the Mindful Healthcare Scale (MHS; Kidney,
2017), a new measure of psychologically flexible helping. To address these
aims the research in this thesis made use of multiple research methodologies
including a systematic review, a qualitative framework analysis study, and a
longitudinal survey design.
Study 1 method and results: The first study was a systematic review of
occupational stress measures used with palliative care professionals; it also
aimed to investigate psychological predictors of occupational stress in this
population. In this review, the COSMIN was used to rate the quality of the
studies with respect to the psychometric properties being addressed in each
study. The results indicated that Maslach Burnout Inventory, Professional
Quality of Life Scale, and Nursing Stress Scale were the most widely used measures and had the most evidence to support their use with palliative care
professionals. However, based on the COSMIN criteria the methodological
quality of the studies was fair overall. In addition, a narrative review of the
psychological predictors of occupational stress was provided. A number of
psychological factors identified as protective (e.g. self-efficacy/competence,
professional social support) and harmful (e.g. psychiatric morbidity, deathrelated anxiety) for palliative care professional wellbeing. Overall, this review
implies that the methodological quality of studies in this area could be
improved particularly by making hypotheses more explicit, reporting missing
data information, and using more longitudinal designs to examine
responsiveness and test-retest reliability of measures.
Study 2 Method and Results: A qualitative framework analysis study was
used to describe and understand the experiences of palliative care
professionals and how they responded in helpful or unhelpful ways to
challenges at work. Semi-structured interviews were conducted with 9
employed palliative care professionals. Participants identified being able to
make a difference to the suffering of others and personal growth as sources
of meaning and purpose in their work. Participants also highlighted emotional
challenges in providing palliative care, difficult patient family dynamics, work
environment factors (e.g. caseload), uncontrollability of patient symptoms,
having goals blocked and public perceptions of palliative care work as
stressful as frustrating aspects of their work. They also noted areas in which
this work had a personal impact such as making them more clear about life
priorities and being more comfortable with death and dying. In addition, a
number of helpful (e.g. accepting of challenges, being present) and unhelpful
(e.g. self-doubt, lack of self-care) responses were explored in relation to their
wellbeing and performance at work. This study provides further
understanding of the experiences of palliative care professionals and has
some implications for the design of interventions/training programs for this
population. Study 3 Methods and Results: This study was a longitudinal survey study
of palliative care provision, general psychological flexibility (i.e.
Comprehensive Assessment of Acceptance and Commitment Therapy
processes [CompACT]; Francis et al., 2016), psychological flexibility in
healthcare providers (MHS), self-compassion, self-as-context, and empathy
in predicting wellbeing in healthcare professionals. Participants were
recruited through social media (e.g. twitter posts with a link to the study),
contacting Marie Curie Hospices in Scotland, and word of mouth. Participants
who completed survey at time point 1 (T1; N = 163) were invited by email to
take part in the survey at time point 2 (T2; N =83). Data from T1 were used to
examine the structural validity of a new measure of psychological flexibility in
healthcare work (Mindful Healthcare Scale [MHS]; Kidney, 2017) and to
conduct a cross-sectional analysis of the relationships between the
psychological predictors and the wellbeing outcomes. Data from T2 was used
to examine the predictive ability of the psychological predictors measured at
T1 and wellbeing outcomes measured at T2.
A confirmatory factor analysis (CFA) approach and an exploratory structural
equation modelling (ESEM) within CFA (EwC) approach were used to
examine the structural validity of the MHS and its subscales (Engaged,
Awareness, and Defusion) in healthcare professionals. ESEM is a less
restrictive approach compared to CFA and allows for the cross-loadings of
items. Of the 163 participants recruited at T1 one participant was excluded
for having incomplete MHS response leaving 162 participants in the analysis.
Two measurement models were tested:
(1) The original MHS model [Higher order factor: PsychFlex. Firstorder factors: Engaged (5 items), Awareness (5 items), and Defusion
(3 items)]
(2) a one factor model [i.e. all items loading onto psychological
flexibility], Results from these analyses suggested that the ESEM approach
outperformed the CFA approach in terms of model fit for the original model
but not for the one-factor model. Furthermore, the original model as analysed
using the EwC approach was the only model that reached satisfactory fit; the
CFA approach to the original model did not reach a satisfactory fit. The onefactor model was not considered to have satisfactory fit in either CFA or
ESEM analyses. These findings suggest that the original model of the MHS
is a robust measurement of psychological flexibility in healthcare
professionals. It also suggests that the MHS may be best conceived as a
multidimensional measure of psychological flexibility with items loading onto
more than one factor.
The cross-sectional survey data at T1 were used to examine the role of
psychological flexibility in predicting wellbeing and burnout in healthcare
professionals. Based on correlational analyses, psychological flexibility (both
the generic and healthcare specific measure) appeared to positively correlate
with general wellbeing and compassion satisfaction and negatively correlated
with burnout and secondary trauma. However, the defusion subscale of the
MHS only significantly and negatively correlate with secondary trauma. In
hierarchical regressions, it was revealed that the subscales of the MHS
added significant additional variance in the prediction of the outcomes over
and above the subscales of the CompACT. However, the defusion subscale
only contributed to additional variance in secondary trauma. Palliative care
and non-palliative care providers differed on the fantasy subscale of the
empathy measure but not on any other measures.
The longitudinal data (including both T1 and T2) were used to examine the
ability of psychological flexibility to predict wellbeing outcomes in healthcare
professionals at a six-month follow-up. The MHS total score, engaged
subscale, and awareness subscale positively correlated with general
wellbeing and compassion satisfaction and negatively correlated with
burnout. However, only the awareness subscale and total scale negatively
correlated with secondary trauma. Defusion was found to only be significantly correlated with compassion satisfaction but in the negative direction (r = -.27,
p <.05). Therefore, a revised MHS was explored in further analyses (Revised
MHS = Engaged + Awareness; i.e. without defusion). The revised subscale
correlated in expected directions with all outcomes. In terms of incremental
validity across time, the revised MHS explained additional variance for
compassion satisfaction and burnout over and above the CompACT.
However, it did not add additional variance for general wellbeing or
secondary trauma across the six-month interval These findings also suggest
that psychological flexibility can predict future wellbeing and burnout
outcomes in healthcare professionals.
The longitudinal data was also used to examine the test-retest reliability of
the MHS. Based on the Intraclass Correlation Coefficients (ICC) the testretest reliability of the original MHS (ICC = .77, p<.001), defusion subscale
(ICC = .78, p <.001) and the revised MHS (ICC = .80, p <.001) were
considered good; whereas the engaged subscale (ICC = .73, p <.001) and
awareness subscale (ICC = .71, p <.001) were considered moderate.
Therefore, the MHS appeared to have moderate-to-good test-retest reliability.
Future research should extend this finding and examine the responsiveness
or sensitivity to change of the MHS. This would determine whether the MHS
can detect change in psychological flexible helping due to interventions or
training.
Discussion: Based on the current thesis, psychological flexibility is an
important theoretical construct to consider in the understanding and
prediction of occupational stress and wellbeing in healthcare and palliative
care professionals. In particular, the current thesis suggests that the MHS
may be particularly useful for predicting outcomes and measuring
psychological flexibility in healthcare and palliative care providers. However,
the current findings suggest that the Defusion subscale poorly contributes to
a robust measure of psychological flexibility. Further research should
determine whether defusion subscale is useful for some healthcare
professionals (e.g. psychological professionals). In addition, together the findings from the qualitative and survey studies suggest that an Acceptance
and Commitment Therapy (ACT) intervention may be particularly useful to
target wellbeing outcomes in palliative care professionals. Future research
should use these findings to develop and test an intervention for palliative
care professionals, should extend the findings of the MHS by exploring
additional psychometric properties (e.g. measurement invariance), and
should examine the relationship between psychological flexibility and other
important outcomes for healthcare providers such as working alliance, client
satisfaction, and turnover rates.