When Betty Ferrell, PhD, FAAN, FPCN, began her nursing career in 1977, the concept of burnout was relatively new. As oncology units, like the one Ferrell worked on, were just getting started, the challenging nature of providing care solely for patients with cancer soon became apparent. Ferrell started hearing more about burnout, which at the time was being attributed to the work itself—an idea she had trouble reconciling with what she was experiencing. As a new nurse, Ferrell found herself questioning whether caring for this population was truly the root cause of burnout, as many seemed to believe. She realized that for her and many of her colleagues, caring for sick, complicated patients was not the problem. On the contrary, it was the patients who kept her coming back day after day. It was the patients who kept her going. She could learn how to care for and comfort the seriously ill and dying, but dealing with an administration that made her job more difficult was another matter.
In a recent interview with Oncology Nursing News
®, Ferrell, a professor and director of nursing research at the City of Hope National Medical Center, shared her insights about burnout and resiliency, and the important role of compassion, particularly during this trying time with the coronavirus disease 2019 (COVID-19) pandemic. Recalling her early years of nursing, Ferrell reflected, “What made me the craziest was that I could not give the care I wanted to give. I remember thinking that when it came to the concept of burnout, it was not just about the patient. The organization has a big role to play as well.”
The issue of burnout is now a well-known and well-researched phenomenon.1
Oncology nurses are at high risk for suffering from its effects, but they are also learning that even amid a pandemic, there is reason to hope, lessons to learn, and strength to be found.
COMPASSION FATIGUE AND RESILIENCY
Unlike burnout, which is defined as workload stress, compassion fatigue is secondary stress from exposure to suffering, and it is unique to caring professions.2
If not addressed, compassion fatigue can lead to burnout.
Courtney Sullivan, MSN, RN, CPNPAC, CPHON, project coordinator of global nursing, and Belinda Mandrell, PhD, RN, PNP, director of nursing research, both with St Jude Children’s Research Hospital, recently completed work on an evidence-based compassion fatigue quality-improvement program on a subspecialty pediatric oncology unit at St Jude.3
They spoke to Oncology Nursing News
® about their work and shared what nurses and organizations can do to address the issue of compassion fatigue.
Sullivan and Mandrell first identified the existence of compassion fatigue as a true problem through validated staff surveys. They also measured resiliency. What they learned was that while nurses experienced much reward from their work, they also experienced much stress. The emotional toll of caring for patients with cancer may be offset by the rewards of the work, but the risk for compassion fatigue remains high.
Having a mechanism for hearing the voice and concerns of staff and a plan for improving resiliency are crucial for preventing/reducing compassion fatigue and, ultimately, burnout. Sullivan noted that shared governance, unit-based councils, and a healthy work environment committee are important structures for nurses to share their concerns with nurse leadership, who can then act upon them and help support nurses with the self-care needs they have.
Their organization created spaces on each newly constructed unit only for nurses, including a lounge with a kitchen and a respite room. Leadership makes a point to come to the unit to let staff know they care.
They also have Resilience in Stressful Events (RISE) responders who are trained, interpro-fessional volunteers who are available 24/7 to provide staff with needed support during stressful events or for mental, emotional, and moral distress.
A new support tool called Code Lavender started at their organization in July. When a Code Lavender is called, a RISE responder comes to the unit with a self-care cart of interventions, such as journaling materials and aromatherapy. Mandrell noted that, “We mustn’t forget that compassion fatigue trickles throughout the orga-nization. [Environmental services], nutrition, registration personnel—everyone is affected by patients and their stories.”
For any intervention program to be successful, someone must own it and make it available. “Unless someone has ownership of the program/project,” said Mandrell, “it will just sit there.”
Sullivan stresses the importance of adminis-trative support. “Through healthy work environment committees and unit councils, that’s where you have your stethoscope to the voice of the unit, the heartbeat of those nurses, your finger on the pulse of what’s going on.”
BURNOUT, MORAL DISTRESS, AND COVID-19
When it comes to burnout, nurses are making a difference. They have learned more about what burnout is and what can be done to offset and even prevent it. By looking at work environ-ments and studying leadership strengths and weaknesses, nurse scientists like Ferrell have a better understanding of why nurses stay and why they leave.
“When you can’t provide the care your patients deserve, that’s a big part of burnout. Saying burnout is from working too many hours is a shallow interpretation. A deeper reflection is to think about what is really creating the burnout and consider the concept of moral injury and distress,” Ferrell said. “We’ve learned a lot. Great people have done important work. Ethics committees, nurse ethicists, and palliative care have become part of our practice. Reducing the moral distress that stems from violating personal values and beliefs regarding what constitutes good patient care can greatly impact the level of burnout experienced by nurses working in oncology.”
With COVID-19, the intensity of being a nurse is escalated on many levels.4
Nurses worry they will get sick and expose their families to risk. Working during the pandemic may mean longer hours, reductions in staff, and added concern for patient safety. Nurses may find themselves caring for patients, but without the proper protective equipment. Going beyond equipment shortages, nurses have also had to abandon the basic princi-ples of oncology nursing that they hold dear. COVID-19 has challenged the core beliefs of hands-on care, human touch, and close human connection. Ferrell leads the End of Life Nursing Education Consortium (ELNEC) project which has developed many resources for nurses including topics such as self care.
“We’ve spent our entire career focusing on patient- and family-centered care. We want families at the bedside. We believe that no one should die alone. [But] we are now told we can’t let anyone at the bedside, even when someone is dying,” Ferrell said. The moral injury nurses feel when they tell a family member over the phone that they cannot visit can contribute to burnout. “These big, important things affect how we do what we do,” Ferrell acknowledged.
Ferrell advises nurses and nurse leaders to step back, have a moment of compassion and grace, and tell each other that they are doing the best they can. There will come a time when they are through this. She hopes oncology organizations will then take the time to talk about what happened. Although orga-nizations may want to just move ahead, Ferrell believes that is not the answer. An important part of the healing will be talking about what it was like and employing debriefing as an opportunity to grow. “When it comes to burnout, self-care, and resiliency, the wise organization will be the one that takes the time to really deal with what happened and how that felt,” she said. She also encourages nurses and organizations to find reason to celebrate. “Part of self-care is to say, ‘What did we do really well? What went right?’”
- Burn-out an “occupational phenomenon”: international classification of diseases. World Health Organization. May 28, 2019. Accessed July 5, 2020. https://www.who.int/mental_health/evidence/burn-out/en/
- Nursing professionals pulse survey: 2020 pandemic. NurseGrid. Accessed July 5, 2020. https://nursegrid.com/help-nurses-now/survey-results/
- Jarrad RA, Hammad S. Oncology nurses’ compassion fatigue, burn out and compassion satisfaction. Ann Gen Psychiatry. 2020;19(3):22. doi:10.1186/s12991-020-00272-9
- Sullivan CE, King AR, Holdiness J, et al. Reducing compassion fatigue in inpatient pediatric oncology nurses. Onc Nurs Forum. 2019;46(3):338-347. doi:10.1188/19.ONF.338-347