Cancer care guidelines in many countries assign a central role to nurses,1 and some have established specific new training programs for oncology nurses.2 A substantial literature also exists on nursing care in oncology, in textbooks and in numerous studies of specific aspects of nurses’ role in this field: patients’ quality of life,3 sexual health and pain management,4 consideration of psychosocial aspects,5 and communication with patients and their families.6 It is nonetheless difficult to define the scope of these nurses’ work because of the multiplicity of roles they can occupy.7
Because of the specific features of oncology care, it has been showed that oncology nurses suffer from more work-related issues compared with other types of nurses8 and often express job dissatisfaction.9 Oncology nurses are exposed to occupational stress,10 compassion fatigue,11 and burnout, with high rates of emotional exhaustion and reduced levels of perceived personal accomplishment.8
This quantitative literature thus focuses on the workplace distress of oncology nurses but does not inform us about their lived experience of work-related issues. Qualitative research, on the other hand, looks at how oncology nurses describe and understand what they experience as difficult in their workplace.
There is in fact a broader qualitative literature on the subject, exploring other aspects of the work-related issues: time pressure,12 barriers to empathy-based care,13 the burden of responsibility,14 and so on. Because qualitative studies are usually conducted with small samples and in specific and limited contexts, the generalizability of their results is often a weak point. We thus applied an approach based on metasynthesis, a systematic literature review, and analysis of qualitative studies on a subject,15 which aims to “achieve analytic abstraction at a higher level by rigorously examining overlap and elements in common among studies.”16
The objective of this study is to perform a metasynthesis of studies exploring the experience of work-related issues of these nurses in order to generate new insights about the issues encountered by oncology nurses and draw concrete implications to improve their working life and thus the quality of care.
This metasynthesis relies on our 6-stage approach17–21 inspired by the model of metaethnography22 and the procedures of the thematic synthesis.23 It complies with the ENTREQ reporting guidelines.24
Our approach consisted of 6 successive stages:
- defining the research question, the subjects, and the types of studies to be included;
- identifying and selecting the studies;
- assessing the quality of the studies selected;
- analyzing the studies, identifying their themes, and translating these themes between the studies;
- generating the themes of the analysis and structuring the synthesis; and
- writing the synthesis.
The thematic analysis contained two phases: one descriptive, which defined and compared the themes, and the other interpretive, which developed original ideas drawn from the review.
Ad hoc algorithms were composed of both thesaurus and free-text terms, during group meetings between nurses, oncologists, a psycho-oncologist, and qualitative researchers. They were based on the key words and related topics found in a preliminary literature search (M.D. and J.S.) (Table 1). We conducted a systematic search in 4 databases (MEDLINE, PsycINFO, CINAHL, and SSCI [Social Sciences Citation Index]). We performed the literature search on July 9, 2016.
To maintain a methodological rigor and quality, we decided to include articles for the last 15 years (from January 1, 2002). This decision was guided by the rapid evolution of oncology nursing but mostly to reduce the final number of studies included, since “too much data due to a large number of studies can undermine our ability to perform a thorough analysis.”25
By extensive lateral searches—systematic checking of reference lists and hand searching of key journals and of the PubMed sidebar of related articles—we further sought to identify articles that might have eluded our algorithms. Three authors, a female nurse (M.D.), a male doctor (J.S.), and a female psychologist (E.M.) independently screened the articles retrieved, initially by title, then by abstract, and finally by full text. After collecting the references and eliminating duplicates, 2 authors (E.M. and M.D.) subsequently read the titles and abstracts to assess their relevance to our target subject and methodology. The database indexing of qualitative studies was rather poor, and most of the references collected were actually quantitative studies. They were eliminated at this step. When the abstract was not sufficient, we read the entire article. Disagreements were resolved during meetings of the research group. The potentially relevant articles were then read in full, and a second selection was made to keep only the articles that met our inclusion criteria. Inclusion and exclusion criteria are detailed in Table 2.
The quality of selected articles was assessed with the Critical Appraisal Skills Programme.26 It comprises 10 questions, 2 screening questions about the aims of the research and the appropriate use of qualitative methodology, and 8 questions considering the sampling strategy, the data collection, the researcher’s reflexivity, the ethical issues, the data analysis, the findings, and the value of the research. Two authors (E.M. and M.D.) performed this assessment independently and then discussed the results within the research group until agreement was reached. The quality of each article was considered an indicator of the validity of the qualitative evidence it reported. However, there is a lack of consensus about the role and function of study quality appraisal as part of systematic reviews of qualitative studies, especially concerning the exclusion of any study based on this assessment. We did not exclude any study from the analysis. Moreover, a Critical Appraisal Skills Programme approach can only judge the quality of the report based on the study but not really the study itself. Caution must be taken when interpreting the results of such appraisal.
Data Extraction and Analysis
Our analysis began with an attentive reading of selected articles (N = 63) and then repeated readings of the titles, abstracts, and texts of each article. Two researchers (E.M. and C.B.) extracted the formal characteristics of the studies, and 3 (J.S., E.M., and C.B.) independently extracted and analyzed the first-order results (ie, the study results) and the second-order results (authors’ interpretations and discussions of the results) in a form of a summary for each study selected; these independent analyses were then compared and discussed at the research meetings, as described in Table 3.
Thematic analysis followed the 5-stage approach. Thematic analysis made it possible to develop themes inductively, from our study data. The work of translation involved comparing and assembling the themes obtained by the analysis of each article to retain the key themes that capture similar ideas in the different articles and then to develop overarching concepts about the research question. The high level of rigor of the results was obtained by triangulation of both the data sources and the analyses: 3 independent analyses and monthly research meetings to discuss the results. NVivo 11 software (QSR International, Australia) was used to manage data, facilitate the development of themes, and verify the researchers’ contribution to the findings. The study is reported in accordance with the ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) statement.24
Assessment of Confidence in the Findings
The CERQual (Confidence in the Evidence from Reviews of Qualitative research) GRADE approach27 was used to assess confidence in the findings of the metasynthesis, following 4 key components: methodological limitations, relevance, coherence, and adequacy of the data. Assessment of these 4 components enabled to reach a judgment. about the overall confidence for each review findings, that is, each category in our results, rated as high, moderate, low, and very low, with “high confidence” being the starting assumption.28
Description of the Studies
Of the 1876 articles initially retrieved, 63 articles—from 61 studies—covering data collected from at least 1000 oncology nurses were included in this metasynthesis (Figure).
We excluded qualitative studies focusing on terminally ill and palliative care, because we considered it to be another issue that required its own metasynthesis. Specific inclusion/exclusion problems concerned the studies that simultaneously included nurses and other healthcare professionals, which included nurse students, as well as those mixing patients and nurses as participants. We applied our inclusion and exclusion criteria strictly and decided to exclude all these studies.
These studies came from 21 countries. The median sample size was 20 (range, 3-392), and data were collected through interviews (32), focus groups (12), or various combinations (19). Cancer hospitals were the site of 39 studies, whereas 9 took place in day surgery and chemotherapy departments, 7 in both (ie, with staff working with inpatients and outpatients), 2 in an acute care hospital setting and 2 more in sites including a hematology ward, bone marrow transplant unit and chemotherapy outpatient department, and 1 each in a neurosurgical unit, a combined oncology special unit and mixed medical-surgical unit, a hematological cancer unit, a general medical-surgical ward, and another among members of a society of oncology nurses.
Table 4 describes the characteristics of the studies finally included. The quality appraisal showed that the overall quality of the studies was high (Table 5). Of 63 articles, 18 had a score less than or equal to 7 (Supplemental Digital Content, Table S1, http://links.lww.com/CN/A26). We could verify retrospectively that these 18 studies contributed less to the results of the synthesis. Moreover, several articles failed to address the role of the researchers’ contribution to the findings and/or interpretations (reflexivity item, 51 studies). Table 6 describes the CERQual assessments of the findings.
Descriptions of the Themes
The articles described a variety of issues and problems, including workload, lack of time to spend with patients,51,81 low salaries, lack of recognition of their skills,51,79 working conditions,64,81 and training.44,49,53,69,81,88
Some articles also described positive experiences, such as recognition of patients, families, and institution,73 autonomy,47 and closeness and compassionate relationship,51,83 of interest for the purpose of this research as these experiences are often described in relation with the previous work-related issues that nurses overcame.
Two themes emerged from the analysis: (1) the relational dimension of work-related issues, on the one hand with other professionals and on the other hand with patients and families; and (2) the strategies for coping with the work-related issues, including partnership, communication and support, and training.
Table 7 presents quotations from participants and from the authors of the primary studies for each theme.
THE RELATIONAL DIMENSION WORK-RELATED ISSUES
Nurses’ relationships with other professionals: a lack of dialogue and support
Nurses described in numerous studies an absence of dialogue and support35,62 between themselves and a very high job turnover.45 Some studies have also described a fear of being judged by colleagues that inhibits exchanges and conversations.86 Nurses reported experiencing isolation when distressed, without support from their colleagues, feeling left alone to deal with their stress and their problems.45
Numerous studies have underlined the lack of communication between doctors and nurses, with nurses complaining about physicians’ failure to collaborate and especially to provide information; the latter is a source of doubt, disquiet, and uncertainty in dealing with patients.46,81,86,88 Nurses also complained that doctors do not listen to them, are inconsiderate towards them, do not provide support,76 and leave them to make decisions alone52,70 while simultaneously excluding them from patient management.80,87 They even thought that the doctors discredit them.78 When nurses reported their communication with physicians, they described it as ineffective.35 Some studies linked the nurses’ feelings of loneliness and impotence to the space monopolized by the medical establishment.41,46,53,86,88 Facing this medical power, nurses in these studies expressed not only anger but also a fear of stating their point of view if it differed from the medical discourse.41,46,53,54,70,86,88 On the other hand, few studies reported direct confrontations with physicians.87
Finally, nurses did not feel adequately supported by either their supervisors or the hospital administration.75 Participants in these studies very often reported a lack of external resources (institutional and community) and support.52,79 They mentioned the lack of a formal structure or supervision to support them in what they call the “burden of caring.”72,81 Authors also reported inhibitions in communication between the nurses and their supervisors,70,79 and nurses directly associated their lack of material and physical resources with lack of support by the hospital administration.52
Relationships with the patients and their families: an experience of loneliness
The nurses reported experiencing loneliness in caring for patients (medical, social, and psychological) and dealing with their need for support (emotional, spiritual/religious)68 in facing death. They also felt lonely with the family.
The nurses considered that they were the only people able to help the patients37,67 who they asserted could feel closer to them than to their own families.63 The nurses also stated they were the patients’ and families’ advocates within the medical profession.47,79 Finally, still others considered they had a social,38,40 psychological, or psychosocial role31,40,48,49,53,82 or that they also served as a counselor,43,44,64 a guide to the healthcare system,61 or a care coordinator.58 Others showed such an investment in the relationship with patients that they felt that the patients considered them equivalent to family members.83 Some nurses shouldered a role to support their patients in facing their imminent death, but reported nonetheless a feeling of loneliness in this preparatory work.39,55 They also reported loneliness in dealing with the distress of patients’ families and friends.38
This lived experience of loneliness, especially toward patients, was associated with feelings of frustration,46,51,64,70,86 guilt,52,70,80 and helplessness.32,43,44,71
The nurses also mentioned moral dilemmas or internal conflicts in difficult clinical situations, such as when they had information about the patient that the patient did not know, or when the patient was starting chemotherapy that the nurse perceived as harmful for the patient.36,80 They thus had the impression of undermining their integrity and their honesty and of having to hide their emotions and put on a “calm mask.”36
STRATEGIES FOR COPING WITH WORK-RELATED ISSUES
One of the strategies found was to develop a partnership, either with colleagues or with patients, to better cope with their workplace distress and especially to bear the burden of the solitude by sharing it.
Some participants talked about a “collaborative relationship” between colleagues, based on mutual confidence, respect, and esteem, as well as on the communications skills of each.66 Some authors stressed the importance of being able to trust others to be able to do this work.50,66 Several studies underlined the association between collaborative work and greater job satisfaction for nurses.43,66,70
This idea of partnership was also described with patients and their families and presented as a means of improving alertness and sharing responsibility: “We’re in this together.”59 The nurses described a necessary stage of instructing patients about their care and health status so that they could collaborate. Some participants have described this nurse-patient partnership as having a dual benefit—for the patients as well as the nurses.44,78
Communication and support
The nurses valued listening and communication as support in their relationships with patients.59,77
They also valued communication with colleagues, which enabled them to obtain support, to share the suffering of oncology patients, and to be alert to the emotional needs of others.45,52,65 They noted further that in the absence of mutual trust50 within the nursing team, communication could be impaired by the fear of revealing vulnerability or by the lack of loyalty and confidentiality.83 Communication was considered mainly at the organizational and interdisciplinary levels, especially for exchanges with physicians and for enabling nurses to coordinate care well.39,61 Nurses thus sought better communication.42,44 Some authors have thus concluded that open dialogues around ethical questions between team members are important for resolving complex clinical situations and thus improving not only the quality of care, but also job satisfaction.52,70
The nurses mentioned the need for support quite often.33,71,83 Some studies underlined the protective dimension of support against emotional exhaustion. Emotional support from colleagues is expressed through statements about teamwork, support for each other, and caring about each other.71 Some studies underlined the positive effects of peer support, such as reduction of both stress and the risk of burnout.33,83 Mutual emotional support within the group of care providers was also mentioned often.45,50,85 Some also found this support in their family and among their friends.45
The studies often reported the need to set up supervision or support groups for the nurses.86,87 The nurses described these supervision groups as a way of setting limits on their professional role in care and of improving and strengthening teamwork.62,79,89 Finally, they consider the existence of time for organized discussion to be a sign of support by their supervisors and linked to recognition of their work.56
Nearly every article has reported that nurses expressed their need for training, and authors have very often concluded that nurses need additional training programs:
- - to learn to guide patients toward acquiring their own resources74;
- - to acquire communications skills,88 especially for approaching the patients’ end of life88;
- - to promote interpersonal relationships and therapeutic communication40;
- - to acquire specific knowledge of cancer and its various treatments, as well as keys for understanding the healthcare system to be able to use it better39,72;
- - to provide knowledge about teaching, especially for group techniques40;
- - to learn more about psychology, specifically grief and theories of mourning29,53,54;
- - to learn how to manage pain49;
- - to acquire knowledge about the stages of cancer development and the impact of a parent’s cancer on the child and how to help parents approach the question of death with their children81;
- - to learn how to deal with the question of preservation of fertility57;
- - to acquire knowledge and skills about sexuality in the context of illness30,60,69,84;
- - to integrate new skill areas (internet) into their practices44;
- - to clarify the role of nurses for cancer outpatients and to help them be better able to identify the needs and objectives of patients in day hospital treatment36;
- - to manage patients in remission (“survivors”)37; and
- - to prevent burnout.33
For the nurses, the purpose of these training programs was to provide them with the skills and autonomy necessary to improve the accomplishment of their work.46,47 They associated their autonomy with their job satisfaction.47 Moreover, when this autonomy was recognized within their professional environment, the nurses felt that their work was valued.47 Some authors underlined that the autonomy of nurses depends on the view of the other staff and on the respect of the team.47,50,83
A lack of recognition by supervisors can be associated with a feeling of helplessness, frustration, and despondency in nurses.34,83 Some nurses then spoke about the need to find solutions in their personal resources.45,51,81 Similarly, the recognition of patients and families, even after the death of the loved one, was a source of motivation for the nurses51,72,73,90 and was perceived as a protective factor against emotional exhaustion.45,71
The results of this metasynthesis clearly show the central place of loneliness in these nurses’ experience of work-related issues. It is important to underline that none of the studies included had initially focused on this as the principal objective of their exploration. To our knowledge, no study, either qualitative or quantitative, has specifically explored this issue. The literature in oncology generally looks at loneliness among patients and their families,91,92 like that in geriatrics93 and palliative care.94
Feeling Lonely and Being Alone
In various situations, nurses reported both “feeling lonely” and “being alone.” On the one hand, they felt lonely with patients and families but also in the face of cancer and the imminent or actual death of patients. On the other hand, our results show that nurses experienced being alone within their multidisciplinary team and in dealing with the hospital administration. These 2 concepts are different. In his theory of relational loneliness, Weiss identified 2 types of loneliness: loneliness through social isolation (“being alone”) and loneliness through emotional isolation (“feeling lonely”). This important distinction has been described in social sciences studies among other populations, including people in grief95 and old people.96 To our knowledge, it has not been described yet among nurses in general and oncology nurses in particular. In fact, only nurses’ social isolation as a potential stress contributor is found in the literature,97 but the issue of nurses’ loneliness in their workplace has not been explored yet. Further research is needed to assess and measure the phenomena.
Our results suggest a confusion between these 2 forms of loneliness in the oncology nurses’ lived experience. The experience of being alone may relate to the absence of institutional support and organizational issues, while the feeling of loneliness derives from an individual stance.
The Question of Training
Several strategies are reported to remedy these experiences of loneliness. They are known in the literature and include especially some aspects of communication98,99 and the quality of the workplace environment, which is essential to the well-being of oncology nurses.100
Studies recurrently describe the needs of nurses, including oncology nurses, for training. Specific fields that have been reported to be useful or necessary include end-of-life support, communication and psychology,101 psychosocial care,5 and management of patients’ pain.4 These findings echo the recommendations of several professional societies of cancer nurses (in the United States and in Europe, for example) for the curriculum necessary for the specialty of oncology nurse.102 In most countries, nurses receive a very complete education in both the theoretical and practical (technical and relational) aspects of nursing,103 and only some countries offer supplementary training specific to oncology nursing.2
In our results, nurses perceive training as a necessary stage for overcoming their feelings of loneliness. Nonetheless, the diversity of the fields of knowledge to be supplemented leads us to question what it is they are searching for in this supplementary education. This complaint about loneliness and the important needs for training appear to us to mirror specific aspects of oncology, a specialty that progresses rapidly and continuously in terms of both knowledge and treatment innovations.104 Some types of cancer have become chronic diseases. Nonetheless, the provision of nursing care to cancer patients is grueling for the nurses, putting them face to face with pain, suffering, and death, forcing them to confront essential elements of being human. Beyond the importance of designing a solid educational structure for them, they appear to need support to enable them to bear the stress of this difficult field; without this, nurses are not able to use their skills effectively. The support group, mentioned in our results, appears to be the simplest tool that oncology departments can implement to aid and reinforce their nurses.
This type of group enables them to bear the loneliness because they have a group in which they can be heard. It is a reality that in dealing with the intense distress of cancer patients and their families healthcare professionals in oncology are compelled to accept a certain level of loneliness, which must not prevent them from mobilizing their skills and their strengths. Should the experience of loneliness become invasive, however, their work becomes extremely difficult, if not impossible. Oncology is a specialty that probably more than any other requires instructors willing to prepare their students to endure these experiences without losing their valuable professional skills.
Strengths and Limitations
This metasynthesis integrates the experience of at least 1000 oncology nurses from 21 different countries. The method we applied is rigorous, has been tested in medical research,22 and meets the criteria of the ENTREQ guidelines (Supplemental Digital Content, http://links.lww.com/CN/A25).24 We analyzed 63 articles, all published in peer-reviewed journals and mostly of good quality. Our method is perfectly adapted to the synthesis of a large number of qualitative studies and enabled us to reach a much broader perspective than any of the initial studies.
Nonetheless, certain aspects of this metasynthesis limit the generalization of its conclusions. A qualitative metasynthesis collects only partial data from the participants and depends on the researchers’ interpretations of the data. Moreover, although the review assembled articles from diverse cultural areas, English-speaking countries are overrepresented as we restricted our selection to articles in that language.
We can wonder if this experience of loneliness among these professionals working in oncology is specific to nurses or if it is also found among other medical and paramedical professionals. Future research among other groups (eg, oncologists, psycho-oncologists) is also necessary here. Another question is whether this experience among these nurses is specific to oncology or if the nature of oncology amplifies a phenomenon that can be found in other medical care contexts.
Five articles included come from the same original studies: 3 articles from 1 study53–55 and 2 from another one.32,33 Although these articles explore different aspects of the lived experience of oncology nurses and avoid redundancy in their results, there is a risk that they exert a greater weight than others in our results.
The studies included in this metasynthesis were particularly redundant from a methodological perspective. It thus appears essential to propose more participatory research methods to involve oncology nurses throughout the qualitative research process and to reach more original and relevant results.
Finally, we performed an update of the literature search and found 28 more studies (Supplemental Digital Content, Table S2, http://links.lww.com/CN/A27). It raised the issue of the significant increase of qualitative publications especially in nursing science and the need for methodological solution to produce high-quality metasynthesis. For the same reasons we restrained our search period, we decided not to include these studies in our review.
This metasynthesis about the lived experience of work-related issues among oncology nurses raised the important issue of nurses: loneliness, with 2 distinct concepts “feeling lonely” and “being alone.” An awareness is required among all healthcare professionals working in oncology about this specific issue as nurses’ loneliness in their workplace could have deleterious effect both on the patient care and the nurses’ mental health. Specific strategies need to be implemented to remedy these experiences of loneliness such as regular support group and specific training for oncology nurses.
The authors thank J. A. Cahn for the translation.
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