The role of psychological factors in oncology nurses' burnout and compassion fatigue symptoms
Introduction
Oncology nursing is one of the areas most affected by occupational stress and burnout (Barnard et al., 2006, Potter et al., 2010). Oncology nursing involves the management of complex pathologies with poor prognosis, close and constant contact with patients who are in severe pain, distress and approaching death, and difficult patient and family situations, which poses an additional challenge to these professionals and further contributes to job dissatisfaction, stress, and burnout (Barrett and Yates, 2002, Potter et al., 2010). In addition, oncology nursing is one area that has been particularly affected by the nursing shortage (e.g., Buerhaus et al., 2001, Glaus, 2007), which significantly contributes to the job dissatisfaction, stress, and burnout in oncology nurses, and increased intent to leave the profession (Toh et al., 2012).
Burnout has been defined as a prolonged response to chronic job-related emotional and interpersonal stressors, characterized by emotional exhaustion, depersonalization, and lack of perceived social accomplishments (Maslach et al., 2001). Compassion fatigue, in turn, is described as a secondary traumatic reaction that results from the close contact with other people's suffering or trauma, and yields an almost identical set of symptoms to those of Posttraumatic Stress Disorder (PTSD). Compassion fatigue has been used interchangeably with secondary traumatic stress and vicarious trauma. By its definition, burnout can affect any worker in any professional field, while compassion fatigue is specific to professionals in helping contexts (healthcare professionals, teachers, police officers), who are in contact with the suffering of others. Nurses, and especially oncology nurses, are at a particular risk of developing compassion fatigue, because they constantly witness and contact intense suffering, pain and trauma of others (e.g., Najjar et al., 2009). In the opposite end of job-related stress, and less discussed in the literature, is the experience of fulfillment and satisfaction resulting from the work of caring for others, also known as compassion satisfaction (Stamm, 2010), which is also an intrinsic aspect of professional quality of life.
Most of the research looking at professional quality of life (burnout, compassion fatigue, and compassion satisfaction) has examined the role of demographic variables (such as professional experience, gender) and situational factors (such as workload, time pressure, role conflicts, job control, etc.). Relatively little attention has been paid to psychological dispositions, which may influence nurses' capacity to effectively cope with the potential negative effects associated with their work. One of such variables is empathy. Healthcare providers, and nurses in particular, are confronted daily with emotionally stressful situations associated with illness, suffering and dying, which require empathic abilities. There have been many definitions of empathy (Batson, 2009). In general, “empathy occurs when observing or even simply imagining another person's affective state triggers an isomorphic affective response. The person experiencing empathy is aware that the source of his or her emotional response is the other person's affective state” (Klimecki and Singer, 2012, p. 370; Singer and Lamm, 2009). Current approaches informed by findings from social neuroscience suggest that empathy is a multidimensional psychological phenomenon (e.g., Decety and Svetlova, 2012). For example, several researchers differentiate between the cognitive and affective aspects of empathy (e.g., Davis, 1983). While cognitive empathy is defined as understanding what the other person is feelings and thinking, affective empathy is related to the ability to feel what the other person is feelings. Also, when witnessing another's negative state, some people experience self-oriented responses, such as feelings of distress and anxiety, also known as personal distress; while others may experience other-focused responses, with feelings that focus on the wellbeing of the other person, labeled empathic concern (Batson et al., 1987, Davis, 1983, Decety and Lamm, 2011). Empathy is a core feature of the patient-healthcare professional relationship, and is associated with greater patient satisfaction (Epstein et al., 2007). However, there can be costs associated with empathy (Hodges and Biswas-Diener, 2007). Being overly sensitive to patients' suffering can lead to deleterious effects, such as burnout or compassion fatigue (Figley, 2002, Figley, 2012), especially if one lacks adequate emotional regulation and control (Decety et al., 2010).
Relatively less studied in the nursing literature is the concept of self-compassion. Self-compassion “involves being touched by and open to one's own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one's suffering and to heal oneself with kindness. Self-compassion also involves offering nonjudgmental understanding to one's pain, inadequacies and failures, so that one's experience is seen as part of the larger human experience” (Neff, 2003a, p. 87). This definition entails the three components of self-compassion, namely self-kindness (as opposed to self-judgment), mindfulness (as opposed to identification with negative thoughts or emotions), and common humanity (as opposed to feeling isolated by one's problems or shortcomings).
Meta-analytic research on self-compassion suggested that this construct is strongly related to less psychopathology (MacBeth and Gumley, 2012), and well-being (Zessin et al., 2015). Self-compassion is also related to positive psychological characteristics such as wisdom, happiness, well-being, and emotional intelligence (Hollis-Walker and Colosimo, 2011, Neff et al., 2007, Neff et al., 2005), and with interpersonal outcomes, such as empathy, altruism, and forgiveness (Neff and Pommier, 2013). Self-compassion could be helpful to oncology nurses because it may be a resilience factor for stress and other psychological difficulties and because of the emerging evidence that self-compassion is associated with compassion for others (e.g., Neff and Pommier, 2013), which has been shown to have a significant impact on patient outcomes (e.g., Fogarty et al., 1999).
Recently, it has been suggested that self-compassion is related to psychological flexibility (Yadavaia et al., 2014), which broadly refers to an individual's ability to fully embrace and connect with the experiences in the present moment, without avoidance, and to change or persist in behaviors that are in line with identified values (Hayes et al., 1999, Hayes et al., 2006). In contrast, psychological inflexibility, sometimes referred to as experiential avoidance, describes an individual's inability of choosing behavior in line with values and goals due to difficulties in connecting with the present moment, following rigid rules, and attempting to control or avoid difficult internal experiences (Hayes et al., 1999, Hayes et al., 2006).
Psychological (in)flexibility has consistently demonstrated associations with measures of psychological symptoms and quality of life (Boulanger et al., 2010, Chawla and Ostafin, 2007, Hayes et al., 2006). In contrast to the large body of research on psychological inflexibility across several conditions and populations, only one study to our knowledge explored the association between experiential avoidance and burnout syndrome, in a small sample of critical care nurses in Spain (Losa Iglesias et al., 2010). Psychological inflexibility may be important for oncology nurses because caregivers frequently have to cope with the experience of traumatic memories, negative thoughts, unpleasant emotions, and physiological sensations associated with the constant exposure to suffering, trauma, and losses. While trying to control or avoid them can provide some relief of discomfort in the short-term, it ultimately becomes maladaptive, increasing distress and getting in the way of other important and valued aspects of life (Hayes et al., 1999). Psychological inflexibly may be particularly important for compassion fatigue. There is ample evidence for experiential avoidance and psychological inflexibility as problematic processes linking trauma to diminished well-being (e.g., Polusny et al., 2004, Orcutt et al., 2005).
Despite the high prevalence rates of burnout and work-related distress and its recognized deleterious consequences, there is a dearth of literature pertaining to burnout, and especially compassion fatigue, in oncology nurses. In addition, the role of psychological dispositions as risk factors for burnout and compassion fatigue remains understudied, not only in oncology nurses but in healthcare workers in general. In particular, self-compassion and psychological flexibility are widely recognized as important factors for well-being across conditions and populations, but few studies to date investigated their role in professional quality of life. This study aims to explore and clarify the links between several dispositional factors (empathy, self-compassion, and psychological inflexibility) and compassion fatigue, burnout, and compassion satisfaction in oncology nurses.
Section snippets
Participants and procedures
This study is part of a larger project exploring the role of psychological factors on professional quality of life. Participants were recruited from five public hospitals from Portugal's north and center regions. Two were oncology hospitals and three were general hospitals with oncology/palliative care units. After approval of hospitals' ethics committees, department chief nurses from oncology/palliative care units were contacted by the researcher who explained the study aims and the importance
Demographic profile and professional background
A total of 221 registered nurses from public hospitals participated in the study. The sample had a mean age of 39.06 (SD = 8.85), ranging between 24 and 58 years of age; the majority of participants were female (n = 196; 91.2%) and married (n = 103; 47.9%). Also, the mean years of schooling was 15.37 (SD = 2.25). Participants had on average 16.25 (SD = 8.89) years of practice.
Empathy, self-compassion, and psychological inflexibility
Descriptive statistics are presented in Table 1. Mean values for empathy subscales were similar to previous studies
Discussion
The current study explored the way individual dispositions, such as empathy, self-compassion, and psychological inflexibility, and age, gender, and practice in nursing, impact on professional quality of life, in its positive (compassion satisfaction) and negative components (compassion fatigue and burnout).
Conclusion
The constant exposure to the suffering of others places high emotional demands on oncology nurses and other healthcare professionals, making them vulnerable to burnout and compassion fatigue as a result of this exposure. Although interventions targeting work-site factors, such as workload and time pressure, social support or job security, may be helpful in reducing burnout, they can be difficult to implement at times, and may not adequately address the problem of burnout, and especially
Funding
This research was supported by the first author's Ph.D. Grant no. SFRH/BD/81416/201, sponsored by FCT (Foundation for Science and Technology), Portugal, and co–sponsored by ESF (European Social Fund), Belgium, through Portuguese POPH (Human Potential Operational Program).
Conflict of interest
No conflict of interest has been declared by the authors.
Acknowledgments
The authors gratefully acknowledge the institutional boards for approving the recruitment of participants in their hospitals.
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