A literature review identifies opportunities to support nurses working in these care settings.
- Resilience helps prevent nurse burnout.
- Continuing education and professional development aid burnout reduction and improve nurse retention.
- Establishing goals of care and providing education regarding hospice and palliative care philosophies can better prepare patients and families for the inevitable struggles at the end of life.
Caring for patients with life-limiting illnesses can be both rewarding and exhausting. Hospice and palliative care nurses endure many stressors that can lead to burnout, which has the potential to harm nurses, patients, and healthcare organizations.
The National Academy of Medicine acknowledged the complex problem of clinician burnout and in 2017 formed a coalition to increase the visibility of the problem, improve understanding of clinician well-being, and advance solutions to address it. In addition, the Hospice and Palliative Nurses Association’s 2023–2026 research agenda made the well-being and self-care of palliative care and hospice clinicians a research priority. Moving forward, we must dedicate time, invest resources, and enact policies that safeguard our nursing workforce and their mental health by cultivating resilience and self-care practices to help mitigate burnout.
What does the literature say?
In an effort to better understand burnout among nurses who work in hospice and palliative care, I conducted an integrative literature review of studies published between 2020 and 2021. I found eight articles that fit the inclusion criteria. My review noted five themes: resilience, professional certification and continuing education, stressors related to caring for patients with life-limiting illnesses, the importance of patient and family education, and additional stress incurred during the COVID-19 pandemic. (See Literature review methodology.)
Literature review methodology
How do hospice and palliative care nurses practice self-care? That research question guided my January 2022 to April 2022 literature review. Using the process outlined by Whittemore and Knafl, I began by identifying that nurse self-care and resilience are essential to excellent patient care. I then searched CINAHL (using the phrase “hospice nurse self-care”) and Web of Science (using the phrase “hospice AND nurse AND resilience”) databases. I also conducted ancestry searching (reviewing citations from the included research articles). I refined the search results to articles categorized by “nursing.”
Inclusion criteria included the following:
- primary sources
- peer-reviewed sources
- nurses or nursing as the main subject of the article
- study of self-care, resilience, or stress within nursing contexts
- publication in 2020 or 2021
Exclusion criteria included the following:
- studies published in a language other than English
- gray literature
- articles without full-text availability
Next, I screened and evaluated resulting data for relevancy and analyzed them for common themes.
Results
I retrieved a total of 14 articles from the databases using the search criteria and two additional articles within the references of retrieved articles. I removed one duplicate record before screening the articles. I read and evaluated the remaining 15 articles, excluding five without a nursing focus and two published outside of my search range. From the remaining eight studies, I identified five themes: resilience, professional certification and continuing education, stress of caring for patients with a life-limiting illness, importance of patient and family education, and the additional stress incurred during the COVID-19 pandemic.
Limitations
Little recent literature on hospice and palliative care nurse self-care created limitations and revealed the need for additional research and discussion on this topic. The intentional narrow date range used to identify recent trends in end-of-life nursing created another limitation.
Resilience
Cho and Cho, who conducted a descriptive study to investigate compassion fatigue among hospice and palliative care nurses, noted the positive impact of nurse resilience. They described nurses with the skills to handle stress as experiencing less burnout and providing higher quality nursing care. Nurses with a sense of purpose and harmony among co-workers showed increased resilience when compared to their counterparts. Nurses who experience extreme compassion fatigue suffer from burnout, are less productive, and are less likely to stay in their nursing roles, all of which directly impact the unit. Prioritizing research to identify practices that cultivate resilience could help nurture nurses and advance the profession.
Rosa and colleagues, who investigated palliative care nursing during the COVID-19 pandemic, described the positive changes associated with the concept of vicarious posttraumatic growth and resilience in an individual’s psychological health and life perception after caring for patients with a life-limiting illness. The authors suggest creating an inclusive environment that provides space for communicating struggles and setbacks while validating the collective trauma that nurses experience. Sharing challenges and accomplishments normalizes the inevitable highs and lows of nursing and cultivates an environment of inclusion, acceptance, and accountability.
Tan and colleagues, who interviewed palliative care workers, identified resilience and reward as the main themes of their study. Participants who indicated strong core values showed increased resilience, strength, and the ability to handle stress. Although research can’t change a person’s core values, it can help to illustrate why some adapt and recover while others struggle within the same situation.
An appreciative inquiry study comprised of interviews with palliative care nurses and subsequent thematic analysis of study data conducted by Whiting and colleagues revealed further information about resilience as a method of coping with stress and distress. The authors also describe the emerging themes of specialty, positivity/making a difference, support, provision of adequate resources, and tailored education/professional development.
Professional certification and education
Continuing education and professional development appear to provide an additional level of confidence and promote nurse resilience. Whiting and colleagues found the theme of professional development key to nurse retention within children’s palliative care. In addition, Zheng and colleagues suggested that employers offer additional educational opportunities to explore nurses’ responses to death and bereavement. Obtaining professional certification and continuing education validates clinical expertise, denotes curiosity, and can improve nurses’ confidence.
Caring for patients with a life-limiting illness
In addition to caring for patients, hospice and palliative care nurses also support families. Their daily experience of death and empathizing with dying patients and their families can result in compassion fatigue. End-of-life conversations, intense emotions, and misconceptions about hospice and palliative care exacerbate reactions and present additional challenges. Diehl and colleagues studied palliative care nurses in Germany, who reported increased emotional demands and higher burdens due to caring for families in addition to patients. Tan and colleagues described the nature of palliative care work and the increased risk of stress, burnout, moral distress, vicarious traumatization, and compassion fatigue.
Caring for patients who aren’t expected to recover can result in feelings of futility and create moral distress. Although the goal of this literature review was to identify self-care within the context of hospice nursing, these additional findings can’t be ignored. Nurse leaders should evaluate nurses’ workloads and resources frequently.
Patient and family education
Cho and Cho noted that factors negatively impacting nurse satisfaction include harmful attitudes about death among patients and family members, absence of spirituality among nurses, and unmarried status (among nurses). Unmarried nurses reported a higher degree of compassion fatigue than married nurses, and those who considered themselves not religious reported more compassion fatigue than nurses who described themselves as religious. Establishing goals of care and providing education about hospice philosophy can better prepare patients and families for the challenges of end-of-life care.
While researching the evolution of palliative nursing during the COVID-19 pandemic, Rosa and colleagues acknowledged the need for community-based outreach and education. They described the importance of supporting nurses with educational resources that build confidence, clinical skill, and ethical decision-making abilities. Nurses, patients, families, and communities can benefit from additional education about hospice, palliative care, death, and the process of dying.
Nursing during a pandemic
The COVID-19 pandemic exposed inadequacies within healthcare systems and the high expectations placed on nurses. It has fundamentally changed the climate of nursing and presented additional stressors. Nurse leaders must pay close attention to the anxiety levels of their nurses and implement strategies to address mental health challenges experienced by their staff.
The pandemic highlighted the critical need for hospice and palliative nurses; however, the current climate of mistrust, stigmatization, and treatment hesitancy has isolated healthcare workers, while the demand for their work increases. With future pandemics a likely occurrence, we must seek strategies to improve conditions for nurses.
Nursing implications
The results of this literature review illustrate the scant amount of current peer-reviewed literature on self-care practices among hospice and palliative care nurses. However, what I did find points to the importance of cultivating resilience among these nurses, which will require additional research. Examining nurses’ perspectives will help identify factors positively correlated with resilience.
Potential strategies for managing stress include embracing flexibility, enhancing nurses’ coping skills, sharing accomplishments, and speaking openly about challenges. Professional development and continuing education enhance a nurse’s knowledge base, increase confidence, and inhibit burnout, which improve staff retention. Nurses who become lifelong learners develop a mindset of curiosity and openness, which promotes evolutionary and fluid thinking to aid resilience. In addition, setting professional boundaries can help promote a work–life balance that separates work responsibilities from personal time.
To address the stress related to the dual responsibility of caring for patients and supporting family members, the entire healthcare team, including nurses, should work with patients and families to establish agreed-upon goals of care. In addition, providing patient and family education about hospice and palliative care philosophies before admission can help ensure everyone is working toward a shared vision. The results of these collaborative efforts may mitigate some of the stressors reported by hospice and palliative care nurses.
The COVID-19 pandemic revealed shortcomings in the healthcare systems and further complicated hospice and palliative care nursing. Nurses and nurse leaders should work with their healthcare organizations to prepare now for future events.
Leadership champions
Hospice and palliative care nursing presents unique opportunities to make connections with patients and families at an important time in their lives. It also offers up challenges related to the stress of end-of-life care. Ensuring that nurses who work in these care settings have the support they need to build resilience and develop positive coping skills requires additional research focused on nurses’ perspectives as well as nursing leadership that champions communication, empathy, and continuing education.
Amanda Camden is an RN claims analyst at Qlarant in Easton, Maryland.
American Nurse Journal. 2023; 18(8). Doi: 10.51256/ANJ082316
References
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Diehl E, Rieger S, Letzel S, et al. Burdens, resources, health and wellbeing of nurses working in general and specialised palliative care in Germany—Results of a nationwide cross-sectional survey study. BMC Nurse. 2021;20(1):162. doi:10.1186/s12912-021-00687-z
Gelinas L. Second thoughts about second thoughts. Am Nurse J. 2022;17(3):4.
Hospice and Palliative Nurses Association. Research agenda. advancingexpertcare.org/practice-research/research/research-agenda-hpna
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National Academy of Medicine. Action Collaborative on Clinician Well-Being and Resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being
Rosa WE, Gray TF, Chow K, et al. Recommendations to leverage the palliative nursing role during COVID-19 and future public health crises. J Hosp Palliat Nurs. 2020;22(4):260-9. doi:10.1097/NJH.0000000000000665
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Tan SB, Lee YL, Tan SN, et al. The experiences of well-being of palliative care providers in Malaysia: A thematic analysis. J Hosp Palliat Nurs. 2020;22(5):407-14. doi:10.1097/NJH.0000000000000678
Thomas A, Bakas T, Miller E, Johnson K, Tubbs-Cooley HL. Burnout and turnover among NICU nurses. Am J Matern Child Nurs. 2022;47(1):33-9. doi:10.1097/NMC.0000000000000780
Whiting L, O’Grady M, Whiting M, Petty J. Factors influencing nurse retention within children’s palliative care. J Child Health Care. 2021;25(4):587-602. doi:10.1177/1367493520971426
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Zheng Z-H, Luo Z-C, Zhang Y, et al. Hospice care self-efficacy among clinical medical staff working in the coronavirus disease 2019 (COVID-19) isolation wards of designated hospitals: A cross-sectional study. BMC Palliat Care. 2020;19(1):1-12. doi:10.1186/s12904-020-00692-0
Key words: hospice, palliative care, self-care, resilience
