Introduction

The world of work has undergone transformations that have changed the physical, mental and emotional way people relate to each other in the workplace. The emotional strain and working conditions to which nursing professionals are subjected can lead to stress and professional burnout.(¹)

Professional burnout or burnout syndrome arises as a prolonged response to stressors related to occupational activities that manifests itself as overwhelming exhaustion, cynicism, detachment from work, as well as a sense of professional dissatisfaction.(²)

This process occurs as a result of personal imbalance with the six work-related dimensions: (1) Workload (excessive demand); (2) Control (when professionals don’t have sufficient control over the necessary resources); (3) Reward (lack of adequate recognition: financial, social or intrinsic); (4) Community (related to interaction between colleagues and managers); (5) Justice, (when injustice is perceived in the workplace, this includes inequality of workload and remuneration) and (6) Values (when professionals have to act against their personal principles and values).(³)

In addition, other social, political and economic aspects, such as: structuring of the organizational environment with high demands and low financial and material resources, weak employment relationships, low salaries, inadequate staffing, excessive workload, injustice and violence in the workplace, can influence this psychological exhaustion in nurses.(⁴)

It has been estimated that health professionals are the most susceptible to developing professional burnout, experiencing physical fatigue and psychological stress as a result of the care provided; such burnout is more prevalent among nurses as they are present on the front line of care in complex treatments and environments.(⁵)

A time-series study analyzed professional burnout among nurses over the last 10 years and found a global prevalence of 30% in this category, highlighting a gradual increase mainly on the European and African continents.(⁶)

Among the specialties that favor the occurrence of burnout are the emergency Intensive Care Unit (ICU), oncology, pediatrics and primary care. These care scenarios are complex and are known to cause stress in professionals who deal continuously with human suffering, treating a fragile patient population using sophisticated machines and technologies during care. Such factors can trigger inner suffering and feelings of repulsion at the high-risk and emotionally heavy environment.(⁵)

It is important to highlight the professional burnout experienced by nurses who deal with critically ill patients and their families in hospital. They are subjected to cold and unhealthy working environments, with complex technological resources, and are prone to occupational risks and stressors.(⁷) These characteristics are similar to those existing in the Hematopoietic Stem Cell Transplant (HSCT) process, where nursing professionals deal with immunocompromised patients who need specialized assistance.(⁸)

HSCT is a therapeutic option for patients with benign and malignant diseases affecting the bone marrow. This is an emerging and highly complex treatment that involves a high risk of morbidity and mortality due to the clinical and immunological state of the patients, with invasive procedures and risks of complications, thus requiring intensive and diversified care.(⁹)

In the context of HSCT, the work of nurses stands out. They are trained to deal with critically ill patients and must have the technical and scientific skills to work with more complex treatments.(¹⁰)

Due to the high level of complexity related to HSCT, there is a tendency for there to be a shortage of professionals in this area, as such assistance requires nurses who are competent to provide critical and intensive care, including managing the suffering of patients undergoing treatment (or at the end of their lives) and their families.(⁸)

In addition to this relevant problem for nurses’ mental health, there is still a lack of studies on nurses’ professional burnout in the context of HSCT.(⁸) Thus, the following guiding question was defined: What factors are associated with professional burnout among nurses working in HSCT?

Therefore, the aim of this study was to map the factors associated with professional burnout among nurses working in HSCT.

Methods

This scoping review was used to identify, map, analyze and synthesize the key concepts and knowledge gaps that exist in relation to a given theme or field. (¹¹) The design of this study followed methodological rigor by carrying out the following four stages: I. Elaboration of the research question (objective) according to the PCC strategy (Population, Concept and Context); II. Delimitation of databases and definition of search strategies and eligibility criteria; III. Selection of studies and data extraction; and IV. Analysis, synthesis and presentation of results.(¹¹)

This scoping review was developed based on the recommendations of the Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).(¹²) and guided by the method of the Joanna Briggs Institute Reviewer’s Manual.(¹¹) The research protocol and the list of references of the studies included in the final sample were duly registered in the Open Science Framework (OSF) (https://doi.org/10.17605/OSF.IO/GK84T).

In stage I, the research question (objective) was drawn up using the mnemonic combination PCC (Population: Nursing professionals; Concept: Professional burnout and Context: Hematopoietic Stem Cell Transplant). Thus, the research question (What are the factors associated with professional burnout among nurses working in Hematopoietic Stem Cell Transplantation?) and the study objective (to map the factors associated with professional burnout among nurses working in HSCT) were defined.

In stage II, the following databases were used: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS, COCHRANE, Web of Science, PsycINFO, Science Direct, Latin American and Caribbean Health Sciences Literature (LILACS), The Education Resources Information Center (ERIC), National Library of Australia’s Trobe (Trove), Academic Archive Online (DIVA), DART-Europe E-Theses Portal, Electronic Theses Online Service (EThOS), Repositório Científico de Acesso Aberto de Portugal (RCAAP), National ETD Portal, Theses Canada, Teses e dissertações da América Latina, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

To compose the search strategy in databases and catalogs of theses and dissertations, the descriptors that represent the object of the study were identified using the Medical Subject Headings (MeSH; for descriptors in English) and Descritores em Ciências da Saúde (DeCS; in Portuguese). The following descriptors were selected: Nurse Practitioners;Burnout, professional; Hematopoietic Stem Cell Transplantation and Bone Marrow Transplantation.

The Boolean operators AND and OR were also applied. It was then possible to structure the strategy in Portuguese as follows: Nursing Professionals OR (Bedside nurse OR Nursing team OR Nurse and nurse) AND Professional burnout OR (Professional exhaustion OR Professional fatigue OR Professional exhaustion) AND Hematopoietic Stem Cell Transplant OR (Bone marrow transplant). The English strategy was structured as follows: Nurse Practitioners OR (Nurses OR Nurse practitioners OR Nurses OR Nursing personnel) AND Burnout, professional OR (Professional burnout OR Occupational burnout OR Burnout, career) AND Hematopoietic Stem Cell Transplantation OR (Hematopoieticstem cell OR Hematopoietic progenitor cells OR bone marrow transplantation).

Eligibility criteria included studies published entirely in electronic form, made available through the Federated Academic Community (CAFe), which answered the research question and met the objective of the study without time or language restrictions. Studies in the form of editorials, letters to the editor and opinion pieces were excluded. Duplicate documents were considered only once.

After selecting the descriptors, an open and broad search of the literature (as well as the OSF) was carried out to investigate the possibility of published reviews or protocols on the subject, but these were not found.

Stage III began with data collection from October to November 2022. In order to standardize data collection in the databases, the selection of materials in the databases and grey literature was carried out through the Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) using CAFe searches. It should be noted that the search was carried out by peers, i.e. two researchers carried out the search (on common days and times, but in different locations) to ensure greater blindness and rigor at this stage.

The studies were selected by two independent researchers. The divergences were analyzed by a third evaluator. To examine consistency with the eligibility criteria listed, the studies were pre-selected by reading the titles and abstracts.

At the end of this stage, the texts were read in full to check that they met the inclusion and exclusion criteria. The main results on the subject were then extracted.

Data collection was guided by a form pre-tested by researchers specializing in onco-hematology and scoping to extract the following variables: database, language, year of publication, country where the study was carried out, objective of the study, methodological design and factors associated with the development of professional burnout in HSCT. The data was then organized and scanned into Microsoft Excel 2017 spreadsheets.

In stage IV, the results were analyzed, summarized and presented. The data collected was organized, interpreted and represented descriptively using a table to facilitate understanding of the results relevant to the study.

As far as ethical aspects are concerned, it was not necessary to obtain approval from the Research Ethics Committee, as this study used data from the public domain and did not involve human beings. However, we stress that copyright was respected and the studies that made up the final sample were cited and referenced.

Results

The database searches identified 1,382,383 studies. A single filter was used to select those that were fully and freely available, resulting in 393,085 studies. The titles and abstracts were then read to find the topic of professional burnout in nursing teams working in HSCT. Twelve studies were then selected for full reading; one was excluded for being a duplicate. In total, three studies met the eligibility criteria. During the database search, a reverse search was carried out on the reference list of the selected studies. The final sample consisted of six studies. The process of identification, screening, eligibility and inclusion of the studies in the final sample of results is shown in figure 1. All the studies were written in English (6; 100%); three of them (50%) were published in the United States of America (USA) and the others in Germany, Italy and Turkey. As for the period of publication, they were published in 2008, 2010 and 2018, with 2009 standing out with three (50%) articles. Table 1 shows the detailed characterization of the selected studies and a summary of the factors for professional burnout.

Discussion

Most of the studies in the sample of this review were published in the USA. This result is justified by the fact that studies on HSCT began in this country, as well as the successful completion of the first HSCT in New York in 1957.(¹⁸) Since then, new studies have been developed with improvements and scientific advances in this area. Nursing is the largest workforce in healthcare. They take on heavy workloads related to direct patient care, management or health promotion, disease prevention, treatment and rehabilitation activities.(¹⁹)

Workload refers to the number of activities to be carried out in a given period, taking into account the difficulty of carrying them out and the volume of information to be processed in relation to the time available.(²⁰)

Thus, the workload of nurses must be proportional to the demand imposed by health services. If it increases, it can negatively affect the working environment and the mental and physical health of workers, culminating in professional burnout.(¹⁹)

In the context of HSCT, nurses are subjected to work overload, long working hours and disproportionate nursing staffing. In addition, the complexity of the patients is another important factor, as they require more care and safer care.(⁸, ¹³, ¹⁴, ¹⁵, ¹⁶)

Often, nurses’ duties are delegated using obsolete methods. When sizing staff, managers only consider the nurse-patient ratio, the proximity of beds in the wards and the medical diagnosis. This should take into account the complexity of the nursing care to be provided, the individual needs of each patient, related activities (such as assessing psychosocial and emotional states) and other responsibilities of the service (such as admissions, transitions of care, transfer and discharge).(²¹)

Inadequate sizing can therefore result in an inadequate, exhausting and stressful workload. This can also affect the quality of care provided, triggering suffering, demotivation, dissatisfaction, professional burnout and illness.(²¹, ²²)

In this respect, professional burnout is related to excessive workload, number of patients assigned, clinical complexity, number of admissions, absenteeism, long working hours (>8 h/day), night work and financial remuneration.(²²)

Thus, improving the nurse-patient ratio, reducing workload, increasing decision-making and leadership, creating work stress management programs, encouraging stronger teamwork and creating healthier environments are strategies that can minimize professional burnout.(⁸, ¹⁵, ¹⁶)

Work overload is also associated with low decision-making latitude, and has been identified as a factor in professional burnout in HSCT.(¹⁴, ¹⁶) This refers to the lack of autonomy in their own work (e.g. not having the autonomy to make decisions and control the care plan for patients), as well as the demands imposed by health services on professional competence. This is linked to stress, contributing to an increase in mental illness among health workers. Thus, support from coworkers and understanding from supervisors and coordinators can effectively alleviate occupational stress.(²³)

Among the results of this study, we highlight the relationship and emotional bond established between nurses and patients and their families/ caregivers. Professions such as nursing, whose essence is caring for people, are at greater risk of developing professional burnout. Altruism and the interpersonal relationship established lead them to prioritize the needs of others, submitting to long workloads and giving their best to provide qualified health care to patients. This bond can be rewarding, but it can also be stressful.(²)

Some of the studies in this review have linked the presence of professional burnout to the female gender and the way in which these people deal with their professional balance and the role socially attributed to gender.(¹⁴,¹⁵,¹⁷)

The finding of this prevalence of professional burnout among women working in HSCT is in line with a study carried out in the pediatric oncology sector. Married nurses combine occupational and domestic tasks. This double shift tends to increase conflicts, stress in the workplace, family tension and difficulty in balancing personal and professional life.(²⁴)

The way nurses reconcile their professional and personal lives was highlighted in one review.(⁸) This reconciliation consists of the proportion of time dedicated to work and personal duties over a 12hour period. However, this is a major challenge for these professionals; they work in demanding and stressful health services that require a balance between satisfactory and safe care for complex patients and work overload. In addition, the social contexts such as the family, participation in leisure activities, etc. must also be taken into account(²⁵) and take on the role of mother(²⁴) Health services must therefore adopt strategies to preserve the quality of life of their employees, thus promoting a healthy environment that brings long-term benefits.(²⁵)

Other aspects cited were low pay(¹³, ¹⁶) and the lack of professional recognition(¹⁶) in the context of HSCT. In the Brazilian health system, nurses make up half of the workforce and are essential for maintaining life and promoting the health of the population. However, this professional category faces some adversities in the workplace, such as low pay, the struggle for a salary floor, a career without a guarantee of special retirement, high turnover of professionals seeking better salaries, unhealthy environments and violence (physical, moral or emotional). In this context, valuing the nursing workforce is a strong point for ensuring a balance between quality of care and professional satisfaction.(²⁶)

As presented in some of the studies in this review,(¹⁴, ¹⁵) the suffering experienced by patients during treatment is one of the factors that lead to professional burnout. Due to the degree of clinical complexity and care, the profile of the patients cared for by the HSCT team is similar to that of cancer patients. The professionals who work in these environments witness all phases of treatment, as well as coping, pain, suffering and even death. As nurses also offer emotional support, there is intense involvement between them and the patients. This can generate high emotional demands, exceed self-management capacity, increasing vulnerability and exposure to illnesses such as depression or anxiety.(²⁴)

Receiving poor prognoses and experiencing unpleasant events (e.g. death of patients) can trigger high levels of stress, anxiety, dissatisfaction, feelings of powerlessness and lack of professional fulfillment in nurses, as they describe their care as ineffective when they are unable to save some patients.(²⁴)

Compassion fatigue is present in HSCT nurses(⁸, ¹⁴) It emerges as a form of professional burnout due to the inner damage caused by empathic contact during health care and the difficulty in balancing professional and personal life. Its emergence is associated with witnessing pain and suffering during treatment, and can lead to long-term negative effects such as: lack of enthusiasm, absenteeism, performing less safe care, sadness, irritability, low productivity, exhaustion, a desire to leave the work unit or change profession. It also has an impact on well-being, health and family and social life.(²¹, ²⁸)

The shortage of nurses in the field of HSCT is a trend, as the lack of experience, specialization and advanced practices reduces the supply of professionals trained to provide care in this context.(⁸, ¹⁷)

Nursing is ageing, as are the populations it serves, and new nurses need to enter the job market.(²⁹) However, age and professional experience are considered risk factors for burnout. There was also a higher prevalence of young nurses with a few years of professional experience compared to older, more experienced workers.(³⁰)

In order to retain professionals in the field of HSCT, continuing education strategies, regular training, organizational measures to motivate older and more experienced nurses in the field and occupational aptitude assessment can be used, as proposed in a study carried out in Turkey.(¹⁷)

This study has limitations because the data is restricted to the work of nurses and does not address the professional burnout of nursing technicians.

The contribution of this study to scientific progress in the areas of Nursing and Health was the mapping of the factors that lead to professional burnout among HSCT nurses. This will make it possible to rethink the organization of the work process in this context and reflect on possible actions to reduce these impacts and the physical and mental illness of professionals with interventions based on healthier working environments.

Conclusion

Nurses working in HSCT can develop professional burnout because they provide care to critically ill patients undergoing complex therapies that require specialized technical and scientific skills to meet their needs and the demands of the health services. Predictors of burnout among nurses working in this context include work overload, high demand for complex care, inadequate nursing staffing, low pay and professional appreciation, little decision-making latitude, shortage of nurses in the area, imbalance between professional and personal lives, responsibility for the care of complex patients, compassion fatigue and deep involvement with patients. It is therefore essential to reflect on the factors mentioned above in order to better understand how they affect the health of nursing professionals, the quality of care and advances in HSCT. It is also necessary to develop new studies to deepen the search for strategies and reduce the factors that contribute to professional burnout, thus promoting healthier working environments, improved working conditions for nurses and qualified and safe care for both professionals and patients.

Acknowledgements

To the Coordination for the Improvement of Higher Education Personnel, for the master’s scholarship granted.

References

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