Journal of Nursing Management, 2014, 22, 519–531

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 (Clinical), PhD

3
,
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
1
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 (2014) Journal of Nursing

DRURY V., CRAIGIE M., FRANCIS K., AOUN S. & HEGNEY D.G.
Desley G. Hegney Management 22, 519–531.
School of Nursing and Midwifery Compassion satisfaction, compassion fatigue, anxiety, depression and
Curtin Health Innovation stress in registered nurses in Australia: phase 2 results
Research Institute
Curtin University
Sir Charles Gairdner Hospital Aim This is the first two-phase Australian study to explore the factors impacting
GPO Box U1987 upon compassion satisfaction, compassion fatigue, anxiety, depression and stress
Perth and to describe the strategies nurses use to build compassion satisfaction into
WA 6845 their working lives.
Australia Background Compassion fatigue has been found to impact on job satisfaction,
E-mail: desley.g.hegney@gmail. the quality of patient care and retention within nursing. This study provides new
com 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 nurse’s 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
ª 2013 John Wiley & Sons Ltd 519
V. Drury et al.
Introduction
The concept of compassion fatigue (CF) emerged in
the early 1990s in North America to explain a phe-
nomenon observed in nurses employed in emergency
departments (EDs) (Hooper et al. 2010). A precursor
to burnout, CF is a well-known phenomenon associ-
ated 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 turn-
over 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 phe-
nomenon that disrupts lives, destroys careers and
adversely impacts on organisations (Henry & Henry
2004, Maytum et al. 2004, Sabo 2006, Aycock & Bo-
yle 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 Austra-
lian nurses, and as our previous work into the Austra-
lian 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 under-
took 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 post-
traumatic 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 work-
place 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 con-
structs were in our sample, which is reported else-
where (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 strat-
egies that could be used to build and maintain psycho-
logical 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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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 ‘abduction–intersubjec-
tivity–transferability’ 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 quanti-
tative and qualitative philosophical positions and
provides ontological and epistemological explanations
for mixed-methods research (Johnson et al. 2007).
Research questions for this study
What are the factors that lead to compassion satisfac-
tion, 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 follow-
up focus group or individual interview. These inter-
views 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 there-
fore participated in Phase 2. Of this number, five
nurses opted for either a face-to-face (three) or tele-
phone (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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Compassion of registered nurses in Australia
Data collection
Interviews and the focus group were guided by a semi-
structured interview guide to encourage discussion.
The guide contained questions that explored partici-
pants’ feelings about the study concepts (compassion
satisfaction, STS, anxiety, depression and stress) and
asked them to identify strategies that might be imple-
mented to alleviate or minimise some of the stressors
expressed by participants and build psychological well-
ness. 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:
● 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 inter-
views took approximately 60 minutes and the focus
group approximately 90 minutes. The focus group
and interviews were led by the same experienced facil-
itator. 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 consult-
ing 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 Clarke’s the-
matic 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 trust-
worthiness was demonstrated.
The criteria for trustworthiness are auditability, fit-
tingness 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 find-
ings 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 pro-
vided 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 inter-
view 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 build-
ing 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 you’re
having a bad day’.
(Participant 1)
‘When you have a trauma, or something that’s
affecting, everybody supports each other and we
talk to each other and it often comes through, if
it’s after hours, we get told who was involved,
so that we can keep, we track, that’s 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; how-
ever, the junior nurses were ambivalent about the
support provided:
‘There’s no mentoring, there’s no clinical
[support]’.
(Participant 4)
‘Our CNS is very good, she was a, she’s quite new
to the role, she was a staff development nurse, so
she’s had experience of being the one, the other
nurses would come in and complain about the work
we’ve been having and this and that, so I think she’s
a bit more understanding, which is good. Nurse
managers can have a big impact on you’.
(Participant 1)
‘When there’s 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 don’t [think there is support for junior nurses]
and I don’t think there’s support there for the
older nurses’.
(Participant 2)
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However, when senior staff were acknowledged for
providing support, including positive feedback, junior
staff perceived it as helping to alleviate stress, espe-
cially 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
you’re all under a lot of stress … their
acknowledgement – it’s good to get it from
management’.
(Participant 3)
Family support was essential; however, most partici-
pants 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, who’s a, who’s just
recently retired, she was a midwife’.
(Participant 1)
‘My sister and I are very close, and she’s a nurse
as well, she works in ED and we, we bounce off
each other a lot and so I’ve got my sort of, I’ve
got an inbuilt debrief basically’.
(Participant 3)
Infrastructure and support
The importance of support and infrastructure was per-
ceived as being essential to facilitating coping among
the nursing workforce. There was a heated discussion
concerning access to the workplace, relating specifi-
cally 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 20–30 minutes of travel time to each
nurse’s 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 late–early shifts. It was also mentioned by
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Compassion of registered nurses in Australia
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)
‘… you’ve just worked five shifts in a row and
you probably do three earlies at that time and
you’d have a late early, and you’d get home at
10 o’clock at night and you’ve just been running
around the whole shift and you couldn’t wind
your brain down until midnight and then the
alarm going off at 6 o’clock in the morning, you
know, you’ve been dreaming about work all
night and then you’re 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 don’t start until 3 o’clock, so you
don’t 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 who’s not
coming in till 3 o’clock. So there’s often an over-
lap, and it’s probably not always used, because
it’s so busy, you know, the morning staff might
want to sit down and write their notes. I know
the concept is that there’s this overlap of at least
an hour or so, but realistically, it’s 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
523
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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:
‘There’s 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 I’ve just basically
stopped, I did one yesterday, and it’s the first
one I’ve done in about 3 years, because I just
think it’s so unfair. And I only work part-time,
but I think to come in on your precious days off,
unpaid, invariably you’re really only benefiting
yourself, which okay, yes, hopefully it will bene-
fit your patients and colleagues, but I think it’s
just asking a little bit too much, on top of what
we’re already asked to do every time we turn up
for work’.
(Participant 1)
Environment and lifestyle
Some participants identified that the working environ-
ment 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 reliev-
ing today?”, because everyone was going reliev-
ing every shift, I think it was around last
Christmas time. I found that quite stressful’.
(Participant 1)
‘… working with people you don’t know. I sup-
pose it’s 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 work-
ing in a different area of the unit:
‘So that you’re aware of it, so that you follow
up with them, with internally, and just monitor
between sick leave and performance, if some-
thing’s impacting on them’.
(Participant 3)
524
‘We try and rotate them so they’re not on that
area, because if the patient’s there for days at a
time, and if you’ve had a bad day the day
before, you really don’t 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 previ-
ously stated. All nurses have to complete mandatory
training and a specific number of professional develop-
ment 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, we’re expected to do it,
it’s mandatory, and we’re not given paid time to
do it, we’ve got to do it in your own time, at
work because you can’t do it at home, and it’s 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 opportu-
nities were not available:
‘… working most of the weekend, it’s not educa-
tional on the weekends anyway, because they do
Monday to Friday education sessions in that
cross-over time, but that doesn’t happen on a
Saturday or Sunday, which are the main days I
work, so I think something to cover those week-
end staff I think would be good’.
(Participant 2)
‘I … never get to use the hospital library or any-
thing like that anyway, but certainly like the
daily tutorials that they do, I don’t really have
anything to do with them’.
(Participant 3)
Leadership
Role modelling by more experienced staff was per-
ceived 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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Journal of Nursing Management, 2014, 22, 519–531

innovative and challenged them. While some partici-
pants viewed role models as clinical coaches, the out-
comes 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 men-
tor’.
(Focus group participant)
‘Observing senior experienced nurses dealing
with those reactions’.
(Participant 2)
‘I do coaching in every sector, like phoning a rel-
ative to tell them that somebody’s died; junior
nurses [saying] “Oh my God, I’m 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 per-
ceived that there was little education available to
assist in skill updates, especially, as previously men-
tioned, for those nurses working outside normal busi-
ness 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
you’re just looking out for them as well because
of the unknown’ .
(Participant 3)
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Compassion of registered nurses in Australia
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:
‘We’ve got people who are in coordinating posi-
tions who think coordinating is all about the
computer; it’s 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 I’m
worrying a lot when I’m at work’.
(Participant 2)
While participants mentioned that taking allocated
breaks was essential in managing stress, some partici-
pants 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 partici-
pants. Symptoms such as fatigue, frustration, anger,
525
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 you’re lacking sleep’.
(Participant 4)
‘… it is difficult to wind down as well when you
haven’t 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 sup-
port 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:
‘… it’s 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, I’m
more comfortable now, you really helped me
when I first came here, I don’t know what I
would’ve 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 refo-
cusing; and education on coping.
Although the staff are able to access external coun-
selling services at no cost, participants spoke disparag-
ingly about these services and most said they would
not use them. A pastoral care person who was avail-
able 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 build-
up 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 envi-
ronment, if it’s possible, you know, and say,
just, here’s a little place for you to go’.
(Participant 1)
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 519–531

‘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 aren’t safe spots, but spots where you’re
interrupted’.
(Participant 5)
Mentoring or coaching of junior staff by more expe-
rienced 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 doesn’t 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 work-
place. Although there were varying opinions on how
these sessions should be delivered, it was clear that
short sessions of 20–30 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 clin-
ical 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.
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 519–531
Compassion of registered nurses in Australia
2006). Investing in programmes that prepare clinical
leaders, including mentors, preceptors and clinical
supervisors, benefits the general workforce. The litera-
ture contends that nurse leaders use mentorship to
develop leadership potential in others (McCloughen
et al. 2011), and that a true mentor promotes a posi-
tive 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 neces-
sary 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 barri-
ers to professional development (Gibson 2002); how-
ever, more recently leadership styles have been found
to influence staff perceptions of professional develop-
ment (Hughes 2005). Increasing quarantined work
time to complete the required professional develop-
ment 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
work–life balance. The importance of family as both a
support network and also as a cause of anxiety, par-
ticularly 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 nurse’s experi-
ence, there were seven themes shared by all partici-
pants 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 Heg-
ney et al. (2008). The findings are also consistent with
other research literature on factors that build resil-
ience (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 enhanc-
ing coping and resilience in the workplace are sup-
ported 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 strate-
gies 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 allevi-
ation and emotion regulation in nurses. Mindfulness is
the ability to pay attention to the present moment,
and relate to one’s 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 symp-
tom 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 psycho-
social interventions aimed at stress reduction and resil-
ience 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.
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 representa-
tive of the general Australian nursing workforce, which
is older and generally works part-time (Health Work-
force 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, com-
munity, aged care) in Australia, as well as in other
countries with a different culture to Australia (e.g. Sin-
gapore, Canada, Mexico). These future studies will
enable a larger sample size from multiple sites through-
out Australia (for the quantitative component) and will
include other countries with different cultures. Addi-
tionally, 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
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 posi-
tive states (compassion satisfaction).
The findings of this study (studies one and two)
indicate that a model of resilience, rather than com-
passion satisfaction, would enable nurses to work in
the challenging nursing environments of the twenty-
first century. Resilient nurses will not only remain in
the nursing workforce but will also provide higher-
quality 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 resil-
ient nursing workforce. Specifically, the data provide
guidance on methods that may be implemented to
build individuals’ resilience. These include:
● 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 sup-
port, and also creating such spaces that enable staff
to withdraw for short periods, is therefore recom-
mended.
● Being taught coping techniques to manage work
and personal stress. These techniques could include
techniques for recognising anxiety, stress, depres-
sion, 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 teach-
ing spaces, that are accessible at all times of the day
and night.
● Promoting a positive workplace that values staff.
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 519–531

● Providing a family-friendly work environment to
accommodate the needs of a diverse and predomi-
nantly female workforce.
The major finding of this study, and the major con-
tribution 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 resil-
ience. Rather, the data themselves led us to this find-
ing. Further work of this team includes a wider study
to explore resilience in the nursing workforce (includ-
ing the student nursing workforce) that will include a
resilience scale (such as the Connor–Davidson Resil-
ience 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, Korn-
haber & Wilson 2011, Mealer et al. 2012, Taylor &
Reyes 2012), we have also developed, and are cur-
rently 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 partic-
ipated in the study hospital. In-kind support was pro-
vided by Dr V. Drury, Dr M. O’Connor, 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.
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 519–531
Compassion of registered nurses in Australia
Ethical approval
Ethical approval was obtained from Sir Charles Gaird-
ner Hospital, HREC Trial No: 2011-160.
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