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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
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Table of Contents
Abstract ……………………………...……………………………………………………………3
Introduction………………………………………………………………………………………..4
A Review of Literature……………………………………………………………………………6
Methods……………………………………………………………………………………………8
Results ………………………………………………………………………………………….10
Discussion………………………………………………………………………………………..11
IRB Approval…………………………………………………………………………………….13
References………………………………………………………………………………………..14
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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.
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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).
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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?
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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
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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
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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.
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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.
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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.”
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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
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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.
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