Compassion: hard to define, impossible to mandateBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3991 (Published 29 July 2015) Cite this as: BMJ 2015;351:h3991
All rapid responses
We read Dr Chadwick’s article on compassion(1) with great interest. This is a word which is being frequently heard in connection with care provided by health and social care professionals but often without the thoughtful attitude seen in this article. Indeed, we have previously suggested that ‘compassion’ is in danger of becoming a jargon term and, as a result, losing some of its power.(2)
Frontline care staff need to have training and support in recognising and coping with the range of feelings – positive and negative – engendered by some people they are called upon to care for. It has long been recognised that these feelings are highly relevant to quality of care and are ignored at our peril.(3) People working in caring roles need to know that it is ok to feel powerful negatives such as disgust, impatience, and even hatred. However, it is essential to find strategies and resources within oneself not to act on them. Perhaps care teams could be encouraged to articulate such feelings – whether in Schwartz rounds as discussed by Dr Chadwick or in Balint groups familiar from psychiatry and general practice contexts(4) – and try to identify if there are individuals in the team who can carry positive regard to certain patients while others hold to the basic courtesies? We all know that our own personal reactions to other people are enormously varied and have their origins in our own stories.
We would like to promote a much more open dialogue about fostering caring compassion – as Dr Chadwick suggests, it can't be prescribed, but it isn't a happy extra which is wonderful when it happens. We believe that it can be learned and must be integrated into practice.
Susan Maciver, Chris McGregor, Jenny Robertson, Tom C. Russ, and Christine Wilson
On behalf of the Working With Older People steering group, Human Development Scotland
Conflicts of interest: none
1. Chadwick, R. (2015). Compassion: hard to define, impossible to mandate. BMJ 351: h3991.
2. Maciver, S. & Russ, T. C. (2014). A plea to “see into the life of things”: thinking psychoanalytically about later life. In: Kate Cullen, Liz Bondi, Judith Fewell, Eileen Francis, and Molly Ludlam (Eds) Making Spaces: Putting Psychoanalytic Thinking to Work. London: Karnac.
3. Menzies, I. E. P. (1959). The functioning of social systems as a defence against anxiety: a report on a study of the nursing service of a general hospital. Human Relations, 13: 95-121. (Reprinted in Menzies Lyth, I. E. P. (1988). Containing Anxieties in Institutions. Selected Essays, Volume 1. (pp. 43-99). London: Free Association Books.)
4. Balint, M. (1957). The Doctor, his Patient and the Illness. London: Tavistock.
Competing interests: No competing interests
This is half correct. There is something ineffable about compassion and attempts by management to force it upon staff will end up being clumsy and probably counterproductive. However, it would be a shame to leave it at this.
We know quite a bit from social psychology about the effect of situations upon human relationships. We know that under certain conditions ordinary people can sometimes behave in ways that are callous, cruel or abusive (Darley & Batson 1973; Milgram 1974; Zimbardo 2004). The exact ways in which this happens are still being debated (Haslam & Reicher 2008, 2012) but it is clear that if the NHS wishes to create situations in which compassion thrives then it must avoid overwork and understaffing, a culture in which powerful figures preferentially reward non-clinical organisational goals and must strive to overcome the Them-and-Us hostility between staff and patients.
We also know from empirical studies that good care can flourish even in the unlikeliest of places. Patterson et al 2011, Section 7, report on an 'enriched ward" existing in the midst of a failing trust. The cause appeared to be the strong leadership of the ward manager. Most clinicians will have met somebody like this and it is time the NHS took seriously the matter of ensuring high quality leadership on all wards, indeed on all shifts on all wards. To change the culture in clinical care we need to invest seriously in leadership (West et al 2015) at the staff nurse and ward manager level. These are the people who can make a Mid Staffordshire event less likely to occur again.
Compassion is like a delicate plant that needs constant care and attention if it is to thrive. Although the main force comes from within the individual and their relationship with particular patients, the situation in which this occurs is crucial. The NHS can either nurture compassion or not. Chadwick is correct, compassion cannot be mandated but it can be supported.
Darley, J., & Batson, C. (1973). From Jerusalem to Jericho. Journal of Personality and Social Psychology, 27(1), 100–108.
Haslam, S. A., & Reicher, S. (2008). Questioning the banality of evil. The Psychologist, 21(1), 16–19.
Haslam, S. Alexander, and Stephen D. Reicher. "Contesting the “nature” of conformity: What Milgram and Zimbardo's studies really show." (2012): e1001426.
Milgram, S. (1974). Obedience to authority. New York: Harper & Row.
Patterson, M., Nolan, M., Rik, J., Brown, J., Adams, R., & Musson, G. (2011). From Metrics to Meaning: Culture Change and Quality of Acute Hospital Care for Older People (pp. 1–253). Retrieved from http://nets.nihr.ac.uk/__data/assets/pdf_file/0003/64497/FR-08-1501-93.pdf
West, M., Armit, K., Eckert, R., West, T., & Lee, A. (2015). Leadership and Leadership Development in Health Care: The Evidence Base (pp. 1–36). The King's Fund.
Zimbardo, P. (2004). A Situationist Perspective on the Psychology of Evil. In Miller the Psychology of Good and Evil, 23.
Competing interests: No competing interests
thank you for being brave enough to write this. There are times when it is appropriate and helpful to have an authentic human connection with a patient or family. Other times it is awkward, unprofessional and makes doing the job much more difficult.
There is a reason why family members do not want to take onthe role of 'professional carer', and at least in part it is because there are times when patients are not behaving reasonably. Sometimes it is important to have a professional, respectful distance in order to challenge their demands/ wants/ expectations which go beyond what is possible, or fair.
Staff cannot be told to feel something, or be expected to disclose their own experiences. We already give out a lot. A requirement to engage and be compassionate will result in burn out, unless it is genuine ( and of course, sometimes it is).
As a patient I would be satisfied to be treated with courtesy, respect, and dignity. I would say that, at times, staff have barely managed that.
Perhaps we should aim to have consistent courtesy, respect, dignity, i.e.. Just being professional. We should not ever have staff more interested in their phones/ friends/chatting; than the patient or family in front of them.
Competing interests: Work as healthcare professional who does not want to be mandated to be compassionate.