The King’s Fund Point of Care programme explores the barriers to providing compassionate care in hospital and how nurses can enable such care.
Cornwell, J., Goodrich, J. (2009) Exploring how to enable compassionate care in hospital to improve patient experience. Nursing Times; 105: 15, early online publication.
This article is the first in a series over the coming months by The King’s Fund Point of Care programme looking at practical interventions to improve patients’ experiences of care. It discusses what compassion means, what might prevent consistent compassionate care, and what practical changes could enable compassion.
Keywords: Compassion, Dignity, Patient experience
Jocelyn Cornwell, PhD, is director; Joanna Goodrich, MA, is senior researcher/programme manager; both at The Point of Care programme, The King’s Fund.
Care, compassion and respect have always been enshrined in the value statements of the health professions (NMC, 2009; 2008).
However, ‘compassion’ has recently gained a higher profile with policymakers. The NHS Constitution sets out certain NHS values, including respect, dignity and compassion: ‘[The NHS] touches our lives at times of most basic human need, when care and compassion are what matter most’ (Department of Health, 2009).
We wanted to look more closely at compassionate care – what is it, what prevents it and what enables staff, day in, day out, to be compassionate towards every patient in their care. To do this, we held a one-day workshop, bringing together people who work in hospital (nurses, doctors, psychologists, chaplains, managers), together with experts who have written on or researched the topic.
We have also published a short paper reviewing the literature on compassion and concepts related to it (Firth-Cozens, 2009). This article is based on the discussions at the workshop as well as the paper (click here to read the paper).
Why does enabling compassionate care matter?
Healthcare staff want to be able to care for patients with humanity and decency and to give to patients the same kind of care that they would want for themselves or their own family and loved ones (Goodrich and Cornwell, 2008).
For many staff, such a desire may have been a motivating factor in their decision to enter the healthcare professions in the first place. Practitioners want to be able to show compassion to the patients under their care.
Compassionate care matters to patients. Anecdotally, it is the presence or absence of compassion that often marks the lasting and vivid memories patients and family members retain about the overall experience of care in hospital and other settings.
Improving patients’ satisfaction about their experience of care is an outcome that most patients and families would agree has value in and of itself, and is emphasised in the goals in recent key policy documents (Department of Health, 2008).
Research evidence suggests that compassion affects the effectiveness of treatment. For example, patients who are treated by a compassionate caregiver tend to share more information about their symptoms and concerns, which in turn yields more accurate understanding and diagnoses (Epstein et al, 2005).
In addition, since anxiety and fear delay healing (Cole-King and Harding, 2001), and compassionate behaviour reduces patient anxiety (Gilbert and Procter, 2006), it seems likely that compassionate care can have positive effects on patients’ rate of recovery and ability to heal.
The elements of compassion
Compassion, in simple terms, is ‘a deep awareness of the suffering of another coupled with the wish to relieve it’ (Chochinov, 2007).
Compassion requires that staff give something of themselves. When fatigue, personal factors and organisational circumstances conspire to create workplace stress, it becomes more difficult for staff to feel and show compassion, creating a gap between their intentions and their capabilities.
Sometimes it is easier to identify when compassion is missing than when it is there. In the broadcast and print reports of failures in hospital care – such as, for example, the reports of the Healthcare Commission’s (2009) and (2007) investigations into Mid Staffordshire and Maidstone and Tunbridge Wells NHS trusts – it is the apparent lack of compassion that fuels media outrage.
It is important to note that the focus on compassion should not reside merely at the ‘sharpest ends’ of care – that is, in emergency situations, or when a patient is known to be dying. Lack of compassion in mundane aspects of acute and everyday care also takes its toll on patients and staff. Indeed, it is the ‘little things’ that patients or carers often recall as having been either present or lacking in their experiences of care. For examples of these ‘little things’ go to www.kingsfund.org.uk/pointofcare_compassion).
The elements of compassion, as defined in particular relation to health care, are described below in Box 1.
Box 1. The elements of compassion
- Compassion starts with good basic care and can be demonstrated in very practical ways – for example, making sure that a patient’s feeding needs are addressed, that pain is managed and that the patient is helped to the toilet as needed. It can be equated with providing both dignity and respect.
- Compassion goes beyond essential care, however, to encompass ‘empathy, respect, a recognition of the uniqueness of another individual, and the willingness to enter into a relationship in which not only the knowledge but the intuitions, strengths, and emotions of both the patient and the [caregiver] can be fully engaged’ (Lowenstein, 2008).
- As such, compassion involves ‘real dialogue’: communication that is human to human rather than clinician to patient.
- The compassionate caregiver never stereotypes but appreciates difference, recognising the common humanity shared by both patient and caregiver.
- Compassion should not necessarily be seen as being sweet and nice. It includes honesty and may require courage.
- It is not a one-size-fits-all: compassion can mean very different things in different situations and to different people. In recognising the individuality of each patient, compassionate carers will also recognise how best to tailor their behaviour to show compassion based on a particular patient’s needs.
- In short, for healthcare professionals, compassion means seeing the person in the patient at all times and at all points of care.
How do we assess how good we are at delivering compassionate care? The question is important, but it also presents an immediate, inherent challenge in an NHS reliant on quantified targets and measures.
If we accept that compassion is a felt experience, it follows that the closest we can come to measuring compassion is to ask patients whether or not they experienced it. Measures of compassion must rely to a large degree on patients’ own subjective assessments of their experiences of care, which can be obtained in a variety of ways: interviews; questionnaires; frequent feedback mechanisms; and surveys.
There are other types of measure that might also be considered: measures of process and measures of structure. Since compassion can demonstrate itself in very practical ways, there are objective, practical measures that may indicate or point to its presence or absence (the ‘feeling for’ the patient) in the way care is delivered.
In this way, we can say that many of the physical indicators already assessed, while they might not measure compassion directly, do point towards it. The measures we have in mind are ones such as: how quickly staff respond to call bells; whether patients’ feeding needs are attended to; how well pain is managed; and how often and at what times of day or night patients are moved from ward to ward. All of these have an impact on continuity of care and relationships between staff and patients.
These basic indicators of aspects of quality of care may tell us something about attitudes and behaviours that are important with respect to compassion. Poor performance in any of these dimensions may not be caused by a lack of compassion but rather might be taken as indications of environments in which patients are at risk of feeling uncared for, and that therefore merit further investigation.
The structural measures that complete the more rounded attempt to measure compassion would be measures of risk in the physical environment or risk to staff capability to deliver compassionate care. Risk in the physical environment of care would need to be observed and audited. Risks to staff capability would be available from feedback in staff surveys to questions about the quality of leadership and support and team-working. They would also be available in some of the human resource data such as: measures of staff turnover; vacancy rates; and the use of bank and agency staff in different locations.
What stops compassionate care from happening?
Why, when staff may have entered the healthcare profession with high ideals, abundant stores of compassion and a strong motivation to treat patients as they themselves would want to be treated, do lapses in compassionate care sometimes occur?
First and foremost of these reasons, perhaps, is the natural human defences we develop in reaction to trauma. In care settings of all kinds, staff experience regular, frequent or in some cases continuous exposure to their fellow human beings in varying states of pain and distress, to suffering, terminal illness and death. Sometimes the defence takes the form of inappropriate joking; sometimes it manifests itself in numbing, a distancing reaction and withdrawal, as described by an acute care nurse in Box 2.
Box 2. An acute care nurse’s view
On staff coping with constant exposure to death and dying:
‘I went to work on an elderly ward where patients died daily and there was great pressure on beds. At first, I did all I could to make the lead-up to a death have some meaning and to feel something when one of them died. But, gradually, the number of deaths and the need to strip down beds and get another patient in as fast as you can got to me and I became numb to the patients; it became just about the rate of turnover, nothing else’ (Firth-Cozens, 2009).
The key point is that under these conditions, practitioners must develop coping mechanisms – some more effective or appropriate than others.
Staff who do not find effective ways of coping may be more susceptible to stress and burnout. Self-reported stress of health service staff in general is considerably greater than that of the general working population (Wall et al, 1997).
Stress and depression is evidenced by high self-criticism (Brewin and Firth-Cozens, 1997), and a lack of compassion towards oneself is likely to work its way through to a lack of compassion towards patients (Gilbert, 2009).
Stress and burnout have their origins in different sources, some of them individual, some of them situational.
- Age and experience;
- Self-esteem levels;
- Personal resilience;
- Job satisfaction.
- Regular exposure to pain and distress;
- Conflicting information about what the organisation expects from staff or what is valued in the organisation;
- Poor feedback systems or lack of recognition or praise for individual acts of compassion and care;
- Lack of time and simultaneous pressure to meet targets.
Compassion, too, can become problematic for staff in settings where displays of emotion are treated as a failure to maintain an appropriate professional distance or authority. Though not necessarily unique to any one profession or role within the hospital, this is particularly relevant to those in roles that place a high value on professional detachment. Such attitudes are more commonly associated with doctors but perhaps increasingly prevalent in nursing.
The role of education in teaching healthcare staff professional values and standards is also important. In medicine, the psychosocial aspects of caregiving have tended to command secondary status, and workshop participants felt this was increasingly common in nursing training. Training that emphasises professional detachment and positions compassion as ‘soft and fluffy’ may have a detrimental impact later on the interpersonal relationships between staff and patients – and to the quality of care delivered.
Finally, even where the value of compassion is taught in the syllabus, there is a concern that, without systematic modelling and explicit endorsement and support for striving to be compassionate towards every patient, every time, it will be eroded and more difficult to practise.
In the practical circumstances in which staff caring for patients feel under pressure, and experience themselves as having very little time, it is often difficult to do just that one thing for the patient that makes her or him feel cared for. Enabling staff to feel and be compassionate towards patients in their care, at all times, requires action on multiple levels.
At the level of the individual, one of the most powerful resources that healthcare professionals consistently cite is patients’ stories.
In cases where professionals themselves, or their loved ones, become patients, the nature of their personal experience of care very often has a profound effect on how they carry out their clinical practice. Where first-hand experiences of care are not available, exercises in which staff are asked to role-play or write a narrative imagining themselves as patients can have a similar usefulness.
Providing practitioners with a forum for open and honest dialogue about their experiences of delivering care is similarly important. A safe and recrimination-free environment in which to discuss the everyday challenges, frustrations and pressures of the job – in which sharing stories and feelings about patients and their care is legitimised – is essential.
It helps to remind busy staff that every patient is individual and unique; it provides support to individuals; encourages communication within the team; and it helps to improve team dynamics.
Good team relations make a difference not only to the quality of interactions among team members but also to the quality of care delivered to patients (see Box 3 for the markers of a good team). As such, enabling good teamworking is important.
Within teams, those in senior positions can enable compassion among staff by modelling compassionate behaviours – towards themselves, other staff and patients – often through relatively simple gestures, for example, by encouraging a junior colleague to take a meal break or by taking one themselves.
We need to focus our attention, too, on the formative stages of the professions, while nurses and doctors are learning their roles within a hospital. If modelling compassionate behaviour is crucial in the message it sends to all levels of staff, it is especially so when students are in hospital to observe and learn. Mentoring is particularly important in teaching settings and for practitioners at the start of their careers.
None of these suggestions will make much impact, however, if staff remain unaware of what is valued in the organisation or feel undervalued in their jobs. Feeding back regularly to staff on their performance and providing recognition when they deliver compassionate care can help alleviate stress and counter poor organisational morale.
Finally, acute care could learn a lesson from palliative care. With its primary emphasis on patients’ experience, on their physical and psychological comfort and quality of life, the palliative care setting can serve as a model of how to better integrate a focus on compassion into care delivery.
Box 3. The characteristics of a good team
- Its task is defined and its objectives are clear
- It has reasonably clear boundaries and is not too large (ideally fewer than 10 people)
- Its members know who leads it and the leadership is good
- There is participation in decision-making by all members, good communication and frequent interaction between them
- It meets regularly to review its objectives, methods and effectiveness
- Its meetings are well conducted
- Its members trust each other and feel safe to speak their minds
- There is a shared commitment to excellence of patient care
Source: Firth-Cozens (2009)
Dignity and Respect in Nursing: national conference
This important new conference organised by Nursing Times will offer a practical guide to delivering compassionate nursing care. Look out for further information in the magazine or on the website, or call 0845 056 7889 to register your interest in attending
Brewin, C., Firth-Cozens, J. (1997) Dependency and self-criticism as predicting depression in young doctors. Journal of Occupational Health; 2: 3, 242–246.
Chochinov, J. (2007) Dignity and the essence of medicine: the A, B, C and D of dignity conserving care. BMJ; 335: 184–187.
Cole-King, A., Harding, K.G. (2001) Psychological factors and delayed healing in chronic wounds. Psychosomatic Medicine; 63: 216–220.
Department of Health (2008) High Quality Care for All – NHS Next Stage Review Final Report. London: DH.
Epstein, R.M. et al (2005) Patient-centred communication and diagnostic testing. Annals of Family Medicine; 3: 415–421.
Firth-Cozens, J. (2009) Enabling Compassionate Care in Acute Hospital Services. London: The King’s Fund.
Gilbert, P. (2009) The Compassionate Mind: A New Approach to Life’s Challenges. London: Constable and Robinson.
Gilbert, P., Procter, S. (2006) Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy; 13: 353–379.
Goodrich, J., Cornwell, J. (2008) Seeing the Person in the Patient. London: The King’s Fund.
Healthcare Commission (2009) Investigation into Mid Staffordshire NHS Foundation Trust. London: HC.
Healthcare Commission (2007) Investigation into Outbreaks of Clostridium difficile at Maidstone and TunbridgeWells NHS Trust. London: HC.
Lowenstein, J. (2008) The Midnight Meal and Other Essays About Doctors, Patients, and Medicine. New Haven, CT: Yale University Press.
NMC (2009) Guidance for the Care of Older People. London: NMC.
NMC (2008) The NMC Code of Professional Conduct: Standards for Performance, Conduct and Ethics. London: NMC.
Wall, T.D. et al (1997) Minor psychiatric disorder in NHS staff: occupational and gender differences. BritishJournal of Psychiatry; 171: 519–523.
Suggested further reading
Macpherson, C.F. (2008) Peer-supported storytelling for grieving pediatric oncology nurses. Journal of Pediatric Oncology Nursing; 25: 148–163.
Smith, P. (2008) Compassion and smiles: What’s the evidence? Journal of Research in Nursing; 13: 367–370.
Youngson, R. (2008) Compassion in health care: The missing dimension of health care reform? NHS Confederation futures debate series: