A similar proportion of the occupational therapy workforce responded to each survey, with 55 completing the baseline survey (approximate response rate – 73%) and 48 completing the second survey (approximate response rate – 64%). There were no differences in the pre intervention and post intervention samples in regards to grades (i.e. professional level), practice experience, practice setting, or experience with LLCs (either overall or in the past month). As shown below in Table 2, clinicians in aged care services and community settings had significantly more practice experience than those in other practice settings [X2 (9, N = 103) = 22.95, p=.006].
Table 2: Study Participant Characteristics and Survey Scores
|
Pre Survey
|
Post Survey
|
|
|
n
|
%
|
|
n
|
%
|
Grades
|
AHA
Grade 1
Grade 2
Grade 3
|
3
21
24
7
|
5%
38%
44%
13%
|
AHA
Grade 1
Grade 2
Grade 3
|
5
11
21
11
|
10%
23%
44%
23%
|
Practice Setting
|
Acute
Rehabilitation
Aged Care
Community
|
18
14
8
15
|
33%
25%
15%
27%
|
Acute
Rehabilitation
Aged Care
Community
|
18
10
9
11
|
38%
21%
19%
23%
|
Practice Experience
|
0-3 years
4-6 years
7-10 years
> 10 years
|
15
14
13
13
|
27%
25%
24%
24%
|
0-3 years
4-6 years
7-10 years
> 10 years
|
13
7
15
13
|
27%
15%
31%
27%
|
Previous experience with life limiting conditions
|
Yes
No
|
33
22
|
60%
40%
|
Yes
No
|
33
15
|
69%
31%
|
Note: AHA = Allied Health Assistants
Being: Demographic characteristics, emotional experiences and self-perception of self-care capacity
Clinicians were asked about their experience of emotional responses (sadness, anger, shock, helplessness) and other lived experiences (low mood, decreased job satisfaction, decreased motivation, strain on personal relationships and intention to continue in current job / position) when providing therapy to people with LLCs, as shown in Figure 1 below. The proportions of clinicians reporting these emotions and lived experiences were very similar across both surveys, with no statistically significant differences found.
Respondents indicated their experiences of working with people with LLCs consistently provoked feelings of sadness, helplessness and/or low mood. However, the emotional responses of shock and anger were less prevalent, as were the other lived experiences specified. Comparable numbers of respondents reported not experiencing any of the identified emotions (2015 – 7.27%, 2016 – 4.17%), and around half reported not experiencing any of the other lived experiences when working with people with LLCs (2015 – 46.25%, 2016 - 50.00%)
While there were no significant changes over time, significant differences were identified in regards to low mood and practice setting, with rehabilitation clinicians more likely to report low mood [96.77% Rehabilitation , 88.16% Other clinicians, p=.020]. Clinicians with between 3-5 years clinical experience were also significantly more likely to identify shock as an emotional response, than those in other career phases [47.62% 3-5 years, 13.41% Other Clinicians, p=.005].
Other emotions identified qualitatively in the surveys reflected negative, positive and neutral responses to working with people with LLCs. The most commonly reported emotion was frustration or stress, which was often in result of clinicians feeling they are not able to provide the level of care and support they would wish; “Worry about not being afforded time to complete timely follow-up”. These experiences were also related to feelings of guilt and incompetence if clinicians felt they were ‘not able to facilitate the outcomes the patients have wanted’. Other negative emotions identified included shock and feeling ‘drained’. The traditional focus of occupational therapy on treatment and rehabilitation (rather than compensation and maintenance) was also identified as a potential dilemma; “This can often make us feel uncomfortable as it is a complete change to that of how we normally respond to our clients and conversation around this can often be difficult”.
Positive emotions were also identified, and were once again related to the perceived quality of care that clinicians could offer; “Happiness, given patients and families are happy with engagement and they have reached the point of satisfaction and acceptance”. The ability to provide meaningful support to patients at the end of their lives, and make a difference to their quality of life, were also related to feelings of joy and relief. Some respondents also reported feeling particularly motivated to work with people with LLCs. The experience of working with these patients also attracted some neutral emotional terms, such as ‘challenging’ and ‘eye opening’. While some clinicians experienced pity when working with this population, other used the more culturally prevalent term sympathy in their comments.
Some changes over time in regard to other lived experiences were indicated in the qualitative comments. Many clinicians initially reported ‘avoidant’ perceptions that sought to evade the need to work with people with LLCs; “Less likely to want a rotation in high palliative patient caseload”. However, there were fewer of these responses in the post-survey data. Comments from clinicians after the implementation of the multidimensional workplace strategy described more experiences of reconciliation to, and personal reflection about the death of patients; “She had her journey in life and was not my place to be involved with that aspect of her journey”, “More concerned for your own health and your loved ones, more so heightened sense of your own mortality”.
Becoming and Belonging - Understanding and awareness of resources available to assist with professional self-care
As shown below in Figure 2, clinicians were asked about their experience of four specific sources of support (supervision, family and friends, leading an active life and other staff) when working with people with LLCs. The majority of respondents identified more than one support as personally relevant, with gaining support from other staff, and supervision prevalent.
While there were no significant differences over time for many of these resources, clinicians were significantly more likely to identify supervision as a support for self-care by the time of the second survey [64.70% 2015, 70.91% 2016, p=0.042]. Practice setting did not have a significant influence on the identification of supports apart from seeking support from family and friends, with junior clinicians significantly more likely to identify this as a strategy [50.00% Junior clinicians, 21.57% Other clinicians, p=0.020]. This was also reflected in an analysis of years of experience, where clinicians with six or less years of experience were significantly more likely to seek support from family and friends [40.54% <6 years experience, 28.79% Other clinicians p=0.040].
There was generally some level of awareness of support for professional self-care amongst respondents, with only one clinician in each survey stating they were not aware of any. While there was an increase in the number of respondents accessing some form of self-care service in relation to their professional roles with people with LLCs over time (2015 – 18.18%, 2016 – 25.00%), this was not statistically significant, p=0.62.
Supervision was identified consistently as a support in qualitative comments, as was the workplace employee assistance program. While the majority of respondents reported they regularly received support for professional self-care during supervision, some participants expressed reservations; “it can certainly be dependent on the supervisory relationship”. However, comments indicated there was less engagement with the employee assistance program; “[service name] has an employee assistance program. I have never used it and I very rarely remember to tell others about it”. Another respondent identified this resource, but said; “I doubt I would realistically even access this”. In the baseline survey, participants also identified peer support or debriefing, professional resilience training and individual access to general practitioner mental health care plans in the initial survey. However, in the second survey professional resilience education and other professional development or training became more prominent.
As shown below in Figure 3, five forms of professional development relevant to professional self-care (post graduate training, external professional development, in-service, university training, previous grief and loss training) when working with people with LLCs were identified. Not all respondents reported attending this form of support, with workplace learning (i.e. in-services) and previous grief and loss training the most frequently identified.
The second cohort were significantly more likely to state they have previously received training in grief and loss [50.94% 2015, 56.00% 2016, p=.034]. Clinicians at higher grades were also significantly more likely to identify previous grief and loss training than junior clinicians [77.78% Senior clinicians, 48.81% Other clinicians, p=.050], and to identify external professional development opportunities [21.43% Senior clinicians, 3.53% Other clinicians, p=.016]. Very few qualitative comments were received regarding professional development, most of which identified courses or modules provided by external providers.
Other, more personalised resources for professional self-care were also highlighted by some participants, demonstrating that respondents used resources both within the workplace and beyond; “singing in the [service] Choir, occasional glass of wine at end of rough week!”. In the initial survey, participant’s highlighted personal strategies such as mindfulness and relaxation, however self reflection was identified as a theme in qualitative responses to the second survey (possibly in response to the workshops offered in the workplace intervention). Overall, a significant majority of respondents reported feeling confident in their ability to access resources to support personal self-care in both surveys (81.81% 2015, 91.67% 2016, p=0.55).
Doing - Impact of implemented strategies on professional self-care for the workforce as a whole
The perceived need for three of the workplace strategies subsequently implemented was measured pre and post implementation. Changes to department culture were not directly measured, as it was assumed to be an emergent outcome of the implementation of these strategies. As shown below in Figure 4, the majority of respondents in both surveys consistently expressed a need for these strategies to support their professional self-care.
Around half of the respondents in each survey (2015 – 49%, 2016 – 52%) stated they had further professional development needs in regards to professional self-care when working with people with LLCs. While not addressed in the quantitative questions, organizational culture was a consistent theme within the qualitative comments. Responses to the initial survey indicated respondents wanted greater resources within the organization, including references to the culture of the occupational therapy department; “Changes to culture re: talking about and developing strategies to manage self-care in the workplace, protected time for these discussions and opportunities to share experiences and provide support to one another/discuss resources available.” There were also comments related to the existing culture, which was perceived to insufficiently support professional self-care when working with these patients; “It just feels like the expectation is often to continue on as if nothing has happened. Although it can be a very sad process, there is opportunity for satisfaction in the work – knowing that you are making a difference at end stage”. However, there was also recognition that professional self-care needed a sustained focus to effect cultural change over time; “With increasing emphasis on throughput and productivity, discussions and support networks for staff need to be prioritised and maintained. It is not always easy for staff to prioritise this due to high workload and personal expectations, so this needs to be modelled across different grades and supported/prompted by management”.
By the time of the second survey, respondents had shifted their focus toward ‘external’ resources including further professional development, attending professional special interests groups and external courses. Consolidation of the multidimensional workplace strategies already implemented was also highlighted, with reference to sustaining these practices in an evolving workforce; “A resource outlining key strategies from the recent resilience training would be great to refer back to - as new staff come through, it would be great to be able to have a record so that a more evidence-based/fuller range of strategies can be provided”. However, there were also some indications of cultural changes at the organization, including a shift in perceptions around professional behavior when working with people with LLCs; “It is important to know – it is ok to feel sad (don’t always need to be brave)”.