Self-Care, Burnout, and Compassion Fatigue in Oncology Professionals.

CONTEXT: With the rising number of cancer cases in India, the stress levels of the treating team have increased. It has affected their self-care and made them susceptible to problems like burnout and compassion fatigue that adversely affect the quality of patient care. AIMS: The aim of the study was to assess and compare the levels of burnout, compassion fatigue, and self-care in three groups of oncology professionals (clinical oncologists, nurses, and psychologists). SETTINGS AND
DESIGN: The study included 134 oncology professionals working in New Delhi, Bengaluru, and Mumbai. METHODS AND MATERIAL: Sociodemographic data sheet, Professional Quality of Life Scale V and Self-Care Assessment Worksheet were used. STATISTICAL ANALYSIS USED: Kruskal-Wallis, Mann-Whitney U test, and Correlation Analysis.
RESULTS: The majority of the professionals reported moderate levels of burnout (60.4%) and compassion fatigue (56%). Oncology nurses reported an elevated risk as they scored significantly higher on these domains and had a lower degree of self-care. Interestingly, psychologists reported comparatively lower levels of burnout and compassion fatigue, despite the fact that they interact with the patients at a deeper level, looking after their psychological and emotional needs. Young age and a poor degree of self-care were identified as major risk factors.
CONCLUSIONS: The moderate levels of burnout and compassion fatigue, though not severe, are a cause of concern and cannot be overlooked. The study highlights the need for self-care in this regard and suggests that individual and institutional level interventions, particularly for nurses and young professionals, would prove useful. Copyright:

INTRODUCTION

Professional burnout is a syndrome associated with exhaustion, depersonalization, and reduced professional efficiency. It is known to occur after repeated and prolonged exposure to emotionally strenuous situations in one’s work environment.[1] Another closely related term is compassion fatigue in which a person has to relinquish her/his sense of compassion towards the receiver of their care in order to prevent oneself from the resulting distress or despair.[2]

Research has shown that oncology professionals like medical oncologists suffer from emotional exhaustion and depersonalization, the core aspects of burnout.[34] Similarly, compassion fatigue has been found to be high in the nursing specialty, particularly among oncology nurses.[5] Others like psychologists are also exposed to grief and death. One out of five psychosocial oncologists is known to experience emotional exhaustion.[6] However, some studies have failed to incorporate this group and many reveal conflicting results and cross-cultural variations.[78]

Since the time burnout and compassion fatigue were coined, a debate is going on around the nature of their relationship. Some have reported a greater similarity between the two, viewing one to be a part of the other.[910] On the contrary, others have found no significant association between them.[1112] These contradictory findings have cast doubts on the nature of the conditions and the links between the two. Regardless of this confusion, both have negative consequences ranging from poor decision making, medical errors, disturbed relations with others to serious physical and psychological problems. These include frequent headaches, insomnia, reduced appetite, stress-related pathology, depressive symptoms, among others.[1314]

Consequently, the concept of self-care is gaining popularity. Poor quality of self-care has been regarded as a risk factor and prevention involves self-care behaviors such as a moderate degree of exercise, consumption of nutritious food, sufficient hours of sleep and rest.[15] It has been found that increased self-care can help in reducing the risk by increasing professionals’ functioning and work efficiency.[16] Since there is a paucity of Indian literature in this area, it would be beneficial to discover the links between burnout, compassion fatigue, and self-care.

A limited number of Indian studies have examined burnout and compassion fatigue in health care professions. Most of them have targeted general physicians[17] and clinicians,[18] but not oncology professionals in particular. Only recently, a study conducted in the field of cancer care in Bengaluru has shown moderate to high levels of burnout and compassion fatigue in cancer palliative care professionals.[19] Given that burnout is reported to be high among Indian doctors and factors like poor doctor-patient ratio and limited specialty training programs that are more specific to the country are regarded as some key reasons,[20] it has become essential to study such phenomena within the Indian context, particularly in a challenging field like oncology.

Thus, in light of these findings, the current study assessed and compared the levels of burnout, compassion fatigue, and self-care between three groups of oncology professionals (clinical oncologists, nurses, and psychologists) working in India. The study also investigated the relationship and the predictive role of compassion fatigue and self-care on burnout. In addition, the effects of demographic factors (age, gender, marital status) and work-related variables (work experience, amount of workload) were explored.

SUBJECTS AND METHODS

The study sample included 134 oncology professionals working in New Delhi, Bengaluru, and Mumbai. This included 53 clinical oncologists (medicine, radiation, and surgery), 42 oncology nurses, and 39 psychologists working in the field of oncology.

The study was reviewed and approved by the Institutional Review Board of Christ (Deemed to be University), Bengaluru. The participants who consented to take part in the study were to complete a printed survey set. An online link of the form was also made available for participants who worked in different cities and those who had a busy schedule and wished to respond to an online form.

A socio-demographic data sheet was prepared to capture the demographic and work profile of the study participants. The Professional Quality of Life Scale (ProQol Version 5) was used. It has three different and independent scales, two of which measure burnout and compassion fatigue.[21] In this study, the internal consistency coefficients as measured by Cronbach’s alpha were. 84 for compassion fatigue, and. 73 for the burnout subscale. The degree of self-care was assessed using the self-care assessment worksheet (SCAW). It is a widely used self-report measure in which the participants rate their frequency of engagement in various self-care activities.[22] The present study reported a Cronbach’s alpha value of. 86. The data were analyzed using IBM Statistics 20.

RESULTS

A total of 81 (60.4%) and 75 (56%) oncology professionals reported moderate levels of burnout and compassion fatigue, respectively.

As shown in Table 1, there are statistically significant differences in the burnout (c² =22.492, P <.01) and compassion fatigue scores (c² =22. 424, P <.01) of the three groups of oncology professionals. Oncology nurses scored significantly higher on burnout (87.31) and compassion fatigue (89.42) as compared to clinical oncologists and psychologists. There was also a significant difference in their degree of self-care (c² =15.717, P <.01) with the highest mean rank obtained by psychologists (85.50), followed by clinical oncologists (67.10), followed by nurses (51.29).

Table 1

Demographic and work profile of participants

Variable	Grouping categories	n	Percentages
Age	20-29	40	29.8
	30-39	51	38.1
	40-59	43	32.1
Gender	Males	66	49.3
	Females	68	50.7
Marital status	Single	57	67.5
	Married	77	58.2
Profession	Clinical oncologists	53	39.6
	Oncology nurses	42	31.3
	Psychologists	39	29.1
Professional experience (in years)	1-5	55	41.0
	6-10	41	30.6
	11-20	38	28.4
Work Setting	Inpatient	15	81.3
	Outpatient	10	11.2
	Both	109	7.5
Working hours (per day)	4-6	46	34.3
	7-9	52	38.8
	10-12	36	26.9
Extra working hours (per day)	0-1	59	44.0
	2-3	63	47.0
	4-6	12	9.0

The pair-wise comparisons for burnout scores revealed a statistically significant difference between all the three pairs, particularly between psychologists and nurses (P < 0.01) where nurses scored higher (mean rank = 67.29). Similarly, for compassion fatigue, there was a significant difference between two pairs, psychologists and nurses (P < 0.01); clinical oncologists and nurses (P < 0.01). In both, nurses obtained higher scores. On comparing self-care scores, a strong difference was observed between psychologists and nurses (P < 0.01) with psychologists scoring higher (See Table 2).

Table 2

Kruskal-Wallis Test comparing burnout, compassion fatigue, self-care based on profession

Variable	Oncology Professionals	n	Mean Rank	χ²	Sig.	Post Hoc (Pair-wise comparisons)
Burnout	Clinical oncologists (1)	53	67.29	22.49**	.000	1 & 2	1<2*
	Oncology nurses (2)	42	87.31			2 & 3	2>3**
	Psychologists (3)	39	46.45			3 & 1	3<1*
Compassion Fatigue	Clinical oncologists	53	63.37	22.42**	.000	1 & 2	1<2**
	Oncology nurses	42	89.42			2 & 3	2>3**
	Psychologists	39	49.51			3 & 1	Not significant
Self-Care	Clinical oncologists	53	67.10	15.71**	.000	1 & 2	Not significant
	Oncology nurses	42	51.29			2 & 3	2<3**
	Psychologists	39	85.50			3 & 1	Not significant

*P<0.05; **P<0.01, 1=clinical oncologists; 2=oncology nurses; 3=psychologists

As shown in Table 3, a positive correlation was found between burnout and compassion fatigue (r =0.618, P < 0.01). Self-care was found to be negatively related to burnout (r = −0.448, P < 0.01) and compassion fatigue (r = −0.262, P < 0.01).

Table 3

Correlation analysis among burnout, compassion fatigue, and self-care

Variables	1	2
Burnout (1)	1
Compassion fatigue (2)	0.618**	1
Total self-care (3)	−0.448**	−0.262**

**P<0.01

A linear regression established that compassion fatigue and self-care together could significantly predict burnout, F (2,131) = 85.267, P < 0.001. Compassion fatigue was a stronger predictor of burnout as it alone accounted for 45.2% of this variability and the remaining (11.4%) was that of self-care (See Table 4).

Table 4

Regression analysis predicting burnout from compassion fatigue and self-care

Predictors	β	t	R2	F
Compassion fatigue	0.596	10.09**	.566	85.267**
Self-care	−0.346	−5.85**

**P<0.01

The burnout scores differed with respect to age. The pair-wise comparisons revealed a significant difference (P < 0.05) between professionals in the age group of 20–29 (mean rank = 76.18) and those in the age group of 40–59 (mean rank = 53.63). Other demographic (gender and marital status) and work variables (experience, workload, and working hours) showed insignificant effects.

DISCUSSION

The current study found moderate levels of compassion fatigue and burnout in oncology professionals. Nurses were at greater risk when compared to clinical oncologists and psychologists. This increased susceptibility could be attributed to factors such as increased routine exposure to human suffering or to intrinsic factors such as willingness to build and sustain relationships with the receiver of care. Moreover, a great amount of time spent with patients contributes to a sense of burden and grief. These further intensify when they experience traumatic events in the workplace.[2324]

Psychologists had lower risk and better self-care than clinical oncologists and nurses. Since they work toward reducing caregiver burnout, they have a greater knowledge of these conditions. Moreover, they are aware of what is called the professional boundary that prevents them from becoming emotionally over-involved with their clients. An understanding of psychological principles coupled with knowledge of such conditions may serve as protective factors for these professionals.[25]

The positive relationship found between burnout and compassion fatigue provides evidence to the side of the debate that considers the two to be strongly connected.[1026] Moreover, the significant predictive role of compassion fatigue is in line with the claims of theorists who believe that compassion fatigue strongly contributes to the development of burnout.[27] This seems plausible given that only one severely stressful event may result in compassion fatigue whereas burnout tends to develop gradually through an accumulation of stressors over time.[28]

Age was identified as an important demographic factor as young professionals had higher burnout levels. This could be attributed to an early career stage that has been identified as a risk factor for burnout.[29] Moreover, additional analysis showed a positive relationship between age and balance dimension of self-care indicating that older professionals are able to maintain a better work-family balance. This appears to guard them against burnout and other stress-related illnesses.[30]

The present study highlights the importance of self-care for cancer care providers. It is essential for oncology professionals, in particular, nurses to participate in a greater number of self-care activities. There is also a need for new training programs incorporating counseling sessions and workshops on professional burnout and associated conditions. Intervention-based studies to assess the effectiveness of such preventive interventions and management plans would be useful.

The study suffered from certain limitations. First, the study did not assess variations in the levels of burnout and compassion fatigue between subdivisions (medicine, radiation, surgery) of clinical oncology. Second, the lack of a control group makes it difficult to conclude that burnout and compassion fatigue occur more in oncology professionals. These could be some important avenues for future research in this area.

CONCLUSION

So far, Indian research in the field of oncology has majorly focused on cancer patients but only a little attention has been given to the health concerns of the treating team. The present study is an initial step in understanding some of these mental health issues faced by oncology professionals in India. It is useful in creating awareness among the professional community about conditions like burnout and compassion fatigue as well as the importance of self-care. The findings highlight the need for effective interventions, ones that are oriented towards enhancing self-care and providing psychosocial support to high-risk groups within the field, specifically nurses. Since a young age was identified as a risk factor, there is a need for preventive measures such as adequate psychoeducation and advanced training programs in order to help them deal effectively with stressful situations at work.

Declaration of participant consent

The authors certify that they have obtained all appropriate participant consent forms. In the form, the participant (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.