An educational program on CF was delivered by de Souza Institute via a virtual classroom. The Institute offers online courses, covering core competencies in oncology and/or palliative care and is linked to regional cancer centres across Canada. All courses integrate best practices and clinical guidelines to support Quality Improvement (QI) initiatives, and therefore, research ethics approval was not required for the evaluation. Participants in this education program were assessed on confidence and knowledge in core domain areas related to CF. At baseline participants also completed a grief inventory. A review of course online postings of case material and personal plans (required for course completion) was also completed.
Participants were 189 health professionals, with the majority (92.6%) being nurses. Most participants were direct care clinicians; 10% were educators/managers/leaders.
The Educational Intervention
The program was developed by a PhD psycho-oncologist with experience in working with grief and loss. The primary aim of the program was to increase knowledge and confidence related to the impacts of exposure to suffering and loss, including understanding CF and burnout and recognition of types of grief experiences. The program was delivered on 14 occasions from 2011 to 2019. Continuing education credits were provided and could be used towards a “de Souza Designation”.
Format: Participants attended weekly 1.5-hour videoconference-based group sessions over six weeks. Each seminar included readings from the literature and was led by a PhD level practitioner/educator with experience in grief/ loss and psychotherapy. Weekly group discussions were further supported with an online community of practice for reflections and sharing of resources.
Content: The content was organized in relation to: personal, system/organization and team- related (interpersonal) factors contributing to CF, and strategies to support resilience. (see Table 1) The first three sessions focused on grief models and reactions, and definitions of burnout and CF. Personal risk factors associated with CF were reviewed, as well as contributing factors related to work settings or the team. Participants were encouraged to have a “working theoretical model of grief” to apply in their clinical work. As an example, readings were provided on the Dual Process Model of grief . The topic of Medical Assistance in Dying (MAID) was also included.
The final three sessions focused on strategies and resources known to facilitate coping and that mitigate against CF. Participants worked towards a personal plan. These plans included strategies “they could do” to support their work/ team/ setting. Participants were encouraged to identify and consider how to address any relevant personal factors. In the final class, potential barriers to implementation of plans were identified and methods to address them.
Grief Experience: The Revised Grief Experience Inventory (RGEI) was given as a self-assessment tool with a score for participants’ own functioning. The RGEI was also used as a teaching aid. For example, the program leader reviewed the tool’s items to illuminate specific domain areas for the assessment of grief reactions and for guidance in its application for assessing patients or caregivers. This exercise provided a type of mirroring experience, as participants reflected on personal experiences related loss (and associated personal reactions), while considering the application of the tool in relation to their clinical work.
Case-based learning: Prior to the first session, participants were asked to post the description of a “difficult case” that felt unresolved to them. Case narratives were reviewed and utilized during class discussions to illustrate variables (e.g. patient variables, health professional variable, work setting or context) that may have played a role in the sense of a lack of resolution. Participants were invited to reflect upon their cases throughout the course, applying their gained understanding of relevant factors that may have played a role, and invited to discuss what “they might do differently, if a similar situation presents once again”.
A demographic questionnaire at baseline collected information on demographics, including age, sex, profession, clinical work setting, and number of patient deaths over the past year and number of significant losses in the participant’s personal life over the past five years.
Revised Grief Experience Inventory (RGEI)
To assess psychosocial functioning in relation to grief symptoms, the RGEI was given at baseline. The 22-item inventory has four domains: depression, existential concerns, guilt and physical distress. The instrument has been utilized in assessment of health professionals.
Knowledge and Confidence in Managing Grief and Loss
A self-report questionnaire to assess knowledge was developed by the research team and lead course educators with content expertise, and included items linked to learning objectives of the program. The survey was given before and after the course and consisted of 13 items with a 4-point Likert-type scale from Not knowledgeable at all (1) to Very knowledgeable (4). Item content included five domains: 1) Recognizing the Signs of burnout and CF and its Impacts; 2) Factors Contributing to Ability to Manage Loss; 3) Reflections on Experiences of Loss and Grief; 4) Strategies that Healthcare Professionals can integrate into their Practice; and 5) Team and Organization Strategies. A single item 10 cm Visual Analogue scale (VAS) was used to assess participant’s confidence in the “ability to recognize and manage your own grief and loss”, anchored with “not confident at all” to “very confident” pre and post the program.
Participants posted and discussed personal plans. They were also asked to rate their intention to carry out specific activities to address grief and loss in relation to the following: i) apply self-assessment tools to identify loss and grief; ii) facilitate discussions with colleagues on issues of grief management and form a peer group with colleagues to obtain support for each other; iii) communicate to supervisor/manager about my grief and loss; iv) apply various stress management techniques to reduce distress and enhance coping; v) seek support from a mental health professional when having difficulties managing grief.
Descriptive analysis was conducted. A step-wise regression analysis examined the association between demographic variables (age, sex, health profession, amount of loss in work setting and in personal life) and the baseline RGEI. A paired t-test was conducted (pre-post survey) to assess impact of the program on pre and post course confidence and knowledge measures. When handling missing items within a standardized measure, prorated scores were used if respondents had <20% of the items missing. A content analysis was conducted using NVivo by the research team for open ended questions and reports related to participants’ plans, with frequencies of each coding category reported.