Artículos
Development of a
cognitive-existential intervention to decrease compassion fatigue in formal
caregivers
Desarrollo
de una intervención cognitiva-existencial para disminuir la fatiga por
compasión en cuidadores formales
Paula Hidalgo-Andrade paula.hidalgo@udla.edu.ec
Universidad de Las
Americas, Ecuador
Silvia Martínez-Rodríguez silvia.martinez@deusto.es
Universidad de Deusto, España
Development
of a cognitive-existential intervention to decrease compassion fatigue in
formal caregivers
Interdisciplinaria, vol. 37,
núm. 2, 2020
Centro
Interamericano de Investigaciones Psicológicas y Ciencias Afines
Los autores conservan la titularidad sobre sus
trabajos y ceden a la revista Interdisciplinaria el derecho a la primera
publicación de cada uno de sus artículos.
Recepción: 28 Enero 2019
Aprobación: 08 Septiembre 2020
Abstract:
Palliative care aims to improve the quality of life of patients
with chronic and advanced illnesses and their families. This requires a
multidisciplinary approach from formal caregivers. Though caring for others
could be rewarding and this satisfaction relates to higher work engagement and
resiliency, formal caregivers of palliative care patients may develop
compassion fatigue due to the nature of their work. This fatigue affects
caregivers, their interpersonal relationships, and the quality of care they
provide.
Supporting formal caregivers and improving communication plays a vital role. Considering the efficacy of the existential interventions in other populations, and the lack of testing of these interventions on formal caregivers of palliative care teams, this article aims to describe the design and development of an eight-session cognitive-existential group-based psychoeducational intervention to reduce compassion fatigue and to promote self-care and satisfaction of formal caregivers of palliative care patients in a Latin American context. The intervention used Frankl’s Logotherapy and Ellis’ rational emotive therapy as the theoretical framework and included the necessities of formal caregivers in this specific setting.
As a result, this
article presents the theoretical development of the intervention and its
structure, as well as the objectives and specific content of each session.
Empirical research, reported elsewhere, has proven its long-term effectiveness
in reducing the compassion fatigue of this population. This makes it a
replicable intervention with promising results. Future studies need to continue
its evaluation and include professionals in other settings outside palliative
care.
Keywords:
caregivers,
compassion fatigue, self-care, cognitive-existential psychology, intervention..
Resumen: Los cuidados paliativos
buscan mejorar la calidad de vida de las personas con enfermedades crónicas y
avanzadas, y la de sus familiares. Este tipo de cuidados requiere un enfoque
multidisciplinario desde un equipo de cuidadores formales, trabajadores o
voluntarios asociados a un sistema de servicios estructurado que brindan
cuidados y atención. Este equipo puede incluir voluntarios y especialistas en
medicina, enfermería, trabajo social, psicología, cuidado espiritual,
nutrición, entre otros. Todos los involucrados deben tener entrenamiento
específico y una actitud humanizada para lidiar no solo con los síntomas
físicos de las enfermedades sino con las necesidades psicológicas y
espirituales que los pacientes y sus familias puedan tener. Por esto, trabajar
en cuidados paliativos demanda conocimiento, autocuidado y fortaleza emocional
y psicológica. A pesar de que cuidar de otras personas puede ser gratificante y
esta satisfacción se relaciona con el compromiso laboral (engagement) y
la resiliencia, los cuidadores formales de personas con necesidades paliativas
también pueden desarrollar fatiga por compasión debido a la naturaleza de su
labor. Esta fatiga afecta a sus relaciones interpersonales y a la calidad del
cuidado que brindan. Desde una perspectiva organizacional, el apoyar a los
cuidadores formales es vital. Investigaciones muestran que el respeto, el
sentido y el perdón pueden influir en la satisfacción laboral y en el
desempeño. La literatura contiene algunas intervenciones que procuran promover
estas y otras características para aliviar la posible carga del cuidador; sin
embargo, es difícil analizar y replicar dichas intervenciones debido a una
falta de rigurosidad en el reporte de sus procedimientos, su desarrollo y su
efectividad. Las intervenciones centradas en el sentido se han mostrado
efectivas en promover la satisfacción en pacientes y familiares de personas con
necesidades paliativas. No obstante, a la fecha de realización de este estudio,
solo una intervención reportaba el uso del enfoque existencial con cuidadores
formales (enfermeras de cuidados paliativos). Considerando la efectividad de
las intervenciones de base existencial en otras poblaciones y la ausencia de
investigación sobre estas en cuidadores formales de equipos de cuidados
paliativos, este artículo tiene como objetivo describir el diseño y desarrollo
de una intervención psicoeducativa grupal de tipo cognitivo-existencial de ocho
sesiones creada para reducir la fatiga por compasión y promover el autocuidado
y la satisfacción de los cuidadores formales de pacientes en cuidados
paliativos en un contexto latinoamericano. Primero, considerando la literatura
existente y las situaciones específicas con las que lidian los cuidadores,
inicialmente utilizamos la logoterapia de Viktor Frankl como la base teórica de
la intervención. De esta manera buscamos abordar los problemas existenciales y
las situaciones que los cuidadores enfrentan diariamente. Después de este
desarrollo teórico, dos expertos en terapia existencial revisaron la
intervención propuesta. Como resultado, se incorporaron técnicas de la terapia
racional emotiva de Albert Ellis. Además, también se tuvo en cuenta un estudio
cualitativo que informaba sobre las necesidades de los cuidadores formales en
este contexto específico con respecto a su fatiga y satisfacción en el trabajo.
De esta manera, se adaptó la versión final de la intervención para satisfacer
las necesidades específicas de la población objetivo. Como resultado, este
artículo presenta el desarrollo teórico de la intervención y la construcción de
su estructura, así como los objetivos y el contenido de cada una de las
sesiones. Tanto el material para los participantes como el manual del
facilitador están disponibles mediante el contacto con el autor responsable de
la correspondencia. Investigación empírica, publicada en otro lugar, ha
demostrado la eficacia a largo plazo de esta intervención para reducir la
fatiga por compasión. Esto la convierte en una intervención replicable con
resultados prometedores. Futuros estudios podrían continuar su evaluación con
cuidadores en entornos fuera de los cuidados paliativos.
Palabras clave: cuidadores, fatiga por compasión, autocuidado, psicología
cognitiva-existencial, intervención..
Introduction
Palliative care is a multidisciplinary approach that aims to
improve “the quality of life of patients and their relatives facing problems
associated with life-threatening illness (…) [by] early identification and
impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual” (World Health
Organization, 2002, p. 84). The people who provide this assistance and who
are associated with a formal service system, either as volunteers or as paid
workers, are known as formal
caregivers. They can work independently, in institutions or
organizations, and at the patient's home (Caregiver
Alliance, 2014). These caregivers should have specialized training and a
humanized attitude to support the patients and their relatives. Formal
caregivers must deal not only with the physical symptoms of the illnesses but
also be able to provide psychological and spiritual support so that patients
live with autonomy and dignity until their death (World Health Organization, 2018).
Caring for others could have positive consequences for
caregivers. Compassion satisfaction is the term used to describe the joy that
comes from working to help others or the pleasure that comes from working with
people who need care (Stamm, 2010).
Caregivers with greater satisfaction show larger commitment, effort, positive
affection, and dedication; communicate difficult issues better; provide more
appropriate information to patients; feel more effective and secure in their
interpersonal relationship with the patients; and perceive their work with
purpose (Hernández-Vargas, Llorens-Gumbau,
& Rodríguez-Sánchez, 2014).
On the other hand, the emotional and psychological burden of
caregiving is also associated with negative repercussions on the health of the
caregiver and the erosion of their relationship with their patients (Benito, Arranz, & Cancio, 2011). The
burden can also result in low productivity, low motivation to care, and
problems in the caregiver's interpersonal relationships (Atukunda, Memiah, & Sibongile Shumba, 2013).
In turn, this can negatively influence the patient’s adjustment to the changes
that occur during the progress of his/her illness (Astudillo & Salinas Martín, 2011).
There is evidence that formal caregivers experience a descent in
their quality of life due to the frequent exposure to patient’s health
deterioration, their inevitable death, and the grieving process of patients and
their families (Failde, Carballo Bouzas,
Lameiras Fernández, & Rodríguez Castro, 2013). Other personal
circumstances also affect the quality of life of caregivers and could be more
prevalent than those work-related (Cohen-Katz
et al., 2005). Even though working in palliative care constantly shows
formal caregivers their vulnerability as human beings, they may neglect their
own care to focus on the needs of others (Figley,
2002).
This deterioration in the quality of life of formal caregivers
is known as compassion fatigue. According to Joinson (1992), Doris Chace, a crisis
counselor, first used the term compassion fatigue and described it as a form of
burnout that specifically affects people in care professions. Compassion
fatigue is often referred to in the literature as secondary traumatic stress or
vicarious trauma (Stamm, 2010),
although there are differences between the concepts (Baird & Kracen, 2006). Burnout is
another term that is often used interchangeably with compassion fatigue (Sorenson, Bolick, Wright, & Hamilton,
2016) even though it is a different construct (Alkema, Linton, & Davies, 2008; Slocum-Gori, Hemsworth, Chan, Carson, &
Kazanjian, 2011) with different symptomatology (Figley, 2002; Maslach, Schaufeli, & Leiter, 2001).
For example, contrary to burnout, compassion fatigue can appear suddenly, it
relates to how work affects the person caring, and it can cause indifferent
attitudes or excessive involvement with the patients (Anewalt, 2009). Compassion fatigue also
reduces the ability and interest to bear the suffering of others, but it is
associated with a greater sense of hopelessness, confusion, and isolation than
burnout (Figley, 2002). Hence, the
term compassion fatigue should be used when discussing the emotional sequel
left by caring for patients and their families (Aycock & Boyle, 2009). In this
article, compassion fatigue is understood as a type of secondary traumatic
stress that appears from the cost of caring for those who suffer (Figley, 2002).
Current research reports some risk factors to develop compassion
fatigue and burnout in caregivers. Some examples include: conflicting
interactions between family and patients, communication of bad or uncertain
news, dealing with death and suffering, involvement with patients and family
members, conflictive work environment, management of workload and work stress,
inability to process emotions, feelings of guilt and anxiety, feeling
overwhelmed by personal concerns, among others (Nolte, Downing, Temane, &
Hastings-Tolsma, 2017; Sorenson et
al., 2016).
Daily, formal caregivers in palliative care face these factors
and other existential issues that urges them to redefine priorities, perceive
life with gratitude and appreciation of the resilience of others, and
experience personal growth (Beaune, Muskat,
& Anthony, 2018). Research shows that organizational virtues such as
support, respect, meaning and inspiration, and forgiveness, influence people’s
actions, contribute to experience a fuller life, and have a direct effect on
job satisfaction and performance levels (Lupano
Perugini & Castro Solano, 2018). Satisfaction may also have the
potential to decrease compassion fatigue (Kelly,
Runge, & Spencer, 2015; Mota
Vargas et al., 2016). Unquestionably, handling the contradiction of
providing care that is meaningful and exhausting at the same time is difficult
(Candrian, 2014).
Thus, different interventions have been developed to care for the
caregiver and increase self-care. The literature reports interventions that
include meaning-centered techniques to increase professional quality of life (Fillion et al., 2009); training on
spiritual care to improve the relationship with the patient (Wasner, Longaker, Fegg, & Borasio, 2005);
coaching caregivers in communication skills (Clayton et al., 2013); mindfulness
training (Cohen-Katz et al., 2005; Mackenzie, Poulin, & Seidman-Carlson,
2006); learning about death anxiety (Melo
& Oliver, 2011); among others. However, it is hard to critically
analyze many of these due to the large heterogeneity between studies (Masoudi & Hosseini, 2019), the
variety of perspectives used, the lack of a solid theoretical framework that
underline and support the intervention activities, the absence of detail in the
themes and protocols employed, the absence of studies with control groups, and
the varied results on the effectiveness of the interventions (Henry, 2014; Hill, Dempster, Donnelly, & McCorry, 2016;
Van Mol, Kompanje, Benoit, Bakker, & Nijkamp,
2015).
Meaning-centered and existential interventions have been shown
to be generally useful (Regehr, Glancy,
Pitts, & LeBlanc, 2014; Vos,
Craig, & Cooper, 2015), especially in patients with cancer and in
palliative care (Breitbart et al., 2015;
Gagnon, Fillion, Robitaille, & Girard,
2015) and their informal caregivers (Applebaum,
Kulikowski, & Breitbart, 2015). However, to date, only one intervention
for formal caregivers that used Logotherapy, a type of existential therapy, has
been rigorously reported (Fillion, Dupuis,
Tremblay, De Grâce, & Breitbart, 2006). Besides, none of the studies
have taken place in Latin America nor have they used a cognitive-existential
theoretical basis for the development of sessions. In addition, most of the
research on interventions do not show their development nor a detailed
explanation of the mechanisms or activities used. Consequently, the purpose of
this study is to report the design and development of a cognitive-existential
group-based psychoeducational intervention (CEGPI) created to promote self-care
and satisfaction and to reduce compassion fatigue of formal caregivers of
palliative care patients in a Latin American context. This research had the
ethical endorsement of the Research Ethics Committee of the University of
Deusto (Ref: ETK 3 / 16-17).
Methods
This article is part of a larger mixed-methods study that had
three main objectives:
1) To explore the reality of formal caregivers of people in
palliative care by analyzing semi-structured interviews about the barriers they
encounter daily and the resources they have to deal with them.
2) To design a replicable intervention to decrease compassion
fatigue and increase compassion satisfaction of formal caregivers.
3) To test the long-term effectiveness of the developed
intervention.
This manuscript answers to the second objective and reports the
design development of the mentioned intervention.
The following steps were taken to develop the CEGPI:
1) To create a draft of the intervention, the first phase was
based on the “Existential Dialogue Circles” (Luna, 2011), an activity centered on
logotherapy and existential analysis. It uses meaningful communication as a
prevention strategy against the existential void. 2) Considering the workload
of formal caregivers and evidence showing that shorter interventions tend to be
more effective (Sheard & Maguire, 1999;
van der Klink, Blonk, Schene, & van
Dijk, 2001), the first draft of the intervention was designed to be eight
sessions long, divided in one-hour weekly meetings (total of eight hours). 3)
Two experts in Logotherapy were consulted to review the intervention and
suggest changes. Both agreed with all aspects of the intervention, and one
recommended adding cognitive strategies to better accomplish the CEGPI’s
objectives. 4) Meanwhile, a total of 84 formal caregivers of palliative care
patients from three institutions in Ecuador were interviewed to explore their
reality as caregivers and the barriers and resources they perceive to perform
their work (Hidalgo-Andrade &
Martínez-Rodríguez, 2019). Taking into consideration the information from
the interviews, some themes of the original draft were adapted, and relaxation
techniques and other didactic elements were included in the intervention.5) The
final versions of the intervention manual for the facilitator and for the
participants were written. The material for participants was a personalized
folder with printed material to deepen the content covered in each session,
recommended readings, and reflection phrases about health, meaning, and caring.
This folder is to be delivered to the participants at the start of each session
so they could take notes, write their thoughts and feelings, and do the
in-session written exercises. At the end of the eighth session, the
participants keep their materials so they can refer back to them. Each session
of the CEGPI followed the same structure as outlined in Table 1.
There was no homework or extra exercises assigned, except for the second
session. The facilitator’s manual and participants' material can be obtained by
contacting the main researcher.
Table 1
Topic |
Description |
Welcome |
Brief technique of muscle relaxation,
breathing, or imagery (Smith, 1999).Welcome
words: “we do not ask life, life asks us, and with courage and bravery, we
will respond.” They sought to encourage participants to share from their
personal experience and place them as actors (versus reactors) of their own
lives. |
Confidentiality and participation |
Reminder of confidentiality and
voluntariness of the participation. |
Development of the session |
Delivery of participants’
materials.Development of the content of the session using Socratic dialogue
and existential questions to allow each participant to find their answer,
thus promoting their freedom and responsibility. |
Conclusion |
Reading of a quote related to the topic of
the day Participants are asked to fill out their “travel diary,” an
individual written reflection exercise to describe the feelings and emotions
participants had in relation to the topic, to themselves, and to the group (Luna, 2011). |
Results
Content of the CEGPI
The workplace is a scenario of formal and informal social interaction
where individual freedom of choice and action should be respected (Lopera Arbeláez & Echeverri Álvarez, 2019).
Accordingly, the content of the CEGPI mainly addresses ways for finding meaning
through caring, exploring personal and professional relationships, and
applicable ways to practice self-care. It also used personal narratives, as
well as many other interventions (Roikjær,
Missel, Bergenholtz, Schønau, & Timm, 2019), and addressed the reported
risk factors to develop compassion fatigue with actions aimed at modifying
them. Also, because existential psychology can be effectively integrated with
constructivism (Lincoln & Hoffman,
2019), the CEGPI explores existential issues and introduces cognitive
strategies to deal with the demands of being a formal caregiver for people with
palliative care needs through Logotherapy and rational emotive therapy techniques.
Rational emotive therapy is a cognitive therapy that uses
emotive and behavioral methods to help people identify their irrational beliefs
(Ellis & Abrahms, 2005). This
perspective assumes that emotional consequences come mainly from ideas, beliefs
or interpretations about experiences, and looks at cognition, behavior, and
emotion as interrelated and indivisible. These strategies were included in the
activities because it has been shown that the most successful interventions
incorporate skills to reappraise maladaptive cognitions (Galbraith & Brown, 2011). On the
other hand, Logotherapy considers how existence finds meaning in work, promotes
freedom and responsibility, and argues that people’s will for meaning prevails
even when faced with hard circumstances such as suffering and death (Acevedo, 2014). It also encourages the
recognition of each person’s dignity and limits and promotes the use of social
skills and human strengths, which have proven to be protective factors against
burnout (Menezes De Lucena Carvalho,
Calvo, Martín, Campos, & Castillo, 2006).
The CEGPI specifically expanded on the main premise of
Logotherapy, that human beings can reach meaning through: (1) creative values,
a way in which people give to the world by means of their creations and work;
(2) experiential values, in which a person receives something from the world
with gratuity; and (3) the attitudinal value that arises when a person is
unable to give nor receive from the world due to bio-psycho-social limitations
(Frankl, 1991). Table 2
describes the main objectives and development of the eight sessions of the
CEGPI.
Table 2
Session |
Main objectives |
Main content and development of the sessions |
1. Welcome |
· To welcome participants · To review the
main concepts of existential therapy, compassion fatigue, health, resiliency,
and satisfaction. |
· Uniqueness and multidimensionality of
human beings · Awareness of the positive and negative consequences of caring |
2. Experiential values |
· To understand how one can find meaning in
personal experiences · To recognize how personal experiences are associated
with how we care for others |
· Reading of a short story about a
psychologist experiencing compassion fatigue; existential questions follow ·
Psychoeducation on experiential values · Introduction of the gratitude
journal · Homework: participants are asked to complete their autobiography
(Lukas, 1990 in Luna, 2011) |
3. My relationships |
· To recognize meaningful relationships in
and outside the workplace · To identify a personal support network |
· Group discussion about the lessons learned
from the autobiography · Reading of chapter 12 of “The Little Prince” (De Saint-Exupéry, 1940). This story
highlights existential issues such as the uniqueness of relationships through
caring, acceptance of differences, responsibility · Group reflection on the
reading to evoke dialogue on social support, relationships among colleagues
and patients, friendships, abstaining from judgment, and caring versus curing
in palliative care |
4. Creative values |
· To understand meaning through creation and
work · To recognize each participant’s uniqueness and personal limits |
· Written exercise by Acevedo (2013) in which all participants
are given four words and are asked to write a short story with them in the
same order they were given. Then, participants share their stories with the
group. The group discussion that follows emphasizes how, even when faced with
the same circumstances, each person writes their own story |
5. Self-transcendence through caring |
· To identify the freedom to choose to work
or volunteer as a caregiver · To recognize the meaning in serving and caring
for others |
· Discussion about the importance of caring
and providing quality of life to patients, especially when curing an illness
is no longer an option · Training of strategies on how to reappraise
situations and effectively problem-solve |
6. Attitudinal values |
· To understand attitude as the ultimate
freedom despite possible unchangeable circumstances · To identify coping
strategies in the face of suffering and death |
· Discussion of an existential dilemma about
grief · Introduction of attitudinal values · Explanation and training on
emotional regulation and assertiveness |
7. Practicing self-care |
· To experience logotherapeutic and
cognitive techniques as self-care strategies |
· Psychoeducation · Participants are asked
to share personal examples of how they have used or can use these methods to
care for themselves. |
8. Self-care with meaning |
· To review the specific self-care
strategies learned throughout the intervention |
· Written exercise where participants
explore how they feel about themselves considering all their dimensions and
how they could implement self-care strategies to their routine · Group
reflection on the personal meaning of care and caring |
Discussion
This manuscript describes the design process of an 8-session
psychoeducational intervention that combines existential and cognitive therapy
techniques to decrease compassion fatigue and increase the compassion
satisfaction of formal caregivers. The construction of the CEGPI shows the
importance of a robust theoretical framework and the inclusion of recipients’
voices to elaborate an effective intervention.
Psychoeducational interventions seem to be cost-effective (Dieng et al., 2019) and have significant
effects at the individual and group level in different population groups (Cipolletta, Simonato, & Faccio, 2019;
Lee et al., 2019; Perrin et al., 2019). Research shows that
structured interventions that include psychoeducation, exercises, and the
direct discussion of meaning in life are the most effective existential therapies
(Vos et al., 2015). Also, it has been
suggested that education about compassion fatigue, burnout, and existential
concepts can improve support and communication among caregivers (Keidel, 2002; Masoudi & Hosseini, 2019) Thus,
psychoeducation was the type of intervention chosen for the CEGPI.
Self-care, education, teamwork, the teaching of resilience and
other coping mechanisms have been proven useful in the prevention of compassion
fatigue (Sorenson et al., 2016).
Satisfaction also positively correlates with emotional and spiritual care and
having a balance between personal and work life (Alkema et al., 2008). As well, in any
organization, it is important to develop interventions so that caregivers can
feel they are supported in their context. Especially considering that,
high-quality communication can positively influence the attitudes of employees
towards organizational changes as well as maintain its proper functioning (Parra Fernández, Visbal Franco, Duran, &
Badde, 2019). Accordingly, the CEGPI also intended to create awareness and
teach specific strategies to develop daily practices directed towards
increasing self-care; promote self-knowledge and the recognition of personal
limits; foster meaningful communication with team members and colleagues;
increase the awareness of meaning in caregiving; and incorporate the
perspective of meaning and transcendence in the daily work of the caregiver.
The CEGPI used Logotherapy as the theoretical backbone of the
intervention because it intends to enhance the sense of meaning and freedom of
being a formal caregiver. It also promotes the creation of a safe environment
where communication and a supportive network with colleagues develop. There is
only one other intervention reported in the literature with this theoretical
basis (Fillion et al., 2006). However,
the CEGPI extends well beyond that framework and includes the cognitive skills
that may help deal with the existential concerns intrinsic in palliative care.
The CEGPI also differs from it in the number of sessions; the incorporation of
the multidisciplinary team and not just palliative care nurses; and the
inclusion of other topics such as compassion fatigue, an existential perspective
of health, specific self-care strategies, relaxation techniques, reflective
writing, and cognitive restructuring.
A non-randomized trial, reported elsewhere, showed that the
CEGPI has the potential to improve well-being by effectively reducing compassion
fatigue in caregivers of people in palliative care with long-term effects (Hidalgo-Andrade, Martínez-Rodríguez, &
Carrasco, 2018). The CEGPI’s effects on other variables are also discussed
in the cited study. This could lead to better patient care, although that
connection still needs to be assessed. Future studies could also incorporate
other measures to evaluate which of the sessions show greater effectiveness,
from which sessions the changes begin to be visible, and which are the aspects
that participants consider most useful in the long-term. Results will further
help explore the benefits and limitations of this intervention.
Conclusions
This study reports the development of the CEGPI, a replicable
and effective intervention based on existential and cognitive therapy, to
reduce the compassion fatigue of formal caregivers in palliative care. This
intervention contributes to improving the formal caregiver’s professional
quality of life and therefore, the quality of care they provide to patients and
their families.
Organizations that promote human development and well-being play
an important social role by creating, strengthening, and developing work and
life skills that benefit the person, the organization, and society as a whole (Lopera Arbeláez & Echeverri Álvarez, 2019).
Given the CEGPI has proven to be beneficial, organizations that provide
palliative care may implement it to increase prevent or decrease compassion
fatigue levels of formal caregivers along with their already implemented
policies. Further research needs to assess the CEGPI’s efficacy in other
cultural contexts and with caregivers outside palliative care.
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