Introduction

“Compassion enables us to look at suffering in all its tortuous varieties without succumbing to despair.” (The Dalai Lama – In Praise of Great Compassion) 

Compassion is seen as one of the fundamental qualities of humanity. Many of the world’s major religions have teachings related to compassion. Thomas Aquinas, a Christian theologian who lived in the 1200s said that compassion was the greatest of Christian virtues, and that the practice of compassion brings humans closer to God (Ryan, 2010). Within Islam, one of the names for God is Rahim (compassionate and merciful), and adherents of this religion are expected to display compassion and mercy to all living beings (plants, animals and humans) (Alharbi & Al Hadid, 2019). Likewise, early Judaic teachings reference compassion, and offer instructions on how to act with compassion towards the sick, the poor, and others who suffer (Käppeli, 2008). Compassion is also a part of Eastern religious and philosophical traditions, such as Confucianism and Buddhism. In writing this book, I drew heavily on the teachings of The Dalai Lama, a Tibetan Buddhist spiritual leader. However, I do not favor any one religion, nor do I think that religious or spiritual belief is necessary to the development of compassion. As you read this book and do the exercises, I invite and encourage you to adapt and modify them in a way that works with your world view.  

It is interesting that spiritual writings on compassion not only view it as a virtue, but they also write that it is a path to happiness and well-being for the practitioner of compassion. The Dalai Lama writes, “Expanding our focus to care about others alleviates...unhealthy self-preoccupation and enables us to connect better with others...To be happy ourselves, we have to care about the welfare of others” (The Dalai Lama & Chodron, 2017, pp. 160-161). Science also supports that when we feel compassion towards others, we experience benefits to our own health. In Chapter 1, I will explore findings from neurobiology that support the notion that caring for others with compassion is beneficial to the health of the care giver.  

Evolutionary biologists view compassion as the glue that holds humanity together. Compassion helps us take care of our infants in the middle of the night when we would rather be sleeping. It helps us take care of our elders at the end of their lives. It helps us live in cooperative societies in which we share resources with others, and care for others when they are sick or incapacitated. Research indicates that humans are hard wired for compassion, but there are limits to our innate ability to be compassionate. In ancient times, humans lived in family units, or in small communities, and often competed for resources with other groups of humans. Out of a need for survival, we naturally felt anger and aggression towards these “other” groups.  

In modern times, we have become a global community. Warfare and competition still occur, but increasingly most people recognize the need for global cooperation so that humans can continue to survive and thrive on this planet. Additionally, most of us live in cities, or at least in larger communities than our ancestors did. We live with a lot of people we will never meet, and because of patterns of migration, many of the people we live near and interact with seem different than us on the surface (e.g., cultural and language differences or differences in skin color). While we can feel compassion towards people who are different than we are, towards those who are not family, and towards those who we have never met, this compassion can be thwarted by our brain’s tendencies to classify people into “us” and “them,” especially if we have been conditioned to see differences as threatening. In Chapter 2, I will discuss how we can nurture feelings of lovingkindness to all people. In Chapter 4, I expand on this concept and discuss how to overcome biases so we can provide compassionate care for all patients.

While the ability to act with compassion is hard wired into the human brain, it can be either enhanced or suppressed by our upbringing and by our society. We first learn to be compassionate from our parents and those who cared for us when we were infants and children. People who experienced abuse, neglect or trauma in childhood may have a harder time acting with compassion. People whose parents or society taught them that compassionate responses to suffering were a sign of weakness and could be detrimental to one’s own long-term survival and success, will have a harder time acting with compassion towards themselves and others. However, the human brain is malleable, and patterns of behavior and thought can be changed. Research shows that compassion is a learned response, and that even adults can be trained (in relatively short periods of time) to be more compassionate. Throughout this book there are exercises you can do to improve your ability to respond with compassion.

Compassion is an integral part of nursing practice. However, a review of the literature on compassion found that it is an ill-defined concept in nursing, and there is no evidence that nurses are specifically being taught how to be compassionate (Ledoux, 2015). In Chapter 7, I will discuss how nursing educators can bring compassion into their teaching practices and how they can more deliberately teach new nurses how to practice with compassion.

As nurses, we care for people who are in various stages of suffering, most of whom were strangers to us when we first encountered them. We may develop relationships with some of our patients in time and come to think of them as friends or family, however, given the limited time we have with patients, this is not always possible. Therefore, we need to learn how to interact with compassion towards relative strangers. In the western world, care for sick people outside of the home was originally done in religious communities by nuns and monks as part of their ministry of compassion (Käppeli, 2008). This tradition led to the formation of formal hospitals, and the profession of nursing. Florence Nightingale, whose writings became the basis for nursing as a formal profession, built on this tradition when she stated that “nurses must strive to alleviate suffering through acts of compassion” (Straughair, 2012, p. 161). 

Today, the concept of compassion can be found in ethical statements of various nursing organizations. The American Nurses Association’s Code of Ethics states in Provision 1 that: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.” (American Nurses Association & Fowler, 2015, p. v. Likewise, the International Council of Nurses’ Code of Ethics (ICN, 2012) says nurses should embody “professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity (p. 2).” Other nursing organizations such as the Canadian Nurses Association and the United Kingdom’s Nursing and Midwifery Board include discussions of compassion in their code of ethics. I encourage readers to examine the code of conducts or value statements of professional organizations to which they belong to see if compassion is included in these statements.  

Several nursing theories, also include the concept of compassion. It is beyond the scope of this book to discuss these in detail; however, I want to briefly mention several particularly salient theories. Dr. Jean Watson states that caring - as opposed to curing, which is the provenance of medicine - is central to nursing practice. Watson’s Human Caring Theory says that nursing care manifests as the “practice of loving-kindness, compassion and equanimity with self/others.” (https://www.watsoncaringscience.org/jean-bio/caring-science-theory/). Note that equanimity, or the ability to maintain a calm mental and emotional state no matter the external circumstances, is part of Watson’s definition of caring. Equanimity is an important quality which can protect the nurse from compassion fatigue and moral distress, and techniques for enhancing equanimity will be discussed in Chapter 2. 

Georges’ (2013) Emancipatory Theory for Compassion in Nursing builds on Watson’s work by stating that “compassion is an essential element of nursing and that persons in the biopolitical spaces in which nurses practice are at an enhanced risk for increased suffering when power relations render compassion impossible (p. 8). Georges (2013) argues that “when compassion disappears, we are no longer nurses” (p. 7). Georges’ theory takes into consideration the power relations and social structures (e.g. sexism, racism, ableism) that contribute to suffering for both patients and nurses, and which impede the expression of compassion. These elements will be discussed in more detail throughout the book. It is important to recognize that individual efforts to increase compassionate care face an uphill battle unless they are accompanied by systemic support. Throughout Section II of this book, I will explore some of the departmental and organizational level elements that can make it difficult for nurses to provide compassionate care and to interact with compassion towards each other.  

I want to take a moment to acknowledge that while compassion might be at the core of nursing, this is not to suggest that technical know-how is secondary. A thorough understanding of the technical side of nursing and providing expert-level care that is error-free are both essential elements of compassionate care. Care that is done without expertise or rigor is not compassionate. On the other hand, technical care without compassion may have limited ability to help patients and families heal. Unfortunately, very little consideration is given to teaching or cultivating compassion in nursing students or in practicing nurses. In fact, some authors have argued that nursing education has actively discouraged compassion, instead teaching that nurses need to remain emotionally distant and detached from their patients (Schantz, 2007). In Chapter 7 I will explore how nursing education can be conducted with greater compassion and will also explore some ways in which nursing educators can help their students build compassion.  

Before we go any further, I want to clarify that I do not believe that people need to feel “called” to go into nursing as a profession. I assume that all nurses have some degree of desire to care for and help others, but there are many reasons that people choose to pursue nursing as a career and seeking stable and gainful employment is a perfectly valid reason. Even though nursing practice is based on the concepts of caring and compassion, I firmly maintain this should not be used as an excuse to exploit nurses. Nurses are vital parts of the healthcare team (can you imagine any healthcare facility which is staffed only with doctors, and not nurses?), and as such should be compensated fairly and equitably. Furthermore, they should not be asked to make sacrifices that are detrimental to their health and wellbeing – for example, asking them to repeatedly work mandatory overtime, asking them to work long hours without breaks or pressuring them to come to work on their days off. In Chapter 6, I explore what nursing leaders can do to compassionately create work environments that allow staff to flourish.

Whatever brought you into the profession of nursing, it is a given that you will be exposed to suffering, and some of this suffering will be difficult to alleviate with technical skills alone. When we are faced with suffering we cannot alleviate, there is a risk that we will experience burnout, compassion fatigue or secondary traumatic stress. I briefly discuss these concepts in Chapter 8. Some of the situations you will encounter might challenge your core beliefs and threaten your view of humanity. Resilience and self-compassion are necessary skills for nurses to survive and thrive in the nursing profession. In Chapter 3, I discuss self-compassion and self-care as a preventative to compassion fatigue, burnout, secondary traumatic stress and vicarious trauma.

I still have a vivid memory of one of the first times I had to come to terms with suffering and mortality. This incident happened during my senior year of nursing school – I was in my early 20s and had not witnessed a lot of illness, and certainly had never been in the presence of someone who was dying. It was in my community health clinical rotation. We were assigned patients who were receiving home visits through a local clinic, and our task was to do a needs assessment. I had been trying to reach one of the patients who I was assigned to visit (I will call her Hilda), but for several weeks no one picked up the phone when I called her house. (This was during the early 1980s when few people had answering machines). I remember thinking, I will try one more time before I give up, and this time Hilda’s daughter (I’ll call her Pat) answered. Pat said that her mother had been in the hospital and had been diagnosed with terminal cancer. There were no more treatment options for her, so Pat brought Hilda home for her last days. Pat said that she was not sure what I could do for her mother since they had home care set up, but she would be happy to have me visit if it would help my education.    

We arranged up a date and time for me to visit. When I got there, Hilda was in a hospital bed in the living room of Pat’s house. She was minimally responsive, and honestly, I do not remember talking with her at all. I went through the assessment form we were supposed to complete for school, and when I got to the part about nutrition, I asked Pat what Hilda was eating. “She is not eating; she gets her meals through the IV.” I have a vivid memory of looking at the IV (which was just dextrose and saline, not TPN) and thinking, “that’s not enough to sustain her”! I was on the brink of saying that when Pat shook her head and silenced me. I do not remember the rest of the visit, but what I do remember is driving around for a long time afterwards while I tried to process the incident. Even though I knew people died, and that withholding treatment and letting nature run its course was often the option. What I came to realize that it was also the most compassionate thing to do. However, I had never been in the presence of someone who was in their final days, and there was not much emphasis in my training on palliative or hospice care. I think I was also shocked that Hilda was not fully informed that she was dying, and that she thought that the IV fluids were keeping her alive (they actually may have been prolonging her life). Intellectually, I knew people died, and I also supported a dignified death at home, but as a 20-year-old, this was the first time I had come face to face with the mortality of humans, and it took me awhile to process this. In this situation, I needed some skills in compassion, and in self-compassion, but had not been taught any in my nursing program.

Throughout my career as a staff nurse, I have witnessed many other instances of suffering and death, some of which have affected me more than others. I vividly recall some of them, the death of a young parent, the death of a young adult child, a sudden unexpected death (after a lengthy code), or a death after a lengthy and painful illness. I have also taken care of people who have experienced immense pain – both physical and mental – that medicine has not been able to alleviate. Exploring these incidents through a spiritual, philosophical and moral lens helped me keep practicing as a nurse and helped me retain my compassion towards those in need. I am sure that all the readers of this book have had similar situations in their professional and personal lives, and it is my hope that this book helps you process your feelings, helps you heal your heart, gives you the strength to continue to provide compassionate care to your patients and their loved ones.  

How to read this book

I have designed this book to be interactive. I feel you will get the most out of it if you take the time to do the exercises. If you like to journal, I suggest you start a compassion journal. Or, you may just add your thoughts on the exercises to an existing journal. If you do not like to write, it is perfectly fine to just think about the answers to the exercises. Perhaps you might say them aloud, to yourself or another person. Which brings me to my next point: working through this book with another person, or a group of people (for example your co-workers) is a great way to add more depth to the exploration of compassion. It is also a great way to create a community of mutual support.  

Some of the exercises involve meditation and creation of a mantra. These are designed to be secular mediations, but please feel free to incorporate your spiritual practice into the reflections. While it is not appropriate for us to impose our spiritual beliefs on our patients, it is very appropriate for us to use them to help us grow our compassionate nursing practice. So, if I suggest that you practice loving-kindness by saying quietly; “may all beings have happiness and be free from suffering” – feel free to change this to something like: “God, please grant happiness to all your creatures, and release us from suffering.” As I stated in the introduction, compassion is a component of all the major religions, and I have tried to make this book accessible to all nurses, regardless of their spiritual beliefs.  

If you are reading this book with others, you may prefer to do the meditation and visualization exercises alone, then discuss them with the group. I for one have a harder time getting deeper into meditation when with a group, but some people actually meditate better with others. Figure out your personal preferences. I suggest you pick a quiet spot where you can do the exercises. Going back to the same spot each time, and adopting the same posture helps prime your body and mind to engage in quiet reflection. That being said, you may find you need to experiment a bit to find the optimal spot and posture.  

Do not feel you have to do every exercise or read every chapter in this book. Some sections or exercises may not resonate with where you are in your career. However, you may want to skim them, and come back to them later if your career path takes you in a new direction. Finally, I hope that you will return to the exercises and this book periodically. None of the exercises are meant to be “one and done.” Just as you cannot do push-ups once and build muscle strength, much less maintain it for very long, to get the most benefit from the exercises in this book, you will need to revisit them periodically. Learning to be compassionate towards everyone you meet, and to tap into compassion at will is a life-long endeavor, and one that requires constant practice.

EXERCISE: Towards a personal definition of compassion

Before you read further, I invite you to take a few minutes to examine what comes to mind when you think about compassion. If you like to journal, perhaps you will write down your answers to the questions I have listed below. I invite you to start a dedicated journal for your compassion practice. Throughout the book there will be exercises that will allow you to practice consciously activating compassion and loving kindness, and it might be interesting to you to explore how your thoughts and feelings change as you read the book. You may also be reading the book with others, if so, you may use these exercises as discussion points.  

As you start this exploration of compassionate nursing practice, I invite you to keep an open and non-judgmental mind as you explore the following prompts:  

• What is your definition of compassion? Of empathy? Of loving-kindness? 
• What does compassionate nursing practice mean to you? How does it manifest in your actual practice?  
• How do you think your interactions with patients, their families and your co-workers might change if you are able to practice with compassion?  
• You may experience some internal resistance towards developing your compassionate side. What are some of the negative outcomes that you think might happen if you become more compassionate?  
• Finally, what motivated you to pick up this book? Think about what you want to get out of it and set an intention to carve out the time to read it and to work through the exercises. 

As you move through the book, I invite you to revisit your thoughts on compassion from time to time. Make a note on how your thinking has changed (or not), and how your ability to show compassion in your personal and professional life has changed.  

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About me 

I envision this book as a conversation between me and you, the reader. Therefore, it is important for me to introduce myself. I am currently a tenured Associate Professor at The University of Washington Tacoma (UWT) in the School of Nursing and Healthcare Leadership. The year I wrote this book was the year in which I turned 59. I am a white, cis-gender female who has been married to the same person for over 30 years. I have two grown children and one dog. My hobbies are camping, doing triathlons, reading, bird watching and doing crossword puzzles. I occasionally dabble in gardening, but generally am unable to find enough time to keep the weeds in check! 

I began my nursing career in 1986 after graduating from the University of North Carolina Chapel Hill. I already had a degree in biology from Oberlin College (graduated in 1984), and my initial motivation for entering nursing school was to become a nurse practitioner. However, having children and being in a geographical location where there were no nurse practitioner programs (this was way before online education!) meant that I deferred this dream. As many nurses did in the 1980s, I started my career on a general medical unit. I had brief stint as a staff nurse at a psychiatric and chemical dependency hospital but left after a few years because I did not like the fact that the hospital operated on a for-profit model. I returned to general medical inpatient care, moved, and ended up at a hospital and on a unit that was my work home for about 20 years. Over time, the unit morphed into a medical-surgical oncology unit, and I gained experience caring for a diverse set of patients. During my career as a hospital staff nurse, I always worked the evening shift, but alternated between working full-time, part-time and on call, depending on the needs of my family.  

As my children grew and the demands at home lessened, I realized that I was ready to move on in my career.  I decided that I was no longer interested in becoming a nurse practitioner, so I enrolled in UWT’s Master of Nursing program with the intention of going into nursing education. While pursuing my MN degree, I became interested in the topic of workplace bullying, and for my final project conducted a small study exploring the experiences of emergency nurses with workplace bullying. I became interested in continuing to do research on this topic and decided to pursue a PhD in nursing.  

Immediately after finishing my MN program, I enrolled in the PhD in nursing program at the University of Washington Seattle campus. Through a NIOSH (National Institute of Occupational Safety and Health) educational grant, I was able to continue my research on workplace bullying. I also started working as a part time instructor at UWT – teaching in their baccalaureate nursing program (BSN). After 5 long years, I finished the PhD program and was offered a tenure-track position at UWT. At UWT I have continued to do research on workplace bullying among nurses. My research, and that of others, has convinced me that workplace bullying is a complex problem, with deep roots into the culture of nursing, that does not lend itself to easy or facile solutions such as just developing a zero-tolerance policy. As I contemplated how the culture of nursing might be changed, I became attracted to the idea of developing a more compassionate leadership culture within nursing. This led me to the work of the Center for Compassion and Altruism Research and Education (CCARE) at Stanford University. It turned out they were offering a 10 month Applied Compassion Training (ACT) program that aligned perfectly with my planned sabbatical. (For those of you who are unfamiliar with the concept of a sabbatical – it is a period of time that universities grant to tenured professors to focus solely on their research or other scholarly interests.) As part of the ACT program, participants are asked to complete a capstone project, and upon successful completion of the program, they are granted the title of “Ambassadors of Compassion.” Writing this book, and conducting some workshops where I shared some of the material in this book, were my capstone project for the ACT program.  

 In the process of developing this book and other materials, I expanded my intended audience from nursing leaders to anyone who is working in the nursing profession. Having worked as a staff nurse for over 20 years, I know that learning how to consciously cultivate and activate compassion is a valuable skill. A more compassionate workforce should be more likely to treat each other with respect, which should help lessen the incidence of workplace bullying. Compassion training can also help mitigate other issues, such as burnout, compassion fatigue and moral distress. Furthermore, I know that the process of educating nurses is not always imbued with compassion. It is my hope that readers of this book will learn how to teach the next generation of nurses with compassion, while still upholding exacting standards of practice.   

I do want to emphasize that I do not believe that individual level interventions will resolve all of the issues that plague healthcare. Modern organizations everywhere seem to be asking more and more from workers, while giving them less and less. Attitudes that view workers as an expendable human resource need to change. The expectation that we can continue to do more with less institutional support needs to change. My hope is that by contributing to a culture of compassion in nursing, this book can be one small step on the road to creating more compassionate healthcare organizations (as well as more compassionate schools of nursing).  

Finally, I need to acknowledge that this book was written during the height of the COVID-19 crisis. During this time, the world saw acts of great compassion, but also of division, dissent, and incivility (and even violence). Nurses have been both revered and reviled during the COVID pandemic. Our societies and healthcare organizations asked much of the nursing profession and gave little in return. My hope is that this book is a small step in the healing process for those readers who need it.  

Acknowledgements 

First and foremost, I would like to thank the people at CCARE who offered the ACT program. In particular my mentor, Monica Hanson, but also the other program facilitators - Robert Cusick and NeeIama Eyres. I would also like to thank the members of the small mentoring group who gave me a lot of support and encouragement, as well as the other members of the ACT program who always showed up with compassion and a willingness to engage openly and honestly on the journey.

I would like to acknowledge UWT’s School of Nursing and Healthcare Leadership for giving me two quarters of sabbatical to complete the ACT program.

My dog Bailey has been a constant companion in the process of writing this book. He spends most of his day on his bed in the study in which I work, and periodically reminds me that it is time to take a break to go on a walk. Finally, I would like to thank my husband, Mark Maurer for his support and encouragement for each new project I take on.

References

 Alharbi, J., & Al Hadid, L. (2019). Towards an understanding of compassion from an Islamic perspective. Journal of Clinical Nursing, 28(7-8), 1354-1358. https://doi.org/10.1111/jocn.14725

American Nurses Association, & Fowler, M. D. M. (2015). Guide to the code of ethics for nurses with interpretive statements: Development, interpretation, and application (2nd ed.). American Nurses Association.

Georges, J. M. (2013). An emancipatory theory of compassion for nursing. Advances in Nursing Science, 36(1), 2-9. https://doi.org/10.1097/ANS.0b013e31828077d2

Käppeli, S. (2008). Compassion in Jewish, Christian and secular nursing. A systematic comparison of a key concept of nursing (part I). Journal of medical ethics and history of medicine, 1, 3-3. https://pubmed.ncbi.nlm.nih.gov/23908713

The Dalai Lama, & Chodron, T. (2017). Approaching the Buddhist path. Wisdom Publications.

Ledoux, K. (2015). Understanding compassion fatigue: Understanding compassion. Journal of Advanced Nursing, 71(9), 2041-2050. https://doi.org/10.1111/jan.12686

International Council of Nursing (2012). The ICN code of ethics for nurses. https://www.icn.ch/sites/default/files/inlinefiles/2012_ICN_Codeofethicsfornurses_%20eng.pdf

Ryan, T. (2010). Aquinas on Compassion: Has he something to offer today? Irish Theological Quarterly, 75(2), 157-174. https://doi.org/10.1177/0021140009360496

Schantz, M. L. (2007). Compassion: a concept analysis. Nursing Forum, 42(2), 48-55. https://doi.org/10.1111/j.1744-6198.2007.00067.x

Straughair, C. (2012). Exploring compassion: Implications for contemporary nursing. Part 1. British Journal of Nursing, 21(3), 160-164. https://doi.org/10.12968/bjon.2012.21.3.160