Clinician Burnout
Clinician Burnout
Clinician Burnout
Online Exclusive
At a Glance
F Caring for patients with cancer can generate work-related
stress, causing nurses to feel dissatisfied with their employers and mentally exhausted.
F Oncology staff working on inpatient units are most likely to
have high-risk compassion satisfaction scores.
F Baccalaureate-prepared RNs had the highest percentage
of high-risk scores for compassion fatigue, and graduateprepared nurses are at the highest risk for burnout.
the traumatization of helpers through their efforts at helping
others, is a relational source of stress that also weighs heavily
on oncology nurses. A growing body of research suggests that
Literature Review
The condition of compassion fatigue was first identified by
Joinson (1992) in a study of burnout in nurses who worked in
an emergency department. The researcher identified behaviors that were characteristic of compassion fatigue, including
chronic fatigue, irritability, dread going to work, aggravation
of physical ailments, and a lack of joy in life. Figley (2002) later
defined compassion fatigue as a state of tension and preoccupation with the individual or cumulative traumas of clients. The
phenomenon of compassion fatigue emerges suddenly and without warning and includes a sense of helplessness and confusion.
It has been described by Figley (2002) as the cost a caregiver
experiences as a result of caring for others. Compassion fatigue
results from giving high levels of energy and compassion over
a prolonged period to those who are suffering, often without
experiencing the positive outcomes of seeing patients improve
(McHolm, 2006). Oncology nurses acquire compassion fatigue
through repeated exposure to patients suffering the effects of
trauma, such as side effects of aggressive treatment and the end
stages of cancer.
In contrast, burnout is cumulative stress from the demands of
daily life, a state of physical, emotional, and mental exhaustion
caused by a depletion of the ability to cope with ones environment, particularly the work environment (Maslach, 1982). Burnout results from prolonged high levels of stress at work and, if
not addressed, contributes to healthcare providers leaving the
workplace (Medland et al., 2004). The concepts of compassion
fatigue and burnout are closely related and sometimes ambiguously defined. Definitions of burnout more often point to envi-
Clinical Journal of Oncology Nursing Volume 14, Number 5 Compassion Fatigue and Burnout
E57
Methods
Design and Setting
This descriptive analysis of a quality-improvement evaluation of
oncology healthcare staff was conducted at a large National Cancer Institutedesignated cancer center in the midwestern United
States. A group of nurse managers from the centers outpatient
oncology treatment centers formed a work group to examine the
issue of compassion fatigue among the staff. Through observations and conversations with staff, the managers perceived the
likelihood that their nurses, medical assistants, and technicians
were experiencing symptoms of compassion fatigue and burnout.
The decision was made to conduct a quality-improvement evaluation to include inpatient and outpatient oncology staff, which
included five inpatient oncology units, four outpatient chemotherapy infusion areas, and three physician office practice areas.
The evaluation involved the distribution of the fourth revision of
The quality-improvement evaluation was approved by the Human Research Protection Office of the affiliated university and
the cancer centers Protocol Review and Monitoring Committee.
Staff who worked in the designated oncology units were eligible
to participate in the evaluation, including RNs (staff clinicians
and advanced practice nurses), patient care technicians, medical
assistants, and radiation therapy technologists. A total of 448 survey packets were distributed in staff mailboxes. An information
brochure describing the evaluation was posted on all units and
used by nurse managers for talking points during staff meetings.
Completed information from the ProQOL R-IV scale was returned
in specially marked envelopes placed in each clinical setting.
Instrument
The quality-improvement team chose to use the 30-item
ProQOL R-IV scale for measuring compassion fatigue, compassion satisfaction, and burnout (Stamm, 2009). The instrument
Table 1. Results of Cross Tab Analysis and Demographics of ProQOL R-IV Subscales
Compassion Satisfaction
High Risk
Low Risk
Variable
Setting (N = 154)
Inpatient
Outpatient
19
7
26
9
54
74
74
91
Years of healthcare
experience (N = 150)
15
610
1120
2143
Years of oncology
experience (N = 149)
15
610
1120
2133
Age groups of
providers (N = 146)
2135
3650
5172
Education level of
providers (N = 152)
High school or GED
Certificate
Diploma
Associate degree
Bachelors degree
Advanced degree
Burnout
0.008
Compassion Fatigue
High Risk
Low Risk
32
27
44
33
41
54
56
67
0.578
7
6
6
7
17
27
14
16
34
16
38
36
83
73
86
84
18
14
19
12
59
25
25
15
14
10
17
16
82
86
81
88
34
46
39
37
27
12
27
27
66
55
61
63
23
14
15
48
44
28
28
8
14
6
77
86
85
39
28
45
35
44
21
17
11
33
11
21
18
7
4
5
16
30
58
13
68
100
89
79
82
93
27
28
37
35
46
53
63
65
32
41
43
30
28
13
25
30
37
37
39
39
32
20
0.274
26
12
14
3
63
63
61
36
41
45
18
46
17
17
14
64
59
55
82
0.427
21
22
10
34
43
30
41
29
23
66
57
70
1
3
2
6
14
27
6
50
40
33
37
38
43
3
3
12
24
44
8
50
60
67
63
62
57
0.988
68
59
57
70
1
23
19
13
0.539
13
9
19
13
61
72
55
65
0.539
2
2
8
13
1
0.655
0.426
14
7
5
0.241
Low Risk
0.985
0.986
13
4
6
2
High Risk
0.641
2
1
7
10
30
5
33
20
39
26
42
36
4
4
11
28
41
9
67
80
61
74
58
64
Data Analysis
Prior to analysis, the data were examined for outlying and
missing data. Descriptive statistics were used to analyze demographic information, including age, number of years as a healthcare provider, number of years working in oncology, and education background. A series of cross tabs were calculated to show
the relationship between demographics and total scores on each
of the three subscales, using Pearson Chi square analysis. In the
case when cross tabs analysis involved only two categories, such
as inpatient versus outpatient nursing units, a Yates Correction
for Continuity was reported (see Table 1).
Although Stamm (2009) recommended reporting summed
scores for the ProQOL R-IV across each of the three subscales,
many users of the instrument prefer to have cut scores to indicate relative risks. A high- and low-risk methodology was used;
cut scores were established based on the levels Stamm (2009)
recommended for an indicator of concern for an institution.
High-risk cut scores were set at scores of less than 32 for compassion satisfaction, greater than 23 for burnout, and greater than
18 for compassion fatigue.
Results
A total of 153 healthcare providers participated in the study,
for a response rate of 34%. Most respondents were RNs (see
Table 2). The average compassion satisfaction score among all
study participants was 38.3 (SD = 7.2). Stamm (2009) reported
an average score among previous users of the ProQOL R-IV of
37. The average burnout score among the current studys par-
Age (years)
Years in health care
Years in oncology
Characteristic
Job title
RN
Medical assistant
Patient care technician
Radiology technician
Education
High school or GED
Certificate
Diploma
Associate degree
Bachelors degree
Advanced degree
No response
Oncology unit
Inpatient unit
Outpatient unit
Medical practice area
No response
Range
39.9
14.8
8.9
2163
14
133
n
132
10
6
5
6
5
18
38
71
14
1
72
47
33
1
N = 153
Clinical Journal of Oncology Nursing Volume 14, Number 5 Compassion Fatigue and Burnout
E59
The other demographic variables were not significantly related to the ProQOL R-IV subscales, including age and education
level. However, the results of high risk for burnout and compassion fatigue were interesting in regard to nurses education level.
Nurses with a bachelors degree had the highest percentage of
high-risk scores for compassion fatigue, and nurses with advanced degrees had the highest percentage of high-risk scores
for burnout. Nurses with associates degrees had the highest
percentage of low compassion satisfaction scores.
Discussion
The inpatient work setting has been described by other
researchers as one that is particularly stressful (Buerhaus,
Donelan, DesRoches, Lamkin, & Mallory, 2001). In this current study, inpatient healthcare staff had significantly lower
compassion satisfaction scores than their colleagues working
in outpatient settings. Although this study did not explore in
depth the myriad factors that might contribute to the workplace stress, the literature offers some explanation. The factors
contributing to inpatient workplace stress that differ from
those of outpatient settings involve higher patient acuity, including exposure to more patient deaths; more complications
of treatment and disease; and more severe clinical symptoms.
In addition, environmental conditions such as inadequate
staffing and weekend and evening hours may add additional
burden.
The scores for burnout and compassion fatigue were statistically comparable between the inpatient and outpatient settings.
Factors contributing to outpatient workplace stress are unique
to the types of relationships that form between outpatient staff
and patients with cancer and their families. Although some
researchers have noted the observance of suffering, ethical
concerns regarding treatment choices, and carryover stress
from seeing patients repeatedly for treatments as stressors characteristic of the outpatient setting (Florio, Donnelly, & Zevon,
1998), an argument could be made that these same stressors
are present in the inpatient setting. Interestingly, the outpatient
area with the highest percentage of compassion satisfaction
and lowest percentage of burnout and compassion fatigue was
the breast health center. In this setting, nurses perform routine
screening and diagnostic procedures and do not see the same
patients frequently over time.
Lewis (1999) suggested that the intense and ongoing losses
experienced in oncology care make oncology nurses very vulnerable to burnout. Numerous stressors have been identified
specific to the oncology workplace, including the nature of cancer, complex treatments, death, a personal sense of failure and
futility, intense involvement with patients and families, ethical
issues in treatment, surrogate decision making, and palliative
care issues (Kash & Breitbart, 1993; Najjar, Davis, Beck-Coon,
& Doebbeling, 2009). Additional factors that correlate with
nursing burnout are role ambiguity, workload, co-worker support, and positive reappraisal (Duquette, Kerouac, Sandhu, &
Beaudet, 1994; Florio, Donnelly, & Zevon, 1998). The influence
of years of general healthcare and oncology experience on compassion fatigue and burnout offers an interesting perspective. In
this current study, the individuals who had worked 1120 years
E60
Limitations
The results of this study are limited by the small sample size,
particularly with respect to a very small number of respondents who were medical assistants and radiology technicians.
Additional studies should explore these professional groups. It
also would be interesting to gather information pertaining to
the incidence of compassion fatigue and burnout by surveying
members of a professional nursing organization, such as the
Oncology Nursing Society. The larger sample size would offer a
broader range of analysis with regard to demographic variables.
An additional limitation is the potential response bias. Those
who chose not to respond to the survey could have had higher
or lower levels of risk for burnout and compassion fatigue. Because the study is a cross-sectional design, the analysis does not
provide an understanding of whether the prevalence of burnout
and compassion fatigue changes over time.
The information that the authors collected also was limited by
the constraints of this particular quality-improvement project.
It would be helpful to gather information about the quality of
the healthcare professionals work and to compare this with
compassion satisfaction, compassion fatigue, and burnout.
Likewise, it would be interesting to assess patient satisfaction
with care and to examine how that interacts with the ProQOL
R-IV subscales. Finally, it would be useful to determine the salient differences between inpatient and outpatient practice to
address the different levels of compassion satisfaction between
these work settings.
Implications
Understanding the effects of caring for patients with cancer
on professional caregivers is a responsibility of healthcare management. Although concepts such as compassion fatigue and
burnout are multifactorial, Maslach and Leiter (1998) argued
that the social environment of a workplace and the organizational structure are particularly relevant contributors. The
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