Strategies to promote coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy: a systematic review

Abstract

Review question/objective One objective of this systematic review is to synthesise the best available evidence on the experience of the extrinsic and intrinsic factors that influence coping and resilience in nurses caring for adult patients with malignancy. The second objective of the review is to synthesise the best available evidence on the effectiveness of strategies to promote coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy. More specifically, the review questions are: What is the experience of the extrinsic and intrinsic factors that influence coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy? What personal and organisational approaches are most effective in promoting coping and resilience of nurses caring for adult patients with malignancy? Background Workplace stress has serious implications for the physical and psychological health of staff. Nurses and those who work directly with patients have been found to encounter more intense stress than other professionals because of high workloads and the demands associated with supporting the physical and emotional needs of the patient.1 High levels of job stress have been correlated to the development of burnout, compassion fatigue and secondary traumatic stress, which in turn may influence staff absenteeism (due to sick leave), nursing turnover, patient satisfaction and patient safety.2-4 Working with cancer patients is considered inherently stressful.2, 5-7 Repeated exposure to death and dying, pain and suffering, moral and ethical dilemmas regarding treatment decisions, the intensive and complex nature of treatment, and managing professional boundaries are amongst the specific stressors that oncology and palliative care staff encounter in their practice.2,3,6,8 Staff shortages and high workloads are additional stressors that while not unique to an oncology and palliative care setting, feature as primary concerns in these areas.3-6 A recent systematic review of the effects of nursing shortages on oncology/haematology nurses' job satisfaction, stress and burnout levels9 found that working full time rather than part time, working in an in-patient setting versus outpatient or community setting, and working overtime were all associated with job dissatisfaction. Many of the studies examined were drawn from an adult setting.9 Coping and resilience are terms that describe how people respond to the stressors they face in the workplace. Coping refers to the ability to manage demands that are perceived as adverse so they can be minimised or tolerated.10 Unlike coping which may be adaptive or maladaptive, resilience refers to the ability to cope effectively and grow as a result of adversity.7,8,11,12 Although these terms are often used interchangeably in the literature, they actually refer to different, albeit related concepts. Consensus on a definition of resilience has not yet been gained. That said, most definitions acknowledge two key points: firstly that resilience is a dynamic process13 that involves the individual's interaction with various factors including their environment14 and access to social support;15 and secondly that resilience is context and time specific.12 These factors interact with others, including psychological and biological factors, character attributes and social support. Developing resilience is essential for oncology and palliative care nurses who inevitably encounter challenges in the workplace. Providing opportunities for nurses to learn to cope effectively and develop resilience is beneficial to their health and well-being, and has been shown to reduce the prevalence of burnout and psychological distress which are commonly reported in cancer care staff.2 Environments that support staff to develop these attributes benefit the organisations by supporting work longevity and quality of patient care.3,4,6 A preliminary search in the Cochrane Database of Systematic Reviews, JBI Library of Systematic Reviews, Medline, CINAHL and PROSPERO has been performed. Systematic reviews that examine coping and resilience in adult oncology and palliative care settings were not found. Several structured, but not systematic, reviews of the literature have been published on coping and resilience in nursing,16,17 and more recently in paediatric oncology.8,9,18 These papers highlight the importance of teaching and learning resilience in nursing.16,17 Additionally, they identify factors that influence coping and resilience in paediatric oncology settings.8,9,18 While some of these will be transferrable to an adult setting, differences in contexts are likely to influence the individual's stress and coping. The purpose of this review is to identify the best available evidence on strategies that promote coping and resilience in nurses caring for adult patients with malignancy. This information will provide evidence to guide the design of support programs to equip individuals and organisations to moderate the effects of stress and cope positively. Definition of terms For the purpose of this review the following definitions will be used. Coping: the ability to manage or minimise the adverse effects of demands appraised as exceeding one's ability.10 Resilience: a psychological concept defined as an individual's ability to utilise strategies that enable them to cope with and grow as a result of stress or diversity.19 Resilience is differentiated from recovery in that recovery from an event infers there is a period in which normal functioning is suspended; whereas resilience involves maintenance of equilibrium, with no loss of normal functioning.20 Oncology nurse: a nurse (registered with a licensing body) working in an oncology/haematology setting; inpatient, outpatient and community setting. Palliative care nurses: a nurse (registered with a licensing body) working in a palliative care, hospice or community setting. Inclusion criteria Types of participants The quantitative and qualitative components of this review will consider studies that include oncology and palliative care nurses caring for adult patients with malignancy in a hospital or community setting. Types of intervention(s)/phenomena of interest The quantitative component of this review will consider as interventions different personal and organisational strategies to promote coping and resilience in nurses working in an oncology or palliative care context. For example: Appraisal focused techniques that change the way the individual thinks, e.g. mindfulness based stress reduction Emotion focused techniques that involve releasing or managing emotions that accompany the perception of stress, e.g. distraction, exercise, music, meditation, use of humour. The qualitative component of this review will consider as phenomena of interest the experience of different extrinsic and intrinsic factors that influence coping and resilience in nurses working in an oncology or palliative care context. For example: Story-telling, talking to friends/family Debriefing Mentoring or buddy systems Reflective practice Problem focused coping Use of serenity or quiet rooms. Types of outcomes For the quantitative component of the review, outcome measures that reflect the effectiveness of personal and organisational strategies to promote resilience and effective coping will be considered. This may include, but will not be limited to, measures of: Resilience Coping Stress Burnout Staff retention, job satisfaction, intention to leave Sick leave/stress leave Staff belief they have ‘value added’ to the patient's experience Quality of patient care. Types of studies The quantitative component of the review will consider both experimental and epidemiological study designs including randomised control trials, non-randomised controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. The qualitative component of this review will consider studies that focus on qualitative data, including but not limited to designs such as phenomenology, grounded theory and action research. Opinion papers and reports will not be considered. Studies excluded from this review include: Those exclusively involving children and adolescents, i.e. <18 years of age Those which do not examine the outcomes or phenomena of interest within the context of oncology and palliative care nursing. Search strategy The search strategy will aim to find both published and unpublished studies. The search will not be limited to English language studies, although an English abstract will be required for the article to be assessed. Translation of non-English articles will be undertaken for eligible studies for which translation resources are available: Italian, German and French. A three-step search strategy will be utilised. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified articles will be searched for additional studies. The databases to be searched include: AustHealth Cochrane Library EMBASE MEDLINE Proquest Health and Medical Complete PsycINFO Qualitative Inquiry (http://qix.sagepub.com/) TRIP (Turning Research into Practice) Quality web search tools, e.g. AllTheWeb, GoogleScholar, Scirus.com, NurseScribe, Agency of Healthcare Research and Quality, NLM Gateway, Netting the Evidence, Medscape EBSCOhost CINAHL PLUS with full text Joanna Briggs Institute Library of Systematic Reviews AMED (Allied Complementary Medicine) NOTE: The Cochrane and JBI library will be searched for systematic reviews on similar topics as a source of primary research studies. Bibliographies of articles will be checked and key articles will be cross-checked in citation indexes. Databases covering the nursing, medical, education and behavioural science literature will be searched. Journals relevant to the topic accessible in local educational and health libraries or on-line will be ‘hand’ searched for the period 2007 to 2012 to ensure studies which have not been listed in the major indexing services are retrieved. The search for unpublished studies will include grey literature and unpublished material such as conference papers, research reports and dissertations. The sources searched to locate unpublished studies will include: ProQuest Dissertations and Theses Index to Theses Grey Literature Report Conference papers Research registers WWW sites of relevant associations Internet search engines Direct communication with researchers and relevant professional organisations. The search strategy will be limited to the years 1980 to 2012. The rationale for commencing the search from 1980 is to include the first published relevant research. The search terms used to locate studies for the review will be drawn from the natural language terms of the topic and the controlled language indexing terms used by different databases, as applicable. Individual search strategies will be developed for each index, adopting the different terminology of index thesauri. Initial keywords to be used will be: malignancy, neoplasm, cancer patients, oncology nursing, oncologic care, hospice and palliative nursing, palliative care, resilience, hardiness, stress, burnout, symptom distress, coping, role stress, stress management, and will be used alone and as combined terms. Truncated versions of terms such as resilien*, nurs*, neoplas*, oncolog* and palliat* will be used. Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. A record of all included articles will be maintained identifying the title, author, source, location and the database they were sourced from. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tools from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Qualitative data will be extracted from papers included in the review using the standardised data extraction tools from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative papers will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratios (categorical data) and weighted mean differences (continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square and also explored using subgroup analyses based on the different quantitative study designs included in the review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorising these finding on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. Conflicts of interest None Acknowledgements None