Stressors linked to palliative care nursing: the importance of organizational, professional and emotional support

Key Implications for Decision Makers

Following restructuring of the healthcare system, the shift to ambulatory care and introduction of the program to battle cancer, nurses involved in the homecare program now play a central role in the delivery of palliative care. Although the emphasis is on delivering care in the community, public funding for homecare services has not kept pace. In many CLSCs, delivery of palliative care is poorly organized, if at all, and with rising demand coupled with a shortage of staff, recruiting and retaining nurses in this sector of specialized care can become problematic.

The research shows that:

  • Organizational stressors are a greater factor than occupational and emotional stressors. The main source of stress for nurses is not daily contact with people whose life is ending, but the fact they constantly must wage battle in a disorganized system so these people can spend their last days in dignity and respect for their personal values. In organizational terms, there is a clear need to adopt a concerted approach involving institutions and specialized teams, to improve access to consistent care and services adapted to the needs of patients and their next of kin.
  • Communication problems and shortcomings in cooperation between professions are major sources of distress and dissatisfaction among nurses. At the professional level, the establishment of interdisciplinary teams centred on the needs of patients and their next of kin should be encouraged, based on a shared philosophy.
  • Although delivery of palliative care can prove psychologically demanding, it can also be the source of positive emotions. End-of-life accompaniment can be a very enriching experience. Nurses-especially those with expertise in and commitment to this care-express satisfaction with their work. Despite the urgency of reducing organizational stressors and recognizing professional expertise, we must not overlook the importance of emotional support. This type of assistance promotes awareness of the emotional issues linked to the experience of death. It also provides an outlet for disturbing emotions and an opportunity to strengthen the quest for inherent meaning in suffering and the end-of-life accompaniment process.
  • Stress levels appear to be lower in CLSCs than in hospitals, while satisfaction with work is higher. Hospitals are viewed as dehumanized environments where the status of palliative care nurses is very low. By contrast, nurses providing home care have greater decision-making flexibility and are less caught up in conflicts between professions. Patients and their next of kin also have a greater sense of acknowledgement of nurses who visit their home.
  • The more organizational, professional and emotional support is available to nurses, the greater sense they have of possessing the personal resources needed to meet the demands of palliative care, and the less psychological burden they feel.

Executive Summary

Given restructuring of the healthcare system and a shortage of staff, attracting and retaining nurses in the palliative care sector-a sector with strong growth-poses a major challenge.

The research focuses on the field of managing and organizing nursing care, especially in light of the shift to ambulatory care and the development of homecare services. In Canada, as in many other Western countries, the population is ageing and the demand for health care is increasing with age. Growing numbers of people in Quebec as well as the rest of Canada, when diagnosed with advanced cancer, are opting to stay home as long as possible and are even choosing to die at home if circumstances allow. Thus, the rise in the number of end-of-life patients wanting to die at home, on the one hand, and the pressure on decision makers and managers to deliver quality care and services to patients, on the other, are highlighting the urgent need to structure the organization of palliative care.

Work-related stress occurs when there is an imbalance between a person's perception of the constraints imposed by her environment and her perception that she has sufficient personal resources to cope. Although a link between stress and satisfaction with work has been documented in various sectors, we have little understanding of the importance of this relationship in the specific context of work in palliative care. This research provides a better understanding of stress related to delivering palliative care and the factors associated with greater satisfaction among nurses in this specialized field.

Implications for decision makers

The study highlights the need for organizational, professional and emotional support mechanisms. To achieve this objective, however, we must consider the synergy of personal, professional, institutional, community and societal sharing of responsibility.

At the personal level, personal commitment by the caregiver is a primary source of work motivation and satisfaction. The accompaniment context is viewed as an opportunity. However, the importance of emotional support cannot be overlooked: it must promote awareness of the emotional issues linked to the experience of death, expression of difficult emotions and strengthening of the quest for inherent meaning in suffering and the end-of-life accompaniment process.

At the professional level, interdisciplinary cooperation centred on the needs of patients and their next of kin, where each person's role is defined in terms of these needs, not the needs of workers, as well as a shared philosophy can provide a source of additional satisfaction. In addition, drawing on the support of other professionals can break the sense of isolation, although this does require the development of complementary expertise and the option of meetings of the various specialized groups.

At the institutional and community level, access to consistent care and services adapted to the needs of patients and their next of kin must be improved. Each institution must introduce organizational measures, such as a clear mission, specific objectives and an action plan that describes tangible measures, such as communication tools, 24/7 medical care, anticipated protocols, an emergency kit, etc. This requires a concerted approach within the institution and between institutions and specialized teams, as found in integrated oncology networks. The idea is to foster continuity of care and services, regardless of where they are delivered. The goal is not necessarily to die at home, but to maximize comfort and home care, with accompaniment through disease and suffering. Finally, at the societal level, we must continue deliberations about the role and values attributed to end-of-life care.

Findings

Stressors

The findings highlight the preponderance of organizational stressors. The greatest stress factor for nurses is not daily contact with people who are dying, but the fact they must constantly fight in a weakened system to enable these people to live out their final days in dignity and respect for their own values. The fact that palliative care is not considered a specialization, that there is no structure, formal planning of care, integration of services, that nurses do not take part in administrative decision making, that resources are lacking and there is an overload of work, are all organizational stressors.

Professional stressors include philosophical differences over the delivery of care, difficult interprofessional cooperation, the almost total lack of recognition of specialized nursing skills, the lack of ongoing training and the absence of qualifications in new recruits, the difficulty of relieving pain and the lack of time to accompany patients and their next of kin.

At the emotional level, the study reveals stressors linked to impotence in dealing with suffering and death, exposure to multiple bereavements, distress in patients and their next of kin, as well as the impossibility of caregivers showing their emotions.

Stress at work, distress and satisfaction

Despite the stress factors, work continues to be satisfying. Stress and distress levels are acceptable and comparable to those in other categories of workers. Although the work is psychologically demanding, it is also a source of positive emotions. Distress and dissatisfaction are primarily the consequence of organizational constraints.

Stress levels based on where care is delivered

The qualitative findings tend to prove that there are few differences between the various locations (home/CLSC and hospital) where care is delivered. However, the quantitative findings show that levels of work-related stress are higher in hospitals. Specifically, working in a hospital appears to be more psychologically demanding for nurses, less satisfying and leaves them with less decision-making flexibility.

Approach

This is a descriptive study that uses a triangulation method through the combination of various populations (nurses and managers) and various data gathering approaches (qualitative and quantitative).

The first phase was conducted with a population of nurses, using a qualitative and quantitative approach. The qualitative aspect, based on a series of focus groups combined with personal interviews, describes the characteristics of stressors, the factors that produce them, and the research on conditions that foster their emergence. The quantitative aspect was based on a questionnaire and describes the relationships between support at work (organizational, professional and emotional), the demands associated with this work (including the psychological and emotional demands) and resources as perceived by the individual (including decision-making flexibility, the rewards and feelings of competence).

In the second phase, the findings from information gathered from nurses were presented to decision makers and managers, who analysed them in two focus groups.