ORIGINAL ARTICLE /ARTICLE ORIGINAL DOSSIER
Supporting oncology health professionals: a review
Soutenir les professionnels de la santé en oncologie : une recension
J. Turner · B. Kelly · A. Girgis
Received: 1 March 2011, Accepted: 26 April 2011
© Springer-Verlag France 2011
Abstract Background: Caring for patients with cancer can be both personally rewarding and stressful. Confrontation with suffering, working with people facing complex life- threatening illness, demanding treatment regimens and fre- quent death of patients are challenging for many clinicians.
Responding to the emotional needs of patients and families is often perceived as among the most stressful. These emo- tional sources of stress can be compounded by organisa- tional factors and work demands. The resulting emotional impact can have an adverse effect on clinicians’performance in and satisfaction with their professional roles, their own health and well-being and the quality of patient care.
Objective: The objective of this paper was to review the fac- tors contributing to emotional stress and burnout in health professionals and identify evidence-based strategies to sup- port health professionals in their role, with illustrations of current Australian initiatives on how to apply these in clinical practice.
Results: Research to date indicates the contribution of a com- bination of individual and contextual factors in the develop- ment of these emotional adjustment problems, reflecting an interaction of clinicians’personal attributes and aspects of their work that influence risk to such stress and“burnout” among cancer clinicians. Evidence-based strategies to address these problems and promote resilience among clinicians include skills development through training and
mentorship, particularly in communication skills and psy- chosocial care. Such training and mentorship can lead to improvements in clinicians’stress management and confi- dence in their role, as well as to patient outcomes through improved response to patients’concerns and suffering.
Conclusion: No single strategy is likely to be successful in alleviating stress related to work in oncology. Interventions must be multi-faceted, flexible and incorporate attention to the complex inter-relationships of clinicians, their personal- ity and experiences, patients and health care systems.
Mentorship and clinical supervision can provide personal support, maintenance of skills and promote reflective prac- tices and translation of these skills into everyday practice.
Service models that also reduce professional isolation and promote inter-disciplinary team function are discussed, with illustrations of current initiatives in Australia. To cite this journal: Psycho-Oncol. 5 (2011).
Keywords Health professionals · Stress · Burnout · Inter-disciplinary team
RésuméContexte: Prendre soin d’une personne atteinte de cancer peut à la fois être une expérience personnelle grati- fiante et souffrante. La confrontation avec la souffrance, l’accompagnement de personnes affrontant une maladie sévère, l’administration de traitements exigeants et l’exposi- tion aux deuils multiples constituent des défis de taille pour plusieurs cliniciens. Répondre aux besoins émotionnels de la personne atteinte et de ses proches est souvent perçu parmi les expériences les plus stressantes. Ces facteurs émotionnels peuvent se voir amplifier par des facteurs organisationnels et propres à l’environnement de travail. L’impact émotionnel peut se répercuter négativement sur la performance clinique, la satisfaction professionnelle, la santé et le bien-être du soignant ainsi que la qualité des soins dispensés.
Objectif: L’objectif est de recenser les facteurs associés au stress émotionnel et à l’épuisement des professionnels de la santé en oncologie et de faire ressortir les stratégies efficaces permettant de soutenir ce professionnel dans l’exercice de son rôle. L’application dans un contexte clinique australien vient illustrer comment appliquer ces stratégies.
J. Turner
MBBS PhD FRANZCP, School of Medicine, University of Queensland, Brisbane, Australia B. Kelly (*)
BMed PhD FRANZCP FAChPM, School of Medicine and Public Health, University of Newcastle,
PO Box 833 Newcastle, NSW, 2300, Australia e-mail : brian.kelly@newcastle.edu.au A. Girgis
PhD BSc(Hons),
School of Medicine and Public Health, University of Newcastle,
Newcastle, Australia
DOI 10.1007/s11839-011-0320-8
Résultats: La recherche indique qu’une combinaison de fac- teurs individuels et contextuels pourrait contribuer au dével- oppement de problèmes émotionnels chez les soignants en oncologie. Un effet d’interaction entre des caractéristiques personnelles du soignant et des conditions de travail influen- cerait ainsi le risque de stress et d’épuisement au travail.
Parmi les stratégies décrites pour affronter ces problèmes et promouvoir la résilience chez les cliniciens, on retrouve le développement d’habiletés par l’intermédiaire de pro- grammes de formation et de mentorat, particulièrement dans les domaines de la communication et des interventions psychosociales. Ce type de soutien pourrait contribuer à l’amélioration de la gestion du stress et du sentiment de con- fiance dans le rôle de soignant. L’effet de ces programmes pourrait également se répercuter positivement sur l’allège- ment de la souffrance de la personne atteinte de cancer.
Conclusion: Il ne semble pas exister de solution unique pour alléger le stress associé au travail en oncologie. Les interven- tions efficaces seraient multimodales et flexibles. Elles pre- ndraient en compte l’interaction entre les caractéristiques des cliniciens, des personnes atteintes de cancer et du système de la santé. Le mentorat et la supervision clinique favoriseraient un soutien personnel, l’acquisition et le maintien de certaines habiletés utiles, la promotion d’une pratique réflective et le transfert de ces connaissances à la pratique. Les modèles de soutien qui permettent la diminution de l’isolement pro- fessionnel et la promotion d’un travail interdisciplinaire en équipe sont également discutés et illustrés avec des initiatives australiennes en cours. Pour citer cette revue : Psycho-Oncol. 5 (2011).
Mots clésProfessionnels de la santé · Stress · Souffrance · Soutien · Travail interdisciplinaire
Introduction
Since the development of the concept of stress and burnout and of the Maslach Burnout Inventory (MBI) [41], health professionals in particular have reflected on the emotional dimensions of their occupational role, including levels of Emotional Exhaustion, Depersonalisation and Personal Accomplishment. Studies of the oncology workforce report high levels of stress [54], with an Australian study reporting that at least 62% of the 134 oncology and palliative care specialists surveyed experienced some degree of stress in a range of practice situations presented [10]. A UK study reported that 36% of physicians experienced features of
“burnout”; those with poorer mental health also admitted that they were irritable with colleagues and patients, and that the standard of their professional work might be affected [53]. In the largest study of burnout in the Australian oncol-
ogy workforce (n = 740), high levels of Emotional Exhaus- tion were found in 32.8% of respondents who had patient contact, high levels of Depersonalisation in 9.91% and low levels of Personal Accomplishment in 14.8%, as measured on the MBI [18]. Significant predictors of burnout included dissatisfaction with leave arrangements for the purpose of preventing or recovering from burnout, increased hours of patient contact and perceived need for communication skills training [18].
While there may be differences across health disciplines and clinical specialities, health professionals in general experience significant levels of emotional distress including elevated levels of depression, anxiety, substance use, poorer physical health and self-care and, in some instances, elevated rates of suicide [13]. The distress experienced by clinicians has the potential to impact adversely on patient care, with reported associations with poorer quality of care, higher rates of clinical errors, diminished empathy in care, and greater absenteeism and adverse impact on professionalism [13]. Alongside growing recognition of demoralisation as an important clinical syndrome among cancer patients, atten- tion has also been given to the potential demoralisation (loss of hope, meaning and purpose) experienced by clini- cians in this field, and its influence on clinical practice [30].
Regrettably, being a health professional does not confer better health care—the converse may be the case for many. A study of oncology interns in France found that 20% were taking anxiolytics/hypnotics on a regular basis and, of par- ticular concern, these were self-prescribed in 88% of cases [8]. UK physicians who had poorer mental health were more likely to engage in consumption of alcohol at hazardous levels [53], and colorectal surgeons with higher level of stress were more likely to be planning early retirement [51]. In a Canadian study of 681 physicians in which 53.3% had high Emotional Exhaustion, nearly one-third of all respondents reported that they had considered leaving for a job outside the cancer care system [20]. Hence, despite betteraccessto health care, health professionals may indeed be less likely to receive appropriate care, especially for mental health problems particularly as the stigma regarding emotional problems, distress and mental health needs is likely to discourage appropriate help seeking for problems such as depression or substance misuse [9].
Underlying factors contributing to health professional stress and burnout
The contributions to clinician distress are complex and multi-determined [58]. Personal characteristics such as past experiences of bereavement and a poor appraisal of stressors [17], along with personality factors including
unrealistic expectations of performance or difficulty assign- ing priorities [1] and younger age [7].
The influence ofeducation and trainingappear substan- tial. Much training focuses on cure, so adverse or unexpected outcomes can seem like a personal failure [21]. There is often limited attention to the stress of professional roles in educa- tion [22], so it is unsurprising that cynicism and diminished empathy emerge during training [48]. Students and recent graduates view depression as stigmatising, suggesting they would be unlikely to seek professional help [12].
Patient factorsare also relevant. Responding to the emo- tional concerns of patients and their families is stressful for staff especially if they lack training and confidence in this area [8]. In the context of end-of-life care, this can culminate in feelings of helplessness and inadequacy [37], further exacerbated by the unrelenting demands for support of others—in the field of trauma this is described as“compas- sion fatigue”[16]. These factors can challenge the clinicians’ own sense of esteem with a feeling of powerlessness, often heightened by their sense of responsibility for patient outcomes [43].
Caring for patients who are young, who have young chil- dren or with whom one identifies for some reason can be particularly distressing [15], as can caring for patients of a similar age. Up to 35% of patients with cancer experience mental illness such as depression [62] and responding to the needs of these patients is likely to be difficult for health pro- fessionals if there is a perception of inadequate training in this area, or a lack of access to psychosocial services.
Patients who are angry, non-compliant or ungrateful can engender frustration and resentment amongst health profes- sionals, but traditionally these strong feelings are seen as
“negative”and not discussed [60], or are“labelled”using a framework loosely based on the work of Kubler-Ross [36].
Describing a patient as“in denial”does not help elucidate the unique concerns of the individual or provide a strategy for responding, so the problems persist.
Exposure to death, dying and suffering can also take a significant toll [8], especially if there are problems with symptom control or pain relief [46]. Distress can spill over into personal life with intrusive thoughts about the death of patients after returning home from work [14]. Coping with the death of large numbers of patients, even when expected, can lead to“accumulative loss”over time [32], necessitating that clinicians become skilled in maintaining objectivity without avoidance or detachment [11].
There are also potentethical issuesfor clinicians in can- cer care, including achieving a balance between maintaining patient autonomy and adjusting to increasing patient depen- dence in the face of disease progression [38].
Organisational factors such as heavy workload [18], tension in relationships at work team conflict and role ambiguity [47], and conflict about the goals of care [3]
also contribute to stress, along with concerns about patient safety when delivering complex treatments [4]. Working long hours or shift work can cause stress directly from fatigue, and indirectly because of the adverse impact on home life [19], which might otherwise have provided a buffer against stress. Lack of support from managers has been linked to higher rates of depression in staff [61].
Cultural issuesmay at least in part shape the ability to cope with the death of patients. Advances in health care and delivery of complex interventions has shifted care of the ill and dying from home and community to hospitals, making illness and death less familiar and perhaps more frightening [2]. Community sanctions against the expression of strong emotions and acknowledgement of grief (reflected in the popular expressions of“achieving closure”or“moving forward”) also inhibit health professionals from expressing distress in relation to their work and obtaining support from family and friends outside of work.
Interventions to address “burnout”
and distress in health care professionals
A range of specific interventions have been explored in order to address stress in the workplace.
Debriefing(Critical Incident Stress Debriefing or CISD) developed as a concept in the field of trauma [44] and was originally applied with fire-fighters and rescue personnel exposed to extreme situations. Despite its popularity, debriefing hasnotbeen demonstrated to reduce psychologi- cal distress or post-traumatic stress disorder [50], and there is some evidence that those who have received debriefing may haveworseoutcomes [23]. This might be because the pro- cess of debriefing involves an explicit open discussion of the event which may, for some, reinforce the awfulness of what has happened and disrupt the person from using his/her habitual coping. Despite this, debriefing has been uncriti- cally applied in many health care settings.
Staff support ranges from informal discussion with a trusted colleague [39] to structured interventions or retreats away from the work environment [42]. In an oncology set- ting, peer support has significantly decreased psychological distress and demoralisation [27]. However, complex dynam- ics may emerge in group discussion, including guilt and anger about clinical problems [45], indicating the need for expert facilitation [5]. Professionals may be reluctant to discuss their concerns with colleagues, instead of using avoidance as a means of coping [56]. In the absence of a culture of sharing concerns, individuals may feel that disclosure of concerns exposes them as being“weak”.
Personal reflectionhas long been advocated by Vachon [60] and others [43] as a means of developing strategies to enable a sense of competence and confidence about one’s
roles and the limits of one’s ability to achieve desired out- comes, especially when faced with patients with poor prog- nosis [60]. Such reflective practices include developing awareness of clinical situations that resonate with personal experiences, and understanding one’s personal responses rather than simple distraction from the demands of work [43] expand on this theme, highlighting the need for clinicians to reflect on any potential adverse impact on clinical care.
Despite professional consensus and evidence regarding the benefits of such strategies, the incorporation of these in service models and organisational practice has been slow.
One strategy to improve acceptance of the need for self- reflection may be to embed this in clinically focused initia- tives. Oncology nurses participating in an educational inter- vention [57] to enhance their ability to provide information and support for parents with advanced cancer found incorpo- ration of self-reflection and attention to the emotional dimensions of work to be acceptable [55]. Of note, while the study was successful in its intended aim of improving nurses’ skills and confidence, nurses also self-reported an increase in the degree to which “I take an active role in caring for myself emotionally and spiritually” after the intervention [55].
Educational initiatives have the potential to lay the foun- dation for realistic attitudes and behaviours, and there has been an increasing focus in health professional education on the need to attend to one’s own health care needs and develop strategies for self-care as important components of professionalism. However, more work is required in helping health professionals to respond to the emotional dimensions of their caring roles [34]. The importance of attention to these emotional issues is highlighted by research, demon- strating that the use of highly emotionally challenging role- play scenarios in communication skills training results in higher use of blocking, leading questions and inappropriate comments than non-challenging role-play scenarios [49].
Hence attention to the emotional issues raised in clinical communication is necessary. However, this requires skilled and experienced facilitators who can provide support and encouragement for participants, as failure to provide a safe and supportive environment could lead to participants feel- ing vulnerable and exposed. Attention to professional confi- dence is also an area which merits attention in training, as lack of confidence is a key issue adversely affecting professional roles [56].
Clinical supervision involves meeting with an experi- enced health professional to discuss clinical cases, including assessment issues, management and progress. Although supervision, not“therapy”, provides support, validation of skills, guidance and assistance as necessary and can include discussion about strategies to deal with personal challenges posed by complex cases, especially in discussing the
emotional concerns of patients, supervisors would normally encourage self-reflection [35] so that participants can iden- tify personal vulnerabilities and strengths which might have an impact on their clinical work. Supervision can potentially help the participant to develop a sense of self-efficacy and optimism about being able to respond to clinical challenges rather than being consumed by themes of self-blame, burnout or withdrawal from the workforce [24]. While the concept of clinical supervision is familiar to psychiatrists and psychologists, until recently its use has been less wide- spread outside those disciplines. There is an emerging litera- ture relating to supervision applied in other disciplines such as nursing, with tentative links between provision of clinical supervision and reduction in experienced burnout [25] and greater workforce retention [28].
A study of clinical supervision for general practitioners caring for patients with terminal illness identified a number of important themes influencing the ways that clinicians approached the detection and management of emotional dis- tress in their patients [29]. These themes included their responses to the death of patients, identification with attri- butes of the patient (e.g. similar age or background to oneself or one’s family members), the difficulties faced in openly discussing death and poor prognosis and the challenges in maintaining realistic hope. Earlier research had indicated a link between clinician attitudes and attributes and the responses of patients to their illness as reflected in the patients’wish to hasten death [31], supporting the need for greater assistance to doctors in addressing the psychological needs of their patients. In keeping with other findings in general practice [33], a model of clinical review can provide an effective tool for discussing the often unacknowledged concerns, especially among practitioners working in relative isolation from peers and without access to interdisciplinary team-based support.
Although membership of a multidisciplinary team can be associated with less stress, not all health professionals are satisfied with their engagement within the team [6]. There are a few formalised mechanisms for communication between health care service providers, and systems of care may contribute to patients receiving poorly coordinated care, especially those who reside in rural areas [26]. Improved team communication can be achieved indirectly through a promotion of professional confidence. A pilot study of peer supervision for oncologists consisted of six 90-minute ses- sions, video-conferenced across five clinical sites. During these sessions participants presented clinical cases which were discussed with the guidance of a consultation-liaison psychiatrist who prepared a summary of discussion and for- warded relevant literature pertaining to the topics discussed.
Participants reported improved confidence about raising psychosocial issues and actively contributing in team meetings:“My communication with medical consultants is
improved. My chart documentation is more relevant to med- ical and nursing staff. I have a better sense of my contribu- tion to multidisciplinary teams”[Turner, unpublished data].
Integration of multi-component approaches into routine cancer care
The authors are currently undertaking health service research aimed at promoting translation of psychosocial skills into clinical practice through mentorship and supervision [59].
Front-line clinical staff (e.g. oncology nurses, allied health professionals) are provided training in detection and man- agement of common psychosocial problems of cancer patients, along with agreed clinical care pathways with the aim of establishing a service model that embeds psychoso- cial care in routine clinical practice. Regular clinical super- vision focuses on the translation of these skills into clinical care using a stepped-care model (i.e. capacity to escalate intensity of interventions according to need). While this model is similar to other recent studies of psychosocial inter- ventions in cancer care [52], this study has a unique focus on the evaluation of the supervision and mentorship, the impact on staff well-being, and the identification of barriers to includ- ing these practices in usual clinical care. In another related study by the authors [Girgis & Kelly, recently funded grant], a similar model is extended to clinicians in rural regions through structured case reviews. Availability of the psycho- oncology team members for additional advice to rural clini- cians will support linking patients to local specialised ser- vices. Where specialised services are not available, outreach specialist assessment by video-conference is provided in col- laboration with the local clinician (e.g. rural clinical nurse).
Conclusions
While an emotional response to the suffering of patients is understandable and human, if not acknowledged, monitored and addressed, the distress or“burnout”experienced by clin- icians can have major unintended consequences—decisions made about patient care, relationships with patients and fam- ily, and conflicts within clinical teams [43]. Despite the cogent case for some of these strategies, it has been difficult to achieve consensus from research evidence to date regard- ing the prevention of burnout [40].
A Cochrane review of the research into a range of strate- gies to prevent occupational burnout failed to identify demonstrable benefits from existing programs, either those focused on the individual (including cognitive–behavioural, relaxation, music and therapeutic massage strategies) or those focused on aspects of work (including attitudes and communication, colleague support, problem solving and work organisation) [40].
It is clear from the above that no single strategy is likely to be successful in alleviating stress related to work in oncol- ogy, and that interventions must be multi-faceted, flexible and incorporate attention to the complex inter-relationships of clinicians, their personality and experiences, patients and health care systems.
Conflict of interest statement:the authors don’t have any conflict of interest to declare.
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