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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3090_Библиотеки_им_академика_М_И_Перельмана
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Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
338
23
complexity of their work in order to realistically manage its
psychological challenges. Psychologically informed inter-
ventions will be described along with a consideration of the
importance of good role and team design and containing
1
management, to maximise the potential for working in pal-
liative care to be fulfilling and rewarding, while managing
its predictable emotional risks and reducing the likelihood
of burnout.
The Context of Palliative Care Practice
Working in palliative care involves supporting people at a
time when their relationship to themselves, their bodies,
their families, and their future is changing in unwanted
ways. Fear of pain, disfigurement, decay, loss of control,
independence, and dignity, and ultimately loss of life are
profound fears we all carry. Being confronted with these
experiences will evoke primitive feelings (including the
fear of abandonment and annihilation) that practitioners
will need to manage in order to carry out their work. Most
will have developed defences
2
to protect themselves, how-
ever, these can become threatened (at a time of personal
Creating Space, Clarity and
Containment in order to Sustain
Staff: Managing the Emotional
Impact of Palliative Care Work
Barbara Wren
Introduction
Palliative care is concerned with improving the quality of
life of patients and their families facing the problems asso-
ciated with life-limiting illness, through the prevention and
relief of suffering. It integrates the psychological, physical,
social, cultural, and spiritual aspects of a patient’s care,
acknowledging and respecting the uniqueness of each
patient and their family. While a specialist area, all medi-
cine requires an understanding of the application of pallia-
tive care to the relief of suffering in serious illness, and at
end-of-life. It can be an immensely rewarding and enrich-
ing area within which to work while also posing predictable
emotional challenges for the practitioner. Learning to meet
these challenges provides a subtle opportunity for health-
care staff to make sense of their own personal relationship
to vulnerability, suffering, death and dying, and integrate
this understanding into their roles in ways that can increase
self-awareness, effectiveness, and impact. The aim of this
chapter is to describe how the well-being of palliative care
providers can be enhanced by helping both individuals and
systems to attend to themselves, and to the contexts and
1
Containment is a crucial function of both managers and organisations. It refers to the skill of enabling individual staff and the team to
manage their work in a way that connects them effectively to their task while ensuring effective management of emotions at work that
enables clinicians to work within role boundaries.
2
Defenses are strategies people use to separate themselves from unpleasant events, actions, or thoughts to manage psychological threats
and unwanted feelings, such as guilt, shame, fear, and helplessness.
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Creating Space, Clarity and Containment in order to Sustain Staff 339
• Managing uncertainty and supporting patients and
family systems to manage uncertainty often indefinitely.
•
Providing effective support for those living with
advanced illness who are suffering from a complex mix of
effects such as fatigue and disability, while navigating pain-
ful changes in roles and identities within work and family
systems.
• Containing
3
anxiety in patients and families and other
health-care professionals while managing complex and
sometimes high-risk clinical scenarios.
•
Withstanding and addressing anger, aggression, denial,
grief, and profound sorrow as individuals and family sys-
tems come to terms with the reality of suffering and dying,
death, and loss.
•
Bearing witness to suffering and making decisions about
what level to address and alleviate it as illnesses progress
e.g. physical, emotional, cognitive, relational, and/or
spiritual.
•
Coming to terms with their own vulnerability and mak-
ing sense of their own relationship to feelings of helpless-
ness, impotence, and fears of “failure” to avoid
over-intervention (e.g. surgery with poor chances of
significant change for patients, extending chemotherapy to
avoid confronting dying, repeated onward referral), unnec-
essary prolonging of suffering or unhelpful management
of hope in patients, family, and health-care systems.
• Managing their own occasional feelings of fear, revul-
sion, and disgust in response to patient physical deteriora-
tion, in order to facilitate patients’ acceptance of bodily
changes, and help them manage associated feelings of
shame, and fears of abandonment.
• Managing natural feelings of tenderness, longing, desire
for intimacy, and attachment, evoked by the work in a way
that ensures that health professionals stay in role and on
task (even though being close to these feelings may fulfil
deep needs in the health professionals, both known and
unknown, seen and unseen).
• Managing their relationship to their own personal expe-
riences of loss in order to maintain well-being and pro-
mote an effective relationship to their role that is
underpinned by an awareness of their motivations and
their limits, and the limits of the system they are working
in. These loss experiences may have drawn them towards
this work in ways that they are aware or unaware of and
can over time cause difficulties (for themselves and others)
loss for example, or of overwhelming exposure to death
and dying which has been a feature of working in health
care during the COVID-19 pandemic). It is in the context
of these powerful emotional experiences that palliative
care is provided. In addition, the necessary imperative it
requires of moving from a curative stance to that of palli-
ation may, for many clinicians, evoke uncomfortable and
challenging feelings of vulnerability, helplessness, and
impotence. Of course, working in palliative care also pro-
vides profound opportunities for experiences of intimacy,
and expressions of creativity, tenderness, and love, which
are immensely rewarding but pose other challenges. For
example, how to work within boundaries, and across mul-
tiple contexts, to set limits for oneself and others, and to
sensitively navigate the many transitions from intimacy
to objectivity and back again, that must occur throughout
the progression of an illness, to ensure that its trajectory
is managed appropriately over time in the interests of the
patient, their family, and the health-care system. Pre-
qualification training for doctors, nurses, and allied
health professionals’ focusses of necessity on content and
clinical skills and there is little time to train these
relational skills which are key both to the quality of the
work and the resilience of staff. Psychological interven-
tions can facilitate the development and deepening of
these skills and of practitioner self-awareness and
psychological flexibility both of which are the corner-
stones of self-care.
The Emotional Complexity in Palliative
Care Work
Working in palliative care poses several predictable chal-
lenges all of which make psychological demands on
practitioners:
• Communicating effectively to be able to sensitively
address the complex ethical, psychological, and social
issues that arise and ensure that care evolves to meet
changing needs of patients and their families as illnesses
progress.
•
Keeping two contexts in view at the same time: working
to maximise well-being, reduce suffering and prolong life
while keeping in mind and addressing the realistic possi-
bility of deterioration and death. Helping patients and
families to navigate various transitions between these two
realities over time.
3
Containment: refers to the skill of enabling individual patients and families to safely feel, express and manage the range of emotions
evoked by serious illness and dying, in a way that connects them to reality and to their own resources, hopes, and needs, while managing
each stage of illness.
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340 Chapter 23
that staff feel psychologically safe by building in role
clarity, good work design, effective teamwork, and con-
taining management.
The view from above: Thinking systemically
Managing the impact of palliative care work in the context
of the hospital or community system.
Putting it all together: Reciprocity and meaning
Designing psychological interventions in order to connect
all three levels above and attend to the importance of
working both from the inside out (that is how individuals
relate to their role and job content) and the outside in (how
the system impacts on individuals and teams). Attending
to this meaning and reciprocity when crafting responsive,
creative psychological interventions.
Looking Inwards
: Individual Well-being
Well-being at work is:
The ability to reach the highest potential possible for the
individual, the role, and the organisation. Staff will feel
engaged, stretched, and challenged in their work and enjoy
growing and learning. They will feel a sense of pride in them-
selves, their work, and their team. It includes short term
emotional outcomes such as levels of happiness and
conversely of distress (which will have cognitive and
performance consequences), and longer term psychological
and physical functioning. It is demonstrated behaviourally
by productivity, satisfaction, commitment, and engagement.
A general sense of well-being provides an overall sense of
purpose that gives direction and meaning to people’s
actions at work. People with higher levels of well-being are
more likely to interpret events at work positively, deal with
other people more constructively, perform better at tasks,
react to positive and negative feedback more construc-
tively and learn and solve problems more effectively [1].
Cognitive style (the relationship to oneself)
This is the way in which individuals make sense of what
happens to them, their patients, and their work, i.e. how
they attribute outcomes, whether they are they optimistic
or pessimistic? Do they generalise? Do they catastrophise?
What attributions do they make for the reasons why events
occur the way they do? How do they relate to themselves?
Do they tend to be self-critical, or are they able to be sup-
portive to themselves when they are distressed or under
without opportunities to acknowledge and understand
them. They can also create opportunities for growth if pro-
cessed in a way that will allow the individual to recalibrate
their relationship to work and to their palliative care role.
•
Working with complex systems both family, and health
and social care systems.
•
Working creatively to respond over time to a range of
needs, preferences, spiritual belief systems, and cultures.
•
Attending sensitively to the uniqueness and newness of
each patient’s illness experience despite one’s own
knowledge of an illness’ trajectory. Balancing hope and
reality by pacing and tailoring information to patients’ and
families’ process of adaptation to progression of an illness
and the reality of their predicament.
Navigating this emotional complexity and attending to its
relational
4
nature will optimise the potential for positive staff
experience. This has benefits for staff but also for patients.
Staff experience creates the emotional climate within which
patients are cared for and will mediate key aspects of the
patient experience including the extent to which patients feel
safe, held, and understood, able to manage their anxiety, and
to adapt to change over time. A productive relationship with
palliative care staff and teams helps patients to relate to their
bodies and their ill-health with dignity, control, and realism,
and to trust that health-care providers can help them man-
age hope over time without becoming overwhelmed by fear.
This experience has huge potential to realign their relation-
ship to themselves and their illnesses and to cope with the
acceptance of realities that will change their futures, their
relationships to their bodies, and their families.
Considering the Options
How can we optimise the experience of staff doing pallia-
tive care work? This chapter will outline the range of
options available from each of the following positions:
Looking inwards: Individual well-being
Providing opportunities to develop and maintain a pro-
ductive relationship to oneself, one’s role, job content, and
the work system through the development of self-aware-
ness, self-compassion, and psychological flexibility.
Looking outward: Work design
Attending to the job, role, and team and how they are
managed. Ensuring that the work is well structured, and
4
The fact that the quality of the work is dependent on the relationship to oneself, one’s colleagues, the patient and their family, and the
health-care system.
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Creating Space, Clarity and Containment in order to Sustain Staff 341
and on task?
5
What resources will they need to achieve
this? The following is an overview of emotional resources
they can draw on.
Self-compassion
Self-compassion entails being warm and understanding
towards oneself rather than ignoring pain or attacking
oneself with self-criticism at times of suffering, feelings of
failure, or being inadequate. Being self-compassionate
involves recognizing that being imperfect, failing, and
experiencing life difficulties is inevitable, and learning to
cultivate ways to be gentle with oneself when confronted
with painful experiences [5]. Mindfulness based cognitive
therapy (MBCT), developed from Jon Kabat-Zinn’s [6]
mindfulness-based stress reduction programme, aims to
increase self-awareness and thus can positively influence
levels of self-compassion. The goal of this approach to
become able to see oneself separately from the negative
thoughts and moods one is experiencing. Compassion-
focused therapy (CFT), developed by Paul Gilbert [7],
focuses on the use of compassionate mind training to facil-
itate the development of self-compassion through
connecting to experiences that instil feelings of safety and
contentment. All these interventions help healthcare pro-
viders develop their self-care resources, enabling them to
maintain compassion for themselves while fielding high
levels of emotional demands [8].
By creating space to think and to choose a response to
emotionally difficult experience these interventions may
also help palliative care providers avoid the pitfall of inter-
nalising system difficulties. That is attributing difficulties
solely to themselves and how “good” or “bad” a practi-
tioner they think they are rather than remaining aware of
the contributions of system problems e.g. when there are
resource limitations, poor communication, or organisa-
tional incoherence. Self-compassion creates more space for
a realistic appraisal of the reality of what can and cannot be
achieved in a work role and work system. This can manage
any tendency to reject oneself instead of accepting that
painful, unwanted emotions may be being produced by the
work and the work system (rather than being a symptom of
failure, incompetence, weakness, or innate “badness”).
Relationship building abilities
Positive and productive relationships are the second cor-
nerstone of well-being at work. How do individuals con-
nect with others? Are they able to make connections in
strain? The concepts of psychological flexibility and self-
compassion, two elements of cognitive style, have been
used to develop individual and group interventions to
improve well-being at work.
Psychological Flexibility
Psychological flexibility is the ability to stay in contact with
the present moment regardless of unpleasant thoughts,
feelings, and bodily sensations, while choosing one’s
behaviours based on the situation, personal values, and the
palliative care role requirement. It describes the ability to
recognize and adapt to various situations; adapt mind sets
or behavioural repertoires when necessary, maintain
balance among important life domains; and be aware,
open, and committed to behaviours that are congruent
with deeply held values. In many forms of dysfunction,
these flexibility processes are absent [2]. Individuals with
greater psychological flexibility are less likely to struggle
with unwanted thoughts and feelings, more in touch with
present moment experience, and more likely to base
actions on values and goals (rather than current internal
states). Psychological flexibility has been found to be pow-
erful predictor of absenteeism, and workplace performance
[3,4].
Healthy Responses to Negative Events
Health-care work is demanding and difficult. Healthcare
contexts are complex, competitive, and under high strain.
Negative events at work are inevitable. How do individuals
make sense of their negative experiences e.g. tensions with
other teams, anxieties about quality of care in different
parts of the system, disruptions, and interruptions, disap-
pointment in the outcome of a good referral they have
made, worry about the quality of a service they are
dependent on, loss, aggression, families in denial, and
frightened patients? Can they persevere despite the pain
these experiences are causing them? Are they able to
understand and make sense of these experiences aside
from their own emotional reactions to them in order to
reposition their relationship to an individual or part of the
health-care system that is causing difficulty in order to do
their work effectively? Can they maintain their equilibrium
and their ability to work within the limits these difficulties
may have revealed? Can they experience sadness, loss,
anger, aggression, and frustration without being unduly
overwhelmed and at the same time manage to stay in role
5
On task: focused on the palliative care role and what is required of it.
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342 Chapter 23
meaningful, and are able to persevere without despair. In
order to provide this sense of containment to distressed
patients, health-care providers themselves need a sense of
coherence. It can be achieved through a reconnection with
fundamental values and beliefs [11–13], through good
management, and teamwork. It is enhanced by organisa-
tional coherence, and interventions which allow staff to
regularly connect to meaning and values and to make
sense of their experience of work from several different
perspectives.
Problem solving skills
Working in palliative care requires solving problems at
several different levels: clinical, relational (patients and
colleagues and the wider system), operational, strategic,
and at the level of the family system. Problem solving
abilities enable health-care staff to assess problems, con-
sider a range of solutions and chose the next step while
anticipating consequences both intended and unintended.
Systems thinking [14] can be an invaluable addition to
problem solving skills allowing clinicians to engage with
the complexity of palliative care contexts in order to
achieve realistic, joined up solutions for patients and their
families. Team meeting, case discussions and presenta-
tions, role consultation and coaching can all develop
individual and team problem solving skills.
Looking Outward:
Work Design
The impact of work stress is determined by the interaction
between the person exposed, the skills and resources
described above, and the system they work in. We know
how to design work roles to minimise negative system
impacts and promote healthy working. The six dimensions
of work that will impact on well-being are: the relative
balance of demands, control and support, the design of the
role, relationships with colleagues, and the way in which
change is managed [15]. Jobs with high levels of demands
but low levels of control and support create the most work
strain. High demand jobs with high control and support
produce productive challenge, learning, growth, and staff
engagement. Managers are often limited in their ability to
reduce the level of demands that their staff are exposed to
in modern health care and therefore focusing on increasing
control and support is important in protecting well-being.
Role clarity
Role clarity is protective of well-being. To be effective an
individual at work needs to be clear about their role and
their task i.e. what does the role need to achieve for pallia-
tive care patients and their families? They need support for
which all parties in a relationship feel heard, understood,
and listened to? Do they have a sense of their own impact?
Can they establish and manage boundaries in a work rela-
tionship that are appropriate for their context and purpose?
Can they create a sense of trust in their relationships? Are
they able to be sensitive to spoken and unspoken commu-
nication and tailor their behaviours accordingly? Are they
able to negotiate intimacy and distance, that is to come
close enough to palliative care patients to comfort and
treat them, and bear witness to their pain and suffering but
also to then reposition themselves sensitively (so that a
patient or their family do not feel abandoned or criticised)
in order to be objective (to revise a treatment plan for
example, or make on onward referral or challenge unreal-
istic hope)?
Emotional Intelligence
Emotional intelligence is the ability to “monitor one’s own
and others’ feelings, to discriminate among them, and to
use this information to guide one’s thinking and action”
[9]. Skills in understanding and managing one’s own emo-
tions, as well as noticing emotions in others and respond-
ing appropriately and sensitively allow caregivers to
manage the relational aspects of providing palliative care.
Those higher in emotional intelligence will have greater
skills in attending to the meaning of patient and colleague
behaviour and responding in a way which is congruent
with that meaning and more likely to promote good com-
munication and understanding and ultimately a more
positive patient experience.
Sense of Coherence
A sense of coherence describes to the ability to maintain
equilibrium at times of difficulty. A sense of coherence
helps people to stay well and even able to improve their
health despite stressful experiences and situations.
Antonovsky [10] described three key components of an
individual’s sense of coherence. These are:
• Comprehensibility—the cognitive component, that is
the ability to understand one’s experiences of life and work,
and to be understood by others.
• Manageability—the perception that one can manage the
situations in which one finds oneself (and to access appro-
priate help to achieve this if needed)
• Meaningfulness—the sense that in times of adversity life
is meaningful enough to find the motivation to continue.
In many ways palliative care is concerned with providing
patients and their families with a sense of coherence
throughout their illness experience by ensuring that they
can relate to it as comprehensible, manageable, and
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Creating Space, Clarity and Containment in order to Sustain Staff 343
interfaces are managed, and the extent to which the system
supports the task of palliative care. Effective working
requires the ability to work across contexts and systems
with self-awareness and the ability to make sense of and
adapt to different system contexts in order to maximise the
impact of palliative care work.
Most health-care organisations are primarily focused on
patient treatment and recovery. They are fast paced sys-
tems under high strain constantly striving to meet patient
demands, to survive in a turbulent world and to innovate
in response to rapid growth in medical and scientific
knowledge (all of which have achieved immeasurably
improved outcomes for patients). Medicine has extended
the limits of what can be achieved, and hoped-for, in
patient outcomes. Patient expectations are high and in
Western societies exposure to death, dying, and their rit-
uals is more limited than in previous generations.
6
Acknowledging endings and limits in this context is pain-
ful. Denial of limits may profoundly impact the culture of
some medical systems with visible and invisible impacts on
palliative care providers which need to be attended to in
the interests of their well-being, skills development, and
the quality of their services. In his book Being Mortal, Atul
Gawande writes about how “our ideas about how to deal
with our finitude have got the reality wrong.”
You don’t have to spend much time with the elderly or those
with terminal illness to see how often medicine fails the peo-
ple it is supposed to help. The waning days of our lives are
given over to treatments that addle our brains and sap our
bodies for a slivers chance of benefit. They are spent in insti-
tutions – nursing homes and intensive care units – where
regimented, anonymous routines cut us off from all the
things that matter to us in life. Our reluctance to honestly
examine the experience of ageing and dying has increased
the harm we inflict on people and denied them the basic
comforts they most need. Lacking a coherent view of how
people might live successfully all the way to their very end we
have allowed our fates to be controlled by the imperatives of
medicine, technology, and strangers. [20, p. 9]
Confronting the limits of treatment is challenging for
organisations and their clinicians and may lead to pallia-
tive care work being side-lined and devalued in overt or
covert ways while the reality of limits and of death are
being denied. The potential for organisational splitting
(that is working with suffering, dying and death being dis-
connected and seen as other from the main “business” of a
hospital), and for palliative care to be related to, not as an
the role e.g. ensuring it is well resourced, provided with
clarity and well positioned so that all those interacting
with a role know its purpose, what it needs, and what it will
provide. Both factors increase the likelihood that a role
will be taken up with maximum effectiveness and
minimum strain. Role clarity also includes knowing where
one role ends and other begins, that is clarity about inter-
faces and interdependencies.
Te a mw o r k
Multi-disciplinary teamwork underpins both good staff
and patient experience and is a protection against stress,
error, and risk [16]. The cornerstone of good teamwork is
clear roles, clear team processes i.e. meetings, opportu-
nities for reflection, and learning. Good management of
team and group processes ensure the team remains on task
and that the organisation gets what it needs from the team
and the team gets what it needs from the organisation.
Poor staff experience can be a result of poorly structured
and led teamwork, a team with little time to reflect on
experience, or to learn and change through this reflection.
Team development and team supervision all provide
opportunities for teams to process work experiences and
have the potential to reduce work strain. Well led and well
managed teams can protect staff from toxins in the system.
Management
Managers have a significant impact on the work experi-
ence of health-care staff both positive and negative.
Various studies have linked poor management style to
emotional exhaustion in staff [17]; low job satisfaction and
intention to leave [18]. A line manager’s behaviour and the
culture they create in their team is the biggest influence on
an employee’s work experience. By improving their
management capabilities managers can improve their own
well-being as well as that of their team, achieving better
results, and benefitting the organisation. The UK CIPD
(Chartered Institute of Personnel and Development) have
produced a management competency framework which
identifies the skills and behaviours of managers that pro-
mote good teamwork and protect staff well-being [19].
Good management is containing.
The View from Above:
Thinking
Systemically
Finally, the well-being of the palliative care provider will be
impacted by the network of systems within which the work
takes place, the way in which interdependencies and
6
The Covid pandemic has changed some of this and highlighted the need for more and better palliative care provision.
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344 Chapter 23
Authenticity and Meaning: Maybe Patients and
Practitioners Have Similar Needs
One of the challenges of palliative care work is the shift
that clinicians must make from “saving lives” to slowing
down to attend to patient’s needs and bear witness to their
suffering. For many, shifting gears can feel threatening, but
it is essential. How do palliative care practitioners make
sense of what their patients need from them while retain-
ing their equilibrium? Listening closely to patients allows
for palliative care to be provided with reference to the
meaning and context of an illness and the hoped-for
quality of remaining time. Helping clinicians honour and
develop their creativity and deepen their ability to pay
attention to meaning develops their courage to simply
listen [21, 22]. The profound impact on patients of feeling
contained and heard by clinicians is immensely rewarding
to the clinician and this experience can over time help
them manage their fears of impotence and helplessness.
If we can stop and listen, patients tell us what they need.
This allows the task of medicine to be refocused and the
work of palliative care to deepen.
In recent years some powerful writing has shared stories
of death and dying providing insights into the palliative
care patient experience. By describing the realities of their
experience patients tell us what they need:
Yes, I am scared but not all the time. When I was first diag-
nosed, I was terrified. I had no idea that the body could turn
against itself and incubate its own enemy. I had never been
seriously ill in my life before: now suddenly here I was face to
face with my own mortality. There was a moment when I
saw my body in the mirror for the first time. Overnight my
own flesh had become alien to me, the saboteur of my hopes
and dreams. It was incomprehensible and so frightening. I
cried “I can’t die,” I sobbed “not me. Not now.” But I’m used
to dying now. It’s become ordinary and unremarkable,
something everyone does at one time or another. If I am
afraid of anything its of dying badly, of getting caught up in
some process that prolongs my life unnecessarily. No, there is
nothing good about dying. It is sad beyond belief. But it is
part of life and there is no escaping it. Once you grasp that
fact good things can result. [23, p. 34]
In When Breath Becomes Air [24], Dr Paul Kalanathi
describes his own attempt to work alongside his oncologist
to treat his lung cancer and his hope that she would share
his data, give him a prognosis, and treat him like a medical
colleague. She did not collude and so he wrote:
It occurred to me that my relationship to statistics changed
as soon as I became one. What patients seek is not scientific
integral part of medicine but a “go to” service when clini-
cians have run out of options poses immense challenges
for palliative care providers in their ability to provide
quality care in a timely way. Maintaining the well-being of
palliative care providers requires attending to this aspect of
the context and creating opportunities for its impact on
individuals and teams to be named and explored. As well
as addressing the impact of this splitting on the quality and
resourcing of palliative care provision, the high burden on
practitioners needs to be regularly attended to in the inter-
ests of staff well-being.
Putting It All Together:
Reciprocity and
Meaning
Maintaining the well-being of palliative care providers
requires attending to the impact of providing care in these
complex contexts. Designing palliative care work to create
the conditions for productive, satisfying working is the
first step. Then creating psychologically facilitated inter-
ventions that support individuals and teams to attend to
seen and unseen layers of the work (as described in the
section below), and of the system that enables it, will allow
them to sustain themselves over time. Making sense of
organisational cultures allows for a consideration of how
the system is relating to the suffering, dying, and death of
all its patients and will enable those providing palliative
care to position their roles and their work wisely and with
reference to system and individual limits. This increases
the likelihood that clinicians can maintain their well-being
over time while attending to their patients and to them-
selves with authenticity. These approaches will all be
described in more detail in the following sections.
The work of palliative care is provided in a complex
system with many layers of context. The innermost layer
is the relationship between the clinician and the patient.
What occurs in this relationship will influence a patient’s
relationship to their illness, their body, and their predic-
ament. The relationship is reciprocal and will also impact
on the clinician who will be exposed to profound emo-
tions e.g. anxiety, fear, hope, desperation, sadness, anger,
resignation, longing, and rage. The system’s ability to
support the clinician to withstand strong emotions while
translating their experience of this relationship into the
design of meaningful palliative care interventions is key
to the quality of the work. If the work is well designed and
they are well held by the system, then the clinicians’
ability to listen to and attend to their patients is sus-
taining and meaningful not just for patients but for
themselves.
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Creating Space, Clarity and Containment in order to Sustain Staff 345
their work system and their colleagues, and finally their
understanding of how their organisation is relating to the
task of palliative care and as a result positioning and
impacting on them.
Psychologically informed interventions can be provided
at the following levels:
Individual
Clinical supervision, role consultation, and coaching all
allow palliative care clinicians to have a space within
which to process the impact of their work. Regular facili-
tated one to one meetings provide an opportunity to
explore the meaning of, and relationship to, this work, and
over time deepen understanding of self and how to make
sense of and manage difficulty. Space can be used to dis-
cuss ongoing clinical cases, deepen understanding of a
clinician’s own impact, address blind spots and make
sense of heaviness, tiredness, and stuckness. This happens
through understanding the impact of serious illness,
group dynamics, and the family system, and exploring
why a clinician may find certain cases, patients, and fam-
ilies more difficult and others more rewarding. Complex
issues such as caring for a colleague or continuing to work
while managing the impact of one’s own illness can all be
covered in these spaces. Clinical supervision also creates
opportunities for a detoxification of aspects of the work
and the work system and an externalising of difficulty that
can deepen understanding over time of the reciprocal
nature of the work and how to understand and manage
oneself in relation to its emotional intensity. Processing
emotion creates space to think more clearly and return to
role refreshed.
Te a m
Team supervision allows palliative care teams to come
together regularly to reflect on the impact of the work
both individually and collectively. This has several bene-
fits. Group members have an opportunity to connect to
colleagues as a community and develop a sense of how col-
leagues are feeling and how their experience compares to
others. There is a development of a shared understanding
of the impact of the work and its contexts and of similar-
ities and differences between team members. Having a
clear structure for these sessions and holding them at reg-
ular intervals creates a sense of containment, coherence,
and connection. Facilitators can explore concepts such as
self-compassion and psychological flexibility and relate
these to ongoing cases whose impact may be discussed in
the group thus deepening participant’s understanding of
their relationship to themselves, their role, and their work
knowledge but existential authenticity. My doctor hadn’t
given me back my identity. She’d protected my ability to forge
a new one. And finally, I knew I would have to. [24, p. 36]
And later in a paragraph that captures the creativity and
sensitivity required of those working in palliative care:
The tricky thing about terminal illness is that as you go
through it your values are constantly changing. You try to
figure out what matters to you and then you keep figuring it
out. It felt like someone had taken away my credit card and I
was having to learn how to budget. Death may be a one-time
event but living with terminal illness is a process. [24, p. 54]
Intervening to Manage the Impact of
Palliative Care Work
If we can stop and listen, patients tell us what they need.
Interventions to protect staff well-being must model this
process and allow palliative care practitioners to stop and
listen to themselves and each other. Providing opportu-
nities for staff to move away from their task focus is key.
Creating confidence that this is possible without causing
them harm or undue anxiety and that they will be able to
return to their tasks, intact and able to resume their role,
is central to the creation of the safety needed to explore
the complex emotional experiences at the heart of pallia-
tive care work. Slowing them down and paying close
attention to what they say, allows staff to listen to them-
selves and to begin to risk moving, even temporarily, away
from busyness. When we create regular opportunities to
pause and listen to staff, stories of their work experience,
and its contexts eventually emerge and begin to take
shape. Though this takes time, as health-care staff find it
easier to listen to and tell their patients’ story rather than
their own.
Interventions need to be designed to give permission to
shift the focus to themselves, to help them find ways to
listen and attend to their own experience and to develop
their confidence that they can manage the transition out
of, and back to, role and task. And then when they have
shared the story of their work – or the story of themselves
that their relationship to the work reveals – these interven-
tions can help them to make sense of their experiences by
considering the levels of context in their stories. For
example, their inner worlds and the ways in which they
relate to themselves, their relationship to their palliative
care role and what drives it, their reciprocal relationship to
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346 Chapter 23
Conclusions
The emotional challenges of working in palliative care are
predictable and can be managed. Once the basics are in
place (role clarity, good work design, effective multi-disci-
plinary teamwork, and good management), interventions
to protect staff health can help by allowing for the release
of deeper emotions that may be evoked by the work but
need to be denied to successfully take up the clinical role.
The psychological challenge of palliative care work is to
stay in touch with meaning, without being overwhelmed
by it, while staying in role and on task. Embedding regular
psychologically informed interventions that support staff
to engage with emotional complexity will allow a slow
repetitive process to take hold in which it is hoped that
staff will deepen their capacity to attend to meaning and to
become more comfortable with witnessing without solving
and listening without rescuing. Creating team and organ-
isational spaces that deepen the ability to do this (for col-
leagues and for oneself), will enhance the ability to do this
for patients and increase the likelihood that staff can stay
well, do meaningful work, and continue to authentically
relate to themselves and their task.
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