Interprofessional Collaboration Under Pressure: How Nurse Burnout and Workload in Terminally Ill Patients’ Wards Affect Physician-Nurse Team Dynamics and Palliative Care Outcomes in Pakistani Tertiary Hospitals

INTRODUCTION

The noble nature of the nursing profession has long been recognized as one that “serves the ailing humanity in hospitals with willpower,” dedicating entire professional lives to those who are sick, injured, or wounded and requiring unique care delivered with love and sympathy. Patients consistently report higher confidence and trust in nurses than in doctors during terminal phases of illness. Yet, this idealized role collides harshly with ground realities in Pakistani public-sector hospitals. Chronic understaffing, excessive workload and systemic neglect have created a perfect storm of nurse burnout, directly undermining the quality of Inter-Professional Collaboration (IPC) between nurses and physicians the very foundation of effective palliative care delivery [2].

Interprofessional collaboration is internationally recognized as the gold-standard model for palliative and end-of-life care. It requires seamless communication, mutual respect, shared decision-making and coordinated action among physicians, nurses and other allied health professionals to achieve holistic outcomes: optimal symptom control, dignified death, reduced family distress and lower rates of moral distress among providers. In theory, Pakistani tertiary hospitals promote such teamwork. In practice, however, the daily pressures on frontline nurses erode the very conditions necessary for IPC to flourish [3,4]. The present study draws heavily on primary empirical evidence from Hamna Zulifqar’s quantitative survey conducted in the seriously ill patients’ wards of Civil and Allied Hospitals, Faisalabad. Using simple random sampling, the study captured responses from 105 nurses (49 from Civil Hospital and 56 from Allied Hospital) working morning and evening shifts across high-dependency units. The findings paint a consistent and alarming picture: the majority of nurses are Muslims working as regular or charge nurses on a permanent basis; they report “nice operating relationships” with fellow nurses and doctors on the surface, yet describe a cascade of minute but cumulative stressors that escalate into major professional and personal crises [5,6].

Excessive workload emerges as the single largest obstacle. Nurses in both hospitals are compelled to handle heavy patient loads amid a grave shortage of nursing staff. In Pakistan, the nurse-to-patient ratio frequently exceeds 1:3000 in public hospitals compared with the WHO-recommended 1:10 in general wards and far better ratios in high-income countries. Beyond direct patient care, nurses are burdened with ward management responsibilities: maintaining medication inventory records, preserving indent books, ensuring the security of machinery and equipment and performing countless administrative tasks that consume critical time and cognitive resources [7,8]. The acute nature of terminal care frequents emergencies, emotional labor of supporting dying patients and grieving families and exposure to lethal illnesses such as HIV/AIDS further intensifies job strain. As a direct consequence, the majority of nurses’ experience physical and mental ailments, including insomnia, dementia-like symptoms, high blood pressure, anxiety, depression and chronic fatigue. These health impacts are not abstract; they translate into delayed handoffs, reduced vigilance in symptom reporting, diminished empathy during family counseling and impaired capacity to engage in joint decision-making with physicians [9].

Compounding the clinical workload are structural and socio-cultural barriers unique to the Pakistani context. Nurses receive insufficient medical allowances, face grievances over the pension system and perceive themselves as chronically underpaid. They are denied “difficult area” allowances for remote postings and MDR (Medical Disaster Relief) allowances even when caring for patients with highly infectious and lethal diseases. Night shifts create acute childcare conflicts for mothers of newborns or young children, while inadequate paid leave prevents attendance at family functions, including religious festivals such as Eid. Societal attitudes add another layer of strain: despite working day and night with dedication, nurses report that nursing remains socially stigmatized. When they introduce themselves in social gatherings, responses range from uncertainty to outright unwanted comments. In a religiously motivated, male-dominated society, families especially in middle- and upper-class households often discourage women from entering nursing, viewing it as a “scandalous” or low-status profession involving close contact with male patients and colleagues. This cultural devaluation manifests in discouraging attitudes from in-laws, who fail to understand the profession’s demands and blame nurses for not devoting enough time to family life. Harassment at the workplace predominantly sexual, but also based on race or religion further erodes psychological safety, with many nurses expressing dissatisfaction over the inadequate response from hospital authorities [10].

Patient attendants, often family members who remain at the bedside around the clock in Pakistani public hospitals, constitute yet another major obstacle to smooth task performance and collaborative care. Nurses describe them as the “largest obstacle” to effective ward functioning, frequently interfering with clinical routines, demanding constant updates and creating additional emotional and logistical burdens. These dynamics directly affect physician-nurse team interactions: when nurses are exhausted, rushed, or emotionally depleted, they are less able to provide timely, comprehensive handovers or advocate assertively for palliative needs during rounds. Physicians, in turn, face incomplete information, delayed responses to deteriorating patients and increased frustration further straining hierarchical relationships that are already influenced by cultural norms of medical dominance [11,12].

The consequences for palliative care outcomes are profound and measurable. Effective symptom management (pain, dyspnea, nausea), psychosocial support for families, advance-care planning and dignified end-of-life care all depend on a well-functioning nurse-physician dyad. When burnout impairs nurses’ cognitive and emotional capacity, the entire care continuum suffers: higher rates of uncontrolled symptoms, increased family dissatisfaction, avoidable readmissions and moral distress among both professions. In resource-constrained tertiary hospitals like those in Faisalabad, where dedicated multidisciplinary palliative teams are virtually non-existent, the physician-nurse partnership becomes the de facto delivery mechanism for palliative care. Any erosion in this partnership therefore has outsized negative effects.

This research article reframes the rich primary data from Zulifqar’s thesis through the explicit lens of interprofessional collaboration under pressure. By integrating the survey’s descriptive statistics, chi-square associations and qualitative insights with recent empirical literature from other Pakistani tertiary centers (including oncology and palliative units in Karachi and Islamabad), the study demonstrates how nurse burnout and workload function as upstream determinants of dysfunctional team dynamics and suboptimal palliative outcomes. It also speaks directly to medical students and residents undertaking clinical rotations in oncology, palliative and high-dependency wards. These learners witness the strained collaborations daily missed opportunities for joint rounds, hurried handovers and missed psychosocial cues yet rarely receive structured training on how to mitigate these pressures. The article therefore proposes simple, low-cost, student-led interventions (structured joint ward rounds, brief shared debriefing sessions and advocacy for basic staffing improvements) that can be tested and scaled even within the constraints of undergraduate and postgraduate training.

In summary, the introduction of this article establishes the critical intersection of nurse well-being, inter-professional teamwork and palliative care quality in Pakistan’s public tertiary hospitals. It grounds the discussion in robust primary evidence from Faisalabad’s Civil and Allied Hospitals while highlighting the broader national and global relevance. The subsequent sections will present a detailed literature review, conceptual framework, methodology, results, discussion of implications and actionable recommendations ultimately arguing that protecting nurse well-being is not merely a workforce issue but a fundamental prerequisite for humane, effective and sustainable palliative care in Pakistan.

Literature Review

The literature on nurse burnout, workload, Inter-Professional Collaboration (IPC) and palliative care outcomes reveals a consistent global and local pattern: frontline nurses in high-acuity, terminally ill patient wards face disproportionate emotional and organizational strain that directly impairs team dynamics and patient-centered care. This section synthesizes international evidence with Pakistan-specific studies, including the foundational quantitative data from Hamna Zulifqar’s thesis on nurses in Civil and Allied Hospitals, Faisalabad. It highlights how excessive workload, staff shortages and socio-cultural barriers erode the nurse-physician partnership essential for effective palliative care [13].

Global Context of Burnout in Palliative Care Nursing

Palliative care nursing is uniquely demanding because it requires repeated exposure to death and dying, intense emotional labor and the delivery of holistic (physical, psychosocial and spiritual) support to patients and families. A systematic review and meta-analysis of 15 studies involving palliative care nurses found prevalence rates of emotional exhaustion (EE) at 24%, depersonalization at 30% and low personal accomplishment at 28%. Workload exceeding 8 hours per day and lack of organizational support emerged as the strongest predictors. A thematic synthesis of qualitative studies further described burnout as a deeply personal experience manifesting in physical fatigue, anxiety, emotional detachment and moral distress, often exacerbated by inadequate preparation for end-of-life conversations [1].

Recent surveys reinforce these findings. In specialized hospice and palliative settings, 78% of nurses reported moderate-to-high compassion fatigue, with burnout subscale scores higher than secondary traumatic stress. Factors such as age, marital status, clinical experience and monthly patient deaths significantly influenced severity. A 2023 scoping review of hospice and palliative care nurses identified three overarching categories of burnout contributors: personal factors (e.g., empathy overload), organizational/workplace issues (e.g., high caseloads, shift work) and professional development gaps (e.g., limited palliative-specific training). Globally, 73% of palliative care nurses experience moderate-to-high burnout, with negative correlations to coworker support and leadership quality. These patterns are amplified in resource-limited settings where palliative care is delivered primarily by generalist nurses rather than specialized teams, leading to role overload and reduced resilience [14].

Pakistani Evidence on Nurse Workload, Stress and Burnout in Terminally Ill Wards

The Zulifqar thesis provides direct, localized evidence from 105 nurses (49 from Civil Hospital, 56 from Allied Hospital) working in seriously ill patients’ wards in Faisalabad’s public tertiary hospitals. Excessive workload was identified as the paramount issue: nurses managed heavy patient loads amid acute staffing shortages (often 1 nurse per 3000+ patients nationally, far exceeding WHO recommendations). In addition to clinical duties, they performed ward management tasks medication inventory, indent books and equipment security while facing patient-attendant interference as the “largest obstacle” to performance. The majority reported job strain leading to insomnia, high blood pressure, anxiety, depression and family disruption (e.g., children’s education affected, inability to attend Eid or other functions). Societal stigma, underpayment, absent allowances (medical, difficult-area, MDR for HIV/AIDS patients), night-shift childcare conflicts and workplace harassment (predominantly sexual) compounded the burden. Despite “nice operating relationships” with doctors, these cumulative stressors created major barriers to effective care [3,15].

Recent Pakistani studies echo and extend these findings. In a qualitative study of oncology nurses at Aga Khan University Hospital (AKUH), Karachi, participants described profound work-related stress from caring for terminally ill patients, including emotional attachment, high death rates, chemotherapy administration pressures and fatigue. Burnout manifested as emotional exhaustion, reduced job satisfaction and compromised patient care quality. Nurses called for specialized palliative training and supportive environments to mitigate these effects. A 2026 cross-sectional study at Saidu Teaching Hospital, Swat, found moderate-to-high workload and burnout in most nurses, with strong positive correlations between the two variables and negative correlations to evidence-based compassionate care [6,16,17].

Nationwide data further illustrate the crisis. In KPK tertiary hospitals, 36% of nurses reported high burnout, primarily due to staff shortages and rising patient volumes; emotional intelligence was positive overall, but insufficient to buffer workload demands. During the COVID-19 pandemic, 48.6% of Pakistani nurses experienced burnout, with 45% reporting psychological distress; public-hospital nurses and those handling higher patient loads were disproportionately affected. A 2025 report on International Nurses Day highlighted that 79% of Pakistani nurses suffer severe burnout and diminished quality of life, linking this to 1:12 nurse-patient ratios in many public wards and chronic under-resourcing. Knowledge gaps in palliative care are also widespread: in Peshawar tertiary hospitals, only 31.8% of nurses demonstrated good palliative care knowledge, with post-RN nurses faring better than BSN or MSN graduates [4,18].

These patterns align with earlier national findings. Nurses in tertiary settings frequently cite heavy workloads (1:50 ratios in some hospitals), long hours and poor compensation as drivers of stress, leading to compromised patient care and high turnover. In palliative contexts, the absence of dedicated units’ forces generalist nurses to handle complex end-of-life care without adequate training or support, amplifying emotional exhaustion.

Inter-Professional Collaboration (IPC) in Pakistani Healthcare Settings

IPC joint decision-making, communication and mutual respect between nurses and physicians is theoretically valued in Pakistani hospitals but frequently undermined by workload pressures. A cross-sectional study of 374 healthcare professionals in Islamabad-Rawalpindi hospitals found that nurses held significantly more positive attitudes toward IPC than physicians across all domains of the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (education/collaboration, caring vs. curing, nurse autonomy and physician authority). Nurses scored higher overall (mean 50.81 vs. 47.48 for physicians, p<0.01), suggesting greater openness to collaborative models [8,20].

Qualitative research in private tertiary settings reveals both facilitators and persistent barriers. In a Karachi NICU study, nurses and doctors acknowledged IPC’s importance for patient outcomes but cited hierarchical attitudes, role ambiguity, physician dominance and time scarcity as major constraints issues intensified during high-acuity palliative shifts. Similar findings emerged in Lahore hospitals, where role/leadership ambiguity and job stress were primary IPC barriers for nursing staff. In cardiac and critical care units (CICU/CCU), nurses and physicians reported positive perceptions of collaboration in theory but strained practice due to workload-induced communication breakdowns [9].

The Zulifqar thesis complements these studies: while surface-level relationships with doctors were described as “nice,” excessive workload and attendant interference prevented sustained, meaningful collaboration (e.g., timely handovers, joint palliative planning). In public tertiary hospitals like those in Faisalabad, the nurse-doctor dyad becomes the default palliative care delivery mechanism because dedicated multidisciplinary teams are rare.

Impact of Burnout and Poor IPC on Palliative Care Outcomes

Burnout and fragmented IPC directly degrade palliative care quality. Globally and in LMICs, understaffed teams delay symptom assessment (pain, dyspnea), family counseling and advance-care planning, resulting in higher patient suffering, avoidable readmissions and moral distress for providers. In Pakistan, where palliative units lack formal structures, nurse burnout translates into reduced compassionate care, increased errors and poorer family satisfaction. Studies link high workload/burnout to lower evidence-based practice and diminished patient safety/satisfaction [13].

In oncology/palliative wards, emotional exhaustion from terminally ill patients correlates with lower job satisfaction and compromised care quality. Resource constraints exacerbate this: generalist nurses without palliative training report feeling unprepared, leading to frustration, burnout and suboptimal outcomes such as unmanaged symptoms and cultural insensitivity in end-of-life discussions [11,19].

Synthesis and Research Gap

Collectively, the literature demonstrates that nurse burnout in terminally ill wards driven by workload, shortages and socio-cultural factors erodes IPC and palliative outcomes in Pakistani tertiary hospitals. The Zulifqar thesis provides granular, Faisalabad-specific evidence that has not yet been reframed through an explicit IPC-palliative lens. While global and national studies document prevalence and correlates, few integrate nurse self-reported stressors with physician perspectives or propose low-resource interventions testable by medical students during rotations. This article addresses that gap by linking the thesis data to actionable strategies for improving team dynamics and care quality [17].

This expanded review establishes the empirical foundation for the study’s conceptual framework, methodology and recommendations [16].

Conceptual Framework

This study is grounded in an integrated conceptual framework that synthesizes three complementary theoretical lenses:

• D’Amour and Oandasan’s [3], Interprofessional Collaborative Practice Framework
• Maslach’s Burnout Inventory (MBI) model of occupational burnout
• The Job Demands-Resources (JD-R) model

Together, these frameworks explain how excessive workload and systemic stressors in terminally ill patients’ wards (as documented in the Zulifqar thesis) deplete nurses’ resources, trigger burnout, erode physician-nurse team dynamics and ultimately compromise palliative care outcomes in Pakistani tertiary hospitals. The integration is particularly relevant to resource-constrained public-sector settings such as Civil and Allied Hospitals in Faisalabad, where dedicated multidisciplinary palliative teams are absent, making the nurse-physician dyad the primary mechanism for delivering end-of-life care [15].

Overview of the Integrated Model

The proposed framework posits that job demands (excessive workload, staff shortages, administrative burdens and socio-cultural stressors) act as upstream antecedents that overwhelm nurses’ personal and organizational resources. This imbalance precipitates burnout across Maslach’s three dimensions, which in turn disrupts the core elements of interprofessional collaboration (sharing, partnership, power balance, interdependency and collaborative processes). The resulting impairment in team dynamics leads to downstream deficits in palliative care quality specifically, suboptimal symptom management, reduced family-centered support, diminished patient dignity and poorer overall outcomes. Organizational and individual resources (e.g., training, support from physicians, or student-led interventions) serve as potential moderators or buffers.

Textually, the model can be represented as a sequential pathway with feedback loops:

• Job Demands (JD-R) ↓ (depletion of resources)
• Burnout (MBI: EE → DP → Low PA) ↓ (impairs collaboration)
• Disrupted IPC (D’Amour: reduced sharing, partnership, interdependency) ↓ Poor Palliative Outcomes (symptom control, family satisfaction, dignified death)
• Feedback Loops Exist: Poor outcomes increase emotional labor (further demands), while successful IPC can replenish resources and mitigate burnout

This integration draws on D’Amour et al. [3], emphasis on collaboration as a dynamic process rooted in organizational sociology, Maslach’s empirically validated burnout dimensions and the JD-R model’s explanatory power for healthcare settings. It addresses gaps noted in the literature: many IPC frameworks overlook burnout as a mediator, while burnout studies rarely link explicitly to collaborative processes or palliative-specific outcomes.

Key Theoretical Components

D’Amour and Oandasan’s Interprofessional Collaborative Practice Framework: D’Amour et al. [3], conducted a comprehensive literature review identifying five underlying concepts that define interprofessional collaboration: Sharing (information, knowledge and decision-making), partnership (mutual respect and joint accountability), power (balanced authority and reduced hierarchy), interdependency (recognition that no single profession can meet all patient needs alone) and process (ongoing interaction, reflection and adaptation). Their framework situates collaboration within broader organizational and educational contexts, arguing that interprofessionality emerges when professionals continuously interact to optimize patient and family outcomes.

A key strength is its explicit recognition that collaboration is not merely teamwork but a relational process influenced by structural factors (e.g., workload, role clarity) and cultural elements (e.g., professional hierarchies common in Pakistan). The model also highlights the need for patient/family integration into the care team often neglected in high-pressure wards. In palliative care, where holistic needs (physical, psychosocial, spiritual) predominate, these elements are critical: nurses’ frontline proximity to patients enables them to share nuanced observations with physicians, but only if burnout does not erode trust and communication [10].

Maslach’s Burnout Inventory (MBI) Model

Maslach and Jackson’s [8], MBI remains the gold-standard tool for measuring occupational burnout, particularly in human services professions such as nursing. It operationalizes burnout across three dimensions:

• Emotional Exhaustion (EE): Feelings of being emotionally overextended and depleted by work demands
• Depersonalization (DP): A cynical, detached, or callous response toward patients, families, or colleagues
• Reduced Personal Accomplishment (PA): A diminished sense of competence and achievement in one’s work

In palliative care nursing, EE and DP are typically the most elevated dimensions due to repeated exposure to death, ethical dilemmas and emotional labor. Pakistani studies (including the Zulifqar thesis) align with global patterns: high EE manifests as insomnia, hypertension and family-life disruption; DP appears as reduced empathy during handovers or family counseling; and low PA contributes to nurses’ sense of underappreciation amid societal stigma and underpayment. The MBI framework posits that burnout is not inevitable but results from chronic mismatch between demands and resources.

Job Demands-Resources (JD-R) Model

The JD-R model [2], (extended in healthcare contexts) complements the above by distinguishing job demands (physical, psychological, social, or organizational aspects requiring sustained effort, e.g., high patient-to-nurse ratios, administrative tasks, night shifts) from job resources (aspects that reduce demands, aid goal achievement, or promote growth, e.g., social support, autonomy, training, or positive physician relationships). High demands without adequate resources lead to an “energy depletion” pathway (burnout) and a “motivational” pathway (disengagement).

In palliative settings, demands such as those documented in the Zulifqar thesis excessive workload, patient-attendant interference, lack of MDR allowances for HIV/AIDS care and harassment directly predict burnout. Resources like interprofessional support or structured debriefings can buffer these effects. Empirical studies in palliative care volunteers and nurses confirm that JD-R explains variance in burnout, connectedness and care quality.

Integration of the Frameworks

The three models are integrated as follows:

• JD-R Provides the Antecedent Structure: Workload and contextual stressors (thesis findings: grave staffing shortages, ward management duties, attendant interference) constitute chronic demands. Socio-cultural factors (stigma, in-law disapproval, harassment) act as additional demands
• MBI Operationalizes the Strain: Unbuffered demands manifest as EE (fatigue preventing timely handovers), DP (detached communication with physicians) and low PA (reduced advocacy for palliative needs)
• D’Amour’s IPC Framework Explains the Relational Consequences: Burnout impairs sharing (incomplete symptom reports), partnership (frustrated joint rounds), power balance (hierarchical friction exacerbated by nurse exhaustion), interdependency (nurses withdraw emotionally) and process (disrupted ongoing collaboration)
• Palliative Outcomes as Endpoints: Impaired IPC leads to measurable deficits delayed pain management, inadequate psychosocial support, lower family satisfaction and higher moral distress consistent with Donabedian’s structure-process-outcome logic applied to palliative care

This integrated model accounts for bidirectional influences (e.g., poor outcomes may intensify demands via increased patient acuity) and contextual moderators relevant to Pakistan: male-dominated hierarchies, resource scarcity and cultural devaluation of nursing.

Application to the Zulifqar Thesis and Pakistani Tertiary Hospitals

The framework directly maps onto the thesis data from 105 nurses in Faisalabad’s Civil and Allied Hospitals. Excessive workload (dominant theme) functions as the primary JD-R demand, leading to MBI burnout indicators (insomnia, hypertension, family disruption). Despite surface-level “nice operating relationships” with doctors (partial IPC partnership), cumulative stressors erode deeper collaboration elements (e.g., timely sharing during rounds). In terminally ill wards (HIV, kidney, ICU), where emotional labor is highest, DP and low PA directly undermine palliative processes. The model explains why nurses in public hospitals facing 1:3000+ ratios versus WHO standards report compromised care despite humanitarian motives for joining the profession.

Propositions Derived from the Framework

• Higher job demands (workload, administrative burden) will be positively associated with MBI burnout dimensions
• Elevated burnout will be negatively associated with IPC elements (sharing, partnership, interdependency)
• Impaired IPC will predict poorer palliative outcomes (symptom control, family satisfaction)
• Job resources (e.g., joint rounds, debriefings, allowances) will moderate the demands-burnout link
• Medical student-led interventions (structured collaboration tools) can strengthen resources and improve team dynamics in real-time clinical rotations

Relevance to Medical Education and Practice

For medical students in oncology/palliative rotations, the framework offers a practical diagnostic lens: recognize burnout cues in nurse colleagues (e.g., rushed handovers as EE/DP signals) and intervene via low-cost actions (joint rounds, debriefings) that bolster IPC elements. It positions students as change agents capable of testing propositions in vivo, aligning with WHO recommendations for interprofessional education.

In summary, this integrated conceptual framework provides a robust, multi-level explanation for how nurse burnout and workload pressures in Pakistani terminally ill wards cascade into dysfunctional physician-nurse dynamics and suboptimal palliative care. It bridges organizational, psychological and relational theories while remaining grounded in the empirical realities of the Zulifqar thesis and national healthcare constraints. The subsequent methodology, results and discussion sections will test and elaborate these propositions.