Developing a culture of compassionate care

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Care, compassion, competence, communication, courage and commitment. These are the six Cs set out in the Chief Nursing Officer's recent consultation paper Developing the culture of compassionate care: Creating a new vision and strategy for nurses, midwives and care-givers.

The paper aims to 'set out a shared purpose' for staff in those roles, with six key areas for action. But why do we need a new vision for nurses, midwives and care-givers? And what difference will this vision make?

Two years ago, the Prime Minister's Commission on the Future of Nursing and Midwifery in England published a vision for nursing and midwifery called Front Line Care, which seems to have disappeared into oblivion. And only five months ago, the Nursing and Care Quality Forum (NCQF) published a letter to this Prime Minister with perfectly sensible recommendations about what to do about nursing. The Chief Nursing Officer is working with the NCQF but the vision does not refer to its recommendations.

The new vision differs a little from the earlier ones. It focuses much more on nurses' and midwives' roles in prevention and health promotion and on ‘making every contact count'. Strangely, given the focus on care and compassion, it does not mention nurses' contribution to caring for the half a million people who die each year, fifty percent of whom die in hospital. The NCQF has been explicit that quality of care is linked to staffing, skill mix, and nurses and midwives being able to spend time with individual patients. This new paper acknowledges that lack of time, lack of support, long shift patterns and expanded roles contribute to the apparent lack of empathy in some areas of nursing. However it defers tackling these challenges until the next stage of the work, without saying when that will start or how many stages will follow.

Fundamentally however, what is troubling about this vision and the others is the attempt to create an independent vision for nursing, midwifery, and care-giving separate from the rest of the health care system. All the visions acknowledge that nurses and midwives are members of a 'wider team', but they are not co-produced with health professionals and managers or with patients and relatives. Of course the professions have their own cultures, their own bodies of knowledge and practice, and their own hierarchies and ways of working. And values and behaviours in nursing and midwifery are critically important. But nurses, midwives and care-givers look after patients in the context of organisations, not in isolation. It's simply not possible to deliver reliable, compassionate care 24/7 unless the system as a whole makes it a priority and the most powerful people in the system actively demonstrate their commitment to the values and behaviours that support caring. Read the excellent 'Preventing Abuse and Neglect in Institutional Care of Older Adults' (PANICOA) Dignity in Care report, or the hundreds of pages of testimony to the Mid-Staffordshire Inquiry, or the report of the investigation into Winterbourne View and then ask yourself how much change nurses, midwives and care assistants can achieve on their own, and without the active support of others in the system.

In the USA a growing number of organisations are appointing Board-level Chief Experience Officers. In the absence of such a role on the NHS Commissioning Board, I would like to see a vision for care for patients and their relatives, jointly written by the Chief Executive, the Chief Nursing Officer, the Chief Medical Officer, the Director of Patient Experience and the Chief Financial Officer and signed off by the whole Board. The Board, by virtue of its position, will shape the wider culture of care and working practices across the whole of the health care system. How good it would be to see those at the top modelling the collaborative leadership and close working that patients and relatives need between the nurses, doctors, therapists, managers and support staff who look after them.

Comments

Paul Crawford

Position
Professor of Health Humanities,
Organisation
The University of Nottingham/ Institute of Mental Health
Comment date
10 October 2012
It is disappointing that the problem of compassion depletion in the NHS continues to be simplistically treated as a problem with the doctor or the nurse, rather than the production-line cold clinics and threat cultures that the 'modern NHS' all too frequently asks its practitioners to work in. The big problem at the moment is that everyone is flagging up compassion - which is a highly complex, under-researched phenomenon - as if it is straightforward. It is not. Accountability is increasingly individuated to practitioners to perform compassionately as opposed to Government and organisations designing the spaces and contexts for compassionate engagements to occur between less-stressed patients and practitioners. In other words, we need Government and NHS organisations to focus on what they are doing to advance the compassionate design of their services (and processes) to maximize the likelihood of compassionate relationships. Compassion is not some kind of cream to be applied by smiling health practitioners. We can predict that the cycle of non-compassionate bad doctor/bad nurse framing which the media likes to switch to from time to time is more to do with anti-NHS commentators, particular politicians and private health companies ready to ride in with the 'solution'. We do need to be vigilant and critical at this point when our nurses and doctors are framed as 'the problem'. We should all ask that our NHS is not turned into a production-line. Our practitioners and our patients do not deserve to work or be treated in threat-cultures. We all deserve more than that. Effectiveness and efficiency in healthcare could be viewed as compassionate, yet there are untold damages to practitioners and patients in the current bent for a factory-style, conveyer belt NHS. We need to celebrate those NHS Trust management boards that are delivering services designed to be compassionate for both our patients and practitioners.

Paul Crawford

Position
Professor of Health Humanities,
Organisation
The University of Nottingham/ Institute of Mental Health
Comment date
10 October 2012
PS. I fully support Jocelyn's suggestion for a 'vision for care for patients and their relatives, jointly written by the Chief Executive, the Chief Nursing Officer, the Chief Medical Officer, the Director of Patient Experience and the Chief Financial Officer and signed off by the whole Board'. The Chief Nursing Officer's 6 Cs mantra could then change to Compassionate design (repeat six times)? It is a shame that the consultation document mentions but almost buries two key aspects to this: ‘supporting positive staff experience’ and ‘supported by organisations that promote compassionate and caring culture and values’. We need to be promoting bi-directional compassion from policy makers harking the evidence on how threat cultures lead to compassion depletion or fatigue and guiding real changes in this area, organisations/ managers taking seriously ‘compassionate design’ as their key standard and using evidence-based management to bring about spaces, processes and resources that are compassionate to practitioners so they, in turn, are more able to demonstrate compassion in their approach to patients, and finally, patients to turn the flow the other way around by showing compassion for hard-pressed practitioners and so on.

Andy Bradley

Position
Founding Director,
Organisation
Frameworks 4 Change
Comment date
11 October 2012
Thank you Jocelyn. Today I have been privileged to work with the following group:-
OT manager
Senior Clinical manager
Manager of In Patient Dementia Service
Community Psychiatric Nurse
Ward Manager
Charge Nurse
OT
All work for a Mental Health NHS Trust. We are 18 months into a 'deep change' programme called 'Everyone Matters' (reinforcing your central point about a 'whole systems approach) in which the leaders in a part of the trust have dedicated themselves (with great courage) to 'creating and sustaining consistent compassion'. Today was day two of six of the compassion trainers project - the trust is building internal capacity to run compassion seminars and compassion circles in which a facilitator simply runs rounds of story sharing re compassionate care (there are a lot of stories) and a round of appreciation. Tomorrow I am going to the DH to discuss progress with the paradigm shift from compliance to compassion (fear to trust) which is at the heart of the thinking of a small but growing number of leaders in local authorities, care providers and the NHS.
I am not sure how relevant the consultation is but welcome its emphasis on compassion - what we long for when vulnerable and what takes many health and social care professionals into the caring space.
Our next step is to create 'The Compassionate Leaders Network' to enable the courageous to stay strong and resilient and to build influence from a place of grounded action and impact.
The people I work with and the impacts made on patient and staff well being fills me with optimism that a deep change of culture is possible. I know this may sound naive and I am often accused of that - but I assume that people are good and that given the right conditions (most) people will reveal their goodness - compassion is the 'keystone habit' that can transform health and social care - remaining focused on seeing patient care and the systems and structures around it through the lens of compassion changes both hearts and minds.
Thank you for your continuing deep care and leadership
Warmest regards
Andy

Helen King

Position
Nurse , Midwife , NHS Manager and Commissioner,
Organisation
NHS North of Tyne
Comment date
11 October 2012
Thank you Jocelyn for profiling the need for the change to be systematic , embedded in the culture and led from the top.
After all if leaders of NHS organisations cannot demonstrate care , compassion , excellence in communication and courage in decision making and supporting change for improvement in patient care and experience , then why are we expecting this from those who work in a more subordinate role?
Andy, thank you for sharing the aspirational work that you are involved in and your words of wisdom . I particularly like the compliance to compassion idea in terms of culture shift but might add a step in the middle : compliance-challenge-compassion.
Is there somewhere I can find out more about the work you refer to in the Mental Health Trust?

Dr Paquita de …

Position
GP, Therapist, Mentor/coach and teacher of medical ethics,
Organisation
Imperial College, King's College, London Deanery and Human Values in Healthcare Forum
Comment date
13 October 2012
I agree wholeheartedly with Jocelyn's commentary as well as that of Professor Crawford, Andy Bradley and Helen King. We need to take a systemic view and to recognise that professionalism, which includes competence and compassion, is in many ways situational, to use Professor Philip Zimbardo's term (author of the Lucifer Effect - how good people turn evil) and needs the right conditions to flourish.
The document does not address the need for regular training in emotional resilience (including CBT, mindfulness, and compassionate mind training), for working well with others in the organisation (Schwartz rounds and appreciative inquiry are useful tools for this), for mentoring and supervision, and an emotional intelligent leadership with an executive that holds the same values and goals as those working in the institution - i.e good patient outcomes and high quality care, not narrow financial or spurious targets. The industrialisation of medicine with the 100 year old Taylorian view of the organisation-as-machine is still pervasive and corrosive. Unfortunately one of the key safeguards - whistleblowing - carries enormous risks. I attended the recent BMA conference on whistleblowing and it was clear that there was a heavy price to pay if you raised concerns about patient care. There is a need for a paradigm shift. I look forward to the Transforming Patient care conference and Compassion in Healthcare conferences in November where these issues will be discussed. The Francis Inquiry report will also be illuminating.

Dr Alister Scott

Position
Co-Founder,
Organisation
The One Leadership Project: enablingcatalysts.com
Comment date
23 October 2012
Thank you all for working to create the care we all would want for ourselves. It is inspiring to see others who share this intent.

I am writing in support of both a) your emphasis on the need to work on the system to avoid demonising individuals and b) to give some support and insight into the work that Andy Bradley is doing.

People who don't really want to change things, or to take on the considerable challenges involved in doing so - especially where problems seem insurmountable due to the complexity of the system in which they are found - often use the convenient trick of locating responsibility on the individual. We see this with energy saving, for example, and environmental protection. I once saw a Minister saying that we need to educate the young on environmental matters because it is they who will be needing to solve the problems, conveniently overlooking the fact that he was in a position of power and potentially able to change things at least a bit if he chose to, by shaping the systems within which we all live our lives. Would this be easy for him and those in his department? No, for sure. But it's both-and, not either-or. We are unable to use public transport, for example, if it simply doesn't get us where we need to get to. The system shapes individual behaviour and, to an extent, vice versa. But systems are largely shaped by policy decisions and organisational routines and cultures, not individuals.

It is in this context that I have seen Andy Bradley do his work. Andy's approach brings a simplicity that paradoxically - and due to his long-term commitment to finding the best ways of making the challenge of compassion real and accessible - cuts through the complexity of the systems that are currently forcing compassion out.

Andy consistently has a profound effect on those who experience his approach, which is why he was recognised as one of the Observer/Nesta 50 New Radicals earlier this year. Andy is an outstanding leader for compassion and it is a privilege to work with him in his work. I look forward to seeing his imminent TED talk take the message and experience of compassion around the world.

Best wishes in your endeavours, Alister Scott


Paul Crawford

Position
Professor of Health Humanities,
Organisation
The University of Nottingham/ Institute of Mental Health
Comment date
02 November 2012
Dear friends, you may wish to read the recent piece I did for Public Servant journal. This refers to issues around health humanities and compassionate design of health care. There is a link below the reference to the online version.
Crawford (2012) Humanity: A precious resource. Public Servant, October: 43
publicservice.co.uk/feature_story.asp?id=21287

Josephine Smit…

Position
Analyst,
Organisation
Religious Order
Comment date
16 November 2012
After reading just a little of the contributions listed;
This has inspired me to add a small contribution myself.
The Health Service whether NHS or private. No comment.
At a Conference several years ago, the Voluntary sector support was
not discussed in enough depth.
This support has proved to be a fallacy.
Facing situations where " unmet need" , falling standards.
Basic Humanity & common sense day to day general care,
These are the important things to be thinking about.
I will give an example:
A patient, having had a serious operation within the last year,
When admitted vomited blood,
then sent home to totally inadequate support.
Cause taking her medication as instructed, but not with food,
as she was struggling to manage.
Their answer, pain management.
Also she was sent home very late considering the time of year,
to an unheated house.
When readmitted to hospital she had pneumonia.
You need very few qualifications to appreciate & evaluate
such cases. Just Respect; understanding, Compassion of course,
Nursing is & always has been a vocation; To become a good nurse
or Doctor these Qualities are essential & always have been.
To be continued.

barbara smith

Position
Lecturer,
Organisation
Coventry University
Comment date
10 December 2012
I have been fighting for the importance of caring and compassion in nursing since 2000, it is a shame that it has taken 12 years for the nursing profession to wake up to just how important these things are.

John Barnes

Position
consultant psychiatrist,
Organisation
an NHS trust
Comment date
15 January 2013
This is a very good thread of conversation about compassionate care with several interesting contributions which look worthwhile following up. Everybody Matters, the The "deep change programme" that Andy Bradley has been involved with seems particularly interesting as it is actually trying to foster compassion in staff in a part of a trust where leaders have committed themselves to "creating and sustaining consistent compassion".
I like that he has been accused of naivety as that has happened to me too on occasion!
I wish to add to this thread the concept of "Intelligent Kindness" developed by John Ballatt and Penelope Campling who wrote a book of the same name recently in 2011 concerning the need for reform of the culture in the NHS.
A 5 page sample chapter from the book is easily downloadable for free at;
rcpsych.ac.uk/files/samplechapter/IntelligentKindnessSC.pdf) .
The authors are a manager/commissioner and a psychiatrist and I believe the book to be a tremendously helpful resource in understanding, from several perspectives, the right conditions for Kindness (and its opposite)to flourish in the NHS.

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