Chapter 7: Building and Sustaining Compassion in Nursing Education and Mentorship

Compassionate nursing practices should be taught in a deliberate manner from the beginning of nursing education, throughout the transition to practice and beyond. Building and sustaining compassion through educational practices means new nurses need to be taught, mentored, and oriented to their new positions in a compassionate manner. Nurses need to learn how to demonstrate compassion, and they need to learn how to sustain compassion. They also need to be taught about systemic issues and practices that inhibit compassion (which we have explored in previous chapters), and how they can work together to change the system. This chapter will provide a starting point for nursing educators, from the classroom to the clinical setting, to explore how to teach nurses to incorporate compassion into their nursing practice, as well as how to teach in a manner that is compassionate and caring. I will start by explaining why compassion needs to be an explicit part of the curriculum, and how suffering shows up in educational settings. I will also discuss how compassion can be incorporated into curricula and lessons, and how nursing faculty and educators can build and sustain compassionate relationships with each other, and with their clinical partners.

The Imperative for Compassion in Nursing Education

The problems of bullying and incivility are one indicator that nursing education needs an infusion of compassion. Nursing schools struggle with issues of incivility and bullying, both between students and faculty, and from faculty to students (Clark, 2013). Similarly, new nurses often face workplace bullying at the beginning of their careers (Berry, et al. , 2012). While supportive colleagues and formal mentoring programs can buffer the effects of workplace bullying (Rush, et al., 2014), there are instances where the perpetrator of bullying is the nurse who has been asked to train and support these new nurses (Topa, et al., 2014).

While compassion is a value that is championed by nursing organizations and written into professional codes of conduct, few nursing scholars or educators have written about how to model compassion in the classroom and in clinical educational settings, or how to teach and mentor in a compassionate manner (Jazaieri, 2018). Indeed, the concept of compassion has never been an explicit part of the curriculum of most nursing schools (Jazaieri, 2018; Younas & Maddigan, 2019). However, that may be changing as healthcare organizations and nursing professional organizations are beginning to highlight the need for an explicit discussion of compassion in nursing (Younas & Maddigan, 2019). The American Association of Colleges of Nursing (AACN, 2021), which sets standards for curriculum for nursing education in the United States, has recently released new competencies that all nursing students (graduate and undergraduate) need to meet. One of the core competencies that AACN (2021) says all nurses need is the ability to provide person-centered care, which they define as “holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriate” (p. 10). They go on to say that entry level nurses need to “demonstrate compassionate care” (p. 29) and “facilitate health and healing through compassionate caring” (p. 50), while advanced level nurses need to “foster caring relationships” (p. 29).

In order to teach students and new nurses how to provide compassionate care, and how to “foster caring relationships” with people they may not automatically feel connected to, educators themselves need to possess these skills. They also need to have the ability to teach in the both the affective and cognitive domains (Younas & Maddigan, 2019). Most educators are more comfortable teaching cognitive and psychomotor skills, and struggle to prepare nursing students for the emotional aspects of their future career (Dwyer & Hunter Revell, 2015).

Nursing educators do not just pass on knowledge to students, they also serve as professional role models. In order to instill the value of compassion in new nurses, they also need to model compassion and caring in their interactions with students. Unfortunately, students often report that their instructors were authoritarian, unsupportive, uncivil, and lacking in compassion (Holtz, et al., 2018; Zhu, et al., 2019).

As I have discussed earlier in this book, in order to act with compassion, we first must recognize suffering. Before I discuss how students suffer, I will outline some of the effects of stress and trauma on learning. Then I will discuss some of the common sources of suffering for nursing students, new nurses, and nursing educators. I will then discuss ways in which educators can respond with compassion to this suffering, how they can create healthy boundaries that prevent them from becoming too enmeshed in their students’ lives, and how educators can support each other. Before reading any further, I invite you to explore your own experiences with and thoughts on compassion and lovingkindness in education by completing the following exercise.

EXERCISE: Exploring your Thoughts and Experiences on Compassion and Lovingkindness in Education

You can either do this exercise alone, or in a group. If you do it in a group, I suggest you each take some time to write your answers to the following prompts on your own, and then share what you feel comfortable sharing with each other.

1. In this exercise, I will invite you to think about your own experiences in nursing education – those which were exemplars of compassion and lovingkindness, and those which were not. Revisiting negative experiences can trigger feelings of distress, trauma or unworthiness. Therefore, before you start this exercise, take a moment to find your anchor and tap into your inner strength. You may wish to focus on your breathing for a few moments, to remind yourself to come back to your breath when negative emotions arise. You may wish to imagine that you are wrapped in a warm blanket of loving and supportive energy. If you start to feel anxious, or your heart starts racing and your breathing becomes shallow, remember that the events you are bringing to mind happened in the past, and while they still may cause some emotional distress in the present, they are in the past. Right now, you are in the present, and you are safe.

2. From this space of lovingkindness and self-compassion, think back to your journey as a student. While there may be several instances where you felt a lack of compassion or lovingkindness, or where you felt an overwhelming amount of stress, just pick one incident. As you recall this event, bring your focus on your emotions and physical sensations. Name the feeling(s) that are arising. What physical sensations are accompanying those feelings? Once you have named the feelings and identified the physical sensations, reconnect with your breath, your anchor and your feeling of warmth and support.

3. Next take a moment to reflect on your experience as an educator – are there times when you sense that your students or mentees are experiencing similar emotions, or are stressed? How does that manifest behaviorally? What is your typical response to these incidents? Keep an open, curious and non-judgemental mind – the goal of this exercise is to open your awareness, not to identify ways you could have, or should have responded differently.

4. Now think of a time when you experienced compassion, lovingkindness, or support in your journey as a student. The source of support, compassion or lovingkindness may have been a teacher or mentor, it may have been a friend or family member. Or perhaps it was a staff person who was associated with the school. For one friend, her support person was the barista who made her coffee before class. Again, notice your emotional response, and name the feeling(s). What physical sensations do you notice?

Once you have named the feelings and identified the physical sensations, reconnect with your breath, your anchor and your feeling of warmth and support. Notice if it is easier to reconnect to a feeling of warmth and support after remembering a kindness or act of compassion. (Some people have a fear of compassion because they have been taught to be tough, and if these memories trigger negative feelings in you, just notice that and explore it at a later date. The Compassionate Mind Workbook by Chris Irons and Elaine Beaumont is a great resource if you feel like there are blocks to your ability to accept compassion.)

5. Again, take a moment to reflect on your experience as an educator – are there times when you sense that your students or mentees have had similar emotional responses to acts of compassion? How does that manifest? What is your typical response to students when this occurs? Keep an open, curious and non-judgemental mind – the goal of this exercise is to open your awareness, not to identify ways you could have, or should have responded differently.

6. Finally, I invite you to explore your overall experiences in formal education. You might want to think of your educational journey in segments. For example: early childhood (K-8), high school (-12), pre-nursing, nursing school, transition to practice, and graduate school (if applicable). Were there parts of your educational journeys that were more compassionate and supportive than others? If so, how did that affect your learning? What specific behaviors did your teachers exhibit that were supportive and kind? What specific behaviors felt non-supportive?

7. You may want to end this exercise with some cleansing breaths and a self-compassion mantra or prayer if you are experiencing residual feelings of distress or unease.

8. Finally, if you are working with a group, I invite you to share your reflections with others. How might you use your own experiences in education, both positive and negative, to change your current practice as teachers and mentors? How might these experiences help you understand your students and what they are going through and their behaviors?

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The Effects of Stress and Trauma on Learning

In order to understand some of the suffering that students experience, and also to underscore the need for compassionate educational practices, I want to provide a brief overview of the effects of stress and trauma on learning. Nursing students have consistently reported moderate to high levels of stress, anxiety and depression during their nursing education (Bhurtun, et al., 2019; Labrague et al., 2017; Spurr, et al., 2021). Sources of stress include learning new material, interactions with patients and nursing staff, fear of making mistakes, and incivility or bullying from peers, nursing staff and professors (Clark & Springer, 2007; Labrague et al., 2017). Stressors and negative experiences have caused an increasing number of nursing students to drop out of school, exacerbating ongoing global nursing shortages (Bakker et al., 2019). New nurses have also reported being bullied, and not receiving adequate support and training, both from staff nurses and from nurses who were assigned to be their mentors or preceptors (Topa et al., 2014). Stressors, incivility, fear of making mistakes, and harsh grading are all impediments to learning. Research consistently supports the notion that, “the best learning occurs in the context of safe, caring relationships” (Lavelle, et al., 2017). Compassionate educators must do more to improve the learning environment for students and new nurses.

The effects of stress on memory encoding (learning new materials) and retrieval of information (application of learning) are complex. Stress that occurs a long time before a student is exposed to new information can impair learning, whereas a mild stressor that occurs shortly before or shortly after a student is exposed to new information can actually enhance memory formation (Vogel & Schwabe, 2016). Stressors can also block the retrieval of recently learned information, and the integration of this information with what the learner already knew (Vogel & Schwabe, 2016). Imagine a scenario where a new nurse just learned about what to do if a patient has an anaphylactic reaction. It is quite possible that if this information has not been integrated into their repertoire of responses, (in other words if they have not activated information retrieval systems to apply this learning), and the nurse’s stress system is activated when they encounter an anaphylactic response in “real life,” they may forget everything they learned about how to manage anaphylaxis. In this scenario, an outside observer might think this nurse is not competent, or does not have the proper knowledge, while in reality their reaction to stress has blocked their ability to apply this learning. In highly stressful situations, new nurses need steady, compassionate support from experienced nurses which can help them to put their knowledge to practice. This type of support will consolidate their “book” learning and allow them to apply it to similar, as well as novel, situations in the future.

Patricia Benner discusses the stages that new nurses go through as they move from novices to experts (Benner, 2001), and I encourage all nurses who are involved in the education of nursing students, or the precepting or mentoring of new nurses in clinical practice to learn about these stages and what to expect from nurses in each stage. Benner also offers suggestions on how educators can support nurses in each stage, and how they can help them advance to the next stage. Unfortunately, many nursing students, as well as new nurses do not receive this support. Instead, they get the message that because they could not put their knowledge to practice the first time they encountered a highly stressful situation, that they are incompetent or just plain “stupid” (Rawlins, 2017).

Nursing educators, whether they are in the classroom or the clinical setting, whether they are teaching new or experienced nurses, need to be aware of the effects of stress on learning and memory recall. Stress is just one example of suffering that occurs in educational settings. In the next section I will discuss further some of the challenges that teachers, students and new nurses experience that impact their ability to learn. Later in the chapter, I will discuss how to address these challenges with compassion, with the goal of enhancing learning. But first, in the exercise that accompanies this section, I invite you to explore how to bring joy to teaching and learning as an antidote to stress.

EXERCISE: Bringing Joy to Teaching and Learning!  

As a teacher, I have found that if I have a particular affinity for the subject matter I am teaching and enjoy the way I am allowed to teach it (or allow myself to teach it), students respond better. I have a similar experience as a learner – engagement with the material as well as enjoyment of the assignments, lectures and readings, means I learn better. I suspect I am not alone in this. One student wrote the following on the end-of-quarter evaluation for an undergraduate research class I taught, (I am paraphrasing): “Research is a dry subject, and I don’t find it interesting. However, Dr. Johnson’s enthusiasm and enjoyment of the topic made this a better class.” In this exercise I invite you to explore what aspects of teaching and learning bring you joy, and how you can use this knowledge to enhance your teaching practice. This exercise can be done with a group or by yourself.

1. First identify all the ways you currently act as a teacher and mentor. Even if you do not have “educator,” “professor,” “lecturer” or a similar label in your job title, take a few moments to think about the various formal and informal opportunities your job gives you to teach and mentor others.

2. Which of these opportunities bring you joy? Are there any that you dislike doing, or find yourself dreading?

3. How might you change your practice to bring more joy, and less drudgery into your practice of teaching? (I recognize that there are certain tasks that will always be part of formal teaching that we may have no control over, like grading. However, consider whether doing more of what brings you joy can counteract some of the effects of what does not bring you joy.)

4. Next think about your past and current experiences as a learning. How do you approach learning about something that is interesting to you? How do you approach learning about something that is of less interest, but is required for your job (or was required during your formal education)?

5. What is your preferred learning style? Are you a hands-on learner? Do you need to hear instructions, read instructions, or watch a demonstration of a physical skill? How about for cognitive learning? How do you memorize facts? Do you prefer writing a paper, giving a speech, or drawing a picture? Everyone has their unique preference for teaching and learning, and ideally our teaching practices should be tailored to a wide variety of learning styles (Mangold, Kunze, Quinonez, Taylor, & Tenison, 2018). How might you tailor your classroom lessons to meet the needs of a variety of learners? How might you adapt your training and style of teaching to the unique learning styles of preceptees, mentees or student nurses in the clinical setting?

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Common Sources of Suffering Experienced by Nursing Educators, Students and New Nurses

There are many challenges faced by students and new nurses as they learn the skills and knowledge they need for their careers. They may experience the stress of everyday life, of caring for families, working to support their education, or any of the other myriad external stressors students and new nurses experience. The modern educational system adds additional stress and trauma for most students (Heissel, et al., 2021). Increasing emphasis on test scores, and learning as a pathway to a career, rather than learning for the sake of acquiring new knowledge and for understanding the world in which we live can squash critical thinking, can take the joy out of learning, and can create anxiety for students (Hunsicker & Chitwood, 2018; Morgan, 2016). By the time they get to nursing school, many students have been traumatized by the education system, and are conditioned to fight for every point (Gallo, 2012), rather than approaching learning as a joyful activity which will set them up for a successful nursing career.

While I am not acquainted with the educational processes for nurses in other countries, I know that in the United States, the country in which I teach, there is increasing pressure for nursing schools to improve their students’ scores on the national licensing exam (NCLEX-RN) (Hunsicker & Chitwood, 2018). This emphasis can lead to anxiety, and to a focus away from learning to a focus on test taking. Some schools are recognizing the anxiety that test taking causes students and are developing programs to help them develop effective ways of reducing test anxiety. One program found that, “commitment to a positive learning environment; engaging course design; and interaction through mentoring, coaching, and instruction on anxiety reducing activities contributed to the positive outcomes [on the NCLEX-RN]” (Christensen & Wissmar, 2018 p. 5).

Nursing students may have also experienced traumatic events in their personal life before entering nursing school, or they may be currently experiencing traumas such as domestic violence and abuse, food and housing insecurity, along with the everyday stressors of modern life (Grant-Smith & De Zwaan, 2019; Hedrick et al., 2021). There is plenty of research that shows the lifelong effects of adverse childhood experiences (ACEs) on learning, critical thinking, anxiety, stress and depression (Doughty, 2020; Hedrick et al., 2021). Nursing educators and preceptors need to be aware that the some of students they teach have experienced ACEs that continue to negatively affect them (Hedrick et al., 2021; Kameg & Mitchell, 2021). Experiences in classrooms and clinical settings may retraumatize students who have experienced ACEs, or other traumas (Cannon et al., 2020). Additionally, nursing students can experience secondary traumatic stress from clinical experiences (Bingol, et al., 2021).

During challenging historic times, such as the COVID-19 pandemic, natural disasters, or war, educators become acutely aware of how events outside of the classroom can affect students (Aslan & Pekince, 2021; Richardson et al., 2015). During COVID-19, many universities around the world switched to online learning. This meant that students were juggling zoom classes and monitoring their own children’s education which was also being delivered via zoom. Students who were already working in healthcare may have been experiencing stressors due to work-related challenges brought on by COVID-19, some had loss of income due to shorter hours, while others were being asked to work longer hours (Aslan & Pekince, 2021; Gelles, et al., 2020). The COVID-19 pandemic was a challenging time for all of healthcare, particularly so for new nurses and students who were just entering the profession during this time (Aslan & Pekince, 2021; Goddard, et al., 2021). I have been writing this book throughout the pandemic and will be interested in seeing how entering the profession of nursing at this time affects students and new nurses in the future.

Educators, whether they work in colleges and universities or are staff nurses who have been asked to oversee nursing students for a few shifts, staff nurses who have been asked to orient new nurses, or nurses who are full-time clinical educators, also have personal and professional stressors that cause suffering. In Chapter 5, I discussed some of the ways our co-workers might be suffering, and the content in that chapter also applies to educators.

Some of the unique challenges that nursing faculty experience include the need to juggle teaching, research and service, which can lead to long hours and role overload (Singh, et al., 2020). Nursing faculty increasingly report difficulty balancing their work-life balance, as technology allows them to interact with students outside of traditional work hours, and students increasingly expect professors to be available during non-traditional work hours (Farber, et al., 2020). Other stressors faced by nursing faculty include incivility and bullying from students, colleagues and clinical partners (Clark & Luparell, 2020; Farber et al., 2020).

Stressors experienced by staff nurses who are asked to precept nursing students, or orient new nurses include the extra work that is entailed in supervising transition to practice, extra paperwork requirements, and concerns over competency and delegating (Quek & Shorey, 2018). When I was a staff nurse and was responsible for overseeing a student nurse or for training a new nurse, I was less efficient, and often was juggling my own case load as well as overseeing the work of my student or orientee. This meant that I often had to stay overtime to finish my charting, or to document the progress of the student or orientee. I recall one shift where I was orienting a new nurse, was also responsible for a student nurse, and had my own load of patients! As recognition for this extra work, I received a mere 25 cents extra per hour.

In the next exercise, I invite you to contemplate the stressors you faced as a student or as a new nurse. I also invite you to explore stressors you face as a teacher. I encourage you to think about how these sources of stress could be mitigated. In the following section I will discuss how teaching with mindful awareness and compassion can help us address stressors as they arise, which may diminish our need for stress-reduction outside of work.

EXERCISE: Exploring Sources of Stress in Teaching and Learning

This exercise may be done with a group, or by yourself.

1. Thinking back to your experiences as a student nurse, what were the top 2-3 sources of stress that you experienced? If you could go back in time and talk to yourself, what would you say to this younger version of yourself about this stress? What coping strategies did you employ at that time that worked? From your current perspective, is there anything that you might have done differently to manage this stressor?

2. Thinking back to your experiences as a brand-new nurse, what were the top 2-3 sources of stress that you experienced? If you could go back in time and talk to yourself, what would you say to this younger version of yourself about this stress? What coping strategies did you employ at that time that worked? From your current perspective, is there anything that you might have done differently to manage this stressor?

3. What are the top 2-3 sources you currently or have recently experienced in your role as a teacher/educator? What are your current coping strategies? What else might you do to cope with stress? What might you do to manage the sources of this stress?

4. If you are working with a group – share some of your ideas. Perhaps you will come up with a plan for helping each other manage your stressors and cope with the stress inherent in everyday life. I find that sharing my problems with supportive colleagues, sharing laughter, and sometimes crying together can be a powerful way of relieving stress. I have also found that giving each other permission to say “no” to extra tasks and responsibilities, and figuring out how to streamline the workload, helps manage stress.

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Teaching with Mindful Awareness and Compassion

As we have discussed throughout this book, mindful awareness is a step on the road to compassion, lovingkindness, and equanimity. Additionally, research has shown that when teachers bring their whole attention to the classroom, and are fully present for each student, they experience more joy in teaching, and are more likely to respond in a way that resonates with students (Miller, 2018). In this section, I will first discuss how educators can bring a more mindful approach into their practice, I will then discuss how to build a compassionate teaching practice, and how all students can benefit from this approach.

One of the easiest ways of incorporating mindful awareness into teaching is by creating a ritual that you do before engaging with learners (Miller, 2018; Ryznar & Levine, 2021). Nurse educators wear many hats, which means they often need to switch from one professional role to another, and these roles can require completely different mindsets and behaviors. Clinical educators might be transitioning from their role as a clinician to their role as a teacher. Educators in academic settings may be going from a committee meeting, or some other administrative task, to the classroom. Both of these transitions require a different way of being, and a different orientation. Ryznar and Levine (2021) suggest that before you enter a classroom where you are the instructor, a clinical setting where you will be educating others, or a workday where you will be training a new nurse or a nursing student, that you “prepare to teach with a mindful transition” (p. 2).

A mindful transition may consist of a formal practice such as a lovingkindness meditation, setting an intention to teach from the heart, or saying a little prayer (Miller, 2018). Miller’s research shows that practicing a lovingkindness meditation before teaching can help teachers feel more present in the classroom, can help them respond with kindness and composure to challenging situations, and can add a dimension of joy to their teaching. However, many of us do not have time to meditate as we rush from one of our professional activities into our roles as teachers. Additionally, we may not have a physical space that is conducive to meditation. Instead of meditating, a short prayer, mantra, or thought can remind us of our intention to approach teaching from a place of lovingkindness and compassion. And, as always, if we fail to live up to our goals, we should contemplate what we could do differently next time from a place of self-compassion.

Creating a small ritual that you do every time, will normalize the practice and provide your body and your brain with a physical cue that it is time to think and act like a compassionate and fully present teacher. This ritual may be something as simple as changing out of a lab coat into a blazer or sweater. Or combing your hair, brushing your teeth and applying lipstick! One of the tasks I do before teaching is to fill up my water bottle. Just like you, I am learning about teaching mindfully, and I am starting to turn that task into a ritual by mindfully watching the water flow into the bottle while thinking, “I am now preparing to teach. I am now giving my students my total attention. I am calm, caring, compassionate and competent.” This small act seems to be helping me feel more focused in the classroom. In the next exercise I invite you to create your own ritual and mantra or prayer that can accompany this ritual.

EXERCISE: Setting an Intention to Teach Mindfully With Compassion

You can do this exercise by yourself or with a group. I suggest you write your thoughts down so you can refer back to them – especially your thoughts on a mantra, prayer or intention that you can repeat to yourself as you transition into your role as a teacher.

1. Take a moment to bring your focus to the present and to let go of thoughts, worries or preoccupations. You may want to take a few deep breaths, you may want to find a more comfortable position in your chair (or a more comfortable chair!), or you may just look around the room or out of a window and remind yourself to bring your focus to the present moment.

2. From the position of being grounded in the present, reflect on your usual transition into teaching. Are there typical behaviors you do, or actions you take, before you enter a classroom, before you begin a shift where you are orienting a new nurse or training a nursing student, or before you engage in a conversation with a mentee? You might notice you initiate each of these sessions in a different way, or that you do not have a usual pattern of behavior. Also notice whether there are any emotions or physical sensations that arise as you think about these situations. For example, I often feel a rush of adrenaline before beginning a lecture, and sometimes my legs feel a bit shaky – especially at the beginning of the semester. I have come to see these sensations as the way my body and mind are getting me ready to teach – and are giving me the energy to stand in front of a group of people for 2-3 hours and talk!

3. As you reflect on your experiences transitioning into your teaching role, and start to identify patterns, think about what works for you, and what does not. How can you do more of what helps you successfully transition into a teaching role, and less of what stresses you out? How can you transform habitual actions that you find useful into a ritual?

4. Finally, start to experiment with a short aspiration, mantra or prayer to use as you transition into your teaching role. Make it short, and meaningful. It might take some time to settle on a mantra, intention, prayer or motivational saying that works for you. Write down your thoughts so you do not forget them. You might put the phrase on a sticky note in a place where you will see it when you engage in the physical transition to teaching. For example, you might just say to yourself, “I strive to be compassionate and fully present as I teach this (class, person, skills lab).”

5. If you have several different roles or ways of engaging in teaching, you may develop different rituals for each. For example, you may find that you have a different way of transitioning into a lecture setting than you do a clinical setting, a skills lab or a one-on-one meeting with a student.

6. If you are working with a group, share your thoughts with each other. You may learn something from one of your colleagues that helps you become a more mindful and compassionate educator. Sharing your intention can make it easier to commit to, and sustain, this practice.

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Teachers can also bring mindfulness into their instructional practice by “approach[ing] teaching and learning with a beginner’s mind” (Ryznar & Levine, 2021, p. 4). Everyone brings unconscious biases into a teaching situation. We may have heard from a colleague that a given student was “difficult” or “struggling,” and this may affect how we interact with them (Decastro, et al., 2019). Additionally, racial and gender biases may affect how we view and interact with students, preceptees or new nurses that we are training (Graham, et al., 2016; Powers, et al., 2018). When teachers approach educational settings mindfully and with a beginner’s mind, they ask themselves if they have any biases that might affect their interactions with students, and notice when they are comparing a student with others (Ryznar & Levine, 2021). Sometimes the mere act of noticing biases or assumptions is enough to change our behavior, but other times we need to actively work on changing our assumptions (Markey, et al., 2021). It is beyond the scope of this book to discuss how educators can create inclusive classrooms that are free from biases. I refer interested readers to resources such as What Inclusive Instructors Do (Addy, et al., 2021).

To optimize learning, educators need to make sure that the classroom or clinical setting has an element of psychological safety. As discussed in the previous section, stress can impair the absorption of new material, as well as the retrieval and application of previously learned material. Teachers can establish an atmosphere of psychological safety by giving students ample time to answer questions without rushing or interrupting them, and by allowing them the opportunity to be wrong and to correct their mistakes (when patient care will not be affected!) (Makhene, 2019). For example, giving students an opportunity to address questions in small groups gives all students the chance to think through problems, and to test their ideas with their peers before sharing it with the whole class and their instructor (Ryznar & Levine, 2021).

Educators can create psychological safety in clinical settings by closely supervising trainees when they do new tasks and letting them complete tasks independently that they have already mastered (Benner, 2001). Students and new nurses also need to know that everyone will make mistakes when they are learning (and even when they are seasoned nurses!). Educators and nursing managers who create the expectation that mistakes are opportunities for learning, and create conditions where nurses who are learning new skills are supported so that their mistakes are not harmful, foster psychological safety and create a supportive environment for new nurses (Lyman, et al., 2020).

New nurses and nursing students also need encouragement and emotional support as they navigate challenging situations such as a patient death (Lyman et al., 2020). At times, this may mean letting go of a lesson plan that emphasizes facts (students can always get fact-based information outside of the classroom) and attending to the affective learning and emotional processing that is an essential, but often overlooked, part of becoming a clinician (Ryznar & Levine, 2021). Compassionate teaching also requires instructors to be aware of how events outside of the classroom, such as a natural disaster, or a pandemic like COVID-19, can affect students’ emotional state (White & Ruth-Sahd, 2020). These events provide an opportunity to teach nursing students about trauma-informed care while creating a safe space for them to discuss their own experiences with trauma, both before and during nursing school. (Cannon et al., 2020)

Providing feedback mindfully and compassionately is a crucial component of a psychologically safe learning environment (Ryznar & Levine, 2021). Learning how to give feedback effectively is a skill that takes practice. It is also a skill that most of us are never taught how to do (Lefroy, et al., 2015). Instead, we model our feedback on the sometimes effective, sometimes awkward, and sometimes harmful, examples from our own experiences. There are several points to keep in mind about feedback. In clinical settings, consider how and when to give feedback – if patient safety is threatened, you might need to intervene immediately, and more forcefully. In other situations, take some time to consider how you can deliver a message in a way that invites growth, however, do not wait too long after the event to give feedback, as that lessens its impact (Lefroy et al., 2015; Ryznar & Levine, 2021).

When mentoring or training a new nurse or nursing student, a trusting relationship is as important as the exact words that are used when giving feedback (Lefroy et al., 2015). Students and new nurses are always watching others to figure out how to enact their new role. Students and new nurses who observe nurses acting in negative ways towards patients and co-workers will have a tendency to emulate these behaviors, even if they consciously feel they are wrong (Randle, 2003). Educators can be mindful of the fact that their trainees are watching them by making their actions explicit, and by always treating others with respect and lovingkindness.

I was once asked to train a nursing student who excelled at “book” learning, but who struggled clinically. She had excellent technical skills but did not have an innate ability to connect with patients. Instead of focusing on this deficit I made a point of role modeling how I established rapport with patients, and I also made a point of explaining to her exactly what I was doing and why. I recall having the following conversation with this nurse:

“I always start the shift by introducing myself to each patient, and to the other people in the room. This gives the patient an opportunity to explain who their visitors are, and to introduce me to their primary care givers, which allows me to evaluate their social support system. As I make ‘idle’ conversation with patients, I learn about their goals for the shift, what the hospital stay has been like for them, and I also assess their cognitive status. Before I leave the room, I let them know how long I will be on duty and reinforce the use of the call light to contact me. By doing so, I also remind myself to check where their call light is located, and to move it and other essentials within reach of the patient.”

Thinking aloud, being transparent about your practice and the decisions you are making during a given shift, and also being honest when things do not go well are all ways you can be a mindful role model and educator in the clinical setting (Ryznar & Levine, 2021). Finally, feedback which emphasizes how an individual’s nursing practice can be improved is more effective than feedback which focuses on personality traits (Lefroy et al., 2015).

Teaching Compassion

While students who pursue a career in nursing probably have some degree of innate compassion, nursing students and new nurses need role models that demonstrate compassionate care in order to learn how to act with compassion in clinical settings while maintaining healthy boundaries (Adam & Taylor, 2014). Unfortunately, it is easy for students and new nurses to find role models who do not demonstrate compassion, as the nursing profession has high rates of workplace bullying (Johnson, 2018). A 3-year study that followed nursing students through their program found that students who witnessed bullying and mistreatment of patients and co-workers by nurses on the unit began to emulate these behaviors (Randle, 2003). Another study reported that new nurses felt less psychologically safe when they overheard gossip or disparaging comments about other staff members (Lyman et al., 2020). Educators, preceptors, and mentors all need to be aware of their behavior, and should strive to uphold compassionate, professional, and ethical standards of nursing care at all times, particularly when they are in the presence of nursing students.

Younas and Maddigan (2019) did a critical review of the literature to ascertain how nursing students’ compassion can be nurtured and sustained. One of their primary findings was that teaching students how to provide compassionate care was not a part of the curriculum in most nursing schools, and there was scant explicit discussion of the topic in the nursing literature (Younas & Maddigan, 2019). From the few articles and books they did find that were related to the topic, they identified the following four characteristics that compassion teaching strategies had in common, “(a) active engagement of students and teachers; (b) student‐centered learning environments; (c) a focus on building students’ reflective skills; and (d) an emphasis on affective learning” (Younas & Maddigan, 2019, p. 1631). These teaching strategies are particularly suited for small groups who have had a chance to develop a trusting relationship with each other and with their instructor, rather than large classroom lecture halls (Adam & Taylor, 2014).

In one program for entry-level nurses, students were asked to write about clinical scenarios which challenged their ability to provide compassionate care (Adam & Taylor, 2014). With their instructor, the students identified skills they needed to develop and came up with personal plans to develop these skills which they presented to the whole group. Skills that these students identified as crucial for learning how to consistently provide compassionate care were effective communication (for example the ability to respond assertively to instances where staff nurses’ actions lacked compassion such as bullying staff or displaying rudeness towards patients), and the ability to respond calmly to patients and families who were experiencing and expressing difficult emotions (such as anger or grief) (Adam & Taylor, 2014). At the end of the class students wrote a reflective piece outlining their progress (Adam & Taylor, 2014).

Teaching students how to provide compassionate care involves an emphasis on affective skills, however, it need not be done at the expense of other skills that they need. In one study students said that they felt more comfortable in their ability to provide compassionate care, and their patients had more trust in them, when they had mastered basic clinical skills (Su, et al., 2021). Students also said that learning about compassion and honing their ability to act compassionately gave them the confidence and courage to point out medical or nursing errors, a skill which when done well involves clinical knowledge, self-confidence and the ability to communicate with compassion (Adam & Taylor, 2014; Su et al., 2021).

Students have also reported that in order to provide compassionate care they needed to learn how to practice self-care, and how to generate self-compassion towards their own shortcomings (Adam & Taylor, 2014). A study of nursing students in China reported that students who had higher levels of self-compassion had lower levels of perceived stress (Luo et al., 2019). Resilience training has become part of the curriculum for many nursing schools (Li & Hasson, 2020), and this training needs to include robust discussions of self-compassion. These discussions should include strategies students can use that allow them to critically evaluate their own practice, and to learn from their mistakes, without being overly self-critical or judgmental. The exercises from Chapter 3 can be adapted for the student population and are a great place to start if you want to incorporate concepts and skills around self-compassion and self-care into your lesson plans.

Finally, if the concepts and skills related to compassionate nursing care are going to be a part of a nursing curriculum, there needs to be a plan to evaluate learning in this domain. Younas and Maddigan (2019) propose that the students can be evaluated using the following three direct indicators of compassionate care and four foundational elements of compassionate care. The direct indicators of compassionate care that they identified include: recognition of suffering, acceptance of suffering, and alleviation of suffering. Under the domain of recognition of suffering, instructors can evaluate whether students attempt to understand how their patients might be suffering by engaging in empathetic conversations with them about their experiences. In the categories of acceptance of suffering and alleviation of suffering, evaluation can include observations of whether students avoid patients who are suffering, or are comfortable sitting with them as they suffer, and actions that they take to “promote patient’s wellbeing and find solutions to their distress” (Younas and Maddigan, 2019, p. 1631).

The foundational elements of compassionate care identified by Younas and Maddigan (2019) are: authentic presence, empathy and understanding, respect and openness to patients’ needs. Authentic presence can be evaluated by measuring whether students connect with patients in a meaningful way. Empathy and understanding can be evaluated by observing students’ ability to listen to their patients, and whether they make an attempt to understand the patient’s perspective. Students demonstrate respect when their actions help patients maintain their dignity and humanity, and when they actively engage patients and their loved ones in their own care. Finally, students exhibit openness to patients’ needs when they collaborate with patients in establishing goals and priorities for care.

Instructors, mentees and preceptors can evaluate the indicators of compassionate care via direct observation and by asking students to reflect on their experiences in written and oral presentations. Ideally, these evaluations would not be graded in the same way a paper or exam would be as that type of evaluation is antithetical to the type of learning that fosters a students’ ability to provide compassionate nursing care.

EXERCISE: Reflection on Your Experiences Learning About and Teaching Compassionate Care

This exercise can be done as a group or by yourself.

1. Reflect on your experiences as a nursing student or a new nurse. Were the concepts and skills of compassion or self-compassion an explicit part of your education? Were there other related concepts or skills that were taught that are similar (e.g. self-care, patient-centered care)? What methods were used to teach any of these concepts or skills?

2. Reflect on any experiences you have had teaching the skills and concepts around compassionate care. What did you do that worked well? What could be improved, and how? If you have not taught these skills or concepts in any of your courses, are there any courses that would benefit from the addition of this material?

3. Explore your institution’s mission and values. Is there any mention of compassionate care? Examine the curriculum – are there any courses that teach about compassion? Are there any courses that have objectives that explicitly mention compassion? You may want to have a discussion with all of the instructors to learn if there are ways that the concepts of compassion are currently being taught.

4. If your institution does not currently address the concept of compassionate nursing care, you may consider having a discussion about whether it could be added to the curriculum, and what courses it might fit in with. Perhaps compassionate care could be a thread that is mentioned in multiple courses, thus reinforcing the importance of it to nursing practice.

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Building a Community of Compassion in Education

Educators, mentors, and preceptors need support giving compassionate guidance to their students and mentees. It can be difficult to maintain compassion with students who take a long time to learn a new skill, who do not grasp new information quickly, or who just struggle with adapting to the fast paced environment that is present in most healthcare settings. Students and new nurses are also not just passive recipients of new information, they can challenge their teachers, often in ways that are interpreted as rude or uncivil. And finally, some students do exhibit uncivil or unethical behaviors that need to be corrected. A community of educators who are interested in exploring mindfulness and compassion in their teaching practices can help each other overcome these challenges (Ryznar & Levine, 2021)

Kucirka and Baumberger-Henry (2021) discussed how they worked to develop and nurture a culture of caring among nursing faculty in their program. They initiated regular end-of-quarter meetings that were structured around a process they called Courageous Caring Conversations. These meetings, which involved a shared meal to create an atmosphere of community, were designed to create a safe place for faculty to share a difficult challenge or situation they encountered during the quarter. To encourage faculty to speak more openly, members of administration are not included in the conversations (Kucirka & Baumberger-Henry, 2021).

After a shared meal, which is designed to create a community atmosphere, the Courageous Caring Conversation begins with a “check-in” where participants set an intention for the meeting, and share how they are feeling (Kucirka & Baumberger-Henry, 2021). The group either establishes ground rules for the meeting or reviews ground rules that were previously established. Next, faculty are invited to discuss a difficult or challenging situation they faced during the previous quarter. After a mutually agreed upon period of time, or when conversation seems to be at a close, the meeting ends with 10-15 minutes of reflection. During this period of closure, group members are encouraged to express appreciation for someone or something that occurred during the session, a reflection on the process, and/or an affirmation of a commitment to engage in compassionate and courageous collegial interactions among faculty going forward (Kucirka & Baumberger-Henry, 2021).

In the school of nursing where I am a faculty member there were a lot of tenure-track faculty that started in the years before and after I did. At one point, there were only 2 senior faculty, the rest of us had been there less than 5 years! We organized an informal junior (non-tenured) faculty group that met once a quarter over coffee with the goal of supporting each other through the journey of becoming a professor. We discussed how to juggle our various commitments (teaching, research and service) as new faculty, and how to survive the tenure process. It was a great opportunity to get some non-judgmental, compassionate feedback on struggles we were all facing. While it was not as structured as the Courageous Caring Conversations I have described above, it was a great source of support during a difficult time in my career. I encourage you to think about how you can develop a support network (even if it is just with one other person) that can help you in the journey to become, or maintain, your ability to educate with compassion, mindfulness and equanimity.

EXERCISE: Identifying Sources of Strength, Support and Encouragement

This exercise can be done alone or with a group. If you are doing this exercise with a group, you may want to offer appreciation for how the group is supporting each other.

1. Take a moment to settle into a reflective mindset. Perhaps you need to take a moment to focus on your breathing. Maybe you need to get in a comfortable position. If you keep a journal, perhaps you will want to get out your journal and write your thoughts down.

2. Once you feel present in the moment, reflect on your journey as an educator, mentor or preceptor. Who or what has been a source of strength, support and/or encouragement when you have had challenges or stressors? It might be someone outside of work – a loved one, a friend, or someone who teaches in a different setting. Your source of strength might be a pet. It might be your practice of taking walks in nature, your faith or religious practice. There may be multiple ways you get support when you go through a rough patch.

3. Next, just spend a few moments appreciating and feeling grateful for this person, place, being or practice. If your support comes from a person (or several people) you may want to let them know how much you appreciate them! Perhaps it is time to take them out for a cup of coffee, or a meal.

4. If you feel you do not have enough support in your practice of teaching, take a moment to appreciate your own strength and resilience. Appreciate how you have navigated challenges on your own! Consider whether there are possible sources of outside support you have not sought out, or have not leaned on. Sometimes we can ignore offers of help because we do not want to seem weak, or we are too busy, or we do not need to be a burden. Gently examine whether this is a tendency of yours (it is something I do at times!).

5. Finally, spend a moment reflecting on your colleagues. Are there any who you feel could benefit from a little support, companionship, or mentoring? Think about what you can do for them – perhaps you can stop by their office and just check in with them or send them a note or an email. Perhaps you can take some time to buy them coffee or tea.

6. If you are working through this exercise with a group, take some time to share your thoughts with each other.

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Systemic and Individual Blocks to Compassionate Teaching

Just as there are systemic and individual factors roadblocks to building a compassionate clinical nursing practice, nurturing compassion towards co-workers, and developing a compassionate leadership style, there are systemic issues that can impede or block our ability to be compassionate and mindful in our teaching and mentoring. One of the primary blocks to compassion in teaching, mentoring and precepting is the impression that compassionate teachers are “softies” who let students get away with a lower level of performance (Rayner, et al., 2021). As we explored in the discussion on compassionate leadership (Chapter 6), performance expectations can be set and enforced in a compassionate manner. Educators are not acting with compassion when they allow learners to under-perform, to engage in unethical behaviors, or to otherwise fail to live up to professional standards. Students, no matter how much they seem to push back against being corrected, know they will not grow if they are not challenged. In fact, students have reported that a caring educational environment includes clear standards and requirements, and easily accessible, understandable instructions (Sitzman, 2010).

Students need feedback, but they need feedback that is respectful, considerate and compassionate. One study compared students’ ratings of three different styles of feedback: compassionate feedback, simple descriptive feedback, and ultilitarian feedback (Bond, et al., 2021). Students in this study reported higher levels of well-being after receiving compassion-based feedback. While their performance on a standardized task did not differ between the three feedback types, they also reported compassion-based feedback was more helpful. The finding that performance was no worse after compassion-based feedback compared to the other methods indicates that even though this type of feedback may be perceived as “soft”, it does not negatively affect student performance. The authors of this study concluded that compassion-based feedback may be more effective in the long run as it is less likely to trigger self-criticism and self-doubt, both of which can negatively affect performance, as well as block compassion (Bond et al., 2021). However, instructors are not often taught how to give effective feedback, much less how to give feedback that is compassionate. This lack of training can be an impediment to providing education in a compassionate manner.

It is my opinion that a combination of utilitarian feedback (e.g. that explicitly and non-judgmentally points out what the learner needs to do to improve performance) and compassionate, or appreciative feedback (e.g. feedback that honors their effort, or their willingness to learn and grow) may be most useful. For example, when grading students’ papers, I might give feedback along the lines of “You have some great ideas in this paper. However, there were sections that I found confusing, either because the grammar was incorrect or because the sentence needed editing. You may consider working with a writing tutor on future papers. I am confident that with practice, your writing will continue to improve, and your thoughts will be more clearly understood.” If giving effective and compassionate feedback is an area that you struggle with, know that you are not alone! This may be a topic that you want to explore a bit more on your own, or with colleagues.

While a lack of focus on compassion in an educational setting can be a roadblock to building a compassionate teaching practice, an overly prescriptive mandate to act with compassion can also block compassion. In one study, teachers who were involved in a compassion-building course reported that a mandate to act compassionately blocked their ability or desire to act compassionately (Rayner et al., 2021). Mandates to act compassionately that are delivered in an authoritarian manner, and which are tied to an evaluation or reward system, may activate the threat self-protection systems or the reward systems in our brains, which will then block the neural pathways needed to activate compassion (Gilbert & Choden, 2013). In Rayner et al.’s (2021) study, participants also discussed how self-criticism for “not being ‘perfectly compassionate’” (p. 720), as well as a tendency to negatively compare themselves with other teachers who seemed to be more compassionate, also blocked their ability to express compassion towards students.

As discussed in Chapter 3, self-compassion is a necessary component of compassion. If you find yourself being overly critical because you did not respond compassionately in a given situation, or if you are comparing yourself to others, I suggest that you explore these tendencies with self-compassion. Remember that none of us are perfect, we are all on a journey of learning to act with compassion, lovingkindness and equanimity, so it is to be expected that on occasion we will fail to live up to our own expectations. When that happens to me, I might spend a little time regretting what I have done, and sometimes fall into self-recrimination. To break this cycle of regret, I spend a little time identifying why I failed to act with compassion, or why I was rude (perhaps I was hungry, or tired, or did not take the time to fully engage with the student). I then offer myself some forgiveness and bring my focus back to the present. While it is important to examine past actions in order to learn from them, when we dwell too much on past events, we lose our mindful focus on the present, which as we have explored throughout this book, is a crucial component of compassion.

Finally, a major block to compassionate teaching, mentoring and precepting is a “hidden curriculum” in nursing (Adam & Taylor, 2014; Drumm & Chase, 2010). In my nursing education, part of the hidden curriculum was that nurses should avoid becoming emotionally attached to our patients and we should erect clear walls between ourselves and those who are in our care. While boundaries are appropriate, teaching about boundaries without a discussion of how boundaries can be established in a way that allows feelings of compassion and lovingkindness to emerge, can create the impression that we must not have any feelings for our patients and families. The unintended, or hidden curriculum, in these types of lessons can lead to a reduction of compassion, and certainly does nothing to help the learner understand how to consciously bring forth feelings of compassion, and why this is important to the therapeutic relationship (Shea et al., 2016)

Nursing education’s emphasis on measurable competencies and high stakes exams is another part of the hidden curriculum. Teaching that emphasizes passing multiple choice exams leaves little room for learning and strengthening affective skills such as how to have a compassionate conversation, how to provide competent care in a compassionate manner, and effective conflict resolution (Tedesco-Schneck, 2013). Furthermore, there seems to be an implicit belief that people who enter the nursing profession are innately compassionate, and therefore compassion training does not need to be part of the curriculum (Drumm & Chase, 2010; Shea et al., 2016). Many nursing instructors, myself included, never received formal training in providing compassionate care (Sinclair et al., 2020), let alone teaching it, and compassion and caring are not major parts of the nursing curriculum in many schools (Younas & Maddigan, 2019). However, compassion training does not have to come at the expense of important didactic and psychomotor skills, instead it can be a thread that is seamlessly woven throughout the curriculum and mentioned in classroom lectures, skills labs and then practiced in clinical settings (Drumm & Chase, 2010). Nursing programs already include classes where communication and leadership skills are taught, and these are other areas where discussions of compassion can be made explicit.

Nurse educators who work in clinical settings and staff nurses who orient new nurses may also encounter roadblocks to teaching with compassion, and to making sure that conversations about compassion are woven into their teaching. In my twenty plus years of working as a staff nurse, I do not recall any inservice, training, or conversation with a mentor or staff educator about how to provide compassionate care. While my experience is just that of one nurse, I suspect it is not unique. However, this may soon change as organizations and health systems such as the National Health System in the United Kingdom are having discussions on how to teach and foster compassion within healthcare settings (Shea & Lionis, 2017).

Schwartz rounds, a structured interdisciplinary forum where healthcare providers meet to discuss the “human” side of healthcare, are being introduced in many hospitals as a way of enhancing compassionate care (Chadwick, et al., 2016; Maben, et al., 2021). (For more information see The Swartz Center: https://www.theschwartzcenter.org/). On the other hand, organizations that promote healthcare improvement measures, such as the Institute for Healthcare Improvement (http://www.ihi.org/about/pages/ihivisionandvalues.aspx) and The Joint Commission (the entity responsible for accreditation of hospitals in the United States) have no overt discussions on compassionate care, or how to create more compassionate healthcare organizations. This silence creates a real roadblock for nurses engaged in education who are interested in creating spaces for teaching and learning about compassion within clinical practice settings and indicates that there is still a lot of work to do in order for compassion to become a central and overt part of healthcare practice.

EXERCISE: Identifying Individual and Systemic Blocks to Compassionate Teaching and Developing Strategies to Overcome these Blocks

This exercise is best done with a work group but can also be done alone. While I have explored several roadblocks to teaching, mentoring and precepting with compassion, my discussion was not exhaustive. There may be roadblocks that you have identified in your own workplaces or within yourselves. In this exercise, I invite you to explore these, and to think of ways to overcome them.

1. What experiences have you had within your organization with teaching concepts related to compassion? How were these efforts received?

2. What internal or external factors impede or block your ability to teach concepts related to compassion?

3. What internal or external factors impede or block your ability or to teach and mentor in a compassionate manner?

4. For each impediment or roadblock you identified, brainstorm some ways of overcoming this roadblock. If the solution will require more than the effort of one or a few individuals, who else would you need to recruit to help you resolve this issue?

5. Finally, rank the systemic (external) issues according to most urgent to fix, and the easiest to fix. Decide where you want to expend your energy making a difference, and first work on what you can easily change. Then build on your success and work on issues that seem too big to change. It can take years to change organizational culture, but you can begin to sow the seeds for change now. While you may not be around to see the change, but just working to make a difference can be rewarding (and also frustrating!)

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CONCLUSION

In this chapter we explored compassionate teaching, mentoring and precepting. Compassionate teaching: “involves faculty awareness of student suffering, followed by sympathetic concern, and then a wish to see relief.” (White & Ruth-Sahd, 2020, p. 294). Compassionate teaching methods include understanding that past traumatic events can impede learning and displaying kindness towards students even when they do not seem to be overtly suffering. Compassionate teaching methods foster a general sense of psychological safety for all students and allow learning to occur without the added stressor of fear. Compassionate teaching requires flexibility when students have extenuating life circumstances, but also requires us to establish firm (but not rigid) boundaries and maintain and uphold standards of practice. While there are organizational impediments to teaching with compassion and teaching the concepts of compassion, it is my hope that people like you will work to overcome these challenges and will work to create a more compassionate educational system that will ultimately benefit both nurses and the patients they care for.

Key Takeaways from Chapter 7

• Students, mentees, and new nurses may experience suffering due to the stress that is inherent in the educational system, from learning a new role, from previous trauma within the education system, and from experiences in their personal lives.
• To facilitate learning and growth, nursing educators, mentors and preceptors need to be aware of the suffering that their students, mentees and orientees may be experiencing and should acknowledge and address this suffering.
• Incorporating mindful awareness into the practice of teaching and mentoring can enhance one’s ability to teach and mentor with compassion.
• Teachers, mentors and preceptors may also experience suffering due to the nature of their jobs, and due to personal issues. Building a supportive community of like-minded teachers can help alleviate stressors teachers may experience.
• Nursing educators, in the classroom and in the clinical setting, should include discussions of compassion in their curriculum. They should role model compassionate care and should help nursing students and new nurses learn how to provide compassionate care while still maintaining appropriate professional boundaries.
• Internal and external factors can interfere with our ability to teach with compassion. Identification of these factors, and working to overcome them, is an endeavor that will help ensure that nurses of the future can continue to build a compassionate nursing practice.

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