Summary

Because the population is aging, the demand for palliative care (PC) at the end of life (EoL) is on the rise, and healthcare services are organizing themselves accordingly. In Québec, EoLPC is mainly found in combination with curative care. There are very few facilities dedicated to palliative care; instead, it is dispensed as part of home care or in the specialized wards of hospital centres, such as oncology or critical care, where nurses play a major role. Because of this organizational choice, nurses experience a very particular work context, since they have to take a mixed approach and dispense both curative care—which can be complex at times—and EoLPC, all under considerable time pressure. In hospitals, where the primary aim is to cure illness, death is often perceived as a failure. This is a source of occupational stress and dissatisfaction for nurses, who have to deal with death frequently, and sometimes the death is a difficult one. They can experience moral conflict and ethical suffering. In addition, there are other stress factors—such as intensification of work and lack of autonomy—that can affect their job satisfaction and well-being.

Against a backdrop of labour shortages and increasing difficulty attracting and retaining nurses, these are very worrisome observations, since job dissatisfaction and high turnover could jeopardize the quality of healthcare. In light of these facts, it appears more and more imperative that nurses’ job satisfaction and adaptability be taken into account in the organization of services and development of PC programs. The aim of our project is to improve the conditions in which EoLPC is dispensed. Five studies were conducted to identify problems in this sector of healthcare and to suggest avenues for action.

STUDY 1. Study of stress factors in ICUs
Objective: To describe the stressors experienced by nurses dispensing EoLPC in intensive-care units (ICUs) in various hospitals in Québec.
Method: We selected five ICUs in three regions of Québec, taking care to ensure diversity in terms of location (urban or rural), organization of care and services (open or closed ICU)  and status (university-affiliated or not). We recruited a sample of 42 nurses (day, evening, night and rotating shifts). Ten focus groups were held.
Observations: The stressors linked to EoLPC nursing in an ICU are numerous and can be grouped into three categories: organizational, professional and emotional.

STUDY 2. Ergonomic study of EoL care in ICUs
Objectives: To describe EoLPC services on the basis of direct observations in an ICU, and to explore the factors that influence job satisfaction for nurses.
Method: Thirty shifts were observed in two of the five sites used in Study 1.
Observations: The ergonomic study revealed several shortcomings in the dispensing of EoL care. The nurses seem to have little say in decisions, and the work is not organized with dying patients in mind. EoL care seems neglected; neither the protocols nor the resources (time, space, training) are adequate. The study also showed, however, that something that can be a source of difficulty can, under other conditions, become a source of job satisfaction.

STUDY 3. Study on moral stressors and ethical dilemmas in ICUs
Objectives: To gain a deeper understanding of moral stressors, to identify ethical dilemmas and their connection with ethical suffering, and to better comprehend how such dilemmas are solved.
Method: Individual interviews with 28 nurses (same selection criteria as in Study 1).
Observations: The nurses reported the following moral stressors and ethical dilemmas: (a) what they perceive as futile medical care; (b) withdrawal of treatment and what they perceive as euthanasia; (c) being powerless to relieve someone’s suffering; (d) failure to respect the patient’s wishes; (e) lies about the patient’s condition.
This study highlights the nurse’s solitude when faced with an EoL ethical dilemma. Nurses have no safe space for discussion that would enable them to restore meaning to their work, and so they retreat into silence that can last for years. In this way, ethical dilemmas lead to ethical suffering.

STUDY 4. Study on conditions conducive to the resolution of ethical dilemmas
Objective: To describe organizational practices that support the resolution of moral dilemmas, as seen from the perspective of managers.
Method: Individual interviews, n=21 managers at the same sites as in studies 1 and 3.
Observations: Analysis of the managers’ discourse reveals their powerlessness and provides little in the way of possible solutions. Developing ethical skill through a systematic training program could be one avenue for attenuating work-related ethical suffering.

STUDY 5. Study of a stress model for better understanding of nurses’ job satisfaction and well-being
Objectives: To improve the stress model (demands/resources) developed during previous research, and to determine whether this enriched model can explain the job satisfaction and distress experienced by nurses providing EoLPC.
Method: Population-based, cross-sectional study of correlations.
Inclusion criteria: Participants had to belong to the OIIQ (Ordre des infirmières et infirmiers du Québec), had to practise in the Province of Québec, and had to be dispensing palliative care, either in palliative care settings, in people’s homes, in oncology or in critical care (n=751).

Observations: The enriched model supports the conclusions of the four qualitative studies described above. It incorporates several key concepts: recognition of the nurse's autonomy, the quality of teamwork, access to qualified human resources, and relief of the patient’s and family’s suffering. The model can explain more than 80% of job satisfaction and 40% of distress, with staffing shortages topping the list of contributing factors. Finally, meaning at work mediates between autonomy and job satisfaction. The model confirms the need to take into account whether the nurse’s values are consistent with those of the organization.

Avenues for action are proposed with a view to improving support—organizational, professional and emotional—for nurses providing EoLPC.