Transformative service in healthcare: understanding secondary vulnerability and coping mechanisms in end-of-life care

Transformative service research (TSR), defined as research focusing on the uplifting of individual, community and ecosystem well-being (Anderson et al., 2013), has seen a steady increase in interest in academic scholarship over the last decade. Specifically, TSR research has examined factors including employee well-being (Tuzovic and Kabadayi, 2021), the design of services to support refugees (Gross et al., 2021) and the unintended consequences of taking a TSR approach (Blocker et al., 2022). This increase in scholarly interest in TSR aligns with both the identification of “improving well-being through transformative service” as a Service Research Priority by Ostrom et al., in 2015, as well as the more recently identified Service Research Priority 4, “customer proactivity for well-being” (Ostrom et al., 2021).

One of the research areas that has emerged as a result of TSR is how services can be designed to support consumers and to a lesser extent, frontline employees (FLEs), experiencing vulnerabilities (Ho and Shirahada, 2021; Riedel et al., 2023). Consumers experiencing vulnerabilities are defined as “unique and subjective experiences where characteristics such as states, conditions and/or external factors lead to a consumer experiencing a sense of powerlessness in a consumption setting” (Riedel et al., 2021, p. 110) while frontline employee vulnerability is defined as “the potential for state-based harm that is induced by job demands and availability of supporting resources that can be enhanced or diminished by individual characteristics” (Riedel et al., 2023, p. 870). The current builds on previous work by introducing the concept of secondary vulnerability. Secondary vulnerability is defined here as the susceptibility for a frontline employee (FLE) who is providing support of a vulnerable consumer to experience state-based harm themselves when the job demands outweigh the resources available. Secondary vulnerability is an important theoretical concept as it is often experienced in under-examined service settings, such as the provision of end-of-life care, and can lead to significant implications for the FLE, the consumer and the service organization.

The current study proposes that FLEs, such as healthcare professionals (HCPs) working in contexts involving vulnerable consumers, like end-of-life care, inherently take on the role of a transformative service provider (TSP). In this role, they deliver exemplary service that facilitates positive changes for both the consumer (patient) and the service system. A TSP is similar to a transformative service mediator (TSM) as they have the capacity to change inputs through their involvement in service provision and can lead to transformative service outcomes for the consumer (Johns and Davey, 2019). However, the study highlights that an HCP’s ability to effectively fulfil the TSP role depends on their capacity to manage secondary vulnerability. Factors such as coping mechanisms and the availability of organizational support services play a critical role in determining whether an HCP can effectively navigate these challenges and provide transformative services to consumers.

The Transactional Model of Stress and Coping (TMSC) (Folkman et al., 1979) offers valuable insight into why an HCP may take on a TSP role or not. The TMSC proposes that when an individual experiences a stressful event, such as caring for a patient at the end-of-life, they undertake a series of cognitive appraisals and draw on diverse internal and external coping strategies to respond to the event (Lazarus, 1966; Folkman et al., 1979). It is these appraisals and coping strategies that ultimately influence the level of secondary vulnerability experienced by the HCP and, in turn, whether they take on a TSP role or not. This then impacts the service outcomes experienced by the HCP, the patient and their family. Therefore, this study aims to 1) develop a theoretical framework of secondary vulnerability and 2) refine and illustrate the framework by examining HCPs who care for patients at the end-of-life. Based on these aims, it then proposes a comprehensive model that describes how the coping strategies employed to manage this vulnerability affect the likelihood of HCPs ability to continue with the TSP role.

In addressing the aim, this study offers three significant contributions to services marketing literature. First, it introduces a secondary vulnerability theoretical framework, expanding the focus beyond consumer vulnerability to include FLEs, particularly healthcare providers (HCPs), and empirically examines its impact on well-being and service outcomes in end-of-life care. Second, it extends the concept of the TSP role, highlighting how coping strategies influence HCPs’ ability to deliver transformative services. Third, the research synthesizes insights from multiple disciplines to develop a comprehensive model of HCPs as TSPs, potentially useful for understanding other complex service interactions. In the next section, the key literature relating to the constructs of interest in the current study will be detailed to provide a theoretical positioning for this paper.

There are differing perspectives in the literature on how consumer vulnerability could be understood. As noted previously, Riedel et al. (2021) took a systematic approach to develop a definition of consumers experiencing vulnerability that focused on the experience of individuals and how characteristics such as states, conditions and/or external factors lead to perceptions of powerlessness in consumption setting. Alternatively, Sudbury-Riley (Sudbury-Riley et al., 2024) conceptualize vulnerability in the context of agency, identifying three key aspects-self-perception, interplay between consumer and marketplace and that everyone can feel vulnerable in certain contexts.

Prior consumer vulnerability and TSR literature have focused largely on trait-based vulnerability by examining customer factors such as age (Berg, 2015), gender (McKeage et al., 2018) and disabilities (Beatson et al., 2020) and how these trait-based factors may exacerbate state-based harms such as the emotional and the psychological (Riedel et al., 2023). However, Riedel et al. (2023) suggest that prior research has yet to thoroughly consider the vulnerability of other actors involved in a service interaction, who may also be susceptible to state-based harms such as FLEs. To move this research area forward, Riedel et al. (2023, p. 870) defined FLE vulnerability as “the potential for state-based harm that is induced by job demands and availability of supporting resources that can be enhanced or diminished by individual characteristics”.

The consideration of other actors in the service exchange who support consumers experiencing vulnerability aligns with prior literature (e.g. Johns and Davey, 2019; Verleye and Holvoet, 2024). Verleye and Holvoet (2024) proposed that in a consumer vulnerability context, a triad exists between the primary customer (those experiencing the vulnerability), secondary customers (family members) and organizations with transformative potential. In this triad, it is suggested that organizations can co-create value with secondary customers who are engaged in the service provision of their loved one. In this way, the secondary customer can be considered as a partial employee. Our research suggests, similar to Verleye and Holvoet (2024), that FLEs who represent the organization and interact with both primary and secondary customers may themselves become vulnerable as a result of these service interactions. This is supported by Polonsky et al. (2024) who identify that spillover effects may cause other actors in an environment to experience foreseen and unforeseen harms. This is termed as secondary vulnerability as defined here in the introduction. This is particularly relevant in the case of HCPs supporting patients in end-of-life care and is different to previous conceptualizations of vulnerability such as psychological vulnerability which focuses specifically on cognitive schemes and stress (Demirci et al., 2021) rather than taking a broader view and considering a wider range of drivers and consequences of vulnerability.

Johns and Davey (2019) suggest that individuals external to a service organization who support vulnerable consumers have the potential to be classified as a TSM. A key element of TSM’s is that the external mediator provides a transformative service experience for the consumer that leads to uplift in their lives. The current study builds on Johns and Davey’s (2019) work by proposing that a service provider who is internal to a service organization but still provides exemplary service and support for a vulnerable consumer and drives positive changes for both the service and consumer (patient) can be classified as a TSP role. This person has the same characteristics as a TSM except they are internal to the organization rather than external.

This study proposes and empirically examines if an individual’s experience of secondary vulnerability which occurs as a result of a service interaction and their ability to cope with the stressors involved is a key determinant of whether an FLE will become a TSP. As such, the research builds on these prior service conceptualizations by proposing that FLEs such as HCPs may themselves experience vulnerability (secondary vulnerability), in their role supporting a vulnerable consumer.

One service setting where other actors who are supporting a vulnerable consumer may be susceptible to secondary vulnerability is that of healthcare. HCPs are often tasked with understanding and meeting patient needs while co-creating value through interactions. In doing so, they are balancing high job demands including high stakes decision-making (Kent et al., 2020) and frequent exposure to distressing situations (Lamothe et al., 2021). As a result, HCPs often experience what is termed “emotional labour” when managing their emotions to meet the expectations of the role (Riedel et al., 2023; Erickson and Grove, 2008; Mann, 2005). This is particularly evident in end-of-life care situations where providing support and care to the patient and their family with varying needs and backgrounds can present challenges for HCPs (Lewis et al., 2021; Bloomer et al., 2022). It is important to note that the vulnerability of HCPs may also be linked to liminality whereby the HCP feels conflicted between meeting the demands of the hospital, patient, the patient’s family as well as their own, personal needs (O’Loughlin et al., 2024). When faced with challenging situations, HCP’s draw on their available internal and potentially limited external resources to manage the complex situation (Riedel et al., 2023). An HCP is susceptible to experiencing secondary vulnerability when the demands are high and the resources low. Such secondary vulnerability warrants further investigation as prior research suggests HCPs are at risk significant impact on their well-being due to the pressures of managing challenging patient interactions and maintaining service quality (Lovell et al., 2023b).

This study research draws on Lazarus and Folkman’s (1987) TMSC, which explains why HCPs may encounter secondary vulnerability and how this affects their ability to assume the role of a TSP. Prior studies have utilized the TMSC to explain why individuals may experience vulnerability after stressful events, such as mothers experiencing low mood following childbirth (Honey et al., 2003), instances of depression (Hankin and Abramson, 2001) and parents caring for children with severe learning difficulties (Quine and Pahl, 1991).

The TMSC proposes that individuals will appraise stressors in their environment, evaluating them as either harmful, threatening or challenging (Lazarus, 1966). These stressors can be external, such as an HCP caring for a patient at the end of life, and can pose a threat to an individual’s well-being (Folkman et al., 1979). If the stressor is appraised as stressful by the individual and requires effort to manage, coping actions are then enacted (Biggs et al., 2017). Coping strategies involve problem-focused coping which seeks to directly manage the stressor or emotion-focused coping which aims to regulate the emotions experienced as a result of the stressor (Biggs et al., 2017). Coping strategies can also involve drawing on internal or external resources (Jordan et al., 2015). The appraisal process and integration of coping strategies can lead to a negative outcome in the service setting if the stressor is high and coping strategies are low.

When considering the TMSC in the context of TSP and the secondary vulnerability of HCPs, it is proposed that it is likely that when an HCP provides care and support for a patient at their end-of-life, they will appraise the situation as stressful. This stressful appraisal is supported by a previous integrative review highlighting intensive care nurses’ emotional responses to patient death and their associated coping mechanisms (Bloomer et al., 2023). As a result of the stress, the HCP will appraise the internal (e.g. self-efficacy, experience) and external (e.g. manager support, hospital resources) resources they have available (Jordan et al., 2015) and employ problem-focused or emotion-focused coping (Biggs et al., 2017). From the experience of stress and the appraisal process, the HCP is likely to experience secondary vulnerability when coping resources are not available which could negatively impact on both consumer (patient) and FLEs (HCPs) outcomes. However, when HCPs do have the available coping resources available, it is proposed that they will take on the role of a TSP and provide a transformative service to the patient.

Drawing on the above discussions, the theoretical framework of secondary vulnerability presented in Figure 1 has been derived. As mentioned earlier, research still needs to explore why FLEs might feel vulnerable when caring for a person experiencing vulnerability and how this affects their ability to take on a TSP role.

This study adopts an interpretive, qualitative approach to explore the concept of secondary vulnerability among TSPs, particularly frontline HCPs caring for patients near the end of life. This approach is appropriate given the intricate and nuanced nature of the research topic, allowing for a comprehensive understanding of the experiences and perceptions of these frontline workers (Pope and Mays, 2020). In addition, there is limited existing data on this specific area of research. Previous TSR studies have not yet explored the phenomenon of secondary vulnerability among HCPs during the provision of end-of-life care. Thus, a qualitative approach offers the opportunity to thoroughly investigate this aspect within a real-life context, and to uncover the meanings individuals attribute to phenomena, providing valuable insights into the social context of information and relationships (Priya, 2021).

HCPs face vulnerabilities due to the emotionally demanding nature of their roles. A US report revealed that nearly half of all US HCPs reported often feeling burned out (Haynes and Houry, 2023). These workers frequently encounter distressing situations while caring for people in need, often with limited job resources (Melnyk et al., 2023). Such chronic exposure to stressors can result in various negative consequences, including work-related stress, depression and decreased job satisfaction (Guixia and Hui, 2020).

The current study took place in a 750-bed public tertiary teaching hospital in south-east Queensland, Australia. Two medical wards were chosen based on their high numbers of in-hospital deaths and the chronic nature of diseases treated there. A convenience sampling approach was used to recruit HCPs as participants from these wards. Information sessions about the study were conducted in both wards, where potential participants received a participant information sheet and consent form. Those willing to participate provided their contact information for interview arrangements.

Data was gathered via semi-structured interviews to allow participants to freely express their views (Fontana and Frey, 2005). Before each interview, participants were briefed on the study’s purpose and provided their consent for the interview. They also completed a brief questionnaire to collect demographic data, including age, gender, current role and years of experience. Cross-disciplinary team members, including registered nurses and a marketing specialist, conducted the interviews, with regular meetings held to refine the process and ensure reliability (Nowell et al., 2017). A semi-structured interview guide was used to guide the exploration HCPs’ perceptions and experiences regarding patient care near the end-of-life. Interviews were digitally recorded and transcribed, with participants given the option to review their transcripts, though none chose to do so.

Data collection lasted from September to November 2019, continuing until saturation was reached (Guest et al., 2020). Eleven HCPs in individual (n = 8) and group (n = 1) settings were interviewed (see Table 1). Most participants were nurses, with one social worker. Interviews averaged 19 min each, with the duration ranging from 10 to 39 min. The mean age of participants was 36, with two identifying as male and nine as female.

Participation in this study was voluntary. The health service organization granted permission for interviews to take place during work hours. Ethical approval for the study was obtained from the Health Service (HREC/18/QGC/206) and University (GU Ref No: 2018/787). Reflection is integral to HCP practice however, discussing topics like death and dying can be challenging. Participants experiencing discomfort during or after the interview were encouraged to contact their employee assistance program or their own general practitioner.

The data analysis process used in this research involved a two-stage combination of inductive and deductive approaches (see Figure 2), adapted from Naeem et al. (2023). To ensure trustworthiness, the analysis was conducted by two members of the research team, and detailed records were maintained to provide transparency (Graneheim and Lundman, 2004), as illustrated in Table 2 – Stage 1 Topics and Resultant Themes, and Table 3 – Stage 2 Convergent Themes. A preliminary stage of the process consisted of a review of each interview transcript whilst concurrently listening to the digital audio recording for the dual purposes of checking the transcription for accuracy and enabling the researcher to take note of verbal cues that may be lost in a written transcription including pauses, tone, expression and emphasis (Onwuegbuzie and Byers, 2014). Notes were added to the written transcription as needed to reflect these verbal cues.

Stage 1 of the data analysis process followed the manual inductive coding approach described by Naeem et al. (2023), where interview transcripts were read and reread, with brief topic notes describing content initially written on the transcript. Topic notes were then transcribed into a Word document with exemplar quotations. Topics representing similar content were grouped. Regular meetings were held to discuss the data and analysis. Through an iterative process of analysis, a review and revision of the topics emanating from the data occurred until consensus was reached amongst the team. The team then followed a similar process to group the topics into what are termed here as themes. The topics and the themes are presented in Table 2.

In Stage 2 of data analysis, the results of the inductive coding analysis presented in Table 2 underwent a deductive process (Elo and Kyngäs, 2008). Here, the research team applied the TMSC discussed in the literature review as a framework to analyse the themes identified in Stage 1. As outlined in the literature, the TMSC facilitates a time-based logic in analysis, wherein situational “stressors” are first identified, followed by appraisal, coping strategies and finally outcomes. Regular team meetings were held to discuss this stage of analysis, allowing for review and revision as needed to achieve consensus. The goal of Stage 2 was to deductively identify common threads, termed “convergent themes”, across the Stage 1 results, using the four components of the TMSC as a framework (refer to Figure 2). The findings of the Stage 2 analysis, presented in Table 3, informed the structure of the Findings section, organized under the TMSC headings: Stressors, Appraisal, Coping Strategies and Outcomes.

By examining HCPs perceptions of caring for patients at the end-of-life and their families, we seek to provide insight into the complexities of vulnerability within this specific context. As noted above, the findings section is structured around the convergent themes identified within the TMSC framework and set out in Table 3.

When examining the factors contributing to stress, three key areas emerged: family emotional unpreparedness, personal challenges in delivering end-of-life care and organizational constraints and delays.

The lack of family emotional preparedness in facing end-of-life situations is a significant source of stress for HCPs. Despite recognizing the necessity of emotional readiness for effective communication, HCPs often express frustration and concern due to families’ lack of preparedness. For instance, one HCP emphasized the ineffectiveness of conversations when families are emotionally unprepared, stating, “If they’re not emotionally prepared... Nothing will sink in” (#4). This highlights the challenge HCPs face in engaging families who are emotionally unavailable, leading to efforts that may not yield fruitful discussions. HCPs encounter resistance or denial from patients and families regarding end-of-life planning, further complicating conversations and decision-making processes. The frustration of HCPs is evident in encounters where patients reject discussions about end-of-life care plans despite their deteriorating health status, as recounted by a nurse unit manager (#3). This disconnect between HCPs’ intentions and patients’ perceptions highlights the challenges in facilitating end-of-life conversations.

HCPs often experience heightened anxiety among families, which complicates discussions about prognosis and future care options. As expressed by a registered nurse, “I find a lot of the challenges [lie in] their [the family] anxiety and trying to calm them down and their understanding of the diagnosis” (#5). This emotional distress can impede interactions and adds to the burden of HCPs who strive to provide support and guidance in difficult situations. While some HCPs may perceive themselves as desensitized to death and dying, this perspective can inadvertently exacerbate stress for families. One social worker acknowledged this, stating, “Just because we’re used to it, for most people it’s the first time they’re experiencing it” (#2). This recognition highlights the importance for HCPs to navigate conversations with sensitivity, considering the emotional impact on families experiencing end-of-life situations for the first time. Furthermore, societal perceptions and fears surrounding death contribute to the complexity of end-of-life conversations. A number of the HCPs interviewed here observed that societal beliefs often influence preferences for care settings, with many patients and families defaulting to hospitals for end-of-life care (#8, #9, #10). This perception not only challenges HCPs’ efforts to explore alternative care options but also reflects broader societal misconceptions about end-of-life care.

The lack of family emotional preparedness in facing end-of-life situations poses a significant source of stress for HCPs, who encounter resistance, denial and heightened anxiety among families, complicating discussions and decision-making processes despite their recognition of the necessity for emotional readiness in effective communication.

Personal challenges for HCPs significantly contribute to stress in end-of-life situations. HCPs often grapple with personal biases and the challenge of navigating individual journeys while providing care, leading to increased stress levels. One HCP candidly expressed this struggle, stating:

These internal struggles can reduce communication effectiveness and add to the emotional burden of HCPs. Furthermore, the importance of self-awareness and clear intent in end-of-life communication highlights the complexities HCPs face in addressing sensitive topics. According to one HCP, “What works? Firstly, as a clinician, you need to have a very clear understanding of your strengths, your vulnerabilities and you need to have a very clear intent” (#3). This necessitates constant self-reflection and evaluation, adding an additional layer of stress to an already emotionally taxing environment.

Concerns about staying within the scope of practice further exacerbate stress, as HCPs strive to balance patient needs with professional boundaries. As one participant highlighted, “As a nurse, I find it challenging because we don’t want to say something that’s out of our scope” (#8). The fear of overstepping professional boundaries or delivering care beyond their expertise weighs heavily on HCPs, impacting their confidence and adding to their stress. A participant voiced this concern, stating, “As a nurse, the biggest challenge I’ve got is... I’m not comfortable really broaching that topic with a patient unless the medics have started the process first” (#3), underscoring how communication barriers contribute to HCPs stress and impact patient care.

Personal challenges significantly contribute to stress of HCPs involved in end-of-life care, as they grapple with biases, navigate individual journeys and balance professional boundaries, ultimately impacting communication and adding emotional burden to an already complex environment.

The study findings show how organizational constraints and delays act as significant stressors for HCPs, impacting the provision of end-of-life care. These challenges were explained through medical team dynamics and communication obstacles, and timeliness and challenges in recognizing end-of-life needs.

Participants revealed how medical team dynamics and communication barriers exacerbate stress. The perception that general medicine views end-of-life care as a palliative specialty reflects systemic constraints, intensifying stress among HCPs. As one participant expressed, “General medicine does not see itself as doing end-of-life care... They don’t have the personal value set, the professional tools or the willingness to engage early” (#3). This attitude not only impedes early action but also complicates timely discussions about end-of-life care preferences and needs, adding to an HCPs’ emotional burden. Additionally, challenges in initiating end-of-life discussions within medical teams highlight communication obstacles, leading to hesitancy in addressing sensitive topics.

Participants expressed frustrations with the lack of timeliness and challenges in recognizing end-of-life needs caused by delayed recognition and initiation of appropriate end-of-life care, further exacerbating an HCPs stress. The practice of aggressively treating patients rather than prioritizing their end-of-life wishes prolongs suffering and again adds to HCPs emotional burden. As one participant noted, “A lot of patients come in... They are aggressively treated to maintain life rather than starting the care of the dying or the end-of-life care sooner” (#1). Additionally, the delayed identification of patients at the end of life within medical teams underscores systemic challenges in timely care delivery, intensifying HCPs stress. This delay not only impedes patient-centred care but also adds to the emotional burden experienced by HCPs. As one participant lamented, “That’s probably our biggest frustration... Whilst the patient continues to slowly deteriorate” (#3), indicating how delayed recognition of end-of-life needs amplifies stress and impacts the quality of care provided.

Organizational constraints, delays and communication barriers significantly impact HCPs, particularly in recognizing and addressing end-of-life needs, exacerbating stress levels and hindering timely and patient-centred care delivery.

Appraisal involves the dynamic and ongoing process where the individuals assess their coping abilities, resources and options in response to changes in a situation. For HCPs, ongoing reassessment of coping strategies and resources is essential to effectively navigate the complexities of end-of-life care.

In the context of the stress and coping model, the identified challenges represent a secondary appraisal for HCP where they evaluate their ability to cope with the demands presented by financial constraints and limited community resources for end-of-life care. One participant explained it this way:

Financial constraints for families in accessing additional resources, such as hiring care services, pose significant stressors for HCPs. The inability of families to afford such services not only places additional caregiving responsibilities on HCPs but also hinders their ability to provide optimal care due to resource limitations. This creates a secondary appraisal where HCPs must assess how they can navigate these barriers while assisting patients to achieve their care goals.

Similarly, the lack of resources for nursing care in the community exacerbates the burden on HCPs, as they may need to compensate for the deficiencies in community support systems. This can lead to increased workload and emotional strain as HCPs strive to meet the needs of patients and families with limited resources available. The impact of family members’ work commitments on providing care adds another layer of complexity for HCPs to navigate. Balancing the demands of caregiving with work responsibilities may require HCPs to explore alternative care arrangements or provide additional support to families, further contributing to their appraisal of the situation.

One notable challenge occurs from the rapid decline or instability of patients, leading to their inability to be transferred to home, presenting HCPs with a secondary appraisal of their capacity to provide appropriate care in situ. As expressed by a social worker:

Furthermore, families are generally not equipped to provide end-of-life care at home, which adds complexity to HCPs’ appraisal process. When families are ill-equipped to handle the challenges of end-of-life care in a home setting, HCPs must evaluate their ability to support and educate families effectively, potentially requiring additional resources and support services. As a nurse unit manager stated, “Just maybe the thought of the lack of support they might get at home, might have been a barrier” (#8). The challenges faced by older carers introduces a secondary appraisal for HCPs regarding the adequacy of support available to both carers and patients. Another participant mentioned, “Because, quite often the main carer for someone who’s older will be old themselves, in which case that becomes problematic in terms of providing the end-of-life” (#2).

The inability of health services to provide rapid response and increased care at home amplifies the stressors for HCPs, who must evaluate their capacity to manage escalating patient needs within existing resource constraints. Reflecting on this, another nurse unit manager noted:

The challenge of rapidly declining or unstable patients poses a significant hurdle for HCPs, prompting a reassessment of their ability to provide suitable care onsite. Additionally, the inability of health services to respond promptly contributes to the complexity of end-of-life care, necessitating careful evaluation of available resources and support services.

In response to stressors, individuals employed coping strategies that were transformative, such as person-centred care that prioritized understanding patients’ needs, preferences, and values. Alternatively, some strategies were non-transformative, including HCPs demonstrating limited accountability due to knowledge gaps from shift work, relying on protocols, deferring end-of-life care decisions to doctors and fearing the consequences of exceeding professional boundaries.

HCPs alleviate stress by empowering patients and families in end-of-life discussions, avoiding information overload and fostering meaningful dialogue. Understanding individual preferences and cultural considerations helps tailor support, reducing HCP stress and provide effective communication. HCPs employ strategies aimed at fostering open and honest discussions about end-of-life care. By equipping families with resources and allowing them to steer conversations, HCPs seek to relieve their own stress while ensuring patients and families feel empowered and well-informed. This approach acknowledges the risk of overwhelming families with information and instead emphasizes the importance of meaningful dialogue, as expressed by a registered nurse:

HCPs recognize the pivotal role of effective communication among patients, families, and doctors in facilitating end-of-life discussions. Patients who have comprehensive discussions with their doctors are more inclined to engage in conversations about their prognosis and available support options. HCPs leverage these interactions to ensure patients and families feel supported and well-informed, thereby reducing their own stress levels. As one participant explained:

Patient and family-centred communication serves as a coping strategy for HCPs, enabling them to navigate challenging end-of-life discussions while ensuring patients and families receive the support and information they need.

Understanding individual preferences in end-of-life care serves as a coping strategy for HCPs, providing them with a framework to navigate challenging conversations and decisions. They recognize that diverse beliefs, cultural considerations and family dynamics influence individuals’ preferences regarding care location and end-of-life experiences. Patient beliefs and their comfort level discussing death were highlighted as significant factors affecting end-of-life care preferences. As one participant noted:

This understanding enables HCPs to tailor their approach to each patient’s needs, potentially reducing their own stress levels. Cultural considerations emerge as crucial in shaping preferences for end-of-life care locations. Participants acknowledge that cultural norms may influence individuals’ preferences, providing HCPs with insights to navigate culturally sensitive discussions and decisions.

HCPs reduce stress by empowering patients and families in end-of-life discussions, tailoring support to individual preferences and cultural considerations and fostering open dialogue, acknowledging the pivotal role of effective communication among patients, families and doctors in facilitating these discussions and serving as a coping strategy for HCPs in navigating challenging conversations and decisions.

Enhanced staff competence and confidence was key for some HCPs, evolving from initial apprehension to eventual proficiency and assurance. Continuous education and training in end-of-life care emerged as important as HCPs highlighted the significance of ongoing learning initiatives. Through active participation in projects, simulation sessions and specialized modules, HCPs sought to augment their knowledge and skills in end-of-life care. For instance, one participant expressed their proactive approach, stating:

Additionally, another participant underscored the necessity for training, particularly for addressing the challenges encountered by junior staff members. Reflecting on this, they remarked:

By actively seeking opportunities to enhance skills and knowledge, individuals empower themselves to better navigate challenging circumstances and build resilience in their professional roles, for example, a registered nurse reflected:

Enhanced staff competence and confidence in end-of-life care evolve through continuous education and training initiatives, enabling HCPs to navigate challenges and build resilience in their professional roles.

HCPs have limited accountability in end-of-life care which serves as a coping mechanism to mitigate the emotional burden, preserve professional boundaries and minimize stress. By avoiding direct involvement in difficult decisions and discussions, staff can protect their well-being and maintain team dynamics. In some cases, HCPs adopted a defensive stance towards end-of-life care, resorting to established protocols rather than engaging in nuanced discussions with patients and families. Reflecting on this, one participant stated, “I suppose it’s knowing how much you can kind of talk to them without making them uncomfortable. [...] It still makes me uncomfortable” (#7). This quote highlights the discomfort HCPs may experience when navigating sensitive end-of-life discussions, leading them to rely on established procedures as a form of self-preservation.

HCPs may harbour fears of working beyond their professional scope and concerns about personal and professional risks associated with end-of-life care. One participant articulated this saying, “Where I really get exhausted quite quickly is so many of the problems are outside of my scope of practice... That I struggle with my personal and professional despair” (#3). This quote emphasizes the psychological toll of grappling with the complexities of end-of-life care and the fear of potential repercussions for stepping beyond professional boundaries.

Some transferred accountabilities by referring to the nature of shift work that hampers HCPs ability to acquire comprehensive knowledge about patients’ conditions and preferences. As one participant expressed, “I guess, I didn’t really get any [patients at end-of-life] – because with the shift work…” (#7). This quote underscores how the transient nature of shifts can impede continuity of care and leave HCPs uninformed about important aspects of patient care.

HCPs tend to assume limited accountability for end-of-life care as a coping mechanism to manage emotional burden, preserve professional boundaries, and minimize stress, often resorting to established protocols rather than engaging in nuanced discussions with patients and families to protect their well-being and maintain team dynamics, while harbouring fears of working beyond their professional scope and concerns about personal and professional risks associated with end-of-life care.

In this section, attention is directed towards the outcomes of the coping strategies HCPs used (or not) to manage the stressors they report as inherent in end-of-life care. These outcomes for patients and HCPs serve as indicators of the efficacy of the coping mechanisms deployed and their impact on the quality of care provided. In turn, they evidence the ability of the HCP to (not) take on a TSP role and (not) provide transformational care.

Improved person and family involvement in decision-making was achieved through person-centred care. The evolving role of families in patient care and the decision-making processes, underscoring their increasing importance over time, was highlighted. As patients’ health conditions evolved, HCPs recognized the growing significance of involving families in decision-making and support. According to nurses, “We observed that as patients’ conditions changed, the family became increasingly important in decision-making. It was crucial to involve them in discussions and ensure they understood the options available” (#9, #10, #11). Likewise, as patients’ health deteriorated, the involvement of families became even more critical, as highlighted by a social worker, “As the patient’s condition worsened, we prioritized family involvement in decision-making. It was essential to provide them with the necessary support and information to make informed choices” (#2). This excerpt emphasizes the vital role of families in care planning and decision-making, emphasizing the need for effective communication and support. Additionally, participants emphasized the importance of open communication with patients and their families, especially in challenging situations, as noted by a social worker:

Furthermore, early preparation and planning for end-of-life emerged as crucial aspects of family engagement. As expressed by a registered nurse, “We should have been thinking about being able to offer to people the opportunity to spend their final few days at home surrounded by loved ones” (#11). This quote illustrates the significance of providing comprehensive support to patients and their families to ensure a dignified and comfortable care experience.

The perceived depersonalization of care within the wards arose from several interconnected factors, each of which diminished the quality of patient-provider interactions and potentially adversely affects patient outcomes.

HCPs inability to draw on coping mechanisms due to shift work and limited knowledge, contributed to a sense of detachment from patients’ individual needs and preferences. When HCPs were constrained by rigid schedules and lacked comprehensive understanding of patient histories, they resorted to standardized protocols rather than engaging in personalized care approaches. Additionally, a reluctance among HCPs, particularly doctors, to take personal responsibility for patient care decisions further exacerbated depersonalization. By deferring decisions to others and avoiding difficult discussions, such as those surrounding end-of-life care, HCPs inadvertently distanced themselves from patients’ emotional and psychological needs. Communication barriers also played a significant role in depersonalizing care. Delays in providing prognoses, driven by uncertainties and fears of alarming patients, hindered transparent and open communication between patients and providers.

The reluctance to initiate changes in care plans, particularly concerning end-of-life care, perpetuated depersonalization. As stated by a registered nurse:

Similarly, a nurse unit manager confirmed:

This delay in addressing patients’ needs and preferences led to frustration and confusion among HCPs, reinforcing the depersonalization of care.

In end-of-life care, HCPs often face multifaceted challenges that extend beyond clinical responsibilities, impacting their overall well-being. These challenges encompass emotional discomfort, professional limitations and systemic barriers, all of which contribute to the complex landscape of providing compassionate care during life’s final stages. In the face of these challenges, staff well-being often becomes compromised.

The evidence from the interviews underscores the profound emotional and professional strain experienced by HCPs when engaging in end-of-life discussions. Statements like “It still makes me uncomfortable” (#7) and “I struggle with my personal and professional despair” (#3) shed light on the nuanced emotions that accompany navigating sensitive end-of-life situations. These sentiments illustrate the need for holistic approaches to support staff members, acknowledging the emotional labour inherent in their roles and providing avenues for coping and self-care.

Conversely, there were indications that investment in professional development initiatives can yield positive outcomes for staff well-being. Testimonies such as “I’ve learnt a lot... So that was a really good resource” (#1) highlight the transformative impact of education and training on HCPs’ confidence and competence. By equipping staff with comprehensive skills and knowledge, organizations empower them to navigate complex end-of-life situations with greater efficacy, thus mitigating feelings of professional inadequacy and distress.

Using the TMSC, the research aimed to explore secondary vulnerability among HCPs caring for end-of-life patients, with a specific focus on developing a conceptual framework to understand how coping strategies, used to address vulnerability, support an HCPs likelihood of assuming a TSP role. Based on the research findings and applying the TMSC as a guiding framework, the research demonstrates how external stressors (such as family emotional unpreparedness, organizational constraints and delays) and internal stressors (including personal challenges in delivering end-of-life care) led HCPs to perceiving a level of secondary vulnerability in their provision of care for end-of-life patients. Consequently, HCPs needed to rely on their coping strategies (such as promoting person-centred care and communication, enhancing staff competence and confidence, and accepting limited accountability) to manage the service interaction. If adequate coping strategies were available, HCPs could provide transformational care to patients drawing on five transformational factors: 1. Providing resources and support for families; 2. Encouraging open communication with patients and families; 3. Considering patient and family preferences; 4. Addressing junior staff needs; and 5. Promoting education and training. This, in turn, could lead to more positive well-being and organizational outcomes. Consistent with the work of Johns and Davey’s (2019) suggestion that TSMs have the capacity to change inputs through their involvement, leading to transformative service outcomes, in this instance, HCP can take the role of TSP representing a shift towards a more patient-centred approach to care, as depicted in Figure 3.

This study provides three significant theoretical contributions to the services marketing literature. The first contribution is the proposal of a theoretical framework of secondary vulnerability as well as a definition of secondary vulnerability. Prior to this, vulnerability research had largely been restricted to consumer vulnerability (Riedel et al., 2021; Raciti et al., 2022) with some more recent articles starting to identify and conceptualize that other actors in a service interaction might also experience vulnerability such as FLEs (Riedel et al., 2023). The study also takes a distinctive approach by identifying that FLEs (HCPs) who support vulnerable consumers (end-of-life patients) might also experience a form of secondary vulnerability. Secondary vulnerability can arise specifically from the tasks that FLEs perform in their roles supporting consumers experiencing vulnerability.

This paper makes a significant theoretical contribution by introducing secondary vulnerability as a critical extension of vulnerability theory within service contexts (Figure 1). It broadens existing frameworks by recognising the interconnected nature of service relationships, where the vulnerability experienced by one actor, such as end-of-life patients, can transfer and manifest as harm to another actor, specifically FLEs like HCPs. By applying this framework to the high-pressure environment of end-of-life care, this study empirically demonstrates that secondary vulnerability can negatively impact an HCP well-being and lead to depersonalized care practices. This insight extends the work of Verleye and Holvoet (2024), who highlighted the benefits of empowering practices for consumer well-being, by revealing that such practices may unintentionally compromise the well-being of HCPs. This paper offers a novel theoretical lens that bridges vulnerability theory and TSR, emphasising the need for dual strategies that support both consumers and service providers. Future research should deepen this conceptual development by identifying specific drivers of secondary vulnerability and designing targeted interventions to reduce its occurrence and impact.

Although the current research focussed on secondary vulnerability in the healthcare setting, it is important to note that secondary vulnerability is likely to be experienced in other service contexts of high emotional labour (Riedel et al., 2023; Erickson and Grove, 2008; Mann, 2005), such as funeral services, law enforcement, emergency services and teaching. Similar to the findings of this research, it is likely that secondary vulnerability will occur in these other service contexts when stressors are high and coping strategies are low. Future research could investigate secondary vulnerability in these other service contexts as well as explore the use of coping strategies such as journaling as a method for FLEs to reflect on their secondary vulnerability. By documenting their emotional responses and experiences related to consumer interactions, this approach could help identify patterns of stress and coping strategies, providing valuable insights into how secondary vulnerability impacts their well-being and service delivery.

The second theoretical contribution this paper makes is to extend the work of Johns and Davey (2019). They initially proposed the concept of TSM and suggested that individuals external to a service organization in mediating roles could significantly impact service outcomes through their involvement. This study proposes that FLE’s who interact with consumers who are experiencing vulnerabilities and have the required coping strategies to deal with the stressful situations they encounter, are in a position to take on a TSP role. Thus, proposing and empirically establishing that an HCP’s coping strategies while working in a mediating role, particularly when experiencing secondary vulnerability, determine their ability to provide transformative service and what we term taking on a TSP role. This understanding of TSPs is crucial, as is the identification that it is the ability of the FLE to draw on coping strategies to deal with a stressful situation that underpins the likelihood an FLE will take on a TSP role. This lays the groundwork for further investigation into supporting FLEs and reducing their vulnerability, thereby increasing the likelihood of exceptional consumer support and transformative service outcomes. Future research should explore this phenomenon by identifying situations where HCPs experience vulnerability and which coping strategies facilitate the transition to TSP. Similar to the identification of transformational factors (see Figure 3) for a TSP role in end-of-life care, future research could explore other complex and intangible service contexts to uncover both unique and shared attributes.

The third and final theoretical contribution is that this research synthesizes diverse literature from services (Johns and Davey, 2019), vulnerability (Riedel et al., 2023), psychology (Lazarus, 1966), and healthcare (Bloomer et al., 2023), to propose a theoretical framework of secondary vulnerability (Figure 1). This interdisciplinary approach enabled a more comprehensive understanding of how a FLE, when engaged in service interactions where consumers may experience vulnerability, may become more vulnerable and in turn, be susceptible to harm. By drawing on these varied fields, the research developed the Comprehensive Model of HCPs as TSPs in End-of-Life Care (Figure 3). In doing so, the research proposed that FLEs, and in the context of this research, HCPs, experience stressors and it is their appraisal of these stresses and availability of coping resources that determine their experience of vulnerability and in turn, service outcomes. Building on findings from O’Loughlin et al. (2024), future research could explore the potential for the persistence of secondary vulnerability among HCPs, particularly in contexts like end-of-life care, where complex and ongoing demands may exacerbate this vulnerability over time. It is hoped that the comprehensive model of HCPs as TSPs in End-of-Life Care will serve as a foundation to encourage further exploration of this dynamic and intricate service experience.

This study has significant implications for HCPs and health service managers. Particularly, the transformation enablers outlined in the comprehensive model presented in Figure 3 provide guidance in three broad areas on the actions to take that could minimize the negative outcomes and alleviate secondary vulnerabilities. First, healthcare organizations should prioritize comprehensive training and support programs for HCPs involved in end-of-life care. These initiatives should include effective communication strategies, cultural competency training and coping mechanisms for managing emotional challenges (Bloomer et al., 2023). Evidence suggests that end-of-life education through workshops, simulations and online learning improves attitudes towards care of dying patients and equips HCPs with the necessary skills for complex situations (Chua and Shorey, 2021; Martin et al., 2022). Integrating formal debriefing and informal support strategies is essential for facilitating effective coping strategies and should be embedded in organizational practices (Bloomer et al., 2023; Carlini et al., 2023). Recognizing the heterogeneous needs of HCPs, based on their type of employment or shift work, is crucial. Part-time or shift employees may require tailored training and support approaches due to their different levels of engagement and availability (Lo Iacono et al., 2024). Future research should assess the effectiveness of educational interventions for HCPs providing end-of-life care in acute care settings.

Second, efforts should be directed to promoting person-centred care by involving patients’ families in decision-making and care planning (Hatzikiriakidis et al., 2023). Clear, timely and effective communication from HCPs helps families identify their roles in end-of-life care, fostering person-centred care and shared decision-making (Walker et al., 2023). Actively involving families in care discussions and providing support reduces stress and ensures that patient preferences are honoured. In addition, healthcare organizations must address systemic barriers impacting end-of-life care. This includes improving communication among multidisciplinary teams, optimizing end-of-life discussions and ensuring adequate resources for timely, patient-centred care (Hatzikiriakidis et al., 2023; Carvajal et al., 2019). Co-designing services with HCPs and consumers can help address organizational challenges, creating a supportive environment for high-quality care (Carlini et al., 2024; Hatzikiriakidis et al., 2023). Fostering transparency, collaboration and continuous improvement within healthcare is essential.

Third, healthcare organizations should prioritize promoting self-care and well-being initiatives for HCPs involved in end-of-life care. By fostering staff well-being through robust support mechanisms and a wellness culture change (Melnyk, 2022), healthcare organizations can address the challenges staff face in providing end-of-life care. Interventions supporting HCPs in demanding clinical environments may improve well-being and staff retention (Lovell et al., 2023a; Carvajal et al., 2019). Furthermore, HCPs need to cultivate self-awareness to identify stressors and coping strategies for self-care (Bloomer et al., 2022). Organizations can facilitate this by encouraging staff to recognize and improve their internal resources through self-assessment tools. This awareness can help staff care for themselves, creating a more resilient workforce equipped to provide compassionate and effective care (Maresca et al., 2022). Future research should evaluate self-care and well-being initiatives for HCPs in end-of-life care to inform practice development and strategy implementation.

While this study offers a number of significant insights, several limitations warrant consideration. The perspectives gathered are exclusively from HCPs within a single tertiary hospital in Australia, limiting the transferability of the findings beyond this specific context. This study involves a small sample of 11 HCPs, with interviews averaging 19 min in adult acute wards. While short interviews are common when discussing sensitive topics, conducting group interviews could enhance participation and extend interview length, allowing HCPs to share insights and build on each other’s responses, leading to more in-depth discussions. As work-related stress and burnout are pervasive across various healthcare disciplines, the implications of this research may extend beyond end-of-life care setting, offering insights applicable to other HCPs facing similar challenges. These limitations underscore the importance of interventions tailored to address distress and foster resilience among HCPs. While participants exhibited various coping strategies, there is a need for additional strategies to enhance their capacity and confidence in their roles.

In conclusion, this study advances the conceptualization of secondary vulnerability and its implications, shedding light on the dynamics of stress and coping mechanisms in vulnerable situations. By recognizing the interplay between situational and personal factors, this research contributes to understanding service outcomes for both HCPs and patients, emphasizing the need for targeted interventions to support HCP well-being and person-centred care outcomes.

This paper forms part of a special section “Service Marketing for Good”, guest edited by Sven Tuzovic, Jörg Finsterwalder and Marjan Aslan.

Thank you to Clinical Excellence Queensland for funding the broader Supporting Discharge from Hospital to Enable Dying at Home project. We extend appreciation to the project committee members and the project lead Laurie Grealish.