Stress and Burnout in Oncology

Introduction

Studies over the past decade have increasingly focused on the stress placed on health professionals and the negative consequences of that stress.[1] Often referred to as burnout, it has been defined by Maslach[2] 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-being—as well as the morale—of the medical staff. Frequently, the effects of burnout influence staff turnover.

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.[12]

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.[13] Ethical dilemmas add a new burden.[14]

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.

Study of Common Stressors

Using a model that was developed by Kobasa[17] 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 needs.[6]

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,[18] Lazarus’ cognitive appraisal theory of stress and coping,[19] and Kobasa’s concept of the stress-buffering effect of a hardy personality style.[17] 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.

Methods

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%).[16] 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 young professionals.[19]

Measures

Outcome Variables

• Burnout—This was measured by the Maslach Burnout Inventory.[2] 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 empathy”—ie, 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.[2] For our sample, internal consistency alphas were .73 for personal accomplishment, .76 for depersonalization, and .90 for emotional exhaustion.

• Psychological Distress: Demoralization—Negative consequences of a psychological nature were assessed by the demoralization scale of the Psychiatric Epidemiology Research Interview (PERI) schedule.[20] 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.[21] 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 Symptoms—To assess physical symptoms possibly related to stress, we employed a modification of the somatization scale of the Hopkins Symptom Checklist.[22] 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.[21] It also offers norms from the general population as well as clinical groups. The internal consistency alpha for physical symptoms was .89.

Moderating Variables

• Hardy Personality—This personality construct from Kobasa[17] 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 diminishes.[23-25]

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 Support—Perceived support from peers at work was assessed through a modified subscale of the Work Environment Scales (WES).[26] 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 Relaxing—The Stress Questionnaire[27] was used to assess 16 actions that reduce stress, as well as the strategies for coping with stress used by Koocher.[28] 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,[27] 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 activities—eg, 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(Drug information on 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.

Independent Variables

• Stressful Life Events—Work and personal events were measured by items from the PERI scale.[20] 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 patient’s 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 Person—Respondents were asked a single question—“Do 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 Information—Respondents 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.[29]