WHAT DOES ‘CARE’ MEAN IN HEALTH CARE

AND WHAT CAN WE DO TO IMPROVE IT?

Dr. Justin BrophyFRCPsych

Before we begin:

Dimensions of Care

Attentiveness

Right Intention

- Compassion

Interconnection

LET’S LOOK AT THE PROBLEMS AROUND

COMPASSION

Some Basics

Empathy is the emotional response to others

Compassion involves an authentic desire to help.

a capacity to meet pain with "kindness, empathy, equanimity and patience",

both in ourselves and in others.

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“There is no compassion left in the NHS”

 the Francis report

at Stafford Hospital identified a lack of compassion

as being amongst the major causes of negligence.

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“Recent scandals”

At Winterbourne View,

vulnerable people were mocked

and even tortured by staff

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Public & Media - “Too posh to wash.”

“university trained nurses lack compassion

 The prime minister seems to agree,

“nurses should serve their time as care assistants

before they even start their training”.

saying that "nurses should be hired and promoted on the basis of having compassion as a vocation and not just academic qualification".

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According to a new national survey,

Compassion is Missing in American Health

Care

Schwartz Center for Compassionate HealthcareBy RICK NAUERT PHD Senior News Editor

September 9, 2011

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Competing tensions

Caring CarefulIndividualisedPerson focusedExperience focusSpontaneous /

Flexible

Satisfaction focus

StandardizedTask FocusOutcome focusStandardisedRisk - Safety focus

As the Francis report notes:

“services can be time-pressured, accounts-driven, and job-threatening,

whereas compassion grows in compassionate, supportive environment”

The Guardian, Monday 1 April 2013 15

THE CONTRARY VIEW…………

Ebola volunteers

Ryanair example

There are effective, ways of ensuring that

crucial tasks are undertaken,

without relying on compassion

“It’s dangerous to rely on compassion as the motivation” to ensure that essential tasks are carried out......says the medical ethicist Anna Smajdor, “

http://www.bbc.com/news/magazine-22773043

“Lack of compassion has also become the new stick to beat the much-beaten NHS with.”

"The effort to become more empathetic

will only increase resentment and your sense of burnout“

‘Compassionate care' has become a new healthcare buzz-phrase, Threat and fear basically inhibit compassion and negatively impact on these systems. While it is very seductive to believe that you can threaten people into becoming compassionate, all the evidence is you cannot

and that you will make things worse.The Guardian, Monday 1 April 2013 20.59 BST

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Peter Carter, head of the Royal College of Nursing

Nurses have been scapegoats in scandals

when the main problem is understaffing,

the recommendations that tend to get implemented

are the ones . . . that don’t have resource implications

http://www.bmj.com/content/348/bmj.g126

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And we know

Selflessness and continually giving will provide a fast-track

to

burn-out, personal health problems,

emotional anguish, and mental weariness.

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The most compassionate are often the most

impaired

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The ‘Kindness Paradox’

We frequently work under conditions no other workforce

would tolerate

Why?

Compassion binds us

- but also blinds us23

WHY IS CARE LIKE THIS?

Those lacking compassion

Some Frankly Uncaring

DetachedIndifferentIntentionally so

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Physicians, trained as biomedical scientists,

have focused on the diagnosis, treatment, and prevention of disease.3 In

the process,

cure, not care,

became the primary purpose of medicine 4,5 

Ann Fam Med. May 2005; 3(3): 255–262

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Care has become Sub-contracted

Most valued

- Professional

Least valued

- Carer

BMJ 2014

Inhibitors of compassion

Personal

Fatigue

StressOver-exposure Excess Demand

DepressionInjustice

InjuryTyranny/Bullying/Abuse

Systemic Inhibitors of Compassion

Fear OppressionBlameShameSystem mistrust

“Threat and fear basically inhibit compassion and negatively impact on these systems.

While it is very seductive to believe that you can threaten people into becoming compassionate,

all the evidence is you cannot and that you will make things worse”

Larger Stage of Shame

Public hearingsPublic ReportsMedia coverageInternet diffusionPersonal ImagesLegal & Regulatory Unforgotten

Effects all grades of offenders

100 GMC suicides

Contextual inhibitors of compassion

Contextual

Pay cuts & pay differentialsAgency staff

Turnover on unitsHostile Discourse

No Right of rebuttal / challengeIngratitude

Lack of time is another major impediment to compassion

An elegant experiment from 1973  observed the behaviour of 40 theology students in a situation inspired

by the Good Samaritan parable. Students walking between two buildings, on their way to give a talk,

encountered a shabbily dressed person slumped by the side of the road. Students in a hurry to reach their destination were more likely to pass by

without stopping.

The time pressure students were under was the only factor that significantly influenced whether they helped.

Individual character traits, religious identification, and the topic of the talk they were about to give had no effect, even when the topic of the talk was the story of the Good Samaritan. 

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NHS Staff Survey Conclusion

When staff feel too much work pressure,

Experience aggression or discrimination

– either physical violence or bullying, harassment or abuse – from patients, members of the public or colleagues,

outcomes are generally worse. www.gov.uk/government/uploads/system/uploads/

attachment_data/file/215455/dh_129656.pdf

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REASONS FOR DECLINE : INDIVIDUALS

Reasons for decline

Meta-analyses show

that clinicians' distress is a key determinant of

empathy decline those who are more sensitive, those who have difficulties regulating their negative

emotions. Or those with overly suppressed pain responses and

insufficient emotional arousalNeumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students and

residents. Acad Med 2011;86:996-1009.

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Reasons for decline

This exaggerated distress reaction

may lead to emotional exhaustion, detachment

and a low sense of accomplishment

Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. 

Acad Med 2011;86:996-1009.

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Fear of being Compassionate

Fear of compassion,

both towards others and towards ourselves, is one of the factors identified as getting in the way of being able to be compassionate.

Fear of being overwhelmed, of becoming too upset and not able to recover… or being helpless to change anything of being too soft, too gullible Of managing hard decisions Of losing professional objectivity 40

Tricky Challenges

managing angry or dissatisfied patients,

de-escalate volatile encounters, deliver bad news,

Enlisting patients into their own treatment,

and engage de-motivated others

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RECOGNISING THE SIGNS

Burnout-only the best!

various studies have shown that

40% to 60% of US physicians are experiencing symptoms of burnout

extra effort often increases risk for burnout, secondary trauma, and poor well-being

Patient Experience: Are We Overlooking a Crucial Element? Medscape. Oct 31, 2014.

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Accessing mechanisms of support?

Sick note?Avenues of recovery?3 Months ‘sick’ leave

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Being or becoming un-compassionate

Frankly UncaringBecoming uncaring Detachment

Indifference Intentionally so

Burned out Wounded Inexperienced Depressed

Compassion becomes un-learnedHouse of God

Penguins jumping off ice

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WHY SHOULD WE BOTHER?

CAREFULNESS AND COMPASSION ARE CONNECTED AND SYNERGISTIC

“Strong evidence that

compassionate care

improves health outcomes and quality of life,

increases patient satisfaction, and lowers health care costs.”

Its not about the feeling......... its about the outcome!

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Empathic communication is associated with

increased adherence to treatment, and fewer malpractice complaints [1].

greater agency in addressing problems such as cancer[11].

Patients' perceptions of empathy are positively related to more favourable health outcomes  [2-4].

Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med 2011;86:996-

1009.

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“one relatively consistent finding

physicians who adopt a warm, friendly, and reassuring

manner

are more effective

than those who keep consultations formal and do not offer reassurance.

The Lancet, Volume 357, Issue 9258, Pages 757 - 762, 10 March 2001

Positive engagement

has significant associations with better patient mortality, infection rates, annual Health Check scores, staff absenteeism and turnover outcomes for that trust

NHS Staff survey ://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215455/

dh_129656.pdf 53

Detached concern is no longer tenable

 teaching and practice of “detached concern”,

a process where physicians establish a certain emotional distance from their patients in order to maintain objectivity is not supported by the literature

negative emotions do not necessarily lead to emotional turmoil 

[11].

Affective engagement improves cognitive accuracy

as well as affective understanding [12].  [14].

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The Psycho-Biological basis for the positive effects of CompassionOxytocin

Endogenous opioids

Psychoneuroimmunolology

Epigenetic effects

+ve Pressor and cardiac effects

Mood effects

Anxiolysis – reduced fear

Recruitment of Coping strategies

Health promoting behaviour

Cognitive and meta-cognitive changes

“Compassion, both given and received, is rooted in affiliative emotion systems. It has major impacts on a range of physiological and psychological processes, including immune, cardiovascular stress and recovery processes that significantly affect outcomes”. Indeed, perceived controllability over a stressor is associated with prefrontal cortex mediated regulation of limbic (amygdala and hypothalamus) and brainstem (dorsal raphe nucleus) structures associated with neuroendocrine and autonomic nervous system reactivity[45].

This provides a direct pathway through which the perception of one's ability to control aspects of his/her disease is capable of regulating physiological processes ranging from glucose metabolism and blood pressure to immunomodulation and neurogenesis [46].

In addition to improving patient

outcomes, clinical empathy is associated with increased overall

well-being for the physician [5].

decreased burnout, personal distress, depression and anxiety,

along with increased life satisfaction and psychological well-being [6, 7].

Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students

and residents. Acad Med 2011;86:996-1009

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WHERE DOES THAT LEAVE US?

Fundamentally

Compassion is a one to one transactionEach time - every time

It is always required of the individual

to the individual regardless of the context

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“PHYSICIAN HEAL THYSELF”.............

.....................BUT NOT BY THYSELF!

WHAT ABOUT COMPASSION ?

Let go of the toxic bits

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Peter Carter, head of the Royal College of Nursing

certainly does not believe that “compassion” can be taught

—as much of the reporting of the Francis report seemed to imply.

http://www.bmj.com/content/348/bmj.g126

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I disagree..........

It’s a competency that can be grown, developed & recovered

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What is the minimum quantum ?

Eye contactPersonalised interactions

Framing StatementsBe less judgemental

Signpost sources

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General Measures – Being CaringBasic Heart support

Understand your role in care of suffering Protect & Renew your ideals Refill the tanks - Take an occasional ‘care

pause’ Keep good company Avoid the angry trap

“Little by little, your frustrations mount”.

Limit commitments but commit to work Stay close to patients / mission Tend your own needs too Preserve personal and collegial relationships

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Can we learn compassion?

Or is it something innate that we either have or don't have?Recent research by Jazaieri and colleagues 

programmes based on mindfulness meditation

are associated with reduced fear of compassion

and a more compassionate attitude

This is a guest post by Dr Lucy Maddox, NHS Clinical Psychologist, lecturer and BSA media fellow. You can read more from Lucy on her blog, Psychology Magpie, and on Twitter @Lucy_Maddox.

 

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A word about Mindfulness

Dissolution of narrow and isolated sense of self

Emotional awareness and stabilisation Less JudgementalSelf acceptance

Less anxiety / depressionLetting go – forgiveness

Liberates joy / bliss / love

For Compassion

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Mental wellbeing

Yourmentalhealth.ie #littlethings

Headspace App

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AT A SYSTEMS LEVEL……

NHS Staff survey

Conclusion

Having a safe working environment is critical

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215455/dh_129656.pdf

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Compassion as Core Value

Not so lean That we carry no slack

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Dov Seidman said that

“the last era of management was about how much performance we

could extract from people.

The next is all about how much humanity we can experience”.

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There are an awful lot of Penguins

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The way it will succeed.....

Small peer led teamwork informed by compassion recovery and maintenance approaches eg Bailint groups etc

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LAST WORDS

Recovering our personal value

in kindness – it doesn’t matterin ourselves - we don’t matter

in the context - It doesn’t matter to anyone

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Healing = care of suffering

Our workOur gift

Our professionOur reward

“The secret of the care of the patient,” Peabody noted, “is caring for the patient.”

 Peabody FW. The care of the patient. JAMA. 1927;88:877–882

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Resources Compassion

Recent research by Jazaieri and colleagues suggests that compassion cultivation programmes, based on mindfulness meditation, are associated with reduced fear of compassion and a more compassionate attitude towards oneself.

https://compassionateaction.org/global-compassion-movement http://greatergood.berkeley.edu/article/item/sustaining_compassion_in_health_care http://www.tibet.emory.edu/cbct/index.html#CBCT Look at the Cleveland clinic empathy series on youtube The Art and Science of Medicine: Guidelines for the Human Physician. Göttingen: Hogrefe

Publishing; 2011. HBR Blog Network How to Spread Empathy in Health Care Social network scientists have shown that emotions and values can spread in a community with

the same patterns as infectious diseases –”compassion cannot be taught, but it can be caught” The Center for Compassion and Altruism Research and Education (CCARE) at Stanford University http://www.psychologicalscience.org/index.php/publications/observer/2013/may-june-13/the-comp

assionate-mind.htm http://www.visimobile.com/wp-content/uploads/2014/03/Transforming-Care-at-the-Bedside.pdf Compassion and Healing in Medicine and Society: On the Nature and Use of

Attachment Solutions to Separation Challenges By Gregory L. Fricchione. Johns Hopkins University Press. 2011

Biol Res Nurs. 2012 Oct;14(4):419-30. Epub 2012 Jul 6. The biology of caring: researching the healing effects of stress response regulation through relational engagement.Zender R1, Olshansky E.

Karen Armstrong 12 steps to a compassionate life Patient Experience: Are We Overlooking a Crucial Element? Medscape. Oct 31, 2014.

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THANK YOUComments welcome justin.brophy1@hse.ie

Synergy

Carefulness↕

Compassion

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LET’S LOOK AT THE PROBLEM OF

ATTENTIVENESS IN THE AGE OF DISTRACTION

Personal Obstacles to Attentiveness

StressDistractionFatiguePerfectionism Carelessness

OverloadNoiseConflictHangovers etc

Time & Boundaries encroachment

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Contextual Obstacles to Carefulness - The age of performance

CrowdingEnvironmentRegulatory

excessBureaucracy 

Performance &Time pressureSectoral changeIgnored

problems

Multitasking http://enlivenwellnessworks.com/wp-content/uploads/2013/10/8036438_l.jpg

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How Multitasking Affects Mental Health

“Inability to focus well on one activity.”

leading to

“Impatience and lack of empathy for others

who are often seen as getting in the way.”

-attention switching is difficult How Multitasking Affects Mental Health

By Rheyanne Weaver

Published January 07, 2012 EmpowHER

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Being Too Careful is also a problem

ScrupulousRisk averse

AnxiousMistrustful

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BECOMING MORE ATTENTIVE

Let go of the toxic bits

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What is the minimum quantum of safe practice ?

3 ChecksTake personal responsibilityRecording

If in doubt don’t proceedConsult and confer

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General Measures – Being CarefulBasic Head support

Beware fatigue - Protect sleep Protect health De-clutter work practices - Don’t Multitask Develop +ve rituals / habits Manage other’s access Take regular ‘attentional pauses’ Analyse and fix your weak points Don’t rely on stimulants - take Tea! Practicing mindfulness, Fun Exercise etc Supervise & review Individualise improvement & Localise the focus

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Use Focus techniques

http://learningfundamentals.com.au/wp-content/uploads/Focus-mindmap-for-web.jpg

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A word about Mindfulness

Clarity Calm

Energising

Short term focus → sustained clarity

Perceptual shiftDiscernment

More Intuitive

For Attentiveness

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Resources Attention

Focus Focus Manifesto focusmanifesto.s3.amazonaws.com/FocusFree.pdf For the Mindmap go to

http://learningfundamentals.com.au/wp-content/uploads/Focus-mindmap-for-web.jpg

Mindfulness Meditation Society of Australia Mindful awareness UCLA http://marc.ucla.edu/body.cfm?id=107 Mindfulness Meditation app Lifestyle Sleep genius App also Relax and Sleep Well App Life Goals App also Get it done App IOS only Recharge App

Resilience Healthcare http://resiliencehealthcarelearningnetwork.ca/98