1 STRESS, BURNOUT, AND COPING MECHANISMS IN HEALTH PROFESSIONALS WORKING IN PEDIATRIC ONCOLOGY by Alix Rothbart A Senior Honors Project Presented to the Honors College East Carolina University In Partial Fulfillment of the Requirements for Graduation with Honors by Alix Rothbart Greenville, NC May 2015 Approved by: Dr. Elizabeth Jones Thomas Harriot College of Arts and Sciences: Department of Biology Dr. Annette Greer Brody School of Medicine: Department of Bioethics and Interdisciplinary Studies 2 Table of Contents Abstract ……………………………...……………………………………………………………3 Introduction………………………………………………………………………………………..4 A Review of Literature……………………………………………………………………………6 Methods……………………………………………………………………………………………8 Results ………………………………………………………………………………………….10 Discussion………………………………………………………………………………………..11 IRB Approval…………………………………………………………………………………….13 References………………………………………………………………………………………..14 3 Abstract Burnout syndrome is a destructive repercussion of experiencing various chronic stressors and is prevalent among health care professionals. It changes driven, ambitious, hardworking people into depressed, apathetic, error-prone individuals. The purpose of this qualitative Senior Honors Project is to identify potential stressors and burnout of physicians and nurses working in Pediatric Oncology at a regional tertiary hospital in the southern United States, and what coping mechanisms individuals use to help avoid or ameliorate this syndrome. Study Design and Methods: This study is ongoing. There is a goal sample of 5-10 subjects. The participants of this qualitative study are gathered using the snowballing effect. Each participant is interviewed and asked 11 open-ended questions designed by the research team. Results: The results are based on the responses by two participants, with an average of 39.5 years of experience. Inabilities to balance family and work life, along with the death of patients are real predictors of stress experienced in the Pediatric Oncology work environment. Lack of psychological intervention exacerbates these predictors. Spirituality, religion, remarkable recoveries, and psychological intervention are all powerful coping mechanisms practiced by health care professionals. The findings of this study can be invaluable in identifying and avoiding key stressors that lead to burnout syndrome. 4 Introduction Burnout syndrome is an increasing problem for many people in the workforce, especially for health care providers. Health care providers have a physically, emotionally, and mentally demanding job. From working overtime and being on-call to grieving losses and rejoicing the successes, health care providers may experience a myriad of emotions in one day’s work. Of these emotions, stress may predominate due to the high-intensity of their environment and involvement with other people that this job requires. Because of how emotionally draining it is, chronic stress is a major factor contributing to the development of burnout syndrome (Maslach 1981). Burnout syndrome is unique in that there is not one single agreed-upon definition, however, Maslach, Schaufeli, and Leiter (2001) define burnout as “a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by the three dimensions of exhaustion, cynicism, and inefficacy.” Cancer is the leading cause of death from disease in children under the age of 15. However, survival rates for childhood cancers have increased greatly since their onset to about 75% (Buchanan, 2014). Pediatric oncology is unique from other health care disciplines because it deals with children up to the age of 21 with cancer. The treatments are often painful, and the health care professionals deal with persistent stress due to the number of deaths and dying patients that come with working in any oncology unit. For many nurses, feelings of emotional exhaustion and lack of control over work arise when they are compelled to disguise their true feelings of sadness and hopelessness for the family and other staff (Davis, Lind, & Sorensen, 2013). Studies have found incidence rates of 40-60% of pediatric oncology health care workers and 40% of nurses experience burnout (Jahromi & Hojat, 2014; Gallagher, 2009; Weber & Jaekel-Reinhard, 2000). 5 There are no specific medications or vaccinations to treat or prevent burnout syndrome. There may be medications available to treat health conditions that are correlates or consequences of burnout, but none exist for the syndrome itself. Typically, these methods used to alleviate the effects of burnout syndrome are termed coping mechanisms: Support systems (social, work, mental, etc.) Healthy work-life balance Resilience Positive attitude Expressing emotions appropriately Professional boundaries Non-work relationships Self-care activities Meditation/spirituality Debriefing (depending on job) Journaling Yoga Stress management education Self-awareness Therapy (psychological support) Stress management education (Gallagher, 2009; Hesselgrave, 2014; Davis, Lind, & Sorensen, 2013) The purpose of this study is to identify potential stressors and burnout of physicians and nurses working in Pediatric Oncology at a regional tertiary hospital in the southern United States, and what coping mechanisms individuals use to help avoid or ameliorate this syndrome. The research questions being studied include: what are the potential for stress and burnout of health professionals working in Pediatric Oncology? What clinical or humanistic issues cause stressors for the health professionals and how are they manifested? What coping mechanisms do health professionals use to improve their job and daily life? 6 Literature Review In a descriptive study at a metropolitan cancer center by Shoni Davis et al. (2013), burnout was studied among oncology nurses in different work settings, along with coping strategies, and job satisfaction. Specifically, the different work settings included: inpatient, outpatient, adult, and pediatrics. The sample used consisted of a convenience sample of 74 oncology nurses, 37 in outpatient, 35 in inpatient, 59 in adult, 15 in pediatric, and two not reported. Three questionnaires were utilized in this study. One was a demographic questionnaire developed by the researchers, along with two sets of questions from the Nursing Satisfaction and Retention Survey, and the Maslach Burnout Inventory to measure burnout. Through this study, the researchers found that: most nurses rely on spirituality and coworker support to deal with stress, emotional exhaustion was highest for outpatient RNs (mostly older nurses) and lowest for the youngest nurses, personal accomplishment was highest in nurses working in adult settings, and job satisfaction correlated inversely with emotional exhaustion. This study demonstrates the importance of social support as a coping mechanism to avoid emotional exhaustion and also suggests that the level of emotional exhaustion is related to age and years of working as a nurse. In a descriptive study implemented at a large pediatric medical center in the Midwestern United States, Gallagher, R., & Gormley, D.K. (2009) sought to explore bone marrow transplant nurses’ perceptions of work-related stress and burnout as well as support systems. Bone marrow transplant patients tend to experience a great deal of pain with their cancer as well as with the transplants themselves, which adds to the stressful environment experienced by pediatric oncology nurses. A convenience sample of a range of 30 pediatric bone marrow transplant nurses was included in the study. The instrument used to gather data was the Maslach Burnout Inventory, as well as a demographic questionnaire. The researchers found that as years as a bone 7 marrow transplant nurse increased, levels of emotional exhaustion and depersonalization decreased. The data suggested that there are moderate to high levels of emotional exhaustion and depersonalization in more inexperienced nurses. The most stressful factor reported by the nurses was critical illness or acuity of patients, and the least stressful factor was long work hours. The majority of nurses reported knowing about support systems in place and that they are accessible, but were undecided about the helpfulness of the support systems. In a pilot study executed by Dr. Patricia Potter et al. (2013), a resiliency program was implemented and evaluated at a National Cancer Institute in the Midwestern United States to determine if a program informing nurses in oncology about compassion fatigue would be beneficial. The researchers used a sample of 13 oncology nurses working in the outpatient chemotherapy infusion center. The program consisted of five 90-minute education sessions on compassion fatigue and resiliency. The participants answered various instruments, which measured compassion fatigue, job satisfaction, and burnout before and after the program. The researchers used a repeated measures design. The instruments used in this study include Scores on Professional Quality of Life IV, Maslach Burnout Inventory-Human Services Survey, Impact of Event Scale-Revised, and Nursing Job Satisfaction Scale. Through this study, it was discovered that there were long-term benefits as a result of the program. Compassion fatigue is a ubiquitous condition amongst healthcare professionals. Education professionals on advantageous methods for managing stress in their lives may help alleviate some factors contributing to compassion fatigue to develop resiliency. In a review of current literature, Edward and Hercelinskyj (2007) found that stress and burnout syndrome are major factors that contribute to the difficulty in recruitment and retention of nurses in the healthcare field. According to several studies reviewed by the authors, “role 8 conflict and role ambiguity, time constraints related to the examination, or long-term stress and frustration caused by strain in daily life, promote or exacerbate burnout.” The literature suggests that burnout syndrome is a widespread problem (mostly among inexperienced staff). In some places, there are programs in place to mitigate the occurrence of burnout syndrome. These programs educate staff and help staff learn how to deal with their range of emotions experienced daily. These programs have exhibited beneficial effects on the staff that utilizes them. Methodology The study is ongoing. The goal sample of 5-10 total physicians and nurses working in Pediatric Oncology at a regional tertiary hospital in the southern United States will be reached by the snowballing effect. Each participant is asked if they would like to recommend another colleague eligible to participate in the study. The recommended participant is then contacted about possibly participating in the study. Each subject is interviewed and asked a series of questions about their job and the history of their career. The interviews are recorded using a LiveScribe pen, which sends the audio file to a computer and also converts the notes taken during the interview into a PDF document. All of the data is coded and kept on a passwordprotected flash drive. The questions asked during each interview are open-ended and use specific language to avoid leading the subject to answering a specific way. The questions include: 1. Tell me, when you wake up and go to work, how do you feel? 2. Describe what kinds of emotions you experience on a typical day at work. 9 3. Tell me how you feel when you are around the parents of your pediatric patients. 4. Tell me how you feel when you are around the child/patient. 5. A) Tell me how you feel if/when the child is in pain. B) What about when they are not in pain? 6. A) Tell me about one of the worst days you have experienced as a health care professional. B) What kinds of emotions did this evoke? 7. A) Tell me about one of the best days you have experienced as a health care professional. B) What kinds of emotions did this evoke? 8. Describe a time (if any) where you have wanted to change the area of health care focus. 9. A) Describe the hospital environment (professional/social interactions between the medical staff) on a typical day. B) If you could change one thing about the hospital environment, what would it be? 10. Tell me about whom you share your feelings with (if anyone) or describe how you handle your feelings. 11. What are your thoughts/opinions on health care professional-patient-family relationships? The answers to these questions are then qualitatively coded and converted into data to answer the research questions of this study. 10 Results (Based on three interviews with two physicians and one nurse, average years of experience being 39.5) The struggle to balance work and family, along with the inadequacy of team performance were real predictors of stress experienced in the Pediatric Oncology work environment. Loss of patients through death, especially those whose outcome was unexpected, caused a range of emotions in the health professionals caring for them. One participant confessed that when a patient dies, they “feel a sense of failure. What more could I have done? Did I miss anything? What if I had used different treatments?” In regards to the team dynamic, one participant claimed: “Everyone on the team needs to feel important. The team dynamic is crucial; it has to be smooth. Each person has to have a voice because bullying will sabotage the team, which is detrimental to the patient’s treatment.” Lack of psychological intervention when experiencing emotions associated with unsettling deaths of patients (such as empathy, sense of responsibility, and sense of failure) created a sense of moral distress, which could contribute to burnout. Providers with deepest empathy were often unsuccessful in separating personal from professional life, resulting in a personal loss. When asked about how he/she shares their feelings, one participant stated, “There weren’t many people I could talk to. I had the wrong idea of how to [share my feelings]. I bottled it, didn’t share it, and unfortunately I would get too full and explode. And it cost me a marriage.” They added, “Psychologists with training in debriefing after difficult deaths for parents, patients, and physicians are invaluable. They are hard to come by. Many times doctors and nurses don’t ask for it.” 11 The extraordinary happiness felt by the health care professional from remarkable recoveries seems to impact career decisions in maintaining focus on children with cancer and their families. Psychological intervention, as well as newfound spirituality and realization of balance between work and family, seemed to alleviate some of the stress experienced by health care professionals on a daily basis. A participant answered that the best days they experience at work evokes “extraordinary happiness. It makes me glad to be in the position I am in. It gives me a sense of pride, and sort of ecstasy. Just thinking about it now puts me in a positive mood.” Discussion The purpose of this study is to identify potential stressors and burnout of physicians and nurses working in Pediatric Oncology at a regional tertiary hospital in the southern United States, and what coping mechanisms individuals use to help avoid or ameliorate this syndrome. The preliminary results uphold the data from other sources of literature. The negative emotions experienced by these professionals are consistent with the emotions that cause chronic stress and lead to burnout syndrome. This study found that the coping skills implemented by the professionals themselves are consistent with some of those found by other researchers and have proven to be advantageous in preventing burnout, and in some cases, overcoming it. More participants are necessary to get a broader range of responses. The study will continue. However, the sample will be limited to physicians and nurses working in Pediatric Oncology at a regional tertiary hospital in the southern United States. More research is imperative to fully understand every aspect of burnout syndrome. In order to progress with research on burnout, the sample would need to be expanded to cover more regions with Pediatric Oncology professionals. Because this study was assessing the potential for burnout, the actual 12 level of burnout should be determined using an instrument such as the Maslach Burnout Inventory. After the actual level of burnout is established, implementing various coping mechanisms to determine their effectiveness in the hospital setting would be necessary. 13 14 References Boyle, A., Grap, MJ., Younger, J, Thornby, D. (1991). Personality hardiness, ways of coping, social support and burnout in critical care nurses. Journal Of Advanced Nursing 6(7):850-7 Buchanan, G.R. (2014). A Career in Pediatric Hematology-Oncology? [Brochure]. Dallas, TX: The American Society of Pediatric Hematology/Oncology. Davis, S. Lind, B.K., & Sorensen, C. (2013). A Comparison of Burnout Among Oncology Nurses Working in Adult and Pediatric Inpatient and Outpatient Settings. Oncology Nursing Forum, 40(4), E303-E311. doi:10.1188/13.ONF.E303-E311 Edward, K., & Hercelinskyj, G. (2007). Burnout in the caring nurse: learning resilient behaviours. British Journal Of Nursing, 16(4), 240-242. Freudenberger, H.J. (1977). SPEAKING FROM EXPERIENCE. Training & Development Journal, 31(7), 26 Gallagher, R., & Gormley, D.K. (2009). Perceptions of Stress, Burnout, and Support Systems in Pediatric Bone Marrow Transplantation Nursing. Clinical Journal Of Oncology Nursing, 13(6), 681-685. doi:10.1188/09.CJON.681-685 Hesselgrave, J. (2014). Coping with Compassion Fatigue in Pediatric Oncology Nursing. Oncology Times , 2-3. Jahromi, K., & Hojat, M. (2014). The Etiology of burnout syndrome and the levels of stress among nurses . Journal of Jahrom University of Medical Sciences , 12 (1), 49-57. 15 Maslach, C., Schaufeli, W.B., & Leiter, M.P. (2001). JOB BURNOUT. Annual Review of Psychology, 52(1), 397-422. Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal Of Occupational Behavior, 2(2), 99-113. Potter, P., Deshields, T., Berger, J., Clarke, M., Olsen, S., & Chen, L. (2013). Evaluation of a Compassion Fatigue Resiliency Program for Oncology Nurses. Oncology Nursing Forum,40(2), 180-187. Taylor, B., Barling, J. (2004). Identifying sources and effects of carer fatigue and burnout for mental health nurses: a qualitative approach. International Journal Of Mental Health Nursing 13: 117-25. Weber, A., & Jaekel-Reinhard, A. (2000). Burnout syndrome: a disease of modern societies? Occupational Medicine , 50 (7), 512-517.