Compassion under pressure: generational perspectives on burnout and inner resources in nursing practice

Abstract

This grounded theory study explores how burnout influences compassionate care among nurses, using Spain’s Balearic Islands as an illustrative context. Twenty-seven in-depth interviews with nursing students and professionals examined how nurses mobilise their inner resources, conceptualised through McGaghie’s “compassionate core” model, to sustain compassion under conditions of burnout. Core resources—including cognitive capacity, affective regulation, awareness of self and others, moral or spiritual grounding, and discernment—shaped how participants managed workplace pressures. Discernment and self-awareness emerged as particularly important in enabling nurses to calibrate compassionate responses and avoid emotional overextension. Although compassion was widely valued, the ways these inner resources were mobilised to use compassion differed across generations. Older nurses are often more driven by awareness of others and meeting patient needs, risking self-sacrifice and burnout, in contrast to younger nurses who tend to be more self-aware and consequently prioritise boundaries and personal well-being. Structural conditions such as staffing shortages, insecure contracts, and heavy workloads were also identified as barriers that constrained compassionate practice. By examining inner resources alongside generational context, this study extends McGaghie’s model and suggests that supporting the development of discernment and self-awareness may help sustain compassionate nursing practice while addressing burnout.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04578-z.

Introduction

Nursing professionals worldwide are grappling with escalating challenges, notably burnout and workforce shortages. Globally, the World Health Organisation estimates a global shortfall of 4.5 million nurses by 2030 [1]. In this study, Spain — and specifically the Balearic Islands — serves as an illustrative case through which these broader pressures can be examined. In Spain, nurse-to-population ratios remain substantially below the European average (620 vs. 827 per 100,000 inhabitants) [2, 3], with projections suggesting continued workforce deficits in the coming decade [4]. The Balearic Islands exemplify these pressures, reporting 5.93 nurses per 1,000 inhabitants, below both national and European benchmarks [5]. While regional factors such as housing costs and employment insecurity contribute to migration [6–9], these local dynamics mirror broader systemic challenges including inadequate staffing, high workload, and sustained occupational stress [1, 10–11]. Despite policy efforts aimed at stabilising contracts and improving practice environments [12–14], recruitment and retention remain significant concerns, raising questions about how different generations of nurses’ experience and respond to these pressures across the course of their careers.

Nursing is consistently associated with substantial occupational stress, with much of the literature documenting high levels of burnout [15–18], which is frequently identified as a key factor in nurses’ decisions to leave the profession [11, 19]. Now recognised in the World Health Organization’s International Classification of Diseases (ICD-11) [20], burnout is defined as a syndrome resulting from chronic workplace stress that has not been successfully managed. It is characterised by emotional exhaustion, mental detachment or negative attitudes toward one’s work, and a reduced sense of professional efficacy and satisfaction [15, 20]. Burnout therefore has personal, social, and economic implications for individuals, organisations, and healthcare systems [21].

At the individual level, sustained workload and emotional strain are associated with anxiety, depression, chronic fatigue, migraines, insomnia, irritability, impaired concentration, and diminished relational engagement [22–30]. As exhaustion intensifies, quality of care may be compromised, contributing to suboptimal standards and reinforcing burnout cycles [31–32]. Fatigue, cynicism, and emotional withdrawal have been linked to reduced patient safety and satisfaction, increased risk of clinical error, and experiences commonly described as compassion fatigue [32–35]. Organisational consequences include absenteeism, reliance on temporary staff, increased workload for remaining colleagues, and escalating economic costs associated with turnover and medical error [11, 18, 31, 36–37]. Taken together, these consequences illustrate that burnout extends beyond individual distress, directly shaping nurses’ capacity to sustain compassionate care in contemporary practice.

As a core value within the nursing profession [38–41], compassion holds significant importance for both patients and nurses [42]. However, under the strain of demanding workloads, it is often among the first qualities to diminish [43–44]. Compassion has been defined as “a virtuous response that seeks to alleviate a person’s suffering and needs through relational understanding and action” [45, p.195]. As such, it underpins therapeutic relationships and person-centred care, fostering trust, emotional safety, and a sense of being genuinely cared for — elements that patients consistently identify as central to their care experience [46–47].

In light of escalating burnout and retention concerns, this study sought to explore how burnout influences nurses’ capacity for compassionate care delivery, and whether compassion may function not only as an outcome under threat but also as a sustaining professional resource [26, 48]. Rather than focusing solely on structural or economic constraints, we examined how nurses draw upon internal resources to influence their care delivery under pressure [21]. Here, inner resources refer to five interrelated elements outlined by McGaghie [49], conceptualised as foundational to compassionate practice among healthcare professionals. These include cognitive resources (e.g., optimism, resilience, hope, self-efficacy), affective resources (e.g., adaptability, collaboration, playfulness), moral resources (e.g., ethical commitment), and awareness of self and others, expressed through reflective capacity and interpersonal interactions [49]. McGaghie’s model was selected because it conceptualises compassion not merely as an emotional response or an outcome measure, but as a constellation of cognitive, affective, moral, and relational capacities that can be cultivated over time. In contrast to frameworks that focus primarily on compassion fatigue or burnout as forms of depletion [32, 50–52], this model accentuates the internal resources that enable compassionate action. This emphasis aligns with a grounded theory approach, allowing inner resources to function as sensitising concepts that guide inquiry while remaining open to refinement through participants’ accounts. In addition, we consider how these inner resources may be shaped differently across stages of professional formation, recognising that generational socialisation may influence how compassion is understood and enacted in practice.

Although burnout and compassion have been widely examined, they are often treated as distinct phenomena, with comparatively little attention to how they intersect through the mediating role of inner resources, particularly across different stages of professional formation [32, 50–52]. Much of the existing research conceptualises burnout primarily in terms of prevalence, risk factors, and organisational determinants, while compassion is frequently examined as an outcome variable or individual trait, rather than as a dynamic practice shaped by internal capacities and socialisation processes. Within the Spanish context, research has largely prioritised prevalence data and structural challenges [26, 41], with limited qualitative exploration of how nurses interpret, sustain, or adapt compassionate practice under pressure. Studies integrating both nursing students and practising nurses remain scarce [37, 53–54], despite the importance of professional socialisation in shaping compassionate capacity.

By examining burnout, compassion, and inner resources together, and by including both students and registered nurses, this grounded theory study offers an integrated and practice-oriented perspective. Specifically, it advances understanding of how inner resources mediate the relationship between burnout conditions and compassionate care, and how these processes evolve across the professional lifespan. In doing so, it contributes a theoretically informed and empirically grounded account of how compassionate practice is sustained, challenged, and reshaped under pressure, with implications for workforce retention, professional formation, and future research on sustaining compassionate care.

Methods

Study aim

The aim of this grounded theory study was to explore how sustained exposure to workplace stress and burnout conditions influences the delivery of compassionate care, and how nurses draw upon inner resources to sustain, adapt, or protect compassion in high-pressure clinical environments. The study included nursing students and registered nurses across career stages in order to examine how compassionate practice develops over time within the profession and how professional formation may shape responses to occupational strain.

McGaghie’s model of the “compassionate core” [49] was used as a sensitising concept to guide inquiry into the cognitive, affective, moral, and relational capacities that may underpin compassionate practice. In keeping with grounded theory methodology [55–56], this model informed early questioning and theoretical sampling while allowing analytic categories to emerge inductively from participants’ accounts.

Researcher reflexivity and context

The lead author (S-L.F.) is a British-trained nurse raised in Spain and a doctoral candidate in Nursing in the Balearic Islands, with prior training in Social Anthropology in the United Kingdom. As a bilingual researcher, she conducted and translated interviews, which are both factors to consider regarding ways of knowing and data interpretation.

The supervisory team contributed interdisciplinary perspectives from nursing, psychology, and sociology during research design and analysis. While data interpretation was collaborative, S-L.F. led data collection, analytic decisions, and manuscript preparation.

Reflexivity was supported through a research journal maintained throughout the study, including post-interview reflections and analytic memos documenting coding decisions, emerging insights, and engagement with relevant literature. This process enhanced transparency by making visible researcher assumptions and their potential influence on interpretation [57–59].

Design

This qualitative study employed grounded theory as an interpretivist lens. Data collection and analysis occurred iteratively through a cyclical process of in-depth semi-structured interviews and concurrent reflective analysis. Transcripts were analysed line-by-line and grouped into codes, concepts, and developing categories using constant comparison, allowing ideas to evolve as data accumulated. Recruitment, data collection, and analysis continued until saturation was met [56, 60–61].

Grounded theory is particularly suited to examining social processes, such as how nurses cope with burnout, and how these processes are shaped by contextual realities within practice environments. This approach thus enabled an in-depth interpretive analysis of nurses’ experiences, complementing existing quantitative findings with a more nuanced understanding [60]. Standards for Reporting Qualitative Research (SRQR) guidelines [62] were followed to ensure methodological rigour (see Annex 10).

Participants and recruitment

Twenty-seven in-depth interviews were conducted, in keeping with grounded theory’s emphasis on data richness over sample size [55, 61]. Participants were either student nurses registered at the University of the Balearic Islands, Spain, or qualified nurses listed on the Balearic nursing register. Recruitment was achieved via emails, posters in relevant workplaces and educational settings, and professional networks.

Participants were purposefully recruited across stages of professional formation to explore how compassion and responses to burnout develop over time. Including both students and practising nurses enabled examination of how inner resources are cultivated, interpreted, and mobilised across the professional lifespan.

To capture this variation, student nurses from all four years of training were recruited [63]. First-year students were interviewed prior to clinical placements to explore baseline perceptions, while more experienced students reflected on placement experiences and evolving views of burnout and compassion. Qualified nurses, with 1 to 37 years of experience across all three Balearic Islands, provided insights shaped by sustained exposure to demanding healthcare environments. Variation in years of experience and clinical context supported analytic comparison consistent with grounded theory principles.

Recruitment strategies were designed to maximise representation across training stages and experience levels. The lead researcher visited lectures in all four years of the nursing programme to introduce the study and invite participation, and practising nurses were approached through institutional mailing lists, professional networks, and word-of-mouth. Participation was voluntary; however, recruitment was monitored throughout to ensure adequate variation in line with emerging analytic needs.

Participant anonymised codes were applied using a combination of letters and numbers to indicate professional status (P – professional; S – student), gender identification (F – female; M – male), years of experience, and randomised initials. For example, PF13HGL refers to a professional female with 13 years of clinical practice. This format is used throughout the text.

Data generation

Individual participant-led interviews were the primary source of data, conducted by the lead researcher (S-L.F.). Open-ended questions enabled participants to express their perspectives freely, with minimal guiding assumptions from the researcher [64]. Participants’ own words were used to clarify meaning and probe deeper insights. At the conclusion of each interview, participants were invited to add further reflections, which often generated additional rich data.

Purposeful sampling was initially employed to select participants with experience of nursing-related burnout, facilitating in-depth exploration of the phenomenon. In keeping with grounded theory methodology [56, 61], theoretical sampling was subsequently used to recruit participants whose perspectives could extend, refine, or challenge emerging categories.

Interviews were conducted, transcribed, and analysed concurrently over a seventeen-month period, allowing emerging codes to inform subsequent data collection and ensure that saturation was met. Interview questions were adapted iteratively to clarify developing themes and explore unanticipated issues (see Annex 2 & 6). For example, early interviews revealed varied and sometimes ambivalent understandings of the term “compassion.” Some participants, particularly more experienced nurses, described the word as “negative”, “patronising” or “belittling,” contrasting with assumptions present in parts of the literature [5, 39, 65] and amongst researchers. To address this discrepancy, additional questions were incorporated, including: “How do you define compassion?” and “What do you think of when you hear the word compassion?” Following participants’ responses, the research team’s working definition was shared to ensure conceptual clarity for subsequent discussion. Participants were also invited to suggest alternative terms, most commonly suggesting: “empathy,” “being with,” “accompanying,” and “support” (see Annex 6). This iterative adaptation of interview questions strengthened conceptual clarity and ensured that data collection remained responsive to participants’ meanings while preserving analytic openness. All interviews were digitally recorded, anonymised, and transcribed for analysis.

Analysis

Analysis followed an inductive grounded theory approach, with data collection and analysis occurring concurrently [56, 60]. The lead researcher conducted initial coding to maintain consistency, with subsequent review by co-authors to enhance credibility through analytic triangulation [57, 59]. Interviews were imported into ATLAS.ti (Scientific Software Development GmbH, version 25, 2024) to facilitate systematic coding and collaborative review, with separate document bundles for students and professionals enabling comparative analysis.

Transcripts were analysed line-by-line using open coding, followed by axial coding to identify relationships between emerging categories [63]. Coding decisions and illustrative examples are provided in Annexes 4 and 5. Analysis continued until theoretical saturation was reached, with codes grounded in participants’ language to preserve analytic closeness to the data [56, 58]. Through constant comparison, categories were refined and integrated into an explanatory framework outlining how inner resources mediate compassionate practice under burnout conditions. This framework is presented in the Findings section.

Rigour and trustworthiness

Rigour was ensured through credibility, auditability, and fittingness [59, 66]. Credibility was supported through variation in participant groups (students and professionals), rigorous translation procedures [67], and the inclusion of both original and translated quotations to enhance transparency (Annex 7). Direct quotations are presented verbatim and followed by participant codes to preserve transparency and emphasise participant voice. Researcher bias was minimised through digitally recorded interviews, reflective journaling [61], independent code review, and strategies to reduce social desirability bias [64, 68–69]. ATLAS.ti facilitated systematic coding and enabled checks for inter-coder consistency. Auditability was addressed by maintaining detailed records of sampling decisions, coding rationale, and interview materials (Annexes 2 & 4–7). Fittingness was established by aligning emerging categories with relevant literature, particularly on global nursing issues such as burnout and retention, and by checking developing interpretations against participants’ accounts through follow-up questioning [62, 64]. Chiovitti and Piran’s strategies [58] and SRQR guidelines [62] informed both analysis and reporting.

Ethical considerations

This study received ethical approval from the Research Ethics Committee of the University of the Balearic Islands (Ref. 324CER23, 21/05/2023) and adhered to principles of confidentiality, autonomy, and fairness. All ethical considerations were made in accordance with the Declaration of Helsinki. Data were anonymised and managed in compliance with university policy and Spanish data protection law (Organic Law 3/2018), with interviews conducted in private settings and securely stored on encrypted devices. Audio files were pseudonymised, and data handling was registered at the university repository, allowing secure storage for five years. Participation was voluntary, with written informed consent obtained and the right to withdraw upheld. Fairness was ensured through purposive recruitment, optional debriefing, and a semi-structured format that allowed participants to control disclosure. Support resources were provided if needed, and all communications were conducted securely via university channels.

Findings

In keeping with grounded theory methodology, analysis began with open coding, generating over 70 initial codes grounded in interview transcripts (see Annex 4). Through constant comparison and iterative refinement, these codes were condensed into five interrelated theoretical families (Fig. 1 illustrates the analytic process).

Fig. 1.

Grounded theory process illustrating the flow of data analysis and concept development.

(adapted from Charmaz, 2014; 2017).

These families capture the structural and personal conditions influencing compassionate care under burnout:

1. Barriers and Bridges to Compassionate Care.

2. Burnout in Context: Conditions, Consequences and Coping.

3. The Inner Toolkit: Personal Strategies for Professional Survival.

4. Compassion as a Tool of Resistance and Care.

5. Generational Shifts in Perceptions of Professional Roles.

While each category contributes to understanding how compassion is sustained or eroded, analysis revealed that generational positioning functioned as a cross-cutting dimension shaping how inner resources were interpreted and mobilised. Accordingly, the findings focus particularly on ‘The Inner Toolkit’ and ‘Compassion as Resistance’, examined through the integrative lens of generational shifts in professional role expectations (Fig. 2). The following sections first outline the structural and experiential conditions shaping compassionate care before examining how inner resources mediate these pressures and how generational positioning influences their deployment in practice. Each thematic section concludes with a brief interpretive summary linking participants’ accounts to the emerging theoretical framework.

Fig. 2.

Influential factors sustaining or eroding compassionate care: Thematic diagram showing core theoretical categories

Barriers and bridges to compassionate care

Both students and professionals consistently identified work conditions — particularly short staffing and time pressures — as major barriers to compassionate care. Descriptions such as “rushed,” “exhausted,” and “impossible” were common, linked to low nurse-to-patient ratios and increasing patient acuity (PM11SNM; PF10EB; SF4SRB; SF2BBG). Despite these challenges, many participants described working additional hours out of commitment to patients and colleagues.

Additional barriers included toxic work environments, lack of supervisory support, job instability, low pay, and work–life imbalance. Students emphasised academic demands and time management pressures, whereas practising nurses highlighted job insecurity and deteriorating workplace conditions.

Perceptions of isolation and being undervalued were prominent. Experienced nurses described feeling “expendable” or like “martyrs” within systems characterised by short contracts and managerial disconnect (PF15EB; PF27MF). Frustration with hierarchical power dynamics led some to feel like “just a number,” while veteran nurses referred to burnout as a form of “institutional violence.” Students, meanwhile, reported feeling dismissed by mentors during placements (SF2BBG; SF4EGG; SF2IM). Pay inequity relative to workload and qualifications was widely cited as contributing to dissatisfaction (PF10EB; PF10ITC; SF2CM), although some noted recent improvements in salary and contract stability (PF20VLG; PM22AJLP).

Alongside these barriers, participants identified “bridges” to compassionate care, including love of nursing, team cohesion, external support, and personal coping strategies (PF10EB; SF4SRR; SM3SMM). These accounts suggest that while structural constraints limit compassionate practice, they do not wholly determine it, as nurses actively seek ways to sustain compassionate engagement despite challenging working conditions.

Burnout in context: conditions, consequences and coping

Burnout emerged as a pervasive and deeply felt experience among both nursing students and professionals. Participants described emotional exhaustion, detachment, and loss of motivation, often using terms such as “devastating,” “derailing,” and “destructive” (PF10EB; PF37MCAG; PF27MF).

Students primarily observed burnout in others, describing declines in compassionate engagement marked by “apathy,” “complacence,” and emotional “distance” (SF2BBG; SM3SMN; SF4SRB). Practising nurses more frequently reported personal overwhelm, physical symptoms, and emotional strain. Across groups, participants described a range of psychological and physiological consequences, including anxiety, depression, migraines, insomnia, and moral distress associated with an inability to provide the level of care they considered acceptable.

While some framed burnout as a catalyst for reflection or boundary-setting, the dominant narrative was one of depletion, absenteeism, and potential exit from the profession. Burnout was therefore experienced not only as individual distress, but as a force shaping care quality and workforce sustainability.

While structural barriers and burnout conditions were widely acknowledged, participants’ accounts revealed significant variation in how compassion was sustained under these pressures. This variation became more visible when examining the inner resources nurses drew upon in practice.

The inner toolkit: personal strategies for professional survival

The idea of exploring nurses’ inner resources was established at the outset of this research. While grounded theory encourages openness to emergent insights, it also permits researchers to begin with a guiding interest or sensitising concept [56, 71]. In this study, McGaghie’s compassionate core model provided such a starting point, shaping the initial inquiry while still allowing theory to emerge from participants’ lived experience [49, 70].

Analysis revealed clear evidence of McGaghie et al.’s compassionate core across interviews with both students and practising nurses (see Annexes 7 & 8). Most elements appeared frequently in the data: ‘Cognitive Capacity’ (475 citations), ‘Affect’ (444), ‘Awareness of Others’ (313, more frequent among professionals), ‘Self-Awareness’ (424, highest amongst students), and ‘Discernment and Judgement’ (421). ‘Spirituality and Moral Grounding’ appeared less often (67 citations). Two additional categories emerged during analysis: ‘Coping Mechanisms’ (227) and ‘Self-Care’ (143). Although related to self-awareness, these manifested differently in practice.

For instance, coping mechanisms included both constructive strategies, such as sport or time in nature, and less positive responses, including “a few drinks after work” or complaining about colleagues (PM22AJLP; PF2LA). By contrast, self-care tended to involve more intentional and restorative activities such as journaling, meditation, long baths, or the use of comforting routines like “special soaps and creams” (PF20VLG; PF15DP; SF4SRR; SF3EGG). While these practices could be interpreted as subcategories of self-awareness, the distinction lay in recognising one’s state and then choosing whether or not to act upon it. Participants who were highly aware of their stress but unable to act on that awareness were often those experiencing higher levels of burnout.

Participants experiencing burnout also tended to prioritise awareness of others over awareness of themselves, frequently placing patient or organisational needs ahead of personal wellbeing. Examples included skipping breaks, staying beyond scheduled shifts, or working on days off. Over time, these patterns contributed to exhaustion, resentment, and feelings of guilt (PF10EB; PF37MCAG; PF35PV).

‘Affect’ was closely connected to this pattern, as a driver for motivation and engagement. Those with more negative affect, i.e. those who could not always control their emotional responses, would respond to external situations by becoming more burnt-out, as a result of the actions they felt compelled to follow (such as staying past the end of their shift). In contrast, those with more positive affect could remain emotionally present and empathise whilst managing their emotional response, so that their feelings directed their behaviour in a more self-protecting way that balanced patient needs and their own. For example, the nurse who could leave work, knowing that: “I did my best and that is enough” (PF10ITC).

‘Cognitive Capacity’ also appeared to influence resilience to burnout. Participants who demonstrated the ability to critically reflect on complex situations, weigh competing demands, and justify decisions were better able to separate emotional reactions from professional judgement. For example, one nurse noted the importance of taking breaks to maintain safe practice: “I need my coffee break, or else I’ll lose focus and maybe make mistakes.” (PF2LA) It is important to note that participants demonstrating strong cognitive capacity were not immune to burnout; however, they appeared better able to contextualise their experiences and maintain perspective within demanding work environments.

‘Spirituality and Moral Grounding’ appeared less explicitly in interviews, possibly reflecting the way initial questions were framed. Few participants described traditional religious or spiritual practices, instead drawing support from relationships, family, or time spent in nature. Over time, however, it became clear that moral motivation was embedded within participants’ awareness of others and their perceived responsibilities toward patients. Those with heightened awareness of others frequently described “going the extra mile” for patients (PF10EB; PF37MCAG), while others emphasised the importance of “maintaining personal boundaries” (SF2ICM; SF3MCG).

This is not to suggest that participants who practiced self-care were less committed to their patients. On the contrary, many of these participants reported lower levels of burnout than their peers. What differed was the motivation underlying their actions and how they understood their professional role. Participants’ perceptions of the “bigger picture” varied, particularly in how they interpreted what it means to be a nurse. Some described nursing as a “vocation” or “calling,” emphasising duty, presence, and moral responsibility. Others framed nursing more as a “profession” grounded in training and skills. This distinction reflects an enduring tension within nursing identity between intuitive care and learned expertise, and it shaped how compassion was interpreted and enacted in practice.

Finally, ‘Discernment and Judgement’ emerged as a particularly influential factor distinguishing nurses who experienced burnout from those who were coping and even satisfied. Many participants experiencing burnout demonstrated the elements of McGaghie’s compassionate core; however, it was their interpretation and response to these internal signals that differed.

[Once home] I feel bad… the patient doesn’t have the quality of care they should because I wasn’t able… and then I feel guilty that my colleagues will have even more workload. (PF10EB)

Nurses who described higher levels of burnout frequently reported “taking work home,” feeling persistent guilt, and perceiving themselves as “never doing enough.” In contrast, participants demonstrating stronger discernment described clearer boundaries between professional responsibility and personal wellbeing:

I finish my shift and think, ‘That went badly,’ but then I leave and unwind on the drive home, and that’s it… I try very hard to keep my personal life separate from work, because otherwise emotions really weigh on you. (SF4SRR)

These participants described maintaining compassionate presence during work while limiting emotional spillover into their personal lives. Their accounts suggest that discernment and judgement played a crucial role in calibrating compassionate engagement without leading to emotional overextension.

Patterns in how these inner resources were prioritised and managed varied notably between participant groups, suggesting that professional socialisation and generational positioning influenced how compassion was sustained under pressure.

Compassion as a tool of resistance

A surprising emergent theme was the contested meaning of “compassion,” which many participants associated with pity, patronisation, or outdated religious connotations, preferring terms like “empathy” or “support” (PM17DN; PF10ITC; PF15MAB; PM15SNM). This semantic tension highlighted how the language of compassion is interpreted differently across professional and generational contexts. Despite this initial discomfort with the term, once compassion was defined as action-oriented empathy, all participants recognised it as central to good nursing care.

Students and younger nurses tended to align more closely with formal or textbook definitions of compassion, whereas more experienced professionals more often described it using relational phrases such as “being with” or “accompanying” patients. Nonetheless, across the board, compassionate acts—such as listening, offering small personal comforts, or simply “being there”—were unanimously valued (SF4SRR; SF4SGL; SF3EGG). Participants consistently linked compassionate practice with personal and professional fulfilment (PF37MCAG; PF2LA; SF2BBR; PM22ALJP; PF10EB).

Those who felt able to enact compassion, often through the support of strong inner resources, described greater satisfaction and motivation:

One would feel more fulfilled—both professionally and personally—on days when you can talk to someone and help them solve a problem. (PM22ALJP)

In contrast, participants who felt unable to express compassion due to emotional exhaustion or internal barriers reported frustration, guilt, and burnout. In these accounts, compassion appeared not simply as an ethical expectation but as an active strategy through which nurses maintained meaning and motivation within demanding working conditions.

This finding aligns with existing research positioning compassion not only as a core value of care but also as a potential protective factor for nursing wellbeing [26, 44, 72–73]. However, our findings suggest that the protective effect of compassion depends partly on how nurses manage their inner resources and emotional boundaries in practice. Even when participants described working within similar organisational constraints, differences in burnout risk appeared to relate to how effectively individuals mobilised these internal capacities to sustain compassionate engagement while protecting their own wellbeing. Taken together, these findings suggested that differences in how compassion was interpreted and sustained were closely linked to participants’ professional socialisation and generational positioning, a pattern explored further in the following section.

Generational shifts in perceptions of professional roles

Across the interviews, clear generational differences emerged in how nurses interpreted their professional role, responded to burnout, and mobilised their inner resources. Participants frequently described contrasting expectations of work, approaches to coping, and interpretations of compassionate practice. For instance, younger nurses often sought greater support and feedback, while older generations exhibited higher levels of organisational commitment, which they in turn expected and failed to see in newcomers.

We had to prove ourselves all the time, to show that we were worthy, that we were capable. (PF30LMH).

They [newer generations] are more demanding, and they care less… having a stable job concerns them more than if it’s compatible with their interests. Personal life is everything… (PF37PV)

These differences were also reflected in the use of boundaries and personal limits. Student nurses more frequently prioritised self-care and emotional wellbeing, placing clearer distance between professional expectations and personal life.

Taking a coffee break is important. If I don’t look after me, who will? Then I can better care for my patient. (SF3BRM)

Students had an acute awareness of personal implications of stress, in contrast to older nurses, who tended to prioritise the needs of others first, sacrificing their own time and self-care in the interests of patients.

I remember shifts when there wasn’t even time to drink or go to the bathroom… Students don’t live like that — they have more boundaries. (PF27MF)

Generational differences were also visible in how inner resources were developed and discussed. Younger nurses were generally more open about mental health and reflective practices, with 60% of students admitting to having had therapy. The language used to discuss coping often reflected this, with terms such as “personal work”, “triggers”, or “emotional awareness”. This awareness frequently shaped how they responded to stress, sometimes by distancing themselves from environments they perceived as harmful.

I don’t think it was fair on me… so for my mental health I decided to leave. (SF3MCG)

In contrast, older participants often described their coping strategies as emerging from prolonged exposure to challenging work environments. These responses ranged from humour and playfulness to emotional detachment and a deeper experiences of emotional exhaustion, depending on each one’s use of affect, or disposition.

We counted 127 call bells in one evening… but it doesn’t affect me because I know it’s part of the job. (PM20AJLP)

My job breaks me. It breaks me emotionally. It destroys me… (PF37PV)

Intergenerational tensions also emerged in how compassion was perceived. Students sometimes described experienced nurses as displaying “apathy”, “being defeatist”, or “forgetting they are dealing with people” (SF2LRMS; SF2BBG; SF4EGG). At the same time, some students recognised the structural pressures contributing to burnout among their colleagues.

Given the circumstances they’re in… it’s understandable that they reach that point [burnout]. (SM3SNM)

Interestingly, experienced nurses frequently expressed concern that students lacked compassion and instead prioritised personal wellbeing over professional commitment. Participants described newer generations as focusing more on schedules, workload, and work-life balance.

They talk more about their own needs… the rota… they prioritise their personal time. (PF20VLG)

This is not to say that students were not caring or compassionate. On the contrary, many described giving their full attention to patients while maintaining firmer personal boundaries than more experienced nurses, whose professional and personal limits had often become blurred over time.

As the theme of generational perspectives began to emerge in the data, further interviews explored how nurses perceived one another across cohorts. A clear sense of “us and them” occasionally surfaced, often framed through the idea of wider societal change. Students sometimes described experienced nurses as resistant to change or disconnected from contemporary practice expectations:

I notice it in older nurses—that they get a bit stuck, which is why they get so overwhelmed if there’s any change. Sometimes it’s younger people who bring that extra element that they have forgotten after so many years. (PF2LA)

Conversely, experienced nurses occasionally interpreted students’ stronger emphasis on work–life balance as a sign of reduced commitment to the profession:

But now it’s like people speak a different language, different things matter. You don’t even have the tools for this new reality. (PF37MCAG)

Despite these tensions, many participants recognised that generational change may also bring positive developments. Some experienced nurses acknowledged that newer generations introduce different perspectives and priorities that may contribute to the evolution of the profession.

Maybe they’re not wrong; maybe we’re the ones who are wrong… they’re the professionals of the future. (PF20VLG)

These findings suggest that generational positioning shapes how nurses interpret their professional role, manage their inner resources, and sustain compassionate engagement in demanding clinical environments. Rather than reflecting differences in caring itself, these variations appear to represent different strategies for balancing professional responsibility, personal wellbeing, and compassionate practice.

This generational dimension therefore extends McGaghie’s compassionate core model by illustrating how the mobilisation of inner resources is shaped not only by individual capacity but also by broader generational expectations surrounding work, wellbeing, and professional identity.

Discussion

Our exploration of how compassionate care is sustained or eroded under conditions of burnout began with an examination of how nurses mobilise their inner resources in practice. McGaghie’s multidimensional model [49], which conceptualises altruism in healthcare as emerging from a set of personal inner resources termed the “compassionate core”, provided a useful conceptual lens for this analysis. Building on this framework, the analysis suggests that the mobilisation of these inner resources is also shaped by generational positioning, which influences how nurses interpret their professional roles, regulate emotional boundaries, and sustain compassionate engagement over time. These inner resources not only shape the capacity to act compassionately but also influence how compassion is sustained over time. Among them, discernment and judgement emerged as particularly influential, enabling practitioners to calibrate their compassionate responses, avoid emotional overextension, and maintain professional satisfaction despite demanding working conditions.

Participants frequently used terms such as empathy, “being with,” or support when describing compassionate care. In this study, compassion is treated as the overarching construct, while these related expressions are interpreted as relational practices through which compassionate care is enacted in clinical interactions.

Overall, the analysis indicates that inner resources can function both as sources of resilience and as foundations for sustained, ethically grounded care that benefits both patients and nurses. At the same time, notable generational differences emerged in how these resources were understood and mobilised. While participants who coped well often shared qualities such as discernment and self-awareness, generational positioning influenced how burnout was managed and how the nursing role itself was interpreted. The following sections explore these patterns through the lens of McGaghie’s inner resources, which have not previously been examined alongside generational attitudes within the nursing literature.

Generational shift

Recent scholarship has increasingly recognised generational differences in nurses’ attitudes toward work, coping, and professional identity. Younger nurses tend to prioritise boundaries, psychological safety, and work–life balance, while older generations often frame nursing through a lens of duty, endurance, and self-sacrifice [74–75]. Similar patterns have been noted in research on evolving professional identities within healthcare, where newer cohorts increasingly emphasise wellbeing, reflective practice, and sustainable engagement alongside professional commitment [76, 80]. Although such studies have offered valuable insights into generational values and stress responses [39, 76–77], few have examined how these generational differences relate to the development and mobilisation of inner resources in sustaining compassionate care. This gap is notable given growing evidence that inner resources play an important role in mitigating burnout and supporting long-term professional satisfaction [26, 32, 44, 78–79]. By examining generational perspectives alongside the use of inner resources, our study contributes a new perspective to the literature, illustrating how generational context may shape not only attitudes toward nursing but also how nurses draw on internal resources to sustain compassion.

Cognitive capacity

In line with McGaghie, experienced nurses’ cognitive capacity often manifested as clinical reasoning honed through exposure and repetition, or “accumulated wisdom” [49, p.376]. These participants tended to approach decision-making through practical logic and accrued experience. For example, one nurse explained, “I try to prioritise and be positive, I plan carefully and leave knowing that I did all I possibly could” (PF10ITC), illustrating how self-knowledge and cognitive capacity in the form of strategic planning shaped behaviour that protected both patient safety and personal wellbeing, fostering compassionate care for both.

Yet, cognitive strategies among experienced nurses sometimes overlooked their own emotional limits. By prioritising logical analysis of patient needs, personal exhaustion was often overridden as they continued to perform under pressure without addressing their internal state. This demonstrates a strong capacity for compartmentalisation, which aligns with previous findings on cognitive resilience [78], but may not always be sustainable over time [80].

In contrast, younger nurses often connected their cognitive processing to mental health awareness, integrating psychological insight and therapeutic language into their practice. This suggests a more holistic understanding of personal stress responses, a dimension acknowledged in recent literature [39, 77], yet not explicitly addressed within McGaghie’s model. While McGaghie acknowledges the role of external factors and the influence of accumulated wisdom, his framework presents inner resources as relatively stable, without considering generational reinterpretations of these capacities.

For instance, students spoke of recognising “triggers” and proactively managing them: “I thought, for my mental health, I would leave that place” (SF3MCG). This reflects a shift in how cognitive tools are applied, not only to navigate patient care but also to support boundaries and self-preservation. While experienced nurses often relied on intuition grounded in practice, younger nurses described combining reflective practice with greater awareness of mental health and emotional wellbeing. Within this context, generational differences became visible in how cognitive capacity was mobilised in practice. Both groups therefore demonstrated cognitive strength but applied it differently: older nurses tended to endure demanding conditions, while younger nurses more frequently used cognitive strategies to adapt and protect personal wellbeing. Recognising and valuing these different approaches may be important for professional environments that have historically prioritised endurance and self-sacrifice over reflective self-awareness.

Affect

The experience and expression of emotions and moods emerged as a significant driver of motivation and engagement, shaping responses such as adaptability, positivity, and playfulness or, conversely, cynicism, detachment, and resignation [81, 82]. Those who were able to adapt under pressure or frame situations in a more playful and positive way reported greater satisfaction and less frustration: “the more entertained I am, well the better my shift… I’m a bit contrary!” (PM20AJLP). In contrast, those who felt overwhelmed or struggled to regulate their emotional responses, were those who felt more guilty, fatigued and burnt-out: “I often want to leave, because it’s overwhelmingly intense” (PF10EB). Burnout could be seen as affect dysregulation, something implied by McGaghie et al. [49, p. 377] who believed that over-responding to altruistic triggers could result in apathy and burnout. Interviews revealed both positive and negative affect across the generations, however, it was manifested differently.

Younger nurses tended to be more emotionally literate, quick to empathise with patients over colleagues and open about their vulnerability. Moods would often influence their behaviour, defaulting to self-protection and personal limits:

You can’t save everyone, we’re not here to be someone’s hero… I know I can’t solve all their problems, but I can show up (SM2SMM)

Students used affect to express their compassion by recognising emotional labour as part of their professional role and adapted so as not to pay an emotional cost.

In contrast, older nurses were motivated by emotional commitment to their patients and their perceived role, with the line between empathy and overextension often becoming blurred: “There are shifts when there isn’t even time to drink or go to the bathroom” (PF27MF). This type of dedication can be seen in studies on older nurses [83–84], although not directly linked to inner resources. Affect influences their reactions to patients, even at a personal cost, their compassion expressed through full presence. This could either result in burnout if not combined with other inner resources or satisfaction if balanced with discernment and self-care.

We can see that affect can be used to guide behaviours towards compassion differently, both generations demonstrated empathy, but the way compassion was enacted differed, with younger generations adapting so as not to pay such high emotional costs, compared to older nurses who often over-extended themselves.

Awareness of self and others

The capacity to perceive, understand, and reflect upon one’s own internal state or that of others is central to compassion, as it allows needs to be recognised — the first step preceding compassionate action [85]. Self-awareness manifested as an understanding of personal emotions, reactions, and behavioural patterns: “I’m a perfectionist”, “I get overwhelmed easily”, “I’m an optimist”. Both interviews and existing literature suggest that recognising these patterns enabled participants to identify personal needs and manage stress more effectively [39, 74, 86]. Coping mechanisms mentioned included “personal space”, “connection”, “reflection”, and “disconnect”.

Awareness of others also featured prominently in interviews, often linked with empathy and participants’ definitions of nursing. Expressions such as “being with”, “knowing”, “alleviate”, and “helping” were frequently used when discussing patient care, reflecting a desire to respond to patients’ needs. Participants commonly described compassion as extending beyond meeting physical needs to providing a more holistic presence in care, for which awareness of others was essential [79]. This emphasis on relational presence reflects the emotional labour inherent in nursing practice [73, 79–80], where sustaining compassionate engagement often requires nurses to manage their own emotional responses while remaining attentive to patients’ needs. While both forms of awareness appeared across the sample, self-awareness was more frequently emphasised by younger nurses, whereas experienced nurses more often highlighted awareness of others.

These differences were reflected in attitudes and behaviours. Students demonstrated greater sensitivity to personal needs and clearer boundaries: “If I don’t look after me, who will?”, whereas older nurses often described prioritising the patient above their own wellbeing: “If I don’t look after the patient, who will?”. Awareness alone, however, did not necessarily lead to action. Although many participants recognised the challenges they faced, they responded to them differently. Those who emphasised awareness of others often reported greater frustration and burnout, as personal needs were subordinated to what was perceived as a professional duty to place the patient first. In contrast, participants who acted on their self-awareness through self-care were better able to maintain emotional boundaries and reported greater satisfaction in their work.

Despite individual variation, a generational pattern became visible. While both groups valued compassion, students were more likely to translate self-awareness into boundary-setting to prevent burnout, whereas experienced nurses often deferred their own needs in order to prioritise patient care. These findings suggest that compassion may be enacted in different ways depending on how awareness is mobilised: either through sustained self-sacrifice or through reflective boundary-setting. This reflects McGaghie’s premise that poorly balanced inner resources may contribute to burnout, highlighting the importance of developing these capacities to support both compassionate care and professional wellbeing.

Spirituality

Spiritual resources were the least evident of the inner resources identified by McGaghie, although strong moral drivers were implicit in how participants responded to questions about the quality of care and their ability to meet standards. This was reflected in language such as “fairness”, “deserving”, and “should be”, suggesting underlying moral beliefs that guided compassionate practice. Only one participant described an active religious faith, with most instead referring to science or professional training when framing their understanding of care.

In contrast to McGaghie et al. and recent studies highlighting the importance of spirituality in sustaining nurses facing burnout [87–88], many participants appeared uncomfortable discussing spirituality in traditional terms. However, forms of personal meaning-making were still evident. Participants frequently referred to sources of grounding such as therapy, relationships, or connection to nature, indicating that a sense of purpose and belonging remained important even when not expressed through formal spiritual language.

This pattern was observed across generations, although differences emerged in how these moral drivers shaped professional identity. Older nurses more often framed their role through a collective moral understanding of nursing, using terms such as “duty” and “obligation” to describe their responsibility toward patients. Younger nurses, in contrast, more frequently described compassion through a more individualised moral framework, emphasising what “I can do” within sustainable limits.

These differences suggest that while moral commitment to compassionate care remains strong across generations, the way it is interpreted and enacted may be shifting. Older nurses often associated compassion with professional duty, sometimes at the expense of their own wellbeing, whereas younger nurses more frequently framed compassion as a practice that must be balanced with personal sustainability. In this sense, moral drivers continue to underpin compassionate practice, but generational differences appear to influence how these motivations are translated into action.

Discernment and judgement

McGaghie et al. [49] describe discernment and judgement as the mediating layer between the compassionate core and external influences, shaping how compassion is enacted. When absent, “this can disrupt the mechanism that reinforces compassion, break the cycle and produce burnout or apathy,” as these faculties enable “the proper form and intensity of altruistic expression” [49, p. 377]. Evidence of this process appeared in multiple interviews. Nurses who demonstrated higher levels of discernment were better able to gauge compassionate responses that neither over- nor under-reached, taking both their own needs and those of their patients into account.

You have bad days… sometimes you think, ‘Look, I’m going to quit everything.’ But then you stop and think — there are patients who will benefit… If you take better care of the professional, the patient will be better too. There’s always something that keeps you going. [PF20VLG]

Nurses who could recognise difficulties (“bad days”, “quitting”) but then pause, reflect, and then discern how to react (“stop and think”, “who will benefit”) were more satisfied with their capacity and reported lower levels of burnout. In contrast, participants who could recognise patients’ needs (awareness), feel compelled to respond emotionally (affect), and make competent clinical decisions (cognitive capacity), yet lacked discernment regarding how far compassionate action should extend, often allowed their compassionate inclinations to benefit others to their own detriment, resulting in burnout:

I’m not doing everything I could do or even everything I should do, so I just can’t anymore. (PF15MAB)

Discernment and judgement therefore emerged as important resources for regulating the interaction between other inner capacities. Nurses who were able to balance compassion for others with awareness of their own limits were better able to regulate affect and cognition, resulting in more sustainable engagement with their work.

Although generational differences were less pronounced in this domain, variations in how discernment was applied were evident. Younger nurses more often implied creating distance from difficult situations through clearer work–life boundaries and emotional disengagement after shifts. In contrast, experienced nurses who reported coping well with burnout tended to describe developing emotional control over time, learning from earlier experiences of professional strain:

As the years go by, you mature, you take some hits along the way, you fall, you get back up, and you give it your all. I’m not saying you give less, but maybe you give differently… (PF15MAB)

Here the subtle difference lay in predisposition in contrast to learned behaviour, in the face of shifts in expectations surrounding what is asked of nursing professionals. While a shared Compassionate Core appears to exist across generations of nurses, the ways in which it develops and is applied are shaped by wider social and cultural contexts (see Table 1). Older nurses often draw on duty-bound notions of care, sometimes to their own detriment, whereas younger nurses more frequently prioritised personal wellbeing alongside compassion, guided by a more individual moral compass. Crucially, discernment and self-awareness emerged as key resources that buffer against burnout by enabling nurses to calibrate their compassionate responses and navigate the tension between caring for others and sustaining themselves in practice. Our findings suggest that discernment functions as the mechanism through which other inner resources are regulated, determining whether compassion is expressed in a sustainable way or results in over- or under-extension. In this sense, the analysis develops McGaghie’s model by showing how discernment mediates the practical application of the compassionate core within contemporary nursing contexts.

Table 1.

Use of Inner Resources via Generational Comparison

Inner Resource	Younger Nurses & Students	Older Experienced Nurses
Cognitive Capacity	Critical reflection taught in training; value mental breaks	Experience-based judgment; may equate endurance with care
Affective Assets	Emotionally open, value boundaries and mental health	Deep emotional investment; may conflate empathy with overwork
Self-/Other Awareness	Strong sense of limits; prioritise personal well-being	Other-focused; often neglect self in favour of patient needs
Moral/Spiritual Grounding	Meaning from personal values, therapy, nature, networks	Sense of duty, vocation, or profession as moral anchors
Discernment & Judgment	Will disengage when overwhelmed; firm about boundaries	Balances detachment with compassion; variable by experience
Compassionate Expression	Expressed through emotional regulation and presence	Expressed through sacrifice, deep patient connection
Burnout Prevention	Proactive strategies (mindfulness, reflection, peer support)	Reactive strategies: some normalise stress or moral injury

Theoretical contribution

This study advances understanding of compassionate practice under conditions of burnout by demonstrating how nurses sustain compassion through the mobilisation of inner resources. While McGaghie’s compassionate core model identifies cognitive, affective, moral, and reflective capacities as foundations of altruistic care, our findings highlight the regulatory role of discernment and judgement in determining how these resources are applied in practice. Importantly, the analysis suggests that caring values themselves remain relatively stable across generations; what varies is how compassion is enacted and sustained in demanding clinical environments. By introducing a generational lens, this study extends McGaghie’s model by showing how broader shifts in professional identity and expectations influence the ways nurses interpret, balance, and deploy their inner resources to maintain compassionate care over time.

Limitations & strengths

Limitations include participant uptake and scope. Volunteers tended to be those who had overcome burnout, were frustrated with the system, or were enthusiastic students, which may have introduced social bias. Only one manager was interviewed, limiting that perspective. As with many qualitative studies, the relatively small sample size limits generalisability, although the rich data reflect local realities and support regionally relevant insights. Diversity regarding spirituality as an inner resource was limited, which may indicate an interview design limitation rather than the irrelevance of the theme. While McGaghie’s model provided a valuable conceptual scaffold, its use as a sensitising framework may have constrained early stages of analysis. However, grounded theory allows prior concepts to guide inquiry provided that emergent findings remain grounded in the data [89].

Despite these limitations, this grounded theory study offers several strengths. By moving beyond numerical indicators of burnout, it provides qualitative insight into how compassion is sustained or eroded in everyday nursing practice. These insights deepen existing research on nursing burnout and workforce retention by illustrating how inner resources support compassionate care while also shaping job satisfaction and vulnerability to burnout.

In particular, the findings show how nurses mobilise inner resources in response to workplace pressures, building on McGaghie’s conceptualisation of the compassionate core [49] by examining how these capacities operate within contemporary clinical environments. Including both students and experienced nurses enabled analysis across the professional lifespan and within multigenerational nursing teams.

Previous research has often examined generational work values and stress responses [74–75] separately from studies on compassion, resilience, and inner resources in healthcare [78–79]. However, relatively little research has examined how these inner resources interact with generational differences in nursing practice. Our findings suggest that compassion is sustained not simply through the presence of inner resources, but through the capacity to regulate them—particularly through discernment—when responding to the pressures of clinical work.

Further research is needed to explore how these inner resources develop and are mobilised across the professional lifespan. In particular, there remains limited research examining how multigenerational nursing teams negotiate different expectations surrounding work, wellbeing, and professional responsibility. Understanding how inner resources such as discernment, self-awareness, and emotional regulation evolve over time may help inform both pre-registration education and ongoing professional development. Future studies could therefore build on McGaghie’s model by examining how educational programmes and workplace environments support nurses in calibrating compassionate care while maintaining their own wellbeing, particularly within teams where different generations of nurses work alongside one another.

Moving forward: theory to practice

Applying these findings to practice requires attention at multiple levels.

At an individual level, nurse education programmes can support the development of inner resources through reflective practice, emotional literacy training, and opportunities for guided self-awareness. These approaches may help nurses recognise and regulate the emotional demands associated with compassionate care.

At a team and educational level, intergenerational mentorship and structured supervision may support knowledge exchange between cohorts. Recognising that younger nurses may prioritise boundaries and self-care while older nurses often emphasise professional duty creates opportunities for mutual learning rather than division.

At a system level, organisations play a critical role in sustaining compassionate care. Protected time for reflection, peer supervision, and professional development may help nurses maintain emotional resilience. However, individual coping strategies alone cannot address structural pressures. Improvements to staffing levels, working conditions, and job stability remain essential if healthcare systems are to support compassionate care sustainably rather than placing responsibility solely on individual practitioners.

Conclusions

This study demonstrates that sustaining or eroding compassionate care under conditions of burnout depends critically on how nurses mobilise their inner resources in practice. Core elements such as cognitive capacity, affective regulation, awareness of self and others, spiritual or moral grounding, and discernment can function as both protective factors and potential vulnerabilities. Nurses who balanced these resources, particularly through discernment and self-awareness, were better able to calibrate their compassionate responses, maintain emotional boundaries, and avoid overextension. In contrast, when these resources were depleted or poorly regulated, compassion was eroded, contributing to emotional exhaustion, guilt, and disengagement.

By examining these dynamics through a generational lens, this study extends McGaghie’s compassionate core model by illustrating how the development and mobilisation of inner resources are shaped by broader professional and social contexts. While experienced nurses often described compassion through duty-driven endurance, younger nurses more frequently emphasised reflective practice and boundary-setting as ways of sustaining their wellbeing alongside compassionate care. These differences did not reflect variations in caring itself, but rather distinct strategies for managing the emotional and professional demands of nursing work.

Although individual inner resources play an important role in sustaining compassion, responsibility for compassionate care cannot rest solely with individual practitioners. Organisational conditions, staffing pressures, and wider health system structures continue to shape nurses’ capacity to deliver compassionate care. Supporting the development of inner resources—particularly discernment and self-awareness—alongside improvements in working conditions may therefore be crucial for ensuring that compassion remains a sustainable and fulfilling aspect of nursing practice across career stages.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

S-L.F. led data collection, analytic decisions, and manuscript preparation. MG-S helped with design and translations. Both N.S and L.G edited, reviewed and supervised the project.

Funding

The publication of this study was supported by funding from the Col·legi Oficial d’Infermeria de les Illes Balears (COIBA). The authors gratefully acknowledge COIBA’s contribution to the advancement of nursing research in the Balearic Islands, Spain.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Research Ethics Committee of the University of the Illes Balears (Ref. 324CER23, 21/05/2023) and adhered to principles of confidentiality, autonomy, and fairness. Ethical considerations were made in accordance with the Declaration of Helsinki. Voluntary, informed consent was gained from all participants. Data were managed in compliance with Spanish data protection law (Organic Law 3/2018).

Consent for publication

All participants were informed about the publication of study results, with all personal details anonymised, before any interviews took place. All the participants included in this study signed voluntary informed consent forms, which were then managed in compliance with Spanish data protection law (Organic Law 3/2018).

Competing interests

The authors declare no competing interests.