Demographic characteristics

We identified age, marital status and sex as factors that increased risk of developing burnout among OTDCs in four papers.3 23–25 Burnout levels were identified as being greater among OTDC who were men,24 with higher educational levels,24 25 full-time coordinators,24 working fewer years as an OTDC3 and being physicians who performed OTDC duties.25 Reports of the role of marital status24 25 and age3 23 24 were contradictory across publications. Therefore, variables such as sex, educational level and type of employment should be considered when investigating burnout risk.26

Exhaustion

OTDCs described feelings of exhaustion as the depletion of emotional and physical resources. We detected this attribute in six papers.3 23 26–28 Dealing regularly with death and loss can evoke feelings of tiredness, sadness and fear among OTDCs.27 They also deal with unpredictable routine, overtime work, fast-paced environment, the constant sense of urgency and on-call shifts, which can lead to physical and emotional exhaustion through sleep deprivation, lack of concentration, intolerance and loss of interest in the job.26–28 Emotional exhaustion, when measured as an underlying factor of burnout, refers to the feeling of depletion due to the accumulated stress in the workplace and it has a higher incidence among professionals who are in a relationship,3 working more hours per week,23 with lower supervisor support,23 more difficult patient interactions,23 greater psychological job demand23 and low psychological well-being.23 Although age was not a statistical predictor of exhaustion, the years of working as an OTDC were a significant predictor, where professionals with fewer years of experience were more susceptible to emotional exhaustion.3 Burnout prevalence may be negatively associated with emotional intelligence but positively related to the incidence of CF among OTDCs.29 Thus, due to the high demand and the nature of OTDCs’ job, these professionals are often affected by emotional exhaustion and/or at an increased risk of burnout and CF incidence.

Personal accomplishment

Reduced personal accomplishment represents the self-evaluation component of burnout, which can include reduction of one’s productivity, competence and self-efficacy, and it is considered one of the core dimensions of burnout.20 We identified this attribute in three papers.23 25 30 One study reported that OTDCs described more personal accomplishment23 than other nurses involved in the process of organ donation and transplantation, while another highlighted that OTDCs had a mid-level score on the personal accomplishment dimension of the Maslach Burnout Inventory.25 OTDCs who were women,23 younger age,23 single,25 non-physician,25 working with lower decisional authority23 and with high levels of discomfort when dealing with difficult patient interactions23 were more susceptible to having a reduced personal accomplishment. Also, OTDCs may face situations where they have responsibilities without authority resulting in a sense of powerlessness that negatively affect their feelings of personal accomplishment.30 Therefore, personal accomplishment is considered a component of burnout, but the studies that investigated this attribute did not report reduced levels of personal accomplishment among OTDCs according to the Maslach Burnout Inventory subscale scores.23 25

Job attitudes

Job attitudes included OTDC behaviour and expectations related to their role and work. We identified this attribute in two articles.9 31 People can have different expectations attached to their job, but when the expectations about the success and nature of the job are too high or unrealistic, this can be a risk factor for developing burnout.4 Because people with higher expectations of their job tend to work harder than others, the lack of results from this effort can lead them to exhaustion and/or cynicism.4 The complexity of organ donation processes often demands a lot from OTDCs. As OTDCs are aware of their central role in the donation process, it is not uncommon for them to dedicate extra time and effort to a case.10 The extra work put into cases can lead OTDCs to develop high levels of self-criticism, resulting in a constant feeling that they have not done enough during the process.9 On the other hand, the fulfilment from work performance and clear perception of the OTDC role might help them to develop a higher sense of satisfaction.31 Although it is important to these professionals to be committed to their job, they also need to develop a balance between self-criticism and work satisfaction, as an imbalance may result in OTDCs resigning from their job.9 31

Job characteristics

There were a number of quantitative and qualitative job characteristics identified in the literature including worked hours, number of patients, the severity of clients’ problems, role conflict and role ambiguity. We identified various job characteristics in three papers.10 23 32 The OTDC role is frequently described as stressful and exhausting, with factors such as cases that surpass 30 hours, with sleep deprivation and little or no time to eat, resulting in fatigue during this period.10 The OTDC role also involves frequent exposure to difficult and uncomfortable interactions with the patient’s family.23 32 Although the complexity of the OTDC role is unquestionable, there is a lack of resources and protocols to support their activities, particularly related to social and psychological support to help them overcome difficult cases.32 Therefore, the use of education and psychological support are highlighted in the literature as possible resources to sustain their psychological health and help them to build boundaries between work and personal life.

Burnout consequences

For this attribute, we included reports of the consequences associated with burnout presented in the personal and professional lives of OTDCs. We identified this attribute in four articles.10 12 28 31 At the professional level, the most common consequences identified in the literature were high levels of stress and emotional burden, combined with an inadequate support system for coping with stressors, leading to resignation10 and use of medical leave.28 Turnover levels were reported as being higher among those who are younger OTDCs,12 spend more days on call,28 31 work long hours, receive poor remuneration, are exposed to poor management and are overstressed or emotionally exhausted.31 Boundaries between professional and personal life are blurred for most OTDCs. The uncertainty of being called to work even during off call hours was reported as negatively affecting OTDCs’ off-call time as it prevents them from disconnecting from their job.28 Therefore, although burnout is a syndrome that originates from work stressors, the consequences also impact OTDCs’ personal life.

Compassion fatigue precursors

The precursors to the development of CF identified in the literature include the constant exposure to suffering or traumatised people. We identified this characteristic in nine reports.9 10 12 27 32–36 In addition to working in a high-pressure and demanding environment, OTDCs are exposed to the suffering of families.9 10 12 27 32–34 OTDCs are responsible for approaching families to inform them of the possibility of organ donation after families have learnt about the death (potential donors from neurological determination of death) or imminent death (potential donors from circulatory determination of death) of their loved one. The unpredictability of the reactions of the family to the approach27 32 33 35 36 generates high-tension and stressful scenarios.27 32 The high level of dedication to organ donation processes may lead OTDCs to feel vulnerable and exhausted.9 Thus, OTDCs can find themselves crying, in a depressive mood and emotionally unstable,9 especially after difficult cases such as the ones involving children32 33 or if the case brings up personal experiences and memories.36 These are some of the reasons why OTDCs refer to the family approach as the most stressful part of their job. As family approaches are an inevitable part of the OTDCs role and are highly emotionally charged,27 32 34 it may be identified as a possible precursor to the development of CF.

Compassion fatigue consequences

We identified six papers mentioning the development of a variety of psychological and physical signs and symptoms consequent to CF.9 28 35–38 The most common symptoms of CF in OTDCs reported in the literature were suffering, despair, anguish, anger, irritability,35 intrusive thoughts about donors and their families9 and difficulty sleeping.9 28 Canadian ODOs that collaborated on this study shared some materials used either to advertise resources to their OTDCs or to train them in recognising and preventing burnout and vicarious trauma. One of the materials pertained to an external course provided to OTDCs and contained a description of physical behaviours and psychological symptoms of CF.36 The other material shared was the outline of a workshop delivered to OTDCs in which the trajectory of CF was highlighted: ‘the zealot phase (excitement, commitment, extra hours); the irritability phase (strained humour, avoidant, irritable); the withdrawal phase (defended, exhausted, neglectful); the zombie phase (automatic pilot, no meaning in work, loss of compassion); pathology and victimisation versus renewal and maturation phase (leaving work vs transformation and resilience)’.37 CF symptoms and signs can be challenging to identify; therefore, it is important that OTDCs are aware of what to look for among themselves and co-workers.

Depersonalisation as a coping strategy

We included three reports describing individual detachment from patients’ families to avoid engagement and/or empathy as a way to deal with pain and suffering.20 27 39–41 Although depersonalisation is considered one of the three dimensions of burnout, it is also linked to CF.42 43 Some OTDCs see depersonalisation as something natural, as an attempt to protect themselves from the exposure to families’ feelings.27 39 40 However, depersonalisation was also identified as a strategy in relation to the patients. For example, some OTDCs provide care for brain dead donors as if they were still alive, putting a barrier in between themselves and the donor in order to be able to provide assistance while not absorbing feelings that might cause sadness and suffering.27 This attitude of withdrawing one’s feelings to look after patients is a protective strategy and a response to emotional exhaustion, and it can happen in such a natural manner that OTDCs may not be aware of their own detachment.27 Therefore, depersonalisation can occur as a result of burnout or CF, and it impacts OTDCs' clinical practice as well as patient and family care, yet it can be difficult to recognise and diagnose.

Management strategies

There were a number of management strategies, including the use of support groups as ways of managing burnout or CF, that were identified in 15 reports.9 10 26 27 32 33 36 37 40 41 44–49 OTDCs frequently seek an equilibrium between positive and negative emotions. Even though the OTDC’s role involves dealing with death and grief, it is also seen as a valuable service that supports family members9 27 and helps save numerous recipients’ lives.9 27 Another important management strategy for OTDCs is the role of colleagues as a continuous source of support.9 32 33 45 OTDCs rely heavily on colleagues when seeking support or advice, as the similarity of experiences brings higher levels of comfort and trust in comparison with management, families or other HCPs.9 10 45 Other common strategies include, but are not limited to, the use of professional support (eg, therapist),33 46 spirituality,40 45 religion,41 45 muscle relaxation exercise,36 self-regulation activities,36 47 reflective journal writing,47 improvement of quality of work life,44 team work,26 33 45 meditation and attitude of gratitude development.36 37 41 48 Management strategies were highlighted in the literature as techniques to help OTDCs cope with and control consequences of burnout and CF, therefore supporting their well-being.

Value conflict

Value conflict describes the consequence of incompatible belief systems that can result in suffering and moral distress.4 50 We identified value conflict in nine papers.9 10 27 30 32 34 36 41 45 OTDCs have a constant focus on increasing donation rates; however, while trying to receive approval from donor families, they can face situations in which their attitudes might not be in accordance with their values.10 30 34 36 45 For instance, OTDCs are often requested to approach families when they believe it is not appropriate, but due to protocols and organisational pressure, they proceed with the approach against their beliefs.10 34 45 In some countries, OTDCs may face situations that violate ethical principles. One example is when families agree to donate the organs of their loved one since it is directed to a specific person, or only if the recipient is of a particular religion. By fulfilling those requests, OTDCs may experience emotional pain and guilt.30

Additionally, sometimes OTDCs know that the donor is not ideal for donation, but they are still told to go forward with the procedure by management, offering less than optimal organs for transplantation, slowing down the process for staff and the donor’s family.9 30 In unfortunate cases, patients declared brain dead receive less optimal and even precarious treatment by the care team since they do not see the point in continuing treatments, causing ethical and emotional conflicts among OTDCs and the care team.41 Some OTDCs do not declare themselves as donors even though they work towards increasing organ donation rates, claiming that they know how the system and procedures work.27 32 In an unremitting attempt to obtain organ donations, OTDCs sometimes end up facing frustration, disappointment and a feeling of helplessness during the organ donation process, resulting in value conflicts and moral distress.45 The constant exposure to conflicts between job demands and core values can make OTDCs susceptible to burnout.50

Emotional contradiction

Emotional contradiction is described as a conflict between enjoying and disliking the work and its tasks, which was identified in two papers.28 34 As mentioned previously, OTDCs have a high level of job satisfaction as their job provides a sense of achievement and fulfilment.9 31 32 However, there is a conflict where satisfaction and compromise may not be enough to counteract the difficulties and requirements involved in the OTDCs’ role.34 The amount of on-call work required from OTDCs can also impact this ambivalence.28 Therefore, due to their demanding clinical practice, OTDCs may face challenges while trying to balance positive and negative feelings toward work requirements and roles.

Job engagement

Job engagement was described as the extent of a work-related state of mind where HCPs feel enthusiastic and energetic about their job, and it can include aspects such as satisfaction, vigour, fulfilling, motivation and dedication.51 52 We identified various aspects of job engagement in 10 papers.9 12 23 26 31 32 35 44 45 53 OTDCs can be negatively affected by stressors in the workplace, but their job also brings positive aspects that help them to overcome obstacles and to build work resilience.45 Resilience can be defined as the ability to recover from difficult situations, and this process can involve the use of coping strategies and protective factors.4 OTDCs describe themselves as having great levels of resilience, as even though they suffer the emotional impact from work situations, they still have the ability to recover and keep working.45 53 Job satisfaction has a positive influence on resilience, and even with stressors and workloads, OTDCs are considered to have a high level of job satisfaction because their job provides a sense of achievement, gratitude, excitement, recognition and fulfilment.9 12 23 26 31 32 35 44 Job characteristics such as work hours, on-call schedule, workload, stress and compensation can directly impact the job satisfaction level among OTDCs.31 53 Also, the quality of work-life was found to have a positive impact on employee morale, satisfaction and retention.44 Therefore, job engagement can impact OTDC resilience and job satisfaction and, if this influence is positive, it can result in increased retention rates.