Key messages

• For staff who choose to work specifically in palliative care, there is no evidence that it is more stressful than other types of health care specialties.
• High levels of burnout are found amongst health care workers providing cancer care services in the Australian health care system. The prevalence of other potential aspects of stress or distress - such as grief, compassion fatigue, moral distress, or demoralisation - have not been well-studied.
• Despite widespread acknowledgement of the importance of self-care and of support for clinicians to maintain their professional and emotional wellbeing, the level of evidence to guide the development of specific programs for that purpose is currently low.

Background
The challenges of working with patients who are approaching death, and their families, may be associated with both satisfaction and stress for clinicians. Clinician stress and burnout are important concerns across the whole health system, as they can affect the quality of care that is provided, patient satisfaction, and may ultimately lead to treatment errors, absenteeism and loss of staff. [1]

Whilst it is often presumed that recurrent exposure to death and to the sadness and distress of patients and families is in itself stressful, working in specialist palliative care has not clearly been identified as more stressful than other areas of health care. [2] However the issues may differ for staff who have chosen to specialise in palliative care, when compared to those who occasionally provide end of life care for patients in other settings.

For non-specialists who occasionally look after dying patients, this role may be experienced as distressing. Provision of palliative care may not be easy to accommodate within the clinician’s usual workload, and may also require a shift in goals and style of care which they may find difficult to manage. For staff working in residential aged care or other long-term care facilities, there are particular issues associated with providing palliative care, including the caregivers’ relationships with their patients. This will be of increasing importance as the aged care sector becomes a more frequent place of death. There may be little organisational support or recognition of the stress associated with provision of palliative care for non-specialist providers. Some of the settings in which these concerns have been identified include intensive care units [3-4] medical and paediatric oncology services, [5] general practice, [6] nursing homes, [7] and generalist and community nursing. [8-11] However, the prevalence or significance of these concerns across the health care system has not been studied.

Active research areas / controversies

• This is a field which, despite its importance, has not been well-studied. No single theoretical model has been used to study clinician stress. Additionally, a variety of instruments have been used to identify stress which makes comparison of results difficult. Some of the issues which have been identified at the level of the individual clinician include burnout, grief, compassion fatigue, demoralisation, and moral distress. Moral distress may occur where a clinician may feel implicated in, or distressed by, their involvement in care for patients which they believe is inappropriate or contributing to patients’ suffering. Relationships between these different aspects of clinician stress have not been well defined, and apart from burnout, the evidence for each derives from mostly small and descriptive studies. We do not know how common or significant any of these problems are. These constructs require further mapping and validation in order to guide the development of appropriate strategies for staff support.
• The concept of compassion fatigue is being discussed in palliative care, [12] however the literature on which the concept was originally based is drawn from the field of trauma, and relates to workers exposed to war, disasters, or extreme violence (including sexual abuse). Extrapolating this model directly to palliative care may not necessarily be appropriate.
• A newer literature also looks at factors which may enhance clinicians’ resilience, coping and professional survival. “Compassion satisfaction” is one construct which has been identified as a protective factor, however this has not been specifically studied in a palliative care setting. The PROQOL measure has been developed as a potential tool for assessing compassion fatigue and burnout, as well as compassion satisfaction.
• Organisational factors are frequently identified as important in relation to burnout. Unsupported staff, those who have little control over their work, or who experience role conflict are at increased risk for burnout. Protective factors within specialist palliative care services may include a shared culture of care and team structure that creates the opportunity for supportive staff relationships, greater time and priority given to patient conversations and effective communication.
• There has been little work on identifying the most effective ways to support clinicians or what self-care strategies should be encouraged, and when evaluated these programs are not always shown to be very effective. [13] Very little evidence is available to guide the development of programs of support for clinicians involved in providing palliative care – whether specialist palliative care providers or others. Mindfulness-based practices have been studied in general medical settings with some demonstrated benefits to participants, including improvements in clinician well-being and attitudes to patient care. [14] Other approaches such as stress-reduction programs [15] and meaning-based group interventions [16-17] have been studied as one-off strategies in palliative care, but were not clearly shown to be beneficial to participants.
• Concepts such as clinical supervision, mentoring, and various types of peer support groups have not been well evaluated in palliative care, despite being frequently identified as potential strategies for providing staff support. [18] Different disciplines have very different cultures and varied access to self-care opportunities. Whether specific disciplines are more or less at risk for burnout has not been investigated. The question of whether volunteers in palliative care experience burnout and what are their self-care needs has also not been well-investigated. 

References

1. Girgis A, Hansen V. Prevalence and predictors of burnout in the COSA oncology workforce. Newcastle (NSW): Centre for Health research & Psycho-oncology (CHeRP), University of Newcastle; 2007.
2. Dunwoodie DA, Auret K. Psychological morbidity and burnout in palliative care doctors in Western Australia. Intern Med J. 2007 Oct;37(10):693-8. Epub 2007 May 21. 
3. Goodridge D, Duggleby W, Gjevre J, Rennie D. Caring for critically ill patients with advanced COPD at the end of life: a qualitative study. Intensive Crit Care Nurs. 2008 Jun;24(3):162-70. Epub 2008 Mar 3. 
4. Kirchhoff KT, Spuhler V, Walker L, Hutton A, Cole BV, Clemmer T. Intensive care nurses' experiences with end-of-life care. Am J Crit Care. 2000 Jan;9(1):36-42.
5. Fanos JH. "Coming through the fog, coming over the moors": the impact on pediatric oncologists of caring for seriously ill children. J Cancer Educ. 2007 Summer;22(2):119-23.
6. Taubert M, Nelson A. 'Oh God, not a palliative': out-of-hours general practitioners within the domain of palliative care. Palliat Med. 2010 Jul;24(5):501-9. Epub 2010 May 25.
7. Ersek M, Kraybill BM, Hansberry J. Assessing the educational needs and concerns of nursing home staff regarding end-of-life care. J Gerontol Nurs. 2000 Oct;26(10):16-26.
8. Burt J, Shipman C, Addington-Hall J, White P. Nursing the dying within a generalist caseload: a focus group study of district nurses. Int J Nurs Stud. 2008 Oct;45(10):1470-8. Epub 2008 mar 3. 
9. Mohan S, Wilkes LM, Ogunsiji O, Walker A. Caring for patients with cancer in non-specialist wards: the nurse experience. Eur J Cancer Care (Engl). 2005 Jul;14(3):256-63.
10. Dunne K, Sullivan K, Kernohan G. Palliative care for patients with cancer: district nurses' experiences. J Adv Nurs. 2005 May;50(4):372-80.
11. Badger JM. A descriptive study of coping strategies used by Medical Intensive Care Unit nurses during transitions from cure- to comfort-oriented care. Heart Lung. 2005 Jan-feb;34(1):63-8.
12. Showalter SE. Compassion fatigue: what is it? Why does it matter? Recognizing the symptoms, acknowledging the impact, developing the tools to prevent compassion fatigue, and strengthen the professional already suffering from the effects. Am J Hosp Palliat Care. 2010 Jun;27(4):239-42. Epub 2010 Jan 14. 
13. van Wyk BE, Pillay-Van Wyk V. Preventive staff-support interventions for health workers. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD003541.
14. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009 Sep 23;302(12):1284-93.
15. Bruneau BM, Ellison GT. Palliative care stress in a UK community hospital: evaluation of a stress-reduction programme. Int J Palliat Nurs. 2004 Jun;10(6):296-304.
16. Fillion L, Dupuis R, Tremblay I, De Grâce GR, Breitbart W. Enhancing meaning in palliative care practice: a meaning-centered intervention to promote job satisfaction. Palliat Support Care. 2006 Dec;4(4):333-44.
17. Fillion L, Duval S, Dumont S, Gagnon P, Tremblay I, Bairati I, et al. Impact of a meaning-centered intervention on job satisfaction and on quality of life among palliative care nurses. Psychooncology. 2009 Dec;18(12):1300-10.
18. Clode D, Boldero J. Keeping the doctor alive: A self-care guidebook for medical practitioners. South Melbourne: Royal Australian College of General Practitioners; 2005. 

Last updated 14 October 2011*