Chapter 4: Building and Sustaining a Practice of Compassion for Patients and Their Loved Ones

“The most important thing we bring to another person is the silence within us. Not the sort of silence that is filled with unspoken criticism or hard withdrawal. But the sort of silence that is a place of refuge. Of rest and acceptance for someone AS they Are. We are all hungry for this other silence…Silence is a place of great power and healing.” – Rachel Naomi Remen

The preamble to The International Council of Nurses’ (2012) Code of Ethics, states that, “Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering” (p. 1). As you have learned in the previous chapters, by definition compassion is the “state of concern for the suffering or unmet need of another, coupled with a desire to alleviate that suffering” (Goetz & Simon-Thomas, 2017, p. 3). Since alleviation of suffering is the outward expression of compassion, it follows that nurses have an ethical duty to practice compassion. However, it is not always easy! In this chapter I will explore how nurses can build and sustain a practice of compassion.

While it is possible to provide nursing care in a task-based manner without feeling any compassion, patients have reported that there is a big difference between being cared for in a compassionate manner versus being cared for in a task-focused manner (Bramley & Matiti, 2014). Furthermore, while there are many reasons for deficient or poor-quality nursing care (and a lot of them are systemic and outside of the control of staff nurses), a lack of compassion is believed to a major contributor to the problem of poor-quality nursing care (Hewison, 2016; Van Der Cingel, 2014). Most nurses were never explicitly taught how to be compassionate, it is a quality we either innately possessed, or we picked up along the way from our mentors (Durkin, Gurbutt, & Carson, 2018). In this chapter, I will present some ideas that can help you build your capacity for providing compassionate care to patients and their loved ones. In Chapter 7, I will discuss how we can teach and mentor nursing students and new nurses how to more deliberately cultivate compassion.

This chapters begins with a discussion of what compassionate patient care looks like in practice. I will then invite you to explore the large and small moments of suffering that patients in your care may experience. The goal of this exploration is to help you build empathy and your tolerance for all sorts of distress. Next, I will discuss why it is easier for us to feel compassion for some people and not others, and how we can overcome this innate tendency. I will specifically address how to maintain compassionate feelings towards people who resist our efforts to help them. I will also offer some concrete suggestions for how you can help patients cope with suffering, as well as how you can communicate in a compassionate manner with your patients. Finally, I will briefly discuss organizational barriers to providing compassionate care and invite you to consider which ones are present in your workplace, and how you might work to resolve them.

Compassion in Action: Descriptions of Compassionate Care

We each may have our own notions of what it means to give care in a compassionate manner, and we probably also have some ideas about what uncompassionate care looks like. In this section I will discuss models of compassionate care that researchers who have studied compassion have developed. As you read this section, I encourage you to think about which components of compassionate care you already incorporate into your practice. This section might also give you some ideas about how to enhance your ability to provide compassionate care, especially in areas where you have struggled in the past. The models presented in this section may also give you some ideas about how you can articulate what it means to provide compassionate nursing care if you are in a situation where you are teaching or mentoring a new nurse.

The Compassionate Heart Model. The first model I will discuss is The Compassionate Heart model (Way & Tracy, 2012). The model was developed from a multi-year study of how multidisciplinary providers in a hospice center provide compassionate care. Way and Tracy suggest that compassionate care and compassionate communication consists of the subprocesses of recognizing, relating and (re)acting to suffering. Recognizing involves noticing suffering. Caregivers do this by “understanding and applying meaning to others’ verbal and nonverbal communicative cues, the timing and context of these cues, as well as cracks between or absences of messages” (p. 307). From their experiences taking care of hospice patients, caregivers are able to recognize when their patients are suffering, even when the patients are unable, or unwilling to articulate this suffering.

Relating involves “identifying with, feeling for, and communicatively connecting with another to enable sharing of emotions, values, and decisions.” (Way & Tracy, p. 307). This action has both a cognitive and affective component. As an example of the cognitive component of relating, Way and Tracy described situations where patients might be exhibiting difficult behaviors or emotions (e.g. acting out in anger) which made it hard for staff to initially connect with them. Compassion was facilitated when staff were able to intellectually understand that this displaced anger was part of the grieving process. This cognitive understanding helped staff connect with patients on an emotional level, even when the patients were pushing them away in anger.

Way and Tracy believe that the third subprocess of their model – (re)acting – is the heart of compassionate care. They describe (re)acting as follows:

The parentheses around ‘‘re’’ indicate that compassionate action need not only be in response to or arise after the recognition of someone else in pain, but can also be proactive. In other words, this process can be ‘‘acting’’ as well as ‘‘reacting.’’ With this understanding, we define (re)acting as engaging in behaviors or communicating in ways that are seen, or could be seen, as compassionate by the provider, the recipient, and/or another individual. (p. 307).

(Re)acting, in this model, is the physical act of caring, and can occur independently of the other two steps. It may also come before or after recognizing and relating. For example, Way and Tracy recounted instances where staff said the physical act of caring for patients, such as bathing them, or combing their hair, elicited feelings of compassion they had not previously felt.

EXERCISE: Applying Way and Tracy’s Model of Compassion to your Practice

Before I discuss the next model of compassionate caring, I invite you to take a few minutes and reflect on Way and Tracy’s model. Either with your study group or by yourself, think about the subprocesses of compassion that Way and Tracy identified – (re)acting, relating and recognizing. I have offered a few discussion points, you may think of other points that you want to discuss about this model. If you can access it, I also suggest you read the original article (see the reference list) which explains this model in greater detail.

1. Do you agree with this conceptualization of compassionate care and communication? Why or why not?

2. In your practice, what are ways in which you have responded, related or (re)acted to suffering of your patients or their loved ones? If you can list examples of each.

3. How might you use this model to help a new employee enhance their ability to act with compassion?

4. Way and Tracy suggest that physical acts of caring for patients, such as combing their hair or bathing them can trigger feelings of compassion. Have you noticed that when you touch a patient or care for their body, your feelings towards them change? Take a moment to reflect on this.

5. Finally, what moments of caring for patients and their loved ones elicits feelings of compassion in you?

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Van Der Cingel’s Model of Compassionate Nursing Care. The second model of compassion that I will discuss comes from Margreet Van Der Cingel (2011). She developed her model based on interviews with nurses and patients in three long-term care facilities. Based on the data from these interviews, she concluded that compassionate care consists of attentiveness, listening, confronting, involvement, helping, presence and understanding (Van Der Cingel, 2011).

Van Der Cingel (2011) defined attentiveness as the “conscious approach of one person who shows interest in whatever issue is important for the other person” (p. 676). Caregivers can demonstrate attentiveness through actions such as making eye contact, sitting at the bedside of a patient, and appropriate touch. Listening to patients is another way of manifesting compassion and is closely aligned with attentiveness. By allowing a patient to guide the conversation, to reminisce, and to tell stories of their lives, caregivers demonstrate an acknowledgement of the suffering that can accompany illness, disability, and aging.

While the first two components of compassion – attentiveness and listening require the nurse to take their cues from the patient, Van Der Cingel (2011) also found that nurses can compassionately lead the conversation. For example, by helping patients confront difficult emotions such as grief, anger, fear, and shame, that often accompany illness, aging and the end-of-life. To help patients confront their own difficult emotions, nurses need to be able to identify these emotions (which requires emotional intelligence) and they need to be comfortable discussing difficult emotions. It is important to understand that it is not compassionate to minimize or gloss over the emotional suffering that accompanies major illnesses, aging and death. People who are experiencing these major life changes need to be allowed space to process their difficult emotions.

In Van Der Cingel’s study, nurses also demonstrated compassion through involvement with their patients. Involvement meant that nurses engaged with patients and their loved ones on a personal level. Nurses who were compassionately involved with their patients shared their own stories of suffering (thereby acknowledging a shared humanity). They bonded with their patients over common interests, and they demonstrated that they were trustworthy by consistently striving to meet the needs of their patients and their loved ones.

The fifth component of compassion in Van Der Cingel’s model is helping. Patients in long-term care (as well as other settings) need assistance with the activities of daily living, and patients described the difference between assistance that was provided compassionately versus assistance that was provided in a task-focused manner. Helping might consist of the nurse doing something for a patient (e.g. feeding them), doing a task with a patient (e.g. assisting them to dress) or by teaching them a new way of doing a task for themselves.

Presence, or just sitting with a patient, was the sixth component of compassion that Van Der Cingel identified. Nurses can use their presence to help patients who are fearful or anxious, to offer support when a doctor is giving them difficult news, or they might offer physical or emotional presence during a painful or uncomfortable procedure.

The final component of compassion in this model is understanding. Understanding involves a willingness to engage in the suffering of another person rather than dismissing it, discounting it or walking away from it. Van Der Cingel says that while no one can never wholly understand what another person is experiencing, nurses can acknowledge that patients’ emotions are valid, and that their suffering is real.

While Van Der Cingel’s model posits that compassionate care is comprised of seven components, they do not all need to be present in order for compassionate care to occur. In the next exercise I will invite you to explore this model, and how you might use it to build and sustain your compassionate nursing practice.

EXERCISE: Applying Van Der Cingal’s Model of Compassion to Your Practice

In this exercise I invite you to take a few minutes and reflect on Van Der Cingal’s model. Again, either with your study group or by yourself, think about the aspects of compassion that she identified. The following are my suggested discussion points, you may think of other points that you want to discuss about this model. If you can access it, I also suggest you read the original article (see the reference list) which explains this research in greater detail.

1. Do you agree with her conceptualization of compassionate care? Why or why not?

2. What were the differences in Van Der Cingal’s descriptions of compassion and Way and Tracy’s model of compassion? What were the similarities? Which do you find more useful?

3. In your practice, what are ways in which you have enacted any of the components of compassion that Van Der Cingal identified? What was your patient’s response to this action? What emotions or thoughts do you have about that experience?

4. How might you use Van Der Cingal’s research to help a new employee enhance their ability to act with compassion?

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Moving Toward Suffering: Building Distress Tolerance

Depending on your practice setting, you may witness suffering at some point during every workday. The suffering you witness may range from relatively minor suffering such as a patient who did not like their dinner to major suffering such as a parent that just lost their child to cancer. In the face of daily suffering, it can be hard to maintain compassion day in and day out. You might find yourself discounting some types of suffering while feeling overwhelmed by others. You might find yourself exhibiting symptoms of burnout or compassion fatigue (these concepts will be discussed more fully in Chapter 8).

Cultivating equanimity and finding a way to provide compassionate care for all types of suffering patients experience, while not becoming overwhelmed by the ongoing suffering you witness as a nurse, is not an easy task, but it is one which is worth pursuing. In this section, I will discuss suffering in the context of patient care and will offer thoughts on how you can build your distress tolerance, which will allow you to sustain your compassionate nursing practice. First, I invite you to revisit how you think about suffering and take a moment to reflect on your current level of distress tolerance.

EXERCISE: Exploration of Your Thoughts on Suffering and Assessment of Your Current Level of Distress Tolerance

This exercise can be done by yourself or with your study group.

1. Think back to your responses to the exercise in Chapter 1: Exploration of your thoughts on suffering. If you wrote them down, read what you wrote. Are your thoughts the same or different from what you wrote at that time?
2. What types of suffering do you typically see in your nursing practice? What are the ways in which this suffering is expressed? What do you think are the root causes of this suffering?
3. When you are in the presence of suffering, how do you typically act? Do you have an urge leave as soon as you can? Do you want to automatically fix the problem? Are there times when you tend to minimize the suffering that the person is experiencing? Do you have different responses to different types of suffering?
4. Suffering and loss are an inevitable part of life. Some of us find solace in religious or spiritual practices. Some of us might find solace in a philosophical worldview. What spiritual, religious, or philosophical beliefs or thoughts help you cope with, or rationalize suffering? What do you do when your beliefs, thoughts or values do not help you cope with the suffering you witness or experience?

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In Chapter 1, I introduced the notion that suffering is something that every human experiences. While death, illness, and loss are the most universal sources of suffering, there are other, unique, ways in which we as humans suffer. There are moments when we experience minor (little s) suffering, and moments that we experience major (big S) Suffering – and what is minor to one person might be major to another (and vice versa). In addition, our outward expressions of suffering might differ, as well as our inward coping mechanisms. These differences can make it challenging for nurses to respond to suffering they witness in their patients and the people who care for these patients.

Simply stated, suffering as an “undesired experience, of considerable intensity or duration, of a negative physical or affective state” (Vanderweele, 2019, p. 58). Suffering can manifest as “a multifaceted experience that can threaten individuals’ physical, emotional, and psychological well-being.” (Younas, 2020), p. 937. Suffering often ensues from a loss of control, from a threat to one’s sense of self, or from a threat to one’s actual physical self (Vanderweele, 2019). Illnesses, end-of-life, and long-term disabilities involve all three of these components. When we are sick, our idea that we are functioning adults who are in charge of our lives may be threatened. We may be forced to acknowledge that we cannot control how fast we heal, or even if we fully recover. When our child, parent or other loved one is sick, we might also suffer if we are unable to help them feel better, and if we are worried about their return to full health.

Physical pain and discomfort cause suffering, but as stated above, loss of control exacerbates this suffering. Take a moment to consider all the ways in which healthcare takes control away from patients – from long waits in doctor’s offices and emergency rooms, to the skimpy gowns that patients are asked to wear. Healthcare settings also take control away from family and loved ones at times, but excluding them from the bedside or exam room, and by not communicating with them fully. In my experience, hospitals, outpatient clinics and other healthcare settings have become more family friendly and patient-provider communication has improved a lot. However, we can always strive to do better.

At the beginning of this section, I briefly touched on the notion of minor suffering and Major Suffering. As nurses, it may be easier to feel compassion to the patient who has Major Suffering than to the one whose suffering seems to be minor. For example, if you have one patient who is angry that they did not get the food they ordered for dinner, and another who cannot eat because they have intense nausea and vomiting from chemotherapy, you may feel more compassion towards the second patient. It is even possible that you might feel a little frustrated about having to take the time to sort out the meal tray for the first patient. If that is the case, it may be useful to consider that the menu mix-up might be the latest in a series of events that have led the patient to feel their life is out of control. While ultimately you may not attend to the request for new food with the same urgency as the need to control the other patient’s nausea, it is important to try not to compare the suffering of one patient to that of another with a judgmental attitude.

It is natural to immediately dwell on the big “S” types of suffering patients experience, and as I mentioned, principles of triage require us to deal with more urgent cases first. However, one of the reasons I want you to reflect on small moments of suffering is that we encounter a multitude of instances of small suffering in our daily practice, and it is important to acknowledge these moments. For example, some patients have such fear of needles that they really suffer every time we need to do a procedure requiring a needle stick (for example, inserting an IV, drawing blood, or giving them a shot). Other patients endure these procedures stoically while a third group hardly seems to mind. It can be easy to get impatient with people who have intense fear of needles, after all, the pain is very short-lived, and for most of us, hardly worth mentioning. What we need to remember is that suffering is not due to pain, the physical discomfort, or the symptom, but the way in which an individual interprets and experiences the event.

Small moments of suffering give us an opportunity to build our distress tolerance and to practice equanimity and compassion. Helping patients in the small moments can also feel very gratifying. Personally, I often found that the small acts of kindness sustained me as much as the larger ones. To this day I remember an evening shift where I was taking care of a woman who was three weeks postpartum and needed her gall bladder removed. While she was in surgery, I noticed that her husband was pacing in the hallway with their infant who was screaming unconsolably. The baby was flailing around in the husband’s arms, and I have a distinct memory of a little bare foot sticking out of the baby blanket. I could have ignored the father, or just offered him a smile, after all, he and the baby were not my patients. Luckily, I was not too busy (lack of time can be a major barrier to acting with compassion – I will discuss this later), so I asked him if he would like some help calming his infant. He indicated that he would, so I showed him how to swaddle the baby snuggly in his baby blanket. Miraculously, the baby calmed right down. The father looked very relieved and was very grateful. I had an emotional boost and a sense of satisfaction that returns anytime I bring that memory to mind.

In the next exercise I invite you to reflect on how you respond to small moments of suffering as a way of understanding your current distress tolerance.

EXERCISE: Reflections on Your Responses to Small Moments of Suffering

You can do this exercise with a study group or by yourself. The purpose of the exercise is for you to explore your current distress tolerance, and to work on increasing your ability to sit with suffering in order to build and sustain your compassionate nursing practice.

1. Think about several different small moments of suffering that a patient, family member or friend has experienced. For example, a patient might be suffering because they did not get an item they ordered for dinner. A friend might be upset because their favorite dress was ruined in the wash.

2. Keeping a curious mind (and actively working to suspend judgement for your thoughts or feelings), explore your reactions to this small moment of suffering. Are there instances when you might feel more compassion than others? What are the external situations (e.g. how busy you are, your level of fatigue or hunger, the acuity of other patients) that might affect your level of compassion for these apparently small instances of suffering?

3. Are there types of patients, or types of suffering that illicit a different degree of compassion in you? Is it easier for you to tolerate minor or major suffering? Again, I do not want you to feel shame or judgmental about this, it is natural to have more affinity towards some people, and some types of suffering, than others. The purpose of this exercise is to build awareness of your natural inclinations so you can be more consistently compassionate.

4. The next time you are in a situation where you find yourself feeling irritated or less sympathetic to a patient (or other person) who is experiencing what you think of as relatively minor suffering, I invite you to silently think to yourself, “This person is suffering. Just like me, this person wishes to be free from suffering. May I have the compassion to help them.” As I mentioned earlier in the book, I have found that sometimes merely thinking the three words, “just like me,” is enough to generate a shift from intolerance and judgement towards lovingkindness and compassion.

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Behavioral Manifestations of Suffering: Different Ways People Express and Cope with Difficult Situations

To understand how to help people cope with suffering, and to build our distress tolerance, we need to have an understanding of typical responses to suffering. People have different ways of coping with distress, some differences are cultural, others are based on personality. While everyone copes with difficult situations in different ways, and expresses distress differently, there are common patterns that can be discerned. Exploring these can deepen our ability to build and sustain compassion.

Janice Morse, a nursing researcher, developed a Praxis Theory of Suffering (praxis means action-oriented) with the goal of helping nurses understand how to best respond to suffering (Morse, 2001). She proposed that there are two distinct behavioral states, which she called enduring and emotional suffering, that are commonly manifested by people who are undergoing intense suffering (e.g. a traumatic accident). The behavioral states do not appear concurrently, instead people cycle from one state to the other. Morse suggests that therapeutic responses to one state are not appropriate to the other.

Briefly, when someone is in the state of enduring suffering, their emotional responses may be shut down while they “come to grips” with the situation (Morse, 2001, p. 50). People who are enduring suffering may look like they are not suffering, and probably do not want to acknowledge they are suffering, as they are holding their difficult emotions in check (e.g. grief, anger, fear) in order to attend to whatever needs to be done at the moment. Enduring can be an active coping method which allows the person to take care of tasks such as planning a funeral or arranging for hospice or long-term care for a loved one. Enduring may be accomplished through cognitive distraction through activities such as reading or doing puzzles. It may be manifested by physical activity such as pacing, or it might manifest as emotional reactions such as hysterical laughter. To release the emotional energy required to endure suffering, people in this state may at times exhibit emotional outbursts – such as sudden bouts of anger – which will often be directed towards healthcare providers. Understanding that inappropriate laughter or sudden bursts of anger are part of the way some people cope with suffering can help you moderate your own emotional response as you continue to provide compassionate care.

While enduring may be an effective short-term coping strategy, after all there are times during the aftermath of an emergency when people need to hold their emotions in check in order to take care of things, it is not an effective long-term coping strategy. That being said, nurses who are taking care of patients in acute care settings, in the immediate aftermath of a tragedy, or right after the delivery of bad news, should allow the person to remain in the state of enduring. People who are in this state do not want to be comforted. They may rebuff physical gestures, and they may seem cold and uncaring. Again, understanding that these can be normal reactions to suffering can help us refrain from judgement. People who are in the enduring state of suffering may appreciate silent support, or messages that they are “holding up well” (Morse, 2001).

The second behavioral state that Morse identified was emotional suffering (Morse, 2001). In this state the person may cry or talk incessantly about their traumatic experience. When people are in the state of emotional suffering, they are often processing the experience. Some people may immediately respond to a crisis with an emotional response. In others, this state may follow a period of enduring, and may indicate the person is moving towards acceptance of the loss and subsequent growth. However, the grieving process is never linear, and a person may move out of emotional suffering into enduring multiple times. People who have a low distress tolerance, low levels of emotional intelligence, poor coping skills or who did not have role models to teach them how to deal with suffering, avoid emotional suffering through dysfunctional behaviors such as drug or alcohol abuse.

EXERCISE: Reflecting on Morses’ Praxis Theory of Suffering

You can do this exercise on your own or with a study group. If you are working with a group, this exercise can be a good way to get some new ideas about how to care for patients who are suffering.

1. Think about an instance where you were taking care of a patient, or their family member, who was exhibiting behaviors consistent with Morses’ stage of enduring. What was your emotional and cognitive response to the way they coped with suffering? Did you feel you connected with them? What actions did you do (if any) to comfort them? How were these actions received? Do you feel they were effective? What might you do the same, or differently in the future when taking care of someone in this stage of suffering?

2. Now think about an instance where you were taking care of a patient, or their family member, who was exhibiting behaviors consistent with Morses’ stage of emotional suffering. What was your emotional and cognitive response to the way they coped with suffering? Did you feel you connected with them? What actions did you do (if any) to comfort them? How were these actions received? Do you feel they were effective? What might you do the same, or differently in the future when taking care of someone in this stage of suffering?

3. Without judging yourself, think about which type of response to suffering is easier for you as a nurse to be around. If you have an affinity for one type of behavioral response to suffering, think of some ways you can increase your tolerance for the other behavioral response.

4. If you are doing this exercise as a group, discuss how family, upbringing and culture affects the way we cope with difficult experiences. What are the ways in which your family expresses suffering? What messages did you receive about public displays of grief or anger? How does your upbringing or cultural background affect your personal experiences with suffering and/or distress tolerance? What is helpful? What would you like to change?

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As you have probably noticed in your own life, everyone responds differently to suffering. VanderWeele (2019), in a literature review on responses to suffering, stated that:

The appropriateness of different responses to suffering may depend on the type or object of suffering, the nature of the event or loss that caused suffering, and the length of time that has elapsed since that event occurred. (p. 63)

VanderWeele divides potentially positive responses to suffering into the following categories: cognitive responses, coping responses, action to change circumstances, re-engagement with the community, character growth, and spiritual or religious engagement. It is beyond the scope of this chapter to discuss each of these responses fully. Instead, I have summarized them in Table 4.1. In the exercise that follows this table I invite you to apply this information to your personal and professional experience.

Table 4.1: Summary of Positive Responses to Suffering (Vanderweele, 2019)

EXERCISE: Reflecting on VanderWeele’s Theory of Suffering

This is an ideal exercise to do in a group. If you do it alone, I encourage you to write your answers. I encourage you to read the original article by VanderWeele (see reference list) if you can access it.

Under each of the positive responses to suffering in Table 4.1, and examples of how nurses can facilitate this type of response answer the following questions:

1. When have you witnessed (or practiced) this response in your personal or professional life?
2. What specific behaviors accompanied this response?
3. If you witnessed the response: what emotions do you think the other person was feeling? If you were the person responding to suffering in this manner, what emotions do you remember feeling?
4. Which of the nursing actions that VanderWeele lists have you done? Which ones do you think you might do in the future? Which ones do not seem appropriate for your professional setting or your style of nursing? Are there any other therapeutic actions that you can think of that might facilitate this style of coping in the population that you serve?

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When Compassion Does not Arise Easily: Why it is Easier to Feel Compassion Towards Some People and Not Others

Hidden biases

It has been well documented that certain populations, such as BIPOC (Black, Indigenous and People of Color) people, LBGTQ (Lesbian, bisexual, gay, trans-gender and queer) people, and people with history of addictions and mental illnesses have reported feeling alienated by the care they have received in healthcare settings. While reasons for the disparities in the health outcomes of these populations is multi-faceted, one fundamental reason might be that healthcare providers have implicit biases which lead to different innate levels of empathy for people based on their perceived identities (Roberts, Puri, Trzeciak, Mazzarelli, & Trzeciak, 2021). Nurses, like the rest of the population, have implicit biases. Even if we think we are not prejudiced, and consciously work on our biases, the messages that we have learned from society at large can affect our interactions with members of communities that are different from ours. Biases often manifest when we are tired, stressed, or when there are many demands on our attention (Burgess, Beach, & Saha, 2017) – all of which are common conditions for nurses.

Mindfulness training, specifically lovingkindness meditation, has been found to be an effective method of helping clinicians overcome their implicit biases (Kang, Gray, & Dovidio, 2014; Lueke & Gibson, 2015). Lueke and Gibson (2015) found that a mere ten minutes of mindfulness training reduced scores on an implicit association test, which indicates that it does not take lengthy meditation sessions to disrupt some of our biases. Perhaps when we become more mindful of our biases, we do not allow them to be expressed. This study did not look at long-term effects of meditation on implicit bias, and it is unlikely that the effects of one ten-minute meditation are long-lasting, so repeated practice is probably needed to help us consistently overcome our implicit biases.

While we should work to overcome biases, it is important to understand that implicit biases are the result of the way our brains our wired, and to avoid judging ourselves for them. Remember, when we think judgmental thoughts, even if they are focused inwards, we cannot access compassion. That being said, the human brain has a pre-frontal cortex that allows us to overcome more “primitive” functions such as implicit biases, so biology should not be used as an excuse to feel an affinity towards some people and not others. If you want to learn more about the science behind implicit biases, The Hidden Brain by Shankar Vedantam is an excellent resource. In the exercise that accompanies this section, I invit you to explore your hidden biases.

Nurses and other healthcare providers may also develop biases against patients they categorize as “difficult.” Patients who do not follow medical advice (often labeled as non-compliant or non-adherent), or those with stigmatized conditions such as mental illness, addiction or HIV/AIDS may be openly discussed in a disparaging manner (Hawking, Curlin, & Yoon, 2017). I certainly witnessed open as well as implicit bias against patients with certain diagnoses or behavioral patterns during my 20 years of bedside nursing!

If we have cared for multiple patients with a common illness who have been “difficult,” or who we labeled as “non-compliant,” we may develop implicit biases towards other patients with that diagnosis. Additionally, patients who struggle with drug and alcohol addiction, or who do not follow recommended medical advice, often express intense negative emotions such as anger, that make them difficult to care for. They may also engage in manipulative or aggressive behavior which makes it challenging for or us to access compassion for them. Because of their anger or aggression, we might feel fearful in their presence, and as discussed earlier in the book, fear stimulates the fight or flight pathway and closes down our compassion.

Furthermore, in the recent past, and indeed in some places in the present, addiction is seen as a lifestyle choice or a moral failure rather than a disease. We may find ourselves thinking, “this person’s actions caused their suffering,” and these thoughts can also block compassion. By being mindful and open to our thoughts and feelings when caring for “difficult” or “challenging” patients, we can work on developing an attitude of lovingkindness towards all, which will ultimately improve the quality of care that we deliver (Hawking et al., 2017). Finally, if their behaviors make it difficult to feel compassionate when we are in their presence, generating compassion towards them when we are in what feels like a safer place will help us take care of them in the future, and will also help alleviate our own stress (remember, feelings of compassion can help lower blood pressure and heart rate!).

EXERCISE: Identifying and Addressing Implicit Biases

This exercise is best done by yourself, however I encourage you to discuss what it felt like to do the exercise with your study group. Before doing this exercise, you may want to explore your implicit biases, Project Implicit https://implicit.harvard.edu/implicit/takeatest.html is a great place to start.

1. Start by finding your anchor, settling your mind, and taking some deep breaths. You may either close your eyes or soften your gaze.

2. Next identify one group of patients who you suspect, or know, that you have implicit biases towards, or that you feel are difficult to work with. If you notice that you are judging yourself for these biases take a moment to explore those thoughts or feelings. This may be a moment to practice self-compassion, and to forgive yourself for any biases or negative thoughts you may have harbored in the past.

3. Now think of one person who you have taken care of who is an example of the type of patient you have a tendency to be biased against. Bring to mind someone in this category of patients who you ultimately developed a connection with, and felt kindness and compassion towards. With this person in mind, say to yourself: “Just like me, XX is human. Just like me, XX wishes to be healthy. Just like me, XX wishes to be happy. Just like me, XX wishes to live a life of ease.” Feel free to use words that feel right to you, or to make this mantra into a prayer, keeping the basic intention of connecting with that persons’ common humanity and wishing them well.

4. Now think of a person who is a member of this group who you felt neutral towards. With this person in mind, say to yourself: “Just like me, XX is human. Just like me, XX wishes to be healthy. Just like me, XX wishes to be happy. Just like me, XX wishes to live a life of ease.” As always, feel free to use words that feel right to you, or to make this mantra into a prayer, keeping the basic intention of connecting with that persons’ common humanity and wishing them well.

5. Finally, think of a person who is a member of this group who you had difficulty connecting with. Perhaps they were angry, or seemed distant and cold. With this person in mind, say to yourself: “Just like me, XX is human. Just like me, XX wishes to be healthy. Just like me, XX wishes to be happy. Just like me, XX wishes to live a life of ease.” As always, feel free to use words that feel right to you, or to make this mantra into a prayer, keeping the basic intention of connecting with that persons’ common humanity and wishing them well. If you find yourself slipping away from compassionate feelings towards this person, just notice that, and move your thoughts back to the first person you thought of. Or you may bring your thoughts to another patient who you felt more compassion towards. The important thing is to end the exercise from a compassionate space.

6. As you close this excercise, think of a short phrase that you can use during your day-to-day professional practice when you are taking care of a patient who is a member of a group that you might have implicit bias towards, or who is “difficult” or “challenging”. My go-to expression is to say to myself, “This person is human, just like me. Just like me they want to be healthy. Just like me they deserve to be taken care of to the best of my ability.”

I suggest you practice this exercise more than once. I also suggest you do it while thinking about different populations or groups of patients. It is best to keep each session short, about 5-10 minutes in length.

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Building and Sustaining Compassion towards People who Refuse Help or do not Follow Medical Advice

As nurses, we have all encountered people who do not follow medical advice, who do not take care of themselves, and who continue to harm themselves even though we think they should know better. Perhaps they failed to follow their low sodium diet and have issues with recurring edema, dyspnea, and hypertension. Perhaps they didn’t monitor their blood sugar and have recurring problems with blood sugar control – and ultimately they need repeated amputations due to sores that do not heal. If you have been a nurse for any period of time, you have probably encountered patients like this. We may call these patients “noncompliant” or “frequent flyers.” Perhaps it is a friend or family member who does not seem to want to take care of themselves, who continually has relapses, and who rebuffs your efforts to help them.

It is easy to get frustrated with people who do not seem to take care of themselves, and to lose compassion for them. Their unwillingness to engage in their care might trigger feelings of anger, resentment or frustration – emotions which will shut off our compassion. We might feel less likely to want to help this person, or someone like them, in the future. If the patient is overtly hostile or rejects our help, practicing equanimity, can allow us to remain detached from their hostility and anger, and can help us to let go of any hurt we might feel from being rebuffed. From a place of equanimity and lovingkindness we can detach ourselves emotionally from their actions without checking out or becoming apathetic. Equanimity allows us to maintain compassion towards this person and makes us available to help them in the future if they decide they are willing to accept our help.

A seminal moment in my nursing education occurred when I witnessed an exchange between a young, white, male medical resident (I’ll call him Dr. Thoms) and an older, black male patient (I’ll call him Mr. Smith). This encounter occurred during the early 1980s, but I am sure that similar ones continue to occur. Mr. Smith was from a rural area in the southern part of the United States and had been referred to the large university-associated hospital where I was a student for diagnosis and treatment. In the incidnt that sticks vividly in my memory, Mr. Smith was sitting by his bedside, and Dr. Thoms and I remained standing throughout the encounter. Mr. Smith had been informed of his diagnosis (lung cancer) earlier and had decided he did not want further treatment. Dr. Thom’s goal was to get him to change his mind.

Dr. Thoms began by reminding Mr. Smith of his diagnosis and treatment plans. While the prognosis for the type of lung cancer that Mr. Smith had was poor, even with aggressive chemo (which has debilitating side effects), Dr. Thoms focused on the possibility that Mr. Smith’s cancer could be cured. When Mr. Smith repeated that he did not want treatment, Dr. Thoms said very emphatically (practically yelling), “Do you know that you are going to die! You are going to die if you do not get treatment.” After getting no response, he then left the room, without exploring palliative or hospice care, which admittedly was practically non-existent at that point in time.

I remember looking at Mr. Smith who was looking down and was very quiet. I was shocked and upset at the paternalistic and condescending way Dr. Thoms had talked to Mr. Smith. I gently asked Mr. Smith what he wanted. He said, “I just want to go home, sit by the river and fish.” He knew he was dying, and he wanted to do it on his own terms, in his happy place, with dignity. I then asked Mr. Smith if there was anything I could do for him right then, and he asked me to get him a pack of cigarettes (you could smoke in the hospital at that time, as long as you were not on oxygen, which he was not). Even though I was adamantly opposed to smoking, and knew it was the cause of his illness, I felt that buying a pack of cigarettes for him was the compassionate thing to do. They sold them in the hospital gift store at that time, so I went down there and got him his cigarettes!

The point of this story is not that we should give into patient’s addictions, I do not think I would get a person who is dying of alcoholism a drink, and if Mr. Smith had been dyspneic or on oxygen, cigarettes would have been very inappropriate. My purpose for telling this story is to give you an example of how our reactions to patients who do not want to follow our suggestions can really inhibit compassion. Dr. Thoms was obviously frustrated that Mr. Smith did not want the care that was being offered to him, and he behaved in absolutely the wrong way. However, even when we do not yell at patients, or overtly disagree with their decisions, we can feel frustrated by their decisions, and we may unconsciously communicate that to them. The following exercise will give you an opportunity to explore your feelings and reactions to patients, family or friends who refuse help.

EXERCISE: Exploring Our Emotional Response To People Who Resist Our Efforts To Help Them

This exercise can either be done alone or with a group. As always, if you do it alone I encourage you to write your responses so you can revisit them later. There are three steps to this exercise which can either be done at the same time, or as separate practices.

1. First think of a time when a patient, friend or family member refused your help. Keeping a curious and open mind about the experience, and your responses to it, take a note of the emotions or thoughts come to mind when you revisit this event.

• Are you judging the other person for refusing help? Are you feeling inadequate for not being able to help them?
• Did you feel some guilt, or relief when you were able to walk away from the situation? Name any emotions you are feeling, and if they are different from what you recall feeling at the time the event occurred, make a note of that.
• What might you do differently (if anything) today?

1. Nurturing Compassion: Depending on your comfort level with your group, you may want to do this part alone, but you can certainly do it with your group. In this step, you will be working on developing lovingkindness and compassion towards the person you identified in Step 1.

• Find your anchor, take some deep breaths, and close your eyes or soften your gaze When you are ready think to yourself, “(The other person’s name) is human, just like me. Just like me they want to be happy. Just like me they want to be healthy. Just like me they want to have a life that is free from suffering.” As you think these words, you may find yourself thinking something along the lines of, “if they want to be healthy, then why didn’t they follow the treatment plan.” If you get stuck here – think of a time when you did not want to follow medical advice, or when you did not want the help of a well-meaning friend or family member. If this does not help, then move to the next step, realizing that there may be some unresolved issues regarding this incident. It might help to talk this over with another person.

1. Practicing Equanimity - Letting Go of the Outcome: In this step I encourage you to honor your intention to help, and to let go of the outcome of your care and compassion. It may help to place your hands in a position with the palms upward – this signals letting go. Find your anchor again and take some moments to just breathe. With your eyes closed, or your gaze averted, acknowledge that you are a loving, caring compassionate person. Acknowledge that your help is not always wanted or needed. If you are a spiritual person, I invite you to give the situation over to a higher power. If that does not work for you, you might think about the concept of autonomy and that we all have our own lives to live, and paths to follow.

This is what I say to myself, “I am a loving, caring and compassionate person. I wish for XXX to be happy, healthy and free from suffering. I believe that my efforts are not needed or wanted at this time. I acknowledge that I cannot control the outcome of this situation (or any situation!). I honor myself for trying. I send my thoughts and prayers to XXX for recovery and healing. I turn this over to a higher power.” You may want to close the reflection by imagining your thoughts, intentions, and prayers flying away on the back of a dove, butterflies or soap bubbles. These images may help you cede control over the situation and may help you feel less frustrated.

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Communicating Compassionately with Patients

As the example with Dr. Thoms and Mr. Smith that I described previously in this chapter demonstrates, the way in which we communicate to patients can contribute to suffering. We may think we know what is the best course of treatment for them, we may think we are explaining their diagnosis in a clear and compassionate manner, and we may honestly think we are involving them in the conversation about treatment options. However, research studies indicate that patients often feel they are not heard, and that they were not really included in the decision making process (Reader, Gillespie, & Roberts, 2014). Patients have also reported actual conflicts and heated discussions with their healthcare providers (Reader et al., 2014). In this section I will briefly describe several techniques that you can use to build and grow your ability to engage in compassionate communication with patients.

In their book, Communication Rx, Chou and Cooley outline a relationship-centered approach that can be used to bring compassion and clarity when we communicate with patients. This approach allows the care giver to bring their expertise and values to the conversation while also honoring the patient’s experience, expertise and values (Chou & Cooley, 2018). The first step in this process involves setting the stage for effective communication. This involves establishing rapport with the patient (and their loved ones), listening to all of their concerns, and then negotiating a shared agenda. When patients or their loved ones have concerns that are beyond what you can address, make sure to also leave room for exploring how these concerns can be met at a later time, rather than merely dismissing them (Chou & Cooley, 2018). Compassionate communication also involves active listening, asking open-ended questions, making room for patients’ ideas and expectations, and responding with empathy. See Table 4.2 for an overview of Chou and Cooley’s PEARLS framework for communicating with empathy.

Table 4.2: Communicating With Empathy: The PEARLS Framework (Chou & Cooley, 2018)

Relational inquiry is another approach that nurses can use to explore and alleviate patient suffering in a compassionate manner (Younas, 2020). This approach, which is complementary to the PEARLS framework discussed above, calls for nurses to use appreciative inquiry, active listening, and a suspension of judgement when communicating. Appreciative inquiry involves looking for strengths rather than emphasizing weaknesses. When practicing active listening, the listener makes sure they understood what the other person is communicating.

Through the use of relational inquiry nurses can explore the interpersonal, intrapersonal and contextual factors that contribute to a patient’s experience of illness and suffering (Younas, 2020). Interpersonal factors are those which involve interactions between people and could include how a patients’ family and friends interpret the situation, the level of closeness between the various people involved, and their economic or social resources. Interpersonal factors are those which reside within the patient, and might include how they interpret their illness, their theology or world view towards suffering, and their experiences with similar types of suffering. Contextual factors are those which are outside the patient and include such things as the socio-economic status of the patient, their ability to access appropriate healthcare or other social services, as well as wider cultural or social views about illness, suffering and how to express compassion. It is important to keep in mind that while all people are capable of responding compassionately to the suffering of others, cultural differences may influence the way in which they respond (or in which they want others to respond) to suffering (Koopmann-Holm & Tsai, 2017).

Relational inquiry is built on the premise that we should never assume that we know why a person is suffering (Younas, 2020). I remember taking care of an elderly woman (Meg) who had just received a diagnosis of terminal cancer. She was understandably upset, and I assumed it was because of her diagnosis. On further inquiry, Meg said she was not afraid of dying (an intrapersonal factor) and had witnessed the peaceful passing of friends and family members (interpersonal factors). She said she had a good support system which could provide her hospice services at home (interpersonal factors). However, she was very concerned about her adult child, who was developmentally delayed and dependent on her for care (interpersonal and contextual factors). Worry about his future was causing her considerable suffering. While we were unable to fully resolve the issue before she was discharged to hospice, bringing this issue to light enabled us to start a conversation with Meg’s support system, and to activate social services who began the process of finding a care home for Meg’s son.

Organizational Barriers to Providing Compassionate Care

Organizational constraints are a major contextual factor which can influence your ability to provide compassionate care. Globally, many healthcare organizations have moved towards a very transactional model of care, which is a barrier to the ability of nurses to provide compassionate care (Iles, 2016). In the transactional model, healthcare is seen “as a set of auditable transactions in the market economy” (Iles, 2016, p. 161), and patients are viewed as consumers of healthcare who are cared for, not cared about. In contrast, a compassionate model of healthcare involves a relationship between the caregiver and the recipient of care (Iles, 2016). In the transactional model, the emphasis moves from creating a meaningful patient-provider interaction which contributes to healing and the alleviation of suffering to creating an efficient, streamlined encounter (Iles, 2016; Rydon-Grange, 2018). An emphasis on efficiency leads to a focus on routines and standardization of care through care plans or pathways, rather than a focus on individual patients and their unique needs. This model of healthcare delivery creates time constraints that severely limit a nurse’s ability to take the time to engage compassionately with patients (Babaei & Taleghani, 2019; Singh et al., 2018).

While you are not able to change the societal factors that are pushing organizations towards a transactional model of healthcare (indeed organizations themselves cannot change many of these factors), being aware of them is important. In Chapters 5 and 6 I will discuss how staff nurses and nursing leaders can work to reduce organizational barriers to compassionate care. In the next exercise, I invite you to reflect on factors within your organization that make it difficult for you to consistently provide compassionate care, and to identify ways to overcome these barriers.

EXCERISE: Identifying Organizational Barriers to Compassionate Patient Care

This exercise may be more impactful if it is done with co-workers. This will enable you to work on ways you can change the barriers that are within your control. You can also help each other figure out ways to provide compassionate care in the presence of barriers you cannot change.

1. On a sheet of paper make three columns. In the first column, write 2-3 organizational factors that create a barrier to the provision of compassionate care. There may be more than 2-3 barriers that you think of, but since it can be overwhelming for us to face multiple obstacles, just start with the ones that seem to be the biggest issues. For example, you may be short-staffed which has created some limitations to the amount of time you can spend with each patient.

2. In the second column, write a short-term solution for each problem. In the above example, a short-term solution might be looking for small acts of compassion that you can fit into your schedule. For example, when you are doing an initial assessment with a patient, take a moment to ask them what their priority is for the day. Or, ask them a question like, “what is one thing that I should know about you so that I can provide you the best possible care?” Small moments like that can help our patients feel seen and respected.

3. In the third column, write a long-term solution to the problem, and one idea for bringing this idea to fruition. Dream big! Even if you have never been fully staffed, or if every time you have asked your manager to change your patient-nurse ratio you have met with opposition, write this idea down if you believe it is truly the solution to the problem. Also think of some ways to bring this idea to reality. Perhaps you need to enlist the help of other nurses to convince management to change your nurse-patient ratios, perhaps you need to recruit some nurses to come work on your unit if you have open positions that have not been filled.

4. Lastly, spend a few moments imagining what your practice setting would look like with no, or very few, barriers to compassionate care. Discuss your vision with your group, or if you are working alone, take a few moments to write about it.

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Conclusion

In this chapter I offered some concrete ideas on how nurses can show compassion for patients. I discussed how to identify suffering, how to build your distress tolerance and how to communicate compassionately. I also discussed how biases, negative experiences with people who did not accept our help, and organizational contexts can block compassion. I hope that the exercises that accompanied this chapter will help you build and sustain your compassionate nursing practice. Developing compassion for everyone, everywhere, in all occasions is a life-long endeavor. I hope that you will return to these exercises more than once as you continue on your journey.

Key Takeaways From Chapter 4

• Learning about different models of compassion can help us build our repertoire of compassionate behaviors. One model of compassionate communication suggests that it consists of the subprocesses of recognizing, relating and (re)acting to suffering. Another model says that compassionate care involves attentiveness, listening, confronting, involvement, helping, presence, and understanding.
• An understanding of how people cope with suffering, both in healthy and counterproductive ways, can enhance our ability to care for them, and can increase our distress tolerance. Suffering may manifest as enduring or emotional suffering, and a different response is needed for each state.
• We naturally feel more compassion for people who are like us. We may also feel less compassion for people who are similar to other people who we have had difficult encounters with in the past. Mindful awareness and the cultivation of lovingkindness can help us move past these innate biases.
• Relational Awareness and Relational Inquiry are approaches to patient-provider encounters that can help us communicate with compassion.
• Organizational barriers can block our ability to provide compassionate care for patients. Nurses should work together to find solutions to these barriers.

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