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Practicing compassion: educating nursing
students to improve patient safety
Anne Hofmeyer RN PhD
Luisa Toffoli RN PhD
Rachael Vernon RN PhD
Interdisciplinary Education, Learning and Practice
Education Research in Nursing, Midwifery and Health Science
Symposium, 7 September 2016
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Research Team and Grant:
Hofmeyer, A., Toffoli, L., & Vernon, R. ‘Making Compassion Explicit
in Undergraduate Nursing Curricula: Teaching the Next
Generation’. Nurses Memorial Foundation of SA Inc.
International Collaborators:
Professor Ruth Taylor, Pro Vice Chancellor & Dean, Faculty of Health,
Social Care and Education, Anglia Ruskin University, Cambridge, UK
Professor Dorrie Fontaine, Sadie Health Cabaniss Professor of Nursing
and Dean, University of Virginia (UVa), School of Nursing,
Charlottesville, Virginia, USA
Professor Hester Klopper and Dr Siedine Coetzee, School of Nursing
Science, North-West University, Potchefstroom Campus, South Africa.
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Background and significance
 Poor patient outcomes linked with austerity measures and perceived
lack of compassion in healthcare. Patients say how they are cared
for matters just as much as receiving quality healthcare (Bray et al 2014).
 Poor working conditions fosters stress, diminished resilience, fatigue
- compromises nurses’ ability to provide safe healthcare and be
compassionate toward patients, colleagues, self (Bauer-Wu & Fontaine
2015).
 Can escalate to compassion fatigue and burnout (Coetzee & Klopper 2010).
 Increased emphasis on teaching compassion in nursing curricula to
foster safe patient outcomes (Adam & Taylor 2013).
 Self-compassion essential to practice compassion (Mills et al 2015; Neff
2003).
 Few studies explored teaching self-compassion to nursing students.
 Can compassion be taught?
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The study
Aim:
To explore and describe undergraduate nursing student’s
understanding and learning about the practice of compassion toward
patient’s, colleagues and self.
Design:
The study consisted of an online knowledge intervention (compassion
module) and pre- and post-intervention qualitative questions. Pilot
study.
Knowledge Intervention: Compassion Module
The compassion module educated students about the importance of
compassion in healthcare; being compassionate toward patients,
colleagues and self; cultivating resilience; and the individual, team and
organisational factors that could serve to hinder or foster
compassionate care.
A question and answer format was used to structure the compassion
module.
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Reflective
questions
and• key
readings
included.
The study: ethics and participants
 All Bachelor of Nursing students enrolled in Stage3, course NURS
3045 Nursing Project, in Study Period 6 (SP6) participated in the
online ‘Compassion Module’ in Weeks 5-6 of the course (n=382).
 An information letter was attached to an email invitation to
participate in the study.
 The information letter introduced the study, investigators,
explained confidentiality, anonymity, informed consent, and
provided the contact details for the University Human Research
Ethics Committee.
 The email contained the link to the open-ended questions hosted
on SurveyMonkey®. Reminder emails were automatically sent to
students at seven and fourteen days intervals, after the invitation
email.
 Forty-two (n=42, 11%) respondents participated.
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Data collection
 Thirty three precent (33%) of students were enrolled as
‘external’ and , 67% were internal. However, regardless of
the students geographical location all students had access
to the Learnonline resources, online module and survey.
 Self selection, anonymous e-survey.
 Pre and post-intervention qualitative questions were
administered via SurveyMonkey®.
 Demographic data (unidentifiable) was collected n relation
to the student cohort.
 Text boxes used to collect open-ended, verbatim written
responses.
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Data analysis
 Demographic data were analysed using descriptive statistics.
 Qualitative analysis of the free text responses was conducted
manually and independently by the investigators. This inductive
approach involved multiple readings of the responses and labelling
relevant sections or words to identify core meanings in the text and
analyse similar and different patterns (Borbasi & Jackson, 2016).
 Emergent findings were compared and differences resolved by
consensus. Significant phrases were identified and categorized into
preliminary themes (Braun & Clark, 2013; Ruona, 2005).
 Preliminary themes were ordered and re-ordered until major themes
and sub-themes were confirmed and findings formulated (Borbasi &
Jackson, 2016).
 Quotations that illustrated themes were selected. The investigators
explored how the themes were connected to each other and to the
literature to confirm resonance.
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Findings
Four major themes and sub-themes that describe
how compassion is understood and practised:
 being present;
 act to relieve suffering;
 get the basics right;
 practice as a newly qualified nurse.
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Being present: placing yourself in
their shoes
Respondents used words and phrases in the pre-intervention data
to describe their understanding of compassion as:
pity, sympathy, empathy, concern for the suffering of others,
and being kind and caring to patients.
Understandings were focused on being compassionate toward
patients and being considerate of their difficulties.
placing yourself in their shoes [1/11].
compassion means caring; it’s about having an understanding
of the patient’s current admission and most importantly their
story’ [1/2].
Compassion meant having the ability to empathize with others and a
strong will to make the situation better for someone who is suffering,
to contribute positively, and maintain patient centred care.
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Being present: Take time to listen
carefully
Several respondents explained compassion as the ability to
connect with a person, to carefully listen to what they are saying,
take account of their wishes, and respond to their needs and
pain.
After the intervention, participants indicated a deeper
understanding:
compassion means emotional intelligence, able to express
empathy, kindness, caring attitude, sensitiveness, respect,
healthy vulnerability towards others: colleagues, patients and
their families, and to yourself’[2/13].
able to stop and respect each individual that you care for in
the midst of the busyness of nursing care’[2/16].
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Act to relieve suffering: Smallest
actions can convey compassion
Ensuring I always put myself in another’s position, without passing
judgement. It means to recognise we are all human and all battling in
some way, and to help even in the smallest way no matter what your
differences are - is incredibly powerful [1/3]
Stopping in a busy workday to foster person-centred care and explained why
their example of listening and spending time illustrated the practice of
compassion:
A teenage patient with cystic fibrosis in hospital for an extended stay
did not want to take morning medications despite understanding the
importance of the therapy. She appeared more angry and frustrated than
usual so I put the medication away to sit down for a chat. She started
talking about her illness and feelings. We discussed what she wanted
and then I consulted with the health team. It was only small changes such
as medication timing and intervention routines, but she responded well,
appearing more positive and responsive. Because for me, compassion is
not just being able to empathise with a person, but should also drive or
direct actions and behaviours with that person [1/4] [our emphasis]
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Act to relieve suffering: Smallest
actions can convey compassion
Post-intervention, respondents provided longer responses about
practising compassion that revealed more comprehensive
understandings. Practising compassion was explained as providing
holistic, person-centred care.
A participant fostered inclusive decision-making:
I asked the resident’s preference, discussing a better way to
manage the wound because thinking from the resident’s point
of view is the most appropriate way to provide holistic care’[2/16].
Acting compassionately to relieve suffering is:
a core component in providing high quality of care’ [2/13], ‘treating
others with respect and dignity [2/5];
caring without judgement or bias [2/8] and providing comfort.
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Doing things that really matter
compassion means a lot to me now because doing things that
really matters to a patient to help alleviate their suffering is a way
of showing care [2/14].
Many described holding a patient’s hand or touching a shoulder
because physical touch reassured patients.
showing gentleness and using touch to reassure patients who
are confused or disorientated because their circumstances are
beyond their control’ [1/9].
Compassion toward relatives was mentioned:
When families do not visit they can be judged quite harshly by
those who do not understand dementia. It’s important to have
compassion toward the family of dementia clients because
dementia is a horrible disease and clients often cannot even say
their own name let alone engage in normal family activities.
Sometimes nurses forget to show compassion to the family [1/17]
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Post-intervention: why their
nursing action was compassionate
Extending visiting hours if a patient requires family support or allowing
more visitors to say good bye to the dying patient because - it puts
their needs into focus. Flexibility helps with family centred care
[2/19]
Persuade dementia residents to change dirty clothes even though they
assume the clothes are clean because it protects their dignity [2/18]
Finding my resident crying after her family left, I was just going in to
give her medication, but I sat with her, held her hand and we chatted
about what had her so upset. She was diagnosed with cancer but was
more worried about how her family was taking the news than for
herself. She didn't know how to tell her family that she didn't want any
treatment, she just wanted to rest. I think it is a good example because
I did not disregard her feelings and kept going with my drug round
so I could finish on time [2/5]
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Post intervention: acting to help
colleagues thrive
Staff supported a young male nurse who had a newborn baby
with colic that was depriving the family of sleep. He took a short
nap on a night shift, it was a quiet night because being
considerate of personal struggles shows team work and
compassion for others’ circumstances and helps people to
function. People often have tough home circumstances [2/19].
Seeing a new staff member struggling to get through their work
and checking if they are coping because having compassion for
new staff and offering assistance is appreciated [2/4].
Consideration towards a colleague - a family member had died
so I took over the palliative patient she was assigned because I
did not want her to be in a distressing situation [2/6].
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Get the basics right: Being resilient
to achieve work goals
the capability of caring for others is only sustainable with personal resilience
[2/2].
Nurses have a lot to bear. They are dealing with death and dying on
a regular basis. They have high workloads and often understaffed. Nurses
need to have resilience so they do not burnout from compassion fatigue or
worn down by systemic failures [2/19].
being resilient means you don’t break while doing those extra tasks no matter
how impossible it may seem. Resilience is important in the profession
because there are times when the job pushes you to your
limits as a person [2/1].
Resilience was also linked to being prepared to effectively care for others, for a
nurse’s own emotional health, preventing burnout, and being able to last in the
profession.
Resilience was understood as having the belief and courage to overcome
difficulties at work. Personal strategies to foster self-care and resilience were
essential to lessen compassion fatigue triggered by toxic work environments.
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Positive lifestyle choices: basics
right (again)
Eating a healthy balanced diet, getting enough sleep, regular exercise,
calm mind, and a positive attitude to maintain physical and mental
health.
Many indicated they chose to use positive lifestyle practices to build
foster their self-care and build their resilience, such as: meditation,
mindfulness, massage, music, aromatherapy, positive thinking, goal
setting and hobbies:
I try to keep active and practice meditation and positive
affirmations. When I leave my workplace my work life stays
behind. I have achieved the best I can during my shift [2/4]
Others it was about taking time out for themselves and solitude both as
a routine practice and when feeling overwhelmed.
find time do something you enjoy or spend time in nature by myself.
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Boundaries as a strategy to provide
clarity and safety
personal boundaries are important so we are not manipulated by
others [2/19],
try to separate work/home life [2/23],
practice within scope of practice to protect patients and ourselves
[2/17].
Cultivating a diverse range of social connections and networks was also
identified as a strategy to cope and gain perspective on work
experiences:
friendships, family relationships, networks, debriefing with coworkers to diffuse emotions and get support [2/5, 2/13].
A few differentiated between de-briefing with co-workers and family for
support and recognising the signs when it was important to seek
professional support (i.e. psychologist) to manage work-related issues.
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Practice as a newly qualified nurse:
new insights
don’t be so hard on yourself, give yourself a second chance
[2/11].
compassion needs to go hand in hand with providing safe
evidence-based practice [2/10].
not to conform to the idea that compassion needs to be
earned; that regardless of the influence of colleagues, I shall
not withdraw compassion from the care I give to my patients
[2/3].
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Practice as a newly qualified nurse:
new insights
Most respondents reported enhanced awareness and learning from
the module to influence their practice as a newly qualified nurse in
terms of nurturing their resilient skills
being more mindful of self-compassion as a new nurse…
watching out for the wellbeing of other nurses on the team, and
influencing factors in the organisation that foster compassionate
care… despite being very aware of compassion and resilience, it
is necessary to continually remind myself of basic self-care
practices to continue to be compassionate’ [2/2].
Several respondents said they now understood they had a
responsibility as newly qualified nurses to analyse situations so they
recognise compassion fatigue and burnout in themselves or
colleagues and to show compassion to colleagues when needed.
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Conclusion
 Concept and the practice of compassion can be taught. The online intervention
shows promise of raising students’ awareness and teaching them how to act with
compassion toward patients, relatives, colleagues and themselves.
 Students talked about being present to patients through actions such as placing
yourself in their shoes and taking time to listen carefully. Doing ‘things’ mattered
and even the smallest actions such as touch conveys compassion to relieve
suffering.
 Acting to help colleagues to cope in work environments and to thrive was
highlighted.
 Being resilient to achieve work goals was dependent on adopting strategies to
foster self-care such as: positive life-style practices, cultivating supportive networks,
and personal boundaries.
 New insights were generated about being more mindful of burnout and compassion
fatigue and to practice self-compassion and self-care in order to thrive as a newly
qualified nurse.
 Recognising the critical contribution of compassionate care to patient outcomes and
provider wellbeing, these findings and exemplars could be used by nurse educators
to develop empirically supported education curricula to teach the practice of
compassion, self-compassion and resilience to the next generation of nurses.
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