Life of Palliative Care Professionals during the COVID-19: History
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Contributor:
Adrià Campos i Arnal
,
Laura Galiana
,
Javier Sánchez-Ruiz
,
Noemí Sansó

The display of compassionate care by palliative care professionals is of the utmost importance to the patients, their families, and even to their own professional well-being. Lately and, especially due to the emergence of the COVID-19 pandemic, palliative care professionals have been subjected to greater pressures stemming from their work environment, organizational standpoint, and emotional sense of view. Not only have these factors made it harder for professionals to deliver compassionate care to their patients, but they have also decreased their overall well-being.

  • compassion
  • professional quality of life
  • palliative care
  • healthcare professionals
  • compassion satisfaction
  • burnout
  • compassion fatigue

1. Compassionate Care, Compassion, and Professional Quality of Life

Caring made from compassion, also known as compassionate care, is a fundamental dimension of the nursing profession and a vital component of high-quality care [1]. This includes taking responsibility for the other’s vulnerability and experiencing the emotional reactions that take place during the interactions with the other person [2]. According to the existing literature, compassionate care is a subjective experience that is based on a quality relationship, takes into account that the person providing care also connects with the other’s necessities, stems from the common human experience and the need to preserve the subject’s integrity while acknowledging their suffering and vulnerability and, finally, and also includes the ability to emotionally connect with the patient and different interpersonal capabilities [3][4][5][6]. Thus, care with/from compassion is a key component to the achievement of high-quality care.
Recently, compassion has been defined as the sensitivity to perceive suffering both in others and ourselves with the purpose of trying to prevent it or, at least, subdue it [7][8]. Moreover, it has also been defined as a response that aims to buffer people’s suffering and needs via the conceptualization of suffering as a common human experience and different relational tasks [9][10][11]. Compassion is also considered to be one of the six main elements that are vital to care provision [12]. Apart from this, other authors suggest that compassionate care requires the person to adopt an empathic attitude, which includes the ability to identify the other’s suffering and the capacity to attune with the other [10].
Different studies have underscored the essential role that compassion has in the professional quality of life of healthcare professionals [13][14] and that receiving compassionate care is one of the most important necessities for patients while, at the same time, rarely satisfied [15]. Compassion is associated with the professionals’ quality of life [16], the health of healthcare workers [17], and their well-being [18]. For example, self-compassion, which is the ability to be compassionate with oneself, has been found to play a protective role in burnout and compassion fatigue [14]. Furthermore, compassion and the well-being of healthcare workers have also been related [19][20].
Professional quality of life can be defined as the way a person feels about his/her job as a care provider [21]. This encompasses both the positive and negative aspects that may influence life’s quality and comprise different elements, such as burnout, compassion fatigue, and compassion satisfaction [21]. Professional quality of life is of paramount importance to palliative care professionals, among other factors like providing quality service and satisfying the patient’s needs [22][23][24][25]. The development of burnout is also associated with a worsening in the care provided by professionals, which, in turn, increases patients’ dissatisfaction [26] and leads to an increase in the number of medical errors [24]. As a result of burnout, in last place, three processes have been known to take place: emotional exhaustion, depersonalization, and a diminished perception of self-realization [26][27].
The definition of burnout provided by Maslach [28] conceptualizes it as a prolonged response to chronic emotional and interpersonal stressors at work that mainly comprise emotional exhaustion, cynicism, and/or depersonalization and a reduction in personal achievements. On the other hand, the term compassion fatigue is used to refer to the stress, exhaustion, or negative effect that stems from the relationship between professionals and patients [29][30]. Previous scientific literature points out that compassion fatigue carries along an increase in the difficulty to providing care and that it can be seen in changes throughout different areas of life, such as the social, physical, emotional, spiritual, and intellectual [29]. Nevertheless, different definitions of compassion fatigue produce alternative proposals for its dimensions. For example, Hotchkiss [31] went on to say that compassion fatigue is made up of two dimensions, those being secondary traumatic stress and exhaustion. As a consequence of compassion fatigue, professionals can feel drained of energy, indifferent toward their patients, apathetic, a decrease in work performance, an increase in thoughts about resigning, etc. [29][32]. As suggested by the model proposed by Stamm [21] for the professional quality of life, apart from its negative dimensions (i.e., burnout and compassion fatigue), there is at least one positive aspect: compassion satisfaction. Compassion satisfaction is the ability to receive gratification from providing care for others; thus, it can be conceived as the degree of joy that results from the experience of helping others while in healthcare [30][31]. Stamm [21] suggested that compassion satisfaction can be thought of as the positive part of caring for others.
These definitions show that professional quality of life is closely related to compassion. Moreover, evidence supports this fact. For example, professional quality of life has been proven to correlate positively with compassion satisfaction and to prevent the effects of compassion fatigue, exhaustion, or burnout [14]. Recent studies, such as the one by Mesquita-García et al. [13], have pointed out that for healthcare professionals, self-compassion relates both to an increase in the professional quality of life and a decrease in the perceived risk of exhaustion and secondary traumatic stress. Furthermore, self-compassion, as laid out by Galiana et al. [14], has a protective role against the development of exhaustion and compassion fatigue. Finally, self-compassion has also been related to other protective factors such as self-care and coping with death skills [14], variables previously related to professional quality of life [30][33][34].

2. Well-Being and Its Relation with Compassionate Care

Well-being has a myriad of diverse definitions [35], making it one of the most debated terms across scientific literature. Nevertheless, these definitions could be grouped into two main groups, those being hedonic and eudaimonic well-being. For example, Diener’s approximation [36] is more akin to the hedonic conceptualization, which is centered around subjective well-being. These types of definitions focus on the person’s positive affect and hedonic pleasure [37], as hedonic well-being is usually thought of as experiencing great levels of positive affect and pleasure while also experiencing low levels of negative affect. On the other hand, eudaimonic approximation suggests that well-being is not the result of external factors but rather the process of accomplishing and fulfilling one’s potential and life projects [38].
In the context of healthcare professionals, the study of well-being has gained importance over the last few years. As it has been previously noted, healthcare workers are specifically exposed to stress in their job and, especially when dealing with patients [29]. In the case of palliative care professionals, their job specifically involves dealing with stress-inducing situations that can affect the worker’s health and well-being on a daily basis [39]. The literature has shown that compassionate qualities/abilities are essential to the well-being of professionals in palliative healthcare [14][40]. Moreover, it has been pointed out that professional quality of life and compassionate care are closely related to the workers’ well-being as greater self-care in professionals translates into more compassionate care for patients and higher perceived levels of happiness for workers [14]. For example, two recent studies have proved this relationship between professional quality of life and well-being [14][40]. In the same direction, Lizano [41] showed that there is a negative impact on the professional’s well-being due to exhaustion. Other investigations have suggested that the professional quality of life can explain 60% of the variance in nurse’s well-being [40]. As shown by Sansó et al. [40], a decrease in the professional’s quality of life can have far-reaching consequences for their well-being. Based on these data, the professional’s quality of life seems to be a crucial variable when it comes to the well-being of healthcare professionals [40][42]. In this sense, greater levels of compassion satisfaction and lower levels of exhaustion can predict a higher well-being. This evidence is acknowledged in different studies in which burnout and compassion fatigue have been shown to have a negative impact on the well-being of palliative care workers [33][37][43].

3. Variables Related to Compassionate Care and Well-Being

In relation to compassionate care, some studies have presented evidence of its relationships with sociodemographic variables such as age, which, for example, has been related to a greater risk of exhaustion [44][45]. Indeed, age and working experience are associated with a greater risk of burnout [27]. This is because those with fewer years of experience tend to stress out while, at the same time, have fewer coping strategies, which leads to a greater risk of exhaustion [46][47][48]. However, some studies have not found these previously cited relationships between age, working experience, and exhaustion [49][50]. As it stands, there is no consensus in the present literature. When it comes to gender, many studies have put forward that being a woman is related to the professional quality of life [51], showing that women experience more exhaustion [25][52][53] and compassion fatigue [54][55]. Nevertheless, other studies have found greater levels of deterioration in men [45][52], and some others have not found a relationship between gender and professional quality of life at all [49][50]. Other variables that have been related to compassionate care are the type of profession and the type of unit one works in. For example, one study found that exhaustion was more prevalent in social workers [56]. Others have pointed out that palliative care professionals who work by commuting to the patient’s home are at a greater risk of developing psychopathological symptoms than those who provide care in a hospital setting [42][56]. On the other hand, research shows that working fewer hours, having clinical supervision, and being young and a woman are associated with a larger level of well-being [17][37][57]. Be that as it may, other studies suggest that there are no significant differences between genders (men/women) when talking about well-being in palliative care professionals [58].
The available resources, the existent organization, and the different demands associated with the job also have an impact on the professional quality of life of palliative care workers. According to some articles, psychological and emotional demands have an impact on the well-being of healthcare professionals [59] and the professional quality of life [36] and can lead to burnout [60][61]. In this same sense, other studies have demonstrated that performing palliative healthcare is a highly demanding activity [43][62]. Thus, it is possible that these dire working conditions could impact the professional quality of life and the self-care abilities of palliative care workers. Specifically, the scientific literature evinces that the specific work/task demands related to it, the presence of illness, and the suffering and death of patients and their families are variables highly related to the exhaustion levels in palliative care professionals [61][63][64]. Furthermore, it has also been shown that excessive job demands, whether from supervisors or organizations, are also related to exhaustion and/or burnout [47][65]. Additionally, plenty of studies have proved that greater working hours [66], too many administrative tasks [64], the working environment, administrative support, and the availability of support services and relationships with colleagues [47] are also related to burnout levels. In the case of palliative care professionals, it is common for them to work in small organizations, for many hours, or work on the weekends, which are factors related to greater exhaustion [48].
Other highly relevant variables that are related to compassionate care and the palliative care professionals’ well-being are the internal resources of the worker. Based on the quantity and quality of the self-care abilities of each professional, they will be able to provide compassionate care and cope with exhaustion, compassion fatigue, and compassion satisfaction accordingly. In this sense, these abilities, in turn, end up having an effect on the professional’s well-being. Resources such as resilience [67], self-care [68], and physical activity [69] can play a vital role in dealing with job demands, with them being related to lower exhaustion. According to Hotchkiss [31], healthcare professionals who use frequent and multiple self-care strategies have a greater professional quality of life. Every type of self-care (physical, psychological, or social) can be considered a strong protective factor against burnout [30], with the use of supportive relationships [70] and conscient relaxation [31][69] being of great importance. In this sense, mindfulness has been related to lower burnout [71]. In fact, mindfulness has also been related to compassion as, via the training of compassion, there is an increase in self-consciousness, the ability to regulate one’s own emotions, and resilience [72]. Moreover, different studies propose that carrying out self-care techniques promotes an increase in well-being [31][33][73]. Based on this, the practice of meditation and different self-care activities that increase compassion, self-compassion, and emotional regulation are related to lower burnout [42]. Finally, the professional’s ability to cope with death is also a key variable in the informed professional quality of life. One example of this is the study carried out by Sansó et al. [30], in which it was evinced that this capacity is negatively related to burnout and compassion fatigue while having a positive relationship with compassion satisfaction. These results have been replicated in other more recent studies, such as Galiana et al. [14].

4. COVID-19 Pandemic and Its Impact on Palliative Care Professionals

The COVID-19 pandemic has had a remarkable impact on healthcare workers [70][74] at many levels: emotionally, in their job routine and demands, their workload, etc. [70][75][76]. In a study carried out by Nestor et al. [77], it was shown that the heaviest load and demands were placed on those professionals whose jobs consisted of providing prolonged, direct, and intimate care to the patient. Other identified factors of COVID-19 that heavily affected the professionals’ quality of life have been the shortages of equipment and personnel, the great risk of infection, the minimum reinforcement, the lack of equipment, isolation, and a lack of support systems [78]. Moreover, the professionals exposed to these factors had their workloads enlarged, were put in vulnerable positions, and suffered from burnout, distress [70], anxiety, lack of sleep, and depression [53].
In general, healthcare workers have been suffering from increased pressure since the start of the COVID-19 pandemic. That is partly due to the fact that these workers had to remain in direct contact with different coronavirus cases, which made them more susceptible to infection and developing mental health problems [53][79]. In fact, the majority of them became infected during the pandemic, and some of them even died [80][81]. Being preoccupied with their coworkers’ and their own health and seeing in their own eyes the death of some of them can increase distress and exhaustion/burnout [82]. Taking this into account, COVID-19 brought about an increase in healthcare workers’ anxiety, distress, burnout [70][77][83], and depression rates [53][84]. In this sense, Lluch et al. [51] pointed out that professionals’ vulnerability to burnout and compassion fatigue has increased due to the cropping up of COVID-19. Furthermore, COVID-19 has also affected palliative care workers’ mental health [85].

This entry is adapted from the peer-reviewed paper 10.3390/healthcare12010004

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