A review of the literature on compassion prepared for the Cultivating …… · ·...
Transcript of A review of the literature on compassion prepared for the Cultivating …… · ·...
1
A review of the literature on compassion prepared for the Cultivating Compassion Project
2014 -2015
University of Brighton and University of Brighton and Sussex Medical School and University of Surrey
2
Contents Section Page Introduction 1 Background 1-3 What is compassion and what defines compassionate ethical practice? 4-8 Compassion in the organisation and as a component of leadership 8-10 Compassion and emotional labour 10-14 The evidence base for compassion training 14-15 Conclusion 15-16 References 17-22
1
1. Introduction
Compassion is an essential component of care. The Mid Staffordshire NHS
Foundation Trust Public Inquiry Report, however, clearly indicated that compassion
values are not always enacted on. In many instances, this had catastrophic
consequences for patients and families. This literature review examines aspects of
compassion in the NHS. It begins by providing a brief overview of some of the key
drivers behind compassion initiatives. The review then moves on to consider what
compassion means, to discuss different perspectives on compassionate care, to
examine the relationship between leadership and compassion within NHS
organisations and to explore the ethical nature of compassion. Following this, the
practicalities of delivering compassionate care, which involve knowledge, skills,
ethics and emotion, are explored by analysing the role emotional labour plays in
bringing these components together. From this analysis, strategies to promote
compassionate care are discussed, culminating in a critical analysis of the ‘train the
trainer’ model advocated in this project. This is not a systematic literature review but
rather a critical appraisal of a selection of pertinent literature that contextualises the
project and demonstrates its underpinning knowledge bases.
2. Background
Health Education Kent, Surrey and Sussex (HEKSS) note in their call to bid (HEKSS Jan
2014) that “compassion is a critical element of all aspects of care and needs to be a
common thread through all learning and education activities”. They suggest that
compassionate care is required in care tasks in combination with knowledge and
skills and “expressive caring which involves the emotional aspects of the
relationship”. This background from HEKSS highlights the centrality of the values in
the NHS Constitution, and the significance of the Francis reports (2009, 2013) in
drawing attention to deficits in the NHS. Whereas a focus on healthcare ethics is not
new, the publication of the Francis reports (2009, 2013) resulted in compassion
2
entering the political agenda. As these disturbing reports of lack of compassion at
Mid Staffordshire emerged, it became clear that patient experience and compassion
needed to be prioritised alongside safety and effectiveness in care, as outlined in the
Darzi Report (DH 2008). The final report of the Next Stage Review states that
compassion was to become one of the values of the Health Service and this is now
clearly embedded in the NHS Constitution: “We ensure that compassion is central to
the care we provide and respond with humanity and kindness to each person’s pain,
distress, anxiety or need (DH 2013a: 5)”.
Government recognition of the role which nursing and midwifery plays in the
provision of compassionate care is demonstrated in a range of policy documents.
The Prime Minister’s Commission Report on the Future of Nursing and Midwifery
(DH 2010) reaffirms the call for high quality compassionate care as part of its vision
for nurses as practitioners, partners, leaders in future healthcare provision. The
Government’s agenda for compassion as a required component of education for the
healthcare professions is clearly stated in their mandate for Health Education
England (DH 2013b). More recently, the Chief Nursing Officer’s campaign for the “6
Cs” in nursing and midwifery practice (DH 2012), echoes the work of Roach (1987), in
a clarion call for care, compassion, competence, communication, courage and
commitment to underpin practice. A critical analysis of this policy emphasises the
importance of organisational initiatives and introduces the idea of the
‘compassionate organisation’ (Dewar & Christley 2013 p.48).
However, the market driven economy of the NHS with its associated target
requirements and heavy workloads, engenders a culture, which is perhaps not
conducive to compassionate care (Austin 2011, Flynn and Mercer 2013). This
creates stress for staff as identified in the Kings Fund Point of Care Programme (Firth
Cozens and Cornwell 2009). It is now recognised that organisations need to consider
the wellbeing of staff in their efforts to enhance high quality compassionate care for
patients (Maben et al 2009, West and Dawson 2012).
3
Compassion is not a new concept within the discipline of nursing, whose scholars
have placed the concept of caring at the heart of nursing values and beliefs. The
contribution of so many nurse theorists to the vast range of literature on caring in
nursing is evidence of its longstanding and continued importance to the profession
(Roach 1987, Benner and Wrubel 1989, Swanson 1991, Eriksson 1992, Watson 1999,
Boykin and Schoenhofer 2000, Brilowski and Wendler 2005).
More recently, a number of significant studies on compassion in the context of
caring relationships have been published in the nursing, care and ethics literature.
Torjuul et al (2007), for example, conducted a qualitative study of nurses and
physicians regarding compassion and responsibility in surgical care in Norway. Van
der Cingel (2011) investigated compassion in relationships between nurses and older
people in the Netherlands. Curtis (2012,2013) researched student nurses’
socialisation in relation to compassionate care in the UK. The most significant UK
study relating to compassion was conducted in Scotland (Adamson et al 2012). The
study ‘Leadership in Compassionate Care Programme’ had four strands: the
establishment of Beacon Wards to ‘showcase excellence in compassionate care’; the
facilitation of leadership skills in ‘key individuals’; influencing the undergraduate
curriculum by ‘embedding relationship-centred compassionate practice’ for nurses
and midwives; and providing support for newly qualified nurses. Insights from this
project and strategies employed inform the development of the ‘cultivating
compassion project’ training initiatives. Dewar’s (2011 p.263) relational perspective
on compassionate care is one that the Cultivating Compassion (CC) Team are
sympathetic towards. She writes:
Compassion…..” is defined by the people who give and receive it and
therefore interpersonal processes that capture what it means to
people, are an important element of its promotion”.
It can be seen from this brief overview that there is both a long held and newly
articulated deep-seated recognition of the importance of compassion to health care
and an urgency to ensure that compassionate care is embedded within the
4
organisational culture, its leadership structures as well as in the day to day care
activities between health care workers and patients.
3. What is Compassion and What Defines Compassionate Ethical Practice?
Defined simply, and taken from the Latin ‘com’: together with, and ‘pati’: to suffer,
compassion means ‘suffering with’. Compassion is understood to involve emotion,
such as empathy or sympathy, and a rational understanding of the suffering that
enables identification with it, i.e. the ability to deliberately and altruistically
participate in another’s suffering (von Dietze and Orb 2000). Compassion therefore
involves an emotion and thought that relates to the suffering of another that results
in an action that acknowledges that suffering and seeks where possible to alleviate
it. This suggests that recognition of suffering precedes the feeling/action of
compassion.
The Dalai Lama reminds us that ‘the importance of cultivating love and compassion’
is emphasised by all major religions. ‘The ethics of compassion’ from Buddhist
teaching argues that compassion has relevance to all aspect of life including ‘the
workplace’. Without compassion, work activities can become ‘destructive’ because
the impact of our actions on others may be ignored and people will be hurt , pointing
out that:
“The ethic of compassion helps provide the necessary foundation and
motivation for both restraint and the cultivation of virtue. When we
begin to develop a genuine appreciation of the value of compassion
our outlook on others begins automatically to change” (The Dalai
Lama 1999 p.128).
A connection can be made between these insights from Buddhism and Iris
Murdoch’s discussion of moral perception and ‘attention’ in the moral life. She
writes of the importance of a ‘just and loving eye’ (Murdoch 1971). The suggestion is
5
that, when we come across people we find it difficult to relate to, we look more
deeply, fairly, and lovingly to better understand their predicament and behaviour.
Bennett (1993) suggests that the parable of the Good Samaritan (Luke 10v25-38)
epitomises the Judeo Christian view of compassion in which
‘Our neighbour’ is the ‘one who needs the help that we can give him,
whoever he may be’ (ibid p.141).
O’Connell (2009:4) notes that for Christians, compassion is the central mark of
discipleship as “compassion can be an effective moral disposition with the capacity to
challenge privatised, individualised and paternalistic responses to suffering at the
hands of others”. The call to discipleship is not just to suffer with, but also to address
unjust suffering. As Austin et al (2013 p.13) suggest:
“The most important sense of compassion that is carried through
from biblical tradition to English is the sense that compassion leads to
action. It seems to be more than a simple feeling or sentiment”.
In applied ethics, compassion is generally discussed as a virtue or moral disposition
of the person. In one of the most popular texts Principles of Biomedical Ethics
(Beauchamp & Childress 2013 p.37) compassion is identified as the first of ‘five focal
virtues’. It is described as ‘a prelude to caring’ and as combining:
“an attitude of active regard for another’s welfare with an
imaginative awareness and emotional response of sympathy,
tenderness, and discomfort at another’s misfortune or suffering.
Compassion presupposes sympathy, has affinities with mercy, and is
expressed in actions of beneficence that attempt to alleviate the
misfortune or suffering of another person. Unlike the virtue of
integrity, which is focused on the self, compassion is directed at
others”. (ibid)
6
Virtues can be thought of in relation to vices, that is, that virtues and vices come in
triads with each virtue ‘flanked by two vices (vicious disposition) – one representing
excess and one deficiency’ (Banks & Gallagher 2009). In thinking of compassion,
then, as a virtue or ethical quality of the person and a disposition to help in response
to the suffering of others, it is helpful to consider the vices of excess and deficiency.
In terms of deficiency, Comte-Sponville (2002 p.103) writes of the ‘antonyms’ of
compassion as ‘ruthlessness, cruelty, coldness, indifference, hard-heartedness,
insensitivity’. In terms of excess, we might consider over-involvement, making
assumptions about the suffering of, and appropriate responses to, others. There is
risk in making unfounded assumptions about the suffering of others and of perhaps
responding to others in ways that are paternalistic or infantilising.
Nussbaum (2001), who distinguishes between compassion and mercy, proposes a
‘cognitive notion of compassion’ requiring three judgements: first, that the suffering
is ‘serious’; second, that it is ‘undeserved’ (that is, not person’s own fault); and third,
‘that the suffering can be imagined to be ones’ own and that it has some bearing on
one’s own flourishing’ (Hordern 2014 p.93). Nussbaum’s (1996) suggestion that
compassion involves judging whether the suffering is deserved is not without
criticism (Van der Cingel 2009; Carr 1999). Van der Cingel (2009) argues that in
health care compassion should involve withholding judgement. This position is
particular to healthcare because, as Curtis (2013) points out, the right to equal
treatment can be found in the majority of all healthcare professional codes of
conduct. Whilst non-judgemental compassion is the ideal, it is interesting to note
that sociological research around health inequalities suggest that in respect to
lifestyle diseases, healthcare workers do make moral judgements. This is well
articulated through Jeffery’s (1979) notion of the ‘Rubbish Patient’ and more recent
developments around the concept of the ‘sick role’. For example, Varul (2010: 89)
notes that the sick role has been influenced by an increase in “chronic illness and
disability” and “a rejection of behaviours and attitudes that are suspected of being
part of their aetiology”.
7
Von Dietze & Orb (2000: 169) argue that compassion transcends difference, and that
this characteristic is what distinguishes it from pity – which implies condescension
and/or paternalism. They argue that “compassion deliberately seeks to avoid
paternalistic care”, it is about solidarity – it is therefore “not so much what we
choose to do for other people but what we choose to do together with them. Thus,
compassion is based on rationale thought and emotion that requires understanding
and deliberation, it is therefore a moral action because if reaches beyond the self to
others.
It may be considered short-sighted to consider that recognition of, and appropriate
compassionate responses, should only be directed towards ‘suffering’. Scheler (cited
by Austin et al 2013 p.19), for example, writes of ‘fellow-feeling’ described as
involving ‘not just sharing in suffering but also in joy’. Many health care episodes
require that staff members join patients in celebration and rejoicing also. Consider,
for example, childbirth and a clear scan following cancer treatment.
The Dalai Lama writes of some of the other risks of compassion as follows:
“Constant exposure to suffering, coupled occasionally with a feeling of
being taken for granted, can induce feelings of helplessness and even
despair. Or it can happen that individuals may find themselves
performing outwardly generous actions, merely for the sake of it –
simply going through the motions [….] when left unchecked, this can
lead to insensitivity towards others’ suffering” (ibid p.129).
The phenomenon of ‘compassion fatigue’ is now frequently reported in the
international literature. Austin et al (2013 p.1) describe this, in relation to health
professionals, as their being ‘too weary to be with the suffering of others in the way
they once were’. The term was first used in relation to public fatigue towards global
problems such as famine and poverty. In relation to the care professions’
‘compassion fatigue’ was first used in the early 1990’s. The experience is related to
others such as burnout, moral distress and secondary/vicarious trauma. Based on
8
their research, Austin et al (2013 p.173) write of the importance of hope in such
situations:
“Without exception, the experience of compassion fatigue is painful.
The journey into and through compassion fatigue is unexpected,
unclear, uncertain, and unfamiliar. During such times, the need for
hope is most apparent”.
There are also critiques regarding the focus on compassion in healthcare. Gallagher
(2013), for example, cautions against ‘monoethics’ and argues that compassion may
be necessary for healthcare practice but it is not sufficient. Other virtues or values
such as justice, courage and trustworthiness etc. are also required to practice
ethically.
In a recent paper, the philosopher Paley (2014) challenges the idea that recent care
deficits were due to compassion failure in individuals. He draws on a substantial
literature in social psychology and argues that care deficits were due rather to ‘an
interlocking set of contextual factors that are known to affect social cognition. These
factors cannot be corrected or compensated for by teaching ethics, empathy, and
compassion to student nurses’. Mindful of this critique and of other research that
highlights the importance of attention to micro (individual), meso (organisational)
and macro (societal) factors (RCN 2009), the CC team’s engagement with
compassion goes beyond individual behaviour.
4. Compassion in the Organisation and as a Component of Leadership
The organisational context in which compassionate care is practiced is fundamental
to cultivating compassion (Paley 2014; Goodman 2014; Rynes et al 2012).
Greenhalgh (2013: 481) points out that despite the Francis Report identifying a lack
of compassion as the root source of the neglect encountered at Mid-Staffordshire
Hospital Trust, ‘almost all [Lord Francis] recommendations relate to documents or
procedures’. She argues that what is needed is a compassionate organisation
because it ‘supports and shapes behaviour by its members, partly through
appropriate incentives, rewards and procedures but mainly by recognising that
9
emotions – feeling, caring, loving, yearning – are an integral component of our
rationality, not something that distorts or detracts from it (ibid)’. Goodman (2014:
1268), in her exploration of nursing care experiences amongst older people argues
that:
“Poor quality care occurs often enough across care organisations
(structures) to warrant analysis beyond simply vilifying and blaming
failing individuals (agents). If only one nurse was abusive and
neglectful we would properly look to the character of that nurse.
However, when many instances of poor quality care arise we should
undertake a political and social analysis for a fuller understanding”.
Rynes et al (2012) ask the question what then does the compassionate organisation
look like? In their review on care and compassion in the organisation they suggest
‘that care and compassion should be the responsibility of everyone in the
organisation’. To achieve this requires a radical shift, for rather than the usual
organisational objectives of profit and efficiency, the organisation should focus on
the ‘health, happiness, well-being and sustainability of the organisation, their
members and those they serve’. When compassionate care is embedded within the
organisation, it recognises the importance of the receipt of compassion and what the
workforce requires in order to sustain and extend compassion to patients and their
family and friends.
Youngson (2011) contends that compassion must be defined as a management and
leader
“The leaders of the very best healthcare organisations provide role
models for the values and principles underlying people centred care:
they are deeply respectful, humane and compassionate towards their
employees, they celebrate diversity, they act fearlessly against
bullying abuse and discrimination, they listen deeply, they role model
openness, integrity, and they are not afraid to say sorry (2011:9)”.
10
A significant contribution to our knowledge of the impact of interventions on
compassionate practice come from data collected as part of the Leadership in
Compassionate Care Programme (Adamson et al 2012), a 3 year appreciative action
research project run by NHS Lothian and Edinburgh Napier University which
emphasises the centrality of developing leaders who can embed compassion within
effective, relationship centred care. Three interventions developed during the
project inform our intervention: use of emotional touchpoints; ‘Knowing who I am
and what matters to me’; and ‘Caring about caring’.
The King’s Fund report ‘Seeing the person in the patient’ (Goodrich and Cornwell
2008) suggests that improvement in patients’ experience of care requires the
cooperation and effort of all staff with direct contact with patients with
encouragement and support from the wider organisation. This operates at 4 levels,
the individual, the team, the institution and the wider health system and is a
function of both organisational and human factors, which interact in complex ways.
Leadership for improvement at team and institutional levels becomes critically
important in the support of compassionate care in the light of evidence which
suggests that staff wellbeing is an antecedent to patient care performance (Maben
et al 2012, West and Dawson 2012).
It can be seen so far that compassionate care is linked to the nature of suffering,
underpinned by wider ethical issues, and requires a compassionate organisation with
leadership role modelling compassionate behaviour. A major theme running through
all the section so far is that compassion is also linked to staff wellbeing and
compassion fatigue. In the following section this will be explored in more detail.
5. Compassion and Emotional Labour
Curtis (2013:212) points out that the giving of compassionate care involves an
emotional endeavour that can take work to achieve. Essentially the carer must be
11
“able to understand another’s suffering, empathise with their situation, think that
suffering is terrible and therefore want to relieve the suffering by doing what is best
for that person”. Yet, in relating to and empathising with the patient, the carer must
also be professional - thus an emotional balance between utilising feelings of
empathy with professionalism in the face of suffering is required – this involves
emotional labour. Emotional labour is a term coined by Hochschild (1983) where the
induction or suppression of emotion is required of the carer in order to ensure that
the person being cared for feels comforted and safe.
There are some inherent difficulties and complexities involved in the emotional
labour in compassionate care. First, in drawing on the self it requires the individual
to relate to the suffering of others. In doing so they need to enter into that suffering.
As Nouwen et al (1982: 4 cited in Von Dietze & Orb 2000: 169) powerfully write:
“Compassion asks us to go where it hurts, to enter into places of pain,
to share brokenness, fear, confusion and anguish. Compassion
challenges us to cry out with those is misery, to mourn with those who
are lonely, to weep with those in tears. Compassion requires us to be
weak with the weak, vulnerable with the vulnerable, and powerless
with the powerless. Compassion means full immersion into the
condition of being human”.
This ‘entering into’ needs to be balanced with making the patient feel safe and
comforting them. Where possible this will also involve the alleviation of that
suffering through action, such as treatment, as well as empathy. Here the emotional
labour involves using compassion as a motivator in inducing the expression of
reassurance, of being in control, rather than weeping with tears or sympathising in
fear; it may also involve suppressing confusion and anguish in order to have a still
hand, or to objectively argue for the individuals care needs in order to get the
required support mechanisms in place. Emotional labour is a balancing act that
requires a high degree of self-awareness, emotional dexterity and clinical knowledge
and skill. As Hochschild (1983) notes, this takes work and is hard to achieve.
12
Smith (2012) in her book Emotional Labour in Nursing argues that the skill of
emotional labour needs to be taught and refined, that an assumption that it is
inherent is detrimental to its development. This is particularly the case when the
individual carer does not naturally feel compassion for their patient. Hochschild
(1983; 2003) describes two processes through which the emotional labourer can
both induce and suppress their emotions. The first is surface acting, this is where the
labourer expresses an emotion they do not really feel, but know that they are only
acting it out. The second is deep acting, which is where the labourer uses their
imagination or memories to work on their feelings so that they come to feel the
required emotion.
Compassion fatigue and burnout is particularly linked to high levels of surface acting
(Erikson 2009; Mann 2004). Conversely, when deeper relationships are forged, the
emotional labour results in a deep attachment, making it harder for the carer to hide
their emotions when they deeply relate or to detach when the relationship comes to
an end (Kelly et al 2000).
Over exposure to suffering presents a particular dilemma to healthcare workers.
Curtis (2013:217) notes in her research with student nurses that they considered it
important to ‘harden up’ or develop a ‘thick skin’. For the difficulty in relating to one
patient, is that one has to move on to the next and be just as available and
connected to them. “Students could see the need to preserve their emotional well-
being alongside the need to be compassionate”. Curtis (2013) suggests that one way
in which this can be enhanced is through promoting discussions on moral courage
and self-compassion. But as Gilbert (2009:xxi) notes this is not always easy. This is
largely due to concerns that self-compassion is linked to ‘letting ones guard down’ “If
they started, to feel self kindness or compassion it could ignite feelings of grief
There is, however, a growing body of research (Weng et al 2014; Morgrain et al
2011; Leiberg et al 2011) that suggests that the practice of compassion increases
happiness and that training individuals in altruistic behaviour enables emotion
regulation and results in emotional rewards such as increased satisfaction. Indeed
Gilbert (2009) points out that evidence suggests that feeling love and compassion for
13
ourselves is deeply healing and soothing. In their research, Hefferman et al (2010)
found a positive correlation between high levels of self-compassion in nurses, and
their ability to relate to the suffering of their patients. Self-compassion is therefore
important to supporting and sustaining compassionate care (Gilbert 2009; 2010).
Birnie et al (2010), drawing on the work of Neff (2003:224) suggest that:
“Self-compassion entails three fundamental components: (1)
extending kindness and understanding to oneself rather than harsh
self-criticism and judgment, (2) seeing one’s experiences as part of the
larger humanity rather than as separating and isolating; and (3)
holding one’s painful thoughts and feelings in balanced awareness
rather than over-identifying with them.
To support self-compassion, many authors are increasingly advocating Mindfulness
as a means of reducing stress and encouraging self-empathy (Gilbert 2009; Birnie et
al 2010; Hefferman et al 2010). Kabat-Zinn defines mindfulness as “paying attention
in a particular way: on purpose, in the present moment, and non judgmentally’
(cited in Black 2011:1). The CC team has taken in to consideration mindfulness
activities as a means of supporting self-compassion in the workforce.
The skill base underpinning emotional labour therefore is fundamental to supporting
and sustaining compassionate care in practice. It is required in simple acts of
kindness through to complex acts in which the practitioner relates yet also holds
back in order to both empathise and alleviate the suffering; in addition, emotional
labour is crucial where carers do not naturally feel compassion and use their
imaginations or own memories to induce such feelings in order to provide the
proper compassionate care required of them. Theodosius (2008) notes that
emotional labour is based on reciprocal interaction – that is in entering into the
suffering of the patient, the carer receives back from the patient gratitude and from
a job well done, a sense of satisfaction. These emotions are important in sustaining
emotional labour in the long term giving of compassionate care to the many, and go
a long way in protecting against compassion fatigue.
14
It is important to note here that resource issues also significantly impact on the
quality of care. Research on emotional labour suggests that low resources negatively
impact on the quality of emotional labour given (Bone 2002). The higher the
staff:patient ratio the more likely nurses will use surface acting, which is directly
linked to compassion fatigue and burnout (Ball & Catton 2011; Erickson 2009;
Rafferty et al 2007). They were also more likely to report low/deteriorating quality of
care on the ward.
It is important that the CC team recognize the pressures staff are under, and the
impact this may have on the delivery of compassionate care.
6. The Evidence Base for Compassion Training
Weng et al’s (2014) research ascertained that compassion training does increase
altruistic behaviour. Their participants were divided into two groups: those who
received compassion training and those who received re-appraisal training. The
results showed a significant increase in altruistic behaviour in the compassion
training group demonstrating that compassion training that involved cultivating
feelings of compassion for different groups of people, does work.
The idea of cultivating compassion across the whole workforce poses educational
questions concerning the best means of achieving this. There is a little evidence to
suggest that delivering training in standard one off lectures by outsourced
educationists has the desired effect. Indeed, Levine et al (2007) found that
traditional lecture style training was not effective so introduced the ‘train the
trainer’ model. The aim of their training was to change physician behaviour in the
management of common geriatric conditions. Experts from the University Faculty
trained 60 non-expert peer-educators based in the geriatric practice setting. These
peer-educators then trained up their fellow geriatricians in the practice setting using
a purposefully designed toolkit by the Faculty educators. Follow up research on the
impact of this method showed statistically significant increases in self-reported
knowledge and attitudes six months after the peer sessions. Levine et al’s
15
(2007:1281) found that the tool kits were important factors in enabling their peer-
educators to facilitate learning.
“Findings suggest that modest positive changes in practice in relation
to common geriatric problems can be achieved through peer-led,
community- based sessions using principles of knowledge translation
and evidence-based tool kits with materials for providers and
patients”.
The ‘train the trainer’ model has been most successfully used in public health
initiatives where large numbers of people spread across a range of community
settings need to be reached. Eresk et al (2006: 42) found in their study examining the
effectiveness of the model in the community hospice setting in America that
“confidence in teaching end-of-life content increased significantly for participants
who used the course materials to prepare and present in service”.
The evidence supporting the train trainer model is not conclusive (Trabeu et al 2008)
but would appear to be the most appropriate model when aiming to raise awareness
across the wider workforce in a variety of clinical settings. The development of the
toolkit is essential to this process. The CC Teams notion of the ‘toolkit’ on the move’
has been designed to enable training by peer-educators to take place in the clinical
setting as well as in bespoke workshops. There is no robust evidence regarding the
impact of compassion awareness training over time. Our proposal provides an
opportunity to generate such evidence.
7. Conclusion
The nature of compassion and the delivery of compassionate care is complex. From
this review it can be seen that compassion can be understood as a virtue, that it is
rooted in moral and ethical thinking; compassion requires the carer to relate to the
suffering which may involve making difficult judgements that are framed within
current socio-political discourse. In order to empathise with those they care for in a
16
constructive way so as to alleviate suffering as well as to suffer with them,
compassion requires emotional labour. Compassion needs to be embedded within
the organisation as a whole and be visible in leadership behaviours. In order to raise
awareness of compassion within the workforce these complexities need to be taken
into account.
The project aims to:
Develop a sustainable programme of compassion awareness training that
enhances patient safety and experience and promotes ethical healthcare
practice;
Engage effectively with healthcare staff building on existing values-based
initiatives and encouraging creative compassion promotion projects; and
Facilitate the development of organisations and teams that respect, reflect
and promote the values of the NHS Constitution.
17
8. References Adamson, Elizabeth, Dewar, Belinda, Donaldson, Jayne H, Gentleman, Mandy, Gray, Morag, Horsburgh, Dorothy, King, Linda, Kalorkoti, Jenny, MacArthur, Juliet, Maclean, Mairi, McCrossan, Gill, McIntosh, Iain, Ross, Janis, Pullin, Simon, Sloan, Sue, Smith, Fiona C, Smith, Stephen, Tocher, Ria and Waugh, A. (2012) Leadership in compassionate care programme: final report. Project Report. Edinburgh Napier University/ NHS Lothian, Edinburgh.
Adamson, E., Moody, J., & Waugh, A. (2012) “Developing a nursing education project in partnership: leadership in compassionate care”; Nursing Times, Vol. 105(35): 23-26 Austin, W. (2011) “The incommensurability of nursing as a practice and the customer service model: an evolutionary threat to the discipline”; Nursing Philosophy 12 158-166 Austin W., Brintnell E.S., Goble E., Kagan L., Kreitzer L., Larsen D.J. & Leier B. (2013) Lying Down in the Ever-Falling Snow: Canadian Health Professionals’ Experience of Compassion Fatigue Wilfred Laurier University Press, Waterloo Ball, J., & Catton, H. (2011) “Planning nurse staffing: are we willing and able?” Journal of Research in Nursing, Vol. 16(6): 551-558 Banks S. & Gallagher A. (2009) Ethics in professional life: virtues for health and social care Palgrave MacMillan, Basingstoke Beauchamp T.L. & Childress J.F. (2013) Principles of Biomedical Ethics 7th Edition Oxford University Press, New York Benner, P. & Wrubel, J. (1989) The primacy of caring: Stress and coping in health and illness, Addison-Wesley Pub. Co. Menlo Park, Calif. Bennett W.J. (1993) The Book of Virtues: A Treasury of Great Moral Stories Simon and Schuster, New York Birnie, K., Speca, M., & Carlson, L. (2010) “Exploring Self-Compassion and Empathy in the Context of Mindfulness-based Stress Reduction (MBSR)”; Stress and Health, Vol. 26: 359-371 Black, D.S. (2011) A brief definition of mindfulness; Mindfulness Research Guide, Accessed from: http://www.mindfulexperience.org
Bone, D. (2002) Dilemmas of emotion work in nursing under market driven health care. International Journal of Public Sector Management, 15( 2): 140 - 150 Boykin, A. & Schoenhofer, S. (2000) Nursing as Caring: A Model for Transforming
18
Practice, Jones and Bartlett Sudbury MA Brilowski, G. & Wendler, M. (2005) “An evolutionary concept analysis of caring”; Journal of Advanced Nursing 50 (6) 641-650 Comte-Sponville A. (2002) A Short Treatise on the Great Virtues William Heinemann, London Cornwell, J. & Goodrich J. (2008) Seeing the Person in the Patient: The Point of Care review paper, King’s Fund London Curtis, K. (2012) Student nurse socialisation in compassionate practice: a grounded theory study. Nurse Education Today. 32: 790-795 Curtis K. (2013) Learning the requirements for compassionate practice: Student vulnerability and courage Nursing Ethics 21(2): 210-223 The Dalai Lama (1999) Ethics for the New Millennium Penguin Putman Inc, New York Dewar B. (2011) Caring about caring: an appreciative inquiry about compassionate relationship centred care PhD thesis - http://researchrepository.napier.ac.uk/4845/ Dewar B. & Christley Y. (2013) A critical analysis of compassion in care Nursing Standard 28 (10) 46-50 (See http://rcnpublishing.com/doi/abs/10.7748/ns2013.11.28.10.46.e7828) Department of Health (2008) High Quality Care for All NHS Next Stage Review, The Stationery Office Norwich DH (2010) Prime Minister’s Commission on the future of Nursing and Midwifery in England. London: DH. Department of Health (2012) Compassion in Practice: Nursing, Midwifery and Care Staff – Our Vision and Strategy DH http://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf Department of Health (2013a) The NHS Constitution, DH London Department of Health (2013b) Delivering high quality, effective, compassionate care: Developing the right people with the right skills and the right values, DH London Eresk, M., Kraybill, B., & Hansen, N. (2006) “Evaluation of a Train-the-Trainer program to enhance hospice and palliative care in nursing homes”, Journal of Hospice and Palliative Nursing, Vol. 8 (1): 42-49
19
Erickson, R (2009) “The emotional demands of nursing” in G. Dickenson & L. Flynn, (eds) Nursing Policy Research: Turning evidenced based research into Health Policy, New York: Springer, p 155-178 Eriksson, K. (1992) The alleviation of suffering- the idea of caring Scandinavian Journal of Caring Sciences 6 (2): 119-123 Firth Cozens, J. & J. Cornwell (2009) The Point of Care: enabling compassionate care in acute hospitals; The King’s Fund London Flynn, M. & Mercer, D. (2013) “Is compassion possible in a market led NHS?” Nursing Times 109 (7) 12-14 Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry The Stationery Office Gallagher A. (2013) Values for contemporary nursing practice: Waving or drowning? Nursing Ethics 20 http://nej.sagepub.com/content/20/6/615.long Gilbert P. (2009) The Compassionate Mind, Constable & Robinson Ltd, London Gilbert P. & Choden (2013) Mindful Compassion Constable & Robinson Ltd, London Goodman, B. (2014) “Risk, rationality and learning for compassionate care; The link between management practices and the ‘lifeworld’ of nursing”; Nurse Education Today, Vol. 34: 1265–1268 Goodrich, J. and Cornwell, J. (2008) Seeing the person in the patient: the point of care review paper. King’s Fund. London. Greenlagh, T (2013) ‘The Compassionate Organisation’; British Journal of General Practice Sept 2013: 481 Hefferman, M., Quinn, M., NcNulty, R., & Fitzpatrick, J.(2010) Compassion and Emotional Intelligence in nurses;” International Journal of Nursing Practice, Vol. 16: 366-373 Hochschild, A. (2003) The Managed Heart, 2nd Ed. Berkeley, CA, University of California Press Hordern J. (2014) What’s wrong with ‘compassion’? Towards a political, philosophical and theological context Clinical Ethics 8 (4): 91-97 Jeffery’s, Roger (1979) ‘Normal Rubbish: Deviant Patients in Casualty Departments’; Sociology of Health and Illness Vol. 1 No. 1: 90-107
20
Kelly, D., Ross, S., Gray, B., & Smith, P. (2000) “Death, dying and emotional labour: problematic dimensions of the bone marrow transplant nursing role?” Journal of Advanced Nursing, Vol. 32(4): 952-960 Leiberg, S., Klimecki, O., & Singer, T. (2011) “Short-term compassion training increases prosocial behavior in a newly developed prosocial game”; PLos One, Vol.6(3): e17798 accessed from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052380? Levine, S., Brett, B., Robinson, B., Stratos, G., Lascher, S., Granville, L., Goodwin, C., Dunnm K., & Barry, P. (2007) “Practicing Physician Education in Geriatrics: Lessons Learned from a Train-the-Trainer Model”; Journal of American Geriatric Society, Vol 55: 1281-1286 Maben, J., Peccdei, R., Adams, M., Robert, G., Richardson, A., Murrells, T., & Morrow, E. (2012) Exploring the relationship between patients’ experiences of care and the influence of staff motivation, affect and wellbeing. National Institute for Health Research HMSO Mann, S. (2004) “’People work’: emotion management, stress and coping”; British Journal of Guidance and Counselling, Vol. 32 (2): 205-221 Murdoch I. (1971) The Sovereignty of Good Routledge and Kegan Paul, London Neff, K. D. (2003). Development and validation of a scale to measure self-compassion. Self and Identity. 2: 223
Nouwen, H., McNeill, D., & Morrison, D. (1982) Compassion: a reflection on the Christian life, London, Darton Nussbaum, Martha (1996) ‘Compassion: the basic social emotion’ Social Philosophy and Policy, Vol 13 (1): 27-58 Nussbaum, Martha (2001) Upheavals of Though: the intelligence of emotions. Cambridge, CUP O’Connell, Maureen (2009) Compassion: Loving our Neighbour in an Age of Globalization, Maryknoll, New York; Orbis Books Paley J. (2014) Cognition and the compassion deficit: the social psychology of helping behaviour in nursing Nursing Philosophy doi.10.111/nup.12047 Rafferty AM., Clarke, S., Coles, J., Ball, J., James, P., & McKee, M. (2007) “Outcomes of variation in hospital nurse staffing in English hospitals: Cross-sectional analysis of survey data and discharge records”; International Journal of Nursing Studies, Vol. 44: 175–182.
21
Roach S. (1984) Caring: The Human Mode of Being University of Toronto Roach, S. (1987) The Human Act of Caring: A blueprint for the healthcare professions, The Canadian Hospitals Association Royal College of Nursing (2009) Defending Dignity: Challenges and Opportunities for Nursing (See http://www.rcn.org.uk/__data/assets/pdf_file/0011/166655/003257.pdf Authors: Baillie L., Gallagher A. & Wainwright P.) Rynes, S., Bartunek, J., Dutton. J., & Margolis, J. (2012) Care and Compassion through an orgnaisational lens: opening up new possibilities’; Academy of Management Review, Vol. 37 (4): 503-523 Smith, P (2012) Emotional Labour in Nursing, 2nd Ed. McMillan, London Swanson, K. (1991) “Empirical Development Of a Middle Range Theory of Caring”; Nursing Research 40 (3): 161-165 Theodosius, C. (2008) Emotional Labour in Healthcare, Routledge, Abingdon Torjuul (2007) Compassion and responsibility in compassionate care Nursing Ethics 14 (4) 522-534 accessed from: http://nej.sagepub.com/content/14/4/522.refs Trabeu, M., Neitzel, R., Meischke, H., Daniell, W., & Seixas, N (2008) “A comparison of ‘Train-the-Trainer’ and expert training modalities for hearing protection use in construction”; American Journal of Industrial Medicine, Vol. 51: 130-137 Van der Cingel, Margaret (2009) “Compassion and professional care: exploring the domain”; Nursing Philosophy, Vol. 10: 124-136 Varul, Matthias, (2010) “Talcott Parsons, the sick role and chronic illness” Body & Society, Vol. 16(2): 72–94 Von Dietze, Erich and Orb, Angelica (2000) Compassionate care: a moral dimension of nursing”; Nursing Inquiry, Vol. 7: 166-174 Watson, J. (1999) Nursing: Human Science and Human Care: A Theory of Nursing, Jones and Bartlett Sudbury MA Weng, H., Fox, A., Shackman, A., Stolda, D., Caldwell, J., Olson, M., Rogers, G., & Davidson, R. (2014) “Compassion training alters altruism and neural responses to suffering”; Psychological Sciences, Vol. 24 (7): 1171-1180 West, M. & Dawson, J. (2012) Employee engagement and NHS performance; The King’s Fund London