Previous research suggests that health care providers working with issues of death and dying may experience increased stress and risk of burnout.1 Burnout has previously been described as "emotional exhaustion, depersonalization, and reduced personal achievement."2 Burnout influences have been proven to affect employees both personally and professionally. Burnout can also negatively impact physical health and can have consequences that make burnout a serious problem.3 Research indicates that burnout often occurs more frequently in those caring for patients who have high mortality rates, which would have a direct effect on the palliative care service. Research suggested reliable factors associated with worsening burnout as working greater than 8 hours a day, a medium/high patient workload, a lack of high professional quality of life, and having a self-care deficit.3 If burnout is left unresolved, it may be linked to earlier retirement, poor professional conduct, and increased risk of medical errors.4
Research suggests that burnout must be identified as a systemic problem and that a culture of self-care and promotion of interventions to improve satisfaction must be endorsed.5 Burnout and resilience cannot be exclusively individual-level issues; instead, the role of the employer must be considered.4 A secondary concept is that of secondary traumatic stress, which is defined as having emotions of wanting to help distressed people. Increased levels of both secondary traumatic stress and burnout are associated with a higher risk of compassion fatigue, also known as the emotional cost of caring.2
Despite the research on the magnitude of the problem of burnout faced by palliative care providers, there have been few interventions studied to potentially improve burnout. Any interventions put in place are typically done by the employee and not the employer. The palliative care advanced practice providers at this organization had many symptoms of burnout and spoke often about how they felt exhausted and burned out and that they likely could not sustain this type of work. These symptoms only worsened with the recent coronavirus disease 2019 (COVID-19) pandemic and the involvement the palliative care service had in aiding not only these patients but also the staff caring for them. A recent study found that more than 40% of nurses directly working with patients are feeling burned out and more affected by secondary trauma.5 Increasing burnout levels lead to decreased compassion satisfaction as health care workers begin to lack empathy because of their emotional exhaustion.5
The palliative care team sees very ill, high-mortality-risk patients who, along with their families, need much attention and support to navigate their illnesses. Specifically, during the COVID-19 pandemic, the palliative care team was the only one updating family members who were not able to see the patients, as well as providing in-person support to the patients, which was emotionally taxing. Members of the palliative care team were noted to be motivated, hard workers and spoke of how they hoped to have time granted to improve policy and education and ensure their own professional growth. Providers who spend time on the part of work they find most fulfilling have been proven to have a significantly lower risk of burnout.5 Ensuring protected time to participate in these activities helps ensure that competing priorities do not overtake this time.5 Research indicates that removing health care providers from high-stress environments, even for a short time, can greatly change their focus and lead to a healthier relationship with work/life balance, therefore decreasing burnout and compassion fatigue.6 This intervention aimed to provide that time away while still promoting meaningful work effort to the palliative care service by way of education, policy updates, individual growth, and so forth. Because burnout can be associated with a reduced sense of professional accomplishment, the addition of professional development (PD) days aimed to improve this.6
PURPOSE
The purpose of this pilot study was to promote PD and reduce burnout, compassion fatigue, and secondary trauma impact. The intervention aimed to allow the palliative care advanced practice providers time away from their taxing clinical work to focus on their own PD.
METHODOLOGY
This pilot study was completed at a large medical university in an urban location where the palliative care service is used as a consulting service. Each provider sees approximately 8 to 10 patients per day, all requiring some type of palliative care support. All the palliative care nurse practitioners (PC NPs) on the service (n = 10) participated in this study; further demographic information can be seen in Table 1. The palliative care service was noted to have high-risk health care professionals for burnout due to their patient population with high mortality rates. Each PC NP verbally consented to be involved with this pilot study and have their results analyzed and further studied. To begin this study, each PC NP completed the Professional Quality of Life Scale (ProQol) to measure both compassion fatigue and compassion satisfaction before the implementation of PD days. Compassion fatigue is split into 2 concepts: secondary traumatic stress and burnout. This instrument measures compassion satisfaction, secondary traumatic stress, and burnout with 10 separate questions.7 Each full-time NP (n = 8) received an 8-hour PD day per month, and each part-time NP (n = 2) received an 8-hour PD day every other month. Professional development days were meant to be completed remotely to ensure that NPs were out of their typical high-stress environment and not pulled into patient care. The following list was presented as ideas of things to work on during this time: in-hospital or community education resources, mandatory education efforts, continuing medical educations, advanced certification efforts, quality improvement projects, research projects, policy work, and so forth. Each NP was to compile a list of tasks worked on during each PD day, and this information was shared with their supervisor. Scores from the initial ProQol were shared with each NP, and then generalized results were shared in a group setting. Professional development days continued for 6 months, and then each NP took the ProQol again to assess compassion satisfaction and compassion fatigue after the intervention. In addition, each NP was asked about the impact of PD days on burnout and job satisfaction; qualitative feedback was also collected as seen in Table 2.
RESULTS
Preintervention Results
After completion of the ProQol, preintervention data suggested that 80% (n = 8) of the PC NPs felt "moderately satisfied" doing the work they do on a daily basis and 20% (n = 2) of the PC NPs felt "highly satisfied." In addition, preintervention data noted that 80% (n = 8) of the PC NPs felt "moderately burnout" from their daily work and 20% (n = 2) felt a burnout level of "low." On average, the team felt "moderately impacted" (80%, n = 8) by secondary traumatic stress and 20% (n = 2) felt a low level of impact from secondary traumatic stress. Complete results can also be seen in Table 3.
Postintervention Likert Scale Results and Satisfaction Results
When using the Likert scale, 100% of NPs (n = 10) answered the question "Do you feel that the PD days helped reduce burnout associated with your clinical role" with "strongly agree." In addition to this question, the PC NP was also asked, "Do you feel that the PD days improved your job satisfaction," in which 80% of NPs (n = 8) answered "strongly agree" whereas 20% (n = 2) answered "agree." Postintervention data found that 80% (n = 8) of the PC NPs felt "highly satisfied" doing the work they do on a daily basis whereas 20% (n = 2) felt "moderately satisfied." Using SPSS for Windows software package version 25, prevariables and postvariables of compassion satisfaction were compared with a paired t test resulting in statistically significant improvement (P = .005). Statistical significance was set at P < .05.
Postintervention Burnout Results
Sixty percent (n = 6) of the PC NPs felt "moderately burnout" from their daily work, and 40% (n = 4) felt a burnout level of "low." Using SPSS for Windows software package version 25, prevariables and postvariables of burnout were compared with a paired t test. These results were found not to be statistically significant (P = .168). Statistical significance was set at P < .05. Although not found to be statistically significant, there was a clear decrease in burnout levels reported. This may not have been enough to changes ranges from low/moderate/high though. Qualitative themes also note the same improvement in burnout symptoms with the implementation of PD days.
Postintervention Secondary Traumatic Stress Results
Postintervention results demonstrated that the team felt "moderately impacted" (30%, n = 3) by secondary traumatic stress. Seventy percent (n = 7) felt a low level of impact from secondary traumatic stress. Using SPSS for Windows software package version 25, prevariables and postvariables of secondary trauma were compared with a paired t test resulting in statistically significant improvement (P = .015). Statistical significance was set at P < .05. For compassion satisfaction, every NP's score (by number) increased post intervention; their result may or may not have moved them into a different range. For burnout, every NP's score stayed stable (n = 4, 40%) or decreased (n = 6, 60%) post intervention. For secondary trauma, every NP's score stayed stable (n = 1, 10%) or decreased (n = 9, 90%) post intervention.
Qualitative Results
Qualitative trends demonstrated that PC NPs felt supported by administrative staff with the implementation of PD days. The NPs also noted that they were able to provide a higher level of care to their patients and that the PD days allowed them to detach from the clinical aspects of their jobs that were, at times, weighing them down. In addition, PD days allowed them as individuals to grow and strengthen their clinical skills through continuing education and research. Additional qualitative trends can be seen in Table 1.
CONCLUSION
Compassion fatigue influences the effectiveness of workers in their work, family, and social life. It can also negatively impact physical health and can have consequences that make compassion fatigue a serious problem.3 If burnout is left unresolved, it may be linked to earlier retirement, poor professional conduct, and increased risk of medical errors.4 Research suggested that burnout and resilience cannot be exclusively individual-level issues; instead, the role of organizational and policy level influencers must be considered.4 A secondary concept is that of secondary traumatic stress, which is defined as having emotions of wanting to help distressed people. Increased levels of both secondary traumatic stress and burnout are associated with a higher risk of compassion fatigue, also known as the emotional cost of caring.8
Members of the palliative care team have been open about their feeling of burnout and have been clear that they need time away from their clinical load to refocus and recharge. This pilot study implementing a monthly PD day allows for just that-time to be away from their stressful clinical environment while still being productive in their roles. This intervention of PD days proved to decrease burnout, improve compassion satisfaction, and decrease secondary trauma for the PC team, especially during the COVID-19 pandemic, when the PC providers experienced high levels of stress and burnout. Professional development days allowed greater exposure and education on PC subjects, promoted autonomous learning, and improved team building and cohesiveness.
Burnout is clearly multifactorial in health care but can worsen in periods of high stress, and interventions must be in place to reduce this threat. Recommendations to further investigate ways to prevent further burnout for this population of health care providers and to promote wellness and PD should be further studied. Results from this pilot study demonstrate that PD days should be continued and even expanded for those providers who are at a high risk for burnout in the hospital setting.
References