CHAPTER 1
A Compassion Primer

INTRODUCTION

Being 'compassionate' is at the core of healthcare work, isn't it? There seems no place in our services for non-compassionate people. How could anyone possibly function in a hospital or any care giving setting, where their care was not based on the basic tenet of being 'compassionate'?

However, and sadly, we have too many cases (that continue to grow) where care has been found to be lacking in compassion. How can this happen? How can a healthcare worker go to work with the desire or the intention to be non-compassionate to patients? I don't believe they do. Yes, there have been professionals who have been found to act criminally and murderously. But while always regrettable and unfathomable, they are rare.

What is sadly less rare, is routine practice that is found to be uncaring.

Consider the following:

Mrs H was a dignified woman who lived in her own home until the age of 88, needing relatively little support. She was deaf and partially sighted and although she could still read large print, communicated through British Sign Language and deaf-blind manual.

Following a fall at home, Mrs H was admitted to the Elderly Care Assessment Unit with acute confusion. Whilst Mrs H was in hospital she had a number of falls, one of which broke her collar bone, but her niece was not informed. Several additional injuries and falls were not included on her discharge summary. Poor nursing records were kept and no personalised plans for her non-medical needs were developed and although at low risk of malnutrition at admission, Mrs H lost about 11 lbs during her first three months in hospital.

Communication with Mrs H was difficult, and her specific needs were not met. No activities or stimulation were provided for her. The discharge arrangements for this lady were confused and no effective handover to the care home was completed.

When Mrs H arrived at the care home, the Manager noted that she had numerous injuries, was soaked with urine and was dressed in clothing that did not belong to her which was held up with large paper clips. She had with her several bags of dirty clothing, (most of which did not belong to her), and few possessions of her own. Mrs H was bruised, dishevelled and confused. She was highly distressed and agitated and the following day was admitted to a local hospital due to concerns about her mental state and her physical condition.

Sadly, Mrs H died soon after in August 2010.

Source: Parliamentary and Health Service Ombudsman (2011).

The above is clearly shocking, but this desperate situation needs to be understood at a deeper level. To achieve this, we need to reflect on the reasons why there was seemingly, a lack of compassion or care. Do I believe those involved in the care of this poor lady wanted to be unkind and careless? No, I don't. I do however, think we, as workers for health, may fail to seek what lies behind the experiences of Mrs H. This book seeks to create opportunities for discussion and deeper understanding of how such care can result and to promote compassionate responses to minimise their future occurrence.

The Chief Nursing Officer (Department of Health/Chief Nursing Officer 2012) instigated the 6C's which eventually formed a direct response to the Francis Inquiry into care and treatment at Mid Staffordshire NHS Trust (Francis 2013). These 6C's (Care; Communication; Courage; Commitment; Competence and Compassion) have formed the basis of many healthcare student assignments ever since. They are drilled into the minds of nurses to form part of their value set (and by extension the value set of all healthcare providers, since there is nothing particular to the nursing profession in any of these C's). Following many conversations with nurses and students about the 6C's, I have asked 'what is "Compassion?"' I am returned with statements that liken compassion to being kind and being caring. In a general sense, these answers are not wrong - but maybe they are not right either.

We need clarity on what we mean by compassion in nursing and healthcare practice. A clearer expression on this critical concept is essential if we are to be the kind of workers we want to be - that is, (I assume) morally engaged, workers for health (Seedhouse 2009).

This book provides an introduction to a perspective on compassion. It is written in the full knowledge that there are many other texts that offer a comprehensive overview of the science of compassion (see Seppälä et al. 2017) and therapeutic approaches (e.g. Gilbert and Simos (2022)). I am particularly indebted to Paul Gilbert, from the Compassionate Mind Foundation (www.compassionatemind.co.uk) for many years of inspiration in cognitive approaches to helping people, most recently through his work on Compassion Focused Therapy (Gilbert and Simos 2022). I would urge those readers seeking deeper scholarship on compassion, to seek out writers and researchers such as these if you wish to sharpen your understanding of what this seemingly simple (but really rather challenging) word means for your practice.

WHAT IS COMPASSION?

Compassion can be considered to be 'a state of concern for suffering or unmet need of another, coupled with a desire to alleviate that suffering' (or need) (Goetz et al. 2010). Therefore, an individual must be aware of suffering (or a need) and engage a range of processes (psychological, biological and social) in order to respond. The biological processes (from an evolutionary perspective) are those that promote care giving and affiliation.

1. Alternatively, Compassionate Mind Training (CMT) (Gilbert and Choden 2015) identifies compassion as 'a sensitivity to the suffering of the self and others with a commitment to relieve or prevent it'. What unites these two definitions is that being compassionate consists of: being aware of the need for compassionate care and
2. the desire to do something about it.

COMPASSION AS AN EMOTION

Health and social care workers are required to enact compassion as per the asserted moral architecture of the NHS. The published NHS Values expressly point to the requirement for compassion to be displayed.

'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. We search for the things we can do, however small, to give comfort and relieve suffering. We find time for patients, their families and carers, as well as those we work alongside. We do not wait to be asked, because we care.'

Source: Taken from the NHS Constitution: Department of Health 2023 (Available at: The NHS Constitution for England - GOV.UK (www.gov.uk)

The central premise of this introduction to compassion is based on an understanding that saying we are compassionate and 'being' compassionate may be different and challenging. Gilbert (2010) has written that humans are a major source of suffering to self and others and indeed other life forms. Human history is replete with the horrors of torture, holocausts, slavery, sexual violence and much else. Compassion is the motivation that stands against this harmful side of us because it's focused on our understanding of the causes of suffering and seeking to alleviate and prevent it. Of course, in the health and social care services, patient suffering is rarely deliberate, but more typically arises from the failure to provide what individuals need for their relief of suffering. Here the inhibitors of compassion can be linked to broader problems of individual providers having a lack of insight and knowledge of what to do, how to employ empathy and prevent burnout. However, evidence suggests that many inhibitors of compassion are organisational and relate to poor management and overburdening services. Hence here compassion requires us to think about how we can operate within contexts that are highly pressurising commonly frustrating and sometimes unsupportive.

Because compassion moves towards suffering, towards the causes of suffering, then it means we are moving towards things that may be painful, distressing or sometimes stimulating rage in ourselves in the face of perceived (or actual) injustice. Engagement with suffering therefore, is not about stimulating a positive emotion, although positive emotions can arise when compassion has been successful. So, compassion may not always be a kind and pleasant emotion. The world is full of evidence where the suffering of people and circumstances are viewed in the abstract. People in need are called 'scroungers; bed blockers; attention seekers', our language can be less than compassionate. People claiming benefits, refugees fleeing persecution or in search of a better future for their family, or people in need of social housing may be on the receiving end of negative discourse from politicians, the media and the general public. We may be in a position to direct our help towards such people, but fail to do so (for a great many reasons).

COMPASSION AS A STATE OR A TRAIT?

A state of compassion is a response to another person at a particular moment in time. This would be true for any disposition such as empathy or kindness. This suggests that we can turn...