Exploring factors influencing the work-related morale for certified nursing assistants in hospice care: A structural equation modeling study

Jong Yi Wang, Hui Lin Zhuang, Jeng Yuan Chiou, Chia Woei Wang, Chen Yu Wang, Li Fan Liu

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4 Citations (Scopus)


Background Certified nursing assistants (CNAs) in palliative care units often encounter the death of patients and undergo emotional burdens because of their altruistic practices. However, the influences of altruism and perceptions of death on the work morale of CNAs remain unclear. The fact that morale can be improved by modifying related factors justifies the necessity of a theoretical model of morale for CNAs. However, such a model is currently absent. Based on relevant literature, factors including altruism, social support, perceptions of death, and job satisfaction are related to morale through the mediation of job stress. Aim This study was aimed toward determining the influencing factors and developing a structural model of morale with regard to CNAs working in palliative care units. Design The hypothesized model was tested in a cross-sectional design with structural equation modeling using AMOS 23. Setting/Participants A total of 413 CNAs from five hospice units in Taiwan participated in the survey. Results Goodness-of-fit indexes, including X2/DF = 2.187, PGFI = 0.461, and PNFI = 0.462, among others, confirmed the modified model fit the data well. Altruism, social support, perceptions of death, and job satisfaction were negatively related to job stress (-0.238, -0.196, -0.204, and -0.131, respectively). Altruism and social support positively affected job satisfaction (0.635 and 0.553). Factors directly affecting morale included altruism, social support, job stress, and job satisfaction (0.837, 0.711, -0.244, and 0.540, respectively). The relationship between altruism and morale was the strongest among all the direct paths toward morale. Job stress was the major mediator in these relationships. Conclusion Altruism is imperative for morale. The confirmed model is called the Five Constructs to Morale (5CM) model. These findings indicate the need to assess the levels of altruism and perceptions of death during the recruitment of CNAs. From the perspective of human resource management and organizational behavior, CNAs with a high level of altruism and a positive attitude toward death assure the well-being of end of life patients because of work involvement and commitment to the challenging work of hospice care. The cultivation of a supportive environment and coping strategies are suggested for the management of CNAs facing patient death. Hospice care decision makers should carefully assess morale levels among health professionals by applying the 5CM model. Identifying modifiable factors that can improve morale among nursing staff in hospice care to ensure work fulfillment and quality care merits emphasis in clinical practice. The establishment of effective strategies to facilitate the work morale of nursing staff is suggested for palliative care units. Morale improvement related task should be a global public health priority.

Original languageEnglish
Article numbere0206281
JournalPloS one
Issue number10
Publication statusPublished - 2018 Oct

All Science Journal Classification (ASJC) codes

  • General


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