Compassion is an integral part of care: the patient perception of any staff in the care setting, with particular emphasis on nurses, is that compassion would be provided. This is a valid expectation in a setting where a patient is undergoing something involving invasive treatment/experiencing a life threatening emergency – compassion is required in such circumstances to meet the basic human emotional needs of patients. However, with staff retention issues in the NHS being a constant factor in why the health service remains so understaffed, and bullying among health professionals estimated to cost over £2 billion to the NHS each year (Kline and Lewis, 2019) due to the implications it has for staff absence and staff leaving the workforce altogether, we are left facing an NHS beleaguered by dissatisfied and burnt out staff, and as a result, a lack of compassion for patients. Low levels of staff morale and high levels of compassion fatigue are key factors in this.
What is compassion?
Health Expectations journal published a study that examined what compassion ‘looks like’ to patients, citing how important compassion is in predicting positive patient and practitioner outcomes, with this also being a professional requirement across the world in the caring professions (Baguley et al, 2022). However, the researchers reported that there is no specific grasp on what compassion actually is, and what is required to have these desired outcomes. The study, therefore, explored limitations in previous work, and focused on a qualitative overview of what patients state that physicians do, that makes the patient feel cared for and helps them see the care as compassionate.
Using topic modelling analysis, empirical commonalities were explored in the responses of 767 patients who described behaviours of doctors that led to them feeling cared for. Baguley et al (2022) found seven meaningful groupings of doctors' actions emerged from these patient responses. These were (Baguley et al, 2022):
- Listening and paying attention (71% of responses)
- Following-up and running tests (11%)
- Continuity and holistic care (8%)
- Respecting preferences (4%)
- Genuine understanding (2%)
- Body language and empathy (2%)
- Counselling and advocacy (1%).
Age and cultural differences in views of compassion
The study was also able to describe significant differences according to age and ethnicity in the responses of patients, suggesting cultural and age-related influences over patient perception of what care and compassion are (Baguley et al, 2022). The researchers could not make direct causations but could consider what contributed to their findings. Baguley et al (2022) stated that with regards to age, the younger people who took part less often responded to questions about their experience of compassion from their doctor, less often reported the speciality of their doctor, and less often had a medical diagnosis. The researchers commented that all this meant their interactions with their doctor would be less frequent, as they tended to be healthier and in less frequent contact with their doctor. Their idea of compassion from their doctor may have been affected by their less frequent direct contact or experience of being ill. The younger participants reported mostly that compassion looked to them like good counselling and patient advocacy. The team thought this pattern indicated that younger patients tend to value explanations, sensitivity, and advocating for patients through making suitable and timely referrals. The younger patients also were mostly of Asian descent. Baguley et al (2022) note that in Asian cultures there is a high stigma associated with any debilitating illness or mental health problem. Due to this stigma, younger Asian people may have come to value the idea of a non-judgmental approach to their care if they were to experience ill health, as this would seem compassionate and to signify a good relationship to them.
By contrast, the older patients valued ‘deliverables’ as compassionate – this would be prompt follow up, appropriate timely tests and phone calls. This may be due to older people having a greater complexity of need, and therefore they would regard these essential parts of their care simply being done as compassionate (Baguley et al, 2022).
Patients who saw compassionate care as involving body language, empathy and a genuine understanding were most often of Pasifika descent. This culture tends to place significant importance on building trust and rapport, valuing a true connection between individuals above some objective task such as a blood test, as a true show of compassion.
With regards to sex, males were underrepresented in the study, but those who did take part most often placed emphasis on feeling understood or believed (Baguley et al, 2022). Overall, the researchers felt there are a myriad of elements that add up to compassionate care, the order of priority to an individual being largely affected by things like age and ethnicity. In my personal experience I would think the nature of one's health indicates what compassion looks like – mental health issues, learning disabilities, chronic pain, cancer – these all present so differently that the nature of the illness or condition/disorder itself indicates a different picture of what compassion may look like to the individual. Empathy is key – but when we are too tired from constant work or stress and pressures within the workplace, what happens then? We sometimes become too tired to truly care, and this is known as compassion fatigue. It is commonplace and has become a popular term since the pandemic affected us all, but existed long before. Emotionally and physically there is only so much one can take, but by professional and moral standards, it is important to treat and to avoid compassion fatigue as it is not good for the health professional or the patient.
Compassion fatigue in nursing
Peters (2018) discusses compassion fatigue in a concept analysis, aiming to clarify the concept of the condition and with an aim to then develop methods for the prevention and mitigation of compassion fatigue throughout the nursing profession. Peters (2018) notes compassion fatigue to occur when a nurse develops a declining ability to empathise, due to the repetitious nature of being exposed to the suffering of their patients. The author notes compassion fatigue is not only exclusive to nursing, but that nurses were predisposed to this due to the repetitive exposure to others' suffering, high stress environment, and the nature of continuously having to give from the self. The author notes the consequences of the condition to be negative on the nurse, patient, organisation and the healthcare system as a whole. It is, therefore, extremely important to prevent, recognise and treat. Peters (2018) notes that all nurses are at risk of the condition, and that prevention of the condition would involve implementation of professional boundaries, self-care measures, self-awareness and education on the concept of compassion fatigue to not only the individual but also on an organisational level. Zhang et al (2018) also note the high prevalence of the issue among nurses, and state that better education and training are the key to mitigate this and to improve the quality of life of the nurse.
Growing demands on nurses
Kawar et al (2019) note that compassion fatigue is also a costly condition to develop, with immediate effects on disrupting the culture of the team the nurse is working on. Kawar et al (2019) noted it is harder for nurses in the current society we live in: with a huge upsurge in people living with chronic complex conditions, the demands on nurses are growing physically and emotionally, with higher patient caseloads and a myriad of symptoms with each patient that require the nurse's help. The team noted this constant stress of busyness and work overload can lead to compassion fatigue, which if ignored can compromise the outcomes of the healthcare offered by the nurse suffering this.
The results of the study by Kawar et al (2019) noted that more experienced nurses and nurses who worked night shifts experienced higher compassion satisfaction levels. Compassion fatigue was higher in newly qualified nurses, and nurses who worked in intensive care, as well as those working 12-hour shifts. The team suggested that nurse managers could apply this evidence to tailored programs depending on nursing specialities, and a program for new or inexperienced nurses to tackle the problem. To improve educational and tailored efforts, Kawar et al (2019) thought the more experienced nurses could be of help to share their wisdom on the issue and to suggest what may help.
Bivins et al (2017) also covered this topic previously, noting compassionate care to not be as easy as people assume it may be for nurses to offer – it involves a high degree of self and emotional energy.
Positives of compassion
However, compassion creates a positive impact on the commitment someone offers to an organisation, and even on the way that person views their colleagues, while also helping them to deal with the distress they may experience during their time in the job. Things that influence the provision of compassion would involve the nurse, for example, witnessing someone else giving or receiving compassionate care. The nurse may aspire to receive the same response from a patient and see the same effect in that person who receives their compassion. Witnessing compassion in the workplace can promote resilience among staff. Bivins et al (2017) note the importance of leaders in this process, as they play a central role through actively demonstrating the importance of noticing, feeling and responding to suffering. When a manager cannot do this, the team suffers. The team leader needs to have a healthy response to their own emotions, that can be observed by the team. This promotes emotional resilience and learning of emotional boundaries and emotional expression, as well as the appropriate reactions to negative emotions, while freely expressing these (frustration, grief, sadness for example). The authors suggest compassion can become ingrained in the institution of the healthcare environment, and it can become self-sustaining in an institution where it is commonplace (Bivins et al, 2017).
System-level change
Bivins et al (2017) discuss the fact that compassionate care is derived from a good team, supporting each other to deliver care, sharing the responsibility of compassion. System-level change is what is required where this is not the case. The authors note that healthcare systems have traditionally undervalued the hard work of the nursing profession on a financial level. There has been over-emphasis on ‘getting things done’, in a target-driven environment and an economically challenged system. Nurses' compassion has been turned into its own set of targets, yet the system does not enable nurses to truly deliver such compassion, being constrained by constant pressures, institutionalised behaviours among staff, and individual health concerns physically or mentally, alongside the constant exposure to suffering people, without emotional support to help themselves, let alone the patient. Education may be missing in an environment that is not well-led.
Getting the job done is only one part of compassion. Bivins et al (2017) recommend that compassion must be promoted and institutionalised by nursing leaders and at a system-level, to enable a self-sustaining delivery of compassion now and in the future. Nurses cannot be the only ones to deliver compassionate care, but they do influence the shaping of empathy and resilience in an organisation.
Conclusion
To help with the problem, it is clear that good team leadership, education, emotional boundaries and resilience through the development of emotional intelligence among staff, a culture of kindness and team support can all contribute to delivering compassionate care, in a supportive healthcare system.