Journal of Nursing Management, 2014, 22, 519531

Compassion satisfaction, compassion fatigue, anxiety,

depression and stress in registered nurses in Australia: Phase 2
results
VICKI DRURY B H l t h S c ( N s g ) , B A ( E d ) , M C l N s g ( M H ) , P h D 1,2, MARK CRAIGIE B S c ( H o n s ) , M P s y c h
KAREN FRANCIS R N , D i p H l t h S c N s g , B H l t h S c N s g , G r a d C e r t U n i T e a c h / L e a r n , M H l t h S C P H C , M e d P h D 4,
SAMAR AOUN B S c ( H o n s ) , M P H , P h D 5 and DESLEY G. HEGNEY R N , R M , B A ( H o n s ) , P h D 6

(Clinical), PhD

Principal Consultant, Educare Consulting, Bunbury, WA, Australia, 2Adjunct Senior Research Fellow,
Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,
3
Adjunct Senior Lecturer, School of Nursing and Midwifery, Curtin University, Perth, WA, 4Professor and Head
of School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Wagga Wagga, NSW,
5
Professor of Palliative Care and 6Professor of Nursing, Curtin University, School of Nursing and Midwifery,
Perth, WA, Australia

Correspondence
Desley G. Hegney
School of Nursing and Midwifery
Curtin Health Innovation
Research Institute
Curtin University
Sir Charles Gairdner Hospital
GPO Box U1987
Perth
WA 6845
Australia
E-mail: desley.g.hegney@gmail.
com

(2014) Journal of Nursing

Management 22, 519531.
Compassion satisfaction, compassion fatigue, anxiety, depression and
stress in registered nurses in Australia: phase 2 results

DRURY V., CRAIGIE M., FRANCIS K., AOUN S. & HEGNEY D.G.

Aim This is the first two-phase Australian study to explore the factors impacting
upon compassion satisfaction, compassion fatigue, anxiety, depression and stress
and to describe the strategies nurses use to build compassion satisfaction into
their working lives.
Background Compassion fatigue has been found to impact on job satisfaction,
the quality of patient care and retention within nursing. This study provides new
knowledge on the influences of anxiety, stress and depression and how they relate
to compassion satisfaction and compassion fatigue.
Method In Phase 2 of the study, 10 nurses from Phase 1 of the study participated
in individual interviews and a focus group. A semi-structured interview schedule
guided the conversations with the participants.
Result Data analysis resulted in seven main themes: social networks and support;
infrastructure and support; environment and lifestyle; learning; leadership; stress;
and suggestions to build psychological wellness in nurses.
Conclusion Findings suggest that a nurses capacity to cope is enhanced through
strong social and collegial support, infrastructure that supports the provision of
quality nursing care and positive affirmation. These concepts are strongly linked
to personal resilience.
Implications for nursing management These findings support the need for
management to develop appropriate interventions to build resilience in nurses.
Keywords: anxiety, compassion fatigue, focus groups, nurses
Accepted for publication: 18 July 2013

DOI: 10.1111/jonm.12168
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519

V. Drury et al.

Introduction
The concept of compassion fatigue (CF) emerged in
the early 1990s in North America to explain a phenomenon observed in nurses employed in emergency
departments (EDs) (Hooper et al. 2010). A precursor
to burnout, CF is a well-known phenomenon associated with emotional exhaustion, depersonalisation and
an inability to work effectively (Stamm 2010). The
symptoms of CF develop over time, are varied and
include sadness, depression, anxiety, intrusive images,
flashbacks, numbness, avoidance behaviours, cynicism
and poor self-esteem (Stamm 2010). In nurses, CF has
been shown to reduce productivity, increase staff turnover and sick days and lead to patient dissatisfaction
and risks to patient safety (Hooper et al. 2010).
The prevalence of CF among nurses in Australia is
poorly understood, although evidence from North
American studies indicates that it is a very real phenomenon that disrupts lives, destroys careers and
adversely impacts on organisations (Henry & Henry
2004, Maytum et al. 2004, Sabo 2006, Aycock & Boyle 2008, Bush 2009, Ainsworth & Sgorbini 2010,
Coetzee & Klopper 2010, Hooper et al. 2010, Potter
et al. 2010, Beck 2011, Boyle 2011). Much of the
nursing research to date has been undertaken in North
America. There is a need for studies to be undertaken
to determine whether this condition is experienced in
other similar and dissimilar cultural contexts. As there
have been no published studies in this area on Australian nurses, and as our previous work into the Australian nursing workforce suggested that these concepts
could be an influence on nurse retention (Hegney
et al. 2006, 2013, Eley et al. 2007, 2010, 2013),
we conducted a preliminary study in one Australian
hospital. As there is evidence that suggests people
experiencing CF respond to intervention, we undertook the study to first ascertain whether CF was
occurring in Australian nurses and whether the levels
were significant. If this was the case, we then planned
to undertake an intervention to build compassion
satisfaction.

Background
The psychological well-being of nurses is important
for several reasons. First, the demanding nature of
nursing work means that nurses are exposed to both
acute and chronic stressors, which can lead to posttraumatic stress disorder or secondary traumatic stress
(STS). The latter disorder is linked to the concept of
CF, which is comprised of both STS and burnout
520

(Radey & Figley 2007, Hooper et al. 2010, Showalter

2010, Stamm 2010). Other psychological states that
have been linked to stressors within the nursing workplace include anxiety and depression. Psychological
states such as anxiety, depression, PSTD, STS and
burnout not only limit the care nurses can provide but
also pose a threat to patient safety (Mealer et al.
2012). Second, nurses who exhibit changes to their
psychological well-being are more likely to resign
from the nursing workforce, or may reduce their
employment fraction, which has an economic cost to
employers of nurses (Mealer et al. 2012). In view of
the current and projected shortages of nurses, both in
Australia and internationally, it is imperative that
nurses be retained within the workforce. Third, the
few studies that have been conducted into resilience (a
positive construct linked to psychological wellness) in
nurses all noted that how nurses can become and
remain resilient is poorly understood (Gillespie et al.
2007, Mealer et al. 2012).
In this study we first set out to assess the level of CF
(STS and burnout), compassion satisfaction, anxiety,
stress and depression in a purposive selected sample of
nurses in one tertiary teaching hospital in Australia.
The study had two phases: Phase 1 used a self-report
survey to gather data on how common these constructs were in our sample, which is reported elsewhere (Hegney et al. 2013); Phase 2 of the study, the
focus of this paper, was designed to explore the factors
impacting upon CF, compassion satisfaction, anxiety,
depression and stress identified in Phase 1 of the study,
and to gather from the nurses information on the strategies that could be used to build and maintain psychological wellness. If the data indicated a need, Phase 3
of the study would aim to develop, implement and
evaluate an intervention to facilitate positive coping in
nurses experiencing CF, depression, stress and anxiety.

Purpose
The purpose of this paper is to report the findings
from Phase 2 of this study, which explored the factors
impacting on compassion satisfaction, CF (STS and
burnout), anxiety, depression and stress through focus
group interviews.

Theoretical framework
This is a three-phase mixed-method study underpinned
by pragmatism (Johnson & Onwuegbuzie 2004, Doyle
et al. 2009). Defined as research that integrates
qualitative and quantitative approaches, methods and
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Compassion of registered nurses in Australia

concepts in a single study (Johnson & Onwuegbuzie

2004), mixed-method research has emerged as a third
research paradigm (Johnson et al. 2007). Morgan
(2007 p. 72) describes mixed-method research as
enabling researchers to take an abductionintersubjectivitytransferability approach, whereby the researcher
works backwards and forwards between a qualitative
approach of induction and subjectivity and quantitative
approach of deduction and objectivity which he calls
abductive reasoning. Pragmatism thus provides the
researcher with a philosophical approach that combines
the traditions and viewpoints of the traditional quantitative and qualitative philosophical positions and
provides ontological and epistemological explanations
for mixed-methods research (Johnson et al. 2007).

Data collection
Interviews and the focus group were guided by a semistructured interview guide to encourage discussion.
The guide contained questions that explored participants feelings about the study concepts (compassion
satisfaction, STS, anxiety, depression and stress) and
asked them to identify strategies that might be implemented to alleviate or minimise some of the stressors
expressed by participants and build psychological wellness. A semi-structured interview sheet was sent to all
participants prior to each interview/focus group to
allow each nurse to reflect on the questions, which
were:

Research questions for this study

What are the factors that lead to compassion satisfaction, CF, anxiety, depression and stress in nurses?
What strategies could be used to build and maintain
psychological wellness in nurses?

Method
Nurses who had participated in Phase 1 of the study
were given the opportunity to participate in a followup focus group or individual interview. These interviews were scheduled in October and November 2012.

Participants and setting

Of the 132 nurses who completed the survey in Phase

1, 15 nurses indicated a willingness to be involved in
the focus group/interviews. However, five were unable
to be contacted (two) or no longer wished to be
involved in Phase 2 (three). A total of 10 nurses therefore participated in Phase 2. Of this number, five
nurses opted for either a face-to-face (three) or telephone (two) interview and the remaining five nurses
participated in a focus group. Three of the nurses were
employed part-time and seven were senior nursing staff
(clinical nurse consultants, nurse practitioners, nursing
unit managers, nurse educators). All the nurses in the
focus group were senior clinical nurses. The remaining
three nurses had been in nursing for <5 years. One
nurse, from a ward area, had been in nursing for over
40 years. The nurses worked in the ED, intensive care
unit, high-dependency unit and the medical ward. No
participants were currently working in the outpatient
oncology area. The study took place in an acute tertiary
hospital in a capital city in Australia.

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How do you recognise stress?

Is your personal and professional life affected by
job-related stress? (Explore).
Is your personal and professional life affected by
personal-related stress? (Explore).
What are the coping skills you use?
Tell us about when you felt anxious at work; what
was going on at the time?
Tell us about what makes you feel good or less
good about nursing work.
Tell us what your day is like when it is a good day
or a less good day.
Tell us about a time when you felt emotionally or
physically exhausted from your work.
What material and/or human resources are used at
work when you feel stressed?
Your education and work skills (do you need
more)?
What are the characteristics of an intervention
to build psychological wellness (how many weeks,
how many hours per week, what should be
included)?
Is there anything else you want to share with us?

Each interview began with these questions but then

explored other issues that the nurses raised. The interviews took approximately 60 minutes and the focus
group approximately 90 minutes. The focus group
and interviews were led by the same experienced facilitator. Interviews and the focus group were informal
and held during the working day. Following each
interview and focus group, data were transcribed
verbatim. To reduce analysis bias, two researchers
undertook separate analysis of the data. Following
separate analysis, the two researchers met and were
able to agree on the common themes without consulting a third researcher. Transcripts were not sent to the
participants to validate.
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V. Drury et al.

Data analysis
Data analysis was guided by Braun and Clarkes thematic analysis method and NVivo9 software assisted
researchers to manage the data (Braun & Clarke 2006).
The method involved: (1) data were read and re-read;
(2) initial codes were noted; (3) themes were identified
and codes collapsed into themes; (4) themes were
refined and collapsed further; (5) main themes were
defined; and (6) a report on the findings was written.

Analytical rigour
Rigour was demonstrated by ensuring transparency in
research methods and allowing the method and audit
trail to be scrutinised by other members of the
research team. By ensuring that the methodological
steps were followed, quality was ensured and trustworthiness was demonstrated.
The criteria for trustworthiness are auditability, fittingness and dependability. Auditability is the degree
to which the methodological stages are transparent
and other researchers would be able to track the
research (Taylor & Kermode 2006). In this study the
decision trail has been open, and included in the final
research report, to indicate and clarify why decisions
were made. Fittingness is the extent to which findings from this study can fit into another context; for
example, nurses in another hospital or country (Taylor
& Kermode 2006). Fittingness will be demonstrated
when other nurses identify with the findings in the
study. Dependability refers to the stability of data
over time (Polit & Beck 2006) and will be judged by
readers after dissemination of the findings.

Ethics
Ethical approval for all phases of the study was provided by and the Human Research Ethics Committee
of Sir Charles Gairdner Hospital and the University of
Western Australia and adhered to the tenets of the
Declaration of Helsinki. Written and verbal consent
was taken prior to the commencement of each interview and focus group to audiotape the interviews and
focus groups.

Results
Participants feedback from the interviews and the
focus group were grouped under seven themes:
(1) social networks and support; (2) infrastructure and
support; (3) environment and lifestyle; (4) learning;
522

(5) leadership, (6) stress; and (7) suggestions for building psychological wellness in nurses.

Social networks and support

All participants highlighted the significant role that
social networks and peer support played in helping
them manage the day-to-day stressors of working as a
nurse in a tertiary hospital. The use of informal
debriefing and incidental mentoring by peers was a key
factor in enabling nurses to carry on with their work:
Being able to bounce off each other when youre
having a bad day.
(Participant 1)
When you have a trauma, or something thats
affecting, everybody supports each other and we
talk to each other and it often comes through, if
its after hours, we get told who was involved,
so that we can keep, we track, thats not the
right word, we touch base with them.
(Participant 2)
Senior nurses spoke at length of the support they
provided for junior or less experienced nurses; however, the junior nurses were ambivalent about the
support provided:
Theres no
[support].

mentoring,

theres

no

clinical

(Participant 4)
Our CNS is very good, she was a, shes quite new
to the role, she was a staff development nurse, so
shes had experience of being the one, the other
nurses would come in and complain about the work
weve been having and this and that, so I think shes
a bit more understanding, which is good. Nurse
managers can have a big impact on you.
(Participant 1)
When theres a clinical incident, then we come
out as seniors to help take the pressure off them,
as having to deal with it constantly.
(Focus group participant)
It was perceived by one participant that there was
no support for either level of nurse:
I dont [think there is support for junior nurses]
and I dont think theres support there for the
older nurses.
(Participant 2)
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Compassion of registered nurses in Australia

However, when senior staff were acknowledged for

providing support, including positive feedback, junior
staff perceived it as helping to alleviate stress, especially if it was provided in a timely manner at the end
of a difficult shift:
Even our bosses actually, you know, when we
have our morning sort of thing and it has been
a crazy day, they will thank us at the start of
the shift and say we have looked at how those
last 3 days have been so busy and we know
youre all under a lot of stress their
acknowledgement its good to get it from
management.
(Participant 3)
Family support was essential; however, most participants felt unable to discuss issues relating to their
work with family and friends, due to the confidential
nature of the work. Participants also identified that it
was difficult to discuss work matters with non-nurses,
as they simply could not understand what the job
entailed, or the nature of the work. However, two
participants who had family members who were
nurses described how they used each other to debrief
and provide support:
Talk to my mum a lot, whos a, whos just
recently retired, she was a midwife.
(Participant 1)
My sister and I are very close, and shes a nurse
as well, she works in ED and we, we bounce off
each other a lot and so Ive got my sort of, Ive
got an inbuilt debrief basically.
(Participant 3)

Infrastructure and support

The importance of support and infrastructure was perceived as being essential to facilitating coping among
the nursing workforce. There was a heated discussion
concerning access to the workplace, relating specifically to parking and public transport. At the time of
the study, nurses were parking off-site and then using
an employee-provided bus to travel to work. This
added about 2030 minutes of travel time to each
nurses day. However, since the data were collected, a
multi-story car park has been completed, negating
most of the concerns about access.
Of particular concern to most participants was the
tiredness they experienced from working shift work in
particular lateearly shifts. It was also mentioned by
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two (junior nurse) participants that it was difficult to

take annual leave at chosen times, due to a lack of
staff. This was not corroborated, however, by the
senior nurses, who identified that annual leave
provided an opportunity to take some time off and
re-energise:
doing the late earlies is just physically and
emotionally exhaust(ing).
(Participant 1)
youve just worked five shifts in a row and
you probably do three earlies at that time and
youd have a late early, and youd get home at
10 oclock at night and youve just been running
around the whole shift and you couldnt wind
your brain down until midnight and then the
alarm going off at 6 oclock in the morning, you
know, youve been dreaming about work all
night and then youre straight back into it the
next morning.
(Participant 2)
Participants identified that there was opportunity to
attend professional development study days and to do
self-directed learning packages. They felt, however,
that the low number of study days meant that they
were obliged to complete the packages in their own
time, which some were not always willing to do.
Although it was identified that the handover period
could be used, participants all stated that the reality
was that this often was simply not possible, due to the
business of the ward:
Staff, they dont start until 3 oclock, so you
dont have an overlap, so the coordinator has to
do, take care of them, or another nurse would
have to pick up the load of the person whos not
coming in till 3 oclock. So theres often an overlap, and its probably not always used, because
its so busy, you know, the morning staff might
want to sit down and write their notes. I know
the concept is that theres this overlap of at least
an hour or so, but realistically, its not often that
people are just sitting around and just doing
things or not doing things.
(Participant 3)
Participants who worked part-time or were less
experienced identified that undertaking professional
development was difficult. They expressed anger that
they had to do it in their own time and verbalised that
they rarely participated in study days other than the
mandatory training. Furthermore, they identified that
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V. Drury et al.

online or package learning simply meant that they

would have to accomplish the learning in their
own time at home, which was not conducive to family
life:
Theres plenty of access, but after your 2 days
are up, you do it on your own time and I really
strongly disagree with that. So Ive just basically
stopped, I did one yesterday, and its the first
one Ive done in about 3 years, because I just
think its so unfair. And I only work part-time,
but I think to come in on your precious days off,
unpaid, invariably youre really only benefiting
yourself, which okay, yes, hopefully it will benefit your patients and colleagues, but I think its
just asking a little bit too much, on top of what
were already asked to do every time we turn up
for work.
(Participant 1)

Environment and lifestyle

Some participants identified that the working environment could invoke significant anxiety. For example,
staff identified that being asked to relieve on other
wards when their own area was quiet made them
uncomfortable and apprehensive. In these cases the
nurses spoke of feeling very anxious:
When the unit was quiet, I used to get quite
anxious coming into work, going, am I relieving today?, because everyone was going relieving every shift, I think it was around last
Christmas time. I found that quite stressful.
(Participant 1)
working with people you dont know. I suppose its just fear of the unknown, you know,
being put out of your comfort zone.
(Participant 2)
Most participants felt that they looked out for
their peers and were able to identify when they were
having a bad day or when they were stressed. In these
circumstances they provided support, often through
ensuring a different environment the following shift,
for example, either having different patients or working in a different area of the unit:
So that youre aware of it, so that you follow
up with them, with internally, and just monitor
between sick leave and performance, if somethings impacting on them.
(Participant 3)

524

We try and rotate them so theyre not on that

area, because if the patients there for days at a
time, and if youve had a bad day the day
before, you really dont want to see [them].
(Focus group participant)

Learning
The construct of learning overlapped with several
other constructs. The ability to undertake formal
learning was hindered by time and access, as previously stated. All nurses have to complete mandatory
training and a specific number of professional development activities annually in order to register annually.
Some participants struggled to achieve licensure
requirements and most reported that they completed
the necessary activities in their own time:
the online component of education at this
hospital is a nightmare, were expected to do it,
its mandatory, and were not given paid time to
do it, weve got to do it in your own time, at
work because you cant do it at home, and its a
joke.
(Participant 3)
It was also mentioned by a number of participants
that staff development was not available outside of
business hours. For part-time staff who often worked
weekends and night shifts, staff development opportunities were not available:
working most of the weekend, its not educational on the weekends anyway, because they do
Monday to Friday education sessions in that
cross-over time, but that doesnt happen on a
Saturday or Sunday, which are the main days I
work, so I think something to cover those weekend staff I think would be good.
(Participant 2)
I never get to use the hospital library or anything like that anyway, but certainly like the
daily tutorials that they do, I dont really have
anything to do with them.
(Participant 3)

Leadership
Role modelling by more experienced staff was perceived by all participants as being invaluable. Senior
participants articulated their own memories of
role models who had inspired them and who were
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Compassion of registered nurses in Australia

innovative and challenged them. While some participants viewed role models as clinical coaches, the outcomes of having access to these staff were consistent
that of support, mentorship and improving the
practice environment.
I still remember my charge nurse being my mentor.
(Focus group participant)
Observing senior experienced nurses dealing
with those reactions.
(Participant 2)
I do coaching in every sector, like phoning a relative to tell them that somebodys died; junior
nurses [saying] Oh my God, Im appalled and
I say, Sit with me and listen.
(Participant 5)

Stress
This theme had two sub-themes: causes of stress and
mediators of stress.
Causes of stress
Diverse causes of stress were mentioned; however, the
main factors identified were skill deficits, family issues
and patient-related issues, such as aggression and
dying patients.
Skill deficits were viewed by many as being the
major cause of stress. This was especially so for those
nurses working part-time or who had recently
returned to the workplace after time away. It was perceived that there was little education available to
assist in skill updates, especially, as previously mentioned, for those nurses working outside normal business hours. Furthermore, lack of staff, working extra
shifts and a high quota of agency staff on shifts
invoked anxiety to regular staff:
I felt anxious just about my skill level and was I
up to scratch to cope with whatever patient that
I might receive?
(Participant 1)
You know even when I look at it [roster], I see
actually lots of people who are agency staff and
I say you know all the more senior girls are
keeping an eye on them as well..you know
youre just looking out for them as well because
of the unknown .
(Participant 3)
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Although participating senior staff perceived that

they were helpful and supportive to junior staff, this
was not always the view of the less experienced nurses,
who spoke of co-ordinators who concentrated on
administrative tasks and were not available to staff. All
the participants identified that developing a rapport
with other staff (especially between senior and junior
staff) was essential in managing stress and providing
support:
Weve got people who are in coordinating positions who think coordinating is all about the
computer; its all about keeping the white board
right up-to-date, writing absolutely neatly and
all that stuff that purely a clerk could do.
(Participant 1)
Family issues were highlighted as a major stressor,
especially for those staff with young children. The lack
of after-hours child care and no family combined with
husbands who worked away or also worked shift
work was a major issue. Participants spoke of being
distracted at work due to concern for a sick child, even
when the child was cared for by a family member:
most of my stress levels, I think, come from
caring for young kids, more so than work I do
in my field.
(Participant 1)
I find it stressful going to work when the kids
are sick and leaving them in the care of my
husband or somebody else. Um, I find that Im
worrying a lot when Im at work.
(Participant 2)
While participants mentioned that taking allocated
breaks was essential in managing stress, some participants mentioned that in previous workplaces they
often had not been able to take breaks. Participants
did not experience difficulties in taking their allocated
breaks at this institution, and this was perceived as
being very positive. The stress of not taking breaks
culminated in people leaving the previous institution
and taking sick days:
the last place I worked at, some shifts you
get 10 minutes and you were lucky to get to the
toilet for your whole shift. So the breaks are
good.
(Participant 4)
The physical and psychological symptoms of stress
in themselves and others were apparent to all participants. Symptoms such as fatigue, frustration, anger,
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V. Drury et al.

tears, distraction and being defensive were identified

as the major psychological indications of stress, while
the major physical symptoms were inability to wind
down after work, resulting in poor sleep, tight muscles
and feelings of physical exhaustion:
In the end you just get so tired and emotional
because youre lacking sleep.
(Participant 4)
it is difficult to wind down as well when you
havent got a moment to catch your breath.
(Focus group participant)
Mediators of stress
Despite what could be perceived as negative comments
indicating high stress levels and limited formalised support structures, none of the participants were planning
to leave nursing. Indeed, participants emphasised that
positive feedback by senior staff, and gratitude, verbally
or through cards from patients and family expressing
thanks, were the major reasons they remained in their
jobs:
its someone hearing or acknowledging you
as a person.
(Participant 1)
think probably feedback is an important
thing, from nurses and patients and doctors.
(Participant 1)
after being in the wards for a few weeks, [a
staff member] says, You really helped me, Im
more comfortable now, you really helped me
when I first came here, I dont know what I
wouldve done. Not just me, you know, others,
and, just getting that little bit of feedback, saying,
you know, I really appreciate you, being there
by my side and guiding me, that type of thing.
(Participant 4)
One nurse emphasised that she was still passionate
about nursing and that, despite all the difficulties she
experienced being a nurse, she continued to enjoy
nursing:
I want to give back to the profession. I have had a
wonderful career.

Suggestions to build psychological wellness in

nurses
Participants were asked to suggest interventions that
would facilitate stress management and minimise CF in
526

the workplace. Some participants mentioned the current

strategies they used, with the most common being to talk
to someone, usually a peer, whilst others spoke of having
some quiet time and trying to clear their minds.
In identifying an intervention, there were four main
strategies discussed by participants: a pastoral worker
(non-religious affiliated); mentoring/coaching as a
formalised process; a quiet area for reflection and refocusing; and education on coping.
Although the staff are able to access external counselling services at no cost, participants spoke disparagingly about these services and most said they would
not use them. A pastoral care person who was available for staff to drop in to see, and who had an
understanding of nursing-related issues, was perceived
to be able to offer a debriefing and support system
external to the ward and independent of management:
a pastoral care person for nurses.
(Participant 2)
be mindful, so they become more self-aware.
Participant 3)
Nursing is so in need of healing so in need of
healing I mean, if I could give kind of pastoral
care.
(Participant 4)
Once we can teach them how to cope with
nursing, they care for themselves and protect
themselves.
(Participant 5)
a peer support person.
(Focus group participant)
Participants described their work areas as being
both busy and noisy. While they acknowledged the
importance of the noise (beepers and machines),
they also identified that a quiet place where they
could take some time out, refocus and relax, even if
only for a few minutes, would help prevent a buildup of stress. Some participants mentioned that they
would go and sit in the toilet to do this. It was,
however, acknowledged that there was a rose garden
nearby that could be used during breaks for this
purpose:
just need to get out, you know, of the environment, if its possible, you know, and say,
just, heres a little place for you to go.
(Participant 1)
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Compassion of registered nurses in Australia

Quiet rooms and some aromatherapy.

(Focus group participant)
One participant mentioned that the room used for
debriefing was not private or conducive to discussion:
the areas that they can put you in debriefing
just arent safe spots, but spots where youre
interrupted.
(Participant 5)
Mentoring or coaching of junior staff by more experienced clinicians as a formalised process was viewed
as an essential strategy. The model appeared similar
to that of clinical supervision, whereby staff are able
to discuss clinical issues as well as their feelings. This
was considered important to staff at all levels:
mentor or a buddy for the more junior staff.
(Participant 3)
Someone senior is just as vulnerable as someone
junior, it doesnt matter.
(Focus group participant)
Education on coping and stress management and
dealing with conflict that included mindfulness and
meditation were viewed by all participants as being
integral to the future management of stress in the workplace. Although there were varying opinions on how
these sessions should be delivered, it was clear that
short sessions of 2030 minutes on the ward would be
welcomed and would provide a starting point:
conflict resolution would be really useful.
(Participant 3)
Coping skills and self-awareness.
(Participant 2)
A drop-in service, building personal coping
skills.
(Focus group participant)

Discussion
This study has explored nurses views and experiences
of stressors in a tertiary hospital in Western Australia.
Access to locally available mentors, preceptors or clinical supervisors that provide peer support was found
to reduce nurses stress, particularly when they were
asked to take on activities that they felt underprepared
for. This is consistent with the literature that argues
that mentoring promotes role and skill acquisition as
well as providing psychosocial support (Mills et al.
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Journal of Nursing Management, 2014, 22, 519531

2006). Investing in programmes that prepare clinical

leaders, including mentors, preceptors and clinical
supervisors, benefits the general workforce. The literature contends that nurse leaders use mentorship to
develop leadership potential in others (McCloughen
et al. 2011), and that a true mentor promotes a positive sense of self-concept in the mentee (McDonald
et al. 2010). Feeling supported at work and being able
to achieve personal goals was associated in this study
with positive perceptions of self and job satisfaction.
Professional development was accepted as a necessary and valuable aspect of nurses roles in this study;
however, the imposition of completing mandatory
training requirements was significant. Lack of time
and resources are cited in the literature as being barriers to professional development (Gibson 2002); however, more recently leadership styles have been found
to influence staff perceptions of professional development (Hughes 2005). Increasing quarantined work
time to complete the required professional development activities was highlighted by participants as one
strategy that would assist nurses meet this requirement
and ensure that they were able to achieve a realistic
worklife balance. The importance of family as both a
support network and also as a cause of anxiety, particularly when loved ones were ill or when child care
arrangements were compromised, was highlighted.
These findings confirm previous studies which found
that, despite the support provided by family members,
juggling family responsibilities was a major stressor to
nursing students (Drury et al. 2008).
In the context of each participating nurses experience, there were seven themes shared by all participants in this study. Five of these themes (social
networks and support; infrastructure and support;
environment and lifestyle; learning; and leadership)
are also reported in the resilience framework of Hegney et al. (2008). The findings are also consistent with
other research literature on factors that build resilience (Masten & Reed 2002, Haglund et al. 2007),
that is, nurses report that their stress management is
enhanced by the use of active self-coping strategies,
such as seeking social support from experienced peers
who could provide debriefing, positive feedback and
mentoring. In addition, emotion regulation skills, to be
more mindful, refocus and relax, were also identified
by participants as important processes that would assist
in stress alleviation. Together, these themes for enhancing coping and resilience in the workplace are supported by a growing body of research demonstrating
how multi-component behavioural interventions that
target problem solving, self-regulation, emotional
527

V. Drury et al.

awareness and building stronger relationships enhance

resilience (Seligman et al. 2005, 2006, 2009, Revich
et al. 2011). The importance of positive coping strategies to build resilience and retain the nursing workforce
has been highlighted in the literature and includes
personal and work-based support (Buykx et al. 2010).
A mindfulness-based intervention may be one such
approach that would facilitate coping, symptom alleviation and emotion regulation in nurses. Mindfulness is
the ability to pay attention to the present moment,
and relate to ones experience non-judgementally
(Kabat-Zinn 1990, Brown & Ryan 2003). A small but
growing body of research supports the benefits of
mindfulness training for stress management and symptom alleviation for professionals (Berger & Gelkopf
2011, Stanley et al. 2011, Wolever et al. 2012), nurses
and nurse aides (Mackenzie et al. 2006, Poulin et al.
2008) exposed to high levels of stress.
Despite the aforementioned, further research is
required to more fully determine the benefits of psychosocial interventions aimed at stress reduction and resilience building in nursing populations, and to address
the myriad practical delivery issues that will need to be
circumvented (e.g. time and resource constraints, shift
work, etc.). To assist with this need, the study team are
now undertaking a pilot intervention, building on these
results and the results of previous interventions, to
build and maintain resilience in nurses.

Conclusions and implications for nursing

management
This study aimed to first identify the factors that lead
to CF, compassion satisfaction, anxiety and stress and
to also ascertain what strategies Australian nurses
used to prevent and manage negative states (such as
anxiety, depression, stress, burnout) and to build positive states (compassion satisfaction).
The findings of this study (studies one and two)
indicate that a model of resilience, rather than compassion satisfaction, would enable nurses to work in
the challenging nursing environments of the twentyfirst century. Resilient nurses will not only remain in
the nursing workforce but will also provide higherquality patient care.
These data, therefore, provide direction to nurse
educators, administrators and nurse policy makers on
strategies that can be used to achieve a goal of a resilient nursing workforce. Specifically, the data provide
guidance on methods that may be implemented to
build individuals resilience. These include:

Limitations
Ten nurses participated in interviews and the focus
group. There are two main limitations to this study.
Firstly, the sample size, while being representative of
the nursing workforce at this hospital, is not representative of the general Australian nursing workforce, which
is older and generally works part-time (Health Workforce Australia 2013). Secondly, the sample was from
one acute-care tertiary hospital in one capital city in
Australia. Our planned future studies therefore include
nurses employed in a variety of settings (hospital, community, aged care) in Australia, as well as in other
countries with a different culture to Australia (e.g. Singapore, Canada, Mexico). These future studies will
enable a larger sample size from multiple sites throughout Australia (for the quantitative component) and will
include other countries with different cultures. Additionally, we believe that the qualitative findings would
be strengthened by interviewing nurses in other settings
and other countries (smaller hospitals, rural and remote
settings, community health care and aged care).

528

Accessibility to locally available pastoral carers to

debrief with, and/or being able to retreat to a quite
space to destress and reassess, are techniques that
participants suggested would improve their capacity
to manage and prevent the work and the workplace
from becoming overwhelming. Providing this support, and also creating such spaces that enable staff
to withdraw for short periods, is therefore recommended.
Being taught coping techniques to manage work
and personal stress. These techniques could include
techniques for recognising anxiety, stress, depression, burnout and STS, as well as providing tools to
assist when confronting difficult situations (such as
mindfulness).
Work-initiated programmes to promote efficacy
among nursing staff, delivered as short sessions and
provided at the ward level during working hours.
These education sessions should be accessible to
nurses who work part-time on shiftwork and at
weekends.
Providing formal and informal mentoring programmes,
particularly for nurses newly employed in the
workforce;
Organisational resources that are available for staff,
such as computers, library and learning and teaching spaces, that are accessible at all times of the day
and night.
Promoting a positive workplace that values staff.
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Compassion of registered nurses in Australia

Providing a family-friendly work environment to

accommodate the needs of a diverse and predominantly female workforce.

The major finding of this study, and the major contribution to knowledge, is the movement away from
compassion satisfaction towards a resilience model in
the individual nurse. While one investigator (Hegney)
has previously studied resilience in the community,
this study did not aim to specifically include resilience. Rather, the data themselves led us to this finding. Further work of this team includes a wider study
to explore resilience in the nursing workforce (including the student nursing workforce) that will include a
resilience scale (such as the ConnorDavidson Resilience Scale) and is carried out in diverse settings
within Australia and other developed and developing
countries.
Based on the findings of this study and informed by
previous work into resilience in nurses (Gillespie
2007, Jackson et al. 2007, Zander et al. 2010, Kornhaber & Wilson 2011, Mealer et al. 2012, Taylor &
Reyes 2012), we have also developed, and are currently trialling in the study hospital, an intervention
that aims to build individual resilience within the
workforce.

Acknowledgements
We acknowledge the support of the nurses who participated in the study hospital. In-kind support was provided by Dr V. Drury, Dr M. OConnor, Professor
David Hemsworth, Mr Tony Doolan, Ms Sue Davies
and the staff of the Centre for Nursing Research at Sir
Charles Gairdner Hospital Mrs Jan Low, Ms
Michelle Sin and Ms Linda Coventry.

Author contributions
All authors contributed to the manuscript: V. Drury,
K. Francis and D.G. Hegney were responsible for the
Methods, Results, Conclusion and Implications for
nursing management sections of the paper; K. Francis,
M. Craigie and S. Aoun were responsible for the
Introduction, Background and Discussion sections of
the paper; and all authors contributed to editing the
paper and provided input into the revisions.

Source of funding
This study was funded by the University of Western
Australia and Sir Charles Gairdner Hospital Perth.
2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 519531

Ethical approval
Ethical approval was obtained from Sir Charles Gairdner Hospital, HREC Trial No: 2011-160.

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