Compassion is the lynchpin of healthcare delivery and its promotion has become a pivotal initiative in the NHS, driven by events in recent years including the launch of the 6Cs (Cummings and Bennett, 2012) and publication of the Francis report (2013). Cummings and Bennett (2012) defined it as ‘intelligent kindness’ and acknowledged that patients recognise and appreciate the times when compassion guides their care. The factors enabling and obstructing the delivery of compassion-based care are complex and merit further exploration. A key recommendation by Francis (2013) was the promotion and facilitation of compassionate caring as a vital step in ensuring a high quality of patient care; this underpinned many of the observations made during the public inquiry into the Mid Staffordshire NHS Trust.
The concept of compassion fatigue has emerged in the last 20 years, having been first introduced by Joinson's (1992) exploration of emergency department nurses who had seemingly lost their ability to nurture. Coetzee and Klopper (2010) recognised that there was no standard definition of the term so conducted a concept analysis based on the available literature on the subject. Their findings suggested that developing compassion fatigue is a gradual process, often caused by stress, and therefore potentially reversible. Manifestations of the problem include: diminished job performance (White, 2006; Smith, 2007), burnout (Adams et al, 2006; Benoit et al, 2007), callousness (Mendenhall, 2006; Benoit et al, 2007), emotional overload (Abendroth and Flannery, 2006; Mendenhall, 2006), and desire to resign position (Fahy, 2007; Smith, 2007).
It is widely reported that mental health services in the UK are facing an unprecedented crisis (Cummins et al, 2018, Csipke et al, 2016). The King's Fund (2015), in their analysis of NHS data, identified that: the vast majority of psychiatric wards had been operating above recommended levels of bed occupancy; the number of nurses on inpatient units had been significantly declining; and out-of-area bed occupancy rates had risen to problematic levels. It is likely that the current climate is influencing staff capacity for delivering compassion-based care.
The impact of current pressures was felt in a clinical area responsible for later life mental health services at a hospital based in north-west England. The problems faced included poor staff morale, inconsistent risk management, high absence levels and low compliance with mandatory training. Delivery of a course on compassion-based care (CBC) was a management initiative intended to reinvigorate ward culture and improve patient experience, by investing in staff development and stimulating behaviour change. The CBC course inspired subsequent staff-driven developments in practice and the Compassionate Healthcare for Excellence in Nursing (CHEN) programme was born—it is a multi-intervention initiative that continues to drive care.
The CHEN programme
Following the CBC course, which is core to the CHEN programme, several members of staff became inspired to adapt elements of care delivered on the ward. As a result, several changes were made to the clinical environment, including the introduction of animal-assisted therapy (AAT), Schwartz rounding (Point of Care Foundation, 2018), the Sonas approach (Sonas, 2018), and staff complementary therapies. The CHEN programme, therefore, consists of a variety of staff- and patient-focused interventions:
The theory driving delivery of the staff-focused interventions, like the CBC course, was that improving staff experience and orientation should lead to consequent improvements in patient experience.
Aim
Despite the multifaceted nature of the CHEN programme, this evaluation primarily aimed to explore staff experiences of participating in the CBC course.
Methods
This was a qualitative evaluation exploring the experience of participants (n=12) attending a 4-day reflective course on CBC. Tayabas et al (2014) argued that this approach to intervention appraisal has value in that it is naturalistic, therefore enabling an evaluation of what has been implemented in practice; thus there is also a pragmatic component to it. They observed that, when previously used, the qualitative evaluation approach has generated results relevant to participant experience and provided practical recommendations for further implementation.
Participants were purposively sampled from the group of nurses and healthcare staff who had completed the CBC. The course had been delivered before this post-hoc qualitative evaluation was conceived. Staff were originally allocated to the course by hospital management. Potential participants for this evaluation were recruited by the course facilitators, in order to avoid the risk of coercion from management-led recruitment. Email invitations were sent out to all eligible staff. Recruitment was open between January and August 2017; uptake was slow early on, which was likely to have been related to distractions caused by an organisational merger at the start of the year. Reminders were sent to staff to reignite the study momentum. All staff who attended the CBC were eligible for interview—more than 40 members of staff from one ward (including associated multidisciplinary (MDT) members) took part in the CBC course; however, only 12 volunteered for the interview. Governance approvals were granted by the Trust Quality Team and University Research Ethics Committee.
Compassion-based care course
The intervention was a 4-day reflective course on the promotion and exploration of compassion-based healthcare. Based on previous development work by Hall and Nelligan (2015), the aim was to guide participants to reflect on key concepts in compassion-based care and link them to current policy. It included supporting and cultivating compassion for self and others, celebrating previous professional successes, and telling stories of personal experiences of compassionate care. Elements of the course were also designed to help participants reconnect to their original impulse to care, through exercises of reflection and self-exploration. Participants were encouraged to feel pride in their profession and to consider reframing their role within a narrative valuing compassion. Attendees were encouraged to reflect on how their personal experience during the course related to the 6Cs (Cummings and Bennett, 2012) and current drivers affecting policy and practice.
Previous evaluation of the course, delivered to nurses in north-west England, had been positive; one previous participant described the impact on their life as:
‘… gaining a deeper understanding of myself, becoming deeply inspired, connecting with the world and human beings around me to give me a deeper understanding of the true meaning of the delivery of compassion’
Other reported effects included nurses being better able to recognise patients in distress and staff remaining compassionate even during times of stress.
The course facilitators were external to the hospital and all were registered mental health nurses with decades of experience between them. The course was based on previous development work, and a structure was used to guide and standardise delivery. Each facilitator was trained and fully versed in the philosophy and design of the course. In fact, more than one facilitator had been involved in its development. Three iterations of the course ran over a 6-month period in 2016.
Data collection
Having enquired, participants were invited to engage in a one-to-one, semi-structured interview with one of three researchers, all of whom were outside the management structure with no involvement in delivery of the course. Consent was taken immediately prior to interview. Time for interviews was allocated during clinical shifts and they were conducted in private, on-site rooms. Interviews were based on a topic guide structured around predefined domains including course acceptability and participant experience. Researchers discussed and agreed a consistent approach before data collection began. All interviews were audio recorded and then transcribed using a pre-approved service provider.
Analysis
A thematic analysis, based on the framework outlined by Green and Thorogood (2004), was conducted. Transcripts were read and re-read to facilitate immersion in the data and two researchers (GD and IW) coded the data inductively. Each researcher constructed their own coding framework, analysing transcripts sequentially, and created codes every time a new concept was encountered that did not map onto existing codes. Discussion between the two researchers, and recognition of the different labels used for describing the same phenomena, confirmed the overall coding framework. The final version was used to interrogate the data and produce categories constructed from related codes, ultimately integrating similar categories to generate the key themes arising from the transcripts. Analysis was conducted using pen and paper and the final themes were agreed by the two researchers performing the analysis.
Findings
Twelve participants were recruited: eight nurses, one healthcare assistant, one occupational therapist, one social worker, and one therapy assistant. Analysis identified five themes (see Table 1) emerging from the data that characterised participant experience: meeting a need; creating the space; reorientation; prioritising self-care; and influencing team dynamics. Each theme is explored and described in turn, illustrated by participant quotes in order to provide evidence of thematic coherence.
| Theme | Description | Sample quote |
|---|---|---|
| Meeting a need | Workplace pressures can be relentless and a compassionate focus may be lost | ‘You can feel like no security, it's all about risk, and then that aspect might be lost along the way, compassion’ |
| Creating the space | Establishing an engaging atmosphere is vital | ‘When we were at the compassion course, it felt meaningful because we could explore ourselves’ |
| Reorientation | Staff were able to reconnect to their natural capacity for compassion and empathy | ‘I think it's generally patience with people. And just learning to look maybe from somebody else's point of view a little bit more than we would have before’ |
| Prioritising self-sare | Participants reflected on how their personal wellbeing impacts on their care delivery | ‘You come to work and you work, and I always do overtime, and you never actually stop to think about yourself’ |
| Influencing team dynamics | Staff reported that participation in the course had facilitated a stronger team | ‘We approach each other more and chat about things, obviously not all the time … it still can be busy as ever but, I don't know, I think it's knitted us together as a team’ |
Meeting a need
The majority of participants said that workplace pressures often felt relentless. The situation had even resulted in one staff member reporting feelings of apprehension on her way to work:
‘It's draining, and you've got that sense of, when you're driving to work, and you're dreading coming in, and you're thinking ‘What's happened? What's happened?’’
One nurse talked about reverting to task orientation as a coping method:
‘I think everybody is just trying to get things done and they get burnt out’
This way of working is likely to detract from the delivery of care with a compassionate focus.
Another participant recognised that staff may be diverted from a compassionate focus by the occupational stresses experienced and the pressures of protecting patient safety:
‘You can feel like no security, it's all about risk, and then that aspect might be lost along the way, compassion’
Suggesting that workplace stressors undermined team cohesion, one participant discussed previous team problems and how the course affected her understanding of her colleagues:
‘Sometimes we are horrible to each other. In the work environment we can be. But don't actually realise we're doing it. And it made me think a little bit more about that, you know, we can't just leave everything at the door.’
This theme suggests that addressing the pressures faced by healthcare staff may be a vital step in facilitating their delivery of compassionate care.
Creating the space
Several factors influenced the successful delivery of the course: supportive facilitation; course format; willingness to engage; group dynamics; and venue. All participants evaluated the course facilitators well; one described how they helped to create a conducive atmosphere for the course:
‘Stefan and Mary are very good, they're very approachable, yeah. They made us all feel comfortable, and at break time and stuff, they were coming up and chatting to us.’
This open-hearted environment helped to make participants feel comfortable enough to share personal stories and feelings, enabling their self-exploration:
‘When we were at the compassion course, it felt meaningful because we could explore ourselves.’
This deeper level of engagement no doubt influenced the effect that the course may have had on participants.
Some people were more willing than others to engage with the spirit of the course at the outset. A number of participants identified as being initially cynical, for example, in addition to others recoiling from the prospect of sharing intimate thoughts and feelings. One participant described journeying from a place of scepticism to one appreciating the benefits that the course experience had had for him:
‘… to be honest when I first went I was a bit sceptical … I guess at work my role is caring but, outside of work, I'm not really a touchy-feely person, I don't really talk about emotions and stuff … and, on the first day, I did think ‘I'm not going to enjoy this’… but I actually found it really worthwhile in the end, I think it was really good. I think spending a bit more time with other work colleagues, outside of work, but normally that's going out for a meal or getting drunk, whatever kind of thing, but actually to be in another environment, and to see people in a different light kind of thing. And it was just really interesting, and to get to know, there were so many things that I realised I didn't know about the people I worked with, even some of them I'd worked with for years, and I didn't know so many aspects of personal things, or things that have happened in their life. And it was challenging the way you think, I think, making you think in a different way.’
Confirming this eventual transformation of attitude, this staff member noted that people's feelings were acknowledged and pro-actively discussed openly in the group:
‘There was some resistance initially by some staff but they verbalised it and that was discussed during the time and they got involved in it, but everybody sort of pulled together and did it.’
The course format and design was universally well evaluated. However, some participants reported feeling that the first day's content was somewhat dry. Despite this, one staff member illustrates their understanding that it was important none the less, for contextualising the nature of the course:
‘I did find the interactions much more useful, but you have to do the talks to understand why you're doing what you're doing. But sitting around for a while and you're…because I'm used to moving about, and I found that difficult…’
Reorientation
Staff reported that their engagement in the course inspired a changed perspective on life and work. They were able to reconnect to their natural capacity for compassion and empathy.
As a foundation for cultivating a changed perspective, this participant reflected on their identity and core values as part of their experience:
‘I didn't know who I was before the course’
Her words suggest an element of having lost herself through managing the pressures of her daily life.
In a different way, another member of staff also discussed how the course had led to her re-evaluating her internal environment and changing her outlook:
‘Before I went to the course, the way I handled things was so hard, very difficult, and I believed that maybe I cannot do it…but when I went to that course, it made me realise and think that I can do it’
In addition to reorienting their relationship with themselves, participants also spoke about how the course had led to a renewed attitude towards their care delivery, and interactions with patients and others.
Describing a renewed compassionate focus when it came to dealing with patients, and others, two staff illustrated how the course had reinvigorated their attitude:
‘I think it's generally patience with people. And just learning to look maybe from somebody else's point of view a little bit more than we would have before’
‘Before I even speak to the patients, before I need to find out how they are, I don't judge. I need to see everybody as an individual and try and empower them, try to find out who they are’
Prioritising self-care
Participants reflected upon how their personal wellbeing could affect the nature of their professional practice. Most had committed to looking after themselves more, with the benefit of building resilience in the face of daily challenges.
Recognising her limited ability to care for others when neglecting her own basic needs, this nurse acknowledged:
‘I have to be mindful to look after myself a lot more now because I'm no use to nobody, either at home or in work. So I'm still trying, but I found it really useful’
Another staff member noted the duality of caring for oneself and for others:
‘I think it's just being made aware to look after yourself and other people, I think, is the most important thing I've learned’
One possible factor necessitating the focus on self-care is the propensity of many staff to neglect their own needs for the sake of their patients and to manage their workload. One participant summarises:
‘You come to work and you work, and I always do overtime, and you never actually stop to think about yourself’
Influencing team dynamics
Many staff saw their colleagues in a different light, having shared personal experiences during the course. The consensus was that course engagement had helped to facilitate a stronger team by improving relationships.
One MDT member felt particularly strongly about how engaging in the course had improved team cohesion and person centredness:
‘I felt everybody opened up. I felt, you know, we know each other now as individuals. We're all positive now. As a team, I think we're positive. We work well together as a multi-agency team. We value our patients. We put them first as well but still knowing who we are as individuals’
Another noted the facilitation of personal connections between staff, which seemed to have a positive effect on team dynamics:
‘We approach each other more and chat about things, obviously not all the time … it still can be busy as ever but, I don't know, I think it's knitted us together as a team’
Discussion
Results suggest that participation in the 4-day CBC course had a transformative effect on attendees, facilitating the ability to meet the intense demands of clinical practice and establishing a foundation for their delivery of person-centred, compassion-based care. Interview data illustrated that staff were enabled in reflecting and reconsidering their engagement with life, work and self-care, which appears to have resulted in the promotion of compassionate care delivery. It was demonstrated that the course had a positive impact on team dynamics, subsequently improving the latent culture of the clinical area.
Although not included in the stated methods of the evaluation, it is worth noting that several key organisational indicators support the positive results described in this paper (see Box 1). Effects, such as reduced absence, also hold the potential for cost efficiency, which is an agreeable by-product of improving the care environment.
While Francis (2013) highlighted a lack of compassion in care delivery at the Mid Staffordshire NHS Trust, it has also been demonstrated that poor staffing, substandard care environments, and limited staff education can be linked to patient mortality (Aiken et al, 2008). Concerns about workload impacting on the delivery of compassion-based care may be legitimate, however. To complicate matters, Sousa and Seabra (2018), in their scoping review, identified that more rigorous methods are needed to adequately assess nursing workload in acute psychiatric settings. Indeed, a recent Care Quality Commission (2017) report suggested that, in the future, it may not be possible to discharge the mental health nursing role in the same way as before, but that caring, in its truest sense, remains vital.
Limitations
There are limitations to this evaluation. The risk, however minor, of bias and coercion should be acknowledged in this case. Some staff may have felt pressured into agreeing to the research interviews if prompted by those in their direct management structure. Additionally, anxiety about repercussions resulting from honest but potentially unpopular answers in the interviews might have influenced the accuracy of the data that our analysis was based on. To the best of our knowledge, these factors did not affect the outcome of the study but that cannot be confirmed.
Conclusion
Our findings suggest a profound effect for the compassion-based care course in members of staff from later life services at a hospital in north-west England. Several factors—including declining staffing levels, stagnating institutional culture, and resulting loss of personal and professional identity—are likely to impact on staff capacity for delivering compassionate care to patients. The CHEN programme, especially the CBC course, should be considered for further rollout and evaluation.