Stress and Burnout in Oncology
Stress and Burnout in Oncology
Studies over the past decade have increasingly focused on the stress
placed on health professionals and the negative consequences of that
stress. Often referred to as burnout, it has been defined by
Maslach and measured by its deleterious effects, such as emotional
exhaustion, a sense of increased distance from patients with reduced
empathy, and diminished sense of accomplishment at work.
As medical care becomes more technical and patient care more complex,
the problems of burnout become increasingly more relevant to the
physical and emotional well-beingas well as the moraleof
the medical staff. Frequently, the effects of burnout influence staff
Studies have also explored the factors that buffer stress.
Interventions have been developed to reduce the stressors experienced
by nurses[3-5] and doctors, particularly house staff.[6-8]
Within this context, nurses and doctors working in oncology are of
particular interest. They must care for many critically ill and dying
patients, be able to maintain highly technical and complex equipment,
and confront the needs and questions of families. These
responsibilities exact a heavy emotional toll.[9-11] When personal
problems, poor support, or organizational difficulties are added, the
psychological burden increases.
Poor communication, interstaff conflict, and the intensity of the
relationships with patients and families, coupled with the awareness
that lives hang in the balance, make the oncology unit an environment
in which burnout is apt to develop and staff are likely to experience
both the emotional and physical symptoms of chronic stress.
Ethical dilemmas add a new burden.
Yet oncology staff, both medical and nursing, not only cope, but
usually have a high sense of accomplishment.[15,16] This seeming
contradiction led to our interest in the factors that buffer the
stressors of cancer care.
Using a model that was developed by Kobasa and modified for the
study of staff in a cancer center (Figure 1),
we measured the common stressors related to work in oncology plus
the stressors experienced in personal life. We also measured burnout
symptoms and the physical and emotional symptoms often associated
with stress, as well as buffers that might modulate the stressors.
We were interested in the impact of burnout on the ability of nurses
and doctors to be sensitive to patients needs and to deliver
compassionate care. We conducted a year-long controlled trial of a
psychosocial intervention administered to house staff and nurses in
one of two similar medical oncology units at our cancer center. Staff
who received enhanced psychosocial support and multidisciplinary
rounds displayed a reduced level of stress, and patients in that unit
reported that nurses and house staff were more sensitive to their
The study was extended to medical oncologists at our cancer center
and to a cohort of oncologists who had trained at the center and had
been in clinical practice for 5 to 15 years. These data provided an
opportunity to compare physicians who had limited exposure to
clinical care of cancer patients with those who had more time to
adapt to its stressors.
The theoretical framework for our research was the stress
paradigm, Lazarus cognitive appraisal theory of stress and
coping, and Kobasas concept of the stress-buffering effect
of a hardy personality style. These concepts were adapted to the
common stressors associated with working in oncology as well as the
positive aspects of that work, such as perceived satisfaction with
supervisory and peer support. Our primary goals were to
(1) identify the stressors, the consequences of stress, and the
factors that moderate these consequences, and (2) compare data
derived from nurses, house staff doing a rotation in an oncology unit
from general hospitals, and mature oncologists working in the
clinical and research aspects of oncology.
Prior to data collection, the study design was reviewed and approved
by the institutional review board (IRB) at Memorial Sloan-Kettering
Cancer Center. Cross-sectional survey data from nurses and house
staff at the cancer center who were studied over a 2-year period are
reported here. Nurses were approached personally and asked to fill
out the questionnaire, either immediately or within a few days. House
staff, comprised of medical interns and assistant residents from two
general hospitals, provided similar data while on their 2- to 3-month
rotation in the medical oncology unit. All oncologists in the
Department of Medicine at the center were asked to respond to the
same assessment via a mailed questionnaire. A similar request was
made of medical oncologists who had received their specialty training
at the center between 1975 and 1985.
Response rates were highest among nursing and house staff, with 83 of
85 nurses (98%) and 76 of 78 house staff (97%) responding. Of 74
medical oncologists on staff, 35 (47%) responded to the mailed
survey, as did 67 (37%) of 200 oncologists who had trained at the
center. This level of participation by physicians receiving the
mailed survey was somewhat higher than that obtained by Whippen and
Canellos (20% to 25%). In total, 178 physicians and 83 nurses
working full time with oncology patients participated.
The study assessment, the Staff Stress Inventory, was composed of
reliable and valid instruments that were selected to test the
components of our theoretical model. Scales assessing work stressors
in oncology were developed in conjunction with the chief residents,
who were familiar with the actual problems encountered daily, and
nursing supervisors, who were experienced in oncology nursing.
Personal stressors were derived from those known to be common among
BurnoutThis was measured by the Maslach Burnout
Inventory. The Inventory has three components: emotional
exhaustion, depersonalization, and lack of personal accomplishment.
The emotional exhaustion subscale assesses feelings of being
emotionally overextended and exhausted by work. The depersonalization
subscale measures diminished empathyie, the
presence of a cynical, impersonal, numb,
distanced-from-patients feeling. The personal
accomplishment subscale assesses feelings associated with
professional competence and achievement. A high degree of burnout is
reflected by high scores on the emotional exhaustion and
depersonalization (diminished empathy) subscales and low scores on
the personal accomplishment subscale.
Staff were asked to indicate how often they experienced several
job-related attitudes on a 7-point scale that ranged from 0 (never)
to 6 (every day). For example, items on the scale included: I
feel emotionally drained from my work or I deal very
effectively with the problems of my patients. Each staff member
received a score for emotional exhaustion, depersonalization, and
personal accomplishment. Maslach and Jackson provided reliability and
construct validity, as well as norms for nurses and physicians.
For our sample, internal consistency alphas were .73 for personal
accomplishment, .76 for depersonalization, and .90 for emotional exhaustion.
Psychological Distress: DemoralizationNegative
consequences of a psychological nature were assessed by the
demoralization scale of the Psychiatric Epidemiology Research
Interview (PERI) schedule. This instrument is actually a
combination of scales developed to measure several dimensions of
distress (not reaching the level of psychiatric disorders) in the
general population. The eight scales are for dread, anxiety,
sadness, helplessness-hopelessness, psychophysiologic symptoms,
perceived physical health, poor self-esteem, and confused thinking.
Taken together, the eight demoralization scales have high internal
consistency, reliability, and validity across sex, class, and ethnic
groups in the general population.
Sample demoralization scale items ask how much or how little certain
characteristics are like the individual being interviewed. For
example: Think of a person who is the worrying type. Is this
person _______ and Think of a person who feels he has
much to be proud of. Is this person _______. Sentences were
completed with one of 5-point fixed alternative responses: 4 (very
much like you); 3 (much like you); 2 (somewhat like you); 1 (very
little like you); 0 (not at all like you). A single score for
demoralization was the measure of psychological distress. The
internal consistency alpha for psychological distress was .93.
Physical SymptomsTo assess physical symptoms
possibly related to stress, we employed a modification of the
somatization scale of the Hopkins Symptom Checklist. This list of
general physical complaints (eg, headaches, pains in the lower back)
was expanded by the authors to include symptoms considered common
early signs of cancer, which create anxiety in oncology staff (eg,
swollen lymph nodes, easy bruising). Staff indicated how often they
were troubled by each of 30 items during the past month, on a 5-point
scale ranging from 0 (never) to 4 (very often). The parent test is
used frequently in stress and health research, and has shown good
reliability and validity. It also offers norms from the general
population as well as clinical groups. The internal consistency alpha
for physical symptoms was .89.
Hardy PersonalityThis personality construct from
Kobasa has three attributes that have been found to be a buffer
against stress: commitment, control, and challenge. The combination
of a sense of commitment to self and work, a sense of being able to
control or influence events, and a sense of challenge in the face of
a changing environment has proven to protect against the mental and
physical adverse effects of stressful life events. Hardiness
influences the perception, interpretation, and handling of stressful
events such that excessive arousal and consequent strain
Staff indicated how much they agreed or disagreed with each
statement, using a 4-point scale that ranged from 0 (not at all true)
to 3 (completely true). Sample items included: I often wake up
eager to take up my life where it left off the day before,
No matter how hard I try, my efforts will accomplish
nothing, and Changes in routine bother me. The
overall alpha for hardiness was .87.
Social SupportPerceived support from peers at
work was assessed through a modified subscale of the Work Environment
Scales (WES). The Peer Cohesion subscale was modified to assess
the extent to which staff perceived each other as friendly and
supportive (ie, we made simple word changes to fit the oncology
setting). For example, the item, People go out of their way to
help a new employee feel comfortable was changed to People
go out of their way to help a new house officer/nurse/physician feel
comfortable. A scale of 0 (not at all true) to 3 (completely
true) was used to determine how much they agreed with each item. The
internal consistency alpha for peer support was .66
Methods of RelaxingThe Stress Questionnaire
was used to assess 16 actions that reduce stress, as well as the
strategies for coping with stress used by Koocher. Discussions
with oncology staff led us to include additional coping techniques to
the list (eg, watching television, getting involved in sports or a
hobby, and partying). Participants indicated how
frequently they employed each item on a 5-point scale ranging from 0
(never) to 4 (always). Items included seeking out others, taking
medication, humor, exercise, and prayer.
Similar to Steinmetz and colleagues, we conducted a principal
components factor analysis using a varimax rotation and found two
distinct factors. One factor (nine items) related to engaging in
socially cathartic activitieseg, talking to someone you know,
using humor, socializing while eating food or drinking coffee, and
exercising, with an alpha coefficient of .72. The other factor (four
items) revolved around smoking, drinking alcohol, or taking
medication (eg, tranquilizers). The alpha for this factor was .55.
The reason this alpha may have been low was because these relaxation
methods were the least used by the medical oncology staff in this study.
Stressful Life EventsWork and personal events
were measured by items from the PERI scale. Each person indicated
how often each of a series of events related to work, family,
interpersonal, marital, financial, and social events had occurred
within the past year. The events covered a range of undesirable (eg,
divorce) and desirable (eg, moved to a better neighborhood), rare
(eg, death of your child) and frequent (eg, worsening of health of a
family member), uncontrollable (eg, death of a parent) and
controllable (eg, engagement), and loss (eg, being the victim of a
robbery) and gain (eg, outstanding achievement at work) events.
Examples of the work-related stressful events developed with staff
were a patient your own age died, discussed a
do-not-resuscitate (DNR) order with the patients family,
and serious argument with a colleague.
Data were calculated to produce four scores: (1) a work stress score
that reflected the frequency of both positive and negative work
events, (2) a personal stress score that reflected the frequency of
marital, interpersonal, family, and social/residential events, (3) a
positive stress score that reflected all positive events, and (4) a
negative stress score that accounted for all negative events.
Perception of Self as a Religious PersonRespondents
were asked a single questionDo you consider yourself to
be a religious person?on a 4-point scale from 1 (not at
all) to 4 (extremely). Data on formal religious affiliation were not collected.
Demographic InformationRespondents were asked
about gender, age, marital status, number of children, and number of
years spent in clinical oncology and research.
The data were examined through a series of correlations, analyses of
variance, and stepwise multiple regression analyses. In the
regression analyses, demographics were entered first, followed by the
stressful life events. Mediating variables of peer support and hardy
personality were entered last. This is consistent with other stress
research in which one can examine the impact of buffer variables
after the contribution of demographic variables and stressors.