Through history, individuals care has been provided primarily by the self and the family in all societies. As defined by the World Health Organization, “self-care in health refers to the activities individuals, families and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health” (WHO, 1983, p. 181).

A review of the self-care literature undertaken during the last decades indicates that studies carried on the self-care arena are mainly focused on two areas: chronic and common illnesses self-care (Khagram, Martin, Davies, & Speight, Reference Khagram, Martin, Davies and Speight2013). However, self-care is also outstanding in general population’s everyday health needs (White et al., Reference White, South, Bagnall, Forshaw, Spoor, Marchant and Witty2012), and the development of self-care skills that lead the general public to adopt more healthy lifestyles starts to be the core of several policies and projects. At this point, special attention deserves the role of self-care in professionals who deal with stressful events, as it is the case of health professionals.

When compared to other professionals, health care workers present higher rates of stress-related sickness, together with other health problems, such as somatic and mental complaints, due to the increased clinical demand, long workdays, and lack of colleagues support (Gibb, Cameron, Hamilton, Murphy, & Naji, Reference Gibb, Cameron, Hamilton, Murphy and Naji2010). Together with all these circumstances, coping with death on a daily basis must be added in the concrete case of palliative care professionals.

Among health professionals, those working in the scope of death and dying are even more exposed to matters of existential character, facing psychological challenges and frequently experiencing emotional distress. The risks of working in this context are well documented, and may lead to burn out (Peters et al., Reference Peters, Cant, Sellick, O'Connor, Lee, Burney and Karimi2012), compassion fatigue and poor quality of care (Kearney, Weininger, Vachon, Harrison, & Mount, Reference Kearney, Weininger, Vachon, Harrison and Mount2009). In the palliative care framework, mindful awareness is thought to enhance professionals’ ability to engage in the rest of protective practices, in concrete, in self-care activities (Harrison & Westwood, Reference Harrison and Westwood2009). Regarding the relation between coping with death and self-care, many authors have found that self-care activities have a positive effect on palliative care practice. For example, Shanafelt et al. (Reference Shanafelt, Novonty, Johnson, Zhao, Steensma, Lacy and Sloan2005) found that oncologists with greater work satisfaction were those who used wellness strategies in caring for themselves. As regards inner self-care, spirituality has traditionally been seen as a way for clinicians to reconnect with their roots and serve those suffering (Puchalski & Guenther, Reference Puchalski and Guenther2012). Social self-care has been also related to well-functioning, in the form of peer support or stable personal relationships (Barnard, Street, & Love, Reference Barnard, Street and Love2006). And most of the literature relates self-care, and specifically physical self-care (i.e., healthy diet, regular exercise) to professional well-being (Harrison & Westwood, Reference Harrison and Westwood2009). In general, self-care has arisen as a predictor of coping with death, being then an indirect key to avoid compassion fatigue or burnout, as recognized in previous literature (Aycock & Boyle, Reference Aycock and Boyle2009). Finally, self-care has also been positively related to compassion satisfaction, and negatively to compassion fatigue and burnout (Harr, Reference Harr2013). In particular regarding social self-care, professionals without an adequate social support become more vulnerable to burnout and compassion fatigue (Adams, Figley, & Boscarino, Reference Adams, Figley and Boscarino2008).

Among the measures used to assess self-care in general population, stands out the Health- Promoting Lifestyle Profile II, developed by Pender (Reference Pender1996), which is developed following her self-care model. According to Pender, health-promoting behaviors are measured as an expression of health, including the areas of health responsibility, physical activity, nutrition, interpersonal relations, spiritual growth, and stress management. Each area represents a subscale on the Health- Promoting Lifestyle Profile II. There is also the Self-Care Assessment (Saakvitne & Pearlman, Reference Saakvitne and Pearlman1996), an instrument that evaluates five facets of the self-care using 55 items: physical, psychological, emotional, spiritual, and workplace self-care. Overall, taking into account these and other self-care instruments, it can be concluded that most of them assess three dimensions of self-care: a dimension related to physical health, an inner dimension (psychological, emotional, spiritual…)and another one based on social care (relationships with family, friends, or colleagues) (Richards, Campenni, & Muse-Burke, Reference Richards, Campenni and Muse-Burke2010).

Most of the instruments measuring self-care suffer from some of these limitations: its specific design (addressed to a concrete population), its extensive length, the lack of proper validations. Furthermore, almost any has been used in a broader international palliative care context, none in Spanish population.

The new scale is based on the World Health Organization (WHO) definition of health, as the ‘state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 1948), and on the dimensions hitherto reported: physical, inner, and social self-care. Physical care has been traditionally understood as the incorporation of physical activities to daily life. A recent study on 249 Portuguese workers offered evidence of how an exercise program can improve, not only physical functioning or bodily pain, but also general health, social functioning, and mental health (Mesquita, Ribeiro, & Moreira, Reference Mesquita, Ribeiro and Moreira2012). Although in palliative care professionals results are not so clear, practicing exercise has been positively related to stress management, control, and social support (Rodrigues, Carneseca, Paiva, & Ribeiro, Reference Rodrigues, Carneseca, Paiva and Ribeiro2014). Inner care, in turn, has been defined as having care of the own inner world (Reference O’ConnorO’connor, 2001). This dimension also includes spirituality components, such as meditation (Schure, Christopher, & Christopher, Reference Schure, Christopher and Christopher2008). Yong, Kim, Park, Seo, and Swinton (Reference Yong, Kim, Park, Seo and Swinton2011), for instance, found that practicing meditation during five weeks improved palliative care professionals’ spiritual well-being and leadership, and diminished their stress. Finally, social care comes both from personal (family and friends) and professional systems (Richards et al., Reference Richards, Campenni and Muse-Burke2010). An example of social care benefits for palliative care professionals can be found in Penderell and Brazil’s (Reference Penderell and Brazil2010) study, in which most of these professionals highlighted the importance of having emotional, social and spiritual support from those with whom they shared their experiences, that is, their colleagues.

Current study presents a new instrument to measure professionals’ self-care in palliative caregivers. They often work in emotionally demanding, very stressful conditions that could affect their quality of life. To approach this research problem a holistic approximation is applied (Čančer & Žižek, Reference Čančer and Žižek2015).

Results

Confirmatory factor analysis

A theoretical structure of three factors was specified, estimated and evaluated with this a priori structure. Overall fit indices mainly supported the one factor structure of the scale: χ²(24, N = 385) = 140.66, p < .01; CFI = .91; GFI = .93; SRMR = .09; and RMSEA = .10. Altogether, the indexes assessed the model as an adequate representation of the observed data, with the exception of the RMSEA, that probably penalized the model because of the little number of indicators.

A detailed examination of the factor loadings gives an idea of the model analytical fit, complementing the overall fit information. All indicators significantly loaded in the hypothesized factors (p < .01), giving support to the adequacy of the three-factor structure. The standardized factor loadings for the physical self-care factor were within a minimum of .49 (item 1, “I do exercise regularly”) and a maximum of .73 (item 5, “I practice activities that help me to relax”), between .51 (item 8, “When I feel emotionally overloaded I try to find time for my own care”) and .96 (item 6, “My self-care includes getting actively involved in spiritual practice, meditation, oration…”) for inner self-care and from .24 (item 9, “When I feel overwhelmed by a clinical situation I feel that I can support on my team in order to elaborate this experience”) to .91 (item 3 “I believe that my relations outside work are satisfactory”) for social self-care, as it is shown in Figure 1. All factor loadings were well above the values considered indicative of an adequate consistency, except for item 9, which factor loading was, nevertheless, statistically significant at .01 level.

Figure 1.

Analytical fit of the CFA

Note: All factor loadings and correlations were statistically significant (p < .01). For the sake of clarity, standard errors are not showed.

Internal consistency

Regarding reliability, Cronbach’s alpha was computed for the 3-item length dimensions of self-care, with a value of .62 for the physical self-care factor, .84 for the inner self-care and .53 for the social self-care. Rho and GLB were also calculated, with values of .64 for the physical self-care dimension, .90 for inner self-care, and .57 for the social dimension. Descriptive statistics, scores’ distribution, item homogeneity, alpha if-item-deleted, and inter-item correlations are presented in Table 1. Means are about the mid-point of the items scale in all cases, with no apparent floor or ceiling effects.

Table 1.

Means, standard deviations, scores’ distribution, item homogeneity, alpha if item deleted, and inter-item correlations for the items of the Professional Self-Care Scale

Notes: M = Mean; SD= Standard deviation; Item hom. = Item homogeneity; Alpha i-i-d = Alpha if item delated.

External evidence of validity

Validity was established by correlating the three dimensions of self-care with constructs referred in the palliative care literature. Specifically, the dimensions were related to awareness, coping with death, compassion satisfaction, compassion fatigue and burnout. Results were consistent with previous literature, and a pattern of positive relationships was found among the three dimensions and awareness (Harrison & Westwood, Reference Harrison and Westwood2009), coping with death (Shanafelt et al., Reference Shanafelt, Novonty, Johnson, Zhao, Steensma, Lacy and Sloan2005), and compassion satisfaction (Harr, Reference Harr2013), whereas negative relationships were found among self-care dimensions and secondary trauma and burnout (Adams et al., Reference Adams, Figley and Boscarino2008; Harr, Reference Harr2013), consistently with literature. Relations were between small and medium, with higher values for social self-care. Results are provided in Table 2.

Table 2.

Correlations among self-care dimensions and related variables in the palliative care context

Notes: *p < .05; **p < .01.

Self-care in Spanish palliative care professionals

A first MANOVA was performed on three dependent variables: physical self-care, inner self-care, and social self-care. Independent variable was gender (women and men). With the use of Pillai’s criterion, the combined dependent variables were significantly affected by gender (F(3, 371) = 3.19, p = .02). Results reflected a small association between gender and the combined dependent variables, with a partial η ² = .03. To investigate the impact of independent variable effect on the individual dependent variables, univariate ANOVAs were performed (Table 3). The effect of gender was statistically significant in inner and social care. Women reported higher inner and social care than men (see Table 4).

Table 3.

Follow-up ANOVAs

Table 4.

Means and standard errors of the dependent variables on each group of the socio-demographic factors

Notes: M = Mean; SE = Standard Error.

The second MANOVA was performed on the same dependent variables, with the discipline of professionals as independent variable (doctors, nurses, psychologists, nursing assistants and others). Following Pillai’s criterion, the combined dependent variables were significantly affected by discipline of professionals (F(9, 1074) = 2.00, p = .04). Again, results reflected a small association between professionals’ discipline and the combined dependent variables, with a partial η ² = .02. Univariate ANOVA showed that professionals’ discipline was statistically significant in inner and social care (see Table 3). Psychologists reported higher levels of inner care than doctors and nurses, and higher levels of social care than doctors (see Table 4).

Correlations between the dimensions of self-care and professionals’ age, years of professional experience in health, and years of professional experience in palliative care were also calculated. No statistically significant relations were found.