Burnout is an important and pertinent topic for nursing in 2021. The challenges presented by the global COVID-19 pandemic have intensified the stressors placed on nurses, leading to burnout and compassion fatigue (Chen et al, 2021). Many nurses have been redeployed into roles created as a response to the COVID-19 crisis and are required to manage complex diagnosis and treatment regimens outside their normal area of work.
Burnout is thought to contribute to poorer patient outcomes and lower care standards (Cañadas-De la Fuente et al, 2018). Staff absenteeism increases and care standards fall, negatively impacting nurse wellbeing, healthcare institutions' performance and patient outcomes (Russell, 2016). Burnt-out nurses are emotionally and physically drained, lack enthusiasm and concentration, and are more likely to make errors (Gómez-Urquiza et al, 2016). Gaining a better understanding of the causes of burnout and effective strategies to reduce or prevent it will help to improve patient care and support staff wellbeing during and after the global COVID-19 pandemic.
Oncology nursing is one of the specialties most affected by burnout within the nursing workforce (Duarte and Pinto-Gouveia, 2017). They carry a considerable emotional burden that heightens the risk of burnout, particularly when they lack appropriate support, and work in settings with high patient:nurse ratios and other challenging workplace conditions (Houck, 2014).
An understanding of burnout from the perspective of oncology nursing can be gained from searching the relevant literature. Such a literature search was carried out in this study to establish the prevalence and causes of burnout in oncology nurses before the COVID-19 pandemic, and also examine strategies that aim to prevent it.
This information is critical to the recovery phase of health services and staff wellbeing, as nursing teams begin to process the true cost of the pandemic.
Defining burnout
Burnout is a state of emotional, physical and mental exhaustion resulting in increased mental distance and low personal satisfaction in work activities (Sabo, 2011; Maslach and Leiter, 2016; Dyrbye et al, 2017; World Health Organization, 2019). Burnout occurs as work environment stress develops past the point of being able to cope (Russell, 2016).
Maslach and Jackson's seminal work in 1981 suggests the three pillars of burnout are: emotional exhaustion; depersonalisation; and low personal accomplishment. Some authors disagree. Hakanen and Schaufeli (2012) and Bianchi et al (2014) suggest that low personal accomplishment should not be a defining characteristic of burnout (unlike emotional exhaustion and depersonalisation) as it could result from other issues.
However, for this review, Maslach and Jackson's (1981) definition, which includes low personal accomplishment as a central construct, is used as it is consistent with the studies reviewed and helps makes sense of the impact of burnout on oncology nurses (De la Fuente-Solana et al, 2017).
Search strategy
An initial scoping search highlighted how burnout and compassion fatigue were connected and used interchangeably within the literature (Wentzel and Brysiewicz, 2017). Stamm (2010) suggests compassion fatigue is made up of burnout (exhaustion, frustration and anger) and secondary trauma (a negative feeling arising from work-associated trauma). The symptoms of compassion fatigue overlap those of burnout, leading to the terms burnout, compassion fatigue, cumulative grief and secondary traumatic stress syndrome being used interchangeably (Houck, 2014; Wentzel and Brysiewicz, 2017).
However, it is important to identify that compassion fatigue and burnout are not the same, although they are closely linked. The causes are different, and symptoms and experiences of the conditions can manifest in similar or different ways and can perpetuate each other (Wu et al, 2016). This means that burnout and compassion fatigue can be investigated alongside each other as influencers, but must not be used as proxy terms for each other. Nonetheless, throughout the literature, burnout and compassion fatigue are used interchangeably.
Consequently, a literature search using the terms ‘burnout’, ‘burn-out’, ‘burnout syndrome’, ‘compassion fatigue’, ‘work-related stress’, ‘secondary traumatic stress syndrome’, ‘nurs*’, ‘cancer’, ‘oncology’, ‘haematology’ and ‘hematology’ were inputted into the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Science Index and Abstracts (ASSIA) and the British Nursing Index (BNI).
The search was limited to articles that were published in the last 5 years (August 2014-January 2020), in English and peer reviewed, and by location. Studies were limited to North American or European countries to focus on the experience of oncology nurse burnout within western culture, which may translate to the British context more easily.
Articles were excluded if they were duplicates, were not exclusively related to adult oncology nurses, had no extractable data or did not have an abstract. This resulted in the final number of articles for review totalling 31. There were no studies that matched the search criteria based in the UK, indicating a need for investigations looking at oncology nurse burnout in the British context.
The literature search found quantitative studies (n=16), qualitative studies (n=2), mixed-method studies (n=3), a meta-analysis (n=1), systematic or integrative reviews (n=3) and opinion or observational papers (n=6). The main themes that emerged were: the prevalence of burnout among oncology nurses; the causes of burnout in oncology nurses; and strategies to prevent burnout or find solutions to it.
Prevalence of burnout
The prevalence of oncology nurse burnout emerged as a key topic throughout the literature search. Burnout was experienced to some degree by 3-65% of oncology nurses (Gómez-Urquiza et al, 2016; Kołpa et al, 2017). The broad range of results indicate the literature needs to be examined more closely.
The majority of studies used the Maslach Burnout Inventory (MBI) as a tool to measure burnout. Maslach and Jackson (1981) devised the MBI to assesses the three constructs of burnout (emotional exhaustion, depersonalisation and low personal accomplishment). It has been used many times in empirical research studies since its construction and is widely trusted to identify the prevalence and severity of burnout (Poghosyan et al, 2009; De la Fuente-Solana et al, 2017). However, the MBI has been criticised for using arbitrary cut-off points to categorise scores into low, moderate and high risk of burnout, leading investigators to examine non-burnout cases and drawing conclusions incorrectly (Bianchi et al, 2015). There is some justification for this argument suggesting the categorisations of burnout lack evidential rigour; however, the MBI is designed to assess burnout experiences among groups of employees as a guide and not to diagnose individual distress. Although the MBI is not without criticism, it is generally thought of as reliable and accurate and is widely used throughout the literature related to oncology nurse burnout (Cañadas-De la Fuente et al, 2018).
Russell (2016) reported a moderate degree of burnout among 61 nurses from Pennsylvania in the US. This study is limited as it does not provide the numerical MBI scores of the nurses who were experiencing burnout, opting instead to offer the mean score of all participants and concluding there was a moderate level of burnout (Russell, 2016). The criticisms previously highlighted regarding the MBI's arbitrary banding of scores are evident in this paper; the study is limited by using only the cut-off points of the MBI and categorising low, moderate and high degrees of burnout according to these cut off points.
A moderate level of burnout has also been demonstrated by Duarte and Pinto-Gouveia (2017), supporting the findings of Russell (2016). This moderate degree is significantly below that suggested by Kołpa et al (2017), who found high levels of burnout were reported by oncology nurses in Poland. Kołpa et al (2017) found burnout was distinctly present in a sample of 100 Polish oncology nurses. A majority (62%) of participants scored high in the emotional exhaustion subscale of the MBI. However, the study's design and methodology had significant flaws and it is considered low-quality evidence, lacking rigour, particularly because of a bias in sample selection. The levels of burnout found are considerably higher than those reported elsewhere, such as in the study by De la Fuente-Solana et al (2017), further indicating unreliable evidence.
De la Fuente-Solana et al (2017) examined 101 oncology nurses' experience of burnout and found that 29.6% of them felt the most severe forms. The findings of Arimon-Pagès et al (2019) were congruent with those of De la Fuente-Solana et al (2017). Half of the participants surveyed by Arimon-Pagès et al (2019) experienced moderate burnout, and 20.2% reported high levels of burnout according to the results of a Professional Quality of Life survey (Stamm, 2010). However, both studies suffered from possible sample selection bias, a small sample size and cross-sectional design, limiting their ability to establish cause and produce results that can be generalised.
A meta-analysis by Cañadas-De La Fuente et al (2018) examined the results of 9 959 oncology nurses' MBI questionnaires. High scores in the emotional exhaustion subscale were demonstrated in an average of 30% of nurses, with a range of 26-33% between studies; high depersonalisation was found in 15% of nurses on average, with a range of 9-23%; and low personal accomplishment was found in an average of 35%, with a range of 27–43%. Many of the studies included were more than 10 years old. Using information that is considered dated means this study is less able to indicate present-day burnout prevalence. The quality of the studies is low because of the descriptive design and cross-sectional nature that are common in studies regarding oncology nurse burnout and can provide only a snapshot in time.
Similar results are seen in a systematic review by Gómez-Urquiza et al (2016), which includes 27 articles and a total sample population of 11 107 nurses. High emotional exhaustion was present in 3–38% of oncology nurses. This broad range indicates that burnout depends on the situation.
Not all studies suggest burnout is high in oncology nurses. Giarelli et al (2016) and Gama et al (2014) both conclude that burnout is low among the participants they surveyed. However, both studies are limited by poor recruiting descriptions and techniques, and the use of small convenience samples and cross-sectional designs. Giarelli et al (2016) included just 20 participants from one hospital; this sample is too small to draw any firm conclusions from.
A broad range of results such as these suggests situational and location-specific prevalence rates of burnout. This is likely to be related to societal and cultural variance, healthcare systems' values and practices, team dynamics and personal risk factors. Transferability is limited as all the studies are based on self-report and self-select methods, often with small samples taken from single institutions. More robust studies are needed to identify the prevalence of burnout within oncology nursing, particularly in the UK, as the studies examined do not offer a consistent analysis of its prevalence.
The individual characteristics of individuals, institutions and cultures can dramatically influence the level of burnout felt, highlighting a need to carry out studies within NHS oncology environments so an accurate measure of oncology nurse burnout can be assessed.
It is reasonable to expect that the prevalence of burnout will increase in light of the challenges experienced by oncology services during the COVID-19 pandemic. Delays in the diagnosis and treatment of cancers are reported widely and will continue to have an impact on oncology nurses' burnout experiences and worsen patient outcomes (Turnbull, 2021). Such delays will inevitably leading to poor prognosis and more aggressive treatments for patients.
Workplace-related causes of burnout
A second theme that emerged through the literature search is understanding the causes of burnout. Personal risk factors and psychological dispositions were explored as causes of burnout (Gómez-Urquiza et al, 2016; De la Fuente-Solana et al, 2017; Duarte and Pinto-Gouveia, 2017). However, workplace-related causes emerged as the most significant determinant. Staffing shortages, unsocial shift patterns, patient suffering and poor communication between professionals emerged as significant contributors to burnout as they negatively impact the way that nurses are able to work according to their values (Russell, 2016). Leiter and Maslach (2009) suggest six factors that contribute to burnout that are directly linked to work-life stress: work overload; lack of control; lack of reward; lack of community; value conflict; and lack of fairness. This literature review suggests that this is concurrent with contemporary empirical studies regarding burnout.
Oncology nurses believe burnout is caused by being short staffed, resulting in increased workload and significant feelings of pressure (Russell, 2016). Higher patient:nurse ratios have repeatedly been demonstrated as a significant cause of burnout (Gama et al, 2014; Gómez-Urquiza et al, 2016; Jakel et al, 2016; Russell, 2016; Blackburn et al, 2020). A lack of community and teamwork also surfaced as a significant cause (Wu et al, 2016). Nurses who said their team at work functioned well reported low levels of burnout and higher levels of compassion satisfaction (Wu et al, 2016). Wahlberg et al (2016) supported these findings and highlighted a link between unsupportive and inefficient teams and burnout, concluding that, when nurses felt supported, had adequate training and received recognition for their work, burnout was less likely to occur. Henson (2017) argues that staff teams with positive and clear leadership that recognises and rewards staff and provides educational opportunities experience less burnout.
Finley and Sheppard (2017) interviewed five newly qualified oncology nurses to explore early career compassion fatigue and burnout. Nurses expressed frustration at not being able to offer the care they thought they should because of time constraints and conflict with doctors, resulting in expectations turning into disappointment and exhaustion (Finley and Sheppard, 2017). This study powerfully demonstrates the impact of value conflict on the wellbeing of oncology nurses when they are not able to provide the care they believe they should. This is particularly pertinent in present times as services face immense difficulties as a result of the COVID-19 pandemic that challenge nurses' ability to work according to their values.
This review shows that oncology nurses believe high patient:nurse ratios and increased workload pressures cause burnout (Gómez-Urquiza et al, 2016; Russell, 2016; Wu et al, 2016). Positive team dynamics and a cohesive working environment reduce burnout, and a poorly functioning team and a socially toxic dynamic increase the risk (Wahlberg et al, 2016; Wu et al, 2016).
It is vital that oncology nurses are listened to for the effective management of burnout. An examination of patient:nurse ratios, as well as an emphasis on protecting break times and encouraging positive community values of support and teamwork among staff groups will help lower the risk of burnout, improve job satisfaction and promote patient safety.
Interventions
A third theme that emerged through the literature was interventions that aim to reduce burnout. Many of the studies investigated different approaches to reducing or preventing burnout that had varying degrees of success. Most of the interventions were small, experimental pilot studies or had no measurable results, so the evidence provided to support the interventions is low quality.
Several studies concerned innovative interventions intended to reduce burnout by supporting relaxation in break times, such as: using a virtual-reality headset to guide relaxation exercises (Michael et al, 2019); a knitting club to help nurses after stressful events (Anderson and Gustavson, 2016); and a massage chair available for use in break times (Hand et al, 2019). While these interventions were well received by participants, there was little evidential rigour in the studies' methods and conclusions. The benefits recorded could easily have been attributed to opportunities for better communication within teams and adequately protected break times.
Several other studies investigated support groups for nurses and reported mixed results. Houck (2014) found nurses were not interested in formal support groups and preferred to manage their grief and emotional difficulties alone. However, Wittenberg-Lyles et al (2014) reported that an oncology nurse support group had enormous benefits. The key difference is that Wittenberg-Lyles et al (2014) examined a self-organised group, involving participants who attended the sessions voluntarily and were willing and open to its benefits.
Blackburn et al (2020) and Kuglin Jones (2017) highlight the benefit of retreats and special training days focused on self-care exercises and building resilience to help manage burnout. Although these studies suggest success, there were either no objectifiable outcomes, with anecdotal accounts or unreliable evidence, or study designs were not replicable. The concept of retreats is interesting and could be beneficial for participants; however, it is unrealistic to expect staff teams to attend weekend retreats, especially if these are self-funded.
Mindfulness reduces stress by directing participants to think about their thoughts and feelings with a non-judgemental outlook (Duarte and Pinto-Gouveia, 2016). Wells-English et al (2019) suggest mindfulness is linked to decreased burnout and increased empathy. A study into the effectiveness of a mindfulness-based intervention by Duarte and Pinto-Gouveia (2016) found mindfulness decreased compassion fatigue, burnout and experiential avoidance, and increased self-compassion.
Most of the interventions reviewed focus on ‘fixing the person’ as opposed to ‘fixing the job’ (Maslach, 2017). Maslach (2017) suggests that a better approach is to challenge employers to limit and reduce workplace stressors that are known to cause burnout, including high patient:nurse ratios, poor communication, and toxic working atmospheres. Maslach (2017) further suggests that employers must support nurses to cope with the physical and emotional demands of their roles by actively encouraging self-care activities and building resilience, as well as providing intensive support for those who are already experiencing burnout.
Conclusion
With a focus on research based in North America and Europe, this literature review has highlighted the prevalence and causes of burnout in oncology nurses and explored interventions trialled. The prevalence of burnout varies greatly between studies, painting a picture of burnout that is culturally and institutionally specific (Gómez-Urquiza et al, 2016; Kołpa et al, 2017). However, the majority of studies have identified that burnout is a consistent problem across the oncology nursing sector and is likely to increase in light of the consequences of the global COVID-19 pandemic and the impact that this has had on cancer services.
Burnout is a working environment issue and is institutionally specific. Oncology nurses believe staff shortages and increased workload lead to burnout and compassion fatigue (Gómez-Urquiza et al, 2016). Further large-scale, multi-site studies that adopt a longitudinal approach are required to robustly decipher the causes of oncology nurse burnout and to begin to understand the impact of COVID-19.
The interventions examined in this review are often small pilot studies and are considered low-quality evidence. Many of the interventions focus on improving personal quality of life and individuals' coping mechanisms, particularly through mindfulness and building resilience. Interventions must also address causes of burnout in workplace settings, as well as provide opportunities for nurses to reflect and talk with colleagues about difficult situations. A dual-aspect approach can help to promote teamwork and create a supportive working environment, consequently reducing burnout and improving patient care.
In light of the global COVID-19 pandemic and the resulting difficulties nurses experience, burnout is likely to be an increasingly significant issue. Those who are struggling with burnout must have a voice and be part of the change that is necessary to improve the quality of nurses' professional lives and, consequently, patient care.
Limitations and implications for practice
This literature review is limited by its focus on North American and European studies and by the quality of the studies reviewed. The lack of studies carried out within the UK suggests a gap in the literature and a need for robust, large-scale investigations into the state of burnout among oncology nurses in the UK.
The information gained from this review can be helpful in other areas of practice. It is likely that burnout will become a significant workplace problem across the nursing workforce as a consequence of the COVID-19 pandemic.
Robust studies investigating burnout and effective interventions for managing and preventing it will inform evidence-based practice, improve patient care and the professional quality of life of nurses in all settings and of all grades.
KEY POINTS
- There is little evidence on the prevalence and causes of burnout in oncology nurses in the UK, and large-scale studies are needed to establish this
- Interventions to combat burnout must address the workplace factors that cause it as well as build resilience and promote self-care in staff
- Local support and guidance must be offered to nurses who are experiencing burnout or are at a high risk of it
- Employers should provide safe spaces for discussion and reflection, and offer regular opportunities for nurses' concerns to be heard
CPD reflective questions
- What aspects of your work do you enjoy the most and how does this prevent you from becoming burnt out?
- Who can you talk to if you are feeling burnt out or feeling compassion fatigue?
- What can you do to protect yourself from burnout?
- Can you think of any team activities or improvements that may help to build resilience and prevent burnout?