Volume: 26, Issue: 1

Page: 95-102
International Journal of Science and Business
2023
Journal homepage: ijsab.com/ijsb

A study of Factors Influencing

Psychological Stress Among Health Care
Workers Providing Palliative and Hospice
Care in Nursing Department
Richard Yunxi Zuo & Lanye Wang

Abstract
A sample of 12 medical staff in the nursing department of a general hospital
was interviewed in a semi-structured way using the Grounded Theory
Analysis method, and the data obtained were compared and analyzed using
Nvivo 11 software. The psychological stress factors of medical staff engaged
in hospice and palliative care in the nursing department based on "emotion
management" were obtained, and the main psychological stress factors were
three dimensions: work, knowledge of death, and educational background,
and the results of the study can be a reference for medical staff engaged in IJSB
Accepted 01 August 2023
hospice care and palliative care to reduce their stress. Published 04 August 2023
DOI: 10.58970/IJSB.2158

ISSN: 2520-4750 (Online) 2521-3040 (Print)

Papers published by IJSAB International are

licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License.

Keywords: Palliative care, Emotional management, Stress management, Psychological stress, Job
burnout.

About Author (s)

Richard Yunxi Zuo (Corresponding Author), Guangdong Experimental High School (GEHS),
Guangzhou, China.
Lanye Wang, Guangdong Experimental High School (GEHS), Guangzhou, China.

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1. Introduction
Hospice care and palliative care, are health services that are widely recognized internationally
as a way to provide dignity and comfort to patients who are dying (Maze et al., 2022). This care
focuses on the physical, psychological, and spiritual needs of the terminally ill, providing pain
relief and improving quality of life. It also supports the patient's family by helping them
understand and cope with the process of their loved one's dying and can provide the patient
with a sense of love and respect, allowing them to pass their final days in a serene and peaceful
manner while reducing the psychological burden on healthcare professionals and family
members in the process of caring for them (Sharma, 2023). Mary et al. (2017) considers
palliative care to be a specialized healthcare service for people suffering from serious illnesses,
focusing on the alleviation of symptoms. Palliative care is a specialized healthcare service for
people with serious illnesses that focuses on relieving symptoms and stress and improving the
quality of life for patients and families. Psychological stress can have a significant negative
impact on a person's physical and mental health. A study published in the Journal of the
American Medical Association (JAMA) found that burnout is a pervasive problem among
physicians in the United States, affecting approximately 45% of all doctors surveyed. High
levels of stress contribute to the development of burnout, leading to emotional exhaustion,
depersonalization, and reduced feelings of personal accomplishment (Sharafelt, 2015). In
addition, healthcare workers, especially nurses, and physicians, are at an increased risk of
developing mental health disorders due to job stress (Sachdeva et al., 2022). Research
published in the Journal of Nursing Care Quality examined the relationship between nurse
burnout and patient safety (Kim et al., 2023). The study found a significant association between
higher levels of nurse burnout and increased patient safety incidents, errors, and adverse
events. Mental stress experienced by nurses can compromise their cognitive abilities, attention,
and decision-making skills, thereby jeopardizing patient care (Tawfik,2018); furthermore,
chronic stress among healthcare professionals has been linked to various physical health issues
(Alfonsi et al., 2023). A study published in the Journal of Occupational and Environmental
Medicine examined the relationship between job strain and cardiovascular disease risk among
nurses. The research found that high job strain was associated with an increased risk of
cardiovascular diseases, indicating the detrimental impact of work-related stress on physical
health(Li, 2015). Therefore, studying the factors influencing the psychological stress of
healthcare workers providing hospice services in the nursing department, understanding their
stressors, taking targeted measures, providing better support and resources to reduce burnout
and avoid mistakes, and focusing on the mental health of healthcare workers can help to
establish a positive work environment, improve the morale and cooperation of the entire
healthcare team and ultimately improve the quality and efficiency of healthcare services.

2. Research sample
2.1 Sample selection
Purposive sampling was used to select the interviewers. The interviewees were from the
nursing apartment of a second-class hospital in the Guangdong-Hong Kong-Macao Greater Bay
Area (GBA). The apartment has about 50 terminally ill patients and has formed a palliative care
and hospice care team with doctors, nurses, and caregivers.
(1) Criteria for inclusion of physicians: licensed physician, experience working in a nursing
department and caring for patients, ability to summarize the experience.
(2) Inclusion criteria for nurses: professional certification as a nurse, experience working in a
nursing department and caring for patients, and the ability to summarize the experience.
(3) Inclusion criteria for caregivers: experience working in a nursing department and caring
for patients, and the ability to summarize the experience.

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2.2 General information about the study population

Interviews were conducted with twelve palliative care and hospice care providers, including
two physicians, six nurses, and four caregivers. They had been practicing from four months to
18 years, with an average of three years in the field.

3. Research methodology and analytical process

3.1 Data collection
(1) Interview questions and outline. The study promised that all interviews would be used for
research purposes only and the interview outline consisted of 8 questions. Interview outline:
1) What is your occupation? 2)What is your length of service? 3)Do you feel that you have stress
at work? 4)What do you feel are the sources of your stress at work? 5)What do you feel are the
factors affecting your stress? 6)Do you feel that you are emotionally stable? 7)Have you had
any particularly impressive cases? 8)What is your usual way of relaxing?
(2) Execution of Interviews. The interviews were conducted between July 16, 2023, and July
18, 2023 by the researcher. The interviews lasted approximately 10 to 15 minutes. The
interviewer was made aware of the purpose of the study and the purpose for which the
interview data was being used for academic purposes; the interviewer recorded the entire
interview with the consent of the interviewee. Interviews were conducted in a semi-structured
interview format. Interviewers were trained in interviewing techniques such as repetition,
clarification, follow-up questions, maintaining neutrality of language, and multiple interviews
based on results.
(2) Organization and analysis of interview data. The interviews were converted into textual
information within 24 hours and checked sentence by sentence and word by word against the
recordings. The collected data were initially coded using the Chinese version of Nvivo.
(3) NVivo is a specialized qualitative data analysis software used to support data management
and analysis in the field of social science and qualitative research. The researcher’s coding
followed the sequence of pen coding, spindle axis coding, and selective coding: the researcher
formed concepts by generalizing the phenomena, then further categorized the concepts with
similar attributes; analyzed the relationship between the categories and the concepts they
belonged to in the data; and finally, generated the core categories to derive the theoretical
framework. The core category includes all categories and can represent the core phenomenon
of the whole study. In the process of collecting and analyzing data, the original data,
phenomena, concepts, and categories are constantly compared, and new codes are constantly
generated and compared with the existing codes so that the resulting theory can explain the
original data.
3.2 Open coding
The statements in the interview text that were useful for this study were selected and given a
code to make them a node (Allsop et al., 2022). For example, in an interview with a nurse, she
mentioned that "when you go to work, for example, you definitely think about the condition
observation, and you're worried that there's going to be some sudden changes in condition that
you’re not paying attention to, and that causes the patients to have a possible adverse event or
something else too late to resuscitate, and it causes some of these problems." The researcher
could have edited this text for human factors-related changes in condition; following this logic,
the text was coded sentence by sentence. This study ended up obtaining 10 nodes, which were
refined to form 9 concepts, and finally, similar concepts were categorized into the same
categories. The final 9 categories were obtained and are shown in Table 1.

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Table 1: Scope of open coding analysis formation

Serial Number Scope Conceptual Number
a1 Perception of death 1
a2 Patient's condition 1
a3 Working environment 1
a4 Handover of work 1
a5 Job familiarity 1
a6 Interpersonal relationship 2
a7 Palliative care and hospice care education experience 1
a8 Match between specialty and job content 1
a9 Communication at work 2

3.3 Spindle Axis Coding

After uncovering the underlying logical relationships between the categories, the research data
were regrouped and the open coding results were further analyzed, categorized, combined, and
abstracted to obtain the three main categories, as shown in Table 2.

Table 2: Main categories extracted

Serial Number Main Category Scope Conceptual Number
A1 Perception of death a1 1
A2 Work-related factor a2 a3 a4 a5 a6 a9 a10 9
A3 Educational background a7 a8 2

3.4 Selective coding

Selective coding summarizes the core category from the main category. A core category is a
category that encompasses and explains the main category to some extent. The core category
was summarized as "emotion management". The structure of the framework and the
relationship between the effects of stress on medical staff providing end-of-life care in the
nursing department are shown in Figure 1.

Figure 1: Impact Framework of Psychological Stress

3.5 Theoretical saturation test
The researcher re-interviewed two interviewees and used the same research methodology
using Nvivo11 to organize, code, and analyze and not to find new nodes, thus completing the
construction of a framework of factors affecting the psychological stress of medical staff
providing hospice care and palliative care services in the nursing department, as shown in
figure 2.

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Figure 2: Factor framework for psychological stress among medical staff providing palliative
care and hospice care service.

4. Discussion
4.1 Perception of death
For medical staff providing palliative care and hospice care service in the nursing department,
working hours have a significant impact on their perceptions of death and psychological stress.
First, medical staff who have been engaged in palliative care and hospice care service for a long
time are exposed to frequent scenes of patients' life and death, and the continuity in time will
allow them to gradually adapt to and understand the inevitability of life and death. Over time,
some medical staff may develop more mature and profound concepts about death and
recognize the fragility and preciousness of life, thus cherishing every moment more and
enhancing their psychological resilience. However, prolonged exposure to the passing away of
patients may also put medical staff under tremendous psychological pressure. Extended
working hours may lead to fatigue and emotional exhaustion, exacerbating the psychological
burden. During end-of-life care, medical staff often develop deep emotional connections with
patients, so they may feel intense sadness and despair at losing a patient, and prolonged
periods of such psychological burdens may lead to mental health problems. In this study, in
most cases, with the increase in working time, medical staff will slowly accept the phenomenon
of patient passing away psychologically, change their conception of death, and realize that it is
an inevitable event, thus decreasing the probability of negative emotions due to patient passing
away.
4.2 Work-related factors
(1) Work environment. Firstly, a comfortable and quiet environment can relieve medical staff's
anxiety and fatigue and make them more focused on patients’ needs, while a crowded or noisy
environment will increase their stress. Secondly, convenience and functionality of facilities are
also key factors. Well-equipped medical equipment and a good working layout can improve
efficiency and reduce the burden on medical staff. On the contrary, outdated equipment and
unreasonable layout may lead to poor work and increase the psychological pressure on the
medical staff.

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In addition, clean and safe work environments are critical to the provision of palliative care and
hospice care service. Dirty environments can pose health risks, causing medical staff to worry
about the spread of infections and increasing their psychological burden.
(2) Patient's condition. The progress of the patient's condition will cause a psychological
burden to the medical staff. In palliative and hospice intervention, the patient's condition if the
rapid deterioration, or the treatment effect is not up to the expectations of the medical staff,
the psychological gap will cause a psychological burden on the medical staff, or due to the
intervention of medical measures are not timely, medical services do not meet the operating
standards caused by the patient's condition changes will also make the medical staff to produce
self-responsibility, the guilt of the negative emotions, which will increase the psychological
pressure on them.
(3) Handover of work. First, poor information transfer and communication during the
handover process may lead to omission or misunderstanding of information, increasing
medical staff's anxiety and uncertainty. Second, the time constraints and heavy tasks during
the handover may cause medical staff to feel doubly stressed, affecting their ability to
concentrate and make decisions, which may lead to incorrect handling and judgment and thus
cause psychological stress. In addition, incomplete handovers may lead to difficulties in
effectively assuming end-of-life care responsibilities and increased psychological burden for
medical staff who are unfamiliar with the new work they are taking over.
(4) Work familiarity. Familiarity with work processes and professional skills can increase the
self-confidence of medical staff when facing the situation of patients' dying, reduce uncertainty
and lower the sense of nervousness caused by unfamiliarity with the work. It is easier for
medical staff who are familiar with their work to cope with the emotions and needs of dying
patients and their families, to effectively provide psychological support and comfort, and to
reduce their anxiety and fear when facing life-and-death issues. In addition, medical staff who
are familiar with their work are more able to rationally arrange nursing measures to alleviate
patients' pain and provide more heart-warming care. However, medical staff who lack job
familiarity may face greater psychological stress. Lack of familiarity with the condition and
treatment options may lead to hesitation and concern in their decision-making, and a less
sensitive response to patients' suffering and needs, which in turn exacerbates psychological
stress.
(5) Work-related communication. Work-related communication is divided into inter-colleague
communication and doctor-patient communication, and the effectiveness of inter-colleague
communication directly affects teamwork and collaboration. Good inter-colleague
communication can promote information flow, reduce misunderstanding and conflict, and
enhance work efficiency. In the process of providing end-of-life care, the communication
closeness of the cooperative team can ease the individual psychological pressure of medical
staff, share responsibilities and emotions, and thus reduce the burden of healing care tasks. In
contrast, doctor-patient communication directly affects the understanding and acceptance of
patients and families. In end-of-life care, medical staff need to communicate with patients and
their families, express care and respect, and explain treatment programs and prognosis. Poor
doctor-patient communication may lead to dissatisfaction and anxiety among patients and
their families, and increase the pressure and challenges of medical staff when facing emotional
situations.
(6) Interpersonal relationships. For medical staff providing palliative care and hospice care
service in the nursing department, interpersonal relationships have a profound effect on their
psychological stress. Firstly, close contact with patients and their families, facing the death of
the patient and the grief of the family, can easily lead to emotional empathy and psychological
burden for medical staff. Secondly, coordinating cooperation between multiple professional

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teams and getting along with colleagues of different personalities and work styles may bring
about communication barriers and conflicts, increasing psychological pressure.
4.3 Educational background
The study found that palliative and hospice-specific training focuses more on emotional
support, ethics, and morals than general vocational training. When receiving this type of
training, medical personnel need to have a deeper understanding of the patient's psychology
and family situation and learn ways to communicate with terminally ill patients and their
families, as well as how to cope with psychological stress and grief. If medical personnel
participate in palliative-and-hospice-specific training in addition to acquiring professional
skills, this will enable them to gain the ability to alleviate the psychological stress caused by
their profession. Additionally, many healthcare professionals have many other work
experiences and educational backgrounds before participating in healthcare outside of the
nursing department; for example, one nurse practitioner had 12 years of experience in
neonatology before participating in the nursing department, and after transferring to a nursing
department to practice in palliative and hospice care, she experienced inconsistencies in the
demands of her career skills, which created psychological stress for her.
4.5 Research flaws and implications for subsequent research
The proposed framework of psychological stress factors for medical staff providing palliative
and hospice care services in the nursing department is only an initial research exploration and
needs to be continuously verified, revised, and improved by subsequent studies. The
establishment of the framework in this study can provide some reference for relevant
departments to alleviate the measures of psychological stress of medical staff providing
palliative care and hospice care service.

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Cite this article:

Richard Yunxi Zuo & Lanye Wang (2023). A study of Factors Influencing Psychological Stress
Among Health Care Workers Providing Palliative and Hospice Care in Nursing Department.
International Journal of Science and Business, 26(1), 95-102. doi:
https://doi.org/10.58970/IJSB.2158

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