Abstract
Compassion has always been a vital component of healthcare anywhere in the world. With numerous definitions in a variety of contexts, it cannot simply be prescribed, measured or given in a bottle. When our patients are ill, great attention is paid to the verbal and non-verbal communication presented by a doctor and the manner in which they are delivered. However, with an ever-growing demand on the NHS workforce, numerous patient surveys across the UK have accused doctors for lacking compassion in their practice, amid the strains of their modern-day commitments. The concept of being caring to our patients is highlighted from the first walks of medical school or indeed any healthcare professional’s training programme, meaning that patients will always be our prime audience for compassion. Yet, so often in medical training, it is emphasised how important it is to demonstrate a personal detachment between oneself and the patient and not to get too emotionally involved. So despite numerous challenges, how do we find the correct balance to optimise our day-to-day service and stay sensitive to the needs of our patients? This article reflects upon compassion from multiple perspectives in the NHS pertinent to doctors of all settings and experience levels, exploring the barriers, internal conflicts and facilitators of its delivery. We examine the objective evidence of measures that have been put in place to overcome these challenges and summarise key considerations to optimise the enablement of a workforce to deliver compassion at universally higher standards in future practice.
Compassion has and always will be a vital component of healthcare anywhere in the world. Defined literally as suffering together with another, participation in suffering; fellow-feeling, sympathy by the Oxford English Dictionary, 1 the means and methods of its physical application to patients knows no bounds. With an ever-growing demand on the NHS workforce, patient surveys across the UK have accused doctors of lacking compassion amid the strains of their modern-day commitments. 2 In an increasingly busy NHS, how do we stay sensitive to the needs of our patients? When we or our patients are ill, great attention is paid to the verbal and non-verbal communication presented by a doctor and the manner in which they are delivered. Compassion, however, is not just about patients, but whether our colleagues and the institution are compassionate to us. This article reflects upon compassion from multiple perspectives in the NHS pertinent to doctors of all settings and experience levels, exploring the barriers, internal conflicts and facilitators of its delivery. We examine the objective evidence of measures that have been put in place to overcome these challenges and summarise key considerations to optimise the enablement of a workforce to deliver compassion at universally higher standards in future practice.
Compassion cannot be measured or administered from a bottle. The late Rabbi Lionnel Blue described on BBC Radio 4 his experience as a patient (18 January 2010) acknowledging how medical technology continually gets more complex, but describes how he has found that kindness is ‘as essential as technology’. He asks ‘How do you teach kindness on a degree course? For vulnerable oldies, and youngsters too, hospitals become a way of life, and kindness is the difference between heaven and hell ’. He goes on to say; ‘In my experience you learn kindness by remembering the kindnesses and unkindnesses you've encountered and how both felt’. So is unkindness dispassion? It was a shock to hear during feedback in consultation skills teaching one trainee say to their peer, ‘you perhaps should have turned on the empathy switch earlier’. The unmeasured value of compassion is floundering in a sea of audit and outcome measures, but it is what matters most to people who are ill. 3
The practice of empathy, seeing the world through the eyes of another, so fervently emphasised in the medical curriculum, can often be very challenging. A very powerful tool for those in a caring profession which can form an important prerequisite for human care, a growing body of evidence has shown that empathy can alleviate pain and anxiety as well as improve the general quality of care and experience of the patient through their journey in a hospital admission. 4 Like compassion, empathy itself has many barriers impeding its effective delivery. For example, a qualitative Dutch study on the clinical encounters of general practitioners felt that guideline-driven care resulted in a disease-centred emphasis rather than a person-centred emphasis. 5
Compassion, empathy, sympathy: what is the difference?
There are many overlaps between the three terms compassion, empathy and sympathy which may lead to confusion. However, there are some key differences between the three which will help put their meanings into context as they are used in the remainder of the article. Having already described the first two terms, sympathy is defined as ‘a (real or supposed) affinity between certain things, by virtue of which they are similarly or correspondingly affected by the same influence’.
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It is therefore described very succinctly and objectively by the clinical pharmacologist Dr Jeffrey Aronson that: Compassion therefore does not require one to achieve complete understanding of the other’s perspective and circumstances, engendering exactly the same feelings, it merely calls on one to imagine what it might be like to suffer in the way that the other is suffering, which, if achieved, will engender the corresponding emotion, which can then be conveyed.
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Compassion to patients: the doctor–patient relationship
Perhaps, it is best to avoid a definition of what cannot be measured, in case this most important aspect of care is denigrated into an algorithm, guideline or another tick box in an electronic portfolio. Indeed, how can one quantify ‘just’ a smile and/or a few thoughtful words to someone who is ill? Sadly, it is possible to demonstrate ‘professionalism’ without truly caring. Ideally, one would like to imagine that when treating any patient, it should be as you yourself or a family member would wish to be treated. It is not what you do, but the way you do it.
Defining what a ‘good doctor’ is, is not easy. However, in essence, the main professional expectation of doctors from patients may boil down to two traits. The first is to be technically good with an ability to apply science and knowledge to be able to make the correct diagnosis and formulate an optimal management plan for any condition that patients present with, however challenging they may be. The second, an expectation which is arguably more important than the first and stressed upon ever increasingly in a modern curriculum for trainee doctors, is to show empathy, be kind and listen to their patients. As a patient, one would undoubtedly seek both qualities in a doctor. Indeed, compassion flows easily when we like our patients and the flipside is true as well. Nonetheless, regardless of how impatient, rude or demanding our patients can be, it is essential to remind ourselves that they are in a position of great stress and suffering. If they were content, then they would not behave in such a way. It is the acknowledgement of patient distress that can minimise tendencies to shift into a tunnel-vision mode and change our defensive or threatened stances to one of wanting to care.
As the concept of being caring to our patients is emphasised from the first walks of medical school or indeed any healthcare professional’s training programme, patients will always be our prime audience for compassion. Yet, so often in medical training, it is emphasised how important it is to have personal detachment between you and the patient and not to get emotionally involved. We are told this is to desensitise us and aid objectivity. But if that is the case, what is left of compassion? It can be difficult to find the appropriate balance, which is indeed one of the barriers to provide compassion to our patients. However, as this article explores, it is not merely just through patient interaction that we can help to increase the satisfaction of the patient journey in healthcare settings.
Compassion in different settings: barriers and facilitators
Environmental factors: institutional and organisational compassion
A healthy work environment is vital rather than insisting on a resilient workforce. The establishment of a collective workforce who pride compassion, engaging staff at all levels is key, with evidence emerging that links patient and staff experience and that the positive experiences are unlikely to happen to one without the other, as highlighted in The Guardian. 9 The article, aptly titled ‘Want a compassionate NHS? Then make sure staff are happy’, summarises the findings of research commissioned by NHS England – Building and Strengthening Leadership – Leading with Compassion, 10 which through a series of follow-up interviews, surveyed a number of NHS clinical and non-clinical leaders on their understanding of compassion in practice with regard to some of the barriers faced by nursing staff in order to maintain compassion at all times. It concluded that a positive and supportive culture and environment at the organisational level can establish a micro-climate that allows compassion to thrive. This study also examines the importance of compassion from a leadership and individual perspective, which is explored in more detail in the subsequent paragraphs.
How much harder is it to be compassionate when suboptimal situations persist and all healthcare workers feel impotent to make a difference? Junior doctors’ frustrations are an important example where recognition of the emergence of traits of dispassion and wanting to avoid it with their logo; ‘Not Safe, Not Fair’. This encapsulated the fear of doctors who reluctantly resigned to a 48-h strike in April 2016 over the risk of a serious compromise to patient safety owing to the new junior doctors’ contract imposed by the Department of Health. 11 Reduced staffing levels and loss of the basics, where technicalities are concentrated on, mean compassion is ‘squeezed out’. Resultant complaints further drain morale and so compassion, dealing with angry and unhappy patients.
Indeed, the time pressures, workload, staff shortages, hunger from long hours without a break and the perceived business model of care were seen as barriers to compassion in the study by Christiansen et al. This article studied the perceptions of 166 pre-qualifying healthcare students and 146 established healthcare professionals in Northwest England via qualitative interviews focused on the following themes: individual and relationship factors that impact on compassionate care practice; organisational factors that impact on the clinical environment and team; and leadership factors that hinder or enable a compassionate care culture. It found commonality in the objective and subjective opinions of both populations on the enablers and barriers for the delivery of compassion. Being pushed for time simply takes time away from being able to empathise and relate to patient’s concerns and deepest issues. 12
Similar issues were also highlighted in the guidelines launched by the Royal College of Psychiatrists in their document Compassion in care: ten things you can do to make a difference. They claimed that the constant demands of frequent contacts with patients who are suffering can take its toll on the workforce. Indeed, it highlights the interplay between burnout and compassion fatigue, with the absence of time off depleting emotional reserves, weakening the tolerance of strong emotions from patients, leading to emotional detachment. 13
Compassion fatigue itself is a very important condition affecting healthcare professionals of multiple disciplines worldwide and was described very sensitively in an editorial blog by anaesthetist Dr Ian R Barker in the BMJ Opinion. He described it as a ‘vicarious traumatization’ resulting in a ‘gradual reduction in compassion over time’, with risk factors including low levels of social support and high levels of personal stress. It was highlighted as a key issue in the Francis Report as one of the main causal factors responsible for the hundreds of deaths at Mid Staffordshire Hospital owing to poor medical care. He argues the importance of its awareness and the need to deal with it constructively. 14 Simple ideas to overcome the issue include exercise, taking regular breaks from work and participating in recreational activities. Based on this belief, it is understood that Mother Theresa was aware of the problem and advised nuns to take a break every four to five years. 15
Hence on a very similar note, the ten things recommended by the Royal College of Psychiatrists to help boost our demonstration of compassion on a daily basis were:
‘Be alive to your internal world’ – don’t be afraid to take a minute to yourself as you have to manage your own capacity to tolerate distress just like anyone else. ‘Support the development of systems at work that give you and your colleagues a space to reflect on what you are doing’. ‘Remember that patients are usually in distress’ – they must be treated as human beings as opposed to a mere diagnosis. ‘Model compassionate behaviour for trainees and other members of staff’ – one must aim to be a role model for others. ‘If there is system problem, do not work around it or ignore it’ – addressing such problems is an inherent duty of the workforce. ‘If there is a problem with someone else’s behaviour or attitude, challenge it appropriately’. ‘Make sure training activities foster the right behaviour and values among trainees’. ‘Respect systems but think of people and relationships’ – emphasising more face to face communication with colleagues to harvest stronger working relationships. ‘Make the patient in front of you your primary concern’ – they are the main reason you are there! ‘Pay attention and be respectful’ – turn off distractions such as phones or tablets when consulting.
Individual factors: self-compassion
Self-compassion is seen to be an ever-increasing predisposition to compassion. Trainees increasingly value time for reflection and mindfulness (balanced reflections on present experiences without ignoring nor ruminating on disliked aspects of oneself or one’s life) with good role models who are compassionate to their needs. It is important to not only pride a favourable ‘work-life balance’ but also recognise that all humans are imperfect and make mistakes, the so-called concept of common humanity. 13
However, reminding trainees to be compassionate to oneself where one feels one has failed a patient or been inadequate in providing a service may not always possible.
Often neglected is supporting colleagues who have received patient complaints. Organised pastoral support and a change in culture are needed to make it acceptable to talk about personal difficulties. However, even simple self-reminders may reinforce the motivation to be compassionate, such as silently repeating ‘may I be of benefit when washing hands or examining a patient’. 16
Leadership factors: a need for compassionate role models
During 2012, the NHS saw the launch of the Compassion in Practice Strategy by Jane Cummings, Chief Nursing Officer for England and Viv Bennett, Director of Nursing at the Department of Health. This initiative lead to the launch of three commissioned programmes in its third year. These were called:
Building and Strengthening Leadership NHS England (led by London region) – for encouraging strong leadership in the NHS. Excellence in Continence Care (south region) – remedying failings raised by the Francis Inquiry to demonstrate how patients’ fundamental continence needs must be addressed at a national level. Always Events® – to support compassionate care to meet the comprehensive needs, values and preferences of the patients that they serve.
Most notably, the first of the three aimed to promote strong leadership to optimise the positive experience for the patients and staff, putting compassion into the heart of how care becomes delivered and led. Approval was given in 37 (62%) of the 60 NHS trusts which were approached to participate in the evaluation of the overall programme. 17 Having good leaders and role models who demonstrate compassion by example, such as a consultant on a ward round or a charge nurse helping to allay the fears of the most anxious patients, is only likely to bode well for the rest of the junior workforce, which is indeed the most sizeable component of the NHS.
The future: preparing our trainees to guard against dispassion
Potential medical students reveal young people with amazing traits of compassion. But arguably to a large extent, undergraduate training, while preparing them to become doctors, does not prepare them to work in the NHS environment. Here, compassion fatigue may occur as a result of increasing demands of complex medicine with its multiple co-morbidities of an ageing population, seeing large numbers of patients within huge time pressures, long shifts, inadequate staffing levels, achieving targets, e.g. seeing a patient in under 4 h in an emergency department. Studies have not only linked compassion fatigue to stress and burnout18,19 but also the traumatic nature of day-to-day clinical encounters.
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In addition, having no time to eat, have a coffee break or go to the toilet leads to a workforce becoming numb to patient needs and what is basic humanity. In the longer term, this leads to burnout, declining levels of performance, depersonalisation, emotional exhaustion and poor personal achievement. This is unintentional and almost inevitably will have an adverse effect on patient care. There are also concerns that modern-day technology in the form of simulated learning environments with mannequins reduces the physical touch that medical students have with real patients. For example, the human touch employed by nurses to check a patient’s pulse often releases the feel-good hormone oxytocin.
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A very warming example of this phenomenon is demonstrated in an account titled ‘The Magic Touch’ by American genealogist and former breast cancer patient Betsy Willis on Pulse Voices.
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She treasures the incredible calming influence brought on the moment that a hand from a young nurse was placed on her shoulder in the pre-surgery room to quell deep anxieties moments before being wheeled into theatre to have surgery to remove a breast tumour: The warmth of her hand on my shoulder felt magical. Smiling, she kept her hand there for a minute or so. Her touch transported me to a place of soothing and ease–the place I'd been yearning for. Maybe it was the pre-op sedative at work, but you'll never convince me of that.
Interestingly, prior research analysing the wide-scale impact of interventions for compassionate care have shown mixed results. The systematic review conducted by Blomberg et al. evaluated 25 interventions from 24 studies looking at the effectiveness of interventions to support compassionate nursing care. Intervention types included staff training, care model and staff support. Overall, none of the studies reviewed presented strong enough evidence to support routine implementations of any of these interventions into practice. 24 On the other hand, a systematic review and meta-analysis studying the effects of empathic and positive communication conducted by Howick et al. showed that such communication can have a small beneficial impact on a range of patient-reported outcomes, including physical outcomes such as hospital length of stay and bronchial function, but most notably for psychological outcomes such as pain in particular. 25 This shows that compassion can benefit patients and that arguably the impact has no limits in form or quantity.
Ultimately, however, perhaps the safest conclusion to draw is that we require more projects to promote and brand the concept of compassion not only in individual institutions, but in multiple institutions at a universal level. One great example can be learned from the Point of Care Programme which was ran at The King’s Fund from 2007 to 2013, with the aim of improving patients’ and families’ experience of care. 26 In April 2013, Joceyln Cornwell, who founded the programme, established a new Foundation, known as The Point of Care Foundation, to spread and build on the work. This is an independent charity with a mission to humanise healthcare, working with clinical teams and managers at all levels (clinical and non-clinical) and frontline staff. 27 One award-winning patient-centred quality improvement project led by this organisation is Quality Time – a research study that took place in the Royal Berkshire Hospital Emergency Department which utilised a novel and innovative qualitative methodology called Experience-based co-design, which brought together staff and patients to make the department a less frightening and more calm and present environment to be in for staff and patients alike. It led to the introduction of several new measures such as volunteer-led refreshments served for patients and staff, increasing training to deal with vulnerable patients such as those with mental health conditions, providing an eight-bay extension to reduce overcrowding and encouraging a culture of open communication with patients to reduce their anxieties. 28 It was awarded the prize for Innovation in Patient and Public Involvement at the Thames Valley Health Research Awards in October 2016 at the University of Oxford. 29
Summary
In summary, the long-term solution involves changing the system to create a more manageable and lifestyle-friendly environment, which will improve patient care. We need role models who establish an ethos of demonstrating a kind and caring attitude at the heart of everything we do while treating our patients. We need time to reflect for ourselves the reason that we entered the profession in the first place, to care for others and not berate ourselves when things do not turn out the way we hope despite our best efforts. Most importantly, we need to mirror the minds of our patients’ who are experiencing great anguish and distress and treat them the way we would want to be were we to be in their situation. The power of simple but effective gestures such as the human touch, serving refreshments and increasing space for our workforce is perhaps somewhat underestimated and can make a great difference in making NHS Hospitals a more satisfying place for all those who pass through it, be it for work, as a visitor or as a patient.
Importantly, at the end of the day, doctors want to be more compassionate doctors, guarding against dispassion where the patient should be at the centre. A GP lecturer once described four possible outcomes of the consultation: being given a prescription; getting a referral to a specialist; being given a sick note; and last, perhaps the most important, receiving a bit of love. Two further quotes stand out in a recent book on compassion:
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the first by a lay person, ‘Compassion is like the sun, it just shines’; and the second by a primary care nurse (Millard, K): Compassion is a kindness that cannot be taught, but can be shown every day. The best skill we have is kindness. Even in the most desperate situation a few kind words or actions are noticed as much as a surgeon’s skill or a key diagnosis.