- Email: [email protected]
Building Resiliency in a Palliative Care Team: A Pilot Study
Accepted Manuscript Building Resiliency in a Palliative Care Team: A Pilot Study Darshan H. Mehta, MD, MPH, Giselle K. Perez, PhD, Lara Traeger, PhD, Elyse R. Park, PhD, MPH, Roberta E. Goldman, BS, Vivian Haime, BS, Eva H. Chittenden, MD, John W. Denninger, MD, PhD, Vicki A. Jackson, MD, MPH PII:
S0885-3924(15)00577-1
DOI:
10.1016/j.jpainsymman.2015.10.013
Reference:
JPS 9002
To appear in:
Journal of Pain and Symptom Management
Received Date: 22 April 2015 Revised Date:
25 October 2015
Accepted Date: 28 October 2015
Please cite this article as: Mehta DH, Perez GK, Traeger L, Park ER, Goldman RE, Haime V, Chittenden EH, Denninger JW, Jackson VA, Building Resiliency in a Palliative Care Team: A Pilot Study, Journal of Pain and Symptom Management (2015), doi: 10.1016/j.jpainsymman.2015.10.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Brief Report
15-00253R1
Building Resiliency in a Palliative Care Team: A Pilot Study
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Darshan H. Mehta, MD, MPH, Giselle K. Perez, PhD, Lara Traeger, PhD, Elyse R. Park, PhD, MPH, Roberta E. Goldman, BS, Vivian Haime, BS, Eva H. Chittenden, MD, John
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W. Denninger, MD, PhD, and Vicki A. Jackson, MD, MPH
Benson-Henry Institute for Mind Body Medicine (D.H.M., E.R.P., R.E.G., V.H., J.W.D.),
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Mongan Institute for Health Policy (G.K.P., E.R.P.), Department of Psychiatry (L.T., J.W.D.), and Division of Palliative Medicine (E.H.C., V.A.J.), Massachusetts General Hospital, Boston, Massachusetts, USA
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Address correspondence to: Darshan H. Mehta, MD, MPH
Benson-Henry Institute for Mind Body Medicine
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Massachusetts General Hospital 151 Merrimac Street, 4th floor
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Boston, MA 02114, USA
Email: [email protected]
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Abstract Context. Palliative care clinicians (PCCs) are vulnerable to burnout as a result of
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chronic stress related to working with seriously ill patients. Burnout can lead to absenteeism, ineffective communication, medical errors, and job turnover. Interventions that promote better coping with stress are needed in this population.
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Objectives. This pilot study tested the feasibility of the Relaxation Response Resiliency Program for Palliative Care Clinicians (3RP-PCC), a program targeted to
major academic medical center.
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decrease stress and increase resiliency, in a multidisciplinary cohort of PCCs (N= 16) at a
Methods. A physician delivered the intervention over two months in five sessions (12 hours total). Data were collected the week before the program start and two months after completion. The main outcome was feasibility of the program. Changes in perceived
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stress, positive and negative affect, perspective taking, optimism, satisfaction with life, and self-efficacy were examined using non-parametric statistical tests. Effect size was
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quantified using Cohen’s d.
Results. The intervention was feasible; all participants attended at least four of
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the five sessions and there was no attrition. Following the intervention, participants showed reductions in perceived stress and improvements in perspective taking. Conclusion. Our findings suggest that a novel team-based resiliency intervention
based upon elicitation of the relaxation response was feasible and may help promote resiliency and protect against the negative consequences of stress for PCCs.
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Key Words: palliative care providers, health care provider wellness, stress, group
Running Title: Building Resiliency in a Palliative Care Team
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Accepted for publication: October 28, 2015.
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intervention, relaxation response, resiliency, mind-body therapies
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Introduction Health care providers are susceptible to the deleterious effects of stress (1,2),
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resulting in consequences such as decreased productivity because of absenteeism, and increased medical errors (3,4). In addition, stress may play a role in quality of care, as elevated stress may lead to poor communication and teamwork in health care settings
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(2,4,5). These negative consequences of stress have been demonstrated in palliative care clinicians (PCCs) as well (6). Not only do palliative care providers experience these
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stressors but also constant exposure to death and loss, time pressures and unpredictable schedules, increasing workloads, and competing role demands (7–9). Given these findings, there has been increased interest in the development of treatments aimed at promoting provider wellness and resiliency in palliative care. Resiliency is the capacity of a dynamic, malleable system to withstand challenges to its
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stability, viability or development. Studies of group interventions to enhance resiliency in health care providers have found improvements in various domains of provider well-
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being (10,11). While these interventions have focused primarily on providers within a single discipline, palliative care services often are unique in their organizational structure
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in that they consist of an interdisciplinary team, which often includes physicians, nurses, chaplains, psychologists, and social workers. Success of the palliative care service is contingent upon the cohesion and well-being of the team members, especially as caseloads and job demands have increased. However, to our knowledge, no intervention to date has explored the feasibility of mind-body resiliency programs among an interdisciplinary palliative care team.
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The Relaxation Response Resiliency Program (3RP) is a mind-body program designed to promote resiliency (12) and has been shown to decrease stress and increase resiliency in a broad range of populations (13–17). For the purposes of this study, we
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adapted the existing program based on our previous qualitative work to meet the specific stressors, challenges and training needs of PCCs (8) . We sought to test the feasibility of this adapted 3RP (12), among a team of palliative care providers. Additionally, we
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explored PCC characteristics that could be associated with higher levels of stress. Methods
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Participants
Our pilot study intervened with a multidisciplinary team of PCCs (physicians, nurse practitioners, nurses, and social workers) at a major academic medical center. PCCs were informed about the 3RP program through e-mails and informal presentations.
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Informed consent was obtained from each participant. There were no specific financial incentives provided to participants, except that their time was protected by the Division Chief. Staff members were expected to participate in the resiliency training sessions as
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part of job responsibilities, but were not required to participate in the research component and could opt out of the self-report questionnaires at their discretion. The primary
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inclusion criterion was full-time employment as a clinician in the Palliative Care Division. There were no exclusion criteria, and the Partners Human Research Committee approved the project. Assessment
Study data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted at Massachusetts General Hospital (MGH), and were de-identified.
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REDCap is a secure, web-based application designed to support data capture for research studies. Study data were collected at two time points: the week prior to the start of the program, and two months after completion of the program. Research assistants performed
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the data collection and analysis. Members of the Palliative Care Division leadership did not participate in data collection or analysis. Data were confidential, and not reviewed by the PC leadership at any time.
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Intervention
The 3RP for Palliative Care Clinicians (3RP-PCC) was adapted from the MGH
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Benson-Henry Institute for Mind Body Medicine (BHI) manualized 3RP program through an iterative process, taking into account the PC needs assessment (9) and discussions with PC leadership. The intervention consisted of an initial four-hour introductory session followed by four two-hour education sessions delivered in a group
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format by a physician from the MGH (BHI). The sessions were held every other week over a period of two months. Based on principles of cognitive behavioral therapy and positive psychology, the goals of the program included: 1) eliciting the relaxation
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response, 2) reducing overall stress reactivity, and 3) increasing connectedness to oneself and others. The 3RP-PCC incorporated a multimodal approach to introduce and reinforce
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new skills, including didactics, in-session activities, discussions and weekly practice assignments. Each education session began with the practice of a new exercise to elicit the relaxation response (e.g., breath awareness), followed by didactics and in-class exercises.
Outcome Measures
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We assessed feasibility as the proportion of full-time MGH PCCs who enrolled in the pilot trial, attended the intervention sessions, and completed the assessments. In addition, six constructs were selected to explore the three core components of the 3RP
was assessed at pre- and post-intervention.
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relaxation response: stress awareness, adaptive strategies, and resiliency. Each construct
Relaxation Response. We evaluated perceived stress using the well-validated
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Perceived Stress Scale (PSS; 10 items, score range 0-40) (18). The PSS assesses the
extent to which life has been stressful, uncontrollable or unmanageable during the past
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week, with higher scores indicating greater stress.
Stress Awareness. Participants’ affect during the past week was assessed with the Positive and Negative Affect Schedule (PANAS) (19). The PANAS comprises two 10item subscales (positive affect and negative affect, score ranges 10-50), with higher
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scores indicating more affect.
Adaptive Strategies. We administered the perspective-taking subscale of the Interpersonal Reactivity Index (IRI) (20). The 28-item IRI was developed to assess
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cognitive and affective dimensions of empathy. The IRI perspective-taking subscale (seven items, score range 0-28) specifically assesses perceived attention to others’ points
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of view, with higher scores indicating greater perspective taking. Optimism was assessed using the Life Orientation Test-Revised (LOT-R) (21), a measure of optimistic versus pessimistic expectations about the future. Higher scores (six items, score range 0-24) indicate greater optimism/lower pessimism. Global satisfaction with life was assessed using the brief Satisfaction with Life Scale (SWLS; five items; score range 5-35) (22), with higher scores reflecting higher satisfaction.
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Resiliency. We evaluated self-efficacy for managing stressful life events using the General Self-Efficacy scale (GSE; 10 items, score range 10-40) (23). The GSE was developed to assess perceived self-efficacy as a predictor of coping with daily stressors
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and adapting to stressful events. Statistical Analysis
We characterized the enrolled sample using descriptive statistics. We also
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explored preliminary associations of select sample characteristics (age, gender, marital status, and years of palliative care experience) with pre-intervention scores and pre- to
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post-intervention change scores on the proposed outcome measures, using non-parametric tests (Spearman’s rho [rs] and independent samples Mann-Whitney U test). In an additional exploratory analysis, we evaluated pre- to post-intervention changes in our six proposed outcomes, reflecting core 3RP components relevant to palliative care providers:
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perceived stress, positive and negative affect, perspective taking, optimism, satisfaction with life, and self-efficacy. Sum scores were imputed for a small number of cases in which one to two items were missing from a scale. Changes in sum scores were evaluated
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for statistical significance with non-parametric Wilcoxon signed-rank tests, using both liberal (P < 0.10) and conservative (P < 0.05) critical values. Cohen’s d effect sizes were
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calculated, controlling for dependence between pre- and post-intervention mean scores. Results
Feasibility
Among 16 palliative care providers, 15 (93.8%) were available to participate and
enrolled in the study. Participant characteristics are noted in Table 1. There was no study attrition among enrollees. All participants attended at least four (80%) of the five sessions
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and completed the pre- and post-intervention study assessments. However, two participants (13.3%) were missing data for a subset of questionnaires within the preintervention assessment.
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Exploratory Associations Between Sample Characteristics and Baseline Outcomes
At pre-intervention, longer time working in palliative care was associated with greater self-efficacy (rs = 0.57, P = 0.04) whereas older age was associated with less
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perspective taking (rs = -0.66, P = 0.01). There were no other associations of age, gender, marital status or years of palliative care experience with the proposed outcome measures
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at P<0.05. Post-Intervention Outcomes
At post-intervention, participants showed a reduction in perceived stress (z = 2.17, P = 0.03; Cohen’s d = 0.65) and increase in perspective taking (z = -1.66, P =0.10;
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Cohen’s d = 0.67), with a medium effect size for change in each factor. Effect sizes for improvements in positive affect (z = -1.37, P = 0.17; Cohen’s d = 0.42), optimism (z = 1.44, P = 0.15; Cohen’s d = 0.36), satisfaction with life (z = -1.18, P = 0.24; Cohen’s d = -0.88, P = 0.38; Cohen’s d = 0.30) were small.
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0.29), and self-efficacy (z =
Reduction in negative affect was negligible (z =
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-0.71, P = 0.48; Cohen’s d = 0.19). Discussion
To our knowledge, this is the first study to examine a team-based resiliency
intervention for PCCs. We found that the intervention and its evaluation were feasible and acceptable. We were not powered to detect changes in our proposed outcomes from pre- to post-intervention. However, in our exploratory analyses, participants showed
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preliminary evidence of a reduction in perceived stress, and a trend toward an increase in perspective taking. There were small improvements in positive affect, perspective taking, optimism, and global life satisfaction; these findings were not found to be statistically
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significant. Taking into account our small sample size and non-randomized design, these findings must be replicated in a larger-scale, randomized controlled trial of this program with PCCs.
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Consistent with our findings, several studies have found that professional self-
care strategies are helpful in preventing burnout, compassion fatigue, and moral distress
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among health care providers (5,10,24,25). Additional factors that may improve professional well-being include regular appraisal of all aspects of work life; developing a network; increasing self-awareness in setting limits; and pursuing reflective practice (26,27). Similar to what has been found in other multidisciplinary team-based approaches
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(28), our intervention included strategies to improve the ability to empathize with others as well as sharing personal and professional sources of meaning. There are several factors that allowed for successful participation and completion
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of this intervention. First, it was supported and co-developed by the leadership of the palliative care service. Second, a needs assessment helped optimize the intervention for
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this specific team (9). Third, we focused on a skills-based approach, which empowered PCCs to use these skills not just in their personal lives but also in professional and clinical contexts.
There are several important limitations to bear in mind with regard to
interpretations of these findings. Because our study used a single-arm, pre-post design and recruited PCCs from a convenience sample of individuals, study findings are limited
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in generalizability. Additionally, it is possible that any observed changes could be attributable simply to the nature of the intervention (time spent away from usual duties, in a social space with colleagues) rather than its specific content. This concern can best be
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addressed by a future controlled trial. However, this study was designed to examine
study feasibility within an academic medical center, and our findings provide pilot data for future studies within palliative care teams. Second, we did not measure the
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sustainability of these effects beyond the immediate evaluation upon conclusion of the
study. Third, the intervention was supported and co-developed by the leadership of the
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palliative care service. This support was central to the successful application of the intervention; as such, although participation in the research component was optional, given the small size of the PC team, we cannot exclude the effect of the hierarchical organizational structure in the interpretation of the findings, and it is likely that the
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excellent attendance rate was impacted by the PC leadership’s messaging that attendance at the sessions should be considered part of job duties. Importantly, our needs assessment (9) was intended to mitigate that effect by tailoring the content of the intervention.
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Finally, we did not calculate the “lost revenues” that happened as a result of participation in the intervention. Having said that, prior studies have found that health care provider
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burnout is associated with lower quality of care, increased medical errors, and reduced work efficiency (1, 29–31)—all factors that lead to increased medical costs. As medicine moves into multidisciplinary team-based care, future interventions
should bear in mind several key issues that need to be substantiated through rigorous outcome measures. First, they would benefit from exploring the effects of this program on PCCs with varying age and varying degrees of experience. This is particularly
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important in light of our baseline data showing greater self-efficacy among seasoned clinicians. Second, in light of evidence suggesting that burnout may lead to physician turnover (8,32), particularly among younger physicians (33), future studies should
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examine the program’s impact on provider retention. Third, as this was a single-arm
study, it will be important to replicate these findings in larger cluster-based designs in other centers. Finally, future studies should examine the potential direct and indirect
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effects of this intervention on patient care. Specifically, they should examine how
improvements in provider resiliency allow for improvements in quality of care (e.g.,
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decreased medical errors, increased patient satisfaction, etc.). Conclusion
Our findings suggest that it is possible to develop a novel and feasible team-based intervention that utilizes elicitation of the relaxation response and cognitive behavioral
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strategies to promote resiliency for PCCs. This intervention is a step forward in providing palliative care teams with an effective program that can be easily integrated and has the potential to minimize provider stress. The effect of such an intervention on
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provider stress and patient level outcomes should be studied in a larger sample using a controlled trial methodology.
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Disclosures and Acknowledgments No competing financial interests exist. AU: WAS THERE ANY FUNDING FOR THIS STUDY?
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15. Vranceanu A-M, Merker VL, Plotkin SR, Park ER. The relaxation response resiliency program (3RP) in patients with neurofibromatosis 1, neurofibromatosis 2,
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and schwannomatosis: results from a pilot study. J Neurooncol 2014;120:103-109. 16. Jacquart J, Miller KM, Radossi A, et al. The effectiveness of a community-based mind-body group intervention for symptoms of depression and anxiety. Adv Mind
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27. Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med 2013;88:382– 389.
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28. Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: results from a randomized trial. Int J Stress Manag 2005;12:164.
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29. Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. J Clin Oncol 2012;30:1235–1241.
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30. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995–1000.
31. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358–367.
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32. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. Health Care Manage Rev 2001;26:7–19.
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33. Chopra SS, Sotile WM, Sotile MO. Physician burnout. JAMA 2004;291:633–633.
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Table 1. Demographic Characteristics of Palliative Care Clinicians (N=15) Mean ± SD 44 ± 8.1
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3 (20%) 12 (80%)
0 (0%) 15 (100%) 7 (47%) 7 (47%) 1 (7%)
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13 (87%) 1 (7%) 1 (7%)
5 (33%) 10 (67%)
6 (40%) 6 (40%) 2 (13%) 1 (7%) 1 (7%) 7 (47%) 7 (47%)
48 ± 8.4
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Age, yrs Gender Male Female Race White Asian Black or African American Ethnicity Hispanic Non-Hispanic Marital Status Never married Married/Living as if married Divorced/separated Children under 18 at home Yes No Role in PC Service Physician Nurse Practitioner Clinical Social Worker Registered Nurse How long in PC Service < 1 year 1-5 years 6-10 years Hours per week in PC Service
N (%)
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Demographic Characteristic
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S0885-3924(15)00577-1
DOI:
10.1016/j.jpainsymman.2015.10.013
Reference:
JPS 9002
To appear in:
Journal of Pain and Symptom Management
Received Date: 22 April 2015 Revised Date:
25 October 2015
Accepted Date: 28 October 2015
Please cite this article as: Mehta DH, Perez GK, Traeger L, Park ER, Goldman RE, Haime V, Chittenden EH, Denninger JW, Jackson VA, Building Resiliency in a Palliative Care Team: A Pilot Study, Journal of Pain and Symptom Management (2015), doi: 10.1016/j.jpainsymman.2015.10.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Brief Report
15-00253R1
Building Resiliency in a Palliative Care Team: A Pilot Study
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Darshan H. Mehta, MD, MPH, Giselle K. Perez, PhD, Lara Traeger, PhD, Elyse R. Park, PhD, MPH, Roberta E. Goldman, BS, Vivian Haime, BS, Eva H. Chittenden, MD, John
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W. Denninger, MD, PhD, and Vicki A. Jackson, MD, MPH
Benson-Henry Institute for Mind Body Medicine (D.H.M., E.R.P., R.E.G., V.H., J.W.D.),
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Mongan Institute for Health Policy (G.K.P., E.R.P.), Department of Psychiatry (L.T., J.W.D.), and Division of Palliative Medicine (E.H.C., V.A.J.), Massachusetts General Hospital, Boston, Massachusetts, USA
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Address correspondence to: Darshan H. Mehta, MD, MPH
Benson-Henry Institute for Mind Body Medicine
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Massachusetts General Hospital 151 Merrimac Street, 4th floor
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Boston, MA 02114, USA
Email: [email protected]
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Abstract Context. Palliative care clinicians (PCCs) are vulnerable to burnout as a result of
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chronic stress related to working with seriously ill patients. Burnout can lead to absenteeism, ineffective communication, medical errors, and job turnover. Interventions that promote better coping with stress are needed in this population.
SC
Objectives. This pilot study tested the feasibility of the Relaxation Response Resiliency Program for Palliative Care Clinicians (3RP-PCC), a program targeted to
major academic medical center.
M AN U
decrease stress and increase resiliency, in a multidisciplinary cohort of PCCs (N= 16) at a
Methods. A physician delivered the intervention over two months in five sessions (12 hours total). Data were collected the week before the program start and two months after completion. The main outcome was feasibility of the program. Changes in perceived
TE D
stress, positive and negative affect, perspective taking, optimism, satisfaction with life, and self-efficacy were examined using non-parametric statistical tests. Effect size was
EP
quantified using Cohen’s d.
Results. The intervention was feasible; all participants attended at least four of
AC C
the five sessions and there was no attrition. Following the intervention, participants showed reductions in perceived stress and improvements in perspective taking. Conclusion. Our findings suggest that a novel team-based resiliency intervention
based upon elicitation of the relaxation response was feasible and may help promote resiliency and protect against the negative consequences of stress for PCCs.
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Key Words: palliative care providers, health care provider wellness, stress, group
Running Title: Building Resiliency in a Palliative Care Team
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Accepted for publication: October 28, 2015.
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intervention, relaxation response, resiliency, mind-body therapies
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Introduction Health care providers are susceptible to the deleterious effects of stress (1,2),
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resulting in consequences such as decreased productivity because of absenteeism, and increased medical errors (3,4). In addition, stress may play a role in quality of care, as elevated stress may lead to poor communication and teamwork in health care settings
SC
(2,4,5). These negative consequences of stress have been demonstrated in palliative care clinicians (PCCs) as well (6). Not only do palliative care providers experience these
M AN U
stressors but also constant exposure to death and loss, time pressures and unpredictable schedules, increasing workloads, and competing role demands (7–9). Given these findings, there has been increased interest in the development of treatments aimed at promoting provider wellness and resiliency in palliative care. Resiliency is the capacity of a dynamic, malleable system to withstand challenges to its
TE D
stability, viability or development. Studies of group interventions to enhance resiliency in health care providers have found improvements in various domains of provider well-
EP
being (10,11). While these interventions have focused primarily on providers within a single discipline, palliative care services often are unique in their organizational structure
AC C
in that they consist of an interdisciplinary team, which often includes physicians, nurses, chaplains, psychologists, and social workers. Success of the palliative care service is contingent upon the cohesion and well-being of the team members, especially as caseloads and job demands have increased. However, to our knowledge, no intervention to date has explored the feasibility of mind-body resiliency programs among an interdisciplinary palliative care team.
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The Relaxation Response Resiliency Program (3RP) is a mind-body program designed to promote resiliency (12) and has been shown to decrease stress and increase resiliency in a broad range of populations (13–17). For the purposes of this study, we
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adapted the existing program based on our previous qualitative work to meet the specific stressors, challenges and training needs of PCCs (8) . We sought to test the feasibility of this adapted 3RP (12), among a team of palliative care providers. Additionally, we
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explored PCC characteristics that could be associated with higher levels of stress. Methods
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Participants
Our pilot study intervened with a multidisciplinary team of PCCs (physicians, nurse practitioners, nurses, and social workers) at a major academic medical center. PCCs were informed about the 3RP program through e-mails and informal presentations.
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Informed consent was obtained from each participant. There were no specific financial incentives provided to participants, except that their time was protected by the Division Chief. Staff members were expected to participate in the resiliency training sessions as
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part of job responsibilities, but were not required to participate in the research component and could opt out of the self-report questionnaires at their discretion. The primary
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inclusion criterion was full-time employment as a clinician in the Palliative Care Division. There were no exclusion criteria, and the Partners Human Research Committee approved the project. Assessment
Study data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted at Massachusetts General Hospital (MGH), and were de-identified.
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REDCap is a secure, web-based application designed to support data capture for research studies. Study data were collected at two time points: the week prior to the start of the program, and two months after completion of the program. Research assistants performed
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the data collection and analysis. Members of the Palliative Care Division leadership did not participate in data collection or analysis. Data were confidential, and not reviewed by the PC leadership at any time.
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Intervention
The 3RP for Palliative Care Clinicians (3RP-PCC) was adapted from the MGH
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Benson-Henry Institute for Mind Body Medicine (BHI) manualized 3RP program through an iterative process, taking into account the PC needs assessment (9) and discussions with PC leadership. The intervention consisted of an initial four-hour introductory session followed by four two-hour education sessions delivered in a group
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format by a physician from the MGH (BHI). The sessions were held every other week over a period of two months. Based on principles of cognitive behavioral therapy and positive psychology, the goals of the program included: 1) eliciting the relaxation
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response, 2) reducing overall stress reactivity, and 3) increasing connectedness to oneself and others. The 3RP-PCC incorporated a multimodal approach to introduce and reinforce
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new skills, including didactics, in-session activities, discussions and weekly practice assignments. Each education session began with the practice of a new exercise to elicit the relaxation response (e.g., breath awareness), followed by didactics and in-class exercises.
Outcome Measures
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We assessed feasibility as the proportion of full-time MGH PCCs who enrolled in the pilot trial, attended the intervention sessions, and completed the assessments. In addition, six constructs were selected to explore the three core components of the 3RP
was assessed at pre- and post-intervention.
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relaxation response: stress awareness, adaptive strategies, and resiliency. Each construct
Relaxation Response. We evaluated perceived stress using the well-validated
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Perceived Stress Scale (PSS; 10 items, score range 0-40) (18). The PSS assesses the
extent to which life has been stressful, uncontrollable or unmanageable during the past
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week, with higher scores indicating greater stress.
Stress Awareness. Participants’ affect during the past week was assessed with the Positive and Negative Affect Schedule (PANAS) (19). The PANAS comprises two 10item subscales (positive affect and negative affect, score ranges 10-50), with higher
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scores indicating more affect.
Adaptive Strategies. We administered the perspective-taking subscale of the Interpersonal Reactivity Index (IRI) (20). The 28-item IRI was developed to assess
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cognitive and affective dimensions of empathy. The IRI perspective-taking subscale (seven items, score range 0-28) specifically assesses perceived attention to others’ points
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of view, with higher scores indicating greater perspective taking. Optimism was assessed using the Life Orientation Test-Revised (LOT-R) (21), a measure of optimistic versus pessimistic expectations about the future. Higher scores (six items, score range 0-24) indicate greater optimism/lower pessimism. Global satisfaction with life was assessed using the brief Satisfaction with Life Scale (SWLS; five items; score range 5-35) (22), with higher scores reflecting higher satisfaction.
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Resiliency. We evaluated self-efficacy for managing stressful life events using the General Self-Efficacy scale (GSE; 10 items, score range 10-40) (23). The GSE was developed to assess perceived self-efficacy as a predictor of coping with daily stressors
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and adapting to stressful events. Statistical Analysis
We characterized the enrolled sample using descriptive statistics. We also
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explored preliminary associations of select sample characteristics (age, gender, marital status, and years of palliative care experience) with pre-intervention scores and pre- to
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post-intervention change scores on the proposed outcome measures, using non-parametric tests (Spearman’s rho [rs] and independent samples Mann-Whitney U test). In an additional exploratory analysis, we evaluated pre- to post-intervention changes in our six proposed outcomes, reflecting core 3RP components relevant to palliative care providers:
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perceived stress, positive and negative affect, perspective taking, optimism, satisfaction with life, and self-efficacy. Sum scores were imputed for a small number of cases in which one to two items were missing from a scale. Changes in sum scores were evaluated
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for statistical significance with non-parametric Wilcoxon signed-rank tests, using both liberal (P < 0.10) and conservative (P < 0.05) critical values. Cohen’s d effect sizes were
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calculated, controlling for dependence between pre- and post-intervention mean scores. Results
Feasibility
Among 16 palliative care providers, 15 (93.8%) were available to participate and
enrolled in the study. Participant characteristics are noted in Table 1. There was no study attrition among enrollees. All participants attended at least four (80%) of the five sessions
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and completed the pre- and post-intervention study assessments. However, two participants (13.3%) were missing data for a subset of questionnaires within the preintervention assessment.
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Exploratory Associations Between Sample Characteristics and Baseline Outcomes
At pre-intervention, longer time working in palliative care was associated with greater self-efficacy (rs = 0.57, P = 0.04) whereas older age was associated with less
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perspective taking (rs = -0.66, P = 0.01). There were no other associations of age, gender, marital status or years of palliative care experience with the proposed outcome measures
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at P<0.05. Post-Intervention Outcomes
At post-intervention, participants showed a reduction in perceived stress (z = 2.17, P = 0.03; Cohen’s d = 0.65) and increase in perspective taking (z = -1.66, P =0.10;
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Cohen’s d = 0.67), with a medium effect size for change in each factor. Effect sizes for improvements in positive affect (z = -1.37, P = 0.17; Cohen’s d = 0.42), optimism (z = 1.44, P = 0.15; Cohen’s d = 0.36), satisfaction with life (z = -1.18, P = 0.24; Cohen’s d = -0.88, P = 0.38; Cohen’s d = 0.30) were small.
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0.29), and self-efficacy (z =
Reduction in negative affect was negligible (z =
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-0.71, P = 0.48; Cohen’s d = 0.19). Discussion
To our knowledge, this is the first study to examine a team-based resiliency
intervention for PCCs. We found that the intervention and its evaluation were feasible and acceptable. We were not powered to detect changes in our proposed outcomes from pre- to post-intervention. However, in our exploratory analyses, participants showed
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preliminary evidence of a reduction in perceived stress, and a trend toward an increase in perspective taking. There were small improvements in positive affect, perspective taking, optimism, and global life satisfaction; these findings were not found to be statistically
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significant. Taking into account our small sample size and non-randomized design, these findings must be replicated in a larger-scale, randomized controlled trial of this program with PCCs.
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Consistent with our findings, several studies have found that professional self-
care strategies are helpful in preventing burnout, compassion fatigue, and moral distress
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among health care providers (5,10,24,25). Additional factors that may improve professional well-being include regular appraisal of all aspects of work life; developing a network; increasing self-awareness in setting limits; and pursuing reflective practice (26,27). Similar to what has been found in other multidisciplinary team-based approaches
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(28), our intervention included strategies to improve the ability to empathize with others as well as sharing personal and professional sources of meaning. There are several factors that allowed for successful participation and completion
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of this intervention. First, it was supported and co-developed by the leadership of the palliative care service. Second, a needs assessment helped optimize the intervention for
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this specific team (9). Third, we focused on a skills-based approach, which empowered PCCs to use these skills not just in their personal lives but also in professional and clinical contexts.
There are several important limitations to bear in mind with regard to
interpretations of these findings. Because our study used a single-arm, pre-post design and recruited PCCs from a convenience sample of individuals, study findings are limited
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in generalizability. Additionally, it is possible that any observed changes could be attributable simply to the nature of the intervention (time spent away from usual duties, in a social space with colleagues) rather than its specific content. This concern can best be
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addressed by a future controlled trial. However, this study was designed to examine
study feasibility within an academic medical center, and our findings provide pilot data for future studies within palliative care teams. Second, we did not measure the
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sustainability of these effects beyond the immediate evaluation upon conclusion of the
study. Third, the intervention was supported and co-developed by the leadership of the
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palliative care service. This support was central to the successful application of the intervention; as such, although participation in the research component was optional, given the small size of the PC team, we cannot exclude the effect of the hierarchical organizational structure in the interpretation of the findings, and it is likely that the
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excellent attendance rate was impacted by the PC leadership’s messaging that attendance at the sessions should be considered part of job duties. Importantly, our needs assessment (9) was intended to mitigate that effect by tailoring the content of the intervention.
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Finally, we did not calculate the “lost revenues” that happened as a result of participation in the intervention. Having said that, prior studies have found that health care provider
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burnout is associated with lower quality of care, increased medical errors, and reduced work efficiency (1, 29–31)—all factors that lead to increased medical costs. As medicine moves into multidisciplinary team-based care, future interventions
should bear in mind several key issues that need to be substantiated through rigorous outcome measures. First, they would benefit from exploring the effects of this program on PCCs with varying age and varying degrees of experience. This is particularly
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important in light of our baseline data showing greater self-efficacy among seasoned clinicians. Second, in light of evidence suggesting that burnout may lead to physician turnover (8,32), particularly among younger physicians (33), future studies should
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examine the program’s impact on provider retention. Third, as this was a single-arm
study, it will be important to replicate these findings in larger cluster-based designs in other centers. Finally, future studies should examine the potential direct and indirect
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effects of this intervention on patient care. Specifically, they should examine how
improvements in provider resiliency allow for improvements in quality of care (e.g.,
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decreased medical errors, increased patient satisfaction, etc.). Conclusion
Our findings suggest that it is possible to develop a novel and feasible team-based intervention that utilizes elicitation of the relaxation response and cognitive behavioral
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strategies to promote resiliency for PCCs. This intervention is a step forward in providing palliative care teams with an effective program that can be easily integrated and has the potential to minimize provider stress. The effect of such an intervention on
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provider stress and patient level outcomes should be studied in a larger sample using a controlled trial methodology.
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Disclosures and Acknowledgments No competing financial interests exist. AU: WAS THERE ANY FUNDING FOR THIS STUDY?
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Table 1. Demographic Characteristics of Palliative Care Clinicians (N=15) Mean ± SD 44 ± 8.1
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3 (20%) 12 (80%)
0 (0%) 15 (100%) 7 (47%) 7 (47%) 1 (7%)
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13 (87%) 1 (7%) 1 (7%)
5 (33%) 10 (67%)
6 (40%) 6 (40%) 2 (13%) 1 (7%) 1 (7%) 7 (47%) 7 (47%)
48 ± 8.4
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Age, yrs Gender Male Female Race White Asian Black or African American Ethnicity Hispanic Non-Hispanic Marital Status Never married Married/Living as if married Divorced/separated Children under 18 at home Yes No Role in PC Service Physician Nurse Practitioner Clinical Social Worker Registered Nurse How long in PC Service < 1 year 1-5 years 6-10 years Hours per week in PC Service
N (%)
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Demographic Characteristic
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