Nurses' mental health: how managers can tackle compassion fatigue

‘Compassion fatigue’ has been cited as an occupational hazard for cancer nurses. What support, if any, is available to help practitioners deal with work-related stress?

‘Compassion fatigue’ has been cited as an occupational hazard for cancer nurses. What support, if any, is available to help practitioners deal with work-related stress?

• Anxiety, stress and depression are major causes of absenteeism among nursing staff

• Mental health issues account for 26% of sick leave among nurses in England 

• Call for nurse managers to provide robust psychological support to help staff

Anxiety, stress and depression are major causes of sickness absence among nursing staff – and those who work in cancer care may be especially vulnerable.

According to NHS Digital figures, mental health issues accounted for more than 26% of all sick leave among nurses and health visitors in England between January and April 2019.

By contrast, colds, coughs and flu caused less than 5% of absence.

Chief nurse of The Royal Marsden NHS Foundation Trust Eamonn Sullivan believes caring for people with cancer places unique demands on nurses.

Good psychological support

Eamonn Sullivan

‘Right the way through all of us in the nursing profession is the same thing – wanting to do the best, with care and compassion,’ he says.

‘But I find cancer nurses go above and beyond all the time. You see them giving an awful lot of themselves.

‘And that’s brilliant and wonderful,’ he adds.

‘But I’m acutely aware of the impact that can have unless you wrap around it good psychological support. If you don’t, there’s a massive risk.’

Good psychological support was certainly critical in getting The Royal Marsden NHS Foundation Trust matron Aly Foyle’s life and career back on track after a downturn in her mental health that led to four months off work.

Ms Foyle attributes much of her recovery to a counsellor in the trust’s staff support team.

‘Cancer nurses go above and beyond all the time. You see them giving an awful lot of themselves’

Eamonn Sullivan, chief nurse, Royal Marsden NHS Foundation Trust

Nurse Sara Lister heads the staff support service at the trust, which works with patients and their families, as well as staff.

Three highly trained counsellors are available to help staff with a range of issues, either work-related or caused by circumstances in an individual’s personal life.

‘Sometimes in cancer nursing we think we have to be tough, we have to be strong. And if a patient gets to us we think we’re failing,’ Ms Lister says.

Compassion fatigue

‘In the support service, we try to say, no, if you’re finding yourself getting irritated or you’re not sleeping or whatever, you’re being a human being.

‘The term I like to use is compassion fatigue.’

‘I lost all perspective’ – how a minor incident proved a tipping point for one nurse

Aly Foyle

‘Not all cancer stories are sad – some are successful and joyous,’ says Royal Marsden NHS Foundation Trust matron Aly Foyle.

‘But the ones that stay with you are the ones where you feel you didn’t succeed. You feel you’ve let the patient down, even though you did everything you could. Over time, that began, subconsciously, to have an affect on me.’

Ms Foyle was finding it impossible to switch off. Despite nearly 30 years as a nurse, she became obsessed with work – things she had to do, tasks she was struggling with, patients who had died.

 ‘I began to feel guilty I hadn’t done enough,’ she says.

‘Up to that point, I had always been tough. Nothing fazed me.'

She had trouble sleeping, and the guilt and obsessive thoughts intensified. ‘Things got bad, except I was not aware of it.’

Work isolation and avoiding contact with colleagues

At the time, she was a sister in the hospital’s outpatient and day care haematology unit, but at work she began to isolate herself, retreating into her office and immersing herself in tasks that meant she avoided contact with her colleagues.

‘And then I began to doubt myself. I started to believe I was rubbish and that everybody else thought that.’

A minor incident at work proved a tipping point. ‘I lost all perspective and rationale. I burst into uncontrollable tears.’

Her boss happened to witness what happened and urged her to go home and take some time. ‘And over that week, I fell apart and it all came tumbling down,’ says Ms Foyle.

‘Sometimes you have to be brave, put up your hand and say I’m not right or I’m finding this difficult. There’s no shame in that’

Aly Foyle, matron

Her slow recovery and eventual phased return to work four months later was helped by The Royal Marsden support service and one-to-one counselling.

Feeling ‘fantastic’ two years on

Now, two years on and promoted to matron, she feels ‘fantastic, very strong’.

‘I still have my moments when I think this is going to be an awful day. But the difference is that I try my hardest to leave work at work.

‘The overriding thing I’ve learned is that sometimes you have to be brave, put up your hand and say I’m not right or I’m finding this difficult. There’s no shame in that.’


The Institute for Employment Studies (IES) says compassion fatigue is characterised by emotional and physical exhaustion, and ‘a decrease in the ability to empathise and nurture others’. It differs from burnout, the IES says, in that it can arrive suddenly.

‘Sometimes in cancer nursing we think we have to be tough, we have to be strong. And if a patient gets to us we think we’re failing’

Sara Lister, head of The Royal Marsden NHS Foundation Trust staff support service 

Is compassion fatigue becoming more common in cancer nursing?

‘I don’t know that we’re beginning to see more of it,’ says Ms Lister.

‘But I think we’re more able to be upfront about it. And I hope we’re getting to the place where we’re normalising it and viewing it as an occupational hazard.

‘Working in an environment like this, unless we take steps to look after ourselves, then emotionally it will impact us.’

As well as one-to-one counselling, The Royal Marsden NHS Foundation Trust staff support service offers monthly supervision groups for clinical nurse specialists and debriefing for teams after an incident or difficult situation.

There are also mindfulness sessions to help staff manage workplace stress.

The service is funded by The Royal Marsden Cancer Charity.

Managing director of the charity Antonia Dalmahoy says: ‘Working in a cancer hospital can bring with it some harrowing and emotional experiences, and the psychological team ensures that support, guidance and counselling is in place for anyone who needs it.’

Elsewhere, Macmillan Cancer Support is similarly aware of the toll those ‘harrowing experiences’ can take on its nurses.

Ellen Lang manages Macmillan’s cancer information nurse team, part of its support-line services. She says Macmillan’s strong service model includes well-being support for staff.

‘For the nurse team specifically, we have regular one-to-ones, coaching, and clinical update forums for knowledge-sharing and development, as well as clinical supervision.’

If, as seems likely, cancer care places unique stresses on the psychological well-being of its practitioners, those pressures may be compounded by wider issues affecting the NHS, in particular growing demand and diminishing resources.

Five tips on ways nurses can preserve their psychological well-being

Remember, it is easier to safeguard and protect your mental health than to recover from crisis.

  • Attend to your basic needs. The RCN encourages nurses not to feel guilty about taking breaks. Breaks are there to protect you and your patients. Rehydrate and refuel, too. And find time to be active and keep fit
  • Plan your off-duty, says the head of The Royal Marsden’s staff support service Sara Lister. ‘Think about things to do on your day off that are going to be nurturing, restorative for you’
  • Be alert to triggers for distress. Always putting in extra hours? Always under pressure? Lacking management support? Is your physical health suffering? It may be time to seek help
  • Use what’s on offer, such as workplace well-being champions, mindfulness sessions, counselling, supervision
  • If you are feeling stressed, low or anxious, try Public Health England’s Every Mind Matters resource for tips and insights. Counter stress, for example, by splitting up big tasks, challenging unhelpful thoughts and allowing time to think about things you are thankful for


Overwhelming caseloads and dealing with distress

Some cancer nurses are at increased risk because of these extrinsic factors, says Macmillan lead cancer nurse for East Suffolk and North Essex Foundation Trust Sarah Orr.

‘I’ve spoken with colleagues about the various pressures on staff,’ says Ms Orr. ‘Nurses often have overwhelming caseloads and are dealing with a lot of distress in their roles. 

‘The NHS needs an engaged workforce that feels valued and at the moment they just feel exhausted. Without an engaged workforce the NHS won’t exist.’

The Interim NHS People Plan published earlier this year acknowledged this problem, saying staffing pressures were causing stress and burnout.

Most nurses, of course, know how to look after themselves. They understand the need to ‘rest, refuel, rehydrate’, as an RCN initiative puts it. They know the importance of sharing concerns, reflecting, ventilating. They make the most of downtime.

But knowing about self-care and acting on it are not always compatible. A ward is short-staffed so breaks are missed and shifts extended. ‘Refuelling’ is a chocolate bar. There is no time to grab a drink or visit the loo. And after work, sleep is interrupted by perceptions of failed care, of letting patients down.

And that, says Mr Sullivan, is where good management plays a part.

Nurse managers need to help staff recognise the mechanisms that enable them to top-up their reserves of caring and compassion, he says. ‘A manager having that conversation with a staff member is useful’.

Hesitancy around the term ‘resilience’

The ability to withstand a degree of stress and emotional strain is a requirement of all nurses, but for some the term ‘resilience’ has become tainted when used in the context of encouraging nurses to cope with unremitting pressures.

‘You can’t sheep-dip people in resilience’

Sara Lister, head of The Royal Marsden NHS Foundation Trust staff support service 

Sara Lister

The Trades Union Congress (TUC), for example, says ‘building resilience’ in individuals shifts the focus from the workplace to the worker, while underlying stressors go uncorrected.

Ms Lister says she too is hesitant about the term ‘resilience’.

‘You can’t sheep-dip people in resilience,’ she says. ‘The image I like to think of is a palm tree when a tropical storm arrives. The palm tree bends and can be almost touching the beach. But when the storm’s passed, the palm tree can bounce back up again.

‘Resilience is about enabling people to be knocked over at times – but not broken – and to respect that and give them some recovery time.’

Promoting well-being in others: how line managers can support their staff

  • Be aware of your own well-being and be a role model, says Caring for Staff, an NHS Wales health and well-being resource. Royal Marsden Hospital chief nurse Eamonn Sullivan agrees. ‘If you’re saying to a junior member of staff, “You need to go home now”, and you’re staying until 10pm every night, that doesn’t have the right impact'
  • Remember the snow globe, Mr Sullivan suggests. Sometimes, everything gets shaken up and it can be difficult for someone to see things clearly. ‘Recognise when one of your staff’s snow globe is shaken too much and everything becomes too difficult.’ When that happens, talk to the person, mentor them and help the snow to settle
  • Take your annual leave and ensure others do, too. ‘There is not one successful leader in the health service I know of who doesn’t take every minute of their leave,’ says Mr Sullivan
  • Routinely ask staff about their well-being, the NHS Wales resource advises. And provide opportunities for your team to share actions they are taking to improve their well-being – at team meetings, for example
  • Build a culture of self-care, charity Mind’s toolkit on supporting healthcare workers’ mental health suggests
  • Encourage perspective. ‘It’s not all as bad as it might be,’ Mr Sullivan says

Find out more

Daniel Allen is a health writer

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