An Innovative Self-Care Module for Palliative Care Medical Learners

Introduction

TO provide optimal patient care, physicians have a professional duty to ensure, to the extent possible, that their own health is well maintained.^1–4 Chronic exposure to distressing situations and the accumulation of unrecognized feelings and attitudes can lead to physical and psychosocial challenges that may impact patient care.^3,5–8 Studies also demonstrate that symptoms of mental health problems, particularly depression, were highest during the first postgraduate year, making this group of learners particularly vulnerable to the stresses encountered in the practice of medicine. ³ The physician-patient relationship is an essential element of a patient's overall care and central to this relationship is the physician's ability to offer him/herself as a therapeutic instrument of healing.^8,9 Therefore, self-care is not only necessary for the maintenance of a physician's well-being, but it also impacts the quality of care physicians are able to provide their patients. Ideally, development of skills, such as self-reflection and self-awareness, that enhance self-care should be integrated into a physician's daily practice. Physician's who are self-reflective and possess a high level of emotional self-awareness are best equipped to understand how their personal attitudes, values, and beliefs impact their behaviors toward other people, and are better able to manage and overcome the stresses that arise in clinical practice.^10,11 Although several methods of practicing self-care exist, the key components include: a practice that is regular or routine and involves an element of self-reflection intended to deepen a sense of self-awareness and engaging in supportive relationships with mentors and colleagues.^2,12–14

Within medicine, however, self-care is often not practiced and is rarely a formal, structured component of medical training programs.^10,15,16 Demands such as intensive study and evaluative processes, heavy workloads and on-call schedules, sleep deprivation, time pressures, social isolation, personal relationship strain, and loss of nonmedical grounding activities all underscore the critical need for creating opportunities to establish effective self-care practices.^17,18 Ideally, concepts addressing physician self-care would be introduced and modeled during both undergraduate and postgraduate training. Very few investigators, however, have reported on educational interventions within postgraduate curricula and only a few have published reports outlining undergraduate educational interventions that target physical and psychosocial measures of well-being. ¹⁹

Due to the common experience of having limited previous clinical exposure, undergraduate and postgraduate learners participating in a palliative care rotation are particularly vulnerable to the stresses they encounter. The emotional, psychological, and spiritual intensity encountered during a palliative care rotation can be difficult for many learners to process on their own. In response to this need, a structured Self-Care Module was developed for medical learners going through a palliative care rotation. A palliative care educational experience is proposed to be an ideal time for a structured self-care learning experience, as learners are often confronted with very difficult clinical scenarios that may challenge their sense of well-being.

An example of a reliable and effective self-care educational tool used commonly in social work training is called the process recording.^20,21 The process recording involves transcribing a client interview, reflecting on the feelings and thoughts that arise during the interview, and sharing these elements with a field mentor or supervisor. This is intended to provide learners with a structured opportunity to practice self-reflection and develop self-awareness within the context of a supportive relationship. Experience and tradition point to the process recording as one of the best learning and teaching tools that social work education has. Within such a context it has been demonstrated that both self-reflection and self-awareness help learners enhance clinical competence, avoid boundary violations, and prevent burnout, which are essential to the self-care and the development of the learner in becoming a professional. ²²

Based upon its identified merits, the process recording was adapted to become a central element to a Self-Care Module that was developed and implemented for medical learners rotating through a palliative care rotation. Although the process recording is widely used in social work training, to our knowledge this innovative adaptation within our Self-Care Module and its use among medical learners has not previously been documented in the literature addressing medical education. The primary objective of the study was to examine the acceptability, utility, and operational feasibility of a self-care educational module among undergraduate and postgraduate medical learners completing a palliative care rotation. The secondary objective of the study was to conduct a preliminary evaluation of the Self-Care Module itself and identify areas of improvement to ensure the most optimal learning experience.

Methods

The population for this descriptive study consisted of medical learners completing a palliative care clinical rotation with the Palliative Care Consult Team from September 2009 to September 2011, at Sunnybrook Health Sciences Centre, a tertiary care teaching hospital affiliated with the University of Toronto. The four elements of the Self-Care Module include: 1) patient/family member interview; 2) transcription; 3) completion of self-reflection questionnaire; and 4) participate in a facilitated group discussion.

Learners were asked to interview one patient or family caregiver with whom they could spend at least 20 to 30 minutes, discussing relevant palliative care issues including physical, psychosocial, and spiritual issues where appropriate. As discussions frequently arise in the routine care of patients that are of a spiritual nature, learners were also provided with a tool to help address and explore these dimensions of a patient's care. To improve learners' comfort level around conversations of a spiritual or religious nature, they were given the HOPE acronym in the Self-Care Module instructions. HOPE stands for H: sources of hope, strength, comfort, and meaning (“What are the sources of hope for you at this time?”), O: role of organized religion (“How are these a source of support to you?”), P: personal spirituality or practices (“Are there any particular spiritual practices that give you meaning at this time?”), and E: effects on medical care and end-of-life decisions (“How would you like me to address some of these spiritual issues?”). ²³ Learners were not obligated to use this tool, but if they did use this tool they could choose which elements to use depending on the nature and needs of the patient or family caregiver.

Following the interview learners were asked to write an accurate transcription of their conversation. Although learners were asked to be as accurate as possible in their transcriptions, accuracy was not the primary goal of this exercise. The intent of attempted accuracy, however, was to have learners pause, review, and recount the details of the interview, thereby affording them an opportunity for deeper reflection. For this reason learners were discouraged from taking notes or using any recording devices during their interviews. Due to the relative novelty of a module like this, learners were provided with a sample transcription in the Self-Care Module instructions as a model for further clarification and guidance. (See Table 1.)

Learners were also asked to complete four self-reflection questions: 1) “What were the strengths and weaknesses of the interview?”; 2) “What feelings were shared by the patient during the interview?”; 3) “What were your thoughts and feelings during the interview?”; and 4) “What do you wish you could have said or done during the interview?”

Following the completion of the transcription and self-reflection questions, learners participated in a facilitated group discussion with other learners and an inter-professional team of facilitators (i.e., palliative care physician and social worker) to share their transcriptions and the responses to the self-reflection questions. Learners were made aware that participation in the facilitated group discussion was voluntary and that their participation would not be evaluated for grading purposes. The purpose of the facilitated group session was to give learners an opportunity to debrief their experiences, and to encourage honest discussion around these experiences in order to promote self-care through further self-reflection and deepening self-awareness. The role of the facilitators was to provide a safe and nonjudgmental environment to support learners and to stimulate discussion. Discussion was stimulated through various techniques such as: asking for clarification to verify and deepen understanding; asking for elaboration on knowledge, beliefs, and attitudes; validating learners' experiences; encouraging learners to recognize their own strengths and limitations; providing advanced information when necessary; and summarizing emerging themes or learning points. The specific methods and skills used by the facilitators to lead these discussions are summarized in Table 2. The inter-professional nature of the facilitation provided each facilitator and the learners with access to a greater breadth of expertise and experience, thereby enriching the experience for all the participants.

At the time of the facilitated discussion, learners were asked to complete a two-part feedback form that included a number of Likert-scale items addressing attitudes on the perceived impact of elements of the Self-Care Module. As well, learners were given an opportunity to provide narrative feedback on the content and process. Given the descriptive nature of the study's design, formal statistical analysis was not completed.

Results

A total of 41 learners participated in the Self-Care Module during the study period and 35 (85%) completed evaluations. Learner demographic data are summarized in Table 3.

The results of the Likert-scale items addressing attitudes are outlined in Table 4. Prior to attending the facilitated group discussion, only 41% felt the process recording exercise and associated self-reflection questions were helpful, and only 24% of learners felt the facilitated group discussion would likely be helpful. Following the facilitated group discussion, 86% of learners found the facilitated discussion to be helpful in reflecting on their clinical encounters, 86% gained an appreciation for the importance of self-reflection and self-awareness as a component of self-care, and 97% gained a greater appreciation for sharing clinical experiences with other learners.

Narrative feedback provided by the learners on the content and process of the module is best summarized by three main categories: impact on clinical skills, role for self-care, and specific process elements.

Discussion

Skills that enhance physician self-care are critical not only for the health and well-being of the physician, but also for the quality of patient care the physician is able to provide. Self-care is particularly important for medical learners on a palliative care rotation due to the difficulties encountered when caring for those who are dying and grieving. The primary purpose of this novel Self-Care Module is to provide learners with an opportunity to practice self-care through a structured educational experience by enhancing their skills in self-reflection and self-awareness within a supportive setting with colleagues and an inter-professional team of facilitators.

Overall, the Self-Care Module was well accepted and found to be useful by medical learners during a palliative care rotation. Although much of the work for the module is completed by learners prior to attending the facilitated group discussion, results of the questionnaire stress the importance of the facilitated group discussion in helping learners understand the value of their own work in self-reflection and self-awareness as components of self-care. The facilitators in this study primarily provided support for learners and encouraged deeper discussion of topics that learners brought out through their sharing.

The majority of learners responded positively to the module and found that it enabled them to reflect on clinical interactions and to examine difficult thoughts and/or feelings. The Self-Care Module also enabled learners to appreciate the importance of self-reflection, self-awareness, and sharing clinical experiences with module facilitators and colleagues as important components of self-care. The learners also appreciated the opportunity to debrief concerns and struggles during the facilitated group discussion, and overall found it to be a valuable learning experience.

Although the majority (83%) of learners responded that overall the Self Care Module was a valuable learning experience, there were a few learners who were uncertain or disagreed (17%) with the module's value. Based on the narrative feedback we received the learners who were less than satisfied with the module may have found the module too time-consuming, preferring instead to just speak about patient cases without having to write out a process recording.

An important limitation for this study and the educational experience in general is that although the expectations regarding all elements for this experience were made clear to learners at the beginning of each palliative care block rotation, a small number of learners arrived to the facilitated group discussion without having completed a transcription or the associated self-reflection questions. To allow for some form of participation, these learners were given an opportunity to share a meaningful clinical experience. On the rare occasion when this occurred, the facilitators observed anecdotally that learners who had adequately completed the first three components of the module (i.e., patient/family interview, transcription, and self-reflection questions) prior to attending the facilitated group discussion demonstrated greater enthusiasm and appreciation for the learning experience. A second limitation is the inability to formally analyze data gleaned from feedback forms given the difficulty in separating out learners who fully prepared for and participated in this experience from those who did not.

Next steps for the Self-Care Module include formal evaluation as well as adaptation and collaborative implementation among other medical training programs/educational experiences as well as the formal development of a facilitator manual.

Conclusions

The Self-Care Module was found to be a well-accepted, useful, and operationally feasible educational experience for postgraduate and undergraduate learners completing a palliative care educational experience.