The Effect of Facilitated Peer Support Sessions on Burnout and Grief Management among Health Care Providers in Pediatric Intensive Care Units: A Pilot Study

Introduction

Over 440,000 American children are living with chronic, potentially life limiting conditions, ¹ and over 54,000 children die each year, mostly in critical care units. ² The toll of providing care for this population on health care providers is significant and often overlooked. In 2009, 18 children died in the pediatric intensive care unit (PICU) at our institution ³ and 656 were ultimately discharged, many of whom continue to cope with chronic illnesses and potentially life limiting conditions.

Our PICU team consists of physicians, nurses, technicians, clerks, respiratory therapists, and a clinical pharmacist. Of the 18 children who died in 2009 the average length of admission was 34.7 days, with a range of 2–117 days. ³ Additionally, most of these children had significant comorbidities at the time of death, requiring intense symptom management. Other than the cause of death, each patient had an average of 13 other diagnoses at time of death. ³ The literature supports palliative care interventions for a length of stay greater than one week and the presence of multiple comorbidities. ⁴

In light of these findings, we designed a pilot study to evaluate the levels of grief, stress, and burnout in our PICU team, as well as the effectiveness of facilitated peer support for grief exploration and management of burnout at our institution. It is our hypothesis that increasing grief support and improving coping skills through facilitated peer support sessions and increasing awareness of the benefits of palliative care will decrease grief and burnout among staff members. Though most previous studies on this topic are limited to a single type of health care worker, we invited PICU team members across disciplines.

Methods

Institutional review board approval was obtained for this study. A pretest/posttest design was used. The researchers enrolled interdisciplinary professionals who provide care to patients in the PICU. Physicians, nurses, social workers, and respiratory therapists were invited to participate in the project. Characteristics of participants are summarized in Table 1.

Prior to the first session, demographic information was collected and previously validated tools, Copenhagen Burnout Inventory (CBI) and Hogan Grief Reaction Checklist (HGRC), were administered. The CBI measures burnout across three domains: client-related burnout, personal burnout, and work-related burnout. Possible responses to 19 questions are rated on a 0–100 scale. The HGRC measures grief among six domains: despair, panic behavior, personal growth, blame and anger, detachment, and disorganization. Sixty-one items are included in the checklist and responses are rated on a five-point Likert scale.

Following instrument completion, session one, consisting of modules on coping and grief in relation to peer support, was presented. The educational content utilized for all module presentations was based on recommendations and findings from current peer-reviewed scholarly literature compiled and organized by the authors.

On a separate date, session two was offered, consisting of modules on expressions of grief among health care providers and provision of palliative care to pediatric patients. Topics covered included coping and grief management skills, identification of unresolved grief, strategies for handling unresolved grief, the benefits of grief expression in a positive manner, and basic philosophies of pediatric palliative care.

All peer support sessions provided time for group interaction and dialogue. Upon completion of the peer support sessions, subjects were asked to again complete the demographic questionnaire, CBI, and HGRC instruments. Each session was offered on three separate occasions.

Results

Twenty-eight participants completed pretest documents. Of these, all 28 completed the pretest HGRC in its entirety, while 3 participants did not fully complete the pretest CBI, resulting in a total of 25 pretest CBIs. Twenty-two participants completed posttest questionnaires. All 22 completed the posttest HGRC, and 18 completed the posttest CBI. Findings are summarized in Table 2.

The mean HGRC score comparisons did not demonstrate statistical significance. The mean score for all responses on the pretest HGRC was 1.81, while the mean score for the post-HGRC was 1.86 (p=0.44). The pretest HGRC/posttest HGRC scores were as follows: despair 1.37/1.42 (p=0.30) panic behavior 1.76/1.65 (p=0.83), personal growth 3.41/3.61 (p=0.12), blame and anger 1.39/1.47 (p=0.28), detachment 1.36 1.45 (p=0.23), and disorganization 1.57/1.57 (p=0.49). CBI pre- and posttest total and domain subscores were also not statistically significant. The overall pretest mean score was 32.48, and overall posttest mean was 34.1 (p=0.40). For the three domains of the CBI, the pretest/posttest scores were as follows: client-related burnout 20.80/21.76 (p=0.38), personal burnout 39.83/41.66 (p=0.31), work-related burnout 36.80/38.89 (p=0.28)

Discussion

There is considerable evidence from scholarly literature that indicates a need for palliative care services and staff support. However, at our institution, as at many, palliative care services, teams, and staff support resources are completely lacking. O'Connor describes that palliative care as an important component of family support, symptom management, and comprehensive care for patients and families facing potentially life limiting illnesses. ⁵ Despite this, health care providers do not receive adequate training and instruction in communicating with and caring for dying children and their families. ⁵ Furthermore, feelings of inadequacy, job-related stress, burnout, and increased attrition are all associated with unresolved health care providers' grief.^7,8 Barnard reported positive correlations between stressors and burnout, and also between peer support and feelings of personal accomplishment. ⁹ Implementation of peer support groups for health care providers leads to a significant improvement in general health scores, and perceived work demands, participation, and support. ¹⁰ Macpherson reported storytelling as an important part of the meaning-making and grieving process for health care providers, and Rushton reported that bereavement sessions are not only important, but allow health care providers to effectively manage their grief responses.^8,11 Furthermore, storytelling has been reported to foster mutual understanding, communication, and positive attitudes, while decreasing stress and moral distress, and allowing for grief exploration.^12,13

This is a small pilot study. Though small group size may maximize group interaction and discussion, the small sample size is a significant study limitation. Additionally, preregistration or attendance at both sessions was not required. Offering each session multiple times was a strategy employed to try to improve attendance and mitigate scheduling problems, but there were still participants unable to attend both sessions in full. The sessions were also offered in close succession, and the posttests administered directly following completion of session two. This may have not allowed the full absorption, consideration, and integration of material, nor adequate time for reflection on the new skills and concepts discussed at the sessions prior to posttesting.

An additional consideration is that perhaps overall, the participants were not actively experiencing high levels of grief or burnout. The pretest scores for both the CBI and HGRC are positively skewed, indicative of low levels of burnout and grief. Also, while validated, these tools may not be applicable for the interdisciplinary population of this pilot study, as the HGRC was developed to address grieving family members and the CBI was developed to assess burnout across human service sectors. Despite inconclusive testing results, it should be considered that the sessions may still be helpful to participants for preventing unresolved grief and burnout.

One area that did show a substantial increase on the posttest instruments, even though statistically not significant, was the domain of personal growth on the HGRC. This may indicate an area for further study in the future to explore the impact of sessions on personal growth more fully, especially since studies by Barnard and colleagues have demonstrated facilitated peer support can foster feelings of personal support and positive attitudes, which can lead to decreased stress among health care providers. ⁹ It could be speculated that this may foster higher levels of perceived personal growth.

Anecdotally, many participants reported that the sessions were helpful and that participation caused them to consider their experiences in a different manner. Gathering data at future sessions on providers' thoughts regarding the topics is a potential area of further qualitative study. This may be accomplished by adding a section of open-ended questions to the demographic questionnaire. Gathering and analyzing this feedback may also aid in the design of interventions in the future to better support staff in preventing and managing grief and burnout.

In conclusion, supportive interventions for providers caring for children with potentially life limiting illnesses are documented to aid providers in the meaning-making process following the death of a pediatric patient, but are not available at our institution. While this small pilot study is not able to show a statistically significant effect of the tested interventions, the staff at our institution has been open and enthusiastic. This is consistent with findings that engaging in peer support sessions can bolster positive attitudes, perceived work demands, and participation at work. Perhaps larger studies with the inclusion of open-ended questions will yield more statistically significant results to support the development of future interventions.