Caring for people who are dying can be stressful for health professionals. While staff may experience both personal and professional growth as a result of their experiences, this work can also be very emotionally demanding. Ultimately, these demands can lead to stress and burnout which can significantly impact on patient care. 
This page discusses the evidence in support of self-care strategies for professional carers. Information on self-care for informal carers can be found on the Family Carers page.
A total of nine systematic reviews are summarised in this review related to self-care of staff. Five reviews were in a palliative care setting [1-5] with two remaining papers indirectly relating to palliative care [6,7] and two papers with an aged care focus only. [8,9]
Overall, the quality of the evidence was generally good with two of the reviews found to be of low quality [2,5] while the remaining papers were deemed either moderate [4,7-9] or high quality. [1,3,6] Study design and quality reporting were the main reasons for lower scoring.
A systematic review of six qualitative and mixed method studies by Zheng et al.  found that new graduate nurses in particular find looking after people at the end of their life an emotionally charged task, 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 person 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 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. These nurses often present with low stress scores in pre-test interventions such as those discussed in the review by Pitfield et al.  In general, organisational support towards staff education and training, particularly person-centred care practices, has been identified as a key component in the improvement of job satisfaction, stress levels and a reduction in staff turnover.  Higher job satisfaction has also been associated with lower burnout for staff working with people with dementia in long term care facilities.  It has been 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.  suggests that staff need to develop ‘resilience’, described as an ability to cope and grow from adversity, as a protective measure against stress and burn out, and 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 are similar to nurses employed in other clinical domains (~25-50%), [1,2] caring for someone at end of life, in particular caring for someone who there is a close identification with, can result in significant levels of stress. Additionally, repeated exposure to death and dying (accumulated loss phenomenon) can also significantly impact wellbeing and lead to prolonged stress and ultimately burnout.  Employers have an obligation to support staff in dealing with the challenges of palliative care work and provide information on how to access personal support.  Support of staff wellness and wellbeing will in turn have an impact on patient care.  Management techniques for coping and self-care are discussed in several of the review papers. [1,2,4]
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. 
A review by Peters et al.  examining coping styles in palliative care nurses, suggests that emotion-focused coping and problem-focused coping were currently employed by nurses to manage their stress, with a preference for problem focused coping. Examples given for the alleviation of ‘stressors’ in problem focused coping were through casual staff being 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 death of a person they care for. Powell et al. noted that nurses taking a technical approach to care i.e. ‘doing’ for a person rather than ‘being’ with a person, found that this assisted with their coping ability.  However, they also believed it limited their timespan of working within palliative care possibly because it was less rewarding.
A study by Byrne and McMurray (1997) discussed in this review,  offered 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 with coping and 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, these reviews refer to other forms of informal support which have been found to support nurses in their professional development and coping. These include reflective discussions in informal gatherings or team meetings ; processing of emotions with colleagues, family or friends; fostering connections within the team through giving and receiving support , and adopting the mindset that their role makes a difference.  A number of these strategies are all also discussed in the review by Gillman et al.,  along with staff retreats and stress inoculation therapy delivered via mobile phone technology.  The importance of preventive measures such as promoting a work-life balance  and refresher training periodically to recharge energy and enthusiasm in all staff is also discussed. 
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 of the people they care for and their families. It would be reasonable to propose that strategies such as fostering staff connections, 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.
- 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
Page updated 17 June 2021