The meaning of compassion
342
they would define compassion. They were given sticky notes and people-shaped cards to encourage participation. A simple descriptive coding technique was used to identify themes to enable further discussion (Bowling, 2014)
What does compassion mean to you? There were 77 responses to this question, including: ‘Compassion cannot be taught it is something you have.’ ‘Compassion is holding your patients hand or giving your colleague a hug when needed.’ ‘Compassion means making time to listen, to talk, to hold a hand and to imagine what the patient is feeling.’ Using thematic analysis, the following themes were identified. Compassion was described in relation to: ■■ Patients by 27% of respondents ■■ People in general by 35% of respondents ■■ Patients and colleagues by 3% of respondents A total of 34% offered a definition of compassion without mentioning patients or people. The words used most frequently in describing compassion were: understanding (21% of statements), care/caring (38% of statements), empathy (17% of statements), and listening (16% of statements). A total of 10 statements specifically included that ‘compassion is treating others as you would wish to be treated.’ Figure 1 illustrates the words used to describe compassion.
Why I came into health care There were 52 responses to this question, including: ‘I became a nurse to help people when they are at their lowest point. For me it’s about showing someone that you care, that you understand. Treating them as an individual with different needs.’ ‘Nursing to me is about providing care for people and treating them how I would want someone to treat my child. I love working with families and ensuring that they have the best possible experience.’
Using thematic analysis, the following themes were identified. ■■ 58% mentioned ‘caring’ as important ■■ 19% mentioned the influence of caring for family members that steered them into healthcare ■■ 13% described the desire to help people ■■ 13% described the desire to make a difference ■■ 11% described the desire to help people at their most vulnerable or at a low point ■■ 8% mentioned delivering care with compassion
Discussion Compassion should be viewed as a thread that runs right through the nursing process, therefore quality of nursing cannot be viewed by measuring compassion alone as competence and education also contribute significantly to quality of care. Nurses are members of a highly skilled profession where, at times, there are competing demands on them and no more so than in the current climate with increasing operational demand and financial constraints. Day (2014) describes how these pressures can ‘squash’ the compassion out of nurses and it can be easier to treat patients as a conveyor belt of tasks. Lee at al (2012) suggest that fundamental caring skills are being lost on the advancing skills agenda and describe how educators need to ensure that curricula include tools for self-reflection that address triggers for fatigue and burn out. However healthcare organisations need to look deeper than this if they are to really understand behaviour and compassionate care. Day (2014) describes that if staff genuinely see patients as individuals they will automatically deliver compassionate care, while Pence (1983) stated that imagination plays a key role in compassion, in achieving understanding of and feeling for suffering of people. This involves self-transposal into another person’s situation. It is more than just ‘putting oneself in another’s shoes’ because health professionals require appreciation and understanding of backgrounds values and needs. Perhaps it is this understanding that differs from nurse to nurse. It is a challenge for anyone to put aside his or her own beliefs and prejudices, therefore this raises the question of whether we judge and apportion compassion according to our own judgement and value system. Key questions can be asked of the findings in the meaning of compassion offered by the
© 2015 MA Healthcare Ltd
C
ompassion is one of the most highly talked about areas in nursing. While compassion may be viewed as an integral and natural part of nursing care delivery, there is an increasing desire to try to measure it and, indeed, question if it can be taught (Burston and Stichler, 2010; Martins et al, 2013). However, there are many complex variables that affect the degree of compassion delivered by nurses, not least their own beliefs and value systems (Pence, 1983). This work describes the output of a safer and compassionate care event that suggests there may be a measurable differentiation between how compassionate nurses are. In 2008, the year of the investigation into the Mid Staffordshire scandal, the Health Secretary at the time, Alan Johnson, stated that he wanted nurses to be rated according to the levels of care and empathy that they provided (Sturgeon, 2008). Four years later, 2012 saw the publication of Compassion in Practice by Jane Cummings, Chief Nursing Officer, and Viv Bennett, Director of Nursing at the Department of Health and Lead Nurse at Public Health England. This document introduced the now widely-used visionary concept of the 6Cs: care, compassion, communication, competence, commitment and courage. While many may have seen this as a return to basics of what nursing care should be about, it was in timely preparation for the Francis Report (2013) and gave both the public and the profession the goal of pushing compassion back to the top of the nursing agenda. Indeed, compassion continues to be pushed higher on the list of indicators by which ‘nursing quality’ is calculated. Despite attempts to quantify compassion, it remains a challenge to measure. Healthcare organisations look at outcomes such as the number of harms to patients while in hospital so perhaps a presumption is made that compassionate care is being delivered if outcomes are good. Before the publication of Compassion in Practice, Dewar (2011) suggested there were several challenges to measuring compassion including that it is rarely articulated and means different things to different people. If this is true, this means staff may deliver varying levels of compassion despite initiatives such as the 6Cs. Staff attending a safer care event were encouraged to describe and write down why they chose to work in health care and how
British Journal of Nursing, 2015, Vol 24, No 6
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
COMMENT
© 2015 MA Healthcare Ltd
77 members of staff. For example, are the two respondents who mentioned colleagues as well as patients most compassionate? That is, they have a great ability to self-transpose with greater imagination as they can identify with both patients and colleagues instead of just with patients. Another question is whether the majority of respondents who mentioned people in general are significantly compassionate but less able to self-transpose with great imagination, as perhaps they can empathise with people in general but do not seem to be able to empathise with patients or individuals in particular. And finally, are the respondents who offered a simple definition least compassionate and least able to selftranspose? A further question raised from this is whether a measurement scale could be produced based on respondents’ descriptions of compassion as outlined above. Martins et al (2013) published a compassion scale assessing levels of compassion in caregivers in the community. Complex but statistically relevant results demonstrate that people with a lower income and lower educational levels will be more at risk of compassion fatigue and Martins et al highlight the need for education and support for these caregivers. Can Martins et al’s (2013) findings be applied to the hospital setting? Potter et al (2010) described how nurses, particularly cancer nurses, are more likely to suffer workrelated stress, burnout and compassion fatigue. It is clear that the variables affecting delivery of compassionate care are complex ranging from the effect of stress levels to educational background, right through to psychological understanding of self-transposition. Similarly, analysis of the themes around why staff chose to come into health care raises some further key questions, such as why is compassion not mentioned more? Why do staff not describe themselves as compassionate or that this is why they chose to work in health care? Perhaps it is simply because compassion is synonymous with caring or it may be that the concept still is not embedded. Interestingly the Royal College of Nursing’s (RCN’s) defining characteristics of nursing do describe what health professionals would relate to as compassion in great detail but never use the word ‘compassion’ within the descriptors (RCN, 2014) Burston and Stichler (2010) described how previous studies focused on caring alone and
that nurses report that caring is impaired by lack of support, and describe emotionally withdrawing from care for reasons of selfpreservation. Satisfaction derived from professional caregiving was subsequently identified as compassion satisfaction (Burston and Stichler, 2010), but no researchers have measured the relationship between compassion satisfaction and nursing. Limitations It should be noted that this work is only the result of questions asked of nurses at a care event in the author’s place of work, which have led to some interesting discussion and potential research questions. It must be remembered that the grade, experience and analytical ability of the staff who participated in the event varied greatly. In addition there was no recognised research question or structure. Recommendations Given the potential depth of new knowledge that could be gained from research in this area, the author suggests that the key question remains; can compassion be measured based on nursing attitude and performance? On a day-to-day basis it is imperative to consider that each nurse is different, as a result of their background, upbringing, culture and beliefs, and others cannot judge or guess at whether they are compassionate or not. The variables surrounding this topic are vast and complex and measurement is problematic.
Conclusion The subject of compassion is not going away, and with every day that passes and every new scandal facing the NHS it is being driven higher up the political agenda both nationally and within local organisations. Never has nursing been under such scrutiny and it is imperative that we not only deliver compassionate care but have
a means to measure this and ensure continued improvement. Alongside this, employers must care for their workforce and avoid compassion fatigue in their nurses as the pressure to deliver high-quality and increasingly skilled work increases without a view to ever ending. The 6Cs are not new, but we must embed them unequivocally in our organisational structures and demonstrate how we deliver care against BJN each and every one. Conflict of interest: none Acknowledgements: the author would like to thank Sarah Spencer Adams, Clinical Nurse Specialist, Palliative Care, King’s College Hospital for her assistance in carrying out this piece of work. Bowling, A (2014) Research Methods in Health: Investigating Health and Health Services. 4 edn. Open University Press, Maidenhead: 381–5 Burtson PL, Stichler JF (2010) Nursing work environment and nurse caring: relationship among motivational factors. J Adv Nurs 66(8): 1819–31. doi: 10.1111/j.13652648.2010.05336.x Cummings J, Bennett V (2012) Compassion in practice. Nursing, midwifery and care staff. Our vision and strategy. http://tinyurl. com/c5lc4n2 (accessed 13 March 2015) Day H (2014) Engaging staff to deliver compassionate care and reduce harm. Br J Nurs 23(18): 974–80. doi: 10.12968/ bjon.2014.23.18.974 Dewar B, Pullin S, Tocheris R (2011) Valuing compassion through definition and measurement. Nurs Manag (Harrow) 17(9): 32–7. doi: 10.7748/nm2011.02.17.9.32.c8301 Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/ omsm882 (accessed 13 March 2015) Lee M, Laurenson M, Whitfied S (2013) Can compassion be taught to lessen the effects of compassion fatigue. Journal of Care Service Management 6(3):121-30 Martins D, Nicholas NA, Shaheen M, Jones L, Norris K (2013) The development and evaluation of a compassion scale. J Health Care Poor Underserved 24(3): 1235–46. doi: 10.1353/hpu.2013.0148 Pence GE (1983) Can compassion be taught? J Med Ethics 9(4): 189–91 Potter P, Deshields T, Divanbeigi J (2010) Compassion fatigue and burnout; prevalence amongst oncology nurses. Clin J Oncol Nurs 14(5):e56-62 Royal College of Nursing (2014) Defining nursing. http:// tinyurl.com/lpuja2b (accessed 17 March 2015) Sturgeon D (2008) Measuring compassion in nursing. Nurs Stand 22(46): 42–3. doi: 10.7748/ns2008.07.22.46.42. c6599
Helen Day
Assistant Director of Nursing King’s College Hospital NHS Foundation Trust
Have an idea for BJN?
( 020 7738 5454 8 [email protected] British Journal of Nursing, 2015, Vol 24, No 6
@BJNursing 343
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
342
they would define compassion. They were given sticky notes and people-shaped cards to encourage participation. A simple descriptive coding technique was used to identify themes to enable further discussion (Bowling, 2014)
What does compassion mean to you? There were 77 responses to this question, including: ‘Compassion cannot be taught it is something you have.’ ‘Compassion is holding your patients hand or giving your colleague a hug when needed.’ ‘Compassion means making time to listen, to talk, to hold a hand and to imagine what the patient is feeling.’ Using thematic analysis, the following themes were identified. Compassion was described in relation to: ■■ Patients by 27% of respondents ■■ People in general by 35% of respondents ■■ Patients and colleagues by 3% of respondents A total of 34% offered a definition of compassion without mentioning patients or people. The words used most frequently in describing compassion were: understanding (21% of statements), care/caring (38% of statements), empathy (17% of statements), and listening (16% of statements). A total of 10 statements specifically included that ‘compassion is treating others as you would wish to be treated.’ Figure 1 illustrates the words used to describe compassion.
Why I came into health care There were 52 responses to this question, including: ‘I became a nurse to help people when they are at their lowest point. For me it’s about showing someone that you care, that you understand. Treating them as an individual with different needs.’ ‘Nursing to me is about providing care for people and treating them how I would want someone to treat my child. I love working with families and ensuring that they have the best possible experience.’
Using thematic analysis, the following themes were identified. ■■ 58% mentioned ‘caring’ as important ■■ 19% mentioned the influence of caring for family members that steered them into healthcare ■■ 13% described the desire to help people ■■ 13% described the desire to make a difference ■■ 11% described the desire to help people at their most vulnerable or at a low point ■■ 8% mentioned delivering care with compassion
Discussion Compassion should be viewed as a thread that runs right through the nursing process, therefore quality of nursing cannot be viewed by measuring compassion alone as competence and education also contribute significantly to quality of care. Nurses are members of a highly skilled profession where, at times, there are competing demands on them and no more so than in the current climate with increasing operational demand and financial constraints. Day (2014) describes how these pressures can ‘squash’ the compassion out of nurses and it can be easier to treat patients as a conveyor belt of tasks. Lee at al (2012) suggest that fundamental caring skills are being lost on the advancing skills agenda and describe how educators need to ensure that curricula include tools for self-reflection that address triggers for fatigue and burn out. However healthcare organisations need to look deeper than this if they are to really understand behaviour and compassionate care. Day (2014) describes that if staff genuinely see patients as individuals they will automatically deliver compassionate care, while Pence (1983) stated that imagination plays a key role in compassion, in achieving understanding of and feeling for suffering of people. This involves self-transposal into another person’s situation. It is more than just ‘putting oneself in another’s shoes’ because health professionals require appreciation and understanding of backgrounds values and needs. Perhaps it is this understanding that differs from nurse to nurse. It is a challenge for anyone to put aside his or her own beliefs and prejudices, therefore this raises the question of whether we judge and apportion compassion according to our own judgement and value system. Key questions can be asked of the findings in the meaning of compassion offered by the
© 2015 MA Healthcare Ltd
C
ompassion is one of the most highly talked about areas in nursing. While compassion may be viewed as an integral and natural part of nursing care delivery, there is an increasing desire to try to measure it and, indeed, question if it can be taught (Burston and Stichler, 2010; Martins et al, 2013). However, there are many complex variables that affect the degree of compassion delivered by nurses, not least their own beliefs and value systems (Pence, 1983). This work describes the output of a safer and compassionate care event that suggests there may be a measurable differentiation between how compassionate nurses are. In 2008, the year of the investigation into the Mid Staffordshire scandal, the Health Secretary at the time, Alan Johnson, stated that he wanted nurses to be rated according to the levels of care and empathy that they provided (Sturgeon, 2008). Four years later, 2012 saw the publication of Compassion in Practice by Jane Cummings, Chief Nursing Officer, and Viv Bennett, Director of Nursing at the Department of Health and Lead Nurse at Public Health England. This document introduced the now widely-used visionary concept of the 6Cs: care, compassion, communication, competence, commitment and courage. While many may have seen this as a return to basics of what nursing care should be about, it was in timely preparation for the Francis Report (2013) and gave both the public and the profession the goal of pushing compassion back to the top of the nursing agenda. Indeed, compassion continues to be pushed higher on the list of indicators by which ‘nursing quality’ is calculated. Despite attempts to quantify compassion, it remains a challenge to measure. Healthcare organisations look at outcomes such as the number of harms to patients while in hospital so perhaps a presumption is made that compassionate care is being delivered if outcomes are good. Before the publication of Compassion in Practice, Dewar (2011) suggested there were several challenges to measuring compassion including that it is rarely articulated and means different things to different people. If this is true, this means staff may deliver varying levels of compassion despite initiatives such as the 6Cs. Staff attending a safer care event were encouraged to describe and write down why they chose to work in health care and how
British Journal of Nursing, 2015, Vol 24, No 6
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
COMMENT
© 2015 MA Healthcare Ltd
77 members of staff. For example, are the two respondents who mentioned colleagues as well as patients most compassionate? That is, they have a great ability to self-transpose with greater imagination as they can identify with both patients and colleagues instead of just with patients. Another question is whether the majority of respondents who mentioned people in general are significantly compassionate but less able to self-transpose with great imagination, as perhaps they can empathise with people in general but do not seem to be able to empathise with patients or individuals in particular. And finally, are the respondents who offered a simple definition least compassionate and least able to selftranspose? A further question raised from this is whether a measurement scale could be produced based on respondents’ descriptions of compassion as outlined above. Martins et al (2013) published a compassion scale assessing levels of compassion in caregivers in the community. Complex but statistically relevant results demonstrate that people with a lower income and lower educational levels will be more at risk of compassion fatigue and Martins et al highlight the need for education and support for these caregivers. Can Martins et al’s (2013) findings be applied to the hospital setting? Potter et al (2010) described how nurses, particularly cancer nurses, are more likely to suffer workrelated stress, burnout and compassion fatigue. It is clear that the variables affecting delivery of compassionate care are complex ranging from the effect of stress levels to educational background, right through to psychological understanding of self-transposition. Similarly, analysis of the themes around why staff chose to come into health care raises some further key questions, such as why is compassion not mentioned more? Why do staff not describe themselves as compassionate or that this is why they chose to work in health care? Perhaps it is simply because compassion is synonymous with caring or it may be that the concept still is not embedded. Interestingly the Royal College of Nursing’s (RCN’s) defining characteristics of nursing do describe what health professionals would relate to as compassion in great detail but never use the word ‘compassion’ within the descriptors (RCN, 2014) Burston and Stichler (2010) described how previous studies focused on caring alone and
that nurses report that caring is impaired by lack of support, and describe emotionally withdrawing from care for reasons of selfpreservation. Satisfaction derived from professional caregiving was subsequently identified as compassion satisfaction (Burston and Stichler, 2010), but no researchers have measured the relationship between compassion satisfaction and nursing. Limitations It should be noted that this work is only the result of questions asked of nurses at a care event in the author’s place of work, which have led to some interesting discussion and potential research questions. It must be remembered that the grade, experience and analytical ability of the staff who participated in the event varied greatly. In addition there was no recognised research question or structure. Recommendations Given the potential depth of new knowledge that could be gained from research in this area, the author suggests that the key question remains; can compassion be measured based on nursing attitude and performance? On a day-to-day basis it is imperative to consider that each nurse is different, as a result of their background, upbringing, culture and beliefs, and others cannot judge or guess at whether they are compassionate or not. The variables surrounding this topic are vast and complex and measurement is problematic.
Conclusion The subject of compassion is not going away, and with every day that passes and every new scandal facing the NHS it is being driven higher up the political agenda both nationally and within local organisations. Never has nursing been under such scrutiny and it is imperative that we not only deliver compassionate care but have
a means to measure this and ensure continued improvement. Alongside this, employers must care for their workforce and avoid compassion fatigue in their nurses as the pressure to deliver high-quality and increasingly skilled work increases without a view to ever ending. The 6Cs are not new, but we must embed them unequivocally in our organisational structures and demonstrate how we deliver care against BJN each and every one. Conflict of interest: none Acknowledgements: the author would like to thank Sarah Spencer Adams, Clinical Nurse Specialist, Palliative Care, King’s College Hospital for her assistance in carrying out this piece of work. Bowling, A (2014) Research Methods in Health: Investigating Health and Health Services. 4 edn. Open University Press, Maidenhead: 381–5 Burtson PL, Stichler JF (2010) Nursing work environment and nurse caring: relationship among motivational factors. J Adv Nurs 66(8): 1819–31. doi: 10.1111/j.13652648.2010.05336.x Cummings J, Bennett V (2012) Compassion in practice. Nursing, midwifery and care staff. Our vision and strategy. http://tinyurl. com/c5lc4n2 (accessed 13 March 2015) Day H (2014) Engaging staff to deliver compassionate care and reduce harm. Br J Nurs 23(18): 974–80. doi: 10.12968/ bjon.2014.23.18.974 Dewar B, Pullin S, Tocheris R (2011) Valuing compassion through definition and measurement. Nurs Manag (Harrow) 17(9): 32–7. doi: 10.7748/nm2011.02.17.9.32.c8301 Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/ omsm882 (accessed 13 March 2015) Lee M, Laurenson M, Whitfied S (2013) Can compassion be taught to lessen the effects of compassion fatigue. Journal of Care Service Management 6(3):121-30 Martins D, Nicholas NA, Shaheen M, Jones L, Norris K (2013) The development and evaluation of a compassion scale. J Health Care Poor Underserved 24(3): 1235–46. doi: 10.1353/hpu.2013.0148 Pence GE (1983) Can compassion be taught? J Med Ethics 9(4): 189–91 Potter P, Deshields T, Divanbeigi J (2010) Compassion fatigue and burnout; prevalence amongst oncology nurses. Clin J Oncol Nurs 14(5):e56-62 Royal College of Nursing (2014) Defining nursing. http:// tinyurl.com/lpuja2b (accessed 17 March 2015) Sturgeon D (2008) Measuring compassion in nursing. Nurs Stand 22(46): 42–3. doi: 10.7748/ns2008.07.22.46.42. c6599
Helen Day
Assistant Director of Nursing King’s College Hospital NHS Foundation Trust
Have an idea for BJN?
( 020 7738 5454 8 [email protected] British Journal of Nursing, 2015, Vol 24, No 6
@BJNursing 343
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
