Clinical Journal of Oncology Nursing Volume 13, Number 6 Perceptions of Stress, Burnout, and Support Systems 681

Regan Gallagher, MSN, RN, and Denise K. Gormley, PhD, RN

Bone marrow transplantation (BMT) is used to treat various conditions, ranging from immune disorders to many types of cancer.
The critical complexity of patients and the environment in which BMT nurses work can lead to stress, burnout, and, ultimately,
poor retention. This study aimed to investigate nurses perceptions of work-related stress and burnout as well as current support
systems for nurses. The study included 30 BMT staff nurses from a large pediatric medical center in the midwestern United States.
Critical illness or acuity of patients was reported as the most stressful factor; long work hours was the least stressful factor. Most
nurses perceived moderate to high levels of emotional exhaustion, and 33% reported moderate levels of depersonalization.
Fifty percent perceived high levels of personal accomplishment, despite the critical illness or acuity of their patients, demanding
patient families, rotating shifts, short stafng, and caring for dying patients. Most nurses felt that support systems were in place
and that staff was accessible, but most respondents were undecided about the helpfulness of the support systems. Results sug-
gest that support systems may signicantly affect work satisfaction and feelings of accomplishment for BMT nurses.
Perceptions of Stress, Burnout,
and Support Systems in Pediatric
Bone Marrow Transplantation Nursing
At a Glance
F Visible support systems may help bone marrow transplanta-
tion (BMT) nurses manage stressful work situations.
F Novice pediatric BMT nurses perceive more emotional exhaus-
tion and depersonalization than experienced nurses and may
need additional support.
F Pediatric BMT nurses feel a sense of personal accomplishment
when caring for critically ill children, despite burnout.
Regan Gallagher, MSN, RN, is a manager of patient services at Cincinnati
Childrens Hospital Medical Center in Ohio, and Denise K. Gormley, PhD,
RN, is an assistant professor and a director of system-focused nursing in
the College of Nursing at the University of Cincinnati in Ohio. (Submitted
November 2008. Accepted for publication February 26, 2009.)
Digital Object Identier:10.1188/09.CJON.681-685
P
atient distress is a primary contributor to the highly
stressful work environment of pediatric oncology
nurses, and patient suffering is a major cause of job
dissatisfaction (Barnard, Street, & Love, 2006; de Car-
valho, Muller, de Carvalho, & de Souza Melo, 2005).
Pediatric bone marrow transplantation (BMT) nurses work with
young patients who suffer greatly from cancer as well as from BMT
side effects. The critical complexity of patients and stressful work
environment can lead to high stress, burnout, and, ultimately, high
attrition rates among BMT unit nurses. Managing medical inter-
ventions has taken precedence in the BMT nursing role, and the
emotional toll on nurses remains under-researched (Kelly, Ross,
Gray, & Smith, 2000). Decter and Villeneuve (2001) reported that
nurses are among the most overworked, stressed, and sick work-
ers. A healthy and satised nursing workforce is important for
patient safety and the achievement of positive patient outcomes
(Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Laschinger, Sha-
mian, & Thomson, 2001); therefore, the current study aimed to
examine relationships among nurse stress, burnout, and percep-
tions of support systems in pediatric BMT work settings.
Background
Many nurses feel that they receive little education to prepare
them for caring for dying patients or coping with death. Rodgers
and Brown (2001) conducted a needs assessment interview with
RNs on a BMT unit in Texas. The ndings indicated that caring for
dying children was a large stressor for the nurses in their practice
(Rodgers & Brown).
Molassiotis, van den Akker, and Boughton (1995) examined
level of job satisfaction, psychological difculties related to work,
stress, and useful stress-reduction techniques in 129 nurses and
26 doctors from 16 BMT centers in the United Kingdom. Eighty
percent felt low personal accomplishment, more than 10% expe-
rienced clinical anxiety, and 0.8% of nurses and 3.8% of doctors
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682 December 2009 Volume 13, Number 6 Clinical Journal of Oncology Nursing
displayed overt depression. Sources of stress were rapid advances
in BMT technology, excessive demands from patients and families,
and excessive responsibility in working with dying patients. Most
staff reported difculties in their personal lives because of stress
at work (Molassiotis et al.).
Molassiotis and Haberman (1996) studied burnout, psycho-
pathology, and job satisfaction in inpatient and outpatient BMT
nurses (N = 40). Four (10%) nurses experienced high emotional
exhaustion, and most reported moderate (n = 21; 52.5%) or low
(n = 9; 37.5%) emotional exhaustion. Seven (17.5%) and nine
(22.5%) nurses reported moderate and low personal accom-
plishments, respectively. Ten (27.5%) exhibited manifestations
of anxiety neurosis, and six (15%) were categorized as having
borderline anxiety. In addition, outpatient nurses were signi-
cantly more satised than inpatient nurses in areas of profes-
sional development, professional support, training, and overall
job satisfaction (Molassiotis & Haberman).
Grimm, Zawacki, Mock, Krumm, and Frink (2000) compared
the emotional responses and needs of nonprofessional caregivers
of adult patients undergoing BMT. Grimm et al.s study involved
an inpatient-outpatient model of BMT compared to studies in a
traditional inpatient BMT setting. The inpatient-outpatient model
incorporates intense outpatient care, medical hotel-like facilities,
quick access to inpatient care, and a smooth transition between
inpatient and outpatient settings. In the inpatient-outpatient
model, BMT preparation, marrow harvest or reinfusion, and
uncomplicated falls in blood counts are managed in the ambula-
tory setting, with the patient and family caregiver in their nearby
residence. The family caregiver was a full partner in all physical
care, emotional care, and monitoring after they completed an
educational program designed for BMT caregivers (Grimm et
al.). Overall, inpatient-outpatient caregivers scored signicantly
lower when compared with inpatient caregivers in areas of anger,
anxiety, confusion, and fatigue and scored higher in areas of vigor
(Grimm et al.). Inpatient-outpatient caregivers also were more
satised with how their psychological needs were met compared
to inpatient caregivers (Grimm et al.).
Researchers have examined factors that affect job satisfaction
in oncology nurses. Cummings et al. (2008) found that leadership
and working relationships with colleagues play an important
role in work environment and nurses job satisfaction. Rheingans
(2008) explored the relationship between patient symptom
management and pediatric oncology nurses job satisfaction.
Rheingans reported that the number and perceived effectiveness
of symptom management interventions for patients were predic-
tive of nurse distress and job satisfaction. In a study of pediatric
oncology nurses, Barnard et al. (2006) found that patients symp-
tom distress contributed to a stressful work environment and was
correlated with perceived burnout, peer support, and feelings of
personal accomplishment.
The literature demonstrates that BMT is a complex nursing
specialty that contributes to high levels of stress and burnout in
oncology nurses. Few studies have examined how stress, burnout,
and perceptions of support affect nurses job satisfaction and
retention in BMT settings. Additional research is needed in the
area of identifying and assessing stressors and burnout factors in
pediatric BMT nursing. As a result, this pilot study investigated
perceived job stress, burnout, and support systems of inpatient
pediatric BMT nurses.
Methodology
The current study used a descriptive nonexperimental design
to describe stressors, burnout factors, and perceived support
systems associated with pediatric BMT nursing. The study was
designed to answer the following questions: What are nurses
perceptions of work-related stress and burnout in pediatric BMT
units? What do nurses on the BMT unit perceive to be the most
stressful aspects of their job? What support systems are available
to nurses in pediatric BMT units? Are the support systems per-
ceived as helpful, visible, and accessible? How could the institu-
tion or program better support pediatric BMT staff?
Setting and Sample
The setting for the current study was a pediatric BMT center
in a large, academic, pediatric medical center in the midwestern
United States. The nurse-patient ratio at the center primarily aver-
aged 1:2 but was 1:3 at times, depending on patient acuity. Most
staff RNs worked 12-hour shifts from 3236 hours per week. The
nurses worked closely with physician hospitalists, nurse practitio-
ners, patient-care assistants, and BMT attending physicians at the
facility on a daily basis.
The current study used an accessible convenience sample of
all eligible pediatric BMT nurses, ranging from new graduates to
senior staff members. The only exclusion factor was traveling RNs
because of the possibility of peripheral concerns or stressors not
centered on BMT nursing at the institution.
Instruments
The Maslach Burnout Inventory (MBI) and a demographic-
informational questionnaire were used to collect data from the
staff pediatric BMT nurses. The questionnaire was used to col-
lect basic, pertinent information not included in the MBI, such
as years of work experience, years as a BMT nurse, predominate
shift worked, and full-time or part-time status. The question-
naire also asked about perceptions of work-related stress and
support systems in the pediatric BMT unit. Nurses ranked the
following stressors in order of importance: critical illness or acu-
ity of patients, dying patients, rotating shifts or schedule, short
stafng, long work hours, and demanding families. Nurses then
were asked whether they felt supported at work and whether
current support systems were in place for staff to use, and if
so, whether the support systems were accessible, visible, and
helpful.
Table 1. Maslach Burnout Inventory Rankings
of Pediatric Bone Marrow Transplantation Nurses
RANK
EMOTIONAL
EXHAUSTION
DEPERSONAL-
IZATION
PERSONAL
ACCOMPLISHMENT
n % n % n %
Low 8 26.7 19 63.3 5 16.7
Moderate 14 46.7 10 33.3 10 33.3
High 8 26.7 1 3.3 15 50
N = 30
Note. Because of rounding, not all percentages total 100.
Clinical Journal of Oncology Nursing Volume 13, Number 6 Perceptions of Stress, Burnout, and Support Systems 683
The MBI is a 22-item scale measuring burnout, which was
dened in the current study as a syndrome combining emo-
tional exhaustion, reduction of personal accomplishments,
and depersonalization (i.e., nurses impersonal feelings and
responses toward recipients of their care). The syndrome
may affect those who work with people regularly. The MBIs
subscales focus on those three aspects of burnout syndrome
(Maslach, Jackson, & Leiter, 1996).
The personal accomplishment subscale assessed nurses
feelings of competence and achievements at work. A score of
39 or higher indicated feelings of low personal accomplish-
ment, 3238 indicated moderate feelings of personal accom-
plishment, and 31 or lower indicated high feelings of personal
accomplishment. The depersonalization subscale measured
nurses impersonal feelings and responses toward recipients of
their care. A score of 13 or higher indicated high depersonaliza-
tion, 712 indicated moderate depersonalization, and 6 or low-
er indicated low depersonalization. The emotional exhaustion
subscale assessed nurses feelings of emotional overexertion
and exhaustion caused by their work. Scores of 27 or higher
indicated high emotional exhaustion, 1726 indicated moder-
ate emotional exhaustion, and scores of 16 or lower indicated
low emotional exhaustion (Maslach et al., 1996).
The MBI has documented reliability as well as convergent
and discriminant validity (Maslach et al., 1996). The reli-
ability coefcients for each subscale were 0.9 for emotional
exhaustion, 0.79 for depersonalization, and 0.71 for personal
accomplishment.
Data Collection
After institutional review board approval was obtained, nurs-
es were approached to participate in the current study. Survey
completion by the nurses served as informed consent. The
researcher distributed the MBI and demographic-informational
questionnaires to one or two nurses at a time during various
shifts and days of the week. Questionnaires were distributed
at different times and days to avoid disrupting patient care and
workow for the nurses. Descriptive statistics of quantitative
data and correlations using SPSS

16 were formulated based on

data from both tools.
Findings
Sample Description
The study sample consisted of 30 staff pediatric BMT
nurses. Years as an RN ranged from less than one to 17 years
(

X = 5.2 years). Years as a BMT nurse ranged from less than

one to 12 years (

X = 4.2 years). The full-time equivalency

(FTE) status of the BMT nurses ranged from PRN to 1 FTE;
19 (63.3%) worked 0.9 FTE. Fourteen nurses (46.6%) worked
day shift, eight (26.7%) worked night shift, and eight nurses
(26.7%) worked days and nights.
Work-Related Stress and Burnout
Nurses were asked to rank their top three work-related
stressors. Perceptions of work-related stress were relatively
consistent among short stafng, rotating shifts or schedules,
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684 December 2009 Volume 13, Number 6 Clinical Journal of Oncology Nursing
4). Twenty-ve nurses (83.3%) felt supported on their unit.
Twenty-seven (90%) felt that support systems were in place,
and 19 (63.3%) stated that support systems were accessible to
the staff. However, nine (30%) reported that support systems on
the unit were not visible, and 17 (56.7%) were undecided about
the helpfulness of the support systems. As length of time as a
BMT nurse increased, participants increasingly reported a lack
of visibility of their support systems. As expected, a strong cor-
relation existed among perceptions that support systems were
accessible and that they were visible and helpful.
Improving Support for Staff
The fourth research question explored how to better support
the pediatric BMT staff with an open-ended single response
item that asked, What would make you feel more supported at
work? Responses fell into three general categories. Ten nurses
(33.3%) reported that better scheduling, stafng, and assign-
ments would improve perceptions of support. Ten (33.3%)
reported that improved teamwork and peer recognition would
improve support. Seven (23.3%) stated that leadership and man-
agement need to be more supportive. One (3.3%) said that bet-
ter pay would improve perceptions of support, and one (3.3%)
reported that knowing families are satised improved support.
One nurse (3.3%) wrote, The longer you are here, the harder
it is to be here. Surprisingly, nurses who reported that support
systems were in place and felt supported still were emotionally
exhausted. However, nurses who were emotionally exhausted
also had impersonal feelings toward their patients (depersonal-
ization) and felt low personal accomplishment.
Discussion
The current study investigated and analyzed nurses percep-
tions of work stress, burnout, and support system availability on
a pediatric bone marrow transplantation unit at a large pediatric
academic medical center in the midwestern United States. Find-
ings demonstrated that the critical complexity of patients and
the environment in which BMT nurses work can lead to stress,
burnout, and, ultimately, poor retention. Nurses also felt that
support systems were in place but were undecided on their help-
fulness. The ndings were similar to Molassiotis et al.s (1995);
however, sources of stress in Molassiotis et al.s study were rapid
advances in BMT technology, excessive demands from patients
and families, and excessive responsibility in working with dying
patients; major sources of stress in the current pilot study were
critical illness or acuity, dying patients, and demanding families.
Critical illness or acuity of patients was the most stressful factor,
and long work hours was the least stressful factor. Demanding
families, rotating shifts or schedules, short stafng, and dying
patients were perceived fairly equally as work-related stressors.
Nurses also completed the MBI to assess perceptions of burnout
(see Table 1). Twenty-two (73.7%) perceived moderate to high
levels of emotional exhaustion, and 10 (33.3%) surveyed reported
moderate levels of depersonalization. However, 15 (50%) per-
ceived high levels of personal accomplishment, despite the criti-
cal illness or acuity of their patients, demanding patient families,
rotating shifts, short stafng, and caring for dying patients.
Relationships among nurses experience, perceptions of sup-
port, and stressors as well as the burnout subscales were ana-
lyzed using Pearson product moment correlations (see Table 2).
Signicant correlations were found among many variables. Years
as a nurse and years as a BMT nurse were positively correlated
with perceptions of visible support and feelings of personal ac-
complishment. Years as a nurse and years as a BMT nurse were
negatively correlated with critical acuity of patients, emotional
exhaustion, and depersonalization. The ndings demonstrated
that as years as a nurse and BMT nurse increased, levels of emo-
tional exhaustion and depersonalization decreased and feelings
of personal accomplishment increased. In addition, nurses felt
less stress from the critical acuity of patients as years as a nurse
increased. Shift work also was moderately positively correlated
with perceptions that support was in place, suggesting that nurses
who work day shift feel that support systems are more available
than nurses who work night shift.
Most Stressful Aspects of Nursing
The second research question aimed to clarify what staff BMT
nurses considered the most stressful aspects of their job (see Table
3). Nurses were asked to rank their highest stressor; no signicant
variation was found among critical illness or acuity of patients,
short stafng, rotating shifts or scheduling, or dying patients. Only
one nurse responded that demanding families was most stressful,
and no nurses ranked long work hours as most stressful. Interest-
ingly, nurses who perceived that support systems were accessible,
visible, and helpful felt less stress from demanding families.
Support Systems
The third research question asked about support systems
that were available to the pediatric BMT nurses and whether
the systems were helpful, visible, and accessible (see Table
Table 3. Stressors in Pediatric Bone Marrow
Transplantation Nursing
STRESSOR n %
Short stafng 8 26.7
Rotating shifts or schedules 8 26.7
Critical illness or acuity 7 23.3
Dying patients 5 16.7
Demanding families 1 3.3
Undecided 1 3.3
N = 30
Table 4. Pediatric Bone Marrow Transplantation
(BMT) Staff Nurses Perceptions of Support Systems
PERCEPTION n %
Support systems are in place. 27 90
Feel supported on the BMT unit 25 83.3
BMT support systems are accessible. 19 63.3
Undecided about helpfulness of BMT support systems 17 56.7
BMT support systems are not visible. 9 30
N = 30
Clinical Journal of Oncology Nursing Volume 13, Number 6 Perceptions of Stress, Burnout, and Support Systems 685
critical illness or acuity of patients, demanding families, shift or
scheduling and stafng issues, and dying patients.
Despite the complexity and critical nature of the BMT envi-
ronment and the identied stressors, many nurses responded
positively on feelings of personal accomplishment associated
with their work. In contrast to Molassiotis et al. (1995), the cur-
rent sample scored signicantly higher on personal accomplish-
ment, despite the fact that perceptions of emotional exhaustion
and depersonalization were moderately high.
The current studys ndings also were similar to those of
Molassiotis and Haberman (1996). BMT nurses in Molassiotis
and Habermans study perceived moderate to high levels of
emotional exhaustion as well as moderate to high levels of per-
sonal satisfaction, satisfaction with standards of care, salary, and
professional support. However, Barnard et al. (2006) found only
weak to moderate positive correlations between peer support
and personal accomplishment and no relationship between
supervisor support and burnout; however, results did indicate
that oncology nurses viewed supervisor support as important.
These studies suggest that support systems for nurses in high-
stress environments may play a signicant role in work satisfac-
tion and feelings of personal accomplishment, but the results
are inconclusive.
Limitations of the current study were its small convenience
sample, single setting, and use of self reports only. Therefore, the
results cannot be generalized to other populations.
Conclusions
Despite moderate to high levels of emotional exhaustion and
depersonalization as well as the complexity and critical nature
of a BMT environment, nurses in the current study perceived
moderate to high levels of personal accomplishment. Most
nurses felt that support systems were in place on the unit but
were undecided on the helpfulness of the systems; therefore,
support may be the mitigating factor in improving feelings of
personal accomplishment. Experienced nurses perceiving a
lack of available support was a surprising nding; additional
studies are warranted to examine the effects of support on job
satisfaction, work commitment, and retention of nurses in this
complex nursing specialty.
Inpatient pediatric BMT nurses provide care for medically
fragile patients for several weeks to months throughout the
course of their BMT process. The current studys results indi-
cated that the participants perceived high levels of personal
accomplishment associated with pediatric BMT nursing, de-
spite the stress and acuity of their job. Concerns about support
systems and their current helpfulness to the staff warrant
additional investigation and intervention. Future studies are
needed to determine what impact changes to the current sup-
port system model would have for staff nurses on pediatric
BMT units. Differences in adult and pediatric BMT settings also
should be explored.

The authors take full responsibility for the content of the article.
The authors did not receive honoraria for this work. The content
of this article has been reviewed by independent peer reviewers
to ensure that it is balanced, objective, and free from commercial
bias. No nancial relationships relevant to the content of this article
have been disclosed by the authors, planners, independent peer
reviewers, or editorial staff.
Author Contact: Regan Gallagher, MSN, RN, can be reached at regan
.gallagher@cchmc.org, with copy to editor at CJONEditor@ons.org.
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