Enhancing professional quality of life in palliative care through a virtual training program

Abstract

Introduction

In palliative care, the intense emotional toll on professionals, volunteers, and trainees is widely recognized, potentially leading to severe emotional strain and burnout. This pilot study presents an innovative solution—an asynchronous, 15-h, cost-free, fully online training program—to enhance the quality of life and self-care practices of palliative care professionals, students, and volunteers in Ecuador.

Methods

The program comprises 5 comprehensive modules, addressing pivotal topics such as palliative care principles, effective relationship-building, crisis and trauma management, and professional quality of life improvement. Leveraging multimedia resources, including videos, readings, and interactive exercises, the modules facilitate engaging and informative learning experiences.

Results

Two hundred and ten individuals involved in palliative care in Ecuador enrolled in the online program. Pre- and post-training questionnaires were administered to assess effectiveness, encompassing various assessment tools to measure changes in professional quality of life and self-care. The assessments also included socio-demographic information and satisfaction surveys. Ultimately, 51 participants successfully completed the training, revealing positive feedback and significant improvements in self-care practices post-training. However, a 75% dropout rate, primarily attributed to time constraints, underscores the necessity for flexible training options during work hours.

Conclusions

This research underscores the critical role of continuous training and supportive environments that prioritize self-care for palliative care professionals. Organizations must recognize the significance of allocating dedicated time during work hours for these essential activities, thereby promoting the well-being of their invaluable staff.

Resumen

Introducción

Los cuidados paliativos implican un intenso coste emocional que provoca tensión emocional grave y agotamiento. Este estudio piloto presenta una solución innovadora (un programa de capacitación asincrónico, gratuito, de 15 horas y completamente en línea) para mejorar la calidad de vida y las prácticas de autocuidado de los profesionales, estudiantes y voluntarios de cuidados paliativos en Ecuador.

Métodos

El programa consta de cinco módulos integrales que abordan: principios de los cuidados paliativos, construcción de relaciones efectivas, manejo de crisis y traumas y la mejora de la calidad de vida profesional. Aprovechando los recursos multimedia, los módulos facilitan experiencias de aprendizaje interesantes e informativas.

Resultados

210 personas dedicadas a cuidados paliativos en Ecuador se inscribieron. Para evaluar la efectividad, se administraron cuestionarios previos y posteriores a la capacitación, que abarcan varias herramientas de evaluación para medir los cambios en la calidad de vida profesional y el autocuidado. Al final, 51 participantes completaron con éxito la capacitación, lo que reveló comentarios positivos y mejoras significativas en las prácticas de autocuidado después de la capacitación. Sin embargo, una tasa de abandono del 75%, atribuida principalmente a limitaciones de tiempo, subraya la necesidad de opciones de capacitación flexibles durante las horas de trabajo.

Conclusiones

Se subraya el papel fundamental de la formación continua y los entornos de apoyo que priorizan el autocuidado para los profesionales de cuidados paliativos. Las organizaciones deben reconocer la importancia de dedicar tiempo de trabajo a estas actividades esenciales, promoviendo así el bienestar de su valioso personal.

Introduction

Professional quality of life is the quality one feels concerning their work as a helper, and it involves positive and negative aspects.¹ Compassion satisfaction is the positive side and reflects a sense of accomplishment and reward of providing care.^1,2 On the other hand, compassion fatigue, which includes burnout and secondary traumatic stress, is the negative aspect¹ and, while some studies treat it as a single entity, others conceptualize it as a multidimensional construct involving elements of physical, emotional, and spiritual exhaustion.² Either way, a good professional quality of life relates to providing good-quality palliative care.^2,3

Working in palliative care could be demanding and gratifying at the same time. Thus, many attempts have been made to improve palliative care health providers’ quality of life. According to a recent review,⁴ interventions to reduce burnout in this population usually target nurses and use strategies such as meditation, improving communication skills, peer-coaching, and art-therapy-based supervision to reduce burnout symptoms. Others have used training in coping and stress management skills.³ The lack of knowledge about palliative care might also contribute to stress and compassion fatigue,³ and having a monthly professional development day can yield positive results such as decreased burnout, improved compassion satisfaction, and decreased secondary trauma.⁵ Many other interventions also focus on self-care. Besides being an ethical practice for professionals, it relates to coping, health promotion, and resilience, among other positive factors contributing to well-being and better professional quality of life.^6,7

Despite the varied interventions in the field, research shows that, in general, better-quality intervention development and more research are needed to evaluate the effectiveness of such interventions.^8,9 Studies suggest that interventions should be critically constructed with solid theoretical frameworks underlying their strategies and activities⁸ to properly evaluate effectiveness.

A team from University of the Balearic Islands developed an online training to promote professional quality of life. This program results from the conclusions obtained in a previous project carried out between 2020 and 2022, where the research team achieved a diagnosis of compassion fatigue and satisfaction in formal helpers in the palliative care and social-health field in Ecuador. This prior study shows the demand for formative interventions to promote their strategies to cope with negative emotions and enhance their positive feelings and self-care practices.^10,11 The data indicated that, although professionals had a high level of satisfaction stemming from their commitment to helping others, the levels of secondary traumatic stress and burnout were moderately high. It was concluded that attending to a high percentage of emotionally demanding patients per week, a daily reality in the palliative care field, resulted in a more significant negative impact on their professional quality of life. Participants with less experience showed higher burnout levels than those with more professional experience.

Given this context, the research question was: Could an online training program designed explicitly for palliative care professionals and volunteers influence an increase in their self-care practices and thereby improve their quality of life by enhancing compassion satisfaction, reducing secondary traumatic stress, and mitigating burnout? Furthermore, the study's aims were to: (1) report the design and development of a training program (intervention) to improve the professional quality of life of palliative care health providers through professional development and self-care and (2) describe the initial results of the engagement and satisfaction of the intervention in a pilot study.

Material and methods

This training was conducted in Spanish and was specifically designed based on the qualitative input of professionals, volunteers, and students of palliative care in Ecuador, which might be similar to other countries with similar backgrounds and health systems. This training aims to be effective in the shortest possible time to facilitate the participation of those profiles.

The people who participated in the previously mentioned project^10,11 were invited via email to complete the training program. They were also asked to forward the information to other people involved in palliative care who might be interested in the program. A total of 210 people registered for the course through an online link. They all met the requirements (being volunteers, students, or professionals related to palliative care in Ecuador) and were registered on the course platform.

They all received an email with their credentials and instructions for accessing the platform. A reminder was sent 5 days and 10 days after the start of the course. Of the 210 registered, 101 started the training; only 51 participants successfully completed it. The program was conducted asynchronously and entirely online using the Moodle platform provided by the University of the Balearic Islands.

The program was available from June 1 until July 15, 2023. The training was free for participants and was initially planned for 1 month. Finally, the period was extended by 15 days to give more people the opportunity to complete the training. The estimated time for the training was 15 h. All participants who passed a final multiple-choice exam received a certificate signed by the University of the Balearic Islands (Spain) and Universidad de Las Américas (Ecuador).

The program’s structure was divided into 5 units (Table 1) with 5 different instructors, all of whom were doctoral-level professors at the university and specialists in their respective modules. Each module had diverse resources, such as recordings of the professors introducing the topic, PowerPoint presentations, readings, and activities to promote knowledge acquisition. The videos were between 15 and 40 min long. There were also forums in each unit to interact with other training participants. Tests and other written exercises let the teaching team check their progress. The intervention was delivered as planned.

Table 1.

Organization of training.

Module	Estimated time (minutes)	Theoretical basis	Material	Task	Participation (N)	Optional forum interaction
Training registration	2’	N/A	Course information poster	N/A	210	N/A
Pre-training questionnaire	13’	N/A	N/A	Socio-demographic questionnaireProQol-VSelf-care scale	100	N/A
Module 1: Introduction to palliative care.	120’	Strategies of the WHO and the palliative care strategy of (the Balearic Islands) (Spain)	1 video presentation1 video syllabusReading	Participation in 2 forums on a debate	67	27
Module 2: The helping relationship	120’	Humanist theory (Carl Rogers)	1 video presentation1 video syllabusReading	3 reflection activities	52	11
Module 3. Intervention in crisis, trauma, and grief	300’	Grief psychotherapy from an integrative relational model and Developmental Trauma Theory	1 video presentation5 videos on the subject	Interpreting one's results of the Adverse Childhood Experiences	51	8
Module 4. Professional quality of life	240’	Professional Quality of Life: Center of Victims of Torture	1 video presentation3 videos on the subject1 video interview1 reading	Interpreting one's results of the ProQol-V professional life scale and 2 activities	51	6
Module 5. Personal and professional self-care practices	340’	Biopsychosocial well-being model	1 video presentation3 videos2 readings	2 exercises in self-care planning in the personal and professional sphere	51	5
Final examination	15’	N/A	N/A	Multiple-choice test. 15 questions	51	N/A
Satisfaction survey	5’	N/A	N/A	Scale and qualitative opinion questions. Anonymous	51	N/A
Post-training questionnaire	10’	N/A	N/A	Socio-demographic questionnaireProQol-VSelf-care scale	44	N/A

*N/A: not applicable.

Each module included a dedicated forum for addressing participant queries, with instructors responding within 48 h. An optional forum for discussion and reflection on the training content was also available. A supplementary folder containing non-mandatory material and a catalog of recommended readings were also provided.

A questionnaire was administered to all participants before the training and 1 month after the end of the course. The questionnaire consisted of the following instruments:

• •

  Ad-hoc socio-demographic questionnaire. This section requested information about gender, age, studies, field of work, number of cases dealt with per month, and their perception of the emotional burden of these cases. This questionnaire was applied only before the program.

• •

  Professional quality of life questionnaire V¹² in the Spanish version¹³ (PROQOL V). This instrument is widely recognized for its ability to assess, in just one instrument, the professional quality of life through 3 main dimensions: compassion satisfaction (0.81), representing a positive aspect; secondary traumatic stress (0.85), and burnout (0.67), which are both negative aspects and represent compassion fatigue. This questionnaire comprises 30 items with response options ranging from 1 (never) to 5 (always). Five items belonging to the BO subscale must be inverted. There is no total value; each construct has its score by adding the values of the 10 items of each subscale. The results of each subscale are interpreted as low, average, or high. This questionnaire has been shown to have adequate psychometric properties in various cultural contexts.

• •

  Scale of self-care behaviors for clinical psychologists.¹⁴ This scale is originally in Spanish and has shown adequate internal consistency and construct validity. It has 10 items to quantify the frequency of self-care behaviors. The answer options range from 0 (never) to 4 (very frequently). A total score is calculated by adding the responses. Higher scores translate to a higher frequency of these behaviors. The following categorization of frequency is used to better interpret the results according to the total score: 0–7 never, 8–15 almost never, 16–23 occasionally, 24–31 frequently, and 32 and above very frequently. The Cronbach’s alpha for this scale is 0.84.

• •

  Satisfaction survey. This questionnaire was applied only after the course completion. It encompassed quantitative inquiries, employing a Likert scale ranging from 1 to 5, in which students rated their satisfaction levels concerning various facets of the course, such as the course materials, content, trainers, and the platform itself. Additionally, qualitative responses were solicited to gain insights into their overall perception, areas for potential improvement, and the essential aspects of the training program as perceived by the participants.

In this manuscript, we analyze the outcomes derived from the utilization of the platform, including learning analytics, comments, video views by participants, and performance on activities and tests. All statistical analyses were conducted using SPSS version 25. We used descriptive statistics to characterize the sample and the overall responses. The significance level was set at p < .05. Only significant results are reported, and where percentages are shown, they are valid percentages.

We have chosen Cohen's d test to address the research question, which is widely used to calculate effect size in experimental or intervention studies, such as training programs or treatments. In the context of a program, Cohen's d test helps assess the variation in outcome measures before and after the intervention. A higher value of Cohen's d indicates a more notable effect of the program. The resulting coefficient can be considered small (d > 0.20), medium (d > 0.50), or large (d > 0.80).¹⁵

This study has the approval of the Ethics Committee from the University of the Balearic Islands, number 333CER23. All participants signed an online informed consent before enrolling in the program.

Results

During the course's promotion phase, 210 individuals registered for the training, comprising 78.1% professionals, 13.4% students, and 8.6% volunteers. Notably, 109 participants never accessed the platform to begin the course, resulting in a 51.9% dropout rate before the course initiation. Of the students who started the course, 50% completed it. Among professionals, only 36% successfully completed the course, while among volunteers, 83% did. Of the 101 individuals who accessed the platform, 100 (21 men and 79 women) completed the pre-training questionnaire. Table 2 presents the breakdown of socio-demographic information alongside the averages for self-care practices and dimensions of professional quality of life.

Table 2.

Socio-demographic data pre-intervention N = 100.

	Percentage%	Self-careMean	CSMean	BOMean	STS mean
Gender
Men	21.0	21.29	44.00	24.52	22.67
Women	79.0	22.81	43.80	22.96	21.34
Type
Professionals	72.0	23.08	44.78	22.83	20.33
Volunteers	16.0	19.87	41.50	26.19	25.62
Students	12.0	22.42	41.33	22.17	24.00
Area
Social work	9	23.44	44.89	21.67	23.89
Nursing	39	22.41	43.28	23.54	22.18
Medicine	20	21.90	44.30	23.35	19.85
Psychology	21	23.29	44.95	24.43	21.05
Others	11	19.50	40.50	21.00	19.50

*CS: Compassion satisfaction / BO: Burnout / STS: Secondary traumatic stress.

Professionals and volunteers in the study had, on average, 6.25 years of experience in palliative care and provided care to an average of 61.49 (SD = 125.9) patients each month. Of these patients, 49.13% (SD = 31.17) were identified as experiencing a high level of emotional burden.

Only 51 individuals obtained course certificates, and 44 completed the post-training survey 1 month after completion. The average score for the final program evaluation was 7.95. Participants' self-care scores averaged 22.09 (SD = 5.95) before the training, increasing to 24.91 (SD = 6.75) 1 month after the course. The analysis of the effect size using Cohen's d in self-management of self-care practices revealed a medium effect between pre- and post-training measurements (d = 0.44), suggesting improved practices after the course.

To further address the research question, effect sizes were calculated before and after the course on variables associated with professional quality of life, according to Stamm. However, both burnout and satisfaction results were not significant in the analysis of mean differences and were contrary to the expected results. In the case of burnout, a slight increase in the mean from 22.93 before the course (SD = 3.43) to 23.59 (SD = 4.24) was observed, maintaining moderate levels according to score interpretations. On the other hand, compassion satisfaction showed a slight decrease in the mean from 42.73 (SD = 4.34) to 42 (SD = 5.74), although it remained at high levels according to manual interpretations. On the other hand, secondary traumatic stress decreased from 22.18 (SD = 4.80) to 21.82 (SD = 5.812), moving from moderate to low. An effect size of d = 0.067 was found, indicating a small effect size relationship. Additionally, an effect size of r = 0.033 was observed between the 2 measurements. These results indicate that the intervention had a limited impact, suggesting the need to consider other factors that may influence this variable in a broader context.

After the final examination, participant satisfaction with the course was assessed. The main results are presented in Table 3. Qualitative feedback was also collected, with recurring comments such as "being online, it adapts to each person's schedule" and "the course was well-explained, with excellent supplementary materials." A notable 90% of participants indicated that they would not add more content to the training.

Table 3.

Participant satisfaction (N = 51).

Item	Score (1–5)
1. The level of the course has been adjusted to your needs.	4.3
2. The content was appropriate	4.4
3. The course is useful for your work	4.5
4. The format of the course has met your expectations	4.3
5. The characteristics of the online platform have been adequate (accessibility, interactivity, usability, etc.).	4.1
6. The interface was of high quality	4.2
7. The duration has been adjusted to the contents	4.3
8. Teachers know and master the subject	4.4
9. It is enjoyable and maintains interest	4.3
10. Teachers convey ideas clearly.	4.3
11. The speed of response to your questions was adequate.	4.3

One final comment highlighted the course's impact on understanding emotional aspects in relationships with individuals, trauma and grief processes, the importance of support and presence in all cases, and the significance of maintaining professional boundaries, i.e., "taking care of oneself to care for others." Overall, it was deemed a comprehensive and informative course covering various aspects of professional development.

Regarding the implementation of self-care plans, 14% reported successful implementation, 27% indicated substantial progress, and 5% reported partial implementation. When asked about obstacles to implementing their personal and professional self-care plans, 90% cited a lack of time for personal care. At the same time, organizational aspects were mentioned as challenges in the professional sphere.

Discussion

This manuscript shows the results of a pilot study of online training with a high attrition rate. The bulk of attrition occurred among participants who never accessed the platform. Another element that requires particular attention is trends in supplementary activities. An intriguing pattern emerged as the course progressed, wherein participation in supplementary activities gradually waned. Those who successfully surmounted the hurdles of Module 2 tended to persist until the course's conclusion. As a 2017 study points out, online time differs from face-to-face time.¹⁶ As the authors highlighted, online training time competes with the personal reality surrounding the student (family, work, etc.) and other services offered by the network (social networks, press, etc.). Online courses require a commitment of several hours of work per week, which is the student’s responsibility, without any control by the teacher. The study concludes that online training is more demanding than face-to-face training regarding concentration, intensity, and production. However, the participants who completed the course expressed their gratitude and satisfaction with the training. The final examination showed that all 51 trainees had acquired the necessary skills to pass the course. Low completion rates of online courses do not undermine students' satisfaction with the usefulness of the courses.¹⁶

The professional vs. volunteer engagement in the course was crucial. Despite an initial enrollment bias toward professionals, a mere 36% of them successfully completed the course, while a striking 83% of volunteers accomplished it. This disparity could be attributed to a lack of interest or time constraints. Professionals and students are often stretched thin due to work-related commitments, contrary to volunteers, many of whom possess the flexibility to engage more intensively with the course material. In addition, an interesting study¹⁷ on distance learning refers to the importance of considering aspects such as family problems, diary conflicts, personal problems, academic integration, social integration, technology skills, and motivation when assessing course compliance.

Results indicate that the course indeed improved self-care practices and reduced secondary traumatic stress. It would be necessary to wait a few months and conduct a follow-up test to see if self-care practices are maintained and have a longer-term effect on professional quality of life over time. Initially, an impact on the reduction of secondary traumatic stress can already be seen, which is now at low levels compared to moderate levels before the course.

Another aspect to be noted is the effects of compassion satisfaction and burnout. The course's immediate impact on increasing compassion satisfaction or alleviating burnout did not reach statistical significance. Burnout is described as a prolonged and chronic response to interpersonal stressors at work, arising from the interaction between the professional and the client and the professional's relationship with the organization.¹⁸ Improving this situation requires time and important structural changes.¹⁹ The aim of the course was not to have an immediate impact on burnout since, from the researchers' point of view, this is not possible and would require other, more specific interventions in the work environment.

This intervention provides interesting information that can be studied in the long term. It is plausible that more than 1 month may be needed to unveil these changes, necessitating extended post-course follow-ups. The most effective element of the course is promoting self-care. The evolution of self-care should continue to be tracked over time to evaluate its long-term trajectory. Another recent study²⁰ on self-care found that in the long term, increased self-care was positively indexed with increased compassion satisfaction and decreased levels of burnout and secondary traumatic stress.

Strengths and weaknesses

One of the main highlights was the challenges in course completion. Despite the course's strong backing from 2 reputable universities, its asynchronous online format, a manageable 15-h duration, and the allure of an official certificate, it faced a considerable challenge with a high dropout rate. Remarkably, only 25% of enrolled participants successfully navigated the course to completion. However, according to a previous study,¹⁶ the reported retention rate for online courses is around 15% of those enrolled. In this case, the course would have a lower dropout rate than others. Moreover, as other studies indicated, professionals involved in palliative care need training in psycho-emotional care, grief, and coping with loss.²¹ Another limitation relates to the self-report measures.²²

Conclusions

Despite the high initial enrollment rate, the online course faced significant obstacles, with a pre-course dropout rate of over 50%, especially among professionals. Only a small proportion of those who started the course successfully completed it, and volunteers had significantly higher completion rates than professionals. Nevertheless, the course positively impacted self-care practices, as indicated by a statistically significant increase in self-care scores after the training, suggesting possible long-term benefits for participants' professional well-being. While the immediate effects on compassion satisfaction and burnout did not reach statistical significance, there was a discernible improvement in secondary traumatic stress levels from moderate to low. These difficulties in completing the course underscore the need for sustained support and resources to facilitate participation, particularly in addressing time constraints and fostering organizational support for self-care initiatives. The critical importance of recognizing self-care as an integral aspect of professional practice in palliative care is underscored, highlighting the essential role of healthcare organizations in allocating resources and time to promote staff wellness. Despite existing challenges, educational programs such as the one reviewed can significantly improve the quality of life of palliative care professionals, provided that ongoing support and resources are available.

Ethics

The current study had the approval of the Ethics Committee of the University of the Balearic Islands (333CER23). All participants accepted an online informed consent prior to enrolling in the program.

Protection of human and animal subjects

The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Funding

This work was supported by the Oficina de Cooperació al Desenvolupament i Solidaritat from the University of the Balearic Islands and the Government of the Balearic Islands [grant number: OCDS-CUD2022/04].