Can you measure compassion?
Compassion is often held up as a basic tenet of nursing. But a perceived lack of this quality in the modern profession has sparked new efforts to ensure nurses embrace it as a core value. Helen Mooney investigates current developments in the compassion debate
At the same time as nurses and other healthcare professionals are often praised for their high levels of compassion, there is a common lament that the ‘heart has gone out’ of nursing and that today’s nurses are not as ‘caring’ as those of the past.
The public’s perception seems to be that the level of compassion with which nurses care for patients has decreased over time, an impression perhaps driven by a succession of national news stories involving high-profile cases such as Mid Staffordshire NHS Foundation Trust and more isolated examples involving care of older people.
The argument has also been made that the development of nursing careers into more advanced roles has taken nurses away from core values and into the more technical aspects of care.
A new King’s Fund report – titled Enabling Compassionate Care in Acute Hospital Services and published this week – also points the finger at a ‘technical shift’, especially in training.
It described core training for the nursing and medical professions as essentially ‘biomedical’, adding that although ‘effective clinical care is clearly fundamentally important… human aspects of care must also be valued in training and in terms of career progression’.
Whether modern nursing care is less – or even more – compassionate than it was in previous decades, and whether this actually matters, has long been a question for debate within the profession. But the government now sees the issue as important enough to feature firmly on the mainstream political agenda.
Last June, in a speech to the NHS Confederation, health secretary Alan Johnson revealed plans to measure compassion within nursing and to assess nurses on their ability to provide compassionate care.
It was the trailer for the NHS Next Stage Review, unveiled a week later, which formally announced that a range of indicators would be developed to determine whether nurses, and the wider NHS, were delivering quality patient care.
Often misquoted as calling for a profession of ‘smiley’ nurses, Mr Johnson said patients wanted to be ‘kept well informed by staff and treated with compassion and sensitivity’. He then went on to quote the profession itself.
‘What nurses tell us is that you can have the best surgeon in the world, who carries out the most terrific operation on you but your stay in hospital won’t be satisfactory if you don’t get the highest level of compassion and care,’ he said.
‘If your experience involves nurses looking grumpy, or someone being rude, or not getting people there when you need them, then it ruins the whole experience,’ he added.
Ten months later the launch of the Prime Minister’s Commission on the Future of Nursing and Midwifery gave ministers another chance to directly name-check the concept of compassion.
Health minister Ann Keen, commission chair, said at the time: ‘As a nurse, I know that our nurses and midwives are at the heart of our NHS, championing the cause of patients and providing dignity, care and compassion, as well as promoting health and well-being.’
The commission is set to have its first full meeting at the end of April and there are high hopes that it will be able to identify the barriers that may be preventing nurses from delivering compassionate care.
Speaking exclusively to Nursing Times last week on how compassion will fit into the commission’s work, Ms Keen said: ‘We need to make sure care and the values of caring are more than just words. They have to be at the centre of how an organisation is run. Compassion has to be shown by staff at every level to every patient.’
She suggested that the key problem that needed to be examined was why nurses often felt they lacked sufficient time to deliver compassionate care. ‘What frustrates nurses is that they have not got time to care,’ she said. ‘They need to be able to have that very special relationship with the patient.’
Ms Keen told Nursing Times she did not think that having more specialist nursing roles was incompatible with those nurses being able to offer compassion and, interestingly, that she did not believe in the argument that nurses were less compassionate now than they were 20 or 30 years ago. ‘We have got to kill this myth that there was ever a golden age of nursing,’ she said.
Former nurse Claire Rayner, chair of the Patients Association and a member of the commission, also suggested that time pressures lay at the heart of the compassion problem.
‘Nurses are under the most awful pressure to perform, very few people go into nursing to make a fortune. There is something called an aptitude for nursing, they have a core of altruism that is more than most people, but this is knocked out of them in the process of working in the system.’
‘It seems like there is no time for talking anymore,’ she said. ‘I have enormous sympathy for nurses because they have got a bitch of a job on their hands.’
But identifying workload pressures as an obstacle to nurses spending time with patients – and therefore being able to offer sufficient compassion – is perhaps not the main challenge. This surely will be finding a solution.
RCN head of policy Howard Catton said he hoped that the commission’s work would ‘go beyond warm words’. ‘They have really got to look at the system and tackle the issues as a whole. We need to do more through policy levers to ensure that compassion is rewarded, for example by making payment by results based more on patient experience.’
Mr Catton suggested that one way of forcing trusts to ensure nurses had more time with patients was to measure staffing levels as one of the profession’s new quality indicators – the so-called nursing metrics.
State of the art metrics for nursing, published last year by the National Nursing Research Unit based at King’s College, London, and recognised as the first step in the development of metrics, identified both compassion and staffing levels as potential measures of quality.
‘Sympathetic pity and concern for the sufferings or misfortunes of others,’ is the Oxford English Dictionary’s definition of compassion. It is, therefore, intrinsically hard to gauge scientifically.
Professor Peter Griffiths, director of the unit and one of the report’s authors told Nursing Times that directly measuring the human quality of compassion was ‘hugely challenging’.
‘I am a strong supporter of trying to find and measure what is measurable, but with compassion we need to be able to see the experience from the patient’s side – we need to go beyond measuring in a way that is very cold,’ he said.
Lesley Baillie, principal lecturer on clinical skills development in the faculty of health and social care at London’s Southbank University, is completely opposed to the idea of trying to develop measurements for compassion for these very reasons.
‘How do you measure a light touch, silence or an important phone call? It is situation – and individual-specific. There is a risk that if you try to turn compassion into a check list it will become less than it really is and how meaningful is that?’ she asked.
However, despite the obvious difficulties, attempts to directly measure levels of compassion in potential nursing recruits are already under way at some trusts, ashas been revealed over several months by Nursing Times.
Nursing applicants at Central and North West London NHS Foundation Trust are being assessed on how compassionate they are.
The mental health trust is in the early stages of attempting to design a tool which will test potential nurses on their ability to be compassionate as well as clarifying their reasons for entering the profession. It has already set up a process which includes an assessment day held once a month to observe how applicants interact with each other, which also includes being interviewed by patients.
The trust hopes to develop a tool that can eventually be rolled out across London.
Peter Walsh, the trust’s director of nursing practice, told Nursing Times that the work had been driven by questions as to why some people were choosing nursing as a career and concerns that compassion was indeed being watered down as a core value in the profession.
‘We have been getting a feeling from some applicants that they weren’t coming in to the profession because they want to offer compassion but because of the money and the fact it is considered to be a stable career,’ he said.
‘We have been coming together with senior nurses at the trust and thinking that anecdotally some staff did not have enough compassion – we want to make sure that we are getting the best staff,’ he added.
But in common with Professor Griffiths, Mr Walsh agreed that coming up with an accurate measure of compassion was not easy. ‘We are still working on it and trying to work out how to measure it – we don’t have a tool to do that at this time,’ he said.
London’s Imperial College Healthcare NHS Trust – the largest acute trust in the UK – thinks it may have found the answer by introducing a psychometric test for all potential nursing recruits.
According to the trust’s director of nursing, Janice Sigsworth, who also sits on the new PM’s commission, the organisation is hoping to be able to ‘screen and recruit’ nurses who have the ‘right values’.
Ms Sigsworth said it was too simplistic to tell nurses in a blanket fashion that they needed to be more compassionate. ‘We need to understand what it is and in more depth, and then we have to put in some measurement as well,’ she said.
The subject of compassion in nursing has aroused strong opinions and will no doubt continue to do so.
Mental health nurse Claire Murdoch, chief executive of Central and North West London NHS Foundation Trust, said: ‘It is an indictment of the state of the profession that we are even asking the question as to whether compassion is part of a nurse’s role – it is absolutely fundamental.’
But, Jill Maben, senior research fellow at the National Nursing Research Unit and co-author of the ‘State of the art metrics’ report, says that asking nurses to be compassionate all the time is a ‘really, really big ask’.
‘Some form of emotional protection develops, it has to, or nurses could not function. If you identified with every patient’s pain you could not get up in the morning,’ she said.
Perhaps significantly, at a time when compassion in nursing is coming under close scrutiny, so too is compassion fatigue – or emotional burnout – among nursing staff.
Writing on the subject in the latest issue of the Journal of Health Psychology, Dr Caroline Carney Doebbeling, associate professor of medicine and psychiatry at Indiana State University, highlighted the emotional burden on healthcare staff.
Ms Carney Doebbeling carried out a review of 57 studies into compassion fatigue among healthcare professionals involved in the care of cancer patients. She warned that those who had developed compassion fatigue were in turn at risk from symptoms, such as chronic tiredness, and destructive behaviours such as drinking to excess.
‘Doctors, nurses and other members of the healthcare team must be steady sources of support for patients. But when the patient encounter is over, at the end of the day, the doctor or nurse needs to be able to process everything they have seen and experienced,’ she said.
‘We are taught in medicine to be brave and to be strong, but there should also be a time and place for emotional expression, and perhaps even for crying,’ she added.
The solution, Ms Maben thinks, is to offer nurses a formal system of support and supervision, which also gives them an opportunity to discuss distressing cases – not just in the informal environment of the pub with their colleagues after work.
‘We need more supervision in terms of mental health and social work, so nurses have the opportunity to talk about the emotions their job as a carer has brought up in them as a person,’ she said.
It would appear that the concept of measuring compassion in nursing has opened a wider debate than could have been predicted.
The suggestion is that for nurses and other healthcare professionals to be effective on the frontline in delivering compassion, they also need to be its recipients. Dr Carney Doebbeling said: ‘We need to support people who work with the sickest of the sick.’