Compassion Fatigue and Burnout: Prevalence Among Oncology Nurses
Compassion Fatigue and Burnout: Prevalence Among Oncology Nurses
Compassion Fatigue and Burnout: Prevalence Among Oncology Nurses
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This descriptive, cross-sectional survey was conducted in inpatient nursing units and outpatient clinics in a cancer center
in the midwestern United States. The sample of 153 healthcare providers included RNs, medical assistants, and radiology
technicians. The fourth revision of the 30-item Professional Quality of Life (ProQOL R-IV) scale was used for measuring
compassion fatigue, compassion satisfaction, and burnout. A series of cross tab analyses examined the relationship between
participant demographics and three ProQOL R-IV subscales. The study sample scored similarly on compassion satisfaction
and burnout when compared with participants who used the ProQOL R-IV in previous studies. Value exists in analyzing the
prevalence of burnout and compassion fatigue among oncology healthcare providers. Understanding the needs of distinct
demographic groups offers valuable direction for intervention program development. Applying internal evidence in the
design of a relevant stress-reduction program will better equip healthcare providers to recognize and manage compassion
fatigue and burnout.
H
ospitals throughout the United States struggle to
deal with a diminishing RN workforce (Robert At a Glance
Wood Johnson Foundation, 2002). Considerable F Caring for patients with cancer can generate work-related
resources are spent in recruiting RNs, as well as stress, causing nurses to feel dissatisfied with their employ-
other healthcare providers, and in developing sus- ers and mentally exhausted.
tainable programs for staff retention. The International Council
F Oncology staff working on inpatient units are most likely to
of Nurses (ICN) released important information in 2006 regard-
have high-risk compassion satisfaction scores.
ing the global nursing shortage and solutions for it. The ICN
(Oulton, 2006) identified six priority areas for action: policy F Baccalaureate-prepared RNs had the highest percentage
intervention, macroeconomics and health sector funding, work- of high-risk scores for compassion fatigue, and graduate-
force planning and policy, retention and recruitment, nursing prepared nurses are at the highest risk for burnout.
leadership, and positive practice environments. Recognizing the
workplace demands and challenges faced by oncology nurses,
the traumatization of helpers through their efforts at helping
more cancer centers are drawing attention to issues involving
others, is a relational source of stress that also weighs heavily
workplace stress (McVicar, 2003) and psychosocial factors such
on oncology nurses. A growing body of research suggests that
as burnout and compassion fatigue (McHolm, 2006; Sinclair &
Hamill, 2007). Medland, Howard-Ruben, and Whitaker (2004)
argued that fostering psychosocial wellness in the workplace is Patricia Potter, RN, PhD, FAAN, is a research scientist, Teresa Deshields,
a crucial strategy for promoting oncology nurse retention and PhD, is a manager, Joyce Divanbeigi, RN, MSN, is a clinical nurse ad-
improving practice environments. ministrator, Julie Berger, D.Min, BCC, is a chaplain, Doreen Cipriano,
Caring for patients with cancer generates significant work- BSN, OCN®, is an assistant nurse manger, Lori Norris, RN, BSN, OCN®,
related stress that can result in employee dissatisfaction and is a nurse manager, and Sarah Olsen, RN, BSN, is a clinical research
mental exhaustion (Ferrans, 1990). The stress comes in part from coordinator, all in Siteman Cancer Center at Barnes-Jewish Hospital and
burnout, the chronic psychological syndrome of perceived de- Washington University Medical Center in St. Louis, MO. (First submission
mands from work outweighing perceived resources in the work February 2010. Accepted for publication March 9, 2010.)
environment (Gentry & Baranowsky, 1998). Compassion fatigue, Digital Object Identifier: 10.1188/10.CJON.E56-E62
E56 October 2010 • Volume 14, Number 5 • Clinical Journal of Oncology Nursing
oncology nurses are at risk of burnout (Barnard, Street, & Love, ronment stressors, whereas definitions of compassion fatigue
2006; Medland et al., 2004). Researchers also have shown that address the relational nature of the condition. Figley (2002)
compassion fatigue can take a toll on the caregiving professional identified compassion fatigue as a form of burnout.
as well as the workplace, causing decreased productivity, more The phenomena of burnout and compassion fatigue are
sick days used, and higher turnover (Pfifferling & Gilley, 2000). significant for healthcare organizations because of the dem-
However, few validated reports have detailed the incidence and onstrated correlations to nurse retention and turnover, patient
prevalence of compassion fatigue in oncology caregivers. A small satisfaction, and patient safety (Garman, Corrigan, & Morris,
number of studies (Perry, 2008; Sherman, Edwards, Simonton, 2002; Halbesleben, Wakefield, Wakefield, & Cooper, 2008).
& Mehta, 2006; Simon, Pryce, Roff, & Klemmack, 2005; Welsh, Halbesleben et al. (2008) suggested that, to understand the ef-
1999) have investigated how oncology caregivers are affected by fects of burnout on healthcare providers, one must understand
their work with patients with cancer. Cancer care providers tend how burnout of the healthcare workforce results in changes in
to empathize with patients’ losses, resulting in a personal sense patient care. In a study conducted by Leiter, Harvie, and Friz-
of futility or failure in their care. However, Perry (2008) learned zell (1998), an inverse correlation was found between nurse
that exemplary oncology nurses were able to avoid compassion burnout and patient evaluations of the quality of care. Patients
fatigue by creating moments of connection and making those cared for on units where nurses felt exhausted or frequently
moments matter. expressed a desire to quit were less satisfied with their care.
Gaining a better understanding of the extent to which Vahey, Aiken, Sloane, Clarke, and Vargas (2004) found similar
nurses and other oncology healthcare providers are affected results in a study involving more than 800 nurses and 600 pa-
by conditions such as burnout and compassion fatigue is criti- tients. In contrast, Friese (2005) showed the value of building
cal for the development of a positive and nurturing practice and strengthening work environments to limit burnout and
environment. This study explored the prevalence of burnout compassion fatigue. Friese (2005) demonstrated that emotional
and compassion fatigue among oncology healthcare providers exhaustion is significantly lower among oncology nurses who
working within a large oncology medical center. The study is work in Magnet®-designated hospitals. To date, no studies have
the first step toward the ultimate design of a comprehensive been conducted on oncology units examining the prevalence
mindfulness-based stress-reduction (MBSR) program to better of both compassion fatigue and burnout.
equip healthcare providers to recognize and manage compas- Healthcare providers benefit from targeted approaches for
sion fatigue and burnout. developing coping and stress management skills (Cohen-Katz,
Wiley, Capuano, Baker, & Shapiro, 2004; Mackenzie, Poulin, &
Seidman-Carlson, 2006). Interventions directed toward nurses
Literature Review who experience compassion fatigue are few and evident only
in more recent literature. Most interventions, such as the
The condition of compassion fatigue was first identified by Accelerated Recovery Program (ARP) developed by Gentry,
Joinson (1992) in a study of burnout in nurses who worked in Baranowsky, and Dunning (1997), focus on mental health and
an emergency department. The researcher identified behav- trauma workers. The ARP is designed to help professionals use
iors that were characteristic of compassion fatigue, including strategies to address and resolve the symptoms and the cause
chronic fatigue, irritability, dread going to work, aggravation of compassion fatigue while helping develop an integrated
of physical ailments, and a lack of joy in life. Figley (2002) later individual self-care discipline that enhances future resiliency
defined compassion fatigue as a state of tension and preoccupa- (Gentry et al., 1997).
tion with the individual or cumulative traumas of clients. The Experts in the field of compassion fatigue have only now begun
phenomenon of compassion fatigue emerges suddenly and with- to understand the potential use and effectiveness of interventions
out warning and includes a sense of helplessness and confusion. in the field of nursing. With the concept of compassion fatigue
It has been described by Figley (2002) as the cost a caregiver becoming better understood, results from newer studies involv-
experiences as a result of caring for others. Compassion fatigue ing use of group interventions for nurses have been published
results from giving high levels of energy and compassion over (Cohen-Katz et al., 2004; Mackenzie et al., 2006). Cohen-Katz et
a prolonged period to those who are suffering, often without al. (2004) and Mackenzie et al. (2006) primarily used the well-
experiencing the positive outcomes of seeing patients improve validated stress reduction model of an MBSR program developed
(McHolm, 2006). Oncology nurses acquire compassion fatigue by Kabat-Zinn (1990) and employed in many stress-management
through repeated exposure to patients suffering the effects of clinics across the United States. The MBSR program teaches par-
trauma, such as side effects of aggressive treatment and the end ticipants to intentionally deal and cope with stress, pain, illness,
stages of cancer. and the demands of everyday life in an intentional way, based
In contrast, burnout is cumulative stress from the demands of on the concept of mindfulness. Mindfulness is defined as being
daily life, a state of physical, emotional, and mental exhaustion fully present to one’s experience without judgment or resistance
caused by a depletion of the ability to cope with one’s environ- (Cohen-Katz et al., 2004). The interventions in the MBSR program
ment, particularly the work environment (Maslach, 1982). Burn- aim to help participants respond more effectively to challenges
out results from prolonged high levels of stress at work and, if to offset the adverse effects of stress.
not addressed, contributes to healthcare providers leaving the Analyzing the prevalence of burnout and compassion fatigue
workplace (Medland et al., 2004). The concepts of compassion within a healthcare organization is an essential first step for
fatigue and burnout are closely related and sometimes ambigu- organizations that aim to implement programs such as MBSR or
ously defined. Definitions of burnout more often point to envi- ARP and establish positive work environments. Therefore, the
Clinical Journal of Oncology Nursing • Volume 14, Number 5 • Compassion Fatigue and Burnout E57
purpose of this study was to explore the prevalence of burnout the Professional Quality of Life (ProQOL R-IV) scale to all eligible
and compassion fatigue among oncology healthcare providers staff working in these settings.
working within a large oncology medical center.
Procedure and Sample
Methods The quality-improvement evaluation was approved by the Hu-
man Research Protection Office of the affiliated university and
Design and Setting the cancer center’s Protocol Review and Monitoring Committee.
Staff who worked in the designated oncology units were eligible
This descriptive analysis of a quality-improvement evaluation of
to participate in the evaluation, including RNs (staff clinicians
oncology healthcare staff was conducted at a large National Can-
and advanced practice nurses), patient care technicians, medical
cer Institute–designated cancer center in the midwestern United
assistants, and radiation therapy technologists. A total of 448 sur-
States. A group of nurse managers from the center’s outpatient
vey packets were distributed in staff mailboxes. An information
oncology treatment centers formed a work group to examine the
brochure describing the evaluation was posted on all units and
issue of compassion fatigue among the staff. Through observa-
used by nurse managers for talking points during staff meetings.
tions and conversations with staff, the managers perceived the
Completed information from the ProQOL R-IV scale was returned
likelihood that their nurses, medical assistants, and technicians
in specially marked envelopes placed in each clinical setting.
were experiencing symptoms of compassion fatigue and burnout.
The decision was made to conduct a quality-improvement evalu-
Instrument
ation to include inpatient and outpatient oncology staff, which
included five inpatient oncology units, four outpatient chemo- The quality-improvement team chose to use the 30-item
therapy infusion areas, and three physician office practice areas. ProQOL R-IV scale for measuring compassion fatigue, compas-
The evaluation involved the distribution of the fourth revision of sion satisfaction, and burnout (Stamm, 2009). The instrument
Table 1. Results of Cross Tab Analysis and Demographics of ProQOL R-IV Subscales
Compassion Satisfaction Burnout Compassion Fatigue
High Risk Low Risk High Risk Low Risk High Risk Low Risk
Variable n % n % p n % n % p n % n % p
E58 October 2010 • Volume 14, Number 5 • Clinical Journal of Oncology Nursing
is a fourth revision of the originally titled Compassion Fatigue
Self-Test survey tool developed by Figley (1995). The scale has
Table 2. Participant Characteristics
—
undergone psychometric evaluation in an effort to improve Characteristic X Range
subscale reliability and validity (Figley & Stamm, 1996; Jenkins
Age (years) 39.9 21–63
& Baird, 2002; Larsen, Stamm, & Davis, 2002). The ProQOL R-IV
Years in health care 14.8 1–4
includes three 10-item subscales: compassion satisfaction, burn- Years in oncology 8.9 1–33
out, and compassion fatigue. Construct validity testing has veri-
fied that the subscales on the ProQOL R-IV do measure different Characteristic n
Clinical Journal of Oncology Nursing • Volume 14, Number 5 • Compassion Fatigue and Burnout E59
The other demographic variables were not significantly re- in oncology had the highest percentage of high-risk scores for
lated to the ProQOL R-IV subscales, including age and education all three ProQOL R-IV subscales. Individuals who had 6–10 years
level. However, the results of high risk for burnout and compas- of general healthcare experience had higher percentages of risk
sion fatigue were interesting in regard to nurses’ education level. scores for burnout and low compassion satisfaction in compari-
Nurses with a bachelor’s degree had the highest percentage of son to the other experience groups. Level of oncology and/or
high-risk scores for compassion fatigue, and nurses with ad- general healthcare experience might be important criteria for
vanced degrees had the highest percentage of high-risk scores targeting interventions to help staff gain enhanced skills for
for burnout. Nurses with associate’s degrees had the highest dealing with stress.
percentage of low compassion satisfaction scores. In this study, a trend existed for increased risk for burnout
and compassion fatigue among nurses with higher levels of
education, but this trend did not reach statistical significance.
Discussion Najjar et al. (2009) argued that higher levels of licensure and
corresponding education degrees characterize professionals
The inpatient work setting has been described by other who also may have increased expectations for work satisfaction.
researchers as one that is particularly stressful (Buerhaus, The nature of oncology practice may produce tensions between
Donelan, DesRoches, Lamkin, & Mallory, 2001). In this cur- a person’s idealistic expectations and what actually occurs in
rent study, inpatient healthcare staff had significantly lower practice. The talent among nurses with advanced degrees is an
compassion satisfaction scores than their colleagues working important resource for oncology programs; therefore, managers
in outpatient settings. Although this study did not explore in and administrators must understand the unique needs of this
depth the myriad factors that might contribute to the work- group, particularly their vulnerability to compassion fatigue
place stress, the literature offers some explanation. The factors and burnout.
contributing to inpatient workplace stress that differ from
those of outpatient settings involve higher patient acuity, in-
cluding exposure to more patient deaths; more complications Limitations
of treatment and disease; and more severe clinical symptoms. The results of this study are limited by the small sample size,
In addition, environmental conditions such as inadequate particularly with respect to a very small number of respon-
staffing and weekend and evening hours may add additional dents who were medical assistants and radiology technicians.
burden. Additional studies should explore these professional groups. It
The scores for burnout and compassion fatigue were statisti- also would be interesting to gather information pertaining to
cally comparable between the inpatient and outpatient settings. the incidence of compassion fatigue and burnout by surveying
Factors contributing to outpatient workplace stress are unique members of a professional nursing organization, such as the
to the types of relationships that form between outpatient staff Oncology Nursing Society. The larger sample size would offer a
and patients with cancer and their families. Although some broader range of analysis with regard to demographic variables.
researchers have noted the observance of suffering, ethical An additional limitation is the potential response bias. Those
concerns regarding treatment choices, and carryover stress who chose not to respond to the survey could have had higher
from seeing patients repeatedly for treatments as stressors char- or lower levels of risk for burnout and compassion fatigue. Be-
acteristic of the outpatient setting (Florio, Donnelly, & Zevon, cause the study is a cross-sectional design, the analysis does not
1998), an argument could be made that these same stressors provide an understanding of whether the prevalence of burnout
are present in the inpatient setting. Interestingly, the outpatient and compassion fatigue changes over time.
area with the highest percentage of compassion satisfaction The information that the authors collected also was limited by
and lowest percentage of burnout and compassion fatigue was the constraints of this particular quality-improvement project.
the breast health center. In this setting, nurses perform routine It would be helpful to gather information about the quality of
screening and diagnostic procedures and do not see the same the healthcare professional’s work and to compare this with
patients frequently over time. compassion satisfaction, compassion fatigue, and burnout.
Lewis (1999) suggested that the intense and ongoing losses Likewise, it would be interesting to assess patient satisfaction
experienced in oncology care make oncology nurses very vul- with care and to examine how that interacts with the ProQOL
nerable to burnout. Numerous stressors have been identified R-IV subscales. Finally, it would be useful to determine the sa-
specific to the oncology workplace, including the nature of can- lient differences between inpatient and outpatient practice to
cer, complex treatments, death, a personal sense of failure and address the different levels of compassion satisfaction between
futility, intense involvement with patients and families, ethical these work settings.
issues in treatment, surrogate decision making, and palliative
care issues (Kash & Breitbart, 1993; Najjar, Davis, Beck-Coon,
Implications
& Doebbeling, 2009). Additional factors that correlate with
nursing burnout are role ambiguity, workload, co-worker sup- Understanding the effects of caring for patients with cancer
port, and positive reappraisal (Duquette, Kerouac, Sandhu, & on professional caregivers is a responsibility of healthcare man-
Beaudet, 1994; Florio, Donnelly, & Zevon, 1998). The influence agement. Although concepts such as compassion fatigue and
of years of general healthcare and oncology experience on com- burnout are multifactorial, Maslach and Leiter (1998) argued
passion fatigue and burnout offers an interesting perspective. In that the social environment of a workplace and the organi-
this current study, the individuals who had worked 11–20 years zational structure are particularly relevant contributors. The
E60 October 2010 • Volume 14, Number 5 • Clinical Journal of Oncology Nursing
results of this study suggest the need for an intervention for tors related to nursing burnout: A review of empirical knowledge.
staff at risk. In addition, the results establish an argument for the Issues in Mental Health Nursing, 15, 337–358.
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is currently being evaluated. It has involved the initial training
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caregiving and learn through experiential participation. Find- Recovery Program for compassion fatigue. Presented at the 13th
ings will be used toward making recommendations for a hos- annual International Society for Traumatic Stress Studies Confer-
pitalwide ARP for all healthcare providers. Radziewicz (2001) ence in Montreal, Quebec, Canada.
stressed the priority of self-care relative to being healthy and Halbesleben, J., Wakefield, B., Wakefield, D., & Cooper, L. (2008).
providing quality care to patients and their families. Applying Nurse burnout and patient safety perception versus reporting
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The authors take full responsibility for the content of the Stress, 15, 423–432. doi: 10.1023/A:1020193526843
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commercial bias. No financial relationships relevant to the con- your body and mind to face stress, pain and illness. New York,
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independent peer reviewers, or editorial staff. Kash, K., & Breitbart, W. (1993). The stress of caring for cancer pa-
tients. In W. Breitbart and J.C. Holland (Eds.), Psychiatric aspects
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pap1212@bjc.org, with copy to editor at CJONEditor@ons.org. Washington, DC: American Psychiatric Press.
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McHolm, F. (2006). Rx for compassion fatigue. Journal of Christian line. To access the test for this and other articles,
Nursing, 23, 12–19. visit http://evaluationcenter.ons.org/Login.aspx.
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Journal of Advanced Nursing, 44, 633–642. doi: 10.1046/j.0309 profile username and password, select CNE Tests
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psychosocial wellness in oncology nurses: Addressing burnout choose the test(s) you would like to take.
and social support in the workplace. Oncology Nursing Forum,
31, 47–54. doi: 10.1188/04.ONF.47-54
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Use This Article in Your Next Journal Club
Suppl.), 34S–39S. doi: 10.1177/1527154406293968 Journal club programs can help to increase your
Perry, B. (2008). Why exemplary oncology nurses seem to avoid ability to evaluate the literature and translate those
compassion fatigue. Canadian Oncology Nursing Journal, research findings to clinical practice, education, ad-
18(2), 87–99. ministration, and research. Use the following questions to start
Pfifferling, J.H., & Gilley, K. (2000). Overcoming compassion fa- the discussion at your next journal club meeting.
tigue. Family Practice Management, 7(4), 39–46. Retrieved from
1. What is the question the author is trying to address?
http://www.aafp.org/fpm/20000400/39over.html
2. Is the purpose of the article described clearly?
Radziewicz, R.M. (2001). Self-care for the caregiver. Nursing Clinics
3. Is the literature review comprehensive and are major con-
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4. What is the difference between compassion fatigue and
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5. How do you take care of yourself to avoid or manage com-
Sherman, A.C., Edwards, D., Simonton, S., & Mehta, P. (2006).
passion fatigue?
Caregiver stress and burnout in an oncology unit. Palliative and
6. What does your workplace offer for someone who may be
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experiencing compassion fatigue?
Simon, C., Pryce, J., Roff. L., & Klemmack, D. (2005). Secondary
7. What changes or recommendations might you consider
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based on the evidence presented in this article?
sion from fatigue and compromising the worker’s worldview.
Journal of Psychosocial Oncology, 23(4), 1–14. doi: 10.1300/ Visit www.ons.org/Publications/VJC for details on creating and
J077v23n04_01 participating in a journal club. Photocopying of this article for
Sinclair, H.A., & Hamill, C. (2007). Does vicarious traumatisa- discussion purposes is permitted.
tion affect oncology nurses? A literature review. European
Journal of Oncology Nursing, 11, 348–356. doi: 10.1016/j New! Listen to a Discussion of This Article
.ejon.2007.02.007
Stamm, B.H. (2009). The ProQOL manual. Boise, IA: Sidran Press. With the simple click of your computer mouse,
Vahey, D., Aiken, L., Sloane, D., Clarke, S., & Vargas, D. (2004). listen to the author shed new light on the topics
Nurse burnout and patient satisfaction. Medical Care, 42(2, discussed in this article, which is the focus of this
Suppl.), II-57–II-66. issue’s CJONPlus podcast.
Welsh, D. (1999). Let’s talk. Care for the caregiver: Strategies for To listen to or download the podcast, visit www.ons.org/
avoiding compassion fatigue. Clinical Journal of Oncology Publications/CJON/Features/CJONPlus.
Nursing, 3, 183–184.
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