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WHAT IS THE IMPACT OF STRESS ON

NURSES WORKING WITHIN THE
DISTRICT NURSING SERVICE?
Word Count: 7504

(Excludes: acknowledgements, subtitles, tables, appendix, brackets and reference).
Submission Date: 05/06/2020

Submitted in part fulfilment of the post graduate diploma in specialist practitioner
district nursing qualification.
Contents Page
Contents Page Number
1: Acknowledgements 3
1.1: Abstract 4
1.2: Introduction 5
1
[Type here] [Type here] [Type here]
1.3: Background and Rationale 6-8

2: Methodology 9 - 17
2.1: Formulating a Research Question 10
2.2: Inclusion and Exclusion Criteria 11
2.3: Database Selection and Search 12
Strategy
2.4: Hierarchy of Evidence 13 - 14
2.5: Appraisal of Quality 15
2.6: Data Analysis 16 - 17
3: Discussion 18 - 25
3.1: Theme One 18 - 20
3.2: Theme Two 21 - 22
3.3: Theme Three 23 - 25
4: Conclusion and Recommendations 26 - 28
5: Research Proposal 29 - 32
6: References 33 - 40
7: Appendices 41 - 56
Acknowledgments I would like to thank my wonderful husband and my incredibly

supportive family who have supported me throughout writing this piece of work. I
would especially like to thank my Mum for proof reading. The friends I have made on
this course have been an incredible support and I am grateful to have been on this
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journey with them. Finally, I would like to thank the academic team who have helped
and guided me whenever I have needed it.
Abstract
Aim: An extended literature review (ELR) was undertaken to explore nurses’
experiences of stress within district nursing teams and the implications this has on
nursing practice and the welfare of nurses.
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Background: District nursing (DN) teams are central in providing empowerment and
high quality, holistic care to people living in the community (QNI, 2015). Resilience is
imperative within DN teams, however, when the demand for services exceeds the
capacity of the team, it is significant to consider how this might be impacting on
nurses and patient care (Duncan, 2019).
Methodology: This ELR has gathered relevant quantitative and qualitative research
by searching databases; British Nursing Index (BNI), Cumulative Index of Nursing
and Allied Health Literature (CINAHL), Internurse, PubMed, Health Management
Information Consortium (HMIC) and Medline.
Results: The results have identified that healthy behaviours, emotional intelligence
and effective caseload and staffing management can reduce the negative impact that
stress can have on nurses.
Conclusion: The impact of stress on nurses within DN teams were burnout and
compassion fatigue; reduced job satisfaction and retention: and emotional injury
Recommendations: Organisations to promote healthy behaviours through support
and training; to reassess how caseloads are managed in correlation with staffing
levels; and coaching in emotional intelligence skills to be provided to all nurses within
the DN service.
Proposal: This study has presented evidence for future research: ‘What are the
experiences of nurses working within district nursing services of organisation support
in preventing compassion fatigue and burnout?’
Einführung
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The purpose of this extended literature review (ELR) is to explore nurses’

experiences of stress within district nursing teams and the implications this has on
nursing practice and the welfare of nurses. The existing literature on this topic will be
critically appraised with the intention of answering the focus question; ‘What is the
impact of stress on nurses working within the district nursing service?’ The Nursing
and Midwifery Council’s (NMC) (2018) code of conduct requires nurses to practice in
concordance with the best up to date available evidence, highlighting the importance
of extended literature reviews. This literature review will outline the background of
the topic and discuss the rationale for doing a literature review, aiming to answer the
focus question. The methodology section will demonstrate the systematic and
rigorous process undertaken in obtaining the relevant literature. This review will then
discuss the findings within developed themes to explore the impact of stress on
nurses working with district nursing (DN) services. Limitations of the studies will be
explored and problem areas within this topic will be identified in order to make
recommendations for best practice going forward. Finally, a research proposal will be
identified and presented for future research.
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Background and Rationale
District nursing (DN) teams are central in providing empowerment and high quality,
holistic care to people living in the community whilst reducing costs in the long term
within the NHS (QNI, 2015). The Royal College of Nursing (RCN) (2019) and the
QNI’s recent report found that the number of district nurses working within the NHS
in England has reduced by 43% in the last 10 years, despite district nursing services
being crucial in the delivery of care to patients in their own homes/community. The
NHS (2019) Long Term Plan identifies the importance of DN teams in boosting out of
hospital care, however, it also highlights the challenges faced due to insufficient
staffing levels, thus, leading to lack of capacity to meet the rising patient need and
complexity within the community setting. Challenges within district nursing are often
not recognised, with the majority of media attention focusing on care within hospitals
(QNI, 2016). DN teams are vital in reducing stress on hospital services, however,
Middleton (2016) describes district nursing as an overlooked field of nursing that is
holding the health service together with invisible glue. The Queen’s Nursing Institute
(QNI) (2016) reassessed their 2020 vision on the future of district nursing 5 years
after the document was first published. Their (2016) report found respondents were
experiencing low morale within district nursing teams due to; continuous change,
poor referrals, heavy workload, lack of capacity to cover absence/sickness, career
uncertainty, blame culture with zero tolerance, poor management, lack of support
from seniors, unpaid hours, cuts to staffing levels and no limit in caseload capacity
(QNI, 2016). The report established that district nurses were experiencing stress and
as a result; sickness, early retirement and resignations (QNI, 2016).
Defining stress can be complex because stress is experienced differently in different

individuals and is a word frequently used to describe how a person is feeling in a
negative situation (Bailey and Clarke, 2013). MIND (2019) describe stress as the
body’s natural reaction when faced with feeling under pressure or threatened and is
often helpful in motivating an individual to achieve their targets. However, too much
stress, also known as chronic stress, could lead to the development of mental health
problems (MIND, 2019). Stress can affect an individual physically. For example, in
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the form of headaches, increased heart rate, mood changes, high blood pressure,
digestive disturbances or problems sleeping but can also have a psychological
impact such as causing anxiety, confusion or depression (Healthline, 2020).
Occupational stress can be defined as the adverse response people experience
when under extreme pressure or demand at work (Burke, 2013). In the UK, 11
million days a year are lost at work due to absence caused by stress (HSE, 2019).
Work related stress should be managed by employers who have a legal duty to
protect their employees from stress (HSE, 2019). Despite this, DN teams are
required to meet the high demand for their services with limited resources, relying on
the resilience of team members to manage capacity with the demand of workload
(Duncan, 2019). Resilience is imperative within DN teams, however, when the
demand for services exceeds the capacity of the team, it is significant to consider
how this might be impacting on nurses and patient care (Duncan, 2019).
Hall (2016) describes the negative impact of chronic work stress as a modern
epidemic. Nursing has always been a highly stressful occupation, however, the
number of nurses and health visitors absent from work due to depression, anxiety,
stress or other mental health disorders has increased progressively over the last 7
years (The Kings Fund, 2019). The Kings Fund (2019) recognises that staff on the
frontline of the NHS frequently face emotional challenges due to the nature of the
profession, therefore, it is a necessity that this high level of absence due to mental
health is addressed. There is a vast amount of literature that addresses stress in
general nurses but there is a lack of up to date evidence that focuses on the impact
of stress on nurses working in the community setting. A study by Stuart et al (2008)
described district nursing as a ‘Ward without Walls;’ a fitting way to depict one of the
main differences between hospital and community nursing. The qualitative study
found that nurses working within district nursing felt overwhelmed by; the lack of
control they had over patients being admitted onto the caseload, increasing workload
and working unpaid overtime to keep up with the demand (Stuart et al, 2008). There
are additional outdated UK studies that also explore this subject. For example;
Snelgrove and Phil’s (1998) study on occupational stress and job satisfaction in DNs,
Rout’s (2000) study on an investigation into stress amongst DNs and Evans’ (2002)
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study of exploration of DN’s perception of occupational stress. However, the amount

of up to date primary research within the UK is lacking, despite statistics
demonstrating that stress in district nursing is still a problem. It is essential that the
impact of this is explored in order to help inform current practice going forward. Hall
(2016) suggests that managing stress in district nursing teams should be prioritised
in order to ensure community nurses feel valued and cared for by the NHS, creating
a happy workforce rather than losing nurses due to burnout (Hall, 2016).
Having outlined the rationale for undertaking a literature review to explore this issue,
it is evident that nurses working within the DN service are faced with multiple
complex challenges. Managing stress is vital, thus, it is imperative that the impact of
stress is explored. The issue is highly relevant to current practice, however, there is
a gap of knowledge that focuses on the impact that stress is having on nurses
working within DN services. This literature review aims to identify the consequences
of nurses working within a highly stressful environment, recognising the impact of
stress and finding possible solutions to inform best practice and make
recommendations for future practice. This will then lead on to the development of a
research proposal. This could assist in reducing the subsequent detrimental effects
that stress can have and, ultimately, improve practice, patient care and the wellbeing
of nurses.
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Methodology
The methodology section will detail the methodical process used in developing a
focus question, identifying appropriate research methods, rationale of inclusion and
exclusion criteria, the systematic approach conducted in locating the literature and
use of the CASP tool in analysis of the literature.
Methodology can, simplistically, be defined as the systematic process that was

undertaken when carrying out research (Campbell, 2016). Mcgregor and Murname
(2010) define methodology as the justification of methods used and theoretical
underpinnings of how a study has been conducted in order to inform research.
Methodology is important when conducting an extended literature review because it
will convey a clear demonstration and rationale of how the literature review was
conducted, thus, reinforcing the validity/robustness of the research. Literature
reviews are secondary data and consist of a comprehensive summary and
interpretation of literature on a specific subject, presenting an analysis of the most up
to date available literature/evidence in order present a broad overview of the topic
(Aveyard, 2019). Extended literature reviews aim to identify a question that is
consequently answered by analysing and synthesising the body of evidence
surrounding the topic (Aveyard et al, 2016). Having a systematic approach within
extended literature reviews and in relation to the selection of literature allows the
researcher to systematically identify, select, evaluate and summarise the research,
resulting in rigorous, unbiased, transparent evidence that is replicable and can be
used to inform practice (Boell and Cecez-Kecmanovic, 2016). Evidence based
practice is imperative within health care and ensures that decisions are made based
9
on the best available evidence, along with the patient concordance/values and
clinical expertise of the health care professional (NHS, 2013). The NMC (2018)
states that nurses must understand the importance of evidence in practice, be able
to evaluate research to inform best practice and identify gaps in research that need
further investigation.
Formulating a Research Question
Developing a research question is essential when conducting an extended literature

review in order to guide and structure the literature review process (Aveyard, 2019).
The question must be clear and focused on what needs to be answered (Moule and
Hek, 2011). Aveyard (2019) suggests using PICOT to develop the research question
because the prompts within the acronym incorporate the components necessary in
creating a clear, focused and unambiguous question. Therefore, the PICOT tool was
used to aid in formation of the research question for this ELR, demonstrated in Table
One.
Table One – Developing a research question using PICOT (Aveyard, 2019).
Population Qualified nurses working within the district nursing service.

Issue The impact that stress can have on individuals and the subsequent
consequences.
Context The district nursing service.

Outcome To increase knowledge of the effects or impact of stress on nursing
working within district nursing teams.
Type of Qualitative and quantitative.

Study
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This literature review aims to identify and analyse the best available evidence in
order to answer the unambiguous question ‘What is the impact of stress on nurses
working within the district nursing service?’
Keywords
Having a systematic approach to searching the literature will ensure all literature on
the topic is found. Identifying alternatives/synonyms of the key words within the focus
question is necessary in order to locate all literature that is relevant to the topic that
has used alternative terminology (Aveyard et al, 2016). Synonyms of the key terms
were identified. Additionally, relevant key terms derived from the background
literature and preliminary reading/searches were also identified. Please see Table
Two for the table of keywords and alternative terminology.
Table Two – Keywords and alternative terminology.
Keywords: District Impact Stress

Nurses
Alternative Community Effect Occupational
terminology: Nurses stress
Primary Care Influence Workplace

stress
Nurses
Pressure
Burnout
Anxiety
Inclusion/Exclusion Criteria
Having identified the research question, it is important to identify inclusion and

exclusion criteria when searching the literature. This ensures appropriate articles are
included using consistency (Garg, 2014). Table Three represents the
inclusion/exclusion criteria and rationale.
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Table Three – Inclusion and Exclusion Criteria
Inclusion Criteria Exclusion Criteria Reasoning

Studies focusing on the Research that does not Relevant to topic. Hospice
impact of stress on nurses address this topic. at home studies included
working within district due to integration of
nursing teams. services and current DN
teams also provide palliative
care at home.
Primary research studies Secondary data – Secondary data relies on

only literature reviews and primary research which has
systematic reviews. already been interpreted by
someone else, this could
present unreliability.
Access the research for Research Research that needs to be

free. unobtainable without paid for could present bias.
paying for access.
English Language Not English Language Inaccuracy of translations

could lead to inaccurate
interpretation of findings.
Studies must be up to date No studies older than Out of date studies could be
dated within the last 10 2010. inaccurate. Up to date
years. literature is in line with the
NMC standards (2018).
Published and peer Unpublished research. Reinforces robustness of

reviewed research. research.
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Research based in the UK Research conducted It may be necessary to

or westernised countries if in countries that are include studies from
not enough UK studies. not westernised. westernised countries if not
enough UK studies
available. Nursing should
be broadly similar across
westernised countries.
Database Selection and Search Strategy
Systematic searches were conducted in six databases; British Nursing Index (BNI),
Cumulative Index of Nursing and Allied Health Literature (CINAHL), Internurse,
PubMed, Health Management Information Consortium (HMIC) and Medline.
Appendix 1 details the rationale for choosing each database.
Each database was searched with the key words and alternative terminology outlined
in Table Two, using the advanced search tool. Boolean operators were used to limit
and widen the searches. The Boolean operator, OR, was used to search for each
key word and its synonyms in order to widen the search and the Boolean operator,
AND, was used to limit the search and link the key terms together to find relevant
literature
(Aveyard, 2019). Quotation marks were used for phrases such as “District Nurse” so
that the database was instructed to limit the search for the words together and
truncation was also used to ensure variations of specific words were included in the
searches (Aveyard, 2019). Results were then limited to be dated within the last 10
years as 5 years limited the searches too much. BNI resulted in a large number of
hits so the search was limited further by limiting the search terms to appear in the
title/abstract, ensuring results were relevant to topic. The technique of skimming the
title and abstract was then used to quickly identify and determine appropriate
literature (Machi and McEvoy, 2016). Thesaurus/MeSH were also searched within
each database, however, no additional papers were found. Please see Appendix 2
for full break down of database searches. Six primary research studies were located
via the databases. Snowballing was then used to acquire a further four studies.
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Snowballing requires searching the reference lists of the identified literature to locate
literature (Jalali and Wohlin, 2012). Greenhalgh (2005) describes snowballing as a
powerful technique because it identifies potentially high-quality literature.
Furthemore, Kreis et al (2012) state that databases often do not provide all journal
articles within certain years or have the most up to date issue, therefore, snowballing
overcomes this limitation and strengthens the search strategy.
Hierarchy of Evidence
Hierarchy of evidence (Appendix 3) refers to the robustness of different research

methods for research seeking to evaluate the effectiveness of an intervention,
however, what is considered strong evidence is dependent on the question being
answered (Aveyard, 2019). As this literature review is not assessing the
effectiveness of an intervention, the robust evidence required to answer the question
would be different to that displayed in the hierarchy of evidence shown in Appendix
3. The impact of stress on nurses could be measured or assessed in a variety of
ways, therefore, both qualitative and quantitative research papers were considered.
Qualitative design studies are used when the researcher seeks to gain a deeper and
holistic understanding of human behaviour and lived experiences through a
naturalistic approach (Gray, 2014). They are valuable in health care because they go
beyond interventions to gain comprehensive insights into human experience
(Cartwright, 2014). Examples of methods used in gathering qualitative primary data
are; observation, semi structured interviews, focus groups and questionnaires
consisting of open-ended questions (Gray, 2014). Ethnography, grounded theory and
phenomenology are all qualitative approaches to research (Holloway and Galvin,
2017). However, as there is a vast variety of qualitative methods, Baumgarten (2010)
argues that they often miss standards of reliability and validity. In contrast,
quantitative research is the collection of numerical data which are facts and figures
(Aveyard and Sharp, 2013). Quantitative data could also be useful in answering the
question because often questionnaires create statistical data. Thyer (2010) argues
that good questionnaires will have undertaken rigorous assessments to certify their
validity and reliability and reduce bias.
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Having considered appropriate research, Aveyard (2019) suggests creating a

hierarchy of evidence specific to the research question to ensure the most relevant
evidence is selected – see Table Four strongest evidence first. The selected papers
(Table Five) have been mapped against this hierarchy of evidence.
Table Four – Developed Hierarchy of Evidence
Systematic reviews (not included in this review).

Qualitative primary studies such as interviews, open
ended questionnaires and observation that explore
nurses’ experiences.
Quantitative studies such as questionnaires or surveys

exploring nurses’ experiences and reported through
numerical data.
Table Five – Studies Meeting Inclusion Criteria for this ELR
1. Begic et al (2019) ‘Risk and protective factors for secondary traumatic stress
and burnout among home visitors.’
2. Samia et al (2012) ‘Home care nurses’ experiences of job stress and

considerations for the work environment.’
3. Haycock-Stuart et al (2010) ‘Emotional Labour within Community Nursing

Leadership.’
4. Terry et al (2015) ‘Workplace health and safety issues among community
nurses: a study regarding the impact on providing care to rural consumers.’
5. Tunnah et al (2012) ‘Stress in hospice at home nurses: a qualitative study of

their experiences of their work and wellbeing.’
6. Karimi et al (2013) ‘Emotional rescue: the role of emotional intelligence and

emotional labour on well-being and job-stress among community nurses.’
7. Durkin et al (2015) ‘A pilot study exploring the relationship between

selfcompassion, self-judgement, self-kindness, compassion, professional
quality of life and wellbeing among UK community nurses.’
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8. Karimi et al (2016) ‘Are organisational factors affecting the emotional

withdrawal of community nurses?’
9. Opie et al (2011) ‘Occupational stress in the Australian nursing workforce: a

comparison between hospital-based nurses and nurses working in very
remote communities.’
10. Ball et al (2014) ‘Survey of district and community nurses in 2013. Report to
the Royal College of Nursing.’
Appraisal of Quality
It is necessary to critically appraise each paper. Critical appraisal is essential in

assessing the reliability, credibility and validity of research by evaluating the methods
used and resulting conclusions (Crow and Sheppard, 2010). In order to consider the
strengths and limitations of each paper, it is essential to use a critical appraisal tool
to be systematic and consistent in determining whether the evidence is free of bias
and a true reflection of the population (Mhaskar et al, 2009). The CASP (2018) tools
are specifically designed for analysing research and are continually developed by
CASP international (Aveyard, 2019). Therefore, the CASP (2018) critical appraisal
tool for qualitative research was used to appraise the qualitative research, however,
the tools for assessing quantitative research were design specific and not
appropriate as there is no CASP to appraise surveys/questionnaires. The
quantitative research was appraised using a step by step guide derived by Coughlan
et al (2007) and recommended by (Aveyard et al, 2016). The mixed method study
(Begic et al 2019) was appraised using both tools to ensure it was sufficiently
analysed. Appendix 5 and 6 display the critical appraisal of all studies included within
this ELR and displays the areas in which the studies did not meet the criteria. It is
significant to note that the majority of the research papers met most of the criteria set
out within the appraisal tools, however, the limitations identified will present a
limitation of this ELR.
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Data Analysis
Having critically appraised the ten research papers, thematic analysis was used to
synthesise the findings by identifying common themes within the research (Clarke
and Braun, 2016). Identifying themes allows the researcher to summarise and
interpret the key findings in response to the research question (Clarke and Brain,
2016). Synthesis of the data will portray an interpretation of research that is superior
than that provided by individual studies (Hannes and Lockwood, 2012). Being
consistent during thematic analysis is essential to enhance the trustworthiness of the
research because thematic analysis relies on the interpretation of the researcher,
thus, consistency will reduce bias as a solo researcher (Noell et al, 2017).
Summarising the research papers (Appendix 4) and highlighting key words and
phrases assisted with identifying common themes. Having examined each paper
comprehensively, the common themes identified were; burnout and compassion
fatigue, reduced job satisfaction and emotional injury, as demonstrated in Table Six.
Please note multiple themes were present in each study so the overarching theme
was chosen in each paper. These themes will be explored within this ELR in order to
draw conclusions in exploring the impact that stress can have on nurses working with
the DN services.
Table Six – Thematic analysis of research papers
Author and Begic Samia HaycockStuar Terry Tunna Karimi Durkin Karimi Opie et Ball et
date: et et t et al (2010) et al h et et et al et al
(2012 (2013) (2015) (2016) al (2014)
al (201 (2011)
(2019) 5 al
(2012)
17
Theme
one:
Burnout
and √ √ √
compassio
n fatigue
Theme two:
reduced job √ √ √
satisfaction
and
retention.
Theme √ √
three: √ √
emotional
injury
Theme One: Burnout and Compassion Fatigue
This chapter will critically analyse the theme of burnout and compassion fatigue in
exploring what the impact of stress on nurses working within the DN service is.
Burnout and compassion fatigue have emerged as significant repercussions of stress
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for nurses working within the community setting. Joinson (1992) first introduced the
phrase ‘compassion fatigue’ which was developed by Figley (2013), describing it as
the manifestation of yielding to the demands of patient care over self-care.
Compassion is a key attribute of a nurse, however, providing emotional support for
patients every day could impact the wellbeing of nurses (Cross, 2016). Similarly,
burnout is the result of becoming emotionally and physically exhausted from coping
with high levels of stress (Nursing Times, 2019).
A quantitative study undertaken by Durkin et al (2015) sought to analyse

associations between burnout, wellbeing, and compassion fatigue in community
nurses. The study had a small sample of 37 participants, which the author
recognises as a limitation and makes recommendations for larger future research.
Despite the sample size, the lack of research on this topic strengthens the findings
because it emphasises that burnout and compassion fatigue is an issue in
community nurses that is not being explored.
The study’s results found that nurses who presented with more self-compassion
were less likely to suffer from burnout and compassion fatigue, and additionally, have
an increased resilience towards occupational stress (Durkin et al (2015). Nurses who
neglected their own emotional wellbeing and who were self-critical were prone to
suffering from burnout and compassion fatigue, highlighting the need for self-care in
community nurses (Durkin et al (2015). Durkin et al (2015) conclude that the
development of self-compassion could be beneficial for community nurses because
their findings support that self- compassion could be linked to lower levels of burnout.
The authors state it is difficult to generalise the findings of this study, however, that
their research highlights a topic that requires further investigation. Tsang (2014)
states that a goal of research is to be able to generalise findings to diverse
populations, thus, weakening the impact of Durkin et al’s (2015) findings.
The qualitative study by Tunnah et al (2012) explored the wellbeing of hospice at

home nurses whilst caring for patients who are dying; compassion fatigue and
burnout are highlighted as consequences of the psychologically demanding specialty
of palliative care. Explorative research is beneficial because it gives insight into an
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issue that is not yet clearly defined, in order to provide a definitive concept for future
research (Emilien et al, 2017). This study includes a small number of participants,
however, its explorative nature adds depth to understanding the impact of stress.
The themes identified from the interviews were; job satisfaction, stressors, coping
strategies and support (Tunnah et al 2012). A predominant comment from the nurses
was that the job was ‘mentally draining’ and the nurses had a need to ‘switch off’
after work (Tunnah et al 2012). Again, self-care is identified as an important factor
along with appropriate support from colleagues and coping strategies as contributing
factors to managing stress. It is significant to note that the interviewer was a member
of the team, although did not have a clinical relationship with them, this could have
influenced the participant’s responses, thus, reducing the validity of the findings. The
authors conclude that more conclusive research is required to assess the potential of
recommended interventions that could improve the wellbeing of nurses caring for
palliative patients at home (Tunnah et al 2012).
Similarly, the theme of burnout and compassion fatigue was present in the qualitative
study conducted by Terry et al (2015). Although the main purpose of the study was
to investigate the impact of health and safety issues for community nurses; one of
the themes derived from the semi structured interviews was burnout and work-
related stress. The nurses interviewed spoke about the difficult challenges they
encounter daily, such as death and heavy workloads, which contributes to becoming
burnt out
(Terry et al 2015). The phrase ‘compassion fatigue’ is reported to have been used by
multiple nurses when describing the impact of caring for palliative patients.
Selfawareness was apparent within the participants; the need for a healthy work –
life balance, support from colleagues and not taking work home with them were all
highlighted as methods used in coping with stress (Terry et al 2015). The research
was completed in Australia so may not necessarily represent UK community nursing;
however, it is evident from UK studies within this ELR, that there are similarities. The
authors discuss the trustworthiness of study, explaining that processes were in place
to ensure the findings were transferable, reinforcing the validity of the paper (Moule
and Hek, 2011). The authors conclude that a proactive approach rather than a
20
reactive approach is imperative in maintaining the health of nurses providing care in

the community (Terry et al 2015).
This chapter has reported the findings of the papers in relation to the theme of
burnout and compassion fatigue. The next chapter will address the next theme:
reduced job satisfaction and retention.
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Theme Two: Reduced Job Satisfaction and Retention
Reduced job satisfaction and retention has emerged as a resulting impact of stress
for nurses working with DN teams. Ball et al (2014) conducted a quantitative study
with 2438 survey responses from community nurses. Quantitative data provides
statistical patterns, reporting data from large populations which strengthen its
reliability because the findings can be generalised (Miller-Cochran and Rodrigo,
2008). Among the key findings were; 40% of nurses working with DN services
reported that they would leave their current job if they could; 69% reported no limits
in referrals and long working hours; 50% mentioned poor staffing levels due to
sickness, poor recruitment and retention; many of the nurses raised concerns about
providing poor quality of care to patients because of lack of time and increasing
pressure to meet demands (Ball et al, 2014). Ball et al (2014) recommend improving
working conditions in order to retain nurses, address care quality and staff wellbeing
concerns raised and enforce robust workplan management to reduce pressure on
nurses. The researchers do not include how the data was analysed and do not
critique the limitations or strengths of the study, however, the study was published by
the Royal College of Nursing (RCN). The RCN are the largest nursing union and
professional body in the world, therefore, increasing the trustworthiness of the study
(RCN, 2020).
Addressing the same theme of reduced job satisfaction and retention, Samia et al,
(2012) used an alternative research design; observations and interviews to describe
home care nurses’ experience of job stress. The researchers used blinding to
conceal agency selection, and triangulation to reduce systematic bias, both
increasing validity (Mullane and Williams, 2013). Samia et al (2012) used thematic
analysis to analyse the findings, with the emerging themes of; loss/lack of control,
role conflict and role overload, contributing to increased stress and reduction in job
satisfaction. Participants described staffing levels as a ‘chronic problem,’ leaving
teams feeling negative and lacking in team support towards one another (Samia et al
2012). The authors emphasise the importance of effective organisational support and
22
system changes to support nurses, thus, creating a positive working environment to

attract and retain them (Samia et al 2012). Effective organisational support included
effective recruitment, adequate resources to do the job efficiently, regular clinical
supervision and a supportive team leader. Despite the small number of participants,
this explorative study provides vital information to support more robust future
research (Hallingberg et al, 2018).
A mixed method study conducted by Begic et al (2019) investigated how burnout

among community nurses might impact on nurses’ intention to leave the profession,
thus, the emerging theme of reduced job satisfaction and retention is apparent. The
study used in-depth interviews and surveys with a small number of participants, in
which only six of whom were nurses, which is a limitation of the study. Vasileiou et al
(2018) state that small samples in qualitative data are insufficient and effects the
validity and generalizability of research. The authors also report the findings without
separating the participants into their different roles, to ensure that anonymity was not
compromised, however, this poses an additional limitation of the study as the
findings are not necessarily representative of nurses’ experiences. The quantitative
data reports that 60% of participants experienced medium to high levels of stress,
73.8 % experienced burnout and just under a quarter thought about leaving their
current role (Begic et al 2019). The qualitative data found that home visitors; often
suffered from secondary traumatic stress but were unsupported with this by
supervisors which resulted in withdrawal and self-isolation; contemplating leaving
their job was a frequent occurrence due to experiencing high levels of stress; flexible
working was an important factor in maintaining a good work-life balance; and the use
of humour was reported as an important coping mechanism when dealing with stress
(Begic et al 2019). The key findings from the quantitative data were supported by the
qualitative data, adding depth. However, it is difficult to apply these findings to nurses
working within the community because other occupations will have different
experiences.
23
This chapter has reported the findings of studies that focused on job satisfaction and
retention, the final chapter will address emotional injury as an impact of stress for
nurses working within DN services.
Theme three: Emotional Injury
Emotional labour, emotional exhaustion, emotional dissonance and psychological

distress were all frequently used to describe the impact of stress on nurses working
within the DN service in the next four papers. This chapter is titled with the umbrella
term, emotional injury, to incorporate the various emotional responses reported in the
research. A quantitative study by Karimi et al (2013) sought to investigate
relationships between the variables, emotional labour and emotional intelligence in
relation to wellbeing and job stress. 312 community nurses in Australia completed
the survey. The researchers use the p-value to demonstrate the significance of their
results. A pvalue of less than 0.05 suggests statistical significance (Simply
Psychology, 2020). Karimi et al (2013) reported a p-value of 0.01 in their hypothesis
that nurses who have higher levels of emotional intelligence have a high level of well-
being and experience less job stress. A p-value of 0.01 was also reported to support
their second hypothesis that a nurse experiencing increased emotional labour, will
have a lower level of wellbeing and increased job stress. This represents statically
significant results that support both of Karimi et al’s (2013) hypotheses and
reinforces reliability. The authors conclude that community nurses have emotionally
demanding roles that, consequently, puts them at risk of the adverse effects that
emotional labour can have (Karimi et al, 2013). Training and support in strengthening
emotional intelligence of nurses could help manage stress from emotional labour and
improve wellbeing (Karimi et al, 2013). Karimi et al (2013) recognise that a limitation
of the study is that the data came from one source which could introduce common
method bias, reducing validity of the paper.
24
Emotional labour was also a theme within Haycock-Stuart et al’s (2010) qualitative
study investigating emotional labour within community nursing leadership. The study
had a small sample of 12 community nurse leaders. The study focuses on nurse
leadership and was included in this ELR because team leaders are a part of the DN
team. The study uses thematic analysis, identifying the emerging themes as;
emotion and decision making, managing emotions at work, feeling unsupported and
emotional injury (Haycock-Stuart et al 2010). Many of the participants described
various emotional injuries related to pressure at work that resulted in illness. Work-
life balance is highlighted as an important factor in having resilience and coping with
stress.
Haycock-Stuart et al (2010) recommend additional support via coaching and
providing on going emotional support rather than only providing access to this when
the nurses became unwell. The authors neglect to identify any limitations to the study
which, in itself, is a limitation. The study has a limited methodology section, no
description on how the results were analysed and no consideration of bias, reducing
the reliability of the study because the authors have not fully evaluated their methods
(Aveyard et al, 2016).
In contrast, a quantitative study by Opie et al (2011) compared the levels of stress

and psychological wellbeing between hospital-based nurses and nursing working
within the community. 626 community and hospital-based nurses responded to the
survey with the results conveying no statistical significance that nurses working in
hospitals report higher levels of psychological distress than those working in the
community. Additionally, the results were statistically significant for community
nurses in linking job demands and conflict with colleagues to emotional exhaustion
and psychological distress (Opie et al 2011). Rumsey (2016) states that it is
important to note that statistical significance within one study does not reflect a whole
population and more studies are required to build evidence in order to support the
findings. The authors identify limitations of the study, highlighting that longitudinal
studies would reinforce the links made within this study to stress and emotional injury
(Opie et al 2011). Opie et al (2011) conclude that levels of stress are extremely high
25
in both community and hospital-based nursing and have an impact on the

psychological wellbeing of nurses.
The final paper by Karimi et al (2016) is a quantitative paper examining how work
organisational factors can impact on emotional withdrawal within 312 community
nurses. The authors hypothesise that emotional dissonance is linked to withdrawal
behaviours and work organisational factors can mediate the link between emotional
dissonance and withdrawal. The study uses the p-value to determine statistical
significance, reporting that a lower levels of job satisfaction are associated with
emotional dissonance and job neglect due to stress, and there is some evidence that
work organisation has a negative impact on emotional dissonance (Karimi et al,
2016). Karimi et al (2016) highlight a limitation of the study; increased risk of bias
due to common method variance. Common method bias is when the relationship
between two variables is influenced, thus, resulting in misleading conclusions
(Ketchen and Bergh, 2006). The authors conclude that emotional labour could lead
to withdrawal behaviour such as job neglect and withdrawal behaviours that could
negatively impact on patient care and reduce the quality of care being provided
(Karimi et al, 2016). Creating a positive working environment could alleviate stress
for community nurses and prevent the negative impact of emotional dissonance
(Karimi et al, 2016).
These three chapters have reported the findings of the 10 studies included within this
ELR. The next section will link the research, critically evaluate the findings and draw
conclusions, in order to make recommendations for future practice.
26
Conclusion and Recommendations for Practice
In conclusion, the aim of this ELR was to answer the question ‘What is the impact of
stress on nurses working within the district nursing service?’ The evidence has
presented the impact of stress as: burnout and compassion fatigue; reduced job
satisfaction and retention; and emotional injury.
Nurses who neglected their own emotional wellbeing suffered with compassion
fatigue and burnout whilst nurses with higher levels of self-compassion, showed an
increased resilience towards occupational stress (Durkin et al (2015). This is
supported by Neville and Cole (2013) who also found relationships between
compassion fatigue, burnout and compassion satisfaction, concluding that promotion
of positive health behaviours in nurses can improve their wellbeing and counteract
negative impacts of stress. Both Tunnah et al (2012) and Terry et al (2015) found
links between compassion fatigue and burnout and caring for palliative patients. A
study by SlotumGori et al (2011) makes the same correlations, suggesting that
27
institutional programs are required to support nurses and reduce the emotional toll of
caring for palliative patients. Motivated by wanting to provide the best quality of care
for their patients, Nyatanga (2013) states that nurses will often ignore signs of stress
in caring for people at the end of their life because they do not want to let the patient
down. The evidence shows that self-care and organisational support are imperative
in counteracting compassion fatigue and burnout. Being proactive rather than
reactive is essential, thus, a recommendation for practice is for organisations to
promote healthy behaviours, coping strategies and self-care through support and
training. It is significant to note that there may be challenges in implementing this.
For example, intrinsic (personal) and extrinsic (organisational) barriers for nurses,
however, organisations should address these barriers where possible to allow for
nurses to take part (Ross et al, 2017).
Reduced job satisfaction and retention was a recurrent theme in the resulting
implications of stress. Samia et al (2012) and Ball et al (2014) both concluded that
positive work environments, system changes and addressing concerns regarding
staff wellbeing would assist in attracting and retaining nurses. Research conducted
by
McVicar (2015) reinforces the connection between stress and job satisfaction, with
the results of the research presenting that increased job stress causes a decrease in
job satisfaction. Additionally, Kumar et al (2016) describe job satisfaction and job
stress as key components in maintaining quality of care provided to patients. Their
research concluded that timely and appropriate interventions must be in place to
improve stress levels of nurses, maintain job satisfaction and enhance quality of care
being provided (Kumar et al 2015). Begic et al (2019) highlighted that nurses
reported using coping strategies as a useful way of managing work related stress.
For example, the use of humour in the workplace and being able to switch off from
work. Manomenidis et al (2016) suggest mentally disengaging after a shift can be
difficult and strategies individuals use to do this can vary, however when done
effectively, this could increase resilience and improve wellbeing. Furthermore, a
study conducted by Williams et al (2018) sought to investigate the relationship
between job stress, job satisfaction and nurses’ health promoting behaviours. The
28
study found that high levels of health promoting behaviour resulted in increased job
satisfaction, therefore, strengthening the need for interventions that reduce stress
levels for nurses (Williams et al, 2018). In addition, improving workplace conditions
and reducing pressure by managing caseloads effectively could assist in retaining
nurses and job satisfaction (Kings Fund, 2016). Therefore, a recommendation for
practice is to reassess how caseloads are managed in correlation with staffing levels
to enable staff to take protected breaks and not work overtime due to workplace
pressure. As district nursing caseloads currently have no limits, this could be a
challenge. However, effectively triaging referrals, utilising other services and having
an efficient skill mix of staff will contribute to achieving this (QNI, 2016).
Nurses’ health and wellbeing has been a significant factor, with all of the studies
within this ELR reporting a variation of emotional injury as a result of stress. As
demonstrated in research by Karimi et al (2016), emotional labour can lead to
withdrawal behaviour that is detrimental to the wellbeing of nurses and could
negatively impact on patient care. This is supported in research conducted by
Delgado et al (2017) who found that, although emotional labour is an issue across all
nursing, resilience can protect nurses from its negative implications. Resilience is
highlighted as significant in combatting emotional injury (Delgado et al, 2017). Karimi
et al’s (2013) research linked the ability of an individual to manage their own
emotions, known as emotional intelligence, as vital in managing stress. Furthermore,
research by Por et al (2011) found that nurses who were in control of their emotions
and were emotionally competent, effectively coped with their stress which
subsequently, enhanced their wellbeing. Resilience and emotional intelligence
appear to be key aspects of managing emotional injury within community nursing,
thus, the final recommendation for practice is for coaching in these skills to be
provided to all nurses within the DN service.
This ELR has provided essential answers in addressing the question, ‘What is the
impact of stress on nurses working within the district nursing service?’ Evidence
shows that there are a variety of negative implications as a result of high levels of
stress. The evidence presented identifies gaps within health care that must be
29
addressed. Focusing on these gaps will provide the basis for future research with the
goal of reducing and managing stress in nurses wherever possible. Therefore, the
next step is to propose future research that addresses one of the areas identified
within this ELR as an area requiring improvement. The next section will outline the
research proposal that has been created from the results of this ELR, with the
primary focus on investigating what support is in place to prevent compassion fatigue
and burnout in nurses.
Research proposal
Introduction and Rationale
The current available evidence has identified compassion fatigue and burnout as
detrimental consequences of stress for nurses working within the district nursing
(DN) service. Chronic stress within nursing is a widespread problem (Hall, 2016).
District nursing teams are presenting with low morale due to issues such as heavy
workloads, reduced capacity and no limits to caseload capacity (QNI, 2016). The
extended literature review ‘What is the impact of stress on nurses working with the
district nursing service?’ explored this issue and identified that the evidence suggests
30
having a proactive approach to tackling burnout and compassion fatigue is essential.

Therefore, making the recommendation to implement organisational support and
training intended to promote coping strategies, healthy behaviours and self-care.
With stress levels remaining high among nurses working in DN services (QNI, 2016),
this ELR raises the issue of whether organisations are providing the appropriate
support to alleviate stress, thus, providing a gap in knowledge for future research.
Titel
‘What are the experiences of nurses working within district nursing services of
organisation support in preventing compassion fatigue and burnout?’
Aim
The aim of this study is to explore, in depth, the experiences of support in managing
stress that nurses working within DN teams have had or not had. The purpose of
doing this is to investigate whether organisations are promoting coping strategies,
healthy behaviours and self-care and whether this has benefitted nurses’
experiences of stress. Preventing compassion fatigue and burnout in nurses is
essential, thus, exploring current organisational support will address the current gaps
evident within the service. The study’s goal is to provide evidence in how nurses are
being supported in managing stress and identify areas which need to be addressed
to prevent compassion fatigue and burnout.
Design and Methodology
This study will use a cross sectional design in order to evaluate the prevalence of
support for nurses working within district nursing services and provide a snapshot of
the outcome and associated risk factors for this population (Levin, 2006). The study
will consist of a mixed methods approach in answering the question. Quantitative
data will be collected through a survey and descriptive qualitative data will be
obtained through semi structured interviews. Using a mixed methods approach will
31
incorporate the aim of understanding human behaviour from the perspective of the
target population and in understanding the social world through numerical data
(Nardi, 2014). The semi structured interviews will use prompting questions to initiate
discussion surrounding the topic. The questions will be open ended and non-leading
so that they do not influence the answer. This will prevent bias. The samples will be
randomly selected with two participants from each DN team across the trust being
asked to take part. A total of 12 participants will be asked to take part in the
interviews. Vasileiou et al (2018) suggest you need at least 12 participants in
qualitative data to achieve data saturation. The sample for the qualitative data will be
relatively small, however, this will gain a deeper comprehensive understanding of the
lived experiences of the nurses (Gray, 2014). Interviews will be recorded with
consent from the participants and then analysed by an additional researcher to
reduce bias. Researchers will be blinded to each other’s critiques to also prevent
bias and increase trustworthiness of the findings (Moule and Hek, 2011)
The survey will provide quantitative data that will address levels of stress, whether
participants are receiving appropriate support and what support is being currently
provided. All nurses working within DN services across the trust will be invited to take
part in an online survey via email which will state that their response will be
anonymous. A large sample will increase generalisation of the findings. Data will be
analysed using a reliable statistical analysis tool (Nardi, 2014).
Ethical Approval
Research must be conducted in line with the highest ethical standard. Ethics
approval will be sought from the ethics committee and permission obtained to
undertake this research (Remenyi, 2011). Participants will be invited to take part in
the semi structured interviews via a letter which includes a consent form and details
of the research being undertaken, guarantying confidentiality and anonymity. The
survey will comprise of an email invitation that includes a consent form, detailing the
nature of the survey and will also reinforce confidentiality and anonymity. All
32
participants will be informed that they have the right to choose not to take part and
can be removed from the study at any time if they wish to. It is significant to consider
that the semi structured interviews might cause some distress if those being
interviewed are experiencing stress at the time of the interview. Additional support
will be available should participants want it.
Preliminary Suppositions and Implications
Due to reported high levels of stress in nurses working with DN services, the results
of this research could find that nurses are not having the training and support
necessary in managing stress, thus, leading to experiences of burnout and
compassion fatigue. Therefore, it will present evidence that organisations need to be
proactive in managing stress to prevent the negative impact that stress can cause.
Influencing organisations to provide this support will be beneficial for both the
organisation and the staff. Staff wellbeing and patient care has the potential to be
improved as a result of this evidence. Alternatively, it might show that the support
and training is there, however, not being utilised by staff. This might present potential
for further research exploring why it is not being used.
Fazit
In conclusion, it is clear from the evidence that stress has detrimental consequences
to nurses working within the DN service and interventions are vital in reducing the
impact of stress. The purpose of doing this research is to explore whether
organisations are promoting coping strategies, healthy behaviours and self-care and
whether this has benefitted nurses’ experiences of stress. Undertaking this study will
identify whether interventions are taking place and whether they are effective in
supporting nurses. Using a mixed methods approach will collect essential in-depth
experiences of nurses and numerical data that will be generalisable because the
survey will be offered to all nurses in DN services across the trust. Lack of support
and training is a potential outcome of this research and will present further
recommendations for future practice. Stress has multiple negative implications to
33
staff wellbeing and patient care and tackling this issue is essential in maintaining an
effective district nursing service.
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health promoting behaviours: knowledge may not translate into self-care,’ AORN J,
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experiences of job stress and considerations for the work environment,’ Home
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Appendices
Appendix 1 – Database Selection and Rationale

Database Rationale
BNI The BNI is a UK nursing database with access to over 400 journals and is
a leading database in the support of research and education for nurses
(RCN, 2019).
CINAHL CINAHL is larger database with a wide range of literature for health care
professionals and is described as an essential tool for research within
nursing (EBSCO, 2020).
Pubmed Pubmed contains biomedical literature and is a large database stating that
it has access to over 30 million citations including Medline (Pubmed,
2020).
Medline Medline, which also contains biomedical literature, was also searched
separately but no additional literature on the topic was found.
Internurse Internurse provides access to 18 peer reviewed journals related to

nursing.
HMIC HMIC contains literature, including gray literature, related to health
service policy (RCN, 2019). Gray literature is literature that is
unpublished, however, although not appropriate for this literature review,
Paez (2017) argues that gray literature can provide significant
contributions to literature reviews by reducing bias that commercially
published research might present.
43
Appendix 2 – Database Search Results Table
Databases Search 1 Search 2 Search 3 Search 4
Keyword 1 Keyword 2 Keyword 3 Additional

Searches
“District nurs*” Impact Stress
OR OR OR
“Community nurs*” A Effect A “Occupational
N N Stress”
D D
OR OR OR
“Primary care Influence “Workplace Stress”
nurs*”
OR
Pressure
OR
Burnout
OR
Anxiety
CINAHL S1= 6672 HITS S1 + S2 = S1 + S2 +3 = 130 Reduced to
1081 HITS HITS last 10
years = 72
HITS
(3
Primary
studies
44
found)
HMIC S1 = 3597 HITS S1 + S2 = S1 + S2 +3 = 27 (1 Primary
311 HITS HITS study found)
PubMed S1 = 6138 HITS S1 + S2 = S1 + S2 +3 = 71 Reduced to

846 HITS last 10
HITS
years = 41
HITS
(1
Primary
studies
found).
Internurse S1 = 5535 HITS S1 + S2 = S1 + S2 +3 = 1391 Reduced to
4580 HITS HITS last 10
years = 55
HITS
(1 Primary
study found)
British S1 = 41,021 HITS S1 + S2 = S1 + S2 +3 = 7181 Reduced to

Nursing 7181 HITS last 10
Index years =
5189 HITS
Keywords to
appear in
title = 8
HITS (no
primary
studies
found)
45
Medline S1 = 414,55 HITS S1 + S2 = S1 + S2 +3 = 7537 Reduced to

16,801 last 10
years = 10
HITS (no
primary
studies
found)
Appendix 3 – Hierarchy of Evidence
(NHS England, 2013)
46
Appendix 4 – Overview of Included Studies
Author and Type of Country Journal / Sample Design Aim of Conclusions

Date of origin database
Study Study
Karimi et al, Quantitative Australia CINAHL / 312 Cross Investigate the The study
2013 Journal of Australian sectional impact of demonstrates
community quantitative emotional links between job
Advanced design. Pencil labour and stress negatively
nurses
Nursing. and paper emotional influencing
survey. intelligence on nurses’ wellbeing,
job stress and resulting in high
wellbeing on levels of
community emotional labour.
nurses.
Durkin et al, Quantitative United CINAHL / Across Standardised To measure Nurses who report
2015 Kingdom Nurse sectional psychometric links high levels of
Education questionnaires selfcompassion
sample of between are less likely to
today
37 self- suffer from
registered burnout.
compassion,
community
nurses compassion
fatigue,
wellbeing and
burnout
in
community
nurses
47
Tunnah et Qualitative United Internurse / 7

hospice Explorative To explore Job satisfaction,
al, Kingdom International at home semi stressors, coping
the
structured strategies and
2012 Journal of nurses interviews experiences of support from
Palliative colleagues were
all significant
Nursing nurses
factors in coping
providing with caring for
palliative palliative patients
care at
home –
aiming to
identify issues
contributing to
stress
HaycockStuar Qualitative United HMIC / 12 Semi Identify how Key outcomes;

t et al, 2010 Kingdom Community community structured leadership is managing
nurse interviews experienced emotions at work,
Practitioner leaders by feeling
community unsupported,
nurses emotional injury –
emotional labour
identified as a
significant result of
stress in community
leadership roles.
Karimi et Quantitative Australia Pubmed / 312 Paper based To Emotional

al, 2016 Australian survey investigate dissonance can
Australian
community effects of trigger withdrawal
Health
nurses work
Review behaviours –
organisation
on emotional improving
labour and organisation factors
withdrawal could prevent this
behaviour in
community
nurses
48
Opie et Quantitative Australia Snowballing 626 Cross sectional Compare High levels of stress
/ Australian Australian design using a working in both samples of
al, 2011
community structured place nurses effected their
Journal of questionnaire conditions psychological
nurses
Advanced and levels of wellbeing
occupational
Nursing
stress in 2
samples of
nurses
Begic et Quantitative USA Snowballing 27 home Surveys and in To 2/3 of participants

al, 2019 and / Journal of visitors (6 depth understand experienced burnout
were structured
Qualitative Human nurses) interviews the role of and secondary
(mixed Behaviour in burnout and traumatic stress
methods) the Social
Descriptive how this during the study and
Environment
and effects ¼ thought about
explorative
home leaving their jobs.
visitor’s Interviews were
likelihood to consistent with
leave the survey findings but
profession added depth.
Samia et Qualitative, USA Snowballing 29 Interviews and To describe Role overload, lack of
al, 2012 descriptive / Home observations home care control and role
home care nurses conflict are all
Health Care experience stressors of home
nurses
Services of job stress care nursing – these
and impact issues must be
Quarterly
of work addressed in order to

retain the nurses.
environment
Terry et Qualitative, Australia Pubmed / 15 Semi structured To Workload, burnout
al, 2015 Narrative community interviews and investigate and work-related
BMJ
enquiry nurses thematic stress was identified
analysis health and as an issue,
safety however, nurses said
they had a good
issues of
work-life balance and
working in shared stress with
the work colleagues,
sharing workloads
community when necessary
and the
impact of
these in
providing
care
49
Ball et al, Quantitative United Snowballing 2438 Cross sectional To 40% of respondents
2014 Kingdom / National completed survey of all reported they would
survey explore the leave their job if they
Nursing received Royal College could, 50% reported
nature of
Research of working poor staffing levels
conditions due to sickness and
Unit
for poor
Nursing recruitment/retention,
members many nurses
nursing
reported poor quality
working within working in
of care delivery due
DN teams
DN teams to high levels of
demand/stress.
Appendix 5 – CASP (2018) Qualitative Checklist – 10 Questions to help you make

sense of qualitative research.
Author and 1.Begic et al 2.Samia et 3.HaycockStuar 4.Terry et al 5.Tunnah et al

date: (2019) t et al (2015)
al (2012)
(2010)
50
Was there a Yes: to Yes: to Yes: to 1) Yes: to Yes: to undertake

clear identify how an assessment of
understand describe investigate
statement hospice at home
of the aims the context of home care leadership is the types of nurses’
of the home visitor nurse’s perceived and workplace experience and
research? wellbeing while
secondary experience of experience health and caring for
traumatic job stress and d by safety issues palliative and
dying patients.
stress and the community rural
burnout, and nurses and 2) community
potential
how this examine the
might affect moderating interaction nurses
intention to characteristi between recent encounter
quit among policy and
cs of and the
home leadership
impact these
visitors. the developme nt
issues have
in the
work on providing
community.
environment care to rural
consumers.
.
1) how do
home care
nurses
describe
stressors
specific
to
their practice
and work
environment .
2) how do
work
environment
characteristi
cs moderate
the level of
job
stress
experienced
by home
care nurses?
Is a Yes: seeking Yes: Yes: Yes: Yes: explorative
to explore the seeking to explorative narrative study seeking to
qualitative
enquiry
51
methodology experiences of explore through through semi understand through

appropriate? participants. experiences semi structured behaviour structured
structured semi
of the interviews. interviews interviews.
participants seeking
to
and interpret
understand
actions. complexity of
Observation community
nursing.
method
allowed
for
understandi
ng of
the
complexity
of home
care
nursing.
Was the Yes: Yes: Yes: semi Yes: semi Yes: semi
research qualitative Interviews, structured structured structured
design data collected field interviews. interviews. interviews.
appropriate using
to address structured observations
the aims of interviews. , formal and
the
casual
research?
observations
.
Was the Yes: small Yes: small Yes: 12 Yes: 15 Yes: 7 hospice at
recruitment sample of 27 sample of community community home nurses who
strategy participants 29 leaders nurses from 4 provide palliative
appropriate
to the aims of invited to take participants were different care to patients in
the part in study, from two recruited regions their own homes.
research? of
no incentives geographic through The nurses
Tasmania. No
were offered settings. All email discussion collaborate with
which reduces participants invitations about other community
participants
bias. were nurses via the nursing teams.
that chose not
Appropriatene caring for nurse to take part. Details provided on
directors. why participant
ss of patients
chose not to take
participants at part.
explained and
discussion home. No
present of why discussion
52
some people about

did not participants
that chose
not to take
part.
complete the
study.
Was the Yes: mixed Yes: clear Yes: it is Yes: data Yes: data collection
explanation collection clearly stated and
research methods study clear how
of data is how interviews
collected in a that clearly data was clearly were conducted is
collection
way that demonstrates and collected. described, explained. Form of
methods, and form of data explained.
addressed data collection Form of
form of data data is not data is clear.
the research with explicit also clear.
issue? clear and
explanation of methodolog
how y section is
not
interviews detailed.
were
conducted.
Has the No: Yes: No: Yes: Yes: role of the

relationship relationship potential relationship researcher researcher
between between bias between does not considered and a
researcher identified
and researchers and researcher examine their nurse in the
participants and minimised. and own role. All research team not
been
participants participants participants included to prevent
adequately
considered? not not were asked to bias. Other forms of
addressed, identified voluntarily bias also
however, and no take part. considered.
there is critical Some bias Limitations
explanation of
examinatio identified addressed.
who was
n of their within
invited to take Participation was
own roles. limitations.
part and why. voluntary.
Bias not
addressed.
53
Have ethical Yes: no Yes: Yes: the Yes: research Yes: permission
issues been discussion of participation was not obtained from
research
taking into
consideratio confidentiality agreement and externally ethics committee.
n? with from funded; Participants were
developme
participants
participants executive nt were informed informed of study
documented, directors department of study and nurses were
s of through
but all data obtained offered counselling
the a
collecting and three health written due to distressing
procedures institutional boards and statement and nature of
review board the gave written
were consent discussion.
approval. research
approved by Confidentiali ethics to Confidentiality was
the verbally discussed
researcher’s ty of committee take part. No and put in writing

institutional approved approval from with the exception
participants
an ethics of disclosure of any
review board. addressed study. committee. illegal/unsafe/unethi
and
Research was maintained. Details of cal practice.
funded The confidentiali
research
through ty and how
was funded
a grant.
by a health researcher
care explained
agency.
study to
participants
not
included.
54
Was the data Yes: Yes: data No: no in Yes: thematic Yes: interviews
analysis qualitative analysed depth analysis were transcribed
sufficiently and analysed using
rigorous? data analysed using description used. grounded theory
using a pattern of analysis Interviews approach to identify
themes. Transcripts
framework coding process. were audio were read and
method comparison One theme recorded and reread by research
of with drawn from clear team who were
each blinded to
analysis. grounded research, description of each other’s
Interviews theory bias not how critiques. Data
analysed by open
were methods. addressed,
coding procedure.
minimal themes were
transcribed Researcher Bias addressed and
data
and coded to identifies derived. limitations
supporting
addressed.
identify bias and findings. Data was
Limitations analysed
themes. ways that it not
Analysed by was addressed. through
at least two minimised NVivo
members of such as software.
researching triangulation Limitations of
team to and study

increase rigor. selecting addressed.
Limitations of
contrasting Bias not
study also
addressed
addressed. cases to during
minimise description of
sampling analysis of
bias. The data.
researcher
is critical of
their role.
Thematic
analysis
is
clear.
Limitations
also
identified.
55
Is there a Yes: findings Yes: table of Yes: Yes: clear Yes: themes clearly
clear are clearly summary of findings are statement of presented and
statement of stated and themes discussed in relation
discussed presented. discussed findings. to research aim.
findings?
in Findings are in relation to Trustworthine Credibility not
detail in also then ss of findings directly addressed.
research
relation to discussed in discussed.
research relation to question but Credibility
question. aim of no clear is
Reliability research. addressed.
discussed, Credibility is statement of
however, also findings.
validity and discussed. Credibility
credibility not not
discussed. addressed.
Appendix 6 – Coughlan et al (2007) Step by step guide to critiquing research.

Part 1: quantitative research.
56
Author and 6.Karimi et 7.Durkin et al 8.Karimi et 9.Opie et al 10. Ball et 1.Begic et al

date: al (2013) (2015) al (2016) (2011) al (2014) (2019)
Is the report Yes: Yes: and concise Yes: Yes: Yes: Yes:
well written? concise, written. well concise concise concise concise and
well written and well and well
and a clear written. and well written with
structure. written. well a clear
written. structure.
Do the Yes. Yes. Yes. Yes. Yes. Yes.

researchers
have
qualifications
in the area of
research?
Is there a Yes. Yes. Yes. Yes. Yes: in Yes.

the form
clear
of an
abstract?
executive
summary.
Is the Yes: to Yes: to Yes: to Yes: to Yes: to Yes: to

purpose examine
investigate measure investigate compare understand
of the
study the extent associations the effects workplace the roles, the context
clearly to which between of conditions staffing of home
identified?
emotional selfcompassion, and levels levels, visitor
labour and compassion work of and skill secondary
emotional fatigue, organisati occupation traumatic
mix of
wellbeing and stress in stress and
intelligenc on on the district
burnout two burnout, and
e are emotional samples of nursing how this
in
community labour Australian might affect
associated teams and
nurses. nurses. intention to
with withdrawal produce a quit among
wellbeing behaviour demograp home
visitors.
and job- of hic profile
stress Australian to inform
community future
among a nurses.
group of
Australian
community workforce
nurses. needs.
57
Is the Yes. Yes. Yes. Yes. Yes. Yes.

research
logical?
Has a Yes. Yes. Yes. Yes. Yes. Yes.

theoretical
framework
been
identified?
Have ethical Yes: Yes: ethical Yes: Yes: Yes: Yes: no

consideration ethical approval approved approved ethics not discussion
granted, and
s been approval participants by by explicitly of
identified? sought. were informed addresse confidentialit
that all data ethics ethics
Nature of d; y with
was
study confidential. committee committee. however, participants
detailed in . No Personalis study was documented
letter informatio ed cover published , but all data
inviting n on letter sent by the collecting
procedures
people to confidentia out with Royal were
take part. lity and survey College of approved by
how rewards the
No detail participant offered for Nursing
researcher’s
on were survey so ethics institutional
informed return. review
confidentia must have
about Confidenti board.
lity study. ality not been
included. mentioned. addresse
d.
Is the Yes: cross Yes: cross Yes: cross Yes: cross Yes: Yes:
methodology sectional sectional sectional sectional cross quantitative
clear and self-report questionnaire paper design survey clearly
appropriate? survey. survey. based structured sectional
explained.
Identified Clearly survey questionna survey of
and identified and identified ire.
nurses
explained. explained. and
explained. working
within
district
and
communit
y services
in
England.
58
What type of Data Data Detail of Data Data All

data and analysed analysed analysed analysis quantitative
statistical
not
statistical by using SPSS analysis not using data was
detailed.
included.
analysis was structural version 20. statistical entered into
undertaken?
equation Spearman’s package SPSS for
modelling rho for the simple
using correlation social statistical
AMOS and Whitney science analysis.
version 19. independent (SOSS),

U test used for VERSION
descriptive 16.
statistics.
Are strengths Yes: Yes: nurses Yes: to Yes: cross No. Yes:
and limitations involved increased sectional limitations
were likelihood identified
limitations were doing a nature of
relying on
identified? post of of study and were; small
a
graduate common unable to sample,
single method
diploma access short
source variance
(method so due data of duration
bias). cross nurses
difficult of
sectional who had
to left study,
nature
generalise to study. profession. limited time
all community frame may
nurses. lead to
Timing of underestima
research tion of stress
during and burnout
course would
also alter as this might
results. Small not develop
number of
for some
participants.
time.
Strengths
include
the
depth and
breadth
of
qualitative
data
obtained.
59
Was the Yes. N/A Yes. N/A N/A N/A

hypothesis (if
identified)
supported by the
findings?
Was a Yes: Yes: multiple

Yes: future No. Yes. Yes: can be
recommendati studies
research used to
recommenda
could guide a
tion further for needed on ons for further include much larger
research training for research other study.
made? made. outcome
nurses to
variables.
improve
emotional
competen
cy and
coping
with
emotional
labour in
order to
improve
well-being
and
reduce
stress.
Was the Yes: clear Yes: clear and Yes: clear Yes: clear Yes: Yes: clear
extensive extensive and and clearly and
research
references. extensive extensive
adequately references extensive reference
references references.
referenced?
. references throughou
. t.
60

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WHAT IS THE IMPACT OF STRESS ON

Word Count: 7504

Submission Date: 05/06/2020

1.3: Background and Rationale 6-8

Acknowledgments I would like to thank my wonderful husband and my incredibly

The purpose of this extended literature review (ELR) is to explore nurses’

Background and Rationale

Defining stress can be complex because stress is experienced differently in different

study of exploration of DN’s perception of occupational stress. However, the amount

Methodology can, simplistically, be defined as the systematic process that was

Formulating a Research Question

Developing a research question is essential when conducting an extended literature

Table One – Developing a research question using PICOT (Aveyard, 2019).

Population Qualified nurses working within the district nursing service.

Context The district nursing service.

Type of Qualitative and quantitative.

Table Two – Keywords and alternative terminology.

Keywords: District Impact Stress

Primary Care Influence Workplace

Having identified the research question, it is important to identify inclusion and

Table Three – Inclusion and Exclusion Criteria

Inclusion Criteria Exclusion Criteria Reasoning

Primary research studies Secondary data – Secondary data relies on

Access the research for Research Research that needs to be

English Language Not English Language Inaccuracy of translations

Published and peer Unpublished research. Reinforces robustness of

Research based in the UK Research conducted It may be necessary to

Database Selection and Search Strategy

Hierarchy of evidence (Appendix 3) refers to the robustness of different research

Having considered appropriate research, Aveyard (2019) suggests creating a

Table Four – Developed Hierarchy of Evidence

Systematic reviews (not included in this review).

Quantitative studies such as questionnaires or surveys

Table Five – Studies Meeting Inclusion Criteria for this ELR

2. Samia et al (2012) ‘Home care nurses’ experiences of job stress and

3. Haycock-Stuart et al (2010) ‘Emotional Labour within Community Nursing

5. Tunnah et al (2012) ‘Stress in hospice at home nurses: a qualitative study of

6. Karimi et al (2013) ‘Emotional rescue: the role of emotional intelligence and

7. Durkin et al (2015) ‘A pilot study exploring the relationship between

8. Karimi et al (2016) ‘Are organisational factors affecting the emotional

9. Opie et al (2011) ‘Occupational stress in the Australian nursing workforce: a

It is necessary to critically appraise each paper. Critical appraisal is essential in

Table Six – Thematic analysis of research papers

Theme One: Burnout and Compassion Fatigue

A quantitative study undertaken by Durkin et al (2015) sought to analyse

The qualitative study by Tunnah et al (2012) explored the wellbeing of hospice at

reactive approach is imperative in maintaining the health of nurses providing care in

Theme Two: Reduced Job Satisfaction and Retention

system changes to support nurses, thus, creating a positive working environment to

A mixed method study conducted by Begic et al (2019) investigated how burnout

Theme three: Emotional Injury

Emotional labour, emotional exhaustion, emotional dissonance and psychological

In contrast, a quantitative study by Opie et al (2011) compared the levels of stress

in both community and hospital-based nursing and have an impact on the

Conclusion and Recommendations for Practice

Introduction and Rationale

having a proactive approach to tackling burnout and compassion fatigue is essential.

Design and Methodology

Preliminary Suppositions and Implications

Aveyard, H., Payne, S. and Preston, N. (2016) A Post-graduate’s Guide to Doing a