Oxford Handbook of Palliative Care (2 edn)
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It is your responsibility to your patients/clients and your human right for yourself, to nurture and maintain your physical, emotional, intellectual and spiritual being.
Brigid Proctor
Impact of caring for dying people
Background
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, and where such work can put staff in touch with personal anxiety about loss and death.1,2,3 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.4
Overall, however, stress and burnout in palliative care has been found to be less than in other specialties. Some research has shown that this is an area where there is very high degree of job satisfaction, and that staff feel they are privileged to be in the position to provide this care.1,2,3 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.1,2,3
It is suggested that the reason for lower stress and burnout within hospice palliative care units is probably 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.1,2,3
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.5 One in four of the specialist registrars (SpRs) experienced stress and more than one in ten showed clinically important levels of depression. 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.5
Supportive environments
The Health and Safety Executive recommend that all organizations have a stress policy that outlines the responsibilities of managers and staff to identify stress in the workplace, and provides 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: 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; and respecting each other’s expertise.
Organizations also need to provide effective training for their staff who work with 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.
One 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 that involve intense human interactions, as occurs in palliative care.6 Another is to the provision of protected time for clinical supervision and/or reflective practice sessions that support clinical learning and development within a supportive framework. Furthermore, there is a need to support staff in developing realistic expectations of clinical interventions in order to minimize any sense of failure and helplessness.4
Sources of stress
Personal life
Personal relationships—spouse/partner, children, carer responsibilities, no close relationships/loneliness
Illness—in self or one close to self
Recent bereavement
Minority related stress—victim of racism, sexism, ageism, disability prejudice, etc.
Gender related stress—pressure to do everything/pressure to provide
Patients/clients
Inability to create relationships
Negative attitudes—hostility, open dislike, anger
Potential/actual physical violence
Emotional pressures
Problems of emotional involvement
Guilt feelings—feeling responsible
Dependent clients
Colleagues
Inability to create relationships
Lack of support
‘Each doing their own thing’—no teamwork
Open conflict—practice undermined
Bullying
Negative/pessimistic attitudes to work
Bringing problems at home to work
Own anxieties about work
Resentful of others’ positions—professional jealousy
Managers
Lack of support—no supervision, etc.
No attention paid to personal development
‘Routines’ before ‘people’
Little positive feedback
Discriminatory behaviour
Bullying
Given inappropriate client group, caseload, etc.
Practice skills not recognized
Overwork, heavy demands
Faced with crises
Lack of involvement in decision-making
Organizational issues
Lack of resources
‘Routines’ before ‘people’—bureaucracy
Impersonal links with ‘hierarchy’
Poor pay/poor conditions of service
Lack of clarity in roles
Little professional ‘expertise’
Administrative procedures/paperwork
Functions limited by resources
Lack of clarity of work expectations—low status
Poor Staffing ratios
Staff shortages/vacancies not filled
Warning signs of prolonged stress
Physical
Palpitations
Chest pains
Recurrent headaches
Heartburn
Stomach cramps
Stomach full of gas
Intellectual
Memory problems
Poor concentration
Anxiety
Errors in judgement
Feeling ‘woolly’ headed
Inability to make decisions
Emotional
Frequent feelings of anger, irritation and frustration
Feeling dull and low
Feelings of helplessness and insecurity
Inability to love and care
Feeling tearful
Sleep disturbance
Strategies for coping with stress
Organizational
Developing a supportive culture within the organization
Opportunities to express work-related feelings and discuss problems in the workplace
Regular team meetings
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.
Personal coping strategies
Having a sense of competence, control and satisfaction in working in palliative care
Having control over workload
Taking time off
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
