This is a cross-posting of a guest blog I did in December 2013 for the Guardian blog ‘Sifting the Evidence‘, usually written by the brilliant Suzi Gage.
Healthcare services have come under fire in 2013 for their lack of compassionate care, particularly post-mid-Staffs scandal. Mid-Staffordshire NHS Foundation Trust was found to have serious failings in provision of care which resulted in patient distress and deaths.
The QC who conducted the Francis report, the investigation into the inadequate care, identified a lack of compassion as being amongst the major causes of negligence. Since then, ‘compassionate care’ has become a new healthcare buzz-phrase, with drives to improve it in NHS trusts nationwide. Somewhat ironically, lack of compassion has also become the new stick to beat the already much-beaten NHS with.
Compassion is described in Buddhist tradition as a wish for all beings to be free of suffering and the causes of suffering. It is also defined as a capacity to meet pain with “kindness, empathy, equanimity and patience”, both in ourselves and in others.
Pain is unpleasant, frightening, sometimes even horrifying in its sadness. This is true whether it is our own or that of those around us. When we think about what compassion actually involves, being open to this pain in ourselves and in others, perhaps it becomes a little easier to see why healthcare workers might find it difficult to be compassionate at all times.
Experiencing or being around others who are experiencing physical or emotional pain can be frightening, and some jobs require this on a daily basis. Fear of being overwhelmed, or being helpless to change anything, of becoming upset and not able to recover… 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.
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 stopped. 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.
Let’s translate this to the NHS. The current, and under-reported, financial cuts , have resulted in hospitals being short-staffed and existing staff trying to do more tasks in the same amount of time. Given what we know about the effects of lack of time on compassion, can we be entirely surprised that mid-Staffs happened? This is not to excuse a gross failure of care which should not have occurred. But perhaps we can understand it, in the hope of preventing it happening again.
The Good Samaritan study has everyday implications as well. How many times have you been caught up in commuter rage when you were late for work? Or felt that you could have stopped to spend more time with someone, if only you hadn’t got quite so much that you needed to do?
The research is a warning to us all, to keep an eye on a lack of time becoming a constraint on our ability to care and connect with the people around us, whether they are a stranger in the street or a close friend.
This fits, too, with the well-described phenomenon of compassion fatigue. Particularly prevalent in workers who are exposed to high levels of emotional trauma, this type of ‘burn out’ involves caring professionals finding it hard to care as much, and therefore distancing themselves from their patients. To some extent, distance is helpful (it is hard to help someone feel less depressed if you end up empathising so much that you feel depressed yourself). But to cut off too much becomes unhelpful and can feel dehumanising, for both the patient and the healthcare worker.
Leading compassion fatigue researcher Dr Charles Figley emphasises the need to be kind to ourselves in order to be able to be kind to others. Again there are implications here for everyday life: the more we can acknowledge when we are struggling, the better we can probably deal with whatever is going on and be able to treat others better.
I asked Figley what advice he would give on maintaining compassion at this time of year. He said, “Compassion fatigue is when the price is too high for dispensing compassion. Compassion satisfaction is when the rewards for dispensing compassion assure being compassionate more. Being compassionate means considering how best to help those less fortunate and also means being kind to yourself. In the Spirit of Christmas, being compassionate involves caring for others and ourselves.”
So if fear, lack of time, and over-exposure to trauma reduce our ability for compassion, what are the factors that boost it and enable us to follow Figley’s advice? Can we learn compassion? Or is it something innate that we either have or don’t have?
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.
This study doesn’t establish whether or not there is a noticeable effect of compassion training on compassion experienced by others. Several NHS trusts are now trialling leadership programmes which take particular notice of compassion promotion, and the outcomes of these will be interesting to see.
Whatever the results of these compassion training programmes, it has been all too easy, this year, to blame an amorphous “NHS” for failures. But what do we mean by “the NHS”? The workers? The management structures? The whole organisation? The government funding and policy direction? It feels odd to me when the government criticises “the NHS” when the NHS is a government-funded and directed body.
One of my concerns about the growing number of services and responsibilities which are being outsourced to private providers or to GPs, is that this enables the government to split off from and criticise the NHS, whilst simultaneously cutting the funding that allows the NHS to function.
The tendency in the media to blame “the NHS” is also misleading. The NHS is made up of nurses, doctors, managers, commissioners and is funded by the Government. To criticise “the NHS” often comes across as saying that all NHS workers are bad or uncaring. In fact, it might be just as valid to attribute at least some responsibility for inadequate care to a lack of funding resulting in difficult working conditions. What we saw in mid-Staffs was awful, but it was also a very human response to a chronically stressful working situation.
Compassion, both towards others and towards ourselves, has been linked to increased personal wellbeing. Maybe 2014 could usher in an attempt to take a more compassionate attitude towards the NHS. It might just end up benefiting everyone.