Who takes care of the burden of emotions in palliative care workers? A study with the job demands-resources perspective

Abstract

Background

This study aims to investigate the risks and challenges that palliative care workers face in their daily work and their relationships with a source of stress typically associated with working closely with end-of-life issues: compassion fatigue, a condition of emotional exhaustion, cynicism, and impaired ability to feel empathy. The Job Demands-Resources (JD-R) model was used as a theoretical framework to understand and interpret the relationships between individual and work demands and resources of palliative care professionals with their perceptions of well-being and their levels of compassion fatigue. Specifically, we focused on surface acting (the need to manipulate the expression of one’s real emotions), emotional self-efficacy, and the perceived meaningfulness attributed to work. We hypothesized that compassion fatigue was positively related to job demand and negatively related to job resources. Conversely, we hypothesized that perceived well-being was positively associated with job resources and negatively associated with job demand.

Methods

The sample consisted of 236 palliative care workers (physicians, nurses, social and health workers, psychologists) from facilities distributed throughout Italy. The structural equation modeling (SEM) technique was used.

Results

The results confirmed the hypothesized protective role of the meaningfulness of work and emotional self-efficacy, and the detrimental role of surface acting.

Conclusions

With the present study, we aim to contribute to a better understanding of how to support the psychological and physical well-being of those who devote their professional lives to providing care and comfort to terminally ill individuals.

Introduction

The effects of working in close contact with other people’s suffering on physical, psychological, and emotional well-being are increasingly considered in research on stress factors in the healthcare sector [1, 2]. However, few studies have focused specifically on compassion fatigue in palliative care professionals, especially in Italy [3]. The present study aims to fill this void by analyzing the construct of compassion fatigue, a phenomenon that involves the depletion of empathic resources and can lead to stress and psychosomatic symptoms [4], in a sample of hospice workers.

In Italy, hospices are specialized wards for the treatment of patients suffering from an illness requiring intensive but no longer healing therapies. They can also serve as accommodations for patients’ families. The aim is to improve the quality of life and psychological condition of the patient and to take charge of the emotional, spiritual, social, and personal aspects of the disease [5]. Hospice workers are frequently exposed to death and to the need to manage the emotional needs of patients at the end of life and the requests from their relatives [6]. They are also exposed to other more hidden emotional risk factors, such as the difficulty associated with having to manipulate their real feelings in favor of the neutrality that the job or the organization more or less explicitly requires [7]. Managing clinical complications, communicating with families, and making difficult decisions represent just some of the demands of the job. Healthcare workers deal with death and suffering regularly, facing intense emotional and psychological demands [6], which can lead to serious risks to mental and physical health. It is estimated that approximately 50% of hospice workers are at risk of experiencing an impoverishment of their psychological well-being due to difficulties in dealing with end-of-life issues [8], the constant demands of patients’ relatives [9], and the repeated exposure to suffering and death [10]. It is a type of work whose daily demands cannot, by their very nature, be eliminated or reduced, which therefore requires a significant investment in terms of resources, defined as those physical, psychological, social, and/or organizational aspects of work that are instrumental in achieving work goals, promoting learning and personal growth, and/or reducing job demands and associated negative impacts [11]. The literature suggests that providing hospice workers with adequate support and resources, such as specific training, psychological support, and professional development opportunities, could be critical to preserving their mental and physical well-being [3, 12, 13].

In this context, the Job Demands-Resources model (henceforth JD-R) [11] has been used as a theoretical framework to understand and interpret the interactions between the positive and negative characteristics of palliative care professionals’ work and positive and negative outcomes [12, 14]. The main assumption of the JD-R is that job demands, where in excess, most often lead to negative outcomes (e.g., burnout, work-related stress), whereas job resources are associated with positive outcomes (e.g., work engagement). In the case of the present study, two personal job resources, emotional self-efficacy and perceived meaningfulness of work, and a job demand that is very present in the literature for its role as a severe stressor, i.e., surface acting [e.g., 15], were assessed. Compassion fatigue, which is conceptually related to the palliative care setting, and the perception of having good levels of general health were assessed as negative and positive outcomes, respectively. The research aims to read the combined effects of all the variables and how they link with each other.

Background

Compassion fatigue and general health perception

In the context of healthcare facilities that want to orient their care services toward the highest quality standards, compassion is a core value [15]. However, the ability to provide compassionate care can be diminished by compassion fatigue [4, 12]. The concept of compassion fatigue was defined as a unique form of burnout associated with care work [16]. It has also been defined as a condition of stress, emotional exhaustion, and cynicism, combined with a reduced ability to feel empathy for the patient [17, 18]. In the hospice setting, the risk of experiencing these states is particularly high. Some studies have highlighted how the repeated emotional demands associated with end-of-life care can suppress hospice workers’ ability and desire to provide compassionate care [19, 20]. In addition, hospice nurses and palliative care professionals show higher levels of compassion fatigue than colleagues who are not involved in palliative care [21].

In several studies, compassion fatigue has been compared with burnout and considered a form of burnout specific to healthcare workers [8, 13, 22]. Although they share some elements, the literature agrees in distinguishing the two concepts [23]. Burnout is a syndrome resulting from a condition of chronic work stress, characterized by emotional exhaustion, negative feelings and attitudes toward users/patients (depersonalization), and feelings of low personal accomplishment and failure [24]. On the other hand, compassion fatigue refers to an acute onset of responses, both physical and emotional, that lead to diminished feelings of compassion toward others, originating from the practice of a specific profession [4, 23]. Moreover, the symptoms of compassion fatigue arise more rapidly than those of burnout and may even occur as a result of a single exposure to a particularly acute situation of pain and suffering [17, 18].

Compassion fatigue has also been associated with secondary traumatic stress (which results from empathy felt toward individuals who have suffered from a traumatic experience) and vicarious trauma (which indicates the cognitive changes in beliefs and thoughts that occur in social workers during their practice with trauma victims) [17, 23, 25]. The literature is not unambiguous in clearly distinguishing between these concepts and identifying their boundaries; therefore, in some cases, they are still used interchangeably [26]. There seems to be agreement, however, that while burnout and compassion fatigue can occur in any type of work that involves interaction with users, secondary traumatic stress and vicarious trauma are specific to jobs that involve interaction with trauma victims [26].

Some antecedent factors of compassion fatigue have been identified in the literature, namely, the propensity for compassion, blurred work-life boundaries, and poor self-care [27–29]. Symptoms associated with compassion fatigue arise at both the physical and behavioral levels [30]. Physical symptoms include exhaustion, insomnia, immune system impairment, somatization, headaches, gastrointestinal complaints, sleep problems, fatigue, emotional exhaustion, hypochondria, and increased vulnerability to illness [30]. Behavioral symptoms include increased use of substances such as alcohol and other drugs, manifestations of anger and irritability, tension in personal relationships, absenteeism, tendency to avoid responsibility, avoidance of patients, impairment of clinical decision-making, and reduction in the quality of care provided to patients [30]. Such conditions of psychological distress also damage practitioners’ personal lives and negatively affect individual and group performance [31]. In addition, compassion fatigue can cause medical neglect and impaired judgment [17], and can lead to frustration, helplessness, and decreased work motivation [28]. In a recent study, in which the JD-R model [11] was used to predict the intention to leave the profession in a nurse sample, compassion fatigue was found to be, along with work-related burnout, positively correlated with the intention to leave the profession [14]. In the literature, nurse turnover has been linked several other times to compassion fatigue [e.g., 33], making the need to address this work-related risk particularly crucial.

As for the perception of general health, in this study it was measured by the General Health Questionnaire (GHQ-12) [32], since it has been widely used on healthcare samples to evaluate the psychosomatic well-being of healthcare workers. In a study on a sample of hospital nurses, a third reported significantly lower scores of mental health (measured through the GHQ), with a particular incidence among nurses working in at-risk wards (such as psychiatric, surgical and emergency services) compared to colleagues in other wards [33]. The presence of symptoms of psychosomatic distress seems to be prevalent among frontline healthcare workers [34]. Psychosomatic distress in healthcare workers co-occurs with burnout, and is related to maladaptive coping strategies [35], which might lock healthcare workers in a vicious circle in line with the health-impairment process theorized by JD-R model. Moreover, a recent study among nurses highlights that emotional load directly and indirectly leads to a decrease in perceived general health through the detrimental effect of surface acting [36].

Emotional labor and emotional self-efficacy

The concept of emotional labor, defined as the process of regulating the expression of one’s emotions in work settings [37], is another element specifically related to the hospice context. In hospices, caregivers must be able to suppress their negative emotions in favor of displaying positive, supportive, or neutral emotions [7]. This ability is essential in a context in which the support provided by professionals also, above all, comes through the emotional support of patients and their families [38]. Emotional labor is considered an intrinsic aspect of healthcare practice [39, 40], and it has been widely linked to compassion fatigue [21, 41–43], because of the need to consistently mask personal emotions [39]. Research suggests that excessive emotional labor can lead to compassion fatigue and burnout [39, 44].

Intrinsically related to the concept of emotional labor is emotional dissonance, i.e., the discrepancy between displayed and truly experienced emotions [37]. Simulating and suppressing emotions generates emotional dissonance, which negatively affects work-related well-being [45]. This is widely recognized as one of the most impactful job stressors, capable of disconnecting individuals from their genuine emotions and causing psychological stress [46–48]. According to [37], there are two emotion regulation strategies. The first, surface acting, is the merely expressive manifestation of emotions not actually felt. The second, deep acting, is an attempt to feel the emotions that need to be felt [37]. In the case of deep acting, the change is profound, and the physiology and expression of emotions depend on this change, albeit induced. In contrast, in the case of surface acting, the individual wears a mask, so the expressive and physiological manifestations of one’s emotionality conflict with those actually felt [46]. The effect of surface acting appears to be particularly harmful, as it is associated with increased levels of stress and exhaustion, impaired job performance, and feelings of inauthenticity [46, 47, 49]. In a recent study, surface acting was positively associated with compassion fatigue and was found to be detrimental to hospice nurses [45].

While emotional dissonance is associated with strain and the possibility of adverse psychological outcomes [7, 46], self-efficacy can mitigate and reduce the negative consequences of emotional labor [50]. Self-efficacy was found to moderate levels of exhaustion and mental distress in a sample of workers in the health and social sectors even under conditions of high emotional dissonance [51].

Many studies have investigated the functioning of the regulation of purely negative emotions and their respective coping strategies. For example, pivotal studies have shown the negative effects of anger and sadness, and the inability to regulate them, on the health of individuals and organizations [52, 53]. People differ in their ability to manage emotional experiences in daily life, both in their actual ability to regulate them and in their perceived ability to do so [54]. Moreover, they are unlikely to be able to govern their emotions (especially negative emotions) if they do not consider themselves capable of doing so [54].

The concept of emotional self-efficacy was developed from the theory of self-efficacy [55] and is defined as the confidence placed in one’s ability to function emotionally [56]. According to [54], regulatory emotional self-efficacy consists of two dimensions, the management of negative emotions and the expression of positive emotions. The former refers to the belief in one’s ability to contain and suppress negative emotions arising from stressful events, whereas the latter refers to the belief in one’s ability to freely express positive emotions in response to pleasant events. The capacity for emotional self-efficacy should enable individuals to cope effectively with negative emotional experiences, manage their intensity, frequency, and duration, and consequently not be overwhelmed by them [57]. Those who fail to modulate negative emotions may inappropriately externalize negative feelings or may be overwhelmed by fear, anxiety, or depression [53, 54, 58, 59]. A recent study confirmed the protective role of regulatory emotional self-efficacy in reducing individuals’ anxiety and depressive symptoms [60]. Therefore, emotional self-efficacy beliefs could also play a protective role in individuals exposed to heavy emotional stressors, such as those characterizing the hospice setting.

To the best of our knowledge, however, there are no studies in the literature linking emotional dissonance to emotional self-efficacy specifically.

Based on these premises, we hypothesize the following:

H1

Surface acting is positively related to compassion fatigue and negatively related to general health perceptions.

H2

Emotional self-efficacy is negatively related to compassion fatigue and positively related to general health perceptions.

Meaningful work

Meaningful work is the perception that work reflects one’s values and is relevant and influential to oneself and others [61]. It has been defined as the degree to which an employee experiences his or her work as meaningful, valuable, and useful [62].

Perceiving one’s work as meaningful could play a protective role against burnout [63, 64], especially in the case of physicians and nurses [65, 66]. Healthcare workers who give a greater sense of meaningfulness to their work are better able to recognize its importance, interpret critical situations differently, and, by giving a greater meaning to these events, are less exposed to the risks of stress [66, 67].

A study highlighted three components of meaningful work that are related to improved performance and engagement: the feeling of being recognized, the opportunity to connect with others, and the perception of making a difference [68]. These components have been found to lead to higher levels of work pleasure and better stress management [61]. A recent study demonstrated the role of meaningful work in positively influencing nurses’ perceptions of work pleasure, even in conditions of high levels of emotional labor and stress derived from dealing with COVID-19 [69]. Another study highlighted the role of meaningful work in improving the level of job satisfaction of hospice healthcare professionals [70]. In addition, studies have shown that the quality of care provided by palliative care health professionals can be improved by enhancing the meaning of work, which may have a protective effect against stress, suggesting that more stressed operators attribute less meaning to their work [67, 71].

Hence, we hypothesize the following:

H3

Meaningful work is negatively related to compassion fatigue and positively related to general health perceptions.

The hypothesized model is represented in Fig. 1.

Fig. 1.

The hypothesized model

Methods

Procedure

The research was designed in January 2023, following the favorable opinion of the Bioethics Committee of the University of Palermo (Resolution No. 120/2022). The questionnaire was structured to include scales useful for the assessment of the variables previously described (see Fig. 1) and some sociodemographic questions such as gender, age, work experience (in years), and job role. The questionnaire also included a free space for participants to anonymously write any comments, their opinions on the research topic, or feedback on the questionnaire in general. To ensure anonymity and protect freedom in response, no additional questions were added that might allow work organizations to recognize the identities of participants. To minimize the risk of automatic and therefore falsified responses, some control items were included (e.g., “select response option 3”). For data collection, 50 hospice facilities distributed throughout Italy were identified, contacted through publicly available web contacts, and invited to participate in the survey. The email contained a clear explanation of the research objectives, some example items for each scale, and a privacy statement. Among the facilities contacted, 33 (66% response rate) agreed to participate in the research and involve their employees. Data were collected through emails containing the link to the questionnaire and the informed consent document. The data collection took place in October 2023.

Participants

Overall, 236 palliative care professionals operating throughout Italy took part in the study. Of these, 78.8% were women (N = 186), 19.5% were men (N = 46), and the remaining 1.7% preferred not to specify (N = 4). With respect to the age range, 10.2% are between 20 and 30 years old, 18.7% are between 31 and 40 years old, 30.6% are between 41 and 50 years old, another 30.6% are between 51 and 60 years old, and 9.9% are over 60 years old. With respect to working role, 41% of the sample is made up of nurses, 32% of health care assistants, 14% of doctors, 7% of psychologists, and 6% of other categories (for example, social workers and volunteers). With respect to years of service in the palliative care sector, 11.4% of the participants had been working for less than 1 year, 20.3% for 1–3 years, 14.8% for 3–5 years, 10.2% for 5–10 years and 43.3% had been working in palliative care for more than 10 years.

Measures

Meaningful work was measured using the 10-item Meaningful work scale of the Questionnaire on the Experience and Evaluation of Work 2.0 (QEEW 2.0) [72], via its Italian adaptation [73]. The items were rated on a 4-point Likert scale, ranging from 1 = strongly disagree to 4 = strongly agree. Higher scores indicate a greater presence of the construct, hence the perception that one’s work is meaningful to oneself and relevant to others. An example item is “In my work I can be meaningful to others”. The Cronbach’s alpha in this study was 0.87.

Surface acting was measured using the Surface acting scale of the Emotional Labour Scale [74]. The items were rated on a 4-point Likert scale ranging from 1 = never to 4 = always. Higher scores indicate the greater presence of the construct, hence the perception that one’s job requires faking emotions that one does not actually feel and/or suppressing emotions actually felt. An example item is: “In certain circumstances of my work I have to hide my true feelings”. The Cronbach’s alpha in this study was 0.70.

Emotional self-efficacy was measured using the Regulatory Emotional Self-Efficacy (RESE) [54]. The RESE measures perceived self-efficacy in managing negative emotions and expressing positive emotions. In the following study, only the 8 items of the scale of self-efficacy in the regulation of negative emotions (anger and distress) were used. The items were rated on a 5-point Likert scale ranging from 1 = not well at all, to 5 = very well. Higher scores indicate a greater self-reported ability to regulate one’s negative emotions, particularly anger and distress. An example item is “How well can you reduce your upset when you do not get the appreciation you feel you deserve?”. The Cronbach’s alpha in this study was 0.73.

Compassion fatigue was measured using the 10-item Compassion fatigue scale from the Professional Quality of Life Scale (ProQOL) [75]. The ProQOL is the most commonly used instrument to assess the positive and negative effects of working with people who experience or have experienced extremely stressful events [75]. In this study, we used the Italian version [76]. The items were rated on a 5-point Likert scale ranging from 1 = never to 5 = very often. Higher scores indicate higher levels of perceived compassion fatigue. An example item is “I feel depressed because of the traumatic experiences of the people I assist”. The Cronbach’s alpha in this study was 0.85.

The perception of general health was measured using the 12-item version of the General Health Questionnaire (GHQ-12) [32], via its Italian adaptation [77]. The instrument consists of two parts. The first 6 items are positively oriented and measure the ability to make decisions, concentrate, and cope with difficulties. They are rated on a 4-point scale ranging from 0 = Much less than usual, to 3 = More than usual. The other 6 items are negatively oriented and assess the presence of negative feelings, worries, and feelings of being tense and overwhelmed. They are rated on a 4-point scale ranging from 0 = No, to 3 = Much more than usual. The scores of the last 6 items were reversed so that the overall score was a measure of well-being. An example item is “Have you recently felt constantly under strain?” (for the negative scale), and “Have you recently been able to face problems?” (for the positive scale). The Cronbach’s alpha in this study was 0.87.

Data analysis

The reliability of the scales was assessed using Cronbach’s alpha index. The accepted values are equal to or greater than 0.70 [78]. Means, standard deviations, correlations, and Cronbach’s alpha were assessed using SPSS 29. To test the study’s hypotheses, the structural equation modeling (SEM) technique was used. Data analysis was performed using Mplus 8. The method of estimation was maximum likelihood (ML). The following indices were used to evaluate the goodness of fit: the χ² likelihood ratio statistic, Tucker–Lewis index (TLI), comparative fit index (CFI), root mean square error of approximation (RMSEA) with associated confidence intervals, and standardized root mean square residual (SRMR). We accepted TLI and CFI values around or greater than 0.90 and RMSEA and SRMR values lower than 0.08 [79]. For reasons of parsimony, the item parceling technique was used on the variable with the greatest number of items, creating two parcels for general health perception on the basis of the two sub-dimensions included in the questionnaire by adding the 6 positive and 6 negative items.

Results

The means, standard deviations, and correlations are shown in Table 1.

Table 1.

Means, standard deviations, and correlations (N = 236)

Variable	Mean (SD)	1	2	3	4	5
1. Emotional self-efficacy	2.70 (0.90)	1
2. Meaningful work	3.25 (0.68)	0.322**	1
3. Surface acting	1.96 (0.77)	0.192**	–0.163*	1
4. Compassion fatigue	1.80 (0.88)	–0.128*	–0.277**	0.374**	1
5. General health	2.32 (0.65)	0.223**	0.358**	–0.295**	–0.629**	1

Note: ** Correlation is significant at the 0.01 level; * Correlation is significant at the 0.05 level (2-tailed)

From the correlation matrix (Table 1), negative relationships are shown between compassion fatigue and the two resource variables (i.e., emotional self-efficacy and meaningful work). In contrast, the correlation between compassion fatigue and surface acting is positive, as hypothesized. The perception of general health is positively correlated with job resources and negatively correlated with both job demand and compassion fatigue.

Following this initial exploratory analysis, we proceeded with testing the hypothesized model using structural equation models. The hypothesized model (Fig. 2) yielded a good fit (𝜒² = 849.326, df = 485, p-value 0.000; RMSEA = 0.055, 90% C.I. = 0.030–0.079; CFI = 0.969; TLI = 0.950; SRMR = 0.059). The hypothesized factorial structure was confirmed. Each item is significantly loaded on its respective construct, with factor loadings all above 0.30. Each measurement scale was found to be reliable, reporting above-threshold values of Cronbach’s alpha (see Measures section for exact values).

Fig. 2.

The structural model (**p < 0.01; *p < 0.05; all factor loadings are significant at p < 0.01)

The variables in this study were assessed exclusively through self-report measures, and data collection occurred at a single time point. This introduces the possibility that some of the observed variance might be due to the measurement method rather than the actual constructs, commonly referred to as common method bias. To evaluate this potential issue, we conducted Harman’s single-factor test. An exploratory factor analysis (EFA) was performed, including all items from every scale, loaded onto a single factor without rotation. The analysis revealed that this single factor explained 23% of the total variance, well below the 50% threshold [80]. Thus, we concluded that common method bias was not a concern in this study.

The initial hypothesis assumed that the demand variable correlated negatively with the positive outcome and positively with the negative outcome, and that the resource variables correlated positively with the positive outcome and negatively with the negative outcome. As hypothesized, the results show a significant and positive association of surface acting (the job demand variable) with compassion fatigue (β = 0.442, SE = 0.070, p-value = 0.000) and a negative association with the perception of general health (β = − 0.401, SE = 0.076, p-value = 0.000). Emotional self-efficacy and meaningful work (the job resource variables) are positively related to the perception of general health (respectively, β = 0.282, SE = 0.085, p-value = 0.001, and β = 0.266, SE = 0.081, p-value = 0.001) and negatively related to compassion fatigue (respectively, β = − 0.202, SE = 0.085, p-value = 0.017, and β = − 0.168, SE = 0.078, p-value = 0.031). Finally, compassion fatigue is negatively related to perceived general health (φ = − 0.576, SE = 0.079, p-value = 0.000). Meaningful work is positively related to emotional self-efficacy (φ = 0.386, SE = 0.071, p-value = 0.000) and negatively related to surface acting (φ = − 0.171, SE = 0.077, p-value = 0.027). The latter, however, showed no statistically significant relationship with emotional self-efficacy (φ = − 0.143, SE = 0.096, p-value = 0.136).

Discussion

The present study aimed to investigate the associations between surface acting, emotional self-efficacy, meaningful work, compassion fatigue, and well-being in a sample of palliative care professionals. The Job Demands-Resources model [11] was used to interpret the direct relationships between the variables and infer how they might simultaneously intersect in generating health impairment or, conversely, motivational processes.

According to the JD-R model, job demands can lead to high physical and mental strain, which, if persistent over time without adequate management, can lead to negative consequences such as stress, burnout and, in the case of palliative care professionals, compassion fatigue [12, 14]. Altering the expression of one’s real emotions in favor of neutral emotional states has been found to be particularly detrimental to workers’ mental health, especially in emotionally charged fields such as healthcare [e.g., 40,44]. In this study, the level of surface acting was found to be significantly associated with compassion fatigue and negatively associated with psycho-physical well-being, which is consistent with recent literature [45].

On the other hand, personal and job resources can act as buffers against the negative effects of job demands [11]. They can help promote enthusiasm, job effectiveness, and job satisfaction [81]. In the case of this study, perceiving one’s work as meaningful and relevant and, at the same time, perceiving oneself as able to manage one’s emotions was found to be significantly associated with better levels of psychophysical well-being and negatively related to compassion fatigue. This result is supported by the literature, which has shown that ascribing important meaning to one’s profession can protect against the stress generated by the job itself [66, 67, 69].

In addition, perceiving oneself as effective in managing negative emotions can greatly help one to manage the whole set of emotions that come into play in contact with terminally ill patients [50], and this can help avoid the onset of compassion fatigue [38].

The JD-R model suggests that it is important to consider both demands and resources to fully understand the impact of work on employee health and well-being. Therefore, the relationships between antecedent variables are also worthy of attention. Job meaningfulness was found to be positively related to emotional self-efficacy and negatively related to surface acting. In the hospice setting, health professionals devote their workdays to providing support and care to terminally ill individuals. These are work tasks to which culturally great significance is ascribed, and which workers themselves perceive as highly relevant. This noble mission, however, comes with no small emotional or psychological burden. In addition to being aware of the importance of their profession, palliative care workers must be equally aware of the need to properly manage and regulate their emotions to perform in the best way both for themselves and for patients and their families. If better emotional regulation allows for more efficient work [82], improved performance could increase overall self-efficacy and engagement [68], which in turn could be linked to higher levels of meaningfulness of work [67] and lead to higher levels of pleasure in working [69].

The meaningfulness of work is a variable somewhere between the personal resource (the weight and relevance that the work has for the individual who performs it) and the organizational resource (an organization that protects the well-being of employees builds their loyalty and increases their involvement and sense of belonging to the profession). Manipulation of displayed emotions, regardless of whether they are required implicitly by the job or explicitly by the organization, could counter or contaminate the perception of meaningfulness [46], especially if passion for the job is not high or workers are already worn out [36]. In fact, almost half of the sample in the present study consisted of workers with more than ten years of experience in palliative care. This may explain the negative relationship between surface acting and meaningful work.

Finally, emotional self-efficacy was not found to be significantly correlated with surface acting, despite the common traits (emotion regulation and emotion manipulation). In other words, the visible emotion manipulation strategy seems to be independent of the perception of being emotionally competent. This may be because the need to manipulate emotions is considered an integral part of the job and therefore must be implemented by all workers, regardless of how capable they feel of doing so. The manipulation of emotions does not occur by personal choice but rather by obeying implicit emotional rules of the organization [7]. Therefore, since it does not depend on an individual’s free will, it may not be correlated with emotional self-efficacy.

Limitations

The main limitations of the study depend on the cross-sectional design, which does not allow for hypothesizing cause-and-effect links between the variables [83], and the use of only self-reported data, which does not allow for comparisons with other objective indicators of the presence of the variables being examined [80]. In addition, the convenience and limited sample size do not allow for the generalization of the results to the broader reference population, and this could be a limitation to the power of the study. The results obtained and the inferences that have been drawn, in any case, can refer exclusively to the Italian context and the characteristics of Italian hospices. Furthermore, the need to protect the privacy and anonymity of the participants prevented the collection of further information that could have had an influence on the variables tested (for example, the geographical area of origin, the type of healthcare facility of affiliation, the precise age and the precise years of work experience).

Conclusions

This study examined the work of palliative care professionals through the lens of the JD-R model, which offers an integrated approach that takes into account both the challenges and resources present in the unique and demanding work environment of hospice. The aim of the study was to emphasize the problem of the effects of compassion fatigue especially on palliative care professionals, whereas research has largely focused on health professionals in general.

Analyzing job demands is crucial for identifying major risk factors, but perhaps even more important is identifying the resources, both personal and work-related, since acting on their enhancement could prevent the occurrence of negative outcomes.

In this context, our study shows the resource role that the perception of meaningfulness plays in some occupations, especially when workers are forced to carry an extremely heavy load. The case of hospice workers is emblematic, especially concerning emotional burdens. In the anonymous testimonies of the respondents, several stated, “It is not a job that everyone can do,” or “If it were not for the support between colleagues, I would have given up long ago”. This study can be used as a starting point to reflect on how the meaningfulness attributed to one’s role and perceived competence in managing one’s emotions can positively impact the perception of well-being and have the potential to reduce the burden of a complex phenomenon such as compassion fatigue. Both dimensions can be addressed through specific interventions, both preventive (through training in adaptive emotional regulation strategies) and protective (through the promotion of effective coping strategies and the sense of significance of one’s work).

In addition, some considerations related to aspects of human resource management within healthcare organizations, especially those that expose staff to direct contact with the risk of death of their patients, are necessary. The first consideration is related to the need to conduct recruitment and selection practices that are based not only on the necessary technical preparation (medical, nursing, psychological, etc.), but also on value aspects regarding the type of activities to be performed. Such attention would produce not only more effective staff, but also greater departmental efficiency and lower turnover, an adequate level of well-being, and a lower risk of exposure to compassion fatigue and burnout.

The second implication concerns the need to support individuals in terms of the type of demand to which they are subjected and preventively supporting their emotional regulation (for example, through specific training, self-help groups, supervision, etc.) to strengthen emotional awareness and the ability to recognize the function of some dissonant emotional expressions, as well as learning to use them consciously.

Although the need to equip healthcare workers with an adequate ability to manage emotions is widely accepted, training actions are often focused on managing the emotions of others (patients and family members), putting the care of caregivers and their well-being in second place. Instead, it is crucial not to forget that a lack of attention to well-being and increased exposure of workers to risks quickly lead to an overall deterioration in the effectiveness of the healthcare system as a whole.

Abbreviations

JD-R

Job Demands-Resources

SEM

Structural Equation Modeling

e.g.

Exempli gratia

i.e.

Id est

GHQ

General Health Questionnaire

No.

Numero

QEEW

Questionnaire on the Experience and Evaluation of Work

RESE

Regulatory Emotional Self-Efficacy

ProQOL

Professional Quality of Life

ML

Maximum Likelihood

TLI

Tucker–Lewis Index

CFI

Comparative Fit Index

RMSEA

Root Mean Square Error of Approximation

SRMR

Standardized Root Mean Square Residual

EFA

Exploratory Factor Analysis

SE

Standard Error

Author contributions

Conceptualization, GS, FS and FP; methodology, GS; data curation, FS; writing– original draft preparation, GS, FS, FP and CM; writing– review and editing, GS, FS, FP and CM. All authors have read and agreed to the published version of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The data that support the findings of this study are openly available in the OSF repository at https://osf.io/bkund/?view_only=ba4eca8c00c44b24b21266b6b4c74c8c.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the University of Palermo with Resolution No. 120/2022. Informed consent was obtained from all the subjects involved in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.