The NHS and the true meaning of compassion

NHS Leadership
Published on Friday, 08 February 2013 14:21
Written by Professor Paul Crawford

Let's compare two statements and see which we think might be nearer the truth in describing the state of present-day healthcare...

 1. "The patient always comes first."

2. "It's a nice way of getting rid of the patient. You scribble something out and rip the thing off the pad. The ripping off is really the 'f*** off'."

The first, of course, is an enduring mantra of healthcare throughout the developed world. The second is a quote from an NHS doctor, interviewed for a 2003 academic study, explaining how prescriptions can serve as a convenient "closure device" – to put it politely – when dealing with patients.

It might be argued that one represents the ideal and one the reality. The Francis Report into the scandalous treatment of patients by Mid-Staffordshire NHS Trust underlines in the starkest possible terms how the two have grown ever more diametrically opposed.

After all, although it continues to appear in numerous policy documents, analyses, reviews and forecasts, the first statement is now routinely employed as little more than a predictable rider to a new set of targets or metrics. It represents an increasingly hollow reassertion of a faded paradigm.

The second is much more in keeping with a healthcare sphere in which a production-line mentality and a procedure-centred approach have seen the language of compassion surrender to the language of threat and the basic notion of humanity reduced to the realm of occasional afterthought. No time to talk. No time to think. No time to feel.

There is clearly a need for a more inclusive, outward-facing philosophy – one that goes beyond the purely medical, fosters a shift from narrow explanations to nuanced understanding and moves away from the ethos of the car factory by affirming that healthcare practice, like the performance of a musician, can be a richer experience for all concerned if there is room for improvisation and originality.

In short, there is a need – an increasingly urgent one – to restore humanity to healthcare.

This brings us to the vexed question of "compassion", a word that in recent years has been championed as utterly central to the nursing profession but, curiously and tellingly, little else in the NHS.

Traditionally, the near-automatic response to the issue of compassion depletion – acting with coldness, cruelty or disinterest to the suffering of others – has been that the fault must lie entirely with the nurse rather than with the target-driven, box-ticking surroundings in which many health systems often demand their practitioners work.

Of course, it is all too easy to attribute the problem to a single group of individuals and thus seek to burden them with the exclusive responsibility for its successful incorporation. It is also quite wrong.

The fact is that compassion should be at the very heart of the design of the healthcare system. It should be fundamental to place, process and person alike and a focus for all the professionals who work in the NHS – and, just as importantly, all those who manage its services.

The ultimate aim should be to generate compassionate environments in which patient and practitioner alike are encouraged to engage for mutual benefit. Patients should not have to be treated amid management-dominated cultures that lead to compassion fatigue and moral slide; and practitioners should not have to work in them.

This transformation will not occur simply through mandating angelic nurses or conjuring up new initiatives that promote compassion as some sort of "skill". It will require a significant and absolutely essential change in both government policy and NHS organisation.

We need egalitarian, appreciative and substantively connected communities of shared hope and solidarity within a healthcare setting. And if that seems too grandiose, maybe even too pompous for some tastes, it may be worth expressing the objective even more plainly while the appalling shortcomings and systemic failures exposed by the Francis Report are still fresh in our memories.

It is as simple as this. The goal should not only be to cultivate a healthcare arena in which a disinterested "f*** off" is never inflicted on a patient: it should be to cultivate one in which the very thought could never be conceived by a practitioner in the first place.

That this will even now sound almost fanciful to some is itself a damning indictment of where we currently find ourselves.

Comments   

 
+1 #11 Where are our values?Values in Healthcare 2013-02-10 18:57
Thank you for your enlightening post. You state, “In short, there is a need – an increasingly urgent one – to restore humanity to healthcare.” We agree. Compassion is essential, yet not sufficient. We must restore core human values—compassi on, respect, integrity & ethical practice, excellence, justice.

We have established an international collaborative effort to restore human values to healthcare. This effort has resulted in the International Charter for Human Values in Healthcare. The Charter's mission is to restore the universal core values that should be present in every healthcare interaction to healthcare around the world.

A focus on values, and placing values as a central focus in healthcare, is essential to prevent the continued assault on the patient-practit ioner relationship and the dehumanization of healthcare we see today. http://charterforhealthcarevalues.org
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+1 #10 DrStuart Berry 2013-02-10 09:13
http://simplestuffblog.wordpress.com/2013/02/10/compassion-debate-nature-or-nurture-why-its-worth-considering-the-bigger-picture-before-rushing-to-fix-the-nhs-through-more-rules-regulations/

It’s the old nature vs nurture debate, and it had its routes in the biological evolution of societies and culture. Tribes of people & staff develop ways of differentiating themselves from the people who are not in their tribe. This is done through words (jargon & abbreviations), appearance (uniforms), and rules or regulations which may not be obvious to the uninitiated.

Regional accents have been attributed n animal like her self, can cause aggression towards people who are not like her.

Maybe if healthcare can find ways of reducing the barriers & improving the flow of information, knowledge and understanding then compassion will stand a chance.

I have read that the Francis report could mean minimum staffing levels are prescribed for hospital wards & midwifery units. These are environments where a body of work is share between a defined workforces at the same time. What should the implications be for jobs that involve one individual seeing a series of people in a clinic.

Who decides on the optimum length of appointment or what can be achieved within it?

The department of health is currently negotiating with doctors leaders about how to change the GP contract. It looks like they plan on more work being added to the current list of “things that your GP could or should be doing
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0 #9 Restore the human dimensions of care!Values in Healthcare 2013-02-10 04:36
Thank you for your enlightening post. You state, “In short, there is a need – an increasingly urgent one – to restore humanity to healthcare.” We agree. Compassion is essential, yet not sufficient. We must restore core human values—compassi on, respect, integrity & ethical practice, excellence, justice.

We have established an international collaborative effort to restore human values to healthcare. This effort has resulted in the International Charter for Human Values in Healthcare. The Charter's mission is to restore the universal core values that should be present in every healthcare interaction to healthcare around the world.

A focus on values, and placing values as a central focus in healthcare, is essential to prevent the continued assault on the patient-practit ioner relationship and the dehumanization of healthcare we see today. Join us! http://charterforhealthcarevalues.org
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0 #8 DrJonathon Tomlinson 2013-02-09 23:09
Ballatt and Campling's essential book, published last year, 'Kindness in Healthcare' which I responded to here: http://abetternhs.wordpress.com/2012/05/04/kindness/
... suggests 4 ways in which we might nurture compassionate care.
1. Prioritise 'relaltional continuity of care' so that carers develop relationships with those they care for
2. Practice 'holistic' (whole person) care, so that those responsible do not assume that someone else is resonsible because they themselves are only responsible for one part (the kidneys, blood pressure, heart etc.)
3. Prioritise care for carers. Care for people in distress, dealing with suffering, repeated exposure to bodily fluids, confronting death ... are emotionally draining and physically exhausting. The carers need time to share their experiences in a way that respects the impact that their work has on them
4. Pay more attention to the positive aspects of care like kindness, comfort and empathy. These are hard to measure and easily ignored in the overwhelming pressure to provide documentation and data.
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+4 #7 Bottom LineProf Paul Gilbert 2013-02-09 10:23
Bottom line then: If you want your staff to be compassionate pay attention to what feeds and fine tunes those systems in our brains! Please let's not be naive about the human mind -surely we have enough history in wars and at other times to show that we are capable of the most horrendous neglect and cruelty-- so let's try to understand the human brain and mind and take a scientific approach to all of this. We know enough to be able to do this -but well intended politically generated fear-based solutions are not the way forward -As with so much in life - careful study and analysis is - compassion is a complex state of mind that and in fact is more fragile than we would like to think,
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+9 #6 What Is So TragicProf Paul Gilbert 2013-02-09 10:22
This is what is so tragic -- to believe that if you try to introduce even more threat and obedience to authority you are going to improve compassion in the system - only people who have rather little idea about how the brain actually works, would come up with a suggestion like that. The Francis report is a legalistic document - very good at observing what went wrong in terms of regulating systems and bodies but of course it's not a scientific document in anyway and doesn't pretend to be, therefore its recommendations are interesting but should not be the basis of how we begin to develop compassion in our health service. What we do know and Paul Crawford and I have done some research on this is recognition that the factory approach to medicine - which looks like it can drive efficiency because it's trying to treat more people faster cheaper -risks being something of a disaster when it comes to stimulating systems in our brain from which compassion emerges.
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+4 #5 Why Are We Creating the Wrong Contexts?Prof Paul Gilbert 2013-02-09 10:20
Although it's understandable to feel a sense of shock horror and scandal, as professionals and scientists we need to think about why and how we are creating contexts where basically cruelty thrives -and that's not to blame people but to recognise that actually cruelty is rather easy to stimulate in us -it's actually quite easy to dissociate from suffering -Now this is nobody's fault it's a fact about the human brain! So we have got to be very careful about how we train people and support people to deal with other people's pain day in and day out.
There is a wonderful book by Kelman and Hamilton (1989) called Crimes of Obedience which I'm reminded of when reading the Francis report -that actually people were trying to be obedient to the rules and their masters etc -and this obedience to hierarchy and authority can be responsible for some terrible things. It is an error to believe that people are purposely and carelessly doing bad things or are being negligent from some personal defect (though of course empathy is an individual trait and variant). So in the Holocaust for example there were very good people who were simply obedient to authority for one reason or another.
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+4 #4 What We KnowProf Paul Gilbert 2013-02-09 10:18
We now know that there are specific regulators of motivational systems like compassion. For example studies show that it's much easier to be compassionate to people we like than people we don't, to people we know than people you don't. When people feel safe they are much more likely to be compassionate than when they feel threatened and stressed partly because stress knocks out certain brain systems for which compassion often relies. Both consciously and unconsciously stress tunes attention. Oxytocin which is a hormone believed to promote caring turns out to be the same hormone that increases aggression to outsiders -for example mothers bond to their infants more with oxytocin but also become more aggressive to potentially threatening others. New research has suggested that oxytocin increases trust and caring to people we identify with and insiders but might actually increase hostility to outsiders. Under threat there is a narrowing of attention to in groups. Time and again them we see that the experience of threat -in whatever form has detrimental effects on the brain systems for compassion.
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+4 #3 The Most Central ProblemProf Paul Gilbert 2013-02-09 10:17
The most central problem is for me is that people simply do not understand compassion terribly well!. We have been studying it for 20 years and I have to say it turns out to be a very complicated state of mind actually -- for example there are many crucial components to compassion such as motivational orientation, attention sensitivity, sympathy, distress tolerance, empathic engagement, knowing what to do -- to name but a few -and each of these have their own regulators too. Empathy is important for compassion but it's also useful for marketing or even torture.
The fact of the matter is that it's very easy for people to dissociate from suffering. Studies of wars, for example as happened in the Balkans showed how people who were neighbours one day turned on each other with viciousness and cruelty the next. Our television programmes are increasingly violent -why is that do you think? There are scientists all over the world now who are studying compassion with debates about the definition and sub classifications , about what turns on and what turns off sympathy and empathy and so on.
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+5 #2 Dehumanising healthB.J. Brown 2013-02-08 22:17
The Francis report is a huge document – I’ve barely managed to skim it since its publication. But many of the events it describes are all too familiar to me from my own experience of visiting friends and relatives in hospital. During the last few years of my mother’s life it became clear to me that for many patients a good deal of the care was provided not by the NHS itself but by relatives. From people bringing cleaning equipment in and wiping down bedsteads and clearing up grime to helping their loved ones to eat – even changing drip feed bags – a lot of the human processes of care were being undertaken by visitors. Patients whose relatives lived long way away or didn’t have visitors were at a disadvantage. The Francis report, as well as the many other reports of shortcomings in health care, from inquiries, pressure groups and concerned relatives suggest that somehow the vast human resources of the NHS have been misdirected. Perhaps the preoccupation with internally directed scrutiny – audits, service evaluations, targets, cost containment initiatives and the like has captured the attention of many of those who work there. But even so, it is hard to imagine that this can fully account for the problems at Mid Staffs, or Maidstone and Tunbridge Wells, nor the ‘excess deaths’ in some trusts identified by Scholars such as Brian Jarman. Something more systematic is afoot. The meticulous manualisation, proceduralisati on and audit of healthcare, the attempts to manage the patient journey and guarantee its quality have inserted something pernicious into the relationship between practitioner and patient. Rather than being founded in the human processes of suffering and healing it is instead mediated by protocols, guidelines, record keeping and quality assurance. It may be legally defensible and pass muster for CQC visits – ‘if you didn’t write it down it wasn’t done’ - but at the same time it is utterly dehumanising.
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+4 #1 Are we ambivalent about caring?Prof Paul M Camic 2013-02-08 20:53
Prof Crawford has written a thoughtful and compelling response to the tragic events at Mid-Stafforshir e and in other NHS trusts. As a health care professional and an academic researcher I find it chilling and hugely disconcerting that events such as these are not rare in NHS healthcare. I wonder if some health care staff have become ambivalent about caring for people and their ambivalence becomes acted out on frail, helpless and yes, challenging patients, in sadistic-like acts of neglect and harm?

I do not believe the problem in compassion is just about targets. It seems there could be something culturally related about the stories of massive neglect that have been reported over the last few years. At Maidstone Hospital in Kent nearly 100, mostly older, patients were left in soiled beds, not properly fed, rooms not cleaned. Many died prematurely. A few years back at the former Kent and Sussex Hospital in Tunbridge Wells dried blood was left for days on floors and walls and nurses went from patient to patient changing bandages without washing their hands. At an outpatient procedure I noticed a nurse enter the procedure room, put down her purse and a shopping bag and begin to prep me for a test. What happened to basic infection control?

Yes, there really is something rotten in Denmark and that Denmark may be our local hospital or GPs office/
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