The struggle for the soul of hospice: stress, coping, and change among hospice workers

'So being here is. . . I feel like I'm being a social worker again, at the hospice': Using interpretative phenomenological analysis to explore social workers' experiences of hospice work

BACKGROUND

Social workers have a significant role in hospices working with clients who are facing death but there is limited detailed understanding of the emotional impact of this work on social workers. Research has highlighted that those involved in hospice work find the work both a struggle (e.g. because of heightened emotions) and rewarding (noting that end-of-life care can feel like a privilege).

AIM

To explore UK hospice social workers' emotional experiences of work and how this influences their practice.

DESIGN

Semi-structured interviews were conducted with hospice social workers. Interviews were transcribed and transcripts were analysed using Interpretative Phenomenological Analysis.

SETTING/PARTICIPANTS

Eight social workers from different hospices in the UK.

RESULTS

Five overlapping superordinate themes emerged: making a difference to clients and families ('the difference made'), the emotional impact of working in hospices ('dealing with people's emotions, and death, and dying, it's serious stuff'), the relational context of this type of work ('awareness of affinity to connect'), the ways in which coping is facilitated in hospices ('seen it coming') and a foundation theme, connection and disconnection to values ('(dis)connection to values').

CONCLUSIONS

The results offer an exploration of social workers' experiences of their work in hospices; how adept they were at coping and how they prepared for and made sense of the often emotionally-laden experiences encountered. Their experience of the rewards and meaning derived from their work offers important findings for clinical practice. Further research is suggested to explore a multitude of healthcare professionals' perspectives across country settings using Interpretative Phenomenological Analysis.

Burnout and quality of life in Portuguese healthcare professionals working in oncology and palliative care-a preliminary study

BACKGROUND

Palliative care is an approach that improves the quality of life of patients and their families who are facing challenges associated with life-threatening illness, through the prevention and relief of suffering. Palliative care health professionals are considered a risk group for the development of burnout, since they live with severe disease and death, on a daily basis. With this work, the authors intend to evaluate the quality of life and risk of burnout in a group of health professionals, who work in a tertiary hospital dedicated to cancer patients.

MATERIAL AND METHODS

The authors conducted a quantitative, descriptive, correlational and transversal study on palliative care professionals working with cancer patients. The evaluation protocol used to collect data included a sociodemographic questionnaire, WHO Quality of life Assessment instrument and Maslach Burnout Inventory. Statistical analysis was performed using the SPSS®Statistics program.

RESULTS

In the sample, there is a predominance of female gender (79,4%) with a mean age of 43,2 ± 10,8 years. The most representative professional group was nursing (47,1%). The sample response rate was 91.9%. Analyzing Maslach Burnout Inventory score, it appears that physicians and nurses have higher levels of exhaustion when compared to the other groups. In relation to quality of life (QoL), it was observed that in all dimensions, there was a homogeneous distribution of responses. It was verified that it was not possible to establish any relationship between the dimensions of burnout and QoL. Thus, the various dimensions behaved independently.

DISCUSSION

Physicians and nurses had the highest burnout levels in the most dimensions of Burnout score, in which they were followed by the operational assistants, who had moderate scores. Despite hight prevalence of Burnout, there is no correlation between Burnout and quality of life in this population. The perception of QoL is very satisfactory in the sample studied may result from the fact that these individuals have developed adequate self-protection strategies, thus preventing QoL from being affected by Burnout.

CONCLUSION

Prevention, diagnosis and intervention at burnout level is an important measure to be taken in health organizations, since the consequences that come from the experiences experienced by professionals will be reflected both in the quality of services provided to patients and in the QoL and well-being of professionals. Interventions are needed to promote better coping mechanisms when dealing with stress in this population. After this study, a Burnout Consultation was created at the Institution, to support professionals at risk or already affected.

Adaptation and continuous learning: integrative review of coping strategies of palliative care professionals

BACKGROUND

Coping is essential to manage palliative care professionals' challenges. The focus has been on the effects of coping mechanism; however, little is known about coping itself in palliative care.

AIM

To synthesise evidence of coping strategies in palliative care professionals, and how different strategies play roles over time.

DESIGN

Systematically conducted integrative review.

DATA SOURCES

PubMed; CINAHL; Medline; PsycINFO and B-ON were searched (1996-2021) combining 'coping' AND 'palliative care'. A predefined data extraction sheet was developed to report data. Two researchers performed constant comparative analysis using Nvivo®.

RESULTS

Thirty-one studies were included. Four main strategies with recurrent reference to time were found: (a) proactive coping, involving activities to achieve self-confidence and control situations and emotions; (b) self-care based coping, including self-protection and self-awareness activities, with behavioural disconnection; (c) self-transformation coping, involving activities to accept limits; and (d) encountering deep professional meaning, is a coping mechanism based on meaning, frequently considering the deepest meaning of work. The dynamic and influencing factors were training, team interaction, professional motivation and family. They were usually protective factors, though sometimes they represented risk factors. The emotional burden associated with healthcare and systemic stressors were always risk factors. An explanatory model describes a complex and dynamic process, in which everyday strategies and more introspective strategies are combined.

CONCLUSIONS

The model showed a process of adaptation and learning to persevere in palliative care. It changes over time under factors and strategies, and evolves in a personal and professional transformation, parallel to the working life. It would be worth assessing coping in healthcare professionals who chose to leave palliative care and to investigate the reasons they did so and their coping mechanisms.

Compassion fatigue, watching patients suffering and emotional display rules among hospice professionals: a daily diary study

Background

Hospice workers are required to regularly use emotional regulation strategies in an attempt to encourage and sustain terminally ill patients and families. Daily emotional regulation in reaction to constantly watching suffering patients may be intensified among those hospice professionals who have high levels of compassion fatigue. The main object of this study was to examine the relationship between daily exposition to seeing patient suffering and daily emotional work, and to assess whether compassion fatigue (secondary traumatic stress and burnout) buffers this relationship.

Methods

We used a diary research design for collecting daily fluctuations in seeing patients suffering and emotional work display. Participants filled in a general survey and daily survey over a period of eight consecutive workdays. A total of 39 hospice professionals from two Italian hospices participated in the study.

Results

Multilevel analyses demonstrated that daily fluctuations in seeing patients suffering was positively related to daily emotional work display after controlling for daily death of patients. Moreover, considering previous levels of compassion fatigue, a buffering effect of high burnout on seeing patients suffering - daily emotional work display relationship was found.

Conclusions

A central finding of our study is that fluctuations in daily witness of patients suffering are positively related to daily use of positive emotional regulations. Further, our results show that burnout buffers this relationship such that hospice professionals with high burnout use more emotional display in days where they recurrently witness patients suffering.

Satisfaction With Work-Family Balance Mediates the Relationship Between Workplace Social Support and Depression Among Hospice Nurses

PURPOSE

The purpose of this study was to investigate the relationship between social support (from personal and workplace sources) and psychological distress (depression, anxiety, and stress symptoms), as well as to examine the mediating role of satisfaction with work-family balance among hospice nurses.

DESIGN AND METHOD

A cross-sectional study design was utilized with a sample of 90 hospice nurses from the southern United States. Participants completed online surveys, including (a) the Depression, Anxiety, and Stress Scale (DASS-21), (b) loosely adapted items from the Affectivity, Burnout, and Absenteeism Scales, and (c) Satisfaction with Work-Family Balance Scale.

FINDINGS

Workplace social support, not personal social support, was associated with lower psychological distress, and satisfaction with work-family balance mediated the relationship between workplace social support and depression symptoms, a component of psychological distress.

CONCLUSIONS

Hospice nurses' social support in the workplace and their satisfaction with the balance between their work and family lives play a role in supporting their mental health.

CLINICAL RELEVANCE

Hospice nurses may benefit from programs fostering the creation of workplace-based interpersonal relationships.

Compassionate collaborative care: an integrative review of quality indicators in end-of-life care

Background

Compassion and collaborative practice are individually associated with high quality healthcare. When combined in a compassionate collaborative care (CCC) practice framework, they are reported to improve health, strengthen care provision, and control health costs. Little is known about how to integrate and measure CCC, yet it is fundamentally applied in palliative and end-of-life care settings. This study aimed to identify quality indicators of CCC by systematically reviewing and synthesizing the current state of the palliative and end-of-life care literature.

Methods

An integrative review of the palliative and end-of-life care literature was conducted using Whittemore and Knafl’s method. Donabedian’s healthcare quality framework was applied in the data analysis phase to organize and display the data. The analysis involved an iterative process that applied a constant comparative method.

Results

The final literature sample included 25 articles. Patient and family-centered care emerged as a primary structure for CCC, with overarching values including empathy, sharing, respect, and partnership. The analysis revealed communication, shared decision-making, and goal setting as overarching processes for achieving CCC at end-of-life. Patient and family satisfaction, enhanced teamwork, decreased staff burnout, and organizational satisfaction are exemplars of outcomes that suggest high quality CCC. Specific quality indicators at the individual, team and organizational levels are reported with supporting exemplar data.

Conclusions

CCC is inextricably linked to the inherent values, needs and expectations of patients, families and healthcare providers. Compassion and collaboration must be enacted and harmonized to fully operationalize and sustain patient and family-centered care in palliative and end-of-life practice settings. Towards that direction, the quality indicators that emerged from this integrative review provide a two-fold application in palliative and end-of-life care. First, to evaluate the existing structures, processes, and outcomes at the patient-family, provider, team, and organizational levels. Second, to guide the planning and implementation of team and organizational changes that improve the quality delivery of CCC.

Compassion Fatigue and Compassion Satisfaction in Hospice Social Work

As part of the interprofessional team of hospice caregivers, social workers are exposed to multiple stressors, both in their work with dying patients and their families and in functioning as professionals within rapidly changing health care organizations. Ongoing exposure to such stressors prompts concern about the emotional and psychological effect working with people who are dying may have on those who do it. Further, an understanding is needed regarding how hospice social workers interpret the costs and benefits of their work and how they cope with the dying and loss that pervade their everyday work lives. This descriptive, cross-sectional study explored the prevalence of compassion fatigue among hospice social workers and considered compassion satisfaction as a means to mitigate compassion fatigue. Fifty-five hospice social workers from 34 hospice organizations in Michigan completed an online survey. Results suggested that compassion fatigue is indeed a concern among hospice social workers. In addition, compassion fatigue and compassion satisfaction were found to be negatively correlated and suggested that compassion satisfaction may act as a protective mechanism against compassion fatigue. These results may provide insight regarding how best to mitigate this professional hazard in end-of-life social work.

The Importance of Perspective: Evaluation of Hospice Care From Multiple Stakeholders

The literature on hospice care and palliative medicine lacks a focus on the combined and concurrent assessment of services. This deficiency is problematic because research findings are then limited in their scope and applicability to particular stakeholder groups. The current study used the perspective of 72 participants and service delivery personnel of a home-based hospice program to address this perceived problem and limitation in the literature through a program evaluation of the multiple perspectives on a single hospice organization. Interviews were analyzed by stakeholder group and then across stakeholder groups to extract themes. Results include a description of the quality of service delivery and participant satisfaction, areas of current weakness, and ideas for potential growth and development for the program. Findings from this study are compared with previous research on hospice care and the implications of the results to the provision and continued development of hospice care are discussed.

Hospice Core Professions' Views on Interdisciplinary Teams: A Qualitative Investigation

The hospice interdisciplinary team (IDT) has been recognized as an ideal model for interprofessional collaboration. To address the manner in which interdisciplinary practices are perceived by team members, this study explored profession-based similarities and differences in perceptions among the four core hospice IDT members (physicians, nurses, social workers, and spiritual care providers) as well as experiences on the IDT. Semistructured interviews with 20 hospice professionals, 5 from each profession, were completed. Findings suggested that while hospice professions share some perceptions and experiences about hospice team membership, strengths of and barriers to teamwork, and individual members' contribution to the team, significant profession-based differences exist largely in the area of hospice team membership beyond the core members, type of language and descriptions used, perceptions of causes and effects of barriers to teamwork, and understandings of how team effectiveness is evaluated. Changes at the team-based, organizational, policy, and educational levels are needed to further maximize strengths of individual hospice IDT member and team qualities.

Burnout and death anxiety in hospice social workers

Hospice work has been regarded as particularly stressful due to the complexity inherent in the provision of end-of-life care. Burnout and death anxiety are especially relevant to hospice social workers because they regularly function in a high-stress, high-loss environment. The purpose of this study was threefold: to determine the prevalence of burnout and death anxiety among hospice social workers; to examine associations between burnout and death anxiety; and to explore the factors which may contribute to the development of death anxiety and burnout. Participants completed four items: the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), the Death Anxiety Questionnaire (DAQ), a demographic questionnaire, and a set of open-ended questions. Findings indicate that mean scores on the subscales of the MBI-HSS ranged from the low to moderate range and that a strong positive correlation existed between death anxiety and the depersonalization subscale of the MBI. Three key themes emerged from the qualitative data: (a) personal interest in hospice social work developed through a variety of ways; (b) although death anxiety decreased from exposure and understanding of the death process, there was increased death anxiety surrounding working with certain patients; and (c) burnout was primarily related to workload or difficult cases.

The experiences of stress of palliative care providers in Malaysia: a thematic analysis

A qualitative study was conducted with semistructured interviews to explore the experiences of stress in 20 palliative care providers of University Malaya Medical Centre in Malaysia. The results were thematically analyzed. Nine basic themes were generated: (1) organizational challenges, (2) care overload, (3) communication challenges, (4) differences in opinion, (5) misperceptions and misconceptions, (6) personal expectations, (7) emotional involvement, (8) death and dying thoughts, and (9) appraisal and coping. A total care model of occupational stress in palliative care was conceptualized from the analysis. This model may inform the development of interventions in the prevention and management of stress in palliative care.

Burnout in palliative care: A systematic review

Burnout is a phenomenon characterized by fatigue and frustration, usually related to work stress and dedication to a cause, a way of life that does not match the person’s expectations. Although it seems to be associated with risk factors stemming from a professional environment, this problem may affect any person. Palliative care is provided in a challenging environment, where professionals often have to make demanding ethical decisions and deal with death and dying. This article reports on the findings of a systematic review aimed at identifying described burnout levels in palliative care nurses and physicians, and the related risks and protective factors. The main findings indicate that burnout levels in palliative care, or in health care settings related to this field, do not seem to be higher than in other contexts.

The Stresses of Hospice Volunteer Work

The purpose of this phenomenological study was to explore the interpretation of stress, the appraisal of the stressors, as well as the top stressors experienced by hospice volunteers. Individual semistructured interviews were conducted with 15 hospice volunteers. The interviews were digitally recorded, transcribed, and analyzed, using qualitative research methods. Although the results indicated that the hospice volunteers did not perceive their work as stressful, 2 main themes regarding challenging experiences did emerge. Hospice-related issues and personal issues were of concern to the volunteers. In addition, the timing of the stressors revealed that the most stress was felt at the beginning of their volunteer services, which has implications for hospice volunteer coordinators as they support their volunteers in the field.

Looming threats to the intimate bond in hospice care? Economic and organizational pressures in the case study of a hospice

Hospice organizations are assailed by stiff competition, ever-rising costs, limited funding, and policy changes. Do such pressures stifle the high quality of care these organizations strive to provide? As a case-in-point, we draw from the mid-1990s accounts of caregivers at a nonprofit hospice in a Midwestern city in the United States. We maintain that economic pressures drive organizational restructuring, which then weakens working conditions and, thereby, weakens the staff-client relationship. We discuss effects upon worker behaviors, the worker-client relationship, and client care. This ethnographic case study signals the need to closely examine the threats that current economic and organizational pressures in the United States may pose to the quality of hospice care.

The nursing contribution to qualitative research in palliative care 1990-1999: a critical evaluation

BACKGROUND

Qualitative research plays an important part in providing evidence for practice in nursing, and is gaining greater acceptance within medicine. However, questions remain about what criteria are most appropriate for evaluating qualitative research. To date, little systematic evaluation of qualitative research in palliative care has been conducted.

AIMS

This paper is based on a larger study in which we conducted a critical review of qualitative research in palliative care from nursing, medicine, specialist palliative care, sociology, death studies, medical anthropology, and gerontology journals published between 1990 and 1999. The aim of this paper is to present an account of the strengths and weaknesses of qualitative palliative care research in nursing, using data from this review.

METHODS

In the larger study, 138 papers from 50 journals were reviewed critically using a tool developed to assess both content and quality; in one part of this tool reviewers recorded open-ended comments on the strengths and weaknesses of each paper. In this paper, we present a thematic analysis of reviewers' comments on a subgroup of 67 nursing papers from the main review, together with an analysis of comments on 29 papers from a comparison group of death studies, medical anthropology, and sociology journals. Patterns of positive and negative evaluation are identified and used to generate an account of strengths and weaknesses in qualitative palliative care research in nursing.

FINDINGS

Over 40% of the subgroup of papers from nursing journals received positive comments on topic and quality of writing; around 30% received positive comments on contribution to understanding, practical value, and conceptual or theoretical issues. Less than 20% received positive comments on other critical dimensions. Over 40% of nursing papers received negative comments on the link between data, analysis, and findings, other aspects of method and theoretical and conceptual issues. A higher proportion of papers in the comparison group received positive comments on conceptual and theoretical issues and contribution to understanding.

CONCLUSIONS

Nearly half the nursing papers reviewed were judged to be well written or to have a well-chosen topic. However, more than 40% of papers drew negative comments about key methods-related issues. Arguably therefore efforts to improve the quality of research evidence should focus on this area.

Beyond principles: virtue ethics in hospice and palliative care

Living ethically in the face of death is a major challenge for the ill person, the family, and the hospice staff. Beyond the recognized need for ethical decision-making regarding medical principles, there are decisions about character for all involved: "What kind of person will I be?" "What kind of family will we be?" What kind of caregiver will I be?" "What kind of community will we be? This article is a discussion of virtues that are appropriate in hospice staff and volunteers: compassion/empathy, faithfulness, justice/advocacy and practical wisdom. The author calls for a wider sharing of their knowledge and experience.