A total of five systematic reviews are summarised in this review of the literature pertaining to self-care in a palliative care setting; [1-3] with two remaining papers [4,5] referenced despite not being aged care focused, but which still had relevance to the subject matter.
Overall the quality of the evidence was generally high with only one of the reviews found to be of low quality;  while the remaining papers were deemed either moderate  or high quality. [1,3,5] Study design and quality reporting were the main reasons for lower scoring when applying the SIGN methodology checklist.
A systematic review of six qualitative and mixed method studies by Zheng et al.  found that new graduate nurses in particular find looking after patients at end of life emotionally charged; creating feelings of anxiety, stress, guilt and helplessness. Such nurses particularly found the act of withdrawing care difficult to come to terms with and were more likely to advocate strongly with the family for extended support. Similarly, once the patient dies, new graduates often feel alone and isolated with limited ability to debrief with anyone on the experience.  The paper surmises that new graduates would benefit from upskilling in counselling skills and general palliative care knowledge. Some nurses had engaged in specialised programs which they felt had been beneficial but others felt hands on experience and observation was of more use. 
Literature suggests more experienced staff who have spent more years nursing and who have engaged in further education may be less likely to feel ‘stressed’ in a palliative care role and often present with low stress scores in pre-test interventions such as those discussed in the review by Pitfield et al. . It is suggested that when nurses learn to ‘cope’ with work stress they may become more effective as palliative care professionals. 
In general it is accepted that palliative care staff (literature generally refers to nursing staff) are likely to experience challenges in the workplace due to the nature of their role. A systematic review by Gillman et al.  suggest that staff need to develop ‘resilience’, described as an ability to cope and grow from adversity, as a method of self-care.
‘Burnout’ and Self-Care
Stress and burnout are terms often used in palliative care literature, describing psychological distress experienced by caregivers. While levels of burnout in palliative care nurses is similar to nurses employed in other clinical domains (~25-50%), [1,2] employers have an obligation to ensure staff wellness and wellbeing, which will in turn have an impact on patient care.  Management techniques for self-care are discussed in two of the review papers. [1,2]
There is no clear consensus in the literature on how employers should manage burnout, but recent qualitative research suggests the need for a skill-building intervention approach  for staff to implement during work.
In a systematic review examining effectiveness of psychosocial interventions with staff in palliative care settings, nine qualitative studies were described. A variety of strategies were utilised in the studies including a stress reduction program, music therapy, a psycho- existential intervention, group based sleep intervention and art therapy. Overall the quality of the studies included in the review were weak, with only two of the nine rated as moderate quality. The review found that none of the interventions offered any significant improvement in psychological outcomes and also noted that in all but two of the studies the participants were not psychologically impaired in their pre-test scores. 
Another review by Peters et al.  examining coping styles in palliative care nurses suggests that emotion focused coping and problem focused coping are currently employed by nurses to manage their stress, with a preference for problem focused coping. Examples given are cases where ‘stressors’ are alleviated in problem focused coping i.e. casual staff brought in to reduce workload, or attempts to suppress negative emotions in emotion focused coping. Both are thought to only postpone stress leading to burnout rather than resolving their causes. In the review by Zheng et al.  student nurses in particular used emotion focused coping strategies, which often resulted in them becoming withdrawn and with decreased resilience to future encounters with patient death. A study by Byrne and McMurray (1997) discussed in this review  offers a different more constructive approach of ‘self-care’. Their observation of Australian hospice nurses found that nurses who took care of themselves and were able to keep work in perspective were often more able to relate to their work as a journey of self-development and were less inclined to stress and burnout. Strategies that have been proposed to help alleviate some of the stress and negative emotion felt by nursing staff, particularly new staff, in palliative care are;
- Formalised mentoring for staff,
- Structured de-briefing,
- Professional supervision. 
In addition, the review makes reference to other informal support also being found to support nurses in their professional development and coping, such as reflective discussions in informal gatherings or team meetings.  These strategies are all also discussed in the review by Gillman et al.,  in addition to staff retreats and stress inoculation therapy delivered via mobile phone technology.  In addition the paper makes mention of the importance of preventive measures such as promoting a work-life balance with refresher training periodically to recharge enthusiasm in all staff .
In summary, the evidence is limited in accurately measuring burnout and recognises that there may be bias in the staff sampled within the studies reviewed. Despite this, qualitative studies do suggest that new graduate nursing staff and nurses in rural and remote communities are particularly at risk of burn out. This is mainly because of their close working relationships with individuals and their isolation from colleagues and lack of formal debriefing or reflection. The research recognises that experienced care staff, or those with ‘inherent’ optimism are best suited to palliative care, but staff retention relies on supporting good ‘self-care’ and supporting new staff in their experiences of managing death and dying patients and their families. It would be reasonable to propose that strategies such as mentoring, supervision and professional development in this area would somewhat assist in managing burnout even in the absence of robust evidence, however more research is required to determine workable formats with clinically significant outcomes.
Page updated 22 May 2017
- Aged Care space and support structures
- Aged Care staff may not recognise themselves as palliative care – the literature does not refer to Aged Care staff but the staff in Aged Care do often provide end-of-life care
- A list of self-care strategies which do not have an evidence basis
- Growing need for organisational institutional self-care practices (performance reviews)
- Further research looking at self-care through a health-promotion and prevention paradigm rather than a coping framework