INVESTIGATING THE PERCEIVED EFFICACY OF SUPPORT GROUPS AS A

SECONDARY-ORGANIZATION STRESS INTERVENTION MEASURE FOR

HOSPICE NURSES

by

Sade Allen

Liberty University

A Proposal Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Philosophy

Liberty University

October 30, 2022

ii

INVESTIGATING THE PERCEIVED EFFICACY OF SUPPORT GROUPS AS A

SECONDARY-ORGANIZATION STRESS INTERVENTION MEASURE FOR

HOSPICE NURSES

by

Sade Allen

Liberty University

A Proposal Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Philosophy

Liberty University

October 30, 2022

APPROVED BY:

________________________________

Name and degree, Committee Chair

________________________________

Name and degree, Committee Member

iii

ABSTRACT

This proposed study aims to investigate the perceived efficacy of support groups as a

secondary-organization stress intervention measure for hospice nurses. Workplace stress

is a common issue in hospice care that impacts them negatively (Kokoroko & Sanda,

2019). It results in declining mental, physical and social wellness. While research

indicates significant benefits of support groups, they are not commonly applied in

hospice care. Support groups have been widely used in mental health for many years to

share information and experiences and discuss problems (Worrall et al., 2018). This

proposed study will use qualitative case study approach to interview eight participants.

The participants will be recruited from one facility and interviewed. The information

obtained will be analyzed using the six steps designed by Creswell in the data analysis.

Peer support groups have been known to help employees discuss their challenges in the

workplace and cope better with stress. This research will provide a framework for future

research to further investigate support groups a stress coping mechanism in organizations.

Keywords: hospice nurses, palliative care, secondary organization-level

intervention, stress, support groups.

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TABLE OF CONTENT

ABSTRACT

CHAPTER 1: INTRODUCTION TO THE STUDY1

Introduction1

Background1

Problem Statement

Purpose of the Study

Research Questions

Assumptions and Limitations of the Study

Theoretical Foundations of the Study

Definition of Terms

Significance of the Study

Summary

CHAPTER 2: LITERATURE REVIEW

Overview

Description of Search Strategy

Review of Literature

Causes of Stress

Poor Working Conditions

Changing Environments

Lack of Support and Training

Physical and Mental Risks

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Workload Causes of Stress in Healthcare Setting

Healthcare Employee Attitude Causes of Stress

Effects of Stress

Absenteeism and Turnover in Healthcare Settings

Decreased Performance and Productivity in the Healthcare Setting

Physical Effects of Stress

Mental Effects of Stress

Social Effects of Stress

Effects of Stress on the Economy

Employee Burnout

Interventions for Workplace Stress Management

The Focus of Stress Management

The Levels of Interventions

Biblical Foundation of the Study

Causes of Stress from a Biblical Perspective

Biblical View on the Effects of Stress

Biblical Interventions for Managing Stress

Summary

CHAPTER 3: RESEARCH METHOD46

Overview46

Research Questions46
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Research Design46

Participants48

Study Procedures49

Instrumentation and Measurement

Data Analysis

Delimitations, Assumptions, and Limitations

Summary

REFERENCES

APPENDIX A: RECRUITMENT DOCUMENT

APPENDIX B: PERMISSION REQUEST

APPENDIX C: PERMISSION RESPONSE

APPENDIX D: INFORMED CONSENT

APPENDIX E: INTERVIEW QUESTIONS

1

McKinless, 2020

Before addressing the techniques for managing stress in hospice nursing, it is important

to understand the possible causes of stress linked to the profession. Some of these causes include

poor working conditions like failure to provide adequate supportive services (Burtson & Stichler,

2010), changing environments such as technological changes (Krick et al., 2019), lack of support

and training (Chan et al., 2019; Datta-Paulin & Salt, 2019), physical and mental risks (Delgado

et al., 2017), workload (Diehl et al., 2021), and healthcare employee attitudes (Mukemo et al.,

2017). These causes of stress are associated with negative impacts such as increased turnover

and absenteeism (Kokoroko & Sanda, 2019; Lockhart, 2020), decreased performance and

productivity (Barnett et al., 2018), physical effects (De Fatima Fernandes & da Silva Gherardi-

Donato, 2017; Salvagioni et al., 2017), mental effects (Dębska et al., 2017), social effects

(Marmo, 2016; Sandi & Haller, 2015), effects on the economy (Brulé & Morgan, 2018), and

employee burnout (Lehto et al., 2020). Understanding the causes and effects of work-related

stress is important in adequately identifying possible stress-management techniques.

There are numerous stress management interventions that can be categorized based on the

focus and level (Holman et al., 2018). These interventions are classified into primary, secondary,

and tertiary stress-management interventions. These levels describe the individual and

organization level stress management interventions. Individual-level interventions aim at helping

workers develop skills to reduce, cope with, and manage stress (Holman et al., 2018).

Organizational-level interventions make more systemic alterations to organizational practices

that target specific employees or all employees in the company (Holman et al., 2018). Primary

interventions aim at preventing stress from occurring, while secondary interventions focus on

reducing the duration or severity of stress once it has occurred (DeFrank & Cooper, 1987). On
2

the other hand, tertiary interventions are those that try to assist workers with chronic or high-

stress levels, which may be impairing their work abilities. The focus of this study is the

perceived effectiveness of support groups as a secondary-level organization intervention. This is

important because research published in the Nursing Times England demonstrated a significant

gap in organization involvement in stress interventions for hospice nurses (Cedar & Walker

2020). Moreover, although research has provided evidence of support groups as a beneficial

stress intervention level in stress management, these methods are not common interventions in

hospice care at the organizational level, as shown in previous research studies (Cedar & Walker

2020).

Support groups have been widely used in mental health for many years to share

information and experiences and discuss problems (Worrall et al., 2018). Their wide application

in this field is because support groups are essentially meetings of people with similar

experiences. For this proposed research study, the intended target is hospice nurses, a group of

healthcare workers who share similar experiences based in their field. Research has shown that

hospice nurses are deemed a high-risk group for compassion fatigue and burnout because they

continuously attend to the terminally ill (Boyle, 2011; Letvak et al., 2013, as cited in Harris,

2013). Thus, the evidence that links stress to reduced performance and job satisfaction

demonstrates the need for hospice care settings to offer adequate support for nurses dealing with

end-of-life care patients.

Peer support groups have been known to help employees discuss their challenges in the

workplace (Holman et al., 2018). According to Lowe et al. (2016), numerous research has

focused on understanding the causes of stress in hospice care. The study recommended
3

organizational support and support groups from family, friends, and colleagues to mitigate the

effects of workplace stress.

Moreover, the Bible demonstrates a significant link between Christian teachings and

stress causes, effects, and interventions. Ross (2020) highlights that the cause of suffering for

human beings is the fallen world, particularly sin. While stress is not directly mentioned in the

Bible, it is described through human suffering like illness, pain, and anxiety, and the Bible also

illustrates how to deal with these issues (Krause & Pargament, 2018). Therefore, stress is viewed

as another part of human suffering that can be managed. Job overcame all the suffering by

having faith in God (English Standard Version Bible, 2001/2016, Job 1:16). The Bible also

acknowledges the effects of stress on the spiritual, physical, and emotional aspects of an

individual. An example of this phenomenon is when King David had to hide from King Saul,

who was planning to murder him (New International Version Bible, 1978/2011, 1 Samuel 19).

This account in scripture suggests effects such as social isolation, emotional stress, and

detachment from the world and other people.

Consequently, organizations can implement Christian teachings on stress interventions,

especially those that aim at encouraging, serving, and carrying other people’s burdens. The Bible

also acknowledges the importance of support groups in people’s daily lives. Hebrews 10:24-25

reads,

And let us consider how we may spur one another on toward love and good deeds, not

giving up meeting together, some are in the habit of doing, but encouraging one another

—and all the more as you see the Day approaching. (New International Version Bible,

1978/2011)
4

This verse is relevant to this research because it emphasizes spirituality and support

groups, which are regarded as some of the most effective ways of coping with work stress among

hospice nurses, as mentioned in Harris (2013).

Problem Statement

Numerous research supports that workplace stress is an existing problem for hospice

nurses that affects their well-being at work and in their personal lives (Kokoroko & Sanda,

2019). Studies indicate that increase in life expectancy and chronic life-impairing conditions

have heightened the demand for hospice services for their professional end of life care (Lehto et

al., 2020). Hospice nurses’ job description requires a holistic approach since they are tasked with

addressing their patient’s physical, emotional and spiritual needs. Aside from that, they are

expected to deliver various services inclusive of the patient’s family members that ensure the

patient’s final days are spent in dignity with minimal suffering. Modern day hospice care is fast-

paced, full of transitioning caseloads, new technology and administrative demands. Their typical

responsibilities encompass heavy caseloads, high patient acuity, intense emotional support and

processing personal grief arising from numerous encounters of patients dying (Lehto et al.,

2020). Other stressors come from harsh working environments such as short staffing,

unpreparedness and lack of proper training, lack of supportive resources, and dynamic

environments. This workplace stress is responsible for the hospice nurses declining health, social

and economic lives.

Available evidence indicates that social support in organizations gives extra resources

that empower and equip nurses to better cope with work stress. Furthermore, according to Ellis

and Miller (1994, as cited in Kokoroko & Sanda, 2019) organization-based support is a more

effective stress mitigation measure compared to non-work based support. They argued that it is
5

more practical to set up a supportive work environment in the organization instead of eliminating

the workplace stressors. However, research indicates little organization stress management

involvement in interventions for hospice nurses (Sapeta et al., 2022). Instead, the nurses typically

practice self-propelled stress coping strategies which are individual-level intervention measures.

Thus, given the evidence on the efficiency of organization-based support interventions, there is a

need to investigate if hospice nurses perceive them as an efficient measure to mitigate the effects

of stress in hospice care.

Purpose of the Study

The purpose of this qualitative case study is to explore the perceived efficacy of support

groups as a secondary-organization stress intervention measure for hospice nurses.

Research Questions

RQ1: How do hospice nurses respond to support groups as an organization intervention

measure to deal with workplace stress?

RQ 2: Why should organizations use support group as a secondary-level intervention

measures to mitigate the effects of workplace stress in palliative care?

RQ 3: How can organizations implement support groups as a stress coping strategy for

hospice nurses?

Assumptions and Limitations of the Study

All research endeavors have both assumptions, limitations and de, and this proposed

study is not immune to these issues. The data will be collected primarily through interview

questions. One assumption arising from this is that the information provided from the

participants will be honest and complete. To mitigate this, Esterberg (2002) recommends open-
6

ended structured questions as opposed to closed-ended which can inhibit the participants’

freedom to express themselves fully. The aim of the interview is to be conversational by making

the participants comfortable with simple open-ended questions. Establishing a good rapport is a

priority in qualitative studies since it can help the participants feel comfortable enough to answer

the questions honestly (Guillemin & Heggen, 2009). Some of the tactics that will be employed

entail introducing one’s name and purpose for data collection, and maintaining friendly body

language, utilizing active listening and dressing appropriately for offline data collection.

Furthermore, the researcher will disclose the purpose of the study, how the data will be protected

and how it will be used to enhance the research.

Another assumption is that the participants in the data collection are aware of, able, and

willing to discuss the issue under investigation. The selected participants will need to confirm

that they have a basic understanding of both the work-stress and support groups. The screening

process will be comprised of two questions addressing work-place stress and concept of support

groups.

This research design can present potential limitations that can interfere with the results of

the study. A significant limitation arising from the procedure in qualitative research during data

collection is the sample size as stated by Assessment Capacities Project (ACAPS) (2012). The

scope of this study will be limited to a single organization. Dealing with a small sample size

limits the ability to generalize any findings because they may not be a true reflection of the issue

on a larger scale (ACAPS, 2012). Therefore, it is not efficient to make summaries generalizable

to the wider population.

Another limitation is that qualitative research is labor intensive through time consuming

interviews, various analyzing processes and need to have a skilled interviewer (Choy, 2014).
7

With the nature of the questions being open-ended, the researcher is at the participants’ mercies.

They can take too long to respond, overlook crucial details or derail from the topic. One way to

minimize time wastage is by providing, fewer well-structured questions.

Another limitation is researcher and participant biases which can compromise the validity

of the results. This issue stems from the hospice nurses’ perceived effectiveness of support

groups and not the actual effectiveness. All the information received from the participants and

how the researcher interprets it is subject to personal beliefs, experiences and knowledge.

Therefore, they are not objectively verifiable (Choy, 2014). Nevertheless, this study can be an

opportunity for future research to determine social support’s effectiveness further if this proposal

demonstrates that hospice nurses perceive it as an effective way to deal with stress.

Theoretical Foundations of the Study

Studies have revealed that social support groups are essential in minimizing caregiver

burden (Rodakowski et al., 2012; del-Pino-Casado et al., 2018, as cited in Benson et al., 2019)

and improving caregiver health. Sarason et al. (1983, as cited in Benson et al., 2019) defined

social support as “the existence or availability of people on whom we can rely, people who let us

know that they care about, value, and love us” (p. 127). Social support can be categorized into

several types, such as emotional, companionship, instrumental, informational, and appraisal

(Cutrona & Suhr, 1992, as cited in Benson et al., 2019). Emotional support involves expressions

pervaded with caring, empathy, sympathy, and concern. Appraisal support entails statements that

are meant to promote another person’s skills or intrinsic value. It is also known as esteem

support and often assumes the form of validation or compliments. Companionship support

entails messages that convey friendship, solidarity, togetherness, and inclusion. It is also known

as social network support. Informational support involves sharing facts, information, knowledge,
8

tips, suggestions, and advice. This could include sharing key facts about stress management

among hospice care nurses. The knowledge of different forms of support will drive the

development of interview questions to ensure that the answers provided by respondents on the

topic are comprehensive.

Little research has been conducted on support-seeking behaviors. Barbee et al. (1993)

proposed the Social Support Activation Model, which described support elicitation as either

indirect or direct, verbal or non-verbal (Benson et al., 2019). Direct elicitation entails making a

request or asking a question, while indirect elicitation involves self-disclosure of information in

revealing a need. While Barbee’s (1993) theory was proposed to elucidate support-seeking

behaviors in face-to-face settings, recent studies have shown that it is also pertinent to online

support-seeking behaviors (Youngvorst & High, 2018; Wang et al., 2015, as cited in Benson et

al., 2019). Thus, group support is a great coping strategy whether they are conducted online or

offline. This knowledge is relevant to the proposed study because the study proposes to gather

information from both online and offline sources.

The Bible also recognizes the social support theory. Galatians 6:2 reads “Carry each

other’s burdens, and in this way you will fulfill the law of Christ” (New International Version

Bible, 1978/2011). This verse reiterates the importance of sharing experiences as it is the will of

God.

Definition of Terms

The following is a list of definitions of terms that are used in this study.

Hospice nurses – Hospice nurses are nurse professionals tasked with providing care, comfort

and support to patients in palliative care (Clayton et al., 2019).

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Palliative care– Palliative care is specialized healthcare that is patient and family-centered that

targets optimizing life of patients with serious illnesses where “curative” therapies are ineffective

(Mercadante et al., 2018)

Secondary organization-level intervention- Secondary organization-level interventions are

interventions that focus on establishing organizational-wide alterations that help workers cope

better with stressful situations (Murphy, 2003)

Stress – Stress refers to the body’s physiological response to challenges (Lu et al., 2021)

Support groups- Support groups are meetings of individuals with similar experiences who

provide support and companionship with one another (Worall et al., 2018).

Significance of the Study

This study will have public health significance. Hospice nurses are among the high-risk

groups for fatigue and burnout due to workplace stress (Benson et al., 2019). The findings of this

case study will contribute to the literature on the perceived significance of secondary-

organization stress management interventions for hospice nurses. Numerous research supports

that workplace stress is an existing problem for hospice nurses that affects their well-being at

work and in their personal lives (Kokoroko & Sanda, 2019). Studies indicate that increase in life

expectancy and chronic life-impairing conditions have heightened the demand for hospice

services for their professional end of life care (Lehto et al., 2020). However, issues such as

workplace stress are negatively impacting the nurses, leading to burnout, dissatisfaction, and

turnover. This proposed study will help the practice by providing information on how hospice

care organizations can support their employees and help them cope with work stress. The

findings will also provide information to existing and aspiring hospice nurses on possible

impacts of the nature of their job and how forming support groups could benefit their careers.
10

Moreover, this study will have a significant contribution to the literature on the social

support theory in caregiving since it will assess the perceived effectiveness of the intervention.

The employers are another category likely to benefit from this research. Organizations need to be

proactive in implementing interventions to help their employees cope with work-related stress. In

one study, the results indicated apart from successful stress reduction, there is a high likelihood

of better business incentives when the organization adopts stress prevention programs (Wijnen et

al., 2020). These benefits are tied to good implementation, high compliance, and regular

monitoring and evaluations for improvement. These work-stresses are known to cause

individual, societal and economic costs. Stress interventions help to mitigate these costs, the

psychological harms and improve employee productivity (Molek-Winiarska & Molek-

Kozakowska, 2020). Hospice nurse employers invested in optimal work productivity, employee

well-being, quality health outcomes and business stability will consider adopting recommended

strategies such as support groups to deal with stress. Thus, through this research, employers and

hospice nurses would be able to recognize and apply group support techniques to cope with

work-related stress.

Summary

This chapter began by introducing the proposed study which aims to by examine the

perceived effectiveness of support groups as a secondary-organization stress intervention

measure for hospice nurses. Then a background and biblical foundation was presented, which

demonstrated what is currently known and what needs to be known about this topic, justifying

the need for this proposed study. Recent studies have mentioned the impact of support groups as

stress management interventions for healthcare workers, including hospice nurses (Kokoroko &

Sanda, 2019). Moreover, other research studies have examined the impact of secondary-
11

organization stress management interventions for hospice nurses (Alkhawaldeh et al., 2020;

Holman et al., 2018; Veiga et al., 2019). This is because workplace stress is a crucial factor

impacting the health and well-being of hospice nurses because of the nature and emotional

demands of their job (Lehto et al., 2020). The bible also provided evidence of support groups in

the verse Hebrews 10:24-25,

And let us consider how we may spur one another on toward love and good deeds, not

giving up meeting together, some are in the habit of doing, but encouraging one another

—and all the more as you see the Day approaching. (New International Version Bible,

1978/2011)

This chapter also well-documented the purpose of the proposed research, the questions

that will drive the methodology, and the assumptions and limitations of the study. One

assumption of this proposal is that the information provided from the participants will be honest

and complete. These will be achieved by using open-ended questions as recommended by

Esterberg (2002) and establishing good rapport (Guillemin & Heggen, 2009). A screening

procedure will be performed to select the ideal participants. However, it is acknowledged that the

proposed research design could present potential limitations that could impact with the results of

the study. These limitations could be because of scope, sample size, high labor-intensity, time

and biases.

A social support theoretical framework will be used to guide the findings of this study.

Furthermore, this theory is recognized in Biblical texts in the verse “Carry each other’s burdens,

and in this way, you will fulfill the law of Christ” (New International Version Bible, 1978/2011,

Galatians 6:2). Thus, the research will have a significant contribution to the literature on the

social support theory in caregiving and the general hospice care profession.
12

The chapter also describes the key terms that will be recurrent throughout the proposal

document. Lastly, this proposed study is significant as the findings of this case study will

contribute to the literature on the perceived effectiveness of secondary-organization stress

management interventions for hospice nurses. It could possibly inspire future research on the

topic. Findings could benefit individuals such as employees and employers and the organizations

as a whole in hospice care stress management. This chapter lays the foundation for tackling the

themes of causes, effects and interventions of stress among palliative care nurses which will be

covered in detail in the next chapter.

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Overview

Job stress is a common problem across occupations that impacts workers’ health,

attitudes and job performance (McKinless, 2020). It mainly occurs when a person is unable

handle the demands and pressure of the job. Therefore, stress is more probable in some

circumstances and people than in others. Aside from that, it can be designated as the detrimental

physical and emotional responses that occur when the job necessities do not meet the employees’

competencies, wants, or resources. According to McKinless (2020), work stress in nursing can

result in poor health through burnouts, emotional injury and reduced job productivity since it can

directly influence an individual’s work and personal life.

Three major themes arose when reviewing the current literature on workplace stress and

stress management for hospice nurses. The first broad theme evident was causes of work stress

that further breaks down to target hospice nurses. The second theme evident was the effects of

stress on the economic, mental, social and physical life and the third covered stress management

interventions. This chapter will cover these themes in deeper detail from a narrow perspective

and funnel them down to target hospice nurses. This proposed research aims to critically analyze

the most effective secondary-organization stress intervention measures for hospice nurses. The

literature review section will elaborate on the three themes and narrow down to the purpose and

problem statement. Through this, the gap in the current literature will become clear, justifying

the need for this proposed study, which aims to investigate the perceived efficacy of support

groups as a secondary organization intervention measure for stress management in hospice

nursing.

Description of Search Strategy

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The search strategy for the literature review utilized several search engines that produced

a variety of current findings. The primary search engine was Liberty University library resources

that were pivotal in obtaining peer-reviewed journals regarding work stress among hospice

nurses. The Jerry Falwell library research portal proved very useful during the search process

since it included various databases like audio-visual materials, journal articles, and dissertations

and theses. Other materials were obtained from local websites, Emerald, and Google Scholar,

which are well-referenced.

The Jerry Falwell Library, Google Scholar, and Emerald database proved very useful in

searching for information about hospice nurses. Searching for certain keywords such as hospice

nurses, palliative care, and work stress made it easier and more convenient to acquire

information in search engines. The articles produced from the search of the above keywords also

led to other citations or articles on the research topic. For Google Scholar, it has a feature that

allows the creation of libraries to save search results. It enabled the creation of a database on

hospice nurses dating from 2017 to 2022. The search engine was therefore based on the

publication of the sources.

More information was also gathered from Google Scholar in case studies that discussed

work stress among hospice nurses. The case studies provided an in-depth investigation on the

topic and proved very useful because the information had been sought from different sources.

Furthermore, the information was gathered through different data types such as surveys,

interviews, observations, and analysis of documents. It was easy to locate case studies

concerning work stress on hospice nurses through a keyword search in the library’s databases

and the Everything search on the library website. The case studies proved to be of much value
15

because they described the work stress among hospice nurses, identified the key issues of the

case, and analyzed the situations using relevant theoretical concepts.

Encyclopedias also added more information, especially when searching for background

information and the key concepts and ideas related to hospice nursing. They were helpful as they

contained factual entries written by different knowledgeable contributors about the topic; hence

information based on different perspectives was useful.

Bibliographies were also useful as search engines. Related publications were quicker to

find, which enhanced the research. Other authors had even included a list of recommended

reading and included their findings on the topic of discussion. There was substantial information

to work with, and having different authors who had given their overviews and insights gave

room for more information.

The Bible is another vital source of information. The Biblical knowledge incorporated in

this proposal is obtained from reading through the Bible, a form of word study. The search

strategies that helped obtain information about work stress included the Bible Background

Commentary, Bible dictionary, and cross-referencing Bible. The Commentary covers the cultural

background of the Bible verse by the verse. It provided an introductory section covering the date,

authorship, setting, purpose, and genre. The Bible dictionary proved useful in identifying or

finding a specific word related to the category of stress. Finally, the cross-referencing helped to

identify other books or quotes in the Bible that discuss the same topic: work stress. They are

written down as footnotes and noted others in the margins.

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Review of Literature

The themes in this literature review section entail causes of stress, its effects and

intervention measures. It is critical to understand these themes and how they apply to hospice

nursing. This review presents the current research and will expose the gap in stress management

for hospice nursing, which justifies the need for the proposed study.

Causes of Stress

A working environment involves those systems, processes, gears, or situations in the

office that influence positively or adversely distinct performance and attitudes (Saidi et al.,

2019). Additionally, it comprises the policies, culture, rules, working relationships, resources,

and internal and external environmental factors that impact how workers execute their job

functions. This section will present some of the environmental causes of stress in healthcare

settings, including poor working conditions, changing environments, lack of support and

training, physical and mental risks, workload, and healthcare employee attitudes.

Poor Working Conditions

Poor work conditions can be derived from work relations in various forms. Specifically,

among staff nurses, one of the main forms of conflict relations is verbal abuse from physicians

which leads to stress (Jennings, 2008). The verbal abuses may affect an employee’s morale,

impacting their attitude towards the job. Problematic work relationships lead to poor working

conditions, which significantly impact workers and their ability to achieve tasks since work

environment significantly impacts employee motivation (Diamantidis & Chatzoglou, 2018). The

exhaustion resulting from the working environment may lead to occupational burnout. Burnout

arises from cumulative workplace stress that displays mental and physical fatigue, negativity
17

about work, and emotional distancing from the work environment (Parola et al., 2017). The

exhaustion results in negative problems for the health organization, such as reduced quality care,

absenteeism, retention issues, and compromised work performance. Additionally, burnout in a

healthcare environment influences other workers adversely as they may encounter workplace

negativity and turnover of workmates when attrition happens.

Associations between staff nurses and nurse managers are particularly important since

management styles are affected (Naseem et al., 2018). Work relationships play a major role in

impacting employees’ attitudes towards work. Head et al. (2019) mention that one of the most

effective stress reduction techniques among palliative and hospice nurses is the formation of

supportive relationships. Supervisors are expected to be supportive and offer quality supervision

to ensure patients receive quality care. However, in poor working conditions, supervisors tend to

provide inadequate supportive services, which affects the provision of care (Burtson & Stichler,

2010). Inadequate services include inadequate unit leadership, which leads to the frequent

turnover of nurse managers, failure to address problems, and insufficient physical presence of the

supervisor on the unit. The lack of sufficient staff is another characteristic of poor working

conditions. Nurses are often required to handle several tasks such as providing clarifications and

explanations for patients and caregivers (Caswell et al., 2015). These tasks results in stress for

the few nurses available since they have a higher workload, which can result to increased

burnout and anxiety cases.

Changing Environments

Like poor working conditions, changing environments also contribute to the

environmental cause of stress. Technology is one area that continues to change and also affects

palliative care (Krick et al., 2019). Over the years, nurses, among other health care specialists,
18

have been obligated to implement digital facilities and information systems as part of patient care

(Kaihlanen et al., 2021). Despite the expectation that the information systems may offer benefits

of economic and quality care, they also have negative consequences for the end-users (healthcare

workers), which comprise augmented stress and strain from learning and adjusting the

information systems to their workflow. This type of stress, stress-related to information systems

(SRIS), is instigated by poorly operational or continually changing information systems

(Heponiemi et al., 2018). These nursing information systems such are demanding and require

detailed documentation in health records take more time out of daily work, causing a high

workload and lack of time which are typical barriers to the acceptance and implementation of the

systems (Kaihlanen et al., 2021). Furthermore, nurses are pressured by the relentless need to

redefine their nursing proficiency to offer care in digital environments.

Additionally, introducing change can create heavy learning demands (Mikkelsen &

Olsen, 2018). These changes can create ambiguity and challenges for employees such as

increased nursing stressors, which can affect the job satisfaction of hospice nurses. Managers and

leaders directly impact their workers’ stress and anxiety levels. Therefore, bringing in new

changes requires an adjustment that may not be easy for every employee (Mikkelsen & Olsen,

2018). The new management is likely to conduct operations differently, creating a gap. The lack

of job satisfaction may result in adverse consequences such as absenteeism, chronic work stress,

less trust in the employer-employee relationship, and high turnover rates.

Lack of Support and Training

Another critical aspect leading to stress is training, which is vital for the management and

staff (Choi & Kwon, 2018). In palliative care, training equips nurses with the knowledge and

skills to deliver on their patients' and their families' emotional, physical, spiritual, and social
19

needs. A lack of training has been linked to low involvement in advance care planning, affecting

employees’ work performance and competency (Chan et al., 2019). This may result to unhappy

employees, high turnover rates, low provision of quality care, an unsafe work environment, and

ineffective staff management. Training for hospice nurses is essential since employees are taught

how to control their emotions and communicate with families (Datta-Paulin & Salt, 2019).

Nurses who do not undergo this find it hard to adapt and communicate, leading to mental health

illnesses such as depression and anxiety (Datta-Paulin & Salt, 2019). The ultimate result may be

employee turnover due to a lack of skills, inadequate job satisfaction, and health issues.

Moreover, without proper training, they cannot achieve the main goal of palliative care, which is

to affirm life and regard dying as a normal process.

In most health organizations, nurses with more experience are often delegated to train the

new staff (Morgan, 2009). They may be forced to limit their time and care with patients to tutor

new employees, leaving their patients in the care of unskilled people. This trend can lead to poor

care provision, affecting the patients and the organization in general. Aside from that, the nurses

who tutor them may not teach them every crucial aspect which leaves room for mistakes when

they start working. Unskilled hospice nurses seek help to perform their jobs, detracting the more

experienced employees. As a result, they monitor the new employees not to cause any harm

instead of caring for their patients.

Hospice nurses must be well trained to make be good decision and communicate

effectively since they care for people with dire illnesses and provide emotional support to both

patients and families (Chan et al., 2019). For an unskilled hospice nurse, delivering quality care

can be difficult. The family will also not feel safe entrusting their patient to an unskilled nurse.
20

The nurse is further exposed to workplace stressors since they are not well trained to handle

strenuous situations when they arise.

Physical and Mental Risks

Physical and mental risks are factors that contribute to workplace stress. Present

organizations function in a dynamic and constantly changing environment (Krick et al., 2019).

As a result, employees face practical and emotional challenges in their job, which may cause

them stress (Hussain, 2021). Most organizations are in rapid transitions, trying to keep up with

modern trends. Workers in such organizations are forced to adapt to these changes.

Unfortunately, this creates high levels of pressure to keep up a high throughput, increasing their

job stress levels.

The demands from unpredictable schedules, work overload, and challenging patient and

family situations result in emotional exhaustion and burnout (Parola et al., 2017). Hospice nurses

are more likely to deal with workplace demands and adversities such as emotional challenge of

seeing patient suffering and being in distress, conflict with other staff members, and

interpersonal difficulties (Delgado et al., 2017). Prolonged mental and physical exhaustion leads

to burnout. Burnout further causes physical risks such as low immunity, frequent headaches, and

change in appetite or sleeping habits, affecting work production. Emotionally, it leads to feelings

of failure, helplessness, loss of motivation, increasingly cynical and negative outlook, and

decreased satisfaction (Parola et al., 2017). When a physical and emotional change occurs, it can

affect workplace conduct. These changes associated with burnout result in include withdrawing

from responsibilities such as absenteeism, retention problems and reduced quality of services

(Lehto et al., 2020). These symptoms impact the hospice nurse’s mental and physical health,

leading to more medical errors, lower quality of patient care, and lower empathy.
21

Death anxiety is a common challenge in hospice care (Hussain, 2021). Nurses may feel

anxious and overwhelmed with the work stressors associated with death and dying. Additionally,

they may feel unprepared to communicate effectively with dying patients and their family

members. Death anxiety tends to affect their attitude towards their work, which may affect their

empathic concern, coping with job-related stressors such as patients’ death, and the quality of

care (Oliver et al., 2018).

Workload Causes of Stress in Healthcare Settings

The workload in the nursing occupation is high, which causes stress that is associated

with poor health (Diehl et al., 2021). Statistics indicate a shortage of skilled hospice care

workers, yet the number of older people in society is rising. Aside from that, patients with

dementia, cancer, multimorbid patients, and those with non-oncological diseases also need to

benefit from hospice care (Diehl et al., 2021). The lack of skilled hospice care nurses in health

organizations results in stress and strain for the few skilled because of the heavy workload. As a

result, fatigue causes high rates of burnout among nurses and the intent to leave their jobs (Diehl

et al., 2021). The workload can be qualitative (the type of aptitudes or effort required to complete

work responsibilities) or quantitative (the amount of work to be completed and the haste to

execute).

Additionally, the lack of resources in hospice care affects the workload among hospice

care nurses (Diehl et al., 2021). The resources can either be personal or social and each plays a

major role in dealing with the demands of hospice care. Personal resources are those owned by

the individual, such as personal qualifications and positive thinking (Diehl et al., 2021). An

individual that lacks the necessary work skills may experience a high workload because they do
22

not know what to do. Social resources comprise the employee’s relations, such as relationships at

work and in their private life.

Healthcare Employee Attitude Causes of Stress

The most significant factors affecting a successful delivery of palliative care to

chronically sick patients are the nurse’s attitudes and knowledge (Mukemo et al., 2017). It

determines their procedure and behavior during the evaluation and treatment of patients (Ayed et

al., 2015). Palliative physicians may feel unprepared and incompetent at work leading to work

stress. Experienced nurses with about 17-21 years on the job and those working daytime shifts

display better work attitudes than youthful nurses and unexperienced ones (Ayed et al., 2015).

Therefore, age, experience and work shift time affect nurses’ attitude which can contribute to

workplace stress.

A negative attitude can stem from work overload. It can lead to adverse effects like mood

disorders, burnout, and illness which are stressful. Research indicates that nursing is one of the

occupations with the highest workloads as compared to doctors, paramedics and even support

workers (Kokoroko & Sanda, 2019). These workloads directly and positively contribute to job

stress creating negative emotions and feelings. Nurses usually find it challenging and

emotionally taxing to deliver palliative care citing issues of incompetence (Ayed et al., 2015).

Such negative employee attitude can lead to poor quality services for healthcare organizations

and patients.

Hospice nurses who appear to experience chronic stressors are likely to develop

depression (Barnett et al., 2018). This situation affects employees’ attitudes contributing to job

stress. Unsupported and unrecognized nurses can destabilize other people’s work. If their

capabilities and talents are not entirely utilized or recognized, they tend to not feel like a part of
23

the team. Thus, they build negative energy toward their managers, colleagues, and the

organization.

Hospice care facilities that experience downturns are likely to make employees develop a

negative attitude. Work and family imbalances are negatively linked to job and family

satisfaction (Barnett et al., 2018). Therefore, insecure employees tend to be negative and it

reflects in their performance. It creates anxiety among them about their future, affecting their

services to patients. Aside from that, it causes stress making it difficult to perform their duties

and responsibilities appropriately.

Effects of Stress

Aside from understanding the causes of stress, it is critical to gather research on the

effects of stress on hospice nurses. This section identifies some of the documented effects of

stress on palliative care workers. They entail increased turnover and absenteeism, decreased

performance and productivity, physical effects, mental effects, social effects, effects on the

economy and employee burnout.

Absenteeism and Turnover in Healthcare Settings

Stress is a factor known to contribute to increased nurse turnovers and absenteeism

(Dewanto & Wardhani, 2018). Nursing is considered a strenuous job, and research indicates that

palliative care nurses are also susceptible to work stress (Kokoroko & Sanda, 2019). Their duties

and responsibilities revolve around continuous exposure to deaths and family grief. According to

a study on a hospice nursing interdisciplinary team (IDT), job stress was linked to burnout which

increased turnover rates (Schneider et al., 2022). Hence, the turnover rates were significantly

correlated with job stress.

24

The turnover intention defines the worker’s readiness or attempts to resign from their

workplace willingly. It is directly influenced by workplace relationship and job satisfaction

(Warden et al., 2020). Occupational stress is excessive pressure caused by an imbalance between

work demands, abilities, and knowledge. According to a study in the United Kingdom, out of

4000 workers, nurses were at the top three most stressful occupations (Warden et al., 2020). In

this study, stress was associated with intentions to leave the workplace because of job

dissatisfaction. Similarly, different studies in England and Australia showed that job stress in

palliative care led to disruptive workflow patterns (Warden et al., 2020). The busiest periods

were characterized by poor workloads and shift work management, staff shortages, absenteeism

and the relieving staff presenting extra demands.

High turnover rates among hospice nurses affect the efficiency of patient care, and most

hospitals worldwide continue to witness a sharp increase in turnover rates annually (Lockhart,

2020). About 18% of new nurses will switch occupations within the first year after graduation. In

the next two years, the turnover increases to a third. The average turnover rates are 19.1%, and

expected to increase (Lockhart, 2020). According to the National Healthcare Retention and RN

Staffing Report (2019, as cited in Lockhart, 2020), the average hospital turnover rate incurs a

financial loss of $4.4 million to $6.9 million annually to replace nurses. Nevertheless, the

turnover intention continually rises and changed from 17.5% to 20.2% in 2020, majorly

influenced by the COVID-19 pandemic (Rogers et al., 2021). These nurses cited strenuous jobs

increased their stress levels due to fear of exposure to the virus.

Decreased Performance and Productivity in the Healthcare Setting

Hospice nurses’ job performance and productivity are affected by stress. According to the

Yerkes-Dodson law (1908, as cited in Nickerson, 2021), performance rises with mental or
25

physiological arousal (stress) up to a certain point. Different tasks need varying levels of arousal

for optimal performance. This positive correlation maintains only if the stress levels are within a

bearable range. Higher stress levels result in a decline in job performance because it interferes

with the individual’s ability to work. It impairs their capacity to focus, manage time effectively,

and recall memory. Nurses typically experience excessively strenuous workplace responsibilities

that affects their physical and psychological well-being (De Simone et al., 2018). Such exposures

can reduce work motivation and the desire to perform well at work. Low morale towards work

decreases job performance, reducing the quality of care for the patients. In organizations, the

physical, social, and mental environment influence the worker’s efficiency and well-being (Saidi

et al., 2019). Job security and safety, physical working environment, relationship with co-

workers, support, supervisor support and working hours have a direct impact on employee

productivity. Excessive burdens without impedes worker their productivity. Such burdens

reduce their ability to execute tasks correctly, stay organized, practice effective time

management, focus, and recall.

Hospice nurses experiencing chronic stressors are likely to develop depressive symptoms

that correlate to decreased job performance and productivity (Barnett et al., 2018). Increased

burnout directly contributes to declining job performances. Physical exhaustions, mental breaks

and prolonged burnouts result in poor job performance. Nurses experiencing psychological

distress are also likely to develop compassion fatigue (Barnett & Ruiz, 2018). Patients who

perceive their nurses as disinterested, uncaring and highly irritable record negative health

outcomes. The patients can be triggered and have increased anxiety, fear and depression that

affect their health conditions.

26

Physical Effects of Stress

Stress poses a significant threat to the physical lives of hospice nurses. Fatigue is one of

the leading problems most nurses face during their duties and is mainly caused by a heavy

workload (Kokoroko & Sanda, 2019). Short-staffing, long shifts and difficult patients contribute

to the physical effects of stress. Excessive fatigue can cause headaches, muscle aches, high blood

pressure, sleep problems, dizziness, shaking, muscle tensions, and digestive problems. Nurses

who experience stress are at risk of getting burnouts. According to Salvagioni et al. (2017),

burnouts are associated with risks of sleep disorders, substance abuse, depression, obesity and

musculoskeletal pains.

Another physical effect of stress is the higher risk of abusing alcohol and drugs (De

Fatima Fernandes & da Silva Gherardi-Donato, 2017). Work stress can predispose these nurses

to abuse drugs as a coping mechanism. The abuse of drug substances destroys their physical

health, leading to a negative impact. Nurses who undergo stress are more likely to have poor

diets, smoke, and abuse alcohol and drugs (Jarrad et al., 2018). The traumatic experiences they

are exposed to increases their likelihoods of becoming irritable, exhausted, low moods and

unable to make decisions. Workplace stress predisposes these nurses to maladaptive coping

mechanisms such as substance abuse which compromises the patients’ quality care.

Mental Effects of Stress

The mental health status of most nurses is affected by work stress. Handling terminally ill

patients can be very strenuous. The prevalent mental effects are anxiety, depression, irritability,

sleep problems and drug abuse (Dębska et al., 2017). Palliative care nurses are vulnerable to

mental breakdown since their job revolves around caring for the elderly, death, and grief.

Witnessing deaths and briefing the patient’s family, especially when they were closely attached
27

to the patient, may cause trauma and depression and can decrease the personal and professional

growth and development of a nurse in charge. The National Institute for Occupational Safety and

Health (1984, as cited in Millar, 1990), outlines mental disorders among the ten foremost work-

related illnesses and has shown that almost 75% of nurses seek psychiatric consultation.

Consequently, a high demanding job such as hospice nursing can affects their mental status. The

job typically requires nurses who are well-trained and confident. Therefore, failure to be so can

cause palliative nurses to have low esteem for their work which can cause them to quit their jobs

(Barnett & Ruiz, 2018).

Social Effects of Stress

Stress also affects the palliative nurses’ social well-being. The work environment and

social relationships has a direct impact on hospice worker’s job satisfaction (Marmo, 2016).

Workplace stress can strain relationships with colleagues, superiors, spouses, children, friends,

and patients. Continuous exposure to high-levels of stress results in a retraction in social

behaviors such as hostility and irritability. Other characteristics are social withdrawal and

aggression (Sandi & Haller, 2015). Considering nursing is a highly stressful occupation,

prolonged stress can causes such behaviors to reflect in their social lives. Stress decreases

nurses’ morale to work, exercise, participate in social functions, keep hobbies and maintain

healthy relationships. It retrogresses their social life due to the high workload demand, burnout,

emotional toll, and frustrations. According to a study on the social effects of stress, higher stress

levels resulted in increased workplace-family imbalance (Marmo, 2016). Individuals unable to

cope with workplace stress presented a higher spousal conflict, child negligence, poor decision-

making, and social isolation.

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Effects of Stress on the Economy

Stress is a factor that reduces the productivity of many organizations (Siegrist et al.,

2016). Palliative care is a major revenue earner for the economy. Most nurses face economic

stress when they cannot work at health facilities due to limited job vacancies and poor working

conditions. The World Health Organization (WHO) branded stress as a 21st Century health

plague (Brulé & Morgan, 2018). This stress accounts for an approximate $300 billion loss

annually on American businesses. This economic stress, in turn, leads to a strain on most public

health facilities (Brulé & Morgan, 2018). These strains include delayed medical workers’

salaries, increased medical services, and lack of medical equipment for patients, disrupting the

workflow. When hospice nurses experience stress, it affects their job performance and

productivity. This effect is tied to the organization's economic expectations since reduced

performance can result in low returns and lawsuits for cases of poor quality of care. When

negative reviews tarnish the organization’s image, it will attract fewer clients and more

turnovers. Stress effects can contribute to financial challenges for the organization and the

nurses. High voluntary nursing turnovers usually contributes to dysfunctional systems in the

organizations leading to high costs of operation and workload demands on the nurses on duty

(De Simone et al., 2018). Consequently, when the organization experiences financial constraints,

it may result in pay cuts, payment delays and the need to short-staff, which further frustrates the

staff. This problem creates a cyclic effect as frustrated nurses have lower performance, reducing

the quality of care and economic returns. These problems can cause many sponsors, donors and

investors to retract their contributions, leading to economic decline.

Employee Burnout
29

Hospice nurses also face burnout, a chief characteristic of occupational stress. The

concept of burnout was first introduced by Herbert Freudenberg in the 1970s (Parola et al.,

2017). Burnout involves signs of fatigue and distant attitudes towards work (Waddill-Goad,

2019). It is also described as the delayed response to chronic stressful conditions in the office

that affects nurses who do not have enough emotional energy to manage and communicate with

diverse patients (Dyrbye et al., 2020). In palliative care, an unequal association between the

number of nurses and workload is the most significant feature influencing burnout. The intensity

of palliative care increases annually since the number of elderly patients in hospitals is rising. As

a result, it increases the work burden on nurses, inclining them to adverse health consequences,

and is likely to impact their performance and the quality of care. Due to this, it affects the work

performance and affects the efficiency of the hospice nurses in caring for elderly patients.

Burnout in most nurses is characterized by emotional changes, physical changes and

exhaustion (Diehl et al, 2021). Nurses will dread going to work, arrive late, take longer breaks or

not show up. Lack of morale is another effect of burnout. Most hospice nurses who are exhausted

lack motivation to work, reducing their energy levels (Lehto et al., 2020). Frequent physical

illness among these health workers, such as headaches, muscle aches, and high blood pressure, is

another effect of burnout. They may also display impaired memory, reduced attention, and

irritability (Lehto et al., 2020)

Interventions for Workplace Stress Management

The third vital theme following the causes and effects of stress in hospice nursing is

interventions. Stress management interventions are activities used by organizations to reduce

stress among employees and enhance their well-being (DeFrank & Cooper, 1987). This section

discusses documented interventions divided into focus and level. The focus entails primary,
30

secondary and tertiary interventions. The level describes the individual and organization level

stress management interventions. This section further explains the focus of this proposed study

which is the perceived efficacy of support groups as secondary-level organization interventions

to mitigate stress levels for hospice nurses.

The Focus of Stress Management

Holman et al. (2018) highlight that stress management literature generally classifies

interventions according to the focus of the stress management and the level at which the

intervention occurs. This perception has been supported by previous literature on the topic,

including articles written by De Jonge and Dollard (2002) and DeFrank and Cooper (1987).

Regarding the focus of stress management, interventions are classified into primary, secondary,

and tertiary. Primary interventions aim at preventing stress from occurring. These interventions

occur by eliminating sources of stress in an individual and improving the causes of their well-

being. On the other hand, secondary interventions focus on reducing the duration or severity of

stress once it has occurred. Finally, tertiary-level interventions aim to help employees

experiencing chronic or high-stress levels that may be impairing their abilities to work. An

example is the Employee Assistance Program (EAP) which provides guidance and counseling to

workers experiencing mental health issues and high-stress levels (Holman et al., 2018)

The Levels of Interventions

In respect of the level of interventions, a simple and common difference is between

organizational and individual levels (Holman et al., 2018). Individual-level interventions aim at

helping workers develop skills to reduce, cope with, and manage stress. On the other hand,

organizational-level interventions make more systemic alterations to organizational practices that

31

target specific employees or all employees in the company. A third type, individual-

organizational level interventions, is applied in some organizations. These interventions are

perceived to be different from others in that they aim to change the relationship between

employees and the organization, such as peer support groups. Nonetheless, some studies have

parsimoniously used organizational-level and individual-level interventions to refer to the same

interventions (Holman et al.,2018).

Primary Individual-Level Interventions. To understand the relevance of these

interventions, it is crucial to provide an in-depth overview of what they entail. Primary

individual-level interventions aim to prevent stress (Velana & Rinkenauer, 2021). These

interventions can be attained through selection and assessment procedures, which select

applicants who possess abilities and skills to manage job demands and those who might be prone

to exhibiting stress in a target role, especially in highly stressful positions such as the nurses.

However, while these interventions are a significant way of managing stress and promoting the

nurses’ well-being, they are rarely applied (Holman et al., 2018).

Secondary-Individual Level Interventions. There is stronger scientific evidence on the

effectiveness of applying secondary-individual level stress management intervention

(Alkhawaldeh et al., 2020). However, these interventions are not differentiable to primary-

individual level interventions and are often applied interchangeably. Like primary individual

level, secondary-individual level focus on equipping the individuals with abilities and skills to

manage stress and allow them to take part in activities that help reduce stress (Alkhawaldeh et

al., 2020). These techniques include meditation, relaxation, cognitive behavioral therapy,

interpersonal skill development, exercise programs, and mindfulness training.

32

Relaxation intervention techniques are founded on the assumption that states of stress and

relaxation are antithetical (Veiga et al., 2019). This concept perceives that an individual cannot

be relaxed and stressed at the same time. Thus, increasing levels of relaxation reduce stress

levels. There are various methods of inducing relaxation, including progressive muscle

relaxation and meditation. Cognitive-behavioral therapies (CBT) suggest that maladaptive

cognitions lead to psychological distress and problematic behavioral responses to stressful

incidents (Tsang et al., 2015). CBT enables hospice nurses to identify misconceptions about

stress's causes and nature and create new conceptions about stress. Moreover, CBT encourages

people to develop new behavioral responses to stress. Mindfulness training is a popular stress

management intervention applicable in hospice nursing that focuses on promoting states of

mindfulness (paying attention to thoughts, emotions, and experiences occurring in a person in a

compassionate, non-judgmental, non-reactive, and accepting way) and new adaptive responses to

negative emotions and thoughts (Evans et al., 2017). Studies have shown that this technique,

when implemented in palliative nurses, improves psychological well-being (Evans et al., 2017).

Mindfulness therapies entail acceptance and commitment therapy and mindfulness-based

cognitive therapy (MBCT). Some individual-level interventions are multimodal, for instance, a

combination of mindfulness exercises, CBT, and relaxation (Holman et al., 2018). Such a

combination of techniques can be used with the hope that it would increase the beneficial

outcomes of both the organization and the individual.

Drawing on the literature on emotion regulation (Scheibe & Zacher, 2013), these

interventions can be comprehended as enhancing antecedent-focused emotion regulation

techniques which seek to remove or reduce the causes of stress. There are other secondary-level

interventions, such as educational programs on stress management and health promotion

33

initiatives (Scheibe & Zacher, 2013). These educational programs increase employee awareness

of how stress can be managed. On the other hand, health promotion strategies focus on

improving employees’ well-being by emphasizing the importance of adopting healthier lifestyles

(Brulé & Morgan, 2018). Furthermore, personal skill development training in goal setting,

communication, and time management also helps reduce stress by preventing the occurrence of

stressful situations in the work environment, such as work conflicts and high workloads.

Primary Organizational-Level Interventions. Primary organizational-level stress

management interventions focus on removing causes of stress in the institution by changing

organizational policies and practices such as occupational health and safety, working time, and

leadership (Roozeboom et al., 2020). Some of these interventions include job-redesign

interventions, which aim to modify job characteristics like ergonomic design, workload, and job

discretion. Regarding job redesign, some interventions aim to change one job characteristic, like

job discretion. In contrast, others aim to change multiple characteristics with the hope that it

would produce large outcomes for employee well-being (Roozeboom et al., 2020).

Secondary Organizational-Level Interventions. Secondary organizational-level

interventions focus on establishing organizational-wide alterations that help workers cope better

with stressful situations (Murphy, 2003). They include the introduction of peer support groups

and communication skills training courses. Peer support groups is also an individual level

intervention which help workers discuss their challenges in the workplace, while communication

skills training courses help them improve their abilities to manage stressful incidents such as

conflict resolution (Holman et al., 2018). It is crucial to note that implementing secondary

organizational-level interventions is challenging and complex. Thus, the most significant part of
34

any secondary organizational-level intervention is the effectiveness of the implementation

process (Holman et al., 2018).

In addition, there are four key activities required for the successful implementation of

secondary organizational-level interventions: preparation, screening, action planning, and

implementation (Holman et al., 2018). Preparation entails securing support, screening involves

identifying the psychosocial risks, actional planning entails coming up with change initiatives,

and implementation involves embedding these change initiatives within the institution.

Furthermore, employee participation is also key to the success of an intervention. Employee

participation can help improve the quality of the initiatives by drawing on workers’ expertise to

make the changes contextually appropriate, as workers have a higher sense of ownership of the

initiatives (Holman et al., 2018).

Organizations can mitigate stress via preventive strategies designed to teach and orient

new employees to available support resources and build support into daily practice (Huggard &

Nichols, 2011). These preventive approaches build a culture of support in the organization,

critical in stress management. Research on the topic has shown the following techniques to

improve emotional support among nurses: creating and maintaining a supportive

interdisciplinary team, team-designated rituals such as memorial services, mentoring from more

experienced professionals, weekly interdisciplinary team meetings, and debriefing when required

or requested (Huggard & Nichols, 2011). In addition, these techniques entail the utilization of

off-site staff retreats that focus on the effectiveness of cultivating team support, developing and

sustaining coping techniques, managing losses to foster emotional support and staff

sustainability, and staff well-being (Hospice Friendly Hospitals Programme, 2013). These
35

organizational interventions provide opportunities for improving connection and support among

end-of-life caregivers.

According to a qualitative study conducted in 2016, little contemporary evidence exists

concerning the stress coping mechanisms in palliative care (Lowe et al., 2016). The study

revealed that these nurses use a combination of strategies to internally and externally cope with

stress, none of which were specific to secondary organization-level interventions. Much of the

research at in the last eight years revolved around understanding the causes of stress in hospice

care (Lowe et al., 2016). The study recommended organizational support and support groups

from family, friends and colleagues to mitigate the effects of stress. Another integrative review

conducted in 2021 revealed that palliative nurses practiced self-prompted coping mechanism

such as self-care based-coping, self-transformation, and proactive coping to stimulate self-

confidence (Sapeta et al., 2022). There was little organization involvement in stress

interventions.

Similarly, another article published in the Nursing Times England, indicated a significant

gap in organization involvement in stress interventions for hospice nurses (Cedar & Walker

2020). The National Health Service (NHS) workplace stress and staffing well-being committee

reported concerning results on stress management programs in organizations. They reported that,

despite 97% of the Foundation Trust Network members claiming to have systems in place to

cope with stress, only 32% of NHS staff who responded to the employee attitude survey said

they were engaged in the workplace stress management (Cedar & Walker 2020). Instead, the

prevalent coping strategies utilized were individual measures such as exercise, mindful training,

hobbies and meditation. While research provides significant proof of support group as a

beneficial stress intervention level in stress management, they are rarely used in hospice care at
36

the organizational level as illustrated in previous research studies (Cedar & Walker 2020).

Therefore, more research is needed to gain a deeper understanding of the effectiveness of support

groups as secondary organizational-level interventions for stress management among hospice

nurses.

Biblical Foundation of the Study

According to Ross (2020), stress is a form of suffering since it paralyzes and prevents

decision making. According to Christian teachings obtained from Genesis chapter three, about

creation, sin entered the world when Adam and Eve defied God by eating from the forbidden

tree. God commanded them, “You must not eat fruit from the tree in the middle of the garden,

and you must not touch it, or you will die” (New International Version Bible, 1978/2011,

Genesis 3:3). However, the serpent convinced Eve to eat from the tree, and she, in turn, gave

Adam the fruit. The consequence of these actions is directly associated with the existence of sin

since they broke God’s command. This defiance bore fruit in the life-long trail of sin, which

often manifests in human suffering. Although God provided eternal redemption through the

sacrifice of His son Jesus Christ, man will continue to suffer until the end of the earth (Ross,

2020). Suffering is part of human life, but it is not necessarily bad (Krause & Pargament, 2018).

It is universal and can serve a divine purpose. The Bible illustrates key reasons for suffering.

People suffer because of the fallen world (Ross, 2020). The wicked and righteous face

immense challenges as the world is no longer what God initially designed it to be (New

International Version Bible, 1978/2011, Philippians 2:25-28). And the root cause, as mentioned,
37

is sin. God is good and holy and demands his creation strive for such. He punishes those who

stray from his words, such as Sodom and Gomorra (Ross, 2020). When Adam and Eve defied

God, it marked the beginning of generational human suffering. Due to this punishment, stress

came into existence since God intended the hardness of life to drive humankind back to

dependency upon him.

Causes of Stress from a Biblical Perspective

The Bible is a significant source of information in Christian literature and can be useful

in understanding the causes of stress. While it does not specifically mention stress, it describes it

through human suffering, such as pain, anxiety, illness and illustrates how to deal with these

issues (Krause & Pargament, 2018). The Bible illustrates various scenarios that cause stress. One

of the main causes of stress is events. An example of this was the Israelites' journey to the

Promised Land under the guidance of Moses. While the journey of wandering through the desert

was no easy task, God had promised the Israelites abundance in food, water and resources,

freedom and leadership under his divine command. However, the Israelites did not keep the faith

as God expected. Instead, they rejected the numerous evidence of God’s power. According to the

Bible, all the spies except Joshua and Caleb sent to conduct the surveillance in Canaan came

back with negative news. Numbers 13:32 states,

So they brought to the people of Israel a bad report of the land that they had spied out,

saying, “The land, through which we have gone to spy it out, is a land that devours its

inhabitants, and all the people that we saw in it are of great height.” (English Standard

Bible, 2001/2016)

These reports caused the Israelites to complain, reject and threaten to stone Joshua and

Caleb for trying to support God. In turn, God was enraged, and instead of the Israelites entering
38

the Promised Land immediately, they lost that privilege and spent 40 years wandering in the

desert. All the individuals above 20 years apart from Joshua and Caleb who rejected God would

perish in the wilderness and not step into Canaan (English Standard Bible, 2001/2016, Numbers

13:36).

Another cause of sin is tests and temptations. Satan claimed that Job was only loyal to

God because he was blessed and asked God to allow him to test Job. With God’s permission,

Satan proceeded to afflict Job by taking his wealth, children and health. Instead of denouncing

God, Job kept his faith throughout the suffering (English Standard Bible, 2001/2016, Job 1-16).

Similarly, Jesus, during his 40 days of fasting and praying in the desert, was tempted by Satan,

but his faith did not waiver amidst his hunger and thirst (English Standard Bible, 2001/2016,

Mathew 4:1-11).

Other causes of stress result from people who pose a threat to others. When the Israelites

were going to war during the reign of King Saul, amid the war, Goliath was gigantic which made

other soldiers feel inferior and scared. And when he demanded a single solder to fight, Saul and

his army were afraid. 1 Samuel 17:11 states, “On hearing the Philistine’s words, Saul and all the

Israelites were dismayed and terrified” (New International Version Bible, 1978/2011).

Another cause of sin is thoughts. Mark 7:21 states, “For from within, out of the heart of

men, proceed evil thoughts, adulteries, fornications, murders, thefts, covetousness, wickedness,

deceit, lasciviousness, an evil eye, blasphemy, pride, foolishness. All these evil things come from

within, and defile the man” (New International Version Bible, 1978/2011).

Just as research demonstrates multiple causes of stress among healthcare workers and

hospice nurses, the Bible provides information that shows the causes of stress. They are events,

tests and temptations, and people who pose as threats and thoughts.
39

Biblical View on the Effects of Stress

Understanding the causes of stress is pivotal in revealing its effects. After looking

through the causes of stress, it is apparent that it is a natural part of life (New International

Version Bible, 1978/2011, 1 Peter 4:12). Stress affects the well-being of Christians by altering

several aspects of their lives. The Bible shows that stress affects an individual's spiritual,

physical, and emotional aspects. King David lived in fear and went into hiding when he had King

Saul plotted to kill him (New International Version Bible, 1978/2011, 1 Samuel 19). Social

isolation and detachment from normal daily routines, relationships, and responsibilities are

physical and emotional effects of stress. David portrayed this effect when he fled his town and

people to live in a cave out of fear and worry. During his time in isolation, he lacked enough

food, water, shelter, and his family's comfort.

Another effect of stress is depression and anxiety. Peter stated he would never deny

Jesus, “Even if all fall away, I will not” and “Even if I have to die with you, I will never disown

you” (New International Version Bible, 1978/2011, Mark 14:26-31,). However, Jesus' prediction

came to pass, and when Peter realized how he betrayed Jesus, he broke down and wept. This

realization brought him great anguish, pain and depression.

Moreover, stress can result in a decline in physical health. Lot’s wife lost her life when

she looked back at the destruction of Sodom and Gomorra. Her physical body was transformed

into a pillar of salt (New International Version Bible, 1978/2011, Genesis 19:26). This

consequence was perhaps a direct impact of her disobedience. Alternatively, she could not let go

of her whole life, and she looked back in her distress (foolishly and longingly) of losing her

beloved city.
40

Stress can also result in low morale, disobedience, and attracting God’s wrath. The

Israelites turned to worship false gods when moving through the wilderness. When Moses

received God’s commandments at Mount Sinai, Aaron, his brother, was left to tend to the

Israelites. The Israelites grew impatient in Moses’ absence, and Aaron succumbed to this

pressure. They built a golden calf which they worshipped. When Moses returned, he was enraged

with that apostasy and broke the ten commandment tablets. He also ordered the death of 3000

males (English Standard Version Bible, 2001/2016, Exodus 32:6; 34:2). Much like the Israelites,

Christians today sometimes lose faith in God. Many people stop praying, going to church, or

engaging in church activities because of their challenges. Others will turn to another non-

Christian religion and negatively view God. In the absence of God’s divine love, support, and

fellowship with others, Christians are likely to experience the effects of stress, which can

negatively influence their overall well-being (Krause & Pargament, 2018). The Bible reflects the

mental, social, and physical effects of stress, supporting similar information obtained from other

research.

Biblical Interventions for Managing Stress

Analyzing the causes and effects of stress allows the development of effective stress

management interventions. Organizations can implement biblical teachings in stress

interventions that practice encouraging, serving and carrying one another's burdens. When

people are faced with stress, the Bible suggests focusing on God and finding comfort in their

sorrows and strength to endure (English Standard Version Bible, 2001/2016, 1 Corinthians 1:3-

4). Therefore, one secondary-level organization intervention to cope with stress encourages

workers to seek God’s help through prayer and worship. Job is a character who used this
41

intervention in his time of stress. When he was overwhelmed with stress, the Bible describes

that,

Job got up and tore his robe and shaved his head. Then he fell to the ground in worship

and said, “Naked I come from my mother’s womb, and naked I will depart. The Lord

gave, and the Lord has taken away; may the name of the Lord be praised.” (New

International Version Bible, 1978/2011, Job 1:20-21).

On another note, an individual’s spiritual or religious calling helps hospice nurses to find

meaning in death; this is an effective coping response linked to the positive emotional quality of

life (Collier, 2019). Therefore, organizations that do not undermine the nurses’ spiritual beliefs

have better stress management outcomes.

The second book of Timothy is an encouragement to faithful workers (Wiersbe, 2009).

At the same time, it calls attention to what responsibilities an organization has towards its

workers. Employees are not only expected to do their best at work but consider what kind of

legacy they want to leave behind. Organizations must remind their workers to be diligent in their

duties, be humble when learning from others and be compassionate enough to teach others. Paul,

the apostle, wrote to Timothy to join him in suffering for the gospel. He further directs him to

pass on all he learned from past generations to future generations by saying,

Hold to the standard of sound teaching that you have heard from me, and You have

observed my teaching, my conduct, my aim in life, my faith, my patience, my love, my

steadfastness, my persecutions, therefore learn from this and hold those before you

accountable. (New International Version Bible, 1978/2011, 2 Tim. 1:13, 3:10)

Consequently, the organization must serve their workers by ensuring that the workplace

operates in a socially and environmentally friendly way. They are expected to respond to their
42

worker’s well-being by setting up stress interventions that can mitigate workplace stress. The

Bible has several verses that task employers to manage their workers fairly and decently.

Colossian 4:1state, “Masters, treat your slaves justly and fairly, knowing that you also have a

Master in heaven” (English Standard Version Bible, 2001/2016). Similarly, Deuteronomy 24:14

states,

You shall not oppress a hired servant who is poor and needy, whether he is one of your

brothers or one of the sojourners in your land within your towns. You shall give him his

wages on the same day, before the sun sets (for he is poor and counts on it), lest he cries

against you to the Lord, and you be guilty of sin. (English Standard Version Bible,

2001/2016)

In addition, Christians need to help in carrying burdens for others. Galatians 6:2 states,

“Carry each other’s burdens, and in this way, you will fulfill the law of Christ” (New

International Version Bible, 1978/2011). Organizations in tune with this belief understand that

their staff are prone to suffering and set up measures to help them cope. Some interventions that

apply this involve regular counselling and addressing feedback reports. Hospice nurses need to

know that the management listens to them and acts on their challenges (Weber et al., 2018). The

organization is responsible for creating a conducive working environment through good

leadership and systems that keep the nurses motivated to work in God’s glory. The Bible verses

in Proverbs 11:25 and Luke 6:38 assert that generosity, caring and helping others are beneficial

to both the receiver and giver (New International Version Bible, 1978/2011). In this case, the

organization acts as the giver. Setting up effective secondary-level interventions will reduce

stress levels for the workers and improve productivity and job satisfaction (Holman et al., 2018).

According to Barnett (et al., 2018), group support can provide emotional support under the
43

organizational-level intervention group. The majority of nurses depend on team emotional

support to process their stress, creating a need for emotional support training. Organizations can

give to their employees by implementing programs designed to teach and orient new employees

to available support resources and building support into daily practice.

Summary

Stress is a mental tension caused by demanding or burdensome circumstances

(Mackinless, 2020). Stress has positive and negative effects depending on the magnitude and

ability to cope. The Yerkes-Dodson law (1908, as cited in Nickerson, 2021), states that

performance increases with mental or physiological arousal (stress). This positive correlation

maintains only if the stress levels are within a bearable range. Higher stress levels result in a

decline in job performance. As a result, excess stress can negatively affect individuals. This

chapter provided an in-depth exploration of the research strategy employed, themes in current

literature, and biblical integration concerning stress in hospice nursing. The literature review

themes included causes and effects of and interventions for this workplace stress.

The causes of stress identified in hospice nursing care entail poor working conditions,

changing environments, lack of support and training, physical and mental risks, workload, and

healthcare employee attitudes. These factors revolve around the work environment. All these

causes were linked to the effects discussed, such as increased turnover and absenteeism,

decreased performance and productivity, physical effects, mental effects, social effects, effects

on the economy and employee burnout. The information on the causes and effects was

instrumental in identifying the stress interventions.

44

The interventions on stress management were categorized based on the focus and level

(Holman et al., 2018). This perception has been supported by previous literature on the topic,

including articles written by De Jonge and Dollard (2002) and DeFrank and Cooper (1987).

Regarding the focus of stress management, interventions are classified into primary, secondary,

and tertiary. In respect of the level of interventions, a simple and common difference is between

an organization and individual levels.

The focus of this proposed study will target support groups as a secondary-level

organization intervention. They entail creating and maintaining a supportive interdisciplinary

team, team-designated rituals such as memorial services, mentoring from more experienced

professionals, weekly interdisciplinary team meetings, and debriefing when required or requested

(Holman et al., 2018).

A biblical integration section was provided to link stress causes, effects and interventions

to Christian teaching. The Bible provides significant evidence on the causes of stress through

events, tests and temptations, people who pose as threats and thoughts. As exemplified in the

Bible verse Mark 7:21,

For from within, out of the heart of men, proceed evil thoughts, adulteries, fornications,

murders, thefts, covetousness, wickedness, deceit, lasciviousness, an evil eye, blasphemy,

pride, foolishness. All these evil things come from within, and defile the man. (New

International Version Bible, 1978/2011)

The effect is further highlighted in the physical, emotional and social effects of the bible

character of Moses, David and Lot’s wife. The Bible further provided information on stress

management that organizations can adopt in-line with intervention measures. They include

support, service and encouragement.

45

This literature review chapter laid the psychological and Biblical foundation for this

proposed research study, identifying what is known and exposing the gap in the current

literature. Research demonstrates multiple causes and effects of stress among hospice workers

and varying focuses and levels of interventions. However, most current research indicates that

hospice nurses practice individual-stress coping mechanisms with little involvement from the

organizations. While research indicates significant benefits of secondary organization-level

interventions, they are not commonly applied in hospice care. This gap justifies the need for the

current proposed study, which aims to determine the perceived efficacy of support groups as

secondary organization-level interventions for dealing with stress in hospice nursing. Now that a

strong foundation and justification for the proposed study have been made, the next chapter will

shift focus to the study’s design and methodology. This information provides the baseline for

formulating the research methods in the next chapter.

Overview

This chapter explains the methodological approach that will be used to execute this

proposal. This section will discuss the detailed procedure the researcher will employ for this

qualitative case study on the perceived efficacy of support groups as a stress intervention

measure for hospice nurses. It contains the research questions that will guide the study, research

design, method of data collection, instrumentation and measurement, data analysis and

methodological issues, and how to mitigate them. It will enable future researchers to evaluate the

reliability and validity of this research proposal. 

Research Questions
46

RQ1: How do hospice nurses respond to support groups as an organizational intervention

measure to deal with workplace stress?

RQ 2: Why should organizations use support groups as a secondary-level intervention

measure to mitigate the effects of workplace stress in palliative care?

RQ 3: How can organizations implement support groups as a stress-coping strategy for

hospice nurses?

Research Design

This proposed research utilizes a qualitative methodology with a case study design. It is

selected for compelling reasons. This methodology generally enables researchers to perform an

in-depth study on intricate issues within a specific context (Rashid et al., 2019). It entails five

significant components of research questions, the purpose of the study, unit analysis, data links

to propositions, and data interpretation criteria which will be implemented in this study. In this

proposal, the phenomenon under study is the perceived efficacy of social support groups as an

intervention measure for stress for hospice nurses.   

           Specifically, a qualitative research design is applicable in studies whose nature entails

exploration (Power, 2002). The research questions often start with "how," "what," or "why" to

solicit information that can facilitate an in-depth understanding of the research topic. The

research questions for this study use this format as stated: (RQ1) how do hospice nurses respond

to support groups as an organizational intervention measure to deal with workplace stress?; (RQ

2) why should organizations use support groups as secondary-level intervention measures to

mitigate the effects of workplace stress in palliative care?; (RQ 3) how can organizations

implement support groups as a stress coping strategy for hospice nurses? Therefore, the research

questions meet the described criteria.

47

           Third, a qualitative approach is ideal when exploring aspects such as thoughts and

feelings that are difficult to explain using traditional research methods (Esterberg, 2002). As

stated, this proposal aims to understand the perceived efficacy, which is not measurable using

quantitative methods. Moreover, it is best suited when investigating phenomena in their natural

setting and when aiming to address social issues in their context. The current proposal focuses on

how nurses perceive social support groups as a coping mechanism in the workplace for stress

management.

Lastly, qualitative research enforces active participation from the researcher. In this

proposal, the researcher is the critical data collector and analyst. It is a case study since intends to

capture a range of perspectives instead of an individual's single view (Baxter & Jack, 2008). This

approach creates a greater understanding of the subject and reduces the chances of bias by

diluting any individual's agenda. Cases are tied by time and activity; researchers need to collect

information using efficient data collection procedures within a specified time frame (Baxter &

Jack, 2008).

A qualitative approach is founded on the need to understand social events in context and

studying their meaning for people who are involved (Esterberg, 2002). It is interpretative and

naturalistic and can help learn what meaning people give to social constructs. Support groups are

essential in minimizing caregiver burden (Rodakowski et al., 2012; del-Pino-Casado et al., 2018,

as cited in Benson et al., 2019) and improving caregiver health. (Sarason et al., 1983, as cited in

Benson et al., 2019). Therefore, qualitative study is the best approach to foster a greater

understanding of what hospice nurses experience in their daily undertakings, factors that cause

stress, the effects, interventions, and the possibility of support groups as effective interventions.
48

Furthermore, it could be instrumental in informing future research on social sciences, notably

support groups.

Participants

The sample selection criteria for this proposal will be purposeful selection. According to

Palinkas et al. (2015), purposeful sampling is a technique used to identify and select information-

rich cases particularly when the resources are limited. It is also referred to as judgmental

sampling, as the participants are purposefully selected based on the researcher's judgment. This

type of sampling will ensure the participants are the best suited to provide helpful information to

achieve this study's objective. It is also ideal when the study needs access to a specific population

with similar characteristics. It can work with small sample sizes. This proposal focuses on

hospice nurses and workplace stress. This specific study will implement a uniform protocol. It

will use homogenous sampling, a tactic that selects focus group participants to reduce variation

(Palinkas et al., 2015). One way to obtain this sample is to consider hospice worker experience,

specifically, two years or more in the job. The participants must also undergo a screening process

where they answer three questions. The first confirms their length of employment as at least two

years. The second question is understanding the concepts of workplace stress and social support

groups. The third question is on the willingness and ability to participate. The researcher will

also identify themselves and explain using the recruitment document the title of the research,

research purpose, researcher and education institution, time/commitment required, location, and

any risks (A copy of the Recruitment Document is included in Appendix A).

Twelve participants will be used in this case study. According to Dworkin (2012), many

books, book chapters, and articles recommend that participants between 5 and 50 are adequate

for qualitative research. The study mentions that some of the most important factors are the
49

scope of the data, the quality of the data, and the amount of useful information gathered from

each participant. Furthermore, another study recommended twelve participants as the ideal

number to attain data saturation (Vasileiou et al., 2018). Hence, selecting twelve participants will

be appropriate because the small sample size will enable the researcher to focus easily on the

scope of the study in order to collect only relevant information. However, if the researcher is

unable to obtain the desired number of participants, the minimum number (five participants) will

be sought. These participants will be located at one hospice facility, a large organization

providing care to thousands of people. The researcher will need to present a conditional

Institutional Review Board (IRB) approval from the University to the facility of choice. VITAS

healthcare company will be the preferred organization because it employs 11,000 professionals,

has more than 18,000 patients, and its headquarters are located in Miami, Florida.

Study Procedures

The proposed research will be conducted by following specific procedures. The first step

will be to obtain permission from the agency to conduct the intended research as required by the

IRB (A copy of the Permission to Recruit Letter is included in Appendix B). The research

organization will also receive a permission response letter to email to the researcher to confirm

approval (A copy of Permission Response Letter is included in Appendix C). Once permission to

recruit is granted, the recruitment process will begin. The researcher plans to recruit by

physically distributing flyers at the research site and will also request for the flyers to be posted

in prominent areas such as the cafeteria and lounges for a period of five days or phone as

directed in the recruitment document within five days. In the event the recruiter is unable to

obtain the minimum of five participants within five days, the recruiter will increase the number

of days to allow more time to recruit participants. The alternative plan will involve using
50

personal networks such as social media platforms to obtain the remaining participants. Once

participants have been recruited, the informed consent document will be distributed one week

before interviewing (A copy of Informed Consent is included in Appendix D). The researcher

will inform them on the specific day the consent forms will be delivered through email. They

will receive them from the receptions desk and deposited in a drop box in the same location once

signed. They will need to return the document to the reception’s desk within 48 hours so that the

researcher can collect them. After informed consent is obtained, interviews will be scheduled for

every individual via email. The participant will be allowed to choose which day and time will

most suit their interview within the provided schedule of 21 days. No more than one interview

will be conducted per day or same time. The researcher will schedule every appointment before

making any visit. Each interview will last approximately 30 minutes. Anyone who needs to

reschedule their interview must contact the researcher using the details provided in the consent

form as soon as possible and set a new appointment within the 21-day range. The interview

responses will be recorded via a voice recorder and saved in individual folders on the recorder

and computer storage. The data in every folder will be protected from unauthorized access using

a single password. It will also be saved in a password protected computer hard disk and internet

cloud drive for backup to prevent data loss.

Instrumentation and Measurement

Every research must utilize carefully selected and appropriate instrumentation and

measurement tools for the study. Interviewing is one data collection measure commonly used in

qualitative studies. Interviews are conversations between the interviewer and interviewee,

conducted by asking questions and receiving answers (Esterberg, 2002).

Interviews
51

The researcher must establish good rapport and trust with the interviewees during the

interviewing process (Esterberg, 2002). For this case study, the researcher must exhibit active

listening and non-judgmental behavior during the interviews. They will first create a conducive

interviewing atmosphere by re-introducing themselves and the purpose of the study while

maintaining friendly body language and dressing appropriately. Furthermore, the researcher will

remind them how the data will be protected and how it will be used to enhance the research. The

interviewer will also ask if the interviewee needs clarification on anything before proceeding to

the interview questions. All interviews will be arranged to meet the participant's schedule and

location of choice within the facility. The participant will need to state when they can be reached

within the provided time-frame. After signing the consent form, every participant will select a

day from the 21 days that will be provided and set preferred time of convenience so that the

researcher can schedule them for a meeting.

This research will employ semi-structured interview questions to solicit information from

the participants. The open-ended questions will encourage participants to be as open as possible

and respond freely to queries. All interviews will be conducted face to face and last

approximately 15 to 25 minutes per individual. The interview questions for this case study will

target six areas: (1) behavior/experience, (2) opinion/belief, (3) feeling, (4) sensory, (5)

knowledge/understanding, and (6) background/demographic. Case studies typically answer the

questions of why and how with the intent to explore, explain, expand, and understand (Schoch,

2020). These six areas for the interview questions will target every general and specific aspect

that can provide information relevant to the research case. Furthermore, the different categories

of social support inspired these six areas. Emotional support involves expressions pervaded with

caring, empathy, sympathy, and concern (Cutrona & Suhr, 1992, as cited in Benson et al., 2019).
52

Appraisal support entails statements that are meant to promote another person’s skills or intrinsic

value. It is also known as esteem support and often assumes the form of validation or

compliments. Companionship support entails messages that convey friendship, solidarity,

togetherness, and inclusion. It is also known as social network support. Informational support

involves sharing facts, information, knowledge, tips, suggestions, and advice. Therefore, these

different support groups helped to define the six categories for the interview questions. This

information must be substantial enough to analyze and make meaningful deductions. It is

important for the reader to gain a mental image of how and why the interviewee is involved in

the proposed research. (A copy of Interview Questions is included in Appendix E). 

The interview responses will be recorded on paper through writing and, with the

participant's permission, on an audio device. The device will have an internal and external

microphone to limit obstructions and ensure audibility and accuracy. This step is part of

confirming that the responses are credible and accurate. Each interview audio will be saved in

the recorder's folder and transferred to a computer. The data in every folder will be protected

from unauthorized access using a single password. It will also be saved in a password protected

computer hard disk and internet cloud drive for backup to prevent data loss. The cloud data will

require authentication and identity protocols when attempting to access.

Data Analysis

This research study will implement the Creswell data analysis and coding steps for

qualitative study. It will use open coding, which focuses on the data collected to identify

common themes and interesting categories (Esterberg, 2002). Creswell (2005) recommends six

linear steps for the data analysis. However, he states that this process is not simply a linear static

analysis procedure but a recursive interactive practice.

53

The first step is data organization and presentation. It will be organized manually through

categorical aggregation (Creswell, 2005). The reviewed audio tapes will be transcribed into a

word-processor document. The second step entails reading through the data. The second step

involves reading through the transcribed data to better understand the flow of information

(Creswell, 2005). This step aligns with Esterberg's (2002) recommendation for this step as a

tactic to familiarize the data. 

The third step is detailed analysis through the coding process. This step signals the start

of the coding process. Each transcribed interview text data will be organized into segments and

classified into specific categories (Creswell, 2005). The categories will be identified with unique

terms based on interview responses. The fourth step involves generating a description of the

people or settings and categories to identify them with. This process will lead to the formulation

of codes for these descriptions, which can be further classified into smaller categories based on

similar traits (Creswell, 2005). These sub-groups set the tone for identifying emerging themes

which can form a general description for this case study.

The fifth step involves the identification and representation of themes formulating the

qualitative narrative (Creswell, 2005). The themes identified will be represented in narrative

paragraphs to provide a logical and presentable flow of information that can be easily

understood. It will include complete illustrative responses from the interviewees. 

The last step involves interpreting the result. Creswell warns of researcher bias in interpreting the

findings and recommends focusing on specific aspects to limit this bias (Creswell, 2005).

Therefore, the researcher must be aware of any personal biases. They will also need to focus on

the concept at hand on workplace stress and support groups as an intervention measure.
54

Delimitations, Assumptions, and Limitations

All research endeavors have assumptions, limitations, and delimitations, and this

proposed study is not immune to these issues. The data will be collected primarily through

interview questions. One assumption arising from this is that the information provided by the

participants will be honest and complete. To mitigate this, Esterberg (2002) recommends open-

ended structured questions as opposed to closed-ended which can inhibit the participants'

freedom to express themselves fully. The interview aims to be conversational by making the

participants comfortable with simple open-ended questions. Establishing a good rapport is a

priority in qualitative studies since it can help the participants feel comfortable enough to answer

the questions honestly (Guillemin & Heggen, 2009). Some tactics that will be employed entail

introducing one's name and purpose for data collection, maintaining friendly body language,

utilizing active listening, and dressing appropriately for offline data collection. Furthermore, the

researcher will remind the interviewees of the purpose of the study, how the data will be

protected and how it will be used to enhance the research. 

Another assumption is that the participants in the data collection are aware of, able, and

willing to discuss the issue under investigation. The selected participants must confirm that they

have a basic understanding of the work-stress and support groups. The screening process will be

comprised of two questions addressing workplace stress and the concept of support groups.

One delimitation is the boundary set on worker experience. The research considers

sampling participants with a minimum of two years of experience in the job, which can affect the

sample size and limit information access. 

This research design can present potential limitations that interfere with the study's

results. A significant limitation arising from the procedure in qualitative research during data
55

collection is the sample size, as stated by Assessment Capacities Project (ACAPS) (2012). The

scope of this study will be limited to a single organization. Dealing with a small sample size

limits the ability to generalize any findings because they may not be a true reflection of the issue

on a larger scale (ACAPS, 2012). Therefore, it is not efficient to make summaries generalizable

to the broader population.

 Another limitation is that qualitative research is labor intensive through the time-

consuming interviews, various analysis processes, and the need for a skilled interviewer (Choy,

2014). With the nature of the questions being open-ended, the researcher is at the participants'

mercy. They can take too long to respond, overlook crucial details or derail the topic. One way to

minimize time wastage is by providing fewer well-structured questions. 

Another limitation is researcher and participant biases which can compromise the validity

of the results. This issue stems from the hospice nurses' perceived effectiveness of support

groups and not the actual effectiveness. All the information received from the participants and

how the researcher interprets it is subject to personal beliefs, experiences, and knowledge.

Therefore, they are not objectively verifiable (Choy, 2014). Nevertheless, this study can be an

opportunity for future research to further determine social support's effectiveness if this proposal

demonstrates that hospice nurses perceive it as an effective way to deal with stress.

Summary

This chapter provided a detailed description of the methodological procedures that will

guide this proposed study. It presented the research questions that will guide the study. The

section also justified the need to use a qualitative case study. A qualitative research design is

applicable in studies whose nature entails exploration when studying phenomena that cannot be

measured with traditional methods, such as quantitative analysis. It is also applicable when
56

investigating aspects such as thoughts and feelings that are difficult to explain using traditional

research methods (Esterberg, 2002).

Moreover, it is best suited when investigating phenomena in their natural setting and

when aiming to address social issues in their context. It enforces active participation from the

researcher. In this proposal, the researcher is the crucial data collector and analyst. With this

justified research design, the chapter explains the sampling procedure. The research will use

purposeful sampling. According to Palinkas et al. (2015), purposeful sampling is a technique

used to identify and select information-rich cases particularly when the resource are limited to

the study. It is also referred to as judgmental sampling, as the participants are purposefully

selected based on the researcher's judgment. This type of sampling will ensure the participants

are the best suited to provide helpful information to achieve this study's objective. 

The primary data collection procedure is interviewing. It is a data collection measure

commonly used in qualitative studies. Interviews are conversations between the interviewer and

interviewee, conducted by asking questions and receiving answers (Esterberg, 2002). The data

analysis will implement the Creswell data analysis and coding steps for qualitative study. It will

use open coding, which focuses on the data collected to identify common themes and categories

(Esterberg, 2002). Creswell (2005) recommends six linear steps for the data analysis.

Lastly, the chapter covered the delimitations, limitations, and assumptions. One

assumption of this proposal is that the information provided by the participants will be honest

and complete. These will be achieved by using open-ended questions recommended by Esterberg

(2002) and establishing good rapport (Guillemin & Heggen, 2009). A screening procedure will

be performed to select the ideal participants. However, it is acknowledged that the proposed

research design could present potential limitations that could impact the study results. These
57

limitations include scope, sample size, high labor intensity, time, and biases. One delimitation is

the boundary set by selecting participants with less than a two-year of working experience in

hospice care. This chapter laid the framework for chapter four of this dissertation, which will

present the study results. 

REFERENCES

ACAPS, M. (2012). Qualitative and quantitative: Research techniques for humanitarian needs

assessment. An Introductory Brief.

Alkhawaldeh, J. F. M. A., Soh, K. L., Mukhtar, F. B. M., Peng, O. C., & Anshasi, H. A. (2020).

Stress management interventions for intensive and critical care nurses: A systematic

review. Nursing in Critical Care, 25(2), 84-92. https://doi.org/10.1002/jts.22729

Ayed, A., Sayej, S., Harazneh, L., Fashafsheh, I., & Eqtait, F. (2015). The nurses' knowledge and

attitudes towards palliative care (Accession No. 2222-288X.). Journal of Education and

Practice, 6(4), 91-99.

Barbee, A. P., Cunningham, M. R., Winstead, B. A., Derlega, V. J., Gulley, M. R., Yankeelov, P.

A., & Druen, P. B. (1993). Effects of gender role expectations on the social support
58

process. Journal of Social Issues, 49(3), 175–190. https://doi:10.1111/j.1540-

4560.1993.tb

Barnett, M. D., & Ruiz, I. A. (2018). Psychological distress and compassion fatigue among

hospice nurses: The mediating role of self-esteem and negative affect. Journal of

Palliative Medicine, 21(10), 1504-1506. https://doi.org/10.1089/jpm.2017.0662

Barnett, M. D., Martin, K. J., & Garza, C. J. (2018). Satisfaction work-family balance mediates

the relationship between workplace social support and depression among hospice Nurses.

Journal of Nursing Scholarship, 51(2), 187-194. https://doi.org/10.1111/jnu.12451

Bateman, D. R., Brady, E., Wilkerson, D., Yi, E. H., Karanam, Y., & Callahan, C. M. (2017).

Comparing crowdsourcing and friend sourcing: A social media-based feasibility study to

support Alzheimer Disease caregivers. JMIR research protocols, 6(4), Article e6904.

https://doi.org /10.2196/resprot.6904

Baxter, P., & Jack, S. (2008). Qualitative case study methodology: Study design and

implementation for novice researchers. The qualitative report, 13(4), 544-559.

Benson, J. J., Oliver, D. P., Washington, K. T., Rolbiecki, A. J., Lombardo, C. B., Garza, J. E., &

Demiris, G. (2019). Online social support groups for informal caregivers of Hospice

patients with cancer. European Journal of Oncology Nursing, 101698.

https://doi:10.1016/j.ejon.2019.10169

Boyle, D. A. (2011). Countering Compassion Fatigue: A requisite nursing agenda. The Online

Journal of Issues in Nursing, 16(1).

Brulé, G., & Morgan, R. (2018). Working with stress: Can we turn distress into eustress. Journal

of Neuropsychology & Stress Management, 3(4), 1-3.

59

Burtson, P. L., & Stichler, J. F. (2010). Nursing work environment and nurse caring:

Relationship among motivational factors. Journal of Advanced Nursing, 66(8), 1819-

1831. https://doi.org/10.1111/j.1365-2648.2010.05336.x

Campbell, S. (2015). Conducting Case Study Research. Clinical Laboratory Science, 28(3), 201-

205. https://doi.org/10.29074/ascls.28.3.201

Caswell, G., Pollock, K., Harwood, R et al. (2015). Communication between family caregivers

and health professionals about end-of-life care for older people in the acute hospital

setting: A qualitative study. BMC Palliative Care 14(35), https://doi.org/10.1186/s12904-

015-0032-0

Cedar, SH., & Walker, G. (2020). Protecting the wellbeing of nurses providing end-of-life care.

[Supplemental material]. Nursing Times, 116(2), 36-40.

Chan, C. W. H., Ng, N. H. Y., Chan, H. Y., Wong, M. M., & Chow, K. M. (2019). A Systematic

review of the effects of advance care planning facilitators training programs. BMC

Health Services Research, 19(1), 1-14.

Choi, G. H., & Kwon, S. H. (2018). The effects of the hospice & palliative care education

program for caregivers. The Korean Journal of Hospice and Palliative Care, 21(1), 33-

39.  https://doi.org/10.14475/kjhpc.2018.21.1.33

Choy, L. T. (2014). The strengths and weaknesses of research methodology: Comparison and

complimentary between qualitative and quantitative approaches. IOSR journal of

humanities and social science, 19(4), 99-104.

Clayton, M. F., Iacob, E., Reblin, M., & Ellington, L. (2019). Hospice nurse identification of

comfortable and difficult discussion topics: Associations among self-perceived

60

communication effectiveness, nursing stress, life events, and burnout. Patient education

and counseling, 102(10), 1793-1801. https://doi.org/10.1016/j.pec.2019.06.013.

Creswell, J. W. (2005). Qualitative research design: An interactive approach (2nd Ed.).

Thousand Oaks, CA: Sage.

Cutrona, C. E., & Suhr, J. A. (1992). Controllability of stressful events and satisfaction with

spouse support behaviors. Communication Research, 19(2), 154–174.

https://doi:10.1177/009365092019002002

Datta-Paulin, L., & Salt, S. (2019). Assessing the impact of a one-day advanced communication

skills course for qualified and unqualified nurses in a hospice setting [Supplemental material].

BMJ Supportive & Palliative Care, (9), Article 14. https://dx.doi.org/10.1136/bmjspcare-2019-

ASP.36

De Fatima Fernandes, M. N., & Da Silva Gherardi-Donato, E. C. (2017). Is workplace stress a

trigger for alcohol and drug abuse? Open Journal of Nursing, 7(3), 435. https://doi:

10.4236/ojn.2017.73034

De Jonge, J., & Dollard, M. F. (2002). Stress in the workplace: Australian master OHS and

environment guide. Sydney, CCH Australia Ltd. https://doi:10.1037/1072-5245.11.2.149

De Simone, S., Planta, A., & Cocotte, G. (2018). The role of job satisfaction, work engagement,

self-efficacy and agentic capacities on nurses' turnover intention and patient satisfaction.

Applied Nursing Research, (39), 130-140. https://doi.org/10.1016/j.apnr.2017.11.004

Dębska, G., Pasek, M., & Wilczek-Rużyczka, E. (2017). Sense of coherence vs. mental load in

nurses working at a chemotherapy ward. Central European Journal of Public Health,

25(1), 35-40.
61

De Frank, R. S., & Cooper, C. L. (1987). Worksite stress management interventions: Their

effectiveness and conceptualization. Journal of Managerial Psychology.

https://doi.org/10.1108/eb043385

Delgado, C., Upton, D., Ranse, K., Furness, T., & Foster, K. (2017). Nurses’ resilience and the

emotional labor of nursing work: An integrative review of empirical

literature. International Journal of Nursing Studies, (70), 71-88.

https://doi.org/10.1016/j.ijnurstu.2017.02.008

Del-Pino-Casado, R., Frías-Osuna, A., Palomino-Moral, P. A., Ruzafa-Martínez, M., & Ramos-

Morcillo, A. J. (2018). Social support and subjective burden in caregivers of adults and

older adults. A meta-analysis, PLOS ONE, 13(1), Article e0189874.

https://doi:10.1371/journal.pone.0189874 

Dewanto, A., &Wardhani, V. (2018). Nurse turnover and perceived causes and consequences: A

preliminary study at private hospitals in Indonesia. BMC Nursing, 17(2), 1-7.

https://doi.org/10.1186/s12912-018-0317-8

Diamantidis, A. D., & Chatzoglou, P. (2018). Factors affecting employee performance: An

empirical approach. International Journal of Productivity and Performance Management.

https://doi.org/10.1108/ijppm-01-2018-0012

Diehl, E., Rieger, S., Letzel, S., Schablon, A., Nienhaus, A., Escobar Pinzon, L. C., & Dietz, P.

(2021). The relationship between workload and burnout among nurses: The buffering role

of personal, social and organizational resources. PloS one, 16(1), Article e0245798.

https://doi: 10.1371/journal.pone.0245798

Dworkin, S. L. (2012). Sample size policy for qualitative studies using in-depth interviews.

Archives of sexual behavior, 41(6), 1319-1320.

62

Dyrbye, L. N., Major-Elechi, B., Hays, J. T., Fraser, C. H., Buskirk, S. J., & West, C. P. (2020).

Relationship between organizational leadership and health care employee burnout and

satisfaction. In Mayo Clinic Proceedings, 95(4), 698-708.

https://doi.org/10.1016/j.mayocp.2019.10.041.

English Standard Version Bible. (2016). the ESV Bible. https://www.theesvbible.com (Original

work published 2001)

Esterberg, K. G. (2002). Qualitative methods in social research: Boston, MA, McGraw-Hill.

Evans, A., Radford, S., Teasdale, J. D., & Dalgleish, T. (2010). How Does Mindfulness-Based

cognitive therapy work? Behavior Research and Therapy, (48), Article e1105e1112.

English Standard Version Bible. (2001). Crossway Bibles.

https://doi.org/10.1016/j.brat.2010.08.003

Guillemin, M., & Heggen, K. (2009). Rapport and respect: Negotiating ethical relations between

researcher and participant. Medicine, Health Care and Philosophy, 12(3), 291-299.

https://doi.org/10.1007/s11019-008-9165-8.

Harris, L. J. M. (2013). Caring and coping. Journal of Hospice & Palliative Nursing, 15(8), 446–

454. https://doi:10.1097/njh.0b013e3182a0de7

Hawkins, A.C., Howard, R.A., & Oyebode, J.R. (2007). Stress and coping in hospice staff: The

impact of attachment styles. Journal of Psychological, Social and Behavioral

Dimensions of Cancer, 16(6), 563-572.  https://doi.org/10.1002/pon.1064

Head, B., Middleton, A., & Zeigler, C. (2019). Work satisfaction among hospice and palliative

nurses. Journal of Hospice & Palliative Nursing, 21(5), E1-E11. https://doi:

10.1097/NJH.0000000000000562
63

Heponiemi, T., Hyppönen, H., Kujala, S., Aalto, A. M., Vehko, T., Vänskä, J., & Elovainio, M.

(2018). Predictors of physicians’ stress related to information systems: A nine-year

follow-up survey study (Accession No. 1472- 6963). BMC Health Services

Research, 18(1), 1-9.

Holman, D., Johnson, S., & O’Connor, E. (2018). Stress management interventions: Improving

subjective psychological well-being in the workplace. In Handbook of Well-being.

https://DOI:nobascholar.com

Hospice Friendly Hospitals Program. (2013). Retraction: end-of-life care and supporting staff.

http://hospicefoundation.ie/wp-content/uploads/2013/04/End-of- Life-Care-Supporting-

Staff-a-literature-review.pdf

http:// doi.org/10.1108/lhs-12-2016-0063

Huggard, J. & Nichols, J. (2011). Emotional safety in the workplace: One hospice’s response for

effective support. International Journal of Palliative Nursing, 17(12), 611-617.

https://doi.org/10.12968/ijpn.2011.17.12.611

Hussain, F. A. (2021). Psychological challenges for nurses working in palliative care and

recommendations for self-care. British Journal of Nursing, 30(8), 484-489.

https://doi.org/10.12968/bjon.2021.30.8.484

Jarrad, R., Hammad, S., Shawashi, T., & Mahmoud, N. (2018). Compassion fatigue and

substance use among nurses. Annals of general psychiatry, 17(1), 1-8.

Jennings, B. M. (2008). Work stress and burnout among nurses: Role of the work environment

and working conditions: Patient safety and quality. An evidence-based handbook for

nurses. PMID: 21328768

64

Kaihlanen, A. M., Gluschkoff, K., Laukka, E., & Heponiemi, T. (2021). The information system

stress, informatics competence and well-being of newly graduated and experienced

nurses: A Cross-Sectional Study. BMC Health Services Research, 21(1), 1-8.

https://doi.org/10.1186/s12913-021-07132-6

Kirby, E. G. (2018). Patient centered care and turnover in hospice care organizations. Journal of

Health and Human Services Administration, 41(1), 26-51.

Kokoroko, E., & Sanda, M. A. (2019). Effect of workload on job stress of Ghanaian OPD nurses:

The Role of Coworker Support. Journal of Safety and health at work, 10(3), 341-346.

https://doi.org/10.1016/j.shaw.2019.04.002

Krause, N., & Pargament, K. I. (2018). Reading the Bible, stressful life events, and hope:

Assessing an Overlooked Coping Resource. Journal of Religion and Health, 57(4), 1428-

1439. https://doi.org/10.1007/s10943-018-0610-6

Krick, T., Huter, K., Domhoff, D., Schmidt, A., Rothgang, H., & Wolf-Ostermann, K. (2019).

Digital technology and nursing care: A scoping review on acceptance, effectiveness and

efficiency studies of informal and formal care technologies. BMC Health Services

Research, 19(1), 1-15. https://doi.org/10.1186/s12913-019-4238-3

Lehto, R. H., Heeter, C., Forman, J., Shanafelt, T., Kamal, A., Miller, P., & Paletta, M. (2020).

Hospice employees’ perceptions of their work environment: A focus group

perspective. International Journal of Environmental Research and Public Health, 17(17),

6147. https://doi.org/10.3390/ijerph17176147

Letvak, S., Ruhm, C., & Lane, S. (2011). The impact of nurses’ health on productivity and

quality of care. The Journal of Nursing Administration, 41(4), 162–167.

https://doi:10.1097/nna.0b013e318211851
65

Lockhart, L. (2020). Strategies to reduce nursing turnover. Nursing Made Incredibly Easy, 18(2),

56. https://doi.org/10.1097/01.NME.0000653196.16629.2e

Lowe, M. A., Gakumo, C. A., & Patrician, P. A. (2016). Coping strategies of nurses in a

palliative care unit. Journal of National Black Nurses' Association, 27(2), 50-54.

Lu, S., Wei, F., & Li, G. (2021). The evolution of the concept of stress and the framework of the

stress system. Cell stress, 5(6), 76–85. https://doi.org/10.15698/cst2021.06.250

Marmo, S. (2016). Sustaining the role of social work in hospice care: Social workers' perceptions

of job satisfaction, interdisciplinary collaboration and organizational

leadership (Doctoral dissertation, Fordham University).

McKinless. (2020). Impact of stress on nurses working in the district nursing service. British

Journal of Community Nursing, 25(11), 555-561.

https://doi.org/10.12968/bjcn.2020.25.11.555

Mercadante, S., Gregoretti, C., & Cortegiani, A. (2018). Palliative care in intensive care units:

Why, where, what, who, when, how. BMC anesthesiology, 18(1), 1-6.

https://doi.org/10.1186/s12871-018-0574-9.

Mikkelsen, A., & Olsen, E. (2018). The influence of change-oriented leadership on work

performance and job satisfaction in hospitals: The mediating roles of learning demands

and job involvement. Leadership in Health Services, 32(1), 37-53.

Millar, J. D. (1990). Mental health and the workplace: An interchangeable partnership. American

Psychologist, 45(10), 1165. https://doi.org/10.1037/0003-066X.45.10.1165.

Molek-Winiarska, D., & Molek-Kozakowska, K. (2020). Are organizations committed to stress

management interventions? Employee relations. The International Journal.

66

Morgan, D. (2009). Caring for dying children: Assessing the needs of the pediatric palliative care

nurse. Pediatric nursing, 35(2), 86.

Mukemo, A. K., Kasongo, N. M., Nzaji, M. K., Tshamba, H. M., Mukengeshayi, A. N., Nikulu,

J. I., & Kaj, F. M. (2017). Assessment of nurses’ knowledge, attitude and associated

factors towards palliative care in Lubumbashi’s hospitals. International Journal of

Science and Research, 6(10), 922-928.

Murphy, L. R. (2003). Stress management at work: Secondary prevention of stress. The

Handbook of Work and Health Psychology, (533).

Naseem, S., Afzal, M., Sehar, S., & Gilani, S. A. (2018). Relationship between leadership styles

of nurse managers and staff nurses job satisfaction in public hospital of Punjab, Pakistan.

International Journal of Social Sciences and Management, 5(3), 201-208.

https://doi.org/10.3126/ijssm.v5i3.20611

New International Version Bible. (2011). The NIV Bible. https://www.thenivbible.com/

(Original work published 1978)

Nickerson, C. (2021). The Yerkes-Dodson law and performance. Simply Psychology.

Noble, H., & Heale, R. (2019). Triangulation in research, with examples. Evidence-based

nursing, 22(3), 67-68.

Oliver, D. P., Washington, K., Demiris, G., Wallace, A., Propst, M. R., Uraizee, A. M, &

Ellington, L. (2018). Shared decision-making in home hospice nursing visits: A

qualitative study. Journal of Pain and Symptom Management, 55(3), 922-929.

https://doi.org/10.1016/j.jpainsymman.2017.10.022
67

Oliver, D. P., Washington, K., Wittenberg-Lyles, E., Gage, A., Mooney, M., & Demiris, G.

(2015). Lessons learned from a secret Facebook support group. Health & Social Work,

40(2), 125–133. https://doi:10.1093/hsw/hlv007 

Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015).

Purposeful sampling for qualitative data collection and analysis in mixed method

implementation research. Administration and policy in mental health, 42(5), 533–544.

https://doi.org/10.1007/s10488-013-0528-y

Parola, V., Coelho, A., Cardoso, D., Sandgren, A., & Apostolo, J. (2017). Burnout in palliative

care settings compared with other settings: A systematic review. Journal of Hospice &

Palliative Nursing, 19(5), 442-451. https://doi: 10.1097/NJH.0000000000000370

Power, R. (2002). The application of qualitative research methods to the study of sexually

transmitted infections. Sexually transmitted infections, 78(2), 87-89.

http://dx.doi.org/10.1136/sti.78.2.87

Rashid, Y., Rashid, A., Warraich, M. A., Sabir, S. S., & Waseem, A. (2019). Case study method

(Accession No. 1609406919862424): A step-by-step guide for business researchers.

International journal of qualitative methods.

Rodakowski, J., Skidmore, E. R., Rogers, J. C., & Schulz, R. (2012). Role of social support in

predicting caregiver burden. Archives of Physical Medicine and Rehabilitation, 93(12),

2229–2236. https://doi: 10.1016/j.apmr.2012.07.004

Rogers, J. E. B., Constantine, L. A., Thompson, J. M., Mupamombe, C. T., Vanin, J. M., &

Navia, R. O. (2021). COVID-19 pandemic impacts on US hospice agencies: A national

survey of hospice nurses and physicians. American Journal of Hospice and Palliative

Medicine®, 38(5), 521-527. https://doi.org/10.1177/1049909121989987.

68

Roozeboom, M. C. B., Schelvis, R. M., Houtman, I. L., Wiezer, N. M., & Bongers, P. M. (2020).

Decreasing employees’ work stress by a participatory, organizational level work stress

prevention approach: A Multiple-Case Study in Primary Education. BMC Public Health,

20(1), 1-16.

Ross, A. (2020). Theological reflection: Management of Stress.

Saidi, N. S. A., Michael, F. L., Sumilan, H., Lim, S. L. O., Jonathan, V., Hamidi, H., & Ahmad,

A. I. A. (2019). The relationship between working environment and employee

performance. Journal of Cognitive Sciences and Human Development, 5(2), 14-22.

Salvagioni, D. A. J., Melanda, F. N., Mesas, A. E., González, A. D., Gabani, F. L., & Andrade,

S. M. D. (2017). Physical, psychological and occupational consequences of job burnout.

A systematic review of prospective studies. PloS one, 12(10), Article e0185781.

https://doi: 10.1371/journal.pone.0185781.

Sandi, C., & Haller, J. (2015). Stress and the social brain: Behavioral effects and neurobiological

mechanisms. Nature Reviews Neuroscience, 16(5), 290-304.

Sapeta, P., Centeno, C., Belar, A., & Arantzamendi, M. (2022). Adaptation and continuous

learning: Integrative review of coping strategies of palliative care

professionals. Palliative Medicine, 36(1), 15-29.

https://doi.org/10.1177/02692163211047149

Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R. (1983). Assessing social support:

The social support questionnaire. Journal of Personality and Social Psychology, 44(1),

127–139. https://doi:10.1037/0022-3514.44.1.127

Scheibe, S., & Zacher, H. (2013). A lifespan perspective on emotion regulation, stress, and well-

being in the workplace. In the role of emotion and emotion regulation in job stress and
69

well-being. Emerald Group Publishing Limited. https://doi.org/10.1108/S1479-

3555(2013)0000011010.

Schneider, C., Bristol, A., Ford, A., Lin, S. Y., Brody, A. A., & Stimpfel, A. W. (2022). A pilot

observational exploratory study of well-being in hospice interdisciplinary team Members.

American Journal of Hospice and Palliative Medicine®, 39(3), 264-269.

https://doi.org/10.1177/10499091211023480.

Schoch, K. (2020). Case study research: Research design and methods: An applied guide for the

scholar-practitioner, 245-258.

Siegrist, J., Wahrendorf, M., & Siegrist. (2016). Work stress and health in a globalized economy.

Springer Berlin Heidelberg.

Tsang, H. W., Cheung, W. M., Chan, A. H., Fung, K. M., Leung, A. Y., & Au, D. W. (2015). A

pilot evaluation on a stress management program using a combined approach of cognitive

behavioral therapy and complementary and alternative medicine for elementary school

teachers. Stress and Health, 31(1), 35-43. https://doi.org/10.1002/smi.2522

Vasileiou, K., Barnett, J., Thorpe, S., & Young, T. (2018). Characterizing and justifying sample

size sufficiency in interview-based studies: systematic analysis of qualitative health

research over a 15-year period. BMC medical research methodology, 18(1), 1-18.

https://doi.org/10.1186/s12874-018-0594-7

Veiga, G., Rodrigues, A. D., Lamy, E., Guiose, M., Pereira, C., & Marmeleira, J. (2019). The

effects of a relaxation intervention on nurses' psychological and physiological stress

indicators: A Pilot Study. Complementary therapies in clinical practice, (35), 265-271.

https://doi.org/10.1016/j.ctcp.2019.03.008.
70

Velana, M., & Rinkenauer, G. (2021). Individual-level interventions for decreasing job-related

stress and enhancing coping strategies among nurses: A systematic review. Frontiers in

Psychology, (12), 2970.

Vlahovic, T. A., Wang, Y.-C., Kraut, R. E., & Levine, J. M. (2014). Support matching and

satisfaction in an online breast cancer support community. Proceedings of the 32nd

Annual ACM Conference on Human Factors in Computing Systems - CHI’ (14).

https://doi:10.1145/2556288.2557108 

Waddill-Goad, S. M. (2019). Stress, fatigue, and Burnout in Nursing. Journal of Radiology

Nursing, 38(1), 44-46. https://doi.org/10.1016/j.jradnu.2018.10.005

Wang, Y. C., Kraut, R. E., & Levine, J. M. (2015). Eliciting and receiving online support: Using

computer-aided content analysis to examine the dynamics of online social support.

Journal of medical Internet research, 17(4), Article e3558.

Warden, D. H., Hughes, R. G., Probst, J. C., Adams, S. A., & Warden, D. N. (2020). Turnover

intention among nurses in nurse managers, directors, and executives: Developing a tool

for measuring environmental factors. Journal of Nursing Measurement.

https://doi:10.1891/JNM-D-19-00013

Wiersbe, W. W., & David, C. Cook. (2009). Be faithful: It's Always too Soon to Quit! NT

Commentary, 1 & 2 Timothy, Titus, Philemon.

Wijnen, B., Lokkerbol, J., Boot, C., Havermans, B. M., van der Beek, A. J., & Smit, F. (2020).

Implementing interventions to reduce work-related stress among health-care workers: An

investment appraisal from the employer's perspective. International archives of

occupational and environmental health, 93(1), 123–132. https://doi.org/10.1007/s00420-

019-01471-y
71

Wittenberg-Lyles, E., Washington, K., Oliver, D. P., Shaunfield, S., Gage, L. A., Mooney, M., &

Lewis, A. (2014). “It is the ‘starting over’ part that is so hard”: Using an online group to

support hospice bereavement. Palliative and Supportive Care, 13(02), 351–357.

https://doi:10.1017/s1478951513001235

Worrall, H., Schweizer, R., Marks, E., Yuan, L., Lloyd, C., & Ramjan, R. (2018). The

effectiveness of support groups: A literature review. Mental Health and Social Inclusion.

https://doi.org/10.1108/MHSI-12-2017-0055

Youngvorst, L. J., & High, A. C. (2018). “Anyone free to chat?” Using technological features to

elicit quality support online. Communication Monographs, 85(2), 203-223.

APPENDIX A

RECRUITMENT DOCUMENT

Research Participants Needed

Investigating the Perceived Efficacy of Support Groups as a Secondary-Organization
Stress Intervention Measure for Hospice Nurses

 Have you worked as a hospice nurse for at least two years?

 Do you know what support groups are?
 Are you able and willing to participate in this study?

If you answered yes to each of the questions listed above, you may be eligible to participate in a
research study.
 72

The purpose of this research study is to explore the perceived efficacy of support groups as a
secondary-organization stress intervention measure for hospice nurses.

Participants will be asked to participate in a one-on-one interview with the researcher that is
expected to last approximately 30 minutes.

If you would like to participate reach out to Sade Allen, contact: +1(786) 910-0818 or
Email: sadeallen8@liberty.edu

A consent document will be given to you one week before the interview at the reception desk.
You will need to sign and submit it in a drop box at the reception’s desk.

Sade Allen, a doctoral candidate in the School of Behavioral Sciences, department of Psychology
at Liberty University, is conducting this study.

Please contact Sade Allen, contact: +1(786) 910-0818, Email: sadeallen8@liberty.edu

APPENDIX B

PERMISSION REQUEST

10/9/2022

General Manager

Liberty University IRB – 1971 University Blvd., Green Hall 2845, Lynchburg, VA 24515

VITAS Inpatient Hospice Unit

9408 SW 87th Ave Ste. 107
Miami, FL 33176, United States.

Dear Manager,

As a graduate student in the school of Behavioral Science, department of Psychology at

Liberty University, I am conducting research as part of the requirements for a doctorate degree.
The title of my research project is Investigating the Perceived Efficacy of Support Groups as a
73

Secondary-Organization Stress Intervention Measure for Hospice Nurses, and the purpose of my
research is to conduct a qualitative case study to determine this efficacy.

I am writing to request your permission to conduct my research at the VITAS Inpatient

Hospice Unit.

I am asking permission to recruit participants from your nursing staff by distributing

flyers in person at your facility and to have some flyers placed in prominent common areas for 5
days. Those who are qualified and interested in participating in my study will contact me, and at
that point, I will email them when I will deliver the informed consent documents. I am requesting
to station a drop box at the reception’s desk for the participants to submit their signed consent
forms. I am also requesting that I will be able to schedule the one-on-one interviews with study
participants at your facility. Taking part in this study is completely voluntary, and participants
are welcome to discontinue participation at any time.

Thank you for considering my request. If you choose to grant permission, please provide
a signed statement on official letterhead indicating your approval. A permission letter document
is attached for your convenience.

Sincerely,

Sade Allen
Doctoral Candidate

APPENDIX C

PERMISSION RESPONSE

24/09/2022

Sade Allen
Doctoral Candidate
Liberty University
15521 SW 106 Ave
Miami, FL, 33157 United States.

Dear Sade:

After careful review of your research proposal entitled Investigating the Perceived
Efficacy of Support Groups as a Secondary-Organization Stress Intervention Measure for
Hospice Nurses we have decided to grant you permission conduct your study at VITAS Inpatient
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Hospice Unit and utilize the consequent resources, distributing flyers, utilizing the reception’s
desk and setting up a drop box.

We grant permission for Sade Allen to contact hospice nursing staff to invite them to participate
in her research study and conduct interviews in the facility.

We are requesting a copy of the results upon study completion and/or publication.

Sincerely,

[Official’s Name]
[Official’s Title]
[Official’s Company/Organization]

APPENDIX D

INFORMED CONSENT

Title of the Project: Investigating the Perceived Efficacy of Support Groups as a Secondary-
Organization Stress Intervention Measure for Hospice Nurses.
Principal Investigator: Sade Allen
Email: Sadeallen8@libety.edu
Study Phone Number: +1 (786) 910-0818

Invitation to be Part of a Research Study

You are invited to participate in a research study. To participate, you must be a hospice nurse
with not less than two year working experience. You must also understand the meaning of
support groups and be willing and able to talk about it. Taking part in this research project is
voluntary.

Please take time to read this entire form and ask questions before deciding whether to take part in
this research.
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What is the study about and why is it being done?

The purpose of the study is determine the perceived efficacy of support groups as a secondary-
organization stress intervention measure for hospice nurses.

What will happen if you take part in this study?

If you agree to be in this study, I will ask you to do the following things:
1. Participate in a one-on-one interview that will last approximately 30 minutes. Your
responses will be recorded on an audio recorder.

How could you or others benefit from this study?

Participants should not expect to receive a direct benefit from taking part in this study.

Benefits to society include adding to the literature of stress intervention strategies for hospice
nurses.

What risks might you experience from being in this study?

The risks involved in this study are minimal, which means they are equal to the risks you would
encounter in everyday life.

How will personal information be protected?

The records of this study will be kept private. Published reports will not include any information
that will make it possible to identify a subject. Research records will be stored securely, and only
the researcher will have access to the records. Data collected from you may be shared for use in
future research studies or with other researchers. If data collected from you is shared, any
information that could identify you, if applicable, will be removed before the data is shared.

 Interviews will be conducted in a location where others will not easily overhear the
conversation.
 Data will be stored on a password-locked audio recorder and computer and may be used
in future presentations. Data will also be backed up on a password protected cloud
storage. After three years, all electronic records will be deleted.
 Interviews will be recorded and transcribed. Recordings will be stored on a password
locked computer for three years and then erased. Only the researcher will have access to
these recordings.

How will you be compensated for being part of the study?

Participants not be compensated for participating in this study.

Is study participation voluntary?

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Participation in this study is voluntary. Your decision whether or not to participate will not affect
your current or future relations with Liberty University. If you decide to participate, you are free
to not answer any question or withdraw at any time.

What should you do if you decide to withdraw from the study?

If you choose to withdraw from the study, please contact the researcher at the email
address/phone number included in the next paragraph. Should you choose to withdraw, data
collected from you will be destroyed immediately and will not be included in this study.

Whom do you contact if you have questions or concerns about the study?
The researcher conducting this study Sade Allen. You may ask any questions you have now. If
you have questions later, you are encouraged to contact her at Sadeallen8@libety.edu or at +1
(786) 910-0818

Whom do you contact if you have questions about your rights as a research participant?
If you have any questions or concerns regarding this study and would like to talk to someone
other than the researcher, you are encouraged to contact the Institutional Review Board, 1971
University Blvd., Green Hall Ste. 2845, Lynchburg, VA 24515 or email at irb@liberty.edu.

Disclaimer: The Institutional Review Board (IRB) is tasked with ensuring that human subjects
research will be conducted in an ethical manner as defined and required by federal regulations.
The topics covered and viewpoints expressed or alluded to by student and faculty researchers
are those of the researchers and do not necessarily reflect the official policies or positions of
Liberty University.
By signing this document, you are agreeing to be in this study. Make sure you understand what
the study is about before you sign. You will be given a copy of this document for your records.
The researcher will keep a copy with the study records. If you have any questions about the
study after you sign this document, you can contact the study team using the information
provided above.

I have read and understood the above information. I have asked questions and have received
answers. I consent to participate in the study.

The researcher has my permission to audio-record me as part of my participation in this study.

____________________________________
Printed Subject Name

____________________________________

Signature & Date

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APPENDIX E

INTERVIEW QUESTIONS

Background
1. What is your name?
2. How many years have you worked in this organization?
3. Apart from this facility, have you practiced hospice care in other places and for how long?
Experience
1. Do you experience workplace stress?
2. What are the factors that contribute to the work-place stress you experience?
3. Have you ever been in a support group? How did it impact you?
Sensory
1. Have you heard about social support groups in this facility for stress management?
2. Do you see staff meeting in groups to talk and share about stress?
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Knowledge
1. Does the organization have stress intervention programs for the employees? If so can you
describe them?
2. Do you think this organization should implement support groups to help you deal with
workplace stress?
3. Why should this organization implement support groups to help you deal with workplace
stress?
Opinion
1. Do you think the current stress interventions, if any are helpful?
2. How can organizations implement support groups as a stress coping strategy for hospice care?
Feeling
1. Do you feel you can be part of a support group that helps one another cope with workplace
stress?
2. How will you respond if this organization implements support group programs to help cope
with stress?