Conducting palliative care research can be personally and professionally challenging. While limitations in funding and training opportunities are well-described, a less recognized barrier to successful palliative care research is creating a sustainable and resilient team. In this special report, we describe the experience and lessons-learned in a single palliative care research lab. In the first few years of the program, 75% of staff quit, citing burnout and the emotional tolls of their work. To address our sustainability, we translated resilience theory to practice. First, we identified and operationalized shared mission and values. Next, we conducted a resilience resource needs assessment for both individual team-members and the larger team as a whole, and created a workshop based curriculum to address unmet personal and professional support needs. Finally, we changed our leadership approach to foster psychological safety and shared mission. Since then, no team-member has left and the program has thrived. As the demand for rigorous palliative care research grows, we hope this report will provide perspective and ideas to other established and emerging palliative care research programs.
Background: To effectively care for dying patients, nurses need to possess death self-efficacy—the state of having both a range of skills and capabilities to provide care to dying patients and confidence in one’s ability to do so. A paucity of death self-efficacy may lead to burnout.
Objectives: The aims of this study are to clarify oncology nurses’ death self-efficacy and to explore its relationships with attitudes toward death and burnout.
Methods: A cross-sectional study was performed in 7 cancer hospitals across mainland China between June and July 2019. Oncology nurses completed an online survey consisting of the Death Self-efficacy Scale, Death Attitude Profile–Revised Scale, and Maslach Burnout Inventory.
Results: The 755 oncology nurses completing the survey reported low death self-efficacy and high levels of burnout. Those who had more years of clinical experience, had the highest professional rank, talked death quite often, and have received palliative care trainings, doing no shift work, scored higher on death self-efficacy. Death self-efficacy was positively correlated with positive attitudes toward death and negatively correlated with levels of burnout. The multiple regression analysis showed that death self-efficacy and attitudes toward death were independent, significant predictors of oncology nurses’ burnout.
Conclusions: Chinese oncology nurses are not well prepared to care for dying cancer patients and cope with death-related issues.
Background: The aim of this study was to analyse the buffering effect of individual, social and organisational resources on health and intention to leave the profession in the context of burden due to quantitative job demands.
Methods: In 2017, a cross-sectional survey was carried out anonymously among nurses in palliative care in Germany. One thousand three hundred sixteen nurses responded to the questionnaire (response rate 38.7%), which contained, amongst others, questions from the German version of the Copenhagen Psychosocial Questionnaire (COPSOQ). Moderator analyses were conducted to investigate the buffering effect of different resources on health (‘self-rated health’ and ‘burnout’) and ‘intention to leave’ in the context of quantitative demands.
Results: ‘Self-rated health’ was significantly buffered by the resources ‘recognition through salary’ (p = 0.001) and ‘good working team’ (p = 0.004). Additionally, buffering effects of the resources ‘workplace commitment’ and ‘good working team’ on ‘burnout’ (p = 0.001 and p = 0.006, respectively) as well as of the resources ‘degree of freedom’, ‘meeting relatives after death of patients’, ‘recognition from supervisor’ and ‘possibilities for development’ on ‘intention to leave’ (p = 0.014, p = 0.012, p = 0.007 and p = 0.036, respectively) were observed.
Conclusions: The results of our study can be used to develop and implement job (re) design interventions with the goal of reducing the risk of burnout and enhancing job satisfaction among nurses in palliative care. This includes for example adequate payment, communication training and team activities or team events to strengthen the team as well as the implementation of some rituals (such as meeting relatives after the death of patients). As our study was exploratory, the results should be confirmed in further studies.
Although burnout syndrome has been investigated in depth, studies specifically focused on palliative home care are still limited. Moreover, there is still a lack of evidence regarding the interplay between emotional flexibility and sensitivity to context in preventing burnout in home care settings. For these reasons, the aims of this study were to examine burnout symptoms among practitioners specializing in palliative home care and to investigate the role of regulatory flexibility and sensitivity to context in understanding burnout. An exploratory cross-sectional design was adopted. A convenience sample (n = 65) of Italian specialist palliative care practitioners participated in this study. Participants were recruited between February and April 2019 from two palliative home care services that predominantly cared for end-of-life cancer patients. The Italian version of the Maslach Burnout Inventory (MBI), the Flexible Regulation of Emotional Expression (FREE) scale (a measure of emotional flexibility), and the Context Sensitivity Index (CSI) (a measure of sensitivity to context) were administered. Analyses of variance were conducted using the three MBI factors as dependent variables and profession as an independent variable. Subsequently, three identical analyses of covariance were conducted with age, work experience, flexibility and sensitivity to context as covariates. The results showed a low burnout risk for all three of the MBI factors, and there were no gender differences. An ANOVA revealed a significant effect of profession type and age on the emotional exhaustion factor of the MBI, and an ANCOVA indicated that these effects persisted after covariates were accounted for. The results also showed a significant effect of the FREE score on emotional exhaustion. These findings can help explain the differential contributions of profession type and age to the burnout symptoms investigated. In addition, the emotional flexibility component, as an aspect of resilience, represents a significant and specific factor of emotional exhaustion. Interventions to prevent burnout must consider these relationships.
Burnout is common in physicians who care for patients with serious illness, with rates greater than 60% in some studies. Risk factors for burnout include working on small teams and/or in small organizations, working longer hours and weekends, being younger than 50 years, burdensome documentation requirements, and regulatory issues. Personal factors that can protect against burnout include mindfulness, exercise, healthy sleep patterns, avoiding substance abuse, and having adequate leisure time. Institutional and work factors that can buffer against burnout include working on adequately staffed teams, having a manageable workload, and minimally burdensome electronic health record documentation.
Objectives: Palliative care workers have continuous exposure to the emotionally draining effects of pain, suffering, death, grief, and mourning. Burnout syndrome is common among these individuals who accompany patients on the way to death. This study evaluated burnout, stress, anxiety, and depression among care givers.
Methods: A total of 47 individuals working in palliative care units or internal disease and neurology clinics participated in the study. The participants were divided into 2 groups: palliative care workers (Group P) and workers in internal disease and neurology clinics (Group A). All of the participants completed the Maslach Burnout Inventory, the Beck anxiety and depression scales, and the Stress Appraisal Measure.
Results: A total of 47 healthcare workers agreed to complete the scales. Emotional burnout and desensitization scores were found to be elevated, and personal success scores were low in both groups. The Beck Anxiety Inventory revealed findings of moderate anxiety in both groups, while cognitive-sensorial, physiological, and pain complaints, as well as signs of stress, were more pronounced in Group A.
Conclusion: Burnout is a significant problem among healthcare workers and signs of stress and cognitive-sensorial, physiological, and pain complaints are particularly common among those working in palliative care units. Structural arrangements aimed at addressing the causes of burnout could positively affect the well-being of healthcare workers.
By 2060, almost 25% (98 million) of the population is expected to be aged 65 or older. Health care professionals who provide hospice and palliative care are overtasked and demonstrate symptoms of burnout. Narrative medicine and mindfulness interventions create meaningful connections with patients, improve the delivery of patient-centered care, and enhance the health of the caregivers. In this pilot program, health care professionals in hospice and palliative care settings were invited to participate in a study to evaluate the impact of narrative medicine or mindfulness on measures of burnout and empathy. Participants completed baseline and 12-week post-intervention surveys of burnout and empathy, as well as weekly journals of their experience. Mean overall scores for depersonalization were significantly reduced at 12-week post-intervention. There were no significant changes in emotional exhaustion or empathy compared to baseline. This brief, weekly intervention may be beneficial for both patients and health care professionals in the hospice and palliative care setting.
BACKGROUND: Clinician burnout in hospice and palliative care (HPC) has potentially widespread negative consequences including increased clinical errors, decreased professionalism, decreased staff retention, and decreased empathy. Reading non-medical literature has been associated with increased empathy, but no studies on the effect of reading on burnout have previously been conducted. We wished to assess reading patterns of practicing HPC clinicians and determine associations between non-medical reading and burnout.
METHODS: Sixteen-item electronic survey regarding reading practices, exposure to non-medical literature, fatigue, quality of life, and burnout symptoms was administered to members of the American Academy of Hospice and Palliative Medicine. Burnout measures of emotional exhaustion and depersonalization were assessed by the validated 2-item Maslach Burnout Inventory. Data were analyzed using descriptive statistics and multivariate regression.
RESULTS: Seven hundred nine members responded (15.2% response rate), of which 129 (18.2%) met the criteria for burnout, with 117 (16.6%) meeting the criteria for high emotional exhaustion and 45 (7.9%) meeting the criteria for high depersonalization. On univariate analysis, burnout was associated with age, reading habits, and fatigue, but not years in practice. On multivariable logistic regression consistent readers had decreased odds of overall burnout compared to inconsistent readers (OR 0.61; 95% CI, 0.39-0.97, P=0.036). This was true across the depersonalization (OR 0.58; 95% CI, 0.36-0.93, P=0.025), but not the emotional exhaustion domain.
CONCLUSIONS: Reading non-medical literature on a consistent basis may be associated with a significantly decreased likelihood of burnout, specifically across the depersonalization domain.
BACKGROUND: Hospice workers are required to regularly use emotional regulation strategies in an attempt to encourage and sustain terminally ill patients and families. Daily emotional regulation in reaction to constantly watching suffering patients may be intensified among those hospice professionals who have high levels of compassion fatigue. The main object of this study was to examine the relationship between daily exposition to seeing patient suffering and daily emotional work, and to assess whether compassion fatigue (secondary traumatic stress and burnout) buffers this relationship.
METHODS: We used a diary research design for collecting daily fluctuations in seeing patients suffering and emotional work display. Participants filled in a general survey and daily survey over a period of eight consecutive workdays. A total of 39 hospice professionals from two Italian hospices participated in the study.
RESULTS: Multilevel analyses demonstrated that daily fluctuations in seeing patients suffering was positively related to daily emotional work display after controlling for daily death of patients. Moreover, considering previous levels of compassion fatigue, a buffering effect of high burnout on seeing patients suffering - daily emotional work display relationship was found.
CONCLUSIONS: A central finding of our study is that fluctuations in daily witness of patients suffering are positively related to daily use of positive emotional regulations. Further, our results show that burnout buffers this relationship such that hospice professionals with high burnout use more emotional display in days where they recurrently witness patients suffering.
Palliative Care (PC) physicians are vulnerable for burnout given the nature of practice. The burnout frequency may be variable and reported between 24 to 38 % across different countries.
OBJECTIVE: The main objective of our study was to determine the frequency of burnout among PC physicians participating in PC Continuing Medical Education (CME) course.
METHODS: A survey including the Maslach Burnout Inventory (MBI) - General along with 41 custom questions were administered to determine the frequency of burnout among physicians attending the 2018 Hospice and Palliative Medicine (HPM) Board Review Course.
RESULTS: Of 110 physicians, 91 (83%) completed the survey. The median age was 48 years with 65% being females, 81% married, 46% in community practice, 38% in practice for 6–15 years. PC was practiced =50% of the time by 62%, and 76% were doing clinical work. About 73 (80%) reported that PC is appreciated at their work, 58 (64%) reported insurance to be a burden, and 58 (64%) reported that the electronic medical record was a burden. About 82 (90%) felt optimistic about continuing PC in future. Maslach Burnout Inventory results suggest that 35 (38%) participants reported at least one symptom of burnout. Only being single/separated showed trend toward significance with burnout (P = 0.056).
CONCLUSION: Burnout among PC physicians who attended a board review course was 38%. Being single/separated showed trend towards association with burnout. Physicians who choose to attend CME may have unique motivating characteristics allowing them to better cope with stress and avoid burnout.
Working with terminally ill patients is regarded as a stressful or traumatic event and may lead to negative outcomes, including job burnout and secondary traumatic stress (STS). Psychological resilience might protect employees from the negative consequences of stress. The aim of this study was to determine the mediating role of job burnout in the relationship between psychological resilience and STS. The study included 72 nurses aged from 22 to 72 years old (M = 46.01, SD = 10.69), working with terminally ill patients. The recipients completed 3 questionnaires: the Secondary Traumatic Stress Scale, the Oldenburg Burnout Inventory, and the Resilience Measurement. The results reveal negative associations between resilience, job burnout, and secondary traumatic stress, and a positive correlation between secondary traumatic stress and job burnout. Mediation analysis showed that job burnout plays a mediating role in the relationship between psychological resilience and secondary traumatic stress. Our findings highlight the role played by job burnout in the manifestation of STS. Professional and nonprofessional interventions for individuals experiencing work-related traumatic stress would benefit from interventions that build personal resources.
Purpose: Burnout in nursing is a global phenomenon. Caring for dying patients could increase nurses' death anxiety. However, minimal information about oncology nurses' burnout and attitudes towards death in Chinese culture has been reported. This study aims to assess Chinese oncology nurses’ burnout, and its relationship with attitudes towards death.
Method: A cross-sectional design was used. A total of 279 oncology nurses from a cancer hospital in northern China were recruited using convenience sampling, and completed a survey containing a demographic form, the Death Attitudes Profile Scale and the Maslach Burnout Inventory. Descriptive statistics, independent t-test and one-way ANOVA, Pearson correlation analysis and multiple regression analysis were conducted to analyze data.
Results: An average of 73.1%–86.9% of oncology nurses reported moderate to high levels of burnout. Specifically, 48.7%, 45.4% and 65.1% of oncology nurses reported high levels of emotional exhaustion, depersonalization and personal accomplishment, respectively. Multiple regression analysis showed that fear of death, escape acceptance, younger age and participation of death education/training were significantly associated with emotional exhaustion ( p < 0.01), accounting for 22.0% of the variance; fear of death, escape acceptance, and neutral acceptance in total explained 17.8% of depersonalization; fear of death, escape acceptance and neutral acceptance accounted for 8.5% of personal accomplishment.
Conclusions: Oncology nurses with more positive attitudes towards death experience less burnout. Death education and death related training including discussion of personal attitudes towards death should be part of nursing education programs, which would in turn prevent oncology nurses from burnout.
Deaths in long-term care (LTC) facilities in Canada have increased over the years,1,2 yet the link between exposure to deaths and dying and staff well-being has rarely been investigated. In this study, we examined predictors of staff burnout, focusing specifically on exposure to deaths and dying in LTC.
Trois caractéristiques des soins palliatifs pédiatriques sont susceptibles de fragiliser les soignants. Il s’agit du processus complexe d’identification à l’enfant, de la confrontation avec la mort d’un enfant et enfin de l’enjeu lié à la triade enfant/parents/soignant pouvant conduire à l’épuisement professionnel. Quelques possibilités pour prévenir ces phénomènes sont étudiés.
OBJECTIVE: Oncologists are exposed to suffering, loss, and death, which can potentially lead to grief reactions. Although grief over patients may be a natural consequence of the close and longstanding oncologist-patient relationship, the empathy that oncologists feel towards their patients may put them at risk for compassion fatigue (CF). This study examined the mediating role of the two components of CF - secondary traumatic stress (STS) and burnout - in the relation between empathy and grief among oncologists.
METHOD: Participants included 71 Israeli oncologists. Measures consisted of a demographic questionnaire, the Texas Revised Inventory of Grief-Present, the Interpersonal Reactivity Index, and the Professional Quality of Life questionnaire.
RESULTS: Oncologists reported moderate levels of grief, and relatively high levels of both STS and burnout. In addition, they reported high levels of the three components of empathy: perspective-taking, empathic concern, and personal distress. The PROCESS SPSS macro revealed support for the mediation model. The mediators (STS and burnout) fully accounted for the relationship between the following two components of empathy - perspective-taking and personal distress - and grief.
CONCLUSIONS: Oncologists commonly experience grief over patients. We found that oncologists' grief was related to their empathy, and that this association was explained by their levels of CF. The current research may mark a step toward recognizing oncologists' grief as well as understanding the processes associated with it.
CONTENT: Burnout is common amongst palliative care clinicians. Resilience helps to reduce burnout, compassion fatigue and is associated with longevity in palliative care.
OBJECTIVES: We aimed to study palliative care clinicians who have remained in the field for longer than 10 years to deepen our understanding on their views on burnout and resilience.
PATIENTS AND METHODS: We conducted a qualitative study using semi-structured interviews and purposive sampling on 18 palliative care clinicians - 5 doctors, 10 nurses and 3 social workers who worked in various palliative care settings (hospital palliative care team, home hospice and inpatient hospice). The mean age of the interviewees was 52 years old and the mean number of years practicing palliative care was 15.7 years (ranging from 10 -25 years). The interviews were recorded verbatim, transcribed and analysed using a grounded theory approach.
RESULTS: 4 major themes emerged from our analysis - Struggling, Changing Mindset, Adapting and Resilience (SCAR). Intervening conditions such as self-awareness, reflection, and evolution were also important factors. The core phenomenon of our study was that of 'Transformational Growth' - a process which palliative care clinicians have to go through before they achieve resilience. We also further classified resilience into both personal and collective resilience.
CONCLUSION: Our findings highlight the evolving process of transformational growth which palliative care clinicians must repeatedly undergo as they strive towards sustained resilience and longevity. It also stresses the importance of taking individual and collective responsibility towards building a culture of personal and team resilience.
PURPOSE: Oncologists cope with unique work characteristics that increase their risk of developing compassion fatigue-that is, burnout and secondary traumatic stress-and can result in reduced capacity and interest in being empathetic to the suffering of others (Stamm B. The concise ProQOL manual, 2010). At the same time, oncologists can experience compassion satisfaction-that is, the positive aspects of caring. This study explored the associations of compassion fatigue and compassion satisfaction with oncologists' grief and sense of failure beyond their reported exposure to suffering and death.
METHODS: Seventy-four oncologists completed self-administered questionnaires examining compassion fatigue, compassion satisfaction, grief, exposure to suffering and death, and sense of failure.
RESULTS: The oncologists reported that they face the loss of approximately 50% of their patients, and that their patients suffer from profound emotional and physical pain. High levels of compassion fatigue and grief, and moderate levels of sense of failure, were reported. Findings showed a lack of association between exposure to suffering and death and compassion fatigue and satisfaction. However, grief and sense of failure were found to predict both aspects of compassion fatigue: secondary traumatic stress (p < 0.001, p < 0.003, respectively) and burnout (p < 0.002, p < 0.025, respectively).
CONCLUSIONS: These results highlight the importance of the oncologists' subjective experiences of grief and sense of failure, beyond their reports of exposure to suffering and death, in terms of their levels of compassion fatigue. Implications of these findings include the need to develop interventions for oncologists that will allow them to acknowledge, process, and overcome negative experiences of failure and grief.
BACKGROUND: Overuse of antibiotics in end-of-life patients with advanced directives increases bacterial resistance and causes morbidity and mortality. Consultations with infectious disease (ID) physicians and burnout, which can affect antibiotic days of therapy (DOT) prescribed by physicians, have not been examined so far.
OBJECTIVES: To assess antibiotic use by physicians in end-of-life (EOL) patients with advanced directives and to investigate the association between ID consultations, physician burnout, and antibiotic DOT in those patients.
DESIGN: A descriptive correlational study.
SETTING: Acute-care and post-acute-care hospitals.
PARTICIPANTS: The study included 213 physicians and 932 their hospitalized patients in the last 2 weeks of life.
METHODS: We distributed questionnaires and analyzed the data collected regarding ID consultation, EOL antibiotics prescription with and without an advanced directive, and physician burnout to 278 physicians, and 213 were completed (response rate 76%).
RESULTS: Of the 932 deaths, 435 of 664 (>50%) were EOL patients with advanced directives. Of these patients, 74% received antibiotics, 29.9% had bacterial resistance cultures, and antibiotics were discontinued in only 5%. Half of the physicians lacked knowledge concerning antibiotics use issues and had significantly fewer consultations with ID physicians in EOL patients with advanced directives (mean rate, 0.27) than those without advanced directives (mean rate, 0.47). ID physicians reported significantly higher emotional exhaustion levels (mean rate, 29) than other medical specialties (mean rate, 19.2). Antibiotic DOT was significantly higher when patients had ID consultations (mean rate, 21.6) than in patients who did not (mean rate, 16.2). In post-acute-care hospitals and/or geriatric wards, antibiotic DOT was significantly higher than in other types of hospitals and/or wards. Depersonalization level was negatively related to antibiotic DOT (P < .05).
CONCLUSIONS: Antibiotics are overused in EOL patients with advanced directives. ID physician burnout and impact of ID consultation should be further assessed.
BACKGROUND: Critical care and palliative care professionals treat and support seriously ill patients on a daily basis, and the possibility of burnout may be high. The consequences of burnout can include moral injury and distress, and compassion fatigue, which are detrimental to both care and staff.
AIMS AND OBJECTIVES: To explore the incidence of moral distress in areas at high risk of burnout in a large cancer centre and to explore possible measures for addressing moral distress.
DESIGN: A cross-sectional survey.
METHODS: The Maslach Burnout Inventory was administered to critical care, critical care outreach, and palliative care teams in a specialist tertiary cancer centre. Open questions on supportive measures were also included. Burnout data were categorised into three domains of emotional exhaustion, depersonalization and personal accomplishment, and free-text analysis was conducted on the open-question data.
RESULTS: A total of 63 professionals responded across the teams (45% response rate). A low level of burnout was observed in the emotional exhaustion domain; depersonalization was higher in the critical care professionals; and overall, personal accomplishment was higher than normative scores. Free-text analysis highlighted three categories of responses: Debriefing, Managing emotional well-being, and Valuing individuals. There was a need to proactively recognize issues; undertake more debriefs; and open forums regarding cases, particularly with difficult deaths. Engaging all professionals, support to deal with families, and mandatory moral distress and resilience training were suggested, alongside a focus on team building through external activities such as group relaxation sessions and walks.
CONCLUSIONS: This study demonstrated a relatively low incidence of emotional exhaustion and depersonalization, and a slightly higher sense of personal accomplishment than normative scores despite staff working in an environment where high levels of burnout were expected.
RELEVANCE TO CLINICAL PRACTICE: Staff highlighted possible solutions to reduce burnout, which included debriefing, managing emotional well-being, and valuing individuals.