Work environment factors in coping with patient death among Spanish nurses: a cross-sectional survey*

Objective: to explore self-perception competence among Spanish nurses dealing with patient death and its relationship with work environment, evidence-based practice, and occupational stress. Method: a cross-sectional web-based survey collected information from a convenience sample of 534 nurses from professional Spanish Colleges who answered four validated questionnaires: Coping with Death Scale, Practice Environment Scale of the Nursing Work Index, Perception of Evidence-Based Practice (EBP) and Nursing Stress Scale. Results: a total of 79% of the participants were women, the average age was 40 years old, 38% had a postgraduate degree and 77% worked in public health settings. Many nurses evaluated their work environment as unfavorable (66%), reported high occupational stress (83.5±14.9), and had high scores on knowledge/skills in EBP (47.9±11.3). However, 61.2% of them perceived an optimal coping (>157 score). The multivariate logistic model indicated positive associations with work environment and EBP characteristics (OR: 1.30, p=0.054; OR: 1.04, p=0.007; OR: 1.13, p<0.001, respectively) but negative associations with occupational stress and short work experience (OR: 0.98, p=0.0043; OR: 0.74, p<0.002, respectively). These factors explained 23.1% of the coping variance (p<0.001). Conclusion: although most nurses perceived optimal coping, the situation could be enhanced by modifying several contextual factors. The identification of these factors would improve the quality of end-of-life care by facilitating nursing management.


Introduction
Regardless of the field of professional care, a dying patient is an emotionally difficult phenomenon (1) that can influence how professionals cope with death. Thus, nurses must feel confident about not only their ability to effectively take care of dying patients (2) but also their ability to maintain their own well-being (1) . Skills for coping with patients' death and favorable work-environment conditions are associated with the quality of end-of-life care. These skills are essential to reduce dissatisfaction and stress (3) .
Some authors (4) refer to the complex multimorbidity during end-of-life care, while others (2) state that hospital management does not commit to the necessary strategies to ensure that nurses feel they are able to face this aspect of their work without difficulty. Therefore, to improve end-of-life care, it is important to know the professionals' perception of coping with death, attitudes about the use of research, characteristics of the work environment (5) , and the degree of stress experienced during end-of-life care.
Nurses may express a variety of emotions and attitudes related to end-of-life care (1,6) , which are particularly stressful because they are constantly interpreting grief or death as a personal failure (7) . Some authors (8) stated that nurses require a wide range of skills to properly deal with death and manage their own fears, beliefs, and attitudes towards dying patients (9) .
Inadequate coping with death decreases job satisfaction (10) and increases nurses' stress, negatively affecting the quality of care (11) . Meanwhile, individuals who perceive themselves as optimally coping with death often assess these difficult situations as challenges and actively face occupational stress (12) .
Occupational stress in palliative care is identified as the combination of the problems involved in caring for others, the lack of self-care strategies, and organizational factors (13) . In addition, health professionals tend to have high occupational stress rates in situations of greater clinical demand, long working hours, and poor manager support (5) , while a favorable work-environment is essential to minimize the negative impact of working with dying patients (14) .
Previously, specialized nurses in emergency and palliative-care settings were a strong predictor of the perception of coping during end-of-life care (6) . Today, special interest is growing in experiential learning because constant exposure to the process of dying helps nurses learn about the care of terminal patients (15) . Insufficient nursing knowledge of research (16) was improved by educational projects and evidence-based practice guides for the care of dying patients and their families (17) . Barriers such as gaps in the knowledge of research and the feeling of a lack of support and leadership on the part of nurses make it difficult to implement evidence-based care in practice (18) .
Specifically, intensive-care professionals recognize the lack of end-of-life education and training as an obstacle to quality care (19) . The health institutions (20) and the increased awareness among palliativecare professionals are the most influential forces for overcoming barriers in the use and development of research with regard to clinical nursing and, thus, improving end-of-life care. Evidence is available concerning the influence of the practice environment, occupational stress, and evidence-based practice in endof-life care. Thus, knowing whether these factors are related to nurses' perception when coping with dying patients can be central for nursing managers to minimize the emotional impact (21) and promote high-quality endof-life care. However, no studies were found on whether all nursing staff members' perceptions of these factors were associated with coping with death. The aim of the present study is to explore self-perception competence among Spanish nurses dealing with patient death and its relationship with work environment, evidence-based practice, and occupational stress.    (24) and consists of 30 items scored on a 7-point Likert-type scale [from 1 (totally disagree) to 7 (totally agree)], with a score range of 30 to 210. A total score lower than 105 indicates inadequate coping, while a score greater than 157 represents optimal coping (23) .

Method
A Cronbach's alpha value of 0.824 was previously reported among Spanish nursing students (23) . four out of the five subscales account for "favorable", "mixed" is represented by scores ≥ 2.5 on two subscales and "unfavorable" is represented by scores ≥ 2.5 on one subscale or no subscales (26) .

C. Perception of Evidence-Based Practice
Questionnaire (EBPQ): Professional skill at using better knowledge for decision making was addressed by the Spanish version of the Evidence-Based Practice (EBP) questionnaire (27) that consists of 19 items structured into three subscales: 1) "practice of EBP" (6 items); 2) "attitude towards EBP" (3 items) and 3) "knowledge/ skills associated with EBP" (10 items) (28) . Cronbach's alpha was 0.87 for Spanish clinical nurses, 0.929 for the practice subscale, 0.722 for the attitude subscale, and 0.916 for the knowledge/skills subscale (27) . All items are evaluated from 1 (totally disagree) to 7 (totally agree) score. High scores indicate more positive attitudes and greater use and knowledge of clinical effectiveness and EBP.

D. Nursing Stress Scale (NSS): The Nursing
Stress Scale questionnaire assesses and detects different potentially stressful situations in nursing (29) .
The validated Spanish version, with good reliability

Results
The descriptive sociodemographic characteristics of the study population (n=534 nurses), according to their self-perceived professional competence in dealing with death, are shown in Table 1 Moreover, being male, having more years of nursing experience, and working in public health clinical settings were also positively and significantly related to selfperceived coping with death (p< 0.05).
Many nurses (66%) evaluated the quality of their work environment as unfavorable (data not shown), and only one out of the five subscales, "interprofessional relations and joint practice", was perceived as favorable (2.5 ± 0.8; Table 2). Regarding self-rating of the implementation of EBP, the highest score was found in the knowledge/skills subscale (47.9 ± 11.3). In this respect, the best scores were found among nurses with postgraduate training for the three different factors of the EBP (data not shown), compared with those with less education. Moreover, more than half of the participants also reported high stress levels (83.5 ± 14.9) during end-of-life care ( Table 2). a higher score on this factor predicts a higher score on coping with death. In addition to nursing occupational stress, short working experience also showed a negative slope, with scoring lower with regard to perceived coping with death associated with less than 10 years of nursing practice (β = -0.18, p <0.001). associated with less than 10 years of nursing practice (β = -0.18, p <0.001).    In the same way, when the outcome was dichotomized, the multivariate regression logistic model also showed that some socio-demographic and work environment characteristics, as well as EBP and occupational stress, were related to coping with death (Table 5) Different previous studies have corroborated these findings (31)(32)(33)(34)(35)(36) . According to these studies, males are rational, decisive, and resilient when working in challenging situations, such as caring for dying patients (31) ; moreover, males often have their own approach to coping with difficult emotions and maintaining their own well-being because male stereotypes of self-sufficiency and competitiveness influence their practices and experiences (32) .
Some studies also emphasize the benefit of having longer nursing experience, fuller training in end-oflife care (33) , and exposure to situations of suffering such as dying (34) . This provides knowledge and skills for improved coping with dying patients in the future, potentially reaching the point of feeling comfortable (6) .
Nurses with less than 10 years of experience were more vulnerable and exhausted, had higher levels of depersonalization, and had lower levels of personal fulfillment (35) . However, at the same time, nurses with more years of experience were able to keep a distance and set boundaries in end-of-life care (36) . These findings also fit with previous evidence pertaining to "interprofessional relations and joint practice" (34) .
In relation to the perception among Spanish nurses concerning their work environment, twothirds of the study population considered the work environment unfavorable because their evaluations were lower than the magnet hospital scores. However, the EBP was assessed according to the nurses' knowledge more than their practice, indicating a discouraging work context. Regarding factors least valued within the PES-NWI scale, a personnel shortage is a restrictive element to fulfilling professional roles and responsibilities (37) . A supportive work environment among colleagues is helpful in dealing with end-of-life care (38) . This perceived unfavorable work environment could also be related to the economic crisis that Spanish health professionals are lately experiencing (39) .
Additionally, the high workload in dying patient care demands the same conditions of care as before the start of the crisis and has not adapted to the shortage of resources (40) . A shortage of staff could force a choice between providing comprehensive care to all dying patients or focusing only on the most urgent cases (41) , causing frustration and emotional exhaustion among professionals (42) .
On the other hand, the low scores on the PES-NWI subscale "nurse participation in hospital affairs" deserve special attention by healthcare administrators because this professional participation in matters of organizational performance positively influences efficiency and effectiveness at the professional team level (43) , and it was observed that more than half of the professionals reported high levels of participation in hospital affairs in the situations posed.
The positive association found between the attitude towards and practice of EBP and the perceived ability to cope with death suggests the importance of having well-founded knowledge of professional safety, that is, to perceive oneself as having the ability to face the death of others. Several studies have indicated that additional training programs help to adequately address dying patients (44) . It should be noted that some institutions have managed to bolster the confidence of nurses to provide the best care to oncological patients after going through EBP educational programs (45) .
However, there are still barriers to the offer of ongoing education for nurses participating in end-of-life care (10) .
The negative association between occupational stress and ability to cope with death, regardless of the nursing workplace, appeared in previous findings (38,46) , This study has several shortcomings and strengths.
It has an observational design, so we could not definitively establish causal relationships. Although the study population could be considered representative of the Spanish population (a country and a culture), the recruitment system limited any generalization. Most of the participants were female, which is in line with the gender distribution in the Spanish nursing profession.
All the questionnaires used were validated but may have led to a bias in information gathering due to a lack of knowledge or other unidentified factors. Additionally, the questionnaires were completed online, restricting the web survey to the nurses who had internet access.
Nevertheless, these questionnaires have been used in numerous studies among the Spanish population to reduce information bias. The sample size was large, the study subjects were from different regions of Spain, and many distinct factors were considered simultaneously.
We should also highlight that to minimize selection bias, the study was performed not only in palliative care or oncology but also in other nursing specialties.
According to our results, this type of survey should be used to detect which nurses may perceive high levels of self-competence in end-of-life care. It is important that nursing professionals become comfortable with dying patients in their work, which implies that attitudes, social awareness, or personal opinions may also influence coping strategies. Moreover, healthcare institutions must be involved to identify the factors that influence the quality of life of the health professional and, therefore, the quality of their practice. Nursing education should also promote specific training to reinforce coping strategies at the end of life or the management of feelings towards the patient who will die to avoid negative influences on the work of future professionals.

Conclusion
Despite the challenges that a nurse faces in an environment with dying patients, this situation has not been a determinant for the optimal level of perceived ability to cope with death. The determining factors are age, years of experience and training. In a predominantly female environment, being male proves to be a determining factor of an optimal ability to cope with death and one of the factors that predicts the self-perceived professional competence in dealing with death. Future studies should thoroughly analyze these gender differences. All the elements of the professional context analyzed were found to influence the level of the nurses' ability to cope with death; however, the moderate explanatory power suggests the need to consider other elements not considered in this study.
Finally, given the importance of the professional team, the nursing administration plays a key role in providing better practice environments, by facilitating the use and training of research in the workplace and identifying occupational stress.