Turning the Lens Inward: The Psychological Elements of Clinician Well Being

Abstract

This is the seventh entry in the Psychological Elements of Palliative Care (PEPC) series. Previous articles have focused on the psychological elements of the care we provide patients and the relationships we build with our referring clinician colleagues. In this entry, we focus on how the PEPC also impact clinician well being. The PEPC are bidirectional: we impact patients, but patients also impact us. The reactions that we have to patients and the boundaries we set around the care we provide are two examples of psychological factors of care that can influence our well being. Creating spaces to explore and reflect on the psychological impact of the clinical care we provide is a key component of wellness. Such spaces vary in their configuration, but all share the opportunity to self-reflect and to experience emotional validation, normalization, and reality testing from peers or mentors. In mental health training, clinical supervision is one common format for creating such a space. While this can be replicated in the palliative care setting, other strategies include integrating a psychological orientation into interdisciplinary team meetings, creating peer support or process groups, and creating small groups within teams for longitudinal self-reflection.

This is the seventh article in the Psychological Elements of Palliative Care (PEPC) series. In prior articles, we have explored many of the PEPC as they pertain to patients. In this article, we will review the PEPC and provide a lens to think about clinician well being.

Health care workers experience high levels of work-related stress. Such stress can contribute to burnout, a constellation of emotional exhaustion, depersonalization, and feelings of reduced personal accomplishment.^1,2 Burnout is associated with poor patient care and adverse health outcomes for clinicians.^2,3 Rates of burnout are significant among palliative care clinicians.^2,4,5 Palliative care clinicians experience unique stressors specific to their emotionally intense work, which includes heavy engagement with mortality, existential distress, and suffering.⁶

Overlaid on the emotionally challenging themes of our work are structural challenges; palliative care clinicians are often called to “fix” chaotic situations, we are expected to establish ourselves within groups with preexisting dynamics, and we are expected to attend to the needs of both referring clinicians and patients. Our clinical work can predispose us to compassion fatigue, vicarious trauma, moral distress, and burnout.^7–10 Many of these stressors have intensified in the context of the COVID-19 pandemic.^11–13

Multiple strategies have been utilized to combat burnout and improve clinician well being.^14,15 Such strategies address personal factors such a mindfulness practice and exercise and institutional/environmental factors, including staffing and workload and schedule flexibility.^16–18 Much of the work on the well being of palliative care clinicians already engages with psychological processes, particularly in the domains of coping and resilience.¹⁹

However, relatively little has been written about how the relational aspects of palliative care, which occur between clinicians and patients or among clinicians, impact well being. Let us check in with the clinician caring for Gloria—a fictional patient we have been following over the course of this article series—to learn a little bit more about this.

As you sit in your clinic between patients, you note a sense of dread. The past few months have been very difficult for several of your patients, including Gloria. Your referring colleagues like Dr. Ko, Gloria's oncologist, are looking to you to ease suffering. But the level of distress among your patients is through the roof—difficult to control symptoms and existential angst are rampant. You feel that you're floundering and worry that your more experienced colleagues will find that you are not providing appropriate care. The way you ought to. The way they would have.

Your work voicemail light is always glowing and you find yourself spending increasing periods of time putting off checking your messages. You're trying hard to do right by your patients and have given several of them your home cell phone number so that they can check in with you directly afterhours. It's been hard to sleep feeling as though you're responsible for your patients' well being 24-7. When you've shared how you're feeling with colleagues and mentors, they respond with empathy and direct you to the hospital's wellness program, which includes lunchtime yoga classes and vouchers for “coffee and a treat” at the lobby café. You like your yoga and coffee, but you're not convinced that will address the underlying issues…

Gloria's palliative care clinician works in a supportive environment with empathetic colleagues and an institutional clinician wellness program. However, they are still struggling with the psychological aspects of the work they do: How do they balance providing good care and creating boundaries to support their own well being? How can they overcome the sense that they are not able to provide the level of care their senior—and more seemingly unflappable—colleagues do?

In many ways, the paradigm of health care training is oriented on emergency functioning. We often find ourselves focusing on the concrete steps necessary to provide excellent care to our patients in the next hour, day, week, or month. We are not conditioned to engage in self-reflection. However, it makes sense that the psychological processes that impact patients so deeply also affect us. Palliative care is relational; we are participants in the process, too. A PEPC focus on well-being involves adding a level of reflection to the processes of self-care through the concepts we discuss in the prior articles such as countertransference, boundaries, and team dynamics.

As with the other PEPC, turning a psychological lens on clinician well-being complements, rather than replaces, existing strategies. In the remainder of this article, we will focus on how two earlier concepts particularly impact clinician well being: countertransference (the reactions we have to our patients) and boundaries. We will then talk a little bit about what psychologically informed well-being interventions might entail, with some suggestions for program development.

Boundaries

The ozone layer forms a shield around the earth that lets in the light and warmth of the sun. Ideally, it keeps out dangerous ultraviolet radiation. Without an ozone layer, life would be impossible. In palliative care, the boundaries established by the treatment frame are our ozone layer. In addition, like the actual ozone layer, they can be eroded to the detriment of both our patients' and our well being.

The treatment frame creates the boundaries of care. Recall that the frame defines everything from what the content of the treatment is and how the clinician and patient communicate to how long and frequent encounters are, and so forth. The outline of the frame sets the boundaries—what is inside the frame (e.g., a 40-minute visit monthly, discussing pain and serious illness) versus what is outside the frame (e.g., meeting a patient for dinner at the mall for a date) helps guide both us and patients to a mutually agreeable relationship.

In the second article in this series, we discussed how the frame helps patients feel secure in the treatment relationship. However, the frame also protects clinicians. Imagine if all our patients had 24/7 unfiltered access to us or if our patients were also our close friends, romantic partners, and family. We would be too overwhelmed and confused to help anybody! The interactions that palliative care clinicians share with patients are emotionally intense; we face profound suffering, existential terror, and bereavement, all overlaid on the medical complexity of seriously ill patients. If we lose the protection of our ozone layer, we cannot expect to provide excellent long-term care.

Some boundaries are non-negotiable—they are built into the ethical and structural framework of medical care. For example, clinicians do not engage in romantic relationships with their patients. However, many boundaries are not set in stone and may be team or clinician dependent. It is important to spend time (we will talk more about how to do this later) reflecting on what boundaries allow you to feel protected, care for yourself, and provide excellent care to your patients.

It is also important to reflect on how your boundaries impact your colleagues. For instance, if you decide to stop answering clinic calls at noon every day, other colleagues providing coverage will likely have to step in and cover you. On the other hand, if you make yourself available to conduct palliative care consultations in the hospital at midnight while on service, it may make it more challenging for your colleagues to sign over the pager at 5 pm and go home to rest when it is their turn to be on service.

Much of the existing literature on boundaries involves protecting patients and managing medicolegal risk.²⁰ However, boundaries also play a vital role in protecting clinicians. We adjust our boundaries all the time—spending a little bit more time with a patient than we might normally, staying late for a terminal extubation, or bringing a patient a beloved treat from outside the hospital. Such adjustments are not inherently harmful to us or to patients. In fact, a delightful interaction with a patient we really like may fill our cup and be an antidote to burnout. However, because these instances differ from the care we normally provide, it is important to reflect on the motivations behind them.

What fuels us to stay late with a patient? What makes us decide that we should purchase a particular patient a cup of coffee before we visit their hospital room? This curious attitude toward our own behaviors can help us identify behavior that may be unproductive for the patient or for our own well being. For instance, it may be that a clinician buys an inpatient a cup of coffee as a purposeful decision to help them feel cared for and facilitate discussion about next steps.

However, it also may be that a clinician might feel they are inadequate for not making headway in a difficult goals-of-care discussion and is responding to these feelings of inadequacy by spending more of their time (and money) on a patient's case. As you might imagine, feeling inadequate about how a case is going and then spending more of our emotional and concrete resources on it could potentially lead to exhaustion, persistent feelings of low self-efficacy, and an empty coffee cash card.

Boundaries help us take good care of patients while also taking care of ourselves. When we cross a boundary we normally maintain, it is a moment to check in with ourselves. However, it is also worth noting that we often lack control over clinical care boundaries. There are many external barriers to boundary setting: the expectations of our institutions and colleagues, the needs of our patients, and the relationships we form with our referring clinicians can all make it difficult to establish boundaries that support our well being. Even in the absence of control, awareness of these tensions can help us recognize our needs. That awareness can translate into utilizing our teams to help us negotiate challenging situations.

Individual clinicians on a palliative care team may have differing boundaries in the care they provide. For instance, even the boundaries of the care provided across disciplines vary tremendously (nurses touch their patients regularly, while social workers may not). When we can explicitly discuss boundaries in our team, we can invite in a more expansive approach to care that is often able to successfully negotiate the well being of clinicians and the needs of patients, referring colleagues, and institutions.

Countertransference

In prior entries in this series, we learned about countertransference—the reactions we have to our patients.²¹ Countertransference involves complex interplay between the behaviors of our patients, the clinical context, and our own psychology. These reactions can inform the care we provide and the formulations we hold about our patients. However, countertransference also impacts our own well being.

Our work with patients is emotional: we may be sad for a patient who is declining or share in the joy of a patient who is on the mend. However, the reactions we have to patients may be more complex. While we may feel sad for a patient, we may also have feelings about the patient, including anger, anxiety, affection, and so forth. Such feelings can make it particularly complicated—and taxing—to provide high-quality care. Often, the reactions we have to patients even end up manifesting through feelings about ourselves, rather than our patients. For instance, when we have patients who respond well to treatment and are very grateful, we may feel particularly effective and confident.

Alternatively, some patients may make us feel inadequate. Even though these are feelings we have about ourselves, when they arise in response to an interaction we are having with a patient, they may still be countertransference. The reactions we experience to patients represent a complex interplay between patients and ourselves. Patients' situations or behaviors may elicit a relatively universal reaction in their clinicians, but often, we have unique reactions to specific patients or scenarios that are also informed by our own past experiences and psychological make-up.²² For instance, we may find the decline of a patient who reminds us of a beloved caregiver particularly emotionally wrenching or we may find it difficult to summon our usual empathy for a patient whose mannerism or behavior reminds us of a childhood bully.

Without a psychologically informed lens through which to understand the feelings we carry from our interactions with patients, our well being is at risk. Every clinician knows that a day spent seeing the same number of patients in clinic or an equal number of consults can vary tremendously. Seeing a patient with whom we are deeply connected may replenish us or guide us in making meaning of our work. However, seeing a panel of patients who make us feel like we are ineffective clinicians or having to field numerous consults in a day that make us feel very angry puts us at risk of compassion fatigue and burnout.^23,24

Participating in the care of patients who makes us feel complicit in care we believe to be inappropriate exposes us to moral distress.⁹ This is compounded by the fact that these reactions we have to patients often shape the care we provide. For instance, a clinician who finds that a certain patient never seems to feel better from their interventions may feel anxious and ineffective caring for that patient. This can manifest in avoidance—delaying returning calls or passing by their room without checking in. Such behavior not only negatively impacts patient care but is also likely to make the clinician feel even more anxious and inadequate.

There is an intimate connection between the boundary discussion above and countertransference. It is not uncommon for clinicians to disregard their usual boundaries for patients who elicit strong reactions. For instance, a “VIP” patient who constantly references important figureheads may cause us to feel insecure and begin seeing the patient more frequently than we otherwise would. Certainly, there are indications to see a patient more frequently than is normal for us (e.g., clinical need or if our boss asks us to see the VIP patient frequently).

However, if every time we encounter a patient who makes us feel a certain way we change our behavior to accommodate those feelings, we may find ourselves going beyond the care we feel able to routinely provide for almost all our patients! And that is unsustainable.

Psychological Clinician Well Being

Even with an understanding of how psychological elements of care such as boundaries and countertransference can impact us, using these ideas to improve our well being is complex. Sometimes, crossing a boundary is a therapeutically wise decision, but sometimes it is a taxing response to a negative feeling in a clinician. Sometimes countertransference guides our care, but sometimes we end up responding to it in ways that may impair our patient care or well being. How is an astute clinician to know? With self-reflection and, ideally, with help.

Even seasoned psychotherapists contending with these questions have forums for reflection. A psychological approach to well being requires spaces of open nonjudgmental curiosity about our reactions to patients and clinical situations. Such spaces utilize common strategies, including validation, normalization, and reality testing (see the discussion between Gloria's palliative care clinician and their mentor in Table 1).^25,26 These strategies are well aligned with the comfort zone of many palliative care clinicians and can be used across settings. We share examples of interventions aimed at creating space for clinicians and teams to use these strategies below.

Table 1.

Validation, Normalization, and Reality Testing in Practice

You: …so, as I was saying, things just aren't going well clinically. I feel like I'm failing my patients. Mentor: I'm not surprised you're feeling that way; you're really worried about your patients. That makes perfect sense to me.	Validation: recognition and understanding of an individual's emotional experience.
You: Yes! It's really weighing on me. I just feel like my cases have been so intense lately. Mentor: We all have periods where many of our patients seem to be struggling. You've had some incredibly challenging cases lately. I think any clinician in your situation would need some extra support. [Normalization]	Normalization (also called universalization): complements validation and entails not only recognizing an emotional response but also situating it as a normative reaction that is not disproportionate or pathological.
You: …I guess. I suppose it just seems like if these patients were being taken care of by someone who was more experienced—someone like you—they wouldn't be suffering so much. I keep wondering if I'm not providing the care they need. Mentor: Actually, I have been so impressed by the care you have been providing. I can't imagine a patient like Gloria could have gotten better care. Sometimes it can be tempting to feel like we have control over our patients' well being—if we just took better care of them, they would be fine. But we aren't omnipotent. I don't think the clinical situation would be different whether I or anyone else was caring for them. [Reality testing]	Reality testing: distinguishing one's internal reactions from external reality.

In psychotherapy, a framework for processing clinical care experiences is clinical supervision. Clinical supervision entails working with a supervisor to cultivate a practice of self-reflection aimed at optimizing patient care while attending to one's own needs. Clinical supervision maintains a dual orientation toward the supervisee's growth and patient care.^27,28 In practice, supervision becomes a space for clinicians to discuss cases, process countertransference, discuss difficult interactions and situations, contemplate interpersonal work difficulties, explore emotions arising in the context of work, and even seek out coaching such as time management help.

It differs from therapy as it focuses on clinical roles and experiences and includes an educational focus. It also differs from traditional medical supervision, such as an attending supervising a resident on a medical admission, which is more purely patient facing. In supervision, the supervisee traditionally is a more junior clinician and the supervisor is a senior. Concretely, traditional supervision might entail meeting once a week in a comfortable private space to discuss one or multiple challenging cases and the supervisee's overall professional development.

Unlike medical models of supervision, in which an attending physician is ultimately responsible for patient care and will see the patient themselves and formulate a plan, clinical supervision in mental health may be oriented around the supervisee and may not entail the supervisor having interaction with or responsibility for a patient. Supervision often includes a focus on both microprocesses, specific exchanges or interactions that seemed significant or impactful, and macroprocesses, such as the overall trajectory of a case or the supervisee's general functioning and growth. It may also include a focus on processes of care such as interactions with colleagues or referring clinicians.

Common questions in supervision might cover inquiries into the therapeutic choices made by the supervisee in patient interactions, exploration of transference and countertransference, exploration of alternative interactional approaches to various clinical scenarios, and linking of theoretical constructs to clinical care. For instance, if a supervisee were to note that they had made an unusual choice not to round on an active patient, a supervisor might share in curiosity with the supervisee and ask, “That's interesting. You normally round on all your inpatients every day. What do you make of deciding against seeing patient A today?”

However, the above description is not the only approach to supervision. There are many models of supervision, including group supervision (several supervisees with a supervisor),^29,30 peer supervision (peers working through the above issues together and acting as both supervisors and supervisees for one another),³¹ and informal introduction of supervisory aspects into other training or group processes.³² A range of such models have been employed in palliative care settings.^33,34

Some palliative care programs have implemented formal supervision models with senior clinicians in their programs. For instance, at the Massachusetts General Hospital, early career, palliative care attending physicians receive a structured program of supervision with mental health clinicians to have a space to explore their experiences in caring for complex patients. Other programs utilize Balint or process groups; groups for clinicians facilitated by a trained group leader, which focus on the emotional and psychological aspects of clinical care and foster reflective practice.^35,36

However, many programs lack resources for such interventions. Fortunately, many of the key functions of supervision can be approximated through optimizing existing team structures.

Senior palliative care clinicians identify interdisciplinary meetings (IDTs) as important for fostering well being.⁴ IDTs do not inherently fill the same needs as supervision; they may be more patient oriented and are not always protected spaces. However, IDTs can be shifted toward fulfilling a supervision role by shared commitments to self-reflective practices such as processing without solving, creating space for vulnerability, utilizing smaller subgroups to shift the tone, and engaging leaders with experience in psychological processes and group dynamics.

Strategies such as validation, normalization, and reality testing can be utilized in IDT settings. Utilizing social workers as leaders may be helpful in achieving some of these practices.³³ Cultivating other supervision-like spaces, for instance, protected group reflection time for clinical teams, may also be helpful (Table 2).

Table 2.

Strategies for Creating Spaces for Supported Self-Reflection

Intervention	Explanation
Interdisciplinary team meetings	Interdisciplinary team meetings are a common element of palliative care services. While such meetings commonly involve discussion of clinical cases, with appropriate leadership, they can also serve as forums to metabolize some of the psychological challenges of palliative care. Utilizing social workers to shift the lens of meetings toward a clinician well-being frame that includes mutual validation, normalization of difficulties, and reality testing of negative clinician self-perceptions may help cultivate a well-being-oriented meeting.
One-on-one supervision	Providing clinicians with one-on-one supervision by senior palliative care clinicians or mental health clinicians to process psychological challenges in clinical care replicates a common model used in the training of mental health clinicians.
Group supervision, Balint groups, and process groups	Creating spaces dedicated to group processing with the guidance of a supervisor or facilitator is another strategy that has been used extensively in multiple settings, including mental health clinician training. Such experiences can help empower clinicians to serve as peer supervisors in team or individual settings through the role modeling of the facilitator.
Peer supervision	Peer supervision entails partnership between colleagues to support self-reflection and support in metabolizing psychological challenges in clinical care. Such models often work most effectively when clinicians are oriented to the supervision model as can occur when this is preceded by a traditional group or individual supervision.
Team reflection	Protected time for teams to reflect together—without necessarily discussing cases—encourages team members to reflect on the individual clinician and team experiences of care. Such spaces may differ from IDTs, in that they are not case focused and can be achieved using smaller subteams to allow for more vulnerability and trust among members.

IDT, interdisciplinary meeting.

Regardless of the effort to cultivate self-reflective spaces, it is important to recognize that clinicians' orientations toward vulnerability and openness vary. What may meet the needs of one individual may feel invasive or uncomfortable to another. Giving team members agency in cultivating their own self-reflective processes is of great importance to avoid contributing to emotional stress.

Conclusions

The psychological processes that underpin palliative care such as boundaries and countertransference have a significant impact on clinician well being. In palliative care, these dynamic processes are particularly complicated and overlaid with the stressors inherent in palliative care practice: immense suffering, multiple stakeholders, and complex situations.

Creating opportunities for a clinician to cultivate self-reflection and obtain support, including validation, normalization, and reality testing, is important for well being. Such opportunities may include formal avenues, such as clinical supervision, a guided process of clinical self-reflection with a mentor or in a group. However, even programs without resources for formal supervision can utilize core concepts from supervisory activities to cultivate a culture of self-reflection and support.

Authors' Contributions

All authors contributed to the conceptualization of ideas and preparation of the manuscript, including editing and cowriting sections. All coauthors have reviewed and approved of the manuscript.

Funding Information

No funding was received for this article.

Author Disclosure Statement

No competing financial interests exist.