Effectiveness of a mindfulness-based intervention on oncology nurses’ burnout and compassion fatigue symptoms: A non-randomized study
Introduction
Job stress and burnout are highly frequent in healthcare professionals (e.g., McCray et al., 2008) and prevalence in nurses can be as high as 40% (Dominguez-Gomez and Rutledge, 2009, Sermeus et al., 2011, Vahey et al., 2004). Several studies have reported that stress and burnout in healthcare professionals are associated with several physical and mental health problems, such as fatigue, insomnia, hypertension, depression, and anxiety (e.g., Maslach et al., 2011, Schulz et al., 2011). Stress and burnout also impact on professional effectiveness and have been associated with suboptimal patient care (Shanafelt et al., 2002) and self-reported medical errors (West et al., 2006). In addition to the impact on healthcare professionals and patients’ well-being, stress and burnout have potential economic costs to the organizations. It is estimated that stressed workers can be 46% more costly than non-stressed workers, and this number can as high as 147% if workers are also depressed (Goetzel et al., 1998).
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).
In contrast to the large body of research examining stress and burnout in healthcare professionals, little attention has been paid towards preventive interventions and the promotion of health and well-being. Among the most frequently identified and empirically-validated interventions to help address stress in several contexts are mindfulness-based interventions.
Mindfulness-based interventions (MBIs) are designed to teach participants to become more aware of thoughts, feelings and body sensations, while approaching these internal states with a non-judgmental curiosity. Mindfulness practice allows for greater awareness of the present moment, and helps cultivate healthier and adaptive ways of responding to stress, rather than habitual and often maladaptive reactions. The cultivation of concentration, attention, and non-judgemental acceptance of whatever is being experienced in the present moment is central to the practice of mindfulness (Kabat-Zinn, 1990, Bishop et al., 2004).
A meta-analysis of 20 studies in a wide-range of clinical populations found consistent improvements in depression, anxiety, coping style, and quality-of-life measures following Mindfulness-Based Stress Reduction (MBSR; Grossman et al., 2004). Recently, a meta-analysis concluded that MBSR is effective in reducing stress, depression, anxiety and distress and in ameliorating the quality of life, in nonclinical populations (Khoury et al., 2015). A recent review also outlined evidence to support the impact of mindfulness meditation on many stress-related medical conditions including psoriasis, type 2 diabetes, fibromyalgia, rheumatoid arthritis, and chronic low back pain, as well as reducing stress among individuals with chronic illness (Greeson, 2009).
Specific to the healthcare field, a systematic review and meta-analysis of 8 studies of the impact of MBIs on healthcare professionals’ health and wellness found that participation in an MBI can have benefits for healthcare professionals in the domains of general and mental health, such as reduced stress, depression, anxiety, burnout, and improve self-compassion, mindfulness, physician empathy, sense of coherence and satisfaction with life (Burton et al., 2016).
Although research on the impact of MBIs with nurses separate from other healthcare professionals is scarce, some studies have found significant improvements in burnout and psychological distress among nurses participating in a MBI compared to control groups (Cohen-Katz et al., 2005, Mackenzie et al., 2006.
Traditional MBSR programs involve a serious time commitment: eight 2.5-h classes, one full-day retreat, and 45 min of meditation practice per day. As a result, recent studies have started to analyse the effects of adapted mindfulness interventions. In the healthcare field, for example, Mackenzie et al. (2006) found significant effects for burnout, relaxation, and life satisfaction in nursing students after a 4-week mindfulness intervention. Similarly, Fortney et al. (2013) found that an abbreviated mindfulness training course adapted for primary care clinicians was associated with reductions in indicators of job burnout, depression, anxiety, and stress.
Despite these promising findings, there is still a paucity of evidence-based studies that focus specifically on MBIs as an effective intervention for burnout, especially in nurses. Also, only one study to our knowledge explored the effectiveness of a MBI in a sample oncology nurses (paediatric; Moody et al., 2013). In addition, no studies to our knowledge explored the impact of a mindfulness intervention in reducing compassion fatigue. There is evidence to suggest that although related, burnout and compassion fatigue have different causes and symptoms (Bride et al., 2007). The term compassion fatigue has emerged in the literature in recent years and has been used interchangeably with secondary traumatic stress and vicarious trauma, because it is used to describe secondary stress reactions (e.g., re-experiencing the traumatic events, avoidance/numbing of reminders, and persistent arousal) related to the provision of care to people who experienced some form of trauma or severe stress (Figley, 1995, Stamm, 2010). Oncology nurses may be especially vulnerable to compassion fatigue given the constant exposure to the suffering and trauma of their patients (Najjar et al., 2009). It has been suggested that without emotion regulatory skills, the repeated exposure to trauma, pain and suffering of others could be associated with adverse consequences such as distress and compassion fatigue (Decety et al., 2010), and impact on the ability to treat. Several studies elucidating the mechanisms of change associated with mindfulness training have suggested that meditation has an effect on brain areas associated with emotion regulation (see Chiesa et al., 2013 for a review) and improves emotional adaptation through attention regulation (Desbordes et al., 2012). In addition, some studies have provided evidence that mindfulness interventions may be helpful in treating trauma-related symptoms (Bhatnagar et al., 2013, Nyklíček et al., 2013). Thus, we speculate that nurses undergoing mindfulness training develop better emotion regulation skills, which in turn may help them regulate their interpersonal sensitivity and negative arousal and protect against compassion fatigue.
This study aims to explore the effectiveness of an on-site mindfulness-based intervention on oncology nurses’ psychological outcomes. It is hypothesised that, compared to a wait-list comparison group, participants receiving the MBI would experience decreases in symptoms of burnout, compassion fatigue, depression, anxiety and stress, and increases in satisfaction with life. Moreover, we hypothesized that the intervention would promote increases in trait mindfulness and self-compassion, and decreases in rumination and experiential avoidance.
Section snippets
Participants
Participants were recruited from two major oncology hospitals, located in the north and centre regions of Portugal, between 2013 and 2015. Individuals in this study were nurses who worked in direct contact with patients in their services. A total of 94 participants agreed to take part in the study. From these, one participant dropped-out before the intervention due to inconvenience. Participants who agreed to take part in the study were assigned to the experimental (n = 45) and waiting-list
Samples’ characteristics
The final sample in which the analyses were conducted was composed by 29 nurses in the experimental group and 19 nurses in the wait-list comparison group. The intervention group was composed by 26 female nurses and 3 male nurses, with a mean age of 38.90 (SD = 8.34), ranging from 25 to 54 years. The majority of the sample was married or cohabiting (n = 24, 75.9%), 5 were single (17.2%), and 2 were divorced (6.9%). The mean years in practice was 15.92 (SD = 7.84), and the mean of years in the current
Discussion
The present study explored the effectiveness and acceptability of a modified mindfulness-based program for oncology nurses. A sample of nurses recruited from two oncology hospitals self-selected into either a wait-list comparison condition (no intervention offered) or a mindfulness intervention condition. We predicted that individuals undergoing the mindfulness intervention would experience reductions in burnout, compassion fatigue, depressive, anxious and stress symptoms, experiential
Conclusion
Oncology nursing is one area that has been particularly affected by the global nursing shortage (e.g., Buerhaus et al., 2001, Glaus, 2007). Moreover, projections from the World Cancer Report show that cancer rates may increase up to 50% to 15 million new cases by the year 2020. (World Health Organization, 2003). These statistics suggest that the number of oncology nurses is far from adequate to meet current and future needs. According to previous studies, nursing shortage significantly
Conflict of interest
No conflict of interest has been declared by the authors.
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).
Acknowledgment
The authors gratefully acknowledge the institutional boards for approving the recruitment of participants in their hospitals and the training offices for their support.
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