Compassion in nursing 1: defining, identifying and measuring this essential quality
An outline of what compassion is and how it might be measured, as this essential nursing quality moves higher up the political agenda
Neil Davison, BN, DipN, FETC, Cert Ed, ONC, RGN, is lecturer and teaching fellow; Katherine Williams, MA, AdvDipEd, DipN, Cert Ed, RGN, is lecturer; both at Bangor University.
Davison, N., Williams, K. (2009) Compassion in nursing 1: defining, identifying and measuring this essential quality. Nursing Times; 105: 36, early online publication.
The first in this two-part unit on compassion examines the concept of compassion, and how it can be identified and measured in practice. It also discusses the level of compassion expected in nursing.
Keywords: Compassion, Empathy, Holistic care
- This article has been double-blind peer reviewed.
- Describe the contribution that compassion makes to clinical practice.
- Identify the challenges involved in defining and measuring compassion.
Compassionate care is a key product of healthcare providers and is expected by the public (Burdett Trust for Nursing, 2006). It is also a vital aspect of good nursing care (Johnson, 2008). However, using computers and doing administrative tasks are part of modern nurses’ daily routine, and it is claimed that these have distracted them from being compassionate (Black, 2008).
Alan Johnson, the health secretary until June 2009, also viewed compassion as important (Carvel, 2008). In June 2008 he trailed plans to develop quality indicators that would rate the performance of ward nursing teams, possibly including compassion (Carvel, 2008). This was followed by Lord Darzi’s NHS Next Stage Review, which formally announced that a set of national metrics would be developed (Department of Health, 2008). In May 2009, the government published a set of over 200 quality indicators, with 53 on patient experience, covering dignity and respect and focusing on the person (The NHS Information Centre for Health and Social Care, 2009). In addition, the NHS Constitution sets out certain NHS values, including respect, dignity and compassion (DH, 2009; Cornwell and Goodrich, 2009).
However, nurses have long expressed concern that they do not have enough time to care for patients properly (British Journal of Nursing, 2004), and that tasks, routines and documentation take priority over holistic care (Pearcey, 2007).
The new metrics may cause dilemmas for nurses. Do they aim to provide high quality care, which they have little enough time for, or do they risk being distracted by addressing indicators which may measure superficial aspects of care?
Compassion and nursing
The link between compassion and nursing is not new, but Schantz (2007) suggested that at present, it is not encouraged in nursing practice where it may have become optional.
Society has witnessed an increase in the power of technology, and this appears to be mirrored in nursing, where the technical and managerial aspects of care take priority over care delivery - possibly because the expansion of nurses’ role has eroded the essence of nursing (Wright, 2004).
There needs to be debate within the profession about what exactly constitutes compassion. Consideration also needs to be given to the most appropriate method of measuring compassion, how it can be identified in nursing applicants and developed in student nurses. Conditions that encourage compassion in nursing practice also need to be explored.
What is compassion?
Compassion, or caring can be viewed as “nursing’s most precious asset” (Schantz, 2007), a fundamental element of nursing care (Dietze and Orb, 2000), and as one of the strengths of the profession. According to Torjuul et al (2007), it involves being close to patients and seeing their situation as more than a medical scenario and routine procedures. The politician’s notion of compassion, according to Alan Johnson, features smiles and empathetic care (Carvel, 2008), but is compassion more than the sum of these two behaviours?
One of the difficulties in considering issues such as compassion is that everyone – patients, nurses and politicians - will have their own personal, subjective definition. Personal definitions fit in with our own view of the world, but may have little in common with the views of others.
Schantz (2007) noted that there may be confusion over the exact definition of compassion because words such as caring, sympathy, empathy, compassionate care and compassion are used interchangeably. The role that empathy and sympathy play in care provision is clarified by Dietze and Orb (2000), who argued: “Empathy and sympathy in or of themselves do not imply good therapy or care: they are simply part of the conditions required for appropriate therapeutic intervention.”
Pearcey (2007) found student nurses considered that it was doing the little things for patients that constituted a caring approach. She offered the perspective that nursing has a functional component or “doing” role, as well as a “being” role.
Ultimately, “compassion impels and empowers people to not only acknowledge, but also act” (Schantz, 2007). This involves focusing on another person’s needs and channelling the emotion generated by their predicament into an active response.
There appear to be two elements involved in professional caring: instrumental caring, which includes the required skills and knowledge, and expressive caring involving the emotional aspects of the relationship. Expressive caring changes nursing actions into caring (Woodward, 1997). This could help to explain why some nurses are technically competent, but do not seem outwardly compassionate.
However, Roach (2002) considered compassion, along with confidence, competence, conscience, commitment and comportment, as one of the six core elements of caring. If nurses claim to genuinely care for their patients, then without compassion their caring may be incomplete and lacking.
Identifying and measuring compassion
Educators have the responsibility of identifying applicants to nurse education programmes who are compassionate, or have the potential to become compassionate nurses. This is problematic because exactly what constitutes compassion is not clear, and trying to identify evidence of compassion in applicants is a difficult task. Proof that an applicant has compassion can be sought from statements on caring made on an application form, or possibly provided by a referee.
Even having selected candidates who display the necessary qualities is no guarantee that at the end of a pre-registration course, they will still have these qualities. During educational programmes, students’ values may be influenced by the informal curriculum (Johnson, 2008).
Teachers and mentors in both clinical and more formal educational environments may impart their own values and it is usually assumed that these influences will be negative, leading to “compassion fatigue” or burnout. This is thought to result from exposure to the realities of professional life including trying to meet patients’ needs while coping with the demands of the service and managers (Johnson, 2008).
Apart from the difficulties in attempting to recognise and develop compassion in applicants and students, there are difficulties and possibly dangers in measuring the compassion shown by nurses. The consequences of measuring compassion needs serious consideration before any attempt is made to rate or judge nurses because compassion is viewed as part of being a human (Proctor, 2000).
If a measurement tool indicates that a team of nurses lack compassion, this equates to saying they lack a fundamental human quality (Schantz, 2007), which could have significant negative consequences for individual team members.
[x head] What level of compassion does the profession expect?
Student nurses are assessed on their ability to provide compassionate care in clinical practice. The NMC (2007) identified compassion, along with “care and communication” as an essential skills cluster that complements the proficiencies student nurses are required to achieve to register. The essential skills cluster states that student nurses need to provide competent and confidential care, treat patients like partners and in a dignified manner, provide care without discrimination in a warm, sensitive and compassionate way.
It seems entirely appropriate for a caring-based discipline such as nursing to specify the fundamental elements needed for professional practice. The problem remains that in the absence of clear, observable behaviours and traits that are agreed as reliable indicators of compassion, mentors will struggle to make judgements about what constitutes compassion in the next generation of nurses.
Mentors also face the difficulty common to all nurses of deciding what compassion really is, and consequently their judgements about the suitability of student nurses to join the register could be influenced by subjective views about compassion in practice.
Registered nurses are guided by the NMC’s (2008) code of conduct, which demands that they respect the dignity of those receiving care. The concept of dignity, like compassion, is abstract and difficult to measure (Fenton and Mitchell, 2002). However, compassion is viewed as an integral part of dignity (RCN, 2008) and nurses’ compassion plays a major role in providing dignified care to patients. Compassionate care enables patients to remain independent and retain their dignity (Dietze and Orb, 2000).
There is agreement in nursing literature and practice that the delivery of compassionate care is more than the competent execution of clinical skills; it involves a “doing role” and a “being role”. Patients consider it is vital that they are “cared for” and “cared about” (National Nursing Research Unit, 2008).
Nurses themselves have to appreciate that clinical practice is changing and will continue to do so, and need to recognise that advanced clinical skills and compassionate care are not mutually exclusive; high tech does not have to mean low care.
This does not ignore the fact that there are and will continue to be tensions when attempting to truly care for patients with increasing use of technology, more acutely ill patients, fewer nurses and increased managerial functions for practitioners (Corbin, 2008).
- Part 2 of this unit, to be published in next week’s issue, looks at factors that influence compassion in clinical practice.
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Burdett Trust for Nursing (2006) Who Cares, Wins. Leadership and the Business of Caring. London: Burdett Trust for Nursing.
Carvel, J. (2008) Nurses to be rated on how compassionate and smiley they are. The Guardian, 18 June 2008.
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