Factors contributing to burnout and work-life balance in adult oncology nursing: An integrative review

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review

Background

Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves.

Aim

To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions.

Methods

Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines.

Data sources

First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied.

Results

We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors.

Conclusions

Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being.

Future work

Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs.

Limitations

The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample.

Study registration

This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

Impact of confrontation to patient suffering and death on wellbeing and burnout in professionals: a cross-sectional study

BACKGROUND

Palliative care and oncology generate a risk of burnout and psychological distress in professionals. The purpose of this study is to identify both psychopathological and positive factors related to mental health at work. It aims (i) to explore the extent to which these professionals are confronted with suffering, illness, and death; and to explore the prevalence of psychological distress and/or burnout, (ii) to identify potential determinants of burnout and psychological wellbeing at work, (iii) to develop an integrative model of mental health; and to identify frequency and impact of confrontations with death, and (iv) to identify profiles of professionals are at risk of developing a mental health disorder or, conversely, characterized by wellbeing.

METHODS

A cross-sectional questionnaire study was conducted in palliative care and oncology evaluating confrontations with death, coping, burnout, psychological distress, personality, self-esteem, well-being and meaning at work. Regressions, clustering, and structural equation modeling analyses were performed.

RESULTS

109 professionals participated (58% from oncology and 42% from palliative care), of which 79% were female, and 65% were between 30 and 49 years old. Aim i: 30% witnessed an intolerable suffering at least 9 times a month, 45% reported moderate to high levels of burnout, 39% suffered from anxiety and 11% from depression. Aim ii: the determinants of burnout were the personality traits conscientiousness and neuroticism, low meaning of work, and low wellbeing (R2 = 0.44). The determinants of wellbeing were work meaning, depersonalization, self-esteem, fulfillment and low emotional exhaustion (R2 = 0.71). Aim iii: the integrative model included both well-being (self-esteem, conscientiousness) and psychopathology (neuroticism, anxiety) parameters, and strongly satisfied the standard SEM goodness of fit indices (e.g., CFI, IFI, and TLI ≥ 0.95). Aim iv: three profiles were identified: (a) a "distressed profile" with a majority of professionals at the patient's bedside, (b) a "disengaged profile" with professionals working as second-line consultants, (c) a "wellbeing profile" contains profiles of caregivers insensitive to psychological distress and with a high level of positive Impact of confrontation on different areas of their lives.

CONCLUSIONS

An integrative approach is essential to understand the full range of mental health issues for professionals. Meaning of work is a key factor in professional interventions that should primarily affect front-line professionals with limited experience.

Factors related to Nursing workload in the Oncology assistance provided to hospitalized women

OBJECTIVE

to evaluate the Nursing workload and its related factors in the assistance provided to hospitalized women with gynecological and breast cancers, according to the Nursing Activities Scores adapted for cancer patients.

METHOD

a cross-sectional and epidemiological study. The participants were women with gynecological and/or breast cancer, over 18 years of age, and hospitalized for a minimum period of 24 hours. The following was collected from the medical records: sociodemographic and clinical data, Karnofsky Performance Status and workload, according to the adapted Nursing Activities Score. The factors related to workload were analyzed by means of multiple linear regression.

RESULTS

the mean Nursing Activities Scores was 29.3%, denoting seven hours of daily care per patient. The factors related to workload differed according to the breast or gynecological cancer diagnosis (β=-0.01; p<0.001), clinical or surgical treatment (β=-0.03; p<0.001) and functional capacity at admission (β=0.07; p<0.001), as per the Karnofsky Performance Status.

CONCLUSION

there was greater workload for the care of women with gynecological cancer undergoing clinical treatment and with lower functional capacity at admission. The findings reveal directions for optimization of resources and improvements in work processes and flows, in order to promote a favorable work environment and good quality assistance.

BACKGROUND

(1) A pioneer study in using the NAS instrument, adapted for Hospital Oncology.

BACKGROUND

(2) The clinical treatment of gynecological/breast cancer demands a greater workload.

BACKGROUND

(3) Functional capacity at the admission of women with cancer influences workload.

BACKGROUND

(4) Gynecological cancer demands a greater Nursing workload than breast cancer.

The influence of distributive justice on job attitudes and life satisfaction of hotel workers

This study uses the social exchange and spillover theories to examine the interrelationships between distributive justice, work attitudes, and life satisfaction of hotel employees in Accra, Ghana. Paper-and-pencil questionnaires were used to collect data from 321 respondents after which descriptive statistics and partial least square structural equation modelling were used to analyse the data. Distributive justice and work attitudes were positively related to the life satisfaction levels of hotel employees. This study adds to the scant literature on how workplace goings-on spillover to affect the life satisfaction of hotel workers. Theoretical and practical implications of the results are discussed.

The cancer nursing workforce in Australia: a national survey exploring determinants of job satisfaction

BACKGROUND

To maintain and improve the quality of the cancer nursing workforce, it is crucial to understand the factors that influence retention and job satisfaction. We aimed to investigate the characteristics of cancer nurses in Australia and identify predictors of job satisfaction.

METHODS

We analysed data from an anonymous cross-sectional survey distributed through the Cancer Nurses Society Australia membership and social media platforms from October 2021 to February 2022. The survey was compared to national nursing registration data. Data were analysed with non-parametric tests, and a stepwise, linear regression model was developed to best predict job satisfaction.

RESULTS

Responses were received from 930 cancer nurses. Most respondents (85%) described themselves as experienced nurses, and more than half had post-graduate qualifications. We identified individual, organizational, and systemic factors that contribute to job satisfaction and can impact in workforce shortages. The findings include strategies to address and prioritize workforce challenges. There were 89 different titles for advanced practice nursing roles. Managing high workload was a reported challenge by 88%. Intention to stay less than 10 years was reported by nearly 60%; this was significantly correlated with job satisfaction and age. Significantly higher scores for job satisfaction were associated with those who had career progression opportunities, career development opportunities, adequate peer support and a clearly defined scope of role. Conversely, job satisfaction scores decreased the more people agreed there was a lack of leadership and they had insufficient resources to provide quality care.

CONCLUSION

Cancer nurses are critical to the delivery of cancer care however, the workforce faces multiple challenges. This study provides an understanding of the Australian cancer nursing workforce characteristics, their roles and activities, and highlights important considerations for retaining nurses in the profession.

Facing negative emotions: Evaluation of a brief training in validating communication for contact nurses in cancer care

BACKGROUND

Contact nurses in cancer care (CNCC) often face challenges when communicating with patients and their families. The overall aim was to evaluate a brief digital validation training for CNCC, to test whether it was associated with increased validation and decreased invalidation. Associations between communication skills in validation and markers of work-related stress were also investigated.

METHODS

This intervention study investigated associations between the training and validation skills using a within-group design with repeated measures (at pre, post, and eight-week follow-up). Additionally, associations between the training and occupational self-efficacy, self-validation, and exhaustion symptoms were explored.

RESULTS

Seventeen CNCCs (all female with relatively long work experience) completed a five-week digital training program. Results indicated a statistically significant increase in validation and a statistically significant decrease in invalidation, showing that the nurses improved their communication skills following the training. No changes were found in markers of work-related stress.

CONCLUSION

The results indicate that digital validation training for CNCCs is potentially beneficial by means of improving communication skills. This study further demonstrates that a brief digital training in validating communication to CNCC is associated with improved person-centered communication regarding strong negative emotions.

Cancer nursing research priorities: A rapid review

PURPOSE

Identifying cancer nursing research priorities is central to influencing the direction of cancer care research. The aim of this rapid review was to explore research priorities identified by oncology nurses for cancer care delivery between 2019 and 2022.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis informed the design of the rapid review. MEDLINE, CINAHL, PUBMED, Web of Science, and Cochrane databases were searched for studies published between December 1st, 2018, and September 30th^, 2022. This timeframe was chosen to account for the latest relevant evidence synthesis, as well as changes in cancer care necessitated by the COVID-19 pandemic. The Quality Assessment of Diverse Studies tool was used to appraise quality.

RESULTS

Four studies met the inclusion criteria. Many of the research priorities identified were influenced by the COVID-19 pandemic. The top cancer nursing research priority identified was the role of technology in improving patient and caregiver symptoms and health outcomes. Other most prevalent research priorities were focused on symptom management, culturally sensitive palliative and psychosocial care, early/integrated palliative care, financial toxicity, modifiable risk factors related to social determinants of health, public and patient involvement in research, and oncology nurses' well-being and scope of practice.

CONCLUSION

The findings indicate a need to steer a strategic programme of cancer nursing research towards digitalisation in cancer care to meet the current needs of people living with cancer and their caregivers. However, cancer nurses' burnout, staff shortages and disparities in specialist education will hinder the implementation of certain models of care.

Perspectives of registered dietitians and factors associated with their personal accomplishment in the management of cancer cachexia

PURPOSE

Registered dietitians (RDs) have the potential in cancer cachexia management. We investigated RDs' knowledge on cancer cachexia and assessed the effects of factors on RDs' perception of playing an important role in cancer cachexia management.

METHODS

This is a secondary analysis of a survey examining the perspectives of health care professionals on cancer cachexia management. We sent the questionnaire to 451 RDs. RDs were divided into two groups: RDs with and without the perception. Comparisons were made using the Mann-Whitney U test or chi-square test. To examine the effects of factors on the perception, estimated crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the logistic regression model were calculated.

RESULTS

A total of 237 RDs were analyzed. Significant differences were observed in the number of cancer patients/month, the primary area of practice, the number of clinical guidelines used, the number of items used, the number of symptoms used, and training for cancer cachexia management (p values all < 0.05). After adjustments, the factors of cancer care experience ≥ 20 years (OR 8.32, 95% CI 1.22-56.70; p = 0.030), the number of patients/month ≥ 50 (OR 27.35, 95% CI 3.99-187.24; p = 0.001), using the clinical guidelines (OR 2.69, 95% CI 1.29-5.61; p = 0.008), the number of items ≥ 5 (OR 3.52, 95% CI 1.47-8.40; p = 0.005), and receiving training (OR 3.91, 95% CI 1.77-8.67; p = 0.001) significantly associated with the perception.

CONCLUSION

Specific knowledge and training as well as abundant experience were associated with the perception.

Coping With the Emotional Impact of Working in Cancer Care: The Importance of Team Working and Collective Processing

Hospitals provide the vast majority of cancer care. A necessary focus on survival has meant that they are less well-developed in terms of supporting patients with the emotional impact of cancer; and in supporting the frontline staff who contend with this. An integration of psychotherapeutic and neurobiological findings is used to develop an understanding of the patient-staff relationship and impact of high levels of distress within it. This includes reference to Transference and Countertransference, Mirror Neurons and Poly Vagal Theory. This paper considers how patients can unconsciously "transfer" emotional distress on to healthcare practitioners; and how this evokes an emotional response from the practitioner via the mirror neuron system (MNS). This can allow the practitioner to "feel into" the patient's experience and develop a more nuanced understanding. However, it may also activate emotions connected to the practitioner's life and can leave them feeling overwhelmed. The practitioner's capacity to regulate their own emotional arousal, via the vagus nerve, has a significant impact on their ability to support the patient and themselves within emotionally distressing interactions. This dynamic often unfolds without either party having significant awareness of it. A Systemic and Process-Oriented perspective is taken to understand this within the broader context of a hospital-based structure; and consider how practitioners on frontline teams may or may not support each other in working collectively with high levels of distress. A team's level of understanding and attunement to emotional experiences as well their primary relational and communication style has significant bearing on capacity for emotion-and-relationship focused coping. A failure to work with the emotional and relational interconnection between patients and staff can contribute to isolated patients, disconnected staff, conflict within teams and an overarching system lacking in compassion. However, due to the often unconscious nature of such processes and limited understanding or training on them, they are regularly left unaddressed. Over time, this can have an accumulated effect on everyone. Group-based collective processing is considered in terms of how it can be used in supporting practitioners to integrate an emotional and relational way of working with a problem-focused approach and integrated into regular daily working.

Health and social care professionals' experiences of providing end of life care during the COVID-19 pandemic: A qualitative study

BACKGROUND

Health and social care professionals' ability to address the needs of patients and their relatives at end of life is likely to have been impacted by the COVID-19 pandemic.

AIM

To explore health and social care professionals' experiences of providing end of life care during the COVID-19 pandemic to help inform current/future clinical practice and policy.

DESIGN

A qualitative interview study. Data were analysed using thematic analysis.

SETTING/PARTICIPANTS

Sixteen health and social care professionals working across a range of clinical settings in supporting dying patients during the first wave (March-June 2020) of the COVID-19 pandemic in the United Kingdom.

RESULTS

Participants reported emotional and practical challenges to providing end of life care during the pandemic, including increases in patient numbers, reduced staffing levels and relying on virtual platforms for sensitive, emotive conversations with relatives. Participants were central to promoting connections between patients and their families at end of life and creating opportunities for a final contact before the death. However, the provision of support varied as a consequence of the pressures of the pandemic. Results are discussed under two themes: (1) challenges and facilitators to providing end of life care, and (2) support needs of relatives when a family member was dying during the COVID-19 pandemic.

CONCLUSION

There is a need for flexible visiting arrangements at end of life during a pandemic. A systems-level approach is necessary to promote the wellbeing of health and social care professionals providing end of life care during and after a pandemic.

Prevalence of burnout and predictive factors among oncology nursing professionals: a cross-sectional study

BACKGROUND

Burnout is a syndrome that mostly affects professionals working in contact with patients and their caregivers. In oncology care, nursing professionals are constantly required to provide emotional support for patients and their caregivers, throughout the process of becoming ill, suffering and dying.

OBJECTIVE

To evaluate the prevalence and factors associated with burnout in a sample of nursing professionals at a cancer hospital.

DESIGN AND SETTING

Cross-sectional study conducted at Hospital de Câncer de Barretos.

METHODS

The study population comprised 655 nursing professionals. Burnout syndrome was assessed using the Maslach Burnout Inventory Human Service Survey. Univariate analysis and binary logistic regression models were used to identify independent predictors associated with burnout.

RESULTS

Among 304 nursing professionals included in the study, 27 (8.9%) were classified as presenting burnout according to the two-dimensional criteria, and four (1.3%) were classified based on the three-dimensional criteria. Workplace characteristics were not associated with burnout, while single marital status (odds ratio, OR = 2.695; P = 0.037), perceived workplace stressors, such as impatience with colleagues (OR = 3.996; P = 0.007) and melancholy (OR = 2.840; P = 0.021) were considered to be predictors of burnout. Nursing professionals who would choose the profession again (OR = 0.214; P = 0.001) were least likely to present burnout.

CONCLUSION

Perceived workplace stressors are strongly associated with burnout. Strategies focusing on restructuring of daily work processes and on activities that stimulate positive relationships are important for professionals' health because motivation to continue working in oncology nursing has a protective effect against burnout.

'Don't forget the children': a qualitative study when a parent is at end of life from cancer

Purpose

Preparation for end of life is one of the greatest challenges faced by parents with cancer who have dependent children (< 18 years old), with requirement for support from professionals. The aim of this study is to explore how parents can be best supported in relation to their children, when a parent is at end of life from cancer.

Methods

This is an interpretive qualitative study, using 79 semi-structured interviews with parents at end of life (n3), bereaved parents (n21), health and social care professionals (HSCPs) (n32) and funeral directors (n23). Data were analysed thematically and triangulated.

Results

Parents are central to preparing their children for the death of a parent. Striving for everyday ordinariness, maximising social networks, maintaining hope and making preparations for the future are helpful for families when a parent is at end of life. Most HSCPs were unaware of the challenges faced by parents at end of life, and psychosocial support was often left outside the caring realm. As a result, funeral directors noted complexities faced by the families after the death. Results are discussed under four themes: (1) communication with the children as a process, (2) coping throughout the unfolding end of life experience, (3) tension and complexities at end of life and (4) preparing for the future.

Conclusions

Parents should be reassured that by involving the children early in the end of life experience when the ill-parent is ‘well enough’ to parent enables them to be actively involved in supporting their child through one of the greatest life changing event. A number of recommendations are discussed for professionals.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06341-3.

Prevalence and predictors of burnout and work-life balance within the haematology cancer nursing workforce

PURPOSE

The effects of burnout can have serious consequence for individual nurse's, patients and healthcare organisations. The aim of this study was to assess prevalence and predictors of burnout and work-life balance amongst haemato-oncology nurses.

METHODS

This study employed a cross-sectional survey design. Haematology cancer nurses attending a 2-day conference in Ireland, during Oct 2019 were recruited. Anonymised data were collected on: 1) socio-demographics and occupational variables, 2) burnout using Maslach Burnout Inventory and 3) satisfaction with work-life balance.

RESULTS

There was an 80.4% survey completion rate (n = 78 of 97). One-third of haemato-oncology nurses reported high levels of emotional exhaustion, with an additional 46% experiencing moderate levels. Despite this, 64% of nurses highlighted a moderate or high level of personal accomplishment. Demographics such as <40yrs old, unmarried, working ≥25hrs per week and having 6-10 years' experience in haemato-oncology, all showed trends towards increased burnout, although none reached statistical significance. Over half (58%) surveyed were dissatisfied with their work-life balance. Nurses with dependent children had statistically significant poorer work-life balance scores. In addition, one-third reported they did not receive adequate support or reasonable adjustments from their organisation, with inpatient nurses finding this particularly challenging.

RELEVANCE TO CLINICAL PRACTICE

Taking into consideration the high levels of burnout, healthcare organisations should have a responsibility to teach approaches of stress management, self-care and foster resilience within their workforce. Oncology nurses with dependent children, working in in-patient settings, have identified a need for greater flexibility with working conditions, to improve work-life balance.