Critique of Article
The article chose for research critique is titled: “Staff burnout in pediatric oncology: new tools to facilitate the development and evaluation of effective interventions”. (Mukherjee, Beresford and Tennant, 2014)
Background: Stress and associated burn-out syndrome, are common among staffs working in pediatric oncology. However, there has been no serious efforts to understand, grade and devise ways to combat this problem. As an initiative in this direction, the study was designed to develop a research instrument that measures stressful and rewarding experiences among staff. The article is organized as introduction, methods, result, discussion, conclusion and acknowledgement. A brief abstract will all essential information to motivate the reader towards the topic is also provided.
Introduction: The introduction presents the need for the study and it is backed by literature support. The articulation is done in a logical fashion. The importance of this work was emphasized by listing out the negative impact of work related stress. Work related stress can have a toll on patients and colleagues. Stress can lead to adverse clinical outcomes, poor decision making, poor quality of care and irritability. It can also compromise safety and increase hazard risk. It can also result in economic loss, as it increases sickness and work related absentees. Each adverse effect of work related stress has been backed by literature evidence. Monotonous, unpleasant work, poor interpersonal relationships, high work load was identified through literature survey, as few factors that cause stress. The stress of the job is unique, and efforts were taken through literature review to identify stress in nursing oncology. Complexities of treatment and management regime was identified as stress factors. In addition, meeting demands of the children, their families and lack of proper support system to help staffs were identified as a reason for adverse health outcomes.
The literature review also identifies the dearth of knowledge, pertaining to stress and related problems in oncology. The present study is justified in the light of the need to identify and measure stress in pediatric oncology staffs. There has been limited research in this area. The background research and literature also identified the lack of a support system for the pediatric oncology staff. The earlier studies that were conducted in related area were identified as having a small sample size. There was also a lack of proper instrument for use in such research. The authors claim that their research will address the gap in the current knowledge. The LIPOP (Life in Pediatric Oncology Project) was developed to address the gap in the literature evidence (LIPOP, 2016). The study was conducted among clinical and non-clinical staff. Psychometric analysis was also done in the study.
The introduction is presented in a concise way. There is clarity in the way things are expressed. There are no jargons and the language is easy to understand. There is also a logical flow to things. Every claim is backed by references.
Review of literature: Most of the references in the paper are published in the year 2000 and ahead. The problem identified from the literature review is valid and needs to be addressed. Stress is indeed a significant issue among hospital staffs, especially those in pediatric oncology. Children need special attention and a high level of personalized care. The communication, tone of words, body language and interaction with child patients, need to be done, taking into consideration their sensitivities. This can be difficult, if the staff has to deal with a lot of stress at work. The evidences present in the introduction supports the claim.
The problem statement is clearly defined. It is to identify ways to measure stress and burnout in pediatric oncology staff. As it is a descriptive study, the research question is not clearly defined. The hypothesis is also not clearly defined.
Theoretical frameworks guiding the research: The study is based on a transactional model of stress and coping explained by Lazarus and Folkman (Lazarus and Folkman, 1984; Lazarus, 1999). According to this model, for a situation or event to be stressful, it has to be perceived so by the individual. The psychological and social organization pattern of the workplace is considered in this model. In accordance with this, the model will develop instruments that will measure the perception of stress in staff. The paper also identifies the strength and weakness of this model. The strength being that it associates easily measurable traits like salary, esteem, security and career opportunity for relieving stress. The weakness is that it fails to identify other rewards that can influence stress. The terms of the theory are easy to understand.
Method: The method is explained clearly. Even a flow chart is provided to understand the step by step approach that was taken. Instruments like interviews, was used in the initial phase to collect preliminary information, based on which more intensive study was planned. The items to be measured, were chosen from the qualitative data obtained. The interview questionnaire used is not revealed in the paper. Thirty-two staffs of pediatric oncology participated in the study. Among these, 10 were doctors, 11 were nurses and 11 were non clinical staff. The job profile of the participants was also varied like: consultant, specialist registrar, social workers, youth workers, play specialist, nurses. The participants were asked to describe experiences that caused them stress in day to day experience and rare events that cause stress. This method helps identify individual rewards. Terms like upsetting, annoying, challenging and hassle, were used to identify stressful events or situation. The initial interview used in this study served to identify factors or items that cause stress. The questions were open ended and no information about their validation is provided. There is also no reference as to from where the questionnaire was taken and it is also not validated. No information of expert opinion was sought for developing the questionnaire.
The items on the questionnaire were analyzed by 6 different researchers. Each questionnaire was analyzed independently by two different researchers. Employing six researchers to analyze the questionnaire independently and to select stress causing items, can help reduce the bias in the study. A total of 752 stresses and 415 rewards were identified. The number is very exhaustive and would probably cover a significant number of events/situations that cause stress. However, of these, 170 stresses and 57 rewards were the only measurable items, while the rest were difficult to measure. This is one limitation of this method.
Following selection, a cognitive interview (McColl, 2006) was used to collect feedback on the measures. This steps acts like a validation process for the questionnaire that was developed to measure stress/reward. The participants who validated the questionnaire, were asked to provide feedback. A “think aloud” technique was used, where the participants can read the questionnaire and state which part was difficult to read, understand or answer. The items (stress/reward) in the final questionnaire were scalable. The draft of this questionnaire was distributed to people in the ward for further validity. Exploratory factor analysis, Rasch analysis, internal reliability and construct validity of the questionnaire was determined. The final questionnaire that is to be used as a research tool to measure stress and burnout was finally approved. The paper has provided step by step process that was employed in the construction and validation of the research tool.
The study design and the method were approved by the NHS Research Ethics Committee. The aim of the study was to develop a questionnaire that can be used in stress and burn out studies at the oncology department. There is no intervention in the study. Participation in the study was voluntary. The study was well published among the staff and its aim was explained. The study was conducted in a hospital setting and the staffs of pediatric oncology, participated in the study. The sample size of 32 is a reasonable number to develop a questionnaire for the study. The parameters in the study were psychometric measures. The rating scale of the “exposure to stress” measure ranged from: rarely, sometimes, often. The level of stress was scaled as: not at all, a little and a lot. The scale seems sensible and logical for the research problem at hand. The data were collected by distributing the questionnaire to the participants. Statistical tools like Chi-square test, Pearson’s coefficient and standard deviation are the statistical methods used to analyze the results.
Results: The results are presented as different subsection and in an organized fashion. The first section provides descriptive statistics. 203 staff took part in the survey done by the validated questionnaire. Nurses, doctors, non-clinical staff and clinical staff. The details of work experience and duration of service of the staff were mentioned. Their work settings are also described. All these factors, help to identify the characteristic of the people being studied. The working hours of the staff were also mentioned in the paper.
Following the description of study participants, the results of the exploratory analysis are provided. The subheading of results, corresponds to the subheadings in the methods. Thus, it is easy to track the paper. The stresses were divided into those arising from caring/treating for the child, those arising from organizational issues, those arising from parents and families. The parameters that were cross loaded in other dimensions were removed. The results of the Ranch analysis and internal analysis were clearly provided in table format and description of the results are also provided. Finally, the results of construct validity of the newly created questionnaire are provided. The construct validity was determined by correlation analysis. The interpretation of the results was done in a logical and unbiased manner.
The description of methods and results are done vividly, providing the readers all essential details. There is also clarity in the description. It is easy to understand the events in the experiments and results. Adequate analytical tools and interpretation is done. All phenomena, like the contents of the questionnaire are provided and the significance of each parameter is discussed.
Discussion: The authors share their experiences in the course of discussing their work. Literature evidence is used to justify the approach. While previous literature emphasized the importance of income and work environment, the present study identified the importance of relationship with the patient and family members as important factors that affects stress. Relationship with colleagues is also identified as a factor that will influence stress and burn out syndrome. The results were discussed in the light of a Transactional Model of Stress and Coping.
The limitations of the study were also presented. There was a poor response rate in the initial phase of the study. This was also seen in the test and re-test procedure that was done to test for internal validity. The other limitation of the study was that the measures of stress or burnout are not as robust as that of a quantitative study. However, the questionnaire can be useful tools to identify stress/burnout in the staff and to devise intervention. The questionnaire or research tools that were constructed through this method are called WSS-PO and WRS-PO. The discussion provides additional perspective about the questionnaire and its use in other clinical setting. A number of predictions about the questionnaire are made in the discussion. The authors also suggest the possibility of adapting the scale to a different setting.
The research problem is addressed by the study. The study was done in a systematic and neat fashion. All factors that could cause a bias were taken care to the extent possible. The approach used by the researcher was consistent with the research problem and the philosophy suggested to address it. The methodology is well described and it is easy to verify the methodology. Care is taken while designing the study and choosing the approach.
A conclusion and acknowledgement section is provided. The conclusion is too long and certain irrelevant facts are discussed. There is too much extrapolation. The authors could have restricted the conclusion to the question at hand. Though the strength of the paper is discussed at length, there has been little effort to identify or discuss its limitation. The sponsors and contributors were acknowledged.
The work will help other hospitals and clinic to use this instrument among their staff. It is essential that intervention done to address stress and burn-out in staff are based on scientific evidences. Though the content validity has been done in this study, the number of participants and participation from different hospitals is essential for the content validity to be more accurate. The content of the questionnaire may have to be adapted based on the situation. Nevertheless, this paper will help other researchers to identify the work and use it in their practice or research.
Stress has become an important issue in clinics and this is a single important factor that motivates people to leave jobs and choose other occupation. A large number of evidences suggest the harmful effect of stress on hospital staff. Clinical oncology is a very challenging environment and it demands a high level of commitment and contribution from participating staff. The demands of the job can be tiring and this stress can adversely affect performance. There is a need to identify stress, so that the administration can find ways to address it. The above study is important in that it aims to devise a research instrument that measures stress in the pediatric oncology. The instrument can be adapted to other clinical settings as well.
On the whole, the paper is comprehensive and written with clarity. The research problem is well addressed. The future applications of the research tool are articulated well. Though the researchers have developed a research tool, there is a need for the study to identify stress using this tool. The research tool does not help to identify the benefits of any intervention done to reduce stress.
References
Lazarus, R. (1999). Stress and Emotion: A New Synthesis. London, U.K: Free Association Book, p.32.
Lazarus, R. and Folkman, S. (1984). Stress, Appraisal and Coping. New York: Springer, p.54.
LIPOP. (2016). LIPOP. [online] Available at: http://www.york.ac.uk/LIPOP [Accessed 21 Mar. 2016].
McColl, E. (2006). Cognitive Interviewing. A Tool for Improving Questionnaire Design. Qual Life Res, 15(3), pp.571-573.
Mukherjee, S., Beresford, B. and Tennant, A. (2014). Staff burnout in pediatric oncology: new tools to facilitate the development and evaluation of effective interventions. European Journal of Cancer Care, 23(4), pp.450-461.
