Compassion,emotions and cognition: Implications for nursing education

Abstract

Compassion is often understood as central to nursing and as important to ensure quality nursing and healthcare. In recent years, there has been a focus on strategies in nursing education to ensure compassionate nurses. However, it is not always clear how the concept of compassion is understood. Theoretical conceptualisations that lie behind various understandings of compassion have consequences for how we approach compassion in nursing education. We present some ways in which compassion is often understood, their philosophical underpinnings and the consequences these understandings can have for nursing education. We argue that it is useful for nursing education to understand compassion as a cognitive emotion and discuss how such an understanding can inform educational approaches to compassion.

Introduction

Since the emergence of modern nursing, the concept of compassion has been linked to the profession. Compassion implied not only sensitivity to other people’s suffering but also included motivational aspects of care. A religious calling to the profession was often seen as a guarantor for the delivery of compassionate care. In the last half of the 20th century, the idea of a religious calling became less appealing.

Nevertheless, the concept of compassion is still central to nursing, ¹ Reports and research focussing on the consequences of lack of care and malpractice in modern healthcare have led to a ‘compassion crisis’ narrative, in which malpractice is understood as healthcare personnel’s lack of compassion, with severe consequences for patients., ² (p. 421) Many studies concern ‘compassion fatigue’, focussing on the cost of caring and distress for those in occupations exposed to suffering that require workers to be compassionate as part of their work. ³ Lately, light has been shed on the antithesis of compassion fatigue: the concept of ‘compassion satisfaction’. Sacco and Copel ⁴ define it as the ‘pleasure that derives from being able to help’. Another interesting innovation is the term ‘compassionomics’, ⁵ which focuses on how the presence of compassion, in addition to increasing the quality of care and healthcare workers’ satisfaction, can lead to more cost-effective healthcare services. This engagement with various aspects of compassion seems to understand compassion as important to ensure quality healthcare. However, it is not always clear how the concept of compassion is understood in this discussion. This lack of clarity may lead to inappropriate strategies for ensuring moral competence in nurses’ education and practice.

One important strategy to ensure compassionate healthcare workers is to pay attention to selection procedures to assure that recruits to the profession possess the right values and capacity for providing compassionate care. ⁶ The focus on values and values-based recruitment seem to assume that compassion and similar moral responses as something innate, natural or at least mainly developed before entering professional education.

Furthermore, attention has been given to developing methods for compassion training in education and practice, emphasising compassion as a trainable skill. However, methods for cultivating compassion vary. For instance, Sinclair ⁷ developed an empirically based clinical model of compassion, seeking to capture patients’ perspectives. The so-called Patient Compassion Model not only emphasises the role of virtues in compassionate care but also highlights the role of communicative skills and relationships (relational space) and the affective aspects of compassion. Ash et al. ⁸ developed a model for cognitively based compassion training, involving exercises such as ‘loving kindness meditation’ and ‘mindful self-compassion’ as cognitive reframing to cultivate a wish to see others free from suffering or being happy.

A recent review article finds that many nursing and medical education programmes use humanities-based reflective practices, clinical simulation, role modelling and contemplative practices to increase compassion. ⁹ Another review article shows that efforts are made in medical education to identify effective methods to increase compassion. These methods address technical skills and behaviours, such as how to speak and how to position oneself physically when meeting patients. They emphasise active listening techniques, involving acknowledgement, validation and support, to enhance empathy and compassion ‘scores’ in healthcare workers. ¹⁰

The terms ‘compassion’ and ‘empathy’ are often used interchangeably, such as in the review described above. However, these terms need not refer to the exact same phenomenon. Empathy is often described as the psychological ability to see or understand another person’s perspective, but with various versions ranging from mere affective identification to thick moral concepts involving understanding, feeling with and action. ¹¹ Some understand empathy as a prerequisite for compassion, ¹² others argue for leaving one or the other aside.^13,14 In this paper, we choose to focus on compassion, as this is a central concept in the debate about good nursing practice.

The literature on compassion training displays a range of different understandings of compassion. In a paper concerning therapy approaches, Kirby ¹⁵ asserts that there is a need for thorough articulation of the theoretical underpinnings of current compassion interventions. Theoretical conceptualisations that lie behind different understandings of compassion also have consequences for how we approach compassion in nursing education, for instance, whether and how it can be developed in education and what kind of interventions then would be appropriate. We therefore present some ways in which compassion is often understood, their philosophical underpinnings, and the consequences these understandings can have for nursing education. We argue that it is useful for nursing education to understand compassion as a cognitive emotion and discuss how this understanding can inform educational approaches to compassion.

Compassion

There seems to be agreement about the claim that compassion is an emotion we (may) experience when we see (or hear of) another person (or animal) suffering some misfortune. ¹⁶ The term compassion comes from Latin, combining com (together) and passion (from pati or passio, meaning suffering or feeling). ² In German, it is often expressed as mitgefühl (feeling with) or mitleid (suffering with).

Compassion, as in this ‘feeling with’, is often understood to involve both an emotional response and a motivation or moving element: Chochinov ¹⁷ describes it as a deep awareness of the suffering of others coupled with the wish to relieve it. However, understanding compassion as involving the two elements of emotional awareness of someone else’s distress and a desire to relieve it may still represent varying approaches to how it can be assured in professional education.

We aim to contribute to a deeper understanding of the philosophical background of compassion. We discuss three common understandings of compassion:

a. Compassion as a raw affection;

b. Compassion as a personality trait that some have more than others, either because it is inborn or because it develops in early life; and

c. Compassion as a cognitive emotion.

Compassion as a raw affection

Compassion and other moral emotions are sometimes understood as raw affections outside the control of the agent.

Dominating strands in moral philosophy are highly impartial and rational, such as in Kantian philosophy and consequentialist ethics. Such impartialist theories require detachment and disinvolvement from one’s emotional make-up. Emotions and cognition are, in this tradition, seen as two distinct domains that are often incompatible. Kant ¹⁸ expressed strong scepticism towards emotions, which he believed to be arbitrary and unreliable. He argues that reason will inform us about right and wrong. His famous categorical imperative demonstrates this understanding: ‘act only in accordance with that maxim through which you can at the same time will that it become a universal law’. ¹⁸ By rationally checking whether an act follows a universal rule in this way, Kant argues that we can know whether the act is right or not. Emotions may simply disturb the picture. ¹

Consequentialist ethics require that an act must contribute to the best consequences, usually maximising well-being for all. ¹⁹ This requirement also relies on a rational assessment of the act, detached from any emotional or relational involvement the agent might have. In such views, emotion can be understood as a mere raw affection.

A raw affection is understood as a spontaneous response to some sort of stimulus. The response is more or less automatic and outside the agent’s control: the agent experiences an affection when exposed to another person’s suffering. This view, according to Pence, ²⁰ results from a desire to fit moral philosophy and moral psychology into a natural scientific paradigm: the effect the suffering has on an agent follows the same structure as the effect gravity has on a falling object. Thus, moral emotions are seen as nature-given responses following the laws of nature and not a result of cognitive activity.

Crisp argues in a philosophical analysis of compassion that no cognitive components need to be present to feel compassion and that ‘what is central to compassion is the non-cognitive element of pain or distress at the pain or distress of others’. ²¹ (p.240) He describes compassion as sheer discomfort.

If we understand compassion as a raw affection that the agent will necessarily experience when exposed to the suffering of others, this has consequences for how to ensure compassion in healthcare workers. Strategies have been introduced to address professional malpractice in healthcare. For instance, in 2012, the UK government published Compassion in Practice in response to several findings of malpractice in the National Health Service. ²² When the Francis Report suggests that prospective nursing students should have experienced healthcare work as a prerequisite to entering a nursing programme, it seems to assume that the mere experience of a care setting in which suffering exists and can be seen will evoke and develop compassion. ² However, such strategies say little about why these experiences in themselves would evoke or develop compassion. It seems that compassion is understood as affect: an effect that will follow when a person is exposed to the suffering of others, without any other components having to be present.

A problem with this view is that it is faulty. It is not necessarily the case that people experience compassion simply by being exposed to the suffering of others, or at least not always. Examples of malpractice in healthcare, where patients are not cared for compassionately, very often involve undue patient suffering that staff are exposed to. However, in these cases, patients continued suffering even if healthcare personnel were exposed to it. Exposure alone does not evoke compassion.

Furthermore, it is unreasonable to suppose that healthcare workers individually lack the ability to experience compassion, as if they all have a moral flaw. The Francis Report points out factors other than healthcare personnel’s moral virtue as central causes: low staffing levels, a hostile work environment, etc. ² It may well be that compassion comes quite naturally when the right conditions exist (see Paley ²³ for such an argument). However, viewing compassion as a raw affection does not explain what these conditions are.

Compassion is seemingly a more sophisticated or complex phenomenon than a mere response to an exposure.

Compassion as a response some people have more than others

When compassion is understood as a force of nature – our response to the suffering of others – it may also follow that some persons are more prone to this response than others. It may simply depend on personality or temperament: some are naturally more compassionate than others.^13,14,21

Several authors argue that whether a person is compassionate is more or less outside their control, and that therefore it is problematic to require compassion of professionals.^7,20,21 Compassion is mostly a matter of whether they are exposed to the right kind of experiences and whether they experience compassion as a result. According to this view, there is little the agent can do to develop or adjust her compassion. In this sense, compassion understood as a naturalistic personality trait is not very helpful in professional training.

Values-based recruitment and assessment of compassion in the selection of students for nursing programmes seem to be based on this understanding of compassion. In the UK, values-based recruitment is compulsory for nursing education institutions to ensure that those accepted to the nursing programmes have the right moral make-up. ²⁴ Candidates are selected based on personal interviews and often elaborate questionnaires to assess whether they are suited for the job. Similar strategies are used in other contexts, for instance, in selection for medical education in the UK, ²⁵ and they are not new to nursing. For instance, Joyce Travelbee discussed such approaches in Interpersonal Aspects of Nursing. ²⁶

However, such assessment seems very complicated – how can we identify who is appropriately compassionate and who is not? Groothuizen et al. ²⁷ argue for a critical approach to values-based recruitment for several reasons: it is unclear which values are desirable, what meaning we give to our expression of a particular value and how values influence our behaviour and practice. Also, such a view seems to disregard the importance of professional education and moral formation in developing compassion and other moral emotions as part of one’s capacity for professional judgement.^28,29

If we understand compassion as mere affect or as traits persons already possess before entering education, education can do little to develop it. One alternative is to consider compassion as superfluous or even confusing as moral guidance for healthcare personnel. Smajdor, for instance, asserts that compassion should be left aside, as it is unreasonable to require healthcare personnel to produce certain emotional responses that are outside their control and more natural to have towards one’s loved ones. ¹³ Paterson contends that compassionate behaviour is a ‘gift from the heart’ that may sometimes take place between a professional and a patient but that goes far beyond what can be mandated. ³⁰ Newham argues for keeping compassion separate from moral judgement because it is too unreliable and unstable. ³¹ In their understanding, compassion is an emotion, and emotions are not central to moral judgement.

This kind of scepticism towards the moral significance of emotions is uncommon in contemporary moral philosophy. Many thinkers see emotions such as compassion as resources, perhaps even prerequisites, for moral judgement. For such an account to make sense, however, we must open up a different understanding of the relationship between emotion and reason. In the following, we present two ways in which compassion is understood as a cognitive emotion.

Compassion as a cognitive emotion

Many thinkers understand compassion not merely as a force of nature or a matter of personal temperament but as moral emotion. Here, compassion is understood as a complex emotion with an intimate relation to reason and cognition, thereby connecting knowledge, critical thinking and reflection to emotive responses. The philosopher Martha Nussbaum represents such a view, classifying compassion as a typical cognitive emotion.

In Upheavals of Thought, Nussbaum argued that ‘… emotions always involve thought of an object combined with thought of the object’s salience or importance’. ³² (p.23) She dedicated a chapter to the emotion of compassion as an example of such cognitive emotions.

Cognitive components of compassion, according to Nussbaum

Nussbaum presented a concept analysis of compassion. For compassion to be a cognitive emotion, it must be possible to identify the cognitive components of that emotion, or so Nussbaum argues. ³² (p.305) Nussbaum builds her concept of compassion on that found in Aristotle’s The Art of Rhetoric. ³³ , (1385b) Aristotle argues that there are three requirements for an emotion to be compassion: a belief that the misery of the other person is serious, a belief that the other person does not deserve this misery and a belief that one may possibly find oneself in a similar situation. Nussbaum follows Aristotle’s two first requirements but dismisses his idea that compassion entails seeing oneself in a similar situation. ³² (pp.306–323) Rather, she contends that for the emotion to be compassion, it must entail a belief that the good of the other person is central to one’s own good – what she calls the Eudaimonistic requirement’. ³² (p.319) Thus, Nussbaum argues, compassion informs us about what matters to us and illustrates how emotions can be judgements of value. ³² (pp.30–33)

Belief about the seriousness of the other’s suffering

Nussbaum holds that compassion involves a belief that the other’s suffering is serious. Crisp rejects this. ²¹ He argues that we could feasibly feel compassion for someone who is not in any form of severe or serious suffering but only mild suffering. He may perhaps be right. At the least, it would be strange to introduce a threshold view of how serious suffering should be for it to commission compassion. Furthermore, as van der Cingel points out, suffering is a deeply individual and contextual matter that cannot reasonably be measured or compared. ³⁴

However, we maintain that compassion essentially involves some belief about the suffering of the other without necessarily requiring just how serious that suffering must be. Nevertheless, in the Aristotelian understanding of compassion, it is not enough that we simply make a judgement that someone is suffering to experience compassion: it also requires beliefs about desert and identification with the plight of the other.

Belief about the other person suffering undeservedly

The desert requirement has also received some attention from Crisp. Is it true that we can only feel compassion for people whom we believe are not to blame for their misfortune? Crisp argues that we could feasibly feel compassion for someone in prison, even though their misfortune is their own fault, and their sentence and conditions are reasonable enough. ²¹ He also points out that ‘… the desert requirement represents a misdirection of attention’. ²¹ (p.237)

It seems as if compassion does not essentially involve making judgements about the other person’s character but rather directs its focus to the distress of the other and what we can do to alleviate it. It may be that our conception of compassion is not only inspired by the Aristotelian and tragic Greek tradition but also finds inspiration from other important sources of history and culture. For instance, compassion is a central value in Christian thinking and is understood as the attitude of seeing Christ in the suffering other. ³⁵ In such an approach, questions about blame and desert become irrelevant. In Eastern religions, such as Buddhism, compassion plays a central role. Here, compassion is often understood as an attitude towards the other person as a fellow human being or living creature, ³⁶ where attention is on our interconnectedness with others rather than questions of blame and desert.

The desert requirement found in Aristotelian ethics is not so convincing when we try to understand compassion today. It also seems as if the Christian and the Buddhist approaches to compassion involve beliefs about suffering in some sense and therefore may also be seen as cognitive approaches to moral emotions.

Eudaimonistic requirement

Aristotle’s similar possibilities requirement and Nussbaum’s eudaimonistic requirement both represent a partialist account of compassion: they require that compassion can only be felt for persons towards whom we can relate our own well-being. Aristotle seems to assume that compassion must involve putting oneself in the shoes of the other to such an extent that it is feasible that one may oneself experience the suffering in question. Nussbaum rejects this requirement, arguing that it is perfectly possible to feel compassion towards persons in situations we could not imagine finding ourselves in. ³² (p. 315-319) Furthermore, she contends that compassion is not essentially about situations oneself may be in but about how we relate to the other person. She claimed: ‘… in order for compassion to be present, the person must consider the suffering of another as a significant part of his or her own scheme of goals and end’. ³² (p. 319)

Several authors have dismissed compassion as an important moral emotion because it is essentially partial. Both Paterson and Smajdor express worries about requiring compassion in healthcare workers, understanding compassion as an essentially partial emotion, an emotion we have towards people close to us.^13,30 This kind of objection rings true if we understand compassion as inseparably linked to the personal flourishing of the moral agent; the importance of the misfortune or suffering of the other in the moral agent’s life and scheme. Crisp solves this problem by discarding the whole idea of compassion as a cognitive emotion. ²¹

Compassion can be demanding. A whole research field is exploring the question of compassion fatigue, which is understood as a result of being overwhelmed or overloaded by the requirements of being compassionate.^37–39

It is important to acknowledge that compassion has a cost. ³⁷ Curtis ⁴¹ found that nursing students find it emotionally challenging to handle the expectations of them as future nurses in a compassionate practice. Cash ⁴² also notes the risk that requiring compassion in nursing may be asking too much of nurses.

Compassion involves beliefs about the suffering of the other, however, we have argued that the requirements of desert and personal flourishing presented by Nussbaum pose some challenges. Nussbaum discusses compassion as a central example of cognitive emotions. In the following, we suggest an alternative approach to cognitive emotions that may be helpful when considering the role of compassion in nursing education.

Emotions in the service of cognition

The philosopher Israel Scheffler presents an alternative account of the relation between emotion and cognition in his classic paper, ‘In praise of the cognitive emotions’. ⁴³ His account may be helpful in this setting. He argues that emotions play an important role in our cognitive reasoning. His understanding is that education, formation and development rely on a strong relationship between emotion and reason. He focuses on the role of emotion in cognitive processes.

Scheffler understands cognitive emotions differently than Nussbaum. First, he starts with our emotional make-up, or what he labels our rational character: that we, to learn, perceive, understand and characterise the environment around us, must develop a balanced ‘rational character’ of engagement, love of truth, resentment of lying, etc. This character is built by cultivating certain emotions in the service of reason and judgement. One central element in developing a rational character is that one must care about the projects one pursues. This involves a value judgement: the agent cares about things that matter to them, that they deem valuable. Learning and understanding involve commitment.

Second, we depend on ‘perceptive feelings’ to signify for us what is salient and important in a situation. In this understanding, sensitivity (also moral sensitivity) is crucially informed by emotions or emotional responses (see also ⁴⁴ for a similar argument). Third, our rational activities are driven by emotions too: engagement, curiosity and excitement drive the rational process forward.

Emotions play a central role in education, formation and development of the individual. Scheffler’s argument is that to make sense of education and formation, students must be guided in connecting reason with their emotions: ‘The growth of cognition is thus, in fact, inseparable from the education of the emotions’, he states. ⁴³ (p.12)

Scheffler does not write about compassion as such. He is concerned with the relationship between emotions and cognition in general. While Nussbaum labels certain emotions as cognitive, Scheffler is open as to which emotions will have importance, depending on the purpose. In a discussion about compassion and its potential and role in educating nurses, we believe it is sensible to understand compassion as one emotion, together with other emotions that may be relevant to moral judgement and nursing practice. We do not want to discuss which emotion is most essential to nursing, whether it is compassion, empathy, sympathy, love or something else. Our purpose is rather to seek to understand compassion as an example of cognitive emotions, given the central role compassion has in the nursing literature.

Implications for professional education

In the previous section, we presented several understandings of compassion and suggested that compassion is best understood as a cognitive emotion. What implications does this have for nursing education? In the following, we briefly discuss how compassion can be a resource in the development of moral competence in nursing education.

It is important to clarify how we see compassion as central to nursing and discuss what kind of resource emotions may play in professional education. Compassion can play an important role in developing a rational character in studying nursing: committing to becoming a good nurse can involve cultivating and reflecting upon one’s compassionate responses. In this way, a ‘rational character’ for a nursing student would involve developing a professional identity where compassion takes a reflected place. ⁴⁵

Being compassionate is part of the professional identity that nurses develop because compassion is so central to our understanding of what good nursing is. We suggest an account of compassion as a cognitive emotion that does not see compassion as a unifying principle from which all other moral reasons can be derived. It is not so that if you ensure you are compassionate, you will always do the right thing. Sometimes it is good to be just, to prioritise and to limit the nurse’s responsibility. Compassion as a unifying principle would be way too demanding. It would involve committing to the (total) good of each patient at all times, requiring nurses to have the same feelings towards patients that they have towards their close loved ones. This could be labelled ‘the love view of nursing’. ⁴⁶ Compassion understood as a cognitive emotion working in the service of professional formation would rather involve committing to the project of becoming a nurse and providing good nursing care, where compassion is one of several ideals. Here, Scheffler offers an alternative account to the value judgement of emotions than the problematic and demanding partialist account. ⁴⁴

One resource that emotions offer in working on developing a professional identity is a personal point of view from which the vast body of professional knowledge can be integrated for the student. ⁴⁷ Professional formation involves embarking on a project in which the student explores what it means for themself to become a nurse and provide nursing care to patients. Nursing education has a long tradition of supporting the formation of professional identity, including approaches that aim at integrating values with knowledge, skills and experience, and a great variety of reflective practices to support such formation.^45,48–50 The aim is often to develop the capacity for discretion and holistic judgement. ⁵¹ In a recent article, Van der Cingel and Brouwer ⁵² claim that compassion ‘needs thinking’ and that compassion understood as a cognitive emotion is useful for developing a professional identity in nurses. Compassion can work as a way of bridging emotion with understanding: when students experience compassion, they can reflect upon why they respond like this, what knowledge they have about the situation, how they relate to the patient and other persons and seek to develop an ability to pick out what is most important in the situation.

Conclusion

We have discussed different understandings of compassion in the nursing and philosophy literature and their consequences for nursing education.

We suggest that it is useful to see compassion as a cognitive emotion rather than as mere affect or as an uncontrollable character trait developed before entering professional education. The cognitive character of compassion makes it promising for professional education.

Many strategies for ensuring compassionate nurses focus on the selection of candidates for nursing education, in what is often labelled values-based recruitment. If we understand compassion as a cognitive emotion that develops by integrating knowledge, values, emotions and skills during the education programme, it seems premature to spend much effort selecting candidates before they have even started their journey towards becoming a professional. It is more sensible, we believe, to expend effort on supporting students in bridging knowledge, emotions and values through various reflective practices and learning strategies.

Emotion and cognition are linked, and nursing education will benefit from exploring different ways in which this relationship can support moral formation for the profession. Compassion is central to the narrative of what good nursing is, and its relationship with professional judgement and morality should be further explored.