Skip to content

Hungry for Compassion

September 1, 2013

OK, here’s the scenario. You’re a student nurse. It turns out that a staff nurse from the ward where you’re on placement lives near you, and one evening she offers you a lift home. She’s not a person you’ve taken to all that much, but it’s been a long day, it’s pouring with rain and and you’re back on an early tomorrow. So you say yes. While you’re in the car (and remember, you’re not on duty now) she asks you why you came into nursing. You trot out some vague generalities about wanting to care for people and make a difference. “Well you can forget about all that!” she snorts. “Once you’re qualified, there’ll be no time for the wishy-washy stuff – you need to get used to leaving that side of it to the HCAs. Patients in, patients out – that’s all anyone’s bothered about”.

Do you: a) agree – you don’t want to make enemies; b) ignore – everyone’s entitled to an opinion and there’s no immediate threat to patient safety; c) challenge – you’ve got your opinion too; d) condemn – it’s a clear case of compassion fatigue and people like this have no place in the modern NHS; or e) empathise – maybe this nurse has had the compassion ‘ground out of her’ (thank you, RCN) – but why?

‘Compassion fatigue’ is rapidly gaining recognition as a problem within the NHS – especially in relation to nurses. The RCN General Secretary, Peter Carter, recently aired the idea that ‘nurses who are stuck in a rut should be offered the chance to change jobs and make a fresh start’. In a separate scheme, the government has injected £560,000 into promoting the spread of ‘Schwarz Rounds’, an initiative described by the Nursing Times as ‘involv[ing] staff meeting once a month to discuss either specific patient cases or a set of circumstances they may face, such as caring for patients with dementia’. A paper by the Kings Fund reported that ‘an independent evaluation of the Rounds in the United States showed that they have benefited both individuals and teams, and have influenced hospital culture. Rounds participants reported that their ability to provide compassionate care improved and they felt better supported in caring for patients’.

So what exactly is ‘compassion fatigue’? Partly because we’ve never been very good at pinning down an exact definition of compassion itself, ‘compassion fatigue’ is actually quite a difficult thing to describe. Coetzee and Klopper had a go in a 2010 article for the journal Nursing Health and Science. They said (in part) that operational compassion fatigue is distinguished by ‘absence of energy…apathy and a desire to quit…unresponsiveness, callousness and indifference towards patients, the spiritual effects of poor judgement and disinterest (sic) in introspection and the intellectual effect of disorderliness’. This state of affairs is caused by ‘prolonged, continuous and intense contact with patients, the use of self and exposure to stress’. Hmmm…sounds nasty.

To be serious though, my problem with this conceptualisation is the attribution of blame: although Coetzee and Klopper don’t say so outright, there is a clear implication that compassion fatigue is the result of an inability to cope, firmly rooted within the individual. This suspicion is made more explicit in the Kings Fund paper, which baldly states that ‘staff with higher levels of empathy are less likely to suffer from burnout’. Phew! What a relief! Thanks to that nugget, we now don’t need to worry about the ‘almost two-thirds of nurses’ who according to yesterday’s Guardian ‘have considered quitting their jobs in the last 12 months because they are so stressed’: with their obvious low empathy indexes, they were never well suited to the job anyway, so they might as well just sling their collective hooks. We’re better off without them.

Viewed from this perspective, Schwartz Rounds (although undoubtedly helpful to some) look less like genuine attempts to confront the problems nurses face every day, and more like a slightly sinister re-education programme. Isn’t there the whiff here of an unspoken hope that staff will emerge loving – if not Big Brother – NHS management?  I have no doubt that there is genuine comfort and support and team-building to be had from attending these monthly sessions, but if you then return to the same old problems of inadequate resources, spiralling workloads and unsympathetic management, how long is the effect going to last?

And now I am going to take a bold step. As a riposte to the creeping acceptance of the reality of ‘compassion fatigue’, I, Grumbling Appendix, am going to propose a new and – I hope (probably vainly) – more helpful concept; one which, while recognising the inability of some nurses to provide compassionate care, does not lay the blame on character defects or individual weaknesses. Instead, it starts from the premise that all nurses want to be compassionate, and looks at what effect the care-delivery environment, in its current configuration, has on that aspiration. Although its symptoms may mimic those of compassion fatigue, its origins are actually the polar opposite. So, rather than compassion fatigue, let’s talk about ‘compassion hunger’.

Compassion hunger is the anger, frustration and sense of unfulfilment a nurse experiences when she does not have the time to build up relationships with her patients and perform for them the basic nursing tasks they value so much. She may have a sense of hopelessness when the compassionate care she longs to give always ends up being delegated to someone who she suspects is somewhat less compassionate. Or she may feel jealousy if the patients’ gratitude and regard is directed not towards her but towards those members of staff with whom the patients have had more contact – the health care support workers, the students or even the tea ladies. She may also feel conflicted – she came into nursing to care, but now finds herself so bogged down with paperwork and ‘management’ that she has very little opportunity to do the one thing they always said she valued the most. If her self-image was strongly based on identification with ‘caring’, she may even wonder who she is.

There are a number of stages in compassion hunger. The first stage, which may begin immediately post-qualification or sometime afterwards, is characterised by the bitterness and disappointment described above. Gradually, the nurse realises that the best, and possibly the only way to preserve her sanity in this situation and continue working, is to accept that ‘caring’ is no longer a big part of her role, and hand it over to someone else. She may still retain a warm and sympathetic personality – but these qualities are now witnessed more by colleagues than by patients because interaction with patients is so limited. Sometimes the old anger still flares up, perhaps provoked by a specific incident – like a patient requesting that his care be carried out by an unqualified nurse ‘because she’s the one I like best’. In ‘end stage’ compassion hunger, the nurse has rationalised her position by convincing herself that caring is not her job anyway, and she no longer even wants to do it. The irony is that although she may appear to be lacking in compassion, her state of mind has actually been brought about by deep and unsatisfied compassion hunger.

The solution to compassion hunger is not nurse-by-nurse re-programming, but systems change. In a nutshell, we need to look for ways of re-energising nurses by re-connecting them with their patients. This entails looking at initiatives to free up time – for example, let’s distribute the responsibility for completing documentation more equally between trained and untrained staff. There also needs to be proper recognition of the torture that is drugs-round. Why can’t we dispense with the trolley, keep the drugs at the bedsides, encourage self-medication and carry out multiple drugs-rounds simultaneously? Discharge planning is now too complex for ward staff to deal with in addition to everything else It should be handed over lock-stock-and-barrel to designated discharge planners from day one.  And we need to look at ways of organising care so that nurses can interact with fewer patients but more meaningfully. There are plenty of ideas out there, but the core message remains the same: pussyfooting around the margins is not enough. Wholesale rethinking is the only way.

Coetzee, S and Kloper, H (2010): Compassion Fatigue within Nursing Practice. Nursing and Health Science; 235-243.
For the Kings Fund paper on Schwartz Rounds, see http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/schwartz-center-rounds-pilot-evaluation-jun11.pdf
For the Nursing Times coverage of Schwartz rounds (with comments) see
http://www.nursingtimes.net/story.aspx?storycode=5059083&PageNo=2&SortOrder=dateadded&PageSize=20#comments
For the Guardian‘s story on nurses wanting to quit, see
http://www.theguardian.com/society/2013/aug/31/nirses-want-resign-two-thirds
For an inspiring account of one student’s brave stand against care without compassion, see
http://shesoffagaindiaryofastudentnurse.blogspot.co.uk/2013/08/compassion-scared-to-care.html

Advertisements
One Comment

Trackbacks & Pingbacks

  1. The Shortfall | Britian Nurses

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: