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Reflections on the C-Word: Is it time to get compassion out of nursing?

October 5, 2013

Compare and contrast: “We simply don’t have enough great social workers doing enough great social work”; “Birmingham’s problems are complex…and we’re taking action to secure properly embedded and sustained improvement…there is no quick fix”; “There was a failure across every agency to see, hear and respond…staff were distracted”; “There was a culture of denial…interpreting evidence in such a way as to justify not acting”.

‘Cameron identified the NHS’s 300,000 nurses as the key group of health professionals to improve patients’ experience of the service…”Nurses should be hired and promoted on the basis of having compassion as a vocation and not just academic qualifications,” Cameron said. “And another issue is whether pay should be linked to quality of care rather than just time served at a hospital. I favour this approach” he added.’

The quotations in the first paragraph are all reactions (from, respectively, Peter Hay, Strategic Director for Children, Young People and Families, Birmingham City Council; Edward Timpson, Children’s Minister; Jane Held, Independent Chair, Birmingham Safeguarding Children Board; and Dr Elizabeth Yardley, Senior Lecturer in Sociology, Birmingham City University) to the findings, published this week, of the Serious Case Review into the horrific death of two-year-old Keanu Williams at the hands of his own mother.

The second paragraph, on the other hand, is an early reaction from David Cameron to the findings of the Francis Report – later strengthened by government plans to force would-be nursing students to work as health care support workers for up to a year before commencing training ‘to improve compassion’ and recent NMC plans that satisfactory feedback from patients should form part of nurses’ revalidation process.

The striking difference between the two is that whatever the failings of Birmingham City Council’s Children’s Department (and there do seem to have been many), not one of them was attributed to staff’s lack of compassion; and, in contrast to the case of nursing in the aftermath of the Francis Report, what one might term ‘compassionate renewal’ was nowhere suggested as a remedy. Compassion, it seems, is a uniquely nursing solution. Why is this?

The obvious answer, of course, is that despite efforts to professionalise nursing through the advent of degree-only entry, the public remains stubbornly wedded to the idea of nurses as the last redoubt of ‘traditional’ feminine values. Shamelessly egged on by politicians and the media, we have been taught to fear the consequences for society should this bastion fall. Into this overheated atmosphere, Dr Anna Smajdor’s controversial recent paper Reification and Compassion in Medicine has come as a breath of fresh air.

The aspect of Dr Smajdor’s paper that provoked most interest in the press (and predictable ridicule in the Daily Mail) was her assertion that compassion is not a necessary prerequisite for effective nursing care. For what it’s worth, I think Dr Smajdor is correct. Patients have a right to expect that nurses will be courteous, competent, approachable, timely with their interventions, honest in imparting information and willing to listen respectfully to clients’ points of view even when they don’t agree with them. If your bank manager, your electrician or anyone else who was providing you with a service adhered to these principles, it’s unlikely you’d have reason to complain. So why should you expect more – in the form of added compassion – from nurses? Isn’t it just a way of enforcing sentimental stereotypes?

“Oh, but nursing is different!” I hear the Daily Mail readers amongst you cry. “Nurses provide intimate care and deal with people at times of intense personal crisis”. Well, yes. But the mistake we are making here (as Hannah Maslen points out in a response to Dr Smajdor’s original article) is to assume that a lack of compassion automatically equates with cruelty. It doesn’t. The NMC code, the function of which is to provide a prism through which our inevitable emotional responses to our work can be regulated and controlled, contains no mention of the word ‘compassion’. Presumably no one is going to argue that we are better nurses for not following the Code? Looked at in this way, to insist on ‘compassion’ as the Prime Minister and as the Chief Nursing Officer have done (through the adoption of the ‘6C’s’, which include compassion) is actually dragging us right back to the Stone Ages.

For this reason, the most refreshing part of Dr Smajdor’s paper is her suggestion that we ‘ditch the term compassion entirely. An outcome-focussed approach could then apply itself more honestly to identifying, measuring and rewarding ‘measurable outcome-improving behaviours”. Dr Smajdor arrives at this conclusion after surveying the ‘deep ideological conflict’ between on the one hand, David Cameron’s belief that nurses should be rewarded on the basis of their ability to demonstrate a the subjective concept that is compassion, and on the other, the pressure to base all activity within the NHS on a measurable evidence base.

Because compassion is not measurable; if you don’t believe me, consider two nurses, each taking as patient to the toilet. One was does it with added compassion while the other merely complies with the NMC Code. Is there be any identifiable difference between them? Does it help if we go back to the etymological origins of the word ‘compassion’ (Latin com (with) + pati (bear or suffer))? Well not really, unless we want to make it a rule that only nurses who are themselves desperate for a pee should assist patients to the toilet. It’s an eloquent case for extra tea-breaks I suppose – but the larger point is: we are attempting to make policy out of an absurdity.

Dr Smajdor’s sensible conclusion is that the two positions are irreconcilable: the only possible compromise is to ‘commodify compassion:…control and manage it and parcel it out in equal portions’. The dilemma is that in doing so we risk losing whatever is valuable or even sacred about compassion and reducing it instead to a ‘Have a Nice Day’ (‘Hello My Name Is’?) tick-box exercise of ‘compassion-denoting behaviours’; in future, we may yet come to view the blanket imposition of Intentional Rounding as an early example of this type of thinking. Is it what we want? Do we really think it would make the public happy? Or yet more cynical? (I know which one my money’s on).

By removing ‘compassion’ from this equation, what we have is liberation – a grown-up profession whose members are judged on the same professional criteria as members of any other grown-up profession. What we do not have is an injunction on nurses never to show compassion any more: of course nurses can – and indeed should – demonstrate compassion whenever it is safe and appropriate to do so, but as long as they are, in all other respects compliant with the NMC code, there should be no compulsion.

One profession where there is absolutely no compulsion to show compassion is of course, politics, as Jeremy Hunt has today demonstrated with his urging of the Pay Review Body to cancel next year’s already miserly 1% nurses’ pay rise. A case of ‘do as I say, not as I do’?

For David Cameron’s views on linking nurses’ pay to the ability to demonstrate compassion, see:

For Dr Anna Smajdor’s paper (highly recommended) see:

For the Daily Mail’s reporting of the above (complete with utterly spurious attempt to discredit the author) see:

For Hannah Maslen’s blog on Dr Smajdor’s paper (also recommended) see:

  1. Ah, the holy grail of ‘compassion’ in healthcare!

    If we are ever to come close to achieving the impossible dream, those in charge need first to create the conditions in which health professionals are allowed the time and oxygen to be able to ‘care’ for patients (in the more rounded sense of the word). We can never hope to realise this ambition this if successive governments and management make so little effort to understand conditions on the ground or blatantly demonstrate so much public disregard for those on the front line of care provision, as David Cameron’s government has so patently done recently. If you combine ever-diminishing staff levels with politically motivated targets, under-funding, never-ending ‘rebranding’, low staff morale and the immense pressures of an ageing/ increasing population presenting with complex health needs, it’s not surprising if the patient at the end of it all becomes to some extent dehumanised or is even regarded as being besides the point by some people.

    In the Buddhist tradition, compassion is frequently described as an ‘aspiration’. It is an empathic and altruistic way of thinking that actively strives to free others from suffering. Compassion is comprised of ‘wisdom’, which is knowledge and understanding of suffering, and the practice of ‘loving-kindness’, which is wishing for and acting to achieve the best outcomes for others. Compassion is what separates those who simply do their jobs in a functional and professional manner, from those who actively ‘give of themselves’ to others. It’s this element of giving or sharing… the transfer of positive energy from one person to another… that has been shown time and time again to promote healing, faster recovery times, improved patient confidence and ultimately greater overall faith in the healthcare system. By way of contrast, the opposite of empathy is apathy, which is a charge that is not often associated with compassionate people. Rather, such a charge is more often laid at the feet of the purely ‘task’ focused who can be more inclined to keep their heads down and sometimes even look the other way when bad things are happening around them. Who would you rather be ‘cared’ for?

    Whilst the ‘aspiration’ of compassion can be taught and nurtured, wisdom is based on experience and understanding. I would suggest that putting more effort into selecting the right people to train as health professionals and broadening their training experiences in the first place would obviously feed into better outcomes much further down the line. As would actively weeding out those who in turn fail to demonstrate empathy or understanding for others as they proceed along the pathway. This includes apathy towards colleagues and the concept of teamwork, not just patients. Competence should be a minimum standard. Once trained these staff should then be actively listened to and given a prominent voice to help shape the care systems of the future (unlikely in a class-based healthcare system infected with antiquated structures and thinking). However, I fear the recent drive to turn nursing into an academic discipline has gotten in the way of this to some extent as it has unfortunately excluded many good people from entering the profession and possibly narrowing the pool of potentially compassionate recruits.

    From my own perspective, before I became a nurse, I was in and out of hospital every year for the first 24 years of my life. I can’t say I’ve noticed any significant deterioration in ‘compassion’ levels since the 1970’s and 1980’s. If pushed, I would say that going into hospital back then was a far colder and less empathic experience than it is today and I experienced my fair share of poor care during these so called golden years. Pushed even further, I might say that that there is nothing exceptionally empathic about healthcare workers as a group, based on my experiences working outside the NHS. I’ve met more than a few nurses who were trained prior to the Project 2000 era (project 2000 being a dirty word these days) who like to boast that they were much better trained than me. I don’t really care to be honest. Delivering compassionate care is about much more than how you were trained or achieving measurable outcomes. It’s intrinsic to the individual.

    Compassion is an intangible entity that exists in the space between two people. As such it is unmeasurable. It will mean different things to many different people. You may gain an inkling that it is happening somewhere in your world when you overhear some comforting words, witness a kindly smile, some fingers gently stroking a dying hand, that first hot cup of tea steaming by the side of a bed after surgery, or the resolution on a patient’s face as they realise their concerns are actively being listened to. Compassion as such has a life of it’s own. It comes from some other place and is guided by the the sum of all your experiences. As a ‘sensible’ person, you may fight hard to deny it’s importance, but one day it may catch you unawares. When that happens you will never be the same again.

  2. Thank you for taking the time to leave such an eloquent and heart-felt response. I agree that compassion is a wonderful and life-enhancing quality, and that we should strive to incorporate it into our practice as much as we possibly can. But as you say yourself, it is also ‘an intangible entity that exists in the space between two people. As such it is unmeasurable’. This makes it fundamentally incompatible with a health service that (for understandable reasons) is obsessed with the ‘measurable’. Dr Smajdor’s point (if I may take the liberty of attempting to interpret it) is that we can only measure compassion by turning it into a ‘thing’ – a clumsy word to describe a clumsy, well…thing, with no vestige of the sacred left clinging to it. This is the paradox David Cameron has failed to understand.
    I am all in favour of conducting research into how behaviours that we might identify as ‘compassionate’ can be encouraged, or how best to select people who will be compassionate. But realistically, we might also need to look at selecting for psycholgically stable individuals who were more likely to maintain these attitudes under pressure, so it gets more and more complex..
    I did my training years ago, before P2K even, and I certainly don’t believe I was living in a Golden Age. One thing I do think though, is that much of the fun has gone out of nursing these days. I was struck by something I read in the Guardian Review at the weekend. Philip Henscher was talking about the work of Paul Klee. He said ‘the machinery of power works by imposing forgetfulness; the way that the individual can fight back is through laughter’. The joyous, uniting power of laughter is much overlooked in today’s NHS. Nurses, patients, we’re all in this absurd situation together, and we can all acknowledge it – even it it’s just through a meaningful smile or a shake of the head – any time we like. True compassion – in its original Latin sense.

  3. Compassion may be an intangible and immeasurable entity but most of us recognise it when it is happening and are usually able to identify a ‘compassionate’ person from the crowd. Those who can’t perhaps ought to be wishing someone ‘a nice day’ in McDonald’s instead. As Bradshaw rightly suggests, the healthcare system needs to take more on faith, to acknowledge intrinsic values in human beings, rather than chasing after ‘metrics’. Or dare I say pandering to an archaic conservative vision which seeks to blame the individual for systemic failings.This may be a complete revolution for many, but we take lots of things in life on faith.

    It’s a lot simpler than all these well meaning but occasionally confused academics think. It’s simply about giving health professionals the time and space to care,. By focusing on, as Pence suggests, the institutional structures that support or undermine compassionate behaviour. In doing so we may even find that the more ‘scientific’ amongst us become a bit more compassionate as they are freed to come to know their patients better and for some perhaps for the first time. Think of compassion as a stream that feeds a river. Keep that stream free of obstructions and debris and it will flow… the river will flow… life will flow!

  4. Steve, I agree with everything you say (although I do believe in degree nursing, for reasons I have stated elsewhere). Your vison is a wonderful one but I fear it is out of step with the times we live in. Especially after Mid-Staffs, the idea of ‘taking things on faith’ has been well and truly parked. But plainly, we have to do something. The idea of ‘getting compassion out of nursing’ was just a silly attention-grabber really, but behind it is the idea (which I think you will endorse) that only if we stop looking for compassion, do we stand any chance of finding it. Otherwise I fear that the word ‘compassion’ will eventually be bandied around in much the same way as ‘professionalism’ is now – it can mean whatever you want it to mean, and is often used as nothing more than a stick to beat staff with. Do we really want this to be compassion’s fate?

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