Discussion
The collective responses of the participants revealed that hospice nurses use a variety of coping strategies (eg, exercising, attending church, laughing and talking with others, participating in hobbies, reading, or eating/drinking) when dealing with workplace stress. However, seeking social support, using humor, and prayer/meditation emerged as the most effective coping mechanisms. Focus group discussions also revealed hospice nurse ideas for how organizations could assist in the coping process.
Consistent with the nursing literature, social support was shown to be a major factor in the coping process. Nurses repeatedly discussed the availability and importance of support from fellow nurses, management, and the chaplain or social worker on their team. They cited multiple examples of being able to vent to colleagueswithout feeling judged or incompetent. It was also noted that having support within the team went a long way in efforts to decompress and keep going. Studies have suggested that belonging to an effective team and adequate social support are vital to the well-being and survival of employees within the hospice/palliative care setting. This study reflected similar results, with support from management and nurse leadership being mentioned numerous times as providing positive reinforcement and reassurance on job performance among these participants. Management support, or the perception thereof, was viewed by nurses as a potential buffer or protective factor against workplace stress.
An unexpected finding was the significance of humor in the coping process. Very few studies in the hospice literature specifically cited humor as a coping mechanism to manage work stress. However, the importance of laughter was underscored multiple times in each of the focus group sessions. Participants indicated that laughter was key, especially in light of the highly emotional circumstances they encountered on a daily basis. Humor was used among the nurses and between the nurses and their patients/families while providing care. In the general humor and coping literature, it is documented that the use of humor results in more positive cognitive appraisal as well as health outcomes. Indeed, humor is viewed as ameans to reframe or mediate a seemingly hopeless situation. The nurses in this study found that the use of humor was an effective self-care tool that allowed them to better interact with patients and relieve tension.
Given the emphasis on spiritual care as an integral component of hospice care, it is no surprise that nurses had strong beliefs about the benefits of prayer/meditation in the coping process. In fact, all of the focus groups discussed the connection between spirituality and a sense of purpose and commitment to the hospice philosophy. The central role of spirituality in hospice/palliative care has been previously documented, establishing the need to address spiritual care for patients facing end of life as well as demonstrating the positive benefits of the integration of spirituality in the workplace (eg, improved job satisfaction and work performance). Consistent with these findings, the participants in this research expressed that assisting patients in the dying process reaffirmed their own spirituality. This affirmation of life through death enabled them to more fully appreciate their own lives and shifted the perspective from emotional distress to a peaceful reflection on themeaning of life. The nurses spoke about how rewarding and calming it was to be a part of the process and towitness such a sacred moment (ie, death). Ultimately, spirituality was viewed as a significant personal coping resource as well as an important strategy in the support of the patient, each aspect informing the other and thereby preserving nurse well-being while enhancing quality of care.
Both positive and negative comments were made regarding the availability and adequacy of organizational resources. Most respondents felt that organizational resources were not adequate and could be strengthened. In contrast to the literature, several participants expressed concern that there were actually no established programs at their agency. Others perceived that the activities that were available did little to actually assist in the coping process. Two nurses identified that EAPs were available at their agency. They spoke positively about this as a resource but did not comment on whether it was frequently used or considered effective. Building wreaths to honor the patient and attending memorial services were sufficient to acknowledge the loss of a patient, but according to the participants, these activities were often deemed inadequate as a coping resource. Given that participants previously indicated that death/dying is not a primary source of stress, resources that emphasize this process are likelymisguided and undesirable. This underscores the need for supportive interventions that enhance overall coping resources rather than a singular focus on dealing with individual grief and loss.
Although the above discussion illustrates that nurses are finding ways to cope, it also highlights an opportunity for agencies to explore ways to build upon the effective coping strategies identified by the staff. It appears that, historically, workplace programs were available at many of the agencies, but as hospice grew, support of this type was eliminated. The hospice nurses in this study reported that managers did what they could to provide some form of support, but efforts were hampered by a lack of resources or support from agency leadership. Ultimately, nurses believed that there was a need for formal organizational resources and expressed a desire to participate in these options should they be made available.
Study Limitations
The sample cannot be considered representative of all hospice nurses. The race/ethnic distribution of the study sample may differ from that of other geographic regions. Transferring results to other settings or contexts should be done with careful consideration. However, it should be noted that generalizability was not the intent of the research. The use of self-reported measures such as those provided in a focus group setting canmean that individuals provide answers based on group influence or that they assume will be desirable.
Recommendations for Further Research
Based on the feedback on the importance and perceived effectiveness of using humor to cope, both among colleagues and with patients, it is clear that this is a concept that needs further exploration. The results may suggest the need to train and/or educate nurses on the use of humor in patient care. In addition, this can provide guidance for developing and refining tools that measure humor as a coping strategy. Future research should also examine the ways in which peer support is developed and provided among nurse colleagues to determine how best to build upon this as a universal resource. Qualitative research that explores hospice nurse perceptions about and experiences with EAP would also be worthwhile because it was not explored in-depth within this study. The results could provide a better understanding on the availability and efficacy of EAP services. Perhaps, this is a resource that should be offered at every agency, or perhaps, funding spent in this area can be repurposed for interventions that better address work conditions. Comparison studies that further explore the availability and adequacy ofworkplace resources may also beworthwhile given the contrasting results of this study. Lastly, although this study focused specifically on nursing staff, it is documented that job stress is common among all health care professionals. There may be opportunities to recommend standard interventions across all hospice agencies that would be supportive for nursing as well as other staff members.