The science of kindness
Monday, 22 July 2019
VetScript Editor's pick - July 2019
Compassionate care can make all the difference, whether the patient is human or animal. Natalie King and Jenny Weston of Massey University’s School of Veterinary Science report back from the 2019 Compassion in Healthcare Conference.
In mid-March, we attended the Compassion in Healthcare Conference hosted by the University of Auckland Faculty of Medical and Health Sciences. This was the first such conference held in New Zealand and only the second in the world. It sold out two months in advance, an indication of the level of interest among healthcare professionals. The Christchurch mosque shooting occurred on the eve of the conference, adding a sense of poignancy to the occasion.
Tony Fernando and Nathan Consedine from the Department of Psychological Medicine opened the conference with a discussion about the difference between empathy and compassion. Empathy is defined as recognising another being’s emotional state and understanding what they are feeling; it can be potentially distressing for the healthcare professional if they take on the other person’s emotions. Compassion is not only recognising suffering in another, but wanting to alleviate it, which can be achieved without becoming burdened by the emotions of others. Each is regulated by different areas of the brain.
For human patients, receiving compassionate care results in better health outcomes, both physically and mentally. Robin Youngson, an anaesthetist world renowned for his work in compassion in healthcare, pointed out that experiences, beliefs and internal stories can actually change our gene expression, altering health outcomes. Compassion is also central to patient values and satisfaction.
Through interviewing hospice patients, Tony Fernando identified that the components of compassion include connection, warmth and presence, respect, and caring. He made the point that compassion is a free service and makes a huge difference.
It is not only patients who benefit from compassionate care, but also the healthcare professionals who provide it. Compassion decreases burnout and improves work-related enjoyment and motivation. We hear a lot about compassion fatigue, but the presenters suggested that the concept is not a useful way to think about compassion in healthcare, as it is possible to be compassionate without becoming emotionally drained.
A variety of factors influence the level of compassion exhibited among healthcare professionals, including physician factors, clinical factors, patient and family factors, and environmental and institutional factors. Patient factors are the best predictors of compassion. Notably, we are more likely to show compassion towards people who are ‘like us’ or who are likeable. Another factor is the work environment. It is more difficult for people who are under pressure or stressed to provide compassionate care. The challenge of providing compassionate care while working within the confines of the public health system was a recurring theme during the conference. Tony suggested that compassion (or the lack thereof) is a systemic issue and needs systemic solutions.
Anne O’Callaghan, a palliative medicine specialist, added to the definition of compassion, suggesting it was tenderness that has an enduring impact, and highlighted that communication and compassion are closely linked. However, she recognised that health professionals don’t always communicate compassionately with each other in the workplace. In her PhD research, she found that the attributes of the teams in which they worked greatly influenced the ability of junior doctors to thrive, and also affected the patients they were caring for. She called these team environments relational landscapes and identified four different relational landscapes: engaging, good enough, undermining and disabling. She used the following example to illustrate.
During rounds, a senior consultant asks a newly graduated doctor to order a scan. However, the junior doctor does not understand exactly what the scan is for. Possible scenarios in each of the relational landscapes are as follows:
- Engaging – the junior doctor can ask the consultant during rounds.
- Good enough – the junior doctor may be able to find someone else to ask later.
- Undermining – the junior doctor may not feel they are able to ask anyone.
- Disabling – the junior doctor may be mocked or humiliated for asking.
A key point was that people quickly learn the cues of whichever relational landscape they find themselves in and adapt to fit in, allowing the cycle to continue for better or worse. The relational landscapes in healthcare were found to be determined by team philosophies. Where they were based on providing services (eg, primarily concerned with throughput of patients), the relational landscapes tended to be undermining or disabling. This was in contrast to where teams were driven primarily by a sense of ‘healthcare as healing’. With this mindset, there was more of a tendency towards the engaging or good enough relational landscapes.
In an effort to engage hospital staff in beneficial collegial discussion, Manaakitia Reflective Rounds have been introduced at Auckland Hospital, open to everyone who works there. During the rounds, participants volunteer to speak briefly about something very difficult or beautiful that they have encountered in their work, then the group discusses the experience. Rather than being clinical rounds situations, the sessions focus on emotions and how complex emotional situations related to patient care affect the people who care for them.
In a pilot study conducted at Auckland Hospital (Shah et al., 2017), participants reported a number of positive benefits, and 97% indicated that they intended to attend the reflective rounds again. The authors concluded that a significant benefit of reflective rounds was for staff to experience a shared understanding in a safe space and the realisation among participants that they are ‘not alone’ in their feelings and that other people find themselves in similar difficult and complex situations. A previous study carried out on reflecting peer support groups and the prevention of stress and burnout (Peterson et al., 2008) found that sharing experiences gave people positive validation, a sense of belonging and feelings of solidarity, helped them gain knowledge and coping strategies, and increased self-confidence. Reflective rounds facilitated connection and laid a foundation for self-compassion.
Health psychologist Anna Friis talked about self-compassion and how a lack of self-compassion can lead to burnout and dissatisfaction. Self-compassion was described informally as “treating ourselves with the same kindness we’d treat a dear friend when things go wrong”. She pointed out that people with greater self-compassion than others experience less depression, anxiety, psychological distress, self-criticism, maladaptive perfectionism, rumination, suicidal ideation and shame. They also tend to experience better health behaviour, greater emotional intelligence, better coping skills and greater life satisfaction. In addition, greater self-compassion leads to decreased compassion fatigue, increased compassion satisfaction and personal resilience. The good news is that self-compassion can be trained relatively easily through psychotherapy, structured mindfulness and compassion training programmes.
It wasn’t difficult to recognise the similarities between the issues faced by human healthcare and veterinary professionals and the role compassion plays in providing veterinary healthcare. As veterinarians we need to provide compassionate care for the animals who come into our care, but also for the people who care for them. Indeed, it is a key aspect of providing quality veterinary care and avoiding client complaints. A few days before the conference, Sarah Heath, a world-renowned veterinary behaviourist, presented a seminar at Massey University on the link between physical and mental wellbeing in animals. Some of the ideas that came through at the conference gelled nicely with those concepts. Sarah outlined how physical disorders in animals can lead to emotional disorders and vice versa. Emotional disorders in animals can influence their perceptions of pain and their predisposition to physical disorders. She pointed out that animals who are stressed at the point of induction of anaesthesia are at greater risk of developing chronic pain. Caring for them compassionately at this time (perhaps ensuring adequate premedication and using stress-free handling techniques) may influence their long-term health and wellbeing.
Similarly, Robin Youngson reported that for human patients, a supportive pre-op visit with the anaesthetist halved the dose of opiates required post-operatively and led to better wound healing and surgical outcomes. While caring for our patients in the best way possible is always at the forefront of our minds, recognising the long-term effects of providing compassionate care in that moment for our animal patients, for the people who care for them and for ourselves further impels us to act with compassion.
It is notable that compassion needs to extend beyond our patients and their owners to our colleagues and ourselves. General surgeon Pat Alley suggested that a good place to start is to assume that everyone is aiming to do the best job they can and to make the effort to ensure our reflective thoughts are positive.
The conference was a great success and presented some of the science behind compassion and the roles of compassion in caring for patients, our colleagues and ourselves. If you are interested in knowing more, the world’s first summit on the ‘Science of Healing’ is planned for Hamilton in November 2020.