The research team, affiliated with St. John University and approved by the Research Ethics Committee of National Taiwan Normal University, recruited participants from one residential long-term care facility and three community-based units, comprising two home-care agencies and one day-care centre. Twenty candidates were initially identified, but four were excluded for being older than 30, leaving 16 eligible participants who all agreed to take part: seven women and nine men with a mean age of 25.44 years and an average of 1.96 years of work experience. The sample was deliberately balanced, with eight workers from institutional care settings and eight from community care settings, and recruitment emphasised diversity in gender, workplace type and geographic location within Taiwan.

Participants were divided into four focus groups of five, five, two and four members; the unusually small third group reflected the strict enforcement of the age criterion, which removed candidates originally scheduled for that session. To be included, workers had to have graduated from a university programme in long-term care, be aged 30 or younger, and be currently employed in either an institutional or community setting. Anyone with less than six months of experience was excluded, a decision the researchers made to minimise the confounding influence of the initial ‘reality shock’ that new care workers typically experience. The goal was to recruit people who had moved beyond the survival phase and begun to develop stable coping patterns and reflective capacities.

Data were collected between March and July 2023 through four focus group interviews lasting 1.5 to 2 hours each, with a mean of 1.8 hours. A semi-structured guide covering background and interactions with clients and colleagues, work-related stressors, emotional responses and coping strategies, and future expectations was validated by two qualitative researchers and a long-term care practitioner and piloted with two care workers without needing revision. Sessions took place in private meeting rooms at the participating institutions, were audio-recorded with permission, and concluded with immediate member checking, in which the moderator summarised the main points and invited participants to confirm or clarify them. An assistant moderator used a standardised checklist to document group dynamics and non-verbal cues such as collective nodding, silence and agitation. Data saturation was reached after four sessions, when no new concepts emerged in the final group.

The analysis followed grounded theory methods, proceeding through open, axial and selective coding. Transcripts were produced verbatim within a week and cross-checked by a three-person research team of medical education researchers. Open coding identified initial concepts drawn from participants’ own words, such as ‘ignoring the client’ or ‘venting to friends’; axial coding linked these into broader categories like Boundary Setting and Social Support; and selective coding refined the categories into the core CHEERS framework. The team met biweekly to resolve coding discrepancies by consensus, revisiting original recordings and field notes to clarify context. An audit trail documents the path from raw quotes to final themes—for example, a participant’s remark that her mood improved once she understood a client’s refusal as dementia-related was coded as perspective taking, then as Empathy and Altruism, and finally as Empathy, a primary coping strategy.

Reflexivity played a decisive role in shaping the framework. The lead researcher, a female PhD-prepared registered nurse and associate professor with over a decade of qualitative research experience, recognised a tendency to view participants’ accounts through a ‘clinical competency lens’, subconsciously judging whether their actions followed standard protocols. Early in the analysis, a participant’s choice to ignore an aggressive client was initially critiqued as professional negligence. Through reflexive dialogues, the team shifted to a strengths perspective: behaviours first coded as ‘distraction’ were reinterpreted as Sensitivity, meaning environmental scanning, and ‘ignoring’ was identified as Exposure, meaning strategic boundary setting. The researchers credit this pivot as foundational to the framework’s development.

The stressors the participants described centred on boundary violations. Physical breaches included a bedridden client using a functional hand to touch a worker inappropriately, prompting immediate withdrawal from the scene to ensure safety, and clients shouting and throwing objects. Emotional violations arose when clients rejected advice or demanded off-duty tasks—one participant reported being told, ‘You might as well clean the toilet’—straining mutual trust. The researchers warn that persistent violations risked what they term boundary collapse, impairing caregiving efficacy, and that effective boundary management emerged as critical for protecting workers’ rights and maintaining care quality.

The CHEERS framework organises the six coping strategies into three stages. Primary coping covers immediate responses: Empathy, in which understanding clients’ conditions such as dementia-related refusal reduced workers’ own distress, and Exposure, in which workers adapted hands-on to unreasonable demands by explaining constraints, as in telling a client, ‘We actually can’t do this, grandma.’ Secondary coping addresses persistent strain: Help-seeking, drawing on supervisors, experienced colleagues, friends and training courses such as dementia caregiving skills, and Compassion, in which workers recognised the distress of clients and families and transformed emotional strain into more stable patterns of interaction, with one participant saying she tried to stand in their shoes. Long-term coping supports sustained adaptation: Reflection, through post-event journaling or discussion about what happened and what could be done better, and Sensitivity, the proactive observation of client cues such as sundowning agitation, which allowed workers to intervene with calming techniques before situations escalated.

The authors situate these findings within existing literature. Empathy’s role in moderating personal distress is consistent with prior research on caregiving resilience; the Exposure strategy aligns with work on boundary management among home care aides; Compassion connects to studies of compassion satisfaction and fatigue in nursing; and Help-seeking reflects evidence that organisational and social support contributes to better psychological well-being and lower turnover intention among long-term care workers. Reflection echoes research on reflective practice and workplace reflection-based interventions that have shown potential to support nurses’ resilience, while Sensitivity parallels person-centred dementia care research emphasising the recognition of behavioural cues and underlying needs. The authors note, however, that the effects of Reflection and Sensitivity on burnout require further longitudinal investigation.

The study carries clear limitations. The sample of 16 participants from Taiwan, though sufficient to reach saturation, limits transferability to other populations and cultural contexts, and cultural and organisational factors may shape how the identified coping strategies are expressed. Focus groups may have introduced social desirability bias, making participants less likely to disclose sensitive interpersonal conflicts with supervisors than individual interviews would have. The exclusion of workers with less than six months of experience means the study does not describe how novices acquire these strategies during their transition period. The researchers also noted an underrepresentation of participants with less than one year of experience despite additional outreach. As implications for practice, the authors suggest that nurse educators could incorporate the Exposure strategy into simulation-based training on responding to aggression and unreasonable demands, and that managers could strengthen supervisory guidance and peer support—particularly for community-based workers, who may have limited access to immediate workplace support—while future longitudinal research should test whether reflection-based interventions support adaptive coping and well-being over time.

Subject of Research: Occupational stressors and coping strategies of young long-term care workers in Taiwan, framed by the CHEERS coping framework

Article Title: Exploring Stressors and Coping Strategies of Young Care Workers in Long‐Term Care: A Qualitative Study Using the CHEERS Framework

Article References: Chang, C.-C., & Tung, C.-Y. (2026). Exploring Stressors and Coping Strategies of Young Care Workers in Long‐Term Care: A Qualitative Study Using the CHEERS Framework. Nursing Open, 13(10), Article e70839. https://doi.org/10.1002/nop2.70839

Image Credits: AI Generated

DOI: 10.1002/nop2.70839

Keywords: long-term care, care workers, coping strategies, CHEERS framework, qualitative research, grounded theory, focus groups, occupational stress, professional boundaries, resilience, Taiwan, dementia care