The concept of ‘compassion’ has recently gained a high profile with debate over health care provision. Responses by the government and by the press to the Francis report into the shortcomings of the Mid-Staffordshire NHS Foundation Trust have made much of the apparent lack of compassion shown by nurses and other health care providers. There is nothing new in the caring professions’ recognition of the place of compassion as one of their core values, and if anything the Francis report reminds us, not of the importance of the compassion, but of the danger of forgetting its primacy or forgetting how to express compassion in practice.
In recent Think about Health discussions of compassion, at the June 2013 one-day conference held in association with the Royal College of General Practitioners (Scotland) and at our principal 2013 conference in Birmingham, I was pleasantly surprised by how robust a concept ‘compassion’ has turned out to be. Despite rigorous and critical debate, it continues to yield insights into the nature of professional care, and to provide an exacting standard against which to evaluate that care. There remain, without doubt, dangers that the concept can be trivialised and subordinated to the very tick-box culture that it is invoked to frustrate. ‘Compassion’, like ‘dignity’ before it, might be operationalised as a list of discrete behaviours, with compliance being readily quantifiable. Already in 2008, the then health secretary Alan Johnson proposed that nurses should be rated on how compassionate and ‘smiley’ they are.
‘Compassion’ may resist such crude attempts to operationalise it precisely because of its depth and significance. It is broadly agreed, not least on the authority of the Dalai Lama, that compassion entails two components: a sensitivity to the suffering of others and the commitment to relieve that suffering. To be compassionate thus entails a capacity to suffer with another, feeling, to some degree, their pain and distress, alongside the motivation to alleviate that pain. Doctors and nurses (and one may hope, many others who work in the NHS in all sorts of positions) are compassionate. They enter the NHS typically because they are sensitive to the suffering of others and want to do something to alleviate that suffering. Against crude quantification and the Taylorist mentality of the tick-box culture, compassion sustains the carer’s sensitivity to the qualitative unique experiences and needs of the patient before them.
Yet, not all who work in the NHS are compassionate, or at least, their compassion and sensitivity to suffering of others gets blunted. Mid-Staffs, tragically, demonstrated this. Perhaps the problem with compassion lies in how burdensome it can become. Burnout, a long recognises malaise of the caring professional, may in part be due to this burden. A compassion fatigue of sorts may set in, precisely as the burden of caring becomes too great. A problem may lie in a certain ambiguity in the description of compassion offered above. The compassionate person suffers with the patient. They are motivated to remove this suffering. It is here that the ambiguity lies, for one may remove one’s own discomfort – one’s own burden of suffering – by either alleviating the pain of the patient, or by protecting oneself from it – hardening and blinding oneself to the other’s pain. The moment I cease to suffer sympathetically I relieve my own burden, and I do so regardless of what has happens to the patient.
Such callousness may seem easy to condemn. However, professional carers do need a certain distance from their patients, and techniques to let go of those sympathetic feelings. To sympathise too closely with the suffering of another will inhibit the carer’s capacity to act effectively and professionally. Further, if that distance is not there, then the threat of burn out will be intense. An equilibrium is required, but such equilibrium rests as much upon the carer’s environment as it does upon their internal, psychological resources.
In certain environments, the suffering of the patient may never seem to be relieved. The patient’s condition may indeed be chronic and worsening, and there is seemingly nothing that the carer can do nothing to help. More drastically, perhaps, an inappropriate organisation of duties and hospital wards prevents the carer from ever seeing the patient’s recovery. They have always been moved on, or you have been reallocated. Perhaps the resources, equipment, drugs or staffing numbers, that are required to relieve suffering are simply not there.
Paradoxically, it is conceivable that it is the most compassionate and highly motivated carers who are most vulnerable to the sort of callousness that I have outlined. Perhaps the most compassionate are the most vulnerable to burnout, and those that survive in adverse circumstances are the most likely to become cynical and blind to the suffering around them.
A staff of compassionate carers cannot then be guaranteed just by the provision of training early in their careers, or even by the careful selection of recruits into the caring professions. A compassionate staff requires continual support, and the clear articulate of reasonable expectations as to what can and not be achieved. Such staff need the time and resources, not least in terms of the support of the colleagues and employers, to balance compassion for others and compassion for themselves, and to reflect upon their practice. Initiatives, such as Schwartz rounds, already exist. Crucially, compassion is therefore not a quick or cheap fix for the ills of the NHS. It is a demand that can simply be imposed upon smiley carers, but rather as product of the careful organising of the systems that facilitate care, and that support the carers.
Compassion is a robust concept. Its importance, both in professional ethics and professional psychology, lies in the demands that it makes upon us to continue to think radically about what care is, and what it demands from the carer and the systems that support them.
(As everyone who was there will have realised, in putting together these reflections I have drawn freely on the wonderful insights of the contributors to the Think about Health ‘Compassion Fatigue’ conference. I thank all the speakers, workshop convenors, and delegates for the success of that conference.)
Convenor – Think about Health