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April 2014, Volume 18, Number 2
Nursing Burnout Interventions: What Is Being Done?
Barbara J. Henry, MSN, APRN-BC
Many studies have documented high prevalence of burnout and compassion fatigue in oncology nurses. Burnout has detrimental effects on nurses, patients, and healthcare organizations. However, burnout interventions have been shown to improve the physical and mental health of nurses, patient satisfaction, and the organizational bottom line by reducing associated costs of burnout. Although treatment centers may prevent and correct burnout in oncology nurses by providing various interventions, few articles focus on those interventions. This article compiles and describes interventions that will serve as a reference to nurses and healthcare organization leaders interested in implementing similar programs.
When nurses reflect on their reasons for choosing oncology, they may recall the pleasant memories and positive rewards that come from helping special people along the cancer journey. However, there may be less reflection on difficult memories of witnessing death, patient and family suffering, and the emotional burdens of losing patients, which may lead to compassion fatigue and burnout (Vachon, 2010). Compassion fatigue occurs when caregivers unconsciously absorb the distress, anxiety, fears, and trauma of the patient (Bush, 2009). Compassion fatigue often is a factor in nursing burnout. Burnout is defined as a prolonged response to physical or emotional stressors that result in feelings of exhaustion, being overwhelmed, self-doubt, anxiety, bitterness, cynicism, and ineffectiveness (Maslach & Leiter, 2005).
The prevalence of burnout is high in oncology nursing clinical settings with high emotional demand (Barnard, Street, & Love, 2006; Potter et al., 2010). According to a study conducted at Memorial Sloan-Kettering Cancer Center (N = 153), 44% of inpatient oncology nurses reported some degree of burnout (Emanuel, Ferris, von Gunten, & von Roenn, 2005). Burnout negatively impacts the physical and emotional health of nurses; organizational costs; and patient satisfaction, outcomes, and mortality (Aiken, Clark, Sloane, Sochalski, & Silber, 2002; Lee et al., 2007).
Psycho-oncology leaders conclude that cancer centers must explore ways to reduce work stress so that professionals are emotionally equipped to effectively communicate and provide support to patients (Kash et al., 2000). The positive effects of person- and work-directed burnout interventions may be apparent from six months to two years after implementation (Marine, Ruotsalainen, Sierra, & Verbeek, 2006). The current author conducted PubMed and CINAHLฎ searches using the terms burnout, compassion fatigue, oncology nursing burnout, and burnout interventions to explore existing literature on these topics. The purpose of this article is to describe burnout interventions (see Table 1) and provide guidance to oncology nurses and organizations interested in implementing similar programs.
Aycock and Boyle (2009) examined existing interventions to manage compassion fatigue in oncology nurses by surveying 231 Oncology Nursing Society chapter presidents, with 103 responses. Twenty-two percent or fewer respondents had on-site resources such as employee assistance programs (EAPs), pastoral care, counselor or psychologist, psychiatric clinical nurse specialist, or support groups (Aycock & Boyle, 2009). Those with EAPs had three free visits available per year with a discount for ongoing services. EAPs provide counseling to help employees deal more effectively with emotional health issues (for more information on EAPs, visit www.eapassn.org/files/public/EAPASTANDARDS10.pdf). The lag time between request and scheduled time available for an appointment was a barrier to obtaining other counseling services (Aycock & Boyle, 2009). Only 5% of respondents reported exposure to staff support groups that were rarely continued over time (Aycock & Boyle, 2009). Although off-site retreats to promote renewal were experienced by only a few respondents, qualitative data reflect the value of these retreats to participants (Aycock & Boyle, 2009).
Medland, Howard-Ruben, and Whitaker (2004) described ways to foster psychosocial wellness in oncology staff by addressing burnout and social support in the workplace and conducting five full-day retreats with 150 oncology staff members. Bauer-Wu (2005) facilitated overnight staff renewal retreats with oncology nurses from a large cancer center located in the eastern United States. The goal of the retreats was to bring staff together outside the work setting to relax, have fun, revisit self-care and reflection, and rekindle spirits so that staff felt rejuvenated and professionally reinspired. Although no evaluation tools were used, the author reported that participants acknowledged appreciation for the unique experience of fun, personal growth, and knowledge (Bauer-Wu, 2005).
Lambert and Steward (2007) reported on a staff retreat located in the southeastern United States and identified goals for strengthening and reenergizing the team, clarifying roles and expectations, and identifying unique contributions of each staff member to the team, after numerous previous attempts to improve work effectiveness and cohesion were unsuccessful. Participants felt the retreat was beneficial for building teamwork and leadership skills, and showed a 25% increase from previous scores in satisfaction with their job role, department, and management (Lambert & Steward, 2007).
Potter et al. (2013) studied the effects of a five-week program that involved five 90-minute sessions on compassion fatigue resilience. Thirteen oncology nurse participants had decreased secondary traumatization scores immediately after the program, which they maintained six months after the programs completion. Participants also had improved Impact of Event scores, showing a statistically significant improvement in compassion fatigue resilience from this intervention (Potter et al., 2013).
A psychiatric clinical nurse specialist in the southeastern United States provided compassion fatigue training and support to oncology nurses, presenting an overview of compassion fatigue and consequences with a handout on being mindful of the present, which generated positive feedback from participants (Walton & Alvarez, 2010).
An eight-week mindfulness-based stress-reduction program was offered to 25 nurses at a hospital and health network located in the eastern United States (Cohen-Katz et al., 2005). Qualitative and quantitative data from the study found the intervention to be effective in improving relaxation, self-care, and work and family relationships; however, at times, the process generated challenges like restlessness, pain, and dealing with difficult emotions (Cohen-Katz et al., 2005).
The use of journaling as a psychosocial wellness tool is sometimes forgotten. Adams and Putrino (2010) conducted an expressive writing workshop to promote self-care for about 40 oncology nurses. Participants were presented with information on permission, balance, privacy, honesty, silence, attention, structure, and reflection. The presenters also shared their experience of guiding expressive writing groups with patients with cancer and oncology health professionals (Adams & Putrino, 2010). The authors reported overwhelmingly positive response from patient group participants and from healthcare providers who used structured journaling.
LeBlanc et al. (2007) evaluated effectiveness of a team-based burnout intervention. The study sample included 664 staff members from 29 oncology wards in 18 general hospitals in the Netherlands. Participants in the experimental group felt significantly less exhausted than those in the control group immediately after the program and again six months later (LeBlanc et al., 2007).
Hayes et al. (2005) wrote about retention strategies implemented at large cancer centers in the eastern United States that decrease burnout and increase support for oncology nurses. All strategies were received with favorable outcomes, despite some initial implementation difficulties (Hayes et al., 2005). In addition, Maslach and Leiter (2005) recommended that individuals and organizations move from burnout to engagement by identifying in which of six areas (community, control, fairness, reward, values, and workload) a bad fit exists between people and their work. Employees take a survey to identify the mismatched areas, and managers target specific interventions based on the results (see Table 2).
Carroll-Johnson (2010) observed the topics of lateral violence, dealing with difficulties in nursing, mentoring, resilience, and self-care as themes in a wide variety of recent nursing journals. Carroll-Johnson (2010) noted the high personal demands of oncology nursing, and challenged readers to look around at coworkers; acknowledge the value of their own work; and recognize the work of colleagues with kindness, consideration, and support. Interventions should be developed targeting these areas to help decrease burnout in oncology nurses.
Burnout interventions for oncology nurses showed positive outcomes as measured by participant comments. However, one limitation of many of the interventions was the lack of objective measurement tools and experimental design to evaluate efficacy. Burnout and job stress have increased, in part, because of technology, insurance changes and demands, and the vast amount of new education needed to understand current and expanding oncology treatment and disease knowledge. Nurses may decrease or prevent burnout by practicing self-care and encouraging treatment centers to support burnout intervention programs. Organizations that implement burnout interventions may experience increased retention, reduced turnover and performance problems, and increase patient satisfaction.
Implications for Practice
ุ Seek out emotional support and healthy coping programs to help prevent or correct oncology nursing burnout.
ุ Encourage organizations to implement and support interventions, such as retreats, therapy programs, and counseling services.
ุ Engage in self-care activities to decrease or prevent burnout.
Adams, K., & Putrino, J. (2010). Expressive writing to promote self-care. Interactive podium presentation at the 11th Annual Oncology Nursing Society Institutes of Learning. Orlando, FL.
Aiken, L.H., Clark, S.P., Sloane, D.M., Sochalski, J.A., & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288, 19871993. http://dx.doi.org/10.1001/jama.288.16.1987
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Barnard, D., Street, A., & Love, A.W. (2006). Relationships between stressors, work supports, and burnout among cancer nurses. Cancer Nursing, 29, 338345.
Bauer-Wu, S. (2005). Seeds of hope, blossoms of meaning. Oncology Nursing Forum, 32, 927933. http://dx.doi.org/10.1188/05.ONF.927-933
Bush, N.J. (2009). Compassion fatigue: Are you at risk? Oncology Nursing Forum, 36, 2428. http://dx.doi.org/10.1188/09.ONF.24-28
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Cohen-Katz, J., Wiley, S., Capuano, T., Baker, D.M., Deitrick, L., & Shapiro, S. (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout a qualitative and quantitative study, Part III. Holistic Nursing Practice, 19, 7886.
Emanuel, H., Ferris, F.D., von Gunten, C.F., & von Roenn, J.H. (2005). Combating compassion fatigue and burnout in cancer care. Retrieved from http://compassionfatigue.ca/wp-content/uploads/2011/09/CF-and-burnout-in-cancer-care.pdf
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Marine, A., Ruotsalainen, J.H., Sierra, C., & Verbeek, J.H. (2006). Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews, 4, CD002892.
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Potter, P., Deshields, T., Berger. J.A., Clarke, M., Olsen, S., & Chen L. (2013). Evaluation of a compassion fatigue resilience program for oncology nurses. Oncology Nursing Forum, 40, 180187. http://dx.doi.org/10.1188/13.ONF.180-187
Vachon, M.L.S. (2010). Oncology staff stress and related interventions. In J.C. Holland, W.S. Breitbart, P.B. Jacobsen, M.S. Lederberg, M.J. Loscalzo, & R. McCorkle (Eds.), Psycho-oncology (2nd ed., pp. 575581). New York, NY: Oxford University Press.
Walton, A.M., & Alvarez. M. (2010). Imagine: Compassion fatigue training for nurses. Clinical Journal of Oncology Nursing, 14, 399400. http://dx.doi.org/10.1188/10.CJON.399-400
Barbara J. Henry, MSN, APRN-BC, is a psychiatric advanced practice nurse with Melvin S. Gale, MD, and Associates in Cincinnati, OH. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the author, planners, independent peer reviewers, or editorial staff. Henry can be reached at firstname.lastname@example.org, with copy to editor at CJONEditor@ons.org. (Submitted June 2013. Revision submitted July 2013. Accepted for publication July 27, 2013.)
Key words: burnout; compassion fatigue; interventions; oncology nurses