Compassion fatigue and burnout are well-established experiences for oncology nurses, often resulting in distress and reduced job satisfaction and prompting nurses to leave the profession altogether. Multiple interventions have been developed to better support nurses experiencing these phenomena, with varying success.
Years of nursing research have provided compelling evidence of the pressing need for healthcare organizations to intervene to prevent and mitigate the symptoms of burnout and compassion fatigue among oncology nurses (Potter et al., 2010). Burnout has been defined as a stress response to physical and mental demands of patient care (Braunschneider, 2013). Compassion fatigue, which is closely associated with burnout, develops when a nurse absorbs the pain and suffering of patients and subsequently suffers from their distress (Henry, 2014). Oncology nurses, who continually are exposed to the intense physical, mental, and emotional suffering of their patients, are particularly vulnerable to developing the characteristic symptoms of emotional exhaustion, cynicism, and depersonalization or emotional detachment (Braunschneider, 2013; Wentzel & Brysiewicz, 2018). These symptoms, which result from chronic distress, not only erode the well-being of nursing staff, but they also have been shown to negatively affect the quality of patient care (Henry, 2014; Spence Laschinger & Leiter, 2006). At the James Cancer Hospital and Solove Research Institute in Columbus, Ohio, the need to prevent and mitigate the impact of nursing burnout and compassion fatigue has been addressed through the development of a dedicated team of psychiatric mental health advanced practice RNs (PMH APRNs) solely to support staff.
A team of four APRNs was developed to support the psychosocial care of staff throughout a hospital system consisting of 316 beds, 8 ambulatory sites, and more than 1,500 nurses. Prior to the development of the team, PMH APRNs served as consultants for patients in the hospital and outpatient clinics. Eventually, patient demand for the team’s services exceeded its capacity, resulting in the development of a new consultation model. Concurrently, the hospital administration recognized an increasing need for education and coaching of nurses on self-care practices for resiliency, creating a new opportunity for the PMH APRN team. This team has been supporting staff in this capacity since 2016.
PMH APRNs are recognized as advanced practice experts in the direct care of patient populations, nurses, nursing staff, and organizational systems (American Psychiatric Nurses Association, 2018; National Council of State Boards of Nursing APRN Advisory Committee, 2008). With expertise in mental health and years of experience as PMH APRNs within healthcare systems, the PMH APRN team is uniquely qualified to recognize, plan for, and respond to psychosocial and wellness issues on an individual or a systems level. The hospital’s professional practice model, relationship-based care (RBC), is foundational for this role.
The role of the PMH APRN team is to enhance the knowledge, understanding, and practice of RBC, which informs and guides nursing care throughout the hospital system. RBC is focused on four major relationships: patients and families, community, colleagues, and self. A PMH APRN is assigned to every unit, both inpatient and ambulatory, resulting in closer relationships and timely interventions. The following four aims for the PMH APRN team are aligned with the RBC model:
• Develop and refine programming to support resiliency.
• Create a culture where nurses are supported and empowered to identify and resolve ethical issues.
• Identify and develop nurse competencies related to end-of-life care.
• Integrate and enculturate RBC throughout the cancer program to promote healthy interprofessional teamwork.
All interventions are aimed at the goal of developing and refining programs in support of well-being and resilience. The major initiatives of the PMH APRN team are outlined in Table 1.
Alongside the PMH APRN team initiatives, the team supports resilience through scheduled and spontaneous integrative therapy sessions, including aromatherapy, breathing techniques, reflexology, and guided imagery. In response to critical incidents, sudden deaths, or intense experiences of cumulative grief, the team provides individual and group debriefings and referrals to the Employee Assistance Program (EAP) or community counselors when needed. To support the care of patients and colleagues, the team has taken a leadership role in educating and supporting nurses to identify and address ethical concerns. PMH APRNs serve as a resource to coach nurses through crucial conversations with families and physicians, promote goals of care conferences, and provide guidance in placing ethics consultations.
The PMH APRN team promotes RBC of colleague enculturation and healthy teamwork through formal lectures and informal “curbside consults,” which are unplanned and often brief education or coaching interventions on relational issues. An example of this is teaching the skills and techniques of responding effectively to verbal aggression or hurtful behaviors. The team coaches managers on responding to complaints of incivility. In addition, the PMH APRN team provides mediation to restore healthy working relationships.
Various staff support resources already were in place when the PMH APRN role shifted to staff care. One of those resources was the STAR (Stress Trauma and Resilience) program, which responds to groups of staff after they have experienced a traumatic event. In addition, the institution has a robust and experienced chaplaincy department, a readily accessible team that is skilled in caring for staff at the bedside. Outside the work environment, counseling is offered through the EAP. All of these ongoing programs serve as important adjuncts to the PMH APRN team.
The PMH APRN team measures outcomes based on the number of programs provided and the number of individuals who have attended. Although some programming initiatives have developed more specific metrics, the PMH APRN team continues to explore avenues for reliable outcome measurement.
The Claiming Resilience program has been offered 45 times from July 2017–March 2018, with 332 staff attending. The Remembrance and Renewal program has been offered in each of the institution’s six building sites, with each site hosting the event twice a year. This resulted in 471 staff members participating from June 2017–May 2018.
From June 2017–May 2018, 49 nurses have completed the THRIVE program. The Compassion Fatigue Short Scale and the Connor–Davidson Resilience Scale were used to measure outcomes preparticipation and at three and six months postparticipation (Bride, Radey, & Figley, 2007; Connor & Davidson, 2003). Outcomes indicated increased resilience scores and decreased burnout scores from preparticipation to three months postparticipation. The increased resilience scores were sustained at six months; however, the lower burnout scores were not maintained. Participant feedback also was collected and included the following:
• “I have started taking care of myself rather than everyone else all the time.”
• “The class reminded me how much I love art and music and how it helps me relax.”
• “I realized that I can’t keep just complaining about how difficult my job is (even though I absolutely love it). I have to work to keep myself healthy and strong so that I can do it to the best of my ability.”
Because of the accessibility of the PMH APRNs, nursing staff have reported the following:
• An increased sense of safety and security when managing challenging situations and complex patient care needs
• Significant benefit from debriefing, educating, and coaching
• Commitment to improving self-care and care of colleagues and staff
• Increased requests for staff care interventions, in-services, and retreats from unit leaders
Oncology nurses serve in diverse healthcare settings, including hospitals, ambulatory clinics, private practices, home health, and hospice. When considering implementing a role that focuses on the health and well-being of oncology nurses, it is important to consider resources available in the practice setting and the scope of practice of the individuals in that setting. An interprofessional approach, including nurses, social workers, chaplains, administrators, and other key stakeholders, can be used to identify priority needs of the workforce, existing resources to address them, and novel ways of providing support at the point of care delivery. The PMH APRN team has content expertise in evaluating the practice environment and identifying challenges and opportunities to support staff health and wellness. Well-developed aims should guide the design, implementation, and outcome measures of the wellness program, ensuring that appropriate institutional approvals (e.g., institutional review board) have been obtained to evaluate participants and their outcomes. Ensuring a collaborative approach for referral if more significant issues are identified is imperative to ensuring the safety and well-being of staff participants in such programming.
The PMH APRN team has demonstrated how the well-defined nursing professional role of a PMH APRN can be implemented in a new way to support the well-being of staff. This model can be used to implement similar programs across practice settings or, in settings where this role does not exist, to inspire evaluation of other existing professional resources and roles that can be applied in new ways.
Ruth Frankenfield, MS, APRN-CNS, PMHCNS, Kathrynn Thompson, MS, APRN-CNS, PMHCNS-BC, and Amy Lindsey, MS, APRN-CNS, PMHCNS-BC, are mental health advanced practice nurses, and Amy Rettig, MALM, MSN, RN, ACNS-BC, PMHNP-BC, CBCN®, is an adult clinical nurse specialist and psychiatric mental health nurse practitioner, all at the James Cancer Hospital and Solove Research Institute and Wexner Medical Center at the Ohio State University in Columbus. The authors take full responsibility for this content. During the writing of this article, Rettig received funding from the James Innovation and Nursing Research Grant. Rettig has previously consulted for the Oncology Nursing Society and served on speakers bureaus for the American Psychiatric Nursing Association, the Mid-Ohio District Nurses Association, and the Self-Made Health Network. Frankenfield can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org.
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