Background High-quality hospice care is dependent on an expert caring and resilient workforce who can cope with the significant physical and emotional demands of palliative care. Consequently, hospices employ a range of strategies to support and develop their staff, but it is not clear which are the most helpful, the best value or whether certain combinations are needed. Though ethical considerations are a prominent and common source of distress for hospice staff, clinical ethics rarely receives as explicit or frequent attention within hospices when compared to other support structures.

Methods We critically reviewed the staff support and development structures at a large hospice in southeast England, spanning: informal colleague support, reflective practice sessions, teaching, line management and specific additional support such as clinical supervision, Clinical Ethics Committee (CEC) and Schwartz Rounds.

Results Our review identified, then compared and contrasted, the key mechanisms of staff support and development: – CEC (what is the ‘right thing’ to do) – Reflective Practice (how to best go about doing the ‘right thing’) – Clinical Supervision (being personally able to do the ‘right thing’) – Schwartz Rounds (how doing the ‘right thing’ feels).

Conclusion Appropriate staff support and development is vital for hospices to deliver high quality, sensitive and individualised patient care. Four mechanisms appeared pivotal in their ability to support and develop staff in their professional roles. Despite clear overlaps, appreciation of their differences was fundamental in understanding their collective benefit: – CECs: being ethical – Reflective practice: being organised – Clinical supervision: being educated – Schwartz Rounds: being human. Subsequently, we propose the ‘Support of Care Cycle’ where each element informs the next in a virtuous spiral. As interdependent, to miss any component would undermine a hospice’s staff support and development structures. Thus, hospices need to provide all four of these cornerstones, including the often neglected clinical ethics.