- Email: [email protected]
Compassion: The missing link in quality of care
Compassion: The missing link in quality of care Margreet van der Cingel PII: DOI: Reference:
S0260-6917(14)00114-2 doi: 10.1016/j.nedt.2014.04.003 YNEDT 2708
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
19 June 2013 12 January 2014 17 April 2014
Please cite this article as: van der Cingel, Margreet, Compassion: The missing link in quality of care, Nurse Education Today (2014), doi: 10.1016/j.nedt.2014.04.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT COMPASSION: THE MISSING LINK IN QUALITY OF CARE
AUTHOR’S INFORMATION Margreet van der Cingel,
Title:
RN, MsN, PhD
Position:
College professor & senior researcher, School of Healthcare, Research group
SC R
Innovation in care for older people
IP
T
Name:
University of Applied Sciences Windesheim, Zwolle, The Netherlands Campus 2-6, P.O. Box 10090, 8000 GB Zwolle, The Netherlands
Email:
[email protected] or [email protected]
Phone:
0031-627100950 (mobile)
NU
Adress:
Keywords: compassion, quality of care, older people, chronic disease, evidence based
MA
practice, professional behaviour, nursing theory, nurse-patient relationship. Word count: 6044 ABSTRACT
D
This article discusses the impact of selected findings from a PhD-study that focuses on
TE
compassion as a guiding principle for contemporary nursing education and practice. The study, of which the literature review and empirical findings have already been published,
CE P
looked at compassion as perceived within the relationship of nurses and older persons with a chronic disease. The patient group was chosen because daily life for them is characterised by long-term dependency on care. The literature review resulted in a theoretical framework of compassion that also explores other closely related concepts such as suffering and
AC
empathy. The empirical part of the study, in which 61 in-depth interviews and 6 group interviews with patients and nurses took place, showed that compassion is a mirroring process in response to grief. Compassion consists of seven dimensions such as attentiveness and presence, in which saliency, so as to anticipate patients’ needs, is of major importance. Compassion is perceived by participants as an indispensable aspect of care, which helps to reveal relevant information in order to establish appropriate outcomes of care. This article focuses on aspects of the PhD-study in which an analysis of compassion in the context of both modern as well as the history of nursing took place. Currently evidence based practice is regarded as the standard for good quality care. Nevertheless there is an on-going debate about what constitutes good quality care. Within this debate two opposing views are apparent. One view defines good care as care supported by the best scientific evidence. The other view states that good care takes place within the nurse-patient relationship in which the nurse performs professional care based on intuitive knowing. It is suggested that compassion is the (missing) link between these views.
ACCEPTED MANUSCRIPT COMPASSION, THE MISSING LINK IN QUALITY OF CARE.
T
INTRODUCTION
IP
Compassion is a phenomenon that has increasingly received worldwide attention over the
SC R
last decade both in public debate and the healthcare sector. The well-known American philosopher Martha Nussbaum discusses compassion at length in her 2001 book on the intelligence of emotions (Nussbaum, 2001). She claims, based on an Aristotelian view of suffering and what suffering evokes, that compassion originates in the idea of ‘the
NU
eudemonistic argument’. People know fate can strike them as it has struck the one they feel compassion for. Recognising a general human vulnerability calls for compassion. Another well-known scholar who pleads for compassion is the British literary scientist Karen
MA
Armstrong. She initiated a Charter for Compassion and in her book has touched a chord with healthcare professionals (Armstrong, 2011). The charter inspired healthcare workers to bring back compassion to healthcare organisations (www.compassionforcare.com). Armstrong
D
claims compassion to be equal to a form of consistent altruism, specifically visible by
TE
practising ‘the golden rule: do not treat others as you would not like them to treat you’. Other authors, such as care ethicists and nurse scientists, plead for compassion to be the central
CE P
focus of care and specific quality for nurses and professional carers (Baart & Grypdonck, 2008; Chambers & Ryder, 2009; Schantz, 2007; Paterson & Zderad, 1988).
AC
Compassion is not a new phenomenon in either nursing practice or theory. Implicitly compassion is present in the foundations of modern nursing, thanks to nursing pioneers who already practised compassion in their work, specifically theorists who leaned on humanistic theories (Meleis, 2007; Paterson & Zderad, 1988). From Nightingale to dozens of modern nursing theories, aspects of compassion can be found (Van der Cingel, 2012). Obviously, there is a need for compassion as a guiding principle for healthcare practices. Nevertheless, compassion as a concept is not easily found in nursing curricula or in the body of knowledge on which nursing curricula and practice are based. Why is that? One answer could be that we do not appear to have a real grip on what compassion is. We do not have much of an idea of the significance of compassion to people who need care and to nurses themselves. Before we can plead for compassion as something to strive for in education and practice, we need to know what compassion is.
ACCEPTED MANUSCRIPT The empirical study ‘Compassion in care’, which was published in 2011 and is part of the thesis ‘Compassion in Nursing Practice, a guiding principle for quality of care’, offers insight into recent experiences and contemporary opinions on compassion from nurses and older people with a chronic disease (van der Cingel, 2011). The thesis, concluded in 2012,
T
answers questions such as ‘what is compassion’ and ‘what is the significance of compassion
IP
for nurse education and practice?’ The study aims to distinguish compassion from other
SC R
concepts such as empathy and pity. It is argued that empathy is to be seen as an ability that functions as a condition for compassion. Pity differs from compassion because of negative connotations and proves to be a separate concept originating from another semantic interpretation. The thesis pleads for a formal position of compassion in nursing care as an
NU
emotion or intelligent judgement, according to the ideas of Nussbaum (2001) on emotions. Convincingly, she argues that an emotion is not simply a feeling. Her theory defines specific
MA
emotions as concepts with cognitive aspects and as ‘part and parcel of ethical reasoning’
D
(2001). The thesis describes compassion in several ways.
A literature review, published in 2009, on compassion in philosophic literature and health
TE
care sciences was undertaken (van der Cingel, 2009). Furthermore, compassion is studied within theories of nursing to find out the way in which it has been described since
CE P
Nightingale? Last but not least, compassion has been studied empirically. In a qualitative study, a total of 51 nurses and 55 older persons with a chronic disease were interviewed individually and in focus-groups. In the individual interviews questions concerned the nature
AC
and significance of compassion, while compassion in the nurse-patient relationship was the focus of attention in group interviews attended by both nurses and patients. Compassion is, according to the study participants, to be interpreted as a phenomenon of moral relevance for the health care sector. Compassion offers nurses and other caregiving professionals a real alternative for the performance of good care.
This article will not describe at length the literature review, the results of the empirical study, nor the study of compassion in nursing theories since Nightingale. However, the results and conclusions of the thesis, as a whole, offer insights for further debate on the connection between compassion and good quality care. These insights have the potential to inform a renewed notion of the importance of compassion for nursing education and practice. There are three issues that stem from perspectives described in the thesis which are relevant to the argument in this article. Two of these issues concern a critique of aspects of both Nussbaum’s as well as Armstrong’s theories of compassion. The third issue concerns a
ACCEPTED MANUSCRIPT short explanation on how compassion as a concept is being confused with servility or servitude because of the historic context in which modern nursing came to be a profession. The article specifically discusses the relevance of compassion for quality of care and pleads for a formal place for compassion as a leading concept in nursing practice and curricula.
T
Compassion should be discussed with student nurses and nurses in practice, not as a
IP
personal quality that a nurse or student-nurse happens to have or not have, but as an
SC R
empowering characteristic that nurses need in order to perform good care. This, of course, evokes one of the central questions of this Special Issue, whether or not nurses can learn to
NU
feel compassion and act likewise.
The article first describes these three issues, followed by a brief summary of the results of
MA
the empirical study, consisting of both individual interviews and focus-groups on compassion. These results describe the seven dimensions of compassion. The article then focuses on compassion in the nurse patient-relationship and specifies how compassion can
D
be developed as a competence for nursing students and nurses, provided a basic empathic ability is present. The article concludes by offering an insight into the close relationship
CE P
TE
between evidence based practice, compassion and excellence of care.
PERSPECTIVES ON COMPASSION IN HISTORY AND TODAY The literature review shows that the concept of compassion and an exploration of its nature
AC
has been an object of study by contemporary philosophers and scientists (Van der Cingal, 2009). But actually, compassion has been deliberated by scholars since Aristotle’s days (384-322 BCE). This is not surprising, since compassion is found in all major religions and ethical and philosophical traditions of the world. In this section three perspectives on compassion and their implications for nursing are discussed.
Compassion, a judgement in tragedies of life One of the most influential philosophers today, Martha Nussbaum (2001), argues that compassion as an emotion should make a contribution to debates on ethical questions because of the normative evaluation and informative role compassion plays in human tragedy and suffering. Nussbaum’s perspective shows that compassion is a response to human suffering. Therefore compassion is of major significance for nursing and other
ACCEPTED MANUSCRIPT healthcare professions. In her eloquent way Nussbaum explains how compassion is an intelligent judgement when fate strikes and people find themselves in tragic circumstances. Compassion is the correct evaluation in answer to suffering when you are the one who is not in bad circumstances (Carr, 1999). However, one aspect of her argument is disturbing to a
T
major principle of professional nursing. Nussbaum claims that compassion has a specific
IP
condition, the condition of an undeserved fate. Only when suffering is undeserved,
SC R
compassion is the correct response (Tudor, 2001). An undeserved fate implies that there can also be such a thing as a deserved fate. This may be logical reasoning for scholars who argue from a position of justice. But compassion does not need to be based on judgements of right or wrong when it comes to care. Nurses do not need to judge as judges do. On the
NU
contrary, in order to care, it is necessary to withhold one’s judgement on right or wrong behaviour. To care for someone implies that you can take care and therefore are in a
MA
position to help someone who is in need. In the act of caring you are able to put the interest of someone who is in need first. This view is supported by professional ethics of care which prescribes the right of equal treatment to everyone who needs care (ICN, 2010). It is a fundamental principle in health care to guarantee equal treatment of all patients. If
D
compassion is to be acknowledged as an important aspect of the concept of care,
TE
compassion needs to be unconditionally available towards everyone who suffers. Whether or not their suffering stems from right or wrong behaviour is irrelevant. Nussbaum’s condition
CE P
violates this rule and therefore puts healthcare professionals in an awkward position. That is not to say that Nussbaum’s explanation of compassion cannot be supportive of nursing, it is. Her statement on compassion as a judgement, an intelligent evaluation of a human condition and tragic circumstances offers insight and is of great help in specifying professional
AC
conduct. Compassion seen as such a judgement is helpful for nurses. However, compassion can never be a judgement of right or wrong for those who help according to a professional ethics of care.
Compassion, ‘the golden rule’ Another influential public figure on the subject of compassion is Karen Armstrong (2011). She proposes the ‘golden rule’ to be a leading principle for our behaviour towards one another. Compassion, from her perspective, signifies acting in accordance to this rule. Armstrong stipulates that the ‘golden rule’ can be formulated in a negative as well as in a positive way: ‘always treat others as you would wish to be treated yourself’. More than one study on compassion however, including the empirical study of the thesis discussed in this article, show the positive version of this rule to be false and even contradictory to
ACCEPTED MANUSCRIPT compassion. As mentioned earlier, we need empathy, the ability to recognise human vulnerability as a vulnerability we each have, in order to have compassion with others. When I am able to see what suffering would do to myself I can see the significance of suffering for someone else. But there is a danger in this argument, and that is the danger of projection. Is
T
this not because the main characteristic of compassion is to focus on the misery of the one
IP
who is suffering, instead of being focused on yourself? So there is the challenge that lies at
SC R
the heart of compassion. We need to identify with each other as human beings who are vulnerable and at risk of the tragedies of life, but at the same time we need to ‘de-self oneself’ in order to see the interest and suffering that the other person experiences. Human beings do not all share the same values or preferences in life. Some people, for example,
NU
prefer to hear bad news upfront; others prefer to hear it in a more indirect way. Also, views on sickness, health or losses in life can differ and therefore be differently valued. What is important to me could be less important to someone else. Therefore, too much identification
MA
or empathy turns into projection and has the tendency to let one’s own values lead (Roeser & Willemsen, 2002; Richmond, 2004). This means that in order to act compassionately we do not want to practise the golden rule in its positive description. We do not always want to
D
treat others as we would wish to be treated ourselves, because we do not know exactly if
TE
that is what someone needs. If I want to be left alone in a moment of grief, because I need time for myself to comprehend what is happening, I cannot assume this is what my patient
CE P
needs as well. The rule for caring should therefore be ‘always assess the needs of someone in need and act upon those needs’.
AC
Compassion, ‘the lady with the lamp’ Last but not least there is a perspective on compassion that stems from nursing history. This perspective is grounded on false or simplified ideas about the start and development of nursing as a modern profession. As ‘the’ pioneer of modern nursing Florence Nightingale is a symbol for those who position the nursing profession next to medicine instead of inferior to medical science (Andrist, Nicholas, & Wolf, 2005). Surprising that still, ‘the Lady with the Lamp’ is able to evoke mixed feelings in many nurses today. It seems ‘Florence’ is also a synonym for the nurse who leaves herself out of the account in a negative way, when putting yourself aside becomes self-sacrifice. How did this happen, knowing that Nightingale always expressed clear opinions on the need for solid nurse education and for nursing to be a paid profession (McDonald, 2010)? How did nursing and self-sacrifice became entangled, despite all the efforts of Nightingale and other pioneers to position nursing as a profession that should have social status and significance? For an answer we have to know that nurses
ACCEPTED MANUSCRIPT before Nightingale were either members of a religious order or had low social status. More often than not the poorest of poor were forced to work in the poor houses, precursors of hospitals, and at the same time prostitute themselves in order to earn a little money. Therefore, in later days women from higher social classes had to stress their ‘calling’ or
T
vocation for the profession in order to neutralise negative associations. Moreover, from the
IP
end of the nineteenth century until far into the twentieth, the ideal of a nursing vocation was
SC R
misused in order to keep wages as low as possible and nurses submissive to male doctors (Van Gemert & Spijker, 1990; Andrist, Nicholas, & Wolf, 2005). Within the context of early professionalization of nursing, which was closely tied to women’s liberation, compassion became equivalent to self-sacrifice. A religious motive for nursing, as claimed by Nightingale,
NU
became contradictory to the ambition of women to develop nursing as an autonomous, paid profession. As such, compassion as a value of worth for nursing has been contaminated.
MA
Fortunately, the true semantic meaning of compassion has never disappeared from nursing. Despite these false connotations from the past, compassion always was and still is a key
D
characteristic for nurses today, as shown by the empirical study presented in this article.
TE
COMPASSION, A MIRRORING PROCESS
CE P
According to participants, the empirical study reveals seven dimensions that describe the nature of compassion. Compassion is found to be a process of intuition and communication,
AC
but clearly recognizable by distinct dimensions.
Seven dimensions
The first dimension is attentiveness, to show an interest in others during a person to person encounter. Attentiveness is described as a conscious approach of one person who shows interest in whatever issue is important for the other person. Appropriate gestures or touches can support this approach. Attentiveness is all about approaching the other person as a human being. Attentiveness is followed by the second dimension: active listening. Active listening is an invitation to the patient to tell his or her story. Active listening is an indispensable component of compassion, according to nurses. Listening means stimulating the other person to tell the story. With silences and questioning, nurses encourage their patients to share their emotions. In the dialogue that follows, the third dimension: naming of suffering, acknowledges the suffering. Acknowledging suffering is important because it turns suffering into a visible aspect of life, instead of something that one should keep to oneself.
ACCEPTED MANUSCRIPT The nurse confronts the patient with the fact that these emotions are rightly felt: there is suffering because loss exists. The dialogue, the verbalization of ‘what is going on’ is not just any conversation. For the nurse it is about paraphrasing what she has heard. It is crucial to value the patient’s situation as being unpleasant, difficult, tedious or bad. For the dialogue to
T
be compassionate it is necessary, however paradoxical this may seem, to confront in order
IP
to help the patient to face his or her loss. It is also a check in order to see the emotional
SC R
significance of the loss for the patient.
Nurses describe in detail how they are able to recognize emotions such as grief, anger, fear
NU
and shame non-verbally, besides inquiring about them. Because of the verbalisation of suffering and the accompanying emotions, the nurse is involved with her patient, which is the
MA
fourth dimension: involvement. At the moment nurses show that the predicament of their patient touches them; a mutuality is established. The emotion has become a shared emotion
D
which offers trust that the emotion will be safe with the nurse.
TE
Helping, the fifth dimension is the practical component of compassion. To help in anticipation of needs is much appreciated by patients, whether it concerns helping to perform daily
CE P
activities or helping the patient in finding his or her way in the complex organisation of healthcare services. Nurses themselves consider compassion to be associated with their wish to help and ‘to do something’. There is an urge to be of value expressed by helping
AC
activities. The sixth dimension concerns being present. To actually ‘be there’ involves a physical as well as an emotional presence. But presence involves most of all a saliency to notice what is of importance for a patient and to know and be there when it is needed. To be salient while being present is what makes presence meaningful. Because of their occupation nurses have the privilege to be in the presence of patients a lot, it is almost a matter of course. But being present is not simply ‘being there’ as a coincidence, it involves a conscious choice to be alert and notice what is necessary.
The last and seventh dimension concerns the understanding of suffering and the emotions that go with suffering and loss. The nurse, who tries to understand what a patient is experiencing, is checking whether her interpretation is a correct one. It is a dimension that is mentioned primarily by nurses themselves. They feel that trying to understand their patients is the human thing to do, but they consider it professional behaviour as well. Showing that
ACCEPTED MANUSCRIPT you try to understand, expresses it best in an inquiring attitude. When emotions about loss and suffering become clear in a mutual understanding, the nurse has specific personal knowledge at hand. This knowledge proves to be of significance in setting the correct goals within the professional nursing process. The study therefore shows that compassion helps to
SC R
IP
T
reveal information which is useful in reaching the outcomes of care (van der Cingel, 2011).
The seven dimensions of compassion can be viewed as a concept that is mirroring the process of grieving. Nurses respond with compassion to emotions of grief because of the suffering caused by losses older people with a chronic disease experience. With their view
NU
on compassion as a main characteristic of professional nursing, participants of the study challenge the standard opinion in health care that there is a need for professional distance.
MA
The phenomenon of ‘tiresome’ or ‘difficult’ patients is irrelevant in the eyes of participants. When patients’ conduct is viewed in the light of compassion, it is explained as an expression of suffering. It is the nurse’s task to figure out the reasons for that suffering and to focus her attention on helping her patient to cope. Compassion, expressed by these seven
D
dimensions, therefore evokes appropriate professional behaviour in response to patients’
CE P
TE
suffering.
COMPASSION, CORE COMPETENCE FOR NURSES Compassion, seen as such a mirroring process, contributes to professional care because it
AC
delivers meaningful information within the process. But we also want to know in what way compassion is important in a professional nurse-patient relationship. Focus group interviews, as part of the empirical study, offered insights to that question. Nurses as well as patients said that personal attachment, saliency and equivalence are important and value compassion as a necessity in their relationship. Compassion facilitates communication within the nurse–patient relationship and is therefore inherent in good quality care.
Compassionate responses Care always takes place within relationships. Young people, mostly women, who choose nursing as a profession, choose to be in such relationships. It is an important motivation. Nurses want to care; they love their profession because of it. Some nurses participating in the study used the words ‘love’ or ‘passion’ for their work. They said that mutuality is an
ACCEPTED MANUSCRIPT important aspect of care. In order to establish a good quality nurse-patient relationship, in which a shared view on how care is delivered is dominant, mutual exchange is shown to be a necessity. Both nurse and patient need to get to know each other’s personality (Jukema, 2011). There is a need to be open to each other’s world. These worlds can be quite apart
T
due to, for example, generation, social or gender differences. It also takes time and, more
IP
importantly, the courage to show who you are. But given these conditions, a nurse- patient
SC R
relationship in which compassion is present, contains equality. In order to build a nursepatient relationship based on mutuality, communication skills are essential.
NU
Research on communication strategies between nurses and patients, show different categories of responses to patient behavior that conceal concerns or emotions (Uitterhoeve,
MA
et al., 2008; Cioffi, 1997). People generally have different ways of showing these. Either they give hints, or they verbalize concerns or emotions, or they plainly show their emotions. Professionals subsequently give inquiring, acknowledging or dismissive responses.
D
Needless to say, the first two are compassionate reactions while a dismissive reaction, for example when a nurse ignores a sad facial expression, is not. Inquiring or acknowledging
TE
responses to establish and confirm mutuality in a nurse-patient relationship (Effken, 2007; Uitterhoeve, Bensing, Dilven, Donders, DeMulder, & Van Achterberg, 2008). When a nurse
CE P
is salient and knows where to look for verbal and non-verbal signals, she knows what is needed and is able to anticipate it. To be able to anticipate and act upon what is needed is much appreciated according to the participants in my study. It is so appreciated because
AC
most patients find it difficult to ask for help. Again saliency, as described above, proves to be a crucial aspect within the nurse-patient relationship that is based on compassion.
Compassion, professional behavior to learn More often than not, people assume compassionate behavior to be something that comes naturally to a person. Some participants in my study agreed with this. Nevertheless, when asked, most nurses in the study stated that compassion was more than merely a personal characteristic and should be addressed in nursing school curricula. Nurses also emphasized the importance of having compassionate care role models in nursing practice (Murphy, Jones, Edwards, James, & Mayer, 2009; Plante, Lackey, & Hwang, 2009). Contemporary neuroscientists offer biomedical explanations on how empathy originates. The existence of so called ‘mirror neurons’ in the brain explain the phenomenon of literally feeling someone else’s feelings. If we practise imitating feelings we notice in other people early in life and
ACCEPTED MANUSCRIPT often enough, we are able to recognize specific emotions in others (De Waal, 2009; Knafo, Van Hulle, Zahn-Waxler, Robinson, & Rhee, 2008). In that moment, what separates us as a person disappears. Thus, empathy is an ability that can be practised from the moment we are born. Provided this is done, and empathy is established in a person, how then does this
SC R
IP
T
relate to compassion?
Empathy is the condition for compassion: we need to be able to feel our patient’s grief or pain, in order to evoke compassion. This is what motivates many nursing students to join the profession. But if we reason that compassion is an emotion, as in an intelligent judgment of
NU
someone’s tragic situation, compassion has cognitive and behavioral as well as affective components to work with. Subsequently it should be possible to develop and discuss in the
MA
classroom how to ‘use’ empathy, the evoked feeling as an affective condition. Compassionate emotions of nurses, seen from that point of view, therefore are a source of moral and professional knowledge (Roeser, 2011). Nurses use knowledge from their experiences of specific cases. They recognize signals from patients because of repetition
D
seen on many occasions. They also ‘know’ what an acceptable response is whether or not
TE
this knowledge comes from experience or a conscious use of communication skills. If compassion is to be positioned as a concept to be learned in nursing curricula, it is important
AC
transferred.
CE P
to acknowledge professional and personal experiences as knowledge that can be
The key to the disclosure of this kind of knowledge is reflective skills. The reflective practitioner is able to critically look at her own behavior in specific situations, to learn from those experiences and to share them with other professionals. Reflection will prevent the pitfalls of compassion, such as projection, pity or self-sacrifice (Perry, 2000). Furthermore, , research shows that it is important for student nurses to be acknowledged by their patients in the development of their professional identity in which professional values are of importance (Rognsted, Nortved, & Aasland, 2004). Participating nurses in my study confirmed this. They want to know if they made a difference to patients. Using narratives as a source of knowledge for nursing students and nurses in daily practice proves to be a suitable method to reflect upon emotions (Widdershoven, Abma, & Molewijk, 2009; Gustafsson & Fagerberg, 2003). Specific stories and dialogues help to see the different shades in nurses’ personal experiences. But compassion would not be compassion if it became an instrumental skill. Therefore it is necessary to revisit the diverse ways in which compassion is practised in nursing education programs.
ACCEPTED MANUSCRIPT
COMPASSION, THE MISSING LINK IN QUALITY OF CARE
T
To offer good quality care, is an everyday challenge for nurses who are motivated to do what is needed for their patients. Healthcare practices nowadays function in a context in which all
IP
kinds of different interests are at stake. For example, over recent decades, good quality
SC R
nursing care is being defined as Evidence Based Practice (EBP) (Swan, Lang, & McGinley, 2004). Unfortunately, most of the time Evidence Based Practice is being understood as professional behaviour based on the most recent scientific findings, preferably derived from quantitative studies and randomised clinical trials. The emphasis on a positivistic approach
NU
to research can be explained by the dominance of medical science in healthcare. Medical science has brought much to humankind during the last century, so that curing has become
MA
the dominant paradigm instead of caring. But not all diseases are curable, especially chronic disease or old age itself. Moreover, not all suffering can be ‘cured’ and an additional healthcare paradigm of caring is required for those who suffer when a cure is not available.
D
Furthermore, Evidence Based Practice according to Sackett’s (1996) definition does not include the weight of patient opinions and professional knowledge as the basis for
TE
professional behaviour and decision making in practice alongside scientific evidence (Munten, Cox, Garretsen, & Van den Boogaard, 1996; Sackett, Rosenberg, Gray, Haynes, &
CE P
Richardson, 1996). The implementation of patient participation in healthcare practices supports an important argument for the use of the full definition of Evidence Based Practice. Current and future generations of (older) patients will want to have a say in the way they are
AC
cared for. However, healthcare and nursing practice still is not over familiar with strategies to give voice to patient participation. This is where compassion comes into the equation. Nurses are familiar with compassion as shown in my study. Compassion helps to reveal information necessary for shared outcomes of care. So, it is crucial that outcome measures include compassionate care indicators of good quality care that have been recognized and supported by patients. The recognition of compassion therefore helps to use patients’ knowledge and information. Patients with chronic illnesses have a great deal of knowledge about coping with their illness and the consequences they have to face. To acknowledge their specific and personal knowledge is to take patient participation seriously. Compassion, as a professional attitude that gives voice to patients’ opinions, can fill the gap between those who state that evidence based practice should be the basis of professional knowledge and those who plead for the importance of a sound nurse-patient relationship in which emotions have their place. Both aspects of compassion hold the answer to good quality care.
ACCEPTED MANUSCRIPT
CONCLUSION
T
Compassion can be viewed as an important phenomenon for nurses who want to emphasize the humane aspects of nursing care for older people with a chronic illness. The wish to take
IP
care of somebody originates in the human characteristic of empathy. In the context of a well-
SC R
established nurse-patient relationship, the outcomes of care are the result of patient participation, professional knowledge and research based evidence.
NU
Because of that the outcomes of care are focused on these activities and aspects of life that are within patients’ reach. But most importantly, compassionate care is focused on the
MA
acknowledgement of the losses that accompany a chronic disease. Compassionate behaviour that coincides with excellent nursing care consists of a range of communication skills. Compassion, from that perspective, is an instrument and a supportive feature in the
D
realisation of Evidence Based Practice. Next to the use of findings of scientific research, compassion is a guiding principle to accomplish excellent, ‘made to measure’ care. Intuitive
TE
and affective reasoning can be translated into conscious and pragmatic nursing, when compassion is the core nurse competence. Compassion is described in my study in terms of
CE P
communication skills and behaviour which makes it applicable and recognisable to nurses and student-nurses. The seven dimensions of compassion are well known aspects in nursing education curricula. Evidence Based Nursing Practice is an important phenomenon
AC
in contemporary healthcare. But when compassion is seen as a guiding principle, patients’ voices and nurses’ professional knowledge can be integrated into Evidence Based Practice. Compassion and excellent care coincide when compassion is viewed as a judgement that represents a moral answer to suffering (Fritz-Cates, 1997). Compassion, if positioned as the main competence for nurses and acknowledged as an integral part of Evidence Based Practice, has great potential to become a powerful support in the realisation of excellent nursing care. If the nursing profession is able to acknowledge compassion as the answer to suffering which lies at the heart of care, compassion will become the equivalent to good quality care in healthcare today.
T
ACCEPTED MANUSCRIPT
IP
References
AC
CE P
TE
D
MA
NU
SC R
Andrist, L., Nicholas, P., & Wolf, K. (2005). History of Nursing Ideas. Jones & Bartlett Publishers. Armstrong, K. (2011). Twelve steps to a compassionate life. London: The Bodley Head. Baart, A., & Grypdonck, M. (2008). Verpleegkunde en presentie, een zoektocht in dialoog naar de betekenis van presentie voor verpleegkundige zorg. Den Haag: Lemma. Carr, B. (1999). Pity and compassion as social virtues. Philosophy(74), 411-429. Chambers, C., & Ryder, E. (2009). Compassion and caring in nursing. Oxon: Radcliff publishing Ltd. Cioffi, J. (1997). Heuristics, servants to intuition in clinical decision-making. Journal of Advanced Nursing(26), 203-208. De Waal, F. (2009). The Age of Empathy, Nature's Lessons for a Kinder Society. New York: Crown Publishing Group. Effken, J. (2007). The informational basis for nursing intuition: philosophical underpinnings. Nursing Philosophy(8), 187-200. Fritz-Cates, D. (1997). Choosing to feel, Virtue, Friendship and Compassion for Friends. Notre Dame Indiana: University of Notre Dame Press. Gustafsson, C., & Fagerberg, I. (2003). Reflection, the way to professional development? Journal of Clinical Nursing(13), 271–280. ICN, I. C. (2010, april). www.icn.ch/about-icn/icn-definition-of-nursing/. Opgehaald van ICN. Jukema, J. (2011). Bewarende zorg, een visie voor verzorgenden en verpleegkundigen. Boom Lemma. Knafo, A., Van Hulle, C., Zahn-Waxler, C., Robinson, J., & Rhee, S. (2008). The Developmental Origins of a Disposition Toward Empathy: Genetic and Environmental Contributions . Emotion (6), 737-752. McDonald, L. (2010). Florence Nightingale at first hand. Waterloo, Canada: Wilfrid Laurier University Press. Munten, G., Cox, K., Garretsen, H., & Van den Boogaard, G. (1996). Evidence Based Practice, Een kritische reflectie. Verpleegkunde, Nederlands-Vlaams wetenschappelijk tijdschrift voor verpleegkundigen(21, 2), 148-156. Murphy, F., Jones, S., Edwards, M., James, J., & Mayer, A. (2009). The impact of nurse education on the caring behaviours of nursing students. Nurse Education Today (29), 254–264. Nussbaum, M. (2001). Upheavals of Thought, The intelligence of emotions. Cambridge: Cambridge University Press. Perry, M. A. (2000). Reflections on intuition and expertise. Journal of Clinical Nursing(9), 137-145. Plante, T., Lackey, K., & Hwang, J. (2009). The impact of immersion trips on development of compassion among college students. Journal of Experiential Education(32 1). Richmond, S. (2004). Being in others: empathy from an psychoanalytical perspective. European Journal of Philosophy(12), 244-264.
ACCEPTED MANUSCRIPT
AC
CE P
TE
D
MA
NU
SC R
IP
T
Roeser, S. (2011). Moral emotions and intuitions. London: Palgrave Macmillan. Roeser, S., & Willemsen, M. (2002). Compassie en verbeelding, over Nietzsche, Nussbaum en de onwenselijkheid van egoisme. Algemeen Nederlands Tijdschrift voor Wijsbegeerte(96), 53-65. Rognsted, M., Nortved, P., & Aasland, O. (2004). Caring motives in late modern society: values and attitudes among nursing students. Nursing Ethics 2004(11 3), 227-239. Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based medicine: what it is and what it isn't. Britisch Medical Journal(312), 71-72. Schantz, M. (2007). Compassion: a concept analysis. Nursing Forum(42), 48-55. Swan, B., Lang, N., & McGinley, A. (2004). Perspectives in Ambulatory Care.Access to Quality Health Care: Links Between Evidence, Nursing Language, and Informatics. Nursing Economic, 22(6), 325-332. Tudor, S. (2001). Compassion and Remorse, Acknowledging the Suffering Other. Leuven: Peeters. Uitterhoeve, R., Bensing, J., Dilven, E., Donders, R., DeMulder, P., & Van Achterberg, T. (2008). Nurse-patient communication in cancer care, does responding to patient's cues predict patients satisfaction with communication? Psycho-oncology, 71-80. Uitterhoeve, R., De Leeuw, J., Bensing, J., Heaven, C., Borms, G., De Mulder, P., et al. (2008). Cue-responding behaviours of oncology nurses in video-simulated interviews. Journal of Advanced Nursing, 61, 1, 71-80. van der Cingel, C. (2009). Compassion and professional care: exploring the domain. Nursing Philosophy , 124–136. van der Cingel, C. (2011). Compassion in care: A qualitative study of older people with a chronic disease and nurses. Nursing Ethics, 672–685. Van der Cingel, C. (2012). Compassie in de verpleegkundige praktijk, een leidend principe voor goede zorg. BoomLemma Uitgevers. Van Gemert, V., & Spijker, T. (1990). Verdichtsel en Werkelijkheid, de waardering van de verpleegkundige zorg door de jaren heen. Lochem: De Tijdstroom. Vosman, F., & Baart, A. (2008). Aannemelijke zorg, over het uitzieden en verdringen van praktische wijsheid in de gezondheidszorg. Den Haag: Lemma. Widdershoven, G., Abma, T., & Molewijk, B. (2009). Empirical Ethics as Dialogical Practice. Bioethics Volume(4 9), 236–248.
S0260-6917(14)00114-2 doi: 10.1016/j.nedt.2014.04.003 YNEDT 2708
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
19 June 2013 12 January 2014 17 April 2014
Please cite this article as: van der Cingel, Margreet, Compassion: The missing link in quality of care, Nurse Education Today (2014), doi: 10.1016/j.nedt.2014.04.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT COMPASSION: THE MISSING LINK IN QUALITY OF CARE
AUTHOR’S INFORMATION Margreet van der Cingel,
Title:
RN, MsN, PhD
Position:
College professor & senior researcher, School of Healthcare, Research group
SC R
Innovation in care for older people
IP
T
Name:
University of Applied Sciences Windesheim, Zwolle, The Netherlands Campus 2-6, P.O. Box 10090, 8000 GB Zwolle, The Netherlands
Email:
[email protected] or [email protected]
Phone:
0031-627100950 (mobile)
NU
Adress:
Keywords: compassion, quality of care, older people, chronic disease, evidence based
MA
practice, professional behaviour, nursing theory, nurse-patient relationship. Word count: 6044 ABSTRACT
D
This article discusses the impact of selected findings from a PhD-study that focuses on
TE
compassion as a guiding principle for contemporary nursing education and practice. The study, of which the literature review and empirical findings have already been published,
CE P
looked at compassion as perceived within the relationship of nurses and older persons with a chronic disease. The patient group was chosen because daily life for them is characterised by long-term dependency on care. The literature review resulted in a theoretical framework of compassion that also explores other closely related concepts such as suffering and
AC
empathy. The empirical part of the study, in which 61 in-depth interviews and 6 group interviews with patients and nurses took place, showed that compassion is a mirroring process in response to grief. Compassion consists of seven dimensions such as attentiveness and presence, in which saliency, so as to anticipate patients’ needs, is of major importance. Compassion is perceived by participants as an indispensable aspect of care, which helps to reveal relevant information in order to establish appropriate outcomes of care. This article focuses on aspects of the PhD-study in which an analysis of compassion in the context of both modern as well as the history of nursing took place. Currently evidence based practice is regarded as the standard for good quality care. Nevertheless there is an on-going debate about what constitutes good quality care. Within this debate two opposing views are apparent. One view defines good care as care supported by the best scientific evidence. The other view states that good care takes place within the nurse-patient relationship in which the nurse performs professional care based on intuitive knowing. It is suggested that compassion is the (missing) link between these views.
ACCEPTED MANUSCRIPT COMPASSION, THE MISSING LINK IN QUALITY OF CARE.
T
INTRODUCTION
IP
Compassion is a phenomenon that has increasingly received worldwide attention over the
SC R
last decade both in public debate and the healthcare sector. The well-known American philosopher Martha Nussbaum discusses compassion at length in her 2001 book on the intelligence of emotions (Nussbaum, 2001). She claims, based on an Aristotelian view of suffering and what suffering evokes, that compassion originates in the idea of ‘the
NU
eudemonistic argument’. People know fate can strike them as it has struck the one they feel compassion for. Recognising a general human vulnerability calls for compassion. Another well-known scholar who pleads for compassion is the British literary scientist Karen
MA
Armstrong. She initiated a Charter for Compassion and in her book has touched a chord with healthcare professionals (Armstrong, 2011). The charter inspired healthcare workers to bring back compassion to healthcare organisations (www.compassionforcare.com). Armstrong
D
claims compassion to be equal to a form of consistent altruism, specifically visible by
TE
practising ‘the golden rule: do not treat others as you would not like them to treat you’. Other authors, such as care ethicists and nurse scientists, plead for compassion to be the central
CE P
focus of care and specific quality for nurses and professional carers (Baart & Grypdonck, 2008; Chambers & Ryder, 2009; Schantz, 2007; Paterson & Zderad, 1988).
AC
Compassion is not a new phenomenon in either nursing practice or theory. Implicitly compassion is present in the foundations of modern nursing, thanks to nursing pioneers who already practised compassion in their work, specifically theorists who leaned on humanistic theories (Meleis, 2007; Paterson & Zderad, 1988). From Nightingale to dozens of modern nursing theories, aspects of compassion can be found (Van der Cingel, 2012). Obviously, there is a need for compassion as a guiding principle for healthcare practices. Nevertheless, compassion as a concept is not easily found in nursing curricula or in the body of knowledge on which nursing curricula and practice are based. Why is that? One answer could be that we do not appear to have a real grip on what compassion is. We do not have much of an idea of the significance of compassion to people who need care and to nurses themselves. Before we can plead for compassion as something to strive for in education and practice, we need to know what compassion is.
ACCEPTED MANUSCRIPT The empirical study ‘Compassion in care’, which was published in 2011 and is part of the thesis ‘Compassion in Nursing Practice, a guiding principle for quality of care’, offers insight into recent experiences and contemporary opinions on compassion from nurses and older people with a chronic disease (van der Cingel, 2011). The thesis, concluded in 2012,
T
answers questions such as ‘what is compassion’ and ‘what is the significance of compassion
IP
for nurse education and practice?’ The study aims to distinguish compassion from other
SC R
concepts such as empathy and pity. It is argued that empathy is to be seen as an ability that functions as a condition for compassion. Pity differs from compassion because of negative connotations and proves to be a separate concept originating from another semantic interpretation. The thesis pleads for a formal position of compassion in nursing care as an
NU
emotion or intelligent judgement, according to the ideas of Nussbaum (2001) on emotions. Convincingly, she argues that an emotion is not simply a feeling. Her theory defines specific
MA
emotions as concepts with cognitive aspects and as ‘part and parcel of ethical reasoning’
D
(2001). The thesis describes compassion in several ways.
A literature review, published in 2009, on compassion in philosophic literature and health
TE
care sciences was undertaken (van der Cingel, 2009). Furthermore, compassion is studied within theories of nursing to find out the way in which it has been described since
CE P
Nightingale? Last but not least, compassion has been studied empirically. In a qualitative study, a total of 51 nurses and 55 older persons with a chronic disease were interviewed individually and in focus-groups. In the individual interviews questions concerned the nature
AC
and significance of compassion, while compassion in the nurse-patient relationship was the focus of attention in group interviews attended by both nurses and patients. Compassion is, according to the study participants, to be interpreted as a phenomenon of moral relevance for the health care sector. Compassion offers nurses and other caregiving professionals a real alternative for the performance of good care.
This article will not describe at length the literature review, the results of the empirical study, nor the study of compassion in nursing theories since Nightingale. However, the results and conclusions of the thesis, as a whole, offer insights for further debate on the connection between compassion and good quality care. These insights have the potential to inform a renewed notion of the importance of compassion for nursing education and practice. There are three issues that stem from perspectives described in the thesis which are relevant to the argument in this article. Two of these issues concern a critique of aspects of both Nussbaum’s as well as Armstrong’s theories of compassion. The third issue concerns a
ACCEPTED MANUSCRIPT short explanation on how compassion as a concept is being confused with servility or servitude because of the historic context in which modern nursing came to be a profession. The article specifically discusses the relevance of compassion for quality of care and pleads for a formal place for compassion as a leading concept in nursing practice and curricula.
T
Compassion should be discussed with student nurses and nurses in practice, not as a
IP
personal quality that a nurse or student-nurse happens to have or not have, but as an
SC R
empowering characteristic that nurses need in order to perform good care. This, of course, evokes one of the central questions of this Special Issue, whether or not nurses can learn to
NU
feel compassion and act likewise.
The article first describes these three issues, followed by a brief summary of the results of
MA
the empirical study, consisting of both individual interviews and focus-groups on compassion. These results describe the seven dimensions of compassion. The article then focuses on compassion in the nurse patient-relationship and specifies how compassion can
D
be developed as a competence for nursing students and nurses, provided a basic empathic ability is present. The article concludes by offering an insight into the close relationship
CE P
TE
between evidence based practice, compassion and excellence of care.
PERSPECTIVES ON COMPASSION IN HISTORY AND TODAY The literature review shows that the concept of compassion and an exploration of its nature
AC
has been an object of study by contemporary philosophers and scientists (Van der Cingal, 2009). But actually, compassion has been deliberated by scholars since Aristotle’s days (384-322 BCE). This is not surprising, since compassion is found in all major religions and ethical and philosophical traditions of the world. In this section three perspectives on compassion and their implications for nursing are discussed.
Compassion, a judgement in tragedies of life One of the most influential philosophers today, Martha Nussbaum (2001), argues that compassion as an emotion should make a contribution to debates on ethical questions because of the normative evaluation and informative role compassion plays in human tragedy and suffering. Nussbaum’s perspective shows that compassion is a response to human suffering. Therefore compassion is of major significance for nursing and other
ACCEPTED MANUSCRIPT healthcare professions. In her eloquent way Nussbaum explains how compassion is an intelligent judgement when fate strikes and people find themselves in tragic circumstances. Compassion is the correct evaluation in answer to suffering when you are the one who is not in bad circumstances (Carr, 1999). However, one aspect of her argument is disturbing to a
T
major principle of professional nursing. Nussbaum claims that compassion has a specific
IP
condition, the condition of an undeserved fate. Only when suffering is undeserved,
SC R
compassion is the correct response (Tudor, 2001). An undeserved fate implies that there can also be such a thing as a deserved fate. This may be logical reasoning for scholars who argue from a position of justice. But compassion does not need to be based on judgements of right or wrong when it comes to care. Nurses do not need to judge as judges do. On the
NU
contrary, in order to care, it is necessary to withhold one’s judgement on right or wrong behaviour. To care for someone implies that you can take care and therefore are in a
MA
position to help someone who is in need. In the act of caring you are able to put the interest of someone who is in need first. This view is supported by professional ethics of care which prescribes the right of equal treatment to everyone who needs care (ICN, 2010). It is a fundamental principle in health care to guarantee equal treatment of all patients. If
D
compassion is to be acknowledged as an important aspect of the concept of care,
TE
compassion needs to be unconditionally available towards everyone who suffers. Whether or not their suffering stems from right or wrong behaviour is irrelevant. Nussbaum’s condition
CE P
violates this rule and therefore puts healthcare professionals in an awkward position. That is not to say that Nussbaum’s explanation of compassion cannot be supportive of nursing, it is. Her statement on compassion as a judgement, an intelligent evaluation of a human condition and tragic circumstances offers insight and is of great help in specifying professional
AC
conduct. Compassion seen as such a judgement is helpful for nurses. However, compassion can never be a judgement of right or wrong for those who help according to a professional ethics of care.
Compassion, ‘the golden rule’ Another influential public figure on the subject of compassion is Karen Armstrong (2011). She proposes the ‘golden rule’ to be a leading principle for our behaviour towards one another. Compassion, from her perspective, signifies acting in accordance to this rule. Armstrong stipulates that the ‘golden rule’ can be formulated in a negative as well as in a positive way: ‘always treat others as you would wish to be treated yourself’. More than one study on compassion however, including the empirical study of the thesis discussed in this article, show the positive version of this rule to be false and even contradictory to
ACCEPTED MANUSCRIPT compassion. As mentioned earlier, we need empathy, the ability to recognise human vulnerability as a vulnerability we each have, in order to have compassion with others. When I am able to see what suffering would do to myself I can see the significance of suffering for someone else. But there is a danger in this argument, and that is the danger of projection. Is
T
this not because the main characteristic of compassion is to focus on the misery of the one
IP
who is suffering, instead of being focused on yourself? So there is the challenge that lies at
SC R
the heart of compassion. We need to identify with each other as human beings who are vulnerable and at risk of the tragedies of life, but at the same time we need to ‘de-self oneself’ in order to see the interest and suffering that the other person experiences. Human beings do not all share the same values or preferences in life. Some people, for example,
NU
prefer to hear bad news upfront; others prefer to hear it in a more indirect way. Also, views on sickness, health or losses in life can differ and therefore be differently valued. What is important to me could be less important to someone else. Therefore, too much identification
MA
or empathy turns into projection and has the tendency to let one’s own values lead (Roeser & Willemsen, 2002; Richmond, 2004). This means that in order to act compassionately we do not want to practise the golden rule in its positive description. We do not always want to
D
treat others as we would wish to be treated ourselves, because we do not know exactly if
TE
that is what someone needs. If I want to be left alone in a moment of grief, because I need time for myself to comprehend what is happening, I cannot assume this is what my patient
CE P
needs as well. The rule for caring should therefore be ‘always assess the needs of someone in need and act upon those needs’.
AC
Compassion, ‘the lady with the lamp’ Last but not least there is a perspective on compassion that stems from nursing history. This perspective is grounded on false or simplified ideas about the start and development of nursing as a modern profession. As ‘the’ pioneer of modern nursing Florence Nightingale is a symbol for those who position the nursing profession next to medicine instead of inferior to medical science (Andrist, Nicholas, & Wolf, 2005). Surprising that still, ‘the Lady with the Lamp’ is able to evoke mixed feelings in many nurses today. It seems ‘Florence’ is also a synonym for the nurse who leaves herself out of the account in a negative way, when putting yourself aside becomes self-sacrifice. How did this happen, knowing that Nightingale always expressed clear opinions on the need for solid nurse education and for nursing to be a paid profession (McDonald, 2010)? How did nursing and self-sacrifice became entangled, despite all the efforts of Nightingale and other pioneers to position nursing as a profession that should have social status and significance? For an answer we have to know that nurses
ACCEPTED MANUSCRIPT before Nightingale were either members of a religious order or had low social status. More often than not the poorest of poor were forced to work in the poor houses, precursors of hospitals, and at the same time prostitute themselves in order to earn a little money. Therefore, in later days women from higher social classes had to stress their ‘calling’ or
T
vocation for the profession in order to neutralise negative associations. Moreover, from the
IP
end of the nineteenth century until far into the twentieth, the ideal of a nursing vocation was
SC R
misused in order to keep wages as low as possible and nurses submissive to male doctors (Van Gemert & Spijker, 1990; Andrist, Nicholas, & Wolf, 2005). Within the context of early professionalization of nursing, which was closely tied to women’s liberation, compassion became equivalent to self-sacrifice. A religious motive for nursing, as claimed by Nightingale,
NU
became contradictory to the ambition of women to develop nursing as an autonomous, paid profession. As such, compassion as a value of worth for nursing has been contaminated.
MA
Fortunately, the true semantic meaning of compassion has never disappeared from nursing. Despite these false connotations from the past, compassion always was and still is a key
D
characteristic for nurses today, as shown by the empirical study presented in this article.
TE
COMPASSION, A MIRRORING PROCESS
CE P
According to participants, the empirical study reveals seven dimensions that describe the nature of compassion. Compassion is found to be a process of intuition and communication,
AC
but clearly recognizable by distinct dimensions.
Seven dimensions
The first dimension is attentiveness, to show an interest in others during a person to person encounter. Attentiveness is described as a conscious approach of one person who shows interest in whatever issue is important for the other person. Appropriate gestures or touches can support this approach. Attentiveness is all about approaching the other person as a human being. Attentiveness is followed by the second dimension: active listening. Active listening is an invitation to the patient to tell his or her story. Active listening is an indispensable component of compassion, according to nurses. Listening means stimulating the other person to tell the story. With silences and questioning, nurses encourage their patients to share their emotions. In the dialogue that follows, the third dimension: naming of suffering, acknowledges the suffering. Acknowledging suffering is important because it turns suffering into a visible aspect of life, instead of something that one should keep to oneself.
ACCEPTED MANUSCRIPT The nurse confronts the patient with the fact that these emotions are rightly felt: there is suffering because loss exists. The dialogue, the verbalization of ‘what is going on’ is not just any conversation. For the nurse it is about paraphrasing what she has heard. It is crucial to value the patient’s situation as being unpleasant, difficult, tedious or bad. For the dialogue to
T
be compassionate it is necessary, however paradoxical this may seem, to confront in order
IP
to help the patient to face his or her loss. It is also a check in order to see the emotional
SC R
significance of the loss for the patient.
Nurses describe in detail how they are able to recognize emotions such as grief, anger, fear
NU
and shame non-verbally, besides inquiring about them. Because of the verbalisation of suffering and the accompanying emotions, the nurse is involved with her patient, which is the
MA
fourth dimension: involvement. At the moment nurses show that the predicament of their patient touches them; a mutuality is established. The emotion has become a shared emotion
D
which offers trust that the emotion will be safe with the nurse.
TE
Helping, the fifth dimension is the practical component of compassion. To help in anticipation of needs is much appreciated by patients, whether it concerns helping to perform daily
CE P
activities or helping the patient in finding his or her way in the complex organisation of healthcare services. Nurses themselves consider compassion to be associated with their wish to help and ‘to do something’. There is an urge to be of value expressed by helping
AC
activities. The sixth dimension concerns being present. To actually ‘be there’ involves a physical as well as an emotional presence. But presence involves most of all a saliency to notice what is of importance for a patient and to know and be there when it is needed. To be salient while being present is what makes presence meaningful. Because of their occupation nurses have the privilege to be in the presence of patients a lot, it is almost a matter of course. But being present is not simply ‘being there’ as a coincidence, it involves a conscious choice to be alert and notice what is necessary.
The last and seventh dimension concerns the understanding of suffering and the emotions that go with suffering and loss. The nurse, who tries to understand what a patient is experiencing, is checking whether her interpretation is a correct one. It is a dimension that is mentioned primarily by nurses themselves. They feel that trying to understand their patients is the human thing to do, but they consider it professional behaviour as well. Showing that
ACCEPTED MANUSCRIPT you try to understand, expresses it best in an inquiring attitude. When emotions about loss and suffering become clear in a mutual understanding, the nurse has specific personal knowledge at hand. This knowledge proves to be of significance in setting the correct goals within the professional nursing process. The study therefore shows that compassion helps to
SC R
IP
T
reveal information which is useful in reaching the outcomes of care (van der Cingel, 2011).
The seven dimensions of compassion can be viewed as a concept that is mirroring the process of grieving. Nurses respond with compassion to emotions of grief because of the suffering caused by losses older people with a chronic disease experience. With their view
NU
on compassion as a main characteristic of professional nursing, participants of the study challenge the standard opinion in health care that there is a need for professional distance.
MA
The phenomenon of ‘tiresome’ or ‘difficult’ patients is irrelevant in the eyes of participants. When patients’ conduct is viewed in the light of compassion, it is explained as an expression of suffering. It is the nurse’s task to figure out the reasons for that suffering and to focus her attention on helping her patient to cope. Compassion, expressed by these seven
D
dimensions, therefore evokes appropriate professional behaviour in response to patients’
CE P
TE
suffering.
COMPASSION, CORE COMPETENCE FOR NURSES Compassion, seen as such a mirroring process, contributes to professional care because it
AC
delivers meaningful information within the process. But we also want to know in what way compassion is important in a professional nurse-patient relationship. Focus group interviews, as part of the empirical study, offered insights to that question. Nurses as well as patients said that personal attachment, saliency and equivalence are important and value compassion as a necessity in their relationship. Compassion facilitates communication within the nurse–patient relationship and is therefore inherent in good quality care.
Compassionate responses Care always takes place within relationships. Young people, mostly women, who choose nursing as a profession, choose to be in such relationships. It is an important motivation. Nurses want to care; they love their profession because of it. Some nurses participating in the study used the words ‘love’ or ‘passion’ for their work. They said that mutuality is an
ACCEPTED MANUSCRIPT important aspect of care. In order to establish a good quality nurse-patient relationship, in which a shared view on how care is delivered is dominant, mutual exchange is shown to be a necessity. Both nurse and patient need to get to know each other’s personality (Jukema, 2011). There is a need to be open to each other’s world. These worlds can be quite apart
T
due to, for example, generation, social or gender differences. It also takes time and, more
IP
importantly, the courage to show who you are. But given these conditions, a nurse- patient
SC R
relationship in which compassion is present, contains equality. In order to build a nursepatient relationship based on mutuality, communication skills are essential.
NU
Research on communication strategies between nurses and patients, show different categories of responses to patient behavior that conceal concerns or emotions (Uitterhoeve,
MA
et al., 2008; Cioffi, 1997). People generally have different ways of showing these. Either they give hints, or they verbalize concerns or emotions, or they plainly show their emotions. Professionals subsequently give inquiring, acknowledging or dismissive responses.
D
Needless to say, the first two are compassionate reactions while a dismissive reaction, for example when a nurse ignores a sad facial expression, is not. Inquiring or acknowledging
TE
responses to establish and confirm mutuality in a nurse-patient relationship (Effken, 2007; Uitterhoeve, Bensing, Dilven, Donders, DeMulder, & Van Achterberg, 2008). When a nurse
CE P
is salient and knows where to look for verbal and non-verbal signals, she knows what is needed and is able to anticipate it. To be able to anticipate and act upon what is needed is much appreciated according to the participants in my study. It is so appreciated because
AC
most patients find it difficult to ask for help. Again saliency, as described above, proves to be a crucial aspect within the nurse-patient relationship that is based on compassion.
Compassion, professional behavior to learn More often than not, people assume compassionate behavior to be something that comes naturally to a person. Some participants in my study agreed with this. Nevertheless, when asked, most nurses in the study stated that compassion was more than merely a personal characteristic and should be addressed in nursing school curricula. Nurses also emphasized the importance of having compassionate care role models in nursing practice (Murphy, Jones, Edwards, James, & Mayer, 2009; Plante, Lackey, & Hwang, 2009). Contemporary neuroscientists offer biomedical explanations on how empathy originates. The existence of so called ‘mirror neurons’ in the brain explain the phenomenon of literally feeling someone else’s feelings. If we practise imitating feelings we notice in other people early in life and
ACCEPTED MANUSCRIPT often enough, we are able to recognize specific emotions in others (De Waal, 2009; Knafo, Van Hulle, Zahn-Waxler, Robinson, & Rhee, 2008). In that moment, what separates us as a person disappears. Thus, empathy is an ability that can be practised from the moment we are born. Provided this is done, and empathy is established in a person, how then does this
SC R
IP
T
relate to compassion?
Empathy is the condition for compassion: we need to be able to feel our patient’s grief or pain, in order to evoke compassion. This is what motivates many nursing students to join the profession. But if we reason that compassion is an emotion, as in an intelligent judgment of
NU
someone’s tragic situation, compassion has cognitive and behavioral as well as affective components to work with. Subsequently it should be possible to develop and discuss in the
MA
classroom how to ‘use’ empathy, the evoked feeling as an affective condition. Compassionate emotions of nurses, seen from that point of view, therefore are a source of moral and professional knowledge (Roeser, 2011). Nurses use knowledge from their experiences of specific cases. They recognize signals from patients because of repetition
D
seen on many occasions. They also ‘know’ what an acceptable response is whether or not
TE
this knowledge comes from experience or a conscious use of communication skills. If compassion is to be positioned as a concept to be learned in nursing curricula, it is important
AC
transferred.
CE P
to acknowledge professional and personal experiences as knowledge that can be
The key to the disclosure of this kind of knowledge is reflective skills. The reflective practitioner is able to critically look at her own behavior in specific situations, to learn from those experiences and to share them with other professionals. Reflection will prevent the pitfalls of compassion, such as projection, pity or self-sacrifice (Perry, 2000). Furthermore, , research shows that it is important for student nurses to be acknowledged by their patients in the development of their professional identity in which professional values are of importance (Rognsted, Nortved, & Aasland, 2004). Participating nurses in my study confirmed this. They want to know if they made a difference to patients. Using narratives as a source of knowledge for nursing students and nurses in daily practice proves to be a suitable method to reflect upon emotions (Widdershoven, Abma, & Molewijk, 2009; Gustafsson & Fagerberg, 2003). Specific stories and dialogues help to see the different shades in nurses’ personal experiences. But compassion would not be compassion if it became an instrumental skill. Therefore it is necessary to revisit the diverse ways in which compassion is practised in nursing education programs.
ACCEPTED MANUSCRIPT
COMPASSION, THE MISSING LINK IN QUALITY OF CARE
T
To offer good quality care, is an everyday challenge for nurses who are motivated to do what is needed for their patients. Healthcare practices nowadays function in a context in which all
IP
kinds of different interests are at stake. For example, over recent decades, good quality
SC R
nursing care is being defined as Evidence Based Practice (EBP) (Swan, Lang, & McGinley, 2004). Unfortunately, most of the time Evidence Based Practice is being understood as professional behaviour based on the most recent scientific findings, preferably derived from quantitative studies and randomised clinical trials. The emphasis on a positivistic approach
NU
to research can be explained by the dominance of medical science in healthcare. Medical science has brought much to humankind during the last century, so that curing has become
MA
the dominant paradigm instead of caring. But not all diseases are curable, especially chronic disease or old age itself. Moreover, not all suffering can be ‘cured’ and an additional healthcare paradigm of caring is required for those who suffer when a cure is not available.
D
Furthermore, Evidence Based Practice according to Sackett’s (1996) definition does not include the weight of patient opinions and professional knowledge as the basis for
TE
professional behaviour and decision making in practice alongside scientific evidence (Munten, Cox, Garretsen, & Van den Boogaard, 1996; Sackett, Rosenberg, Gray, Haynes, &
CE P
Richardson, 1996). The implementation of patient participation in healthcare practices supports an important argument for the use of the full definition of Evidence Based Practice. Current and future generations of (older) patients will want to have a say in the way they are
AC
cared for. However, healthcare and nursing practice still is not over familiar with strategies to give voice to patient participation. This is where compassion comes into the equation. Nurses are familiar with compassion as shown in my study. Compassion helps to reveal information necessary for shared outcomes of care. So, it is crucial that outcome measures include compassionate care indicators of good quality care that have been recognized and supported by patients. The recognition of compassion therefore helps to use patients’ knowledge and information. Patients with chronic illnesses have a great deal of knowledge about coping with their illness and the consequences they have to face. To acknowledge their specific and personal knowledge is to take patient participation seriously. Compassion, as a professional attitude that gives voice to patients’ opinions, can fill the gap between those who state that evidence based practice should be the basis of professional knowledge and those who plead for the importance of a sound nurse-patient relationship in which emotions have their place. Both aspects of compassion hold the answer to good quality care.
ACCEPTED MANUSCRIPT
CONCLUSION
T
Compassion can be viewed as an important phenomenon for nurses who want to emphasize the humane aspects of nursing care for older people with a chronic illness. The wish to take
IP
care of somebody originates in the human characteristic of empathy. In the context of a well-
SC R
established nurse-patient relationship, the outcomes of care are the result of patient participation, professional knowledge and research based evidence.
NU
Because of that the outcomes of care are focused on these activities and aspects of life that are within patients’ reach. But most importantly, compassionate care is focused on the
MA
acknowledgement of the losses that accompany a chronic disease. Compassionate behaviour that coincides with excellent nursing care consists of a range of communication skills. Compassion, from that perspective, is an instrument and a supportive feature in the
D
realisation of Evidence Based Practice. Next to the use of findings of scientific research, compassion is a guiding principle to accomplish excellent, ‘made to measure’ care. Intuitive
TE
and affective reasoning can be translated into conscious and pragmatic nursing, when compassion is the core nurse competence. Compassion is described in my study in terms of
CE P
communication skills and behaviour which makes it applicable and recognisable to nurses and student-nurses. The seven dimensions of compassion are well known aspects in nursing education curricula. Evidence Based Nursing Practice is an important phenomenon
AC
in contemporary healthcare. But when compassion is seen as a guiding principle, patients’ voices and nurses’ professional knowledge can be integrated into Evidence Based Practice. Compassion and excellent care coincide when compassion is viewed as a judgement that represents a moral answer to suffering (Fritz-Cates, 1997). Compassion, if positioned as the main competence for nurses and acknowledged as an integral part of Evidence Based Practice, has great potential to become a powerful support in the realisation of excellent nursing care. If the nursing profession is able to acknowledge compassion as the answer to suffering which lies at the heart of care, compassion will become the equivalent to good quality care in healthcare today.
T
ACCEPTED MANUSCRIPT
IP
References
AC
CE P
TE
D
MA
NU
SC R
Andrist, L., Nicholas, P., & Wolf, K. (2005). History of Nursing Ideas. Jones & Bartlett Publishers. Armstrong, K. (2011). Twelve steps to a compassionate life. London: The Bodley Head. Baart, A., & Grypdonck, M. (2008). Verpleegkunde en presentie, een zoektocht in dialoog naar de betekenis van presentie voor verpleegkundige zorg. Den Haag: Lemma. Carr, B. (1999). Pity and compassion as social virtues. Philosophy(74), 411-429. Chambers, C., & Ryder, E. (2009). Compassion and caring in nursing. Oxon: Radcliff publishing Ltd. Cioffi, J. (1997). Heuristics, servants to intuition in clinical decision-making. Journal of Advanced Nursing(26), 203-208. De Waal, F. (2009). The Age of Empathy, Nature's Lessons for a Kinder Society. New York: Crown Publishing Group. Effken, J. (2007). The informational basis for nursing intuition: philosophical underpinnings. Nursing Philosophy(8), 187-200. Fritz-Cates, D. (1997). Choosing to feel, Virtue, Friendship and Compassion for Friends. Notre Dame Indiana: University of Notre Dame Press. Gustafsson, C., & Fagerberg, I. (2003). Reflection, the way to professional development? Journal of Clinical Nursing(13), 271–280. ICN, I. C. (2010, april). www.icn.ch/about-icn/icn-definition-of-nursing/. Opgehaald van ICN. Jukema, J. (2011). Bewarende zorg, een visie voor verzorgenden en verpleegkundigen. Boom Lemma. Knafo, A., Van Hulle, C., Zahn-Waxler, C., Robinson, J., & Rhee, S. (2008). The Developmental Origins of a Disposition Toward Empathy: Genetic and Environmental Contributions . Emotion (6), 737-752. McDonald, L. (2010). Florence Nightingale at first hand. Waterloo, Canada: Wilfrid Laurier University Press. Munten, G., Cox, K., Garretsen, H., & Van den Boogaard, G. (1996). Evidence Based Practice, Een kritische reflectie. Verpleegkunde, Nederlands-Vlaams wetenschappelijk tijdschrift voor verpleegkundigen(21, 2), 148-156. Murphy, F., Jones, S., Edwards, M., James, J., & Mayer, A. (2009). The impact of nurse education on the caring behaviours of nursing students. Nurse Education Today (29), 254–264. Nussbaum, M. (2001). Upheavals of Thought, The intelligence of emotions. Cambridge: Cambridge University Press. Perry, M. A. (2000). Reflections on intuition and expertise. Journal of Clinical Nursing(9), 137-145. Plante, T., Lackey, K., & Hwang, J. (2009). The impact of immersion trips on development of compassion among college students. Journal of Experiential Education(32 1). Richmond, S. (2004). Being in others: empathy from an psychoanalytical perspective. European Journal of Philosophy(12), 244-264.
ACCEPTED MANUSCRIPT
AC
CE P
TE
D
MA
NU
SC R
IP
T
Roeser, S. (2011). Moral emotions and intuitions. London: Palgrave Macmillan. Roeser, S., & Willemsen, M. (2002). Compassie en verbeelding, over Nietzsche, Nussbaum en de onwenselijkheid van egoisme. Algemeen Nederlands Tijdschrift voor Wijsbegeerte(96), 53-65. Rognsted, M., Nortved, P., & Aasland, O. (2004). Caring motives in late modern society: values and attitudes among nursing students. Nursing Ethics 2004(11 3), 227-239. Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based medicine: what it is and what it isn't. Britisch Medical Journal(312), 71-72. Schantz, M. (2007). Compassion: a concept analysis. Nursing Forum(42), 48-55. Swan, B., Lang, N., & McGinley, A. (2004). Perspectives in Ambulatory Care.Access to Quality Health Care: Links Between Evidence, Nursing Language, and Informatics. Nursing Economic, 22(6), 325-332. Tudor, S. (2001). Compassion and Remorse, Acknowledging the Suffering Other. Leuven: Peeters. Uitterhoeve, R., Bensing, J., Dilven, E., Donders, R., DeMulder, P., & Van Achterberg, T. (2008). Nurse-patient communication in cancer care, does responding to patient's cues predict patients satisfaction with communication? Psycho-oncology, 71-80. Uitterhoeve, R., De Leeuw, J., Bensing, J., Heaven, C., Borms, G., De Mulder, P., et al. (2008). Cue-responding behaviours of oncology nurses in video-simulated interviews. Journal of Advanced Nursing, 61, 1, 71-80. van der Cingel, C. (2009). Compassion and professional care: exploring the domain. Nursing Philosophy , 124–136. van der Cingel, C. (2011). Compassion in care: A qualitative study of older people with a chronic disease and nurses. Nursing Ethics, 672–685. Van der Cingel, C. (2012). Compassie in de verpleegkundige praktijk, een leidend principe voor goede zorg. BoomLemma Uitgevers. Van Gemert, V., & Spijker, T. (1990). Verdichtsel en Werkelijkheid, de waardering van de verpleegkundige zorg door de jaren heen. Lochem: De Tijdstroom. Vosman, F., & Baart, A. (2008). Aannemelijke zorg, over het uitzieden en verdringen van praktische wijsheid in de gezondheidszorg. Den Haag: Lemma. Widdershoven, G., Abma, T., & Molewijk, B. (2009). Empirical Ethics as Dialogical Practice. Bioethics Volume(4 9), 236–248.