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How Leaders, Teams and Organisations can prevent Burnout and build Resilience: a thematic analysis’
  1. Mervyn Yong Hwang Koh1,
  2. Hwee Sing Khoo2,
  3. Marysol Dalisay Gallardo1 and
  4. Allyn Hum1
  1. 1Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore
  2. 2Health Outcomes and Medical Education Research (HOMER), National Healthcare Group, Singapore
  1. Correspondence to Dr Mervyn Yong Hwang Koh, Palliative Medicine, Tan Tock Seng Hospital, Singapore 308433, Singapore; mervyn_koh{at}ttsh.com.sg

Abstract

Content Burnout occurs commonly in palliative care. Building resilience helps to mitigate the effects of burnout. Little is known about the importance of leaders, teams and organisations in preventing burnout and promoting resilience in palliative care.

Objectives We studied palliative care clinicians with more than a decade’s experience looking into their experiences on the role leaders, teams and organisations play in burnout and resilience.

Patients and methods This is a thematic analysis focusing on how leaders, teams and organisations influence burnout and resilience. 18 palliative care clinicians—5 doctors, 10 nurses and 3 social workers—who worked in various palliative care settings (hospital, home hospice and inpatient hospice) were interviewed using semistructured questionnaires. The mean age of the interviewees was 52 years old, and the mean number of years practising palliative care was 15.7 years (ranging from 10 to 25 years). The interviews were recorded verbatim and were transcribed and analysed using a thematic analysis approach.

Results The following themes featured prominently in our study. For leaders: being supportive, caring and compassionate, being a good communicator and showing protective leadership. With teams: being like-minded, caring for the team, sharing the burden and growing together. For organisations: having a strong commitment to palliative care, supporting staff welfare and development, open communication, adequate staffing and organisational activities promoting staff well-being were described as protective against burnout and promoting resilience.

Conclusion Leaders, teams and organisations play an important role in helping palliative care teams to reduce burnout and promote resilience.

  • psychological care
  • quality of life

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Key messages

What is already known about this topic

  • There is a significant amount of literature on ways to address and prevent burnout and build resilience in palliative care teams.

  • The role that leaders, teams and organisations play in reducing burnout has also been addressed and reported in the business literature and some fields of medicine.

  • However, this area has not been explored nor studied in depth in palliative care.

What this study adds

  • We report on the roles and traits that palliative care leaders, teams and organisations should embrace and embody in their efforts to manage burnout and foster resilience in their teams.

  • We also provide some practical recommendations (based on the findings of our study) to palliative care leaders, teams and organisations on how they can promote a better sense of psychological well-being at the workplace.

Introduction

Burnout is commonly encountered in palliative care, with recent studies showing a prevalence of 17%–39%.1–3 Maslach et al4 described the consequences of burnout as leading to emotional exhaustion, cynicism, detachment, a lack of effectiveness and a poor sense of accomplishment. Burnout needs to be acknowledged and addressed in palliative care as it leads to increased job turnover, medical errors, reduced empathy and compassion fatigue.5 Resilience, however, is a dynamic, evolving process of developing positive attitudes and effective strategies in the face of challenges. Resilience lowers burnout, increases compassion, improves quality of care and leads to longevity in healthcare.6 7 While there are several subtypes of resilience (including physical, moral and community resilience), in this paper, we are focusing primarily on psychological resilience.

We studied a group of palliative care clinicians (PCCs) with more than 10 years of experience to better understand their views on burnout and resilience.8 These clinicians underwent a transformational growth process of ‘Struggling, Cognitive re-framing, Adapting and Resilience’ (SCAR Model) as they moved along the path of achieving resilience. We also discovered prominent themes in our research that points to the crucial roles that leaders, teams and organisations play in reducing burnout and promoting resilience.

There is ample literature on how palliative care teams can build resilience and avoid burnout9 including the use of art therapy,10 controlling workplace factors,5 adopting coping strategies like relaxation and meditation and reducing negative self-talk.11 12 However, there is a paucity of studies on the role that leaders, teams and organisations actually play in mitigating burnout and building resilience.

We aim to address the lacuna in this field and hope the insights gleaned from the experienced clinicians in this study can shed light into how leadership characteristics can contribute to building team and organisational cultures to minimise the ‘impending crisis’ of burnout in palliative care.13 Based on the results of our study, we also present some recommendations that palliative care leaders, teams and administrators can consider adopting to prevent burnout and increase the resilience of their teams.

Methods

Study design and participants

Palliative care is well-established in Singapore, with services in all hospitals as well as a comprehensive network of hospice home care and inpatient hospices.14 The country is also ranked 12th globally in the Quality of Death Index.15

We included doctors, nurses or social workers who had practised palliative care full time in either a hospital or home palliative care team or inpatient hospice for 10 years or more. Participants were selected through purposive sampling based on our previous study,1 and all interviews were conducted in person by an independent trained interviewer with a background in social work. Eighteen PCCs participated in our study over a 4-month period in 2018. The duration of interviews was between 60 min and 90 min, and they were digitally recorded, anonymised and transcribed verbatim.

This is a secondary analysis of a previously published study on burnout and resilience in palliative care.8 While analysing the initial study findings, we were drawn towards the data that emerged around the themes of leadership, teams, organisations and their roles in influencing burnout and resilience in palliative care, which formed the primary research question of our current study. The data was primarily gathered from the respondent’s replies to certain questions including: ‘What are some of the challenges which you face and how do you cope with them’ and ‘Were there other means of support which you felt was important in keeping you in palliative care?’.

Data analysis

We conceptualised this paper and analysed our data using Braun and Clark’s reflexive thematic analysis (TA) approach.16 The exploratory nature of the approach is situated in a interpretivist paradigm and aligned with our research team’s beliefs on how the researcher should be continuously questioning, engaging and immersed in the data in an iterative process. We enacted reflexive TA from a social constructivist lens: the team identifying with a constructivist epistemology where we view the meaning of a situation as constructed through interaction and shared experiences.16 This approach is suitable for examining the multifaceted phenomena of burnout and resilience and its relation to leaders, teams and organisations, involving complex webs of social relations. We used an inductive and data-driven approach to our analysis, managing the coding process with NVivo V.12 software. The study followed Braun and Clarke’s six-step TA process.17 Our team coding process emphasised a collaborative and reflexive thoughtful engagement with the data as reflexive TA strives for an active convergence of the researcher’s theoretical assumptions, analytic resources and skill, and the data itself, distinguishing it from postpositivist coding reliability approaches stressing coding within strict frameworks.16 The two principal investigators (PIs) (MYHK and AH) familiarised themselves with the data, rereading the transcripts iteratively and conducted line-by-line open coding independently to generate the initial codes, comprising in vivo phrases related to the research question. A third researcher (HSK), a non-clinician qualitative researcher, then joined the PIs to review, identify and categorise recurring and relevant codes into themes. Regular investigator meetings were held where iterative discussions comparing newly generated codes and previously coded data were compared until distinctive patterns and themes gradually emerged. Our team coding process ensured that multiple perspectives were incorporated, alleviating bias and enhancing reflexivity. Interpretive research requires reflexivity, acknowledging how assumptions and views may impact the interpretation of multiple realities and the social and cultural construction of knowledge.18 The team maintained a reflexive approach to enhance the confirmability and trustworthiness of our analysis. During team meetings, we endeavoured to identify personal and work identities such as gender, age, social power, organisational hierarchies and viewpoints that might influence the researcher’s interpretation of the data in our interaction with the empirical material, as well in the selection of representative participant voices in the analysis.19 An audit trail of correspondence emails, meeting notes and personal reflective journals were kept to establish the dependability of the study while data accuracy was ensured through clarification with participants during the interviews.

Results

The 18 PCCs (5 doctors, 10 nurses and 3 social workers) were interviewed and worked in various healthcare settings, including hospital palliative care services, inpatient hospices and home hospices. The mean age of the interviewees was 52 years old, and the mean number of years practising palliative care was 15.7 years (ranging from 10 to 25 years) (table 1).

Table 1

Demographics of palliative care clinicians

We classified our findings into three major groups: (1) leaders, (2) teams and (3) organisations, -focusing on the themes that emerged with regards to burnout and resilience in these groups. For leaders: themes like being supportive, showing care and compassion, being a good communicator and exhibiting protective leadership were important. For teams: possessing like-mindedness, caring for the team, sharing the burden and growing together were paramount. With organisations, having a common purpose, prioritising staff welfare and development, promoting open communication, ensuring adequate staffing and having organisational activities to promote staff well-being were crucial.

Leaders

The palliative care leaders described in our study were clinician leaders of their teams. Our respondents felt that their leaders needed to be ‘present’ and to be there for them during times of difficulties or crisis to support them as well as create a ‘safe space’ for them to air their concerns and grievances honestly.

Supportive

I feel that at work, it’s important that your boss should be there and should be the one that gives you support. If you don’t feel safe enough or you don’t feel supported, then naturally you won’t want to share your problems. (P4 – nurse)

Nurse managers performing administrative roles appreciated superiors who trusted and empowered them to do their jobs. They enjoyed being given the freedom to grow into their new roles, having clear instructions yet not being micromanaged. That ‘trust’ allowed them to thrive in their new roles.

Empowering

I think the trust from my superiors, the empowerment my superior gives me, also gives me the confidence that I can do it. And that’s how I try to drive myself. I’m seeing that I can do it, so I’m fine. I will be able to do it. (P1 – nurse)

Autonomy: not micromanaging

I think my superiors and my boss gave me a lot of autonomy and they did not ‘micromanage’ me. They allowed me to do things. They just told me that ‘oh, I need you to do this’, and that’s it. You find your way, how to do it. ‘if you need help, you come back to me.’ I felt honoured that my boss gave me the chance to do something that I had never done before, and also hearing that they trusted me, that was very important. (P1 – nurse)

This was in contrast to other nurses who felt ‘suffocated’ and micromanaged in their daily tasks leading them to experience significant emotional distress.

‘I had to change, change, change!’ No matter how well I did the roster, it was never good enough for my manager. She always picked on me and I was always criticised. I felt like screaming. (P8 – nurse)

Caring and compassionate

Leaders also helped to reduce burnout by caring in simple and practical ways like bringing food for the team. Compassionate leaders also showed their understanding of their team members’ family needs and allowed them to take time off.

Caring

My boss, she loves to bring food, so she brings food as a sort of encouragement, and also to support our staff. (P1 – nurse)

Understanding

I am not very strict when they want to take their annual leave. I am not so strict on saying ‘no you can’t go’ - not unless 3 or 4 people want the same day off. So I do give them the allowance to go. I think when I grant them leave, it also means that they are more committed when they return to work. (P14 – nurse)

They were also forgiving when mistakes were made, reflecting the point that if we could be compassionate towards our patients and families, we should similarly show the same compassion towards our colleagues.

Compassionate

I think (as leaders) we need to be very compassionate because I think the nature of palliative care is such that a lot of unexpected things can happen with patient care. And I think if we can be so forgiving, so compassionate towards patients and families, the same should apply to our colleagues. (P18 – social worker)

Good communicator

Clinicians also felt that their leaders should possess good communication skills and should be the ones they could communicate openly with. A communicative leader was someone who was able to empathise with their challenges, ‘share their burdens’ and allowed their subordinates to express their own views candidly. Two-way communication—where the leader also shared their own opinions openly with their team members—was also looked on positively in building a trusting working relationship and promoting resilience.

Allowing for open communication

I have a wonderful boss. I will call her up and we speak nearly every day, so I will air my views and she will share her opinions as well and it’s very useful. Because no one really understands what you're going through. It’s difficult to share your concerns with your juniors because you need to protect them.

So having someone to talk about issues, someone to share that burden, someone to assess them, has been useful. (P9 – doctor)

Constant and regular communication by the team leader especially when a new team or service was formed was deemed essential in getting ‘buy-in’ and troubleshooting any new issues.

Constantly communicating with the team

What I realised especially when forming a new team is that you really have to sit down and communicate very regularly in order to get them ‘onboard’ and also getting them to know what is important in the ward. (P1 – nurse)

Protective leadership

Another facet of leadership that helped against burnout was having leaders who protected their teams from complaints and abuse. Team members wanted their leaders to be more involved when the team faced challenging cases and help to provide guidance and direction in helping them to resolve issues.

Protecting the team

Once you are the leader, if let’s say there are challenging cases or any complaints that are coming in…you have to help your colleagues to co-manage it. You have been appointed and you are the one who is supposed to help them solve the problem. (P5 – nurse)

On extreme occasions when nurses were being verbally abused repeatedly, they appreciated ‘protective’ leaders who prioritised their welfare and was willing to even discharge the patient from the service.

My boss told me that if I wanted to discharge this (abusive) patient, he will support me. To be given that choice, I found him to be very supportive. (P5 – nurse)

Protective leaders also watch out for the psychological well-being of their staff and notice when they have not been taking their vacation leave and will encourage them to do so to prevent burnout. The leader should also be self-aware of their own need for breaks and intentionally schedule leave to model the importance of ‘self-care’ for the team.

Watching out for burnout in the team

I am quite conscious in pacing myself. In intentionally schedule leave for myself and if I notice that someone from my team has not been taking their leave regularly, I would speak to them about it. I realised that if we keep pushing ourselves to the point that we are no longer effective, that defeats the purpose. (P10 – social worker)

Teams

The themes related to protecting teams from burnout and enhancing their resilience included being like-minded, caring for the team, sharing the burden as well as growing together.

Like-mindedness

A social worker commented on the importance of the palliative care team being ‘like-minded’. They reflected on the importance of ‘speaking the same language’ and having common goals in caring for patients and their families. Having this ‘like-mindedness’ obviated the need for the social worker to spend time and effort convincing medical teams of the value of their interventions or reasons for delays in discharge, which non-palliative care teams with different mindsets may not understand so readily.

It’s very good to work with people with a certain degree of like-mindedness, speaking the same language… you spend less time trying to convince them of the importance of certain things. And you just work better together towards a common goal. (P12 – social worker)

Another factor that prevents burnout was having positive team dynamics like enjoying working together and having similar work ethics and values.

Working well together as a team

I just want to add that to prevent burnout, the other area which is important is also about the team that you work with. The team dynamics is very important. Like-minded people, people who can work together and who stay together in the team. I think that helps. (P2 – doctor)

Conversely, considerable workplace tensions arise when there is a breakdown in working relationships within the team or if there are personalities who may not fit in with the team culture. This can make the working environment unpleasant and also leads individuals to burnout.

Breakdown in working relationships

As for the working environment. Certainly, I think working relationships are important. When there’s some breakdown in the working relationships, certainly it can affect the working environment. (P17 – doctor)

Individuals who do not fit in with the team

There are one or 2 who cannot get along with the others, within the nursing team but they have come and gone. (P2 – doctor)

Caring for the team

Expressing genuine care for teammates that extends beyond the workplace and showing concern for their personal well-being serves to build trust and bonds within the team.

Care and concern for teammates

People are closely knit and help each other out. They are concerned about your lives. And I think that gets the whole team together to work towards a common goal, that helps, in preventing burnout. (P2 – doctor)

Our respondents also shared that they appreciated it when other team members ‘looked out for them’ and noticed their fatigue or emotional distress after reviewing challenging cases. It was important to have someone empathise or encourage them during these situations.

Watching each other’s backs

People (clinicians) coming back from the wards, coming from difficult situations, … sometimes they may not necessarily want to talk about the case, but just having a colleague empathise – ‘You look tired’ – having somebody who’s just looking out for you, it helps. (P10 – social worker)

Sharing the burden

Being part of the palliative care team also meant sharing the ‘burden of care’ with other colleagues who had other areas of expertise or points of view that could lead to a better understanding of a challenging situation. It also meant having the humility to admit that we do not always have all the answers or have become ‘too enmeshed’ and need the help of other team members to help us care for the patient.

Sharing the burden as a team

You have to act as a team. It’s not just you. The team will look at that complex problem from different perspectives, so you gain a better understanding of the complexity of the family. We need to acknowledge that we don’t work alone, and that it’s not only your problem, but it’s the problem of the team, so you share the burden – that’s very important. In palliative care, the interdisciplinary and multi-disciplinary teamwork approach is very crucial. (P11 – doctor)

Needing help from other team members

So there were moments I had actually ‘surrendered’ and said ‘I can’t do this alone’, I felt that I was probably too enmeshed or involved or whatever you call it, like you are just ‘too deep’ into it and you need the support of your other colleagues to make this work. It’s moments like these that you feel, I can’t do this alone. (P14 – nurse)

Growing together

The process of going through challenges and seeing ‘tough’ cases together appears to build the spirit and camaraderie of the team. Another aspect of growing together as a team is in positive conflict resolution, where team members feel comfortable enough to share and discuss their views and disagreements openly and constructively.

Going through tough cases together

It’s so hard, it’s so sad, you know when certain patients die and those colleagues that I’ve worked closely with… sometimes we do talk about it and sometimes just knowing that they’re around and we’re all in this together, the camaraderie helps. (P10 – social worker)

Resolving conflicts positively

Every team experiences conflict. It’s good to talk about it openly. I always tell the team that we should voice our unhappiness. Because I can’t see my own behaviour, I need somebody to tell me the truth. That’s the way to really resolve conflicts. (P16 – nurse)

Organisations

Organisations that had a strong commitment to palliative care, supported staff welfare and development, had channels of open communication, provided adequate staffing and held organisational activities promoting staff well-being helped their clinicians build resilience and combat burnout.

Strong commitment to palliative care

Strong support and belief in palliative care from senior management of hospitals and hospices was described as an important element in preventing burnout. This sense of confidence in palliative care often percolates down to the rest of the organisation.

I think it really helps when an organisation believes in palliative care. So I think I’m really fortunate, how in XXX (name of organisation), the senior management set up palliative care… we’re even more blessed here because I think amongst senior management, a certain core group of people believe in palliative care. I found that extremely supportive. That everybody believes in it. (P10 – social worker)

Staff welfare and development

Our clinicians also reported that institutions that make staff welfare and growth an important part of their core mission helped reduce staff burnout. Staff welfare could be interpreted as having ‘family-friendly practices’ and flexibility towards leave matters like allowing staff to take time off to attend to young children or elderly parents. These considerate actions by the employers go a long way towards fostering loyalty towards the organisation.

It was also important for organisations to build in support systems like providing counselling services or psychological support to their staff as this allows them to have a ‘safe space’ to express their fears and concerns and to receive advice and psychological support.

The clinicians appreciated their organisations who invested in them and supported their further training, including their participation in local and overseas courses, conferences or fellowship programmes.

Staff welfare

I consider the organisational support here to be good, because we have staff who have elderly parents or young children and although we are working ‘office hours’, the organisation is flexible in the way that it allows us to take urgent leave for family matters. That is important to staff as we feel that if the organisation supports us when we need time away from work, that breeds loyalty to the organisation. (P5 – nurse)

Professional supervision/counselling

We have a clinical supervisor who is a psychologist (based abroad) who specialises in grief and bereavement. We Skype her once every 2 months and share particular issues regarding work including the team itself, or patients, or caregivers and she supports us in these 1 hour sessions. She is able to give us a different perspective and we find that it really helps us a lot. (P5 – nurse)

In our organisation, there are systems in place for the nurses, for the clinical staff, to attend regular meetings with counsellors. (P2 – doctor)

Staff development

The organisation is willing to support us when we want to attend conferences, even conferences abroad. So I’ve been through a lot of training and attachments. They have been very supportive. (P11 – doctor)

I went to further my studies. I went to do a fellowship in palliative care social work, and I received mentorship for about two years. It was very good. (P12 – social worker)

Open communication

CEOs who made regular efforts to ‘walk the ground’, listen to their staff and allowing them ‘air time’ to share their feedback and views were lauded by their employees. Our respondents felt that the primary concern of the organisation should be towards the welfare of their staff and once the staff felt well-taken care of, patients would automatically be well-cared for too.

I think listening to your employees is very important, because I believe that your first customers are your employees, so if you take care of your employees very well, your patients will also be well taken care of.

Our CEO will go on a regular rotation to different teams…to get a sense of what we feel, what are our complaints, what do we want, what are our problems. That gives us an avenue to air our views and share our suggestions, and I think that is very good. (P11 – doctor)

Adequate staffing and resources

Respondents shared that it was important that palliative care teams are adequately staffed to meet the constant challenges and intensity of caring for patients and families near the end of life.

Nowadays things are better, we have more social workers who can provide the counselling support. We also have more nurses which means we all have a ‘lighter load’ and that makes work easier and our ‘hearts lighter’ and less burdened. (P6 – nurse)

Conversely, some respondents felt that they were not given ‘protected time’ by the organisation for other non-clinical responsibilities like preparing for lectures and engaging in research.

We are invited to give lectures at other institutions but you have to prepare the lectures on your own time. They don’t give you that ‘protected time’ to prepare. And it’s not so straightforward that you can do it in 1–2 hours. There is a lot of time spent reading around the topic and preparing for it beforehand. (P5 – nurse)

‘Most of my time is spent on clinical work and teaching. Whatever I do in research is really in my own time’ (P9 – doctor)

Activities to promote staff well-being

Good organisations paid attention to the psychological well-being of their staff and made it a management priority. They arranged regular activities and gatherings that allowed the team to socialise and focus on self-care as well as team building. These activities serve to mitigate burnout, bonds the team and promotes resilience.

One good thing about YYY (name of organisation) is that they have a lot of activities, so during management discussions, we also talk about how we can support staff regularly to help manage their stress, to bring them away from ‘this kind of work’. Every month we have a social activity, we have handicraft, we have gardening, we have themed celebrations. We try and celebrate every occasion. (P1 – nurse)

Discussion

We conducted a thematic analysis on the attitudes and views of 18 experienced PCCs working in various settings towards the role that leaders, teams and organisations played in reducing burnout and building resilience. This study builds on the literature on how burnout and resilience in palliative care is actually a transformational growth process we termed ‘SCAR’, where clinicians experience various ‘struggles’ undergo a mental process of ‘cognitive reframing’ and form ‘adaptive’ strategies before achieving individual and collective ‘resilience’.8

Role of leaders

We found that positive leadership traits that reduced burnout were being supportive, caring and compassionate, possessing good communication skills as well as the ability to protect the team from abuse. Conversely leaders who were ‘too controlling’ or ‘micro-managing’ led to greater burnout. Clinicians in our study reported that supportive leaders who encouraged autonomy, empowered subordinates and resisted micromanagement20 reflected a prominent trait of transformational leadership (whereby leaders encouraged team members to take ownership of their work) that helped to reduce occupational burnout.21 Leaders who were caring and exhibited individualised consideration to their subordinates also helped to lower their rates of burnout.22 The ability of leaders to communicate well and effectively and to be people oriented23 was also found to be important in our study. Protective leaders who ‘watched their team’s backs’ were rewarded with more positive engagement at work from their subordinates.24

Role of palliative care teams

Palliative care teams also had a significant role to play in helping colleagues and coworkers manage burnout and remain resilient. Teams who work well together experience reduced emotional exhaustion, make fewer medical errors and improve patient safety.25 We found that teams that were more like-minded in their thinking and outlook, having teammates who genuinely cared for and looked out for each other as well as sharing the burden of caring for patients tend to be stronger. Team members who displayed like-mindedness, described as ‘being on the same page’26 and who shared trusting relationships and had mutual respect, were often more united27 and consequently less burnt out. On the contrary, those who did not fit into the team culture well tend to leave. Teams who went through ‘tough cases’ together appeared to form positive and stronger bonds. Those able to resolve conflicts positively and constructively were also able to build up the team’s resilience. We postulate that the like-mindedness and genuine caring environment of these teams tend to create a positive workplace environment that helped reduce burnout. Going through challenging situations together as a team does ‘solidify’ bonds and builds trust among team members. Sharing the burden was identified early in palliative care as being protective against burnout.28 While conflicts are an unavoidable part of healthcare, the ability to work through it and emerge unscathed fosters a closer team identity and therapeutic team relationship that ultimately leads to a positive working environment.29 In a recently published study on team approaches in palliative care,30 teamwork was perceived by many experts as an indispensable functionality of palliative care teams. Being able to cope with conflict in a positive manner may also be reflective of more mature teams who have found ways to grow and mature together. Conversely, conflicts that lead to a breakdown in relationships caused significant stress amounting to burnout and usually leading to one of the parties leaving the team.

Role of organisation

Burnout correlates with poorer quality of care, decreased patient satisfaction and may ultimately affect the organisation’s ‘bottom line’ and financial viability.31 Our respondents shared that their individual organisations played an important role in helping the clinicians to build resilience. Those organisations who ‘believed’ in the philosophy and importance of palliative care tended to support their staff more positively. Administrative leaders like CEOs who held regular engagement sessions with the team were also lauded for their efforts in preventing burnout by listening and communicating with staff better. Having these open communication lines with senior leadership was described as one of the key criteria for promoting organisational change and investing in physician well-being.31 Clinicians also felt that it was important that their organisations provided opportunities for growth and development. Many of our clinicians have gone on to take up positions of leadership after this ‘investment’ from their organisations,32 perpetuating the positive culture of continual ‘growth’. Having systems in place for their staff to attend counselling sessions and having activities that build team morale and promote resilience was also viewed positively. The usefulness of mindfulness-related activities within palliative care organisations have been described recently in helping to reduce burnout.33 Managing workload by having enough staff and being given sufficient ‘protected time’ for non-clinical activities was viewed as an important organisational prerogative in reducing burnout as well. In general, having a manageable workload was one of the key drivers behind physician engagement in the Mayo Clinic experience.34 Unfortunately, the continued understaffing of palliative care teams35 remains a major issue for countries like the USA. Understaffing palliative care teams potentially leads to poorer quality of patient care and clinician burnout. Organisations that valued palliative care, whose leaders listened, placed priority on staff well-being, had organisational ‘bonding’ activities and who conscientiously managed staff workload were able to build more positively resilient organisations.

While we presented our findings in three distinct categories: leaders, teams and organisations, we would like to affirm that in reality, these categories do not exist in isolation and must coexist together to successfully help a PCC and their teams manage burnout and become resilient. Having a good leader and team without a supportive organisation may still cause clinicians to burnout.

Implications for practice

We present some recommendations (table 2) based on the findings from our study as a guide for palliative care leaders, teams and administrators to consider adopting to maintain the psychological well-being and build resilience in their teams.

Table 2

Recommendations and practical measures for preventing burnout and promoting resilience

Strengths and limitations

Our study included experienced PCCs with an average of 15 years of experience. The involvement of doctors, nurses and social workers working in different palliative care settings–hospital, home hospice and inpatient hospice—allows our study to be more inclusive and generalisable.

We also acknowledge that while we have limited the discussion on leadership to clinician and organisational leaders, clinical leadership could come from within the team itself with members using leadership skills in their everyday work to improve care and job satisfaction within their own teams.36

Future studies can delve deeper into the types of leadership styles37 like ‘authentic leadership’ and how it directly impacts on palliative care team members’ coping, burnout and resilience.

Conclusion

Having empowering and compassionate leaders, like-minded teams who care for each other and share their burdens and supportive organisations that promote staff well-being and growth are key factors behind managing burnout and building resilience in palliative care teams.

Acknowledgments

The authors acknowledge the work of the interviewer, Ms Lim Lizhen Sthenos, whose expertise enabled the interviews to be carried out smoothly. We also acknowledge Ms Carin Low and Jermain Chu for preparing and submitting the article.

References

Footnotes

  • Contributors MYHK, AH, SHK were involved in the conceptualising and data analysis of the paper. All authors including MDG were involved in the writing of the paper.

  • Funding This study was funded by a grant from Health Outcomes and Medical Education Research, National Healthcare Group (Grant no. FY18/A03).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study received ethical approval from the National Healthcare Group Domain Specific Review Board (NHG DSRB Ref: 2017/00667).

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. The study participants details were deidentified.