This is the eighth official document of the SIOP Working Committee on Psychosocial issues in Pediatric Oncology, instituted in 1991.
It deals with a topic discussed and approved by the SIOP Committee; namely, "Recognition, prevention, and remediation of burnout in health care professionals participating in the care of children with cancer."
It is addressed to the Pediatric Oncology community and outlines:
1) the general definition of burnout as mental and physical exhaustion, indifference, sense of failure as a professional, and sense of failure as a person;
2) the causes of burnout from the nature of the work itself, the work environment, and the characteristics of the individual;
3) the prevention of burnout, changing the detrimental aspects of one's work environment and modifying one's own behavior; and accepting methods to remediate burnout when it occurs.
INTRODUCTION
Health care professionals are increasingly aware of burnout and are concerned with its impact on the individual and the health care team. Those whose work revolves around the problems and challenges facing others are especially vulnerable to burnout; health care professionals head the list of those who are susceptible. The impact of burnout can be profound: on the individual, on the team, and therefore on the patients and families for whom health care is provided. The resulting loss of energy, idealism, and enthusiasm coupled with a feeling of futility and dissatisfaction with work, is disruptive and frightening, leading to seriously compromised interactions within the work setting. This disquiet associated with burnout at work can be carried home and can severely affect home life.
This set of guidelines addresses three important questions:
1) How does burnout manifest itself in health care professionals treating children with cancer?
2) What are some of the causes of burnout for professionals treating children and adolescents with cancer or serious haematological disorders?
3) How might burnout be prevented in professionals in this field and remediated should it occur?
DEFINITION OF BURNOUT
Burnout in health care
professionals treating children with cancer often manifests itself as a multi-step process progressing slowly over time. Reversal of the pattern and prevention of further personal harm can be accomplished more readily at the beginning of the health care professional's downhill slide towards burnout. This occurs rapidly for some, but, for most, it is a very slow, almost imperceptible process occurring over time. Recognized "stages" in the development of burnout follow. Teams as well as individuals can be affected by burnout, and the use of the word "individual" in this context can be translated to include a team under certain circumstances. It is important to understand that an individual or team will not necessarily progress in an orderly fashion from one "step" to the next.
Mental and Physical Exhaustion
Individuals at this stage feel emotionally empty, with little or no energy or desire to relate to the children and their families or to fellow staff members. This stage may encompass some of the following: no longer feeling rewarded for doing good for others in this field or seeing positive outcomes in the treatment setting; seeing work that was once fulfilling as now being depressing; becoming emotionally exhausted from constant confrontation with death, loss, distress, and pain, feeling unable to face the suffering of yet another child and family, feeling overwhelmed by the need for additional resources and the futility of seeking these resources. These feelings are associated with physical symptoms of exhaustion, poor sleep, changes in appetite, poor concentration, and feelings of depression. Over time, the next step may evolve.
Indifference
In this step, individuals may appear to be cynical, uncaring, unmotivated, and disinterested and may demonstrate a growing bitterness. An individual with burnout may manifest ill-temper, irritability, lack of participation, and inability to communicate effectively. The effects on others become even more apparent: Patients and their families become dehumanized and are treated as objects by the individual or team. Over time, a third step may evolve.
A Sense of Failure as a Professional
The individual develops an increasing sense of professional failure, the belief that one is no longer as capable, caring, or competent as one used to be. This is often accompanied by a fear of committing serious errors and a loss of balance in life. There arises a feeling of being helpless ever again to achieve the same level of professional competence and caring as before. Very often, the professional's increased withdrawal creates alienation and a sense of despair on the part of the patient and family being treated. An even more internally painful fourth stage can ensue.
A Sense of Failure as a Person
With progression to this fourth stage, burnout turns in on itself, leading to a despairing self-hatred and isolation and a sense of hopelessness that creates a distorted belief that one is no longer a good or worthwhile person. This increased resentment permeates all aspects of one's personal life, with serious detrimental effects on one's family. At this stage, absenteeism from work becomes common. If not resolved at this point, over time a fifth and even more self-destructive stage may evolve.
"Dead Inside"
At this stage, the individual feels numb and "dead inside." The individual lacks affect, reflecting this emptiness and numbness; the individual performs his or her responsibilities without involvement, commitment, or enthusiasm. It is not uncommon at this stage for an individual to leave the profession, nor, unfortunately, it is uncommon for an affected individual at this stage to contemplate suicide seriously.
CAUSES
In addition to a level of burnout that can be caused by the nature of the work itself, the causes of burnout in health care professionals in pediatric cancer can be both institutional (the work environment) and personal.
The Nature of the Work Itself
The management of children with cancer and their families can be a major cause of personal burnout. Examples include dealing on a daily basis with a life-threatening illness; seeing many young children with compromised health; being in frequent contact with children having difficult treatment/recovery trajectories; having to assume the emotional burdens of the patients and their families; seeing many children die; living within a professional culture of never being allowed to complain; always having to be "up" for all patients and families; and being harassed and drained by dissatisfied families, with little or no time left over for the rest of the families.
The Work Environment
A major cause of burnout is a tense work atmosphere: when the setting is excessively authoritarian, with little opportunity for input into decision-making processes, and there is an atmosphere of hostility and tension among fellow staff members; when there is low team morale, within-staff disagreement and competition, and an atmosphere that lacks social support among peers when difficulties and problems arise; when working in a setting with too many demands and not enough time, with staff cutbacks and communication problems adding to tension, such as not having one's needs heard by those in positions of leadership. These constraints may lead one to being forced to choose between one ' s ethical and medical position regarding the continuation or discontinuation of treatment and the conflicting institution-based demands of those in positions of leadership, because resources do not match needs or expectations.
Characteristics of the Individual
Individual characteristics, such as the personality of the health care worker, can be a factor in burnout. Examples include: poor preparation for this type of work; high demands on oneself; expecting too much from one's work; difficulty in asking for help; difficulty in asking for or taking time off, especially when one is more experienced or in a position of authority; difficulty in asking for counselling when needed; not sharing thoughts; not making use of the social support system of peers; fear, guilt, and helplessness at thoughts of not having done all that should have been done; becoming too deeply involved with particular patients; difficulty in sharing work-related feelings and issues at home with partner and family; needing the family members' support during hard times but not wanting to burden them further; not getting enough rest when tired; wanting to change jobs but feeling financially trapped; being unable to say "no" to demands of families or staff. Burnout can occur more readily when one has serious problems simultaneously both at work and in one's private life or when one lacks a healthy balance between work and outside life.
PREVENTION AND REMEDIATION
The general principles for the prevention of burnout apply across centers, but the specific circumstances both of the individual and of the institutional setting will determine how best to apply them. Because the nature of the work remains challenging, individuals from the start should assess their suitability to work with these children and their families. No one should be obliged to work with this particular patient population except under extraordinary circumstances.
This section details a series of possible avenues for the amelioration and prevention of burnout. It is not the in-tent of this section to suggest that an individual or center should have to apply all or even most of the suggestions listed in order to prevent burnout. The listing is a compilation of suggestions from pediatric hematology and oncology health care practitioners, ideas that various practitioners have found helpful in their own centers. It is presented so that individuals might have a full list from which to select those modes for prevention that would best apply to their centers, each with its own needs, re-sources, and circumstances. The major suggestions are directed towards: 1) changing the detrimental aspects of one's work environment and 2) modifying those aspects of one's own behavior that predispose one to burnout.
Ways to Influence the Workplace Environment
As a general principle, an effective and caring leader with direct influence on the clinic setting can be a very powerful factor in the prevention of burnout. Most critical to the smooth functioning of a health care team is a common mission, a common set of goals and objectives. A good team leader will engage group members on a regular basis in defining and redefining group goals so that each member feels personally engaged in the decision-making process and feels that his or her own role is important to the mission as a whole. Thus, a good leader can help prevent burnout through careful initial recruitment of staff members and proper training; helping set up a general atmosphere of calm, support, and lack of tension in the work setting, so that staff members feel good about coming to work and feel respect for their work; finding in-hospital mechanisms to control work stressors, using both formal and informal support systems; allowing staff members the flexibility to determine some of the elements in their work; engaging staff members more actively in decision-making processes regarding patient care; encouraging staff to communicate with colleagues on a regular, daily basis while at work so that they can benefit from normal social support while on the job; facilitating debriefing meetings with health care team members at moments of critical patient transitions (re-lapse, entering terminal phase, death); helping organize staff retreats and educational leave days; having staff rotate within the department and outside the department when feasible and desired; allowing short leaves on occasion in order to prevent depression and consequent absenteeism; encouraging parents to advocate on the staff's behalf when appropriate. Parents can be supportive by demonstrating solidarity with staff by raising supplementary funds to help advance research and clinical care facilities, especially where resources are limited.
A periodic, regularly scheduled staff meeting with the senior administrator present and a psychologist or trained social worker presiding can be of considerable help. The purpose is to allow free and open discussion of problems that lead to burnout: Departmental policies, interpersonal difficulties, or other potential or actual points of conflict and dissension can be brought forward. A skilled leader is needed to develop such discussion in a constructive direction so that those attending can believe that positive results will ensue. It should also be made clear that private consultations with the psychologist will be available for those wishing further and more personal conferences.
Personal Factors
A carefully recruited and trained individual can do some of the following while in the work setting: learn to set personal limits both for time and for energy; avoid over-involvement; let needs be known both to work peers and to supervisors, especially when limited resources lead to overwork; engage in staff socials at work when feasible; keep communication lines open with colleagues and patch up minor differences as they occur; when appropriate and not additionally burdensome, help achieve closure by attending funerals or post-death meetings with parents and siblings; and attend workshops and sensitivity training sessions concerning burnout.
An individual had best learn to make personally acceptable and comfortable transitions from the work to the home setting; maintain a healthy balance between professional and private life; dedicate as much effort to family, relaxation, play, and leisure as one does to work; find specific at-home mechanisms to escape from work-related stressors on a daily basis; and find a relaxing activity such as a hobby to engage in during longer periods of leisure time, something that will distract one and take one away from the work setting mentally as well as physically.
However, when stress-related symptoms do emerge, it is important to recognize them at an early stage. Psychotherapeutic intervention programs have been developed to prevent and treat burnout. The aim of the intervention is to reduce symptoms, to facilitate reintegration into work, and to prevent a relapse of work-related problems. Relaxation training, stress management, cognitive therapy, and step-wise reintegration planning have been shown to be effective psychotherapeutic interventions. The goal is the restoration of the individual's overall sense of efficacy and worth.
SUMMARY OF ESSENTIAL POINTS
Members of the health care team should:
1) recognize "stages" in the development of burnout,
2) understand the causes of burnout,
3) adopt measures to prevent burn-out, and
4) accept methods to remediate burnout.
ADDITIONAL READING
Storlie FJ. Burnout: the elaboration of a concept. Am J Nurs 1979;19: 2108-2111.
Maslach C. Burnout: the cost of caring. Englewood Cliffs, NJ: Prentice Hall Inc.; 1982.
Koocher GP. Pediatric cancer psychological problems and the high costs of helping. J Clin Child Psychol 1980;10:2-5.
Emery JE. Pediatric oncology nurses burnout. J Pediatr Oncol Nurs 1990;7:47.
Kushnir T, Rabin S, Azulai S. A descriptive study of stress management in a group of pediatric oncology nurses. Cancer Nurs 1997; 20:414-421.