key: cord-0910902-zunyofns authors: Swan, Amy; Azhar, Ahsan; Anderson, Aimee E.; Williams, Janet L.; Liu, Diane; Bruera, Eduardo title: Empowering the Health and Well-Being of the Palliative Care Workforce: Evaluation of a Weekly Self Care Checklist date: 2020-09-23 journal: J Pain Symptom Manage DOI: 10.1016/j.jpainsymman.2020.09.024 sha: 5ace44723476e804ada4a27bdc95cf06c84f8c64 doc_id: 910902 cord_uid: zunyofns BACKGROUND: Workplace interventions are needed to prevent burnout and support the well-being of the palliative care workforce. INTERVENTION: We implemented a 13-item self care checklist, included in a handbook on palliative care carried in the lab coat of all clinical personnel, to remind them to care for their own well-being. MEASURES: We conducted a survey of all palliative care clinical staff to evaluate the usefulness and feasibility of checklist items and the checklist itself. We collected demographics, perceptions of professional satisfaction and burnout, and qualitative feedback aimed at improving the checklist. OUTCOMES: Of 39 personnel contacted, 32 (82%) responded. Most (20; 62%) found the checklist useful. Exercise was the most highly ranked item, while Watching Visual Arts was the lowest ranked item. CONCLUSIONS: and Lessons Learned: Numerous opportunities were identified to improve the checklist and facilitate achievement of checklist items. Survey data will be used in the next checklist version. Burnout is a multi-faceted occupational syndrome characterized by depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment, with severe consequences for both the worker and the workplace. (1) (2) (3) (4) Physician burnout has reached epidemic levels in the United States, and some of the highest levels are seen in Palliative Medicine specialists (5) (6) (7) (8) who face unique stressors, including constant exposure to death and dying, and high levels of distress experienced by patients and their family members. (9) (10) (11) (12) (13) These problems are exacerbated by the rapid growth in the palliative care profession, driven by increasing demands for symptom relief, improved treatments that prolong the lives of patients with serious illnesses like cancer, and higher levels of serious and chronic disease in the aging population. (14) (15) (16) In healthcare, burnout is associated with increases in depression, medical errors, chemical coping, suicidal ideation, poor physical health, and many other adverse effects for personnel. (2, 3, (17) (18) (19) (20) (21) (22) (23) Burnout hurts organizations and the healthcare system, as personnel increase their rates of absenteeism and leave their jobs through career changes or early retirement. (24) Attrition from the palliative care workforce is particularly dire in a time when demand exceeds supply. Thus, the palliative care workforce needs validated strategies for combatting burnout and increasing clinician engagement and wellness. The Department of Palliative, Rehabilitation, and Integrative Medicine (PRIM) at the University of Texas MD Anderson Cancer Center implements numerous evidence-based interventions aimed at increasing wellness and engagement among its personnel. Many interventions targeting burnout in the palliative care workforce have been explored; (for example, (25) (26) (27) (28) (29) ) most have focused on increasing personal resiliency, though evidence suggests that organizational changes are also necessary to combat burnout. (30) (31) (32) In 2015, we introduced a Weekly Self Care Checklist ( Figure 1 ) -a one-page, 13-item list of evidence-based items, contained in a palliative care handbook that is distributed to all PRIM clinical personnel and carried in the lab coat pocket at all times. Adherence to checklist items is highly endorsed by departmental leadership and reinforced by its inclusion in the handbook as an organizational support component. Anecdotal feedback from personnel has suggested the checklist is useful. However, the frequency which with personnel adhere to the checklist items, their impressions of these items, J o u r n a l P r e -p r o o f and the relationship between adherence and professional satisfaction remain unknown. Moreover, both stressors in the work environment and available interventions for relieving stress and burnout have evolved since its original inception. We therefore conducted a survey to explore personnel use and perception of the checklist, suggestions for improvement, and any associations with job satisfaction, burnout, and general well-being. The long-term goal of this study is to improve the checklist to maximize its usefulness and feasibility, and identify opportunities to re-engineer the workplace to facilitate checklist adherence and well-being. The "SCPC Departmental Checklists" handbook is distributed to all palliative care clinicians in the department. Each page of the handbook's 11 checklists details vital information on standard operating procedures all clinicians should use in their practice. Included among these is the Weekly Self Care Checklist, a self-care checklist to remind clinicians to take care of their wellbeing. Its inclusion among the clinical SOPs is intended to stress that self-care is considered a cornerstone of good clinical practice. The checklist utilizes evidence-based practices for increasing health and well-being (33) (34) (35) (36) (37) (38) (39) (40) and reducing stress and burnout (35, 36, 39, (41) (42) (43) (44) (45) (46) (47) . See Figure 1 for the checklist. Survey: We designed a customized survey to better understand respondents' use and perception of the Self Care Checklist. We collected basic demographic information, including age range, gender, and profession. We asked respondents about their perception of the usefulness of the Self Care Checklist as a whole and each individual checklist item, with possible responses including Very Useful, Useful, Neither Useful nor Useless, Useless, and Very Useless. For any checklist item that was deemed Neither Useful nor Useless, Useless, or Very Useless, respondents were asked to indicate if the item should be retained, discarded, or modified in future versions of the checklist; respondents were also given the opportunity to describe potential modifications for any items that they indicated should be modified. To generate a more complete picture of the perceived usefulness of checklist items, respondents were also asked to rank all checklist items in order from most useful to least useful. To better understand the feasibility of each checklist item, we asked respondents how often they were able to achieve each checklist item with Every Week, Most Weeks, Occasionally, and Never as possible answers. The primary purpose of the Self Care Checklist is to support the health, well-being, and engagement of clinicians. Therefore, we included two questions that have been previously validated as useful for assessing burnout, (48) in addition to asking respondents about their professional satisfaction. Table 1 . When asked to rank the items in order of usefulness, "Exercise Most Days" was the item ranked highest by participants, while "Watched Visual Arts" was ranked last ( Table 1 ). The Visual Arts item was also least likely to be rated as Useful or Very Useful by participants. Interestingly, the items that were rated Useful or Very Useful by the most participants did not take the top spots in the ranking activity; for example, "Met with friends in person" was rated Useful or Very Useful by 30 participants (94%) but ranked fourth, and "Achieved at Least One Personal Self Care Goal" was perceived as Useful or Very Useful by 90 participants (91%), but was ranked tenth. These disparities reveal potential differences in the way participants view the checklist items when asked to think about them in different ways. No significant differences in perception were identified by profession, gender, or age. The frequency of use of checklist items reveals that the items perceived as most useful are not necessarily those that participants were able to achieve on a regular basis. For example, while participants ranked Exercise Most Days as the most useful item, with 78% perceiving it as Useful or Very Useful, only 18 (56%) reported that they achieved this item each week or most weeks. Overall, there is considerable discrepancy between participants' perceived usefulness and their reported frequency of achievement for each item. No significant differences in use were identified by profession, gender, or age. We next asked how many items respondents were able to complete most weeks ( Table 2 ). All were able to complete at least one checklist item regularly. Encouragingly, 9 participants (28%) reported that they achieved at least twelve of the thirteen items every week or most weeks. In fact, 20 participants (62%) reported achieving eight or more items every week or most weeks, a frequency of achievement deemed "complete success" in the checklist instructions. or Every Day. This question from the Maslach Burnout Inventory (MBI) has been previously found to correlate with the MBI's Emotional Exhaustion dimension. We also asked participants to rate the frequency with which they felt "I have become more callous toward people since I took this job," an MBI item that has been found to correlate with the MBI's Depersonalization dimension. In contrast to the burnout question, only one participant (3.2%) indicated feeling this way a few times a week; none chose once a week or every day. Use of the Self Care Checklist by Clinicians: We are encouraged that only 25% of participants reported feeling burned out once a week or more, given the high rates of burnout reported for palliative care workers (8) and the U.S. physician workforce (6,7). However, our goal is to achieve a fully engaged workforce. A major concern raised in recent studies of workforce engagement is that self-care strategies that focus only on employee resilience cannot be effective without organizational strategies to promote well-being and prevent burnout. Furthermore, personnel sometimes feel that resiliency strategies that rely on actively changing their behavior are burdensome, shifting additional responsibility to employees who may already be feeling overworked or overwhelmed. It should be noted that the checklist is only one of many interventions used by our department, encompassing both organizational (such as shared governance models and open door policies) and resilience strategies. Moreover, while the checklist is discussed and endorsed by departmental leadership in e-mail messages, at meetings, and in poster format (placed in clinical and conference spaces), its use is not actively enforced. Instead, to provide organizational-level support, we sought to make the checklist a part of our standard clinical procedures by including it in the Departmental Checklist Handbook, along with our standard clinical operating procedures. Carried always in the lab coat, it is easily accessible and includes items that personnel are likely to find enjoyable, such as enjoying art and movies, and spending time with friends and family. We were encouraged that more than half of respondents consulted the checklist frequently and expressed a perception of usefulness of the checklist overall. We are optimistic that by understanding the differences in perceived usefulness of the individual checklist items, as well as the frequency that personnel were able to J o u r n a l P r e -p r o o f achieve the items, we have been able to propose an improved Checklist 2.0 ( Figure 2 ) that is useful and feasible for an even greater proportion of our personnel, and can be modified for use in other healthcare settings. A striking example of the gap between perceived utility and achievement is the "Exercise Most Days" item. It was ranked #1 overall by participants, and 78% felt it was Useful or Very Useful. However, only 56% reported achievement of this item weekly or in most weeks. This is a prime example of a self-care item that most respondents feel they should do, but for one reason or another, do not achieve, perhaps reflecting lack of time, energy, or space for exercise. This presents an opportunity for an organizational effort on the part of the department to engineer the workplace and help personnel achieve their exercise goal. For example, personnel could be encouraged to log their steps by providing them with a pedometer. Signage in the workplace reminding personnel of the availability of exercise options to use on their breaks (such as the employee gym, indoor and outdoor walking trails) or work habits encouraging movement, such as visiting offices rather than using telephone or e-mail, may also be helpful. Opportunities for Checklist Improvement: The "Visual Arts" item was ranked last, perceived as useful by the least number of participants, and was the item to which the fewest adhered to most weeks or weekly. However, some useful qualitative feedback on this item suggested that it may instead be modified to allow users to participate in or view a setting that speaks to them personally, such as spending time in nature or participating in/viewing/listening to their preferred art form (like music or dance). We have now combined the item with other art forms ( Figure 2 ). There was also useful feedback on wording used for the items; for example, replacing the word "junk" as it is highly subjective for art forms such as literature and cinema. This is consistent with a study suggesting that reading genre fiction is as effective as reading classical works in bibliotherapy for mental health. (49) Checklist items in times of social distancing: It was striking that meeting with family and friends in person were highly rated in terms of usefulness (ranked 3rd and 4th, respectively, and third and first most likely to be deemed useful), and were also items that were achieved frequently by the second highest and highest proportion. Meeting with family outside their household could be challenging for many of our personnel, who have come to work at PRIM in Houston, TX, from around the world; in fact, this concern was voiced by one of the respondents, J o u r n a l P r e -p r o o f as the current checklist item qualifies meeting with family and friends as "in person." The COVID-19 crisis struck after the completion of the survey, and at the time of writing this manuscript personnel were presented with new challenges for meeting with family and friends. However, it has also presented a new opportunity with the new popularity and refinement of videoconferencing tools that can allow meaningful connections across distance (Figure 2 ). Lessons Learned: Many personnel find the checklist useful, and most achieve at least nine items most weeks. This has encouraged us to continue its use and generate an improved version. The survey successfully identified checklist items that are working well and items that can be improved, and suggested areas where we can facilitate participation in more highly valued items through workplace engineering. We will continue to modify and evaluate the checklist to optimize employee engagement and well-being. The improved checklist can be adapted to any healthcare setting or profession. 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