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A review of the literature on compassion prepared for the Cultivating Compassion Project

2014 -2015

University of Brighton and University of Brighton and Sussex Medical School and University of Surrey

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Contents Section Page Introduction 1 Background 1-3 What is compassion and what defines compassionate ethical practice? 4-8 Compassion in the organisation and as a component of leadership 8-10 Compassion and emotional labour 10-14 The evidence base for compassion training 14-15 Conclusion 15-16 References 17-22

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1. Introduction

Compassion is an essential component of care. The Mid Staffordshire NHS

Foundation Trust Public Inquiry Report, however, clearly indicated that compassion

values are not always enacted on. In many instances, this had catastrophic

consequences for patients and families. This literature review examines aspects of

compassion in the NHS. It begins by providing a brief overview of some of the key

drivers behind compassion initiatives. The review then moves on to consider what

compassion means, to discuss different perspectives on compassionate care, to

examine the relationship between leadership and compassion within NHS

organisations and to explore the ethical nature of compassion. Following this, the

practicalities of delivering compassionate care, which involve knowledge, skills,

ethics and emotion, are explored by analysing the role emotional labour plays in

bringing these components together. From this analysis, strategies to promote

compassionate care are discussed, culminating in a critical analysis of the ‘train the

trainer’ model advocated in this project. This is not a systematic literature review but

rather a critical appraisal of a selection of pertinent literature that contextualises the

project and demonstrates its underpinning knowledge bases.

2. Background

Health Education Kent, Surrey and Sussex (HEKSS) note in their call to bid (HEKSS Jan

2014) that “compassion is a critical element of all aspects of care and needs to be a

common thread through all learning and education activities”. They suggest that

compassionate care is required in care tasks in combination with knowledge and

skills and “expressive caring which involves the emotional aspects of the

relationship”. This background from HEKSS highlights the centrality of the values in

the NHS Constitution, and the significance of the Francis reports (2009, 2013) in

drawing attention to deficits in the NHS. Whereas a focus on healthcare ethics is not

new, the publication of the Francis reports (2009, 2013) resulted in compassion

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entering the political agenda. As these disturbing reports of lack of compassion at

Mid Staffordshire emerged, it became clear that patient experience and compassion

needed to be prioritised alongside safety and effectiveness in care, as outlined in the

Darzi Report (DH 2008). The final report of the Next Stage Review states that

compassion was to become one of the values of the Health Service and this is now

clearly embedded in the NHS Constitution: “We ensure that compassion is central to

the care we provide and respond with humanity and kindness to each person’s pain,

distress, anxiety or need (DH 2013a: 5)”.

Government recognition of the role which nursing and midwifery plays in the

provision of compassionate care is demonstrated in a range of policy documents.

The Prime Minister’s Commission Report on the Future of Nursing and Midwifery

(DH 2010) reaffirms the call for high quality compassionate care as part of its vision

for nurses as practitioners, partners, leaders in future healthcare provision. The

Government’s agenda for compassion as a required component of education for the

healthcare professions is clearly stated in their mandate for Health Education

England (DH 2013b). More recently, the Chief Nursing Officer’s campaign for the “6

Cs” in nursing and midwifery practice (DH 2012), echoes the work of Roach (1987), in

a clarion call for care, compassion, competence, communication, courage and

commitment to underpin practice. A critical analysis of this policy emphasises the

importance of organisational initiatives and introduces the idea of the

‘compassionate organisation’ (Dewar & Christley 2013 p.48).

However, the market driven economy of the NHS with its associated target

requirements and heavy workloads, engenders a culture, which is perhaps not

conducive to compassionate care (Austin 2011, Flynn and Mercer 2013). This

creates stress for staff as identified in the Kings Fund Point of Care Programme (Firth

Cozens and Cornwell 2009). It is now recognised that organisations need to consider

the wellbeing of staff in their efforts to enhance high quality compassionate care for

patients (Maben et al 2009, West and Dawson 2012).

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Compassion is not a new concept within the discipline of nursing, whose scholars

have placed the concept of caring at the heart of nursing values and beliefs. The

contribution of so many nurse theorists to the vast range of literature on caring in

nursing is evidence of its longstanding and continued importance to the profession

(Roach 1987, Benner and Wrubel 1989, Swanson 1991, Eriksson 1992, Watson 1999,

Boykin and Schoenhofer 2000, Brilowski and Wendler 2005).

More recently, a number of significant studies on compassion in the context of

caring relationships have been published in the nursing, care and ethics literature.

Torjuul et al (2007), for example, conducted a qualitative study of nurses and

physicians regarding compassion and responsibility in surgical care in Norway. Van

der Cingel (2011) investigated compassion in relationships between nurses and older

people in the Netherlands. Curtis (2012,2013) researched student nurses’

socialisation in relation to compassionate care in the UK. The most significant UK

study relating to compassion was conducted in Scotland (Adamson et al 2012). The

study ‘Leadership in Compassionate Care Programme’ had four strands: the

establishment of Beacon Wards to ‘showcase excellence in compassionate care’; the

facilitation of leadership skills in ‘key individuals’; influencing the undergraduate

curriculum by ‘embedding relationship-centred compassionate practice’ for nurses

and midwives; and providing support for newly qualified nurses. Insights from this

project and strategies employed inform the development of the ‘cultivating

compassion project’ training initiatives. Dewar’s (2011 p.263) relational perspective

on compassionate care is one that the Cultivating Compassion (CC) Team are

sympathetic towards. She writes:

Compassion…..” is defined by the people who give and receive it and

therefore interpersonal processes that capture what it means to

people, are an important element of its promotion”.

It can be seen from this brief overview that there is both a long held and newly

articulated deep-seated recognition of the importance of compassion to health care

and an urgency to ensure that compassionate care is embedded within the

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organisational culture, its leadership structures as well as in the day to day care

activities between health care workers and patients.

3. What is Compassion and What Defines Compassionate Ethical Practice?

Defined simply, and taken from the Latin ‘com’: together with, and ‘pati’: to suffer,

compassion means ‘suffering with’. Compassion is understood to involve emotion,

such as empathy or sympathy, and a rational understanding of the suffering that

enables identification with it, i.e. the ability to deliberately and altruistically

participate in another’s suffering (von Dietze and Orb 2000). Compassion therefore

involves an emotion and thought that relates to the suffering of another that results

in an action that acknowledges that suffering and seeks where possible to alleviate

it. This suggests that recognition of suffering precedes the feeling/action of

compassion.

The Dalai Lama reminds us that ‘the importance of cultivating love and compassion’

is emphasised by all major religions. ‘The ethics of compassion’ from Buddhist

teaching argues that compassion has relevance to all aspect of life including ‘the

workplace’. Without compassion, work activities can become ‘destructive’ because

the impact of our actions on others may be ignored and people will be hurt , pointing

out that:

“The ethic of compassion helps provide the necessary foundation and

motivation for both restraint and the cultivation of virtue. When we

begin to develop a genuine appreciation of the value of compassion

our outlook on others begins automatically to change” (The Dalai

Lama 1999 p.128).

A connection can be made between these insights from Buddhism and Iris

Murdoch’s discussion of moral perception and ‘attention’ in the moral life. She

writes of the importance of a ‘just and loving eye’ (Murdoch 1971). The suggestion is

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that, when we come across people we find it difficult to relate to, we look more

deeply, fairly, and lovingly to better understand their predicament and behaviour.

Bennett (1993) suggests that the parable of the Good Samaritan (Luke 10v25-38)

epitomises the Judeo Christian view of compassion in which

‘Our neighbour’ is the ‘one who needs the help that we can give him,

whoever he may be’ (ibid p.141).

O’Connell (2009:4) notes that for Christians, compassion is the central mark of

discipleship as “compassion can be an effective moral disposition with the capacity to

challenge privatised, individualised and paternalistic responses to suffering at the

hands of others”. The call to discipleship is not just to suffer with, but also to address

unjust suffering. As Austin et al (2013 p.13) suggest:

“The most important sense of compassion that is carried through

from biblical tradition to English is the sense that compassion leads to

action. It seems to be more than a simple feeling or sentiment”.

In applied ethics, compassion is generally discussed as a virtue or moral disposition

of the person. In one of the most popular texts Principles of Biomedical Ethics

(Beauchamp & Childress 2013 p.37) compassion is identified as the first of ‘five focal

virtues’. It is described as ‘a prelude to caring’ and as combining:

“an attitude of active regard for another’s welfare with an

imaginative awareness and emotional response of sympathy,

tenderness, and discomfort at another’s misfortune or suffering.

Compassion presupposes sympathy, has affinities with mercy, and is

expressed in actions of beneficence that attempt to alleviate the

misfortune or suffering of another person. Unlike the virtue of

integrity, which is focused on the self, compassion is directed at

others”. (ibid)

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Virtues can be thought of in relation to vices, that is, that virtues and vices come in

triads with each virtue ‘flanked by two vices (vicious disposition) – one representing

excess and one deficiency’ (Banks & Gallagher 2009). In thinking of compassion,

then, as a virtue or ethical quality of the person and a disposition to help in response

to the suffering of others, it is helpful to consider the vices of excess and deficiency.

In terms of deficiency, Comte-Sponville (2002 p.103) writes of the ‘antonyms’ of

compassion as ‘ruthlessness, cruelty, coldness, indifference, hard-heartedness,

insensitivity’. In terms of excess, we might consider over-involvement, making

assumptions about the suffering of, and appropriate responses to, others. There is

risk in making unfounded assumptions about the suffering of others and of perhaps

responding to others in ways that are paternalistic or infantilising.

Nussbaum (2001), who distinguishes between compassion and mercy, proposes a

‘cognitive notion of compassion’ requiring three judgements: first, that the suffering

is ‘serious’; second, that it is ‘undeserved’ (that is, not person’s own fault); and third,

‘that the suffering can be imagined to be ones’ own and that it has some bearing on

one’s own flourishing’ (Hordern 2014 p.93). Nussbaum’s (1996) suggestion that

compassion involves judging whether the suffering is deserved is not without

criticism (Van der Cingel 2009; Carr 1999). Van der Cingel (2009) argues that in

health care compassion should involve withholding judgement. This position is

particular to healthcare because, as Curtis (2013) points out, the right to equal

treatment can be found in the majority of all healthcare professional codes of

conduct. Whilst non-judgemental compassion is the ideal, it is interesting to note

that sociological research around health inequalities suggest that in respect to

lifestyle diseases, healthcare workers do make moral judgements. This is well

articulated through Jeffery’s (1979) notion of the ‘Rubbish Patient’ and more recent

developments around the concept of the ‘sick role’. For example, Varul (2010: 89)

notes that the sick role has been influenced by an increase in “chronic illness and

disability” and “a rejection of behaviours and attitudes that are suspected of being

part of their aetiology”.

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Von Dietze & Orb (2000: 169) argue that compassion transcends difference, and that

this characteristic is what distinguishes it from pity – which implies condescension

and/or paternalism. They argue that “compassion deliberately seeks to avoid

paternalistic care”, it is about solidarity – it is therefore “not so much what we

choose to do for other people but what we choose to do together with them. Thus,

compassion is based on rationale thought and emotion that requires understanding

and deliberation, it is therefore a moral action because if reaches beyond the self to

others.

It may be considered short-sighted to consider that recognition of, and appropriate

compassionate responses, should only be directed towards ‘suffering’. Scheler (cited

by Austin et al 2013 p.19), for example, writes of ‘fellow-feeling’ described as

involving ‘not just sharing in suffering but also in joy’. Many health care episodes

require that staff members join patients in celebration and rejoicing also. Consider,

for example, childbirth and a clear scan following cancer treatment.

The Dalai Lama writes of some of the other risks of compassion as follows:

“Constant exposure to suffering, coupled occasionally with a feeling of

being taken for granted, can induce feelings of helplessness and even

despair. Or it can happen that individuals may find themselves

performing outwardly generous actions, merely for the sake of it –

simply going through the motions [….] when left unchecked, this can

lead to insensitivity towards others’ suffering” (ibid p.129).

The phenomenon of ‘compassion fatigue’ is now frequently reported in the

international literature. Austin et al (2013 p.1) describe this, in relation to health

professionals, as their being ‘too weary to be with the suffering of others in the way

they once were’. The term was first used in relation to public fatigue towards global

problems such as famine and poverty. In relation to the care professions’

‘compassion fatigue’ was first used in the early 1990’s. The experience is related to

others such as burnout, moral distress and secondary/vicarious trauma. Based on

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their research, Austin et al (2013 p.173) write of the importance of hope in such

situations:

“Without exception, the experience of compassion fatigue is painful.

The journey into and through compassion fatigue is unexpected,

unclear, uncertain, and unfamiliar. During such times, the need for

hope is most apparent”.

There are also critiques regarding the focus on compassion in healthcare. Gallagher

(2013), for example, cautions against ‘monoethics’ and argues that compassion may

be necessary for healthcare practice but it is not sufficient. Other virtues or values

such as justice, courage and trustworthiness etc. are also required to practice

ethically.

In a recent paper, the philosopher Paley (2014) challenges the idea that recent care

deficits were due to compassion failure in individuals. He draws on a substantial

literature in social psychology and argues that care deficits were due rather to ‘an

interlocking set of contextual factors that are known to affect social cognition. These

factors cannot be corrected or compensated for by teaching ethics, empathy, and

compassion to student nurses’. Mindful of this critique and of other research that

highlights the importance of attention to micro (individual), meso (organisational)

and macro (societal) factors (RCN 2009), the CC team’s engagement with

compassion goes beyond individual behaviour.

4. Compassion in the Organisation and as a Component of Leadership

The organisational context in which compassionate care is practiced is fundamental

to cultivating compassion (Paley 2014; Goodman 2014; Rynes et al 2012).

Greenhalgh (2013: 481) points out that despite the Francis Report identifying a lack

of compassion as the root source of the neglect encountered at Mid-Staffordshire

Hospital Trust, ‘almost all [Lord Francis] recommendations relate to documents or

procedures’. She argues that what is needed is a compassionate organisation

because it ‘supports and shapes behaviour by its members, partly through

appropriate incentives, rewards and procedures but mainly by recognising that

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emotions – feeling, caring, loving, yearning – are an integral component of our

rationality, not something that distorts or detracts from it (ibid)’. Goodman (2014:

1268), in her exploration of nursing care experiences amongst older people argues

that:

“Poor quality care occurs often enough across care organisations

(structures) to warrant analysis beyond simply vilifying and blaming

failing individuals (agents). If only one nurse was abusive and

neglectful we would properly look to the character of that nurse.

However, when many instances of poor quality care arise we should

undertake a political and social analysis for a fuller understanding”.

Rynes et al (2012) ask the question what then does the compassionate organisation

look like? In their review on care and compassion in the organisation they suggest

‘that care and compassion should be the responsibility of everyone in the

organisation’. To achieve this requires a radical shift, for rather than the usual

organisational objectives of profit and efficiency, the organisation should focus on

the ‘health, happiness, well-being and sustainability of the organisation, their

members and those they serve’. When compassionate care is embedded within the

organisation, it recognises the importance of the receipt of compassion and what the

workforce requires in order to sustain and extend compassion to patients and their

family and friends.

Youngson (2011) contends that compassion must be defined as a management and

leader

“The leaders of the very best healthcare organisations provide role

models for the values and principles underlying people centred care:

they are deeply respectful, humane and compassionate towards their

employees, they celebrate diversity, they act fearlessly against

bullying abuse and discrimination, they listen deeply, they role model

openness, integrity, and they are not afraid to say sorry (2011:9)”.

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A significant contribution to our knowledge of the impact of interventions on

compassionate practice come from data collected as part of the Leadership in

Compassionate Care Programme (Adamson et al 2012), a 3 year appreciative action

research project run by NHS Lothian and Edinburgh Napier University which

emphasises the centrality of developing leaders who can embed compassion within

effective, relationship centred care. Three interventions developed during the

project inform our intervention: use of emotional touchpoints; ‘Knowing who I am

and what matters to me’; and ‘Caring about caring’.

The King’s Fund report ‘Seeing the person in the patient’ (Goodrich and Cornwell

2008) suggests that improvement in patients’ experience of care requires the

cooperation and effort of all staff with direct contact with patients with

encouragement and support from the wider organisation. This operates at 4 levels,

the individual, the team, the institution and the wider health system and is a

function of both organisational and human factors, which interact in complex ways.

Leadership for improvement at team and institutional levels becomes critically

important in the support of compassionate care in the light of evidence which

suggests that staff wellbeing is an antecedent to patient care performance (Maben

et al 2012, West and Dawson 2012).

It can be seen so far that compassionate care is linked to the nature of suffering,

underpinned by wider ethical issues, and requires a compassionate organisation with

leadership role modelling compassionate behaviour. A major theme running through

all the section so far is that compassion is also linked to staff wellbeing and

compassion fatigue. In the following section this will be explored in more detail.

5. Compassion and Emotional Labour

Curtis (2013:212) points out that the giving of compassionate care involves an

emotional endeavour that can take work to achieve. Essentially the carer must be

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“able to understand another’s suffering, empathise with their situation, think that

suffering is terrible and therefore want to relieve the suffering by doing what is best

for that person”. Yet, in relating to and empathising with the patient, the carer must

also be professional - thus an emotional balance between utilising feelings of

empathy with professionalism in the face of suffering is required – this involves

emotional labour. Emotional labour is a term coined by Hochschild (1983) where the

induction or suppression of emotion is required of the carer in order to ensure that

the person being cared for feels comforted and safe.

There are some inherent difficulties and complexities involved in the emotional

labour in compassionate care. First, in drawing on the self it requires the individual

to relate to the suffering of others. In doing so they need to enter into that suffering.

As Nouwen et al (1982: 4 cited in Von Dietze & Orb 2000: 169) powerfully write:

“Compassion asks us to go where it hurts, to enter into places of pain,

to share brokenness, fear, confusion and anguish. Compassion

challenges us to cry out with those is misery, to mourn with those who

are lonely, to weep with those in tears. Compassion requires us to be

weak with the weak, vulnerable with the vulnerable, and powerless

with the powerless. Compassion means full immersion into the

condition of being human”.

This ‘entering into’ needs to be balanced with making the patient feel safe and

comforting them. Where possible this will also involve the alleviation of that

suffering through action, such as treatment, as well as empathy. Here the emotional

labour involves using compassion as a motivator in inducing the expression of

reassurance, of being in control, rather than weeping with tears or sympathising in

fear; it may also involve suppressing confusion and anguish in order to have a still

hand, or to objectively argue for the individuals care needs in order to get the

required support mechanisms in place. Emotional labour is a balancing act that

requires a high degree of self-awareness, emotional dexterity and clinical knowledge

and skill. As Hochschild (1983) notes, this takes work and is hard to achieve.

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Smith (2012) in her book Emotional Labour in Nursing argues that the skill of

emotional labour needs to be taught and refined, that an assumption that it is

inherent is detrimental to its development. This is particularly the case when the

individual carer does not naturally feel compassion for their patient. Hochschild

(1983; 2003) describes two processes through which the emotional labourer can

both induce and suppress their emotions. The first is surface acting, this is where the

labourer expresses an emotion they do not really feel, but know that they are only

acting it out. The second is deep acting, which is where the labourer uses their

imagination or memories to work on their feelings so that they come to feel the

required emotion.

Compassion fatigue and burnout is particularly linked to high levels of surface acting

(Erikson 2009; Mann 2004). Conversely, when deeper relationships are forged, the

emotional labour results in a deep attachment, making it harder for the carer to hide

their emotions when they deeply relate or to detach when the relationship comes to

an end (Kelly et al 2000).

Over exposure to suffering presents a particular dilemma to healthcare workers.

Curtis (2013:217) notes in her research with student nurses that they considered it

important to ‘harden up’ or develop a ‘thick skin’. For the difficulty in relating to one

patient, is that one has to move on to the next and be just as available and

connected to them. “Students could see the need to preserve their emotional well-

being alongside the need to be compassionate”. Curtis (2013) suggests that one way

in which this can be enhanced is through promoting discussions on moral courage

and self-compassion. But as Gilbert (2009:xxi) notes this is not always easy. This is

largely due to concerns that self-compassion is linked to ‘letting ones guard down’ “If

they started, to feel self kindness or compassion it could ignite feelings of grief

There is, however, a growing body of research (Weng et al 2014; Morgrain et al

2011; Leiberg et al 2011) that suggests that the practice of compassion increases

happiness and that training individuals in altruistic behaviour enables emotion

regulation and results in emotional rewards such as increased satisfaction. Indeed

Gilbert (2009) points out that evidence suggests that feeling love and compassion for

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ourselves is deeply healing and soothing. In their research, Hefferman et al (2010)

found a positive correlation between high levels of self-compassion in nurses, and

their ability to relate to the suffering of their patients. Self-compassion is therefore

important to supporting and sustaining compassionate care (Gilbert 2009; 2010).

Birnie et al (2010), drawing on the work of Neff (2003:224) suggest that:

“Self-compassion entails three fundamental components: (1)

extending kindness and understanding to oneself rather than harsh

self-criticism and judgment, (2) seeing one’s experiences as part of the

larger humanity rather than as separating and isolating; and (3)

holding one’s painful thoughts and feelings in balanced awareness

rather than over-identifying with them.

To support self-compassion, many authors are increasingly advocating Mindfulness

as a means of reducing stress and encouraging self-empathy (Gilbert 2009; Birnie et

al 2010; Hefferman et al 2010). Kabat-Zinn defines mindfulness as “paying attention

in a particular way: on purpose, in the present moment, and non judgmentally’

(cited in Black 2011:1). The CC team has taken in to consideration mindfulness

activities as a means of supporting self-compassion in the workforce.

The skill base underpinning emotional labour therefore is fundamental to supporting

and sustaining compassionate care in practice. It is required in simple acts of

kindness through to complex acts in which the practitioner relates yet also holds

back in order to both empathise and alleviate the suffering; in addition, emotional

labour is crucial where carers do not naturally feel compassion and use their

imaginations or own memories to induce such feelings in order to provide the

proper compassionate care required of them. Theodosius (2008) notes that

emotional labour is based on reciprocal interaction – that is in entering into the

suffering of the patient, the carer receives back from the patient gratitude and from

a job well done, a sense of satisfaction. These emotions are important in sustaining

emotional labour in the long term giving of compassionate care to the many, and go

a long way in protecting against compassion fatigue.

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It is important to note here that resource issues also significantly impact on the

quality of care. Research on emotional labour suggests that low resources negatively

impact on the quality of emotional labour given (Bone 2002). The higher the

staff:patient ratio the more likely nurses will use surface acting, which is directly

linked to compassion fatigue and burnout (Ball & Catton 2011; Erickson 2009;

Rafferty et al 2007). They were also more likely to report low/deteriorating quality of

care on the ward.

It is important that the CC team recognize the pressures staff are under, and the

impact this may have on the delivery of compassionate care.

6. The Evidence Base for Compassion Training

Weng et al’s (2014) research ascertained that compassion training does increase

altruistic behaviour. Their participants were divided into two groups: those who

received compassion training and those who received re-appraisal training. The

results showed a significant increase in altruistic behaviour in the compassion

training group demonstrating that compassion training that involved cultivating

feelings of compassion for different groups of people, does work.

The idea of cultivating compassion across the whole workforce poses educational

questions concerning the best means of achieving this. There is a little evidence to

suggest that delivering training in standard one off lectures by outsourced

educationists has the desired effect. Indeed, Levine et al (2007) found that

traditional lecture style training was not effective so introduced the ‘train the

trainer’ model. The aim of their training was to change physician behaviour in the

management of common geriatric conditions. Experts from the University Faculty

trained 60 non-expert peer-educators based in the geriatric practice setting. These

peer-educators then trained up their fellow geriatricians in the practice setting using

a purposefully designed toolkit by the Faculty educators. Follow up research on the

impact of this method showed statistically significant increases in self-reported

knowledge and attitudes six months after the peer sessions. Levine et al’s

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(2007:1281) found that the tool kits were important factors in enabling their peer-

educators to facilitate learning.

“Findings suggest that modest positive changes in practice in relation

to common geriatric problems can be achieved through peer-led,

community- based sessions using principles of knowledge translation

and evidence-based tool kits with materials for providers and

patients”.

The ‘train the trainer’ model has been most successfully used in public health

initiatives where large numbers of people spread across a range of community

settings need to be reached. Eresk et al (2006: 42) found in their study examining the

effectiveness of the model in the community hospice setting in America that

“confidence in teaching end-of-life content increased significantly for participants

who used the course materials to prepare and present in service”.

The evidence supporting the train trainer model is not conclusive (Trabeu et al 2008)

but would appear to be the most appropriate model when aiming to raise awareness

across the wider workforce in a variety of clinical settings. The development of the

toolkit is essential to this process. The CC Teams notion of the ‘toolkit’ on the move’

has been designed to enable training by peer-educators to take place in the clinical

setting as well as in bespoke workshops. There is no robust evidence regarding the

impact of compassion awareness training over time. Our proposal provides an

opportunity to generate such evidence.

7. Conclusion

The nature of compassion and the delivery of compassionate care is complex. From

this review it can be seen that compassion can be understood as a virtue, that it is

rooted in moral and ethical thinking; compassion requires the carer to relate to the

suffering which may involve making difficult judgements that are framed within

current socio-political discourse. In order to empathise with those they care for in a

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constructive way so as to alleviate suffering as well as to suffer with them,

compassion requires emotional labour. Compassion needs to be embedded within

the organisation as a whole and be visible in leadership behaviours. In order to raise

awareness of compassion within the workforce these complexities need to be taken

into account.

The project aims to:

Develop a sustainable programme of compassion awareness training that

enhances patient safety and experience and promotes ethical healthcare

practice;

Engage effectively with healthcare staff building on existing values-based

initiatives and encouraging creative compassion promotion projects; and

Facilitate the development of organisations and teams that respect, reflect

and promote the values of the NHS Constitution.

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