The findings of this study have provided an insight into the impact of a multidimensional workplace strategy on the being, becoming, belonging and doing of professional self-care for occupational therapists working with people living with a life limiting condition. While many of these findings align with and complement previous research, some are novel and indicate new areas for investigation and development.
The findings of this study clearly illustrated the complex and personalised nature of emotional responses and other lived experiences around working with people with LLCs. There were no significant changes in these experiences during the implementation of the multidimensional workplace strategy, but this was not an aim of the strategy in any case. Similarly complex responses were also identified in a qualitative study with eight occupational therapists working with people with LLCs in the United States [31], who described experiences of satisfaction, hardships and difficulties, coping, spirituality and growth. Previous occupational therapy researchers have suggested that emotions are heightened when working with people with LLCs, particularly due to additional time pressures [31-34]. However, respondents in this study did not identify spirituality as a key aspect of their lived experience, despite it being identified in previous research within occupational therapy [31,35].
Emotional responses were much more prevalent for respondents than other lived experiences (particularly those related to job perceptions). While the service was initially concerned about the impact of insufficient supports for professional self-care on retention, job satisfaction, mental health, and work life balance, they were not reported to be a major issue by respondents in this study. Similar findings have also been found in other research [5], where despite the challenges of working with people with LLCs the majority of occupational therapists intended to continue in their roles and reported relatively high levels of job satisfaction.
While shock and anger were less prevalent in this sample, related emotions such as frustration and stress were identified consistently within the qualitative comments. Stress and burnout in palliative care has been found to frequently be related to professional issues, but is not significantly more prevalent than rates found in other service settings [36]. The source of frustration and stress for occupational therapists in this study was attributed to feelings of not providing best care for people with LLCs, which is also similar to the experiences of loss of control and uncertainty reported by other occupational therapists working with similar patient cohorts [5,10,31,37].
Respondents in this study (and others) also highlighted that working with these patients challenges the traditional focus in occupational therapy (and indeed healthcare) on therapy and rehabilitation [23,31]. Functional maintenance and symptom management are generally perceived as subordinate to recovery or cure, however these support aspects of quality of life which are a priority to people at the end of life [38]. Theoretical approaches now beginning to emerge in occupational therapy [39,40] may assist the discipline to resolve this perceived dilemma, as will increased awareness of what it can contribute to this population of patients [10,32,33].
In regards to seeking support for professional self-care, the majority of respondents expressed confidence in being able to access relevant resources. Along with peer support from other staff, supervision emerged as a key support for professional self-care, being identified by respondents significantly more frequently by the end of the implementation period. Supervision has previously been identified as an element of professional self-care in general healthcare [41], with the need for facilitation of deep reflection emphasized. It has also been highlighted as a key professional self-care strategy for nurses in palliative settings [42], however Edmonds et al. [43] acknowledge the best way to apply this strategy to enable professional self-care remains unclear. The findings in this study indicate that supervision for professional self-care is also relevant to occupational therapists working with people with LLCs more broadly, indicating further research in this area is indicated.
However, respondents were not so engaged with the workplace support program. While employee assistance programs have been shown to have positive outcomes for both employees and employers [44], previous research has shown there may be some stigma attached to attending [45] and professional self-care is not a prevalent presentation problem in these services [46]. The role of employee assistance programs in supporting professional self-care therefore remains poorly defined.
In regards to support for knowledge and skill building, workplace learning remained the predominant source for the respondents in this study. The significant increase in respondents stating they had previously received grief and loss, or in-service, training in the second survey is indicative of the impact of the multidimensional workplace strategy over this time. However, relatively few respondents (<20%) identified their undergraduate training supporting their capacity for professional self-care when working with people with LLCs, which has also been flagged as a capacity issue by other authors [15,23]. As highlighted by Hammill [8], there is potential to expand the professional development opportunities for occupational therapists beyond those offered in this workplace strategy to include clinical scenarios, face-to-face contact with clients, and additional workshops and seminars around topics relevant to professional self-care such as the occupational therapy role, disease trajectory, and communication. Expanding opportunities for professional development may be encouraged by the recognition of its relevance across multiple services and settings, beyond the relatively niche area of palliative care.
Several demographic factors were found to be influential on respondents experiences and needs in regards to professional self-care when working with people with LLCs. Rehabilitation occupational therapists were significantly more likely to report low mood, while those with between 4-6 years clinical experience were significantly more likely to experience shock. Age and clinical experience were also found to be influential in regards to the seeking of support from family and friends, and the identification of previous grief and loss, or external professional development. Cipriani et al., [6] also found that young therapists tended to lack knowledge and experience around death and dying, meaning they required greater support to practice professional self-care. These findings suggest that the supports required for occupational therapists to practice effective professional self-care may differ between practice settings and over the course of their career. A standard, organisational wide approach to support may therefore be less effective than one which enables flexibility between individual and group supports, and the content of capacity building initiatives.
Despite the implementation of the multidimensional workplace strategy, just over half of respondents still identified unmet need in regards to professional self-care when working with people with LLCs. The shift in qualitative data to ‘external’ sources of support in the second survey may indicate that the strategy was meeting needs more effectively at the organizational level, but could not meet all of the workforces needs. The findings of this study highlight the significant challenges that evaluation of multi-dimensional interventions for professional self-care pose, given the potential influences of individual lived experience and demographics, support availability, and factors external to the organization itself. A recent systematic review of psychosocial interventions to support staff in palliative care [24] also highlighted the lack of high quality research currently available on this topic, and the need to develop thoughtful interventions which enable professional self-care.
The multidimensional workplace strategy implemented in this study directly addressed several of the determinants known to increase the effectiveness of allied health knowledge translation [49]. The strategy was aligned with organizational systems (such as supervision) which helped to embed it into practice, and leadership structures at multiple levels of the organization were utilized to drive and maintain momentum, particularly in regards to cultural changes. Professional development provided to the workforce has addressed the need to build capacity for professional self-care with this patient group, while the use of the initial survey to support strategy design took an inclusive approach that included contribution from stakeholders beyond the implementing team. As a result, the findings of this study have provided some evidence in support of the use of a multidimensional strategy to improve the professional self-care of occupational therapists working with people with LLCs.
Limitations
However, there are several important limitations to this study which impact upon the generalizability of its findings. The mixed methods pre-post methodology does not control for confounding factors, and therefore the findings reported may have also been influenced by other variables. The assumption that departmental change would emerge from the workplace strategy may also have been mistaken, and cannot be demonstrated by the data collected. By categorizing the occupational therapy workforce into acute, rehabilitation, community and aged care cohorts, the findings may not adequately reflect differences within these broad service categories. The survey utilized only provided a limited number of categorical options in response to each question, which the qualitative data indicates may not have been fully inclusive of common experiences and resources. While the health service is large, the study was undertaken within a single service and geographical setting. Finally, analysis of the multidimensional workforce strategy was limited to the occupational therapy workforce, which excludes insights and perspectives from other members of the multidisciplinary team.