How do we sustain compassionate healthcare? Compassionate leadership in the time of the COVID-19 pandemic

Abstract

Compassion is central to human wellbeing, benefiting those who give and those who receive it. Compassionate cultures in healthcare enhance staff wellbeing, learning and innovation, and reduce stress, absenteeism and errors, leading to improved patient outcomes. Compassionate cultures need collective, inclusive, compassionate leadership, good teamwork, compassionate design, and a shift from the model of the organisation as machine to one of the organisation as a living, complex system. Developing and sustaining leadership and cultures of compassion are key to the ability for healthcare organisations to provide safe, high quality, patient centred care, even at times of crisis. This is particularly relevant during the COVID-19 pandemic which has created added strains to already-burdened healthcare systems in many countries.

Key points.

• •Solid, empirical evidence shows that a compassionate culture in healthcare leads to improved staff wellbeing, retention, engagement, and patient outcomes.
• •Inclusive, collective, compassionate leadership is key to compassionate cultures in healthcare, offering a clear vision and fostering autonomy, shared purpose, and a sense of belonging.
• •Leading with compassion is particularly challenging at times of crisis and requires the virtues of courage, humility, practical wisdom, and equanimity with high levels of self-awareness, and the ability to be agile and adaptable.
• •By providing emotional and practical support, compassionate leadership acts as a buffer to staff stress and promotes innovation, resourcefulness, and enhanced resilience – essential to health services during the COVID-19 pandemic.

Introduction

We are living in turbulent, uncertain, and threatening times. The COVID-19 pandemic and the consequences of climate change are creating massive disruptions, millions of deaths, progressive chronic disease, impoverishment and suffering in all parts of the globe. Many healthcare systems are buckling under the strain of caring for those who are sick or dying from the infection whilst trying to maintain services for those with other medical conditions. Healthcare staff are valiantly struggling to cope. Stress and mental illness have risen sharply among nurses and doctors in the UK.¹ The focus of this article will be in the UK healthcare context, but much of the review will be relevant to healthcare systems in other countries.

This is a time when there is an urgent need for compassionate leadership and cultures in healthcare and more widely in the societal and political landscape. Compassion is essential for those working in healthcare organisations to thrive and for patient care to be optimised.² Substantial evidence shows that compassionate, inclusive, and collective leadership is needed for high-quality, person-centred, safe cultures of care.³ I will explore the key ingredients needed for compassionate cultures and leadership, how these can be supported and nurtured and what contextual factors can enhance or militate against compassionate healthcare. Additionally, I will consider how the crisis of the pandemic has created a stronger imperative for compassionate healthcare as well as added challenges.

What is compassion?

Compassion is described in different ways, but in essence it is a dynamic, iterative process with four components: 1) An awareness and openness to the suffering of others; 2) an empathic, imaginative concern enabling one to understand another person's suffering – ‘to step into their shoes’; 3) a deep motivation to alleviate the suffering in a thoughtful and appropriate way leading to 4) compassionate action.⁴ Compassion flows inwards (self-compassion) and outwards, as well as reciprocally between individuals. Experiencing compassion fosters compassion to others. It involves positive emotions and an approach (rather than withdrawal) mindset. Compassion creates distress tolerance and buffers against a self-preoccupied aversive response that can lead to avoidance of those who are suffering. Empathic personal distress fatigue needs to be distinguished from ‘compassion fatigue’ – a term that implies compassion is both a finite resource and burdensome, even dangerous, to individuals. In fact, the reverse is true. Neuroscience research show us that compassion activates common neural networks of the brain associated with caring, feelings of social connection, and altruism.⁵ As social creatures with highly developed affiliative systems, humans have (to a greater and lesser extent) an innate predisposition to compassion and altruism, but this can be vulnerable to adverse experiences in early childhood as well as contextual factors.⁴

Why we need compassion in healthcare

Consistent with the neuroscience research, the great majority of empirical studies show that empathy and compassion are inversely correlated with burnout among healthcare professionals – in other words, compassion is a protective factor and can also be associated with ‘compassion satisfaction’.³ Compassion is a central value and motivation for most people who work in health and social care and the more the organisation reflects this value, the greater the levels of engagement and satisfaction.⁶

Aside building resilience for caregivers and a greater capability to respond compassionately to distress and suffering, compassion also has positive outcomes for patients: quicker recoveries, reduced mortality (in the acute sector), and enhanced patient experience and enablement. Compassionate cultures reduce stress and litigation and lead to fewer referrals and readmissions. They even cost less!³

How can compassionate healthcare systems and cultures be nurtured?

A paradigm shift

Culture can be defined as the shared values, assumptions and beliefs within an organisation or group. These are translated into norms of practice and shared narratives. For compassion to flourish and be sustained requires a paradigm shift from a production line mindset, viewing the organisation as a machine, with a relentless focus on cost-effectiveness and productivity targets underpinned by rigid processes, transactional rather than relational care, and the instrumentalisation of both staff and patients. Instead, organisations need to be viewed as complex, living, adaptive human systems focusing on the wellbeing and contributions of the people who form part of them.⁷ Organisations that prioritise a vision and strategy for high-quality compassionate care rather than financial and rigid bureaucratic targets have been shown to be the best performing at providing safe, effective, person-centred care.⁸ Collective noticing of suffering, allowing emotions to be expressed and shared, and collective responding enable organisations to respond with grace and agility.⁹ Small acts of kindness in organisations can have wide positive consequences.

Teamwork and collective design

Good teamwork is also a crucial factor – and cohesive, well organised teams were prominent in the response to the pandemic - with leaders working across disciplines and departments, not in silos. Cultivating compassion in individuals and teams by training and support helps to create compassionate organisations, but compassionate design - structures and processes that enable or constrain compassion - is also required. Simple measures can make a significant difference, such as ensuring that water fountains, healthy snacks, common rooms and protected time for relaxing and interacting with others are available for hard-pressed staff, as well as places for quiet reflection and prayer. Sharing stories allows for multiple voices in the organisation, restores connection, common purpose, and realignment with the organisation's central goals of healing and care. Schwartz Rounds provide for facilitated, shared storytelling and have been shown to reduce stress and improve staff wellbeing.¹⁰

Compassionate leadership

The most influential factor in creating compassionate healthcare cultures has been found to leadership: the behaviour of leaders individually and collectively at all levels of the organisation. Compassionate leadership offers a clear vision, ensuring direction, alignment of values, and a commitment to prioritising high quality care. Staff show high levels of engagement and enjoy a strong sense of shared purpose, values, and common humanity.

Collective vs personalised leadership

The concept of ‘heroic’, individualistic or personalised leadership needs to be abandoned in favour of collective, inclusive leadership where everyone carries leadership responsibility. This is particularly relevant in healthcare organisations where those on the frontline are highly educated, intelligent, resourceful individuals carrying considerable responsibility for the lives of others. Shared leadership in teams means that leadership is taken up by the person most suited to the role for the situation at hand – this may sometimes mean a junior nurse or doctor. Conversely, hierarchical ‘command and control’ leadership with pronounced power asymmetries robs those working in the organisation of their autonomy and creates a tendency for fear and blame, rather than pride and joy, to infuse the organisation, leading to poor outcomes and low morale.¹¹

Compassionate leadership behaviours

Compassionate leadership can be framed according to four key components (in line with the four compassion processes): Attending, empathising, understanding, and helping. Leaders support staff by providing the resources they need as well as removing obstacles for the provision of safe, compassionate care.³ In a high intensity, fast moving situation where rapid decisions and life-saving tasks are a priority, the ability to notice the emotional state of others may be compromised.⁷ Leaders must therefore be highly self-aware and attuned to others. They also need to be able to manage their emotions and respond wisely and calmly in times of crisis. Leaders will actively notice and praise compassionate behaviour and regularly communicate a vision of compassion and competence and ensure this is communicated at all levels. They will view mistakes as opportunities for learning and not foster blame and shame cultures which create feelings of inadequacy and fear, which in turn lead to ‘toxic’ organisations. Leaders also need to be skilled at conflict resolution.

Promoting intrinsic motivation

Self-determination theory (SDT) for intrinsic motivation and flourishing at work has been validated by extensive empirical research.¹² Compassionate leaders need to facilitate the enactment of the key principles so that staff can flourish and remain committed and engaged. These are: 1) Purpose and meaning in work, 2) autonomy, with scope for making decisions ‘on the ground’ according to the circumstances, 3) connectedness with others - developing good trusting relationships, and 4) mastery, facilitating the honing of skills and knowledge. a

Individual and team training for leadership

Solid evidence shows that compassionate mindfulness training increases clinician compassion, resilience to distress and burnout, as well as improving wellbeing.³ Leaders must be agile and adaptive such that they can balance social skills with cognitive problem-solving skills, and this requires training and experience. Psychological flexibility enhances individual compassion in organisations.¹⁵ Generally, evidence shows that training is best carried out with teams within the institutional setting.³

Barriers to sustaining compassionate leadership and cultures

Even though we may have a clear vision of what compassionate care and compassionate leadership should be, the reality on the ground is more complex and challenging. Many barriers exist in the healthcare setting that militate against compassionate action. Hospitals and care homes are intrinsically anxiety-laden and even threatening places. Caregivers regularly witness intense suffering and vulnerability, death and dying, and loss of human dignity. Experiences of loss, grief and empathic distress can make people feel overwhelmed, leading them to adopt self-protective psychological defence mechanisms, such as denial, disengagement, and even dehumanisation or scapegoating of patients.¹³ Other factors such as lack of sleep, exercise, healthy food, and social support can also undermine resilience and capability to respond sensitively and compassionately.

The fear factor

Empirical studies and scientific research show that fear triggers the threat response (fight, flight, or freeze) and this in turn impairs working memory, problem solving, creative insight and compassion. People become tunnel visioned and hunker down into survival mode. This is understandable, but at the same time very unfortunate when lives need to be saved and patients (and their relatives) need to be calmed and reassured. Compassion, conversely, creates a sense of safety and connectedness and will act a strong buffer to fear and a motivating force, enabling people to function with equanimity and hope.

The socio-political context

Organisations and leaders do not exist in a vacuum, but in a social and political milieu - the zeitgeist. Politicians and the media play a role in creating environments that foster compassion and altruism or, conversely, selfishness and callousness. If political and organisational leaders display a lack of courage, honesty, integrity, and empathy this will impact on those working in healthcare organisations and on the wider society.

The challenges of COVID-19 for sustaining a culture of compassion

Adverse effects

The pandemic has added another layer of fear and demand to an overstretched NHS with pre-existing shortages of staff and resources. Lack of staff and resources places an intolerable burden on those at the frontline leading to considerable moral distress when they feel unable to provide optimal care. Sick patients are now threatening vectors of an invisible and sometimes deadly virus, as are their relatives who are often barred from providing desperately needed care and support. Patients can deteriorate and die with terrifying speed.

In the early stages, there were many uncertainties regarding the most appropriate treatments and there was no vaccine available. Staff needed to be re-located to wards and specialties they were unfamiliar with, leading to disorientation and distress. PPE was in short supply and often substandard, not providing the protection healthcare staff needed, causing fear, anger, and a sense of betrayal. Healthcare staff have died in disproportionate numbers, causing huge distress and grief to their colleagues. Staff were more likely to be infected, exacerbating staff shortages. The situation was even worse in social care with massive loss of life of care home residents. This situation played out in the UK and other countries.

The fear of contagion extended to the fear of infecting family members, robbing them of the support and normal social contact with family and friends. The need to wear extensive PPE – gowns, masks and visors, and gloves, eclipses much of the richness of human communication and feels dehumanising. The more severe second wave led to the NHS being overwhelmed with sick and dying patients. Staff were tired and public support was waning, and at times even hostile. As I write, we are now in the third wave with fewer hospitalisations and deaths, thanks to vaccine immunity, but it is still of sufficient severity to stress the system. The backlog for those requiring treatment for other conditions is huge.

Positive effects

On the positive side, the crisis galvanised the profession to do all they could to save lives and alleviate suffering. These clear imperatives temporarily cast aside the preoccupation with cost-efficiency, financial savings, and other bureaucratic productivity/performance targets, loosening up rigid systems, and freeing staff to be more fluid, creative and innovative. Teams were strengthened and continuity of care enhanced. Strong public support and acts of solidarity also made staff feel valued and encouraged.

A shining example of sustaining compassionate healthcare in the pandemic

COVID-19 highlights the need for compassionate leadership. Northumbria Healthcare Foundation NHS Foundation Trust provides a shining example of how to develop a nurturing compassionate organisation, even in times of crisis, using both patient and staff experiences and feedback to shape care. During the pandemic several initiatives were introduced to facilitate communication between patients and their relatives. Communication with staff was also prioritised with regular communication from the chief executive and the sharing of positive stories to inspire and motivate. A new web-based platform was created - ‘Corona voice’ - for staff to reflect anonymously on their experiences and for management to respond rapidly to their needs. Safety was prioritised and PPE was manufactured locally. Teams were supported with built-in time and space for reflection and action planning. Teams under stress were provided with rapid support, including specialised psychological support if needed. Staff were provided with free food, parking, and, if needed, free accommodation and financial support. Positive actions were acknowledged and celebrated. Unsurprisingly this trust has the highest scores in the country for workplace satisfaction.¹⁴

Conclusion

Compassionate leadership catalyses, fosters and sustains compassionate healthcare. It requires embodied compassion as well as courage, wisdom, and agility. To be at their best, healthcare staff need to feel cared for and cared about, to be valued, and to be given a sense of belonging, as well as control over their work. Staff wellbeing correlates with patient wellbeing. Leadership involves the provision of emotional and practical support, encouraging trust, cooperation, and good teamwork as well as removing or minimising barriers to compassionate care. COVID-19 has shone a light on the inestimable value of compassionate, competent healthcare. It has also exposed the weaknesses and flaws in some current systems and policies as well as lack of preparedness and inadequate resources. It has given us a clear message: It is time for a radical reset. Only compassion and compassionate leadership can offer us the way to a better future. We need them now.