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the voice of NHS leadership
Futures debate
MAY 2008 PAPER 2
Key points
• Care, compassion and some
aspects of basic care delivery
appear under strain in health
systems around the world.
• Is compassionate care
fundamentally at odds with
modern healthcare?
• Individuals, including clinicians,
can feel powerless to
raise concerns.
• Aligning policy, leadership and
practice can make real, practical
diff erences to the way in which
patients are cared for.
• Putting compassion and care
back into healthcare requires
action at system level; by
organisational leaders; and
by individuals.
www.debatepapers.org.uk
The Futures debate series is designed to stimulate new thinking on future challenges to the health and social care
system, and you can be part of the debate. Have your say now in our forum at www.debatepapers.org.uk
The debates will feed into the NHS Confederation’s annual conference and exhibition, Delivering the future today,
in Manchester from 18 to 20 June.
Both here and around the world, there is a concern that, despite the increasing
scope and sophistication of healthcare, the huge resources devoted to it and
the focus on improvement, it is still failing at a fundamental level. Caring and
compassion, the basics of care delivery, and the human aspects that defi ne it
seem to be under strain.
Robin Youngson is a UK-trained anaesthetist and clinical leader working in
New Zealand who has refl ected deeply on these issues. Below, he gives his
personal view on the need for more attention to be given to the central role
of compassion in healthcare.
Chloe’s story:
a de ning moment
In any campaign to change a system
there comes a defi ning moment
when personal commitment
becomes absolute: choice is removed.
That moment came to me on
witnessing the plight of my 18-year-
old daughter Chloe, tied to a hospital
bed in traction for a broken neck. Flat
on her back, her head was completely
immobilised so that she could see
only the ceiling. She was unable to
see people who came into her room,
she couldn’t see out of the window,
she couldn’t see a television or read
a book. To sensory deprivation was
added starvation. There was no
system to ensure that my daughter
would receive adequate food – a
critical component of her healing and
recovery. Although she had the use
of her limbs, she was unable to feed
or toilet herself. For a day or two this
might be a tolerable state of aff airs;
her sentence was three months.
In the beginning, we imagined that
this neglect was a simple oversight
Compassion in healthcare
The missing dimension of healthcare reform?
Futures debate 2 Compassion in healthcare
02
in a busy public hospital with the
usual chronic shortage of staff .
However, annoyance turned to
disbelief and anger when it became
apparent that the hospital system
was incapable of responding to
these simple human needs.
There was no system to respond
to the disability needs of hospital
inpatients, nor was it anyone’s job to
ensure that patients received good
nutrition on a daily basis on a busy
acute ward. The potential clinical
consequences of these failures were
severe depression, malnutrition,
delayed healing and the requirement
for prolonged rehabilitation. I had
worked in this hospital as a senior
clinician and manager and I had
extensive networks of infl uence. But
no amount of pleading, persuasion
or anger would overcome the fact
that there was a systemic failure or
that the culture of the hospital was
allowing it to happen.
In the event, Chloe walked unaided
out of the hospital seven days after
being released from her bonds.
That she did so was a testament to
the support of family and friends. I
designed and built all of her disability
and communication aids. My wife,
Meredith, attended the hospital every
one of the 100 days that Chloe was
in hospital and ensured that she had
tasty and nutritious food. We spent
more than NZ$1,000 on hospital
car parking. The impact on the
whole family was profound. We felt
deeply fearful for the patients whose
families did not have the privilege or
resources to provide this kind
of support.
In general, the standard of clinical
care was excellent and we are
deeply grateful that our daughter
was able to heal from her injuries
with the dedicated care of many
professionals. However, the neglect
she experienced of her basic human
needs can only be described as
callous.
I wish Chloe’s experience was an
isolated case, but it is not. Ever since
I began at medical school in 1980
I have been profoundly concerned
about the experience of patients
within the system. I have campaigned
for patient-centred care, I teach
communication skills to health
professionals, I run workshops on
humanity and compassion and I
provide support for our vulnerable
junior staff . In every workshop I have
ever run, the participants tell me
that my daughter’s experience is
typical of what they see every day.
In nearly 25 years of practice I have
yet to fi nd a hospital that responds
compassionately to the basic human
needs of its patients.
I defi ne compassion as “the humane
quality of understanding suff ering in
others and wanting to do something
about it”.
How could so many health
professionals witness so much
suff ering and yet fail to respond?
The problem seems to exist at two
levels. In the experience of Chloe,
most of the failings were not the
fault of individuals but were the
consequences of gaps in the system
– human needs that were simply not
catered for. But there is also the failure
of individual practitioners to respond
with simple measures to relieve
distress, even when all the necessary
resources are present. One of the
commonest causes of complaints by
patients in emergency departments
is the lack of pain relief while waiting
many hours for assessment and
treatment. This failure is universal; it is
the rule rather than the exception.
Has the healthcare system
become less compassionate?
I do not think we have the data
to answer that question, but I
have observed changes in the
hospital system that have profound
Loved one in pain
“I doubt there is a more
distressing experience for a
health professional than seeing
a loved one in excruciating
pain within a system with the
resources to treat that pain
rapidly, but where no-one is
willing to take responsibility for
the necessary steps. I watched
Chloe lie for four hours in nine
out of ten pain [on the pain
measurement scale] as I called
every professional I could think of
to respond to the situation. The
drug required was visible to me
through the glass window of the
locked medication store.”
“In every workshop I have
ever run, the participants
tell me that my daughter’s
experience is typical of what
they see every day. In nearly
25 years of practice I have
yet to fi nd a hospital that
responds compassionately
to the basic human needs
of its patients.”
Futures debate 2 Compassion in healthcare
03
Action plan
• Declare ‘compassion’ as a core
value.
• Reward rather than punish
compassionate caring.
• Hone communication and
relationship skills.
• Provide space for staff to
discuss diffi cult issues.
• Challenge models of
professionalism.
• Hard-wire new behaviours.
• Declare compassion as a
management and leadership
competence.
• Engage health consumers in
the change.
consequences for the experience
of patients and their families.
Some things have improved to
lessen suff ering. In general, the
standard of post-operative analgesia
has improved beyond recognition.
The introduction of acute pain
teams in the 1990s replaced the
hideously inadequate four-hourly
intra-muscular injections of morphine
with sophisticated techniques such
as patient-controlled analgesia and
epidural infusions. The widespread
availability of such proven techniques
makes the failure to apply them ever
less defendable.
The organisation and context of
nursing and medical care in hospital
has changed profoundly during my
career. When I was a house surgeon,
the average length of stay of patients
was eight to nine days. Now it is three
and a half. Where previously we had
the luxury of waiting three or four days
for trust to build and for the patient to
open up about deeper concerns, now
we need exceptional communication
and relationship skills to get to the
heart of the matter in hours.
The times have changed, but skill
development has not. As a resident
doctor, I worked inhuman hours,
but I was the one and only doctor
responsible for the coordination of
care of all the patients on a ward. I
knew my patients well, sometimes
intimately, and I had a profound sense
of personal responsibility. In recent
times, the reduction of junior doctors’
hours has resulted in shift work
and extreme fragmentation of care.
The opportunity to build a trusting
relationship with patients and the
sense of personal responsibility has
been lost.
In that same period of time, in
New Zealand and other developed
countries, nursing training has moved
out of the hospitals and into the
universities. I wonder how much
the roles of caring, comfort and
compassion have been replaced with
a critical focus on pathways, tasks
and documentation. In my country,
ever-increasing demand on acute
care systems and staff shortages
have led to work environments in
emergency departments and wards
that resemble battlefi elds more than
healing sanctuaries. In the meantime,
as nursing practice extends farther
into the previous domains of medical
practice, there is increasing tension
between evidence-based nursing
care with its scientifi c research
agenda, and broader policy directions
for nursing with a holistic concern for
the whole patient.
Societal expectations have changed,
too. Almost every industry except
healthcare provides exceptional levels
of personal service. My bank provides
a ‘personal relationship manager’ who
knows me by name and who has
the authority and resources to solve
problems on my behalf. I can get a
bank loan the same day and I receive
a text message to confi rm that the
funds are available. In contrast, the
lack of personal service and the highly
visible reminders of unreliability in
healthcare lead to ever-growing
criticism. Healthcare professionals
who previously enjoyed high status
and unquestioning authority now feel
beleaguered and threatened. It’s hard
to feel compassionate if you think
that your patients are enemies who
are just looking for the opportunity to
complain or to sue.
A prescription for compassion?
Far from feeling helpless about the
situation, I have left behind my
fear and destructive beliefs after a
long personal journey. Now I am
delighted to report that my own
personal practice of medicine has
never been more joyful, satisfying
“Healthcare professionals
who previously enjoyed high
status and unquestioning
authority now feel
beleaguered and
threatened. It’s hard to
feel compassionate if you
think that your patients are
enemies who are just
looking for the opportunity
to complain or to sue.”
Futures debate 2 Compassion in healthcare
04
and fearless than it is today. I have
no ‘diffi cult’ patients, nor do I experience
what I perceive to be unreasonable
demands. I try to bring open-hearted
compassion to my patients and I am
able to witness suff ering and loss
in a way that brings deep meaning
rather than personal trauma. Along
that journey I have hopefully helped
others strengthen their humanity and
compassion and have begun to see
how that might be woven into the
fabric of a whole organisation.
In New Zealand, we have founded
a national Centre for Compassion in
Healthcare as a charitable trust. These
are the things we think may help
strengthen the heart of healthcare.
Declare ‘compassion’ as a core value
I believe the fi rst step is to declare
compassionate caring as a core value
of our healthcare services.
Compassion is an assumed value
but it is scarcely mentioned in any
of the documents about healthcare
strategies or aspirations. When I
searched the websites of all the
quality-improvement organisations,
I was unable to fi nd the word
‘compassion’ at all. In New Zealand,
the word ‘compassion’ is not
mentioned in the national healthcare
strategy, it is not a dimension of
healthcare quality and it is not
mentioned in the NZ Code of Health
and Disability Services Consumers’
Rights. After my daughter’s
experience, I vowed to begin a
campaign to amend the Code of
Rights and to add, “The right to be
treated with compassion”.
I think that the overwhelming
majority of health professionals are
motivated by a desire to serve. I
am unconvinced of the arguments
about ‘Generation Y’ and greater
self-centredness. When I have
deep conversations with health
professionals of any generation the
response is always the same – a
passion to do the best for their
patients and to relieve suff ering.
Organisational support for this core
value deepens the commitment of
health professionals.
Reward rather than punish
compassionate caring
The acid test for me is the supervisor’s
response to witnessing a staff nurse
sitting quietly with a patient for ten
or 15 minutes, to be present
and to listen to concerns. In almost
all of the hospitals I have worked
in, that behaviour would be
reprimanded not rewarded.
The reality is that we cannot aff ord
the time NOT to listen. There is
compelling research from the Studer
Group to show that empathic concern
and investing time up front to check
a patient’s needs increases effi ciency,
safety and patient satisfaction.
An hourly round of patients by
nurses dramatically reduces the use
of call buttons, freeing up nursing
time. Patient satisfaction improved
8.9 points on a 100-point scale and
patient falls reduced by 60 per cent.
To the daily reinforcement of good,
compassionate practice should
be added the celebration of star
performers. A simple thank-you
card from the general manager to
a staff member acknowledging the
positive impact on patient care of an
act of listening or kindness has an
enormous impact on morale.
Hone communication and
relationship skills
In today’s pressured healthcare
environment, we cannot aff ord to
wait days to learn what our patients
really need. I have learned that it is
possible to build trust in minutes
and to get to the heart of concerns
in the course of one visit. For most of
my career I did not have those skills
and I was completely unconscious
of the way I used power to control
the agenda of a patient consultation.
Empathy is as much a skill as an
inborn character trait.
Although most health professionals
have very good communication
skills, further training can make a
measurable diff erence, including a
reduction in the risk of being sued.
The Medical Insurance Groups of
Australia (MIGA) off er a 10 per cent
discount on medical indemnity
fees for doctors who complete a
programme in communication skills
and risk management.
Given the evidence of the relationship
between communication skills
and patient satisfaction and
“There is compelling
research to show that
empathic concern and
investing time up front to
check a patient’s needs
increases effi ciency, safety
and patient satisfaction. An
hourly round of patients by
nurses dramatically reduces
the use of call buttons,
freeing up nursing time.”
Futures debate 2 Compassion in healthcare
05
outcomes, a case might be made
for mandatory annual training of all
staff . Communication skills should
be regularly measured by the use of
patient satisfaction surveys. Individual
performance can be ranked on a
percentile basis against national
data sets for well-validated survey
instruments.
Create a safe space for deep
conversations in the workplace
The deep meaning and purpose of
our work is not a safe conversation
to have in the workplace. For several
years I have been meeting with two
medical colleagues over a shared
concern for the health and well-being
of doctors. One day our conversation
deepened and we began to talk
about the spiritual nature of the work
we do. In over 50 years of hospital
practice (between us), that was the
fi rst time we had ever used the ‘s’
word in front of another doctor.
Talking about personal vulnerability
is another conversation that is ‘off
limits’. I can recall only a handful of
occasions in my whole career when a
fellow health practitioner has spoken
openly about personal fears or
feelings of professional inadequacy.
We cannot expect health
professionals to bring compassionate
caring to their patients without some
personal healing, and the fi rst place
to start is with open conversation on
these diffi cult issues.
In the United States, the Kenneth
B. Schwartz Center sponsors
compassion rounds in 139 hospitals.
The Schwartz Center Rounds are
multidisciplinary forums in which
care-givers discuss diffi cult emotional
and social issues that arise in caring
for patients. Over 27,000 clinicians
across the US participate in these
interactive discussions and share their
experiences, thoughts and feelings
on diff erent topics. These kinds of
conversations need to be sponsored
in every hospital.
Challenge models of
professionalism
The Western model of medical
professionalism rests on foundations
of a bio-medical approach, rational
detachment and objectivity. There
is also a widespread belief that too
much empathy and attachment to
patients would lead to compassion
fatigue and that clinical detachment
is a necessary defence when
witnessing so much suff ering and loss
in the course of clinical practice.
Research shows that medical
students lose the ability to
empathise with their patients during
clinical training and instead identify
with the hero model of the medical
practitioner. Professor Johanna
Shapiro, author of Walking a mile in
their patients’ shoes, says they are
“drawn to doctors whom they have
idealised as healthy, invulnerable,
authoritative, skilled and eff ective
individuals who possess powerful
and still somewhat mysterious
knowledge and skills”.
We have much to learn from other
cultures. Contrary to prevailing
Western beliefs, the experience of
all who empathise deeply with their
patients and bring open-hearted
compassion to their work is that they
increase their store of love. Empathy,
compassion and loving kindness have
a biological basis. The daily practice
of compassion may immunise the
practitioner from negative emotions
and diminish the risk of burnout.
There is a world of diff erence
between open-hearted compassion
with non-attachment and
the Western model of clinical
detachment, which leaves patients
feeling so abandoned.
In Walking a mile, Professor Shapiro
writes a comprehensive review of
the psychological and emotional
responses to the traumas of clinical
training and practice and shows
how a more humanistic approach
can strengthen empathy and the
capacity for compassionate caring.
It should be compulsory reading for
every professional body reviewing
models of professionalism and codes
of practice.
Hard-wire new behaviours
into the organisation
It is often easier to change people’s
behaviours fi rst and allow the
experience to shift beliefs. Those who
practice empathic communication
with their patients are instantly
rewarded by the changed quality
of relationship with their patients.
“There is also a widespread
belief that too much
empathy and attachment
to patients would lead to
compassion fatigue and
that clinical detachment is
a necessary defence when
witnessing so much suff ering
and loss in the course of
clinical practice.”
Futures debate 2 Compassion in healthcare
06
The Studer Group is leading change
of this type in many US hospitals
through a didactic programme of
practices that ‘hardwire’ some key
behaviour into the fabric of daily
practice. Hourly ‘rounds’ by nurses
in which they proactively recognise
patient needs and demonstrate
empathic concern were mentioned
earlier. The precise form of words
used is important.
Careful scripting teaches staff to
use ‘key words at key times’ such as
concluding with, “Is there anything
else I can do for you at this moment?
I have the time”.
De ne compassion as a
management and leadership
competence
Healthcare organisations are a mirror.
The experience of people and their
families seeking care is a refl ection of
how the organisation treats its own
employees. 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 or discrimination,
they listen deeply, they role model
openness and integrity, and they are
not afraid to say sorry.
But what is the experience of the
most vulnerable young healthcare
professionals starting out? Bullying
and abuse are widespread. When
our new graduates feel truly safe and
supported in the workplace, and have
great role models, they will have an
opportunity to develop as humane
and compassionate practitioners.
Compassionate leaders create
compassionate organisations.
Engage health consumers
in the change
There is no greater moral authority
than a patient or family member who
with dignity speaks of grievous loss
and who challenges health leaders
to prevent such catastrophe from
happening again.
Health practitioners have an odd
capacity to dissociate their own
less-than-ideal experience of
healthcare from their thinking about
their own practice. The most powerful
way to open hearts is to put a patient
in the room to speak about their
experience of the behaviour of health
practitioners, the devastating impact
of cold detachment, and the deep
gratitude for compassionate caring.
Final word
I will fi nish as I began, with the story
of my daughter Chloe. I am still
completely undone by the memory
of one act of kindness on the fi rst day
of our shared trauma.
Chloe made many trips within the
hospital on the fi rst day: from the
resus room to the CT scanner; back
to the trauma unit; off to the MRI
scanner; transfer to the operating
theatre; back to the intensive care
unit. As parents, we followed our
daughter in these journeys and
witnessed the loving care of a transit
nurse. He came wonderfully prepared
and was enormously thoughtful
about Chloe’s potential needs, with
a whole kit of drugs, including a
generous supply of analgesia.
“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 or discrimination,
they listen deeply, they
role model openness and
integrity, and they are not
afraid to say sorry.”
Speaking out
It is not always easy for patients
and carers to speak out.
“In trying to get the right care for
Chloe I felt completely impotent in
a hospital in which I had been a
senior leader. I escalated the pleas
and requests and demands for help
until eventually I was taken aside
by the duty manager. We had to
be extremely circumspect within
a system on whose goodwill we
depended for the survival of our
daughter.”
Futures debate 2 Compassion in healthcare
07
At the junction between two hospital
buildings, there is a join in the fl oor.
Mindful of Chloe’s broken neck, this
wonderful nurse stopped the trolley
and carefully lifted each wheel over
the join in the fl oor to prevent any
painful jolting of her injuries. To
bewildered and frightened parents
he was a trusted guide in a foreign
land. He did not give us directions but
took us by the hand to the places we
needed to fi nd. As the months went
by, we met this nurse from time to
time. He would mysteriously appear
on the ward at a time when Chloe
was most distressed and off er wise
counsel and loving concern.
Few hospital patients ever remember
what was said to them, or what was
done, but the emotional experience is
lived for a lifetime.
Our questions
The NHS Confederation believes
Robin’s powerful case for change and
call for action has a strong resonance
for the NHS, particularly in the light of
the results of the recent staff survey
which showed that only 46 per cent
of staff thought that patient care was
their organisation’s top priority. The
patient survey and research by the
Picker Institute, Which?, Age Concern
and others highlight many of the
same issues. Do all of the causes he
identifi es apply in the NHS: are there
additional issues that he has not
mentioned?
Does the leaching of compassion
from the system that Robin describes
explain other failures of basic care
such as poor cleanliness, problems
with nutrition, lack of respect for
privacy and other criticisms of the
NHS and other healthcare systems?
Robin places a strong emphasis
on personal responsibility for
compassion being taken by all staff
– a theme echoed in Royal College
of Nursing (RCN) chief executive
Peter Carter’s recent address to
the RCN conference. Are staff too
ready to blame the system or others
rather than take action themselves?
If they want to make a change for
the better do they know how, do
they have the time and do their
managers and the organisation
support them when they do? Do they
understand the organisation or have
the improvement skills to make a
diff erence?
Compassion, safety and quality
all seem to be part of a growing
movement that requires a focus on
the basics: measurement systems,
new skills, time to change, curiosity
and the willingness to admit personal
and organisational weaknesses. This is
a major cultural, clinical, management
and leadership challenge. Is the NHS
ready for this?
How much do some of the current
changes facilitate or threaten
compassionate care? Does the
education and training strategy that
we have pay enough attention to
these issues? Does the European
working-time directive, an all
graduate nursing profession and
other changes undermine the
development of a more caring
and compassionate service?
If we tried to follow Robin’s action
plan, how would we know that we
were succeeding? The traditional
approach of metrics and targets
hardly seems to fi t this agenda, but
measurement will be needed and
it will need to be designed in ways
that ensure that measuring does
not destroy the very thing we are
trying to nurture.
Robin does not mention the current
favourite policy instruments of
incentives, penalties, contracts and
regulation. Instead he argues for
something much more emotionally
engaging and personal that speaks
to the basic values of staff and
professionals. His argument suggests
that technocratic solutions of this
sort not only have limits but may
fundamentally miss the point. It
might be that the exclusive pursuit
of incentives and the avoidance of
penalties might detract from what is
truly important: nurturing a “humane
quality of understanding suff ering
in others and [the desire] to do
something about it”.
“Are staff too ready to
blame the system or others
rather than take action
themselves? If they want
to make a change for the
better do they know how,
do they have the time and
do their managers and the
organisation support them
when they do?”
Futures debate 1 Funding tomorrow todayFutures debate 2 Compassion in healthcare
08
The NHS Confederation
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Email enquiries@nhsconfed.org
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INF13001
Further copies can be obtained from:
NHS Confederation Publications
Tel 0870 444 5841 Fax 0870 444 5842
Email publications@nhsconfed.org
or visit www.nhsconfed.org/publications
©NHS Confederation 2008. This document may not be
reproduced in whole or in part without permission.
Registered Charity no: 1090329
The content of this briefi ng does not represent the views of the NHS Confederation. The NHS Confederation is grateful
to Robin Youngson, consultant anaesthetist, Waitakere Hospital, Auckland, New Zealand, and co-founder of a national
Centre for Compassion in Healthcare in New Zealand for contributing his ideas.
Robin.youngson@waitematadhb.govt.nz www.compassioninhealthcare.org
Join the debate
• Has the healthcare system become less compassionate and less focused on getting the basics of care right?
• How can we help both organisations and individuals admit when there are weaknesses and help them take
appropriate action?
• Are staff too ready to blame the system or others rather than take action themselves?
• Would Robin Youngson’s prescription for compassion work in the NHS? And if we tried to follow his action plan,
how would we know we were succeeding?
• Does the pursuit of incentives and avoiding penalties detract from focusing on compassionate care?
Have your say now in our forum at www.debatepapers.org.uk
The debates will feed into the NHS Confederation annual conference and exhibition, Delivering the future today,
in Manchester from 18 to 20 June. Visit www.nhsconfed.org/2008
Resources
Studer Group. Call light study.
www.studergroup.com/dotCMS/
knowledgeAssetDetail?inode=262036
You ngs on R. T he orga nis ati onal
domain of patient centred care.
www.wpro.who.int/sites/pci/
publications.htm
Dignity and the essence of medicine.
bmj.bmjjournals.com/cgi/content/
full/335/7612/184
World Health Organisation. Patients
for patient safety.
www.who.int/patientsafety/patients_
for_patient/en
Essence of care.
www.dh.gov.uk/en/Publicationsand
statistics/Publications/Publications
PolicyAndGuidance/DH_4005475
Picker Institute.
www.pickereurope.org
