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Abstract
Background Poor psychological well-being among healthcare staff has implications for staff sickness and absence rates, and impacts on the quality, cost and safety of patient care. Although numerous studies have explored the well-being of hospice staff, study findings vary and the evidence has not yet been reviewed and synthesised. Using job demands-resources (JD-R) theory, this review aimed to investigate what factors are associated with the well-being of hospice staff.
Methods We searched MEDLINE, CINAHL and PsycINFO for peer-reviewed quantitative, qualitative or mixed-methods studies focused on understanding what contributes to the well-being of hospice staff who provide care to patients (adults and children). The date of the last search was 11 March 2022. Studies were published from 2000 onwards in the English language and conducted in Organisation for Economic Co-operation and Development countries. Study quality was assessed using the Mixed Methods Appraisal Tool. Data synthesis was conducted using a result-based convergent design, which involved an iterative, thematic approach of collating data into distinct factors and mapping these to the JD-R theory.
Results A total of 4016 unique records were screened by title and abstract, 115 full-text articles were retrieved and reviewed and 27 articles describing 23 studies were included in the review. The majority of the evidence came from studies of staff working with adult patients. Twenty-seven individual factors were identified in the included studies. There is a strong and moderate evidence that 21 of the 27 identified factors can influence hospice staff well-being. These 21 factors can be grouped into three categories: (1) those that are specific to the hospice environment and role, such as the complexity and diversity of the hospice role; (2) those that have been found to be associated with well-being in other similar settings, such as relationships with patients and their families; and (3) those that affect workers regardless of their role and work environment, that is, that are not unique to working in a healthcare role, such as workload and working relationships. There was strong evidence that neither staff demographic characteristics nor education level can influence well-being.
Discussion The factors identified in this review highlight the importance of assessing both positive and negative domains of experience to determine coping interventions. Hospice organisations should aim to offer a wide range of interventions to ensure their staff have access to something that works for them. These should involve continuing or commencing initiatives to protect the factors that make hospices good environments in which to work, as well as recognising that hospice staff are also subject to many of the same factors that affect psychological well-being in all work environments. Only two studies included in the review were set in children’s hospices, suggesting that more research is needed in these settings.
PROSPERO registration number CRD42019136721 (Deviations from the protocol are noted in Table 8, Supplementary material).
- Psychological care
- Hospice care
- Education and training
- Supportive care
Data availability statement
No data are available.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Poor psychological well-being among healthcare staff has implications for staff sickness and absence rates, and impacts on the quality, cost and safety of patient care. Staff who work with dying patients are exposed to specific potential stressors, such as death anxiety due to recurrent exposure to death, patient suffering, and having to break bad news. Hospice staff are key providers of end-of-life care, but data about hospice staff well-being have not previously been reviewed or synthesised.
WHAT THIS STUDY ADDS
This review investigated what factors are associated with the well-being of hospice staff. We found strong and moderate evidence that 21 of the 27 factors identified influence well-being. Some of the factors identified were specific to working in a hospice environment, such as the complexity of the hospice role and the hospice environment. The review found that, contrary to some of the relevant literature, the well-being of hospice staff is affected by the same factors that have been found in other roles and work environments. More research is needed in children’s hospices.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Many of the factors identified are amenable to intervention. Hospice organisations should seek to continue or commence initiatives to address those factors that can harm staff well-being, protect the factors that make hospices good environments in which to work and recognise that hospice staff are affected by factors that exist in all work environments.
Introduction
Hospice staff play an important and valued role within the healthcare system.1–3 An estimated 56.8 million people each year globally are in need of palliative care (care and support for people with a life-limiting or life-threatening illness, their family and friends), with approximately half of these requiring end-of-life care.4 The UK hospice sector supports more than 300,000 people with terminal and life-limiting conditions each year.5 6
Concern about the well-being of the health and care workforce is widespread,7 8 with poor staff well-being shown to have implications for staff sickness, absence rates and staff retention9–15 and has impacts on the quality, cost and safety of patient care.15–19 Staff who work with dying patients are exposed to specific potential stressors, such as death anxiety due to recurrent exposure to death, patient suffering, and having to break bad news.7 8 13 20 21 As a result, it could be anticipated that they are more likely to experience negative responses (eg, absorption of negative emotional responses, immersion in emotional clashes) and outcomes (eg, psychological distress, secondary trauma).20 22–24
However, there is evidence that burnout and distress are lower among health professionals who work in palliative care than those who work in other specialties.13 22 25–28 Research has suggested this could be because they feel able to express grief to colleagues, are more able to have meaningful relationships with patients and their families, and because death is not seen as a failure as it is in other healthcare settings.29–32 In the UK, research has suggested that hospices can be a rewarding setting to work in,2 but there is little evidence to support this.
Although there is a growing body of research on the factors that affect staff well-being in palliative care generally,25 the evidence specific to the hospice sector has not been reviewed and synthesised. All roles present unique demands and resources,33 so it is critical that the determinants of psychological well-being for hospice staff are understood in order to help staff retention and maintain the quality of care in this sector. Equally, identifying the distinct factors that are relevant to well-being in this setting is likely to provide an evidence base that can inform the selection of appropriate interventions to improve psychological well-being.34
The aim of this systematic review is to describe and synthesise what the existing research tells us about the factors that are associated with the psychological well-being of staff who have a paid caring role in hospice services. This will include specific demands and resources associated with the work itself (eg, communicating with families, frequent exposure to death), the factors that may affect exposure to potential stressors (eg, workload) and factors that, when staff are exposed to stressors, protect against or increase risk for poor outcomes (eg, professional training, staff support provision).
Theoretical framework
This review is informed by the job demands-resources (JD-R) theory of occupational stress, which was designed to encompass the strengths of both the demand-control model and the effort-reward imbalance model, which are frequently used in research that examines staff well-being.35 JD-R theory argues that work-related stress is a response to an imbalance between work demands (such as work pressure and role ambiguity) and the resources (such as social support and autonomy) available to meet those demands.35 36
Demands are defined as those physical, psychological, social or organisational aspects of the job that require sustained effort or skills.35 36 They are separated further into challenging demands and hindering demands.37 The former are those that can contribute towards a worker’s sense of achievement when they are met, including time pressures and workload, the latter are those that thwart personal growth and goal attainment, such as working relationships.37 Resources are defined as those aspects of the job that are functional in achieving work goals, reduce the impact of job demands and their associated costs and/or stimulate personal growth, learning and development.35 36
Demands and resources also interact through motivation and strain, which can determine work-related well-being, through ‘job crafting’ and ‘self-undermining’ (see figure 1). Job crafting is defined as self-initiated changes to job design, such as changing tasks or how tasks are completed.37–39 Self-undermining can be defined as behaviour that creates obstacles that may undermine performance.39 40 In this review, we use factors as a collective term for job resources, personal resources, job demands, job crafting and self-undermining.
Job demands-resources (JD-R) theory. Source: Bakker and Demerouti.39
The JD-R model also incorporates work engagement (defined as ‘a positive, fulfilling, work-related state of mind’) in addition to the negative psychological state of burnout,36 which are both used as measures of psychological work-related well-being—defined as comprising feelings (ie, subjective well-being or positive emotions) and functioning (ie, the sense that we are doing something purposeful).41 42 This theory provided the review team with a shared understanding of how the factors associated with hospice work may influence staff well-being. It guided the synthesis of factors identified in the review, our interpretation of the review findings and our assessment of the current evidence gaps in relation to research on hospice staff well-being.
Methods
To ascertain what existing empirical research tells us about the factors that may contribute to hospice staff well-being, we carried out a mixed-methods systematic review. The review protocol was registered on PROSPERO (CRD42019136721) and is reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Search strategy
The search strategy was developed by one reviewer (AP) in collaboration with an information specialist (SG) and two members of the review team (JT, LF). The search strategy was developed using terms for hospice, health professionals and psychological well-being. Searches were run in MEDLINE, CINAHL and PsycINFO (see online supplemental table 7 for full search strategy) using a combination of Medical Subject Headings, keywords and free-text terms. We used filters designed by the Centre for Reviews and Dissemination, University of York, to exclude articles not reporting empirical research (eg, commentaries, letters, news, notes, literature reviews).35 All three databases were searched on 8 April 2019, with update searches of the same databases conducted on 21 April 2020, 10 March 2021 and 11 March 2022. To identify further studies focusing on hospice staff in the grey literature, we ran Google Scholar searches (restricted to the first 50 PDFs) and contacted paediatric palliative care experts, and hospice and children’s hospice stakeholder groups.
Supplemental material
Eligibility criteria
Papers were included if they presented empirical quantitative, qualitative or mixed-methods research examining the factors associated with or contributing to psychological well-being among hospice staff. Studies were included if they reported on outcome measures that are related to psychological well-being, such as burnout,43 stress,44 45 compassion fatigue46 47 and compassion satisfaction48; there is no universally accepted measure of well-being,49 so studies that included these data were likely to be relevant. Due to the differences in how hospice services are delivered in different countries, all studies where the authors specified their focus to be on either hospice services or hospice staff were included. We limited the review to studies conducted in high and middle-income countries (defined as Organisation for Economic Co-operation and Development member states). Searches were restricted to articles published from 2000 onwards to ensure that only research relevant to the current state of the hospice sector was included. We only included studies published in peer-reviewed journals and available in the English language. Table 1 presents the detailed inclusion and exclusion criteria.
Inclusion and exclusion criteria
Study selection
Searches were imported to EndNote50 for de-duplication then uploaded to Covidence51 for screening. The title and abstracts of each citation were screened independently by at least two of four reviewers (BB, LF, AP, JT) to identify potentially eligible articles, with two reviewers (AP and JT) then resolving disagreements by consensus. AP and JT independently reviewed the full text of the remaining potentially eligible studies and resolved disagreements by consensus with the involvement of a third reviewer (BB) where necessary.
Data extraction
Study details including country, year of publication, study aim, staff and patient populations, organisation and setting, study design and methods were extracted into Excel by one reviewer (VF) and checked by two other reviewers (MO'N and AP).
Quantitative findings (including any qualitative results reported in mixed-methods studies) relevant to the review question were extracted into a review-specific Excel data extraction form, which was piloted on three studies and subsequently refined before implementation. One reviewer (AP) identified and extracted relevant data. Twenty per cent of the extraction was checked by two other reviewers (MO'N and AB).
Qualitative findings relevant to the review question were imported into NVivo by one reviewer (VF). These included all author-reported results and participant quotations in the paper and in any online supplemental materials.
Quality appraisal
Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT), which is designed to appraise quantitative, qualitative and mixed-methods studies.52 53 When applying the MMAT we found that the quantitative categories did not map comprehensively to the study designs of included studies. We followed an approach used by other review teams who had experienced this and selected a hybrid of relevant MMAT questions for each study design (see online supplemental material).53 Each study was assessed independently by two reviewers (quantitative studies by AP and MO’N; qualitative studies by VF and AP) and scored according to the recommendations of the MMAT authors54 and in line with the requirements of the best evidence synthesis used for the review (see below).55
Synthesis
Data synthesis was conducted using a result-based convergent design,56 57 which involved an iterative, thematic approach of collating data into codes (which for this review comprised distinct factors associated with staff well-being that were reported) and descriptive categories (groups of related factors that could be synthesised together). This process was initially inductive as we identified individual factors from the quantitative and qualitative studies separately before then iteratively mapping them onto the JD-R theory.39
For the qualitative data, one reviewer (VF) made notes of interesting concepts and ideas that pertained to factors associated with staff well-being (herein referred to as ‘codes’). These codes were discussed and refined by VF, AP and JT, after which VF applied the codes systematically across the qualitative data set in NVivo and organised them into meaningful descriptive categories. For the quantitative data, one reviewer (AP) summarised the results for each reported factor, and organised them into meaningful descriptive categories.
Two reviewers (AP and JT) then worked together through discussion to combine these two groups of categories, drawing on the JD-R theory to aid our understanding of how factors should be grouped together, making sure to incorporate any contradictory results or findings that appeared to sit outside the JD-R model. Three further reviewers provided input during this final stage (BB, LF, SM), which led to further refinement of the categories and interpretation of the evidence.
To assess the strength of evidence for each of the identified categories and aid our understanding of the current evidence gaps, we adopted a best evidence synthesis58 algorithm used in previous reviews by Breslin et al 55 and Alves et al,59 which uses criteria based on the quality and quantity of studies, and the agreement between them, to determine whether the evidence is strong, moderate, limited, mixed or insufficient (see table 2). This approach was chosen because the heterogeneity of the studies—including the study design (qualitative/quantitative/mixed methods), the measures and questionnaires used, and study quality—meant it was not possible to use a standard method of synthesis, such as a meta-analysis or qualitative evidence synthesis.58
Criteria for best evidence synthesis assessment
We adapted the algorithm to incorporate the findings from studies that reported descriptive statistics (eg, the percentage of participants identifying a particular factor as contributing to work-related distress) or qualitative findings, recognising that while these study designs are not used to test the association between factors and psychological well-being, they provide important experiential evidence that particular factors are likely to contribute.
Results
A total of 4016 unique records were screened by title and abstract, 107 full-text articles were retrieved and reviewed and 27 articles describing 23 studies were included in the review (see figure 2).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. OECD, Organisation for Economic Co-operation and Development.
Of the 23 included studies (see online supplemental table 1 for detailed study characteristics), 13 specifically examined the relationships between a priori specified factors and outcomes, seven explored the experiences of hospice staff generally but with a focus on staff well-being and three examined the demands and resources that hospice staff experienced. Fourteen studies used quantitative methods, one used mixed methods and eight used qualitative methods. The majority were conducted in the UK (10) and the USA (8), with others conducted in Australia (1), the Czech Republic (1), Hungary (1), Israel (1) and Italy (1). A total of 2713 participants were included across the 23 studies.
Quality appraisal
Nine studies were rated as high quality, nine as medium quality and four as low quality (see table 3). The low-quality studies used non-standardised or unvalidated measures or had particularly low response rates. Even among high-quality studies, there was a large variety of measures used for both factors and outcomes of psychological well-being.
Factors identified as being associated with psychological well-being
Factors associated with psychological well-being
Twenty-seven factors were identified in the included studies. Twenty-six of these were mapped to the four JD-R components and this is shown in table 4. The final factor ‘staff characteristics’ is not included within the JD-R model and is presented as a separate category.
Strength of evidence for identified factors
The Results section is organised into these categories with each separated into the individual factors. We have included a brief explanation of both the strength of evidence and the influence on well-being for each factor, and given specific examples of findings from the synthesised studies to provide further detail or illustration. The detailed synthesis results for the individual factors within each category, comprising all the data extracted from the studies and how evidence from different study designs was mapped onto the JD-R components, are provided in online supplemental tables 2–6. The summary results of the best evidence synthesis are summarised in table 4.
Staff characteristics
There was strong evidence (three high-quality studies60–62) that staff characteristics, such as age, were not associated with the psychological well-being of hospice staff. All three studies found no significant relationship (p≤0.05) between burnout and age, marital status or having children.
Job demands
Workload
There was strong evidence (five high-quality studies2 7 61–63) that high workload is associated with poorer psychological well-being among hospice staff. For example, ‘workload’ was ranked as one of the ‘most important sources of stress’ by participants in one high-quality study.61
Working relationships
There was strong evidence (five high-quality studies2 7 61 62 64) that poor working relationships (including conflicts or disagreements with other staff members) are associated with poorer psychological well-being. For example, ‘Team conflict’ was identified as a key stressor by nearly all the participants in one high-quality study.2
Organisational culture
There was strong evidence (five high-quality studies2 7 61 63 65) showing that factors such as change management and the overall organisational culture in a hospice are associated with poorer psychological well-being. For example, one study reported that how organisational change is managed and communicated in the organisation was a significant predictor of depression (n=91, beta=−2.684, p≤0.01).66
Death and suffering
There was strong evidence (five high-quality studies7 61–63 67) showing that experiencing the death and suffering of patients is associated with poorer psychological well-being. For example, a participant in one study said: ‘Seeing that degree of human suffering […] on such a frequent basis. That’s the bit that is really difficult.’68
Role complexity and diversity
There was strong evidence (four high-quality studies2 61 63 67) showing that the unpredictable, ambiguous and/or complex nature of the hospice role is a factor that can contribute towards poorer psychological well-being. For example, one study reported that participants sometimes found hospice work stressful because ‘a day of hospice work almost never unfolds the way it appeared like it would when the day began’.63
Relationships with patients and families
There was strong evidence (five high-quality studies2 7 62 63 67) showing that difficulties in staff relationships with patients and families are associated with hospice workers having poorer psychological well-being. For example, the participants of one study ranked this as the fourth highest (out of nine) source of stress.62
Non-care duties and other factors
There was moderate evidence (two high-quality studies62 63) to indicate activities categorised as ‘non-care’, which is not related to the direct delivery of care, were a job demand. Activities reported on included administrative work and long travelling times for community staff. For example, 28% of participants in one high-quality study said this factor was a source of stress (ranked most important out of nine scenarios).62
Work intrusiveness
There was insufficient evidence suggesting that hospice workers’ psychological well-being is affected by ‘work intrusiveness’, the extent to which their work intrudes into their private life.65
Job resources
The hospice environment
Exploring the role of place of work in relation to staff well-being included comparisons between working in a hospice and working in other healthcare settings, and comparisons between working in an inpatient setting with working in the community. There was strong evidence (five high-quality studies2 7 62 65 67) that working in a hospice environment protected against poor psychological well-being, but mixed evidence on whether well-being was better for those staff who worked in inpatient settings versus community settings (and vice versa). For example, one study reported that elements of the hospice environment, such as having supportive work colleagues and having more time to listen and talk to patients, were resources not found in other similar roles.7
Making a difference
There was strong evidence (three high-quality studies2 63 67) that being able to ‘make a difference’ was a resource related to hospice work that may help protect against poor psychological well-being. For example, one study reported that making end-of-life situations somewhat easier was one of the most positive experiences in hospice work.67
Privilege to be at the end of someone’s life
There was moderate evidence (two high-quality studies7 63) that being able to be present at the end of someone’s life was a rewarding part of hospice work that may help to protect against poor psychological well-being.
Doing a good job
There was moderate evidence (two high-quality studies2 7) that ‘doing a good job’ was a rewarding part of hospice work that may help protect against poor psychological well-being. This included ‘getting it right’ so that families received a good service,2 and giving a patient a ‘good death’.7 69
Recognition from patients and families
There was insufficient evidence that receiving recognition from patients and families was a rewarding part of hospice work that may help protect against poor psychological well-being. No high-quality studies included information explicitly on this factor, but receiving praise from families was mentioned as being a part of ‘making a difference’ by one high-quality study.2
Formal organisational support
There was strong evidence (five high-quality studies2 60 63 67 70) that formal organisational support, including debriefing and clinical supervision, could improve psychological well-being. For example, one study reported that ‘supportive structures’ were significantly negatively correlated with burnout (r=−0.65, p≤0.01) and secondary traumatic stress (r=−0.407, p≤0.01),60 meaning greater organisational support was associated with better psychological well-being.
Informal workplace/peer support
There was strong evidence (six high-quality studies2 7 60 62 65 67) that informal workplace/peer support could improve psychological well-being. For example, one study reported there was a significant, negative correlation between peer support and work-related burnout (r=−0.32, p≤0.001) and caregiver-related burnout (r=−0.2, p=0.04),65 meaning greater organisational support was associated with better psychological well-being in these aspects.
Personal resources
Experience
There was moderate evidence (two high-quality studies61 62) that a hospice worker’s experience (duration of employment) was related to their psychological well-being. For example, one high-quality study found that experience was not significantly related to burnout (r=0.13, p=<0.05).62
Education
There was strong evidence (three high-quality studies60–62) that a hospice worker’s education level was not associated with psychological well-being.
Personality, resilience and personal values/attitudes
This factor included elements such as emotional regulation, attachment style, sense of humour and self-belief. There was strong evidence (four high-quality studies2 7 61 71–73) that this factor, as a whole, was associated with psychological well-being.
Personal support
There was mixed evidence (three high-quality studies7 62 70) on whether personal support (from the family or friends) was associated with work-related psychological well-being. Three qualitative studies suggested that having personal support was important to help hospice workers cope with the stress of their job,7 68 74 but two quantitative studies presented mixed results.62 70
Psychological self-care
There was moderate evidence (including from one high-quality study60) on whether hospice workers practising psychological self-care was associated with improved psychological well-being. The high-quality study found that mindful self-care was significantly negatively correlated with burnout (r=−0.726, p≤0.01).60
Other self-care activities
This factor included activities such as meditation, physical activity and comfort eating. There was strong evidence (six high-quality studies2 60–63 67) that staff engaged in these sorts of activities to help them manage their psychological well-being.
Personal circumstances
There was limited evidence that personal circumstances could have an impact on hospice workers’ psychological well-beingwith one high-quality study stated that ‘several participants described negative events in their own lives that had impacted on their resilience at work’.2
Job crafting
Training
There was strong evidence (four high-quality studies2 62 63) that increased staff training is associated with the improved psychological well-being of hospice staff. For example, one study found that staff who lacked training in grief and bereavement had significantly higher levels of guilt and depression.75
Changes to work and the workplace
There was moderate evidence for this factor—one high-quality study asked hospice workers to list the elements about their work or workplace they would like to change.62 Changes included having better workplace equipment and having a quiet room at the hospice.
Seeking support
There was moderate evidence (one high-quality study61) that hospice workers seek support from others when trying to cope with poor psychological well-being.
Work-life balance
There was moderate evidence (two high-quality studies63 70) showing that work-life balance was a factor associated with the psychological well-being of hospice staff. For example, one study found that improved work-life balance was significantly negatively correlated with burnout (r=−0.496, p≤0.05) and compassion fatigue (r=−0.482, p≤0.05).48
Discussion
This review has found strong evidence that the following factors are likely to contribute to hospice staff well-being: ‘Workload’; ‘Working relationships’; ‘Organisational culture’; ‘Death and suffering’; ‘Role complexity and diversity’; ‘Relationships with patients and families’; ‘The hospice environment’; ‘Making a difference’; ‘Formal organisational support’; ‘Informal workplace/peer support’; ‘Personality, resilience and personal values/attitudes’; ‘Other self-care activities’; and ‘Training’. The summary of each of these factors in the Results section of the paper, with online supplemental tables 2–6 outlining all extracted data and study quality, provides greater detail for each of these factors. The review also found strong evidence that staff characteristics and the education level of staff are not associated with staff well-being. This is a finding that is supported by the JD-R model and other theories about work-related stress and well-being,35 36 39 76 which primarily focus on work demands and resources as the key factors that influence staff well-being.
The review found moderate evidence that the following factors are likely to contribute to hospice staff well-being: ‘Non-care duties and other factors’; being a ‘Privilege to be at the end of someone’s life’; ‘Doing a good job’; ‘Experience’; ‘Psychological self-care’; ‘Changes to work and workplace’; ‘Seeking support’; and ‘Work-life balance’.
Currently, there is insufficient, mixed or limited evidence that the following factors are likely to contribute to hospice staff well-being: ‘Work intruding into personal life’; ‘Recognition from patients and families’; ‘Personal support’; and ‘Personal circumstances’. However, we know from wider research about palliative care staff across settings77–79 and the studies included in this review that explored these,2 62 69 70 80 81 that some of these factors are likely to influence hospice staff well-being.
The factors that were identified as being associated with staff well-being (strong or moderate evidence) included those that are specific to the hospice role and the hospice environment. For example, in the ‘Role complexity and diversity’ factor, one study highlighted that balancing complex respite care alongside end-of-life care could be demanding, and three studies included evidence on the unpredictability of the hospice role. In the ‘Hospice environment’ factor, two studies highlighted hospice-specific resources such as staff being able to spend more time with patients and families than in other settings, and staff being able to work in a peaceful and spacious setting. The review also showed that there are both challenging and hindering demands for those who work in hospices.37 For example, seeing the suffering of patients was viewed as a demand by some participants in some studies,62 63 but ‘doing a good job’ in the face of these demands was also seen as a rewarding element.7 74
Some factors identified as being associated with staff well-being (strong or moderate evidence) in hospices have been found in other settings where care is provided for dying patients and their families (see table 5). There is evidence in the literature that some of these factors are experienced to different extents in different settings. For example, hospice staff have been found to experience death anxiety less than critical care nurses,28 and workload has been found to be less of a stressor for hospice staff than learning disability nurses,82 and intensive care unit nurses and medical-surgical nurses.83 Research has suggested that healthcare staff in paediatric oncology do not find death to be a rewarding experience,34 but this review reinforces evidence that hospice staff can derive rewards from a patient’s death.7
Factors identified in this review found in other settings
The majority of the factors identified as being associated with staff well-being (strong or moderate evidence) were those that affect the staff irrespective of their role and work environment, that is, that are not unique to working in a healthcare role. These include, for example, workload, work-life balance and team relationships.77 78 84–86 There have been suggestions in the literature that staff working in a hospice see their role as a vocation, and that this might explain why hospices might be more rewarding and less stressful to work in than other environments.87 This review shows that hospice staff are still affected by factors that are not specific to working in a hospice. Hospice organisations must, therefore, also pay attention to these wider issues.
Collectively, the factors included in the synthesis support previous research that has argued for the importance of assessing both positive and negative domains of experience to determine coping interventions.88 89 The inclusion of job and personal resources in the factors identified in this review also demonstrates the benefit of using the JD-R model as a guiding theory, as according to this theory, psychological well-being outcomes result from the interaction of an individual with the environment.35–37 90
The aim of this review was focused on identifying the range of factors explored in the literature to date, rather than determining the relative contribution of factors identified. According to Lazarus, any attempt to categorise stressors is problematic because individuals appraise events as stressful or not based on their own assessments.91 92 Equally, research in other healthcare settings supports the view that, at the individual level, psychological well-being outcomes are the result of an interaction of multiple factors,93 and that these factors have an ‘interactive and synergistic relationship’ with one another.2 This is also noted in theoretical understandings of psychological well-being,91 92 94 and is supported by the data in two high-quality studies included in this review, which suggest that, for example, reducing workload could allow an individual more time to spend with their patients and their families, as well as the time to practise self-care and improve their work-life balance.2 67
Overall, this review suggests that interventions to improve psychological well-being will need to encompass multiple strategies that have wide-ranging influences on multiple factors, and that will allow each individual to have access to something that works for them. An example of this comes from research in counsellors, which suggests that a holistic approach to self-care strategies is required for mitigating compassion fatigue and increasing compassion satisfaction.95 96
A review of the experiences of healthcare staff who provide palliative care to children concluded that staff well-being can be improved through education focusing on the key challenges of the work, timely multidisciplinary debriefs and re-emphasising the importance of self-care.25 Other palliative care research has stated that psychological well-being is likely to be improved through a combination of organisational support and improvements to personal coping.13 97
Some studies, however, suggest that while improved institutional and collegial support do have an impact on psychological well-being,79 98 personal psychosocial interventions have little effect.99 Whether this is also true for hospice staff is beyond the scope of this review, but the evidence presented here suggests that there are steps organisations could take, including: reducing staff workload (as mentioned above)2 7 61 100–103; providing training for the complexity of the role; including staff in change management2 62 81 102; providing formal and informal opportunities to nurture peer support2 7 60 62 67 71 74 75; providing organisational support; and providing training on work-related stress, debriefing and grief management.2 67 75 It is important that future research in all settings considers both organisational and personal factors.
Knowledge generated from this study has the potential to provide an important evidence base from which to identify staff support systems and organisational practices that offer the greatest potential to improve staff well-being and its associated outcomes in hospices. Service and organisational level initiatives to improve psychological well-being among this population, or in other similar populations, could use this review as a starting point.
Mapping the factors onto the JD-R theory highlighted some gaps in the current evidence. First, it shows that the amount of research focused on job demands is greater than the amount of research on job resources and personal resources. Second, there is very little research on the concept of job crafting, which is defined as self-initiated changes to job design.37–39 Third, in the literature synthesised in this review, there is no research on the influence of self-undermining behaviours, which are those that create obstacles that may undermine performance.39 40 Finally, only two included studies were set in children’s hospices, which shows very clearly that more research is needed in these settings.
Strengths and limitations
This review used a robust search strategy and screening process to identify relevant research. The mixed-methods approach led to the identification of all the relevant research in this area and facilitated a broad understanding of staff well-being in hospices. The process of quality appraisal and best evidence synthesis enabled an assessment of the relative strength of support for each factor that was identified. Mapping the factors to JD-R theory added theoretical rigour and allowed the current gaps in the literature to be clearly displayed.
The most significant characteristic of the synthesised research is its heterogeneity—notably in study design, study focus andsampling. In terms of the latter, setting is of particular importance for international research in the hospice sector because of the varied models of hospice provision. There is no guarantee that evidence generated in one country is applicable to another. Nevertheless, the evidence available to synthesise would have been much more limited had this review only included evidence from just one country. Equally, of the 23 studies included, 13 reported on mixed samples of professionals, and in some instances the make-up of these mixed samples were not clearly identified. Because of this, and the differing standards of reporting found in the studies, it is challenging to make pronouncements about how these factors operate differently among different healthcare professionals—for example, if there was a difference between clinicians and non-clinical staff. This is important because previous research in similar settings has highlighted that there are differences in the stressors experienced by different staff groups.29–32
Conclusion
This review has shown there is strong evidence that there are hospice-specific resources and demands that can affect staff well-being. These include the demanding nature of the role due to its complexity and diversity, and the resource (benefit) that staff derive from being able to spend more time with patients and families than in other settings. It has also shown that hospice staff are still affected by issues that are seen in other workplaces, such as workload, work-life balance and working relationships. Many of the factors identified in this review are amenable to intervention. To optimise staff well-being, the evidence in this review suggests hospice organisations should seek to continue or commence the provision of organisational support and training for staff, reduce workload, introduce initiatives that foster good working relationships and maintain the other important elements that are protective of staff well-being and which make hospices good environments in which to work.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
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Footnotes
Contributors Conception and design of study: JT, AP, BB, LF, SM. Acquisition and assessment of studies: AP, JT, SG, BB, LF, SM, LZ, MO'N, VF, AB. Analysis and/or interpretation of data: AP, JT, VF, LZ, BB, LF, SM. Drafting the manuscript: AP, JT, LZ. Approval of the version of the manuscript to be published: all authors. LZ is responsible for the overall content as the guarantor.
Funding This study was funded by the Martin House Research Centre: a partnership between the University of York and Martin House Hospice Care for Children and Young People.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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