In aircraft safety demonstrations, we are repeatedly advised to put on our own oxygen mask before looking to help others. For those working with the dying, maintaining our own physical, emotional, and spiritual health is a crucial component of sustaining quality care.
Sources of stress are multiple, may be accumulative, and are linked to all areas of an individual’s life. Working with dying people may be stressful, particularly if staff experience personal bereavement and loss. Such work can put staff in touch with personal anxiety about loss and death.1, 2 Palliative care staff also find it very stressful to deal with patients who experience intractable pain, those who have young children, and those patients who are afraid to die. Symptoms that leave nurses feeling helpless, useless, and impotent are the most stressful to deal with, as is dealing with distressed relatives.
Overall, however, stress and burnout in palliative care have been found to be less than in other specialties. Some research have shown that this is an area where there is a very high degree of job satisfaction; staff feel they are privileged to be in the position to provide this care. Working with dying people has also been found to influence the attitude of staff towards death and dying. In death anxiety scoring, people who coped well in this field of work scored higher on inner-directedness, self-actualizing value, existentiality, spontaneity, self-regard, self-acceptance, acceptance of aggression, and capacity for intimate contact. They were also more likely to live in the present, rather than the past or future. It is suggested that the reason for lower stress and burnout within hospice palliative care units is due to the recognition that stress may be inherent to the field of death, dying, and bereavement, and consequently more robust support mechanisms have been built into those organizations that provide palliative care.
Hospice and hospital palliative care teams differ considerably, and it has been found that palliative care physicians based in hospitals experience more stress than their hospice colleagues. However, a comparison of 401 specialist registrars’ experience of occupational stress in palliative medicine, medical oncology, and clinical oncology showed there was no significant difference between the specialties. One in four of the specialist registrars (SpRs) experienced stress, and more than one in ten showed clinically important levels of depression.3 The most common suggestions for reducing stress were improved relationships with colleagues and having ‘supportive seniors’. The importance of coping strategies received far more emphasis from the group of palliative medicine trainees than those SpRs in clinical or medical oncology.
References
1. Wein, S., Baider, L. (2015). Coping in palliative medicine. In N. Cherny et al. (eds), Oxford Textbook of Palliative Medicine (5th edn) (pp. 1067–73). Oxford: Oxford University Press.
2. Koh, M.Y.H., et al. (2015). Burnout, psychological morbidity and use of coping mechanisms among palliative care practitioners: A multi-centre cross-sectional study. Palliative Medicine, 29(7), 633–42.
3. Berman, R., Campbell, M., Makin, W., Todd, C. (2007). Occupational stress in palliative medicine, medical oncology and clinical oncology specialist registrars. Clinical Medicine, 7(3), 235–42.
The Health and Safety Executive, UK, recommend that all organizations have a stress policy that outlines the responsibilities of managers and staff to identify stress in the workplace, and provide strategies that may be used to manage this stress and support the staff within the organization. Of note, they recommend the provision of specialist advice and awareness training. A supportive environment and supportive working relationships are essential ingredients in managing the potential stress of working with dying and bereaved people; in addition, it has been found that satisfaction with support in training is protective against stress.
Of importance are the following:
•regular team meetings, where time is provided to evaluate and reflect on difficult situations encountered by the team
•promoting shared decision-making in the management of patient care as the norm
•respecting each other’s expertise
Provision of protected time for clinical supervision and/or reflective practice sessions that support clinical learning and development within a supportive framework are essential, as is a need to support staff in developing realistic expectations of clinical interventions in order to minimize any sense of failure and helplessness.
It is also important that managers provide effective education opportunities for staff who care for dying and bereaved people, such as the development of advanced communication skills and ‘professional competence’, i.e. knowledge, technical skills, relationship insight, and the appropriate attitudes. Interventions to improve resilience and develop positive coping can also help protect against the impact of stress and adverse events. Another means by which this can be achieved is through education in ethics: specifically, virtue ethics or philosophy of care. This is an important component of education in fields of care which involve intense human interactions, as is the case in palliative care.
•personal relationships—spouse/partner, children, caregiver responsibilities, no close relationships/loneliness
•illness—in self or one close to self
•minority-related stress—victim of racism, sexism, ageism, disability prejudice, etc.
•gender-related stress—pressure to do everything/pressure to provide
•inability to create relationships
•negative attitudes—hostility, open dislike, anger
•potential/actual physical violence
•problems of emotional involvement
•guilt feelings—feeling responsible
•inability to create relationships
•‘each doing their own thing’—no teamwork
•open conflict—practice undermined
•negative/pessimistic attitudes to work
•bringing problems at home to work
•resentful of others’ positions—professional jealousy
•lack of support—no supervision, etc.
•no attention paid to personal development
•given inappropriate client group, caseload, etc.
•practice skills not recognized
•lack of involvement in decision-making
•‘routines’ before ‘people’—bureaucracy
•impersonal links with ‘hierarchy’
•poor pay/poor conditions of service
•little professional ‘expertise’
•administrative procedures/paperwork
•functions limited by resources
•lack of clarity of work expectations—low status
•staff shortages/vacancies not filled
•frequent feelings of anger, irritation, and frustration
•feelings of helplessness and insecurity
•developing a supportive culture within the organization
•opportunities to express work-related feelings and discuss problems in the workplace
•mandatory clinical supervision
•provision of a counselling service for staff
•support in developing competencies for working in palliative care
•robust education programmes for staff that include developing insight into individual/personal potential areas of difficulty, avoiding excessive involvement with particular clients, handling emotions, advanced communication skills, etc.
•having a sense of competence, control, and satisfaction in working in palliative care
•having non-job-related outside activities
•engaging in physical activities and diversions
•ensuring adequate sleep and nutrition
•using relaxation techniques, e.g. physical activity, yoga, meditation, complementary therapies
•developing a personal philosophy regarding death that may or may not relate to individual religious or spiritual beliefs
Further reading
Gillman L., et al. (2015) Strategies to promote coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy: a comprehensive systematic review. JBI Database of Systematic Reviews and Implementation Reports, 13(5):131–205.
Heinze K., et al. (2017) Strategies for promoting high-quality care and personal resilience in palliative care. AMA Journal of Ethics, 19(6):601–7.