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Are you for real? A personal view of compassion in nursing

October 22, 2013

My father was an orphan. By the time he was ten both his parents had died and he and his two siblings (both younger) had been taken in by relatives. Perhaps because I never met them, my grandparents are often in my thoughts. I know little of what they were like as people of course; my father can barely remember them and – apart from a few old photos and my granddad’s WWI campaign medals – I don’t even have anything that was theirs. It’s a sadness I have carried with me all my life.

Years and years ago, I was looking after a lady with a prognosis of weeks. Like my grandmother, she would be leaving behind a young family. As I spoke to her, I suddenly found myself overwhelmed by tears. I just couldn’t hold them back. The only way I could explain what was happening to the astonished patient (and my equally astonished self) was “you’re feeling so many of the things my grandmother must have felt, and it makes me feel closer to her”. She put her arms around me and started crying too. But who were we crying for? Her? Her children? Or a woman who’s been dead since 1932?

The debate about compassion is often conducted in fairly black-and-white terms: can it be taught, or is it innate? In my view, this is far too simplistic. Compassion, as demonstrated by the example above, is first-and-foremost a process, one where all participants bring something to the table – their life experiences, their life expectations – and use them to create something new. Sure, the ‘it’s innate’ argument does have some traction – the degree to which an individual is interested in learning about and connecting with other people could well be pre-determined – but what’s really important is how adept we are at manipulating and controlling the whole ‘bundle’ (to deploy a current NHS buzzword) that is ourselves to interact with others. In this reading, compassion is as much about understanding yourself as it is about understanding your patients.

I’m aware that the inclusion of the words ‘manipulating’ and ‘controlling’ in a discussion about compassion probably strikes some as cynical or even perverse: “compassion is that is forced, or lacking in spontaneity” they are asking “is that really compassion at all?” The answer, I think, is that it depends how you play it – with the emphasis on ‘play’. I have always thought of nursing as being as much about performance as it is about anything else. When I step into the bed bay, my instinctive feeling is that I am stepping out onto a stage, but with the patients not as the audience but as fellow cast-members in the daily production. Because let’s face it, unless you’re lucky enough to have a side room, hospital’s no place for those who crave privacy.

As a conceptualisation of the nurse’s role, what I might describe as the ‘performance art’ model has got a lot going for it. For one thing, although the nurse, as the person who is (usually) the one most familiar with hospital routines, may act as the ‘lead’, everyone has an equal opportunity to choose the part they want to play. This in turn creates an environment where patients’ contributions are viewed as welcome additions to the development of the production, and so builds on the idea of compassion as interaction between patient and professional.

And actually, I have no patience with commentators who believe all compassion in nursing has to be ‘genuine’. If we’re going to insist on everything being ‘kosher’, the logical next question is: are we also supposed to show it when we feel really, really angry or really, really frustrated with patients? Or what about a mixture of the two: I love you but you do my head in? How are you going to play that one? Because emotions rarely have neat boundaries. And while we’re about it, why should nurses be singled out in this way anyway? Acting is the stuff of life. We all do it all the time; we expect it of each other. Even more to the point – the patients themselves are acting. If they weren’t, half of them would be hanging out of the windows, screaming their heads off.

Nursing (and, indeed, patienthood) has to be performance in order to regulate these emotions. Although the shared experience I described at the top of this piece is one that resonated deeply and which I have remembered for a long time, as professionals we obviously can’t go around bursting into tears or blowing our tops every five minutes. But the way we handle it isn’t as simple as outright pretence; it’s more about subtly adapting our normal persona in such a way that allows us to react appropriately and sensitively to situations while at the same time remaining slightly removed from them. Being in and out of the river at the same time, if you like.

And that’s the real beauty of this model: its infinite flexibility – hence the references to ‘manipulation’ and ‘control’. I visualise it as something like the valve on an intravenous giving set: you can open it up a little, or you can open it up a lot, as patient need dictates. You don’t even have to stick to one role. My own repertoire encompasses self-conscious hamming (to the perpetrator of inappropriate behaviour: “Unhand me Sir, for it is to another that I belong!”; it’s a way of distracting attention away from him and onto me) to the occasional letting go of acting – something which is not possible if most of the rest of the time is spent ‘in character’.

Don’t go away with the idea, though, that compassion is only about letting someone cry on your shoulder and nothing more; it’s not. It’s just as much about offering practical help and assistance in a way that shows you are devoting thought to solving the problems another person might face. Unlike his parents, my father did not die young. Today he is an eighty-eight year-old Normandy Veteran with a packed engagements diary and a love of life undimmed. Since my mother passed away four years ago, a number of his neighbours have taken to preparing home-made food for him. He’s often in receipt of fruit pies, soup and even Sunday lunches with all the trimmings.

There are times, I must confess, when I find myself feeling mildly irritated by this carry-on – he’s MY dad for God’s sake! Are the neighbours trying to tell me I neglect him? – but I accept it, as does he, as essentially an unforced expression of compassion, of people asking themselves what sorts of things an elderly widower might be in need of. It’s also a rather touching demonstration of the value they place on his continuing presence amongst them – and in return, they get vegetables from his garden. (But note to Jeremy Hunt – in the unlikely event that you’re reading this – you do NOT have permission to cite the example of my father and his neighbours next time you’re wittering on about your latest ‘care in the community’ idea).

The question for the government, in its mission to select candidates for nursing courses partly on their ability to demonstrate compassion, is what exactly are you looking for? A general interest in other people would seem to be a good starting point – but it seems improbable that anyone without this would be applying for nursing anyway, so its potential to differentiate is limited. The complexity of compassion in nursing suggests that a variety of attributes – some of them less-than- obvious – may be helpful: self-awareness, stability, good problem-solving to name but a few. ‘Compassion’ on its own seems more like the beginning than the end.

This is the last in this short series of articles about compassion. Moving on to pastures new next time.

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