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Developing compassion in pre-registration education

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Choosing the right recruits to education programmes, and providing appropriate educational content, will foster compassion among nursing students


Compassion is a fundamental aspect of nursing and student nurses have to be able to demonstrate compassion in practice. Nurse educators in higher education institutions and clinical settings need to work together to prepare and support student nurses to deliver compassionate care. This article discusses the key components of compassionate care, and how students can be enabled to deliver high-quality care within rapidly changing, complex environments. A second article explores how nurses can be recruited with the values of the 6Cs.

Citation: Pryce-Miller M, Emanuel V (2014) Developing compassion in pre-registration education. Nursing Times; 110: 37; 17-19.

Authors: Maxine Pryce-Miller is senior lecturer in applied professional studies at the Institute of Health and Society, University of Worcester; Vernel Emanuel is senior lecturer at the School of Health and Wellbeing, University of Wolverhampton.


Nursing has been associated with caring, empathy and compassion since the days of Florence Nightingale, who felt nurses should have an innate empathy for their patients (Nightingale, 1860).

The Department of Health defines compassion as care given through relationships based on empathy, respect and dignity (DH, 2012). Compassion can also be described as intelligent kindness, and is central to how patients perceive their nursing care.

Dewar (2013) has commented that understanding and experience are needed when giving and receiving care, because delivering compassionate care is a complex process.

Public perceptions

The Francis report brought nursing and nurse education under scrutiny, making challenging recommendations with significant implications for nurse education (Francis, 2010). One recommendation was that there should be a greater focus in nurse training, education and professional development on the practical requirements of delivering compassionate care, in addition to the theory. For example, good communication with patients and their families is essential to compassionate care and is reflected in a three-year strategy and vision for nurses that encompasses the 6Cs of nursing practice - care, compassion, competence, communication, courage and commitment (Cummings and Bennett, 2012).

The Care Quality Commission (2011) has stated that public confidence in the nursing profession needs to be restored. One way to achieve this is to ensure that nurses have the knowledge, skill and competence to deliver high-quality care to patients and their families.

This knowledge must be acquired throughout nurse training and beyond. This is imperative if nurses are to provide a positive experience for patients, thereby improving public confidence. Nurse education has an important role in preparing future nurses for their professional caring role. However, it has been questioned whether compassionate care can be taught and, if so, how it can it be measured. From our experience, compassionate care involves relationships and should be a core element of nurse education and care.

Nurse education and compassionate care

There is no doubt that the majority of nurses deliver high-quality, compassionate care. However, Burhans and Alligood’s (2010) study among 12 nurses qualified for less than a year, which explored the meaning of high-quality nursing care, found that individual nurses’ attitudes and behaviour can play a part in delivering poor nursing care.

Maben et al (2010) said that when newly qualified nurses entered the workforce, their values, ideals and compassion were clearly evident. Over time, this diminished as they dealt with increasing bureaucratic and organisational factors that led to some of the more satisfying and fundamental aspects of the nursing role being lost.

A drive for increased productivity and efficiency can often result in substantial time being spent on administrative tasks, taking nurses away from care delivery. This can lead to them feeling frustrated and disillusioned in not being able to do their jobs properly. To deliver compassionate care and increase and improve public confidence, organisational culture has to change. Service users’ views must be incorporated and nurses must be proactive in articulating and escalating concerns about poor standards and practice.

According to Lowenstein (2008), the majority of pre-registration nursing students enter into the profession with a sense of altruism. However, as they get further into their training, they appear to become less empathetic and more distant from patients. Disturbingly, other research has demonstrated that the process of nurse education can reduce the capacity for expressive care (Murphy et al, 2009).

For example, throughout their training, students are taught that individualised, person-centred, holistic care is paramount. There is an expectation placed on student nurses entering clinical settings to bring knowledge, skills, empathy and compassion to deliver high-quality care. However, the reality of working in a modern hospital can be overwhelming for students as they learn to grasp ward routines and develop relationships with their mentors and other health professionals. This is compounded by other issues such as staff shortages, and students are now reporting their reliance on healthcare assistants for support in clinical settings (O’Driscoll et al, 2010). It is therefore important that student nurses are provided with the right education and skills to equip them fully for their roles.

The Willis Commission (2012) explored the essential features of pre-registration education, support mechanisms in place for newly qualified nurses and what was needed to create and maintain a workforce of competent, compassionate nurses to deliver future health and social care. Its recommendations (Table 1) have implications for both nurse education and clinical practice.

There is a need to improve the patient experience and pre-registration education clearly has a role to play in this. One way to achieve this is by higher education institutions (HEIs) recruiting and retaining students of the right calibre who value positive patient outcomes. This means looking at how students are recruited now and how this can be improved.

The literature suggests that emotional intelligence should be a prerequisite for recruitment in nurse education. As far back as 1994, Taylor identified that emotional intelligence incorporates the human skills of empathy, self-awareness, motivation and self-control, which are all recognised as essential in clinical practice. If students lack those qualities, how can they be expected to show care and compassion?

Student nurses are actively involved in patient care and form relationships with patients and their families, hence they need to have empathy. Cadman and Brewer (2001) have suggested that emotional intelligence cannot be developed overnight, and it is essential that nurse educators create assessment strategies that will identify emotional intelligence at recruitment.

Teaching and communication

Hopkins et al (2009) said, to deliver compassionate care, nurses should be able to communicate effectively with patients and their families so they can address issues that are of concern to patients. There are a number of ways in which nurse educators can assist and support students in this. In light of the Willis Commission report (2012), the role of the nurse educator is not only to teach about medical conditions but also to use a variety of teaching methods that consider the patient as a whole.

Hemingway et al (2011) recommended comprehensive case studies and having service users share their experiences with students as ideal ways in which students can improve their understanding of the implications of living with a medical condition. This understanding will enhance the delivery of compassionate care in that students will be able to respect and maintain patients’ dignity.

Interprofessional learning based around clinical scenarios is another valuable way of teaching students, giving them opportunities to work alongside other disciplines and live actors posing as patients. Scenarios can be captured using video clips with students watching, critiquing and discussing them. Other teaching sessions could explore clinical situations through role play or simulation.

Communication is a vital aspect of delivering compassionate care, as student nurses deliver bedside care to patients and interact with them and their families, as well as building professional relationships with colleagues. Learning good communication skills are, therefore, central to nursing (Apker et al, 2006). Interpersonal relationships are key; as Miller and Apker (2002) identified, modern nursing requires nurses to enact traditional communication processes, for example those 0f education and empathy with patients and their families. Miller and Apker (2002) also said that communication skills covering issues such as conflict resolution or change management when interacting with colleagues are essential.

As well as teaching self-awareness to student nurses, nurse educators need to be aware of their own behaviour and attitudes, as these can have a positive or negative influence on students. Communication and collaboration are essential in maintaining professional relationships, which will benefit nurse educators and student nurses in feeling supported throughout their training and being able to speak up for patients and families. While it is challenging for students to raise concerns about bad practice in clinical settings, students are advocates for patients (Nursing and Midwifery Council, 2010); it is therefore imperative that educators encourage and support them in this endeavour.

According to Dewar (2013): “Knowing who people are and what matters to them, understanding how they feel, and working with them to achieve compassionate relationship-centred care that has meaning for both those who give and receive care, are integral to providing compassionate care.”

Strong leadership, supervision and professionalism should be explicit in the curriculum and in clinical practice. The ward manager and mentor in clinical practice are crucial in teaching and supporting undergraduate student nurses in delivering compassionate care to patients and their families (O’Driscoll et al, 2010). Students need to feel valued and acknowledged for their contribution to the team. Ward managers have strategic responsibilities for learning at ward level alongside mentors who are responsible for delivering leadership on a day-to-day basis for learning. This is key to students delivering compassionate care in practice. For example, they will look to their mentors as role models so they must demonstrate a humanistic approach, as observable behaviours can shape future behaviour. Nurse educators need to collaborate with and support ward staff by maintaining regular presence in clinical areas.

Generally, student nurses in the UK are taught about the process of reflection as a method of learning and are encouraged to keep a reflective diary. This enables them to improve their practice for the benefit of patients and their families, and is a developmental goal for them as individuals. According to the Quality Improvement Agency (2008), learners need to feel confident about taking and acting upon the decision to appreciate the value of reflecting on learning, and decide whether learning has been effective or whether they need to try another approach. This will enable students to reflect on care delivery in an effort to deliver compassionate care.


Nurse educators play a vital role in delivering the curriculum in relation to compassionate care, which is a fundamental part of caring for individual patients. To achieve this, it is vital that recruitment processes are robust in identifying prospective students who can be supported throughout nurse education to develop, embrace and deliver compassionate care as part of their professional role.

Key points

  • Compassion can be described as intelligent kindness
  • Recruitment to pre-registration courses should take account of applicants’ emotional intelligence
  • Educators should involve service users and use a variety of teaching methods, including case-based learning and role play
  • Mentors and ward managers are crucial in helping students to deliver compassionate care
  • Good leadership can help to support students in raising concerns about poor practice
  • 1 Comment

Readers' comments (1)

  • "Burhans and Alligood’s (2010) study among 12 nurses qualified for less than a year, which explored the meaning of high-quality nursing care, found that individual nurses’ attitudes and behaviour can play a part in delivering poor nursing care".


    Sometimes I wonder whether our higher educational care-speak colleagues actually inhabit the same planet or whether we are all actually having our leg pulled.

    Twenty years ago registered nurses called upon junior "enrolled" nurses to undertake any tasks which enabled the registered nurse to focus upon her immediate priorities..even to manage the ward directly via personal involvement involving direct observation and participation in care, teaching/guiding junior staff or participating and equals and dare I say it, "leaders" within the multi-disciplinary team.

    Now however, her lot is to spend most of her shift distributing and managing myriads of individually boxed paracetamols whilst agonizing about the absolute accuracy of their documentation in the knowledge that three file-notes and she's out with a referral to the NMC whilst she hopes that in her absence the unaccountable senior carer who is actually present on the unit and directly managing the direct care staff team and who has been appointed for her drive and inherently competitive nature is doing so on her behalf and that she will at some point be properly briefed and not consciously or unconsciously become or continue to be the subject of quiet contempt particularly given the seniors half pay reward as opposed to the former enrolled nurses 2/3 pay. Enrolled nurses were selected for particular personal qualities of their caring and supportive natures but could undertake and stand in for the registered nurse..unlike their counterparts who ruefully remind the registered nurse that they are unqualified to undertake the very routine task being currently undertaken by the hapless nurse and would-be leader whilst they disappear out of the office/clinic looking for the carers who respond immediately to her directives. Welcome to the realities of the modern "basic" nursing experience of the average general nurse.
    Interesting to see the most recent nurse image from the NMC appears to be a perfect female model holding not a sphyg, nor a stethoscope, nor any piece of medical equipment associated with nursing but a clip-board!
    PS I can remember very clearly cuff and cap wearing ward sisters who would choke at the idea that compassion is something to be learned or even developed apart from the experience of working alongside the singularly unique qualities of the average enrolled nurse (led by sister of course)

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