European Journal of Oncology Nursing: Louise Gribben, Cherith Jane Semple

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European Journal of Oncology Nursing 50 (2021) 101887

Contents lists available at ScienceDirect

European Journal of Oncology Nursing


journal homepage: www.elsevier.com/locate/ejon

Factors contributing to burnout and work-life balance in adult oncology


nursing: An integrative review
Louise Gribben a, Cherith Jane Semple b, c, *
a
Southern Health and Social Care Trust, Craigavon Area Hospital, 68 Lurgan Rd, Portadown, Craigavon, Northern Ireland, BT63 5QQ, United Kingdom
b
Ulster Univeristy, Jordanstown Campus, Shore Road, Newtownabbey, Co. Antrim, BT37 0QB, United Kingdom
c
South Eastern Health Social Care Trust, Belfast, Northern Irealnd, BT16 1RH, United Kingdom

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: Occupational stress and burnout are highlighted as the most prevalent workplace issues for adult
Oncology nurses oncology nurses. With today’s global nursing workforce shortage; coupled with oncology being an inherently
Adult cancer nursing challenging and complex speciality, this clearly indicates the need to understand factors that contribute to
Burnout
burnout in adult oncology nurses and improve work-life balance. The aim of this integrative review is to syn­
Occupational stress
Work-life balance
thesis the evidence on burnout and work-life balance for adult oncology nurses.
Workplace Method: A systematic search of four databases (CINAHL, Ovid Medline, PsycINFO and Scopus), identified 17
Integrative review quantitative and three mixed-method studies. Studies were critically appraised using the Mixed Methods
Appraisal Tool. Following data extraction, a qualitative evidence synthesis utilising an inductive approach was
adopted to better understand influential factors, generating analytical themes.
Results: One study had a specific focus on what ameliorates work-life balance for oncology nurses; depicting an
area that warrants further study. All studies reported on burnout, of which six analytical themes were further
categorised into two broad themes, namely: (1) ‘Inability to thrive’: struggling with workplace burnout due to
organisational challenges and (2) ‘Personal perspectives influencing burnout’, for adult oncology nurses. Burnout
was influenced by multiple oncology-specific factors due to quantitative workload demands and disease acuity.
Workplace culture, shift in additional hours being worked remotely and personal characteristics of the nurse, also
influenced susceptibility for the development of burnout in oncology nurses.
Conclusion: Confronting burnout and promoting wellness are the shared responsibility of both individual adult
oncology nurses and their organisations to build resilience and help sustain and build workforce capacity.

1. Introduction evokes much fear and uncertainty. Consequently, oncology nurses are
frequently communicating bad news, confronted with supporting pa­
Providing high-quality, person-centred care to patients and their tients and relatives in the grieving process and involved in
families with a potentially life-threatening illness, such as cancer, can decision-making for ethically complex situations (Grech et al., 2018).
afford nurses with an immense level of satisfaction (Barrett and Yates This is coupled with the responsibility of delivering highly complex care,
2002). Adult oncology nursing is a rewarding profession and derives often to ill patients. These factors can contribute to chronic stress and
high levels of intellectual stimulation, especially with evolving scientific can provoke significant burnout (Emold, 2011).
discoveries being translated steadily into clinical practice (Toh et al., Burnout was first described in the 1970s as a condition that occurs
2012). However, a large body of international evidence would suggest when work, combined with additional life pressures exceeds the ability
that oncology professionals are subject to greater occupational stress to cope, resulting in physical and mental distress (Freundenberger
than healthcare workers in any other speciality (Eelen et al., 2014, 1974). Burnout was further characterised by Maslach in the 1980s
Gomez-Urquiza et al., 2016, Shanafelt et al., 2016 and Murali et al., (Maslach and Jackson 1981; Maslach et al., 1986), as typically devel­
2018). In oncology units, due to the nature of the speciality, nurses are oping slowly along a continuum and conceptualised as a
inherently dealing with those in receipt of a cancer diagnosis which three-dimensional syndrome, comprising of: (1) emotional exhaustion

* Corresponding author. Ulster Univeristy, Jordanstown Campus, Shore Road, Newtownabbey, Co. Antrim, BT37 0QB, United Kingdom.
E-mail address: cherith.semple@setrust.hscni.net (C.J. Semple).

https://doi.org/10.1016/j.ejon.2020.101887
Received 27 June 2020; Received in revised form 24 November 2020; Accepted 27 November 2020
Available online 9 December 2020
1462-3889/Crown Copyright © 2020 Published by Elsevier Ltd. All rights reserved.
L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

(EE), (2) depersonalisation (DP) and (3) low sense of personal accom­ 3. Methods
plishment (PA). This model theories that as an individual’s EE intensifies,
empathy declines (DP) and a low sense of personal accomplishment (PA) An integrative review design was used as a framework for ensuring
follows. More recently, Barnard et al. (2006) and Guo et al. (2019) re­ comprehensive inclusion, appraisal and synthesis of a range of qualita­
ported burnout as a recognised occupational disease in some European tive, quantitative and mixed-method studies (Hopia et al., 2016).
counties. In May 2019, the World Health Organisation (WHO) added
burnout to the 11th revision of the International Classification of Dis­ 3.1. Search strategy
eases (ICD-11), portraying it as a syndrome of three dimensions, akin to
that of Maslach; including feelings of energy depletion or exhaustion, A range of keywords were identified during the scoping and pre­
increased mental distance from one’s job or feelings of cynicism or liminary literature search phase. A table of keywords were identified by
negativism about one’s job, and reduced professional efficacy (Inter­ the research team using Population; Interest, Outcome (PIO) (see
national Classification of Disease 2019). Table 1).
The phenomenon of burnout among adult cancer nurses inevitably The medical subject headings (MesH) used included oncologic
has a negative impact on their well-being, home life, work and re­ nursing, burnout, professional and work-life balance. In consultation
lationships, causing irritability sleeplessness, fatigue and for some can with an experienced librarian the search sensitivity was expanded uti­
lead to alcohol and drug consumption (McMillan et al., 2016; Cana­ lising keywords and truncation where applicable. Keyword searches
das-De la Fuente et al., 2018). The adverse effects of burnout can also included, oncology nurs*, cancer nurs*, oncology professional, burn-
place demands on healthcare organisations. Patient care can be out, burnout, occupational stress, stress and “worklife balance”. In
compromised due to suboptimal care delivery and higher rates of order to broaden or narrow the search results, Boolean operator “OR”
treatment errors. These factors, in conjunction with increased absen­ and “AND” were utilised. The search was limited to publications written
teeism and sick leave (Magtibay et al., 2017), collectively cost the health in English that were published between 2009 and 2019, to ensure the
service millions of pounds (Arigoni et al., 2009; Banerjee et al., 2017). focus of this integrative review was relevant to recent studies addressing
Various studies have been undertaken to evaluate both prevalence workforce issues. The search strategy used the following four electronic
rates and influencing factors contributing to the development of burnout databases, CINAHL, Ovid Medline, PsycINFO (PsycINFO search strategy
for oncology nurses, such as age, education, length of employment, job provided in Appendix 1) and Scopus and was conducted in December
satisfaction and workload; resultant in disparate findings (Giarelli et al., 2019 by the first author (LG). To ensure the identification of literature
2016; Duarte and Pinto-Gouveia 2017; Kotpa et al., 2017). Conversely, not listed in the electronic databases, grey literature searches were
relatively less attention has been given to the impact of work-life bal­ conducted using google scholar and manual searches of reference lists
ance on the emotional well-being of adult oncology nurses. Unlike the from extracted articles.
concept of burnout, there is a lack of widely accepted validated tools to
measure work-life balance and no universally accepted definition
3.2. Inclusion and exclusion criteria
available; nonetheless, the concept is complex. Suggested definitions for
work-life balance include ‘equilibrium or an overall sense of harmony in
Inclusion and exclusion criteria were applied. Studies included were:
work and private life’ (Clarke et al., 2004) or ‘an adequate amount of
primary research papers, published in English, available in full-text,
resources to respond effectively to the demands of their work and family
using quantitative, qualitative or mixed-methods, across any health­
roles’ (Valcour, 2007). Anandan and Karthikeyan (2016) purport if you
care setting that focused on burnout or work-life balance for adult
can fulfil the respective demands in a way that satisfies you, then it is
oncology nurses, published between 2009 and 2019. Secondary
reasonable to say you have the right balance between work and family
research, systematic reviews, opinion articles, editorials and research
life. For the purpose of this study we will operationally define work-life
that focused on paediatric oncology nursing were excluded. Studies
balance as having sufficient time, energy and resources to meet the
were also excluded that did not specifically address burnout and/or
commitments of home and work.
work-life balance and studies that were multiprofessional where the
Within the field of adult oncology nursing, burnout and inadequate
nursing information was not clearly segregated.
work-life balance has many implications on the availability of a skilled
workforce, as burnout has been correlated with poorer staff retention of
oncology nurses, a desire to change speciality, reduce working hours or 3.3. Data screening
retire early (Langerlunf et al., 2015). A recent study in the United
Kingdom (Macmillan Cancer Support, 2017) found an increased The initial search from the four electronic database searches and the
shortage of adult oncology nurses, across a range of specialist settings, grey literature were collated in RefWorks (being a reference manage­
amid an expanding cancer workforce. This is compounded by the ment software tool) by LG (first author), generating a total of 88 studies,
globally nursing workforce shortage. Combined with an ever-growing of which 37 duplicates were removed. The remaining 51 studies were
cancer population, this clearly indicates the need to understand the reviewed by title and abstract, being screened to identify studies that
factors that contribute to both burnout in oncology nurses and those that met the inclusion and exclusion criteria. Based on this screening, 34
improve their work-life balance, in an effort to enhance and promote
resilience for the oncology nursing workforce. Table 1
PIO search terms for integrative review.
2. Aim PIO component Key terms Final search synonyms

Population Registered nurse Nursing


The aim of this integrative review was to gain an improved under­ “Nurs”
standing of influential factors contributing to burnout and work-life Oncology nurs*
balance for nurses working in adult oncology by synthesising the evi­ Cancer nurs*
dence. More specifically, to address the following two research Interest Working in oncology Oncology professional
Outcome measures Burnout Burnout
questions: Work-life balance Burn-out
What factors contribute to burnout for nurses working in an adult Stress
oncology setting? Occupational stress
What factors influence work-life balance for adult oncology nurses? Compassion fatigue
“worklife balance”

2
L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

articles were selected for full-text screening. Once full-text articles were moderate or low quality. The earlier 2011 version of the MMAT has a
screened against the inclusion and exclusion criteria, 14 studies were scoring matrix, however, the authors of the most recent, 2018 version,
excluded, resulting in 20 eligible papers. The process of identification, discourage the use of matrix, purporting that a single number is not
screening, eligibility and inclusion is displayed in a PRISMA flowchart, informative. All studies were retained irrespective of their MMAT clas­
Fig. 1. The process was confirmed by the second author (CS). sification, as represented in Table 2, to ensure the integrative review was
as comprehensive as possible.

3.4. Data extraction and appraisal


3.5. Data analysis and synthesis
To enhance rigour, data were extracted independently by both au­
thors using an extraction form. The following relevant characteristics The focus of this integrative review was to gain an improved un­
were extracted: author (s), year, country, study aim (s), research design, derstanding of influential factors contributing to burnout and work-life
sample size and characteristics, key findings, outcomes while noting balance for oncology nurses, therefore extracted data for all 20 studies
strengths and limitations of each study (Table 2). The studies were were converged for the purpose of a qualitative evidence synthesis and
critically appraised using the Mixed Methods Appraisal Tool (MMAT) by subject to thematic synthesis. This inductive approach was adopted and
CS (Hong et al., 2018). In keeping with guidance provided for MMAT deemed appropriate, primarily due to the aim of this integrative review,
(Hong et al., 2018) a scoring matrix has not been applied to this inte­ in gaining an improved understanding of a complex phenomenon and
grative review, but instead each study has been classified as high, generating higher-order themes following the aggregation of exiting

Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) diagram for current study.

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L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

Table 2
A summary of the included studies.
Authors/year Study aim (s) Study design/ Outcome Sample Key findings MMAT

Country measures characteristics

Cheng et al. Relationship between job Quantitative: Maslach Burnout n = 328 High level of burnout among High
(2015) burnout and professional Descriptive correlation Inventory (MBI) oncology nurses
values in oncology nurses study nurses directly Caring was the top concern for
involved in the oncology nurses and took actions
clinical care of to improve quality of nursing
cancer patients care
China Nurse Professional MBI
Values Scale
➢ 45%: had high EE
➢ 94%: had low DP
➢ 66%: had high PA
Job burnout and caring were
positively correlated
EE and DP were negatively
correlated with professional
value, whereas PA was positively
correlated with professional
value
➢ Nurses feel valued and job
important reduced burnout,
whereas if young isn’t valued
then burnout occurs
Davis et al. Investigate differences in Quantitative: Nursing satisfaction Convenience sample 22% had high EE Moderate
(2013) burnout among oncology Observational, and retention survey of n = 74 full time
nurses by type of work setting descriptive oncology nurses Burnout was lowest in staff <
(in-patient v out-patient), 40yrs old
USA coping strategies and job Maslach burnout ➢ Increased yrs. Experience =
satisfaction inventory (MBI) decreased BO
➢ Poor staffing levels =
increased BO
➢ Support from colleagues and
spirituality were protective
factors against burnout.
➢ EE and burnout higher in
outpatient nurses compared
to inpatient nurses.
➢ Inverse correlation between
EE and job satisfaction and a
desire to leave oncology
nursing
De la Fuente- Analyse relationship between Quantitative: Maslach burnout Convenience sample Burnout - 29.6% had severe Moderate
Solana et al., burnout and personality observational, cross inventory (MBI) n = 101 nurses burnout
2017 factors for oncology nurses sectional multi-centre working in oncology
study. units Personality has a key role in
developing burnout
Spain NEO-FFI to assess ➢ EE and DP positively
personality traits associated with neuroticism,
whereas PA was negatively
associated
➢ Increased EE and DP had
positive correlation with
anxiety and depression
Educational-Clinical ➢ PA had negative correlation
questionnaire with anxiety and depression
No significant relationship with
burnout correlated with age,
marital status or having children
Significant negative relationship
with rotating shifts

➢ Increased anxiety/depression
= Increased burnout.
➢ Personality factors play a key
role in increased Burnout
➢ Increased neuroticism
increases BO
Duarte and Examine the relationship Quantitative: Cross- Professional QOL 221 oncology nurses ➢ Nurses who are more self- High
Pinto-Gouveia between dimensions of sectional convenience scale ProQOL-5 from several public judgemental and psycholog­
(2017) empathy, self-compassion, sample, multi-sites hospitals, oncology/ ically inflexible = increase
psychological flexibility, palliative care units burnout (29%) and compas­
compassion satisfaction and sion fatigue (18%)
burnout for oncology nurses.
(continued on next page)

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L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

Table 2 (continued )
Authors/year Study aim (s) Study design/ Outcome Sample Key findings MMAT

Country measures characteristics

➢ Years of experience did not


independently influence
burnout
Portugal Interpersonal ➢ Increased years in current
Reactivity Index position significantly
correlated with increased
burnout
IRI ➢ Negative association with
psychological inflexibility
and increased burnout,
explaining 29% of the
variance
➢ Empathy and self-compassion
decrease burnout symptoms
and increase compassion
satisfaction
Self-Compassion
Scale SCS

Acceptance and
Action Questionnaire
Eelen et al. Investigate the prevalence of Quantitative: Maslach burnout n = 550 oncology 22.2% specialist nurses and High
(2014) burnout among oncology inventory (MBI) professionals, 20.8% nurses in oncology had
professionals including 483 nurses problematic levels of EE
Multi-centred ➢ Females’ greater risk of
observational study burnout
Belgium Job satisfaction ➢ Work setting is a major factor
in burnout scores, with
increased burnout when
combining work in private
hospitals and university
hospitals
➢ No significant effect of age,
experience or marital status
on BO
➢ Specialist nurses’ lower level
of EE and DP, with increased
PA than other nurses and
professionals
Emold et al. To examine the association Quantitative: Maslach burnout n = 39 oncology ➢ 60% had increased EE Moderate
(2011) between communication, self- inventory (MBI) nurses from 6 relatively frequently (several
efficacy, working environment oncology units times a month)
perception and burnout among Multi-centred ➢ 82% reported positive,
oncology nurses observational study professional self-actualisation
often
Israel Communication skills ➢ 72% reported cynicism
self-efficacy towards their work only
inventory rarely
➢ Increased communication
skills reduced EE and BO.
Working ➢ Higher levels of EE and
environment scale cynicism associated with
lower self-esteem
➢ Statistically significant
association between self-
efficacy and burnout
➢ Positive perception of work
environment reduced EE and
BO.
Giarelli et al. To examine factors that Mixed methods study – Self-report n = 20 haemato/ ➢ 30% nurses had high levels of Moderate
(2016) influenced nurses perceived descriptive questionnaire oncology nurses in a burnout
quality of work-life and risk of covering level of haemato/oncology
compassion fatigue personal stress & unit in a large
quality of work life teaching hospital
➢ 30% had severe impact of
event scale (impact on
wellbeing from personal life
events).
USA Impact of events scale ➢ Overall work experience as
affirming
➢ Sources for work-related
stress included: communica­
tion breakdown, reduced
(continued on next page)

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L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

Table 2 (continued )
Authors/year Study aim (s) Study design/ Outcome Sample Key findings MMAT

Country measures characteristics

resources, increased work­


load, family/patient
expectations
Life events scale ➢ No relationship between
personal life and compassion
fatigue – major source of risk
is the social aspects of the
working environment
➢ Having a health work-life
balance mitigated for burnout
ProQOL ➢ 90% desire to remain in
oncology nursing

Yu et al. (2016) To explore the prevalence of Quantitative: Pro-QOL Convenience cluster Higher rates of burnout and CF in High
Compassion fatigue (CF), sample nurses
Burnout and Compassion Cross sectional design n = 650 oncology ➢ More than 15 years
satisfaction (CS) among survey nurses from 10 experience
oncology nurses tertiary hospitals and
5 secondary hospitals
China Jefferson scale of ➢ Adopted passive coping
empathy
➢ Unmarried
Coping style ➢ Personality type - neuroticism
questionnaire
➢ Passive coping or
neuroticism- this is strongest
predictor of CF
Perceived social Decreased burnout with
support scale
➢ Additional Training
Chinese big 5 ➢ Occupational support
personality inventory
-brief version
➢ Cognitive empathy
➢ Positive personality traits
(openness and
conscientiousness)
Training (on alleviating death-
related grief, psychological care
of cancer patients, psychological
adjustment for nurses) improved
compassion satisfaction
Kamisli et al. Evaluate the clinical Mixed methods study: Caring Assessment n = 70 oncology Reported challenges that Low
(2017) perception of oncology self-evaluation scale Questionnaire (Care- nurses increased burnout included:
nursing and face to face Q)
interviews ➢ Younger nurses
Turkey Quality of Oncology ➢ Inexperienced
Nursing Care Scale
(QONCS)
➢ Complex disease and
treatments
➢ Frequent patient deaths
➢ Physical/emotional
Exhaustion
➢ Psychology problems of the
patients
Protective burnout factors
included:
➢ Increased Years of experience
➢ Job satisfaction
➢ Clinical skills
➢ Emotional support
➢ Perception of life
Kolpa et al. Investigate the scale of Quantitative: Maslach Burnout n = 100 haemato- Prevalence of burnout: Moderate
(2017) professional burnout among Descriptive survey Inventory (MBI) oncology nurses
nurses working in haemato- working in 2 ➢ 62% had acute EE
Poland oncology wards hospitals in Poland ➢ 30% showed DP
➢ 64% had low/no PA.
Increased burnout
➢ Older nurses (over 40yrs)
➢ Less experienced
Decreased burnout with
increased:
➢ Competence
(continued on next page)

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L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

Table 2 (continued )
Authors/year Study aim (s) Study design/ Outcome Sample Key findings MMAT

Country measures characteristics

➢ Education
➢ Job satisfaction
McMillan et al. Prevalence of burnout and Quantitative: Maslach Burnout n = 230 haemato- Burnout was lower than the Moderate
(2016) individual factors associated Inventory – General oncology nurses norms for nurses
with burnout among cancer Scale (MBI - GS) providing care to
nurses Cross sectional, online cancer patients from Factors associated with burnout:
survey a variety of
Australia 2016 Areas of worklife organisations ➢ Belief about adequacy of
survey training
➢ Frequency of supervision
Psychosocial care ➢ Sense of control over work
questions
➢ Heavy workload and lack of
support
➢ Dissatisfaction with pay
Lack of community, predictor of
cynicism
Neumann et al. Determine prevalence of and Quantitative: Maslach Burnout n = 1514 from 6 Predicators of burnout: for High
(2018) factors contributing to work- Inventory (MBI) professional groups, nurses:
related distress, plus to Cross sectional web- including 763 nurses’ ➢ Longer working hours (nurses
examine perceptions of based survey hospital or clinic- working >50 h/wk Had 2.3-
work–life balance and career based staff fold increase in burnout)
USA satisfaction and their Moral distress scale ➢ Working in out-patients
association with burnout. ➢ Higher workload demand
Work-life balance – ➢ Moral distress
single -item scale
➢ Nurses over 40yrs old
(increased DP)
Career satisfaction- Inpatient nurses had less EE than
single item scale outpatient and
Career satisfaction = decreased
burnout

Increased burnout:
➢ Inadequate work-life balance
(32% nurses that work
schedules didn’t give enough
time for personal or family
life)
➢ Increased hours spent
working at home on research
tasks and
➢ High acuity work
environments and complex
treatments and
➢ More patient deaths
Burnout associated with career
satisfaction
Ostacoli et al. Comparison of burnout Quantitative: Maslach Burnout n = 92 oncology Clinical setting influenced all Moderate
(2010) symptoms for oncology nurses observational study Inventory (MBI) nurses from hospital levels of burnout
working in hospital oncology units (n = 59) and Nursing in hospital unit
units or in hospices hospices (n = 33) compared to hospice _
Italy Hospital anxiety and ➢ Increased EE, DP and lower
depression scale PA
Working in hospice acted as a
protective factor against
burnout:
Attachment style ➢ Depression increased EE and
questionnaire reduced PA
➢ Absence of significant
difference in anxiety and
depression in relation to
burnout among the two
groups of nurses
Park and Ahn Relation of compassion Quantitative: Not reported n = 419 oncology Increased burnout: Moderate
(2015) competence to burnout, job Descriptive correlation nurses working in a
stress turnover intention job cancer centre ➢ Unmarried
Korea satisfaction and organisational ➢ Inpatient nurses
commitment in oncology ➢ Younger - aged 26-30
nurses ➢ Higher turnover intention
Job stress lower in older nurses
and married and inpatient wards
Improved compassionate
competence and decreased BO
(continued on next page)

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L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

Table 2 (continued )
Authors/year Study aim (s) Study design/ Outcome Sample Key findings MMAT

Country measures characteristics

with organisational commitment


and training

Job satisfaction higher:


➢ Married
➢ Senior nurses
➢ Working longer than 11 years
and full-time
Perry et al. Exploration of the experience Qualitative: Participants wrote a n = 19 clinical Compassion fatigue and BO Moderate
(2011) of compassion fatigue in Descriptive narrative oncology nurses reduced with
clinical oncology nurses exploratory
➢ satisfactory work life balance
Canada Participants completed ➢ good teamwork
a framework called the
stress process model.
Narratives were
analysed thematically
➢ maturity
➢ experience
➢ acknowledgement from pts
and colleagues
Compassion fatigued, and BO
increased with:
➢ lack of support from
colleagues
➢ insufficient time
➢ over 40 yrs.
➢ patient suffering
➢ unrealistic expectations
➢ personal health struggles
➢ increased compassion fatigue
had negative effects on home
life and personal
relationships
➢ home stressors had a direct
effect on compassion fatigue
at work
Potter et al. To explore prevalence of Quantitative: Professional Quality n = 53 oncology Clinical environment of inpatient Moderate
(2010) burnout and compassion Descriptive cross- of Life (ProQOLR-IV) professionals. v outpatient:
fatigue among oncology staff sectional study scale ➢ Inpatient nurses
USA in a large oncology medical • 44% BO and 37% CF
centre ➢ Outpatient nurses
• 33% BO and 35% CF
➢ Not statistically significant*
between groups*
Trends notes but not statistically
significant:
➢ Inpatient nurses had less
compassion satisfaction than
outpatient nurses*
➢ Nurses with 11–20 years of
oncology experience had
highest BO scores and highest
CF scores*
➢ Nurses with advanced
degrees had higher risk scores
for burnout*
➢ Reduced burnout with
effective leadership and team
work
Russell (2016) To identify perception of Quantitative: Maslach Burnout n = 61 inpatient Moderate level of perceived Moderate
burnout within inpatient descriptive study Inventory (MBI) nurses from 3 burnout
oncology nurses hospital units Due to:
USA ➢ Increased nurse: patient ratio
➢ Skipped or missed breaks
➢ High level of demand
➢ Poor staffing
➢ Lacking resources
Protective measures:
➢ Adequate resources
➢ Collaboration among staff
➢ Adequate sleep/rest
➢ Team work
increased burnout caused by Moderate
(continued on next page)

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L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

Table 2 (continued )
Authors/year Study aim (s) Study design/ Outcome Sample Key findings MMAT

Country measures characteristics

Taleghani et al., To define the level of empathy Descriptive correlation Jefferson scale of 67 oncology nurses
(2017) Iran and its association with study Quantitative nurse empathy working at least 1
burnout and demographic questionnaire year in a professional ➢ Complex treatments
characteristics of oncology oncology hospital in Maslach Burnout Inventory
nurses Iran (MBI)
➢ Patient death

➢ Close relationships with


patients/family

➢ Decreased staffing levels

➢ Increased workload

➢ Psychological issues in nurse

Negative
relationship
between
empathy and
burnout
(inverse
correlation)
Decreased burnout:
➢ Increased empathy
➢ Work experience (most
influential factor)
➢ No correlation with factors
such as, marital status or
education
➢ Inverse correlation with
age and BO.
Woonhwa and Identify stress levels and Mixed- methods Nursing stress scale n = 40 participants ➢ Over 50% (21) had moderate Low
Kiser-Larson stressful factors of nurses from 4 outpatient stress
(2016) working in oncology oncology units.
outpatient units and to explore Greatest stress factors:
USA coping behaviours for work- 3 open ended ➢ workload
related stress of oncology staff questions
nurses in outpatient units. ➢ patient death
Highest burnout scores:
➢ aged 41-50
➢ married
➢ 11–15 years in oncology
➢ Degree educated

The three most frequently used


coping behaviours to relieve
occupational stress were
verbalizing, exercising or
relaxing, and taking time for self

Variables of marital status,


education level, and work
experience in oncology units
showed no significant differences
on stress levels
Wu et al. (2016) To examine the experiences of Quantitative: Professional Quality n = 486 USA nurses Increased Burnout scores in; Moderate
compassion fatigue, burnout descriptive, non- of Life (ProQO) scale and
and compassion satisfaction experimental online
among oncology nurses survey
n+63 Canadian ➢ Younger nurses <40, more
nurses prone to secondary traumatic
stress and increased
compassion fatigue and BO
USA and Canada Modified Abendroth
demographic
questionnaire
Reduced burnout and CF and
increased CS:
➢ Cohesiveness within teams
➢ Supportive work
environments
➢ Increased experience (26yrs
or more)
(continued on next page)

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L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

Table 2 (continued )
Authors/year Study aim (s) Study design/ Outcome Sample Key findings MMAT

Country measures characteristics

➢ Higher level education


(masters doctoral degrees)
➢ Nurses who worked more hrs

evidence. In this context, findings reported across studies were used to following subthemes: (1) demands from workload and clinical setting,
explore similarities and/or differences between different studies (Mayes (2) impact of work colleagues and (3) culture of the working
et al., 2005). Thematic analysis provided a means of organising and environment.
summarising the findings from this relatively large and somewhat
diverse body of research. (1) Demands of workload and clinical setting
The following process was utilised, which commenced by both au­
thors reading and re-reading the papers, followed by independent Although a variety of organisational factors contributed to burnout
extraction of data onto an extraction form. The first author (LG) coded among adult oncology nurses, a prominent area highlighted in many of
the findings of the included studies according to its meaning and con­ the studies was the direct correlation between burnout and an increased
tent, which was checked by the second author (CS), with disparities workload (Taleghani et al., 2017; Neumann et al., 2017; McMillan et al.,
resolved through face-to-face discussion. Following this step, was the 2016; Giarelli et al., 2016; Woonhwa and Kiser-Larson 2016). Despite
development of descriptive themes at team meetings (LG and CS, both McMillan et al.‘s (2016) study identifying workload as the most signif­
authors), which involved translating and comparing the concepts from icant independent factor in the development of burnout among adult
one study to another and a hierarchical structure was created by oncology nurses, deliberation should be given to other aspects, such as
grouping the codes based on similarities and differences between the unsocial shift patterns (Neuumann et al., 2017).
codes and potential relationships to the findings. The final step was Other specific components of workload that impacted on adult
initially conducted independently by both authors, which was the gen­ oncology nurses’ experience of burnout were a lack of time allocated to
eration of analytical themes that went beyond the content of the original provide high-quality person-centred care (Perry et al., 2011; Neumann
articles. Following discussion, the emergence of six analytical themes et al., 2018), staff shortages (Davis et al., 2013,Taleghani et al., 2017
were identified and these were further categorised into two broad and Russell 2016), insufficient breaks or annual leave (Russell 2016) and
themes to determine the key messages. This process of thematic analysis poor staff: patient ratios (Russell 2016 and Potter et al., 2010). These
offers good transparency and outcomes are accessible. factors tend to contribute to all three dimensions of burnout, namely
increase EE, DP and reduce PA (Neumann et al., 2018 and Russell 2016).
4. Results Of note, the dimension mostly affected was EE, with over half the
oncology nursing workforce in a number of the studies reporting me­
4.1. Overview dium to high level scores. In comparison, DP was much less affected,
suggesting that although adult oncology nurses were showing signs of
Twenty studies were included in the review. The majority of the burnout (high EE scores) and simultaneously not feeling completely
studies in this integrative review originated from North America (n = 8) fulfilled by their work (low PA), they tend not to have negative or
(Davis et al., 2013; Giarelli et al., 2016; Neumann et al., 2018; Perry cynical attitudes towards their patients, as the DP scores were much less
et al., 2011; Potter et al., 2010; Russell 2016; Woonhwa and striking (Ostacoli et al., 2010).
Kiser-Larson 2016; Wu et al., 2016), followed by Europe (n = 6) (Duarte Causative factors relating to burnout for oncology nurses span
and Gouveia 2017; Eelen et al., 2014; Emilia et al., 2017; Kamisli et al., beyond mere demands caused by actual workload. For instance, disease
2017; Kotpa et al., 2017; Ostacoli et al., 2010), then Asia (n = 5) (Cheng acuity of this patient group is also a pivotal factor in provoking the
et al., 2015; Emold et al., 2011; Yu et al., 2016; Park and Ahn 2015; development of burnout. Direct care for patients with cancer is
Taleghani et al., 2017), with the final one originating in Australia increasing complex, mainly due to progressive development in treat­
(McMillan et al., 2016). Of the 20 studies, 17 were quantitative and ment protocols (Kamisli et al., 2017, Taleghani et al., 2017 and Giarelli
three adopted a mixed methods approach. Whilst no study was excluded et al., 2016). Also, adult oncology nurses have frequent and prolonged
solely on the merit of the quality assessment appraisal, two studies were exposure to highly emotive situations (Woonhwa and Kiser-Larson
rated low quality, four high quality and the remainder moderate. Full 2016; Neumann et al., 2018), patient suffering and none more so than
characteristics of the included studies are presented in Table 2. the death of patients and grief of families (Perry et al., 2011; Taleghani
Of note, only one study had a specific focus on what ameliorates et al., 2017; Giarelli et al., 2016; Woonhwa and Kiser-Larson 2016 and
work-life balance for oncology nurses (Neumann et al., 2017), which Neumann et al., 2017).
clearly depicts an area that warrants further study. What can be drawn Whilst the evidence depicts that physical workload and the
from this study of Neumann and colleagues is that work-life balance is emotional demands of caring for cancer patients contributes to burnout,
associated with burnout, with approximately one third of the oncology the findings are inconsistent as to whether providing care in an inpatient
nurses feeling that their work schedule did not provide enough time for setting compared to an outpatient environment influences burnout for
personal or family life. Hence, the remainder of the findings will focus adult oncology nurses. It would appear that both settings have their own
solely on the data pertaining to burnout. unique stressors, with outpatient nurses often reporting stress from
From the six analytical themes, the two broad themes were: (1) supporting patients receiving difficult news following planned in­
‘Inability to thrive’: struggling with workplace burnout due to organ­ vestigations and lack of continuity of patient care, hence lower job
isational challenges’ and (2) ‘Personal perspectives influencing satisfaction (Davis et al., 2013; Neumann et al., 2018). On the other
burnout’, for oncology nurses. hand, Park et al. (2015) and Ostacoli et al. (2010) highlighted inpatient
Theme 1: ‘Inability to thrive’: struggling with workplace burnout due nurses’ burnout scores were higher, largely due to the acuity of patients’
to organisational challenges. conditions within the inpatient wards.
Nearly all of the studies reviewed reported on a range of organisa­
tional factors which influenced the development of burnout among adult (2) Impact of work colleagues
oncology nurses. Factors influencing burnout will be discussed under the

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L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

The personal and social constructs of working within a team are and Kirer-Lason’s (201) Woonhwa and Kiser-Larson (2016) smaller
particularly important and can influence burnout for adult oncology study of USA oncology outpatient nurses, revealed much higher burnout
nurses (Perry et al., 2011, Potter et al., 2010, Russell 2016, Wu et al., scores for married participants. Interestingly, two further included Eu­
2016 and Taleghani et al., 2017), especially cohesiveness within the ropean studies found no significant correlation between the marital
team and effectiveness of workplace communication (MacMillan et al., status of the nurse and their burnout scores (Eelen et al., 2014; Emilia
2016, Russell 2016, Yu et al., 2016, Wu 2016, Davis et al., 2013, Perry et al., 2017). Considering the disparity of findings across differing
et al., 2011 and Emold et al., 2011). A healthy supportive work envi­ contexts and countries, the respondents may have differing cultural
ronment is key in the wellbeing of nurses and their job satisfaction perspectives in relation to marriage and the roles within a marriage, that
(Giarelli et al., 2016; Wu et al., 2016), and when absent this is a major may explain this variance.
source of risk for burnout (Giarelli et al., 2016). A number of studies examined the relationship between the age of
Establishing supportive relationships through positive feedback, the oncology nurse and burnout, with many demonstrating that younger
peer support, debriefing following challenging situations, open and nurses have higher rates of burnout, most often relating to increased
concise communication and positive role modelling were considered as levels of EE (Perry et al., 2011; Parks and Ahn 2015; Wu et al., 2016;
protective factors against burnout amongst adult oncology nurses (Perry Kamisli et al., 2017; Taleghani et al., 2017). Although this body of extant
et al., 2011; Davis et al., 2013; McMillan et al., 2016; Yu et al., 2016). evidence appears suggestive that a greater degree of burnout is experi­
This includes ensuring immediate and effective communication links enced by younger oncology nurses, contradictory evidence has been
between staff and management are established (Davis et al., 2013; provided by other studies in this review (Kotpa et al., 2017; Yu et al.,
Giarelli et al., 2016; Emold et al., 2011). Furthermore, Russell (2016) 2016; Neumann et al., 2017; Cheng et al., 2015; Davis et al., 2013;
suggested that even the perception of having a high level of support from Woonhwa et al., 2016). These studies infer that burnout scores were
colleagues and management; is associated with a reduction in burnout amplified with the increasing age of the nurse. Given these incongruent
scores. results, it is difficult to reach a definite conclusion on how the age of the
oncology nurse relates to burnout.
(3) Culture of the working environment It would appear that the personal physical and mental health of in­
dividual nurses has a strong relationship with burnout experienced
The literature suggested that the commitment of an organisation to (Kamisli et al., 2017; Taleghani et al., 2017; Neumann et al., 2018).
its adult oncology nursing workforce, is heavily influenced by the Emilia et al. (2017) suggested the prevalence of burnout was higher in
workplace culture (Cheng et al., 2015; Davis et al., 2013; Emold et al., nurses with pre-existing anxiety and depression, with PA score nega­
2011; Kamisli et al., 2017; Kotpa et al., 2017; Giarelli et al., 2016; Wu tively correlated with anxiety and depression, furthermore; increased EE
et al., 2016; Russell 2016). Workplace culture was instrumentally and DP scores had a positive correlation with anxiety and depression.
influenced by visible organisational leadership, clarity of beliefs and Physical and emotional exhaustion were also associated with burnout
professionals’ values of the team, commitment to nurses’ professional­ symptoms. The majority of other studies have suggested similar find­
ism and connectedness within the adult oncology team (Perry et al., ings, with causative directional relationships with depression, personal
2011; McMillan et al., 2016). Cheng et al. (2015) demonstrated that a stress, moral distress and burnout (Cheng et al., 2015; Taleghani et al.,
positive workplace culture, which inspired professional values, enabled 2017, and Neumann et al., 2017).
the delivery of vital high-quality care and support. Within this context
adult oncology nurses felt valued, and in turn had a belief in the (2) Professional attributes of the oncology nurse
importance and value of their job, resulting in job satisfaction and
reduced the presentation of burnout. Evidence is also incongruent on whether experience gained as an
There appeared to be an increasing culture of acceptance to under­ oncology nurse may provoke or prevent the development of burnout.
taking work-related activities outside of the clinical environment, and Nonetheless, the majority of studies, identified years of experience
more often at home (Neumann et al., 2018; Perry et al., 2011). The within an oncology setting as a protective factor against burnout,
emergence of this, was in keeping with an increase in administration enabling nurses to gain intuitive knowledge and equipped to handle
tasks often linked to email communication, advances in technology and difficult situations (Park et al., 2015, Taleghani et al., 2017, Kotpa et al.,
remote access to clinical notes. These hours spent working at home, 2017, Potter et al., 2010, Kamisli et al., 2017 and Wu et al., 2016). In
electronically accessing emails and medical records, appears to contrast, studies reporting years of experience as eliciting burnout
contribute to an increase in burnout (Russell 2016; Emold et al., 2011). amongst this professional group, are those who have a long-serving
This in turn is impacting negatively on burnout by creating substantial career in oncology, for example, 11–15 years, or greater than 15 years
tension between personal and professional life (Perry et al., 2011; respectively (Woonhan et al., 2016; Yu et al., 2016). Therefore, the
Neumann et al., 2018). perceived variance may be due to the increased duration of exposure to
Theme 2: Personal perspectives influencing burnout. the pain and suffering of patients or perhaps the occurrence of more
It is important to recognise that it is not just organisational factors personal suffering and challenges within their own lives.
that contributes to burnout; but personal characteristics, in conjunction There was no consensus on the role of education on burnout rates for
with an individuals’ mindset, can determine their response to, and oncology nurses within the studies reviewed. Several studies reported
management of a challenging work environment. The literature dem­ nurses who continued with higher education having lower burnout
onstrates these factors through the following subthemes: (1) de­ scores and improved compassionate competence (Kotpa et al., 2017; Wu
mographics of the oncology nurse, (2) professional attributes of the et al., 2016; Park and Ahn 2015). In contrast, education of oncology
oncology nurse and (3) personality of the oncology nurse. nurses with post-graduate advanced degrees had higher risk scores for
burnout (Yu et al., 2016; Potter et al., 2010). Perhaps nurses who have
(1) Demographics of the oncology nurse progressed in their education place greater expectations upon them­
selves and become increasing frustrated when these expectations cannot
When oncology nurses’ demographic variables were examined be fulfilled.
across the studies, there were inconsistent findings on the role of martial
status, age and personal health of the adult oncology nurse in deter­ (3) Personality of the individual nurse
mining their risks to developing burnout. Two larger studies conducted
in Asia reported that being married was significant association with Many of the studies reviewed suggest that personality factors play a
reduced burnout (Park et al., 2015; Yu et al., 2016), whereas Woonhwa key role in burnout among oncology nurses (Emilia et al., 2017; Emold

11
L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

et al., 2011; Ostacoli et al., 2010; Yu et al., 2016). Personality traits such of this review illustrated that the personal resourcefulness of an indi­
as resilience and hardiness are key protective factors against burnout vidual also plays a crucial role in determining their responses to a
(Emilia et al., 2017; Emold et al., 2011). It would appear that individuals challenging work environment. The oncology workforce is frequently
who have a hardy personality and are psychologically flexible are more confronted with multifaceted challenges, however, if an individual adult
able to feel a commitment to themselves and their work by feeling more oncology nurse presents with the personality trait of hardiness, which
in control of events (Duarte and Pinto-Gouveia 2017). On the other includes a sense of commitment and control to embrace challenge, this
hand, passive coping and neuroticism are negative predictor and in­ in turn is a protective factor against burnout. In addition to hardiness;
creases burnout (Yu et al. et al., 2016, Emold et al., 2017 and McMillian optimism, emotional competence, self-efficacy and resourcefulness can
et al., 2016). also guard against developing burnout in an oncology setting (Hlubocky,
2018).
5. Discussion It is difficult to translate an intrinsic trait such as resilience into an
intervention that may mitigate the effects of burnout for adult oncology
Adult oncology nurses today are experiencing exceptional challenges nurses, however self-compassion is a component of resilience that can be
within the current healthcare system due to political constraints, limited taught (Grafton et al., 2010). Guo et al. (2019) also recognised that
resources, increasing workloads and staff shortages (Lim et al., 2010; having the ability to adapt well to adversity, trauma or stress was an
Sabzevari and Rad 2019). Having analysed the data presented from the extremely important quality. Similarly, Guo et al. (2019) described this
20 included studies, it is clear that confronting burnout and promoting as one’s ability to self-care and could be learned. More specifically,
wellness within the oncology nursing workforce should be the shared self–care comprises of a spectrum of knowledge, skills and attitudes,
responsibility of oncology nurses’ and their organisation. This integra­ including self-reflection and self-awareness, which could form elements
tive review highlighted three factors, namely, (i) demanding workload, of therapeutic wellness interventions to bolster resilience. Of note,
(ii) culture of the working environment to include social constructs, and resilience has been identified as a hallmark of successful leaders within
(iii) individual personality traits, which influenced and contributed to oncology nursing (Cline 2015; Dyess et al., 2015).
burnout for adult oncology nurses. All three factors were supported by a In addition to r, optimal communication and positive role models
substantial body of evidence. The review revealed a lack of consistency within oncology teams, clinical supervision, orientation programmes for
of how demographic factors, namely age, marital status, education and newly recruited staff; other interventions have demonstrated positive
years’ experience influence burnout within the adult oncology nursing results to reduce adult oncology nursing burnout. , These include brief
workforce. psychological skills to aid management of emotionally challenging
From an organisation perspective, presenting adult oncology nurses clinical encounters (Traeger et al., 2013). Taking into consideration that
with a demanding workload is a key detriment to burnout. This is a protective psychological skills can be taught, healthcare organisations
prominent finding in similar studies with medical oncologists (Shanafelt should have a responsibility and a vested interest to teach approaches of
et al., 2009; Leigh et al., 2011). Shanafelt et al. (2014) illustrated that stress management, self-care and foster resilience within the adult
each additional hour spent on work-related tasks at home, increased the oncology nursing workforce. This approach should encompass early
risk of burnout. This is an important finding in today’s society, with identification of at-risk individuals such as younger nurses, in an
technological innovations and advances providing more opportunity to endeavour to reduce the long-term personal and professional conse­
work remotely, with a rapid emergence as a consequence of the quences of burnout. Waiting too long until burnout develops, is likely to
COVID-19 pandemic. Hence, the need to ensure healthy professional have very costly implications in both organisational and personal terms.
and personal boundaries are established is every more pressing. Therefore, both the prevention of burnout and effective wellness stra­
Furthermore, the subjective measure of workload in terms of perceived tegies should be incorporated systematically into routine oncology care
job stress and perception of time pressure, irrespective of quantitative settings for nurses.
workload, has been frequently reported as an important correlate of As aforementioned, technology has enabled employees to more
burnout in studies with medical oncologists (Murali et al., 2018). easily perform work related tasks at home, which potentially can impact
Therefore, when considering workload as an influential factor, it is work-home interface. Research has indicated that the demands that
important to note that the concept of workload is much more that actual contribute to a work-life imbalance may be precursors to burnout
quantitative workload, but spans satisfaction with workload, and impact (Shanafelt et al., 2014). An area that warrants further exploration is the
of role intensity, as influenced by disease acuity of this patient group. relationship between work-life balance and burnout for adult oncology
Moreover, managing and coping with workload demands is closely nurses, as to-date limited attention has been placed here (Garrosa et al.,
intertwined with the culture of the workplace environment and the 2008; Görgens-Ekermans et al., 2012). In contrast, there is a substantial
support provided both within teams and from those in leadership roles body of work on this topic with oncologists, depicting a conflict between
within the organisation. The concept of a therapeutic workplace culture workload and home-life for over half of this professional group (Sha­
must be valued at an individual and an organisational level. There are a nafelt et al. 2009, 2015, 2016; Dyrbye et al., 2011; Arigoni et al., 2009).
number of components that can promote the development of an effective Oncologists who incorporate a philosophy of work-life balance and
workplace culture, enabling staff to flourish; of which a shared purpose focus on the important things in life, appear to have much lower risks of
is key (Manley and Titchen, 2012). Furthermore, the studies in this re­ burnout (Banerjee et al., 2017; Shanafelt et al., 2014; Glasberg et al.,
view highlight the instrumental protective value of fostering effective 2007). Therefore, promoting work-life integration and flexibility,
relationships and good communication within the team. This can be adjusting working hours and schedules would seem to be important.
acquired through peer support, regular clinical supervision, debriefing However, we cannot extrapolate these findings for oncologist and uni­
after challenging situations and clear communication channels from versally apply them to oncology nurses. Nursing is predominantly a fe­
management within the organisation. In addition to working as a male profession and likely to experience additional caregiving roles and
cohesive adult oncology nursing team, a workplace culture can be personal expectations for the family, with the potential for provoking
further optimised by facilitating active learning to transform care, stress and burnout (Hyder et al., 2016; Shanafelt et al., 2019). Given the
embracing research and development initiates, identifying and limited research on the effect of a healthy work-life balance and its
empowering champions and ensuring visible leadership (Gesme and relationship with burnout among oncology nurses, this necessitates a
Wiseman 2010). Such an environment is conducive to maximising staff’s commitment to future research to include this conceptually important
potential, increasing job satisfaction and reducing burnout. variable.
Workplaces were work feels unmanageable and uncontrollable, tend
to allow burnout rates to thrive (Emold et al., 2011). However, findings

12
L. Gribben and C.J. Semple European Journal of Oncology Nursing 50 (2021) 101887

5.1. Limitations wellness are the shared responsibility of both oncology nurses and their
organisations. From an individual perspective, oncology nurses have an
Although careful consideration was given to the initial screening important role in identifying symptoms of burnout, learning resilience
process, it was only conducted by the first author and it is possible some strategies and cultivating positive relationships within the team. At an
relevant articles may have been unseen. Also, within the literature there organisational level, an effective workplace culture that systematically
is an inconsistent use of terminologies with some authors referring to the incorporates preventative and therapeutic wellness strategies routinely
term burnout and others referencing compassion fatigue, which again for oncology nurses can help build workforce capacity. Finally, little is
many contribute to pertinent studied not being included in this review. known about the impact of, and factors contributing to work-life balance
for oncology nurse and this is an obvious gap in the literature that
6. Conclusion warrants further attention.

Burnout in today’s cancer nursing workforce is a significant problem


requiring urgent attention. Burnout is influenced by multiple oncology- Declaration of competing interest
specific factors due to workload, but also workplace culture, increased
accessibility of working at home due to remote access and the personal Both authors have no competing interest and have no conflicts of
characteristics of the nurse. Confronting burnout and promoting interest in regards to the research described in this paper.

Appendix 1

Search terms and strategy used PsycINFO


results

8 1 and 4 and 7 14
7 5 or 6 1603
6 (worklife balance or work-life balance).mp. [mp = title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, 1603
keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique
identifier, synonyms]
5 exp Work-Life Balance/ 553
4 2 or 3 911834
3 (burnout or occupational stress or burn out or compassion fatigue or stress).mp. [mp = title, abstract, original title, name of substance word, subject heading 911834
word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease
supplementary concept word, unique identifier, synonyms]
2 exp Occupational Stress/ 12972
1 (oncology nurse* or cancer nurse*).mp. [mp = title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, 21966
keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique
identifier, synonyms]

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