A Continuing Educational Program Supporting Health Professionals to Manage Grief and Loss

Round 1

Reviewer 1 Report

Thank you for the opportunity to review “Continuing Educational Program Supporting Health Professionals to Manage Grief and Loss.”

The authors describe online educational program facilitated by mental health provider in psycho-oncology about compassion fatigue, management of grief and loss to health care providers who largely cared for patients with cancer. This was done via a national educational institution over ~8 years in the pre pandemic phase. In addition to difficult case discussion, the revised grief experience inventory was used to teach as well as assess response to the intervention. The program increased knowledge about grief and its management and had high satisfaction score. The following concerns need to be addressed.

Introduction

The focus is largely on compassion fatigue with little mention about how healthcare providers manage grief. Please consider revising accordingly.

How does the current online educational program differ from ARP? [reference #27]

Methods:

Majority of the participants were nurses with more than 50% caring for all cancer patients, but no one dropped out. Is it because the course was part of online education requirement for core competency? Was the participation voluntary?

More description of the RGEI measure will be helpful, for example, score range, what is the recommended cut off score? Why was it considered as a teaching tool?

Why was no other tool used, for example, to assess compassion fatigue or secondary trauma response?

At what time point was post test done, for example, immediately after completion of course?

Results:

Participant characteristics: Why were participants who were already seeing a grief counselor included in the study?

The authors provide a comparison RGEI score table which is unique.

Discussion

If authors could elaborate reasons for possible variation in RGEI scores in the 3 different study samples, i.e., primary care giver, pediatric nurses and the current study that would be helpful.

Other limitations include sample limited to females and nurses. It appears most of the health care providers were in ambulatory setting, but needs more clarification.

Author Response

Response to Reviewer 1:

Thank you for the positive comments on our paper and suggestions.

In relation to the Introduction, the reviewer noted that the focus of the paper is on compassion fatigue with “little mention about how healthcare providers manage grief” or linkage to grief.

Our program aimed to improve knowledge of both grief reactions and strategies to support its management and see exposure to loss and grief as being linked to CF.  We have added further clarification to link the concepts and have aimed to be more consistent in the paper to show that the program attended to content on both areas (see revisions in introduction and background sections).

The reviewer asked how the current online educational program differs from ARP?

We included, in the literature review, the Flarity intervention [Flarity 2013] which is based on the Accelerated Recovery Program (ARP) for compassion fatigue. The intervention includes two components:  a 4- hour seminar with some similar content to our program on CF, what it is, symptoms, strategies for self care; and multimedia video and resources. So it was educational, but less intensive.  The report suggests it was well received by emergency nurses (a smaller sample). Mostly qualitative feedback was provided.

In relation to Methods, the majority of the participants were nurses, with more than 50% caring for all cancer patients.  The reviewer noted that no one had dropped out. The reviewer inquired if the course was part of online education requirement for core competency and if participation was voluntary?

We have added this information into the manuscript, in methods section. The program was voluntary, advertised on an educational website that offers the course. While a credit was given for the course, the participation is not mandatory. It was recommended, in some cases, by managers or co-workers who had taken an earlier offering. The high retention rate speaks to the need of our program and its quality.

The reviewer suggested providing more description of the RGEI measure, including score ranges and if there is a cut off. And inquired as to why it was considered as a teaching tool?

We included the measure to assess grief symptoms /emotional well-being of participants as it provides detailed questions on certain domains related to grief symptoms (physical domains, emotional, spiritual). We found that by having participants complete the tool and discuss it in class that it facilitated knowledge around what symptoms to assess in patients / family members (and self) and to further understanding on the range of potential grief experience symptoms. The self- reflection/ completion component generated discussions in the course and opportunity to reflect on losses and personal experience/ feelings/symptoms.  We revised the last second paragraph under 2.3 Content to address this issue.

The reviewer asked “Why was no other tool used, for example, to assess compassion fatigue or secondary trauma response was used”?

When we originally planned the course, we focused more on knowledge/ confidence as outcomes and developed our questionnaire to assess those. We did not plan the course as a “psychosocial intervention” per se. However, realizing now the importance of the shared group experience via the community of practice and the role of education in supporting functioning/ coping and emotional well-being we regret not including a measure of CF or trauma related measure. Qualitative comments from participants suggest benefit in psychosocial / functioning domain but we have no data to support this conclusion. This is a limitation of the evaluation and we have noted it in the paper.

There was a question raised concerning the time of post test survey.

It was completed within one week of course completion. This has been added to the manuscript, under 3.3 Kirkpatrick Model for Evaluation of Training Programs.

In relation to the Results section, the reviewer asked why participants who were already seeing a grief counselor included in the study?

This question asked if they had seen a grief counselor in the past and we do not know if this was related to work or prior personal loss nor asked when it occurred. We were not conducting a study of a psychosocial intervention, and therefore, did not consider a need to have a screening instrument or question prior to entry. In fact, we welcomed all participants interested in learning more on the topic.  We added a footnote to Table 3 on this issue.

In relation to the Discussion, it was recommended to add further information concerning potential reasons for possible variation in RGEI scores in the 3 different study samples, i.e., primary care giver, pediatric nurses and the current study.

We have now added further elaboration in the manuscript in the results section 5.2, as well as in the discussion section.

It was suggested to note an additional limitation to the sample, in that it was females and chiefly of nurses.

That limitation has now been noted in the manuscript, under limitations.

Thank you again for the through and helpful feedback. We hope that these changes will be satisfactory and look forward to hearing further about our paper’s consideration for Current Oncology special issue.

Best,

Mary Jane

Reviewer 2 Report

 Continuing Educational Program Supporting Health Professionals to Manage Grief and Loss

This paper describes an important innovation for an educational program aimed to support health care professionals working in the oncology setting in order to manage the implications of their work. Working in an oncology setting is characterized by extensive exposure to death and suffering, and developing interventions for this population is significant in response to the accumulating reports of high levels of compassion fatigue, burnout, and grief among these professionals.

In general, the paper is comprehensive, well-written and clear. However, before publication there are some issues that need to be addressed:

General:

My main concern regards confusion about the main variables that the intervention targets and that are discussed throughout the paper. The title of the paper, as well as the instrument being used in the study, focuses on health professionals' grief and loss, whereas the introduction focuses mainly on compassion fatigue and burden. Although the authors refer to the lack of a compassion fatigue measurement in the limitations section (which is a major disadvantage given that the intervention refers to compassion fatigue), I recommend that the authors clarify what the main purpose of the intervention is, what this specific paper refers to (compassion fatigue or grief and loss management), and address the associations between these concepts in the introduction and in the discussion. This comment pertains to everything from the paper’s title to its conclusion.

Introduction

• Concerning the above comment, although the title and the measurement tool focus on grief and loss, the introduction solely discusses health care professionals' compassion fatigue and does not discuss their grief reactions. This lack of congruence is confusing and needs to be addressed.
• A reference to the uniqueness of the oncology setting is missing.
• Objective: The objective is not clearly phrased. In addition, I would also recommend moving the evaluation model to the method section.

Method

• Please explain what "online community of practice" is.
• Please explain what the "importance of having a ‘working’ model of grief and loss” is (Table 1).
• I would urge the authors to explain in more detail the course strategies – the explanation appears now only in Table 1 and it is crucial in order to understand the intervention.

Evaluation components

• There is redundancy between Table 2 and the participants’ section. In addition, I recommend moving the table to the participants’ section.
• Was the evaluation tool reliable?
• How were the specific behavioral changes selected?

Evaluation analysis

• What open-ended questions were asked (i.e., the questions whose content was later explored)?
• A pre-post analysis of grief is not mentioned.

Results

• References to tables in the text need to be added.
• Table 3 is not clear. It introduces a comparison between the study's results on the RGEI and other studies, but it is not clear whether a statistical comparison was made and whether it was statistically significant. It is not clear who the “primary care givers” are, and the Note for this Table is not clear at all. I wonder if this whole comparison should not be part of the discussion when discussing the current results in light of the existing literature.
• In order to better understand the results of the Kirkpatrick model for evaluation I recommend that the authors add the possible range of the different sub-scales.
• There is redundancy between Figure 1 and the text (page 7).
• What is "the average rating for individual items"? The meaning of this result is not clear.
• The authors report a change from pre to post on the VAS item, but do not report T and p values.
• What was the post-course feedback that is reported on page 8? It is not clear from the method section.

Discussion

The authors discuss the role of the "self" in providing supportive and psychosocial care (page 9) – it is not clear what this means.

A more focused discussion of the very interesting intervention delivered in the current study is missing, in light of the study's encouraging results.

Author Response

Response to Reviewer 2

We thank the reviewer for the positive comments suggesting that the program for developing an intervention for health care providers in oncology populations is significant, given the accumulating reports of high levels of compassion fatigue, burnout, and grief among these professionals. We also appreciate the comments that the paper in general is “comprehensive”, “well-written” and “clear”.  The reviewer’s suggestions and recommendations have strengthened our manuscript.

A main concern expressed was related to the confusion about the main variables that the intervention targets and that are discussed throughout the paper. The reviewer noted that the title of the paper, as well as the instrument being used in the study, focuses on health professionals' grief and loss, whereas the introduction focuses mainly on compassion fatigue and burden. 

We have clarified the main purpose of the and have provided further linkage between grief and loss and its role in contributing to CF. The primary focus of the course is managing grief and loss. However, we had a lot of content in the course on CF, symptoms and risk factors so that health professionals could gain knowledge about what to look for and how multiple losses in their practices can lead to symptoms. We also aimed to have the health professionals gain an appreciation of how their own personal variables (prior losses  personally, attachment style, or characteristics) can play a role in how they cope and deal with loss, as well as how organization and team- related factors can contribute to coping / and over time contribute to CF and burnout. The introduction and background sections have been revised. We hope that our focus is now more clear to readers.

Other comments:

A reference to the uniqueness of the oncology setting is missing

We have added statements that loss is part of working in oncology care.

It was recommended to more clearly state the objective and to move the evaluation model with evaluation.

We have revised the objective to try to state our objective of paper and program more clearly. We also adjusted section 3 evaluation components

Explain more what online community of practice is

As suggested, we have added details of the online community of practice and indicated why we included it into the program, in the manuscript’s intervention section 2.2.

Please explain what the "importance of having a ‘working’ model of grief and loss” is (Table 1). I would urge the authors to explain in more detail the course strategies – the explanation appears now only in Table 1 and it is crucial in order to understand the intervention.

Also as recommended, we have clarified the need to have an understanding of “working model” of theory of grief and its symptoms. We believe health professionals should have a clear understanding of concepts of loss, grief reactions, severity of grief reactions, and how to assess /respond, as well as to reflect on own experiences. Grief models help clarify concepts, reactions, phases, etc.  We have also added some further detail about the course strategies or content. These changes are shown in section 2.3 Content.

Suggestions were offered in relation to the Evaluation components section to reduce redundancy between Table 2 and the participants’ section.

We have moved table 2 and reduced participant section to remove redundancy.  In relation to our evaluation analysis section, we have included the open-ended questions that were asked. We also explained that the knowledge and confidence survey tool was based on course learning objectives.

The reviewer noted that a pre-post analysis of grief was not mentioned.

The reviewer is correct. We only gave the grief measure prior to the course to assess baseline functioning coming into the program.  We then use it in our teaching/ reflections. We included the measure to assess grief symptoms /emotional well-being of participants as it provides detailed questions on certain domains related to grief symptoms (physical domains, emotional, spiritual). We found that by having participants complete the tool and discuss it in class that it facilitated knowledge around what symptoms to assess in patients / family members (and self) and to further understanding on the range of potential grief experience symptoms. The self- reflection/ completion component generated discussions in the course and opportunity to reflect on losses and personal experience/ feelings/symptoms. We revised the last second paragraph in section 2.3 Content.

References to tables in the text need to be added.  It was recommended to further clarify Table 3 as it provides comparison scores between the study's results on the RGEI and other studies, as it was not clear who the “primary caregivers” are and if further information could be included in the discussion in light of the existing literature.

We have clarified table 3, added references, and expanded paragraphs in our discussion section reflecting the literature, our study finding and the comparison with the literature, as well as its implication.

For the results of the Kirkpatrick model for evaluation, It was recommended to add possible range of the different sub-scales. What is "the average rating for individual items"? The meaning of this result is not clear.

Ranges and further descriptions have now been added to the manuscript. We have also tried to reduce redundancy. T and p values have also been provided for VAS item, and we added description of the open ended post-course feedback.

For the Discussion, the reviewer asked for clarify of the role of the "self" in providing supportive and psychosocial care.

We have tried to note the role of health provider/ patient having a relationship which involves interpersonal process (and therefore health care provider’s self).

The reviewer also suggested a more focused discussion of the intervention delivered in the current study, in light of the study's encouraging results.

We have added to and reorganized our discussion.

Thank you again for the through and helpful feedback. We hope that these changes will be satisfactory and look forward to hearing further about our paper’s consideration for Current Oncology special issue.

Best,

Mary Jane

Round 2

Reviewer 1 Report

Thank you for harmonizing and clarifying the questions. 

Reviewer 2 Report

Review of "Continuing Educational Program Supporting Health Professionals to Manage Grief and Loss".

This paper is describing an important innovation for educational program aimed to support health care professionals working in the oncology setting to manage the implications of their work. This work is characterized by extensive exposure to death and suffering. Developing interventions for this population is significant as an answer to the accumulating reports on high levels of compassion fatigue, burnout and grief among these professionals.

In general, the paper is comprehensive, well written and clear.

After reviewing the new version of the paper, I find it suitable for publication. The authors responded to the comments and suggestions that were offer to them, what made their paper better, clearer and more comprehensive. The intervention described in the paper is significant and might help to decrease compassion fatigue and help oncology health professionals manage grief and loss they experience daily as part as their work.  

I recommend to accept this paper for publication.