In healthcare, having the ability to demonstrate compassion enhances patient care, creating a higher level of trust, resulting in the sharing of information that can lead to greater understanding and more accurate diagnosis (Mannion, 2014). Synonymous with the nursing profession (Straughair, 2012), compassion is defined by Perez-Bret et al (2016) as:
‘the sensitivity shown in order to understand another person's suffering, combined with a willingness to help and to promote the well-being of that person, in order to find a solution to their situation’.
Essentially, the aim being, to alleviate suffering.
However, encountering others’ suffering leaves healthcare professionals such as nurses at risk of compassion fatigue (Sacco et al, 2015), a phenomenon defined as:
‘the formal caregiver's reduced capacity or interest in being empathic or bearing the suffering of clients’ (Figley, 1995).
Compassion fatigue is characterised by the inability to cope with the emotional stress caused by long-term exposure to those who are suffering, and can lead to emotional, physical and spiritual exhaustion (Todaro-Franceschi, 2013), empathy imbalance (Cross, 2019) and a decline in effective decision making (Stoewen, 2020); situations that many nurses can unwittingly find themselves in.
Compassion crisis
The delivery of compassionate care is considered a cornerstone of nursing practice (Peters, 2018). Demonstrating compassion, however, has the potential to predispose nurses to compassion fatigue, depriving nurses of ‘the gift of compassion’ (Gustafsson and Hemberg, 2022) and in a predominantly female workforce, women, it is argued, are at increased risk (Aslan et al, 2022). Gender differences in ability to demonstrate self-compassion may provide some insight, with research suggesting that women are less likely than men to expound this (Yarnell et al, 2015). Despite such insight, it is important, as Yarnell et al (2015) purport, that the gender differences associated with self-compassion are not overemphasised.
Creating compassionate workplaces, led by compassionate leaders, has the capacity to create the conditions that enable staff to flourish in their work and when faced with significant challenge, are sensitively supported using the four elements of compassion, as defined by West (2021).
To facilitate the development of such workplaces requires leaders to lead with compassion. Compassionate leadership emphasises the importance of developing strong relationships through being present with others; listening carefully, seeking to understand and appraise situations, empathising without becoming overwhelmed, and providing help, by taking considered and appropriate action (West, 2021). Central in the development of compassionate workplaces is the development of compassionate cultures. Defined as ‘the way we do things around here’ (Balogun and Johnson, 2004), cultures dictate the behaviours and characteristics of the workplace. Compassion is a deep understanding of the awareness of the suffering of others and the wish to, and effort to, relieve it (Gilbert, 2009).
Disappointingly, a publication exploring compassionate workplaces suggests that commissioners of services are willing to sacrifice compassion during times of great pressure; not only considering it an attractive extra but also failing to acknowledge nurses and other healthcare professionals as being ‘second victims’ (The Flourish Team, 2018). This situation is also associated with the phenomenon of post-traumatic stress disorder or PTSD, a disorder through which sufferers experience continued emotional distress (Baas et al, 2018).
Moral injury
Despite compassion fatigue being prevalent in nursing, the onset of the pandemic has not limited nurses’ ability to care for others. Nurses across the globe have continued to respond with compassion and a collective responsibility to the suffering of others, even when at times being fearful for their own lives and those of their families (Sun et al, 2020). Such experiences have led to a phenomenon known as moral injury, a situation that occurs following events that challenge a person's moral or ethical beliefs (Litz et al, 2009), and is especially associated with service members and war veterans (ibid).
Moreover, Egan et al (2019) identified a propensity for nurses to prioritise patients’ needs before their own and avoid seeking support from colleagues who are equally stressed to protect their wellbeing. Essentially, nurses are afraid of being judged for seeking help (ibid).
However, all is not lost, for encouragingly, the professional nurse advocate (PNA) programme introduced in March 2021 in England, has been designed to help support staff with such challenges. The PNA programme provides staff with the skills to work collaboratively with colleagues and teams across the country to facilitate restorative supervision, encourage learning and development, to monitor and improve patient care in clinical practice and to encourage nurses to take action for quality improvement using the A-EQUIP (Advocating and Educating for Quality ImProvement) model of professional nursing leadership and clinical supervision (NHS England and NHS Improvement, 2021).
Self-compassion
Furthermore, Gilbert's (2014) compassion focused therapy (CFT) is designed to support those whose personal experiences, intense feelings of guilt and shame, and unrelenting self-criticism have led to the inability to be kind to oneself. CFT has the capacity to support self-compassion, which in turn can promote positive mental health and wellbeing and, as Duarte et al (2016) purport, the ability to demonstrate self-compassion may help to play an important role in maintaining mental health, especially for nurses. Furthermore, research undertaken by Durkin et al (2016) explored the relationship between self-compassion and wellbeing among community nurses, and found that community nurses who reported elevated levels of self-compassion also reported less burnout and increased compassion for others.
Disappointingly, however, as Mills et al (2015) argue, professional bodies, such as the Nursing and Midwifery Council (NMC) in the UK, do not prioritise self-care. This is evident by the NMC failing to mention the importance of self-care in the 2015 edition of the Code (NMC, 2015a) and again in the latest version (NMC, 2018).
Despite the update in 2018, there remains a continued failure to recognise the importance of a nurses’ health and wellbeing, other than that required to ‘uphold the reputation’ of nursing (NMC, 2018).
Irrespective of this, nurses can cultivate compassion in self and others by adopting a variety of approaches, through which resilient practitioners can emerge. A useful way in which to do this, is by the use of an effective framework or model to encourage compassion, essentially becoming a conduit, through which patient care can be enhanced.
Therefore, it is evident that a paradigmatic shift is required, one that recognises that we are all in need of compassionate care supported by compassionate leaders. Receiving compassionate care by compassionate leaders enhances the personal motivation of staff and reinforces altruism (West et al, 2017). What is more, it creates psychological safety and enables staff to develop the confidence to ‘speak up’ and feel empowered and supported to develop new ideas and new ways of working to improve service delivery and, ultimately, patient care (West et al, 2017).
Models of compassion
The G.R.A.C.E model of compassion is an actionable approach designed for nurses to cultivate compassion, while engaged in stressful situations (Halifax, 2014) (Table 1). Intended to create a ‘reflective pause’, G.R.A.C.E (Halifax, 2014) is an acronym for the essential steps in the model, which grew from a previously established version, that enabled active compassion through experiential learning (Halifax, 2012).
Table 1. The G.R.A.C.E model
| G | Gathering attention: focus, grounding, balance |
| R | Recalling intention: the resource of motivation |
| A | Attuning to self/other: affective resonance |
| C | Considering: what will serve |
| E | Engaging: ethical enactment, then ending |
The ART (Acknowledge, Recognise and Turn Towards) model of compassion developed by Todaro-Franceschi (2013) focuses on promoting resilience and bringing meaning and purpose back into the profession. Both models use a stepwise approach, involving a period of reflection. Reflective practice is an essential element in a nurse's professional development; by thinking about clinical experiences new insights emerge, which have the capacity to inform competence (Jasper, 2013). Furthermore, having the ability to reflect is a requisite of nurse registration, as evidenced through the process of revalidation (NMC, 2015b).
‘Having the ability to demonstrate compassion is considered an essential quality in professional nursing practice.’
G.R.A.C.E (Halifax, 2014) involves cognitively exploring an experience in the moment, providing the basis for healthy compassion. In contrast, ART (Todaro-Franceschi, 2013) provides an opportunity to reflect-on-action, enabling rationalisation and the drawing of conclusions after an incident.
Both types of reflection serve a purpose; reflection-on-action, for example, may provide an opportunity for further exploration to inform future practice. However, it could be argued that reflection-in-action is more appropriate when referring to compassionate care, as it enables the nurse to adapt their behaviours with patients as the interaction progresses. Both reflection in and on action have been developed by the work of Schön (Schön, 1991).
Leaning in
A further model is that of self-compassion developed by Kristen Neff (2011). Given nurses’ inclination to focus on others before themselves, this model is considered appropriate in cultivating compassion towards one's self. Instead of a stepwise approach as suggested with G.R.A.C.E (Halifax, 2014) and ART (Todaro-Franceschi, 2013), there are three possible directions to follow: self-kindness; common humanity; and mindfulness (Neff, 2011). The course of action depending on the situational context, and essentially being guided by the person.
As with G.R.A.C.E (Halifax, 2014) and ART (Todaro-Franceschi, 2013), self-care is the focus of the self-compassion model (Neff, 2011), the psychological aspects of which, reflect Neff's (2011) professional background, while the common humanity of self-compassion overlaps with attunement to self and others in G.R.A.C.E (Halifax, 2014). In recognising common humanity, this model encourages an approach in keeping with universal compassion, which reduces the propensity towards referential or biased compassion (Halifax, 2012). Each model has merit; however, the self-compassion model focuses more on the importance of health professionals demonstrating self-care and could be considered an essential element in the delivery of compassionate care.
Back et al (2015) suggest health professionals either overplay their role or disengage when experiencing feelings of helplessness, a process they call hyper-engagement or, in direct contrast, hypo-engagement. They suggest ‘constructive engagement’ is warranted whereby the professional leans into personal suffering to engage with the patient and reframes this as a challenge, enabling a deep commitment to serving.
Training in compassion – a panacea?
While having the ability to care and demonstrate compassion has long been associated with the image and role of the nursing profession (Tierney et al, 2019), a number of high-profile failings in recent years, the most current being that evidenced by the Ockenden Report (2022), has led to the belief that compassionate behaviours are lacking and may need to be taught through formal teaching (Shea et al, 2016); a concept anathema to many.
Furthermore, Dewar (2013) asserts that delivering compassionate care is a complex process, that requires the understanding of ‘the experience of giving and receiving care’ which can be potentially strengthened and cultivated through education and training (Shea et al, 2016) as advocated in the Francis Report (2013).
Cognitively-Based Compassion Training (CBCT), for example, takes an analytical perspective, and uses meditations to encourage participants to gain insights into how they interact interpersonally and intrapersonally, essentially promoting two areas of skill development – emotional flexibility and social interaction – both of which can support the ability to demonstrate compassion (Ash et al, 2021).
Conclusion
Given the number of healthcare failings in recent years, it is clear that the discourse that surrounds compassion, or more discernibly a lack of compassion, is going to continue.
Having the ability to demonstrate compassion is considered an essential quality in professional nursing practice. However, various societal variables obstruct compassionate care delivery, including social disconnect, resistance to acknowledging empathic distress by an oppressive health care culture, and nurses themselves.
Therefore, it is important, in the interest of the profession, to incorporate compassion practices into working lives. Anticipated outcomes of which include resilience, retention and sustainability of the nursing workforce. There are suitably valid models of compassion that can be used in clinical practice and equally reliable compassionate training available, improving not only self-compassion but also compassion towards patients. Nurses who engage with these models and also support others in their professional journeys, may find that rather than succumbing to the suffering associated with compassion fatigue, they are able to recognise when their wellbeing is being affected by the suffering of others and act accordingly. Helping to build the resilience that is needed now, perhaps more than ever.
Key points
- Compassion is essential to nursing practice
- Encountering others’ suffering leaves healthcare professionals such as nurses at risk of compassion fatigue
- The ability to demonstrate self-compassion may help to play an important role in maintaining mental health, especially for nurses
- Nurses can cultivate compassion in self and others by adopting a variety of approaches including frameworks or models
CPD REFLECTIVE PRACTICE
- Consider yourself. Do you identify any compassion fatigue? How does this impact you and your patients?
- How could you incorporate compassion practices into your working life?
- Could your leaders better support you with compassion? Is this something you feel capable of raising with them?