Data were collected from 36 healthcare staff (29 females, 7 males), with differing amounts of experience in working with patients who had type 2 diabetes (range from one month to 36 years). We achieved variation in the professional groups represented: Nurses (including specialist nurses) = 13; Doctors (including consultants and general practitioners) = 7; Podiatrists = 6; Healthcare assistants/support workers = 5; Dieticians = 3; Administrative staff = 2. Three of the focus groups (the first consisting of 3 doctors, 2 nurses and a podiatrist, the second a mix of 3 nurses and 3 healthcare assistants, and the third composed of 2 nurses and a support worker) involved HCPs based in a hospital. The final one was attended by 8 podiatry team members working in the community, including two of their administrative staff (it was felt relevant to involve them in the discussion because they were the first port of call for patients contacting the service). As for the 13 interviews, most (n = 9) were conducted with staff from primary care or working in the community. The rest of the interviewees (n = 4) were secondary care employees.
Throughout the project, the research team discussed a number of topics to arise from the data, such as the meaning of compassionate care in terms of being a professional and how compassionate care ran along a continuum rather than being something that was turned on and off. These discussions resulted in the focused codes listed in Table 1, which were clustered into the key categories that underpin the model developed as an end product of the research (see Fig. 2). It centres on the overarching concept to emerge from the analysis - the flow of compassionate care. This represents an ideal way of being that is associated with the aspirations of HCPs, the expectations of patients and is generated within a healthcare system. Key categories contributing to this overarching concept include professional compassion, which is affected by drainers and defenders. We will describe each of these key categories, and their contribution to the compassionate care flow, along with illustrations from the data, before commenting on the implications of our findings for practice and policy.
Fuelling the flow through professional compassion
Compassion itself was described by participants as innate and a driver to undertaking a career in healthcare. However, several people used the qualifier ‘professional’ when talking about compassion in the workplace. Professional compassion was said to be exhibited by good communication, being alert to patients’ needs and small acts of kindness. It appeared to be part of participants’ job-related repertoire, alongside medical skills and knowledge. As a workplace experience, professional compassion was described as involving some degree of learning from peers (e.g. watching how others behaved, discussing clinical encounters informally or in supervision). It was depicted as functional, being used to improve people’s health by helping staff to connect with patients to build a rapport with them in order to promote good self-care. Similarly, it was painted as a tool that enabled HCPs to be patient-centred:
FG2 P2: “You can be professional and kind of just get through it and then compassion kind of makes you an individual, it makes that person feel like they are an individual, so the care’s for them directly…”
Int 3: “I think it’s just trying to understand where that person is at the moment and what they are physically capable of and just saying to them…in the ideal world this, this and this should happen but actually today we’ll concentrate on this one element. It’s about developing that relationship.”
Sometimes participants provided what was described as “tough love” (FG4 P5), including the use of “scare tactics” (FG4 P3) (e.g. emphasising what medical problems might befall patients). Adopting such an approach was still seen as professional compassion by most because it was driven by a wish to prevent future medical problems. This highlights that although professional compassion could be spontaneous, occasionally it was a more conscious encounter, requiring effort:
Int 4: “Some days you have to physically think about doing it [compassionate care]. Most of the time I would suggest, or I hope that it just comes naturally…but I think tough times maybe you have to think to yourself OK…those groups of patients that very much have done it to themselves, through their lack of own self-care. It’s about supporting them through that realisation because they do get it in the end but think damn, I’ve done this to myself and then people get angry and I think it’s really important then to sort of show them…that’s where real compassion comes.”
In sum, professional compassion represented a work-based standard. It was something that individuals employed to facilitate their interaction with patients and to improve people’s health. It prompted them to do their best for a patient and, in that sense, energised the compassionate care flow. Professional compassion was likewise sustained by sensing that compassionate care had been delivered by them (e.g. when a patient thanked them for their work) or by their colleagues, suggesting that a feedback loop was at play (see Fig. 2):
Int 5: “I feel appreciative at work, if a colleague…gives me good feedback about a patient who may have given good feedback about me to them…I’ve felt satisfied from a professional point of view…it makes you appreciate that actually you try to do a good job and I think that receiving compassion enables you and it motivates you more to give compassion back…”
This feedback loop could be fractured by a range of factors that made individuals question whether what they were doing was worthwhile or sustainable. As outlined in the next section, if they felt overwhelmed and unable to contain their anxieties or frustrations, it threatened to damage the compassionate care flow.
Drainers puncturing the flow of compassionate care
The flow of compassionate care could be affected by the presence of what we have defined as drainers, which stifled the ability to express professional compassion. They came in a range of guises. For example, although eliciting and addressing patients’ needs was alluded to when participants discussed compassionate care, this could be impeded by a lack of rapport; when patients were perceived as dismissive or demanding or overly dependent on HCPs, there was a sense of compassionate care depleting:
FG3 P1: “We get people coming in and shouting at us. Not often, not often, but we do and that can be quite hard and it’s quite hard to feel compassionate to someone when they’re yelling at you…”
Compassionate care was similarly said to diminish when faced with someone who did not alter their health behaviours and engage in self-care. Interactions with such patients did not replenish the compassionate care flow because staff felt a lack of positive feedback from doing a good job; instead, they could believe they were failing in their professional role:
Int 1: “If someone comes in saying I’m not really interested in any of this, I don’t need it then the passion goes out and I, I sort of like do the minimum…I remember vividly wanting to walk away from nursing…because I couldn’t get it right. So I really felt that I was failing people… I think this is actually quite key in terms of compassionate care because you can deliver, you keep giving and then sometimes you don’t see the results, so you can’t see success…”
Int 2: “… [you feel] you’ve not been effective in being able to convince them to change things to prevent a diabetic complication that’s irreversible…personally it’s a difficulty sometimes because I feel I have personally failed…”
The system within which participants worked could be another drain on their expression of professional compassion and, therefore, the flow. Time pressures in particular (e.g. only having 10 min appointments) left HCPs feeling unable to connect with a patient because of insufficient opportunities to sit back, listen and reflect on what someone was saying. This lack of time was compounded by the following competing demands that diverted energy away from activities that contributed to compassionate care: increasing caseloads, lack of privacy to discuss things on a ward, chasing targets, completing paperwork/logging data on a computer, being short staffed, fear of litigation. The following data extract illustrates this point:
FG4 P1: “I think you’re expected to do more and more in your time slot. You have thrown at you all the time about litigation and your notes…you’re there ultimately for patient care and it can be really frustrating that everything else gets in the way, having to put your mileage on and sort it…
FG4 P8: …time constraints and various other pressures, it doesn’t alter your level of compassion. It just, it might be squeezed a little bit. It’s a bit squeezed.
FG4 P5: The more they put on us, the less we’ve got to give out.”
Working under such competing demands could mean the patient’s agenda was lost according to participants, blocking the compassionate care flow by jeopardising professional compassion in terms of being patient-centred. There was also a danger of HCPs becoming desensitised to others’ distress and executing tasks by rote. One participant (Int 11) noted being pulled in two directions – having to tick boxes and audit her work whilst bearing in mind that for the patient, receiving and living with a diagnosis of diabetes was life changing. Another participant suggested that this split started early in her professional career:
Int 12: “…medical school punctures the compassion out of you …I remember my first two years I did 74 exams in various different subjects…you get tired and then, you don’t talk to people out of intrigue of their life, you talk to people to get a history, to get a diagnosis…Actually we’re talking about people and illnesses and that’s not stressed at med school.”
A further factor that could impede HCPs’ ability to focus on the person in front of them was the presence of personal stressors (e.g. family illness, problems in their relationship), although one participant was clear that this should not interfere with how a patient was treated:
Int 4: “…it’s difficult to come to work if you’ve had things happen at home. You might not always feel very kind…I’d just ignore the personal life until I got home. If I couldn’t do it I wouldn’t come to work…it’s not their fault something might not be OK somewhere else.”
Defenders of the compassionate care flow
In contrast to drainers, defenders reinforced the compassionate care flow by upholding professional compassion (see Fig. 2). Defenders included acknowledging the reality of patients’ circumstances (e.g. diabetes as a lifelong, difficult condition to regulate) and being curious about someone’s behaviour in order to connect and be with that individual rather than taking a defensive or detached stance. It might call on HCPs to suppress negative emotions:
FG2 P3: “…patients are all different and some you will just bite your lips with because…they are here, treating us like servants…”
Int 7: “I might have seen a lady in clinic and she hasn’t really got that much to worry about but to her it is such a big deal and it’s very hard cause I feel like I have to bite my tongue cause if I look at what I see other people going through and they’re coping, it’s very hard not to say or not to feel frustrated…”
This seemed easier to do with more experience in the role and participants noted that over time their view of what constituted compassionate care was affected by a better understanding of patients as people:
FG1 P1: “I think respect for patients. Treat them as people rather than diseases is one thing because you can get carried away with this type 2 diabetes, hypertension, obesity and you start treating that rather than the person.”
Int 2: “I’ve come to recognise we can make small strides and where we make them we should celebrate but also recognise that two steps back doesn’t mean it’s going to be 3 and 4 steps back, that actually we can, that might just be a temporary blip and then finding what motivates that person onwards.”
Data indicated that personally identifying with a patient’s situation could bolster the flow of compassionate care by supporting professional compassion through focusing on the individual’s needs. This might involve HCPs contemplating how they would want a loved one to be treated and admitting that they also found adopting healthy behaviours difficult. It was said to be helpful to reflect on one’s limitations to engender change in patients and not be self-critical. This ability to avoid blaming oneself seemed to be another skill that developed with experience; when first qualified, participants recalled expecting to make a difference to the health of each person they cared for, but became more pragmatic overtime. A couple of HCPs did talk about deciding to perceive patients who seemed to lack motivation to self-care as a welcomed challenge, which enabled them to continue providing professional compassion:
FG4 P1: “…there’s been the odd few where I’ve thought you are difficult, I’m struggling with you but in the end you really, cause when you do get them to open up you understand why they can be difficult. Some of the like cantankerous old men can really become my favourites.”
Autonomy in the workplace facilitated compassionate care according to several participants; it let them plan their own timetable and extend their contact with a patient, if required, to develop a rapport that was linked to professional compassion. Likewise, drawing on supportive colleagues helped with upholding the flow because when individuals felt they had engaged in a difficult consultation, they were able to vent with team members or could seek their advice on how to proceed. If a clinical interaction was becoming too fractious or unproductive, the patient could be transferred to a colleague rather than risking the flow of compassionate care collapsing. For this support to be realised, participants emphasised the importance of belonging to a team that saw the humanity of staff and showed compassion towards providers of care. In this respect, work culture was noted as assisting with the compassionate care flow by having positive role models and a supportive organisation:
FG1 P6: “…if everybody around you is compassionate, it’s natural to be compassionate, whereas if everybody around you isn’t then it’s quite difficult to be the only one in that group.”
Int 8: “…[the Trust] needs to think about duty of care to staff because…it can impact on the clinician because they can’t do a good job, they’re not achieving results they should be achieving…So there does need to be some compassion there and understanding.”
Three participants talked about being inspired by their faith to remain compassionate in the face of drainers outlined above, seeing compassion as fundamental to their religious beliefs. In addition, being humble could buttress the flow of compassionate care. This was described as providing compassion as a professional, with no expectation of anything in return. Accepting that lapses in practice could occur and striving to put these right was another example:
Int 5: “…I was getting a call from reception saying a patient’s kind of kicking off, threatening to sue you…because you were running late and I was like OK, so when the patient came in I just greeted the patient, he had a few words to say and I apologised, explained to him the situation and then his whole tone, the whole tone of the situation just changed and actually he left the consultation shaking my hand and thanking me, happy, positive.”