Background
Coronavirus disease 2019 (COVID-19), the third known zoonotic coronavirus disease after severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS), is an acute, infectious pneumonia caused by a novel coronavirus [
1]. Because of its high transmissibility, strong infectivity, high mortality rate (1–15%) and absence of clinically approved antiviral drug or vaccine, it has become a pandemic and has been seriously endangering human health and life [
2‐
4]. As of 15:00 on September 25, 2020, the World Health Organization (WHO) reported that there were 7,512,285 confirmed cases of COVID-19 and 987,415 deaths, and that number was increasing [
5]. A large number of patients with severe pneumonia died in COVID-19 designated hospital or inevitably faced death during the pandemic. Symptoms of patients with severe COVID-19 can escalate rapidly [
6,
7], and patients often suffer from anxiety, depression, and insomnia. These symptoms positively correlated with fatigue, dyspnoea, myalgia, and sore throat [
8]. In response, a series of emergency medical and psychology plans as well as strategies used to manage deterioration and potential deaths were became necessary [
9].
Hospice care generally falls into the category of palliative care [
10]. It is a philosophy and system of care for terminally ill patients that allows them to accept death in an affirmative way, and provides palliative care and emotional support for dying patients and their families [
11]. Hospice care aims to improve the quality of life rather than its length, and to prepare patients and their families for the end of life [
12] by meeting the needs of terminally ill patients through expert symptom management, facilitation of caregiver support, and even provision of home-based care [
13]. Hospice care is truly a philosophy of care that embodies the concept of patient-centred care [
12,
14]. Evidence showed that hospice care was not only beneficial to terminally ill patients and families (e.g., emotional support, companionship, and practical assistance,), but also to hospice caregivers (e.g., being able to make a difference in the lives of others, personal growth, and greater appreciation of what is really important in life) [
15‐
17].
Hospice care is most often provided at home; however, it can also be provided in an inpatient setting, including hospital, nursing home, or stand-alone hospice facilities. Hospice care requires a multidisciplinary team-based approach to care and relies on families, friends, and other loved ones as well as volunteers to assist in quality care [
12]. However, because of the need to control nosocomial infections and make the best use of limited personal protective equipment (e.g., mask, goggles, medical protective clothing, etc.), patients’ family members and other medical personnel who were not responsible for this kind of infectious disease have less chance to intimately contact patients with confirmed COVID-19. To a large extent, instead of a multi-disciplinary team, the clinical nurses and physicians who are involved in fighting against COVID-19 become the main providers of hospice care for dying COVID-19 patients.
Nurses and physicians involved in fighting against pandemics such as the COVID-19 suffer from high physical and mental workloads, stress, and risk of infection [
18‐
20], all of which affect their comfort and health [
21,
22]. Researches also reported that nurses might adopt negative attitudes or actions, including avoiding confirmed or suspected cases, when they were involved in the management of patients who are infected or even who died of infectious diseases [
23,
24].
Self-efficacy refers to the personal judgment of how well an individual can execute required courses of action to deal with prospective situations, and the hospice care self-efficacy is targeted at hospice care and addressed the health workers’ confidence regarding the provision of mental and spiritual care for the terminally ill and their family members [
25]. Studies found that high level of hospice care self-efficacy helps hospice care givers avoid negative emotions (e.g., escape, fear) [
26,
27], and actively assume their professional responsibilities [
28]. Queries regarding the attitudes and self-efficacy of clinical nurses and physicians involved in fighting against COVID-19 during the implementation of hospice care for patients with dying COVID-19 was the focus aim of this study.
The aim of this study was to investigate hospice care self-efficacy and to identify its predictors among Chinese clinical medical staff in the COVID-19 isolation wards of designated hospitals. The findings may provide clinical managers in China and in other countries with experience on psychological strategies regarding the fight of medical staff against COVID-19 so as to develop more effective strategies to cope with COVID-19 deaths and dying patients.
Discussion
To our best knowledge, this was the first study to investigate hospice care self-efficacy among caregivers treating fatal infectious diseases in mainland China. Hospice care has been reported as being an effective measure to improve the life quality of dying patients and to help their families cope with bereavement [
12]. Medical staff employing effective hospice care might avoid the adverse effects of sleep disorders, irritability, interpersonal problems, and other issues [
44]. For these reasons, it is essential to investigate hospice care self-efficacy and to identify its predictors among clinical medical staff involved in fighting against the COVID-19 pandemic.
In this study, clinical nurses and physicians reported moderate levels of hospice care self-efficacy while offering care to dying COVID-19 patients. The COVID-19 pandemic led to the emergence of a large number of confirmed patients in a short period of time [
5], which further led to shortages of medical supplies (e.g., medical protective equipment, etc.) and health professionals. Communication was difficult between medical staff and patients because the latter needed to wear personal protective equipment and in some cases patients were delirious or had hearing or sight impairments [
9]. More importantly, nurses and physicians who were involved in fighting against COVID-19 pandemic suffered from heavy workloads and stress [
18,
19], which might further restrict the time and energy that they could have spent implementing hospice care.
These findings may be related to the Chinese traditional philosophy of life that includes the ethical thoughts in traditional Chinese culture, including Confucianism (e.g., paying attention to the present world and pursuing living forever), Taoism (e.g., believing that life and death are unified and life is immortal), and Buddhism (e.g., deeming that individuals are reincarnated without extinction) [
45]. The traditional Chinese philosophy of life respects the natural law of death and values life; however, it places taboos on death and attaches great importance to the continuation of life. To some extent, Chinese traditional philosophy of life is dissonant with the concept of hospice care, and this could affect the development and implementation of hospice care in China. Therefore, exploring the traditional Chinese philosophy of life to learn from its strengths and compensate for its weaknesses and examining the psychology of hospice care providers may be conducive to providing new directions for the integration of dilemmas faced by hospice care providers in the context of infectious diseases characterized by high infectivity and mortality.
We found that nurses and physicians with higher self-competence in death work had better hospice care self-efficacy. Self-competence in death work refers to ‘the competence required to cope with the emotional and existential challenges to self in working with death or matters related to death’ [
46]. Assessing self-competence in death work among hospice care professionals may help to better reflect their needs in facing death [
34]; successfully development of self-competence in death work may improve attitudes and self-efficacy, resulting in better job performance of hospice care, especially for those who had early experiences with patient death [
44,
47]. A systematic review and qualitative meta-synthesis found that continuous education regarding how to face and accept death would promote hospice care professional growth among nurses [
32]. Hospice care education, especially scenario simulations to place medical staff into simulated bereavement or death situations and to allow them to become aware of their personal needs in facing death, were used urgently to improve medical staff self-competence and self-efficacy in the death work associated with treating emerging infectious diseases [
32,
35].
Nurses and physicians who had acquired hospice care experience by giving hospice care for dying or dead patients in a hospital or hospice prior to the COVID-19 pandemic also had better hospice care self-efficacy, as did those from higher-level hospitals. Medical staff might acquire relevant knowledge and skills from their own hospice care experience and then display higher hospice care self-efficacy. Medical staff from level 3 hospitals may have more access to continuous hospice education and may have better knowledge of and attitudes towards hospice care than those from lower level hospitals; this might be beneficial for their hospice care self-efficacy [
48,
49]. However, studies showed Chinese health care providers in general lacked systematic and professional knowledge and skills for caring for terminal patients [
50‐
52]. A survey investigated 141 trainees in the 2016 National Hospice and Palliative Medicine Training Program and found that only 21.3% had attended any hospice and palliative care course prior [
53]. Even in the Hospice Care Department of Community Hospice Care Pilot Settings, only 50.8% medical staff had received continuous hospice care education in Shanghai [
54]. Hospice care developed slowly nationwide, mainly in large cities such as Shanghai, Tianjin, and Guangzhou [
55]. There remains much work to establish hospice care service with professional multi-disciplinary teams. Medical staff who assisted and worked at the COVID-19 designated hospitals in Hubei province or their own provinces were recruited from hospitals, rather than from hospice care settings. Equipped with limited knowledge and skills on hospice care, they might not be competent enough to implement hospice care. This may be one of causes of their lower level of hospice care self-efficacy.
Clinical nurses and physicians in the COVID-19 isolation wards of designated hospitals with positive coping and PAC had better hospice care self-efficacy, especially those who respected life, and had strong responsibility and professional ethics. This result was similar to that of Zheng et al. [
32]. Research showed that exposure to death influenced the way health care workers perceive death [
56]. Individuals with positive coping have positive thoughts and solutions (e.g. taking constructive actions and creating better living conditions and higher performance levels) [
57,
58]. PAC is considered a subjective event that participates in enhancing caregiver health; PAC among caregivers is often associated with a sense of pride, self-worth, and higher self-esteem [
59,
60]. In short, positive coping and PAC, as protective psychological factors, are useful for medical staff to effective deal with death work during the COVID-19 pandemic. Therefore, taking a series of measures (e.g., strengthening humanistic care, venting emotions through crying or other means rather than keeping them suppressed, improving working and rest condition, etc.) to mobilize medical staff’s positive psychological resources were critical to helping them face death or dying in fighting against the COVID-19 pandemic [
61‐
63].
By contrast, medical staff with occupational exposure had lower hospice care self-efficacy in fighting against the COVID-19 pandemic. Health-care workers had high risk of occupational exposure to COVID-19 through intimate contact with patients with confirmed or suspected COVID-19 [
64]. Medical personnel subject to blood-borne occupational exposure are easily susceptible to psychological problems and post-traumatic stress disorder, both of which are detrimental to the job performance and mental health of medical staff as well as patient outcomes [
65]. Therefore, providing a safer practice environment and exploring comprehensive strategies for effective prevention and control of the occupational exposure of front-line medical staff in the fight against the COVID-19 pandemic are crucial for occupational safety and health, as well as practicing hospice care. In addition to the reasonable use of personal protective articles, it is necessary to implement more effective prevention and control measures for occupational exposure to infectious disease scientifically and in a standard fashion, as well as to intensify engineering, management, and behaviour control during prevention and control of infectious diseases [
66].
The present study has some limitations. First, this is a cross-sectional study; therefore, the relationship between self-competence in death work, positive aspects of caregiving, coping strategies, and hospice care self-efficacy cannot be established. Second, based on the purpose of this study, self-reported questionnaires were used to collect the data. These methods are subject to social desirability bias [
67]. Third, our study set only one question named ‘had ever given hospice care for dying or dead patients before fighting against COVID-19?’ to measure the hospice care experience of medical staff. Important as it is, the set of Chinese medical staff’s knowledge and skills in hospice care could not be included in our statistical analysis model and therefore, it might not directly reflect the inner connection between the medical staff’s skills and experience and self-efficacy in hospice care, even though the results of previous studies on this topic were cited, presumably reflected the connection in hospice care between the medical staff’s knowledge and skills and self-efficacy. Nevertheless, this study provides a foundation for future empirical research among medical staff in relation to hospice care self-efficacy and self- competence in death work and it adds to the body of knowledge on Chinese medical staff.
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