This study explored the meaning and practice of self-care as described by palliative care nurses and doctors. These findings contribute new knowledge in several ways, with implications for clinical practice, research and education.
A proactive and holistic approach to promoting personal health and wellbeing to support professional care of others
The holistic nature of self-care as revealed in this study is consistent with the discourse analysis conducted by Breiddal . Findings from the present study extend this existing knowledge by providing new insight into the meaning of self-care, and also through further evidence of the relational context in which self-care is practised, as voiced by practitioners in the field. For palliative care professionals, self-care is not a selfish endeavour apathetic to the needs of others; rather, it is a proactive and relational practice cognisant of practitioners’ health and human needs, and motivated by the professional context of sustaining compassionate care in therapeutic relationship with patients and their families. This was especially evident in the words of one participant: …if you don’t feed yourself, you’ve got nothing to give; much of what we do in palliative care is about human connectedness. It also supports Kearney and colleagues’  assertion that self-care is not a selfish luxury, but is instead essential to clinicians’ therapeutic relationship with patients.
Personalised self-care strategies within professional and non-professional contexts
While most research has to date focused on strategies used to cope with occupational stressors ; these findings, situated in the broader context of self-care, reveal not only the variety of effective strategies employed, but also the challenges and complexities involved with maintaining effective self-care strategies in practice. The need for reflective practice to build self-awareness, as well as the management of multiple barriers and enablers to self-care practice, clearly demand ongoing attention from practitioners and palliative care services.
That mindfulness exercises were used spontaneously by participants in practice settings suggests that the benefits of formal mindfulness training initiatives extend beyond the training room and into the clinical milieu [23, 24]. Clinical supervision was effective for many, but not for others; and in many instances, it was not available at all. This seems to reflect, in part, a different attitude to clinical supervision within the nursing and medical disciplines; when compared to other disciplines such as social work, in which supervision has long been a cornerstone. As a social worker, Firth  explains that many nurses may feel threatened by supervision, whilst doctors have traditionally avoided it. Given the potential benefits to self-awareness and staff wellbeing, the provision of supervision should nonetheless be considered; perhaps with an emphasis on the restorative aspects of clinical supervision [25,26,27].
Formal and informal debriefing was consistently described as an effective self-care strategy, and thus should be encouraged. Similarly, laughter and the use of humour formed a fundamental part of self-care, and should be fostered as appropriate. Laughter has long been considered a coping strategy to manage stress in palliative care settings ; however, this finding extends a new context in terms of self-care behaviours to support health and wellbeing. Indeed, there is evidence to suggest not only psychological, but also physiological health benefits from laughter, including enhanced cardiac and immune function [29,30,31].
Establishing and maintaining effective boundaries within and outside of the workplace was an effective self-care strategy for participants in this study, as was work-life harmony. Whilst so-called work-life balance was discussed by some, and has also featured in other palliative care research into coping mechanisms ; this concept was incongruous to the experience of others. Overall, it was important to acknowledge that different life-domains require varying degrees of attention at any given time, and finding one’s individual harmony between personal and professional roles was thus a key strategy towards flourishing in life. This is consistent with McMillan and colleagues’  definition of work-life harmony as ‘an individually pleasing, congruent arrangement of work and life roles that is interwoven into a single narrative of life’. It also corresponds with recent research findings that work-life interference, or conflict, is associated with higher levels of burnout in nurses and predicts intention to leave an organisation or the nursing profession . Thus, work-life harmony is an important aspect of effective self-care. Given this finding, future self-care education might usefully incorporate this new emphasis on work-life harmony over the common parlance of ‘work-life balance’ which is ill-defined and otherwise problematic in practice for some .
Another interesting finding related to participants electing to work part-time as a self-care strategy. While only 42% of participants worked part-time in the present study, the majority of participants who had earlier completed a survey worked part-time. Given these and earlier research findings , working a part-time load appears to be a common self-care strategy for palliative care professionals. Indeed, one participant suggested that part-time roles should perhaps be encouraged in favour of a full-time load, given the emotionally demanding nature of palliative care. However, this would need to be weighed up by the individual in relation to feasibility of lower income and potentially limited opportunities for career advancement in roles where full-time work is required.
Barriers and enablers to self-care practice
While positive workplace cultures were discussed as enablers of self-care, there were many who described their current workplace culture as a barrier to effective self-care, in that it was not supportive of self-care practice. This finding is alarming, yet not altogether surprising when taken in the context of self-care being highly stigmatised – as either selfish or weak – in some participants’ workplaces. Perhaps more concerning, is that this stigma may serve to not only impede effective self-care practice in the workplace; it could also discourage palliative care professionals from taking personal leave or seeking professional support when they become unwell. As described by Hill , a paediatric palliative care physician, showing vulnerability or seeking help is often viewed as a sign of weakness; and acknowledging one’s shared humanity and vulnerability through self-compassion is vital to self-care behaviours. Understanding factors that contribute to supportive workplace cultures and facilitate self-care is therefore essential. Some palliative care services in Australia might benefit from the experience of their counterparts in Canada and the United Kingdom, who have focused on leadership to foster workplace cultures of self-awareness, self-care, and staff support [36, 37].
Several enabling factors to self-care practice were identified in this study, both interpersonal and environmental. Authenticity, courage, and leadership were highlighted by participants. Being authentically human in acknowledging one’s own vulnerability; having the courage to challenge stigma or be assertive in saying ‘no’, when acquiescing to additional workload may compromise one’s own wellbeing; and leading by example in supporting and normalising self-care as an essential aspect of palliative care practice. Authenticity, courage, and leadership have been recognised as character strengths that can be measured and cultivated . Development of these character strengths in palliative care teams should therefore be encouraged to assist in transforming any unsupportive workplace cultures.
In this study, positive emotions such as gratitude and self-compassion enabled self-care. This is consistent with a growing field of positive psychology research, in which positive emotions not only have a biological basis for physiological health benefits; but have also been shown to broaden repertoires of positive thoughts and actions which, in turn, help to build personal and social resources that lead to wellbeing and flourishing [39,40,41,42,43]. Whilst, in the context of psychological flexibility, negative emotions are not necessarily to be avoided ; awareness of, and capacity for the cultivation of, positive emotions should thus be fostered as part of self-care practice. This may serve to promote resilience and emotional intelligence both individually and across the palliative care team [45, 46].
That self-compassion was considered enabling to self-care, corresponds with findings from a recent correlational study  in which perceived self-care ability was significantly associated with increased self-compassion in palliative care nurses and doctors. Indeed, as highlighted by Vachon , self-compassion entails knowing and caring for oneself. The self-care barriers identified in the present study provide a valuable context which may also explain the low levels of self-care ability identified in some doctors and nurses from the previous study. Building from emerging evidence to support compassion-oriented training interventions in palliative care teams , future research should therefore investigate any causal relationship between these variables longitudinally. Potential studies could incorporate interventions that draw upon loving kindness meditation or other compassion training programs which have been shown to enhance compassion for self and others, and may therefore contribute positively to both self-care and compassionate care of others [49,50,51,52,53].
In other research [13, 54], palliative care professionals’ reported self-care practices have corresponded with physical, social, and inner domains of self-care. Importantly, findings from the present study underscore the imperative that strategies from these self-care domains are implemented and maintained in both personal and workplace settings. Findings from this study can thus inform the self-care education and training interventions recently called for , especially in relation to self-care planning, work-life harmony, and management of identified barriers and enablers to effective self-care practice. Educational resources might usefully draw upon this qualitative evidence previously lacking in the literature, to articulate and foster the meaning and practice of effective self-care in the palliative care workforce. For example, clarifying staff confusion about the shared responsibility for self-care practice – as identified in this study.
The issue of balance between individual and organisational responsibility is multi-faceted and requires careful consideration by palliative care services. Clearly, an organisation cannot practise self-care on behalf of its workforce; however, it can enable and enhance self-care through corporate leadership and a variety of structural supports to foster positive workplace cultures that are conducive to effective self-care practice [36, 37]. At the same time, individual practitioners carry a personal responsibility for self-care to maintain their health and capacity for professional practice. This was highlighted by one participant, who stated: It’s the responsibility of every team member to look after themselves, but having management or organisational strategies in place to support someone doing self-care is incredibly important… it’s a dual process. This collaborative approach to promoting health and wellbeing in workplace contexts is reflected in the World Health Organisation’s (WHO)  Healthy Workplace Framework.
While individual responsibility relates to implementing and maintaining self-care strategies, organisational responsibility is thus oriented towards supporting staff in effective self-care practice to promote health and wellbeing. This support represents an investment, with a host of potential organisational benefits including increased patient and family satisfaction, increased staff retention and reduced absenteeism, improved staff morale and job satisfaction . Conflict between colleagues can be a common source of staff stress, and is an important workplace concern where all parties must take some responsibility. While the degree of responsibility will vary according to context, the use of employee assistance programs and adoption of the WHO Healthy Workplace Framework can provide support and guidance in this area.
Clarity may also be lacking with regards to shared responsibility for self-care practice where clinicians experience chronic illness and or disability. Health services, as institutions, have the potential to promote health and wellbeing not only for health care consumers; but also for health care professionals . Indeed, some argue that hospitals should serve as exemplars of healthy workplaces . Given this context, a collaborative approach encompassing individual self-management and organisational support would be consistent with the WHO Healthy Workplace Framework, which recommends that workplaces be supportive of employees living with chronic disease and disability . Palliative care services might usefully draw upon this or similar approaches.
Given the highly personalised nature of self-care, palliative care services should also consider ways in which a variety of self-care strategies can be supported. For example, providing opportunities for both informal debriefing and formal clinical supervision – depending on individual preference; as well as scope for the supported development of individual self-care plans for those who feel they would benefit from them.
A novel finding from this study was the concept of team-care to promote a healthy team. As an encouraging sign of positive workplace cultures, this highlights an additional dimension to the relational context of self-care practice, whilst underscoring the importance of supporting interdisciplinary teamwork as an integral part of the philosophy of palliative care. It also contributes to the literature on positive relationships and workplace wellbeing in the context of self-care and positive health . Taken together, the practice of team-care as an antecedent to a healthy team in palliative care represents a potential avenue of qualitative inquiry for future research. This would be enhanced with the inclusion of participant observation and patient-reported outcomes on any perceived benefits to the quality of care provided.
Limitations to this study should be noted. Socio-cultural considerations were not represented in the demographic data collected or subsequent analysis. Whilst, to our knowledge, any significant impact of culture on self-care has not featured in the literature to date, we acknowledge that palliative care professionals from culturally and linguistically diverse backgrounds may understand and approach self-care practice in ways other than as described in this study sample. Additionally, the sample was somewhat limited in terms of participants’ geographical location. While the study recruited participants from metropolitan and inner or outer (rural) regional locations of nearly all Australian States and Territories, remote area locations were not represented. The meaning and practice of self-care may have unique characteristics in remote area practice, thus transferability of findings from this study should be gauged by remote area practitioners. Despite these limitations, which may be addressed in the future by discrete population-specific studies, this research has generated new knowledge in line with the study aim.