Faculty of Medicine and Health
A thesis submitted in fulfilment of the requirements for the degree of
Doctor of Philosophy
BN (Hons I) GCertHlthPromPall (La Trobe) GradDipMHN (RMIT) ProfCertPosEd (Melb) MCHMed (ANU)
April, 2018
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.
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.
ii
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.
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
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.
v
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.
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
The University of Sydney
vii
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).
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.
community. Oral paper presented at the 14th Australian
Palliative Care Conference: ‘Connection with Community’,
Adelaide, SA.
Fundamental to Fostering the Workforce. Oral paper
presentation at the 7th Biennial Palliative Care Nurses Australia
Conference: ‘Fostering Excellence in Palliative Care’,
Brisbane, QLD.
Chapter Introduction………………………………………………………………….…14
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 Introduction………..……………………………………………………….…..42
Research Questions………..……………………………………………………….……42
Mixed Methods Research..………………………………………………………….…..43
Chapter Introduction………..…………………………………………………….……..57
Examining self-care, self-compassion, and compassion for others……………….…….64
Chapter Conclusion………..……………………………………………………….……73
Chapter Introduction………………………………………………………………….…74
Chapter Conclusion……….……………………………………………………………101
Chapter Introduction…………………………………………………………….……..109
Chapter Conclusion………………………………………………………………...…..114
Strengths and Limitations………………………………………….…………….……..141
Chapter Introduction……………………………………………………………….…..144
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
xi
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 4
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
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
Chapter 8
xii
Dimensions of self-care…………………………………………………........................……33
Chapter 4
Scatter plot of individual Anderson-Rubin factor scores…………………………………….69
Chapter 5
The meaning and practice of self-care……………………………………………………….83
Chapter 6
xiii
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.
14
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
15
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
16
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
17
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.
18
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:
19
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
20
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
21
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.
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
Abstract Introduction: 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, RN, BN(Hons), MCHMed,
FACN, PhD Candidate. Lecturer, School of
Nursing, Queensland University of Technology,
QLD Australia
Midwifery, The University of Sydney,
NSW Australia
Faculty of Nursing and Midwifery, The
University of Sydney, NSW Australia
Corresponding author: jm.mills@qut.edu.au
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.
Methods A 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 strategy First, 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 exclusion All 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 review The 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 articles Year Authors Country Population Review themes
2014 Doka USA Palliative care (PC)
Workforce
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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Results A 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-care The 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 articles Author (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)
Feld and Heyse-Moore (2006)
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 being Promotion of health and maintenance of wellbeing
Awareness, expression, planning
Balanced compassion
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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 planning Awareness, 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-care As 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 compassion Compassion 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)
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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.
Discussion The 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 research This 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.
Limitations As 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.
Conclusion This 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
Acknowledgements:
the University of Sydney.
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l What resources could you draw upon in your workplace to build self-awareness and expression,
or develop an individual self-care plan?
l What steps could you take to maintain balance in your compassion for others and compassion for
yourself?
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