Combating Compassion Fatigue and Burnout in Cancer Care

8/20/2019 Combating Compassion Fatigue and Burnout in Cancer Care

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Combating Compassion Fatigue and Burnout in Cancer CareLinda Emanuel, MD, PhD, Frank D. Ferris, MD, FAAPHM, Charles F. on !unten, MD, PhD, "aime H. #on $oenn,MD

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Editor's Note:

This text has been excerpted and adapted from: Emanuel LL, Ferris FD, von Gunten CF, Von Roenn ,eds! EPEC)*+ Education in Palliatie and End*o-*li-e Care -or +ncolog/ "odule #$:Cancer Doctorsand %urnout&, Cop'ri(ht The E)EC* )ro+ect, Chica(o, L, -..$&! The EPEC) /0 curriculum 1as

produced b' The E)EC* )ro+ect , 1ith ma+or fundin( provided b' the 2ational Cancer nstitute, and 1ithsupplemental fundin( provided b' the Lance 3rmstron( Foundation!

Compassion Fatigue and Burnout in Cancer Care

0orking as a healthcare proider 1ith patients 1ho hae cancer has man re1ards, but can also bechallenging and stress-ul. Healthcare proiders caring -or persons 1ith cancer and their -amilies are atincreased risk o- deeloping burnout and compassion -atigue, 1ith potentiall deastating conse2uencesnot onl -or themseles, but also -or patients and -amilies.

3his oncologist is sho1ing eidence o- burnout ** anger, e4haustion, and detachment. His co1orkersoice concerns.

Burnout

Burnout, a pschological sndrome, is a response to chronic interpersonal stressors on the +ob. 5(6 3heconcept o- burnout 1as -irst deeloped in the (78%s. 5'6

3he 9 ke dimensions o- this response are

• :ndiidual oer1helming e4haustion; -eelings o- being oere4tended and depleted o- one and detachment -rom the ?ob. Cnicism re-ers to a

negatie, callous, or e4cessiel detached response to arious aspects o- the ?ob; and

• @el-*ealuatie sense o- ine--ectieness and lack o- accomplishment ** :ne--ectieness re-ers to

-eelings o- incompetence and a lack o- achieement and productiit at 1ork.


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Pines suggests, 3he root cause o- burnout lies in people than those in priate adult oncolog practice /&9>.

@till other studies b !raham and $amire= hae -ound prealence rates on 9 dimensions o- burnout -rom(9 to 9G, 1ith an estimated prealence o- pschiatric diagnoses among oncologists o- 'G. 5('6

Another stud o- 97 head and neck surgeons, also using an inestigator*constructed 2uestionnaire,-ound that 9 o- respondents reported -eeling burned out, '8 indicated -rustration 1ith disease, &8indicated -rustration 1ith goernment, and G indicated -rustration 1ith the economics o- medicalpractice. 5(96

:n the nited ingdom, the percentage o- clinicians reporting high leels o- e4haustion on the MaslachBurnout :nentor 1as similar to that o- the normatie sample /9( s 99, respectiel>. 5(,(6 Amongboth the cancer clinicians and the normatie sample, 99 reported a sense o- lo1 personalaccomplishment. @igni-icantl -e1er o- the cancer clinicians reported high leels o- depersonali=ationcompared 1ith the @ sample /'9 s 99, respectiel>. :n general, Iorth Americans reported higherleels o- burnout than did Europeans. 5(6

:n a stud b Cancer Care +ntario, the comparable -igure -or phsician e4haustion 1as 9.9; -or alliedhealth pro-essionals, 98.(; and -or support sta--, 9%.. Almost hal- /7> o- phsicians reported hainglo1 -eelings o- personal accomplishment, as did o- allied health pro-essionals and 9(. o- supportsta--. 5(&6 3he -eelings o- depersonali=ation in the Canadian group 1ere similar to those o- the sample,1ith ''.( o- phsicians /s .9 o- allied health personnel and . o- support sta--> reporting -eelingso- depersonali=ation. 3hese -igures ma be uni2ue to +ntario, or ma indicate an increase in stress inoncolog partl as a result o- eer*increasing 1orkloads and limited resources.


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A stud o- oncologists, housesta--, and oncolog nurses -rom Memorial*@loan ettering Cancer Centerreported that housesta-- e4perienced the most burnout, emotional e4haustion, -eeling o- emotionaldistance -rom patients, and a poorer sense o- personal accomplishment. 5(86Iurses reported more phsicalsmptoms than housesta-- or oncologists; ho1eer, the 1ere less emotionall distant -rom patients.

Potter and co1orkers 5(76 inestigated the prealence o- compassion -atigue and burnout among oncolognurses, using the Pro-essional Jualit o- Li-e $eised, ersion :# /ProJ+L $*:#> scale, a commonl used

instrument -or measuring the positie and negatie e--ects o- 1orking 1ith people 1ho hae e4periencede4tremel stress-ul eents 5'%6. :t consists o- 9 subscales, measuring compassion satis-action, compassion-atigue, and burnout. Among the (9 respondents /mostl registered nurses 5$Is6>, sta-- 1orking oninpatient nursing units had the highest percentage o- high*risk compassion satis-action scores. High*riskscores -or compassion -atigue 1ere e2ual among inpatient and outpatient sta-- /98 and 9respectiel>; but o- inpatient sta-- /s 99 o- outpatient sta--, a non*signi-icant di--erence> 1ere athigh risk -or burnout. +ther studies o- oncolog nurses -ound bet1een 98 and 8 reporting highemotional e4haustion, ((*8 reporting high depersonali=ation, and '%* e4periencing lo1personal accomplishment.

@imon 5'(6 e4amined the prealence o- secondar traumatic stress among oncolog social 1orkers, and-ound that the e4perienced compassion -atigue and burnout, 1hich 1as inersel related to compassionsatis-action and that empath 1as compromised b compassion -atigue.

@ome studies 5''*'6 seem to indicate that hospice and palliatie care phsicians and nurses -are better thantheir oncolog associates 1hen it comes to compassion -atigue and burnout, 1hereas other studiesdispute this. :n studing hospice nurses, Abendroth and Flanner 5'6-ound G% to be at moderate to highrisk -or compassion -atigue.

3aken together, these studies illustrate that healthcare proiders caring -or persons 1ith cancer/phsicians, nurses, social 1orkers, and others>, e4perience signi-icant rates o- compassion -atigue andburnout.

$isk Factors -or Burnout and Compassion Fatigue

A number o- indiidual, cultural, and personalit characteristics are associated 1ith burnout andcompassion -atigue. +rgani=ational -actors also pla a role.

Individual Risk Factors

:ndiidual characteristics can be related to burnout. Ho1eer, these associations are 1eaker than those-or burnout and situational -actors, suggesting that burnout is more a social phenomenon than anindiidual one. 5(6

Age. People ounger than % ears o- age hae more burnout than those older than % ears o- age. Ageis con-ounded 1ith 1ork e4perience, so burnout ma be a greater risk earlier in one


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Cultural Factors

0hen phsicians in 3he Ietherlands 1ere compared 1ith those in the nited @tates, older phsicians inthe nited @tates reported a greater sense o- control oer their 1ork enironment compared 1ith ounger phsicians, 1hile in 3he Ietherlands this age di--erential 1as much less pronounced. 5'76

:n the nited @tates, male phsicians described haing signi-icantl more 1ork control than -emale

phsicians. European 1orkers generall tended to hae lo1er aerage leels o- e4haustion and cnicismcompared 1ith similar Iorth American samples. @ome aspects o- burnout, particularl cnicism, ma bemore acceptable in the strongl indiiduali=ed Iorth American culture, or the orientation to1ard higherachieement in Iorth American societ ma cause more stress. 5(6

Personalit

Compulsiveness. 3he compulsie characteristics o- phsicians, 1hen present in con?unction 1ith othercharacteristics o- oerl controlled emotions and lo1 need -or rela4ation and pleasure, makes the medicalstudent, and later the phsician, more ulnerable than others to depression, alcoholism, pschiatricdisorders, and suicide. 59%6 An oncologist said, Lots o- us 1ho -eel oerloaded and oer1orked create itourseles. 0e start dancing to a tune that ou, and sho1 greater inolement andsatis-action 1ith their 1ork. 59'6

"evelopmental sta#ilit. Phsicians 1ith the least stable childhood and adolescent ad?ustment haebeen identi-ied as being the most ulnerable to occupational ha=ards. 5996

Personalit c!aracteristics. 3he personalit characteristic o- hardiness, consisting o- commitment,control, and challenge, is associated 1ith improed coping among house sta--. 59%,9,96 Hardiness isassociated 1ith less demorali=ation and a greater sense o- accomplishment. Housesta-- and nurses haea lo1er sense o- accomplishment than oncologists. 5(86 $esilience has been -ound to be an importantcharacteristic in coping 1ith negatie circumstances. :n his stud o- pediatric oncolog nurses, Kander-ound that the resilience correlated 1ith hope, sel-*e--icac, control, competence, and coping. 3hose 1itha range o- positie coping strategies -ared better than their counterparts 1ho emploed a narro1 range o-coping strategies, or 1ho used negatie coping strategies. 59&6

$evel of Social Support and Spiritualit%Religion

Female phsicians 1ith oung children are % less likel to e4perience burnout 1hen the hae thesupport o- colleagues, spouses, or signi-icant others in balancing 1ork and home issues. 5'86 :n anealuation o- burnout among nurses, -ello1s, and oncologists, those 1ho reported being 2uite a bit toe4tremel religious had lo1er leels o- diminished empath or depersonali=ation and less emotionale4haustion on the Maslach Burnout @cale, compared 1ith those 1ho 1ere not as religious. 5(86

&ork $ife

$ong !ours. Burnout is strongl associated 1ith long 1ork hours and 1ork*home inter-erence in both thenited @tates and 3he Ietherlands.5'76

'olume of work. 3oo high a olume o- 1ork, 1ith inade2uate sta-- to do the ?ob properl, leads to

pressure to make deadlines, con-licting demands on time, and disruption o- home li-e as a result o-e4tended 1ork hours. 5(&6 3he combination o- being oerloaded, e4periencing inter-erence 1ith one


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displa or suppress emotions on the ?ob, re2uirement to be emotionall empathic>, and has -ound thatthese emotional -actors account -or additional ariance in burnout scores oer and aboe ?obstressors. 5(,986

Models o- Burnout

$ecent research has -ocused on the degree o- match or mismatch bet1een the indiidual and & domains

o- the ?ob enironment. 5(6 3he greater the (ap or mismatch bet1een the person and the enironment, thegreater the likelihood o- burnout. 3he greater the match or -it, the greater the likelihood o- engagement1ith 1ork. Mismatches arise 1hen the process o- establishing a pschological contract leaes criticalissues unresoled, or 1hen the 1orking relationship becomes unacceptable to the indiidual. Mismatcheslead to burnout.

3he -ollo1ing & areas o- 1ork li-e come together in a -rame1ork that encompasses the ma?ororgani=ational antecedents o- burnout

(. 0orkload

'. Communit

9. Control

. Fairness

. $e1ard

&. #alues

Burnout arises -rom chronic imbalances bet1een a person


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A number o- li-estle management techni2ues ma help reduce one.

+a#le ,. Signs and Smptoms of Burnout

Boredom

Lo1er 2ualit o- care

Depression

Fatigue

Frustration

!astrointestinal disturbances

Headaches:nsomnia

@ta-- turnoer

Lo1 morale

Phsicalemotional e4haustion

0eight loss

:mpaired ?ob per-ormance /decreased empath, increasedabsenteeism>

Deterioration o- phsician*patient relationships

Less satis-action, desire to reduce time spent seeing


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patients, greater likelihoodo- ordering tests or procedures, greater interest in earlretirement

:nabilit to leae 1ork /1orking longer and longer hours>,absenteeism, less ?obsatis-action, lo1er sense o- personal accomplishment

Management o- Burnout and Compassion Fatigue

A paucit o- eidence*based interentions has been sho1n to be e--ectie -or either the preention or thetreatment o- compassion -atigue or burnout in healthcare proiders caring -or persons 1ith cancer.Preliminar inestigations and anecdotal and empirical reports o--er suggestions such as communicationskills training, stress management 1orkshops, sel-*care behaior coaching, indiidual counseling,mentoring programs, sta-- retreats, and sabbaticals.

+ne program that has been studied and -ound to be e--ectie is the Accelerated $ecoer Program/A$P>, a *session coprighted protocol deeloped to address the smptoms o- compassion -atigue andburnout in caregiers. 5(6 A Certi-ied Compassion Fatigue @pecialist 3raining -or A$P 1as deeloped, and-ound to be e--ectie in reducing smptoms o- compassion -atigue in participants 1ho attended the train*the*trainer sessions. 5'6

Another approach that has sho1n promise in small obserational and a -e1 controlled clinical trials ismind-ulness*based stress reduction /MB@$>. :t combines mind-ulness, meditation, and oga in astructured G*1eek program, and has been demonstrated to reduce stress, increase coping, and improeempath in health pro-essionals 1ho complete the program. 596 +- interest, inestigators studingindiiduals 1ho hae undergone MB@$ training hae identi-ied, on 1hole brain analsis, increases in gramatter densit in seeral areas o- the brain, including the posterior cingulate corte4, the temporo*parietal

?unction, and the cerebellum, 1hen compared 1ith pre*interention and controls.56

Preention and earl detection are thought to be the best approaches to minimi=e the risk -or seriousconse2uences -rom burnout and compassion -atigue. A ariet o- li-estle management techni2ues mahelp healthcare proiders maintain balance in their lies and reduce the risk -or burnout /3able '>.

+a#le -. $ifestle Management +ec!niues

Monitoring -or and recogni=ing smptoms earl

Maintaining good nutrition

Maintaining spiritual li-e; meditating; spending time innature

!rieing losses e--ectiel

$educing oertime 1ork


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E4ercising aerobics, oga, 2i gong, tai chi

Maintaining energ $eiki, healing touch, therapeutictouch

Maintaining a sense o- humor

@eeking consultation i- smptoms are seere

Discussing 1ork*related stresses 1ith others 1ho sharethe same problems;isiting counterparts in other institutions; looking -or ne1solutions to problems

Meier and colleagues 56 recentl proposed an approach to phsician a1areness that inoles identi-ingand 1orking 1ith emotions that can a--ect patient care. Although originall proposed 1ith the phsician inmind, the approach has applicabilit to other healthcare pro-essionals. 3he approach inoles looking athealthcare pro-essional, situational, and patient risk -actors that can in-luence proider emotions andpatient care. 56 3he steps include

(. :denti- the -actors that predispose to emotions that might a--ect patient care.

'. Monitor -or signs /behaioral> and smptoms /-eelings> o- emotions.

9. Iame and accept the emotion.

. :denti- possible sources o- the emotion.

. $espond constructiel to the emotion.

&. @tep back -rom the situation to gain perspectie.

8. :denti- behaiors resulting -rom the -eeling.

G. Consider implications and conse2uences o- behaiors.

7. 3hink through alternatie outcomes -or patients according to di--erent behaiors.

(%. Consult a trusted pro-essional colleague.

More research needs to be done on organi=ational changes to reduce burnout. Hierarchical organi=ationsthat oeremphasi=e standardi=ation and e--icienc, combined 1ith increasing e4pectations o- per-ection/b patients, corporations, and colleagues> ma promote burnout and reduce the 2ualit o- pro-essionalpractice. 5&6 3he underling theme in burnout and 1ork engagement is that group and management

processes hae to promote more open -utures in 1hich emploees are better able to deplo their gi-ts inmeaning-ul 1as and gro1 as human beings.

:t ma be essential to measure the moral climate, assess the culture o- each 1orkplace, and ealuatespiritual concerns o- sta--. 3he latter might include clari-ication and strengthening o- meaning and purposeconducie to both personal italit and that o- the organi=ation.

:nterentions that combine changes in managerial practice 1ith educational interentions, on the basis o-the & areas o- 1ork li-e, ma reduce burnout. 5(6 People ma be able to tolerate heaier 1orkloads i- thealue the 1ork and -eel the are doing something important, or i- the -eel 1ell*re1arded -or their e--orts.


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:nterentions can target alues and re1ards. A stud b Fallo1-ield and co1orkers 586 sho1ed thatimproements in communication skills o- oncologists leads to more personall and pro-essionallre1arding consultations, 1hich can hae a signi-icant impact on clinical care and the 1ell*being o- bothpatients and phsicians.

Points to $emember

Burnout is prealent among cancer care proiders and phsicians. 0omen are more o-ten a--ected bburnout than men. Age is an independent predictor o- burnout, 1ith a higher prealence o- burnout inpeople at earlier stages o- their careers. 3o preent ** or address ** burnout, monitor oursel- -or signs andsmptoms o- burnout and compassion -atigue. 3he li-estle management techni2ues 1ill help oumaintain balance in li-e and reduce the risk -or burnout. Changes in management strategies combined1ith educational interentions ma -urther reduce burnout.

/e +ake01ome Points

• e dimensions o- burnout are e4haustion, cnicism, and a sense o- personal ine--ectieness;

• Burnout o-ten presents as a -eeling that ou don


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Cite this article Linda Emanuel, Frank D. Ferris, Charles F. on !unten, et. al. Combating Compassion Fatigue andBurnout in Cancer Care. "edscape. "un %&, '%((.
http://www.medscape.com/medline/abstract/18387018http://www.medscape.com/medline/abstract/21071182http://www.medscape.com/medline/abstract/11743845http://www.medscape.com/medline/abstract/11879860http://www.medscape.com/medline/abstract/18387018http://www.medscape.com/medline/abstract/21071182http://www.medscape.com/medline/abstract/11743845http://www.medscape.com/medline/abstract/11879860

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Combating Compassion Fatigue and Burnout in Cancer Care