ONCOLOGY NURSES ARE AT RISK for compassion fatigue, which is defined as emotional exhaustion resulting from caring for patients experiencing various degrees of suffering.1 Contributing factors may include the rapidly advancing pace of care, inadequate healthcare staffing, high patient acuity, and leadership challenges. This article explores barriers to self-care and self-compassion that confront hospital-based oncology nurses and describes a quality improvement project designed to meet these challenges using a validated quality of life assessment tool.
Burnout and compassion fatigue
The World Health Organization defines self-care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability, with or without the support of a health-care provider.”2 Self-compassion is defined as “a positive emotional attitude toward oneself that includes feelings of kindness towards self and others.”3 Both can reduce burnout in the nursing staff but these qualities must be facilitated and supported by managers to foster compassionate care.4
Advanced treatments of more complex diagnoses have resulted in an increase in oncology patients, including older adults. For oncology nurses, this is an exciting time to provide care, but increasing patient acuity and numerous educational requirements can be stressful and contribute to compassion fatigue, which is characterized by both physical and psychological symptoms such as nausea, headaches, insomnia, depression, and anxiety.1
Oncology nurses are at increased risk for compassion fatigue compared with nurses in other healthcare specialties due to longer patient stays, higher patient mortality, and opportunities to form strong nurse-patient relationships.5 A 2017 survey demonstrated that novice oncology nurses were more vulnerable to these contributing factors and more likely to experience compassion fatigue.6 In addition, a correlation was found between secondary traumatic stress, burnout, and poor working conditions such as increased work hours, reduced break times, and the inability to tend to personal needs. Secondary traumatic stress is a component of compassion fatigue that results from stressful or traumatic events at work; burnout is associated with feeling helpless to deal with difficulties at work.7
Compassion satisfaction refers to the pleasure experienced from performing work in a chosen field.7 Assessing for compassion fatigue and compassion satisfaction in nursing staff is crucial and can be accomplished using the Professional Quality-of-Life (ProQOL) scale, which measures the positive and negative aspects of patient care.7 Oncology nurses have been surveyed with ProQOL scores consistent with “high risk,” indicating low compassion satisfaction and an increased risk for compassion fatigue.6
Creating an environment that improves compassion satisfaction scores is crucial, as oncology nurses are at an increased risk for emotional exhaustion and decreased personal achievement.6 As such, nurse managers must understand the implications of compassion fatigue and recognize barriers to fostering supportive work environments.6
A quality improvement initiative
A quality improvement project was conducted within two oncology units from the authors' 520-bed tertiary care hospital in Pittsburgh, Pa. Using the plan-do-study-act model, three surveys and a focus group were implemented in two phases to assess nursing perceptions on quality of life, prepare self-care interventions, evaluate efficacy, and address any barriers to the interventions.8
In the first phase, the participating nurses completed the ProQOL survey. They also completed surveys regarding their current self-care activities, institutional resources, stressors at work, and support from coworkers. Combined with a review of the literature, this information helped in the creation of a tailored intervention to address burnout and increase compassion satisfaction. The goal was to provide a compassion fatigue tool kit and subsequently reduce its prevalence among the oncology nurses.
The tool kit was a compilation of resources kept in a large file at the nurses' station. Inside were flyers with information on health coaches, mental health professionals, mentorship opportunities, and other therapies at the integrative medicine center. While some of these services can be accessed over the phone, others are located within or near the hospital. One major benefit was the opportunity to receive massage, acupressure, or other therapies; these had to be scheduled outside of working hours, however, and required the staff to return to the city.
The second phase explored barriers to using the tool kit and completing the associated self-care activities. All responses were compared between the two units.
The ProQOL survey tool included 30 items to assess the prevalence of burnout, secondary traumatic stress, and compassion satisfaction among healthcare professionals.7 The second survey contained items related to work environments, existing self-care practices, emotional support, and support services provided by the hospital. It utilized questions with both a 5-point Likert scale and free response sections to create personalized self-compassion tool kits for each unit.
The third survey quantified how nurses accessed the tool kit, its perceived value, and what was utilized. The fourth tool relied on responses to four open-ended questions from a focus group session of 10 random clinical nurses convened to explore barriers to self-care and use of the tool kits.
Nurses completed the ProQOL tool and second survey during staff meeting times and morning huddles in September 2017. The ProQOL was completed on paper; the second and third surveys were completed anonymously online using the Qualtrics survey system of the University of Pittsburgh. In November 2017, a link to the second survey was emailed to the participating nurses after the tool kits had been made available. The third survey was distributed in February 2018. Each survey was available for 3 weeks (see Survey response rates). For the focus group session, nurses were approached randomly during their scheduled shifts and interviewed in March 2018.
After the participating nurses completed the second survey, their responses were evaluated descriptively and thematically for commonalities. A literature review of self-care practices for nurses and healthcare professionals was also completed, and the information gleaned from each was combined to create the self-compassion tool kits. These included information on the unique resources available on each unit, self-care practices shared among nurses, hospital resources for health and wellness, and a spiritual “prayer” to be said after a patient's death.
Analyzing the results
The first nursing unit reported lower rates of compassion satisfaction and a slightly higher risk for burnout and secondary traumatic stress compared with the second unit. This combination may lead to increased compassion fatigue among caregivers, but the participants' overall risk for experiencing negative outcomes was low according to their exact ProQOL scoring.7 (See Baseline ProQOL assessment.)
Despite in-person and email reminders about the tool kit's availability and contents, it was accessed only twice during the implementation between October 2017 and February 2018. Due to low utilization and response rates, statistical analysis was not carried out. So few nurses indicated that they used the tool kit when responding to the third survey that an additional inquiry was required to explore its underutilization. This prompted the focus groups. Participant responses were analyzed thematically and fell into four main categories (see Nurses' feedback).
Support. Participants felt that lack of support for time off and off-shifts such as evenings, nights, and weekends had a negative impact on self-care. Dedicated weekend staff has decreased over time, leading to the implementation of a rotating schedule and increased night and weekend requirements for the entire nursing staff. The participants also reported limited and denied vacations and the use of weekend and night-shift staff to fill gaps during weekdays. Previously, two nurses had been allowed to take vacation at the same time, but this has since been restricted to one nurse at a time due to staffing gaps.
Retention was another major challenge throughout the hospital during the project. Although bonuses were offered for new hires, the nursing staff felt that those loyal to the organization received little support, recognition, or reward.
Work schedule. When access to self-care activities or services required commuting away from home and closer to work, the participating nurses were not enthusiastic about navigating traffic or returning to the hospital. Additionally, working long shifts and rotating between nights and days required longer periods of recovery, during which time the staff felt too exhausted to engage in the self-care activities in the tool kits.
Although nurses are not mandated to work overtime, a weekly overtime list with the number of nurses needed for each shift is emailed to the staff. This communication results in feelings of guilt for those who know how their coworkers will struggle from short staffing. Nurses feel pushed to work overtime and frequently stay over their 40 hours or work double shifts to make accommodations and ensure adequate staffing and patient safety. The stress of rotating shifts can be limited by assigning regular day and nighttime staff or implementing a 2-week on-and-off schedule for night shifts. These strategies may be options for restructuring.
Acuity and staffing. Nurses reported that high acuity and subsequent staffing insufficiencies were the biggest factors in not performing self-care or accessing the tool kit. They noted having limited time for these activities and said that considering them served as a reminder of the stress of work.
Personal barriers. The participants often reported feeling guilt associated with self-care and self-compassion activities that may impact their time with friends and loved ones. Consequently, they ended up sacrificing personal time.
The initial goal of this project was to create a self-care tool kit to reduce compassion fatigue. Although this was unsuccessful, it created relevant insights into the challenges that prevented oncology nurses from accessing the tool kit and utilizing the available resources. The results were limited by a poor response rate and small sample size, but the topics discussed had implications for preceptors, charge nurses, and nurse leaders and managers.
Limited utilization of the tool kit prompted a focus group approach to determine barriers to understanding or awareness. The focus groups addressed issues such as staffing and patient acuity, but the questions used were not previously validated. After discussion with the staff, it became clear that the assumed intentions of enhancing self-care and increasing compassion satisfaction were not what the nurses desired from leadership. It was not self-care in terms of comfort that they wanted, but resources to believe they were doing a good job, extending compassion to their patients, and making time for their families and loved ones.
Lack of time off due to additional shifts, difficult rotations, chronic understaffing, and coming in on vacation days was considered a barrier to using the tool kit. This was compounded by feelings of guilt associated with self-care when the nurses believed patient care needs were negatively impacted.
The project also aimed to assist nurse leaders in developing interventions to support their staff. As nursing leadership significantly shapes the working environment, which impacts burnout, the unit director or manager has the most evident influence from a structural standpoint. These healthcare professionals have a formal title and the ability to create policies that enhance or impair staff satisfaction.9 Participant feedback indicated an expectation of a proactive approach in preventing staff shortages. (See Potential solutions.)
The difference between management and leadership is the anticipation of changes and preparedness based on goals and strategic planning.10,11 Although leadership was responsive and took action to provide resources by approving overtime, interviewing candidates, and attempting to hire new nurses, there was a perceived lack of appreciation, reward, and awareness of the efforts of current nursing staff. Engaged leaders must be in tune with unit culture to understand the needs and motivations of the nursing staff, such as providing quality care, feeling empowered, maintaining work-life balance, and having autonomy.10,11
Responses from the focus group indicated a loss of control over the participants' work-life balance in several ways. First, they often thought about work when they were outside of the hospital, leading to stress at the thought of self-care practices. Second, as they felt obligated to care for their loved ones over themselves, the nurses had little time to utilize the self-compassion tool kit.12 In taking on the caregiver role in all aspects of life while neglecting self-care, a cycle of stress may occur and create negative outcomes.
A team leadership approach based on the Blake Mouton managerial grid encourages nurse leaders to develop relationships with their team while working toward goals simultaneously.10 This model demonstrates the importance of engagement and relationship building in achieving outcomes, and the focus on teamwork places a high value on productivity and valuing employees. For example, nurse managers should learn about staff members' personal lives and goals, celebrate their achievements, share tasks, and provide opportunities to expand knowledge and skills.
The Blake Mouton managerial grid leads to a sense of appreciation among staff, as well as increased engagement, motivation, and involvement in decision-making. Each is related to decreased burnout and improved satisfaction.9,13 Shared decision-making can create solutions for scheduling issues, as well as hiring and retention.
Each strategy discussed in this article coincides with the American Association of Critical-Care Nurses' standards for a healthy work environment, which include skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.14
Informal nurse leaders, including charge nurses and preceptors, are key players in preventing burnout, serving as mentors and role models. Much like formal leaders, they must demonstrate empathy, manage the team, and communicate effectively.15 One study on charge nurse perspectives noted that one of the most satisfying aspects of mentoring staff was to develop nurses' confidence, leadership skills, and clinical competence and witness their professional growth.15 These frontline leaders can also mentor younger nurses to develop coping strategies and time management and communication skills.16
Charge nurses and preceptors may also practice transformational leadership, in which they use motivation, empowerment, and individualized challenges to elevate staff and create a cohesive team and positive social identity within the unit.17 Working in a strong, encouraging social group can mediate the daily stressors of nursing practice. Nurses in this situation will be more likely to participate in unit decision-making and create solutions to scheduling or staffing barriers.16
Implications for the future
Input from the frontline staff is necessary to combat compassion fatigue and burnout. Nurse managers must balance goal setting with relationship building and enlist the help of informal leaders to serve as role models for positive coping, work-life balance, and professional practice. Gaining insights into how nurses want to be recognized is an important step. Additionally, working to retain seasoned nurses and implementing recruitment strategies to fill empty positions quickly may reduce the overall workload to maintain a healthy environment. Nurse leaders can further engage with the staff by discussing personal challenges, leading to decreased turnover and a resilient, lasting team.
This project demonstrated the difficulties of adopting top-down solutions without staff perspective, input, or consensus. The development of interventions to improve satisfaction and engagement among nurses via safe workloads, clear expectations, transparent decision-making, staff recognition, and an enhanced sense of community is recommended.13
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