Work-related issues such as coping skills, stress management, burnout, and compassion fatigue are among the challenges faced by clinical and other staff in cancer treatment centers. Given the emotional consequences of professional caregiving, staff support group meetings are valuable resources for health-care providers. Such meetings provide a safe environment for employees to express emotions, share experiences, build resilience, and balance work responsibilities.
Although support groups vary in intention and composition, they are typically voluntary and led professionally or chaired by colleagues with similar experiences and challenges. The objective is to provide emotional comfort and information in a strictly confidential setting.
Formal support group meetings may be traced back to Alcoholics Anonymous (AA). Established in 1935, this self-help group aims to assist recovery from alcoholism. Extended families, fraternal organizations, guilds, and informal social gathering formed the basis of AA’s contemporary groups. In today’s hospital settings, support groups accommodate patients, staff, family members, and caregivers, offering in-house as well as online gatherings.
Oncology Support Groups Reduce Stress
Research documents the many stresses experienced by oncology nurses and physicians. They include compassion fatigue, which results from the trauma of long-term care of the ill and suffering1; burnout syndrome, the occupational chronic stress that results from emotional exhaustion2; feelings of low personal accomplishment3; and reduced ability to cope with patients’ pain and death.4,5
Oncology professionals contribute significantly to patients’ well-being. Their ability to manage grief and loss, and to sustain their own psychological and physical health while maintaining optimal relationships with patients, represents a major challenge. Sustaining quality of work and the determination to remain in their jobs are common professional challenges.6 Research illustrates that oncology staff including physicians, allied health professionals, and support staff display emotional exhaustion, feelings of depersonalization, and thoughts of leaving the oncology field.7
Interventions such as Care for the Professional Caregiver Program, a group discussion module that addresses burnout, coping with grief, loss and trauma, and self-care strategies, effectively decrease oncology professionals’ emotional exhaustion.8 Additional interventions such as the Compassion Fatigue Resiliency Program9 and a self-organized monthly nurse support group10 demonstrate the importance of helping oncology workers manage their professional stressors.
Interventions such as an ongoing educational course11 modeled after mindfulness-based stress reduction demonstrated reduction in burnout and increased mental well-being for health-care providers including doctors from diverse specialties, and a biweekly physician discussion group12 resulted in increased work satisfaction and reduced feelings of depersonalization with results that lasted for more than a year. Additional interventions such as peer support,13 panel discussions involving topics such as balancing work and personal life, and mentoring and professional support groups are helpful,14 and Communication Skills Training shows promise for improved professional communication skills and effectiveness.15
Variety of Support Group Measures
The development and impact of support group meetings for oncology staff in a variety of settings have demonstrated the use of diverse coping mechanisms. For example, a survey of physicians both in training and practice found personal growth techniques such as self-awareness, prioritizing, setting limits, and cultivating a personal philosophy are successful self-care tools for coping.16 Also illustrative, pediatric and medicine residents respond positively to half-day stress management workshops that focus on interpersonal skill building; balancing educational, personal, and work demands; developing a positive outlook and awareness; and cultivating adaptive behavioral responses.17
An interdisciplinary team of an oncology pediatric service participated in a weekly narrative writing instruction class for 6 weeks.18 By writing about their attachment to patients and how they felt emotionally about their relationships with patients and families, there was a definite increase in empathy. This reinforced team building and led to a better understanding of their colleagues with the potential to improve clinical care and professional experiences.
Nursing staff support groups assist in reducing stress, promoting member cohesiveness, and reducing interdisciplinary conflicts and perceived lack of support from nursing administration.19 One inpatient oncology unit initiated a bereavement support group to combat compassion fatigue and promote staff support.20
A remembrance tree was displayed in an area for staff only and changed seasonally. The intervention permitted staff to discuss patients who passed away, remember them, and bring closure to the experience. Schwartz Center Rounds21 provide the opportunity for interdisciplinary staff members to support one another as they discuss patient cases, explore the emotional and human components of clinical care, build team cohesiveness, and improve patient care.
Support Group Structure
In 2011, we established support group meetings for the Memorial Sloan Kettering Integrative Medicine Service. They are monthly meetings open to all staff members. Guidelines were established to maintain a focus on patient-centered interactions.
The meetings often begin with a meditation and a selected reading or discussion, but they also may begin immediately. The role of the facilitator is to support attendees as they introduce topics, respond to the discussion, encourage interaction, and maintain sensitivity to each member’s needs.22 In our group, the facilitator is a licensed social worker employee who can readily understand member concerns.
Support Group Participants
Core attendees of our support group meetings are the Memorial Sloan Kettering Integrative Medicine massage therapists, all licensed professionals, each with many years of experience. Massage therapists play an important role, supporting inpatients and outpatients throughout each stage of the patient’s medical journey. Patients report reduced pain, nausea, fatigue, procedural anxiety, and stress after receiving massage therapy.
A massage therapist may provide care on an ongoing basis, sometimes for years. Such long-term relationships may profoundly affect the therapist, due in part to the special nature of the interaction. The therapist’s one-to-one relationship with the patient is devoid of machines and medicine, and it is hands-on. We are touching, feeling, communicating with the patient, as does the physician, but specifically and exclusively to provide comfort in quiet and peaceful circumstances. During their sessions, patients speak of their fears, money troubles, family dynamics, spiritual concerns, and other personal matters.
Professional Boundaries
We are trained to adhere to professional boundaries, to care deeply, but to avoid emotional attachments. If a patient fails to thrive, dies, or is transferred to another facility, our grieving and the loss we may feel cannot impact our job effectiveness or our mission to help patients.
The support group helps us maintain these boundaries. By sharing our experiences with colleagues who have similar experiences, we feel less isolated and less emotionally fatigued. We learn from suggestions and comments, and we benefit from the group’s teamwork and communication. The group sessions also provide an opportunity to reflect on and assess our work.23
Workplace Dynamics
What are the dynamics of working in this environment? We work with patients of all ages, from the pediatric to the geriatric population. Often, depending on a family’s structure, an inpatient child may not have a guardian, and an older patient may have no family members who visit.
In treating such people on a regular basis, a therapist may feel like a surrogate family member. The death of such a patient results in a sense of painful loss. Some therapists may feel as though they have lost their own child. If a patient relapses or dies, how does the therapist integrate this information, give a voice to these thoughts and ideas, and share this with colleagues? The support group performs these functions.
As therapists, we have access to a patient’s medical records and the results of their tests. Sometimes, we know the results before patients receive such news from their physicians. If it is not good news, we hold this information in confidence and make sure it does not interfere with treatment. For example, many times a patient has said, “I know I’m okay; I’m nervous about the results, but I feel so good, I know it’s going to be fine,” and we know otherwise.
A young newly married patient in the intensive care unit with her husband at bedside may share with the therapist their plans for the future, and this includes having a family. The therapist has read her medical records indicating that the cancer has spread. Or a patient who you have massaged for many years at our outpatient center has relapsed, with accompanying metastases. Her oncologists urged chemotherapy, but her partner tells her to decline chemotherapy and try an “alternative” therapy, which she does. Over time, you watch her grow weaker until she passes away. Although you have maintained professional boundaries, it feels as though you have lost a very close friend. The support group is a forum for sharing these experiences, validating your feelings, offering insight to coping mechanisms, and suggesting self-care strategies.
On a day-to-day basis, our massage therapists hold hands or feet while inpatients receive painful procedures or apply a very gentle massage as a patient is dying with family members looking on, or we share in the joy of learning that a patient is in remission and is going home. These are very private moments, and yet we are invited to bear witness.
Core staff members attend our support group meetings on a monthly basis. Other employees attend following a particular situation that has put them into crisis mode. Consider the staff person who schedules our therapists for all inpatient work—massage therapy, music therapy, acupuncture, mind-body therapies, yoga, etc—and is familiar with patients, their medical histories, and current status. She has never met them face-to-face, but she feels as if she knows these patients. If that patient has a lengthy hospital stay and passes away, scheduling staff also may experience a profound sense of loss.
Other Stressors
In monthly meetings, our own lives enter into the discussions: we may address aging parents, their medical needs, finances, and end-of-life care; family members with cancer and how best to manage their illness, emotionally and physically; the joys and fears of upcoming parenthood; our own aging; spouses with a history of cancer, and how to cope with anxiety each time a spouse goes for a test or checkup; and team members with a history of cancer, who must be mindful of maintaining boundaries between their own experience and the needs of their patients.
Once the discussion is underway, we offer suggestions for coping. We provide different points of view without judgment, acknowledging feelings and encouraging strategies for problem-solving.
Our staff support group helps therapists not to feel alone in their work. Shared experiences and perspectives are reassuring and very helpful. This improves workplace satisfaction and promotes comfortable communication among staff and between staff and patients.
Ongoing Benefits
The Memorial Sloan Kettering Integrative Medicine Service support group is held monthly regardless of how many people attend. Integrative Medicine Service staff employees are aware that if they require support, encouragement, suggestions for self-care, or camaraderie, or if they just want to talk, there is a group of people who want to listen. This is important for mental health and stability anytime, but it is critical in a workplace environment that confronts issues of health, suffering, and death and dying on a regular basis.6
Research has demonstrated the benefits of support groups for promoting self-care, refining communication strategies, and processing loss.10 It is reassuring to be among coworkers who share similar commitments and experience.24 The ability to make connections with other people in the group is helpful because it is necessary to connect with patients and their families.
As health-care providers, we want to help our patients. Employees feel best when they are compassionate, when patients appear to be helped by our efforts, when patients show their appreciation, and when they are recognized in the workplace5 for doing a good job. Staff support groups support employees’ patient care efforts, reinforcing the intentions and skills of its members so that their work is consistent, exemplary, and true to the mission of caregiving. ■
Disclosure: Ms. Schuman reported no potential conflicts of interest.
References
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2. Demirci S, Yildirim YK, Ozsaran Z, et al: Evaluation of burnout syndrome in oncology employees. Med Oncol 27:968-974, 2010.
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4. Potter P, Deshields T, Divanbeigi J, et al: Compassion fatigue and burnout: Prevalence among oncology nurses. Clin J Oncol Nurs 14:E56-E62, 2010.
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10. Wittenberg-Lyles E, Goldsmith J, Reno J: Perceived benefits and challenges of an oncology nurse support group. Clin J Oncol Nurs 18:E71-E76, 2014.
11. Goodman MJ, Schorling JB: A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med 43:119-128, 2012.
12. West CP, Dyrbye LN, Rabatin JT, et al: Intervention to promote physician well-being, job satisfaction, and professionalism: A randomized clinical trial. JAMA Intern Med 174:527-533, 2014.
13. Hu YY, Fix ML, Hevelone ND, et al: Physicians’ needs in coping with emotional stressors: The case for peer support. Arch Surg 147:212-217, 2012.
14. Eckleberry-Hunt J, Van Dyke A, Lick D, et al: Changing the conversation from burnout to wellness: Physician well-being in residency training programs. J Grad Med Educ 1:225-230, 2009.
15. Kissane DW, Bylund CL, Banerjee SC, et al: Communication skills training for oncology professionals. J Clin Oncol 30:1242-1247, 2012.
16. Quill TE, Williamson PR: Healthy approaches to physician stress. Arch Intern Med 150:1857-1861, 1990.
17. McCue JD, Sachs CL: A stress management workshop improves residents’ coping skills. Arch Intern Med 151:2273-2277, 1991.
18. Sands SA, Stanley P, Charon R: Pediatric narrative oncology: Interprofessional training to promote empathy, build teams, and prevent burnout. J Support Oncol 6:307-312, 2008.
19. Guillory BA, Riggin OZ: Developing a nursing staff support group model. Clin Nurse Spec 5:170-173, 1991.
20. Fetter KL: We grieve too: One inpatient oncology unit’s interventions for recognizing and combating compassion fatigue. Clin J Oncol Nurs 16:559-561, 2012.
21. Gibson S: Schwartz Center Rounds: Focusing on the patient-caregiver relationship. This national model offers emotional support to doctors and other medical professionals. Health Prog 89:40-43, 2008.
22. Zabalegui A, Sanchez S, Sanchez PD, et al: Nursing and cancer support groups. J Adv Nurs 51:369-381, 2005.
23. Barnes K: Staff stress in the children’s hospice: Causes, effects and coping strategies. Int J Palliat Nurs 7:248-254, 2001.
24. Lederberg MS: Staff support groups for high-stress medical environments. Int J Group Psychother 48:275-304, 1998.
Ms. Schuman is a member of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.
Guest Editor
Integrative Oncology is guest edited by Barrie R. Cassileth, MS, PhD, Chief of the Integrative Medicine Service and Laurance S. Rockefeller Chair in Integrative Medicine at Memorial Sloan Kettering Cancer Center, New York.
The Integrative Medicine Service at Memorial Sloan Kettering Cancer Center developed and maintains a free website—About Herbs (www.mskcc.org/aboutherbs)—that provides objective and unbiased information about herbs, vitamins, minerals, and other dietary supplements, and unproved anticancer treatments. Each of the close to 300 and growing number of entries offer health-care professional and patient versions, and entries are regularly updated with the latest research findings.
In addition, the About Herbs app, Memorial Sloan Kettering Cancer Center’s very first mobile application, can be downloaded at http://itunes.apple.com/us/app/about-herbs/id554267162?mt=8. The app is compatible with iPad, iPhone, and iPod Touch devices.
