Combating Compassion Fatigue and Burnout in Cancer Care

Linda Emanuel, MD, PhD; Frank D. Ferris, MD, FAAPHM; Charles F. von Gunten, MD, PhD; Jaime H. Von Roenn, MD


June 06, 2011

In This Article

Risk Factors for Burnout and Compassion Fatigue

A number of individual, cultural, and personality characteristics are associated with burnout and compassion fatigue. Organizational factors also play a role.

Individual Risk Factors

Individual characteristics can be related to burnout. However, these associations are weaker than those for burnout and situational factors, suggesting that burnout is more a social phenomenon than an individual one.[1]

Age. People younger than 40 years of age have more burnout than those older than 40 years of age. Age is confounded with work experience, so burnout may be a greater risk earlier in one's career.[1]However, in another study,[14] age younger than 55 years was an independent risk factor for burnout.[14]

Stage in work life. Residents report higher levels of burnout than attending physicians.[17,26] Oncology nurses with 6-10 years of experience exhibited more high-risk burnout and low compassion satisfaction scores than those with 11-20 years experience. Conversely, compared with baccalaureate-prepared RNs, graduate-prepared nurses were at higher risk for burnout.[19]

Sex. In the Physician Work Life study, women were 1.6 times more likely to report burnout than men.[27]The odds increased by 12%-15% for each additional 5 hours worked per week over 40 hours. Female oncology housestaff and nurses reported higher levels of emotional exhaustion and psychological distress than staff physicians of any sex or male housestaff. Of all groups, female housestaff showed the greatest sense of demoralization and the least sense of accomplishment within a highly stressed environment.[17]In only a single study were male oncologists at more risk for burnout than female oncologists.[28]

Marital status. For oncologists of either sex, being unmarried was an independent risk factor for burnout.[18]

Cultural Factors

When physicians in The Netherlands were compared with those in the United States, older physicians in the United States reported a greater sense of control over their work environment compared with younger physicians, while in The Netherlands this age differential was much less pronounced.[29]

In the United States, male physicians described having significantly more work control than female physicians. European workers generally tended to have lower average levels of exhaustion and cynicism compared with similar North American samples. Some aspects of burnout, particularly cynicism, may be more acceptable in the strongly individualized North American culture, or the orientation toward higher achievement in North American society may cause more stress.[1]


Compulsiveness. The compulsive characteristics of physicians, "when present in conjunction with other characteristics of overly controlled emotions and low need for relaxation and pleasure, makes the medical student, and later the physician, more vulnerable than others to depression, alcoholism, psychiatric disorders, and suicide."[30]An oncologist said, "Lots of us who feel overloaded and overworked create it ourselves. We start dancing to a tune that you're called to play by yourself."[31]

Psychological health. People who were psychologically healthier in adolescence and early adulthood are more likely to enter, and remain, in interpersonally demanding jobs (eg, emotionally demanding "helper" roles or jobs that deal with people in stressful situations), and show greater involvement and satisfaction with their work.[32]

Developmental stability. Physicians with the least stable childhood and adolescent adjustment have been identified as being the most vulnerable to occupational hazards.[33]

Personality characteristics. The personality characteristic of hardiness, consisting of commitment, control, and challenge, is associated with improved coping among house staff.[30,34,35]Hardiness is associated with less demoralization and a greater sense of accomplishment. Housestaff and nurses have a lower sense of accomplishment than oncologists.[17] Resilience has been found to be an important characteristic in coping with negative circumstances. In his study of pediatric oncology nurses, Zander found that the resilience correlated with hope, self-efficacy, control, competence, and coping. Those with a range of positive coping strategies fared better than their counterparts who employed a narrow range of coping strategies, or who used negative coping strategies.[36]

Level of Social Support and Spirituality/Religion

Female physicians with young children are 40% less likely to experience burnout when they have the support of colleagues, spouses, or significant others in balancing work and home issues.[27]In an evaluation of burnout among nurses, fellows, and oncologists, those who reported being "quite a bit" to "extremely" religious had lower levels of diminished empathy or depersonalization and less emotional exhaustion on the Maslach Burnout Scale, compared with those who were not as religious.[17]

Work Life

Long hours. Burnout is strongly associated with long work hours and work-home interference in both the United States and The Netherlands.[29]

Volume of work. Too high a volume of work, with inadequate staff to do the job properly, leads to pressure to make deadlines, conflicting demands on time, and disruption of home life as a result of extended work hours.[16]The combination of being overloaded, experiencing interference with one's home life, dealing with suffering, and feeling low levels of satisfaction with work from not having adequate resources to perform one's role leads to burnout.[14]

Subspecialty. Radiation oncologists report that work-related stress is increased by treatment toxicity and errors, whereas medical oncologists report more stress from organizational responsibilities or conflicts.[14]

Patient population. Dealing with chronically ill, incurable, or dying patients, with a potential lack of hope, can create burnout.[28]New research has focused explicitly on emotion-work variables (eg, requirement to display or suppress emotions on the job, requirement to be emotionally empathic), and has found that these emotional factors account for additional variance in burnout scores over and above job stressors.[1,37]


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