Journal of Nursing Management, 2014, 22, 506518

Compassion satisfaction, compassion fatigue, anxiety,

depression and stress in registered nurses in Australia:
study 1 results
DESLEY G. HEGNEY R N , R M , B A ( H o n s ) , P h D 1, MARK CRAIGIE B S c ( H o n s ) , M P s y c h ( C l i n ) , P h D 2,
DAVID HEMSWORTH C E T , B A S , B A , M B A , P h D 3, REBECCA OSSEIRAN-MOISSON M P h i l ( H e a l t h S c i ) 4,
SAMAR AOUN B S c ( H o n s ) , M P H , P h D 5, 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 ,
6
7
MHlthSCPHC, Med, PhD and 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
5
4
1
Professor of Nursing, Professor of Palliative Care, Research Fellow, Curtin University, School of Nursing and
Midwifery and Curtin Health Innovation Research Institute, Perth, Western Australia, 2Adjunct Senior Lecturer,
School of Nursing and Midwifery, Curtin University, Perth, Western Australia, Australia, 3Professor of Business,
Professor of Nursing, Nipissing University, School of Business, School of Nursing, Toronto, Ontario, Canada,
6
Professor and Head, School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Wagga
Wagga, New South Wales, Australia and 7Adjunct Senior Research Fellow, National University of Singapore,
Yong Loo Lin School of Medicine, Department of Ophthalmology, Singapore, Singapore

Correspondence
Desley G. Hegney
Curtin University
School of Nursing and Midwifery
and Curtin Health Innovation
Research Institute
GPO Box U1987
Perth
Western Australia, 6845
Australia
E-mail: Desley.Hegney@curtin.
edu.au

HEGNEY D.G., CRAIGIE M., HEMSWORTH D., OSSEIRAN-MOISSON R., AOUN S., FRANCIS K. &

(2014) Journal of Nursing Management 22, 506518.

Compassion satisfaction, compassion fatigue, anxiety, depression and
stress in registered nurses in Australia: study 1 results

DRURY V.

Aim To explore compassion fatigue and compassion satisfaction with the

potential contributing factors of anxiety, depression and stress.
Background To date, no studies have connected the quality of work-life with
other contributing and co-existing factors such as depression, anxiety and stress.
Method A self-report exploratory cross sectional survey of 132 nurses working in
a tertiary hospital.
Result The reflective assessment risk profile model provides an excellent
framework for examining the relationships between the professional quality of
work factors and contributing factors within the established risk profiles. The
results show a definite pattern of risk progression for the six factors examined for
each risk profile. Additionally, burnout and secondary traumatic stress were
significantly related to higher anxiety and depression levels. Higher anxiety levels
were correlated with nurses who were younger, worked full-time and without a
postgraduate qualification. Twenty percent had elevated levels of compassion
fatigue: 7.6% having a very distressed profile. At-risk nurses stress and
depression scores were significantly higher than nurses with higher compassion
satisfaction scores.
Implications for nursing managers The employed nurse workforce would benefit
from a psychosocial capacity building intervention that reduces a nurses risk
profile, thus enhancing retention.
Keywords: anxiety, compassion fatigue, depression, model, nurse, resilience, stress
Accepted for publication: 3 July 2013

506

DOI: 10.1111/jonm.12160
2013 John Wiley & Sons Ltd

Psychological well-being of nurses

Introduction
Internationally there is concern about a rising nursing
workforce shortage that can be attributed to both
recruitment and retention issues (Drury et al. 2009).
In Australia, a recent publication by Health Workforce Australia estimated that there would be a shortfall of 109 000 nurses by 2025 (Health Workforce
Australia 2012). Additionally, this report noted that,
while efforts had been made to increase recruitment
into the nursing workforce, more attention should be
paid to retaining nurses within the workforce (Health
Workforce Australia 2012).
In Australia, there are two regulated types of nurses
enrolled and registered. Enrolled nurses form approximately 18% of the total nursing workforce and have
completed an approved vocational education and training course (Australian Institute of Health & Welfare
2012). Registered nurses form the remainder of the
workforce with the majority prepared in university
based programmes (Australian Institute of Health
& Welfare 2012). The aforementioned shortage is
projected in both enrolled and registered nurses.
Concern about nurse retention and previous studies
into job satisfaction in the nursing workforce (Eley
et al. 2007, 2010, Tuckett et al. 2011) led the
research team to investigate the prevalence of the concepts of compassion fatigue (CF) [made up of secondary traumatic stress and burnout (BO)], compassion
satisfaction (CS), anxiety, depression and stress in a
purposive sample of registered and enrolled nurses
employed either full or part time in an acute care tertiary hospital in Australia.

Background
The concept of compassion fatigue (CF) emerged in
the early 1990s in the scholarly literature from North
America to explain a phenomenon observed in nurses
employed in emergency departments (Coetzee & Klopper 2010, Potter et al. 2010, Boyle 2011). Compassion fatigue is a construct associated with workers
who practise compassion in situations with extended
exposure to the suffering, both physical and emotional, of others as well as a lack of emotional support
within the workplace (Radey & Figley 2007, Boyle
2011). It has been linked to secondary traumatic stress
syndrome (STS), a negative feeling driven by fear and
work related trauma (Gentry 2002, Rourke 2007). A
component of CF that may also arise is the workrelated stress syndrome known as burnout (Meadors
& Lamson 2008), a well-known phenomenon associated
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Journal of Nursing Management, 2014, 22, 506518

with emotional exhaustion, depersonalisation and an

inability to work effectively (Gentry 2002, Coetzee
et al. 2012).
Compassion fatigue develops over time and is associated with changing behaviour and loss of the capacity to interact and engage intimately with others for
whom they have responsibility (Gentry 2002, Coetzee
& Klopper 2010). The work of health professionals
involves supporting and caring for the ill, the traumatised and the dying. For some, the emotional investment becomes overtaxing and they become less able
to manage the demands of being compassionate and
empathetic (Maytum et al. 2004, Sabo 2006, Aycock
& Boyle 2008). Compassion fatigue is a recognised
occupational hazard for those working with people
experiencing trauma (Rourke 2007, Bush 2009).
Whereas compassion satisfactory (CS) is an expression
of the positive aspects of care giving by nurses, CF
may be part of the cost of caring for others in emotional stress (Hooper et al. 2010). The symptoms of
CF are varied and include sadness, depression, anxiety, intrusive images, flashbacks, numbness, avoidance
behaviours, cynicism, poor self-esteem and survivor
guilt (Hooper et al. 2010). Compassion fatigue
reduces productivity, increases staff turnover and sick
days, and leads to patient dissatisfaction and risks to
patient safety.
Stamm (2010) provides an interpretation of the
three scales (CS, STS and BO) in her professional
quality of life tool (PROQOL) to allow for interpretation of the scale scores in combination. From the databank of 1289 cases created for multiple studies, five
profiles that describe risk at each level have been generated. These are: normal/positive reinforcement from
work profile (high CS, moderate to low BO and STS),
at-risk profile (high BO and moderate to low CS and
STS), overwhelmed profile (high STS and low BO
and CS), high-risk situations profile (high STS and CS
and low BO) and very distressed profile (high STS and
BO and low CS).
Figure 1 shows the reflective risk assessment model
that integrates the six constructs examined in the study
and places them within Stamms (2010) risk profile
framework. The model is reflective in that as we move
through each of Stamms five risk profiles (e.g. positive
reinforced) the differences are reflected in both the
professional quality work life scales (right side) and
the potential contributing factors (left side). The twoway arrows in the centre indicate the hypothesised
interaction between the contributing and professional
quality work-life factors. The curved lines represent
the potential correlation among these constructs. Thus
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D. G. Hegney et al.

Figure 1
Reflective risk assessment model.

the reflective model provides a novel approach to consolidating these constructs into Stamms (2010) risk
profiles. Additionally, Stamm gives some insight into
the origin of how these different profiles may have
manifested within individuals in the workforce and
some suggested approaches to helping individuals.
Interventions to prevent and manage CF in nurses
have been seen to involve both those focusing on the
individual as well as those targeting the supervisors or
managers of nurses (Beck 2011, Boyle 2011). The
majority of studies, however, have focused on interventions that build capacity in the individual as it is
believed that without an effective intervention, health
professionals experiencing CF become increasingly less
able to practise effectively, impacting on the quality of
care provided and ultimately health outcomes for
those with whom they interact (Henry & Henry 2004,
Boyle 2011). Research indicates that people experiencing CF respond positively to treatment (Showalter
2010, Berger & Gelkopf 2011) with positive outcomes
apparent up to 6 months to 2 years postintervention
phase (Rotsalainen et al. 2008).
Skills advocated to manage compassion fatigue
include self-help strategies such as theoretical knowledge of the triggers of compassion fatigue, meditation,
reflection, boundary setting, conflict resolution, exercise and formal education programmes and therapeutic interventions including counselling (Coetzee &
Klopper 2010, Berger & Gelkopf 2011, Boyle 2011).
Bush (2009) advocates caring for self as a positive
practise that has proven capacity to limit the onset of
symptoms indicative of CF (Bush 2009).

Purpose
While anxiety and its effect in the student nursing
workforce has been studied previously (Melincavage
2011) and anxiety and depression have been studied
508

with relation to critical events (for example SARS; de

Boer et al. 2011), we were unaware of any studies
that also examined anxiety, stress and depression in
the nursing workforce along with the concepts of CS
and CF. This study, therefore, is the first to integrate
the contributory constructs of CS, STS and BO with
the professional quality work-life variables of anxiety,
stress and depression into a life risk profile framework, allowing us better to understand the overall systems at work underlying these constructs and the
dynamics among these variables. Additionally, this
study is the first to examine levels of these variables in
the Australian nursing workforce and will serve as a
benchmark for future comparisons, both nationally
and internationally.
The overall aim of this programme of research is to
determine what strategies could be used to build and
maintain psychological wellness in nurses and thus we
proposed the following three research questions in this
study:
1 Are Stamms (2010) risk profiles, as delineated by
different levels of CS, STS and BO, associated with
a specific pattern of depression, anxiety and stress
levels as seen in Figure 1?
2 Are higher levels of CF associated with higher levels
of anxiety, depression and stress and lower CS?
3 Are higher CS associated with lower levels of anxiety, depression and stress?

Method
The results presented are those collected in phase one
of a three phase mixed method study underpinned by
the pragmatic paradigm (Cherryholmes 1992). Phase
two of the study collected qualitative data (using
interviews and focus groups) and aimed to explore
the impacting factors and to gather from the nurses
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Journal of Nursing Management, 2014, 22, 506518

Psychological well-being of nurses

information on the strategies that could be used to

build and maintain psychological wellness or resilience
(Drury et al. 2013). Phase three of the study will,
using the resilience framework emerging from phase
two of the study, develop, implement and trial an
intervention that aims to build resilience in the nursing workforce.

Setting and sample

A survey was conducted amongst registered and
enrolled nurses at an acute care tertiary hospital in
Australia in MayJune 2012. All nurses employed in
the intensive care unit, one high dependency area, a
medical ward, outpatient chemotherapy and the emergency department and who met the inclusion criteria
(currently registered or enrolled nurses, employed at
the participating hospital either full or part-time) were
invited to participate in the study. We chose these
units/wards of the hospital as they were similar environments to those in a study carried out by Hooper
et al. (2010).
Initially the study commenced as an on-line study via
the hospital Intranet. However, due to access issues
and in response to requests, this was changed to a
paper based survey which was sent to each individual
nurse on the same day the survey was taken off-line.
As nurses used their unique identifier (hospital
employee number) on the online study, we were able
to identify those who had already responded and
exclude them from the paper-based survey. Packages
included the individually addressed letter of invitation,
the participant information sheet, the questionnaire
and a coffee voucher (worth $3.50). Follow-up
reminders were sent out to non-respondents after 1
and 4 weeks. Non-respondents could be identified as
the unique identifier was included on all paper surveys.
Of the 374 nurses who were eligible and invited to
participate, 132 returned a completed survey (35%
response rate).

Measures
The survey was written in English and consisted of
three parts. Part one captured demographic and professional data. The Professional Quality of Life Scale
version 5 (PROQOL5) formed the second part of the
survey and the Depression Anxiety Stress Scale (DASS
21-short form) formed the third part of the survey.
The demographic data collected included: age,
gender, marital status, country of initial qualification,
citizenship, dependents, employment, level of nurse,
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Journal of Nursing Management, 2014, 22, 506518

post registration qualifications of the nurse, previous

qualifications, length of time in nursing, length of time
in current position and expected time to work in
nursing.
The Professional Quality of Life Scale version 5
(PROQOL5, Stamm 2010) measures levels of compassion fatigue and compassion satisfaction: the latter
concept is composed of burnout and secondary traumatic stress. The PROQOL5 utilises 30, five-point
Likert scale items to measure each of these three subscale components (10 items each). Although PROQOL
was originally developed for emergency personnel and
trauma counsellors, the scale has been utilised internationally and also has been psychometrically validated
in different studies for various target populations
(Stamm 2010).
Depression Anxiety Stress Scales (DASS) (Lovibond
& Lovibond 2004) is a survey instrument used to
measure mood symptoms over the past week. The
DASS21 is a 21-item version of the longer 42-item
DASS. The DASS21 contains three subscales: depression, anxiety and stress. The DASS and DASS21 have
demonstrated high internal consistency and strong
psychometric properties in both normal and clinical
populations (Brown et al. 1997, Antony et al. 1998,
Lovibond & Lovibond 2004).

Data analyses
All statistical analyses were performed with the IBMStatistical Package for the Social Sciences (IBM-SPSS,
Chicago, IL, USA) for Windows version 19. To examine the relationship between linear variables bivariate
correlations were performed. t-Tests and analysis of
variance (ANOVA) were performed to determine the
relationship between categorical demographic and
work related variables on DASS subscale and PROQOL5 scores. Non-parametric tests (KruskalWallis
K, MannWitney U) were performed to examine
group differences when assumptions for parametric
tests were violated and the sample size was less than
100. Bonferroni corrections were conducted to maintain the family-wise alpha level at 0.05. In addition,
medium effects or larger were considered of research
interest and therefore reported along with the respective P-value. Cohens (1988) guidelines for reporting
effect sizes were used (g2 of 0.01 is small; 0.06 is
medium; 0.14 is large).
Data screening showed there was a low rate of missing data across demographic variables and study measures (mostly <2%). However, 15.1% of the sample
had no age data, 9.2% of the sample did not report
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D. G. Hegney et al.

whether they were studying for a postgraduate qualification and 10.6% of the sample did not report how
long they expected to continue working in nursing in
the future. Consequently, analyses involving these
independent variables only included cases for which
data for these variables were present.

Results
Prior to analyses, assumptions underlying statistical
tests were examined. Normality and KolmogorovSmirnov tests showed all DASS subscales having a
non-normal distribution (P < 0.05) with modest positive skews. The stress scales level of skew was the
smallest (<1), and as such the assumption of normality
could be assumed for this scale. Transformation of
scores is one option for addressing violation of normality and skew assumptions underlying parametric
tests. However, t-tests and ANOVAs are highly robust
to skewness and deviations from normality (Norman
2010). Moreover, Tabachnick and Fiddell (1996)
argue that for samples greater than 100, modest
departures from normality identified by inference tests
are unlikely to have a significant impact on analyses
and the visual appearance of distributions is more
important for assessing normality (Tabachnick &
Fiddell 1996). Given these arguments and that examination of distribution plots suggested the DASS
subscales approximated normality, it was decided to
perform all analyses on non-transformed data.

Demographics
The participants in this study were mostly female
(86.0%) and aged between 20 and 49 years (88.5%)
with a mean age in years of 36.76 (SD 10.83). The
majority of respondents were married or living in a
de-facto relationship (63.6%) and about a quarter of
respondents (28.8%) were single. Just over half of the
respondents were born in Australia (54.5%). Those
nurses that were born outside Australia were mainly
from Europe (60%), the remainder from Asian Pacific
regions (25%). The majority of nurses (78.8%) had
Australian citizenship. Almost half of the respondents
(44.2%) had dependent persons, mainly children
(76.9%).
Table 1 displays the work and professional profile
of the study sample. The majority of respondents were
Registered Nurses (98.5%). A small number were
employed as either Senior Registered Nurses (nurse
managers, 9.8%) or Staff Development Nurses (educators, 3.8%). Respondents worked principally full time,
510

and almost half of the nurses worked three rotating

shifts (morning, afternoon, night) and about the quarter of them worked morning and evening shifts. A
large majority of nurses had been working in the
profession for more than 5 years (78%, range of
050 years) and planned to stay in nursing for greater
than 5 years (about 92%). Table 1 also shows that
most respondents had been working in the current
hospital for up to 15 years with nearly half for less
than 5 years, Registered Nurses, which included Registered Nurses, Clinical Nurses, Staff Development
Nurses and Senior Registered Nurses, had mainly a
Bachelor of Nursing or a Bachelor of Science (Nursing) (73.1%). About half of them had completed postgraduate qualifications and 16.1% were currently
studying to gain postgraduate qualifications.

Stress, anxiety and depression summary statistics

DASS21 stress, anxiety and depression scales presented good and very good internal consistency (stress
a = 0.84, anxiety a = 0.79, depression a = 0.90), and
were quite similar to normative data presented in the
DASS Manual (Lovibond & Lovibond 2004). Table 2
shows the current sample means for the DASS21 in
comparison with normative means of an Australian
general adult population established by (Crawford
et al. 2011). As can be seen, the means of the current
sample on all DASS21 subscales are quite similar to
the Crawford et al. (2011) sample, well within 1 SD.
Table 3 shows the calculated DASS means for the
total sample and according to gender, as well as percentages of the sample in each clinical severity category. As can be seen, males formed a minority of the
sample population. Means on the DASS scales for
males, females, and combined shown in Table 3 were
all comparable to normative sample means as
described in the DASS Manual. Table 3 also shows
that a large majority of the current study sample fell
well within the normal range (78th percentile) for
each subscale. The percentage of individuals within
the study sample that had stress, anxiety or depression
symptoms in the moderate or higher range was 11.4,
15.2 and 13.6%, respectively.

CF and CS summary statistics

PROQOL5 CS and CF subscales of burnout and STS
demonstrated good to very good internal consistency
(CS, a = 0.92; BO, a = 0.74; STS, a = 0.82). Table 4
shows the descriptive mean and standard deviations of
the overall sample and according to gender. As can be
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Psychological well-being of nurses

Table 1
Work and professional profile means, frequencies and percentages (n = 132)
Variable
Current position
Assistant in Nursing (AIN)
Enrolled Nurse (EN)
Registered Nurse (RN)
Clinical Nurse (CN)
Staff Development Nurse (SDN)
Senior Registered Nurse (SRN)
Full/Part Time
Full time
Part time
Shifts employed
Working all three shifts (a.m., p.m., nights)
Day shift worker (6 a.m. and 6 p.m.)
Evening shift worker only
Night shift worker only
Morning and evening shift worker
Evening and night shift worker
Day and night
Morning and night
Other
More than one job
No
Yes, but not all are in nursing
Yes, and all are in nursing
Yes, but no precision kind of job
Reason to have more than one job treated*
Maintaining clinical skills in other areas
Insufficient income from one job
Other financial reasons
Variety/diversity of two jobs
Cannot find full time employment
Running a family business
Choice/lifestyle balance
No reason provided

Frequency

(%)

0
2
81
31
5
13

0.0
1.5
61.4
23.5
3.8
9.8

85
44

65.9
34.1

63
12
0
11
36
0
9
1
0

47.7
9.1
0.0
8.3
27.3
0.0
6.8
0.8
0.0

104
5
22
1

78.8
3.8
16.7
0.8

10
5
5
0
1
9
3
1

29.4
14.7
14.7
0.0
2.9
26.5
8.8
2.9

Frequency
Time worked in nursing
Mean (SD)
<5 years
29
515 years
50
>15 years
53
How long do you plan to work in nursing
Mean (SD)
<5 years
10
515 years
52
>15 years
56
Time worked at SCGH
Mean (SD)
<5 years
64
515 years
53
>15 years
15
Time worked current ward/unit
Mean (SD)
<5 years
78
515 years
42
>15 years
11
Belong to union/professional organisations
Yes
118
No
14
Number of memberships
No membership
14
1 membership
92
2 memberships
20
3 memberships
3
First membership
ACCCN
1
ANF
110
Unknown/Other
4

(%)

14.1 (10.8)
22.0
37.9
40.2
16.3 (9.2)
8.5
44.1
47.5
6.71 (6.9)
48.50
40.20
11.40
5.42 (6.1)
59.5
32.1
8.4
89.4
10.6
10.6
69.7
15.1
2.3
.9
95.7
3.5

ACCCN, Australian College of Critical Care Nurses; ANF, Australian Nursing Federation.
Category frequency totals range from 129 to 132 due to missing data.
*Multiple answers.

Table 2
DASS21 subscale means and standard deviations (SD) for the current study sample and in comparison with Crawford et al. (2011)
normative sample means
Subscale
Stress
Anxiety
Depression
Total

Current sample
Mean (SD)
4.80
2.17
2.88
9.85

(3.76)
(2.79)
(3.83)
(9.22)

Crawford et al. (2011)

Mean (SD)
3.99
1.74
2.57
8.30

(4.24)
(2.78)
(3.86)
(9.22)

Current sample, n = 132. Crawford et al. (2011) adult sample, n = 497.

seen, the means for males and females are within 1

SD of each other.

Relationships between demographic and work

variables with study measures (DASS and
PROQOL5)
Table 5 shows bivariate Pearson correlation coefficients
capturing the linear component of the relationship
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Journal of Nursing Management, 2014, 22, 506518

between variables. As expected, the DASS subscales

were all positively and significantly correlated. The
magnitudes of the observed correlations between DASS
subscales were all in the large effect size range. Likewise
for the PROQOL5, there was a large and significant
correlation between burnout and STS subscales. There
was also a medium negative correlation between burnout and CS. However, CS and STS were not significantly related.
When examining the relationship between DASS and
PROQOL5 subscales, Table 5 shows large and significant positive correlations for burnout with stress and
depression symptoms, and a medium correlation with
anxiety. For STS, there was also a significant and large
positive correlation with stress and anxiety, and more
medium positive correlation with depression. As
expected, CS had a significant negative correlation with
depression, although the magnitude of this effect was
small. However, correlations between CS and other
DASS subscales were all small and non-significant.
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D. G. Hegney et al.

Table 3
DASS subscale means and standard deviations (SD) by gender, and severity category percentages for the current study sample
Percentage of sample in each DASS severity category

Subscale

Mean (SD)
(n = 132)

Mean (SD)
Males (n = 18)

Stress
Anxiety
Depression

9.61 (7.53)
4.33 (5.58)
5.76 (7.67)

8.67 (9.25)
3.11 (5.19)
6.78 (11.11)

Mean (SD)
Females (n = 111)

Normal
(078)*

Mild
(7887)

Moderate
(8795)

Severe
(9598)

Extreme
(98100)

9.80 (7.16)
4.63 (5.67)
5.71 (7.09)

82.6 (109)
75.7 (100)
81.8 (108)

5.3 (7)
9.1 (12)
4.5 (6)

6.8 (9)
11.4 (15)
8.3 (11)

5.3 (7)
0.8 (1)
1.5 (2)

0.0 (0)
3.0 (4)
3.8 (5)

DASS full subscale scores (042) are calculated by multiplying DASS21 raw subscale totals by 2 and then calculating subscale means for the sample.
Severity category membership for each subscale score were calculated by comparing DASS full subscale scores to severity cut-offs as described in
DASS Manual (2004 p.28).
*Percentile cut-offs.

Table 4
PROQOL5 raw score means and standard deviations (SD) for the
current study sample
Subscale

Mean (SD)
(n = 132)

Mean (SD)
Males (n = 18)

Mean (SD)
Females (n = 111)

CS
BO
STS

35.66 (7.60)
23.66 (5.91)
18.60 (5.71)

31.33 (11.72)
23.83 (8.30)
17.67 (7.29)

36.28 (6.61)
23.64 (5.52)
18.79 (5.45)

For STS item 2, nine cases (6.8%) did not provide a response. Following Stamm (2010), this item was scored as 0.

For the demographic variables age and years in

nursing, Table 5 shows these variables were significantly and very strongly positively correlated with
each other. They also had a significant and medium
negative correlation with DASS anxiety. However,
apart from the significant and small negative correlations these variables had with DASS stress, all other
correlations with the DASS and PROQOL5 subscales
were small and non-significant at the more stringent
alpha level of P < 0.01.
t-Tests and ANOVAs were also conducted to
explore the relationship between demographic and
work variables with study measures. For the DASS,
analysis showed that registered nurses reporting a
postgraduate qualification had lower anxiety scores
compared with those registered nurses without a postgraduate qualification, t(93) = 3.17, P = 0.002 (M
2.85, SD 3.76; vs. M 5.94, SD 6.77). The size of this
difference was in the medium effect size range
(g2 = 0.07) and was significant after Bonferroni correction (0.05/12 = 0.0042). In addition, nurses working part-time had lower anxiety scores compared with
those working full-time, t(127) = 2.78, P = 0.006 (M
2.77, SD 3.48; vs. M 5.18, SD 6.33). The group difference between part-time and full-time nurses was
again in the medium effect size range (g2 = 0.06), but
was not significant after Bonferroni correction.
512

For the PROQOL5 scales, group differences for CS,

BO and STS across the different demographic and
work categories were generally small and non-significant after Bonferroni correction. However, a medium
group difference was observed for CS according to
number of years worked in current ward/unit
(<5 years, 515 years, >15 years), F2,128 = 4.81,
P = 0.01, g2 = 0.07, although not significant after
Bonferroni correction. Nurses with less than 5 years
of experience had on average lower CS than nurses
with more than 15 years (M 34.69, SD 7.85, vs. M
42.09, SD 5.92). Likewise, nurses with greater than
15 years of experience had on average higher CS than
those nurses with between 5 and 15 years of experience in their ward/unit (M 35.74, SD 6.87).

CF and CS risk profile analysis

To determine the risk profile for the sample, raw
scores were converted to t-scores according to the
algorithm defined by the PROQOL5 Manual (Stamm
2010 p. 16). Table 6 shows the PROQOL5 risk profile percentages and frequencies that were calculated,
and the corresponding DASS mean and median scores
for each profile. As can be seen, about 20% of respondents had a positive reinforcement from work profile
that involved high CS and moderate to low burnout
and STS symptoms. In contrast, approximately 20%
of the sample had a profile that involved potential risk
due to elevated levels of STS or burnout symptoms,
with 7.6% of the sample having a very distressed
profile.
KruskalWallis tests were conducted to evaluate differences among the three PROQOL5 profiles (positive
reinforcement from work, at-risk and very distressed
profiles). Typically unique to high-risk situations profile was not included in this analysis due to the very
small group size (n = 2). The tests were significant for
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Psychological well-being of nurses

Table 5
Bivariate correlations (Pearson) between age, years in nursing, DASS and PROQOL5 subscales
Variable
Age
Years in nursing
DASS Stress
DASS Anxiety
DASS Depression
PROQOL5 CS
PROQOL5 STS

Years in Nursing

DASS Stress

DASS Anxiety

DASS Depression

0.86**

0.29**
0.28**

0.30**
0.34**
0.70**

0.13
0.18*
0.70**
0.64**

PROQOL5 CS

PROQOL5 STS

0.05
0.15
0.13
0.04
0.26**

PROQOL5 BO

0.09
0.14
0.63**
0.56**
0.48**
0.03

0.11
0.14
0.55**
0.37**
0.052**
0.40**
0.55**

*Significance at alpha level 0.05 (2-tailed). **Significance at alpha level 0.01 (2-tailed). r = 0.1 to 0.29 small; r = 0.3 medium; r = 0.5 large correlation
(Cohen 1988). Correlations with significance level of 0.01 are shown in bold. n = 112.

Table 6
PROQOL5 CF and CS risk profile percentages, frequencies, DASS mean and median scores
DASS Mean (SD) Median (range)
Profile

(%)

Frequency

Stress

High CS and Moderate to Low BO and STS

(Positive reinforcement from work profile)
High BO and Moderate to Low CS and STS
(At-risk profile)
High STS and Low BO & CS
(Overwhelmed profile)
High STS and CS and Low BO
(Typically unique to high-risk situations profile)
High STS and BO and Low CS
(Very distressed profile)

20.4

27

10.6

14

0.0

1.5

7.6

10

16.0 (8.54)
14.00 (4.0032.00)

6.22
6.00
12.4
13.00

(4.34)
(0.0014.00)
(6.80)
(4.0026.00)

Anxiety

Depression

2.81 (3.25)
2.00 (0.0014.00)
3.57 (4.09)
2.00 (0.0012.00)

1.70 (2.58)
0.00 (0.0010.00)
13.0 (10.1)
10.00 (2.0040.00)

10.0 (8.79)
8.00 (2.0032.00)

13.0 (12.27)
10.00 (0.0032.00)

n = 132. For CS, the 25th and 75th percentile thresholds are T-scores of 44 and 57, respectively. For BO, the 25th and 75th percentile thresholds are
t-scores of 43 and 56, respectively. For STS, the 25th and 75th percentile thresholds are t-scores of 42 and 56, respectively.

each scale; stress (v2 (2, n = 51) = 14.48, P = 0.001),

anxiety (v2 (2, n = 51) = 10.22, P = 0.006) and
depression (v2 (2, n = 51) = 24.88, P = 0.001) scores.
Follow-up MannWitney U tests were conducted to
evaluate pairwise differences among the three profiles
for each DASS scale. The result of these tests indicated
a significant difference in level of stress, anxiety and
depression. The nurses in the at-risk and very distressed groups had significantly higher stress and
depressed mood scores when compared with nurses
with positive reinforcement profile, while there was no
significant difference between nurses with at-risk and
very distressed profiles. Nurses with a very distressed
profile were significantly more anxious than nurses
with positive reinforcement or with an at-risk profile,
while nurses with a positive reinforcement profile had
a similar level of anxiety as nurses with an at-risk profile. The magnitude of mean group differences were
both in the large range for stress (Cohens d range =
1.11.5) and depression (Cohens d range = 1.51.8).
Similarly, there were large differences in the mean
level of anxiety between the positive reinforcement
and the distressed group and between the at-risk
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Journal of Nursing Management, 2014, 22, 506518

group and distressed profile group, although the latter

difference was not significant after Bonferroni correction. Both group differences were in the large effect
size range, Cohens d = 1.2 and 1.0, respectively.
However, nurses in positive reinforcement and at-risk
groups had similar levels of anxiety, and there were
no significant differences for stress and depression
between at-risk and distressed profile groups.
The information contained in Table 7 was derived
from the numeric values presented in Table 6, and
reformatted for easy interpretation. Table 7 therefore
demonstrates the interrelationship between the PROQOL5 and DASS constructs across the three risk
profiles as depicted in the risk assessment model presented in Figure 1. As can be seen in Table 7, progression from the positive reinforcement at work group
(normal) to the at-risk group involves a decrease in
CS and a corresponding increase in BO. With respect
to the DASS we also see a corresponding marked
increase in depression and stress levels. Progression
from the at-risk group to the very distressed group is
defined by an increase in STS, with corresponding
increases in anxiety and stress.
513

D. G. Hegney et al.

Table 7
Building a profile: interrelationship
between the PROQOL5 and DASS

PROQOL5
PROQOL5 risk profile
Positive reinforcement
At-risk
Very distressed

CS
H
L
L

DASS

STS

BO

Depression

Anxiety

Stress

L
L
H

L
H
H

L
H
H

L
L
H

L
M
H

The designations of L, M, H (low, medium and high) for the DASS only indicate relative magnitudes based
on the information presented in Table 6, they are not clinical level indicators.

Discussion
Reflective risk assessment model
Sample PROQOL5 and DASS profiles
With respect to Stamms (2010) five risk profiles,
approximately 20% of the nurses in the sample had a
profile that involved potential risk due to elevated levels of compassion fatigue symptoms, with 12.4% falling in the at-risk category and 7.6% being in the very
distressed profile. The remaining 79% fell into the
normal (positive reinforcement) profile.
When examining mood symptoms on the DASS, the
sample means were comparable to adult normative
samples (e.g. Lovibond & Lovibond 2004, Crawford
et al. 2011). For the anxiety subscale, 15.2% of the
sample had symptoms in the moderate or higher
range. Examination of recent Australian and British
adult population normative data suggests rates of
between about 7 and 9% for moderate and higher
anxiety on the DASS (Crawford & Henry 2003,
Crawford et al. 2011). The possibility that this finding
may represent an elevated rate of clinical levels of
anxiety in the nursing profession compared with the
general adult population is a concern. A higher level
of anxiety is also consistent with the relationship
found between younger nurses and higher anxiety, the
relatively low mean age of the current sample and previous research (Schmeiser & Yehle 2001, Melincavage
2011). While it is conceivable that this finding may
just be an artefact of what may occur in the general
adult population, it seems unlikely, as research by
Crawford and colleagues has demonstrated only small
to very small correlations between DASS anxiety and
age in Australian normative samples.
Risk profile reflection in the DASS and PROQOL5
Central to the reflective risk assessment model presented in Figure 1 are the Stamm (2010) risk profiles.
As mentioned, respondents essentially only fell into
three of the five groups (normal - positive reinforcement, at-risk, very distressed people). As reported in
Table 6 and illustrated in Table 7, the normal (positive reinforcement) profile was associated with low
514

levels of depression, anxiety and stress. If we examine

the at-risk profile we see that DASS depression levels
have increased, anxiety has stayed the same, and stress
levels have moderately increased. As we move from
the at-risk to the very distressed profile we see that
DASS depression levels remain high and anxiety levels
increase. All these changes in the levels of the DASS
corresponding to the different risk profiles of the
PROQOL5 were significant and consistent with the
first research question and the reflective risk assessment model. Thus this research has been able to
extend the three PROQOL5 risk profiles to include
the three constructs measured by the DASS.
Relations between the DASS and PROQOL5
The reflective risk assessment model presented in
Figure 1 incorporates interactions between DASS and
PROQOL5 scales. As predicted, the CF constructs of
BO and STS were significantly related to higher levels
of anxiety, stress and depression. However, contrary
to expectation, higher compassion satisfaction had
only a weak relationship with lower depression scores,
and no significant relationship with anxiety or stress.
From these results, CS appears to be largely independent of the clinical constructs of anxiety, stress and
depression as measured by the DASS. Notwithstanding, higher burnout was moderately related to lower
CS, although STS had no significant relationship with
CS. Therefore the results show that people with high
STS can still have a good level of CS, but when levels
of CS reduce, negative mood and burnout are likely to
increase. These results therefore suggest that anxiety
and depression symptoms are likely to be more of an
issue for dealing with high burnout and STS, but less
so for individuals with low CS. Moreover, if levels of
anxiety in nursing populations are elevated compared
with the normal adult population, as may be the case
here, it follows that they may be at an added risk for
the later development of CF.
Relations among the DASS constructs
As presented in Table 5 there were moderate and significant positive correlations among the three constructs of stress, anxiety and depression. The
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Psychological well-being of nurses

magnitude and direction of these relationships, summary statistics (Tables 2 and 3), and lack of appreciable gender differences were consistent with past DASS
validation studies in normative adult samples (Crawford & Henry 2003, Lovibond & Lovibond 2004,
Crawford et al. 2011). The findings demonstrate that
the DASSs psychometric characteristics had been reliably replicated. In addition, they provide preliminary
evidence for the DASS as a valid tool for measuring
negative mood symptoms in nurse populations and
support the measurement validity of the reflective risk
assessment model.
Relations among the PROQOL5 constructs
While the current study cannot delineate causal pathways to CF and low CS, it is possible from the results
to infer potential causal hypotheses that may be worthy of future modelling and that inform future psychosocial interventions. First, the results presented in
Table 5 show that STS and burnout are constructs
that are strongly intertwined and related to negative
mood symptoms, with low CS a possible consequence
of CF in terms of its relationship to burnout. Second,
while STS is a likely contributor to burnout (and vice
versa), it does not appear to have a direct influence on
CS which is a similar finding to Hemsworth et al.
(2011). Third, low CS maybe a consequence of burnout, although work-related, organisational and
individual variables are likely to be important contributing factors requiring further assessment.
It follows that, when considering a future design of
an intervention for CF, enhancing CS and targeting
burnout and negative mood symptoms may be a more
parsimonious and effective approach than directly targeting secondary traumatic stress (STS), which generally involves more acute and disabling symptoms. STS
may be harder to treat using a brief broad-spectrum
psychosocial intervention, rather, requiring a more
focused and tailored intervention (Gentry et al. 2002).
In contrast, a capacity building intervention that teaches adaptive ways of managing negative mood symptoms, self-care, and where possible organisational
factors, may benefit a wider range of individuals that
are at potential risk. It is clear from the results of
other studies that burnout not only leads to poor
retention of new graduates, but also has longer term
negative impacts in relation to patient safety and overall quality of care (Schaufeli & Buunk 2003, Poghosyan et al. 2010). Moreover, if negative mood
symptoms are a key causal factor contributing to an
increased risk profile, then addressing their presence
as early as possible seems a priority. As past theory
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Journal of Nursing Management, 2014, 22, 506518

and research have shown, enhancing resilience may be

one important factor to investigate as a way of preventing the negative impacts of high levels of work
stress (Masten & Reed 2002, Haglund et al. 2007,
Berger & Gelkopf 2011, Mealer et al. 2012).
A better understanding of the dynamics among
these variables will also build an empirical foundation
for later studies that examine how resilience may buffer or ameliorate the worst effects of stress in nursing
populations and inform how an intervention might be
designed to increase nursing resilience. This strategy,
along with others such as those of the positive practise environment (Aiken et al. 2008, Burtson & Stichler 2010, Coetzee et al. 2012, Klopper et al. 2012),
could improve nursing retention and patient outcomes.

Demographic impacts
Analyses of the relationships between work and personal variables with study measures revealed that
higher anxiety levels were correlated with nurses who
have a lower educational level, work longer hours, are
less experienced, and generally younger. While anxiety
has been found in employed nurses facing critical incidents (de Boer et al. 2011) and nursing students
(Schmeiser & Yehle 2001, Melincavage 2011) no previous studies have examined the linkages between
anxiety and the concepts of CF and CS. Therefore the
finding of higher anxiety in nurses who were younger,
had less postgraduate education and who worked in
high risk areas such as the Emergency Department
and Intensive Care would be expected. The effect of
hours worked on levels of anxiety has previously been
unreported. Additionally, lower levels of nursing education and years of experience may be risk factors for
experiencing higher levels of negative mood, which in
turn may contribute to symptoms of burnout. This
finding is consistent with studies of burnout of nursing
students in their first year post-registration (Laschinger
et al. 2009, Rudman & Gustavsson 2012). Similarly,
those nurses who experience burnout are less likely to
engage in further studies (Rudman & Gustavsson
2012). However, in contrast to other studies (e.g.
Rudman & Gustavsson 2012), this study did not find
any correlation between intention to leave the profession and burnout.
In relation to CS and CF, there were no significant
relationships with any of the work and demographic
variables assessed. Nurses with less experience in their
ward/unit had lower levels of CS compared with more
experienced nurses, although this medium effect failed
515

D. G. Hegney et al.

to reach significance after Bonferroni correction. The

relative paucity of significant relationships observed
may have been due to insufficient power to capture
medium effects, or that multiple personality, attitudinal, organisational and patient-related factors contribute to occupational stress (for review see Sabo 2011).
As Sabo (2011) has argued, it is difficult to design
general instruments that can capture a wide range of
variables implicated in contributing to occupational
stress, and that qualitative designs may be better at
identifying factors of influence (Sabo 2011).

Limitations and suggestions for future

research
This study utilised a reflective risk profile model containing professional quality work life (PROQOL5)
and negative mood symptom constructs (DASS). The
data from this phase and phase two suggest that
future studies should extend this model to include
other constructs such as passion for work and
resilience.
The sample in the study only included nurses that
essentially fell into three of the five risk profile categories. Further research, potentially with larger sample
sizes could determine if nurses potentially fall providently into the other categories and what corresponding patterns that these factors form (if any).
Replication studies in larger samples and across different hospital sectors are also required to determine if
the current preliminary findings can be generalised to
the broader nursing populations. While the current
results do not delineate causal pathways, more sophisticated analytic techniques in larger samples might be
employed to model potential causal links between negative mood symptoms, CS, STS and burnout.
Moreover, the addition of resilience related or adaptive coping skill measures may also be beneficial in
identifying the type of psychological factors that can
ameliorate the impacts of negative mood symptoms
and reduce the risk of CF. Such an analysis might prove
fruitful in determining how interventions could be
designed in the future to alleviate CF and mood symptoms and to build adaptive stress coping capacities.
Finally, given anxiety may be an important causal
factor in the development of CF, it will be important
for future research to employ measures of anxiety that
assess broader cognitive and emotional aspects of anxiety. The DASS anxiety subscale measures symptoms
of anxiety that are predominantly somatic focused. It
is conceivable that this subscale may not be fully
capturing other cognitive and emotional aspects of
516

anxiety that may be a causal risk for the development

and maintenance of compassion fatigue.

Conclusions and implications for nurse

managers
This study provides a risk assessment framework for
integrating different constructs into Stamms five risk
profiles. This research allows managers to better predict the risk profiles of their workers based on depression anxiety and stress as well as on the established
compassion satisfaction, secondary trauma and burnout factors. This extension to our general understanding of the risk profiles may allow managers to
recognise easier, factors that categorise higher risk
profiles (e.g. anxiety may be easier to recognise and
report than more complex constructs such as compassion fatigue) and identify appropriate treatment.
The results of the study, if replicated in the broader
nursing community, raise significant concern about
the possible negative impacts of elevated levels of CF
and negative mood symptoms on the quality of patient
care and staff retention. Along with the qualitative
data collected in phase two of the study (Drury et al.
2013), these findings can also be used to inform an
intervention design for the workplace that builds individual resilience in the student and employed nursing
workforce. Preventative interventions that enhance
resilience may also help to buffer against the development of CF. For example, a recent large study by
Mealer et al. (2012) of intensive care nurses in the
United States found that higher levels of CF related
symptoms were associated with lower resilience.
In recognition of the importance of continuing professional education and in line with previous studies
into burnout in pre-registration nurses, educators
should advocate including strategies in undergraduate
and postgraduate nursing programmes that facilitate
students identifying and managing compassion fatigue
and build personal resilience through the development
of positive coping strategies. Boyle (2011 p.1) asserts
that fundamental to the management of CF is
acknowledging its existence in a proactive manner.
Although it is essential to address CF within the work
environment, in order to improve CF in nursing, interventions should also include education and work-life
balance strategies (Boyle 2011).
Practise implications should focus on increasing
nurses knowledge of CF and developing effective
strategies that enable individual nurses to identify and
manage CF. Addressing compassion fatigue and
increasing individual resilience in the nursing workforce
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Journal of Nursing Management, 2014, 22, 506518

Psychological well-being of nurses

may improve retention rates as well as contribute to

more empathetic care for patients.

Acknowledgements
We acknowledge the input into the study design by
Dr M. OConnor. We also thank members of the Centre for Nursing Research at the study hospital for their
assistance Mrs Jan Low, Ms Michelle Sin and Ms
Linda Coventry. Finally we wish to thank all the
nurses who participated in the study.

Author contributions
All authors have contributed to the manuscript. Craigie, Hemsworth, Hegney, Aoun and Osseiran-Moisson
were responsible for the methods, results and discussion sections of the paper. Hemsworth was responsible
for the conceptualization of the reflective risk assessment model. Hegney, Francis, Craigie and Hemsworth
were responsible for the introduction, background and
discussion sections of the paper. Hegney and Francis
were responsible for the background sections of the
paper. Drury contributed to the limitations and was
responsible for the conclusions and policy implications. All authors have contributed to editing the
paper and the revised paper.

Source of funding
The study was funded by the University of Western
Australia and the study hospital.

Ethical approval
Ethical approval was obtained from the Human
Research Ethics Committees (HREC) (equivalent of
Institution Review Boards in Australia) of the study
hospital, the University of Western Australia and Curtin University. The return of a completed survey was
considered to be consent.
The survey was not anonymous as nurses were given
the option of providing contact details for their results
and/or for participation in phases two and three of the
study. Thus a unique identifier (nurses hospital
employee number) was provided for each respondent.
A password protected master file that linked the identifier to the individual nurse was kept on a secure computer located at the study hospital. A separate file with
de-identified information (removal of the unique identifier) was created for data analysis. This file was
encrypted before being sent to other research team
2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 506518

members. Data storage and management conformed to

National Health and Medical Research Council Guidelines and as approved by the HRECs in this study.

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