In brief
Cancer nurses across Cheshire and Mersey showed improving average depression scores over six months of the pandemic recovery period, but 32% still reported severe depression at 6 months. Professional identity, peer support, and personal coping mattered more than formal well-being services, which nurses found hard to...
What this article is about
Quick Answer
Cancer nurses across Cheshire and Mersey showed improving average depression scores over six months of the pandemic recovery period, but 32% still reported severe depression at 6 months. Professional identity, peer support, and personal coping mattered more than formal well-being services, which nurses found hard to access.
Student takeaways
Key Takeaways
- In a repeated-measures survey of cancer nurses (baseline n=69, 3 months n=40, 6 months n=29), mean depression scores decreased significantly over time (F(2,44)=17.094, p<.001), while anxiety, self-efficacy, resilience, and general well-being showed no significant change across the three time points.
- Despite the improving group-average depression score, 32% of respondents (9 of 28) met criteria for severe depression at the 6-month time point, indicating a subgroup whose symptoms worsened even as the overall mean improved.
- Thematic analysis of 29 interviews identified four themes: principles and practice of nursing, the impact of COVID-19 on nurses' identity, self-management strategies, and organisational responses.
- Nurses described sustaining well-being primarily through professional identity, peer support, established work routines, and personal coping strategies such as exercise and reflection, rather than through formal organisational interventions.
- Focus group data (7 nurses; 5 well-being service providers) converged on the theme 'engaging nurses,' highlighting that existing well-being services were often inaccessible or poorly communicated (e.g., via email), with nurses calling for responsive, personally-offered, and confidential support delivered in safe environments.
Student summary
Why This Research Matters
This 2025 BMC Nursing study, led by Lynda Appleton and colleagues (including Helen Poole of Liverpool John Moores University), asked a simple but important question: how did the COVID-19 pandemic affect the psychological well-being of cancer nurses working across the Cheshire and Mersey region of Northwest England, and what helped them cope?
The researchers used a multi-methods design, combining three data sources so findings could be checked against one another (a process called triangulation). First, 69 registered cancer nurses from community, primary, secondary, and tertiary care settings completed a repeated-measures survey between February and October 2022, at baseline, 3 months, and 6 months. The survey used validated tools: the Hospital Anxiety and Depression Scale (HADS), the Warwick-Edinburgh Mental Well-being Scale (WEMWBS), the Self-Efficacy Scale (SES), and the Brief Resilience Scale. Response numbers dropped over time (40 nurses at 3 months, 29 at 6 months), which is a common challenge in longitudinal nursing research. Second, 29 nurses took part in semi-structured interviews. Third, two focus groups were held, one with 7 nurses and one with 5 well-being service providers. Ethical approval came from Liverpool John Moores University, and all participants gave informed consent.
Statistically, most measures (anxiety, self-efficacy, resilience, and general well-being) stayed fairly stable across the three time points. Depression was the exception: mean depression scores dropped significantly between baseline and both later time points. On the surface, this looks like good news. But when the researchers looked at the proportion of nurses in different symptom categories rather than just the average score, a more worrying pattern appeared: at 6 months, 32% of respondents (9 of 28) were scoring in the severe depression range, even though the group average had gone down. This tells students an important lesson about research appraisal: average scores can hide the fact that a meaningful subgroup is struggling more, not less, over time.
The interview data added depth. Four themes emerged: (1) the principles and practice of nursing, where nurses described drawing on professional identity, adaptability, and "thinking on their feet" to keep delivering safe care; (2) the impact of COVID-19 on nurses' identity, as service disruptions meant patients arrived with more advanced disease and fewer treatment options, even as some described patients receiving unusually attentive care during quieter lockdown periods; (3) self-management strategies, including exercise, peer support through group chats, reflection, and recognizing that self-care was necessary in order to care for others; and (4) organisational responses, which were inconsistent — some managers were highly supportive, but formal well-being communications (often sent by email) were seen as impractical given nurses' workloads. The focus groups reinforced this last point, emphasizing that support needs to be responsive, face-to-face, personally offered rather than generic, and delivered in environments nurses feel safe using.
For nursing students, the take-home messages are twofold. Clinically, this study is a reminder that resilience and coping are active, ongoing processes shaped by professional identity, peer relationships, and daily routines — not something nurses either "have" or "don't have." Organisationally, it shows that having a well-being service available is not the same as it being accessible or used; design and delivery matter as much as existence. As you read the findings, notice how the authors triangulated survey, interview, and focus-group data to build a fuller picture than any single method could offer alone, and consider how the sample (mostly female, mostly White-British, senior nurses somewhat overrepresented) may shape which experiences are captured and which may be missing.
Source abstract
Study Overview
Abstract Background Cancer nurse well-being is crucial for the delivery of high-quality patient care. During the COVID-19 pandemic, fear and anxiety negatively impacted nurse well-being. Understanding the factors contributing to well-being amongst cancer nurses is a priority, as chronic stress can negatively influence job satisfaction and standards of care. Methods A multi methods approach comprising a repeated measures survey (n = 69), semi-structured interviews (n = 29) and two focus groups was used. This enabled in-depth exploration of nurses’ experiences over time. Following ethical approval, nurses from different cancer settings were recruited from NW England. The survey measured anxiety, depression, self-efficacy, resilience and well-being at three time-points [baseline; 3 months and 6 months]. Data was collected Feb-Oct 2022. Participants were also invited to participate in an interview and focus group. This data was subject to Thematic Analysis. Data sources were triangulated to substantiate findings. Ethical approval was obtained and participants provided informed consent. Results Survey data revealed anxiety, well-being, self-efficacy and resilience were broadly consistent over time. The only significant difference was depression, where mean scores at times 2 and 3 were significantly lower than time 1. While most participants reported mild to moderate anxiety and depression throughout the study, at time 3 a significant minority (32%, 9/28) reported severe depression. Four themes arose from interviews: (i) the principles and practice of nursing, (ii) the impact of COVID-19 on nurses’ identity, (iii) self-management strategies, (iv) organisational responses. Focus group data emphasised the need for improved communication concerning well-being services. Conclusions Nurses used coping strategies throughout the pandemic and beyond, drawing on professional and personal experiences and adapting to clinical service changes. Well-being was sustained through peer and patient interactions, and work routines. Workplace cultures supporting and normalising nurses’ well-being should be encouraged and co-creation of interventions to build resilience and improve communication. Importantly interventions should be evaluated for their effectiveness and barriers to accessing support removed. Our findings build on theory addressing workplace culture, high stress environments and individuals’ self-awareness of well-being needs. Research is needed to understand the well-being needs of cancer nurses according to banding, work setting, and pre-existing psychological morbidity. Clinical Trial Number Not applicable.
Evidence appraisal
Main Findings
- In a repeated-measures survey of cancer nurses (baseline n=69, 3 months n=40, 6 months n=29), mean depression scores decreased significantly over time (F(2,44)=17.094, p<.001), while anxiety, self-efficacy, resilience, and general well-being showed no significant change across the three time points.
- Despite the improving group-average depression score, 32% of respondents (9 of 28) met criteria for severe depression at the 6-month time point, indicating a subgroup whose symptoms worsened even as the overall mean improved.
- Thematic analysis of 29 interviews identified four themes: principles and practice of nursing, the impact of COVID-19 on nurses' identity, self-management strategies, and organisational responses.
- Nurses described sustaining well-being primarily through professional identity, peer support, established work routines, and personal coping strategies such as exercise and reflection, rather than through formal organisational interventions.
- Focus group data (7 nurses; 5 well-being service providers) converged on the theme 'engaging nurses,' highlighting that existing well-being services were often inaccessible or poorly communicated (e.g., via email), with nurses calling for responsive, personally-offered, and confidential support delivered in safe environments.
Practice transfer
Clinical Relevance
- Well-being screening and support programs for cancer nursing staff should track both average symptom trends and the proportion of staff crossing clinical severity thresholds, since group averages can mask a meaningful subgroup whose depression is worsening.
- Organisations should consider replacing purely email-based well-being communications with responsive, on-site, and personally-delivered outreach, since nurses in this study reported that time pressure made email-based service information impractical to act on.
- Formal clinical supervision and informal peer debriefing appeared valued by nurses and may be worth protecting or expanding as low-barrier support structures embedded in existing workflows.
- Because senior nurses were overrepresented in this sample and the most distressed staff may be least likely to participate in well-being research or programs, managers should proactively seek out and check in with nurses who are not engaging with available supports.
- Well-being initiatives are likely to be more effective when co-designed with nursing staff and tailored to individual needs and settings, rather than delivered as generic, one-size-fits-all programs.
Faculty notes
Educational Relevance
This multi-methods study (Appleton et al., BMC Nursing, 2025) examined psychological well-being trajectories among cancer nurses in the Cheshire and Mersey region of Northwest England across the COVID-19 pandemic recovery period (February–October 2022). It offers useful teaching material on mixed/multi-methods triangulation, the distinction between mean-level and categorical outcome interpretation, and workplace well-being intervention design.
Design: A repeated-measures survey (baseline, 3 months, 6 months) used four validated instruments — HADS, WEMWBS, the Self-Efficacy Scale (SES), and Brief Resilience Scale — administered to 69 cancer nurses at baseline, with attrition to 40 (58%) at 3 months and 29 (42%) at 6 months (21–23 with complete matched data across all three points). Qualitative data came from 29 semi-structured interviews and two focus groups (7 nurses; 5 well-being service providers), analysed using Braun and Clarke's six-step thematic analysis in NVivo. Ethical approval was obtained from Liverpool John Moores University (ref. 21/PSY/027).
Key quantitative result: repeated-measures ANOVA showed a statistically significant reduction in depression scores over time, F(2,44)=17.094, p<.001, ηp²=0.437 (Time 1 M=9.6; Time 2 M=7.2; Time 3 M=7.44), with Bonferroni-corrected comparisons confirming Time 1 differed significantly from both later points. Anxiety, self-efficacy, resilience, and well-being showed no significant change over time. Critically, categorical HADS analysis revealed that 32% (9/28) of respondents met criteria for severe depression at 6 months, despite the improving group mean — an instructive divergence for teaching students to interrogate whether averages mask subgroup deterioration.
Qualitative themes: (1) principles and practice of nursing — professional identity and adaptive problem-focused coping sustained safe care delivery; (2) impact of COVID-19 on nurses' identity — disrupted services meant nurses managed patients with more advanced disease and fewer options, alongside some accounts of unusually attentive care during lower-census lockdown periods; (3) self-management strategies — exercise, peer support (including informal WhatsApp networks), reflection, and recognition that self-care underpins the capacity to care for others; (4) organisational responses — variable managerial support and largely ineffective, email-based communication about well-being services given nurses' time pressures. Focus group data converged on a single overarching theme, "engaging nurses," with sub-themes of responsiveness (on-site, immediate support), tailored/personal invitation rather than generic messaging, and safe, confidential environments.
For classroom discussion, this paper supports critical appraisal exercises on: (a) interpreting divergence between mean-level and categorical/clinical-threshold findings; (b) triangulation logic in multi-methods design; (c) selection bias in longitudinal workplace research (senior nurses and the well-being-interested may be overrepresented, while the most distressed staff may not participate); and (d) translating qualitative themes about "what nurses actually want" into actionable, co-designed organisational policy rather than top-down, one-size-fits-all interventions. The authors' own limitations — smaller-than-anticipated and attrited sample, self-selection bias, an all-White-European research team, and incomplete linkage between survey and interview data — are worth walking through explicitly as exemplars of honest limitation reporting appropriate to modelling for undergraduate and graduate research courses.
Critical appraisal
Limitations
- The survey sample was smaller than anticipated and experienced substantial attrition, dropping from 69 participants at baseline to 29 at 6 months, with only 21–23 nurses providing complete matched data across all three time points.
- Senior nurses appear to have been overrepresented in the sample, and participation was likely subject to self-selection bias toward nurses already interested in research or well-being, meaning the most psychologically distressed staff may be underrepresented or missing entirely.
- The study could not fully link individual nurses' survey responses with their interview data, limiting the ability to connect quantitative symptom trajectories to specific qualitative accounts.
Classroom use
Discussion Questions
- Why is it important to examine categorical (clinical-threshold) depression rates alongside mean depression scores, and what could have been missed if the researchers had reported only the improving group average?
- What does the divergence between improving mean depression scores and a growing severe-depression subgroup suggest about how psychological distress may evolve differently across individuals during a prolonged crisis?
- How did triangulating survey, interview, and focus group data strengthen the credibility of this study's conclusions compared with using only one method?
- In what ways did participants describe professional identity and 'principles and practice of nursing' as a source of resilience, and how might nurse educators reinforce this in training?
- Why might email-based communication about well-being services have failed to reach or help time-pressured cancer nurses, and what alternative approaches does the study suggest?
- How could selection bias (overrepresentation of senior nurses, self-selected research participants) have shaped which experiences and needs are reflected in this study's findings?
- What role did peer support (e.g., informal group chats, shared reflection) play in nurses' coping strategies, and how could organisations formally support these existing peer networks?
- The focus groups emphasized 'responsiveness,' 'tailored support,' and 'safe environments' as key needs. How would you translate each of these into a concrete organisational policy or program change?
- What ethical and practical challenges arise in retaining participants across a six-month repeated-measures study of frontline healthcare workers during an ongoing pandemic recovery period?
- The authors note their research team was entirely white European. How might researcher identity and background influence the interpretation of qualitative themes about workplace culture and well-being?
Knowledge check
Quiz
1. How many cancer nurses completed the baseline survey in this multi-methods study?
- 29
- 40
- 69
- 9
Rationale: The abstract and extracted methods state the repeated measures survey had n = 69 at baseline.
2. Which psychological outcome showed a statistically significant change across the three survey time points?
- Anxiety
- Depression
- Self-efficacy
- Resilience
Rationale: The study found that 'the only significant difference was depression, where mean scores at times 2 and 3 were significantly lower than time 1,' confirmed by ANOVA (F(2,44)=17.094, p<.001).
3. At the 6-month time point, what proportion of respondents reported severe depression despite the improving group-average score?
- 9%
- 21%
- 32%
- 58%
Rationale: The abstract states that at time 3, 'a significant minority (32%, 9/28) reported severe depression,' even though mean depression scores had improved.
4. How many semi-structured interviews were conducted as part of this study?
- 7
- 12
- 29
- 69
Rationale: The methods describe 'semi-structured interviews (n = 29)' conducted with cancer nurses.
5. Which of the following was NOT one of the four themes identified from the interview data?
- Principles and practice of nursing
- The impact of COVID-19 on nurses' identity
- Self-management strategies
- Patient satisfaction with telehealth services
Rationale: The four interview themes were the principles and practice of nursing, the impact of COVID-19 on nurses' identity, self-management strategies, and organisational responses; telehealth satisfaction was not a theme.
6. What was the overarching theme identified from the focus group data?
- Engaging nurses
- Patient safety
- Staffing shortages
- Digital transformation
Rationale: The focus group analysis converged on the theme 'engaging nurses,' with sub-themes of responsiveness, tailored support, and safe environments.
7. According to the interview findings, what did nurses identify as a key reason formal well-being communications (often sent via email) were ineffective?
- Nurses did not have email access
- Time pressure and heavy workloads made it impractical to engage with them
- The well-being services were too expensive
- Nurses were unaware such services existed
Rationale: One participant described being 'so busy' that they felt they would 'never have the chance' to engage with email-based well-being communications.
8. Which validated tool did the study use to measure anxiety and depression?
- Hospital Anxiety and Depression Scale (HADS)
- Beck Depression Inventory
- PHQ-9
- GAD-7
Rationale: The extracted methods specify that anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS).
9. Which of the following is a limitation the authors themselves acknowledged?
- The survey instruments used had never been validated before
- Senior nurses were overrepresented and the sample was subject to self-selection bias
- No ethical approval was obtained
- The study included nurses from outside the nursing profession
Rationale: The authors note a lower-than-expected sample size, overrepresentation of senior nurses, and self-selection bias toward research-interested, well-being-conscious participants as limitations.
10. What did the study conclude nurses primarily relied on to sustain their psychological well-being during the pandemic, rather than formal organisational interventions?
- Government financial support
- Professional identity, peer support, work routines, and personal coping strategies
- Mandatory counseling sessions
- Reduced patient caseloads
Rationale: The conclusions state well-being was sustained through peer and patient interactions, professional and personal coping experiences, and work routines, more so than through formal organisational well-being services.
Study cards
Flashcards
What was the primary aim of this multi-methods study?
To explore the impact of the COVID-19 pandemic on the psychological well-being of cancer nurses across Cheshire and Mersey, Northwest England, over a six-month period.
What three data collection methods made up the 'multi-methods' design?
A repeated-measures survey (n=69), semi-structured interviews (n=29), and two focus groups (7 nurses; 5 well-being service providers).
At what time points was the survey administered?
Baseline, 3 months, and 6 months, with data collected between February and October 2022.
Which four validated instruments were used in the survey?
The Hospital Anxiety and Depression Scale (HADS), Warwick-Edinburgh Mental Well-being Scale (WEMWBS), the Self-Efficacy Scale (SES), and Brief Resilience Scale (BRS).
How did the survey sample size change over the study period?
It dropped from 69 participants at baseline to 40 (58%) at 3 months and 29 (42%) at 6 months, with only 21-23 nurses providing complete matched data at all three points.
Which psychological measure showed a statistically significant improvement over time?
Depression, which decreased significantly from baseline to both the 3-month and 6-month time points (p<.001).
Which measures showed no significant change across the three time points?
Anxiety, self-efficacy, resilience, and general well-being (WEMWBS) showed no significant change over time.
What surprising finding emerged when looking at categorical depression severity at 6 months?
Despite the improving average depression score, 32% (9 of 28) of respondents reported severe depression at 6 months.
What method was used to analyze the interview and focus group data?
Thematic Analysis (Braun and Clarke's six-step process), supported by NVivo software.
What is the first of the four interview themes?
Principles and practice of nursing, reflecting professional identity, adaptability, and problem-focused coping.
What is the second interview theme, and what did it describe?
The impact of COVID-19 on nurses' identity, describing how service disruptions led nurses to see patients with more advanced disease and fewer treatment options.
What is the third interview theme?
Self-management strategies, including exercise, peer support, reflection, and recognizing the need for self-care.
What is the fourth interview theme?
Organisational responses, which were inconsistent, with email-based well-being communications seen as impractical given nurses' workloads.
What was the single overarching theme from the focus group data?
'Engaging nurses,' comprising the sub-themes of responsiveness, tailored support, and safe environments.
What did nurses say about formal well-being service communication (e.g., via email)?
They found it impractical due to time pressure; one nurse said, 'we are so busy... I'll never have the chance.'
What personal coping strategies did nurses describe using?
Exercise, reflection on difficult situations, maintaining peer connections (e.g., WhatsApp groups), and recognizing self-care as necessary to care for others.
Which institution provided ethical approval for the study?
Liverpool John Moores University Ethics Committee (reference 21/PSY/027).
What sample or selection-related limitation did the authors acknowledge?
The sample was smaller than expected, senior nurses were overrepresented, and self-selection bias likely favored research-interested, well-being-conscious participants.
What did the authors recommend for future research?
Further research examining cancer nurses' well-being needs according to job banding, work setting, and pre-existing psychological morbidity.
What overall conclusion did the study reach about how nurses sustained well-being during the pandemic?
Well-being was primarily sustained through professional identity, peer and patient interactions, and personal work routines, rather than through formal organisational well-being interventions, which need redesign to improve accessibility and tailoring.
Search-ready answers
Frequently asked questions
What was this study about?
It explored how the COVID-19 pandemic affected the psychological well-being of cancer nurses in the Cheshire and Mersey region of Northwest England, using a combination of surveys, interviews, and focus groups over six months in 2022.
How many nurses took part in the study?
Sixty-nine nurses completed the baseline survey (dropping to 29 by 6 months), 29 nurses were interviewed, and 7 nurses plus 5 well-being service providers took part in two focus groups.
Did nurses' anxiety improve during the study period?
No. Anxiety, along with self-efficacy, resilience, and general well-being, showed no statistically significant change across the three survey time points.
Did depression improve among cancer nurses over the six months studied?
On average, yes—mean depression scores decreased significantly from baseline to 3 and 6 months. However, 32% of nurses still reported severe depression at 6 months, showing the average improvement masked a struggling subgroup.
What coping strategies did cancer nurses use during the pandemic?
Nurses described exercise, reflection, peer support through informal group chats, maintaining work routines, and recognizing the importance of self-care in order to keep caring for patients.
Were hospital well-being services helpful to nurses in this study?
Not consistently. Nurses reported that email-based communication about well-being services was impractical given their workloads, and they called for more responsive, personally-offered, and confidential support instead.
What themes emerged from interviews with cancer nurses?
Four themes: the principles and practice of nursing, the impact of COVID-19 on nurses' identity, self-management strategies, and organisational responses.
What did the focus groups reveal about how to better support nurses?
They highlighted the need for responsiveness (immediate, on-site support), tailored/personal invitations rather than generic messages, and safe, confidential environments for accessing help.
What are the main limitations of this study?
A smaller-than-expected and attrited sample, overrepresentation of senior nurses, likely self-selection bias, incomplete linkage between survey and interview data, and an all-white-European research team.
What do the researchers recommend going forward?
They recommend co-designing well-being interventions with nurses, improving accessibility of support services, normalizing conversations about mental health, evaluating intervention effectiveness, and further research examining well-being by job banding, work setting, and pre-existing psychological morbidity.