compassionate nursing essay

12 Ways to Show Compassion in Nursing (With Examples)

It is not uncommon to face difficult, often heartbreaking, situations as a nurse. Knowing what to say or how to respond is not always easy. Even the most experienced nurses can struggle at times. What happens when you don't know what to say to a patient or how to act when a loved one is given bad news? How can nurses show compassion in nursing practice while still maintaining composure and professionalism? Is that even possible? The good news is even though some days are easier than others, it is possible to learn ways to be more compassionate as a nurse. In this article, I will share why compassion in nursing is essential and offer 12 ways to show compassion in nursing practice.

What Does Compassion in Nursing Practice Exactly Mean?

Why is compassion important in nursing practice, 1. patients are more comfortable., 2. compassionate nursing practices improve patient outcomes., 3. compassion in nursing practice extends beyond patient care, affecting interprofessional relationships., 4. compassionate nursing helps strengthen nurse-patient relationships., 6 key skills a nurse must-have for delivering compassionate care, 1. resilience:, 2. excellent communication:, 3. emotional intelligence:, 4. confidence:, 5. cultural awareness:, 6. critical thinking:, how can nurses show compassion in nursing practice, 1. listen to what your patients and their loved ones say (and what they do not say)., for example:, 2. show genuine interest., 3. learn to express empathy when appropriate., 4. acknowledge your patient’s feelings., 5. be patient., 6. respect your patient’s need for privacy., 7. take the time to explain treatment plans and answer questions., 8. get to know your patients., 9. be present., 10. be aware of moments that require high levels of compassion., 11. even if you can’t empathize with your patient, you can sympathize., 12. take care of yourself., what causes compassion fatigue in nursing practice, 5 tips to prevent compassion fatigue in nursing practice, 1. set emotional boundaries., 2. practice self-awareness., 3. establish a healthy work-life balance., 4. implement active coping mechanisms., 5. develop a support system., useful resources to develop compassion in nursing practice, youtube videos, my final thoughts.

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• Volume 18, Issue 3
• Compassion is an essential component of good nursing care and can be conveyed through the smallest actions
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• Katherine Curtis
• University of Surrey, School of Health Sciences , Surrey , UK
• Correspondence to : Dr Katherine Curtis, University of Surrey, School of Health Sciences, DK Building Guildford, Surrey GU2 7TE, UK; k.curtis{at}surrey.ac.uk

https://doi.org/10.1136/eb-2014-102025

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• ETHICS (see Medical Ethics)
• NURSE EDUCATION
• QUALITATIVE RESEARCH

Commentary on : Bramley L , Matiti M . How does it really feel to be in my shoes? Patients’ experiences of compassion within nursing care and their perceptions of developing compassionate nurses . J Clin Nurs 2014 ; 23 : 2790 – 9 . OpenUrl CrossRef PubMed

Implications for practice and research

Patients’ experiences of compassion and lack of compassion contribute to current understanding of complexity within compassionate nursing practice.

Patients believe that nurses can develop compassionate practice through exposure to vignettes of their experiences.

Further research on patient experiences could help identify how to enable ‘fleeting acts’ that convey compassion.

Compassion is not a new concept within healthcare . 1 However, compassion has become the focus of much research and debate during the past 10 years, following reports of lack of compassion within UK healthcare practice. This recent intense focus has addressed many aspects of care practices and education, recognising that compassion is a complex concept. 2 This study adds a further dimension to understand the complexity of compassion, through a focus on patients’ perceptions.

Three main themes were found within the data: (1) patients saw compassion as based on acts that demonstrated human relationships ‘knowing me and giving me your time’; (2) patients believed the impact of compassion was a sense of empathising with their situation or ‘being in their shoes’; (3) compassion was the essence of nursing and required communication alongside inherent values-based care.

The study provides a further contribution to understand compassion within healthcare practice through the patient's experience and to promot and develop compassionate nursing.

During the past 10 years, reports of poor standards of care and outright cruelty have frequently been in the press and quite rightly have caused outrage within and outside healthcare professions. Compassion has been the focus of numerous recent research studies that have led to debates on how best to promote compassion within healthcare and health professional education. Some commentators reflect longingly back to several decades ago when healthcare systems supported a different and more limited scope of practice for nursing and where organisations supported higher levels of qualified staff to patient acuity. They suggest that nursing should go back to its ‘old ways’. They also suggest individual or society morality and the changes in nurse education are responsible for deficits in compassion today. However, identifying and correcting the ‘fault’ in the system is not as simple as some suggest. Time cannot be turned back and why would society want to when some of those ‘old ways’ included: parents kept away from their hospitalised children; people with mental health problems being shut way in institutions and restrained; far less sophisticated and less effective surgical and medical treatments for trauma and disease.

This study reaffirms compassion within 21st century healthcare as a complex concept. It has multiple predisposing and constraining factors within today's practice and education environments. 3 Compassionate practice does not simply rely on an individual demonstrating empathy and kindness but on the moral, emotional and organisational environment within which that individual learns their caring craft. 4 , 5 Attempts to identify and address deficits in compassion require recognition of this complexity in order to avoid over-simplified or single focused solutions. Dr Jocelyn Cornwell explained this clearly at the Kings Fund ‘One year on from Francis’ event, suggesting how UK healthcare systems, within which compassion is an expectation, are perfectly designed to produce the results they currently get. 6 It is therefore important to consider the findings from this study within a whole system approach to improving compassionate healthcare provision.

• Leninger MM

Competing interests None.

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"nurse: just another word to describe a person strong enough to tolerate anything and soft enough to understand anyone.", empathy and compassionate care essay by: olivia gagne, december 4, 2019 ogagne.

One important thing I have learned in clinical is that I have the power to make a difference in patients lives, one patient at a time.  To do so, a nurse must remember to not only use empathy, but compassion as well.  One story that I always remember is the star fish story.  It’s about a five year old girl on a beach in Florida after a hurricane had destroyed their land.  There were thousands of star fish washed up on the shore.  The little girl was throwing starfish back into the ocean, one starfish at a time.  When her father saw her, he said “why are you even bothering?  You will never be able to save them all”.  As the little girl looked at her father, she picked one up and threw it back into the ocean.  She then said, “I saved that one”.  This is a story my high school guidance councilor told me.  It has always stuck with me and has made me realize one important lesson in nursing.  It’s not about how many lives you saved, its about making a difference one person at a time.

From the hallway of the hospital I heard my patient moaning.  When I walked in for the first time, they reached for my hand but spoke no words.  They squeezed my hand, very tight, and immediately calmed down.  As I introduced myself, they intimately looked at me and moaned “hi”.  At that moment I realized a few things.  They could hear and understand me, but they cannot talk due to the accident the patient was in.  Secondly, they needed human touch.  No student nurse had taken care of this patient prior to when I had arrived that day.  The nurses said the patient has been agitated and emotional since the morning.  But as I held the patients’ hand, they were relaxed and showed their half dropping smile.

Throughout my clinical I took care of this patient.  In the beginning, I immediately had empathy.  I put myself in the patients’ shoes and started to picture how scared I would be if I was waking up from a coma.  I pictured what it would feel like if I couldn’t talk or communicate the way I wanted to.  But during this time, I learned that communication isn’t always through speaking, but can also be from hand squeezing for yes, or shaking their head for no.  I could tell they were scared when they moaned after trying to speak to their PT instructor.  Later in the night, it was time to give the patient a bed bath.  After washing my patients’ body with a warm wet cloth, I asked the patient if they wanted lotion and a foot massage.  Immediately they squeezed my hand for yes.  When we massaged my patients’ feet, once again, their whole body relaxed.  At the end of the night, I realized that it’s important to focus on the small things for each individual patient.  Although some wouldn’t know how to comfort this patient, I slowly figured it out over my seven-hour clinical.  You need to have patience, and to focus on going above and beyond to make your patient feel cared for.  As a good nurse, you need to use compassionate care, and focus on the small actions throughout your shift.  During this shift I started to realize what compassionate care was.  It’s not about going into the patients; room, taking their vitals and leaving.  It’s about using empathy to feel what they feel and putting to action what you think would make them feel better; such as a foot massage with lotion and holding their hand when they reach out.

            As a future nurse, in order to use empathy and compassion in my future practice, it’s important to understand what they mean and how they intertwine with nursing.  Empathy is being able to feel what the patient is going through while putting yourself in their shoes.  How would you feel if this was you?  It’s important for nurses to use empathy.  By putting ourselves in the patients’ shoes, we are only then able to further understand what they are feeling, and what they are going through.  Jean Watson, a nurse herself, put together ten carative factors that help to support empathy in nursing.  She stated that it’s important to “create a healing environment for the physical and spiritual self, while respecting human dignity” (Watson, 2018).  While respecting the patient and creating an environment of healing, this encompasses empathy in nursing.  By trying to understand how they feel and what they are going through, the nurse then can move on to compassionate nursing.

Compassionate nursing is using kindness, empathy, and love to ultimately care for the patient.  It’s being able to focus on the patients’ needs and to help relieve their suffering.  Jean Watson’s carative factor one focuses on “the formation of a humanistic-altruistic system of values” (Gonzalo, 2019).  This refers to using love and kindness in your care of practice.  For example, this could be as simple as holding your patients’ hand while they are crying.  It’s holding back their hair while they throw up and giving them an ice pack when the medications haven’t relieved their pain.  Compassionate care is going above and beyond what one needs to do.  It’s not only providing physical healing, but as said in carative factor eight, it’s the “provision of support, and corrective mental, physical, societal, and spiritual” help for the patient (Gonzalo, 2019). 

A nurse who demonstrates compassionate care is able to “understand a deeper meaning of (the patients) healthcare situation”, as demonstrated throughout Jeans ten carative factors (Watson, 2018).  Both empathy and compassion are found throughout Jean Watsons Carative factors.  By using both, it truly changes the patients’ outcomes.  Carative factor four states the importance of the “development of a helping-trusting, human caring relation” (Gonzalo, 2019).  Therefore, by using empathy and compassion, the patient trusts the nurse more, and builds a stronger foundation of hope, care, and love between both the nurse and the patient.  This increases patient healing far past only physical healing, and truly benefits the clients outcomes.  Both compassionate care and empathy help to demonstrate the amazing power of a compassionate nurse in healing the patient not only physically, but mentally.

My role for the patient talked about above was wanting to help them feel loved and cared for.  By holding their hand when they reached out, and focusing on the small things the patient needs,  I was able to build a stronger patient nurse relationship.  I also met the patients’ spouse multiple times, and learned more about what they patient did before the accident.  In my future, I want to remember this patients impact on me, and my impact on the patient.  The patient made me realize that they aren’t only patients.  They are a mother, father, aunt, uncle, daughter, cousin, and friend.  They might be a couch, teacher, firefighter, singer, gymnast, or swimmer.  In my future, I want to improve in remembering that each patient has a different identity than what the nurse knows them as.  They are more than just a patient.  They are human.  They need touch just like we need touch, they need love and kindness, and ultimately they need understanding and care. 

In my future I will have more patients, more documentation, and more priorities.  But I need to remember this one special thing I have learned.  In my future, I want to remember why I joined nursing.  This includes something I learned from the starfish story.  It truly does not matter the amount of patients you helped compared to how many your co-worker helped.  It comes back to providing compassionate care for one patient at a time and being the best nurse you can be for that individual patient.  This includes helping people heal not only physically, but socially, emotionally, and mentally.  My goal is to improve on focusing on each patient for who they are and helping to provide the patient with what they need.  I will incorporate this into my everyday life as a future nurse by coming back to the core of nursing.  This includes being kind, loving, caring and compassionate.  By remembering a nurses’ core values, I will be able to focus on the little things every day to make a small difference one patient at a time.

Gonzalo, A. (2019, September 12). Jean Watson: Theory of Human Caring. Retrieved November 12,

2019, from https://nurseslabs.com/jean-watsons-philosophy-theory-transpersonal-caring/ .

Watson, J. (2018, October 7). Jean Watson Theorist Presentation. Retrieved November 12, 2019, from https://www.youtube.com/watch?time_continue=313&v=o1EN0VH9xCE&feature=emb_logo

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Defining compassionate nursing care

Affiliations.

• 1 The Chinese University of Hong Kong, Hong Kong; Sun Yat-sen University Nanfang College, China.
• 2 The Chinese University of Hong Kong, Hong Kong; University of Dodoma, Tanzania.
• 3 The Chinese University of Hong Kong, Hong Kong; University of the Philippines Manila, Philippines.
• 4 University of Nebraska, USA.
• PMID: 31284827
• DOI: 10.1177/0969733019851546

Background: Compassion has long been advocated as a fundamental element in nursing practice and education. However, defining and translating compassion into caring practice by nursing students who are new to the clinical practice environment as part of their educational journey remain unclear.

Objectives: The aim of this study was to explore how Chinese baccalaureate nursing students define and characterize compassionate care as they participate in their clinical practice.

Methods: A descriptive qualitative study design was used involving a semi-structured in-depth interview method and qualitative content analysis. Twenty senior year baccalaureate nursing students were interviewed during their clinical practicum experience at four teaching hospitals.

Ethical considerations: Permission to conduct the study was received from the Institutional Review Boards and the participating hospitals.

Results: Baccalaureate nursing students defined and characterized compassionate care as a union of "empathy" related to a nurse's desire to "alleviate patients' suffering," "address individualized care needs," "use therapeutic communication," and "promote mutual benefits with patients." Students recognized that the "practice environment" was characterized by nurse leaders' interpersonal relations, role modeling by nurses and workloads which influenced the practice of compassionate care by nursing personnel.

Conclusion: Compassionate care is crucial for patients, nurses, and students in their professional development as well as the development of the nursing profession. In order to provide compassionate care, a positive practice environment promoted by hospital administrators is needed. This also includes having an adequate workforce of nurses who can role model compassionate care to students in their preceptor role while meeting the needs of their patients.

Keywords: Baccalaureate nursing students; China; clinical practice; compassionate care; qualitative research.

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Recognizing Care and Compassion in Nursing, Essay Example

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Introduction

Professional nursing requires expert knowledge and understanding of a variety of health concerns that impact the live of patients and affect their wellbeing. To accommodate patients, nurses must also express emotion and compassion to support their needs and to raise awareness of the emotional context of health and healing. Patients often recognize when nurses do not show compassion for their situations and may experience setbacks in the process. Therefore, from a conceptual point of view, nurses must be able to perform their roles effectively and to support patient care quality through their actions towards patients. This process encompasses a moral component that requires nurses to provide a high standard of care and treatment to patients at all times (Beckett, 2013). However, in some respects, this is a learned concept that requires further investigation and evaluation in order to ensure that patient care is not compromised and that they respond favorably to direct care and compassion in the healthcare environment. Nurses who demonstrate compassion must be effective communicators and encourage a positive and meaningful environment to promote patient healing and recovery.

Nurses may not always demonstrate compassion in the work environment because it is somewhat ambiguous in nature, thereby creating a challenging environment in which patients are likely to experience the lack of emotion and connection to their needs (Beckett, 2013). Caring should be inherent with all nurses; however, this concept often requires learning and an understanding of patient care needs that will satisfy patient outcomes and stimulate healing (Beckett, 2013). Some nurses have not likely experienced a caring and nurturing home or family environment, thereby contributing to the disconnect to patients that is often observed, and as a result, requires some degree of nurturing and support to ensure that patients receive the best possible care and treatment in a timely manner (Beckett, 2013).

Nurses may disconnect from their responsibility to be compassionate with patients because they may not recognize that it is absent and that their own actions do not coincide with patient needs (Castledine, 2005). Therefore, it is necessary to develop a framework that will enable nurses to recognize how to exercise compassion and to be present for their patients at all times (Castledine, 2005). Furthermore, nurses also possess limitations of their own, and these must also be addressed in the context of their ability to be compassionate towards their patients (Castledine, 2005). First and foremost, patients who experience compassion from their nurses are likely to be receptive to this emotional context and will be successful in achieving the desired results in terms of their recovery (Castledine, 2005). Also, it is necessary to support an environment that embraces change and also supports progress for patients who experience compassion from their nurses with each interaction (Castledine, 2005).

From a conceptual point of view, nurses should recognize how patients from different age groups with different areas of need require compassion to promote recovery, and this is an important step towards the discovery of new challenges that will impact quality of care and also support the growth of practice settings to achieve the desired outcomes (Van der Cingel, 2011). Nurses must demonstrate a humane and moral approach to their practice that depends on offering a compassionate perspective and level of support to meet their needs (Van der Cingel, 2011).  The process of advancing healthcare practice through compassion is essential for nurses because it supports their own growth and maturity in the profession and provides patients with a caring and nurturing environment (Van der Cingel, 2011). Compassion is not a learned concept but it requires significant attention and focus by all nurses in order to achieve greater health and wellbeing for all patients (Van der Cingel, 2011).

Finally, nurses with limited levels of experience may find it difficult to exercise compassion and to determine how much compassion is required to support their patients (Horsburgh & Ross, 2013). In this capacity, nurses may not be up to the task of providing optimal compassion for their patients, and therefore, this process is likely to improve with experience (Horsburgh & Ross, 2013). At the same time, nurses with lower experience levels may find themselves conflicted regarding their roles and responsibilities, which requires an increased understanding of these roles to ensure that patient needs are met as required (Horsburgh & Ross, 2013). As a result, nurses must be exposed to compassionate care in the work environment so that they are able to effectively adapt to this process in their own experiences to improve patient recovery and satisfaction (Horsburgh & Ross, 2013).

Compassion is a key nursing concept that requires significant understanding and focus across all practice settings. Nurses must be able to provide a compassionate care and treatment environment that supports change and stimulates recovery and wellbeing. Although some nurses exercise compassion at higher levels than others, the concept is critical to the practice setting and requires much nurturing and ongoing support in order to facilitate the desired results. Compassion in nursing is essential to facilitate high quality patient care and treatment for all patients and requires an ongoing effort from nurses to be effective contributors to the practice setting in order to achieve effective results. Patients must be provided with an environment in which nurses show compassion towards their needs and encourage them to follow the steps that are necessary to encourage recovery.

Beckett, K. (2013). Professional wellbeing and caring: exploring a complex relationship. British Journal Of Nursing , 22 (19), 1118-1124.

Castledine, G. (2005). Castledine column. Recognizing care and compassion in nursing. British Journal Of Nursing , 14 (18), 1001.

Horsburgh, D., & Ross, J. (2013). Care and compassion: the experiences of newly qualified staff nurses. Journal of clinical nursing , 22 (7-8), 1124-1132.

Van der Cingel, C. J. M. (2011). Compassion in care: A qualitative study of older people with a chronic disease and nurses. Nursing ethics , 0969733011403556.

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• Debate article
• Open access
• Published: 11 July 2016

Reflections about experiences of compassionate care from award winning undergraduate nurses – What, so what … now what?

• Stephen Smith 1 ,
• Asha James 3 ,
• Allison Brogan 2 ,
• Elizabeth Adamson 1 &
• Mandy Gentleman 1  

Journal of Compassionate Health Care volume  3 , Article number:  6 ( 2016 ) Cite this article

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From 2007 until 2012 Edinburgh Napier University’s School of Nursing Midwifery and Social Care in conjunction with NHS Lothian, collaborated on a programme of action research entitled, the Leadership in Compassionate Care Programme. One strand of this research focused on learning and teaching about compassionate care within the undergraduate curriculum. This debate article focuses on the care issues raised by two award winning nursing students who reflected on the development of their compassionate caring skills during their three year Bachelor of Nursing programme.

The reflective accounts debate the following issues related to compassionate care; Personal drivers supporting the provision of compassionate care, Challenging and influencing care practices, Providing relationship centred care and, Living with what can’t be achieved. Throughout the debate a model of compassionate care developed from the Leadership in Compassionate Care Programme is used to reflect on key practice issues and provide a framework for practice development.

The care issues presented in this paper identify a need to support students in healthcare to; Develop strategies in questioning care practices which do not meet expectations of compassionate care; undertake focussed reflective activities where each student can explore personal drivers, values and perspectives of compassion; actively connect learning in practice with theory in university, enable development in compassionate caring and strategies that support self-compassion; facilitate an understanding and development of emotional intelligence supporting development of resilience.

Implications for healthcare staff are to; Collectively seek, hear and respond to feedback about their service; activate caring conversations within the healthcare team; consider how the model of compassionate care presented in this paper, can be used to reflect on practice and provide a framework for development; consider how we maximise the experience of care during brief moments of contact with patients/families; activate leadership that promotes a culture of openness facilitating the development of compassionate care.

From 2007 until 2012 Edinburgh Napier University’s School of Nursing Midwifery and Social Care in conjunction with NHS Lothian, collaborated on a programme entitled, the Leadership in Compassionate Care Programme (LCCP) [ 1 ]. NHS Lothian provides a comprehensive range of primary, community-based and acute hospital services for the second largest residential population in Scotland - circa 800,000 people, it employs approximately 24,000 staff. The School of Nursing, Midwifery and Social Care at Edinburgh Napier University provides undergraduate and post graduate education to nurses, midwives and multidisciplinary staff involved in health and social care. There are approximately 1600 students in the school.

The LCCP utilised an action research approach with the aim of embedding compassionate care in NHS healthcare practice and within undergraduate nursing and midwifery education. The LCCP encompassed four key strands of work: developing compassionate clinical practice; supporting newly qualified practitioners; leadership development and undergraduate nurse education. This action research programme was funded by a private benefactor. A key outcome of this action research identified a model for compassionate care in practice which incorporates six components, see Fig.  1 . This model relates to activities undertaken between care providers, service users and their families/important others, for example caring conversations should take place between care providers as well as between staff and service users. Debating, challenging and celebrating care provision is an important activity to be undertaken amongst staff. The LCCP action research identified that this was a key activity if compassionate care is to flourish in a care setting. Throughout this article reference will be made to this model and how the reflections presented highlight its key components.

Model for compassionate care in practice [ 14 ]

This debate article focuses on the care issues raised by two nursing students (adult field) who reflected on development of compassionate caring skills during their three year Bachelor of Nursing programme. These reflections were written as part of their successful submission for the Simon Pullin award. The Simon Pullin award is given to students who have shown excellence in the development of person centred, compassionate caring skills during their programmes of study. The award is dedicated to the memory of Simon Pullin, who was a Senior Nurse on the Leadership in Compassionate Care Programme from its commencement in December 2007 until his death in July 2011. This award highlights the fundamental importance of compassionate care as part of contemporary Nursing and Midwifery practice. The award winners Alison Brogan and Asha James have contributed their reflections and analysis of compassionate care in the planning and writing of this paper and they have agreed to be identified within this writing. The key issues related to the provision of compassionate nursing care debated in this article are as follows:

Personal drivers supporting the provision of compassionate care

Challenging and influencing care practices, providing relationship centred care, living with what can’t be achieved.

This article incorporates the What, So what and Now what [ 2 ] reflective model as a way of reflecting on experiences of compassionate care.

Borton’s model asks individual’s to consider three questions: “What?”, “So what?” and “Now what?” The first question asks a person to consider what has happened, the second question is to allow the person to try and make sense of what has happened and evaluate events and the last question is to consider a way forward and think about what could happen in the future [ 3 ].

The LCCP identified that discussions about care ‘caring conversations’ and working with feedback are key activities enabling compassionate care to thrive. The use of a reflective model acts as a as a springboard supporting such discussions in practice (Table  1 ).

‘I was a child carer from a very young age for my mum, who suffered with alcohol dependency. Life was far from easy, but I always understood that my mum did not choose to live like this and what she had was an illness. However it appeared that many healthcare professionals did not share this understanding and their lack of compassion, respect and dignity often left my mum feeling judged, embarrassed and worthless. This caused a lot of distress for my mum and for the family. This was the beginning of my dream of becoming a nurse… if I was a nurse I would be kind to my patients and care for everyone the way I would have liked my mum to be cared for…. The negative attitudes we experienced as a family by healthcare professionals have enforced my passion for person centred, compassionate care.’ Asha

It is evident from this reflection that past negative experiences of healthcare had provided a strong personal driver to enter the nursing profession but moreover to develop a future focus on care that is compassionate and directed towards the person, their needs and their context. The negative elements of this account point to feelings of injustice, frustration and are a consequence of care experiences resulting in emotional distress for a vulnerable person and their family. It is indeed commendable on a personal level that despite these significant negative experiences this generated a desire for Asha to become a nurse and ultimately lead to successful completion of a nursing degree and recognition of excellence in the development of her compassionate caring skills.

This reflection triggers questions about how health and social care educators can support students to learn from their life experiences and consider their individual values and how this may support developments of caring and compassionate attributes in practice. In Asha’s reflective account, development in compassionate caring arose from her previous negative experiences of healthcare and this appears to have been integral to her approach to care and her values. It is necessary to support each student within their own context and personal experience. When considering Asha’s experience of caring for her mother, the complexity of this situation and the impact on Asha’s own health and wellbeing are key factors to consider.

‘ Like many children in my situation, I was exposed to domestic violence and parental mental health illness, as a result my functioning was adversely affected. School in general was a struggle and I left with practically no qualifications. I had no confidence and low self-esteem. When I was twenty four, my mum died, she had Cirrhosis of the liver. This was a devastating time for myself and my family. I went to counselling and gradually started to turn my life around. It’s taken many years and with the support of my husband, who has always believed in me, I started college to gain the qualifications I needed to get me into nursing. I could not ask for more. I am confident and happy in what I am doing today.’ Asha

It is clear from this candid reflection that considerable work and energy from Asha herself, her family and professionals have enabled a sense of wellbeing and healing to emerge. This in turn enables her to practice with emotional intelligence and to raise a challenge with colleagues when care standards are not achieved. It is critical to consider how colleagues, teams and organisations support this maintenance of functioning over time.

Questions are therefore raised as to how we support learners who have less clear articulation of past experiences of care, their personal values and where this leads in the development of caring skills. Indeed how does this issue play out for learners who have directly experienced abuse or life contexts where experiences of compassion would be deemed less than positive? There appears something fundamentally crucial about mirroring a compassionate, person centred learning experience for our students whilst we encourage them to explore their values and approach to care. This in turn raises questions about academic staff modelling attributes of care and compassion within their professional practice.

As we have discussed when students embark on their programme of study they bring with them their own life experience, values and beliefs, and some of these will be challenged as they experience healthcare practice. One way that students can be encouraged to reflect on the experiences of those who give and receive care is through listening to and reflecting on stories gathered within clinical practice and relating this to their own experiences of giving care ([ 4 – 6 , 1 ]). Nursing students often make reference to their own personal care encounters, episodes that have been deemed less than compassionate can present a strong driver for student nurses to achieve more positive experiences for others. Teasing out learning from stories provides a student centred approach to considering issues of care and compassion. What do I make of the care experience? What would I have done in this situation and why would I respond in this way? What possibilities of compassionate caring are evident in this story/context? Reviewing stories in a group learning context facilitates the student to further explore varied perceptions and approaches to care and compassion. This form of group learning requires careful facilitation enabling students to safely question practice and approaches to care, then consider possibilities for their future practice.

The intertwining of practice learning experiences with the students’ life experiences and values provides a potentially provocative opportunity for development. There are some thorny practical issues here that require deliberation if we are to maximise this practice learning. How do we support students and mentors to capture these learning stories from practice and how do we integrate these within theoretical learning about compassionate care within the university context? If personal stories and narratives are a key component of learning about compassionate care we need to activate the integration of this learning between theory and practice.

Caring is fundamental to nursing and therefore must be an integral part of nurse education. Concerns about poor care and lack of compassion are frequently reported in the media, those responsible for nurse education are acutely aware of this as they develop curricula and focus on preparing students for the profession. Whether compassionate care can actually be taught has been debated [ 7 ]. McLean [ 8 ] makes a case for a values based curriculum that encourages self-awareness through a values based enquiry model which encourages the student to challenge existing beliefs and values and develop the character they require to be providers of care and compassion. Nurse Educators can teach the theory of compassionate care but application in practice can be challenging as demonstrated in the reflective accounts in this paper. Curtis [ 9 ] found that student nurses wanted to provide compassionate care but felt unsure of their capacity to do this and sustain it in practice. Others suggest that students’ ideals of care, though already present as a strong motivator when they commence their studies, increased as they grew in knowledge and competence [ 10 ]. They also found that when students experience moral distress when these ideals are challenged through witnessing poor care, these ideals are upheld. These emotionally challenging situations can however become a vehicle for personal and professional growth when students find the courage to uphold their ideals and increase their ability to provide care that is more compassionate [ 10 ].

While nurses are focused on caring for others, it has been argued that practitioners require to be compassionate with themselves [ 11 ], and this is associated with the development of emotional intelligence [ 12 ]. The emotionally intelligent nurse is said to be one” that can work in harmony with thoughts and feelings” ([ 13 ], p. 94) therefore is able to respond to both when working directly with patients and their families. This form of emotional intelligence provides the potential of understanding and connecting with those being cared for whilst recognising and responding to personal strengths and vulnerabilities. Research evidence suggest a connection between emotional intelligence and cultural intelligence (Moon, [ 14 ]) and this is evident in the reflections of care shared by Asha and Allison. Cultural intelligence relates a person’s capacity to function successfully in culturally diverse situations (Ang, Dyne & Koh [ 15 ]). In the account of a clinical placement experience overseas, Asha expressed astonishment and concern at the discriminatory custom and practice she encountered. The cultural approach to care for indigenous people was in direct conflict with her ideals of compassionate person centred care and she felt unable to act in the way directed. Instead she engaged in building a trusting relationship with the family and was rewarded with expressions of gratitude. Not only did it take courage as a student to challenge the practice of a registered nurse but particular resolve and determination to do this in a different culture. By demonstrating how a person centred accepting approach could be not only successful but welcome by a patient and their family she challenged her colleague.

Whether compassionate care can actually be taught has been debated [ 7 ]. McLean [ 8 ] makes a case for a values based curriculum that encourages self-awareness through a values based enquiry model which encourages the student to challenge existing beliefs and values and develop the character they require to be providers of care and compassion.

In addition it has been argued that unless a healthcare practitioner is compassionate to themselves they cannot provide compassionate care for others [ 11 ], and this is associated with the development of emotional intelligence [ 12 ]. The emotionally intelligent nurse is said to be one” that can work in harmony with thoughts and feelings” ([ 13 ], p. 94) therefore is able to respond to both when working directly with patients and their families. This form of emotional intelligence provides the potential of understanding and connecting with those being cared for whilst recognising and responding to personal strengths and vulnerabilities. Research evidence suggest a connection between emotional intelligence and cultural intelligence (Moon, [ 14 ]) and this is evident in the reflections of care shared by these students.

Considering the model of compassionate care identified by the LCCP [ 1 ] it would seem appropriate that Caring conversations and Feedback would be critical components of the model to concentrate on. Observing and participating in caring conversations in practice will provide opportunities to hear debates and have discussions about how to care, and develop understanding of the real dilemmas of care. In addition receiving feedback about their own caring and compassionate skills from practice mentors will complement the potential for students to develop caring skills and reflexive practice. All of these activities will provide opportunities to both challenge and construct learning based on their own drivers and values.

Both of our students incorporated the issue of challenging and influencing compassionate care practices within their reflective accounts. They took different approaches to influence staff. It is recognised that for students and NHS staff raising concerns about practice with mentors and practice staff can be a daunting experience [ 16 ].

‘Encouragingly I recognised that as a third year student I was starting to feel confident in being able to influence colleagues. Whilst in the community setting I cared for a patient who could be rude and verbally aggressive. He was abrupt with me during my first solo visit and referred to me as student. He had COPD and leg wounds, he was very particular about everything and was quite obsessive. I realised that this man had little control over anything in his life and I suspected this is what drove his behaviour. By my third visit I had worked out exactly how he liked things done and instead of letting him get anxious and out of breath telling me what to do, I gently took control of the situation. I did things in the order he liked….. this didn’t take any more time – in fact it saved time. By the end of my fourth visit he asked my name. I was able to relay this during handover with my community colleagues and I explained that I thought his behaviour had been driven by fear and loss of control. With this understanding and consideration of what was driving his aggressive behaviour his relationships with the nursing team improved significantly. He seemed more content during nursing visits and so did some of the nursing staff.’ Allison

This reflective account highlights a particular approach to a challenging caring situation, namely approaching it with eyes wide open, thinking what is happening here and what could my contribution be? It is evident behaviours were observed with a view to understanding them and importantly considering how this guided practice. It is evident that emotional intelligence was key in considering and moderating practice behaviour in this context. ‘ Theoretical and editorial literature confirms emotional intelligence concepts are central to nursing practice. Emotional intelligence needs to be explicit within nursing education as emotional intelligence might impact the quality of student learning, ethical decision-making, critical thinking, evidence and knowledge use in practice’ [ 17 ]. The challenge to her community colleagues was to adapt their practice in the light of an enhanced understanding of the person’s situation. Talking about this openly with colleagues as part of a formal forum facilitated an enhanced change of communication style and active recognition of the reasons behind the patient’s irritable behaviour. In turn this gave an opportunity to consider action/practices which would enhance the care experience for both the patient and the nursing staff? Smith et al [ 18 ] highlighted the importance of reflective forums when considering an understanding of compassionate care in the workplace, findings from this action research identified three key themes; leadership, culture, professional and personal development. It is evident that these findings and key themes have congruence with Alison’s reflective account and the outcomes for the community team.

The influence and challenge here was based on Alison’s perceptions and experience of care provision. She used her own observations and positive practice experience to influence colleagues asking, can we learn from what I have done? This approach differs to asking the question what can we do about this? This way of influencing appeared natural and real, focusing on an approach which had been successful in practice ensured relevance for staff and additionally provided tangible possibilities for development.

Allison also identified,

‘The nurse manager in this setting was a role model to the team and often openly reflected on her experiences both positive and negative. This encouraged the nursing team to mirror this practice….. The team got together twice daily to discuss patient care. The nurse manager would often make a point of asking what went well and what would you improve. Change was not something to be feared rather it was embraced.’

With this insight Alison was able to utilise this team’s strengths to influence a development in care, further evidence of active emotional intelligence impacting upon practice.

Asha’s influence on care practices adopted a different approach.

‘I was fortunate to undertake a student placement in Western Australia, I was placed in a medical ward in one of Australia’s public hospitals where many of the patients lived in relative poverty. This was a fantastic learning opportunity for me…… There were a lot of aboriginal people attending the hospital and I witnessed some discrimination from Australian healthcare professionals which really surprised me. I was given three patients to care for, one was aboriginal. The nurse I was working with said to me that when caring for this particular patient I had to leave the room once I had done what I was supposed to do. I was not to make eye contact with the patient or the family and not to engage in conversation other than health related topics. I could not believe that I was hearing this from a healthcare professional, this goes against my own values and everything I have been taught. I challenged the nurse about her behaviour…… I was told that this is just how it is and aboriginal people take it as a threat if you make eye contact. I explained I cannot provide care like this and thought it was only fair to treat people as individuals. The next time we worked together she was surprised at how quickly I had built good trusting relationships with the patient and family. I spent time demonstrating empathy, kindness, dignity and respect I got to know everyone…… The family expressed how grateful they were to me for my care which made it all worthwhile!’ Asha

In this reflection the challenge to practice was forthright and highlighted concerns about the provision of compassionate, person centred care. It would appear that a growing awareness of discriminatory care in this clinical context triggered this response to the mentor. It is evident that Asha demonstrated commitment to the quality of care she wanted to provide, moreover she was able to articulate this clearly and challenge current practice with her mentor. This confidence is admirable given she was working in an unfamiliar setting where a culture of discrimination had been identified and working with unfamiliar staff. This brief scenario demonstrates a student nurse whose values, life experience, academic development and clinical practice enabled this way of challenging practice. Clinical confidence, commitment to quality of care and influence is demonstrated and indicates that this can be achieved by student nurses towards the conclusion of their studies.

Asha stated, ‘ when you are a student it is quite easy to feel unsure of yourself or your skills as a nurse, especially when faced with a new situation. Challenging my mentor was not something that came easy to me, however, being firm in my belief by speaking up I feel certain I have helped and cared. I continually set goals to push myself to have the confidence to speak up if I felt it was important to me. You are always going to meet people in life with negative attitudes, but it is important to me not to let them influence my thoughts and actions in any way. I found it difficult relating to the nurse who I reacted to as I felt that she stereotyped this patient and her family. I have no doubt that my own personal experience motivated my decision to question her practice. Having a bit of knowledge also gave me confidence to speak up. I had done a little research about communicating with Aboriginal people prior to visiting Australia, and I was aware that some (but not all) Aboriginal people are uncomfortable with direct eye contact. I felt that I was mature enough to make my own judgements on how to communicate effectively to overcome any barriers.’

Within recent public failures of NHS care, an inability to speak up and raise concerns about practice were highlighted as a factor in the general lowering of care standards, recommendations aimed at addressing this culture and behaviour were identified, ‘Ensure openness, transparency and candour throughout the system about matters of concern’ [ 19 ]. It is therefore critical that caring conversations are healthy and can positively influence the behaviour and care provided by practitioners and the culture of the caring environment. There is evidence of a need to talk about our healthcare organisations with positive values and a clear vision of how compassionate organisation should function [ 20 ].

It is evident that feedback from the patient, their family and the mentor indicated that the care experience provided by Asha was very positive. Unfortunately from this brief reflection we do not have evidence of influence on the mentors practice in this area of care other than her surprise at the positive level of therapeutic relationship developed. There is evidence however that the care provided to this patient and family was influenced and became consistent with Asha’s standards of compassion and person centeredness.

As discussed above Asha made earlier reference within her reflective account to personal experience early in her own life where she experienced discrimination as a consequence of family circumstances, and which enabled her to empathise with the indigenous family who may have felt isolated and misunderstood. Determination to provide compassionate care and challenge established practice took courage, confidence and commitment all of which are identified as fundamental values of care [ 21 ]. This emphasises the need to actively engage with each student throughout their period of study exploring their values, attitudes and caring behaviours.

Cultural sensitively is clearly an element of compassionate person centred care as demonstrated in this example and there is growing awareness that this should be taught within nursing education [ 22 ]. For some time nursing curricula has focused on fitness for practice and clinical competence and this is vital for patient safety but nursing is more than this. Nurses education is increasingly challenged to ensure that graduates are equipped with a spectrum of knowledge, skills and ability where compassionate, person centred care is consistent with safe and effective care. This requires acknowledgement that the students who enter our programmes of study come from a variety of life experiences and cultural backgrounds and as educators we too must meet the challenge to provide a learning experience that addresses and meets the needs of a diverse group of students. This raises the question of how this can be done and how can we ensure that nursing graduates are ready to meet the needs of the people in their care, can also care for themselves, and be able to grow with an ever changing healthcare system?

In relation to the LCCP model of compassionate care the examples provided above in relation to challenging and influencing care highlight the themes; Person centred risk taking and Involving valuing and transparency. Both reflections highlight practices that were focussed on adapting practice to individual need, for example following the instructions of the patient in order to develop trust and reduce anxiety whilst understanding their need for control. Similarly having an awareness of cultural practices but focusing and responding to the patient as an individual. Risks taken here related to deliberately doing things differently from colleagues and experiencing potential negativity as a consequence. Also taking a different approach may not be accepted by colleagues in the long run.

‘I will never forget one of the patients I cared for. After ten weeks she shared that she had outlived all her relatives ….. she said she didn’t know what she had done to deserve this and was so lonely she had no one to cuddle her, then she asked me for a hug. I will never forget the solitary tear drop running down her face when she gave me a hug. I wonder how long it had been since that woman had been hugged? This is one defining moment of my training which makes me strive to build appropriate compassionate therapeutic relationships at every opportunity.’ Allison

This example from practice highlights that personal connection is important in the delivery of compassionate care and that although the patient’s overall care was not being criticised, the emotional aspect of her being had somehow been forgotten. The question, what was important to that individual at that particular time had not been asked. This example also shows that relationships can take time to foster and develop. After 10 weeks of contact with Alison, this woman shared her feelings and vulnerability allowing Alison to respond to her needs in a simple but profound way. There is much debate in the nursing literature focused on terms such as relationship centred care, person centred care and compassionate care [ 23 ]. Following a pragmatic stance they each point to an approach to care that focuses on enhancing the experience of care itself, however relationship centred care provides a balance to this approach whereby the experience of the care giver and care receiver must equally be acknowledged to achieve an overall enriched environment of care [ 24 ].

This care experience emphasises the importance of touch, specifically the request for a hug when feeling isolated and lonely. Perhaps focusing on the appropriate use of touch within a caring relationship can support staff to maximise the caring experience when brief moments are all that are available to staff within busy clinical settings. Touch is not comforting or appropriate for everyone but the questions is, how can we maximise the appropriate use and effectiveness of touch when we have minimal time to care?

‘Many nurses hold the opinion that building relationships and honing communication skills are key to excellent patient care…. During my first year at university I observed that building therapeutic relationships and adapting communication style both saved time and improved patient care. I observed a colleague waking a patient abruptly in keeping with ward routine. The patient who had dementia did not take kindly to being rushed out of bed. She became tearful and ultimately aggressive. This resulted in two members of staff having to assist in calming the situation. In contrast, I witnessed another nurse gently rouse the patient in the morning. She held her hand and physically brought herself down to her level. This nurses’ tone and demeanour was gentle and patient centred, this initial interaction did take longer, however overall it saved time as the patient was happy to allow staff to assist her with her daily care. Inconsistency within the nursing team on this particular ward was very evident.’ Allison

How do we share and provide an opportunity to maximise good practice such as described in this account, and what is the role of a leader in promoting and sustaining compassionate care such as this? Role modelling has been celebrated in an earlier reflection by Allison. The intent and behaviours of leaders are important when establishing a culture of openness and transparency where feedback is viewed as “the norm”. This form of culture facilitates the possibility of sharing and maximising positive practice as well as giving consideration to practice situations which are challenging and fraught. In essence this is working directly with local feedback from patients and staff and holding a persistent focus on caring conversations.

‘What factors drive poor behaviours like this where there appears to be inconsistent approaches to patient care? Notably, the nurse manager on this ward was rarely available. The lack of direct leadership resulted in poor team work and communication within the team. How can we create environments where all patients are given this type of individualised care? Is this primarily driven by influential leadership? I believe a strong inspirational leadership style is a key factor in driving culture change? I believe cultures can be changed when staff are empowered to suggest improvement and champion change.’ Allison

This reflective account highlights the key theme of ‘Creating spaces that work’. What would it take to develop consistency of practice within the care team? Allison’s focus rests on leadership but moreover the need for the team to share, debate and consider how care can be enhanced, in essence work with ’Caring conversations’.

It is considered that most nurses will experience what is commonly termed Compassion fatigue. This concept has been debated widely within the nursing arena. Coetzee and Klopper [ 25 ] conclude that this this develops gradually and is a cumulative process. It is thought that this occurs when one is consistently subject to intense, acute interactions with patients and families. Compassion fatigue can be described as feeling negative emotions as a result of feeling unable to fulfil their moral role as nurses. Have more experienced healthcare providers become burnt out? In tandem with compassionate skills should we should also teach nurses to avoid becoming fatigued. This would allow compassion to be preserved rather than eroded. If this is the case how do we go about safeguarding ourselves and others from the effects of compassion fatigue? Indeed, what makes one person more adept at sustaining their compassion whilst working in highly charged emotionally draining environments? Can resilience be taught or nurtured? Gentry [ 26 ] highlighted that a healthcare providers ability to “self-care” seemed to have a positive influence on their ability to deal with the effects of compassion fatigue.

Self-care was identified primarily as anxiety management and included practices such as speaking to colleagues, exercise and meditation. During the three year nursing programme at Edinburgh Napier University students are given ample opportunity to reflect in peer groups there are also sessions teaching mindfulness. During one module nursing students were invited to organise aerobic exercise classes. Is the UK nursing workplace ready or able to uphold and commit to providing organisational strategies to combat the effects of compassion fatigue? There has been little research into techniques on how to reduce fatigue in healthcare professionals and the resulting effect this would have on standards of care, this is an area which would benefit from further research.

‘Within one clinical setting where I worked a colleague experienced the loss of her spouse. She was regularly involved with palliative patients and was given the option to move to a different role within the team. This role did not involve palliative care and is allowing an experienced and dedicated member of staff to better deal with her grief. It also means she is still effectively contributing to the workplace. What makes it possible for one clinical area to offer this type of support where as other areas do not? How can this become the norm as opposed to the exception?’ Allison

The example of good practice above highlights that relationship centred care is critical to staff relationships. This provides a practical but considered example of the theme Knowing you knowing me. Understanding a staff members context and vulnerability and responding to this may enhance the ability to care in practice and sends a message to staff that they are of value and matter.

As a student nurse, the relationship between myself the patient and their family is vital. Holistic care and having excellent verbal and non-verbal communication skills are essential in order to understand the needs of each patient and their loved ones whilst they are receiving healthcare…. I have learned how a person’s body language can say a completely different thing as to what they are telling you, thereby taking the time to listen and by doing the little things can not only make the patient feel cared for but actually cared about.’ Asha

The authors of this paper would acknowledge that courage can be required to pick up on non-verbal behaviours and then comment or respond to them [ 21 ]. These forms of interaction may take longer than originally anticipated but aim to get at the heart of what matters. In addition recognising the needs of the family/carers in the provision of care to promote a sense of caring for all involved is also important.

‘For the first time I felt inadequate in terms of providing compassionate care. It was my first exposure to an emergency medicine environment. During one shift I was very conscious of a daughter sitting with her mother. The mother was having an acute breathlessness problem and her daughter was crying. I was dealing with a patient who had a gastric bleed. On my way to get some clean linen for this patient, the only thing I could offer this distressed daughter was a tissue and a few words which seemed very inadequate…. I really felt I was letting someone down…. My thoughts were interrupted when my patient said you are so gentle thank you for being so gentle. I realised I was doing my best and providing care to the patient with the greatest need…. The lesson learned here is that in the demanding role of nursing I will have to prioritise and make decisions such as these.’ Allison

This reflection highlights the dilemma experienced by care providers when they identify distress and are unable to respond in a manner that meets their aspirations of care. A feeling of inadequacy related to compassionate care provision was acknowledged, this did not relate to an absence of compassion or a failure to respond, rather it points to a busy clinical context where priorities need to lie with those who have the most acute needs. A compassionate response was evident in the provision of a tissue and a few words and this is commendable practice amidst a busy clinical setting. It is interesting to note however that this intervention was deemed inadequate.

This reflection raises a number of key questions about the context and environment of care and the impact these factors have upon staff experience.

Was this area short staffed or experiencing an acutely busy period and feeling stretched at this time? What is the norm of practice here, do other members of the team feel similarly and where are these experiences and feelings discussed and debated as a team?

How would other members of the team manage this situation and how can staff retain their awareness and desire to be compassionate when the busyness of the area necessitates a focus on clinical priorities?

A further question relates to the resilience of staff, how do staff stay resilient and work with potential compromises to the compassionate care they aspire to deliver?

Brown [ 27 ] debates these issues concluding that, ‘in organisations there needs to be clear intention, leadership and determination for compassionate care to become central in all healthcare practice’. His conclusions focus on small group experiential reflection and learning by healthcare workers as the most effective way to consolidate compassionate care values in practice. Indeed within the LCCP [ 1 ] staff coming together to debate and discuss what compassionate care looks like in their service was a key activity in negotiating a definition for practice; moving the potentially nebulous concept of compassionate care into a more tangible approach for local practice. Principles of compassionate care were most usefully derived from hearing and understanding experiences of patients, relatives and staff and initiating responsive action [ 28 ].

Paley [ 29 ] argues that organisational and situational factors directly impact upon care delivery and that this results in care providers being too busy or focused on other organisationally directed issues to recognise or address compassionate care. It is argued that the blame for a compassion deficit therefore rests with the organisation. In a related issue Timmins and De Vries [ 30 ] also point to organisational factors that determine outcomes of poor care. These authors focus on cognitive dissonance as experienced by care providers; the aim is to provide good care however due to organisational pressures which dominate the context this form of care is not achievable. In order to rationalise this dissonance between care aspirations and the actual, less positive, care experience, standards of care are revised to a lower level thereby managing the dissonance experienced. In the reflection provided above neither of these two phenomenon were evident. Frustration was expressed due to the busyness of the practice area and a need to focus on clinical priorities but distress was identified and a compassionate response elicited.

It is interesting however that this student was dissatisfied with her compassionate response in this busy context, this response raises questions about how staff are supported and able to work through these situations when optimal care has not been possible. There is a wealth of evidence available testifying to the significant challenges facing healthcare professionals in contemporary practice (Iles, & Vaughan Smith [ 31 ] therefore it is important to consider how staff develop resilience and self-compassion as a counter to this situational and cultural context as well as responding to physical and organisational factors impacting upon compassionate caring.

The following practice example from Allison demonstrates tensions in achieving her desired standards of care and how she has been developing strategies to address these.

‘I have been a qualified nurse for a year now and often miss being a student. There was certainly more time to spend with patients. Instead of supporting an upset patient with post-operative nausea and vomiting it is my first priority to organise the administration of an anti-emetic. There is often no extra time to spend with the patient following this as I could have another patient returning from theatre. How do we make these shortened interactions count and make our patients feel cared for as an individual? Is it about tone and communication style? Is it about delegation and recognising that other members of the team can help. I have certainly asked student nurses or care assistants to comfort patients when I have been unable to fulfil this role due to time restraints.’ Allison

The challenge raised of maximising the positive impact for patients of brief interactions when a brief moment is all that is available, seems an important focus for learning. It is unreasonable for staff to experience a sense of guilt regarding care experiences such as those described above when staffing and situational variables dominate practice and are out with a nurses’ sphere of control or influence. What would help nurses and other care staff discuss their experiences, learning, and the positive strategies employed which would enable the possibility of working towards a shared understanding and improvement?

In regard to the LCCP model of care the key themes related to the reflections above could relate to Feedback and Creating spaces that work. It would have been fascinating to hear directly from the patients described in the reflections detailed above. What was their perception of the care and compassion they received? Did a tissue and a few words, or the provision of an anti-emetic meet their needs? Patients can be acutely aware of the busyness of clinical areas and consequently try to minimize the work load of staff as a response. Without seeking feedback directly from these people and their experience of care, we are left with assumptions and possibilities. There is the possibility that care staff can be unduly critical of their practice when deficits are perceived in the care provided, however such deficits may or may not be the experience of those we care for. Actively seeking, hearing and responding to feedback within the local context can provide a reality check and focus for both celebrating excellent care and genuinely understanding care deficits. Considering, Creating spaces that work, would focus reflections on issues connected to the physical environment, culture and ways of working. A group discussion may reassure the team that they are doing all they can, it may raise possibilities for change or connecting with the broader organisation for direct support and development.

Summary - Now what?

The student nurse reflections discussed within this paper prompt us to pause and be encouraged as we glimpse examples of excellent care and celebrate what can be achieved. They also remind us that provision of compassionate care is indeed possible, it does take place on a day to day basis and often hinges on the little things that make a massive difference to those receiving and providing care. However personal drivers, values and perspectives of quality care are critical aspects of providing compassionate care. These elements though are not little things to articulate and develop for individuals, teams and indeed organisations engaged in the provision of contemporary healthcare.

To support the development of compassionate care this article focused on key issues identified from the reflective accounts of two award winning student nurses. These included supporting students in healthcare to;

Develop strategies in questioning care practices which do not meet their expectation of compassionate care

Undertake regular focussed reflective activities where each student can explore personal drivers, values and perspectives of compassionate caring.

Actively connect learning in practice with theory and reflective activities within university, enabling consistent development in compassionate caring.

Facilitate an understanding of emotional intelligence, leading to strategies for self-compassion and the development of resilience

It is necessary to consider the implications of these reflections in terms of supporting healthcare staff to;

Collectively seek, hear and respond to feedback about their service

Activate caring conversations within the healthcare team, celebrate what works well and understand the reasons for this, considering what can be done differently and better and how can we learn and support one another.

Consider how the model of compassionate care, presented in this paper, can be used to reflect on practice and indeed provide a framework and focus for local practice development.

Consider how we maximise the experience of care during brief moments of contact with patients/families.

Activate leadership that strives for a culture of openness which facilitates the development of compassionate care.

Abbreviations

LCCP, Leadership in Compassionate Care Programme

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The information presented in this debate article does not originate from original research but from material presented by undergraduate nursing students as part of an award portfolio submission. As this paper does not represent research no ethical approval was sought.

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Students who win the Simon Pullin Award receive £250.00 prize money and an award letter from the university. The application process involves submitting a portfolio which contains the following: a reflective account written by the student identifying their experience of learning and development in compassionate caring during their undergraduate studies; accounts of feedback about compassionate care development from practice mentors, service users and university academic staff, usually the students’ personal development tutor. The portfolios are reviewed by a panel of academic staff and service users.

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Smith, S., James, A., Brogan, A. et al. Reflections about experiences of compassionate care from award winning undergraduate nurses – What, so what … now what?. J of Compassionate Health Care 3 , 6 (2016). https://doi.org/10.1186/s40639-016-0023-x

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Why Is Compassion Important in Nursing?

In the field of nursing, Compassion is a critical part of patient care. Nurses must be compassionate to provide quality care for their patients. They are not allowed to take a detached approach and focus solely on tasks and procedures because this can lead to errors that could compromise the patient’s health. But the question is, Why Is Compassion Important in Nursing? Why not for doctors?. Because nurses deal with people on the most vulnerable days of their lives. 

Nursing is a profession where compassion and empathy are essential qualities. They are often in the room when someone takes their last breath, and it takes a genuinely compassionate person to handle this type of emotional weight. 

However, not all nurses have the same level of empathy or show compassion for their patients as much as they should – which can cause problems down the line.  Providing emotional support can be difficult to do.

The holistic approach to nursing being present, doing for patients, and forming a connection embodies the caring profession. New research shows that emphasizing the art of nursing and compassionate care during orientation can improve outcomes, including boosting patient satisfaction and reducing the incidence of falls and pressure ulcers.

This is the reason why Compassion is important for nurses, but it’s not enough. We will discuss why Compassion is essential for nursing professionals, what causes a lack of empathy among some nurses, and how that lack could lead to disaster at work.

To turn Compassion into care:

What is compassion.

According to systematic literature, Compassion is the result of empathizing with others in suffering. It leads to a desire to help; Compassion is the emotion associated with these reactions.

To better understand what we mean by “compassion,” let’s look at some definitions:

The word “com-” comes from Latin meaning together or with; so, “with” feeling for one another – feeling sorry for someone else when they’re sad or hurting. 

Compa- means very much; so, very much pity – having great sympathy or sorrow for someone who has been hurt.

So, it’s feeling sorry for someone else when they’re sad or hurting ( being sympathetic ) and wanting to help them out.

Compassion is what nurses do every day: They provide care to understand our patient’s needs; they know how much pain the patient might be in, but still give hugs anyway because nurses want to show love and support through difficult times.

Every major religion has something about Compassion at its center. Because as a human it is in our nature that we can’t see anyone in pain. Compassion has been defined as “a deep awareness of someone else’s suffering coupled with a strong wish to alleviate it” (Batson et al. 1997). At its best, it motivates us to take care of other people who need our support and share their burdens.

It’s significant for nurses because they provide care to patients and their families and offer emotional support. And the success of patient outcomes depends on how compassionate a nurse is with them and the rest of their staff members.

So being compassionate helps nurses do what they need to do for it to be effective.

And just as important as having Compassion towards your patients, you should have Compassion for yourself too because if you’re not caring or feeling sorry for yourself, then you won’t have enough energy left over to take care of someone else’s needs which means that there will be consequences like burnout over time from working without breaks, lack of sleep, etc. so self-compassion is significant.

How to Be Compassionate with Patients

Being compassionate for nurses can be difficult, but it is essential. Nurses are often faced with many challenges in the workplace, and they must do their best to maintain a compassionate attitude. Compassion can make all the difference for patients as well as nurses themselves.

To improve Compassion at work:

• Maintain an open communication line between staff and management; this will help foster trust and reduce misunderstandings that can lead to conflict.
• Encourage empathy from one another by building relationships over time
• Focus on the strengths of other team members when conflicts arise or mistakes happen, so people feel valued.

Take ownership of your role in care delivery; strive always to provide quality patient care no matter what situation you’re in. You have to take care of your patients and yourself.

Respect and support are essential to promote wellness in the workplace; this will help staff provide better care to patients and themselves.

Why Do We Need Compassion in Nursing?

The ultimate goal of Compassion within nursing, or any field, should be quality patient care that benefits both nurses and their patients.

According to the research of the U.S. National Institutes of Health’s National Library , “Compassionate care is vital to patient satisfaction, which in turn helps the patient improve their perception of care and quality of life and mitigates patient complaints and malpractice suits.”

Compassionate nurses listen to and understand the needs of their patients. They have empathy for others, which is a key component in providing care that’s personalized.

When you’re able to see this side of life and how difficult your job can become at times, Compassion comes naturally. 

A nurse’s goal should be to provide excellent patient care and strengthen the rapport between caregiver and patient through understanding each other on an emotional level.

The importance of Compassion in nursing is something that has been studied for decades, and the benefits are wide-ranging. It can help nurses feel more satisfied, less stressed, and better equipped to care for their patients.

Conclusion:

We hope this post was helpful. If you’re interested in learning more about how empathy plays a role in healthcare or want some tips on being more compassionate with your loved ones at home, please read our other blog posts. If you have any questions or comments about this article, we would love to hear from you. Thanks again for reading, and remember – it’s not always easy, but it is always worth it.

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• Why Caring Is Important in Nursing
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Caring and Compassionate Experience in Nursing Essay

As a nurse, I understand that care and compassion are the cornerstones of my competence and performance. A nurse should often be of utmost competence and professionalism, and the aspects of personal approach can be disregarded. The responsibilities that a nurse faces and must carry out, for example, creating a safe environment or collecting data, should be undertaken with care and compassion (“Nursing: Scope and standards of practice ” ). As an example of this, I would like to present my personal experience with a patient who suffered from dementia. The subject of this case was very difficult to communicate with, and initially, I struggled with doubts about my abilities and expertise. Through research, I have discovered that other professionals also find this matter to be challenging (Low et al., 2019). Reading about their experiences enabled me to find strength and empathy for my difficult patient.

Through the experience of seeking guidance from sources of authority, I realized that compassion is a matter that supersedes myself and the patient. It should include other professionals in the field, and I have sought help from others; I feel ready to extend my own hand to my colleagues. This notion especially rings true since I have taken the iCARE Self-Assessment and considered that my scores were specifically high in aspects of communication. As effective and fruitful communication is essential to good team building and patient safety, it should be one of the nurse’s priorities to consider and study it in their practice. It is important to ensure that workplace communication follows ethical engagement rules (Priest, Goodwin, & Dahlstrom, 2018). Therefore, I believe that compassion and care in nursing involve caring for the patient and considering cultural and social interactions among colleagues.

American Nurses Association. (2021). Nursing: Scope and standards of practice. American Nurses Association.

Low, L. F., McGrath, M., Swaffer, K., & Brodaty, H. (2019). Communicating a diagnosis of dementia: A systematic mixed studies review of attitudes and practices of health practitioners. Dementia , 18 (7–8), 2856–2905.

Priest, S., Goodwin, J., & Dahlstrom, M. F. (2018). Ethics and practice in science communication . University of Chicago Press.

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This essay, will be explore and discuss why ensuring compassionate care in nursing is important and how it relates to the NHS (National Health Service) values. Compassion can be described as, feeling sympathy for someone else’s misfortune (WordReference, 2015, cited in Perez-Bret et al., 2016). There is no correct definition for compassionate care as it is mainly demonstrated through the unique bond formed between the patient and nurse. It can be characterised by actions taken by the nurse to care and show an understanding for the patients’ needs and their suffering (Baughan & Smith, 2013). This essay will cover the different legislations which require nurses to provide compassionate, humanistic care to patients, theoretical frameworks and evidence-based practices which express the significance of compassionate care and therapeutic relationships. Additionally, how nurses implement techniques to form relationships with patients and relatives to provide patient-centred care.

Care and compassion being two of the 6 C’s express the importance of compassionate care and its importance to nursing. Being caring and compassionate is the minimum expectation of nurses, and it is endlessly stated by the NMC that care should be given effectively, without delays; this represents the significance of a caring nurse as they are the main aspects of nursing (NMC, 2015). Compassion is also stated in the NMC Code of Conduct (2015), it proclaims, compassionately is the way to respond to the needs to patients especially those who are in the last few days and hours of life. Compassion is fundamental, building trust between patients and nurses, also indicating patients are being treated as people rather than procedures. Bramley and Matiti (2014) held a study in compassion and what it means to patients; majority of patients stated, compassion is when nurses give them time and portray a caring attitude. This study also retrieved that patients find a striking link between care and compassion thus they would substitute care for compassion and vice versa. One of the patients in the study described compassion as “… a caring attitude to people as people and not things (Participant 5, ward D: L 4)” (Bramley and Matiti, 2014, p. 2794).  Bramley and Matiti (2014) found that patients express nurses demonstrating caring and compassionate attributes through giving them time, talking to them as people, nurses placing themselves in the situation of patients and caring about their feelings. This study helps nurses as knowledge of patients understanding of compassionate care can help them improve on attributes patients anticipate when being cared for.

The NHS constitution establishes the principles and values of NHS England. The purpose of this is to clarify the right entitlements for service users, the public and also staff. NHS values are also included, these have been inspired by patients, the public and staff, making sure nothing is missed. A few of the values are; respect and dignity, commitment to quality of care, compassion, improving lives and everyone counts (Department of Health & Social Care, 2015). These values are to ensure patients are the centre of attention and they are delivered humanistic, person-centred care. NHS values explain the significance of compassion as it is a key value that is naturally expected from nurses and other health care staff. The Royal College of Nursing (2018) developed eight principles with the help of the Department of Health and the NMC (Nursing and Midwifery Council), the public and health care staff were also a part of the progression process. The principles are there for nurses and student nurses to apply when caring for patients. One of the eight principles are, nurses and nursing staff treat everyone with care ensuring dignity and humanity is maintained throughout – nurses should understand the patients’ needs and requirements and are to show compassion and sensitivity, overall nurses should provide care in a way in which everyone is respected and treated equally (Royal College of Nursing, 2018).

Professionalism in nursing is the autonomous decision-making of a group of medical professionals who share similar values (NMC, 2017). Nurses providing good healthcare through excellent, professional practice and behaviour upholds the expected nursing standards. The NMC focuses nurses on professionalism to guarantee safe and effective, person-centred care (Glasper, 2017). Professionalism being a vital attribute to nurses is to prevent publicised scandals such as the ‘Mid-Staffordshire Inquiry’. Partnership is recognised in healthcare guidelines therefore is an attribute for nurses to either develop improve on (Baillie, 2016). Nurses working in partnership with their patients allows patients to make decisions about their own treatment, also this leads to improved communication skills between a nurse and service user (Baillie, 2016). A scenario of working in partnership with patients can be, a patient at a&e is suicidal and overdosed on paracetamol. The nurse is responsible for taking care and explaining the effects and treatments for overdose. While explaining to the patients the effects, the nurse is able to build a therapeutic relationship with the patient over time as partnership means the service user can ask questions. On the other hand, if the patient refuses treatment and disregards the recommendations of the nurse, it could lead to conflict.

Conflict can occur when a nurse tries to build a relationship/partnership with the service user. However, conflict can also arise between healthcare professionals due to poor leadership and change, plus issues with interpersonal relationships (McKibben, 2017). This type of conflict can affect the quality of care patients receive, therefore the NMC has highlighted, nurses must communicate and work cooperatively in partnership to resolve any conflict within healthcare teams (NMC, 2015). There are many different reasons of why conflict can arise between nurses and patients, reasons like disagreements in decision-making, conflicting medical and religious beliefs additionally, conflicting opinions. Through conflict, nursing standards can rise. Oglethorpe and Oglethorpe (2009) stated, nursing conflict can result in critical thinking leading to well thought-out/quality decision-making by nurses, resorting in enhanced care quality received by patients.

A therapeutic relationship is when nurses and patients communicate effectively, whether it is regarding treatment or general conversations asking how they are. Through communication, nurses can provide exceptional medical care. Good communication and interpersonal skills allow nurses to communicate with patient’s relatives as well as other health professionals. A therapeutic relationship is called ‘therapeutic’ because it helps nurses to meet the needs of patients through a shared agreement (McQueen, 2000). Therapeutic relationships are fundamental as they signify compassionate care since it shows there is good nurse-patient interaction, which aid nurses with smoother care plan administration as patients are more trusting of nurses.

Marsham (2012) explored learning disability nurses therapeutic role and found that it is a big focus when it comes to interventions raising standards in nursing. This is because patient-nurse relationships reflect a more humanistic approach to nursing which can also be referred to as compassionate care since nurses take time to build a rapport with patients to provide unique patient centred care. Therapeutic relationships are all the more important as they are seen as the “… heart of care” (Marsham, 2012, p. 237). To build a relationship with patients, it can be easy for nurses to start using jargon without realising, also it is very easy for them to dominate treatment as nurses are the professionals and the patients are not. Therefore, the NMC stated “work in partnership with patients to make sure you deliver care effectively” (NMC, 2015, p. 4). Nurses are to make sure their patients understand their treatment and care plans. To help explain procedures to patients and build a relationship, there are a few key attributes nurses should acquire. Being sensitive, showing empathy, being approachable, a good listener and also being receptive to the patient. Callery and Milnes (2012) undertook a study of communication between nurses, patients and their parents. The study showed that there is a ‘triadic’ relationship formed when communicating with 3 people. In their study, the child was known as the ‘dyad’ who observed the conversations between the nurse and parent. Overall evidence from this study showed, communication is imperative with everyone including children (Callery and Milnes, 2012). Callery and Milnes study links to clinical practice as communication helps provide effective nursing care, in addition to improvement in patient mental health.

To provide person-centred care, the main focus for a nurse should be, is the patient happy. Carl Rogers, a humanistic psychologist believed patient health improves better once they improve their psychological state of mind (McLeod, 2014). This theory links to clinical practice as nurses are not just helping patients medically but also mentally. Hence, nurses tend to focus on encouraging elderly patients to focus on something or someone instead of an unconscious motive. McLeod (2014) stated, Carl Rogers’ humanistic approach to therapy is to ensure patients are benefitting by feelings of greater self-worth. Nurses are able to use Rogers’ person-centred approach to build therapeutic relationships with service users by taking time to ask them ‘how are you’. The main emphasis on a therapeutic relationship with patients is to increase the care and compassion received by the service users. Bettering nurses on attributes alike care and compassion improves quality of care; as stated by Glasper (2017); professionalism enhances and guarantees safe and effective patient-centred care, therefore professionalism is the leading attribute which nurses should possess and is repeatedly stated in the NMC: Code of Conduct. Rogers (1975, cited in McLeod, 2014) stated, showing empathy to patients means the nurse is able to understand the patients’ feelings, in return this slowly allows the patient to open up to the nurse. The best way to form a therapeutic relationship with patients is to show sensitivity, receptiveness and empathy towards patients. Contrariwise, showing sympathy can be demeaning for patients (Rogers, 1975, cited in McLeod, 2014).

With nursing comes a great deal of legal issues. With healthcare involving many laws and legislations, it means there is a bigger spotlight on the performance of health professionals, more importantly, nurses. The NMC: Code of Conduct incorporates many different laws to ensure nurses perform safe clinical practice. Nurses have a duty of care, to protect patient’s rights to privacy and confidentiality (NMC, 2015). The ‘duty of care’ nurses have is to provide humanistic care as it is their human right, and to prevent any neglect and poor, unsafe practice. The Nursing and Midwifery Council has set Codes of Conducts for nurses to follow when practicing their profession; nursing without being registered on the NMC register is a crime (NMC, 2015). An example of failed duty of care is the Mid-Staffordshire Inquiry of which’s findings were, poor leadership within healthcare teams and inadequate staff policies leading to extremely low standards of care (Hughes, 2013). Dimond (2015) states the accountability and expectations of nurses to the public also how nurses can be liable whether or not they are aware of the laws which are imposed in the nursing profession. An example of this could be, if there is a road traffic accident, if there is a nurse present (not on shift), they are expected to help and in some circumstances can be morally responsible if they refuse to assist, even if there is no legal obligation to volunteer nursing services (Dimond, 2015). To prevent any scandals like the Mid-Staffordshire inquiry, nurses should have knowledge of the laws they are to follow and aim to care for patients compassionately, with patient needs having the most attention.

Compassionate care is having the patients best interest at heart. Ethics are a fundamental in nursing; respect for autonomy, beneficence, non-maleficence and justice are the four principles of biomedical ethics (UK Clinical Ethics Network, 2001). In the Mid-Staffordshire inquiry, findings showed patients autonomy was not respected and were faced with maleficence as the Francis Report (2013) highlighted, patients were ‘so dehydrated they resorted to drinking water from vases’ (Hughes, 2013). Autonomy can be demonstrated by treating patients as autonomous individuals. An example of this is, although dementia patients do not have capacity, it is still the nurses’ responsibility and duty of care to treat them as an autonomous individual by being caring and compassionate and having a ‘holistic’ view (Skår, 2010). Correspondingly, attempting to get to know the patient no matter their capacity demonstrates autonomy; nurses carry out autonomous practice when they show courage and competence while taking dominating situations they are responsible for (Skår, 2010). Compassion and care are basic attribute to when providing ‘humanistic’ care. Humanistic care is to be received by all patients, majorly palliative patients as providing humanistic care for patients is to promote consolation and protect patient dignity in their last stages of their life (Wu & Volker, 2012).

To conclude, care and compassion are the most important attributes nurses should possess to provide exceptional patient-centred care. Building therapeutic relationships/partnerships with patients and relatives can help provide adequate tailored care as patients can make decisions concerning their treatment, leaving both patient and nurse in mutual agreement (McQueen, 2000). Conflict can arise between patients if therapeutic relationships are not formed. Conflict develops between healthcare professionals also due to changes in leadership. Nurses should follow laws and legislations when caring for patients, demonstrating professionalism and also as the NMC incorporates professionalism numerous time in the NMC: Code of Conduct. Overall, compassionate care can be demonstrated through excellent implementation of laws and the Code of Conduct in clinical practice.

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Nurses’ experiences of compassionate care in the palliative pathway

Anett skorpen tarberg.

1 Medical department, Møre and Romsdal Hospital Trust, Ålesund Norway

2 Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Science, European Palliative Care Centre (PRC), Norwegian University of science and Technology (NTNU, Trondheim Norway

Bodil J. Landstad

3 Department of Health Sciences, Mid Sweden University, Östersund Sweden

4 Levanger Hospital, Nord‐Trøndelag Hospital Trust, Levanger Norway

Torstein Hole

5 Faculty of Medicine and Health Sciences, NTNU ‐ Norwegian University of Science and Technology, Trondheim Norway

Morten Thronæs

6 Cancer Clinic, St. Olav Hospital, Trondheim University Hospital, Trondheim Norway

Marit Kvangarsnes

7 Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, NTNU – Norwegian University of Science and Technology, Ålesund Norway

8 Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund Norway

Associated Data

Aims and objectives.

The aim was to explore how nurses experience compassionate care for patients with cancer and family caregivers in different phases of the palliative pathway.

Compassion is fundamental to palliative care and viewed as a cornerstone of high‐quality care provision. Healthcare authorities emphasize that patients should have the opportunity to stay at home for as long as possible. There are, however, care deficiencies in the palliative pathway.

This study employed a qualitative design using focus groups and a hermeneutic approach.

Four focus groups with three to seven female nurses in each group were conducted in Mid‐Norway in 2018. Nurses’ ages ranged from 28–60 years (mean age = 45 years), and they were recruited through purposive sampling ( N  = 21). Compassionate care was chosen as the theoretical framework. Reporting followed the COREQ guidelines.

Three themes expressing compassionate care related to different phases of the pathway were identified: (a) information and dialogue, (b) creating a space for dying and (c) family caregivers’ acceptance of death.

Conclusions

This study showed that it was crucial to create a space for dying , characterized by trust, collaboration, good relationships, empathy, attention, silence, caution, slowness, symptom relief and the absence of noise and conflict.

Relevance to clinical practice

The quality of compassion possessed by individual practitioners, as well as the overall design of the healthcare system, must be considered when creating compassionate care for patients and their family caregivers. Nursing educators and health authorities should pay attention to the development of compassion in education and practice. Further research should highlight patients’ and family caregivers’ experiences of compassionate care and determine how healthcare systems can support compassionate care.

What does this paper contribute to the wider global clinical community?

• It provides insight into nurses’ role in compassionate care in different phases of the palliative pathway.
• It highlights the importance of early engagement with family caregiver as a key element of compassionate care.
• Nurses play a crucial role in creating a space for dying w hich is important for patients’ and their family members’ preparation for death.

1. INTRODUCTION

Compassion is fundamental to palliative care and can create an environment of safety for patients and family caregivers. Compassionate care is built on trust and good relationships between the patient, the family and healthcare personnel (Brito‐Pons & Librada‐Flores, 2018 ; Larkin, 2016 ).

There are various definitions of compassionate care (Crawford et al., 2014 ; Feo et al., 2018 ; Strauss et al., 2016 ). In this study, we followed a broad description of compassion as involving an awareness of, or a sensitivity to, the pain or suffering of others that results in taking verbal, nonverbal or physical action to remove, reduce or alleviate the impact of such affliction (Gilbert, 2013 ). This description is relevant because research has shown that patients and their family caregivers experience deficiencies in palliative care provision (McEwen et al., 2018 ; Røen et al., 2018 ; Tarberg et al., 2019 ). A Norwegian study found that family caregivers experienced limited involvement, a lack of preparation for the dying phase, and unsystematic follow‐up after death (Tarberg et al., 2019 ). An Australian study showed a gap between guidelines and family caregivers’ experiences of emotional and psychological support in palliative care (Aoun et al., 2017 ).

The integration of palliative care with oncology is recommended; however, this has been insufficiently addressed in healthcare systems (Kaasa et al., 2018 ). Six main elements of patient‐centred care are highlighted: (1) respect for patients’ values, preferences, and expressed needs; (2) coordination and integration of care; (3) information, communication, and education; (4) physical comfort‐relief of bothersome symptoms; (5) emotional support‐relief of fear and anxiety; and (6) involvement of family and friends (Kaasa et al., 2018 ). Nurses can play a key role in integrating palliative care and oncology by providing compassionate care (Brito‐Pons & Librada‐Flores, 2018 ).

In this study, we explore nurses’ experiences of compassionate care for patients and family caregivers in the palliative pathway. Nurses work closely with patients and family caregivers and are therefore a relevant population in which to explore compassion.

2. BACKGROUND

One recent study, which included participants from 15 countries, explored nurses’ understanding of compassion (Papadopoulos et al., 2017 ). Nurses reported that sociopolitical structures constrained and influenced their provision of care. Lack of time was also identified as an obstacle for the provision of compassionate care. Five components were identified as comprising compassion: (1) investing time in the nurse–patient relationship, (2) presence, (3) going the extra mile, (4) personalization and (5) advocacy (Papadopoulos et al., 2017 ).

Compassion requires action (Larkin, 2016 ). True compassion is expressed through the highest level of clinical practice, which addresses the totality of symptom burden and complex needs. Compassion implies a sense of coherence, nurses being able to communicate a compassionate essence, based on knowledge, proactivity and interconnectedness in the delivery of nursing. Compassion is not just about individual responses, but rather about how nurses are enabled by the system to sustain and support themselves in the complexity of palliative care (Larkin, 2016 ).

To support the patient in the process of dying, previous researchers have identified some key elements deemed important by community nurses: symptom control, patient choice, honesty, spirituality, interprofessional relationships, organization and the provision of seamless care (Griggs, 2010 ). Building trust and knowledge with patients and their families is valuable during end‐of‐life care. Building trust depends on nurses’ availability (Stajduhar et al., 2011 ). Compassionate care facilitation includes the personal and relational characteristics of the primary care nurse, the organizational framework and an individually tailored care system. Barriers to compassion include personal challenges, relational challenges, system challenges and maladaptive responses (Singh et al., 2018 ).

Nurses have a coordinating role between patients, families and other health professionals, which is also challenging (Sekse et al., 2018 ). Wilson et al. ( 2014 ) reported that primary care nurses have noted that family dynamics impact on complex and difficult situations. The family, patient and nurses may all be at different stages in the acceptance of death. Further, conflict may arise when patients conceal information about their medication or misunderstand and feel suspicious around its use (Lund et al., 2015 ; Wilson et al., 2014 ).

Many of the definitions of compassionate care are general and do not consider that compassionate care will have different expressions in different contexts for different patients and situations. A discursive paper from New Zealand presented a bi‐cultural approach to providing compassionate care during end‐of‐life care (Robinson et al., 2019 ). The Kapakapa Manawa Framework was developed by drawing on empirical research that captured the experiences of palliative care in hospitals from the perspectives of bereaved families (Dewar & Nolan, 2013 ; Durie, 1985 ; Gott et al., 2019 ). The researchers extended the framework to encompass Māori values of compassion during end‐of‐life care. This model differs from others by noting how compassion should be integrated into nursing practice by referring explicitly to compassion as a verb. The model considers patients’ cultural background in care provision and the family members involved, which may be used to support the implementation of the relational component of ‘Fundamentals of Care’ (Robinson et al., 2019 ). Knowing enough about patients and developing trust is an important element in this framework. Conceptualizing compassion as an action may be used as a platform on which to develop meaningful relationships (Robinson et al., 2019 ).

This framework outlines four values, which optimize compassionate nursing in the palliative pathway: (1) relationships that express care, (2) the process of establishing good relationships, (3) the use of contextualized knowledge and (4) a reciprocal process of mutual respect between people. This model refers to a Māori concept that relates to the process of establishing relationships and nurturing ongoing connections through effective inter‐relational caring. This understanding of compassion brings the nurse and the patient closer together and provides a better understanding of the patient as a person (Robinson et al., 2019 ).

In our study, we explored compassionate care in the Norwegian context. In Norway, 13 per cent of the population died at home in 2018 (The Norwegian Institute of Public Health, 2019 ). The health authorities have recommended that, as more patients choose to stay longer at home, they should have the opportunity to die at home (Norwegian Ministry of Health & Care Service, 2020 ). Targeted measures have been designed to give everyone a dignified end of life in line with their needs and wishes. Expertise on palliation, resources and cooperation is necessary to enable nurses to fulfil these aims (Kaasa et al., 2018 ).

In this study, we understand compassionate care as consisting of three dimensions: noticing, feeling and responding. In addition, we consider compassionate care as an overall design of healthcare organizations (Blomberg et al., 2016 ; Crawford et al., 2014 ; Gilbert, 2013 ; Kanov et al., 2004 ; Larkin, 2016 ). We have divided the palliative pathway in three different parts: the first phase is defined as the first days following the diagnosis of an incurable disease, the second phase is the middle part of the incurable disease, and the third phase, also termed as the terminal phase, constitutes the last weeks and days before death (Tarberg et al., 2019 ). The aim was to explore how nurses experience compassionate care for patients with cancer and family caregivers in different phases of the palliative pathway.

3.1. Design

The study employed a qualitative design with a hermeneutic approach (Gadamer, 1989 ; Patton, 2015 ). Focus groups were chosen to explore nurses’ experiences through discussions with other participants with whom they had something in common – in order to promote self‐disclosure (Brinkmann & Kvale, 2015 ; Krueger & Casey, 2015 ; Malpas & Gannder, 2017 ). The Consolidated Criteria for Reporting Qualitative Checklist were followed, see File S1 (Tong et al., 2007 ).

3.2. Sampling

Informants were chosen by means of purposive sampling ( N  = 21) (Brinkmann & Kvale, 2015 ; Krueger & Casey, 2015 ). Four focus groups with three to seven female nurses in each group participated in the study. Nurses’ ages ranged from 28‐60 years (mean age = 45 years). Nurses from primary care facilities and from nursing homes were recruited because they had experiences in different phases of palliative care. Nurses from urban and rural areas were also included to increase data variation. Participants worked in different municipalities in Mid‐Norway with 2000 to 43,000 inhabitants. Inclusion criteria were nurses who had worked in palliative care for more than three years and who could speak fluent Norwegian. Administrative nurses were excluded. Participants’ demographic characteristics are shown in Table ​ Table1 1 .

Characteristics of study participants

3.3. Data collection

Nurses were recruited face‐to‐face by contact persons in the municipalities. A question route with open‐ended questions was developed based on the study aim and earlier research (Crawford et al., 2014 ; Krueger & Casey, 2015 ; Tarberg et al., 2019 ). The questions were related to how nurses had experienced compassionate care in different phases of the palliative pathway: namely the first, the second and the third phase. The question route was as follows:

• Can you tell me how you experience palliative care?
• What is important when communicating with patients and family caregivers in different phases of the palliative pathway?
• How do you wish to collaborate with family caregivers throughout the pathway?
• What is important about the nature of the care offered in different phases of the palliative pathway?
• What challenges and ethical dilemmas did you experience?
• Is there something else you want to add?

The first author was a moderator and the second author was an assistant – taking field notes and summarizing what nurses said at the end of the interviews. The focus groups, conducted in Norwegian, lasted between 60 and 90 min. They were audio‐recorded and transcribed verbatim shortly thereafter by the first author (Krueger & Casey, 2015 ; Polit & Beck, 2012 ).

The interviews provided rich descriptions of nurses’ perception of compassionate care in different phases of the palliative pathway. Data were collected in 2018, until no substantially new information was obtained from the last group. We considered that the data were saturated regarding all the preliminary themes. Saturation was discussed between the researchers after the interviews. Data collection and analysis went hand‐in‐hand (Patton, 2015 ). The moderator let the discussion flow naturally between participants, that is they were given the opportunity to speak openly and to participate in the focused discussion. (Krueger & Casey, 2015 ).

3.4. Data analyses

We used compassionate care as a theoretical framework when interviewing the nurses. All the authors read the interviews to gain a holistic impression of the data (Brinkmann & Kvale, 2015 ). The first author coded the interviews related to compassionate care in the first, second and third palliative phase. The first author has worked as an oncology nurse in primary care for 10 years. Leaning on a hermeneutic approach, we were aware that her preunderstanding influenced data interpretation (Gadamer, 1989 ); therefore, all authors engaged in discussing the analyses and a new understanding was developed from group discussions (Brinkmann & Kvale, 2015 ). We used the hermeneutic circle, in which the meaning of the parts is determined by the global meaning. Consequently, we gained a new and deeper understanding of compassionate care in different phases of the pathway – both for patients and for their family caregivers (Gadamer, 1989 ). In the process of interpretation, it was important to read the interviews with empathy, that is we tried to understand the intentions behind what was said. This enriched our previous interpretations. In all our interpretations, our perceptions of the nurses’ view of compassionate care were central (Alvesson & Sköldberg, 2018 ). Quotations, subthemes and themes are presented in Table ​ Table2 2 .

Development of quotes into themes

3.5. Ethical considerations

The project was undertaken according to research ethics guidelines (World Medical Association, 2013 ). The Regional Committee on Medical and Health Research Ethics determined that the study did not require ethical approval (no. 2016/978/REK NORD). The Data Protection Official for Research approved this study (no. 2016/960‐25). All nurses were given oral and written information that they could withdraw whenever they wanted. Informed written consent was obtained by all nurses at the start of the interviews. All data were anonymized. The informants were colleagues, and we were conscious of presenting the interviews in a respectful manner (Brinkmann & Kvale, 2015 ).

3.6. Rigour

Decisions were carefully described to enhance the transparency of this study (Polit & Beck, 2012 ) and to enable readers to evaluate the research process. Two researchers conducted the interviews, and both were experienced in performing qualitative interviews. The theoretical framework was carefully described to increase data interpretation validity (Patton, 2015 ). A coding tree and various stages in the analysis were described to enhance reliability in the analysis. All authors participated in discussions about data interpretation (Tong et al., 2007 ). Participants’ quotations were presented to illustrate the themes (Table ​ (Table2 2 ).

Twenty‐one nurses working in palliative care shared their experiences of compassionate care for patients and family caregivers in the palliative pathway. Three themes were identified: (a) information and dialogue in the first phase, (b) creating a space for dying and (c) family caregivers’ acceptance of death. The first and the second theme relate to compassionate care for patients and family caregivers in the first and second phase of the palliative pathway, respectively. The third theme relates to family caregivers’ acceptance of death in the second and third phase.

4.1. Information and dialogue

Nurses emphasized the importance of early contact in order to provide information about what services they could offer. They often had little contact with patients and family caregivers in the first phase of the pathway. Nurses conveyed that patients and family caregivers felt shock and sadness in this first phase, and often they were not ready to meet oncology nurses from primary care. The nurses thought that this might contribute to a delayed provision of health services. An explanation provided by them was that patients and family caregivers might not have sufficient knowledge or experience to understand the importance of early involvement with health personnel: ‘ When we manage to establish early contact , it becomes easier to work together at the end ’. Hence, the nurses highlighted the importance of dialogue between patients, family caregivers and healthcare personnel through the course of the disease, and noted that early involvement increased their ability to provide compassionate care. Interdisciplinary collaboration between specialist healthcare services and primary healthcare was considered important to improve compassionate care.

The nurses emphasized that physicians and nurses in the hospitals had a key role in communicating the importance of early involvement in primary health services. They considered it vital to plan the palliative pathway together with the patients and family caregivers before the patient had reached the third and terminal phase. The need for advance care planning was described: ‘ We need to help them create a palliative plan and to clarify important aspects , try to avoid situations where decisions must be made quickly , and where patients and family caregivers may not be prepared’ . The nurses indicated that a palliative plan should provide patient‐centred care and carry out the patient's wishes. They experienced that advance care planning led to useful information being conveyed to patients and family caregivers, created a sense of security and prepared patients and family caregivers for what was to come.

Nurses discussed the value of including family caregivers as part of the team. ‘ It was a good process because we cooperated : palliative team , general practitioner , the nursing home and family caregivers ’. Close collaboration between family caregivers, primary care providers and healthcare specialists made it possible to fulfil patients’ wishes to die at home. Collaboration was seen as an important element of compassionate care.

4.2. Creating a space for dying

The second phase needed to be a quiet period in which patients and family caregivers were provided with security, predictability and clarification. Nurses were engaged and emotionally affected when they talked about this topic. They emphasized the importance of creating a space for dying, and that there were better facilities than hospitals in which to create this space: ‘ We have the opportunity to create a space , where patients and families can prepare for death ’. According to the nurses, a space for dying was characterized by trust, collaboration, good relationships, empathy, attention, silence, caution, slowness, symptom relief and the absence of noise and conflict. Nurses perceived that patients and families had best experienced compassionate care in primary healthcare at home and in nursing homes.

Challenges in the interactions with patients and family caregivers were a topic in the focus groups. Balancing a conflict of interest between family members could be challenging and could prevent adequate planning for the impending death. This could hinder the process of ‘creating a space for dying’. Nurses expressed that patients and family caregivers, as well could have different needs: ‘Family caregivers sometimes express , “You must get the patient to the nursing home ; but please don't tell him / her that the words come from us . ”’ In such a situation, just whose interests should be prioritized, becomes an ethical dilemma for health personnel. Nurses had to be aware of patients’ and family caregivers’ mental and physical needs. The importance of trust and good interpersonal relationships in providing compassionate care was crucial.

Communication skills were also an essential competence with regard to providing compassionate care. Nurses described how they tried to prepare patients and families for the last days and death. They indicated that certain patients could not relate to their impending death: ‘There was a mother with small children who said she hoped to recover . The nurse then replied , “yes , I hope so too ; but we must have an alternate plan . ”’ This way of responding to the patient illustrates that the nurse is listening to the patient in a way that conveys both hope and realism. Communicating in an empathic way is an important part of compassionate care.

Another recurrent topic was the importance of nurses having expertise in symptom relief. Nurses experienced that there was a lack of collaboration between physicians and nurses. This could result in patients not receiving adequate medication in time. The nurses argued for the importance of interprofessional collaboration with regard to the provision of symptom‐relieving medication in the third phase. This allowed for combined planning and the anticipation of possible difficulties, at a system level. It also required that professionals find new ways of collaborating with each other.

4.3. Family caregivers’ acceptance of death

The nurses experienced the last phase as difficult. Dilemmas arose when healthcare professionals and family caregivers had a different understanding of treatment choices; for instance, if family caregivers wanted health personnel to provide treatment and the patient did not want it. The need for information to family caregivers about palliative treatment was highlighted, especially relating to fluid and nutrition: ‘ Family caregivers require explanations about the death process , and how to meet the needs of a dying patient ’. Nurses had experienced that family caregivers could become despairing and angry when the patient could not eat and drink in the third phase. They had often experienced that treatment limits had not been made clear in advance. Hence, a common understanding between healthcare personnel and family caregivers was important.

After a patient's death, nurses had bereavement routines to follow, in which contact was offered to grieving family members: ‘ We offer bereavement counseling , four to six weeks after the death ’. Nurses in the focus groups vehemently discussed communication with the bereaved. The routines seemed, however, to differ both between municipalities and within municipalities. In some municipalities, nurses offered calls only to the bereaved family of patients who had died of cancer.

Nurses experienced that the bereaved had different needs, and some nurses expressed that it was especially important for the bereaved to meet the health professionals who had been present when the patient died. A nurse expressed it like this, ‘This provides an opportunity to ask questions about what occurred’ . Some of the bereaved needed several conversations to get over the loss of their beloved ones. Nurses thought that almost everyone would benefit from a conversation with healthcare personnel after a patient had died. To help the bereaved to get over their loss was an important part of compassionate care.

5. DISCUSSION

The focus groups provided rich data and gave a new understanding of the meaning of compassionate care in different phases in the palliative pathway. The analyses have revealed that compassionate care is contextual. Information and dialogue with patients and family caregivers was crucial in the first phase. In the second phase, the nurses highlighted the importance of creating a space for dying. In the third phase, family caregivers’ acceptance of patients’ death was important.

Information and dialogue with patients and family caregivers early in the pathway was an important finding in this study. Earlier research has indicated that building trust, knowledge and good relationships are important in end‐of‐life care (Robinson et al., 2019 ; Stajduhar et al., 2011 ). This is in accordance with the results presented in this study. The nurses advised that family caregivers should be seen as part of the team around the patient.

Our study show the significance of advance care planning, which involves patients and family caregivers in the process. The goal of advance care planning is to ensure that medical care is consistent with patients’ and family caregivers’ values, goals and preferences (Kaasa et al., 2018 ). Nurses experienced that advance care planning gave patients and family caregivers a sense of security and prepared them for future challenges. In this, they mirror the findings of Pfaff and Markaki ( 2017 ), who, in an integrative review, highlighted the significance of collaborative and patient‐ and family‐centred care.

Nurses expressed that creating a space for dying was crucial for patients and family caregivers. The significance of creating this space has not been highlighted in previous research about compassionate care in the palliative pathway. Based on the findings in this study, it is urged that the provision of primary health care for the dying, whether at home or a nursing home, is provided with facilities, and a philosophy, which facilitates a compassionate culture for both patient and family caregiver. Larkin ( 2016 ) has argued that compassion is not just about individual responses, but rather about how practitioners are able to sustain and support themselves in the complex field of palliative care.

The importance of creating a space for dying demands that nursing managers and policymakers prioritize resources for healthcare personnel to assist them in shaping a compassionate culture (Crawford et al., 2014 ; Martinsen & Kjerland, 2006 ). Our findings support the understanding that the organization and design of services are important in compassionate care.

Family conflicts, different stages of accepting death within the family and denying families a role in decision‐making are obstacles to creating compassionate care (Lund et al., 2015 ; Wilson et al., 2014 ). In this study, nurses experienced that they played a significant role by being active in creating a space for dying. We consider this space as important for patients and families in accepting and preparing for death.

Further, a lack of interdisciplinary collaboration, specifically, physicians’ failure to prescribe sufficient pain relief medication were problematic. This may be an obstacle to patients receiving symptom relief in the third and terminal phase. Griggs ( 2010 ) describes symptom control as a key element in supporting patients’ process of dying. International recommendations (Kaasa et al., 2018 ) have also highlighted the importance of physical comfort‐relief of bothersome symptoms. Nurses experienced that they play a crucial role in collaboration with physicians to ensure that a patient receives effective pain relief. The supply of care and medication needs to be well‐organized, so that dying patients get symptom relief also in weekends and holidays.

5.1. Strengths and Limitations

This study illustrated compassionate care in the palliative pathway from the perspective of nurses and not from the experiences of patients and family caregivers. The study provided rich data, which we believe offers new insight into compassionate care in various phases of the palliative pathway. In the future, it is suggested that compassionate care in the palliative pathway be studied from the perspectives of patients, family caregivers and physicians, to enable us to develop a more holistic understanding.

Compassionate care was chosen as the theoretical framework (Blomberg et al., 2016 ; Brito‐Pons & Librada‐Flores, 2018 ; Crawford et al., 2014 ; Robinson et al., 2019 ). This framework had an impact on how the data were collected and interpreted. A hermeneutic approach assumes that the findings are an interpretation based on a theoretical framework and should be interpreted in a cultural and historical context (Patton, 2015 ). This background is important in interpreting compassionate care expressed by nurses in the Norwegian context. In Norwegian, there are no expressions that are synonymous with ‘compassionate care’. It was therefore important to have a theoretical framework when studying this phenomenon in the Norwegian context. There is thus a need to develop concepts in Norwegian which communicate the content of compassionate care in the community of practice in Norway.

Although this study was conducted in Norway, the findings may be generalized to other countries with similar health services (Polit & Beck, 2012 ). The theoretical framework (Blomberg et al., 2016 ; Crawford et al., 2014 ; Gilbert, 2013 ; Kanov et al., 2004 ; Larkin, 2016 ) was important in revealing key elements of compassionate care at various stages of the pathway. In the interviews, we used Norwegian terms that corresponded with terms and concepts in the English theoretical framework of compassionate care. The study provides new insights of international relevance because the findings reveal existential and general challenges related to caring in the palliative pathway.

The first author has been working as an oncology nurse in primary health care for many years, and she has experience in the concepts discussed in this study. However, all the authors collaborated in the data interpretation to develop a new understanding and to ensure a holistic perspective (Gadamer, 1989 ; Patton, 2015 ).

6. CONCLUSION

Compassionate care is different in the three phases of the pathway, and the nurses should take an active role in creating compassionate care throughout the pathway. It is crucial to create a space for dying. Trust, collaboration, good relationships, empathy, attention, silence, caution, slowness, symptom relief and absence of noise and conflicts characterize compassionate care when crating a space for dying. It is likely that the findings can provide insight into caring in the palliative pathway for patient groups with other chronic diseases.

7. RELEVANCE TO CLINICAL PRACTICE

Nurses should involve family caregivers as a part of the team around the patient in the first phase of the palliative pathway. It is important that nurses spend time building trust. Nurses should take a coordinating role in creating a space for dying. Managers and policymakers should prioritize resources for healthcare services in shaping compassionate culture. Healthcare personnel should offer bereavement counselling in a systematic way. Compassionate care in the different phases of the palliative pathway should be addressed in nursing education and further research. In the future, investigations of patients, family caregivers, physicians and policymakers perspectives of compassionate care could present us with a more holistic understanding.

CONFLICT OF INTEREST

There are no conflict of interest to declare.

AUTHOR CONTRIBUTIONS

All authors made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. AST and MK conducted the interviews, AST transcribed them verbatim. All authors were involved in drafting the manuscript or revising it critically for important intellectual content. All authors have given final approval of the version to be published, participated sufficiently in the work to take public responsibility for appropriate portions of the content. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Supporting information

Acknowledgement.

We want to thank the nurses for sharing their experiences.

Funding information This research was founded by Helse Møre and Romsdal Hospital Trust.

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How to make compassionate leadership in nursing a reality, jennifer trueland health journalist.

Empathetic and inclusive leaders enable teams to achieve better outcomes for patients, but can be difficult to find in the hierarchical organisations of the NHS

Compassionate leadership is good for staff and good for patients, with a growing evidence base showing that it results in staff being more motivated and delivering high-quality care.

Nursing Management . 29, 5, 6-8. doi: 10.7748/nm.29.5.6.s2

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06 October 2022 / Vol 29 issue 5

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