Over the last decade, access to palliative care and hospice services have grown rapidly around the world . Recently, the World Health Organization emphasized the need for improving the quality of life of patients and relatives facing the problem of life-threatening illness by addressing their physical, psychological, social and spiritual needs [2,3,4]. In this sense, hospice care professionals (HCPs) provide intensive interventions aimed at improving quality of life and relieving suffering [5, 6].
According to a recent systematic review on wellbeing of HCPs, “there is relatively little research to address the psychological wellbeing of the staff” who deal with death and dying on a daily basis in hospice context (p. 2) .
Working in palliative care context may expose staff to recurrent distressing events on a daily basis, such as exposure to death and dying, patient suffering, and observing extreme physical pain in patients, resulting in the risk of absorbing negative emotional responses, coping with inability to cure and potentially, deep engagement in emotional clashes [8,9,10,11,12,13]. It has been calculated that 50% of HCPs are at risk of reduced psychological well-being as a result of inadequate organizational strategies related with many of these demands .
Among those stressors that may affect staff emotional work, limiting HCPs true emotions as health care workers, witnessing the extreme suffering of patients represents an intense challenge for HCPs in terms of emotional management, ethical obligations and personal integrity as individuals and professionals [15,16,17]. Working in hospice context entails daily recurrent and intense interactions with patients and families that require regular use of emotional labor regulation strategies which may lead to reduced well-being [5, 16, 17]. Emotional labor has been defined as the effort involved when workers “regulate their emotional display in an attempt to meet organizationally-based expectations specific to their roles” (p. 365) . Furthermore, emotional labor is linked to perceived display rules defined as those shared expectations around what emotions workers should and should not show. Specifically, displaying positive emotions (salutogenic factor) and suppressing negative ones (pathogenic factor) are common rules in hospice context, and are considered as in-role (emotional) job requirements [17, 18]. For example, displaying positive emotions during social interactions with patients and families as part of their role as clinicians in attempt to influence (positively) patients’ attitudes and behaviors, encouraging and sustaining patients and family .
According to Joinson , this intense and recurrent emotional labor may expose HPCs to vicarious stress and development of compassion fatigue (CF). CF is defined as “a state of tension and preoccupation with traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders and persistent arousal associated with the patient” [21, 22]. According to the Compassion Stress/Fatigue Model [23, 24], CF has been considered as the resulting caregivers’ behaviors and emotions linked to knowing about a traumatizing event experienced or suffered by a person” [22, 25] and the resulting reduced capacity or interest of those in “bearing the suffering of clients”.
In this sense, HCPs are at high risk of developing CF as they provide prolonged involvement and compassion for those who are suffering, frequently without seeing patients improving . Furthermore, not only prolonged or continuous exposure to stressful events may play a crucial role in generating CF, but a single intense event may also be decisive. Hereafter, CF is the fatigue associated to constantly dispensing compassion, day after day .
CF has been theorized as a multi-component construct, comprised of secondary traumatic stress (STS) and burnout [23, 28]. STS has been defined as the condition when care providers report symptoms related to reexperiencing the traumatic experience of patients (vicariously experience) . Burnout is a form of cumulative work related stress and is characterized by emotional exhaustion, cynicism, and reduced personal accomplishment . While CF is considered as a form of reaction to traumatic patient experience, job burnout is associated with workplace context, such as high job demands, low job control, and low job support .
Simon, Pryce, Roff, and Klemmack  found that working with dying patients exposed workers to secondary traumatic stress and that it was the recurrent emotional demand that led to CF. Hence, HCPs suffering from CF may be not able to effectively regulate their emotional display . In this sense, an additional implication is that being in a condition of CF may booster the effect of witnessing suffering patients on emotional display. Thus, we hypothesized that the effects of witnessing suffering patients on emotional display rules would depend on the HCPs’ previous levels of CF, such that this relationship should be strongest for those HCPs with higher CF.
As most of the stressors are likely to occur within the same workday, the main purpose of the present study was to investigate the relationship between potential short-term fluctuations in witnessing suffering patients and daily use of positive display emotion rules.