Victorian cancer nurses experiences of work-related stressors and supports: a multiple case study describing job demands and job resources during 2019-2021

Registered nurses are the largest single professional group working in the field of cancer care and support one of the most vulnerable patient cohorts in the healthcare system. Cancer nurses require specialised knowledge and skills to undertake emotionally demanding work. Some of their key responsibilities include cancer prevention and detection, cancer treatment delivery, and end-of-life care. The COVID-19 pandemic presented challenges to cancer care services that at times resulted in a rationalisation of healthcare services with ongoing negative impacts, such as delays to cancer diagnoses, treatments, and care. Despite cancer nurses being critical to providing care for people with cancer, this group experiences high rates of burnout. There are significant limitations to current research findings on the stressors experienced by cancer nurses resulting from specific job demands, and the job resources which may act to buffer these stressors. A more nuanced understanding of the stressors uniquely associated with cancer nursing is required, particularly in the context of the COVID-19 pandemic. In this study, the Job Demands- Resource Model (JD-R model) is employed to better understand the work experiences of cancer nurses and identify aspects which mitigate burnout and stress. The aim of this study is to describe Victorian cancer nurses’ experiences of work-related challenges, alongside positive job resources that may buffer the challenges inherent in their work, across different geographical locations, both prior to and during the COVID-19 pandemic. A multiple case study research design was employed, with two groups making up a total of 30 participants, allocated to separate cases bounded by geographical location. A two- phase study of cancer nurses across a spectrum of age and experience in Victorian metropolitan and regional public healthcare services was conducted over a two-year period that coincided with the COVID-19 pandemic. Data included field notes and the transcripts from semi-structured interviews which were conducted on-site at participants’ workplaces in the initial phase, and online during the second phase due to existing COVID-19 restrictions at the time. Data analysis used a process of elaborative coding, with a pre-conceived coding framework based on the JD-R model. A combination of thematic analysis and storyline analysis was employed throughout the process of analysing the data. Once each case was analysed, a cross-case analysis of similarities and differences resulted in a case descriptor of the job demands affecting cancer nurses that could lead to burnout, and conversely, any positive job resources which may mitigate these. Job demands identified in both cases appeared to have similar causes but were more explicitly linked to poor resourcing in the regional group. There appeared to be less discernible workplace supports available in the metropolitan group, where workplace incivility also seemed to be more widespread. There did not appear to be the same degree of abusive behaviour present in regional workplaces. Participants’ close connection to community members in regional areas presented as both a job demand and job resource, depending on the context of how it was experienced by individuals. Emotional demands were experienced in both cases, however, the close involvement with community members in regional communities presented a unique dimension of this job demand for regional participants. The metropolitan case similarly included high emotional demands as a key job demand linked to the difficult nature of cancer nursing work and compounded by a lack of support at work. Job resources identified in both cases were similar, but it was noted how few job resources were available to buffer the many demands inherent in cancer nurses’ work. In both cases, job significance was a key job resource as both groups of participants identified their work as both meaningful and rewarding. In the case of regional cancer nurses, these participants more explicitly linked the motivation for their work to their close connection to their communities, whereas metropolitan participants identified broader societal reasons as to why they chose to remain in the profession. Metropolitan cancer nurses who participated commonly described task variety as an important job resource which had a significant impact on reducing burnout. Opportunities to job craft was not available in the case of regional cancer nurses. Metropolitan cancer nurses provided far fewer examples of supportive peers and managers than regional cancer nurses, but in the few instances cited, supportive peers and managers were identified as a key job resource which had a direct influence on how they managed the difficulties associated with work. In the case of regional cancer nurses, many examples of supportive peers and managers were provided, particularly in the pandemic phase of the study. Supportive managers in the case of regional cancer nurses were considered pivotal to advocating for better resourcing and supports. Clinical supervision was identified as a key job resource by regional cancer nurses, while interestingly metropolitan cancer nurses explicitly linked the absence of this resource in their workplace to burnout. Findings from this study highlight the importance of social support and supportive leadership as job resources that could be fostered by health services with the aim of reducing burnout and associated attrition in cancer nurses. Effective leadership in cancer nursing is important not only in terms of clinical leadership to ensure safe nursing practice, but also in identifying and providing support to nurses through cultivating a psychologically safe work environment. While cancer nurses are highly engaged in their work, task variety, such as secondments to research projects, or seeking further professional development opportunities, have potential to improve cancer nurses’ perceptions of job significance and overall satisfaction. Finally, the potential of clinical supervision as a job resource for cancer nurses needs to be explored as a method of building resilience in this and other groups of nurses who share a high level of emotional labour in their work. This multiple case study found that the work of cancer nurses is high in demands and low in resources. Despite challenging work conditions, findings identified a highly engaged workforce who are committed to improving outcomes for people with cancer. The job resources identified in this study point to modifiable strategies and the important function of nurse leadership in cultivating a supportive work environment necessary for cancer nurses to provide quality care. Identification of positive job factors that enable cancer nurses to manage their roles in a highly demanding work environment offers healthcare leaders a better understanding of specific challenges associated with burnout in cancer nurses more generally.