Those caring for seriously ill patients are known to experience stress from situations such as dealing with death and dying, team conflict, amount of direct patient care provided and time pressures which can lead to burnout. Levels of burnout have not been shown to be greatly elevated within specialist palliative care, [1-3] however, a recent study from the US suggest a much higher rate at around 62%.  Burnout levels of the oncology health professionals appear similar to the general population. 
What is known
The best established measure of stress and distress in health care workers is that of burnout. The assessment tool most frequently used for identifying burnout is the Maslach Burnout Inventory  which measures three domains - emotional exhaustion, depersonalisation, and lack of personal accomplishment. Personality and personal characteristics influence the burnout process  with correlations between attachment style and levels of burnout shown to exist,  as well as work factors.  Palliative care units seem to have protective factors that need to be explored further to prevent burnout. [9-10]
Some of the aspects of work practices that have been shown to affect clinician stress are: self confidence in own communication skills with patients and relatives  and multidisciplinary decision making.  The skills, attitudes and approach of individual clinicians when responding to difficult encounters may affect their risk of burnout. Clinicians who have received communication training have their self confidence increased in dealing with difficult situations, so are less likely to experience burnout. 
What it means in practice
- Individuals should take responsibility for their own self care, which comprises of knowledge, skills and attitudes including self reflection and self awareness, identification and prevention of burnout, appropriate professional boundaries to maintain their personal well being  and their quality of patient care. This needs to be acknowledged and supported by employers and managers through the provision of education and training.  This consists of monitoring those who have a substantial amount of patient contact, neglect to take adequate leave or who have not attended communication skills training,  particularly focusing around end of life issues. Clinicians who possess a high level of emotional self-awareness are better able to manage and overcome the stresses that arise in clinical practice that benefit both themselves and their patients.
- There remains limited evidence about self care programs and skill training for clinicians in palliative care. Though this is increasing and a structured Self-Care Module, based on an awareness-based model of self-care,  has been evaluated to show it is useful and operationally feasible as a method to provide this skill training, for medical learners going through a palliative care rotation.  Where organisations are developing programs, documenting these approaches, evaluating them using validated tools and reporting them back to the field could improve our understanding of this issue.
- Health care organisations have a responsibility to ensure that their culture and structure provide education about potential effects and possible management strategies and opportunities to reflect about feelings related to interaction with patients and their families as required by the Standards for Providing Quality Palliative Care for all Australians  Organisational interventions can include structured debriefing, mentoring, and professional supervision which are well-known staff support mechanisms that have been reported as having a positive effect on staff.  Creating an environment that helps staff to reflect and develop coping mechanisms can be helpful in reducing stress.  Changing work schedules can also reduce stress, but other organisational interventions have no clear effects. 
- The importance of self care is also supported by many of the palliative care related professional associations [17-19] and palliative care expert group.  They provide clear recommendations about managing stress through self-care and note the importance of preventive health care practices for both physical and mental health, strategies for maintaining work / life balance, and peer support arrangements. These activities should be encouraged and facilitated by health care organisations, and modelled and mentored by clinicians.