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Faculty of Medicine and Health A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Jason Mills, RN FACN FHEA BN (Hons I) GCertHlthPromPall (La Trobe) GradDipMHN (RMIT) ProfCertPosEd (Melb) MCHMed (ANU) April, 2018 Self-care, Self-compassion, and Compassion for Others Jason Mills

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Page 1: Self-care, Self-compassion, and Compassion for Others

Faculty of Medicine and Health

A thesis submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy

Jason Mills, RN FACN FHEA

BN (Hons I) GCertHlthPromPall (La Trobe) GradDipMHN (RMIT) ProfCertPosEd (Melb) MCHMed (ANU)

April, 2018

Self-care, Self-compassion, and Compassion for Others

Jason Mills

Page 2: Self-care, Self-compassion, and Compassion for Others

ABSTRACT

Introduction: This study of self-care arose through increasing interest in the relationship between the

quality of health care, and the health and wellbeing of health professionals providing that care.

Self-care practice is especially relevant for palliative care professionals, with the use of effective self-

care strategies mandated as a vital part of palliative care practice in Australia since 2005. Yet, there has

been little research to inform education and guide practice. The aim of this study was to explore

palliative care professionals’ self-care practice, and examine levels of, and relationships between, self-

care ability, self-compassion and compassion for others.

Methods: Using a mixed methods research design, a national survey of palliative care nurses and

doctors was conducted. The survey comprised a questionnaire about self-care practice, and validated

outcome measures of self-compassion and compassion for others, as well as a control measure of social

desirability. From the 372 respondents who completed the survey, 24 nurses and doctors participated in

semi-structured interviews. Quantitative and qualitative data were analysed separately using IBM SPSS

and QSR NVivo software.

Results: Self-care was practised across multiple health-related domains, with physical self-care

strategies used most frequently. Palliative care nurses and doctors recognised the importance of self-

care practice, but most participants had not received any self-care education or training. Levels of self-

care ability, self-compassion, and compassion for others varied. Self-compassion and self-care ability

were positively correlated; at the same time, a negative correlation was observed between compassion

for others and self-compassion, raising concerns about compassion literacy. Qualitative findings

revealed three themes relating to the meaning and practice of self-care: (1) A proactive and holistic

approach to promoting personal health and wellbeing to support professional care of others; (2)

Personalised self-care strategies within professional and non-professional contexts; and (3) Barriers

and enablers to self-care practice. From a synthesis of the combined results, middle range theory

statements were generated for further testing and refinement in practice and future research.

Discussion: Self-care is a proactive approach to promoting personal health and wellbeing to support

professional care of others. Effective self-care practice involves maintaining a variety of personalised

self-care strategies within personal and professional settings, and across physical, social, and inner

health domains. Consistent with the broaden-and-build theory of positive emotions, self-compassion

supports effective self-care practice. However, further research and intervention is recommended to

support individual capacity for self-compassion. Self-care training programs should be evaluated to test

whether compassion training and education enhance compassion literacy and promote health and

wellbeing in palliative care professionals.

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ACKNOWLEDGEMENTS

To my supervisory team, Associate Professors Jennifer Fraser and Timothy Wand, thank you.

I am deeply grateful for your unfailing patience, encouragement and expert guidance. Beyond

what I have learned, I also have a greater appreciation of all that is still to be learned.

My thanks go to the palliative care nurses and doctors who gave their time and careful

consideration as participants in this research. I found their courage, candour and commitment

as health care professionals to be deeply inspiring. I also acknowledge the generous support

of Palliative Care Nurses Australia and the Australian and New Zealand Society of Palliative

Medicine with recruitment during the survey component of this study. This research would

not have been possible without the support of an Australian Postgraduate Award from the

University of Sydney. I also thank Judith Fethney for her expert statistical guidance.

To my family, thank you for your love and support that has carried me through the

many twists and turns of this learning journey. Kristoff and Emely, Margie, Pete and Sue;

each of you have encouraged and supported me in so many ways that words cannot begin to

express how grateful I am. Jasper and Felix, this is the book that I promised to include your

names in. It’s also the reason for all those late nights and early mornings when you would

wake and find me at my desk. I now look forward to more walks and playing in the park with

you and Chai, rather than late nights at my desk.

Shyla, I could not have completed this work without your tireless support. Whether it

was taking the kids away for the weekend so that I could write at home, or sending me off on

a writing retreat to Boudhanath, Kathmandu. You always seemed to know just when and

what I needed to keep me going and on track. Thank you for believing in me and this work.

This belief proved infectious because I too, eventually, began to believe. You’ve been so

thoughtful and generous in many ways, but it is this gift that I will always treasure most.

Thank you.

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CANDIDATE’S STATEMENT

This is to certify that, to the best of my knowledge, the content of this thesis is my own work.

This thesis has not been submitted for any degree or other purposes. I certify that the

intellectual content of this thesis is the product of my own work and that all the assistance

received in preparing this thesis and sources have been acknowledged.

Jason Mills

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AUTHORSHIP ATTRIBUTION

This thesis contains published journal articles for which authorship attribution is provided by

the candidate below.

Chapter Two of this thesis is published as:

Mills, J., Wand, T., & Fraser, J. A. (2017). Palliative care professionals' care and

compassion for self and others: A narrative review. International Journal of

Palliative Nursing, 23(5), 219-229.

As the first named author, I developed the review objective and formulated the search

strategy, conducted the screening and review of the literature, and prepared the manuscript

for publication.

Chapter Four of this thesis is published as:

Mills, J., Wand, T., & Fraser, J. A. (2017). Self-care in palliative care nursing and

medical professionals: A cross-sectional survey. Journal of Palliative

Medicine, 20(6), 625-630.

AND

Mills, J., Wand, T., & Fraser, J. A. (2018). Examining self-care, self-compassion, and

compassion for others: A cross-sectional survey of palliative care nurses and

doctors. International Journal of Palliative Nursing, 24(1), 4-11.

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As the first named and lead author, I led the conception and development of the study design;

drafted the initial questionnaire and refined it in response to feedback; developed the

REDCap survey and tested online functionality; managed participant recruitment and

administered the open and closing of survey responses; performed data analysis with

guidance; and prepared the final manuscript for publication.

Chapter Five of this thesis is a journal article currently in press for publication as:

Mills, J., Wand, T., & Fraser, J. A. (2018). Exploring the meaning and practice of

self-care among palliative care professionals: A qualitative study.

BMC Palliative Care (In Press).

As the first named and lead author, I led the conception and design of the study, recruited

participants, performed data collection, data management and analysis, and prepared the final

manuscript for submission.

I understand that if I am awarded a higher degree for my thesis entitled Self-care, Self-

compassion, and Compassion for Others being lodged herewith for examination, the thesis

will be lodged with the Director of University Libraries and made available for immediate

use.

Jason Mills

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SUPERVISOR’S STATEMENT

As supervisor of Jason Mills’ higher degree research, I certify that the thesis entitled

Self-care, Self-compassion, and Compassion for Others is in a form suitable for examination.

As supervisor for the candidature upon which this thesis is based, I can confirm that the

authorship attribution statements above are correct.

Associate Professor Jennifer Fraser

Susan Wakil School Nursing and Midwifery

The University of Sydney

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PUBLICATIONS

Mills, J., Wand, T., & Fraser, J. A. (2017). Palliative care professionals' care and compassion

for self and others: A narrative review. International Journal of Palliative Nursing,

23(5), 219-229.

Mills, J., Wand, T., & Fraser, J. A. (2017). Self-care in palliative care nursing and medical

professionals: A cross-sectional survey. Journal of Palliative Medicine, 20(6), 625-

630.

Mills, J., Wand, T., & Fraser, J. A. (2018). Examining self-care, self-compassion, and

compassion for others: A cross-sectional survey of palliative care nurses and doctors.

International Journal of Palliative Nursing, 24(1), 4-11.

Mills, J., Wand, T., & Fraser, J. A. (2018). Exploring the meaning and practice of self-care

among palliative care professionals: A qualitative study. BMC Palliative Care

(In Press).

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PRESENTATIONS

2014 Do nurses care about self-care? Research priorities

and implications for practice. Oral paper presented at the

Australian College of Nursing ‘National Nursing Forum’,

Adelaide, SA.

2015 Are we fit for the future? Self-care strategies to future-proof

compassionate palliative care. Oral paper presented at the

13th Australian Palliative Care Conference: ‘Fit for the Future’,

Melbourne, VIC.

2017 The primacy of compassion: An essential connection with

community. Oral paper presented at the 14th Australian

Palliative Care Conference: ‘Connection with Community’,

Adelaide, SA.

2018 Understanding the Meaning and Practice of Self-care:

Fundamental to Fostering the Workforce. Oral paper

presentation at the 7th Biennial Palliative Care Nurses Australia

Conference: ‘Fostering Excellence in Palliative Care’,

Brisbane, QLD.

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TABLE OF CONTENTS

Preliminaries………………………………………………………………………………….ii

Abstract………………………………………………………………………………..….ii

Acknowledgements……………………………………………………………………....iii

Candidate’s Statement.………………………………………………………….………..iv

Authorship Attribution……………………………………………………………….…...v

Supervisors’ Statement………………………………………………………….………vii

Publications……………………………………………………………….…………….viii

Presentations……………………………………………………………….…………….ix

Table of Contents………………………………………………………….……………...x

List of Tables……………………………………………………………….…………...xii

List of Figures………………………………………………………….……………….xiii

Chapter One: Introduction and overview of the thesis…………………………………...14

Chapter Introduction………………………………………………………………….…14

Background….……..……………………………………………………………………14

Key Terms………..……………………………………………………………………...21

Study Aims………..……………………………………………………………….…….25

Thesis Overview………..………………………………………………………….…….26

Chapter Conclusion………..……………………………………………………….……26

Chapter Two: Literature review………..…………………………………………….……27

Chapter Introduction………..…………………………………………………………...27

Palliative care professionals’ care and compassion for self and others………….……...28

Professional Self-Care Scale developed for Spanish palliative care professionals…..….39

Mindful self-care, compassion satisfaction and burnout among hospice professionals...39

Summary………..……………………………………………………………………… 40

Chapter Conclusion………..………………………………………………………….…41

Chapter Three: Research design and methods…………………………………………...42

Chapter Introduction………..……………………………………………………….…..42

Research Questions………..……………………………………………………….……42

Mixed Methods Research..………………………………………………………….…..43

Philosophy of Pragmatism………………………………………………………….…...45

Research Methods………………………………………………………………….…....47

Ethical considerations……………………………………………………………….......55

Chapter Conclusion………………………………………………………………….......56

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Chapter Four: Quantitative Strand Results………………………………………………57

Chapter Introduction………..…………………………………………………….……..57

Self-care in palliative care nursing and medical professionals…………………….……58

Examining self-care, self-compassion, and compassion for others……………….…….64

Chapter Conclusion………..……………………………………………………….……73

Chapter Five: Qualitative Strand Findings……………………………………………….74

Chapter Introduction………………………………………………………………….…74

Exploring the meaning and practice of self care...............................................................74

Chapter Conclusion……….……………………………………………………………101

Chapter Six: Study Results………………………………………………………………..109

Chapter Introduction…………………………………………………………….……..109

Answering the research questions………………………………………………….…..109

Chapter Conclusion………………………………………………………………...…..114

Chapter Seven: Discussion………………………………………………………………..115

Chapter Introduction…………………………………………………………………...115

Discussion of Key Findings…………………………………….………………….…..115

Contribution of the Study…………………………………………….………….……..140

Strengths and Limitations………………………………………….…………….……..141

Recommendations……………………………………………………………………...142

Chapter Conclusion…………………………………………………………...….….....143

Chapter Eight: Generating Middle Range Theory……………………………………...144

Chapter Introduction……………………………………………………………….…..144

Middle range theory……………………………………………………….…………...144

Chapter Conclusion……………………………………………………………….…....147

Chapter Nine: Conclusion…………………………………………………………...…....148

Thesis conclusion……………………………………………………………….……...148

References…………………………………………………………………….…………....150

Appendices………………………………………………………………………………....195

Appendix A: Professional Self-care Scale……………………………………...……...196

Appendix B: Mindful Self-care Scale………………………………………….............197

Appendix C: Survey Questionnaire………………………………………………….....200

Appendix D: Reflexive Journal Extract……………………………………...………...205

Appendix E: Human Research Ethics Approval……………………...………..……....207

Appendix F: Survey Participant Information Statement………………………..……...210

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Appendix G: Interview Participant Information Statement and Consent Form…….….214

Appendix H: Self-Compassion Scale – Short Form……………………………………220

Appendix I: Santa Barbara Brief Compassion Scale…………………………….…….221

Appendix J: Marlowe-Crowne Social Desirability Scale – Short Form…………...…..222

LIST OF TABLES

Chapter 2

Summary of theoretical articles………………………………………………………………29

Summary of empirical articles………….……………………………………………………30

Chapter 4

Participant demographics…………………………………………………………….………60

Characteristics of participants’ perceptions and practice of self-care…………………..……60

Content analysis of self-care strategies………………………………………..………..……60

Descriptive statistics for study variables and subscales……………………………….……..68

Partial correlations between self-compassion, self-care ability and compassion for others…68

Hierarchical linear regression model…………………………………….………….….…….68

Chapter 5

Interview guide…………………………………………….…………….………….….…….77

Participant demographics and professional characteristics………….…………….....…...….80

Theme 1: A proactive and holistic approach to promoting personal health and wellbeing

to support professional care of others……………….....................................................….….82

Theme 2: Personalised self-care strategies in professional and nonprofessional contexts…..86

Theme 3: Barriers and enablers to self-care practice ………….…………….....…...……….91

Chapter 7

Areas of Key Findings………………………………………………….………….….…….116

Chapter 8

Middle range theory statements………………………….…………….………….….…….145

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LIST OF FIGURES

Chapter 2

Themes identified from the literature…………………………………………………...……31

Dimensions of self-care…………………………………………………........................……33

Chapter 3

Parallel convergent study design…………………………………………...…………...……45

Chapter 4

Word cloud from reported self-care strategies………………………………………….……61

Scatter plot of individual Anderson-Rubin factor scores…………………………………….69

Chapter 5

Coding categories and thematic content………………………………………………..….....81

The meaning and practice of self-care……………………………………………………….83

Chapter 6

Self-compassion supports self-care……………………………………………………...….111

Self-care domains and contexts……………………………………………………………..112

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CHAPTER 1

INTRODUCTION AND OVERVIEW

Chapter Introduction

The purpose of this chapter is to introduce the study and present an overview of this thesis.

The chapter begins with background to situate the study within the context of current theory

and practice. An orientation to key terms informing the research is then provided, followed

by the study aims. Finally, a stepwise description of each chapter is provided as an overview

to this thesis.

Background

The capacity of health care professionals to provide high quality, compassionate care to

patients is influenced, in part, by their own health status and level of wellbeing. The

importance of workforce wellbeing to both care performance and patient experience of care

has been established through large-scale studies of national health services’ staff (Boorman,

2009; Maben, Adams, Peccei, Murrells & Robert, 2012). The wellbeing of health

professionals is an important antecedent of patient care performance (Maben et al., 2012).

For example, in a multi-site mixed methods study using 498 patient experience surveys, 106

patient interviews, 427 staff wellbeing surveys, 86 staff interviews and 206 hours of

observation, Maben et al. (2012) concluded that efforts to enhance the wellbeing of staff were

not only important in their own right, but also for the quality of patients’ experience of health

care. The relationship between the quality of health care and the health and wellbeing of staff

providing that care is therefore significant.

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In recent years, there has been increasing evidence of chronic illness and growing

concern about poor physical health and psychological wellbeing in the Australian health care

workforce, particularly in the nursing and medical professions (Beyond Blue, 2013;

Bogossian et al., 2012; Lamont et al., 2017; Perry, Gallagher & Duffield, 2015; Perry,

Lamont, Brunero, Gallagher & Duffield, 2015; Ross & Barr, 2013; Ross, 2014; Schluter,

Turner & Benefer, 2012). Indeed, age-standardised rates of suicide in Australian nurses and

doctors between 2001 and 2012 were higher than those in other occupations outside of health

care (Milner, Maheen, Bismark, & Spittal, 2016). Given these concerns and the potential

implications for compromised patient care, more thorough investigation of health promoting

practices such as self-care is warranted.

Although caring is central to nursing practice, many nurses neglect self-care

(McAllister & McKinnon, 2009). Similarly, in medicine, self-sacrificing behaviours have

traditionally been viewed as noble (Rowe & Kidd, 2009). But self-care practice is an

important factor in preventing burnout and building resilience (Newell, 2017; Skovholt &

Trotter-Mathison, 2011). This is highlighted in Newell’s (2017), competency-based model

for professional resilience in human service professionals, which features self-care as one of

its key components.

Physician wellness was identified as a missing health care quality indicator in The

Lancet nearly 10 years ago (Wallace, Lemaire & Ghali, 2009), yet there appears to have been

little progress in prioritising the health and wellbeing of clinicians as an antecedent to optimal

patient care. Discussion of a ‘clinician-burnout crisis’ featured in a recent issue of the New

England Journal of Medicine, reminding health care professionals that they too are human,

and thus vulnerable to illness which may compromise clinical care (Dzau, Kirch & Nasca,

2018). In the same journal, Hill (2017), a palliative care physician, provided a poignant

account of human vulnerability in the context of addiction, depression, suicidal ideation and

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stigma, followed by recovery, self-awareness and self-care. Indeed, Hills noted his first

lesson in recovery was to prioritise self-care and wellbeing, instead of abusing alcohol to

cope with the demands of modern health care practice. While self-care is increasingly

discussed in the general nursing and medical literature (Mills, Wand & Fraser, 2015; Mills &

Chapman, 2016), it is especially relevant to those working in the specialty practice area of

palliative care.

Palliative care professionals represent a relatively small yet essential part of the health

care system, with nurses and doctors forming the majority of palliative care teams across

Australia (Australian Institute of Health and Welfare, 2017). As a specialty area of clinical

practice, the palliative care workforce is characterised by its holistic and team-based

approach, as well as a central focus on therapeutic relationships with patients and their

families to provide ‘total care’ (Clark, 1999; Canning, Rosenberg & Yates, 2007). This total

care requires an ongoing and, at times, intensive therapeutic use of self that demands constant

attention to self-care (Beng et al., 2015; Wakefield, 2000). This practice reality has been

reflected in professional and competency standards for more than a decade now, with the use

of effective self-care strategies mandated in Australia (Palliative Care Australia, 2005;

Canning, Yates & Rosenberg, 2005). However, the uptake and utility of self-care practices

appears largely unknown.

Chiarella and Duffield (2007) had previously identified concerns about the Australian

palliative care workforce that, in their view, warranted greater attention to ensure sufficient

staff would be available to meet the increasing demand for palliative care provision over

time. These concerns are further compounded by significant workforce shortages projected in

both nursing (Health Workforce Australia, 2014a) and medical professions (Health

Workforce Australia, 2014b) in the coming years. Given that nurses and doctors provide a

large majority of direct care work; these issues, coupled with concerns about health and

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wellbeing in the nursing and medical disciplines, raise important implications for the

sustainability of high quality palliative care in Australia.

Despite some evidence to suggest that palliative care professionals do not experience

higher levels of burnout or psychiatric morbidity than those working in other specialty areas

(Dunwoodie & Auret, 2007), Vachon (2011) outlines a broad variety of occupational

stressors that have featured over the past four decades. While suggesting that early

recognition of the important role of self-care in the palliative care field may have gone some

way towards alleviating the extent of stress experienced, Vachon cautioned that occupational

stressors appear to be increasing and thus complacency must be avoided. This position is

supported by research in Australian and international contexts of stress and burnout reported

in studies of palliative care nurses (Peters, Lee & O'Connor, 2013; Peters et al., 2012). While

much of the literature focuses on the prevalence of negative emotion and its relation to ill

health, positive emotions such as compassion represent an important yet under-researched

phenomena that may help palliative care professionals to thrive rather than just survive

(Vachon, 2011).

Studies have investigated positive emotions in relation to wellbeing among palliative

care patients (Beng et al., 2014), but positive emotions in this context have yet to be

examined in palliative care professionals. While a cursory discussion of positive emotions

such as compassion and self-compassion exists in relation to coping with occupational

stressors (Beng et al., 2015; Vachon, 2011), empirical research into positive emotion is more

broadly oriented towards flourishing and the promotion of health and wellbeing. Recent

concerns that compassion is lacking in care of the dying (Vachon, 2016a) highlight a further

need for investigation of positive emotions among palliative care professionals.

As understood through the interface of emotion science and evolutionary theory,

positive emotions have served an important adaptive function and are linked to increased

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social support and physical health (Shiota, 2014). Past research has established multiple links

between positive emotions, physical health, psychological wellbeing, and prosocial

behaviour. For example, the Nova Scotia Study (Davidson, Mostofsky, & Whang, 2010)

found that increased positive affect was protective against coronary heart disease over a 10-

year period. In studies led by Carnegie Mellon University in the USA, positive emotions were

associated with greater resistance to viral illnesses such as Rhinovirus (Cohen, Doyle, Turner,

Alper & Skoner, 2003), and Influenza A (Cohen, Alper, Doyle, Treanor & Turner, 2006). In

other research, Richman and colleagues (2005) found that higher levels of hope were

associated with decreased likelihood of having or developing hypertension, diabetes mellitus,

or respiratory tract infections; and similarly, higher levels of curiosity were associated with

decreased likelihood of hypertension and diabetes mellitus. Gratitude, as a positive emotion,

is also linked with a variety of benefits including improved sleep, cardiac function, and other

biomarkers of physical health (Emmons & McCullough, 2003; McCraty, Atkinson, Tiller,

Rein, & Watkins, 1995; Mills et al., 2015; Jackowska, Brown, Ronaldson, & Steptoe, 2015;

Redwine et al., 2016; Wood, Joseph, Lloyd & Atkins, 2009; Wood, Froh & Geraghty, 2010).

A meta-analysis of data from 35 studies found that positive psychological wellbeing

was significantly correlated with reduced cardiovascular mortality in healthy populations, as

well as reduced mortality rates in patients with renal failure or human immunodeficiency

virus (Chida & Steptoe, 2008). In addition to these links with wellbeing, positive emotions

also drive prosocial behaviour. There is evidence to suggest this occurs through a positive

feedback loop between positive emotions, prosocial behaviours and wellbeing (Layous,

Nelson, Kurtz & Lyubomirsky, 2017). Positive psychological wellbeing is thus an important

consideration for overall health and wellbeing in the context of caring for others.

The study of positive emotions in relation to psychological wellbeing, prosocial

behaviour, and physical health is largely informed by the field of positive psychology.

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Pioneered by Martin Seligman, positive psychology aims to focus equal attention on positive

affect and human flourishing to redress the traditional emphasis placed on negative affect and

human pathology (Seligman, 2012; Seligman, 2008; Seligman & Csikszentmihalyi, 2000).

The following quote illustrates the importance of this approach to workforce applications:

The field of positive psychology at the subjective level is about valued

subjective experiences: wellbeing, contentment, and satisfaction (in the past);

hope and optimism (for the future); and flow and happiness (in the present).

At the individual level, it is about positive individual traits: the capacity for

love and vocation, courage, interpersonal skill, aesthetic sensibility,

perseverance, forgiveness, originality, future mindedness, spirituality, high

talent, and wisdom. At the group level, it is about the civic virtues and the

institutions that move individuals toward better citizenship: responsibility,

nurturance, altruism, civility, moderation, tolerance, and work ethic

(Seligman & Csikszentmihalyi, 2000, p.5).

Seligman later developed a model for human flourishing (2012) and positive health (2008)

based on Positive emotion; Engagement; Relationships; Meaning; and Accomplishment

(PERMA). Positive emotions are significant in forming the foundation of the PERMA model,

yet this area has been neglected in studies of wellbeing in the workplace. The health and

wellbeing of health care professionals, in particular, might usefully be examined in this way

(Wiesmann, 2016); especially as the benefits of positive emotion and positive health may

potentially extend beyond health care professionals to their patients as care recipients

(Gudmundsdottir, 2011). Joseph (2015, p.5) explains that:

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As human beings, we are motivated to fulfil our potential, function at optimal

levels, and achieve a pleasurable and meaningful life; positive psychology is

concerned with how best to support these aspirations in us—in ways that are

both good for us, and those around us.

Two main approaches to wellbeing research are evident in the social sciences, adopting either

hedonic or eudaimonic perspectives to wellbeing (Deci & Ryan, 2008). Hedonia is associated

with the experience of short-term pleasure, positive affect, and enjoyment of material

comfort; whereas eudaimonia is characterised by a longer-term pursuit of meaning, purpose,

authenticity, and growth towards self-actualisation (Ryff, 2013; Ryff & Singer, 2008).

Eudaimonic wellbeing, in particular, is yet to be fully applied in health care settings.

(Weismann, 2016). While the experience of positive emotions represents a core aspect of

hedonic wellbeing, there is empirical evidence to suggest that positive emotions forecast and

induce increases in eudaimonic wellbeing, with both contributing to physical wellbeing

(Fredrickson, 2013). Thus, hedonia and eudaimonia are interrelated and complementary

facets of wellbeing, which together play a key role in human flourishing (Fredrickson, 2016;

Huta, 2015). This is consistent with the broaden-and-build theory of positive emotions.

According to Fredrickson’s (2001) broaden-and-build theory of positive emotions, the

experience of positive emotions broaden the individual’s mindset, leading to greater

behavioural and psychological flexibility. This then builds personal and social resources that

promote resilience and support physical health (Cohn & Fredrickson, 2009; Fredrickson,

2004; Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008; Fredrickson, Tugade, & Waugh,

2003). In this way, although the experience of positive emotions may be transient, the

supportive resources accrued are lasting (Fredrickson, 2008). Taken together, this body of

work indicates that the study of positive emotions represents an important avenue of inquiry

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in the context of health, wellbeing, and self-care. This thesis views health and wellbeing

through the lens of positive psychology, with positive emotions forming the foundation of

flourishing.

Key terms

Self-care. The term self-care came to prominence with Dorothea Orem’s Self-care Theory in

Nursing (Renpenning & Taylor, 2003). Self-care, in this context, relates to the identification

of a patient’s self-care deficit, and requires nurses’ appreciation of the agency, capacity and

responsibilities of patients in promoting their own health and wellbeing. Perhaps more

importantly, Orem stressed that self-care was fundamentally a human endeavour.

It is in this broader context that self-care is situated within this thesis, given that

health professionals are themselves human. In his seminal work The Nature of Suffering and

the Goals of Medicine, Cassell (1991) described nature and causes of suffering in medical

patients. In a corresponding text The Nature of Suffering and the Goals of Nursing, Ferrell

(2008) drew attention to the shared humanity and suffering of nurses, declaring that caring

for others without caring for oneself was unsustainable. Thus, self-care is not only a matter of

personal survival or optimal wellbeing; it also represents an important consideration for

sustaining clinicians’ capacity for patient care. This is reflected in Watson’s (2008) Theory of

Human Caring and the Foucauldian (2003) concept known as care of the self. Whilst noting

that Foucault’s philosophy of the self was not confined to the physical body, Perron (2013)

introduced the primacy of the self-self relationship as central to nursing and argued that care

of the self was a fundamental condition for nurses to care for others.

Self-care is not limited to coping with stress, and there may be merit in moving

beyond the confines of traditional stress and coping paradigms (Frydenberg, 2002) towards a

more positive paradigm of understanding how people flourish and thrive in their work, rather

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than merely survive (Moore, 2002). For the purpose of this thesis, self-care has been defined

as the self-initiated behaviour consciously adopted to promote health and wellbeing. Whilst

the capacity to cope with stress is important to resilience, coping strategies are not within the

scope of this thesis, in the same way that health is not merely the absence of disease or

infirmity (Gudmundsdottir, 2011; World Health Organisation, 1946).

Compassion for others. The origin of the term ‘compassion’ can be traced to its Latin

root: compati, meaning ‘suffer with’ and denoting a shared sense of human vulnerability

(Larkin, 2016a). As Nelson Mandela (2000) once observed, ‘…our human compassion binds

us the one to the other; not in pity or patronisingly, but as human beings who have learnt how

to turn our common suffering into hope for the future’. Common humanity is thus an intrinsic

element of compassion. Described by Nussbaum (1996) as the basic social emotion,

compassion and its cultivation have been the subject of considerable thought across

interdisciplinary discourse in philosophy, medical ethics, and the health humanities (Gelhaus,

2012, 2013; Leget & Olthuis, 2007; Nussbaum, 1996; Ozawa-de Silva, Dodson-Lavelle,

Raison & Negi, 2012; Vachon, 2012).

While much of the literature on compassion and its cultivation incorporates

perspectives from various Buddhist traditions (Gilbert & Choden, 2014; Halifax, 2011;

Hopkins, 2001; Jinpa, 2015; Masel, Schur & Watzke, 2012), compassion is universal to many

religions and wisdom traditions (Larkin, 2016a). Indeed, Larkin (2016a) argues that Dame

Cicely Saunders, widely acknowledged as the founder of the modern hospice movement,

established the philosophy and practice of palliative care as an expression of compassion

informed by her ‘profound Christian belief’ (p.169). According to the Dalai Lama (2003), a

noted scholar of compassion, the human capacity for compassion does not come from

religion; it comes from biology, but in this form, it is limited and biased towards kin - unless

it is consciously cultivated and expanded to include others in broader prosocial contexts.

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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

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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).

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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.

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Thesis overview

This thesis is presented in nine chapters. Following this introductory chapter, Chapter 2

provides a review of the literature to situate the study within the context of the current body

of knowledge. It also summarises the gaps identified in the literature review.

Chapter 3 outlines the research questions, research design, and methods used in the

study. Philosophical and ethical considerations are also discussed. Chapter 4 reports and

discusses the quantitative results of the study.

Chapter 5 reports and discusses the qualitative findings from the study. Chapter 6

presents answers to the research questions through integration of both quantitative results and

qualitative findings from the study.

Chapter 7 provides a discussion of the overall results of the study in the context of this

thesis. It discusses the key study findings and their implications for practice, as well as

recommendations for future research. It also outlines the study’s contribution to the literature,

noting its relative strengths and limitations. Chapter 8 discusses the role and development of

middle range theory in relation to the study findings and other relevant theoretical literature.

Chapter 9 provides a conclusion to the thesis.

Chapter Conclusion

This chapter has introduced the study as well its aims and background, in the context of

current theory and practice. An orientation to key terms informing the research has been

provided, followed by a chapter overview of the thesis.

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CHAPTER 2

LITERATURE REVIEW

Chapter Introduction

This chapter provides a review of the literature to situate the study within the context of the

field. This chapter includes one journal article published in the International Journal of

Palliative Nursing. Details of this publication are outlined below. More recent studies

published since this paper was accepted for publication are then considered before the chapter

concludes with a summary of what was known at the commencement of this study.

Palliative care professionals' care and compassion for self and others

Published Article:

Mills, J., Wand, T., & Fraser, J. A. (2017). Palliative care professionals' care and compassion

for self and others: A narrative review. International Journal of Palliative Nursing,

23(5), 219-229.

Author Contributions:

JM developed the review objective, formulated the search strategy and conducted the

screening and review of the literature, under the guidance of JF and TW. As the

corresponding author, JM drafted the initial manuscript and revised it with important input

from JF and TW.

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International Journal of Palliative Nursing 2017, Vol 23, No 5 219

AbstractIntroduction: Compassion is arguably central to palliative care. However, calls for the restoring of compassionate care suggest a need for greater understanding and promotion of compassion in practice. Drawing upon the Foucauldian concept ‘Care of the Self’, this review explored the literature relating to palliative care professionals’ self-care, self-compassion, and compassion for others. Methods: Three electronic databases were searched using identified key words. A thematic approach was used to synthesise and critically discuss the literature in the form of a narrative review. Results: Four themes were identified: (1) importance of self-care; (2) awareness, expression, and planning; (3) dimensions of self-care; and (4) balanced compassion. Approaches to self-care practice and research focused mainly on compassion fatigue or a coping paradigm. Conclusions: This review highlights both the importance and multifaceted nature of palliative care professionals’ self-care, in relation to self-compassion and compassion for others. Despite widespread discussion, empirical knowledge of these variables is limited. Future research could usefully explore health promotion interventions in self-care practice, or a positive psychology paradigm that encompasses compassion and self-compassion as positive emotions associated with wellbeing.Key words: l Compassion l Self-care l Self-compassion l Palliative care

This article has been subject to double-blind peer review

Compassion has traditionally been a hallmark of care for the dying (Saunders et al, 1981), but there is increasing

concern that the expression of compassion as a value in palliative care is being compromised (Kellehear, 2005). There is now growing clinical and research interest in the nature and place of compassion in palliative care internationally (Larkin, 2015). This, coupled with outside developments in the scientific study of compassion as expressed towards others and oneself (Singer and Bolz, 2013), presents a valuable opportunity for members of the palliative care profession to better understand and promote compassionate care. The Foucauldian concept ‘care of the self’ provides a pertinent perspective from which to understand care and compassion for others:

‘Care for others should not be put before the care of oneself. The care of the self is ethically prior, in that the relationship with oneself is ontologically prior.’ (Foucault, 2003)

According to Foucault, in order to take care of others, one must first learn to take care of oneself. This has been increasingly discussed in the health professions generally (Mills et al, 2015; Mills and

Chapman, 2016) and is now appearing in the palliative care discourse. For example, Vachon and colleagues (2015) have highlighted a link between self-care and self-compassion, and argued that self-compassion is a prerequisite to compassion for others. These perspectives suggest that more research is needed to examine the relationship between compassionate care for others, self-compassion and self-care.

In the context of health care professionals, self-care has been defined as ‘the self-initiated behaviour that people choose to incorporate to promote good health and general well-being’ (Sherman, 2004). Within the caring professions self-care is associated with resilience and burnout prevention, while a lack of self-care has been linked to compassion fatigue (Skovholt, 2001; Figley, 2002). As an ethical imperative, the Oxford Textbook of Palliative Social Work describes self-care as best practice in palliative care (Clark, 2011); and the relevance of self-care to quality patient care is also echoed in related disciplines of nursing, medicine, and allied health professions working in palliative care (Watson et al, 2009; Cherny et al, 2015; Vachon et al, 2015).

Self-care practice has even been mandated nationally and internationally through discipline-specific professional standards

Review

Jason Mills, Timothy Wand and Jennifer A Fraser

Jason Mills, RN, BN(Hons), MCHMed,

FACN, PhD Candidate. Lecturer, School of

Nursing, Queensland University of Technology,

QLD Australia

Timothy Wand, NP, RN, MN(Hons), PhD.

Associate Professor, Faculty of Nursing and

Midwifery, The University of Sydney,

NSW Australia

Jennifer A Fraser, RN, PhD. Associate Professor,

Faculty of Nursing and Midwifery, The

University of Sydney, NSW Australia

Corresponding author:[email protected]

Palliative care professionals’ care and compassion for self and others:

a narrative review

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(Canning et al, 2005; American Academy of Hospice and Palliative Medicine, 2009; Palliative Care Nurses New Zealand, 2014), and also within palliative care quality standards at the health service level (Palliative Care Australia, 2005; Hospice New Zealand, 2012). Despite this, there has yet to be a comprehensive review of self-care in the palliative care literature. Moreover, self-care has not yet been examined in relation to compassion for self and others. The objective of this review was to critically examine the literature relating to palliative care professionals’ self-care, self-compassion, and compassion for others; identifying implications for practice and future research.

MethodsA narrative review of the peer-reviewed literature was undertaken. This method was chosen in consideration of both the review objective and the emergent area of investigation, less suited to protocol-driven reviews that include empirical evidence only (Coughlan et al, 2013).

Search strategyFirst, a systematic search of the peer-reviewed literature was conducted. MEDLINE Complete, CINAHL Complete, and PsycINFO electronic databases were searched using the key words: compassion; self-compassion; self-care; palliative care; hospice. This search was then supplemented with an electronic search of key palliative care journals. Finally, bibliographies from articles were hand searched to identify any additional papers relevant to the literature review.

Criteria for inclusion and exclusionAll searches were limited to full-text articles published between 2000 and 2016 in English-language peer-reviewed journals. Articles were included where content directly informed the focus and objective of the literature review, including discursive papers as well as scientific papers reporting qualitative and or quantitative research. Papers were excluded if their focus was not directly relevant to one of the search terms, or where they focused on populations outside of the palliative care workforce. Editorials and conference abstracts were also excluded. For the purposes of this review, the term ‘hospice’ was used to accommodate variance throughout international terminology in relation to hospice and palliative care. A date restriction was not applied, considering the absence of any prior published reviews of the topic area.

Article management and reviewThe initial categorisation and storage of articles was managed using Thomson Reuters’ EndNote X7 bibliographic software. Full-text articles for inclusion were then imported to a dedicated database using QSR NVivo 10 data management software. Articles were read and re-read with annotations made to inform the review, and subsequent coding was performed to aid identification of patterns and common themes throughout the articles. As noted by Coughlan et al (2013), this is an effective approach to facilitate the integration of both theoretical and empirical literature. Further synthesis of the literature was then organised into themes for critical discussion.

Table 1. Summary of theoretical articlesYear Authors Country Population Review themes

2014 Doka USA Palliative care (PC)

Workforce

Importance of self-care

2014 Fernando and

Consedine

New

Zealand

PC workforce Balanced compassion

2013 Sanchez-Reilly et al. USA PC physicians Importance of self-care; dimensions of self-care; awareness, expression, and planning

2012 Radwany et al. USA PC workforce Awareness, expression and planning

2012 Halifax USA PC workforce Balanced compassion

2011 Halifax USA PC workforce Balanced compassion

2010 Showalter USA PC workforce Importance of self-care

2009 Kearney et al. USA PC physicians Importance of self-care; awareness, expression and planning; balanced compassion

2009 Morgan USA Paediatric PC nurses Importance of self-care

2005 Coulehan and Clary USA PC physicians Awareness, expression and planning; balanced compassion

2005 Jones USA Hospice workforce Awareness, expression and planning; dimensions of self-care

2005 Rokach Canada PC workforce Importance of sc; dimensions of self-care

2002 Katz and Genevay USA PC workforce Awareness, expression and planning

2002 Keidel USA Hospice workforce Importance of self-care

2000 Wakefield UK PC nurses Importance of self-care

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Review

ResultsA total of 38 articles were included in the review, comprising 15 theoretical papers and 23 empirical reports. Table 1 and Table 2 provide an overall summary of these articles. Four themes were identified from the literature: (1) importance of self-care; (2) awareness, expression and planning; (3) dimensions of self-care; and (4) balanced compassion (Figure 1).

Importance of self-careThe holistic promotion of health and the maintenance of personal wellbeing are defining characteristics of self-care within the palliative care literature (Sanchez-Reilly et al, 2013). Self-care is further defined as a process of maintaining one’s wholeness (Radwany et al, 2012). In this context, the importance of self-care in the palliative care workforce is well established in the literature. This is evident through widespread discussion and research into coping with occupational stressors such as grief, as well as burnout, and compassion fatigue (see for example: Keidel, 2002; Alkema

et al, 2008; Showalter, 2010; Harris, 2013; Kamal et al, 2016).

In his paper exploring the experiences of carer grief, Doka (2014) identified the ongoing exposure to loss and suffering as a danger to both the wellbeing of palliative care professionals as well as their capacity for effective care provision. This, he argued, is the risk when the experience of grief is either unexpressed, or otherwise disenfranchised through the professional context of the caring role. Doka further suggested that coping with grief relies on a variety of individual strategies such as acknowledgement, acceptance, and sharing of one’s grief. By way of an informal case study discussion, Wakefield (2000) argued for ‘relentless self-care’, meaning an enduring commitment to self-care practice as an important component of practice for palliative care nurses.

Citing unprocessed grief from ongoing exposure to loss, Sanchez-Reilly and colleagues (2013) highlighted self-care as a means to mitigate the harmful effects of burnout and compassion fatigue. Similarly, Kearney et al

Table 2. Summary of empirical articlesAuthor (Year) Country Design Population Review themes

Kamal et al (2016) USA Quantitative Hospice/PC workforce Importance of self-care

Beng et al (2015) Malaysia Qualitative PC doctors and nurses Importance of self-care; balanced compassion

Edmonds et al (2015) Canada Case Report PC workforce Awareness, expression and planning; importance of self-care

Forster and Hafiz (2015) Australia Qualitative Paediatric PC workforce Importance of self-care

Perez et al (2015) USA Qualitative PC workforce Importance of self-care

Shimoinaba et al (2015) Japan Qualitative PC nurses Importance of self-care; awareness, expression and planning

Sansó et al (2015) Spain Quantitative PC workforce Importance of self-care; dimensions of self-care; awareness,

expression and planning

Harris (2013) USA Qualitative Hospice nurses Importance of self-care

Kim et al (2013) Canada Quantitative PC medical trainees Awareness, expression and planning

Slocum-Gori et al (2013) Canada Quantitative Hospice/PC workforce Importance of self-care

Whitebird et al (2013) USA Quantitative Hospice workforce Importance of self-care

Breiddal (2012) USA Qualitative PC workforce Importance of self-care; balanced compassion

Melvin (2012) USA Qualitative Hospice/PC nurses Importance of self-care

Way and Tracy (2012) USA Qualitative Hospice workforce Balanced compassion

Lobb et al (2010) Australia Quantitative PC nurses Importance of self-care

Rushton et al (2009) USA Mixed methods PC workforce Balanced compassion; importance of self-care; awareness,

expression and planning

Swetz et al (2009) USA Qualitative PC physicians Importance of self-care; dimensions of self-care

Alkema et al (2008) USA Quantitative Hospice workforce Importance of self-care; dimensions of self-care

Rose and Glass (2008) Australia Qualitative PC nurses Importance of self-care; balanced compassion

Desbiens and Fillion (2007) Canada Quantitative PC nurses Importance of self-care

Abendroth and Flannery (2006)

USA Quantitative Hospice nurses Importance of self-care

Feld and Heyse-Moore (2006)

UK Quantitative PC junior doctors Awareness, expression and planning

Wasner et al (2005) GER Quantitative Hospice/PC workforce Importance of self-care; balanced compassion

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(2009) outlined various stresses that can lead to burnout and compassion fatigue, while emphasising self-care as an imperative when providing end-of-life care. In another review paper, Rokach (2005) suggested that each member of the palliative care team can and should attend to their own needs through self-care to cope with burnout. This was in recognition that palliative care professionals also experience suffering, just as patients and their families do. The cost of caring can significantly impact on the health and wellbeing of physicians, nurses, social workers, chaplains and volunteers in palliative care (Showalter, 2010). Keidel (2002) suggested that too many palliative care professionals have left their role because they were unable to continue as they had little capacity to care for others. However, capacity for self-care is also important, as many professionals in caring roles neglect self-care despite its importance (Showalter, 2010).

A range of research designs have been employed to examine self-care in relation to coping with occupational stress, burnout, and compassion fatigue. A qualitative study by Melvin (2012) explored compassion fatigue and coping strategies used among hospice and palliative care nurses in northeast USA. Through content analysis of interview data, the study concluded that physical and emotional health

consequences exist for nurses working in hospice and palliative care; and while some general strategies were reported, further research into coping strategies was recommended.

Abendroth and Flannery (2006) investigated burnout and compassion fatigue in a cross-sectional survey of 216 nurses across 22 hospices in Florida. In their study, burnout was related to physical and emotional exhaustion caused by exposure to emotionally demanding situations, while compassion fatigue was conceptualised as a secondary traumatic stress reaction from helping others. Hospice nurses in their study were deemed to be at moderate to high risk for both burnout and compassion fatigue. Additionally, these nurses were identified as at greater risk of compassion fatigue if they did not report self-care practice.

Beng and colleagues (2015) developed the total care model of occupational stress in palliative care, with total care conceived as an approach that integrates self-care into caring for others. Through focus group discussions with American hospice nurses, Harris (2013) found that social support, humour, and prayer/meditation were reported as the most effective ways of coping. Commonly used coping methods in a study by Perez and colleagues (2015) included ‘engaging in healthy behaviours and hobbies’ and ‘seeking emotional support from colleagues and friends’. Taken together, the vast majority of discussion and research reflects the discourse of self-care as a way of coping. There are, however, other ways in which self-care is viewed as important.

Research by Breiddal (2012) suggests that self-care is also understood and practised by the palliative care workforce as a way of being. Breiddal argued that historically self-care has been socially constructed as a series of disconnected activities in response to stress rather than as an agent of prevention, or early intervention for stress and burnout. Through her discourse analysis, Breiddal interpreted self-care to mean an active and responsive way of being, in relation to personal and organisational values, responsibilities and resources.

Apart from a way of coping or a way of being, self-care can also be understood as a way of promoting health and maintaining wellbeing. From their qualitative study of Australian nurses, Rose and Glass (2008) highlighted the importance of self-care in enhancing emotional wellbeing when providing palliative care. As the only study to allude to barriers to self-care, this research also found that stigma prevented some nurses from prioritising self-care, highlighting influence of peers. Apart from this, it is evident Figure 1. Themes identified from the literature

The importance of self-care

Way of coping (stress, grief, burnout, compassion fatigue)Way of beingPromotion of health and maintenance of wellbeing

Awareness, expression, planning

Mindfulness and meditationDebriefing, clinical supervision, poetryIndividual self-care plans

Balanced compassion

Self-compassionCompassion for others

Dimensions of self-care

Physical, psychological, emotional, spiritual, professional, balance Physical, inner, socialPersonal, professional

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that very little research into self-care has explicitly focused on health promotion and the fostering of wellbeing, outside of a paradigm of coping with stressors. Nonetheless, the peer-reviewed literature is unequivocal in both its volume and emphasis with regards to the importance of self-care. In addition to this, it also highlights key aspects of self-care.

Awareness, expression, and planningAwareness, expression, and planning, together represent significant aspects of self-care. This is evident through widespread discussion and research into associated activities such as debriefing, clinical supervision, reflective writing, poetry, mindfulness and other meditative or planning techniques (see for example: Katz and Genevay, 2002; Jones, 2005; Rushton et al, 2009; Edmonds et al, 2015; Sansó et al, 2015).

Awareness relates both to the suffering of others as well as ones’ own emotional responses and suffering. Katz and Genevay (2002) outlined the complexity and potential impact of counter-transference issues that may arise in emotional responses when providing end-of-life care. Self-awareness is therefore considered to be central to self-care. To this end, the use of mindfulness meditation and reflective writing has been discussed as an effective means to foster self-awareness and facilitate self-care (Sanchez-Reilly et al, 2013; Kearney et al, 2009). For Kearney et al (2009) self-awareness is essential to maximising individual wellness. Others have reported the use of clinical supervision as an effective self-care strategy to promote the expression of thoughts and feelings (Edmonds et al, 2015). Expression, in this way, represents an important aspect of self-care; although it is not limited to clinical supervision or debriefing. For instance, writing poetry has also been discussed as an effective self-care strategy, and has been used in team activities as a creative and effective outlet for personal expression (Radwany, 2012; Coulehan and Clary, 2005).

Planning for self-care is also considered important for palliative care professionals. In the same way that dedicated care plans contribute to optimal care for patients, there is a view that self-care should be systematic rather than haphazard. According to Jones (2005), to relieve stress and prevent burnout an individualised self-care plan should be developed and used to balance ones’ own needs with the needs of patients. Sanchez-Reilly et al (2013) go further, to recommend self-awareness plans in addition to a self-care plan. Despite this recommendation, there appears to have been no research to date

into the uptake or utility of self-care planning in the palliative care workforce.

There has, however, been research involving awareness and expression as key aspects of self-care. Findings from a qualitative study of Japanese palliative care nurses highlighted the importance of self-awareness and expression of emotions, in relation to self-care (Shimoinaba et al, 2015). These findings are supported in part by other research (Sansó et al, 2015) that investigated awareness and coping in a large multidisciplinary sample of Spanish palliative care professionals. Results from this study indicated that greater awareness positively predicted compassion satisfaction and negatively predicted both compassion fatigue and burnout. Participants with higher levels of self-awareness were also those with greater scores in competence in coping with death.

As a targeted educational intervention for Canadian doctors training in palliative care, Kim and colleagues (2013) developed and evaluated a structured self-care learning module that involved participation in a facilitated group discussion. Evaluation revealed that most participants gained an appreciation for the importance of self-reflection and self-awareness as a component of self-care. While the majority of participants described this training as a valuable learning experience, some were uncertain or did not consider it to be valuable. Other research by Feld and Heyse-Moore (2006) evaluated the implementation of support groups in the UK, for junior doctors working in palliative care. Similarly, most participants reported this to be helpful, particularly in sharing clinical experiences for confidential discussion. However, some reported barriers such as trust among peers and difficulties raising issues within the support groups. This was identified in relation to traditional medical training, leaving doctors either unaccustomed or reluctant to express feelings, fearful of being judged, or concerned that issues expressed would be perceived as weakness. Consideration of these challenges is therefore necessary in team-based self-care initiatives that foster awareness and expression.

Awareness also featured prominently in the evaluation of a contemplative end-of-life training program by Rushton and her colleagues (2009) in the USA. Mindfulness and self-care formed core components of this training, and its evaluation was informed by 95 online survey responses and 40 telephone interviews. The majority of participants indicated that mindfulness practices enabled them to better recognise and express their own grief through

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self-awareness, leading to a heightened focus on patient care as well as self-care. Some also expressed the importance of having a self-care plan. In summary, the literature reviewed highlights awareness, expression and planning as key aspects of self-care. At the same time, it is also important to appreciate that self-care practice is multifaceted.

Dimensions of self-careAs a holistic concept, self-care is multi-dimensional in the way it is understood and practised by palliative care professionals. Within the theoretical literature three authors have discussed different dimensions of self-care. Jones (2005) incorporated physical, emotional/ cognitive, relational, and spiritual self-care into a proposed self-care plan; while Rokach (2005) focused more broadly on either personal or professional dimensions of self-care. Sanchez-Reilly et al (2013) discussed these two dimensions, adding further distinction between individual or team-based self-care strategies within the professional dimension. Self-care dimensions have been discussed in the literature more extensively than they have been studied. Within the research literature, only two studies have explicitly examined dimensions of self-care (Figure 2).

First, in their study of hospice workers Alkema (2008) investigated the relationship between six different self-care dimensions as well as compassion fatigue, burnout, and compassion satisfaction. The most common dimensions of self-care reported for this sample were spiritual self-care, physical self-care, and psychological self-care. Results further indicated that compassion fatigue was significantly negatively correlated to five dimensions of self-care (all except for physical self-care); while compassion satisfaction was significantly positively correlated with only emotional, spiritual, and balance self-care dimensions. As previously noted, this study was limited by a very small convenience sample

of 37 hospice professionals from two hospices in Midwest America. It should also be noted that the instrument used in this study was an informal self-report rating tool, not a validated scale to measure self-care psychometrically as a construct.

Second, Sansó and her colleagues (2015) studied three dimensions of self-care in a cross-sectional survey of nearly 400 palliative care professionals in Spain. Development of these dimensions was informed by both theoretical and empirical work; focusing specifically on physical, inner, and social wellbeing. In contrast to the Alkema et al study, results from this research indicated that self-care was practised predominantly through a social dimension, followed by dimensions of physical and then inner self-care. All dimensions of self-care were significantly positively correlated with compassion satisfaction, and significantly negatively associated with compassion fatigue and burnout. Inner and social self-care dimensions were also positively correlated with respondents’ ability to cope with death.

While several dimensions of self-care have been discussed in the theoretical literature for over a decade, research has been limited. Taken together, the studies suggest that while individual uptake may vary, practising self-care across a range of dimensions may be positively associated with compassion satisfaction and inversely related to burnout and compassion fatigue.

Balanced compassionCompassion is defined in the literature as an emotion one experiences when feeling concern for others’ suffering and wanting to alleviate that suffering (Halifax, 2012). For palliative care professionals, the cultivation of compassion for oneself is considered equally important as compassion for others. The relevance of balanced compassion to self-care is evident across the theoretical and empirical literature, with compassion conceptualised in multiple ways (see for example: Halifax, 2011; Way and Tracy, 2012; Fernando and Consedine, 2014).

Way and Tracy (2012) conceptualised compassion as ‘recognising’, ‘relating’, and ‘(re)acting’. In their study of communication among hospice staff, it was found that compassion was exemplified when staff were able to recognise suffering, relate to others, and react in a meaningful way to alleviate suffering. Fernando and Consedine (2014) proposed a theoretical model of physician compassion, highlighting compassion as transactional in nature, rather than being a finite quality that becomes depleted as it is used. Within this model it was suggested Figure 2. Dimensions of Self-Care

Alkema et al (2008)

1. Physical

2. Psychological

3. Emotional

4. Spiritual

5. Workplace

6. Balance

Sansó et al (2015)

1. Physical

2. Inner

3. Social

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that physician compassion arises from interrelated influences between physician, patient and family, clinical situation, and environmental factors. For Halifax (2011), compassion is necessary not only for patients, but also for clinicians themselves.

Similarly, from her self-care discourse analysis, Breiddal (2012) concluded that having compassion for oneself is mutually beneficial for self and others. This is supported by Rose and Glass (2008) who argued that compassionate care for oneself can enhance wellbeing for palliative care professionals in the same way as with patients. Further, it has been suggested that those neglecting self-care and experiencing burnout or compassion fatigue tend to display a lack of compassion toward themselves and others (Kearney et al, 2009). However, these claims have not been supported through research to date.

Given that the psychometric constructs of compassion fatigue and compassion satisfaction do not directly relate to compassion itself, very little research has investigated compassion or self-compassion in the palliative care workforce. Of those studies that have investigated these direct ly, none have used a val idated psychometric instrument.

Wasner and col leagues (2005) used standardised scales to measure religiosity, self-transcendence, and aspects of spirituality, in their evaluation of spiritual care training for palliative care professionals in Germany. Self-compassion and compassion for others were examined as general attitudes on a self-rated numeric scale from 0 (not at all) to 10 (very much). The mean levels of self-rated compassion and self-compassion reported at baseline were found to increase significantly after spiritual care training, although the concepts were tested as general attitudes rather than tested as constructs using validated instruments.

In summary, compassion and self-compassion are considered important for palliative care professionals. Research suggests there may be a relationship with self-care, and can be increased through contemplative practices. However, these studies are few and have limitations Current empirical knowledge of these variables in palliative care practice is limited.

DiscussionThe objective of this review was to examine the literature relating to palliative care professionals’ self-care, self-compassion, and compassion for others; identifying implications for practice and future research. Key areas of consideration for current practice and future research include the

importance of self-care; awareness, expression and planning; dimensions of self-care; and ba lanced compass ion. Pa l l ia t ive care professionals’ self-care may be supported firstly by prioritising it, and subsequently by employing a variety of self-care strategies that promote awareness, expression and planning. The provision of staff support in the workplace may help promote professional self-care activities, but this alone is not sufficient (Showalter, 2010). It is also clear that compassion for self and others is important.

The notion that compassion should be a practice imperative is not new to the field of palliative care. Kellehear (1999; 2005) had previously argued for compassion to become a priority, declaring that the expression of compassion should not be idiosyncratic, nor its analysis impressionistic. Yet, approaches to research, education and practice in palliative care have, to date, been less than systematic or thorough in their exploration of compassionate care. Much of the attention towards compassion has been in the context of so-called compassion fatigue or, to a lesser extent, compassion satisfaction. However, these terms appear somewhat misleading in that these psychometric constructs do not measure levels of compassion. It is evident from this review that compassion, itself, is yet to be measured in this population.

Compassion and self-compassion can be investigated empirically, either through functional magnetic resonance imaging or as psychometric constructs (Singer and Bolz, 2013). In the context of positive emotions, compassion and self-compassion are increasingly examined within the field of positive psychology, with its strengths-based emphasis on wellbeing (Cassel, 2009; Neff and Lamb, 2009). Despite this, empirical knowledge of these is lacking in palliative care practice. While this may also be the case in health care generally, the literature is unequivocal about the need for palliative care professionals to practise compassion for oneself and for others. There is also a premise that self-compassion is a prerequisite to compassion for others.

This is increasingly discussed within general medical and nursing literature, in which self-compassion is understood as a mindful practice oriented toward the emergence of compassion and holistic care for all who experience suffering (Mills and Wand, 2015; Mills and Chapman, 2016). In palliative care, the apparent theoretical association between compassion and self-compassion is best encapsulated by Vachon’s (2015) assertion that one cannot practise compassion for others if one does not practise

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self-compassion. However, this has yet to be established empirically, and there is no evidence that compassion is in fact lacking in the palliative care workforce. Understanding of an apparent association between self-compassion and compassion for others is thus limited to theoretical discussion, as is also the case with the relationship between these variables and self-care.

There is a lack of evidence in relation to the Foucauldian perspective that one must first learn to take care of oneself in order to take care of others. The literature suggests a dominant and more reactive paradigm of self-care as a way of coping with various occupational stressors. The dominance of this paradigm seemingly shifts focus away from self-care itself, and more onto coping. While professional and quality standards require that palliative care professionals implement and maintain effective self-care strategies, the large majority of literature instead reflects an explicit focus on coping strategies.

This is perhaps because occupational stress has featured prominently in the palliative care literature over time, stemming from perceptions that caring for the dying is particularly stressful (Vachon, 2011). Yet, the literature is inconclusive as to whether clinicians working in palliative care experience higher levels of stress or burnout than other specialty areas of practice. Systematic reviews of stress and burnout in the palliative care workforce have found that studies indicate prevalence of these is comparable to that of other clinical specialties (see for example: Peters et al, 2012). That is not to suggest palliative care practice is not stressful per se, or that self-care as a way of coping is not important; in the same way that understanding of palliative care practice is not confined to negative factors such as stress, coping represents an important aspect of self-care, but not its entirety. This is highlighted through Breidall’s (2012) conceptualisation of self-care as a way of being, and also in the distinction between surviving and thriving made by Peters and McDermott (2012).

It is evident from the literature that occupational stressors and associated coping strategies are themselves discrete subjects of research. Moreover, coping strategies may not necessarily be constructive. For example, drinking alcohol is reported as a strategy used by hospice workers to cope with stress (Whitebird et al, 2013). Further, there is research to suggest that palliative care professionals who use avoidant coping strategies are at higher risk for post-traumatic stress disorder symptoms (O'Mahony et al, 2016). Coping is understood in the literature as pertaining to ones’ cognitive or

behavioural efforts to manage internal and external demands appraised to be taxing or exceeding ones’ resources (Lambert and Lambert, 2008), whereas self-care is much broader in its focus on the promotion of health and maintenance of wellbeing.

Health promotion is intrinsic to self-care, however, health promotion approaches to self-care in palliative care professionals appear largely unexplored. While self-care as a way of coping may be viewed through a narrow lens of harm-minimisation, there is merit in considering other health promotion principles such as prevention or reorientation to more supportive work environments (Kellehear, 2005). Given that exploration of these areas appears largely neglected, a greater focus toward understanding self-care outside of a coping paradigm is indicated.

Future researchThis review highlights a number of gaps to be addressed. Although self-care is considered important, the utility and general uptake of self-care practice among palliative care professionals remains largely unknown. For example, the concept of self-care planning was introduced over a decade ago, yet this review did not identify any research investigating whether palliative care professionals actually use individual self-care plans; and if so, the extent to which they are found to be effective. Ascertaining the level of awareness around use of self-care plans, or engagement with self-care training in general, would further contribute to this.

Understanding of the meaning of self-care within the palliative care workforce also remains limited. Beyond theoretical definitions or analyses of textbooks, a greater understanding of how self-care is perceived across the broader palliative care profession might serve to inform education and training initiatives. This knowledge would also build from the conceptualisation of self-care as a way of being. At the same time, it will be important to identify barriers and enablers to effective self-care practice experienced by palliative care professionals. To date these areas remain largely unexplored. Further, if as Wakefield (2000) recommended, self-care is to be relentless, then investigating the regularity of self-care practice among palliative care professionals is another priority.

Other opportunities for future research into self-care include foci such as resilience, health promotion, or positive psychology approaches to health and wellbeing. For example, correlational studies might usefully examine self-care practice in relation to resilience as a dependant variable.

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Given the relevance of health promotion to self-care, fruitful explorations may be undertaken in this area. While most interest in health promoting palliative care has to date focused on the general community, it is clear from its public health context, that health promotion practice and research should also consider palliative care professionals. Specific health promotion areas for research might include uptake of health promoting behaviours and the evaluation of prevention campaigns implemented in workplaces. But self-care research more relevant to compassion and self-compassion will likely encompass the positive psychology elements of wellbeing, or flourishing.

Flourishing is the stated goal of positive psychology, and to this end positive emotions form the foundation of wellbeing (Seligman, 2012). Cassel (2009) argued that development of education programmes and interventions to instil compassion, as a vital emotion for health care professionals, falls under the remit of positive psychology. Compassion and self-compassion both represent positive emotions that may foster personal wellbeing and, more broadly, contribute to one’s flourishing as a palliative care professional (Neff et al, 2007; Cassel, 2009; Neff and Lamb, 2009; Vachon, 2012). Specifically, compassion and self-compassion have been linked with positive factors in health professionals such as improved sleep and resilience (Kemper et al, 2015). Further investigation of this area within palliative care practice would contribute to the nascent field of positive health, as proposed by Seligman (2012). Moreover, it would add to a growing body of literature that suggests interventions to promote these positive emotions in health care professionals offer not only the potential for positive health and wellbeing, but also improved patient care.

LimitationsAs this literature review was limited to full text articles published in the English language, there may be other literature outside the scope of this paper.

ConclusionThis review has highlighted the importance and multi-faceted nature of self-care to palliative care professionals’ practice, in relation to compassion and self-compassion. Despite growing interest and widespread discussion, current empirical knowledge of these variables remains limited. Future directions for research include health promotion and positive psychology approaches to self-care in the context of health and wellbeing. Through exploration of these areas, palliative care professionals’ understanding and practice of self-care can progress beyond a paradigm of coping, and toward a more positive paradigm of flourishing. ●IJPN

Declaration of interests

The author have no conflict of interest to declare

Acknowledgements:

JM is supported by an Australian Postgraduate Award from

the University of Sydney.

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Professional Self-Care Scale developed for Spanish palliative care professionals

A newly developed self-care scale for Spanish palliative care professionals was published

online towards the end of 2015 in the Spanish Journal of Psychology, (Galiana, Oliver,

Sansó, & Benito, 2015), that is, several months after quantitative data collection had ceased

for the present study. A feature of this scale is its focus on the physical, social, and inner

domains of self-care – consistent with the definitions of health and self-care (see Appendix A

for scale items); however, problems with item-level reliability were identified by the scale

authors in the reporting of the scale’s psychometric properties. This issue, combined with

item linguistics and other potential cultural considerations, may prove a barrier to the

application of this scale outside of Spain. Nonetheless, the theoretical basis of this scale

appears sound and, in the future, it might usefully be adapted and validated for reliable use in

non-Spanish populations.

Mindful self-care, compassion satisfaction and burnout among hospice professionals

A study of hospice professionals using a newly developed mindful self-care scale (Cook-

Cottone & Guyker, 2018) was published online in late February 2018 (Hotchkiss, 2018). See

Appendix B for full details of this 33-item scale. Analyses of data from a cross-sectional

survey of 324 hospice care professionals in the USA indicated that participants who engaged

in multiple and frequent self-care strategies experienced higher levels of professional quality

of life. The construct of mindful self-care was positively correlated with compassion

satisfaction and negatively correlated with compassion fatigue. However, this study did not

measure compassion itself, and its findings are consistent with past research already

reviewed.

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Summary

Four themes were identified from the literature: (1) The importance of self-care; (2)

Awareness, expression and planning; (3) Dimensions of self-care; and (4) Balanced

compassion. In reviewing the literature, several key knowledge gaps became apparent.

Despite widespread discussion of their importance, the evidence base from empirical

knowledge of self-care, self-compassion, and compassion for others is limited. Compassion

and self-compassion are positive emotions that may contribute to the health, wellbeing and

flourishing of palliative care professionals. However, these variables have not been measured

together in this population, meaning that balanced compassion is difficult to discern.

Moreover, assertions that one cannot practise compassion for others if one does not practise

self-compassion are yet to be established empirically.

The uptake, regularity, and specific nature of self-care practices among palliative care

professionals is largely unknown. The ways and the extent to which palliative care

professionals are able to implement or maintain effective self-care strategies remains unclear.

Moreover, it is not known whether any self-care training is provided by palliative care

services to support effective self-care practice. An understanding of factors that facilitate or

impede self-care practice is important, yet these have been neglected in the literature so far.

Qualitative perspectives from palliative care practitioners are also lacking, leaving expert

accounts of the meaning and practice of self-care from the field relatively limited.

Palliative care research has typically focused on coping strategies in the context of

occupational stressors. Accordingly, there has been relatively little research into self-care as a

discrete practice. Given that effective self-care practice has been an explicit professional

practice requirement in Australia since 2005, further research in this area is warranted.

Positive psychology offers a valuable perspective from which to investigate self-care,

particularly in the context of positive emotions and their relationship to health and wellbeing.

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Chapter Conclusion

This chapter has provided a review of the literature to situate the study and thesis within a

context of the current body of knowledge. In addition to the narrative review published in the

International Journal of Palliative Nursing, a further update of relevant literature was

discussed in relation to the 5th edition of Palliative Care Australia’s (2018) National

Palliative Care Standards, and two other studies published after the initial review. The next

chapter will outline the specific research questions addressed by the study, as well as the

research design and methods used.

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CHAPTER 3

RESEARCH DESIGN AND METHODS

Chapter Introduction

The purpose of this chapter is to outline the research design and methods used in the study.

Philosophical and ethical considerations relating to the research will also be discussed. The

chapter begins by outlining the research questions to be addressed.

Research questions

The following research questions (RQ) were formulated from the literature review presented:

RQ1: Which self-care strategies are most commonly used by palliative care nurses

and doctors?

RQ2: How important is self-care considered to be in palliative care practice?

RQ3: How regularly is self-care practised?

RQ:4 How many in this group have received self-care education or training?

RQ:5 To what extent and affect are self-care plans used as part of self-care practice?

RQ:6 What levels of self-care ability, self-compassion, and compassion for others

are reported by palliative care nurses and doctors?

RQ7: What is the relationship between self-compassion and self-care ability?

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RQ8: What is the relationship between self-compassion and compassion for others?

RQ:9 What it is the meaning of self-care, as described by palliative care nurses and

doctors?

RQ10: How do palliative care nurses and doctors describe effective self-care

practice?

RQ11: What inhibits effective self-care practice?

RQ12: What promotes effective self-care practice?

Mixed Methods Research

The decision to use mixed methods in this study was guided by the research questions being

investigated (Gelling, 2014; Halcomb & Hickman, 2015; Hesse-Biber, 2010). By combining

the strengths of both quantitative and qualitative research methods, a more detailed

understanding of relevant phenomena can be obtained than otherwise through the use of one

method alone (Creswell & Plano Clark, 2011; Halcomb, Andrew, & Brannen, 2009; Östlund,

Kidd, Wengström, & Rowa-Dewar, 2011; Shannon-Baker, 2016). Mixed methods research

systematically combines the collection and analysis of qualitative and quantitative data within

the same study (Johnson, Onwuegbuzie, & Turner, 2007; Lewis, 2011; Taket, 2013). It is

increasingly used in palliative care research because it resonates with the complexity of

palliative care practice (Farquhar, Ewing & Booth, 2011; Seymour, 2012).

Within mixed methods research, careful consideration of the study design is required.

For example, clarity regarding the prioritisation, timing and systematic integration of

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methods and data is necessary (Grbich, 2013; Halcomb & Hickman, 2015; Morgan, 2014a).

A parallel convergent mixed methods design was used in this study. This design involved the

collection and analysis of both quantitative and qualitative data during the same phase of the

study, followed by the triangulation of results from each strand of the study into an overall

interpretation (Creswell & Plano Clark, 2011; Grbich, 2013). Triangulation, in this context,

refers to the combining of multiple methods and data sources (Grbich, 2013), with

quantitative and qualitative methods prioritised equally. As explained by Creswell and Plano

Clark (2011, p.77), the purpose of the parallel convergent design is to ‘obtain different but

complementary data’ to best understand the phenomena of interest and answer the research

questions. In this way, the study design provides a structure and systematic process in which

findings from the qualitative strand may extend or complement results from the quantitative

strand (Creswell & Plano Clark, 2011; Grbich, 2013; Morgan, 2014a). Figure 1 illustrates the

triangulation of these strands within the parallel convergent design, as adapted from Creswell

and Plano Clark, 2011, p.78).

Figure 1. Parallel convergent study design

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Philosophy of Pragmatism

While philosophy is neither a solely theoretical endeavour, nor a branch of empirical inquiry

(Rescher, 2013), it is a central pillar which underpins research design (Baldwin, 2014). The

research design for this study was underpinned by the philosophy of pragmatism. Pragmatism

was initially developed as a philosophical position through the work of Charles Sanders

Pierce, and was later informed by William James and John Dewey (Levi, 2012). Some

diversity of thought is evident within the writing of pragmatists; however, it is clear that

functional efficacy is the common and fundamental concern of pragmatism (Rescher, 2013).

That is, in the context of mixed methods research, pragmatism prioritises, as an outcome, the

function of methods to answer research questions in a way that is both appropriate and

meaningful; thus functional efficacy takes priority over adherence to other methodological or

paradigmatic doctrines (Feilzer, 2010; Grbich, 2013; Muncey, 2009; Nowell, 2015; Shannon-

Baker, 2016).

It is important, however, to consider the strengths and limitations of adopting a

pragmatic approach to research. As a relatively new research paradigm, pragmatism has been

considered disruptive to the philosophical assumptions of older paradigms (Morgan, 2014).

As a philosophy, it has thus been subjected to ongoing critique for more than a century

(Moore, 1905). Limitations to the use of a pragmatic approach include issues relating to both

the researcher and the research process. For example, pragmatism would not be considered an

appropriate research paradigm where it is incongruent with a researcher's personal worldview

relating to assumptions of epistemology or ontology (Grbich, 2013; Nowell, 2015). During

the research process, careful consideration is required when analysing or integrating

quantitative and qualitative data, given that a lack of methodological rigour can weaken the

credibility of the research (Feilzer, 2010; Shannon-Baker, 2016). One of the most significant

limitations of adopting a pragmatic approach relates to misconceptions about the credible use

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of pragmatism as a research paradigm. Being 'pragmatic', for example, can be interpreted, in

the everyday vernacular, as being 'expedient'; or as otherwise synonymous with the phrase

'anything goes' (Morgan, 2014). Indeed, Morgan (2014, p.1046) concedes that a 'crude

summary of pragmatism as merely asking about “what works” has been a perennial problem'.

However, it has been argued that the strengths and potential benefits of adopting a

pragmatic approach outweigh these limitations, particularly when they have been addressed

through careful consideration (Feilzer, 2010; Margolis, 2003; Nowell, 2015). The key

strengths of a pragmatic approach relate to its middle-ground positioning, between

traditionally polarised approaches, which effectively supports the use of mixed methods to

gain a broader and more in-depth understanding of phenomena to answer research questions

and better inform practical concerns (Feilzer, 2010; Morgan, 2007, 2014a, 2014b; Shannon-

Baker, 2016). While the combining of quantitative and qualitative methods is problematic

when viewed from either positivist or constructivist paradigms, pragmatism represents a lens

through which ‘reality exists not only as natural and physical realities, but also as

psychological and social realities which include subjective experience and thought, language

and culture’ (Grbich, 2013, p.313). In this way, a pragmatic use of mixed methods brings

with it an intersubjectivity that is situated between the dichotomous extremes of complete

objectivity or complete subjectivity (Shannon-Baker, 2016). This is further reflected in the

pragmatist process of abduction that is favoured over approaches that use either induction or

deduction (Feilzer, 2010; Grbich, 2013; Shannon-Baker, 2016). Consistent with

intersubjectivity, abductive reasoning cycles between inductive and deductive processes

(Feilzer, 2010; Grbich, 2013; Morgan, 2007; Shannon-Baker, 2016). The mixed methods

research design employed in this study is thus supported by the philosophy of pragmatism.

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Research Methods

Sampling. The use of mixed methods in this study encompassed both probability and non-

probability sampling (Grbich, 2013). Thus a parametric, representative sample was obtained

for the quantitative strand of the study, whereas a non-parametric, purposive sample was

obtained for the qualitative strand. Recruitment of the study sample was guided by specific

inclusion criteria.

Recruitment and Inclusion Criteria. Participant invitations were sent to members of

Palliative Care Nurses Australia (PCNA) and the Australian and New Zealand Society of

Palliative Medicine (ANZSPM) via email from the secretariat of each respective professional

association. In addition to this, invitations were sent to palliative care services whose contact

details were listed on Palliative Care Australia’s national service directory. Participants were

eligible for this study if they were a nurse or doctor practising in Australia, with palliative

care as their main area of practice. This population was chosen because the nursing and

medical disciplines represent a large majority of the palliative care workforce (Australian

Institute of Health and Welfare, 2017) and, unlike other Australian allied health professions

in palliative care, are accessible nationally through survey distribution from their respective

member organisations (PCNA and ANZSPM).

Quantitative strand. In this strand of the study, a cross-sectional survey was

administered to collect quantitative data from research participants for the purpose of

generalising results (Fowler, 2014; Schofield & Forrester-Knauss, 2013). The survey was

developed using Research electronic data capture (REDCap) software, and was administered

online over a period of approximately six weeks between April and May, 2015. REDCap is a

secure and widely used web-based survey platform that was designed to support data

collection in academic research (Harris, 2009). While survey research is an effective method

for nursing and palliative care research (Addington-Hall, 2007a; Keough & Tanabe, 2011), it

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is important to discern the most appropriate mode of survey in relation to the study aims and

population (Addington-Hall, 2007b). Web-based surveys are an efficient and cost-effective

alternative to telephone or hardcopy paper-based surveys (Schleyer & Forrest, 2000), but

response rates can vary significantly (Schofield & Forrester-Knauss, 2013). A web-based

mode of survey was chosen for this study because of its advantages in relation to

geographical reach as well as both time and cost-efficiency. However, this decision brought

with it a need for considered strategies to achieve a satisfactory response rate.

Unique factors must be taken into account when conducting surveys in the health

professions compared to the general population. For example, survey response rates are

typically lower due to clinical work demands and time scarcity, especially in physicians and

other medical professionals (Flanigan, McFarlane & Cook, 2008). Careful consideration

regarding the design and delivery of a survey is therefore required to enhance participation

and overall response rate when surveying people working in these disciplines.

Strategies to improve survey participation have been explored in both nurses (Cooper

& Brown , 2017; VanGeest & Johnson, 2011) and physicians (Cunningham et al., 2015;

Flanigan, et al., 2008), emphasising brevity and content relevance. From their systematic

review, VanGeest, Johnson and Welch (2007) concluded that surveys designed to be concise

and personalised were more likely to be successful, particularly where they had been endorsed by

relevant professional associations. This strategic approach was thus adopted in designing the

cross-sectional survey of palliative care nurses and doctors.

Apart from designing a brief questionnaire structure, a number of web-based design

strategies were implemented. For example, the use of embedded data and adaptive

questioning (Helms, Gardner & McInnes, 2017) drawing upon the branching logic function in

REDCap. That is to say, the questionnaire was designed to be efficient and responsive to

individual participants by only asking them questions that are relevant, as determined by their

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previous responses. After being asked: Do you use a self-care plan? only those participants

who responded affirmatively were next asked: Do you find it effective? In contrast, those who

responded in the negative were asked: Would you consider developing a self-care plan if you

were provided with the time and resources to do it? Rather than frustrating participants with

irrelevant questions, these advanced aspects of web-based survey design serve to enhance the

individual participant experience and improve the overall response rate (Helms, Gardner &

McInnes, 2017).

Other strategic design features were also incorporated. Manual programming of

Hypertext Markup Language (HTML) in REDCap was used to customise the presentation of

questionnaire content, and thus present a more visually appealing user interface for

participants accessing the survey. Moreover, the inclusion of a visual progress indicator made

participants aware of how close they were to completion of the survey at any given stage. The

REDCap platform also accommodated mobile data entry, making the survey widely

accessible. For example, participants could view and respond to the survey in any location

with internet connectivity, via multiple devices such as smartphones, tablets, or

laptop/desktop computer; with the display size and functionality automatically optimised to

each device by REDCap. The survey content and accessibility was piloted among a small

group of palliative care nurses and refined prior to being finalised (Addington-Hall, 2007a).

The survey comprised a brief questionnaire including demographics and a

combination of open and closed questions about self-care practices. All numeric

questionnaire fields were coded appropriately as either categorical or continuous data

variables (Field, 2013; Schofield & Forrester-Knauss, 2013). Three validated measures of

self-compassion, compassion for others, and social desirability were also included: (1) Self-

Compassion Scale - Short-form (SCS-SF) (Raes Pommier, Neff & Van Gucht, 2011); (2)

Santa Clara Brief Compassion Scale (SCBCS) (Hwang, Plante, & Lackey, 2008); and (3)

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Marlowe-Crowne Social Desirability Scale - Short-form (MC-SDS-SF) (Reynolds, 1982).

Sound validity and reliability of these scales has been reported within the psychometric

properties published across a number of studies (Fischer & Fick, 1993; Hwang et al., 2008;

Neff, 2016; Plante & Mejia, 2016; Raes et al., 2011; Reynolds, 1982).

While the SCS-SF and SCBCS were used as outcome measures, the MC-SDS-SF was

employed as a control measure to minimise the potential for social desirability response bias.

The importance of controlling for socially desirable responding in self-report research is

highlighted in the nursing literature (van de Mortel, 2008). Together, these measures are

identical to those used in other research by Neff and Pommier (2013). Given the absence of

any validated self-care measures at the time of this study, participants were asked to rate their

ability to implement and maintain effective self-care strategies using a horizontal sliding

visual analogue scale (VAS). This metric was administered using the REDCap survey VAS

tool, ranging from zero (not able) to one hundred (fully able), with ‘somewhat’ midway

between these. Electronic versions of a single-item VAS have been recognised as valid and

reliable survey instruments when measuring other phenomena such as pain and quality of life

(Bird et al., 2016; de Boer et al., 2004). Appendix C details the survey questionnaire in its

entirety, generated as a print report in REDCap.

All survey data were managed using REDCap software hosted at the University of

Sydney. Numeric data were exported directly to IBM SPSS Statistics 22 for descriptive

analysis of frequencies, means and percentages; or as appropriate, inferential statistical testing

(Field, 2013; O'Halloran, 2013). After performing Little’s (1988) Missing Completely at

Random Test in SPSS, it was determined that missing data were minimal and data imputation

was therefore not necessary (Field, 2013). All relevant assumptions such as normal

distribution of data and homogeneity of variance were met for parametric statistical tests

undertaken (Field, 2013). Confidence intervals were set at .95 and tests of significance were

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two-tailed with p values < .05 considered statistically significant (Buettner, Muller & Buhrer-

Skinner, 2011). Inferential statistical analyses included hierarchical linear regression and

Pearson’s partial correlation coefficients using the widely accepted effect sizes of r =.1

[small], r = .3 [medium], and r = .5 [large] (Cohen, 1988; Field, 2013; Pierson, 2013).

Exploratory factor analysis was performed to provide a more detailed understanding

in relation to the self-compassion (SCS-SF) and compassion for others (SCBCS) scale data.

While exploratory factor analysis is most frequently used in the development and validation

of psychometric scales, in this study it was employed in a descriptive manner to explore

underlying dimensions of quantitative data by observing where they cluster together across

multiple dimensions. This method of analysis is particularly useful in illustrating individual

participant placement across multiple factors (Hershberger, 2005).

This exploratory analysis proceeded with all scale items from the SCS-SF and SCBCS

being loaded for factor analysis using maximum likelihood extraction and varimax rotation

methods (Field, 2013; Hershberger, 2005). From the resultant factors obtained, value

loadings were then computed as Anderson-Rubin scores and saved as a new variable in SPSS

to allow for descriptive analysis of both factors as a standardised composite (Field, 2013;

Grice, 2001).

Textual survey data from open question responses were exported into QSR NVivo 10

for coding and content analysis (Serry & Liamputtong, 2013; Liamputtong & Serry, 2013).

Content analysis is a systematic method of describing and quantifying phenomena, as a means

to distil words or phrases into representative categories based upon related content (Elo &

Kyngas, 2008). In this way, the content analysis deductively drew upon a framework of

physical self-care, inner self-care, and social self-care. This is consistent with the World

Health Organization’s (1946) definition of health with each self-care domain corresponding

to physical, mental, and social wellbeing, respectively. The use of content analysis was well

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suited to this mixed methods study, as it can be performed either deductively or inductively.

Qualitative strand. In this strand of the study, in-depth interviews were conducted to

collect equally important qualitative data to extend or complement the quantitative data

(Payne, 2007; Serry & Liamputtong, 2013; Welch, 2011). After completing the survey,

participants were offered the opportunity to provide contact details—in an online form

separate to the survey—if they were interested in participating in a telephone interview.

These participants were contacted and interviewed by the researcher over a period of several

months until data saturation was reached (Payne, 2007; Welch & Jirojwong, 2011).

In-depth interviews were conducted via telephone using a semi-structured interview

guide. This was developed from the research questions after reviewing the literature

(Musselwhite, Cuff, McGregor, & King, 2007; Serry & Liamputtong, 2013). The interview

guide was piloted and refined in response to feedback received from a small group of

palliative care professionals not involved in this study (Payne, 2007). As outlined by

Musselwhite et al. (2007), telephone interviewing is an effective method of data collection

when the interviewer understands the benefits as well as its inherent challenges

(Musselwhite, Cuff, McGregor, & King, 2007). Thus, considerable effort was made to

minimise communication barriers such as the absence of non-verbal cues. Clarification was

frequently sought to confirm that the interviewer had correctly heard and understood the

content and meaning of what participants had conveyed verbally. Conducting interviews in

this way was considered more efficient and cost-effective than interstate travel and other

logistics associated with face-to-face interviews; ultimately, the use of telephone interviews

provided a broader geographical sample for the qualitative strand of the study.

Field notes were taken to inform iterative analysis, and audio recordings of all

interviews were transcribed verbatim for inductive qualitative content analysis (Liamputtong

& Serry, 2013; Welch & Jirojwong, 2011). This began with the reading, re-reading, and

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initial coding of raw data, and progressed with the identification of categories and

interpretation of emerging themes (Elo & Kyngas, 2008; Hsieh & Shannon, 2005). Given the

relatively large data set, all qualitative data management was assisted by QSR NVivo

software (Serry & Liamputtong, 2013). To minimise unnecessary duplication, further details

of research methods used in both strands of the study are presented in the Methods section of

each journal article either published or in press.

Middle range theory. The integration of quantitative and qualitative data is a

preliminary step towards further theory development. In turn, middle range theory statements

then inform practice and future research. The development of middle range theory represents

a practical yet underutilised research strategy, providing the potential to combine the strands

of research and practice to form a synthesised and more meaningful thread (Liehr & Smith

(1999).

Rigour and Reflexivity. The demonstration of rigour and researcher reflexivity

throughout the research process is of great importance to nursing research (Freshwater, 2005;

Welch, 2011). Despite a lack of clarity regarding methods for demonstrating rigour in mixed

methods designs (Halcomb & Hickman, 2015) this research has demonstrated

methodological rigour in both qualitative and quantitative strands of the study, as advocated

by Creswell and Plano Clark (2011). For example, sound internal and external validity have

been shown in the quantitative strand. Rigour is also supported by peer-review and

publication of study findings in high-quality journals. Similarly, trustworthiness, credibility

and potential for transferability have been demonstrated within the qualitative strand (Elo et

al., 2014; Graneheim & Lundman, 2004); although, as noted by Elo and colleagues (2014),

transferability to other settings or contexts, ultimately, can only be discerned by others.

To ensure trustworthiness in the research process, the researcher undertook

specialised training in underdeveloped areas, such as quantitative data analysis and software

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packages, so that requisite knowledge and practical skills were obtained to conduct the study

(Halcomb & Hickman, 2015). Expert statistical guidance was sought before and after data

collection to ensure quality and rigour in quantitative data analysis. Authenticity and

confirmability were established through the reporting of participant quotations and careful

synthesis of perspectives to support the qualitative findings and ensure that conclusions were

well grounded in the data (Welch, 2011).

According to Halcomb and Hickman (2015), ‘rigour in mixed methods research

involves providing the reader with a clear audit trail and with well-considered, justified

rationales for the decisions made throughout the research process’ (p.46). Thus, to ensure

rigour and trustworthiness, a decision-making trail was reported throughout the study with

clear rationales justified where key decisions were made, for example, to guide data analysis

(Liamputtong & Serry, 2013; Welch & Jirojwong, 2011). Credibility and confirmability have

also been supported through the presentation and publication of study findings to national and

international nursing, medical, and palliative care audiences.

Finally, reflexivity was documented to situate the researcher within the context of the

research conducted. Reflexivity refers to an ‘ongoing analysis of personal involvement’

throughout the research process (Jootun, McGhee & Marland, 2009, p.45). According to

Jootun and colleagues (2009), ‘reflecting on the process of one’s research and trying to

understand how one’s own values and views may influence findings adds credibility to the

research and should be part of any method of qualitative enquiry’ (p.42).

It has been argued that reflexive studies are only valid ‘if the researcher’s bias is fully

incorporated and becomes transparent throughout the study’ (Mantzoukas, 2005, p.311).

However, Freshwater (2005) asserts that a researcher’s bias can never be known fully and

only that which is conscious can be articulated. Bracketing, as a cognitive process of

detaching from one’s own thoughts and beliefs, is discussed in the nursing research literature;

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however, nurses’ ability to fully achieve this separation within an interpretive process is

contested (Jootun et al., 2009). Given that self-awareness and transparency are key factors for

promoting rigour, the task of the researcher is thus to engage in reflective practices

throughout the research process to promote self-awareness and provide transparency (Jasper,

2005; Clarke, 2009).

Having previously realised the benefits of reflective writing to support the research

process (Mills, 2012), a reflexive research journal was kept by the researcher throughout the

present study. For example, personal values and beliefs about the phenomena under

investigation were documented in a prior reflective account to enable awareness and analysis

of the researcher’s potential influence on the collection or analysis of data. Appendix D

outlines this reflective account, as an excerpt from the reflexive journal used to support the

research process.

Ethical considerations

Consideration of ethical principles that guide and govern research practice is important for

nurse researchers (Ingham-Broomfield, 2017). A number of ethical considerations were

relevant to the conduct of this study, in accordance with the National Statement on Ethical

Conduct in Human Research (National Health and Medical Research Council, Australian

Research Council, & Australian Vice-Chancellors’ Committee, 2015). As detailed in

Appendix E, the research protocol was subjected to ethical review and revised prior to

approval (2015/013) being granted by the University of Sydney Human Research Ethics

Committee (USYD HREC).

In accordance with this approval, participant recruitment and collection of data did

not commence until this approval had been obtained. For survey participants, informed

consent was implied after navigating through the participant information and completing the

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online survey (see Appendix F for Survey Participant Information Statement). Informed

written consent was obtained from all who participated in an interview (see Appendix G for

Survey Participant Information Statement and Consent Form). Considerable care was taken in

the survey design and development, ensuring that anonymity of individual survey response

data was protected, whilst also facilitating means for survey participants to provide their

name and contact details securely and separately to the survey data provided. Care was also

applied to data management processes, including the de-identification of interview participant

data and allocation of pseudonyms for the reporting of qualitative data. All necessary

reporting to the USYD HREC was completed.

Chapter Conclusion

This chapter has outlined the research questions, research design, and methods used in the

study. Philosophical and ethical considerations relating to the research were also discussed.

The next chapter will present results from the quantitative strand of the study.

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CHAPTER 4

QUANTITATIVE STRAND RESULTS

Chapter Introduction

The purpose of this chapter is to report results from the quantitative strand of the study. This

chapter presents two journal articles published in the Journal of Palliative Medicine and the

International Journal of Palliative Nursing.

Self-care in palliative care nursing and medical professionals

Published Article:

Mills, J., Wand, T., & Fraser, J. A. (2017b). Self-care in palliative care nursing and medical

professionals: A cross-sectional survey. Journal of Palliative Medicine, 20(6), 625-

630.

Author Contributions:

JM, JF, and TW contributed to the conception and development of the study design. JM

drafted the initial questionnaire and refined it in response to feedback from JF and TW. JM

developed the REDCap survey and tested online functionality with input from JF and TW.

JM managed participant recruitment and administered the open and closing of survey

responses. JM performed data analysis with guidance from JF. As the first named author, JM

drafted and revised the manuscript, with input from JF and TW.

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Self-Care in Palliative Care Nursingand Medical Professionals:A Cross-Sectional Survey

Jason Mills, RN, BN (Hons), MCHMed, FACN,Timothy Wand, NP, RN, MN (Hons), PhD, and Jennifer A. Fraser, RN, RM, PhD

Abstract

Background: Self-care is an important consideration for palliative care professionals. To date, few details havebeen recorded about the nature or uptake of self-care practices in the palliative care workforce. As part of abroader mixed methods study, this article reports findings from a national survey of nurses and doctors.Objective: The objective of this study was to examine perceptions, education, and practices relating to self-careamong palliative care nursing and medical professionals.Design: A cross-sectional survey using REDCap software was conducted between April and May 2015.Perceived importance of self-care, self-care education and planning, and self-care strategies most utilized wereexplored. Descriptive statistics were calculated and content analysis used to identify domains of self-care.Setting/Subjects: Three hundred seventy-two palliative care nursing and medical professionals practicing inAustralia.Results: Most respondents regarded self-care as very important (86%). Some rarely practised self-care and lessthan half (39%) had received training in self-care. Physical self-care strategies were most commonly reported,followed closely by social self-care and inner self-care. Self-care plans had been used by a small proportion ofrespondents (6%) and over two-thirds (70%) would consider using self-care plans if training could be provided.Conclusions: Self-care is practised across multiple health related domains, with physical self-care strategiesused most frequently. Australian palliative care nurses and doctors recognize the importance of self-carepractice, but further education and training are needed to increase their understanding of, and consis-tency in, using effective self-care strategies. These findings carry implications for professional practice andfuture research.

Keywords: doctors; nurses; palliative care; self-care; survey; workforce

Introduction

Palliative care professionals are highly trained incaring for others, but they may receive little to no

training in caring for themselves. In palliative care, a clini-cians’ expertise is rightly directed toward the care needs ofpatients and their families accessing palliative care. From aworkforce perspective, however, due consideration must alsobe given to the individual’s needs with regard to health andwell-being. Concerns about increasing demands on the pal-liative care workforce have featured on the palliative careagenda for some time,1,2 but related workforce issues such as

self-care, while espoused through professional practice andquality standards, have received relatively little researchattention.

Self-care encompasses the caring behaviors used to pro-mote health and well-being3 and is increasingly discussed inthe nursing and medical literature.4,5 The palliative care lit-erature does highlight the importance of self-care for pallia-tive care professionals in supporting their caring role. It isapparent, however, that self-care is discussed in the palliativecare literature more than it is researched, with most studiesfocused on strategies used to cope with burnout or other workrelated stressors rather than self-care strategies used to

Faculty of Nursing and Midwifery, The University of Sydney, New South Wales, Australia.Accepted December 19, 2016.

JOURNAL OF PALLIATIVE MEDICINEVolume 20, Number 6, 2017ª Mary Ann Liebert, Inc.DOI: 10.1089/jpm.2016.0470

625

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promote health and well-being. Key gaps in the palliativecare literature include a lack of evidence to inform self-carepractice and limited knowledge relating to the uptake of self-care practices such as the utilization of self-care plans. InAustralia, for example, therapeutic guidelines developed by apalliative care expert group6 highlight a need for palliativecare professionals to consider their own health needs; yetthere is scant research to support the specific self-care strat-egies recommended.

Given that the use of effective self-care strategies is man-dated in national quality and practice standards across multiplecountries,7–11 further research into palliative care profession-als’ self-care is warranted. Within the context of a broadermixed methods study, the objective of this study was to ex-amine perceptions, education, and practices relating to self-care among palliative care nursing and medical professionals.

Materials and Methods

Design and participants

This study was conducted in Australia using a cross-sectional survey design and administered through REDCap(Research Electronic Data Capture). REDCap is a secureweb-based application designed to support data capture forresearch studies.12

A brief questionnaire was developed from a review of therelevant literature and refined in response to feedback re-ceived from a small cohort of palliative care nurses anddoctors. From this process, a clear definition of self-care wasadded to the survey for respondents’ reference. No errors orfurther ambiguity was identified.

Participant invitations were sent to members of PalliativeCare Nurses Australia, the Australian and New ZealandSociety of Palliative Medicine, and to palliative care serviceswith contact details listed on Palliative Care Australia’snational service directory. Participants were eligible for thisstudy if they were a registered nursing or medical profes-sional practicing in Australia, with palliative care as theirmain area of practice. This study population was chosenbecause the nursing and medical health workforce representsa large majority of the palliative care workforce and unlikeother allied health professions in Australia are accessiblenationally through survey distribution from their respectivemember organizations.

Questionnaire

The questionnaire included 13 items relating to profes-sional role and sociodemographic variables, as well asparticipant perceptions, education, and practices relating toself-care. Most items were multiple choice questions allow-ing single answer responses, with subsequent questions pre-sented, where relevant, using the branching logic providedthrough REDCap. One open question was included to elicitfree text qualitative data describing specific self-care strate-gies most used by respondents. An electronic link to thesurvey was distributed to 609 eligible palliative care nursingand medical professionals in April 2015, through e-mail. Thesurvey remained open for a total of six weeks, with twofollow-up reminders sent during this period. While no in-centive to participate was provided, a number of consider-ations were factored into the survey design to help maximize

the survey response rate.13 These included the provision ofreminder e-mails, participant anonymity, and ensuring thesurvey was brief and easily accessible online for completionby participants at a time of convenience.

Data analysis

All survey data were collected and managed using RED-Cap electronic data capture tools hosted at the University ofSydney. Quantitative data were exported directly to IBMSPSS Statistics 22 for descriptive analysis of frequencies andpercentages. Qualitative data were exported into QSR NVivo10 for coding and content analysis.

Content analysis is a systematic method of describing andquantifying phenomena, as a means to distil words or phrasesinto representative categories based upon related content.14 Inthis way, qualitative content analysis was performed deduc-tively, drawing upon a recently published framework that de-lineates categories of physical self-care, inner self-care, andsocial self-care.15 This framework is consistent with the WorldHealth Organization’s definition of health,16 with each self-care domain corresponding to physical, mental, and socialwell-being, respectively. In addition, the inner self-care domainencompasses spiritual well-being and, therefore, includes but isnot confined to mental well-being. Thus, self-care strategies,including exercise activities or nutritional intake, were coded asphysical self-care; strategies involving relationships or inter-action with friends, family, or colleagues were coded as socialself-care; and strategies relating to psychological, emotional, orspiritual dimensions were coded as inner self-care. The analysiswas conducted to identify the use of self-care domains at anindividual level and across the sample as a whole.

Ethical considerations

Ethical approval for this study was received from theUniversity of Sydney Human Research Ethics Committee(2015/013). Detailed information about the study was pro-vided in recruitment e-mails to participants, as well as theinitial online page viewed before accessing the survey. Par-ticipation was voluntary and anonymous, with consent im-plied through commencement of the survey.

Results

A total of 372 palliative care nursing and medical profes-sionals completed the survey, giving a response rate of 61%.In addition, 11 incomplete responses were excluded fromanalysis. With respondents from all Australian States andTerritories, the overall demographic profile of the sample wasconsistent with recent palliative care workforce data and,therefore, considered representative of the palliative carenursing and medical workforce in Australia (totalling 3560based on 2014 data).17

Respondents from each profession were mostly female,and approximately two-thirds of all respondents were nurses.While most were based in metropolitan areas, the proportionof respondents working in full-time or part-time roles wasrelatively similar. The majority was aged over 50 and morethan half had worked in palliative care for more than a de-cade, with nearly one-third having worked in this specialtyfor 16 years or more. Detailed demographics and professionalrole characteristics are presented in Table 1.

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Participant responses to the self-care questionnaire aredetailed in Table 2. A majority of respondents consideredself-care to be very important for nurses and doctors workingin palliative care. While others thought it was important, onlya few considered self-care not important. The regularity ofrespondents’ self-care practice was mostly either frequent orintermittent; however, a considerable proportion rarely en-gaged in self-care strategies. Less than half of respondentshad received any workplace training or education about ef-fective self-care strategies.

The utilization of self-care plans was also low, with only6% of respondents reporting they used a self-care plan.However, of these, 100% reported that they found the use of aself-care plan to be an effective self-care strategy. Of thosenot using a self-care plan, 70% indicated they would considerdeveloping a self-care plan if they were supported to do sowith training.

A total of 1501 self-care strategies were reported by par-ticipants when asked to describe examples of self-carestrategies they used most, with self-care defined as ‘‘the self-initiated behavior that people choose to incorporate topromote good health and general well-being.’’3 Several re-sponses were not included as they were not entirely consistentwith this definition and did not correspond directly with theself-care framework used for content analysis. For example,without further contextual data, it was considered that re-sponses such as ‘‘watching television’’ or ‘‘providing directpatient care’’ did not directly correspond to the health related

domains of physical self-care, inner self-care, or social self-care. This was subsequently confirmed by advice receivedthrough electronic correspondence with the researchers whodeveloped this framework (Dr. Amparo Oliver, personalcommunication, September 19, 2016); therefore data such asthese were excluded from content analysis.

On average, respondents could identify 4 self-care strate-gies, and a total of 1476 were coded for analysis. Physicalself-care strategies were used most frequently, followed bysocial self-care and inner self-care strategies, although therewas a relatively even distribution across all three domains.These results were comparable between both professions androles. Examples of physical self-care strategies includedjogging, hydrotherapy, and yoga. Common social self-carestrategies included group debrief or clinical supervision withcolleagues and spending time with friends or family. Ex-amples of inner self-care strategies included meditation,mindfulness, and spiritual practice. See Table 3 for self-caredomain frequencies and percentages derived from the contentanalysis of all self-care strategies reported. At the individuallevel, 11% of respondents used only one self-care domain,while 89% used either two or three domains.

Table 1. Participant Demographics (N = 372)

Demographic/professional role n (%)

GenderFemale 306 (82)Male 66 (18)

Age group18–29 years 6 (2)30–39 years 62 (17)40–49 years 95 (25)50–59 years 154 (41)‡60 years 55 (15)

ProfessionPalliative care nurse 252 (68)Palliative care doctor 120 (32)

Main roleClinician 300 (81)Educator 44 (12)Manager 17 (4)Researcher 11 (3)

Work statusFull time 178 (48)Part time 194 (52)

Population focusAdult palliative care 341 (92)Pediatric palliative care 16 (4)Aged palliative care 15 (4)

Years worked in palliative care0–5 years 82 (22)6–10 years 96 (26)11–15 years 76 (20)‡16 years 118 (32)

Table 2. Characteristics of Participants’

Perceptions and Practice of Self-Care (N = 372)

Questionnaire n (%)

How important do you think self-care is for nursesand doctors working in palliative care?Not very important 4 (1)Important 50 (13)Very important 318 (86)

How regularly do you practice self-care strategies duringa working week?Rarely 41 (11)Intermittently 165 (44)Frequently 166 (45)

Have you received specific training/education or resourcesin your workplace about effective self-care strategies?No 226 (61)Yes 146 (39)

Do you use a self-care plan?No 349 (94)Yes 23 (6)

(Yes) Do you find it to be effective?No 0 (0)Yes 23 (100)

(No) Would you consider developing a self-care planif you were provided with training to do it?No 106 (30)Yes 243 (70)

Table 3. Content Analysis of All

Self-Care Strategies

Self-care domain Frequency (%)

1. Physical self-care 570 (38.7)2. Social self-care 455 (30.8)3. Inner self-care 451 (30.5)

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Figure 1 illustrates a word cloud generated from thequalitative survey data using the word frequency queryfunction within NVivo, as described by Glasper and Rees.18

While limited if used alone, visual representation throughword clouds has been shown to be an effective tool to in-crease comprehension of qualitative survey data when used tocomplement other qualitative analysis methods such ascontent analysis.19 This word cloud contains the 50 wordsmost commonly used by respondents when describing theirself-care strategies in the survey. The words vary in size andcolor density according to their frequency. ‘‘Time’’ was themost commonly used word (frequency = 145) and was relevantto the context of all self-care domains. Beyond this, the nextmost frequently used words were consistent with the contentanalysis ranging in frequency from the physical self-care do-main down to social and inner self-care domains: ‘‘exercise’’(124); ‘‘walking’’ (87); ‘‘family’’ (86); ‘‘friends’’ (80); ‘‘col-leagues’’ (75); ‘‘meditation’’ (63); and ‘‘reading’’ (55).

Discussion

This study examined the perceptions, education, andpractices relating to self-care among palliative care nursingand medical professionals in Australia. The study findingsaddress key gaps in the palliative care literature relating toprovision of self-care education, as well as the nature anduptake of self-care practices such as the use of self-care plans.While past research has largely focused on self-care as a wayof coping with occupational stressors, this study examinedself-care in the context of promoting health and well-being.

Perceptions within the palliative care workforce are con-sistent with discussion in the literature, with regard to theimportance of self-care. Although it had been argued thatself-care is important,20,21 there are now empirical data toshow that a majority of the workforce shares this position.With this knowledge, palliative care services should considerprioritizing resources to support self-care practice, especiallywith regard to training.

Adequate education and training are important for self-care.6 That only 39% of nurses and doctors had receivededucation about self-care is alarming. Especially given that inAustralia, since 2005, palliative care professionals have beenrequired to initiate and maintain effective self-care strategiesin accordance with Palliative Care Australia’s nationalquality standards.10 This professional expectation is sharedinternationally,7–11 yet many staff may not have received the

necessary training to do so. This finding supports other na-tional data suggesting that the provision of self-care educa-tion across palliative care services may be limited.22 Takentogether, they indicate that addressing self-care learningneeds is a priority. Given that self-care is a professional ex-pectation, equipping palliative care professionals with themeans to understand and engage in effective self-care prac-tices should be prioritized. Content and pedagogical ap-proaches to self-care training could be drawn from programsalready piloted. These have so far focused on mindfulness,poetry, clinical supervision, and other structured reflectivepractice.23–27 The broader development and provision of self-care education can usefully inform emerging palliative careworkforce development frameworks.28

The use of self-care plans has been promoted in the liter-ature for more than a decade,20,21 yet before this study noresearch had investigated the utility or uptake of self-careplans in the palliative care workforce. In the current study, allof the nurses and doctors who used a self-care plan reported itto be an effective self-care strategy. However, the uptake ofself-care planning was very low. Further qualitative researchcould usefully explore the context of this finding. This may berelated to the lack of self-care education reported, as a con-siderable majority of those not using a self-care plan indi-cated they would consider doing so if provided with trainingand resources. The reported lack of self-care planning mayalso relate to the infrequent nature of some participants’ self-care practice. That 11% of nurses and doctors rarely practiceself-care is a concern and suggests a need for education andfurther exploratory research.

As with a previous study of hospice professionals in NorthAmerica,29 the nurses and doctors in this study most fre-quently practised physical self-care. The use of physical self-care strategies such as engaging in regular physical activity,following dietary guidelines, and getting adequate sleep isconsistent with the healthy lifestyle behaviors observed in acohort study of Australian and New Zealand nurses andmidwives.30 While physical self-care was most common inthe current study, the self-care strategies described by re-spondents were spread relatively evenly across the domainsof physical, social, and inner self-care. This is consistent withother research15 that investigated these self-care domains in asample of Spanish palliative care professionals and indicatesthat a variety of strategies are important to self-care practicein palliative care. Thus palliative care professionals shouldconsider broadening their self-care practice where it is

FIG. 1. Word cloud from reported self-care strategies.

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currently limited to one self-care domain. The findings fromthis study also add empirical support to the palliative caretherapeutic guidelines’ recommendation for self-care prac-tice to encompass broad development areas such as educationand peer and professional support.6

Future research

From the results of this study, a number of areas for futureresearch become apparent.

First, further qualitative inquiry into the personal or pro-fessional contexts of infrequent self-care practice and lowuptake of self-care planning could assist educators and pal-liative care services in promoting effective self-care practice.Future research should also focus on the development andevaluation of innovative self-care education programs im-plemented by palliative care services. Studies could usefullycompare baseline knowledge and understanding of self-care instaff, as well as the uptake of self-care planning and regularityof self-care practice. While the current study explored the self-care strategies most used by participants, it would be useful forfuture research to examine the strategies reported as most ef-fective. Since strategies found to be most effective may notnecessarily be the most commonly utilized, the identificationof barriers and enablers to effective self-care practice is alsoimportant. This broader context of self-care practice could beinvestigated through in-depth exploration of relevant personaland professional factors.

It will also be important for future research to better un-derstand the subjective meaning of self-care, from the per-spective of those working in palliative care. In the currentstudy, nurses and doctors were provided with a definition ofself-care from the literature to guide their understanding inreporting the self-care strategies they used most. Despite this,a considerable proportion of responses reported the use ofself-care strategies that, without further context, did not ap-pear consistent with the promotion of an individual’s healthand well-being.

In the case of ‘‘watching television,’’ for example, longi-tudinal data from a large cohort study of female nurses haveshown that the sedentary nature of television watching isassociated with higher risk of becoming obese and develop-ing diabetes mellitus.31 A more recent meta-analysis oftelevision viewing data also identified a higher risk for car-diovascular disease and all-cause mortality.32 Ensuring thatpalliative care professionals understand effective self-carestrategies will be important if palliative care services are tosupport self-care practice and, thus, promote the provision forquality palliative care.

Strengths and limitations

To the best of the authors’ knowledge, this is the first studyof its kind to explore the perceptions, education, and practicesrelating to self-care among palliative care nursing and med-ical professionals. While this study has a number of strengths,it is somewhat limited by its self-report and cross-sectionalresearch design. There is also potential for nonresponse biaswithin the study population; however, this is mitigated tosome extent by the representative nature of the sample andresponse rate achieved.33

The survey response rate of 61% in this study is consideredsatisfactory.33 As a national survey, this response rate is rela-

tively high compared to past surveys of palliative care pro-fessionals in Australia. Doctors in particular have beenassociated with response rates of 29% and 35%, depending onthe survey methods and questionnaire content.34,35 The re-sponse rate in the current study may have been maximized by avariety of factors such as a high level of participant interest inthe survey subject matter or the survey design considerationsundertaken to achieve a satisfactory response rate. As no par-ticipation incentive was offered, it is likely that participants’intrinsic motivation influenced their completion of the survey.

Conclusion

Physical self-care strategies are most commonly used bypalliative care professionals among a variety of health relatedself-care practices. Most palliative care nurses and doctorsrecognize the importance of self-care and engage in effectiveself-care practice either frequently or intermittently.

However, a considerable proportion rarely engage in self-care, or do so only through one domain, and a majority have notreceived education or training in the use of effective self-carestrategies. The use of self-care plans is reported to be an effectiveself-care strategy; however, there is very low uptake amongpalliative care nurses and doctors. These limitations to self-carepractice should be addressed through targeted training and self-care education, as most indicated they would be receptive to this.

Given that self-care practice is a professional expectationin palliative care, requisite education is necessary to supporteffective self-care in the palliative care workforce. Suchinitiatives could promote greater understanding of self-care,awareness of domains, and uptake of self-care plans. Furtherresearch is needed to understand the broader context of self-care practice and to develop and evaluate the effectiveness ofself-care education programs.

The findings of this study can inform current practice andemerging palliative care workforce development frameworks.

Acknowledgments

J.M.’s PhD candidature is supported by an AustralianPostgraduate Award from the University of Sydney. Theauthors gratefully acknowledge all nurses and doctors fortheir participation in this study, as well as Palliative CareNurses Australia and the Australian and New Zealand So-ciety of Palliative Medicine for their generous support of thisresearch. The authors also thank the anonymous reviewersfor their valuable feedback.

Author Disclosure Statement

No competing financial interests exist.

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15. Sanso N, Galiana L, Oliver A, et al.: Palliative care pro-fessionals’ inner life: Exploring the relationships amongawareness, self-care, and compassion satisfaction andfatigue, burnout, and coping with death. J Pain SymptomManage 2015;50:200–207.

16. World Health Organisation: Constitution of the WorldHealth Organisation Geneva. 1946. www.who.int/governance/eb/who_constitution_en.pdf (last accessed October 6, 2016).

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29. Alkema K, Linton JM, Davies R: A study of the relation-ship between self-care, compassion satisfaction, compas-sion fatigue, and burnout among hospice professionals. JSoc Work End Life Palliat Care 2008;4:101–119.

30. Tuckett A, Henwood T: The impact of five lifestyle factorson nurses’ and midwives’ health: The Australian and NewZealand nurses’ and midwives’ e-cohort study. Int J HealthPromot Educ 2015;53:156–168.

31. Hu FB, Li TY, Colditz GA, et al.: Television watching andother sedentary behaviors in relation to risk of obesityand type 2 diabetes mellitus in women. JAMA 2003;289:1785–1791.

32. Grøntved A, Hu FB: Television viewing and risk of type 2diabetes, cardiovascular disease, and all-cause mortality: Ameta-analysis. JAMA 2011;305:2448–2455.

33. Addington-Hall JM: Survey research: Methods of data col-lection, quesionnaire design, and piloting. In: Addington-HallJM, Bruera E, Higginson I, Payne S (eds). Research Methodsin Palliative Care. New York, NY: Oxford University Press,2007, pp. 61–82.

34. Hardy JR, Spruyt O, Quinn SJ, et al.: Implementing prac-tice change in chronic cancer pain management: Clinicianresponse to a phase III study of ketamine. Intern Med J2014;44:586–591.

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Address correspondence to:Jason Mills, RN, BN (Hons), MCHMed, FACN, PhD (c)

Faculty of Nursing and MidwiferyThe University of Sydney

M02 Mallett StreetNew South Wales 2050

Australia

E-mail: [email protected]

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Examining self-care, self-compassion, and compassion for others

Published Article:

Mills, J., Wand, T., & Fraser, J. A. (2018). Examining self-care, self-compassion, and

compassion for others: A cross-sectional survey of palliative care nurses and doctors.

International Journal of Palliative Nursing, 24(1), 112-119.

Author Contributions:

JM, JF, and TW contributed to the conception and development of the study design. JM

drafted the initial questionnaire and refined it in response to feedback from JF and TW. JM

developed the REDCap survey and tested online functionality with input from JF and TW.

JM managed participant recruitment and administered the open and closing of survey

responses. JM performed data analysis with expert assistance from Faculty Biostatistician,

and under the guidance of JF. As the first named author, JM drafted and revised the

manuscript, with input from JF and TW.

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4 International Journal of Palliative Nursing 2018, Vol 24, No 1

AbstractThis study examined levels of, and relationships between, self-care ability, self-compassion, and compassion among palliative care nurses and doctors. Methods: A total of 369 participants across Australia completed a cross-sectional survey comprising a demographic questionnaire and outcome measures for each variable. Descriptive and inferential statistics were analysed, controlling for potential social-desirability bias. Results: Levels of compassion, self-compassion and self-care ability varied, with some individuals scoring high or low in each. Self-compassion and self-care ability were positively correlated (r = .412, p<.001), whereas a negative correlation was observed between compassion and self-compassion (r = -.122, p<.05). Linear regression further indicated that: increased compassion was associated with a decrease in self-compassion, and increased self-care ability was associated with an increase in self-compassion. Conclusion: These results suggest important implications for self-care in the palliative care workforce. Moreover, this study contributes an empirical basis to inform future research and education to promote balanced compassion and compassion literacy in palliative care practice.Key words: l Compassion l Compassion literacy l Palliative care l Self care l Self-compassion l Survey

This article has been subject to double-blind peer review

Compassion is considered the essence of palliative care (Larkin, 2015). To sup-port this compassionate care, self-care

for palliative care professionals is also viewed as essential. Despite their importance, however, there is little evidence to inform self-care strate-gies or enhance compassionate care in palliative care practice. Research to-date has primarily focused on a coping paradigm, and constructs of burnout or compassion fatigue, rather than a positive paradigm that examines compassion itself (Mills et al, 2017a).

Balanced compassion was identified as a key theme in a recent review of the palliative care literature, proposing the relevance of a positive psychology approach to research into self-care and compassion (Mills et al, 2017a). In this context, compassion and self-compassion represent positive emotions that contribute to psychological flexibility and emotional resilience to support one’s own health and wellbeing as well as that of others (Neff et al, 2007; Cassel, 2009; Neff and Tirch, 2013; Seppala et al, 2013; Stellar and Keltner, 2014; Tugade et al, 2014; Kemper et al, 2015; Warren et al, 2016). This approach is informed by Fredrickson’s (2001) seminal broaden-and-build theory of positive emotions, as well as Seligman’s (2008; 2012) work on positive

health and flourishing. While many definitions exist, compassion can be understood as a positive emotion involved in the recognition of—and therapeutic response to—others’ needs and suffering (Cassel, 2009; Stellar and Keltner, 2014). Thus compassion, according to Perez-Bret et al (2016), is intrinsic to the daily clinical practice of health-care professionals. Compassion is most commonly understood in the context of feeling compassion for others; however, the practice of self-compassion is less familiar.

Self-compassion involves directing this same compassion inwards to oneself with self-kindness, and it is therefore commonly discussed as important to self-care (Mills et al, 2015). Self-care involves a variety of strategies to promote one’s own health and holistic wellbeing and ensure that personal needs are not neglected while caring for others (Mills and Chapman, 2016). Research has shown that palliative care professionals consider self-care very important to their practice, and this importance is reflected internationally within professional and quality standards for palliative care practice (Mills et al, 2017a; 2017b). In countries such as Australia, palliative care professionals have, for more than a decade, practised under national quality standards requiring that they initiate and

Research

Jason Mills, Timothy Wand and Jennifer A Fraser

Jason Mills,Registered Nurse; Lecturer/Unit Coordinator, School of Nursing, Faculty of Health, Queensland University of Technology, Queensland, Australia

Timothy Wand,Nurse Practitioner; Registered Nurse;Associate Professor,Faculty of Nursing and Midwifery, the University of Sydney, New South Wales, Australia

Jennifer A Fraser,Registered Nurse; Associate Professor, Faculty of Nursing and Midwifery, the University of Sydney, New South Wales, Australia

Corresponding author:[email protected]

Examining self-care, self-compassion and compassion for others:

a cross-sectional survey of palliative care nurses and doctors

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International Journal of Palliative Nursing 2018, Vol 24, No 1 5

Research

maintain effective self-care strategies as part of their palliative care practice (Palliative Care Australia, 2005). However, only a minority of this workforce reports having received self-care education or training, and research has yet to investigate palliative care professionals’ ability to implement and maintain effective self-care strategies (Mills et al, 2017b).

In the same way that theoretical links between self-compassion and self-care are discussed in the literature, it is also argued that self-compassion is associated with compassion for others; however, supporting evidence is limited (Mills et al, 2017a). Given their importance, there is surprisingly little research to inform palliative care professionals’ understanding of self-care or compassion in practice. To address these gaps in the literature, and as part of a broader mixed-methods study, this research aimed to examine relationships between self-care ability, self-compassion and compassion for others. Specifically, the present study addressed the following research questions:

●What levels of self-compassion, self-care abilityand compassion for others are reported bypalliative care nurses and doctors? ●What is the relationship between self-compassion and self-care ability? ●What is the relationship between self-compassion and compassion for others?

MethodsEthical approval was first obtained from the relevant human research ethics committee. As part of a cross-sectional survey design, a 28-item questionnaire was administered over a 6-week period, using Research Electronic Data Capture (REDCap) software. REDCap is increasingly used internationally as a secure, web-based survey platform, designed to support data collection in academic research (Harris et al, 2009).

MeasuresCompassion and self-compassion were measured using validated self-report instruments available in short form. A validated measure of social desirability was also administered to control for social desirability bias. These measures are discussed below.

CompassionConsistent with similar research in other populations (Neff and Pommier, 2013), compassion was measured using the Santa Clara Brief Compassion Scale (SC-BCS) (Hwang et al, 2008). In this study, participants were scored from zero (not at all true of me) to five (very true

of me) in responses to item questions such as: ‘When I hear about someone going through a difficult time, I feel a great deal of compassion for him or her.’ This scale has shown sound psychometric properties over time as a valid and reliable measure of compassion (Plante and Mejia, 2016).

Self-compassionSelf-compassion was measured using the Self-Compassion Scale-Short Form (SCS-SF) (Raes et al, 2011). This 12-item Likert scale was developed as a brief version of the widely used  26-item Self-Compassion Scale, which has been shown to be a valid and reliable measure of self-compassion (Neff, 2003; 2016). Participants are scored from zero (almost never) to five (almost always) in responses to item questions such as: ‘When I’m going through a very hard time, I give myself the caring and tenderness I need.’ Within this scale, self-compassion is operationalised as a six-factor structure: (1) self-kindness, (2) mindfulness, (3) common humanity, (4) self-judgement, (5) isolation and (6) over-identification. Self-judgement, isolation, andover-identification subscale items are reverse-scored and then combined with the othersubscale scores to measure a total self-compassion score. The SCS-SF has a strongcorrelation with the longer form scale and hasdemonstrated sound psychometric propertieswhen measuring a total self-compassion score(Raes et al, 2011).

Self-care abilityGiven the absence of any validated measure of self-care ability at the time of this study, respondents were provided with a definition of self-care from the literature (Mills et al, 2017a) and asked to rate their ability to implement and maintain effective self-care strategies via sliding visual analogue scale (VAS). This metric was administered as a customised survey tool in REDCap, ranging from zero (not able) to one hundred (fully able), with ‘somewhat’ midway between. A numeric value was visible to respondents as they moved the slider bar across a horizontal axis. This was not intended to measure self-care ability as a construct, but rather to quantify individual self-care ability as perceived by respondents.

The wording of the VAS prompt ‘Rate your ability to initiate and maintain effective self-care strategies’ was developed and refined in response to feedback received from a small cohort of palliative care nurses and doctors prior to finalising the survey. As this wording mapped directly to

❛Compassion isintrinsic to thedaily clinicalpractice ofhealth careprofessionals❜

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Standard 13 of Palliative Care Australia’s (2005) quality standards, requiring an ability to initiate and maintain effective self-care strategies, this approach was viewed as an appropriate way to investigate self-care ability in this study.

Social desirabilityAlthough the provision of anonymity in this survey represents a key strategy to minimise socially desirable responding, a short form of the seminal Marlowe-Crowne Social Desirability Scale (MC-SDS-SF) (Strahan and Gerbasi, 1972) was also used as a control measure. This is consistent both with recommendations made in the literature (van de Mortel, 2008) and other research using the same scale to examine compassion and self-compassion in other populations (Neff and Pommier, 2013). This 10-item dichotomous scale has demonstratedgood psychometric properties (Fischer and Fick,1993) and comprises ‘true’ or ‘false’ responsestatements, such as ‘I have never been irked whenpeople expressed ideas very different from myown.’ Socially desirable response scores rangefrom zero–ten for each participant.

Participants and procedurePalliative care nurses and doctors practicing in Australia were eligible to participate in this study. A total of 609 participant invitations were sent to members of Palliative Care Nurses Australia and the Australian and New Zealand Society of Palliative Medicine, as well as palliative care services with contact details listed on Palliative Care Australia’s national service directory. The survey link remained open for a period of 6 weeks, with two follow-up reminders sent. Detailed information about the research was provided in the recruitment email, in addition to the initial page viewed prior to accessing the study survey. Participants were informed that responses were voluntary and would remain anonymous, with participant consent implied through completion of the survey.

A total of 369 usable survey responses were received and included for analysis in the present study (60% response rate). All survey data were collected and managed using the REDCap survey platform. These data were exported directly from REDCap to IBM SPSS Statistics version 22 for descriptive and inferential statistical analysis. An SPSS missing values analysis indicated that data imputation was not required, as missing data were minimal (less than 5%), thus list-wise deletion of cases was employed during statistical testing. All relevant assumptions were met for statistical tests undertaken. Confidence intervals

were set at .95, and tests of significance were two-tailed with p values (probability) <.05 considered statistically significant.

ResultsThe sample comprised 67% palliative care nurses and 33% palliative care doctors across each state and territory in Australia. Most participants were female (82%), worked as clinicians (81%) and were based in metropolitan areas (68%), compared with those in regional (29%) or remote (3%) areas of Australia. Participants came from the following age groups: 60+ years (15%), 50–59 years (41%), 40–49 years (25%), 30–39 years (17%) and 18–29 (2%). Over half of the sample had been working in palliative care for more than a decade, and approximately one third had worked in this specialty for 16 years or more.

The SC-BCS and SCS-SF were found to be reliable measures of compassion and self-compassion in the present study. Internal reliability as measured by Cronbach’s Alpha was .86 and .85 respectively. Table 1 reports descriptive statistics for study variables, including self-compassion sub-scales.

Based on past research, in which gender was observed as a main effect on compassion and self-compassion in the general community, an independent samples T-Test was performed for comparison in this study sample. While the difference in self-compassion between males (mean (M) = 3.39, standard deviation (SD) = .64) and females (M = 3.23, SD = .63) was marginally significant (p = .054), the difference in compassion between males (M = 3.67, SD = .64) and females (M = 3.81, SD = .72) was far from statistically significant (p = .2).

Next, Pearson’s r coefficients were calculated to examine associations between compassion and self-compassion, and between self-compassion and self-care ability. Partial correlations controlling for social desirability are shown in Table 2. A significant positive association was observed between self-compassion and self-care ability in females (r = .387, p = <.001), males (r = .499, p = <.001) and the sample as a whole (r = .412, p = <.001).

A significant negative association was found between compassion and self-compassion in females (r = -.158, p = <.05) and the sample as a whole (r = -.122, p = .019).

A hierarchical linear regression analysis was then conducted to further examine the relationship between self-compassion as a dependent variable and self-care ability and compassion for others as independent variables. Based on past research, social desirability and

❛Theimportance ofself-care isexplicit withininternationalpalliative carepracticestandards, yetunderstandingof thecomplexities ofself-care abilityis, to-date,limited❜

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gender were entered consecutively into the first two steps of the model to control for any effect of these variables. Self-care ability and compassion for others were then entered separately in the third and fourth steps of the model respectively. Table 3 shows the four steps in this model, indicating that as self-care ability increased, self-compassion also increased, and as compassion for others increased, there was a decrease in self-compassion.

Lastly, exploratory factor analysis (EFA) was conducted to better understand the compassion data in relation to self-compassion data. Although EFA is commonly used to guide development of psychometric scales, here it was employed in a descriptive manner to explore underlying dimensions of these data by observing where they cluster together across multiple dimensions. This method is particularly useful in illustrating individual participant placement across multiple factors (Hershberger, 2005). First, all scale items from the SCS-SF and SCBCS were loaded for EFA. This initial analysis resulted in a three-factor structure. A two-factor structure was then specified using maximum likelihood extraction and varimax rotation methods. From this analysis, all scale item data from the SCS-SF loaded onto Factor  1, and all scale item data from the SCBCS loaded onto Factor 2, indicating that these data had clustered together.

Factor 1 was interpreted as ‘Compassion for self ’, and Factor 2 was interpreted as ‘Compassion for others’. As outlined by Grice (2001), value loadings from both factors were then computed as Anderson-Rubin scores, and these were saved as a new variable in SPSS to allow for descriptive analysis of both factors as a standardised composite (M = 0, SD = 1). These data are illustrated in Figure 1 (scatter plot) by gender, with Factor 1 on the horizontal axis, and

Factor 2 on the vertical axis. Cross-tabulation indicated that 23% of females and 28% of males scored positive on both Factor 1 and Factor 2. In total, 29% of females and 20% of males scored negative on Factor 1, but positive on Factor 2.26% of females and 22% of males scored negative on both Factor 1 and Factor 2.

Table 2. Partial correlations between self-compassion, self- care ability and compassion for others (controlling for social desirability)

Sample Females Males

Self-care ability .412** .387** .499**

Compassion for Others -.122* -.158* .126***

* p = < .05 ** p = < .001 (two-tailed) *** p = .32

Note: P value relates to statistical significance

Table 3. Hierarchical linear regression modelSelf-compassion b SE b 95% CI ß ΔR2

Step 1 .032***

Social desirability .059 .017 .026, .092 .186***

Step 2 .046*

Social desirability .067 .017 .033, .100 .210***

Gender .214 .087 .044, .385 .132*

Step 3 .204***

Social desirability .048 .016 .017, .079 .152***

Gender .186 .079 .030, .342 .115

Self-care ability .013 .002 .010, .017 .403***

Step 4 .211*

Social desirability .051 .016 .020, .082 160***

Gender .178 .079 .023, .334 .110*

Self-care ability .013 .002 .010, .016 .400***

Compassion for

others

-.085 .043 -.171, .000 -.095*

Note: Gender is coded 0 = females and 1= males; * p ≤ .05; ** p ≤ .005; *** p ≤ .001;

R2 = .220; b = unstandardised beta; SE b = standard error for unstandardised beta; CI = confidence intervals; β = standardised beta; ΔR2 = adjusted R-squared

Table 1. Descriptive statistics for study variables and subscalesSample Females Males

Variable M (SD) Min Max M (SD) Min Max M (SD) Min Max

Self-care ability 71.0 (19.1) 8.0 100 70.8 (18.8) 8.0 100 72.0 (20.5) 15.0 100

Compassion for others 3.79 (.70) 1.80 5.00 3.81 (.72) 1.80 5.00 3.67 (.64) 2.00 4.80

Self-compassion 3.26 (.63) 1.25 4.92 3.23 (.63) 1.25 4.92 3.39 (.64) 1.92 4.58

Self-kindness 3.11 (.79) 1.00 5.00 3.08 (.79) 1.00 5.00 3.26 (.79) 1.50 4.50

Self-judgement 2.80 (.95) 1.00 5.00 2.85 (.96) 1.00 5.00 2.57 (.91) 1.00 4.50

Common humanity 3.43 (.80) 1.00 5.00 3.40 (.82) 1.00 5.00 3.60 (.72) 1.00 5.00

Isolation 2.81 (.96) 1.00 5.00 2.82 (.95) 1.00 5.00 2.78 (.98) 1.00 5.00

Mindfulness 3.67 (.73) 1.00 5.00 3.65 (.74) 1.00 5.00 3.75 (.69) 2.00 5.00

Over-identification 3.07 (1.0) 1.00 5.00 3.10 (1.0) 1.00 5.00 2.90 (1.0) 1.00 5.00

Note: M = mean; SD = standard deviation.

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DiscussionThis study aimed to examine levels of—and associations between—self-care ability, self-compassion and compassion for others. While these variables are increasingly discussed in nursing and medicine generally (Mills et al, 2015; Mills and Chapman, 2016), to the authors’ knowledge this is the first study to examine them together in the palliative care workforce.

These findings provide new insight into palliative care nurses’ and doctors’ perceived ability to implement and maintain effective self-care strategies. The importance of self-care is explicit in international palliative care practice standards, yet understanding of the complexities of self-care ability is, to-date, limited. While nurses and doctors in this study rated their abil ity reasonably high on average, a considerable number reported very low levels of self-care ability. This finding may have been influenced by a lack of self-care education and training, and it supports a recommendation for more educational initiatives to support self-care practice (Mills et al, 2017b).

Given the l imited understanding of compassion in health care, this study has extended empirical knowledge of compassion

beyond the coping paradigm of compassion fatigue and compassion satisfaction commonly found in the literature. Through the lens of positive psychology, it has identified varying levels of compassion and self-compassion as positive emotions reported by palliative care nurses and doctors. This line of inquiry is highly valuable to self-care, as these positive emotions form part of a foundation for emotional resilience, health and wellbeing (Fredrickson, 1998; Seligman, 2008; Seppala et al, 2013; Stellar and Keltner, 2014; Tugade et al, 2014; Kemper et al, 2015; Warren et al, 2016).

While concerns have been raised in the literature that compassion is lacking, findings from this study suggest that palliative care nurses and doctors have generally higher levels of compassion and self-compassion than other populations, such as undergraduate students or the general community (Neff and Pommier, 2013). This is perhaps not surprising, given these nurses and doctors work in a profession where compassionate care is essential. Nevertheless, in light of the discourse on coping with compassion fatigue and burnout, this finding is, on the whole, encouraging.

However, it must be noted that these levels varied at the individual level, as indicated by EFA and corresponding Anderson-Rubin scores, with some respondents scoring low in either compassion, self-compassion, or both. This finding suggests that nurses, doctors and pall iative care services should not be complacent in viewing compassion as a constant that does not require considered and ongoing attention. Although some argue that compassion cannot be taught, there is increasing evidence that it can be cultivated, and those low in compassion and/or self-compassion may therefore benefit from training to cultivate compassion (Mills et al, 2015; Mills and Chapman, 2016). The need for compassion training in health-care professionals has also been voiced by patients (Sinclair et al, 2016).

This study provides preliminary evidence to support the theoretical discussion in the literature regarding a positive relationship between self-compassion and self-care. This knowledge can support self-care planning and practice as well as informing training or education initiatives. However, further research incorporating a validated self-care scale is needed to build from this initial evidence-base. That self-compassion was negatively associated with compassion was somewhat surprising. In contrast, significant positive associations have been observed in samples of the general community and

Figure 1. Scatter plot of individual Anderson-Rubin (A-R) factor scores

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meditators (Neff and Pommier, 2013). This finding might be explained by clinical or environmental barriers to compassion in practice, or other factors unique to a health-care provider context (Fernando and Consedine, 2017). While compassion for others is a social and professional expectation, the expression of compassion for oneself is subject to a stigma of being selfish (Mills et al, 2015). Moreover, specific education or training in compassion is largely absent in nursing, medicine and palliative care curricula (Mills et al, 2015; Mills and Chapman, 2016; Mills et al, 2017a).

These results are suggestive of limited compassion literacy. As described by Burridge et al (2017), compassion literacy is characterised by an understanding that self-care is not selfish, as well as an ability to balance compassion for patients with compassion for oneself . Interestingly, both orientations of compassion can be subject to fear. That is, for some people, feelings of compassion for others may be inhibited due to fear of being taken advantage of, or perceived as weak. Similarly, feelings of compassion for oneself can be inhibited due to performance-related fears of underachievement (Jazaieri et al, 2013). The development of compassion l i teracy in pall iat ive care professionals may therefore be critical to provide an understanding of balanced compassion, as well as the ability to enact this in the context of p rac t i s ing s e l f - ca re wh i l e p rov id ing compassionate care for patients.

This study highlights several other avenues for future research. As identified in a recent systematic review (Hill et al, 2016), there is an urgent need for targeted psychosocial interventions to improve the wellbeing of pal l ia t ive care profess ionals . Further interventional research into the role of positive emotions in this context is therefore recommended. Future research could usefully draw upon Fredrickson’s (2001) broaden-and-build theory of positive emotions to establish a sound theoretical base for compassion literacy.

A growing body of literature suggests potential benefit in the use of psychological interventions, such as loving-kindness meditation and compassion training, to cultivate positive emotions and benefit health and wellbeing in both community and health professional populations (Hofmann et al, 2011; Boellinghaus et al, 2014). Consistent with the broaden-and-build theory of positive emotions, loving-kindness meditation results in increased positive emotions and personal resources that predict increased life satisfaction and reduced depressive

symptoms (Fredrickson et al, 2008). It has been identified as an effective approach to enhance compassion, self-compassion and self-care in trainee psychotherapists (Boellinghaus et al, 2013). Loving-kindness meditation has also produced improvements in compassion, self-compassion and wellbeing in a range of health professionals, with research positing it to be a practical and viable tool to promote resilience and the quality of patient care (Seppala et al, 2014; Rao and Kemper, 2017).

An alternative to this is compassion training, with several formal protocols developed and found to enhance compassion, self-compassion and self-care in the general community. These include the Compassion Cultivation Training programme developed at Stanford University (Jazaieri et al, 2013), Neff and Germer’s (2013) Mindful Self-compassion Program and the Cognitively-based Compassion Training programme developed at Emory University (Ozawa-de Silva et al, 2012). In health care workers, there is growing evidence that programmes such as these can enhance compassion and resilience, and may be helpful in improving patient care and preventing burnout (Mascaro et al, 2016; Scarlet et al, 2017).

Other emerging approaches can also be found in the nursing literature. For example, the novel use of a ‘clinical compassion café’ has been reported to improve compassion literacy in nurses (Winch et al, 2014), and online learning modules have also been developed to teach compassionate care to nursing students (Hofmeyer et al, 2017). Surprisingly, none of the above approaches appear to have been used in palliative care research to date. Taken together, there appears sufficient evidence to warrant investigation of these approaches in a palliative care workforce context. Specifically, research should examine the role of compassion literacy in the context of compassionate care for patients as well as self-care. Future studies could also extend knowledge of self-care ability through qualitative designs to explore barriers and enablers to effective self-care.

LimitationsLimitations to this study are acknowledged. A cross-sectional design provides a snapshot, but does not address variability over time. Also, self-report instruments can be prone to participant response bias. This potential bias was addressed through provision of participant anonymity and use of a control measure. Notwithstanding these limitations, this study serves to advance knowledge and inform future research in an area of significance to palliative care practice.

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ConclusionTo the authors’ knowledge this is the first published study to examine compassion, self-compassion and self-care together in palliative care nurses and doctors. These results suggest that the promotion of individual compassion literacy within palliative care teams may be important to self-care practice and support compassionate care for patients. Moreover, they contribute an empirical basis to inform future research and education to promote compassion literacy in the palliative care workforce. Given the international focus on promoting compassion in practice, this new knowledge can serve to maintain the imperative of compassion as the essence of palliative care.

Declaration of interests:

The authors declare that no conflicts of interest exist.

Acknowledgements:

The authors gratefully acknowledge the palliative care

nurses and doctors who participated in this study. Thanks

also go to Judith Fethney, Biostatistician at the University

of Sydney, for assistance with data analysis.

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Continuing professional development: reflective questions l How would you rate your current ability for self-care practice?

l How would you rate your current level of compassion for others?

l How self-compassionate are you? Dr Kristin Neff’s full self-compassion scale is available online at

https://tinyurl.com/ky9bx5x

Key pointsl Levels of self-care ability, self-compassion, and

compassion for others varied greatly, with some

individuals scoring quite low or very high

l Self-care ability was linked to higher levels of self-

compassion

l Compassion for others was associated with lower

levels of self-compassion, suggesting limited compassion

literacy

l Compassion literacy involves a healthy balance of

compassion for others with compassion for oneself;

these findings suggest that some palliative care nurses

may benefit from compassion cultivation training to

support self-care and compassionate care for patients

and their families●IJPN

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Call for papersIs there a subject you would like to see covered in the International Journal of Palliative Nursing?

The journal invites submissions on all aspects of palliative nursing care. We would particularly welcome reviews of clinical management issues, non-cancer diagnoses, and commentary or discussion pieces.

If you have any queries or questions regarding submitting an article to the journal, please contact the Editor: [email protected] www.ijpn.co.uk

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Chapter Conclusion

This chapter has presented results from the quantitative strand of the study, as published in

the Journal of Palliative Medicine and the International Journal of Palliative Nursing.

Chapter five will present findings from the qualitative strand of the study.

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CHAPTER 5

QUALITATIVE STRAND FINDINGS

Chapter Introduction

The purpose of this chapter is to report findings from the qualitative strand of the study. The

chapter presents an accepted journal article in press at BMC Palliative Care. This paper was

formatted and referenced according to the requirements of this journal. Bibliographic details

for this accepted article, in press, are below.

Exploring the meaning and practice of self-care

Mills, J., Wand, T., & Fraser, J. A. (2018). Exploring the meaning and practice of self-care

among palliative care professionals: A qualitative study. BMC Palliative Care

(In Press).

Author Contributions:

JM and JF contributed to the initial conception and design of the study, whilst TW

contributed to its refinement and finalisation. JM recruited participants, conducted the data

collection, data management, and qualitative content analysis with guidance from JF and TW.

As the corresponding author, JM drafted and revised the manuscript with important input

from JF and TW.

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ABSTRACT

Background: Self-care practice within the palliative care workforce is often discussed,

yet seemingly under-researched. While palliative care professionals are required to

implement and maintain effective self-care strategies, there appears little evidence to guide

them. Moreover, there is an apparent need to clarify the meaning of self-care in palliative

care practice. This paper reports qualitative findings within the context of a broader mixed-

methods study. The aim of the present study was to explore the meaning and practice of self-

care as described by palliative care nurses and doctors.

Methods: A purposive sample of twenty-four palliative care nurses and doctors across

Australia participated in semi-structured, in-depth interviews. Interviews were digitally

recorded and transcribed prior to inductive qualitative content analysis, supported by QSR

NVivo data management software.

Results: Three overarching themes emerged from the analysis: (1) A proactive and

holistic approach to promoting personal health and wellbeing to support professional care of

others; (2) Personalised self-care strategies within professional and non-professional

contexts; and (3) Barriers and enablers to self-care practice.

Conclusions: The findings of this study provide a detailed account of the context and

complexity of effective self-care practice previously lacking in the literature. Self-care is a

proactive, holistic, and personalised approach to the promotion of health and wellbeing

through a variety of strategies, in both personal and professional settings, to enhance capacity

for compassionate care of patients and their families. This research adds an important

qualitative perspective and serves to advance knowledge of both the context and effective

practice of self-care in the palliative care workforce.

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BACKGROUND The concept of relentless self-care is well known to those in the field of palliative social work

[1]. Interest in self-care is growing within the nursing and medical disciplines [2, 3], and its

importance to all palliative care professionals is evident internationally through a suite of

quality standards, core competencies, and practice standards in which self-care practice is

mandated [4-10]. But what does self-care mean?

Self-care is broadly defined by Sherman [11] as ‘the self-initiated behaviour that

people choose to incorporate to promote good health and general well-being’. Despite this

health-promoting emphasis on good health and wellbeing, the palliative care literature

focuses largely on coping strategies in the context of occupational stressors such as burnout

or compassion fatigue [12]. Clearly, management of stress is very important; however, there

are other important aspects of promoting good health and wellbeing that extend beyond the

scope of coping with stress. In many cases there also appears to be conflation between the

terms coping strategy and self-care strategy. Further confusion about the meaning of self-care

was highlighted in an Australian survey of palliative care professionals [13]. Beyond

academic definitions, there is a need to understand and articulate the meaning of self-care in a

palliative care practice context. Given that some palliative care professionals have reported

low levels of self-care ability, there is also an urgent need to explore barriers and enablers to

self-care, and identify examples of effective self-care strategies used in practice. In reviewing

the literature [12], significant gaps are apparent in the current evidence base for self-care

practice and education.

To advance knowledge in these areas, this study aimed to explore the meaning and

practice of self-care as described by palliative care nurses and doctors. Specifically, the

following research questions were addressed:

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1. What it is the meaning of self-care, as described by palliative care nurses and

doctors?

2. How do palliative care nurses and doctors describe effective self-care practice? METHODS Research Design

Given the nature of the research questions, a qualitative research design was employed [14].

An interview guide (see Table 1) was developed to address the study aim in consideration of

gaps identified from the literature. The initial guide was refined in response to feedback

received from a small group of palliative care professionals not involved in this study. Open

questions were used to elicit deeper exploration of meaning and experience within a flexible

yet focused discussion about participants’ self-care practice [15].

Table 1. Interview Guide

• In the context of palliative care practice, what does self-care mean to you?

• From your experience, how would you describe effective self-care practice?

• Tell me about the self-care strategies you find to be most effective

• What supports your self-care practice?

• What, if anything, gets in the way of your self-care practice?

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A purposive sample was recruited into this qualitative research from a pool of palliative care

nurses and doctors who had completed a self-care survey as part of a broader mixed-methods

study [13]. Consistent with the purpose of obtaining relevant and rich data from an

appropriate source, eligible participants were nurses and doctors practising in Australia with

palliative care as their main area of practice. Informed written consent was obtained from all

participants through initial email contact prior to being interviewed via telephone. A total of

24 semi-structured, in-depth interviews were conducted over a six-month period in 2015,

with recruitment ending once data saturation was reached. That is, when the collection of

additional data served only to repeat existing rather than generate new content, as identified

from the use of field notes and iterative analysis. The first author, an experienced qualitative

researcher, conducted all interviews and recorded field notes to support a process of iterative

analysis throughout the data collection period. The average duration of interviews was

approximately 50 minutes, with audio content digitally recorded, transcribed verbatim, and

de-identified. Gender-appropriate pseudonyms were randomly allocated to each respondent.

Data Analysis

Interview transcripts were initially read and re-read to make note of key words and phrases

before importing them into QSR NVivo 11 data management software for open coding and

qualitative content analysis. Qualitative content analysis is a widely used method for

interpreting the content of textual data through a process of systematic classification, coding,

and identification of patterns or themes [16]. As recommended by Graneheim and Lundman

[17], a number of decisions were made to guide content analysis and ensure trustworthiness.

First, it was decided that a conventional approach to content analysis would be adopted

[16]. That is to say, the analysis was inductive and focused on latent content, or words and

sentences that required an interpretation of underlying meaning. Second, whole participant

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interviews were discerned to be the most appropriate unit of analysis in terms of providing a

context for meaning units during the analytical process [17]. Finally, it was decided that these

meaning units would comprise interrelated words, sentences and paragraphs from interview

transcripts. In this way, interview data were analysed inductively through the generation of

codes, grouping and collapsing of codes into common categories, and subsequent abstraction

to identify overall themes that represent the raw data in an aggregated form [18, 19]. Figure 1

outlines the thematic coding and category content generated from the content analysis.

Sample

The sample of 24 participants comprised 12 nurses and 12 doctors working in community,

inpatient, or consult palliative care services located in both metropolitan and regional/rural

settings across six of the eight States and Territories in Australia. These were clinical nurse

specialists, nurse educators, clinical nurse consultants, nurse practitioners, nurse unit

managers, senior medical officers, consultant physicians, and heads of department. They had

an average of 15 years’ experience working in either adult, aged, or paediatric palliative care

settings. Most were female, aged between 40 and 49, and worked in full-time roles. See Table

2 for detailed participant demographics.

RESULTS Three overarching themes emerged from the analysis in relation to the meaning and practice

of self-care: (1) A proactive and holistic approach to promoting personal health and

wellbeing to support professional care of others; (2) Personalised self-care strategies within

professional and non-professional contexts; and (3) Barriers and enablers to self-care

practice. Figure 2 illustrates these themes as the meaning and practice of self-care. Thematic

data from these themes are reported in Tables 3, 4, and 5, in the form of participant

quotations to ensure trustworthiness [20].

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Demographic n (%)

Gender

Female 15 (63)

Male 9 (37)

Age Group

30-39 years 4 (17)

40-49 years 11 (46)

50-59 years 7 (29)

≥ 60 years 2 (8)

Population Focus

Adult Palliative Care 19 (79)

Paediatric Palliative Care 2 (8)

Aged Palliative Care 3 (13)

Work Status

Full-time 14 (58)

Part-time 10 (42) Years Worked in Palliative Care

1-5 years 1 (4)

6-10 years 3 (13)

11-15 years 12 (50)

≥ 16 years 8 (33)

Table 2. Participant Demographics and Professional Characteristics (N = 24)

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Figure 1. Coding Categories and Thematic Content

• Meaning• Relational context• Balancing care for others with care for self• Promotion of health and wellbeing• More than just a tick-box checklist

A proactive and holistic approach to promoting personal health and wellbeing to support professional care of others

• Self-care strategies used inside the workplace setting• Reflective practice• Accessing other staff support• Boundaries• Regulation of workload• Work-life harmony• Team-care/healthy team• Laughter and use of humour

• Self-care strategies used outside the workplace setting• Separating work from home• Meditation• Spiritual practice• Positive social relationships• Rest and relaxation• Preventative health behaviours• Accessing support from health care professionals

• Shared responsibility• Individual self-care practice• Staff support from employer

• Self-care as a personalised and ongoing practice• Practised according to the individual and context• Ongoing nature

A range of personalised self-care strategies within professional and non-professional contexts

• Facilitators of self-care• Recognising importance of self-care• Planning and prioritising self-care in a preventative approach• Self-awareness• Supportive work culture and leadership• Leadership/role models to normalise self-care• Positive emotions and relationships• Character strengths

• Impediments to self-care• Unsupportive work culture and environment• Stigma• Busyness• Lack of planning/prioritising self-care• Inadequate boundaries between work and home• Self-criticism and low self-worth

Barriers and enablers to self-care practice

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Theme 1: A proactive and holistic approach to promoting personal health and wellbeing

to support professional care of others

The meaning of self-care was described in terms of its positive relational context with self

and others. Although self-care was focused primarily on individual needs, it was informed by

the broader clinical context of capacity to engage in positive and therapeutic relationships to

provide patient care. Self-care meant fulfilling a fundamental part of palliative care practice,

with one participant commenting that self-care is intrinsic to the work itself.

Self-care also meant balancing care for others with care for self, with the promotion

of personal health and wellbeing central to its meaning. Self-care was described as a

conscious and deliberate practice that meant much more than just a ‘tick-box’ checklist to be

completed within a set of allocated tasks.

Table 3. Theme 1

A proactive and holistic approach to promoting personal health and wellbeing to support professional care of others

Prudence Gwendolen Darrell Felicity Patrick Merilyn Winston Prudence Mason

Through self-care, what we are doing is developing a relationship with ourselves – which actually supports us in developing relationships with everybody else. Self-care - it’s looking after me to look after patients, so to speak; if I’m not of a good healthy physical state or emotional state, I’m hardly likely to be able to support someone. You can’t look after dying patients without looking after yourself, really, can you? And do a good job of that, in a compassionate way? Balancing care for yourself and others is essential. It’s part of a holistic approach… if you’re not caring for yourself then you’re less able to care for others. [It’s about] maintaining a good balance between body and mind… being able to stay fit and healthy. You look after your own health so that you can deliver patient-centred care. That’s what self-care is; it’s a way of living, it’s a way of living every moment. The thing is, [self-care] is not a tick-box commodity.

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Figure 2. The meaning and practice of self-care

Theme 2: Personalised self-care strategies within professional and non-professional

contexts

Effective self-care practice was described as a personalised and ongoing endeavour. In the

words of one participant, it’s a constant work in progress. Participant descriptions of

effective self-care practices were consistently characterised by a variety of self-care strategies

that were maintained both within, and external to, workplace settings.

Self-care in Personal Settings. Effective self-care strategies used outside of the

workplace settings included a range of health behaviours, meditation and spiritual practice. A

healthy diet, adequate sleep, and moderation of alcohol intake were considered important. In

addition to exercising for fitness, other physical activities such as yoga and massage were

found to be effective self-care strategies. Rest and relaxation at home in a bath were

described as effective self-care strategies when feeling overwhelmed or needing to wash

away (metaphorically) thoughts of the workplace. Socialising and maintaining positive

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relationships with friends and family was both supportive and meaningful. Meditation

practice was also an effective self-care used within both personal and professional contexts.

A variety of meditation practices were used by participants, including loving kindness

meditation. Spiritual practice was also considered an effective self-care strategy.

Finding harmony between personal and professional roles was consistently described

as an effective self-care strategy. Some described this harmony in terms of work-life balance.

Interestingly, others found the concept of work-life balance to be problematic in practice.

Given the elusive nature and individual context of what constitutes a balance between work

and life, most considered it more important to acknowledge that different life-domains

require varying degrees of attention at any given time; and that finding individual harmony

between personal and professional roles was a key strategy towards flourishing in life. One

participant explained:

It’s never like you’ve got this nice balance - where work finishes, then

you’ve got an hour to sort of wind down before the rest of life begins…

[it’s more about] just trying to keep all the different areas of life

flourishing (Darrell).

Establishing and maintaining boundaries between home and the workplace was

considered an effective self-care strategy. Some boundaries involved commuting to the

workplace via modes of transport that prevented over-working, while for others the commute

time itself constituted a process of unwinding from work so as to separate from it when

arriving home.

Self-care in Workplace Settings. Boundaries were also relevant to effective self-care

within the workplace. Awareness of boundaries in this context was supportive in terms of not

over-working due to resource limitations, whilst also ensuring clarity of expectations for

multiple stakeholders. In the words of one participant:

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The amount of resources [allocated to the] palliative care service - that

actually creates a certain set of boundaries within which I can work -

I’m not going to step over those boundaries; if they want additional

work, they need to increase the resourcing… It’s about managing

expectations around what I will do and what I won’t do - and being

able to be very upfront in relation to that… with management… with

staff that I work with, so [they] are aware of what we can do, and what

we can’t; but more importantly, with patients and their families, so

there’s a very clear set of expectations around what can reasonably be

done for them (Gordon).

Self-regulation of workload was important, but often difficult to achieve. It involved being

assertive about one’s capacity in relation to workload and wellbeing. Taking meal breaks,

taking recreation leave for regular holidays, and taking personal leave during illness were

also considered effective self-care strategies. For some, choosing to work part-time was an

effective self-care strategy that provided ongoing regulation of workload in relation to other

competing demands.

Self-regulation as a self-care strategy was often supported by other members of the

team. In this way, team-care was considered an aspect of effective self-care that contributed

to a healthy team. One participant described an example of team-care in terms of checking in

with colleagues about how they are feeling, as a reminder and invitation to attend to self-care.

Having a cohesive team was important and this contributed to a supportive working

environment. Mindfulness exercises were an effective self-care strategy in the workplace,

both in individual and group contexts. A sense of allowing oneself to be human, in the

context of displaying emotion in the clinical setting, was also part of effective self-care

practice.

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Table 4. Theme 2: Personalised self-care strategies within professional and nonprofessional contexts Philis Carmel Felicity Gwendolen Abbie Larissa Doreen Abbie Lucas Reece Deanna Sandra

It’s really not formulaic; it’s really quite individual, and so everybody has to find their own way of doing it. You not only need self-care strategies in the workplace - but also in your personal life. I do try and exercise a reasonable amount and I try and get to bed on time because I have to get up at a reasonable time… and diet’s important. I regularly exercise, do yoga and have a regular massage as well. [Having] a bath; it’s almost like I’m washing the hospital off me. I have an extremely supportive, very good husband and I have an extremely good network of friends, so… spending time with family and friends. Maintaining relationships with family; making sure I’m spending a reasonable amount of time with my children makes me feel that all is right in the world. Meditate for half an hour a day; that’s all I actually need to do to function well - I’m great at work, I’m calm with [son]. But if I don’t do that, then I get irritable [and] I don’t have as much to give at work. With just half an hour of meditation a day as my top priority for the day, I’m just better all round. I’m quite involved in my Church, and faith is actually a big anchor [that keeps me grounded]. …my spiritual practice which, for me, is a very reliable tool; Buddhist practices… to do with strengthening my connection with compassion or loving kindness for self and others. Work-life balance is really important. There's no such thing as work-life balance, it's rubbish.

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Cathi Felicity Deanna Winston Cathi Larissa Scott Doreen Carmel Darrell Deanna Abbie

If it’s after five o’clock: (a) I won’t be [at work]; and (b) my diary will be sitting on my desk with my mobile phone on it turned off, with my name tag sitting on it. My computer will be off. [It’s] about making certain that work is at work, so I don’t take my mobile phone home. I don’t take my diary home [to follow up on things]; no, sorry that’s work, and it will wait… work stays at work. I take the train… I can only arrive at a certain time and leave at a certain time – those boundaries are actually very helpful. I’ve never been very good at placing boundaries, so I actually have to do this physical boundary of ‘Right, the train’s leaving, and I have to go’ - and that’s worked quite well. My de-escalating time is driving home and when I walk in the door at home, work stays at work… and I find that something to be really important to me actually – that the two don’t intermix. It’s not sustainable to give out more than you really can on an ongoing basis… absolutely [regulating work demands is important]. I take regular holidays. I’m not somebody who’s got an annual leave balance; I always take my meal breaks, take my days off, and sick leave when ill. I chose [to work] part-time. It’s very difficult to do self-care without [team] support, and so you support each other in doing self-care at work, definitely. A mindful activity, just grounding yourself …this conscious thing of ‘Okay, what can I see? What can I feel? What am I touching? Supervision [provides] a safe and guided reflective space that allows you to talk about your practice; to think about what is meaningful to you, about a time, something you did, something you’ve been experiencing recently… allow yourself to really drill into - not just the story - but how did it make you feel… how did you behave… what would you change? [informal debriefing] is a sign of a healthy team because that’s… self-initiated, as opposed to organised or imposed. It’s Friday, I’m tired. A lot has gone on, and I’m giving a handover. I get half-way through the ward and then I start wrapping up. And they go, ‘What are you doing? There’s still the other half of the ward to go yet’, and I’m like, ‘Oh, damn’! So, being able to [make a mistake] and be able to laugh about it was important. Being kind and being compassionate about that. Being able to accept that you are human. We’ve all got a very black sense of humour, so it works really well.

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Reflective practice, especially through participation in clinical supervision, was described by

many as an effective self-care strategy, although formal supervision was not available in all

participants’ workplace. Importantly, respect and confidentiality were important components

for clinical supervision to be effective. But formal supervision was not necessarily helpful for

everyone, with many finding informal debriefing with peers to be effective. However, this

also required trust among colleagues. While the use of informal debriefing among colleagues

was considered a sign of a healthy team, formal, structured debriefing was also common in

some workplaces to support self-care. Use of humour and laughter was also an effective self-

care strategy used in the workplace, with laughter often expressing a sense of acceptance,

kindness and compassion for oneself rather than self-judgement during times when feelings

of inadequacy arise.

Participants reported accessing a variety of professional supports as part of effective

self-care practice. These ranged from Employee Assistance Programs and private counsellors

to psychologists, general practitioners and other medical specialists. For doctors, it was

considered especially helpful to seek objective medical advice from a general practitioner.

Interestingly, choice of employer was a self-care consideration in terms of gauging

organisational commitment to support staff with workplace self-care activities such as

clinical supervision. Finally, effective self-care practice was described as a shared

responsibility between palliative care professionals and the health services in which they

practised. However, there can be a lack of clarity with regards to this shared responsibility.

Theme 3: Barriers and enablers to self-care practice

Participants described the ongoing need to manage self-care barriers and enablers as part of

maintaining self-care strategies in both personal and professional contexts.

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Self-care barriers. Multiple impediments to self-care were identified in the workplace

including busyness. For some, this workload was compounded by limited opportunity to take

holidays from work. Workplace culture was also identified as problematic, where it was not

conducive to self-care. In some workplace cultures there was a stigma associated with self-

care, making it difficult for individuals to engage in self-care practice without feeling judged

as being selfish. Bringing work home was described as a barrier to self-care, and related to

workplace culture and expectations. Self-worth was also discussed as a common concern for

effective self-care, where self-criticism and a lack of self-worth undermined self-care as an

important priority. Finally, a lack of planning for self-care, or otherwise adopting a solely ad

hoc approach was considered a barrier to effective self-care.

Self-care enablers. Several factors were described as facilitators of effective self-care.

Recognising the importance of self-care was considered an important enabler by all. Some

became conscious of this through previous experiences of illness or being unwell after having

initially neglected self-care. Prioritising self-care was an important enabler which correlated

with noticeable benefits. Adopting a preventative approach to self-care was important, whilst

recognising that additional strategies may need to be implemented, as required, according to

context. While formal self-care plans were used by some, for most participants it was more

important to engage in reflection and self-assessment as part of an ongoing planning process,

rather than have a static document.

Positive workplace cultures supportive of self-care were described as vital to effective

self-care practice. Where a supportive culture was absent, the normalisation of self-care within

workplaces was considered a key enabler, requiring leadership from the top-down to effect

positive change towards a culture more supportive of self-care. One participant explained:

Normalisation… the reason I bang on about [self-care] is because I

think, yes, you do need to normalise it. I think the key thing is the ethos

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of the unit, and I think that’s set firstly through the medical head but

then also the administrative or hierarchal structure [helps] - if it’s

normalised and supported from the top then I think that flows down

through the service… [from my observation] it is the leadership group

of the team, and unfortunately that is still medical, who set the ethos

of the unit. So, if you want to change the culture of the place, my

approach would be to get the most senior consultants on board,

(Winston).

Leadership and positive role models were considered key enablers to effective self-care. This

also related to the allocation of reasonable workloads. Other facilitators of effective self-care

were more intrapersonal. These included having a positive outlook, self-awareness and positive

emotions. Self-awareness was described as central to effective self-care practice. Gratitude and

taking a positive perspective, even in the face of negative circumstances, enabled self-care.

Self-compassion was considered essential to self-care, and relational to compassion for others

- as expressed through patient care. One participant explained:

Self-care is built on self-compassion. If your compassion does not

include yourself, it is not complete; it extends to yourself and to your

clients equally. And if you’re not doing that, then something’s not

working (Carmel).

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Table 5. Theme 3: Barriers and enablers to self-care practice Cathi Patrick Scott Merilyn Gordon Larissa Winston Peggie Prudence Sandra Philis Carmel

There’s too many patients and you can’t get enough done… busyness contributes to poor self-care because you actually don’t stop to go ‘How has this affected me? What can I do? What do I need to make me ‘okay’ about it?’ There is an expectation that people won’t take holidays, but how are people supposed to recharge so they can keep working? There’s this… culture sometimes where you just sort of ‘soldier on’ and do what’s expected – take work home. It just follows you home and it can really impact on your home life and your health, because you’re just… stressing about things The biggest hindrance to self-care is organisational culture. There’s a big culture shift that needs to happen in order for people to be able to look after themselves properly. There is still a lot of stigma around having feelings or accepting feeling or being vulnerable… we do see confronting things but there is still that superhero, you know, not letting it affect you. People are considered to be selfish if they do something for themselves… you know, if you take a day off because you’re on a mental health day people think ‘Oh, she’s so selfish because she’s let her team down’ Lack of self-worth and self-value is a bit of an issue… I can see that in how my colleagues - how people treat themselves, and that’s not a judgment - it’s an observation coming from someone doing pretty much the same kind of thing. Self-care always get shoved down to the bottom… that self-worth thing of… you know, something else always being much more important. I certainly used to be quite critical about myself… which isn’t a particularly helpful thing to do really… [most of us] just beat ourselves up emotionally and physically… and then eventually work out why you can't keep doing that for the rest of your life. Self-care goes down the toilet when it’s random… there’s no effective random self-care.

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Peggie Gordon Abbie Winston Reece Carmel Kaleb Cathi Doreen Reece Gordon Lucas

I’m very conscious of [self-care] because I’ve been a in bad spot before with palliative care… I really didn’t cope very well, so I’m [now] highly vigilant about self-care. I was ‘young and bullet-proof’… and I found [that] to be a fairly unpleasant experience; ‘young and bullet-proof’ didn’t work very well. But it took me about seven years to work that out, and I became significantly burnt out… So, having burnt out… taken time off, and readjusted… I’m now very conscious of how important self-care is. When I do [prioritise self-care] I’m calm and I’m more compassionate. Preventative maintenance… Yeah, well it is [like having a regular check-up and a tune-up] I have written self-care plans for myself… but I don’t approach that in a sense of, you know, at six months – ‘now I need to redo my self-care plan’. An ongoing planning process is the critical element rather than just the piece of paper. Leadership. It’s got to come from the top. You can’t have someone at the top who thinks that people who need to go for counselling are 'poor little things'. Seriously, it’s not going to work Having a reasonable degree of self-awareness is hugely important [for effective self-care], particularly in our line of work. Finding the positive in situations… also taking account of things that have negatively impacted me [but still finding] something positive. …intentionally choose how I want to be each morning, and how I want to leave work, and respond to events; having a mindset of gratitude. Practising self-compassion is a really important enabler – without that I’m not really sure how authentic my self-care would be. Being realistic about your limitations is central to self-care… self-care involves being honest about a whole host of things, and it’s primarily being honest with yourself - and being prepared to take that up with other people where you need to - but it’s about being honest with yourself in relation to your limitations. Contemplating my own mortality is very important in terms of self-care. I have to have confronted that; there but for the Grace of God go I… and this could be me [dying]… Really puts things into perspective and helps you to live and enjoy your life to the full.

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Importantly, self-compassion did not necessarily come naturally, and in many cases had to be

learned. For some, self-compassion was viewed as an emotion that became more apparent

later in life, when career achievement was less of a priority. Authenticity and courage were

also described as self-care enablers. These encompassed self-advocacy and self-acceptance –

in terms of being realistic about limitations; and being, in the words of one participant,

authentically human. Lastly, reflecting on and having an appreciation of one’s own mortality

was considered important and enabling for self-care practice.

DISCUSSION This study explored the meaning and practice of self-care as described by palliative care

nurses and doctors. These findings contribute new knowledge in several ways, with

implications for clinical practice, research and education.

A proactive and holistic approach to promoting personal health and wellbeing to

support professional care of others. The holistic nature of self-care as revealed in this study

is consistent with the discourse analysis conducted by Breiddal [21]. Findings from the

present study extend this existing knowledge by providing new insight into the meaning of

self-care, and also through further evidence of the relational context in which self-care is

practised, as voiced by practitioners in the field. For palliative care professionals, self-care is

not a selfish endeavour apathetic to the needs of others; rather, it is a proactive and relational

practice cognisant of practitioners’ health and human needs, and motivated by the

professional context of sustaining compassionate care in therapeutic relationship with patients

and their families. This was especially evident in the words of one participant: …if you don’t

feed yourself, you’ve got nothing to give; much of what we do in palliative care is about

human connectedness. It also supports Kearney and colleagues’ [22] assertion that self-care is

not a selfish luxury, but is instead essential to clinicians’ therapeutic relationship with

patients.

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Personalised self-care strategies within professional and non-professional contexts.

While most research has to date focused on strategies used to cope with occupational

stressors [12]; these findings, situated in the broader context of self-care, reveal not only the

variety of effective strategies employed, but also the challenges and complexities involved

with maintaining effective self-care strategies in practice. The need for reflective practice to

build self-awareness, as well as the management of multiple barriers and enablers to self-care

practice, clearly demand ongoing attention from practitioners and palliative care services.

That mindfulness exercises were used spontaneously by participants in practice

settings suggests that the benefits of formal mindfulness training initiatives extend beyond the

training room and into the clinical milieu [23, 24]. Clinical supervision was effective for

many, but not for others; and in many instances, it was not available at all. This seems to

reflect, in part, a different attitude to clinical supervision within the nursing and medical

disciplines; when compared to other disciplines such as social work, in which supervision has

long been a cornerstone. As a social worker, Firth [25] explains that many nurses may feel

threatened by supervision, whilst doctors have traditionally avoided it. Given the potential

benefits to self-awareness and staff wellbeing, the provision of supervision should

nonetheless be considered; perhaps with an emphasis on the restorative aspects of clinical

supervision [25-27].

Formal and informal debriefing was consistently described as an effective self-care

strategy, and thus should be encouraged. Similarly, laughter and the use of humour formed a

fundamental part of self-care, and should be fostered as appropriate. Laughter has long been

considered a coping strategy to manage stress in palliative care settings [28]; however, this

finding extends a new context in terms of self-care behaviours to support health and

wellbeing. Indeed, there is evidence to suggest not only psychological, but also physiological

health benefits from laughter, including enhanced cardiac and immune function [29-31].

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Establishing and maintaining effective boundaries within and outside of the

workplace was an effective self-care strategy for participants in this study, as was work-life

harmony. Whilst so-called work-life balance was discussed by some, and has also featured in

other palliative care research into coping mechanisms [32]; this concept was incongruous to

the experience of others. Overall, it was important to acknowledge that different life-domains

require varying degrees of attention at any given time, and finding one’s individual harmony

between personal and professional roles was thus a key strategy towards flourishing in life.

This is consistent with McMillan and colleagues’ [33] definition of work-life harmony as ‘an

individually pleasing, congruent arrangement of work and life roles that is interwoven into a

single narrative of life’. It also corresponds with recent research findings that work-life

interference, or conflict, is associated with higher levels of burnout in nurses and predicts

intention to leave an organisation or the nursing profession [34]. Thus, work-life harmony is

an important aspect of effective self-care. Given this finding, future self-care education might

usefully incorporate this new emphasis on work-life harmony over the common parlance of

‘work-life balance’ which is ill-defined and otherwise problematic in practice for some [33].

Another interesting finding related to participants electing to work part-time as a self-

care strategy. While only 42% of participants worked part-time in the present study, the

majority of participants who had earlier completed a survey worked part-time. Given these

and earlier research findings [32], working a part-time load appears to be a common self-care

strategy for palliative care professionals. Indeed, one participant suggested that part-time

roles should perhaps be encouraged in favour of a full-time load, given the emotionally

demanding nature of palliative care. However, this would need to be weighed up by the

individual in relation to feasibility of lower income and potentially limited opportunities for

career advancement in roles where full-time work is required.

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Barriers and enablers to self-care practice. While positive workplace cultures were

discussed as enablers of self-care, there were many who described their current workplace

culture as a barrier to effective self-care, in that it was not supportive of self-care practice.

This finding is alarming, yet not altogether surprising when taken in the context of self-care

being highly stigmatised – as either selfish or weak – in some participants’ workplaces.

Perhaps more concerning, is that this stigma may serve to not only impede effective self-care

practice in the workplace; it could also discourage palliative care professionals from taking

personal leave or seeking professional support when they become unwell. As described by

Hill [35], a paediatric palliative care physician, showing vulnerability or seeking help is often

viewed as a sign of weakness; and acknowledging one’s shared humanity and vulnerability

through self-compassion is vital to self-care behaviours. Understanding factors that contribute

to supportive workplace cultures and facilitate self-care is therefore essential. Some palliative

care services in Australia might benefit from the experience of their counterparts in Canada

and the United Kingdom, who have focused on leadership to foster workplace cultures of

self-awareness, self-care, and staff support [36, 37].

Several enabling factors to self-care practice were identified in this study, both

interpersonal and environmental. Authenticity, courage, and leadership were highlighted by

participants. Being authentically human in acknowledging one’s own vulnerability; having

the courage to challenge stigma or be assertive in saying ‘no’, when acquiescing to additional

workload may compromise one’s own wellbeing; and leading by example in supporting and

normalising self-care as an essential aspect of palliative care practice. Authenticity, courage,

and leadership have been recognised as character strengths that can be measured and

cultivated [38]. Development of these character strengths in palliative care teams should

therefore be encouraged to assist in transforming any unsupportive workplace cultures.

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In this study, positive emotions such as gratitude and self-compassion enabled self-

care. This is consistent with a growing field of positive psychology research, in which

positive emotions not only have a biological basis for physiological health benefits; but have

also been shown to broaden repertoires of positive thoughts and actions which, in turn, help

to build personal and social resources that lead to wellbeing and flourishing [39-43]. Whilst,

in the context of psychological flexibility, negative emotions are not necessarily to be

avoided [44]; awareness of, and capacity for the cultivation of, positive emotions should thus

be fostered as part of self-care practice. This may serve to promote resilience and emotional

intelligence both individually and across the palliative care team [45, 46].

That self-compassion was considered enabling to self-care, corresponds with findings

from a recent correlational study [47] in which perceived self-care ability was significantly

associated with increased self-compassion in palliative care nurses and doctors. Indeed, as

highlighted by Vachon [48], self-compassion entails knowing and caring for oneself.

The self-care barriers identified in the present study provide a valuable context which may

also explain the low levels of self-care ability identified in some doctors and nurses from the

previous study. Building from emerging evidence to support compassion-oriented training

interventions in palliative care teams [24], future research should therefore investigate any

causal relationship between these variables longitudinally. Potential studies could incorporate

interventions that draw upon loving kindness meditation or other compassion training

programs which have been shown to enhance compassion for self and others, and may

therefore contribute positively to both self-care and compassionate care of others [49-53].

In other research [13, 54], palliative care professionals’ reported self-care practices

have corresponded with physical, social, and inner domains of self-care. Importantly,

findings from the present study underscore the imperative that strategies from these self-care

domains are implemented and maintained in both personal and workplace settings. Findings

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from this study can thus inform the self-care education and training interventions recently

called for [55], especially in relation to self-care planning, work-life harmony, and

management of identified barriers and enablers to effective self-care practice. Educational

resources might usefully draw upon this qualitative evidence previously lacking in the

literature, to articulate and foster the meaning and practice of effective self-care in the

palliative care workforce. For example, clarifying staff confusion about the shared

responsibility for self-care practice – as identified in this study.

The issue of balance between individual and organisational responsibility is multi-

faceted and requires careful consideration by palliative care services. Clearly, an organisation

cannot practise self-care on behalf of its workforce; however, it can enable and enhance self-

care through corporate leadership and a variety of structural supports to foster positive

workplace cultures that are conducive to effective self-care practice [36, 37]. At the same

time, individual practitioners carry a personal responsibility for self-care to maintain their

health and capacity for professional practice. This was highlighted by one participant, who

stated: It’s the responsibility of every team member to look after themselves, but having

management or organisational strategies in place to support someone doing self-care is

incredibly important… it’s a dual process. This collaborative approach to promoting health

and wellbeing in workplace contexts is reflected in the World Health Organisation’s (WHO)

[56] Healthy Workplace Framework.

While individual responsibility relates to implementing and maintaining self-care

strategies, organisational responsibility is thus oriented towards supporting staff in effective

self-care practice to promote health and wellbeing. This support represents an investment,

with a host of potential organisational benefits including increased patient and family

satisfaction, increased staff retention and reduced absenteeism, improved staff morale and job

satisfaction [27]. Conflict between colleagues can be a common source of staff stress, and is

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an important workplace concern where all parties must take some responsibility. While the

degree of responsibility will vary according to context, the use of employee assistance

programs and adoption of the WHO Healthy Workplace Framework can provide support and

guidance in this area.

Clarity may also be lacking with regards to shared responsibility for self-care practice

where clinicians experience chronic illness and or disability. Health services, as institutions,

have the potential to promote health and wellbeing not only for health care consumers; but

also for health care professionals [57]. Indeed, some argue that hospitals should serve as

exemplars of healthy workplaces [58]. Given this context, a collaborative approach

encompassing individual self-management and organisational support would be consistent

with the WHO Healthy Workplace Framework, which recommends that workplaces be

supportive of employees living with chronic disease and disability [56]. Palliative care

services might usefully draw upon this or similar approaches.

Given the highly personalised nature of self-care, palliative care services should also

consider ways in which a variety of self-care strategies can be supported. For example,

providing opportunities for both informal debriefing and formal clinical supervision –

depending on individual preference; as well as scope for the supported development of

individual self-care plans for those who feel they would benefit from them.

A novel finding from this study was the concept of team-care to promote a healthy

team. As an encouraging sign of positive workplace cultures, this highlights an additional

dimension to the relational context of self-care practice, whilst underscoring the importance

of supporting interdisciplinary teamwork as an integral part of the philosophy of palliative

care. It also contributes to the literature on positive relationships and workplace wellbeing in

the context of self-care and positive health [59]. Taken together, the practice of team-care as

an antecedent to a healthy team in palliative care represents a potential avenue of qualitative

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inquiry for future research. This would be enhanced with the inclusion of participant

observation and patient-reported outcomes on any perceived benefits to the quality of care

provided.

Limitations. Limitations to this study should be noted. Socio-cultural considerations

were not represented in the demographic data collected or subsequent analysis. Whilst, to our

knowledge, any significant impact of culture on self-care has not featured in the literature to

date, we acknowledge that palliative care professionals from culturally and linguistically

diverse backgrounds may understand and approach self-care practice in ways other than as

described in this study sample. Additionally, the sample was somewhat limited in terms of

participants’ geographical location. While the study recruited participants from metropolitan

and inner or outer (rural) regional locations of nearly all Australian States and Territories,

remote area locations were not represented. The meaning and practice of self-care may have

unique characteristics in remote area practice, thus transferability of findings from this study

should be gauged by remote area practitioners. Despite these limitations, which may be

addressed in the future by discrete population-specific studies, this research has generated

new knowledge in line with the study aim.

CONCLUSIONS

The findings of this study reveal a context and complexity of effective self-care practice

previously lacking in the literature. Taken together, the findings of this research provide new

insight to support palliative care practice and education. Self-care is a proactive and

personalised approach to the promotion of health and wellbeing through a variety of

strategies, in both personal and professional settings, to support capacity for compassionate

care of patients and their families. Importantly, it is a shared responsibility between palliative

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care professionals and the palliative care services in which they work, with staff support and

positive workplace cultures required to manage various barriers and enablers to effective self-

care practice. This research adds an important qualitative perspective and serves to advance

knowledge of both the context and effective practice of self-care in the palliative care

workforce.

Chapter Conclusion

This chapter has presented findings from the qualitative strand of the study. The next chapter

will provide overall results of the study, answering the research questions via the integration

of both quantitative results and qualitative findings.

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CHAPTER 6

STUDY RESULTS

Chapter Introduction

The purpose of this chapter is to present answers to the research questions through integration

of findings from the quantitative and qualitative strands of the study. Each of the study

research questions are addressed in turn, drawing upon either or both strands of the study as

appropriate.

Answering the research questions

RQ1. Participants practised self-care strategies across all three health-related domains of self-

care: (1) Physical; (2) Social; and (3) Inner-self-care. Physical self-care strategies were most

commonly used (39%), followed by social (31%) and inner self-care strategies (30%). The

most commonly used physical self-care strategies related to exercise and walking. The most

commonly used social self-care strategies involved spending time with family and friends.

Finally, the most common inner self-care strategies related to meditation and reading.

RQ2. Most participants (86%) considered self-care to be very important for nurses

and doctors working in palliative care. Others (13%) thought it was important, whilst some

(1%) considered self-care not very important to palliative care practice. Participants

commented that self-care was important in the context of longevity of being able to keep

caring for others.

RQ3. The regularity of participants’ self-care practice was mostly either frequent

(45%) or intermittent (44%), however, a considerable proportion (11%) rarely engaged in

self-care strategies.

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RQ4. Less than half of all participants (39%) had received specific training, education

or resources in their workplace about effective self-care strategies.

RQ5. Self-care plans were used by a small proportion of participants (6%); however,

more than two-thirds (70%) of participants reported they would consider using self-care plans

if training was provided. All participants who used self-care plans reported they were an

effective self-care strategy. Qualitative findings revealed that an ongoing process of planning

was considered an enabler to effective self-care practice.

RQ6. On average, the level of reported self-care ability in this sample was moderate

(M = 71, SD = 19; however, individual scores ranged as low as 8 from a maximum of 100.

The average level of participants’ reported self-compassion was also moderate (M = 3.26, SD

=.63), with some individual scores as low as 1.25 from a maximum of 5. Compassion for

others was, on average, reported at levels in the upper range of moderate (M = 3.79, SD

=.70); however, individual scores were reported at levels as low as 1.8 from a maximum of 5

RQ7. A positive and statistically significant relationship existed between self-

compassion and self-care ability in this sample, as indicated by a medium effect size

Pearson’s partial correlation coefficient, controlling for socially desirable responding (r =

.412, p = <.001). This association was further supported by hierarchical linear regression

indicating that self-care ability increased with higher levels of self-compassion. Qualitative

findings revealed that self-compassion was a key enabler to effective self-care practice.

Together, the quantitative and qualitative strands of this study suggest that self-compassion

supports self-care in this population (see Figure 1).

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Figure 1. Self-compassion supports self-care

RQ8. A modest, but negative, and statistically significant relationship was found

between self-compassion and compassion for others, as indicated by Pearsons’ partial

correlation coefficient, controlling for socially desirable responding (r = -.122, p = .019).

Hierarchical linear regression further indicated that as compassion for others increased, there

was a decrease in self-compassion. Exploratory factor analysis performed using composite

Anderson-Rubin scores suggests that a considerable proportion of participants scored either

low in both compassion for self and others, or high in compassion for others but low in

compassion for self. These results contrast with qualitative findings suggesting a contextual

connection between self-compassion and compassion for others, as enabling positive

emotions in the context of self-care practice. Self-compassion and compassion for others are

considered relational and enabling to self-care practice; however, there is an apparent

discrepancy in this population where increased compassion for others is associated with

decreased compassion for self. Taken together, the relationship between self-compassion and

compassion for others appears to vary.

RQ9. The meaning of self-care was described by palliative care nurses and doctors as

a proactive and holistic approach to promoting personal health and wellbeing to support

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professional care of others. Self-care was further described as a relational and fundamental

part of palliative care practice – in the words of one participant, intrinsic to the work itself.

RQ10. Effective self-care practice was described as the implementation and

maintenance of personalised self-care strategies within professional and non-professional

contexts and the ongoing management of barriers and enablers to self-care practice.

Effective self-care practice encompasses a variety of strategies—both within and outside the

workplace—to enhance capacity for compassionate care provided through therapeutic

relationships. It is a shared responsibility between palliative care professionals practising self-

care, and the palliative care services in which they work. Positive workplace cultures and the

provision of staff support can assist staff to manage barriers and enablers to effective self-

care practice. Taken together, the self-care domains identified from the quantitative results

combined with the qualitative findings relating to the need for self-care across settings,

suggest that effective self-care practice involves the application of physical, social, and inner

self-care strategies in both personal and professional contexts (see Figure 2).

Figure 2. Self-care Domains and Contexts

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RQ11. A lack of planning for self-care, or otherwise adopting a solely ad hoc approach to

self-care practice was considered a barrier to effective self-care. Self-criticism and lack of

self-worth were discussed as common barriers to effective self-care. Multiple impediments to

self-care were identified in the workplace including busyness, workload, and limited

opportunities to take leave for holidays. Workplace culture was also identified as

problematic, where it was not conducive to self-care. In some workplace cultures there was a

stigma associated with self-care, making it difficult for individuals to engage in self-care

practice without feeling judged as being selfish. Bringing work home was also described as a

barrier to self-care, and this was identified in relation to workplace culture and workload

expectations.

RQ12. Recognising the importance of self-care and prioritising it was considered an

important enabler of effective self-care practice. For some, this recognition arose through

previous experiences of illness or being unwell after having initially neglected self-care.

Reflecting on and having an appreciation of one’s own mortality was considered important

and enabling for self-care practice. Adopting a preventative approach to self-care was

important, whilst recognising that additional strategies may need to be implemented, as

required, according to context. Self-awareness was described as central to effective self-care

practice. Having a positive outlook, positive relationships, and positive emotions such as

gratitude or compassion for self and others were also considered enabling.

Planning for self-care was a key enabler of effective self-care practice. Participants

who used formal self-care plans found them enabling, while others who did not have formal

self-care plans considered an ongoing planning process to be more enabling than having a

static document. Positive workplace cultures conducive to self-care were described as vital to

effective self-care practice. Where a supportive culture was absent, the normalisation of self-

care within workplaces was considered a key enabler, requiring leadership from the top-down

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to effect positive change towards a culture more supportive of self-care. Positive role models

and leadership were also considered key enablers to effective self-care.

Chapter Conclusion

This chapter presented the integrated results of the study. It has addressed the research

questions by drawing upon both quantitative and qualitative strand data as appropriate. The

next chapter will discuss the overall results of the study in the context of this thesis.

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CHAPTER 7

DISCUSSION

Chapter Introduction

The purpose of this chapter is to discuss the overall results of the study in the context of this

thesis. The chapter begins with discussion of key findings and their implications for practice,

as well as recommendations for future research. It then proceeds by outlining the contribution

of the study to the literature. The chapter concludes with discussion of strengths and

limitations of the study.

Discussion of Key Findings

The key findings of this study add new knowledge and extend current understanding across

several areas, particularly in the Australian context of palliative care practice (see Table 1).

These findings are now discussed in relation to the existing literature. Whilst the study

findings related to all four themes identified from the literature review, the most significant

findings were those that address the fourth theme, balanced compassion.

Self-care strategies most commonly used. The self-care activities most frequently

practised by participants were physical. This is consistent with previous research involving

hospice professionals in North America (Alkema, Linton, & Davies, 2008). The use of

physical strategies such as regular physical activity, healthy dietary intake, and adequate

sleep also correspond with the healthy lifestyle behaviours observed in a cohort study of

Australian and New Zealand nurses and midwives (Tuckett & Henwood, 2015).

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Table 1. Areas of Key Findings

Self-care strategies most commonly used

Perceived importance of self-care in

palliative care practice

Regularity of self-care practice

Provision of self-care education and

training

Uptake and utility of self-care planning

Ability to implement and maintain effective

self-care strategies

Levels of compassion for others

Levels of self-compassion

Relationship between self-compassion and

self-care ability

Relationship between self-compassion and

compassion for others

Compassion literacy The meaning and practice of self-care

Barriers and enablers to self-care practice

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While physical self-care was most common in the present study, the self-care strategies

described by participants were spread relatively evenly across the health-related

domains of physical, social, and inner self-care. This is consistent with other research that

investigated these domains in a sample of Spanish palliative care professionals (Sanso´ et al.,

2015), and suggests that employing a variety of strategies is important to palliative care

professionals’ self-care practice. Thus, palliative care professionals should consider

broadening their self-care practice where it is limited to one or two self-care domains.

Perceived importance of self-care in palliative care practice. Perceptions of

palliative care nurses and doctors in Australia are consistent with discussion in the literature

with regard to the importance of self-care. Whilst scholars have argued that self-care is

important (Jones, 2005; Kearney et al., Sanchez-Reilly et al., 2013; Kearney, Weininger,

Vachon, Harrison, & Mount, 2009), the perception of those in the broader field of palliative

care practice was to date largely unknown. This study provides empirical data to suggest that

a majority of the Australian palliative care workforce may share this position. Palliative care

services in Australia can use this knowledge to prioritise resources to support self-care

practice, especially with regards to targeted education and training for those receptive to it.

Moreover, education can be tailored to the small proportion of people who do not

consider self-care to be important to palliative care practice. These initiatives might usefully

draw upon these and other findings from this study to manage barriers and enablers to self-

care practice. For example, demonstration that a large majority of the study sample consider

self-care to be important might serve to break down stigma and help to normalise self-care in

workplace cultures where it is stigmatised as selfish.

Regularity of self-care practice. Renzenbrink (2004) argues the need for ‘relentless

self-care’, but the regularity of palliative care professionals’ self-care practice has not

featured in previous research. This knowledge could be useful in situations where

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palliative care professionals might appreciate the importance of self-care but not engage

with self-care in practice. The finding that less than half of the participants practised self-

care frequently and more than 10 per cent rarely engaged in self-care practice is cause for

concern; this suggests a need for greater attention towards self-care education and

training. As alluded to previously, understanding the barriers and enablers to self-care

practice may be pivotal in improving the regularity of self-care practice so that it is more

consistent.

Provision of self-care education and training. Although adequate education and

training is important in supporting self-care (Palliative Care Australia, 2018; Palliative

Care Expert Group, 2016), only 39 per cent of nurses and doctors in this study had

received self-care education or training. This is concerning, especially given that in

Australia, for more than a decade now, palliative care professionals have been required to

initiate and maintain effective self-care strategies in accordance with Palliative Care

Australia’s (2005) national quality standards. This finding suggests that many staff may

not have received the necessary training to promote effective self-care practice. It also

supports the previous recommendations for increased self-care training (Palliative Care

Australia, 2016). More importantly, this finding underscores the importance of the recent

changes to the national standards (Palliative Care Australia, 2018) which, in effect, now

mandate the provision of self-care training for health care professionals working in palliative

care services in Australia. Indeed, the relevant survey paper was published during the

standards review consultation period, and this key finding helped to inform the changes

made.

This shift is significant in that there is now more emphasis on the responsibility of

palliative care services to provide adequate training to support self-care practice. Given

that self-care is a professional expectation, equipping palliative care professionals with

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the necessary means to understand and engage in effective self-care practices represents

a priority for palliative care services in Australia. While content and pedagogical

approaches to self-care training might usefully be drawn from programs already piloted

(Edmonds et al., 2015; Kerr, 2016; Kim, Rapp, Gill, & Myers, 2013; O’Connor &

Peyton, 2015; Radwany et al., 2012), findings from the present study suggest merit in the

consideration of compassion-based interventions to enhance self-care in the context of

promoting positive emotions. However, these interventions should be evaluated to test

for their effect on compassion levels, as well as health and wellbeing in palliative care

professionals.

Uptake and utility of self-care planning. The use of self-care plans has long been

promoted in the literature (Jones, 2005; Sanchez-Reilly et al., 2013); yet, prior to the

present study, data to indicate the utility and uptake of self-care plans in the palliative

care workforce was not available in the published research literature. In the current

study, all nurses and doctors who used a self-care plan reported it to be an effective self-

care strategy. However, the uptake of self-care plans in this sample was very low.

This might relate to the infrequent nature of some participants’ self-care practice,

or indeed, the lack of self-care education provided; as a considerable majority of those

who did not use a self-care plan indicated that they would be receptive to doing so, if

provided with requisite training and resources. This finding was further clarified by the

qualitative findings from this study. The low uptake of formal self-care plans was

contextualised by participants who described an ongoing process of planning as an enabler

to effective self-care practice, and more important than having a formal self-care plan that

represented a static document. Taken together, the study findings suggest that ongoing

planning for self-care practice is important, and that for some, formalising this process

through individual self-care plans is effective. Future education and training initiatives should

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therefore offer flexibility around the use of either formal or informal methods of self-care

planning.

Ability to implement and maintain effective self-care strategies. Despite an

international mandate for self-care in palliative care practice, palliative care professionals’

ability to implement and maintain effective self-care strategies had not been investigated in

the published research literature prior to this study. Collectively, participants in this study

reported a moderate level of ability to implement and maintain effective self-care strategies.

Individually, however, a proportion of very low ratings indicate that some palliative care

professionals feel limited in their capacity for self-care practice. This may be associated with

the previous finding relating to infrequent self-care practice.

Traditionally, self-care has not featured in general nursing or medical training, and the

findings herein suggest this is also the case for most nurses and doctors specialising in

palliative care. It is perhaps not surprising then, that some clinicians may find it challenging

to balance care of others with care for self. Indeed, in writing about self-care, Rogers (1980)

claimed it was more difficult than caring for others, and that it took time to learn. Rogers

(1980, p.80) conceded ‘I have always been better at caring for and looking after others than I

have in caring for myself. But in these later years I have made progress’. Elaborating further,

Rogers (1980, p.81) recounted a period when he felt particularly challenged in relation to

self-care whilst caring for his wife:

I was close to breaking point from being on call as a 24-hour nurse,

a housekeeper, a professional person in much demand, and a writer...

I explored and tried to meet my own needs. I explored the strain that

this period was putting on our marriage. I realised that it was

necessary for my survival to live my life, and that this must come

first, even though Helen was so ill.

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This realisation is consistent with the Foucauldian philosophy of the care of self, in which

people must first take care of themselves in order to better take care of others (Foucault,

2003). Individual results from the present study relating to self-care ability suggest that some

palliative care nurses and doctors may benefit from targeted education and training in this

area. Given the apparent importance of effective self-care practice, these findings suggest

room for improvement towards building capacity among palliative care professionals to

implement and maintain effective self-care strategies.

Levels of compassion for others. Despite growing concern that compassion is lacking

in care of the dying (Vachon, 2016a), there was very limited empirical understanding of

compassion for others in the palliative care literature prior to the present study. Overall,

participants in this sample reported a moderate level of compassion for others, with a mean

score of 3.79 as measured by the Santa Clara Brief Compassion Scale. Perhaps not

surprisingly, this sample of palliative care nurses and doctors scored higher in compassion for

others than did college students from Santa Clara University in North America, with mean

scores ranging from 3.09 in Engineering graduates to 3.69 in social science graduates, using

the same scale (Plante & Halman, 2016).

In other research using the Santa Clara Brief Compassion Scale, Neff and Pommier

(2013) compared undergraduate students with general community members. Palliative care

professionals in the present study scored higher than both, with the mean score of 3.22 in

undergraduate students and 3.31 in the general community. Whilst health professionals may

be expected to have higher levels of compassion than student and general community

populations, this finding is highly encouraging given that the literature is replete with

discussion of compassion fatigue. Nonetheless, on an individual level, there appears to be

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some cause for concern, with participants in the present study scoring as low as 1.8 on the

Santa Clara Brief Compassion Scale.

Lower levels of compassion for others might be explained by specific barriers to

compassion experienced in the clinical setting. While barriers to so-called medical

compassion have been investigated in physicians (Fernando & Consedine, 2017), future

research might usefully examine associations between identified barriers and levels of

individual compassion for others among broader health professional populations including

nurses. Other factors that may block compassion include coping and communication styles.

In conceptualising non-violent communication as a language of compassion,

Rosenberg (1999) argues that life-alienating communication involving moral judgement,

comparison, and denial of responsibility represent significant barriers to compassion. To this

end, preliminary work has been undertaken to examine and catalogue various characteristics

of compassionate communication in physician-patient dialogues (Cameron, Mazer, DeLuca,

Mohile, & Epstein, 2015); building on earlier work that established the mutual benefits of

non-verbal communication of compassion (Kemper & Shaltout, 2011). Although human-

centeredness lay at the heart of health care practice, there is also evidence to suggest that the

dehumanising of patients is a coping strategy for some nurses and doctors (Schulman-Green,

2003; Trifiletti, Di Bernardo, Falvo, & Capozza, 2014), and this may inhibit their expression

of compassion. Gilbert (2014) explains that many psychological difficulties relate to social

relational problems with feeling a caring, affiliative orientation towards others and oneself.

For example, self-criticism and negative emotions such as anger, disgust, or anxiety can

restrict feelings of compassion for oneself or others (Gilbert, 2014; Jinpa, 2015; Gilbert &

Choden, 2014).

Additionally, the phenomena of compassion fade (Västfjäll, Slovic, Mayorga &

Peters, 2014) and compassion collapse (Cameron (2017) may reveal insights into the

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experience of palliative and other health care professionals. Based on his research into

motivated regulation of affect (Cameron & Payne, 2011), Cameron (2017) explains that

compassion collapse – or the strategic avoidance of compassion – can occur as a protective

response where individuals feel overwhelmed by the magnitude of suffering they encounter.

The form of emotion regulation apparent in this compassion collapse is distinct from the

construct of compassion fatigue commonly discussed within the health care literature.

Another phenomenon described in the psychological literature is that of pseudoinefficacy.

Associated with psychic and psychophysical numbing, a sense of pseudoinefficacy is said to

occur when one feels non-rationally deterred or ineffective at engaging in compassionate

behaviours, based upon the scale of suffering that is apparent (Västfjäll, Slovic, & Mayorga,

2015).

These phenomena warrant further investigation within palliative care settings, given

the ongoing exposure to death, loss and grief. As explained by Remen (2002), ‘the

expectation that we can be immersed in suffering and loss daily and not be touched by it, is as

unrealistic as expecting to be able to walk through water without getting wet’ (p.52). As a

physician, Remen (2002) cautions, however, that protecting oneself from loss rather than

grieving and healing it, is a major cause of burnout. Taken together, the results of the present

study point to a need for further investigation of potential barriers to compassion, as well as

targeted interventions to help palliative care professionals better engage with suffering in

clinical practice - in a way that is both compassionate and sustainable. Indeed, sustainable

compassion is an important theme highlighted by Larkin (2016b).

Levels of self-compassion. Increasing attention has been paid to self-compassion in

the palliative care literature however, a lack of research has meant that empirical knowledge

is limited. This study found a moderate mean level of self-compassion among participants

(3.26). This is higher than was found in other research involving community nurses (Durkin,

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Beaumont, Hollins Martin, & Carson, 2016) and student midwives (Beaumont, Durkin,

Hollins Martin, & Carson, 2016) in the United Kingdom, with mean self-compassion scores

of 2.8 and 2.89 respectively. Limitations of these studies included an absence of control

measure for social desirability bias, and small sample size. Therefore, direct comparison with

these results may not be reliable.

Neff and Pommier’s (2013) study comparing undergraduate students with general

community members found mean self-compassion scores of 3.01 and 2.95 respectively. This

suggests that, on average, palliative care nurses and doctors have higher levels of self-

compassion than students and members of the general community. However, on an individual

level, self-compassion scores in this study ranged as low as 1.25. That some participants

reported very low levels of self-compassion is concerning and may impact on individual

capacity for self-care practice.

Lower levels of individual self-compassion may be explained by environmental

factors. For example, the health care system, itself, can be experienced as dehumanising to

the health care professionals working within it (Youngson & Blennerhassett, 2016); and this

experience, in turn, can lead to self-dehumanisation (Bastian et al., 2013l; Yang, Jin, He, Fan,

& Zhu, 2015). Given that appreciation of common humanity is a key component of self-

compassion, a diminished sense of one’s own humanity, in this context, may inhibit capacity

for self-compassion. Personal factors such as fear of positive emotion might also be involved.

A fear of giving or receiving compassion, for example, could contribute to the

variance in levels of compassion for self and others. As explained by Gilbert (2014), it is not

uncommon for self-compassion or compassion for others to be inhibited by fear. For

example, a nurse may fear being actively compassionate to patients whilst simultaneously

feeling in a state of emotional exhaustion; or a doctor may avoid feeling self-compassion

from a fear of it being perceived as weak, or otherwise antithetical to performance and

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achievement. Considering this, the expression of compassion for oneself or others is not

weak; it requires great courage not only to overcome these potentials fears, but to actively

engage with suffering with compassionate presence and action (Gilbert & Choden, 2014;

Jinpa, 2015). The requisite courage to engage in compassionate action in work settings is also

highlighted in the organisational literature (Kanov, Powley, & Walshe, 2017).

Self-criticism is correlated with a range of psychopathologies, such as depression and

anxiety (Longe et al., 2010), and people who are highly self-critical can find it especially

challenging to develop self-compassion (Gilbert, 2009, 2011; Jinpa, 2015; Neff & Tirch,

2013). Indeed, a study by Gilbert and colleagues (2012), found that self-criticism was

significantly correlated with a fear of compassion for self. This was evident in the qualitative

findings of the present study, with perceptions that achievements are largely accomplished by

beating yourself up a bit – to get a bit further and get better. This perception contrasts with

evidence that self-improvement motivation, personal improvement, and mastery achievement

goals are positively associated with a self-compassionate approach of accepting personal

failures (Breines & Chen, 2012; Neff, Hsieh, & Dejitterat, 2005; Zhang & Chen, 2016). The

fear of positive emotions may thus represent a considerable challenge to effective self-care

practice. Future research could advance knowledge in this area by investigating this

relationship using the fears of compassion scales (Gilbert, McEwan, Matos & Rivis, 2011).

According to Gilbert and his colleagues (2011), ‘it is not just the absence of compassion that

is important, but also the fear of compassion. This means that people may actively resist

engaging in compassionate experiences or behaviour’ (p.252).

Nonetheless, a number of benefits may be realised for those who embrace self-

compassion. For example, in a study of 213 health professionals and trainees, self-

compassion was strongly and significantly associated with resilience, mindfulness, improved

sleep, and reduced stress (Kemper, Mo & Khayat, 2015). It is also associated with physical

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health (Arch et al., 2014), psychological flexibility and emotional wellbeing (Marshall &

Brockman, 2016). This association is also supported by findings of a randomised controlled

trial of Acceptance and Commitment Therapy (ACT), in which the ACT intervention led to

large increases in self-compassion, mediated by psychological flexibility, with combined

reductions in psychological distress (Yadavaia, Hayes, & Vilardaga, 2014). Given that self-

compassion and its components of self-kindness, mindfulness, and common humanity are all

significantly correlated with emotional intelligence (EI) in nurses (Heffernan, Griffin,

McNulty, & Fitzpatrick, 2010; Şenyuva, Kaya, Işik, & Bodur, 2014), it may be that

differences in self-compassion in the present study can be explained by varying levels of EI

in this population of nurses and doctors. EI is fundamentally characterised by a capacity to

combine cognition and emotion towards achievement of a desired outcome (Hurley &

Linsley, 2012). In positive psychology, this capacity, or intelligence, is highly relevant in

relation to the utility and judicious use of positive emotions (Salovey, Mayer, Caruso, & Yoo,

2009; Bar-On, 2010). Tugade and Fredrickson (2002) speak to the intelligent use of positive

emotions as an ability to discern when they are appropriate, or not; and how best to use them

according to situational context. That self-compassion was negatively correlated with

compassion for others, in the case of the present study, may reflect limited EI in this self-care

context of positive emotion. Future research and education should therefore consider the

potentially mediating roles of EI and psychological flexibility when developing self-care

training programs. While the importance of EI to self-care among palliative care

professionals has been recognised, there is a need for future research in this area (Codier,

Muneno, & Freitas, 2011).

The relationship between self-compassion and self-care ability. Prior to this study,

the relationship between self-compassion and self-care ability had not featured in the research

literature. That self-compassion was strongly and positively associated with self-care ability

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is perhaps not surprising; however, this finding serves to establish an empirical basis to

support the theoretical literature positing a relationship between self-care and self-

compassion (Ajimol, 2011; Ozan, Okumuş & Lash, 2015; Vachon, 2016b; Watson, 2008,

2009; Youngson and Blennerhassett, 2016). According to Watson’s (2012) nursing theory of

human caring, loving-kindness, self-compassion and self-care are the building blocks of an

authentic, compassionate care for others. This finding also builds upon Fredrickson’s (2004)

broaden-and-build theory of positive emotions, in that self-compassion was significantly

associated with self-care ability, and participants considered self-compassion as enabling to

their self-care practice. In line with previous evidence to support the broaden-and-build

theory, self-compassion as a positive emotion may help to broaden one’s scope of attention,

cognition and action, whilst building and mobilising a range of personal resources and social

supports within an upward spiral to enhance physical health and psychological wellbeing

(Cohn & Fredrickson, 2010; Fredrickson, 2016; Fredrickson, 2013; Fredrickson et al., 2013;

Fredrickson, Cohn, Coffey, Pek & Finkel, 2008; Fredrickson & Branigan, 2005; Garland et

al., 2010; Hall, Row, Wuensch, & Godley, 2013; Odou & Brinker, 2015).

While a correlation does not indicate a causal relationship, the additional hierarchical

linear regression analyses, coupled with contextual qualitative findings identifying self-

compassion as an enabler to self-care practice, are suggestive of this. Thus, the fostering of

self-compassion as a positive emotion in the palliative care workforce may support and

enhance self-care practice. However, further research is needed to test this longitudinally,

through evaluation of self-compassion interventions in the palliative care workforce.

The relationship between self-compassion and compassion for others. A surprising

result from this study was that self-compassion was negatively correlated to compassion for

others. Yet these were described by participants as related positive emotions that enable self-

care. That these same variables were positively associated in a study of non-health care

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professionals with identical outcome and control measures as used in the present study, raises

questions about potentially unique factors inhibiting self-compassion in these nurses and

doctors. Given the association between self-compassion and self-care ability, this relationship

may be influenced by contextual factors such as barriers and enablers to self-care practice in

the workplace. Indeed, Chambers and Ryder (2009) suggested the culture of the practice area

is key to enabling compassionate care.

Vachon (2016b) wrote that self-compassion is necessary for compassion for others.

But the findings from the present study have indicated that palliative care nurses and doctors

report being capable of high levels of compassion for others, despite a lack of self-

compassion. As balanced compassion was an important theme identified in the literature, this

issue warrants further consideration, especially given that compassion for others was

negatively correlated with self-compassion in this study. According to the Dalai Lama

(2003), a respected scholar of compassion, ‘caring for others requires caring for oneself’

(p.125). This position is consistent with that espoused by Watson’s (2012) nursing theory of

human caring. Taken together, it may be that compassion for others, as a positive emotion, is

strengthened or more sustainable over time, when coupled with self-compassion; but since

these variables were negatively associated in this sample, further research is needed to test for

a causal relationship. The apparent discrepancy in balanced compassion raises implications

for compassion literacy (Burridge, Winch, Kay & Henderson, 2017).

Compassion literacy. As described by Burridge and colleagues (2017), compassion

literacy encompasses the capacity to balance compassion for patients with compassion for

oneself. That the present study found a negative correlation between compassion for others

and self-compassion raises concern that compassion literacy may be lacking in this

population. Thus, there is a need for further research to investigate this as well as factors that

might inhibit or promote compassion literacy. This line of inquiry may be particularly

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fruitful, given there is, in the psychological literature, a compelling body of evidence to

suggest the cultivation of self-compassion and compassion for others is beneficial to physical

health and psychological wellbeing (MacBeth & Gumley, 2012; Klimecki, Leiberg, Lamm,

& Singer, 2013; Klimecki, Leiberg, Ricard, & Singer, 2014; Kemper, Mo & Khayat, 2015;

Kok et al., 2013; Lutz, Brefczynski-Lewis, Johnstone, & Davidson, 2008; Lutz, Greischar,

Perlman & Davidson, 2009; Neff, Rude, & Kirkpatrick, 2007; Pace et al., 2009; Petrocchi,

Ottaviani & Couyoumdjian, 2017; Stellar, Cohen, Oveis & Keltner, 2015; Stellar & Keltner,

2014; Svendsen et al., 2016; Thayer, Ahs, Fredrikson, Sollers & Wager, 2012; Weng et al.,

2013).

However, further work should be undertaken to strengthen the theoretical basis and

inform future assessment of compassion literacy. While strategies for enabling compassion

literacy are discussed in the nursing literature, there is a lack of high quality evidence for

interventions to increase it as an outcome variable. This could be addressed through the

development and validation of an instrument to measure compassion literacy.

Given its relation to the important theme of balanced compassion, compassion literacy

and its measurement as a psychometric construct represents a priority for further study.

Future research should therefore undertake scale development and validation to enable the

reliable measurement of compassion literacy in the context of training interventions.

The research literature within the health professions is mixed in terms of articulating a

sound theoretical basis and methodological rigour where curricula or training interventions

designed to enhance compassion in health care professionals have been evaluated (Halifax,

2014; Hofmeyer et al., 2017; Lown, 2016; Rao & Kemper, 2017; Rushton et al., 2009; Winch

et al., 2014). Cullen (2016) argues that Schwartz Rounds represent an intervention that can

promote compassionate care and healthy organisations. Schwartz Rounds have been

implemented extensively across the USA (Lown & Manning, 2010) and increasingly in the

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UK, (Robert et al., 2017), including community, mental health (Farr & Barker, 2017), and

hospice settings (Reed, Cullen, Gannon, Knight & Todd, 2015). Given its broad uptake, the

acceptability and utility of this staff support intervention appears promising. However, a

stronger case for the implementation of Schwartz Rounds could be made with evidence that it

increased compassion in participants, which is to date lacking in the published literature.

Taken together, there is a lack of high-level evidence to support the effectiveness of

compassion-based interventions developed for health care professionals.

Given that contemplative emotion training can reduce negative emotional behaviour

and promote prosocial responses (Kemeny et al., 2012), future training interventions and

research could draw upon a number of compassion-based training programs that were

developed outside of the health care professions, but have been shown to enhance self-

compassion and or compassion for others (Brito-Pons, Campos & Cebolla, 2018; Jazaieri et

al., 2013; Kirby, 2017; Neff & Germer, 2013; Ozawa-de Silva et al., 2012), in addition to

promoting wellbeing (Jazaieri et al., 2014; Jazaieri et al., 2016; Jazaieri et al., 2017). A recent

systematic review by Kirby, Tellegen and Steindl (2017) conducted a meta-analysis of the

effects of compassion-based interventions from 21 randomised controlled trials involving

more than 1,000 participants. They found significant between-group differences in change

scores of compassion, self-compassion, mindfulness, depression, anxiety, psychological

distress, and well-being; concluding that the current evidence base indicates the potential

benefit of compassion-based interventions on a range of outcomes (Kirby et al., 2017). A

notable finding from research into the compassion cultivation training (CCT) protocol

developed at the Stanford University School of Medicine (Jinpa, 2013), is that caring

behaviours for oneself and others were significantly increased; from being negatively

associated at baseline, to being positively and strongly correlated post intervention (Jazaieri

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et al., 2016). In light of the present study, such change in caring behaviours may prove

significant if it can be replicated in the palliative care workforce.

Another strength of the CCT protocol is that it incorporates multiple foci including

mindfulness meditation, loving kindness meditation, and compassion-based contemplative

practices oriented towards oneself and others. Informed by both Buddhist and Western

psychology, the CCT program not only supports participants to generate loving kindness and

compassion for close companions; it also trains for compassionate responding towards

strangers and other people perceived to be difficult or challenging, by embracing a shared

sense of common humanity (Jinpa, 2015). As explained by Chodron (2002), ‘compassion is

not a relationship between the healer and the wounded. It’s a relationship between equals…

Compassion becomes real when we recognise our shared humanity’ (p.67). Thus, this

capacity may be particularly useful in the context of clinical practice. Indeed, a recent study

into the effects of CCT on health care professionals in North America found significant

improvements in mindfulness, interpersonal conflict, self-compassion, and compassion for

others (Scarlet, Altmeyer, Knier & Harpin, 2017). The authors of this study concluded that

CCT may be helpful in improving health and promoting resilience in health care

professionals.

Resilience, defined as ‘the ability of an individual to positively adjust to adversity’, is

an essential quality for health professionals that can be strengthened through self-care

(Jackson, Firtko & Edenborough, 2007, p.1). The present study has addressed previous calls

for exploratory qualitative research into different ways that resilience can be developed, and

strategies to promote self-care (Jackson et al., 2007). Qualitative findings relating to positive

emotion, positive relationships, character strengths, and self-awareness as enabling to self-

care, are entirely consistent with strategies identified for building resilience to survive and

thrive in the workplace (Jackson et al., 2007; McAllister & McKinnon, 2009). Moreover,

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there is growing theory and evidence linking positive emotions and character strengths to

resilience (Fredrickson, Tugade & Waugh, 2003; Tugade & Fredrickson, 2004; Tugade,

Fredrickson & Barrett 2004; Tugade, Devlin, & Fredrickson, 2014; Martínez-Martí & Ruch,

2017). Whilst negative emotions are considered a short-term evolutionary technique for

coping and survival, positive emotions are more durable and contribute to a reserve of

personal resources that can be drawn upon when resilience is required (Luthans, Vogelgesang

& Lester, 2006). Thus, effective self-care practice incorporating the development of positive

emotions may enhance resilience in palliative care professionals. Given that there has been

limited research into resiliency among palliative care professionals, these findings may serve

to inform tailored interventions to build resilience (Perez et al., 2015; Back et al., 2016).

Research involving the cultivation of positive emotions among healthcare

professionals may benefit through insights gained from new and emerging fields such as

positive neuroscience (Ashar, Andrews-Hanna, Dimidjian, & Wager, 2016) or more

specifically, compassion science (Seppala et al., 2017). Recent findings from these fields

highlight key associations between compassion, the amygdala, and activity in the vagus nerve

which connects the brain with visceral organs throughout the body (Man, Ames, Todorov &

Cunningham, 2016; Porges, 2017). One example of potential implications for research in the

health professions is the newly proposed role of heart rate variability for training and

assessing compassion (Kirby, Doty, Petrocchi & Gilbert, 2017).

Organisational perspectives. Having identified positive emotions, positive

relationships and character strengths as facilitators of effective self-care practice, this study

reveals the relevance of other research fields from which palliative services may stand to

learn in their efforts to promote health and wellbeing through self-care. For example, insights

from the field of positive organisational scholarship may help understand and implement

workplace interventions that impact beyond individuals, and within an organisational context,

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build more supportive cultures that promote self-care, positive emotions, and health and

wellbeing through the development of positive institutions (Cameron, Dutton, & Quinn,

2003; Cote, 2014; Garcea, Harrington & Linley, 2010; Peterson & Park, 2006).

The broaden-and-build theory of positive emotions has been applied to the context of

positive organisational scholarship (Vacharkulksemsuk & Fredrickson, 2013), and research

into compassion within organisations has been building for several years (Atkins & Parker,

2012; Dutton, Workman, & Hardin, 2014; Dutton & Workman, 2012; Frost, 1999; Kanov et

al., 2004; Lilius et al., 2008; Rynes, Bartunek, Dutton, & Margolis, 2012). A positive

example of this outside of palliative care, is the use of Appreciative Inquiry as a method to

develop a compassion awareness training program within a group of hospitals, mental health,

and primary care services in the United Kingdom (Curtis et al., 2017). Indeed, health services

research has demonstrated that explicit organisational measures to provide and support

compassion in the workplace are associated with positive patient experience ratings and

wellbeing in nurses (McLelland, Gabriel & DePuccio, 2018; McLelland & Vogus, 2014).

A key construct in positive organisational scholarship is that of psychological capital.

Luthans et al. (2007, p.542) define psychological capital as:

an individual’s positive psychological state of development characterised

by: (1) having confidence (self-efficacy) to take on and put in the necessary

effort to succeed at challenging tasks; (2) making a positive contribution

(optimism) about succeeding now and in the future; (3) persevering towards

the goals, and when necessary, redirecting paths to goals (hope) in order to

succeed; and (4) when beset by problems and adversity, sustaining and

bouncing back and even beyond (resilience) to attain success.

Building psychological capital in the workplace is said to be beneficial to the

individual, their colleagues, and the organisation; given that psychological capital

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comprises self-efficacy, hope, optimism, and resilience (Luthans, Vogelgesang, &

Lester, 2006; Youssef & Luthans, 2010). Psychological capital in nurses is

associated with greater work engagement (Bonner, 2016); however, it does not

appear to have been researched in the palliative care workforce.

Building from the concept of ‘healthy hospitals’, as discussed by Baum (2002) and

later by McAllister and McKinnon (2009), the findings from this study serve to advance the

field of healthy workplaces through the contribution of new knowledge. The World Health

Organisation (2010) provide the following definition:

A healthy workplace is one in which workers and managers collaborate to use

a continual improvement process to protect and promote the health, safety, and

wellbeing of all workers and the sustainability of the workplace (p.16).

The WHO (2010) further qualify this definition, stating that it is intended to primarily address

primary prevention aspects of health promotion, that is, to prevent illness happening in the

first instance; whilst at the same time, not precluding secondary or tertiary prevention. In a

health promotion context, this may help to clarify some apparent conflation in the literature to

date, by situating self-care strategies as most relevant to the primary prevention domain of

health promotion, as distinct from coping strategies and self-management, which may be

more relevant to secondary and tertiary domains of health promotion.

As highlighted by McAllister and McKinnon (2009), working in the health

professions is not without challenge or adversity; to the contrary, the complexities of

contemporary nursing and medical practice can at times be overwhelming from the ethical

challenges and emotional adversity encountered. Given that many nurses and doctors in

Australia are either experiencing or at risk of chronic illness, further intervention and research

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into self-care as part of health promotion would be beneficial. Indeed, nurses are commonly

viewed by patients as role models for health promotion (Mills et al., 2015), and it has been

argued in the Medical Journal of Australia, that hospitals should be exemplars of healthy

workplaces (Russell, Anstey, & Wells, 2015).

Such an achievement would require a reorientation of foci from those of treating

pathology or coping with stress and illness, to broader foci associated with promoting health

and wellbeing. Clearly, this kind of aspiration may represent a significant challenge for

hospitals or palliative care services, if undertaken in isolation and without support. However,

advances in effective self-care, workplace culture, and indeed, the health and wellbeing of

palliative care teams, may be more achievable if hospitals or palliative care services were to

join and actively participate in initiatives such as the World Health Organisation’s (2007)

International Network of Health Promoting Hospitals and Health Services. This network

was created with a purpose to promote and support the concept of health promotion in

hospitals and health services internationally. Active participation in this network would

go some way towards challenging the perceived conceptual dissonance between health

promotion and palliative care services, as well as demonstrating congruence with the growing

field of health promoting palliative care as a public health approach relevant to whole

communities (Rosenberg, Mills, & Rumbold, 2016; Mills, Rosenberg & McInerney, 2015;

Rosenberg & Yates, 2010).

The meaning and practice of self-care. The meaning of self-care, described by

participants as a proactive and holistic approach to promoting personal health and wellbeing

to support professional care of others, is consistent with the Foucauldian philosophy of the

care of self, in which people must first take care of themselves in order to better take care of

others. Thus, the meaning of self-care was described in a relational context that was

supportive and caring of others, rather than one that is solely self-serving. For palliative care

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professionals, self-care is not a selfish endeavour apathetic to the needs of others; rather, it is

a proactive and relational practice cognisant of practitioners’ health and human needs,

motivated by the professional context of sustaining compassionate care in therapeutic

relationship with patients and their families. This finding reflects the following practice

sentiment captured in the Oxford Handbook of Palliative Care:

It is your responsibility to your patients, and your human right for yourself,

to nurture and maintain your physical, emotional, intellectual, and spiritual

being (Brigid Proctor, cited in Watson, Lucas, Hoy & Wells, 2009, p.965).

Moreover, it is consistent with the mandate for effective self-care practice as part of

maintaining a therapeutic relationship with patients and their families (Canning et al., 2005);

whilst supporting assertions from Kearney and colleagues (2009), that self-care is not a

selfish luxury, but is instead essential to clinicians’ therapeutic relationship with patients.

The practice of self-care was described as a process of maintaining a range of

personalised self-care strategies within both professional and non-professional settings. While

most research has to date focused on strategies used to cope with occupational stressors, this

finding, situated in the broader context of self-care, reveals not only the variety of effective

strategies employed; but also the challenges and complexities involved with maintaining

effective self-care strategies in practice. While palliative care professionals’ reported self-

care practices have previously corresponded with physical, social, and inner domains of self-

care (Sansó et al., 2015), findings from the present study underscore the imperative that

strategies from these self-care domains are implemented and maintained in both workplace

and personal settings. This recognition is important, as there can be a tendency to frame self-

care solely within organisational contexts, which leads to the neglect of other significant self-

care needs outside the workplace (Newell, 2017). Moreover, this finding underscores the dual

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importance of sustaining the professional self, whilst nurturing the personal self (Skovholt &

Trotter-Mathison, 2011).

Clinical supervision was an effective self-care strategy for many, but not for others;

and in some instances, was not available. Given the potential benefits to self-awareness and

staff wellbeing, the provision of supervision should be considered where it has not already

been made available with a focus on the restorative aspects of clinical supervision (Edmonds

Yeung, Onderdonk, Mitchell & Thornberry, 2015; Firth, 2011; Kearney & Weininger, 2011).

Mindfulness exercises were used spontaneously by participants in practice settings,

suggesting that the benefits of formal mindfulness training initiatives impact beyond training

rooms and into the clinical milieu (O'Connor & Peyton, 2015; Orellana-Rios et al., 2017).

Formal clinical supervision and informal debriefing were effective self-care strategies, and

thus should be encouraged. Similarly, laughter and the use of humour formed a fundamental

part of self-care, and should be fostered as appropriate. Laughter has long been considered a

coping strategy to manage stress in palliative care settings (Dean, 1998); however, this

finding extends a new context in terms of self-care behaviours to support health and

wellbeing. Indeed, there is evidence to suggest psychological and physiological health

benefits from laughter, including enhanced cardiac and immune function (Bennett &

Lengacher, 2009; Berk, Felten, Tan, Bittman & Westengard, 2001; Miller & Fry, 2009).

Establishing and maintaining effective boundaries within and outside of the

workplace was also an effective self-care strategy, and was related to work-life harmony.

While so-called work-life balance was discussed by some, and has also featured in other

palliative care research into coping mechanisms (Zambrano, Chur-Hansen & Crawford,

2014); this concept was incongruous to the experience of others. Overall for participants, it

was important to acknowledge that different life-domains require varying degrees of attention

at any given time, and finding one’s individual harmony between personal and professional

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roles was therefore a key strategy towards flourishing in life. Thus, work-life harmony is an

important aspect of effective self-care. Given this finding, future self-care education might

usefully incorporate this new emphasis on work-life harmony rather than using the term

‘work-life balance’ which is ill-defined and otherwise problematic in practice for some

palliative care professionals. For participants in this study, the practice of self-care also

involved managing barriers and enablers to self-care practice.

Barriers and enablers to self-care practice. The identification of specific barriers and

enablers to self-care practice has to date been lacking in the literature. Participants in this

study identified a number of barriers to effective self-care including stigma, busyness,

inadequate boundaries, self-criticism, low self-worth, and a lack of planning or prioritising

self-care. The barriers identified provide a valuable context which may also explain the low

levels of self-care ability identified in some doctors and nurses from the quantitative strand of

this study.

Perhaps the most prominent barrier discussed was that of unsupportive team cultures

or workplace environments that were not conducive to effective self-care practice. This

finding is highly alarming, yet not surprising, when considering that self-care was stigmatised

as either selfish or weak in some participants’ workplaces. Perhaps more concerning, is that

this stigma may serve not only to impede effective self-care practice in the workplace; but it

might also discourage palliative care professionals from taking personal leave or seeking

professional support when they require it. Compassionate organisations are vital to the

enactment of compassionate care for palliative patients and their families (Renzenbrink,

2016). In the words of Larkin (2016b) ‘compassion is not just about individual responses but

rather how practitioners are enabled by systems to sustain and support themselves in the

complex and challenging work that they do’ (p.204). Therefore, understanding the factors

that contribute to supportive workplace cultures and facilitate self-care is essential (Speck,

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2006; Thompson, 2011). Palliative care services in Australia may benefit from the experience

of counterparts in the United Kingdom and Canada, who have focused on effective leadership

to foster workplace environments and team cultures of self-awareness, self-care, and staff

support (Dechamps, 2011; Wainwright & Breiddal, 2011).

Several enablers to self-care practice were identified in this study, both environmental

and interpersonal. Courage, authenticity and leadership were highlighted by participants:

being authentic in acknowledging one’s own human vulnerability; having the courage to

challenge stigma or be assertive in saying ‘no’, if acquiescing to additional workload might

compromise one’s own wellbeing; and leading by example in normalising and supporting

self-care as an essential aspect of palliative care practice. Courage, authenticity and

leadership have been recognised as character strengths that can be measured and cultivated

(Peterson & Park, 2009). Development of these strengths in palliative care teams should thus

be encouraged to help transform any unsupportive workplace cultures.

In this study, positive emotions such as self-compassion enabled self-care. This is

consistent with a burgeoning field of positive psychology research, in which positive

emotions not only have a biological basis for physiological health benefits; but also broaden

repertoires of positive thoughts and actions which, in turn, help to build personal and social

resources that lead to psychological wellbeing and flourishing (Cohn & Fredrickson, 2009;

Fredrickson, 1998, 2001; Kreibig, 2014; McCraty & Rees, 2009). While, in the context of

psychological flexibility, negative emotions are not necessarily to be avoided (Kashdan &

Ciarrochi, 2013); an awareness of and capacity to cultivate positive emotions should thus be

fostered as part of self-care practice. This might serve to promote resilience and emotional

intelligence both individually and across the palliative care team (Tugade & Fredrickson,

2002, 2004). Self-care planning was also enabling to self-care practice, but this process did

not necessarily require documentation of a formal plan.

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The finding that self-compassion was considered enabling to self-care corresponds

with the results from the quantitative strand of this study, in which self-care ability was

significantly associated with increased self-compassion in palliative care nurses and doctors.

Building from emerging evidence to support compassion-oriented training interventions in

palliative care teams (Orellana-Rios et al., 2017), future research should investigate any

causal relationship between these variables longitudinally. Studies could potentially

incorporate interventions that draw upon loving-kindness meditation or other compassion

training programs which have been shown to enhance compassion for self and others, and

may therefore contribute positively to both self-care and compassionate care of others

(Fredrickson et al., 2008; Jazaieri et al., 2013, Neff & Germer, 2013).

The ongoing need for reflective practice to build self-awareness, as well as the

management of multiple barriers and enablers to self-care practice, clearly demand increased

attention from practitioners and palliative care services. Given the personalised nature of self-

care practice, palliative care services should also consider ways in which a variety of self-

care strategies can be supported. For example, providing opportunities for formal clinical

supervision and informal debriefing, depending on individual choice; as well as supported

opportunities for the development of individual self-care plans for those who would benefit

from them.

Contribution of the study

The results from this study address key gaps in the palliative care literature relating to

provision of self-care education, as well as the nature and uptake of self-care practices such

as the use of self-care plans. The findings provide new insight into palliative care nurses’ and

doctors’ perceived ability to implement and maintain effective self-care strategies.

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Furthermore, this study contributes an important qualitative perspective and serves to

advance knowledge of both the context and effective practice of self-care in the palliative

care workforce. In elucidating the meaning and practice of self-care through the voice of

palliative care professionals, this study extends current knowledge through a detailed account

of the context and complexity of effective self-care practice previously lacking in the

literature. In highlighting a shared responsibility for self-care practice, between palliative care

professionals and the palliative care services in which they work; key barriers and enablers to

self-care practice have also been identified, especially in relation to workplace culture.

While past studies have largely focused on self-care as a way of coping with

occupational stressors, this original research examined self-care in the context of promoting

health and wellbeing – firstly, by identifying the use of self-care domains that directly

correspond with health through physical, social, and emotional wellbeing; and secondly,

through the measurement and analysis of self-compassion and compassion for others, as

positive emotions associated with health and wellbeing. In addition to the development of

new education and training resources to support individual self-care practice, the uptake and

integration of findings from this study would be beneficial to existing resources such as the

Therapeutic Guidelines (Palliative Care Expert Group, 2016), and the national Palliative

Care Curriculum for Undergraduates (Australian Government Department of Health, 2017),

both of which include explicit content relating to self-care practice. The results of this study

might also be of use to other health professionals working outside of palliative care.

Strengths and Limitations

The use of a mixed methods research design represents a strength of this study, in combining

the strengths of quantitative and qualitative research. The representativeness and survey

response rate achieved in a national sample was also a strength. The use of a validated

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measure to control for social desirability added further strength to the findings. Given that

reflexivity is not always addressed in mixed methods research, a final strength of this study is

the demonstrated rigour and trustworthiness achieved with regards to qualitative content

analysis, and ensuring transparency in relation to researcher reflexivity.

Nevertheless, a number of limitations to this study must also be acknowledged. First,

there were no validated scales available at the time of this study to measure self-care. The

visual analogue scale used in the survey therefore captured participant perceived self-ratings

of their own self-care ability. Future research should confirm the results of this study using

validated scales to measure self-care as a psychometric construct. Subsequent studies should

consider using the scales developed by Galiana and colleagues (2015) or Cook-Cottone and

Guyker (2018).

Second, the cross-sectional survey design was limited in its ability to only explain one

time point. Finally, consideration of potential cultural diversity in the expression of

compassion for self or others did not form part of this study. While this limitation is

consistent with other studies and scales developed to measure compassion, it is

acknowledged that potential differences may exist in the way that compassion is expressed.

This should be investigated through a discrete program of research testing the universality of

compassionate behaviours across cultures. Notwithstanding these limitations; as the first

study of its kind, this original research serves to advance knowledge and inform future

research in an area of significance to palliative care practice.

Recommendations

Having discussed the study findings in the context of current research literature, the following

key recommendations are made from this thesis to inform practice and future

research:

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1. Increased self-care education and training for palliative care professionals.

2. Longitudinal research to investigate for any causal relationship between self-

compassion, self-care, and other variables such as resilience, measuring self-care as a

psychometric construct using validated scales.

3. Evaluation of compassion-based education and training interventions to test for

effect on compassion levels, as well as health and wellbeing in palliative care

professionals.

4. Further empirical investigation to strengthen the theoretical basis of compassion

literacy and inform the assessment of it through a validated measure.

Chapter Conclusion

This chapter has discussed the overall findings of the study, implications for practice, and

recommendations for future research. It has also outlined the strengths, limitations, and

contribution of this study to the literature. The next chapter will discuss the role and

development of middle range theory in the context of this thesis.

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CHAPTER 8

GENERATING MIDDLE RANGE THEORY

Chapter Introduction

Having answered the research questions and discussed the study findings in detail, this

chapter discusses the generation of middle range theory. From the empirical basis established

in this study, as well as consideration of the existing theory and research already discussed,

middle range theory statements are generated as a preliminary step towards further theory

development to inform practice and future research.

Middle range Theory

While the development and application of theory is evident in palliative care discourse

through the use of research methodologies such as grounded theory (Kuziemsky, Downing,

Black & Lau, 2007; Stiel et al., 2010; Shimoinaba et al., 2015), it is limited in the broader

context of practice. In describing the practitioner as theorist, Ellis (2012) argues that

theorising is an essential, but often neglected aspect of contemporary nursing practice. Given

that further theory development can serve to extend current theoretical knowledge and

advance practice in palliative care (Dobrina, Tenze & Palese, 2014; Desbiens, Gagnon &

Fillion, 2012), attention is now directed towards the generation of middle range theory.

Middle range theory is recognised as a meaningful organising structure within a

growing body of nursing knowledge that can be applied to both research (Lenz, 1998a) and

practice (Lenz, 1998b). Indeed, Liehr and Smith (1999) used the analogy of a wool spinner to

liken the impact of middle range theory, to the spinning of research and practice strands

together to form a synthesised and more meaningful thread. The origin of middle range

theory can be traced to sociologist, Robert Merton, who described middle range theory as

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theories situated between everyday minor hypotheses, and theories that are systematically

developed and unified (Merton, 1968). In further conceptualising middle range theory, Smith

and Liehr (2003) refer to a ladder of abstraction comprising three distinct levels of discourse:

(1) philosophical; (2) theoretical; and (3) empirical, with middle range theory represented by

the middle rung – above the lower concrete level of empirical discourse, yet underneath the

higher level of philosophical discourse. Others situate middle range theory in between

practice or micro-range theory, grand theory, and meta-theory; with meta-theory representing

the most abstract and universal of four levels of theoretical thinking (Higgins & Moore, 2012;

McEwen, 2011a). Middle range theories function to describe, explain, or predict phenomena,

whilst being both specific and testable (McEwen, 2011b). While grand theory has

traditionally been the focus of much nursing research (Smith, 2014), middle range theory

serves greater practical utility through the development of generalisable theories that can

easily be applied, tested and refined in both practice and research (Higgins & Moore, 2012).

Moreover, the development of middle range theory is an effective approach to integrating

qualitative and quantitative findings into a synthesised thread (Liehr & Smith, 1999). As a

preliminary step towards the development of a formally named middle range theory as

described by Liehr and Smith (2017), middle range theory statements were developed under

the relevant domains of context, meaning, and practice (see Table 1).

This approach is consistent with other nursing research involving the generation of

similar middle range theory statements (Wand, White & Patching, 2011). The generation of

middle range theory is best achieved via multiple approaches (Liehr & Smith, 1999),

therefore the following middle range theory statements were developed through combination

of: (1) inductive theory building from the present study; (2) deductive theory building from

grand theory; and (3) synthesis of other theoretical literature (Liehr & Smith, 2017), as

discussed in chapter seven.

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Table 1. Middle range theory statements

Domain Middle range theory statement

Context Self-care is a relational aspect of palliative care practice.

Meaning Self-care means adopting a proactive and holistic approach to

promoting personal health and wellbeing to support capacity for

the professional care of others.

Practice Effective self-care practice involves maintaining a variety of

personalised self-care strategies across physical, social, and

inner health domains, within both personal and professional

settings.

Self-compassion is a positive emotion that supports effective

self-care practice in health care professionals.

The relationship between self-compassion and compassion for

others varies according to individual compassion literacy.

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While these are intended as generalisable statements for further application outside the scope

of this thesis, an important next task will be to test and refine them in practice, education, and

further research (Liehr & Smith, 2017).

Chapter Conclusion

This chapter has discussed the role of middle range theory and outlined preliminary middle

range theory statements generated to inform practice and future research through further

theory development. The next and final chapter will conclude the thesis.

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CHAPTER 9

CONCLUSION

Thesis Conclusion

Through the reporting and discussion of a mixed methods study, this thesis has explored self-

care practice in palliative care nurses and doctors, and examined levels of and relationships

between self-care ability, self-compassion and compassion for others.

As noted in the review of the literature, there has been much discussion about self-

care, self-compassion, and compassion, yet relatively little research or empirical evidence.

This is despite the insistence of Kellehear (1999) that, in palliative care contexts, the

expression of compassion should not be idiosyncratic, nor its analysis impressionistic. While

positive emotions and wellbeing have been investigated in palliative care patients, similar

research has been lacking in workforce studies.

This thesis makes an original contribution towards the development of a more robust

body of knowledge to guide self-care education and thus support palliative care practice. It

has revealed the meaning and complexity of self-care practice as described by palliative care

nurses and doctors. It has also contextualised self-care strategies within the health-oriented

domains of physical, social, and mental wellbeing. In identifying a lack of self-care training

around Australia, the findings of this research have been of influence to the National

Palliative Care Standards (Palliative Care Australia, 2018). Increased education and more

widespread training is required to support palliative care professionals’ self-care practice.

This thesis also calls for greater compassion literacy and training to enhance it. The levels of

self-compassion and compassion for others measured in this study suggest a need for further

investigation into compassion literacy, and targeted interventions to promote it.

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A preliminary middle range theory arising from this thesis posits that self-compassion

is a positive emotion that supports effective self-care practice. This along with other middle

range theory statements generated as part of this thesis should be tested in practice and

refined through further investigation. As the first mixed methods study of the palliative care

workforce to have examined self-care in relation to the positive emotions of self-compassion

and compassion for others, this research serves to establish the foundation of an empirical

evidence base for the relationship between positive emotions and self-care practice to

promote health and wellbeing in palliative and other health care professionals.

A sound basis for the scientific study of compassion—for self and others—is already

established outside of the palliative care literature. Future research should draw

methodological insights from the nascent field of compassion science (Seppala et al., 2017)

to establish a credible evidence base to support and guide the promotion of positive emotions

in palliative care practice. While the direct examination of health and wellbeing was outside

the scope of the present study, there is a significant body of evidence in support of the

broaden-and-build theory of positive emotions, suggesting that self-compassion and

compassion for others also contribute to the health, wellbeing, and flourishing of those who

experience and cultivate these positive emotions. However, further research involving direct

measures of health and wellbeing is required. Future studies should evaluate self-care training

programs to test whether compassion-based training and education enhance compassion

literacy and promote health and wellbeing in palliative care professionals. Given the

relationship between staff wellbeing and patients’ experience of care, this line of inquiry is

important, and may also serve to benefit health professionals working outside of palliative

care.

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