In 2012 and 2013, ASCO surveyed oncologists in the United States regarding burnout and career satisfaction.1,2 Although most oncologists reported being satisfied with their career (83%) and their choice of specialty (80%), 45% were considered burned out on the emotional exhaustion and/or depersonalization domain of the Maslach Burnout Inventory.1
Oncology nurses also experience moral distress and burnout because of the intensity and proximity to pain, suffering, and death. Early-career nurses are particularly susceptible because they are simultaneously learning their profession and encountering distressing situations.
Repercussions of burnout include staff turnover, reduction of hours, experienced individuals leaving the profession, and many negative personal consequences. Identification of burnout and management strategies is the focus of the Education Session “Burnout in Oncology Health Care Providers: Identifying Silent Despair and Maintaining Purpose” to be held Monday, June 1 from 8:00 AM-9:15 AM, in room S404. The session will be chaired by Anthony Back, MD, of Seattle Cancer Care Alliance.[image:1:right]
Early in his career as a clinical oncologist, Dr. Back observed that some of his colleagues thrived while others did not. Working in oncology is rewarding but at the same time is difficult and stressful, and this combination takes its toll on those providing care and their patients.3-5 Encounters with stressed patients and families can be very challenging. In addition, continuous pressure to be more efficient in the workplace has exacerbated the problem. “We have to figure out how we can thrive individually and as a community, and it’s more important than ever,” Dr. Back said.
Some of the early signs of burnout are irritability, not feeling recharged after time away from work, and the feeling that work totally consumes your life. Dr. Back emphasized that burnout is a real problem and is more than the feeling that you no longer enjoy your job and should retire. “My experience, and my experience working with other oncologists, is that people move in and out [feelings of burnout], and that there is quite a bit of fluidity to it. Recognizing this is important, and recognizing that there are things you can do is also important,” Dr. Back said.
Research Continues to Provide Insight
Tait D. Shanafelt, MD, of the Mayo Clinic, has been studying physician well-being for more than 15 years. “Physicians in all specialties are at risk, but there are fairly sizable differences in the prevalence of burnout by specialty,” Dr. Shanafelt said. Studies of physician burnout have provided a better understanding of its complexity and natural history. He noted that burnout is just one aspect of physician well-being; other dimensions include work–life integration, fatigue, stress, depression, professional satisfaction, and engagement. Mid-career, 10-20 years after entering practice, seems to be the time frame when physicians have the greatest challenge with work–life integration, burnout, and professional satisfaction. The rate of burnout of U.S. oncologists in the ASCO survey (45%) was similar to the average rate across all specialties reported in a sample of more than 7,000 U.S. physicians in 2011.6
“The dimension of well-being that oncologists struggle with most is work–life integration. In fact, satisfaction with work–life balance among oncologists in the ASCO study was the lowest of any specialty we’ve ever evaluated. In this regard, oncologists look very similar to many surgical disciplines, with average rates of burnout but very high degrees of dissatisfaction with work–life balance,” Dr. Shanafelt said.
Oncology Nurses also Affected
Cynda H. Rushton, PhD, RN, FAAN, of Johns Hopkins University, will address burnout in oncology nursing. Dr. Rushton’s interest in moral distress and resilience grew from her career as a pediatric nurse. She recognized that to remain effective in her job she needed to find strategies to cope with suffering, death, and the ethical questions tied to caring for seriously ill and dying patients.
She noted that nurses are frequently unprepared to manage issues they encounter, and this may catch them by surprise. “Being clinically competent doesn’t necessarily mean that we have all the personal tools we need to navigate the complex issues in oncology practice, especially with the burgeoning technology and treatments that are available that can increase survival but can threaten the quality of life of the people they aim to help,” she said.
Nurses who experience burnout often have higher levels of emotional exhaustion, particularly if they feel moral distress. This can often stem from a divergence between their intention and values and the reality of the clinical situations they face. Nursing burnout leads to physical, emotional, relational, and spiritual suffering and can cause a loss of meaning in work.
Burnout Management Strategies
There is a large body of evidence demonstrating that people work better when they take a break. No one can work continuously and expect to be at their best. This session will review practical steps that can be implemented to alleviate burnout.
Promoting mindfulness skills by organizing practices that allow physicians to immerse themselves in their work and live in the moment can help. Having a community of supportive people at work is also important. “It’s not a luxury item; it’s actually really important for your well-being. We are social creatures, and our work as clinicians is intensely social,” Dr. Back said.
Clinicians also need to actively plan times to disconnect from work. This renewal time has a positive influence and needs to be taken seriously and protected. Dr. Back also suggests that physicians reflect on the meaning and purpose of their work. “Most oncologists went into this business because there is something personally meaningful about it, and that meaning is not something you can take for granted. It requires a recommitment from time to time, and you need to figure out how to do it,” he said.
Dr. Shanafelt will review strategies physicians can use to alleviate burnout, starting with identifying professional and personal values. Physicians frequently have trouble integrating those two spheres of life, so he recommends developing an integrated list in a deliberate way. Then individuals can consider what changes could be made to their practice and career to achieve this integrated list. He agreed that meaning in work needs to be cultivated by thinking of how professional effort is spent and determining which activities derive the most meaning.
Dr. Rushton emphasized that individuals are not powerless and can take action by recognizing the early signs of burnout and moral distress and seek support and resources. Because burnout has become a more prominent issue, there is an opportunity to develop solutions to foster integrity, resilience, and enjoyment in work. “There are some very practical ways that we can begin to shift the way we show up at work and how we respond to the complexities and ethical challenges that are part of everyday practice,” she said. Each individual needs to commit to their well-being and find the approach that works best for them.
Organizational Changes Needed
All three experts agreed that changes need to be made in medical systems and at the institutional level in addition to individual efforts. The ultimate goal is to have engaged, dedicated, compassionate professionals who can sustainably work to meet the needs of patients with cancer. “Clinicians need to practice in environments that support their integrity and well-being in fundamental ways. Health care organizations need to be able to live the values they espouse by investing in their most precious, scarce resource: the people who provide care,” Dr. Rushton said.
Although cutting back hours can be a useful strategy for individual physicians, it will compound the projected shortage of oncologists and is not a good strategy at the societal level. This fact underscores the importance of addressing workload and efficiency. Process improvements that encourage relational engagement can reduce burnout and increase clinician satisfaction, thereby benefiting the medical system.
Which organizational interventions are the most effective remains an unanswered question. Dr. Shanafelt believes that controlled trials of these interventions will help institutions take action. “Hospitals and health care organizations recognize there is a big problem and are looking for solutions. The challenge is that there are a million different things that can be done and, in an era of limited resources, the key question is what is most likely to be effective. We want to invest resources in the things that truly make a difference,” he said.