At University Hospitals Birmingham Foundation Trust, interactions between staff and patients have been observed to assess compassion and ultimately improve care
Compassion is often hidden in plain sight. How do you measure compassion in interactions between staff and patients? At University Hospitals Birmingham Foundation Trust, we wanted to find a way of systematically assessing compassion and use the results to improve our provision of compassionate care. Using the Person, Interactions and Environment (PIE) tool, we conducted an ‘observation of care’ study in all our inpatient wards over two years. This article describes the study and explains how it has provided a framework to provide evidence of compassionate care and embed it into practice.
Citation: Denner L et al (2019) Observing everyday interactions to uncover compassion in care. Nursing Times [online]; 115: 1, 54-57.
Authors: Louise Denner is lead nurse standards; Liesel Thompson, Belinda Chambers, Deborah Jackson, Helen Cooke and Lisa Magill are practice development nurses; Joanne Bubb is activities coordinator; Juliet Miller is clinical nurse specialist dementia; Margaret Harries is lead nurse older people; Sue Atkins is clinical nurse specialist dementia and learning disability; all at University Hospitals Birmingham Foundation Trust.
- This article has been double-blind peer reviewed
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University Hospitals Birmingham Foundation Trust recognises the importance of a person-centred, compassionate approach to communication with patients. To improve this aspect of care, we wanted to explore ways of ‘measuring’ the compassion shown by staff in their interactions with patients. We did this by conducting an ‘observation of care’ study in all our inpatient wards using an adapted version of the Person, Interactions and Environment (PIE) tool.
Compassion in healthcare policy
In recent years, reports on high-profile healthcare failures – for example, Francis (2013), Parliamentary and Health Service Ombudsman (2011) – have highlighted an absence of compassion among healthcare staff. In response, healthcare organisations are required to put compassion at the heart of service delivery.
In 2012, the Department of Health published Compassion in Practice, a strategy for nursing, midwifery and care staff that included the ‘6Cs’ – care, compassion, courage, communication, competence and commitment (DH, 2012). Two years later, the chief nursing officer’s review confirmed this renewed interest in promoting compassion (NHS England, 2014). Indeed, the 6Cs remain a core component of the 10 commitments that underpin the current nursing, midwifery and care staff strategy (NHS England, 2016).
What is compassion?
Compassion is a moral virtue that can be defined as “a deep awareness of the suffering of another, coupled with the wish to relieve it” (Chochinov, 2007), especially where an emotional relationship to another person arises (Gelhaus, 2012). A compassionate approach in healthcare encompasses the skills needed to deliver compassionate care as well as the interaction style of the carer (Pulsford et al, 2016). Person-centred communication (Sinclair et al, 2016) and patient-centred interactions (McCabe, 2004) are central to compassionate care.
The experience of compassion is, however, often hidden in plain sight. A patient may know they have been treated with compassion but the act may have gone unnoticed or, indeed, been unconscious.
The work environment of nurses – or any member of the healthcare team who interacts with patients and their families – may influence whether compassion can be expressed. There is also a suggestion that, for practitioners to be able to provide compassionate care, they themselves need to have regular reviews of, and feedback on, their communication performance (Millis et al, 2002).
Observing care as it is delivered, and learning from the observations, can be a basis for quality improvement (Royal College of Nursing, 2004). It allows the observer to:
- See the reality of care (Underwood, 2014);
- Understand the environmental and emotional context in which communication takes place.
An external or ‘fresh-eyes’ perspective is often required to assess communication, as participants themselves often lack self-awareness and/or are inaccurate evaluators of their own performance (Schirmer et al, 2005). Communication is complex and multifactorial and may, for example, involve the interpretation of non-verbal cues, which a participant may miss or make sense of unconsciously. External observers, who will not be distracted by the clinical setting and/or other priorities, can provide valuable feedback (O’Hagan et al, 2014).
Successful observation requires a clear structure and process (Underwood, 2014). Data collection commonly starts with observing the environment, immediate surroundings, activities undertaken and events taking place to produce a description (Robson, 2002). The PIE observational method allows observers to document that descriptive information, which can later support an accurate recall of events and situations if required for the purposes of scoring.
The PIE tool was originally designed for the hospital audit of dementia (Royal College of Psychiatrists, 2011). It requires compassionate communication to include relevant clinical information and expects health professionals to put themselves in the patient’s shoes and, if appropriate, share aspects of themselves with the patient (Sinclair et al, 2016). It has been tested to capture compassionate dementia care and is considered valid and reliable in that setting.
Adapting the PIE tool
For our study, we adapted the PIE tool to capture interactions involving all patients, not only those with cognitive loss. To help us identify themes and trends, we split the original ‘negative’ and ‘positive’ categories into two, which gave us five scoring categories:
- PE: positively enriching;
- E: enriching;
- N: neutral;
- NC: negatively controlling;
- NR: negatively restricting.
Table 1 gives examples for each category; these were collated as a guide for observers.
Modelling compassion and embedding a culture of compassionate care requires the commitment of all staff, not just those providing direct care (Dewar and Christley, 2013). The PIE tool was, therefore, further adapted to allow observers to categorise interactions by staff group (such as nurses, medical staff, allied health professionals, porters, domestic staff and volunteers). All staff interacting with patients were observed, including visiting personnel such as clinical nurse specialists, therapy staff and pharmacists.
Two audits were undertaken by observers from the practice development and dignity in care team, who visited each ward in turn in 2015/16 and again in 2016/17. Before the first audit period, 10 observers completed a training exercise to collect data using the observation tool. They practised on video-taped episodes of patient-staff interactions and then directly observed care on pilot wards. Crib sheets reinforced instructions on how to use the tool.
In the first audit period, all inpatient wards were visited in turn; each was notified in advance, and staff and patients were given information. Patients were asked to give verbal consent and assured that observers would never invade their privacy – for example, by entering an area behind a closed curtain.
Each ward audit was undertaken over a two-hour period by two observers; they allowed a settling-in period before beginning data collection to allow staff to become accustomed to their presence. Observers sat separately and swapped places midway through the observation period, as recommended in the Point of Care Foundation’s experience-based co-design (EBCD) toolkit.
Awareness of being observed or assessed is thought to alter how people behave (Roethlisberger and Dickson, 1939). To counter this effect on staff, observers chose as unobtrusive a position as possible and did not wear uniforms – again something recommended in the Point of Care Foundation’s EBCD toolkit.
At the end of an observation period, the observers reflected on what they had seen and the scores they had recorded. Disagreements and inconsistent or ambiguous assessments were analysed. Observers were encouraged to challenge and discuss ratings before results were fed back to the ward team.
In the second audit period, observations were repeated in all wards in turn, as described above.
Feedback to wards
When possible, observers gave immediate verbal feedback to staff. This could involve praise for an enriching interaction or guidance on how a negative interaction might be improved. The ward manager or nurse in charge was also given immediate verbal feedback. This was followed by a written report and draft action plan for agreement with the team. The reports contained anonymised details of both negative and positive interactions, to encourage effective behaviour and use any deficits as learning opportunities.
Observers noted that staff were sometimes presented with an opportunity to have an enriching interaction but missed it, a phenomenon previously described by Clisset et al (2013). Neutral interactions were either reported as missed opportunities or deemed appropriate. The latter was justified when, for example, a patient clearly preferred minimal conversation and/or wanted uninterrupted respite.
It was apparent from the study that staff can engage in warm, compassionate interactions even when busy, something also noted by Crawford et al (2014). Observers found that this was not only possible but also occurred routinely.
Feedback to the organisation
As audits were completed, written reports detailing individual ward scores and progress were regularly presented in trust-wide forums, such as local divisional quality meetings and the care quality group. They included examples of interactions illustrative of the scores achieved.
At the end of the first audit period, feedback was provided to leads for the different staff groups. This gave each lead the chance to examine the unique ‘disciplinary’ features of the results and themes identified. For example, one non-clinical group of staff were routinely observed to be reticent to engage with patients when entering ward bays and bed spaces. Through discussion with their lead, it emerged that they did not routinely receive training on communication or customer care on induction; they may never have been ‘given permission’ to engage with patients. In partnership with the learning and development team, bespoke customer care training was developed and made available for ward and department teams.
Examples of observed interactions were embedded into corporate communication tools and customer care training. Giving positive feedback and providing meaningful evidence helped foster compassionate behaviour among staff.
Results were presented for each individual ward/department. Fig 1 shows an example of interactions observed on one ward by PIE tool category and staff group.
At the end of the second audit period, we were able to compare scores and explore whether the feedback and training had brought about any improvement. Table 2 shows trust-wide results for the two audit periods. Although caution must be exercised when using a two-point comparison, these results appear to show an increase in enriching interactions and a reduction in neutral and negative interactions.
The ‘observation of care’ study has given the organisation an opportunity to celebrate exemplary practice. A significant number of interactions observed illustrated enhancing and compassionate approaches to care. Exploring interactions constructively, providing clear and prompt feedback, and raising awareness of the value placed by the organisation on compassion all contributed towards enhancing the quality of interactions.
We hope feedback prompted staff to reflect on communication approaches. Staff valued individual praise and recognition when they had delivered enriching care. Senior managers and hospital patient governors responded positively to the study, recognising that it provided qualitatively different and ‘refreshing’ data, compared with data traditionally reported as part of performance monitoring.
Observation of care has been demonstrated to be an effective strategy for illuminating a culture of compassion. It is now embedded as part of our strategy to ensure continual attention to providing compassionate care.
- Person-centred interactions are central to compassionate care
- The experience of compassionate care is often hidden in plain sight
- Observation of care is an effective method of measuring compassion
- Constructive exploration of staff-patient interactions provides useful feedback
- A study has shown that staff can engage in compassionate interactions even when busy
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