Self-Care in Palliative Care Nursing and Medical Professionals: A Cross-Sectional Survey

Abstract

Background:

Self-care is an important consideration for palliative care professionals. To date, few details have been recorded about the nature or uptake of self-care practices in the palliative care workforce. As part of a broader 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-care among 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 were explored. 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 in Australia.

Results:

Most respondents regarded self-care as very important (86%). Some rarely practised self-care and less than 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 of respondents (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 strategies used most frequently. Australian palliative care nurses and doctors recognize the importance of self-care practice, but further education and training are needed to increase their understanding of, and consistency in, using effective self-care strategies. These findings carry implications for professional practice and future research.

Introduction

Palliative care professionals are highly trained in caring for others, but they may receive little to no training in caring for themselves. In palliative care, a clinicians' expertise is rightly directed toward the care needs of patients and their families accessing palliative care. From a workforce perspective, however, due consideration must also be given to the individual's needs with regard to health and well-being. Concerns about increasing demands on the palliative care workforce have featured on the palliative care agenda for some time,^1,2 but related workforce issues such as self-care, while espoused through professional practice and quality standards, have received relatively little research attention.

Self-care encompasses the caring behaviors used to promote health and well-being³ and is increasingly discussed in the nursing and medical literature.^4,5 The palliative care literature does highlight the importance of self-care for palliative care professionals in supporting their caring role. It is apparent, however, that self-care is discussed in the palliative care literature more than it is researched, with most studies focused on strategies used to cope with burnout or other work related stressors rather than self-care strategies used to promote health and well-being. Key gaps in the palliative care literature include a lack of evidence to inform self-care practice and limited knowledge relating to the uptake of self-care practices such as the utilization of self-care plans. In Australia, for example, therapeutic guidelines developed by a palliative care expert group⁶ highlight a need for palliative care professionals to consider their own health needs; yet there is scant research to support the specific self-care strategies recommended.

Given that the use of effective self-care strategies is mandated in national quality and practice standards across multiple countries,^7–11 further research into palliative care professionals' self-care is warranted. Within the context of a broader mixed methods study, the objective of this study was to examine 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 secure web-based application designed to support data capture for research studies.¹²

A brief questionnaire was developed from a review of the relevant literature and refined in response to feedback received from a small cohort of palliative care nurses and doctors. From this process, a clear definition of self-care was added to the survey for respondents' reference. No errors or further ambiguity was identified.

Participant invitations were sent to members of Palliative Care Nurses Australia, the Australian and New Zealand Society of Palliative Medicine, and to palliative care services with contact details listed on Palliative Care Australia's national service directory. Participants were eligible for this study if they were a registered nursing or medical professional practicing in Australia, with palliative care as their main area of practice. This study population was chosen because the nursing and medical health workforce represents a large majority of the palliative care workforce and unlike other allied health professions in Australia are accessible nationally through survey distribution from their respective member organizations.

Questionnaire

The questionnaire included 13 items relating to professional role and sociodemographic variables, as well as participant perceptions, education, and practices relating to self-care. Most items were multiple choice questions allowing single answer responses, with subsequent questions presented, where relevant, using the branching logic provided through REDCap. One open question was included to elicit free text qualitative data describing specific self-care strategies most used by respondents. An electronic link to the survey was distributed to 609 eligible palliative care nursing and medical professionals in April 2015, through e-mail. The survey remained open for a total of six weeks, with two follow-up reminders sent during this period. While no incentive to participate was provided, a number of considerations were factored into the survey design to help maximize the survey response rate.¹³ These included the provision of reminder e-mails, participant anonymity, and ensuring the survey was brief and easily accessible online for completion by participants at a time of convenience.

Data analysis

All survey data were collected and managed using REDCap electronic data capture tools hosted at the University of Sydney. Quantitative data were exported directly to IBM SPSS Statistics 22 for descriptive analysis of frequencies and percentages. Qualitative data were exported into QSR NVivo 10 for coding and content analysis.

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.¹⁴ In this way, qualitative content analysis was performed deductively, drawing upon a recently published framework that delineates categories of physical self-care, inner self-care, and social self-care.¹⁵ This framework is consistent with the World Health Organization's definition of health,¹⁶ with each self-care domain corresponding to physical, mental, and social well-being, respectively. In addition, the inner self-care domain encompasses spiritual well-being and, therefore, includes but is not confined to mental well-being. Thus, self-care strategies, including exercise activities or nutritional intake, were coded as physical self-care; strategies involving relationships or interaction with friends, family, or colleagues were coded as social self-care; and strategies relating to psychological, emotional, or spiritual dimensions were coded as inner self-care. The analysis was conducted to identify the use of self-care domains at an individual level and across the sample as a whole.

Ethical considerations

Ethical approval for this study was received from the University of Sydney Human Research Ethics Committee (2015/013). Detailed information about the study was provided in recruitment e-mails to participants, as well as the initial online page viewed before accessing the survey. Participation was voluntary and anonymous, with consent implied through commencement of the survey.

Results

A total of 372 palliative care nursing and medical professionals completed the survey, giving a response rate of 61%. In addition, 11 incomplete responses were excluded from analysis. With respondents from all Australian States and Territories, the overall demographic profile of the sample was consistent with recent palliative care workforce data and, therefore, considered representative of the palliative care nursing and medical workforce in Australia (totalling 3560 based 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 proportion of respondents working in full-time or part-time roles was relatively similar. The majority was aged over 50 and more than half had worked in palliative care for more than a decade, with nearly one-third having worked in this specialty for 16 years or more. Detailed demographics and professional role characteristics are presented in Table 1.

Table 1.

Participant Demographics (N = 372)

Demographic/professional role	n (%)
Gender
Female	306 (82)
Male	66 (18)
Age group
18–29 years	6 (2)
30–39 years	62 (17)
40–49 years	95 (25)
50–59 years	154 (41)
≥60 years	55 (15)
Profession
Palliative care nurse	252 (68)
Palliative care doctor	120 (32)
Main role
Clinician	300 (81)
Educator	44 (12)
Manager	17 (4)
Researcher	11 (3)
Work status
Full time	178 (48)
Part time	194 (52)
Population focus
Adult palliative care	341 (92)
Pediatric palliative care	16 (4)
Aged palliative care	15 (4)
Years worked in palliative care
0–5 years	82 (22)
6–10 years	96 (26)
11–15 years	76 (20)
≥16 years	118 (32)

Participant responses to the self-care questionnaire are detailed in Table 2. A majority of respondents considered self-care to be very important for nurses and doctors working in palliative care. While others thought it was important, only a few considered self-care not important. The regularity of respondents' self-care practice was mostly either frequent or intermittent; however, a considerable proportion rarely engaged in self-care strategies. Less than half of respondents had received any workplace training or education about effective self-care strategies.

Table 2.

Characteristics of Participants' Perceptions and Practice of Self-Care (N = 372)

Questionnaire	n (%)
How important do you think self-care is for nurses and 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 during a working week?
Rarely	41 (11)
Intermittently	165 (44)
Frequently	166 (45)
Have you received specific training/education or resources in 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 plan if you were provided with training to do it?
No	106 (30)
Yes	243 (70)

The utilization of self-care plans was also low, with only 6% of respondents reporting they used a self-care plan. However, of these, 100% reported that they found the use of a self-care plan to be an effective self-care strategy. Of those not using a self-care plan, 70% indicated they would consider developing a self-care plan if they were supported to do so with training.

A total of 1501 self-care strategies were reported by participants when asked to describe examples of self-care strategies they used most, with self-care defined as “the self-initiated behavior that people choose to incorporate to promote good health and general well-being.”³ Several responses were not included as they were not entirely consistent with this definition and did not correspond directly with the self-care framework used for content analysis. For example, without further contextual data, it was considered that responses such as “watching television” or “providing direct patient 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 received through electronic correspondence with the researchers who developed this framework (Dr. Amparo Oliver, personal communication, September 19, 2016); therefore data such as these were excluded from content analysis.

On average, respondents could identify 4 self-care strategies, and a total of 1476 were coded for analysis. Physical self-care strategies were used most frequently, followed by social self-care and inner self-care strategies, although there was a relatively even distribution across all three domains. These results were comparable between both professions and roles. Examples of physical self-care strategies included jogging, hydrotherapy, and yoga. Common social self-care strategies included group debrief or clinical supervision with colleagues and spending time with friends or family. Examples of inner self-care strategies included meditation, mindfulness, and spiritual practice. See Table 3 for self-care domain frequencies and percentages derived from the content analysis of all self-care strategies reported. At the individual level, 11% of respondents used only one self-care domain, while 89% used either two or three domains.

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)

Figure 1 illustrates a word cloud generated from the qualitative survey data using the word frequency query function within NVivo, as described by Glasper and Rees.¹⁸ While limited if used alone, visual representation through word clouds has been shown to be an effective tool to increase comprehension of qualitative survey data when used to complement other qualitative analysis methods such as content analysis.¹⁹ This word cloud contains the 50 words most commonly used by respondents when describing their self-care strategies in the survey. The words vary in size and color density according to their frequency. “Time” was the most commonly used word (frequency = 145) and was relevant to the context of all self-care domains. Beyond this, the next most frequently used words were consistent with the content analysis ranging in frequency from the physical self-care domain down to social and inner self-care domains: “exercise” (124); “walking” (87); “family” (86); “friends” (80); “colleagues” (75); “meditation” (63); and “reading” (55).

FIG. 1.

Word cloud from reported self-care strategies.

Discussion

This study examined the perceptions, education, and practices relating to self-care among palliative care nursing and medical professionals in Australia. The study findings 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. While past research has largely focused on self-care as a way of coping with occupational stressors, this study examined self-care in the context of promoting health and well-being.

Perceptions within the palliative care workforce are consistent with discussion in the literature, with regard to the importance of self-care. Although it had been argued that self-care is important,^20,21 there are now empirical data to show that a majority of the workforce shares this position. With this knowledge, palliative care services should consider prioritizing resources to support self-care practice, especially with regard to training.

Adequate education and training are important for self-care.⁶ That only 39% of nurses and doctors had received education about self-care is alarming. Especially given that in Australia, since 2005, palliative care professionals have been required to initiate and maintain effective self-care strategies in accordance with Palliative Care Australia's national quality standards.¹⁰ This professional expectation is shared internationally,^7–11 yet many staff may not have received the necessary training to do so. This finding supports other national data suggesting that the provision of self-care education across palliative care services may be limited.²² Taken together, they indicate that addressing self-care learning needs is a priority. Given that self-care is a professional expectation, equipping palliative care professionals with the means to understand and engage in effective self-care practices should be prioritized. Content and pedagogical approaches to self-care training could be drawn from programs already piloted. These have so far focused on mindfulness, poetry, clinical supervision, and other structured reflective practice.^23–27 The broader development and provision of self-care education can usefully inform emerging palliative care workforce development frameworks.²⁸

The use of self-care plans has been promoted in the literature for more than a decade,^20,21 yet before this study no research had investigated the utility or uptake of self-care plans in the palliative care workforce. In the current study, all of the nurses and doctors who used a self-care plan reported it to be an effective self-care strategy. However, the uptake of self-care planning was very low. Further qualitative research could usefully explore the context of this finding. This may be related to the lack of self-care education reported, as a considerable majority of those not using a self-care plan indicated they would consider doing so if provided with training and resources. The reported lack of self-care planning may also relate to the infrequent nature of some participants' self-care practice. That 11% of nurses and doctors rarely practice self-care is a concern and suggests a need for education and further exploratory research.

As with a previous study of hospice professionals in North America,²⁹ the nurses and doctors in this study most frequently 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 is consistent with the healthy lifestyle behaviors observed in a cohort study of Australian and New Zealand nurses and midwives.³⁰ While physical self-care was most common in the current study, the self-care strategies described by respondents were spread relatively evenly across the domains of physical, social, and inner self-care. This is consistent with other research¹⁵ that investigated these self-care domains in a sample of Spanish palliative care professionals and indicates that a variety of strategies are important to self-care practice in palliative care. Thus palliative care professionals should consider broadening their self-care practice where it is currently limited to one self-care domain. The findings from this study also add empirical support to the palliative care therapeutic guidelines' recommendation for self-care practice to encompass broad development areas such as education and peer and professional support.⁶

Future research

From the results of this study, a number of areas for future research become apparent.

First, further qualitative inquiry into the personal or professional contexts of infrequent self-care practice and low uptake of self-care planning could assist educators and palliative care services in promoting effective self-care practice. Future research should also focus on the development and evaluation of innovative self-care education programs implemented by palliative care services. Studies could usefully compare baseline knowledge and understanding of self-care in staff, as well as the uptake of self-care planning and regularity of self-care practice. While the current study explored the self-care strategies most used by participants, it would be useful for future research to examine the strategies reported as most effective. Since strategies found to be most effective may not necessarily be the most commonly utilized, the identification of barriers and enablers to effective self-care practice is also important. This broader context of self-care practice could be investigated through in-depth exploration of relevant personal and professional factors.

It will also be important for future research to better understand the subjective meaning of self-care, from the perspective of those working in palliative care. In the current study, nurses and doctors were provided with a definition of self-care from the literature to guide their understanding in reporting the self-care strategies they used most. Despite this, a considerable proportion of responses reported the use of self-care strategies that, without further context, did not appear consistent with the promotion of an individual's health and well-being.

In the case of “watching television,” for example, longitudinal data from a large cohort study of female nurses have shown that the sedentary nature of television watching is associated with higher risk of becoming obese and developing diabetes mellitus.³¹ A more recent meta-analysis of television viewing data also identified a higher risk for cardiovascular disease and all-cause mortality.³² Ensuring that palliative care professionals understand effective self-care strategies will be important if palliative care services are to support self-care practice and, thus, promote the provision for quality palliative care.

Strengths and limitations

To the best of the authors' knowledge, this is the first study of its kind to explore the perceptions, education, and practices relating to self-care among palliative care nursing and medical professionals. While this study has a number of strengths, it is somewhat limited by its self-report and cross-sectional research design. There is also potential for nonresponse bias within the study population; however, this is mitigated to some extent by the representative nature of the sample and response rate achieved.³³

The survey response rate of 61% in this study is considered satisfactory.³³ As a national survey, this response rate is relatively high compared to past surveys of palliative care professionals in Australia. Doctors in particular have been associated with response rates of 29% and 35%, depending on the survey methods and questionnaire content.^34,35 The response rate in the current study may have been maximized by a variety of factors such as a high level of participant interest in the survey subject matter or the survey design considerations undertaken to achieve a satisfactory response rate. As no participation 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 by palliative care professionals among a variety of health related self-care practices. Most palliative care nurses and doctors recognize the importance of self-care and engage in effective self-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 not received education or training in the use of effective self-care strategies. The use of self-care plans is reported to be an effective self-care strategy; however, there is very low uptake among palliative care nurses and doctors. These limitations to self-care practice 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 expectation in palliative care, requisite education is necessary to support effective self-care in the palliative care workforce. Such initiatives could promote greater understanding of self-care, awareness of domains, and uptake of self-care plans. Further research is needed to understand the broader context of self-care practice and to develop and evaluate the effectiveness of self-care education programs.

The findings of this study can inform current practice and emerging palliative care workforce development frameworks.

Footnotes

Acknowledgments

J.M.'s PhD candidature is supported by an Australian Postgraduate Award from the University of Sydney. The authors gratefully acknowledge all nurses and doctors for their participation in this study, as well as Palliative Care Nurses Australia and the Australian and New Zealand Society of Palliative Medicine for their generous support of this research. The authors also thank the anonymous reviewers for their valuable feedback.

Author Disclosure Statement

No competing financial interests exist.

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