Hospice and palliative care refer to professional medical care that improves the Quality of Life (QoL) of patients with terminal diseases by relieving their pain and physical, psychological, social, and spiritual suffering [1]. Beyond medical care that delays the death of the patient, hospice and palliative care actively work to relieve pain and uncomfortable symptoms and address the patient's psychological, social, and spiritual needs [2]. Hospice and palliative care nurses provide integrated holistic care to improve QoL for terminally ill patients who may fear the physical changes of their illness as well as death. In addition, hospice and palliative care nurses provide direct care to patients and play an important role as team coordinators [3].

Job stress refers to the discomfort, pressure, and tension felt by employees due to working conditions, including the work environment, job complexity, workload, workplace conflict, role ambiguity, job instability, and an irrational and authoritarian organizational culture [4]. Nurses experience job stress during the nursing process. For hospice and palliative care nurses, major stressors include a lack of confidence in the pain management of patients with terminal cancer, time pressures, difficulty delivering bad news, and end-of-life care [5].

Job stress affects an organization by negatively impacting workers' physical or mental health and increasing turnover [6]. As caregivers of dying patients, hospice and palliative care nurses can experience a decline in their Professional QoL (ProQOL) due to physical and emotional exhaustion [7]. Thus, hospice and palliative care nurses require both physical and mental measures to relieve stress.

ProQOL is a subjective assessment of the QoL of people in professions that provide services to a target population, particularly how they experience their jobs [8]. Compassion fatigue can also be described as burnout and secondary traumatic stress. Thus, ProQOL is comprised of three aspects: compassion satisfaction, burnout, and secondary traumatic stress [8]. Compassion fatigue is experienced as a loss of motivation, indifference toward patients, and inability to cope. However, compassion satisfaction moderates compassion fatigue and enables nurses to continue caring for patients [9, 10]. As a highly sensitive group, hospice and palliative care nurses can experience compassion fatigue because they internalize anger, anxiety, fear, and sadness, much like the patients and their caregivers going through the pain, terminal symptoms, and eventual dying process [11]. Thus, a supportive environment in which hospice and palliative care nurses can perform their work is required to maintain a positive mindset and reduce compassion fatigue.

Nurses play an important role in hospice and palliative care as members of multidisciplinary teams. They participate in various programs for pain management, symptom control, end-of-life care, and bereavement care to improve the QoL of patients [12]. The pressure experienced by hospice and palliative care nurses depends on the difficulty of the care required (i.e., this varies with the type of cancer or disease), mental exhaustion, conflict with the hospice team [8], and the high stress of delays during end-of-life care [13]. As the symptoms of hospice patients worsen, their physical and psychological demands increase, and their families experience various degrees of death anxiety [14]. The high levels of stress experienced by hospice and palliative care nurses differ from those experienced by general ward nurses [15], as they are expected to take on emotionally stressful tasks [16].

In previous studies, oncology nurses with high resilience reported low burnout and job stress, high job satisfaction, and a strong ability to cope [17]. Resilience is the ability to adapt to situations and overcome adversity [18] and can help nurses perform well in their jobs, thereby reducing the prevalence of post-traumatic stress and emotional burnout [19]. The higher the job satisfaction and the lower the job stress and burnout, the more influence nurses' resilience and ProQOL were shown to have on caregiving [20, 21].

Nursing care seeks to restore and promote the health of patients [22] by paying attention to patients' needs while providing care. Because a decline in the ProQOL of nurses can negatively impact patient care, enhancing the ProQOL of nurses is important [23]. Recent studies of the ProQOL of nurses in general, as care providers focused on their patients' health and recovery, showed that hospice and palliative care nurses have high levels of job stress and psychological burnout, because they are required to care for patients who are dying [15, 16]. However, to our knowledge, no study has identified the mediating effect of resilience, which can mitigate job stress and improve QoL, on the relationship between job stress and ProQOL in hospice and palliative care nurses. Thus, the present study aimed to confirm the mediating effect of resilience on the relationship between job stress and the ProQOL of hospice and palliative care nurses. This study can facilitate the creation of policies that improve ProQOL and strengthen the resilience of hospice and palliative care nurses.

To determine the degree of job stress, resilience, and ProQOL among hospice and palliative care nurses and explore the mediating effect of resilience on the relationship between job stress and ProQOL, we performed the following:

This study determined the mediating effect of resilience on the relationship between job stress and ProQOL among hospice and palliative care nurses. In the three aspects of ProQOL, compassion satisfaction averaged 3.02±0.08 points, secondary traumatic stress averaged 2.48±0.56 points, and burnout averaged 2.44±0.53 points. A study of nurses working with COVID-19 patients, using the same instrument [29], found a score of 3.22 for compassion satisfaction, 2.72 for secondary traumatic stress, and 2.89 for burnout, much like the present results. Nurses experience physical and emotional exhaustion while serving as caregivers of dying patients, causing a deteriorating ProQOL [7]. Furthermore, nurses can experience high levels of stress due to the difficulties of caring for different types of cancer. This can lead to feeling overwhelmed and experiencing mental burnout, emotional distress [12], and delays in end-of-life care-related tasks [13]. To improve the ProQOL of hospice and palliative care nurses who care for patients facing death, measures should be taken to increase compassion satisfaction, as well as reduce the levels of burnout and secondary traumatic stress by identifying their causes.

In this study, differences in resilience were observed according to the nurses' years of clinical experience. A similar study observed that nurses with over 7 years of clinical experience exhibited higher resilience than nurses with 1~4 years of clinical experience [30]. It was found that skilled clinical experience can help nurses overcome difficult situations and successfully adapt, and that resilience can also be improved through education [31]. Thus, educational programs that improve resilience should be developed.

When considering the differences in ProQOL according to the participants' general characteristics, burnout was significantly different based on hospice ward experience. In post hoc analysis, burnout was significantly higher among those with 1~3 and 3~5 years of hospice unit experience than those with 10+ years of experience. A similar study found that burnout varied by the length of time caring for patients with COVID-19 [29]. Since shorter work experience showed higher rates of burnout, a burnout management intervention program tailored to work experience should be introduced. Furthermore, to improve ProQOL by increasing compassion satisfaction and reducing burnout, hospice nurses should also be empowered to choose the hospice ward they work on.

Job stress was negatively related to resilience and compassion satisfaction, and positively related to secondary traumatic stress and burnout. Resilience was positively related to compassion satisfaction, and negatively related to secondary traumatic stress and burnout.

Regarding ProQOL, compassion satisfaction was negatively associated with secondary traumatic stress and burnout, and positively associated with resilience. This differs from previous studies that examined the relationship between resilience and ProQOL in healthcare workers, where resilience had a statistically significant association with all three subscales of ProQOL [32]. A study of generalist nurses [33] also found that higher resilience was associated with lower burnout. The likely reason for this variation in findings was that these studies did not include hospice and palliative care nurses. Applying a stress reduction program that actively manages job stress and enhances resilience may help hospice and palliative care nurses view the last days of their patients' lives positively and enhance their ability to provide quality care to dying patients.

This study found a direct effect of job stress on compassion satisfaction in hospice and palliative care nurses, and an indirect mediation effect through resilience. Although resilience had no mediating effect on job stress and secondary traumatic stress, resilience did have a mediating effect on job stress and burnout. Direct comparisons were difficult to achieve because only a few studies investigated the same research subjects, research variables, and relationships to be confirmed as the present study. However, the mediating effect of resilience in our study did reveal results like those in a study of patients with multiple sclerosis, which found the moderating effect of resilience on depression and health-related QoL [34]. In a separate study involving patients on hemodialysis, the findings mirrored the mediation effect of resilience on the relationship between symptom experience and QoL [35]. Resilience is the ability to use adversity and difficulties as a springboard to leap forward [18]; the application of resilience-building programs can be an effective alternative to improve ProQOL. This study was significant because it showed the relationship between hospice and palliative care nurses' job stress and compassion satisfaction, a subdomain of ProQOL. The direct effect of job stress on compassion satisfaction was confirmed, as well as the indirect effect of resilience on burnout. Therefore, it is necessary to improve resilience to improve the ProQOL of hospice and palliative care nurses. This study showed that resilience had no mediating effect on the relationship between job stress and secondary traumatic stress in hospice and palliative care nurses. Therefore, repeated studies are needed to validate this result. Based on this study, the active development and application of resilience enhancement programs are needed to improve the ProQOL of hospice and palliative care nurses. Hospice and palliative care nurses should not feel that they are expected to sacrifice for their patients as part of their profession. Resilience-building programs that include psychological support must be applied to enable them to provide the holistic and individualized care that dying patients need and allow them to view dying more comfortably.

This study is significant since it was conducted among nurses who care for hospice patients nationwide. Moreover, it identified resilience as an important variable for reducing job stress in hospice and palliative care nurses to improve their ProQOL. Based on this study, we made the following recommendations. First, in an era where healthcare providers are increasingly aware of providing a comfortable death rather than life-sustaining treatment, hospice and palliative care nurses must identify their level of job stress and apply regular counseling programs to reduce mental and psychological burdens. Second, it is necessary to develop a customized resilience-building program that caters specifically to hospice and palliative care nurses. Third, active nursing policies should be supported that enable nurses to choose the hospice and palliative care department they wish to work in.

A limitation of this study was that it did not consider other variables, such as the satisfaction of hospice and palliative care nurses with working conditions. The indirect mediation effect of resilience on secondary traumatic stress, a subdomain of ProQOL, was not found; therefore, future studies are needed to confirm the relationship between secondary traumatic stress and resilience