Psychological Well-Being amongst Cancer Palliative Care Professionals working in Bengaluru, India

INTRODUCTION

Professionals working in cancer palliative care settings are exposed to higher levels of stress, suffering, loss, and grief^[1,2] which make them vulnerable to psychosocial stress and burnout.^[3] Earlier studies have indicated that burnout and compassion fatigue have an adverse impact on professional well-being.^[4-6] Quality of patient care has been seen to be impacted by staff well-being^[7] while high well-being scores have been seen to be related to less compassion fatigue and burnout in professionals.^[4] Being young, being a male, working for a lesser number of hours, undergoing clinical supervision, having satisfaction with one’s work environment, and having positive self-judgement are associated with increased well-being.^[8,9] A very high secondary traumatic stress and above average levels of burnout in cancer palliative care professionals have been reported earlier.^[10] Increased levels of psychological distress and burnout have implications for both well-being of staff and for their employing organisations.

The best-known approach to the understanding of psychological well-being (PWB) is from the movement of positive psychology and positive functioning.^[11,12] Although in the west, impact on well-being has been studied but no meaningful utilisation in research can be found because of inconclusive issues surrounding its measurement and conceptualisation.^[13] Researches done in the area of well-being have been generally derived from two major perspectives: The hedonic (pleasure and positive affect) and eudaimonic approach.^[13] Eudaimonia captures the realisation of one’s true potentialand congruency of a person’s life activities with his/her values and when the individual is holistically or fully engaged.^[12,14] Theoretically, PWB has been defined as ‘engagement with existential challenges of life’ and ‘a person’s perception about meaning in life.’^[15,16] Meaning in life has been seen to be related to work enjoyment and coping in adverse situations.^[17,18] Six distinct aspects of human actualisation have been thought to be indicative of eudaimonic well-being: Autonomy, purpose in life, personal growth, positive relatedness, environmental mastery, and self-acceptance (SA).^[12]

The concepts of well-being and quality of life (QoL) have followed an intertwined path in health sciences literature.^[19] QoL is understood and interpreted differently as it comprises subjective satisfaction and feelings of well-being to physical, occupational, and social functioning.^[20] Latha reported that professional caregivers of cancer patients had poor QoL as compared to carers of acquired immune deficiency syndrome (AIDS) patients.^[21] There is an immense literature on QoL and the well-being of cancer patients and their informal caregivers; however, to date, we have not come across any published study on PWB in cancer palliative care professionals in India.

The aim of the present study was to assess PWB amongst cancer palliative care professionals. The study objectives were (a) to study the levels of PWB amongst professionals working at cancer palliative care centres and (b) to study the relationship of sociodemographic and professional characteristics with PWB amongst professionals working at cancer palliative care centres.

MATERIALS AND METHODS

RESULTS

DISCUSSION

PWB is an intricate construct. The present study focuses on the eudaimonic approach which focuses on meaning and self-realisation and defines PWB in terms of a person’s sense of EG, PR with others, SA, and sense of MC.^[12,13]

In the present study, participants obtained an above average score for SA which suggests that majority of the participants held a positive attitude toward themselves. They are most likely to possess a positive attitude toward the self; acknowledge and accept multiple aspects of self, including both good and bad qualities and feel positive about their past. It has been observed earlier that participants with a higher tendency for self-judgement were less compassionate toward both themselves and others, had reduced well-being, and reported greater burnout and compassion fatigue.^[4]

On MC, the present study participants obtained a below average score which is indicative of a below average sense of MC in managing the environment and being able to control an array of external activities around. This suggests that the majority of the participants in the present study are more likely to have difficulty in managing everyday affairs and lack a sense of control over external matters in their lives. They may have difficulty in making efforts at managing work demands to accomplish the valued outcomes, dealing with situations, and moulding environments to suit their needs.

Nearly half of the participants have not undergone additional training nor have opportunities for supervision at the workplace, the majority being young and having feelings of not being able to do much for the patients or feeling of unpreparedness to join the field. It has been observed earlier in oncology nurses by Papadatou et al.^[22] that having a sense of personal control over things that happen in life was found to protect nurses from burnout.

Participants obtained nearly an average score on PR with others, which suggests that participants had moderate levels of warm, satisfying, and trusting personal relationships. Most of them are likely to have average levels of capacity for empathy and intimacy. The ability to love and care can be viewed as a central component of mental health and compassionate caring itself is the main element of palliative care. Most of the participants were having moderate levels of PR which could also be interpreted with the help of Erikson’s^[23] psychosocial development stage theory. For young and older adults, the achievement of close unions with others (intimacy) and the guidance and direction of others (generativity) would be important as far as the psychosocial stages are concerned. Thus, making efforts to develop and nurture relations with others through investing in relationships, providing support, having empathy, being open to seeking support, and engaging in dialogues to resolve conflicts is important for the life stages of most of the participants. However, the same components could make them vulnerable to developing compassion fatigue. Empathic feelings were observed to be important for deriving satisfaction for the helping professionals, but at the same time seen as a risk factor for compassion fatigue, especially if the individual lacks self-compassionate abilities.^[24]

In the present study, participants obtained an above average score for the sense of EG. This finding is indicative of the majority of the participants having an insight into their own potential and being open to new and challenging experiences. They are likely to hold goals and beliefs that support their sense of direction in life and feel that their life has a purpose and meaning. In addition, the majority of the participants seem to have meaningful life goals and a sense of directedness. They may feel that there is meaning to their lives and they hold beliefs that give a purpose in their lives. Earlier studies^[7,25,26] have addressed the importance of a sense of meaning and purpose in life to function well as a professional, to be able to provide quality care to the patients. The need to ‘actualise’ oneself and realise one’s potentialities is central to their personal growth.

The total score for PWB was found to be average, which suggests that the majority of the participants seem to have moderate levels of positive psychological functioning. This finding needs to be seen in the light of studies that have indicated that burnout and compassion fatigue have an adverse impact on professionals’ well-being.^[4-6]

The comparison based on age (in years) showed that professionals in the present study belonging to 25–40 years of age, and 40 years and above had a significantly higher sense of EG in comparison to professionals in the 18–24 years age group. This would mean participants in the age range of 25–40 years would have a better sense of EG than participants of any other age group. The high sense of EG in the group of age range 25–40 years could be understood in terms of their attainment of identity development and maturity to be able to seek purpose and meaning in their life goals as per Erikson’s theory^[23] of psychosocial development. Furthermore, 25– 40 years would be the most productive period between mid-life crisis/afternoon of life (above 40 years) and identity development/morning of life (around 18–20 years) as per Jung’s^[27] interpretation of youth and ageing. In addition to these explanations, being 50 years or lesser has been observed to be linked to better well-being in professionals.^[8]

Professionals who reported carrying out self-care practices (activities undertaken with the intention of enhancing health, preventing disease, limiting illness, and restoring health) were observed to have better overall PWB, MC, PR, and sense of EG, as compared to those who did not engage in any self-care practices. The findings from the present study are in accordance with several studies which suggested that engagement in self-care practices promoted better well-being of the professionals.^[4,25,28-31]

In addition, self-care has been defined differently by different researchers as it involves three components: Inner/spiritual care, social care, and personal care.^[2] Personal care usually involves physical or pleasurable activities. Further, no significant differences were observed on any of the PWB domains among professionals who practice religious and spiritual strategies for self-care and those who do not practice it at all. This finding is contrary to findings of a larger systematic review of 850 studies that involved professionals providing mental healthcare and stated that the higher levels of religious involvement were associated positively with indicators of PWB (life satisfaction, positive affect, happiness, and higher morale).^[32]

In a correlation between PWB measures and demographic and work-related characteristics [Table 3], it was found that only EG had a significant positive correlation with age; and EG also had a significant positive correlation with income per month. These findings indicate that having goals and beliefs that support meaningfulness of life and a sense of direction and purpose in life increase with increasing age and better salary provided from the workplace. In some studies, carried out on different populations, zero-order correlations have been observed between income and well-being frequently in the vicinity of 0.10–0.20.^[33,34] Similarly, in the present study, income per month was seen to have no significant correlations in the vicinity of 0.04–0.20 except for the EG domain.

While this is the first known study on PWB amongst cancer palliative care professionals in India, it is limited by its small sample size and having participants who were fluent in English or Hindi languages and working in Bengaluru city. More sample size with diversity could have added to the generalisability of the results. Furthermore, the levels of PWB were assessed cross-sectionally using only one scale, there is a possibility that an individual’s assessment of his/ her perceptions can change overtime due to individual work-related conditions.

This is an initial attempt toward understanding the PWB amongst cancer palliative care professionals. Similar studies are required in other parts of India to explore the construct better. More studies are needed to understand the relationship between PWB and self-care practices. The impact of better PWB on the quality of patient care could be explored and ways to enhance PWB could be studied.

CONCLUSION

Findings from the present study suggest that professionals working at cancer palliative care centres experience moderate levels of PWB suggestive of positive psychological functioning. This also suggests the need to develop relevant psychological interventions which could target enhancing PWB in cancer palliative care professionals.