Nursing is often viewed as an altruistic profession that requires commitment and compassion. Although nurse education consists of a strong evidence base, Crane and Ward (2016) suggested that it is a nurse's intrinsic desire to help people that draws them to the profession. Nurses are usually acutely attuned to the physical and mental health needs of patients but are not always as good at applying the same values and efforts to themselves. If this goes unchecked, it can lead to negative impacts for nurses, both occupationally and on the nurse's wider wellbeing. Compassion fatigue and mental health difficulties can negatively affect the nurse's ability to provide optimum patient care and, in the most extreme cases, may lead to prolonged periods of time off work, career changes or severe mental health difficulties, including leading to suicide (National Confidential Inquiry into Suicide and Safety in Mental Health, 2020). Alongside the personal and psychological costs of caring for the individual nurse, there is also the impact of compassion fatigue on the institution. There is a significant financial cost to institutions of having nurses who have low levels of job satisfaction and high levels of compassion fatigue. Therefore it is imperative that hospital managerial teams develop infrastructures to support employees (Cavanagh et al, 2020).
The impact of COVID-19 on the health service has been well documented and has exposed the psychological burden faced by nurses and other healthcare workers (Brooks, 2020; Highfield et al, 2020; Kendall-Raynor, 2020; Lai et al, 2020; Maben et al, 2020). Within the literature this is often referred to as vicarious or secondary trauma (McCann and Pearlan, 1990). Secondary trauma has been identified as the leading cause of burnout, compassion fatigue and staff retention problems. The longer secondary trauma goes unprocessed, the harder it becomes to care for the self and others (Harris and Griffin, 2015).
Research on the concept of secondary trauma among student nurses is limited, although there is an acknowledgement that providing care in the capacity of a learner can be emotionally challenging (Jack, 2017). Now, more than ever, there is a need to understand how secondary trauma impacts on the student nurse's emotional and psychological wellbeing. This is crucial so that educators can develop strategies to prevent compassion fatigue among student nurses and prevent the negative impacts on the healthcare system due to learners leaving the profession (van Mol et al, 2015; World Health Organization (WHO), 2020a; 2020b).
In order to explore the concept of secondary trauma further within the student nursing workforce, a sequential exploratory mixed methods research project was undertaken by the authors to explore professional quality of life in nursing students. Themes emerging from the research included the impact of providing care during the COVID-19 pandemic, the psychological impact of caring and experiences that shape learning. These themes were also echoed in research undertaken that explored the psychological cost of caring on the HIV nursing workforce (Piercy et al, 2022). The research findings, alongside the existing evidence base on secondary trauma, compassion-focused therapy and post-traumatic growth (Gilbert, 2010; Van Der Kolk, 2015; Neff and Germer, 2018; Schwartz, 2020) was used to develop a 6-week programme that explores resilience development through a compassion-focused approach to developing self-compassion.
Compassion-focused therapy (CFT) is a psychotherapy approach developed by Professor Paul Gilbert (2010) that integrates concepts from cognitive behavioural therapy, evolutionary psychology, developmental psychology and neuroscience. It focuses on themes of shame and self-criticism, which can be associated with high levels of distress (Gilbert, 2010).
The central therapeutic technique of CFT is compassionate mind training, which teaches the skills of compassion and self-compassion. Compassionate mind training helps transform problematic patterns of cognition (thoughts) and emotions, such as anxiety, anger and shame, which are often related to thoughts such as self-criticism, into less distressing emotions. CFT aims to understand basic emotions and their purpose from an evolutionary perspective, using the three systems model of emotional regulation (Gilbert, 2010).
What is the difference between compassion-focused therapy and cognitive behavioural therapy?
Cognitive behavioural therapy (CBT) is primarily focused on thinking and behaviour change, CFT looks at the emotion behind people's thoughts.
What is the three systems model?
The role of emotional regulation is a central principle in CFT and can be used to help us understand and manage our inner world. The three systems: drive, threat and soothing, have evolved to help us survive a difficult world. The drive system activates us to find food, shelter and sexual partners, all very important for our survival. It also drives us to accomplish goals and is associated with feelings of joy and positive energy. The threat system signals danger, and is designed to protect us by responding to potential risk. It is associated with feelings of anxiety, anger and disgust, which function to keep us alert and safe. Whereas the threat system activates our survival mode (fight, flight, freeze), the soothing system encourages us to rest, digest and form nurturing bonds. It is associated with feeling connected and safe, slowing our physiology down.
The three systems interact with each other, with external and internal events triggering activation, meaning one system can become dominant. Which one is dominant will be dependent on the circumstances and the individual's internal response to it (Gibson et al, 2021). Ideally, these systems are flexible with each other and there is a general sense of balance. However, the threat system is particularly powerful, designed to overpower the others, prioritising instinctive responses to danger and blocking rational thought. Often in health care we become out of balance, with threat and drive systems becoming dominant in response to work stressors and internal and external standards and expectations. This can make it difficult to access the soothing system to restore equilibrium.
Self-compassion in health care
Self-compassion theories are heavily influenced by CFT and compassionate mind theories but have their own theoretical and evidence base (Neff et al, 2020). Self-compassion is a practice where we learn to become a good friend to ourselves when we need it the most. Through self-compassion we learn to become our inner ally rather than our inner enemy.
The core elements involved in the definition of self-compassion are self-kindness (loving), common humanity (feeling connected) and mindfulness (presence), which can be accessed when in emotional pain. Self-kindness enables us to be less judgemental about mistakes and failures, and replaces ‘beating ourselves up’, with ‘putting a caring arm around our own shoulder’. Common humanity provides a sense of interconnectedness, a central component in recognising all humans are flawed and fallible ‘works in progress’, making mistakes and experiencing hardship. Mindfulness prevents our minds from moving backwards (ruminating on past difficulties) and forwards (worries about the future) in time, enabling us to be aware of moment-to-moment experience. This allows us to accept and process our current reality and the impact that may be having on our emotional world, which is beneficial for wellbeing (Orzech et al, 2009; Neff and Germer, 2018).
Theory, research and practice of self-compassion in practice
A leading researcher in the field of self-compassion, Kirsten Neff, examined the efficacy of the Self Compassion for Healthcare Communities (SCHC) programme (Neff et al, 2020) for enhancing wellbeing and reducing burnout among health professionals. The research found that individuals who are very hard on themselves are more likely to benefit from self-compassion training. The research highlighted that what appears to be most needed are easy, practical self-compassion tools that health professionals could use on the job to help them deal with stress.
Further research exploring self-compassion in nursing demonstrated a positive correlation with emotional intelligence (Heffernan et al, 2010; Senyuva et al, 2014) linking self-compassion with an increase in compassion for others (Neff and Germer, 2018). Thus, self-compassion has been demonstrated to be a protective factor for empathy and has implications for care delivery and professional quality of life (Durkin et al, 2016).
Based on the self-compassion research evidence within the healthcare setting, the authors were keen to develop an online learning package that was underpinned by these theories, to establish if they could improve outcomes in relation to wellbeing, retention and compassion satisfaction for nurses.
Developing an online programme to enhance self-compassion
The overall aim of the online self-compassion programme was to advance the health and wellbeing of the nursing workforce through developing proactive evidence-based preventive teaching and learning strategies to promote compassion satisfaction and prevent compassion fatigue by improving self-compassion.
Throughout the programme the learners are encouraged to develop their own self-compassion tool kit based on the resources provided. The ethos of the programme is clear from the start, in that we are not saying that it is acceptable for healthcare workers to be underpaid, overworked or experience secondary trauma. It is also made clear that the emphasis on developing resilience is not solely the responsibility of the nursing student/nurse and that the course is not designed to make them feel guilty about how they may have coped in the past. The aim is to equip them to better care for and protect themselves in an emotionally challenging work role and environment.
On successful completion of the programme, the learner will be able to define self-compassion, explore some common myths about self-compassion and consider the benefits of self-compassion, when building the foundations of high-quality practice. Learners will also be able to describe the science of self-compassion by exploring the underlying theory alongside the current evidence base. The overall aim of the programme is to help learners develop strategies to enable the implementation of self-compassion with a view to developing and growing compassionate practice.
Over the 6-week programme learners will be encouraged to develop knowledge, awareness and resources around topics such as the physiology of self-compassion, managing difficult emotions, resilience and developing self-compassion in health care. Sessions within the programme use a variety of different teaching and learning strategies such as asynchronous teaching periods (lasting between 20 and 30 minutes), reflection points, audio recordings and activities to engage the learner, such as developing as a compassionate friend to themselves or to others.
In order to establish the effectiveness and acceptability of the programme an evaluation has been built in to the course to review how it meets the learning outcomes, the impact upon the lives of nurses taking the course and to highlight any financial benefits for the employing organisation accrued as a result of the course. Although developed with nurses in mind, the course could benefit the wider healthcare workforce, given the shared stressors and experiences across clinical roles.
The authors have run tests and a small pilot with some of the course material. The course will be launched by the National HIV Nurses Association (NHIVNA), with a pilot study involving the HIV nursing workforce planned for early 2023. Information on the course will be available on the NHIVNA website later in the year (https://www.nhivna.org).
There is an increasing need to develop a resilient nursing workforce to minimise the impact of stress, compassion fatigue and burnout that is contributing to the snowballing workforce crisis, compounded by the recent COVID-19 pandemic. The pandemic's impact on healthcare services and those delivering the care has been unprecedented. A rapidly growing body of evidence indicates the enormous associated psychological burden on nurses and other healthcare workers, which is resulting in high levels of wellbeing problems. These will have profound effects on individuals and have long-term ramifications for healthcare systems. Effective interventions that can counter the adverse psychological effects of caring during the COVID-19 pandemic and beyond are urgently required.
Self-compassion training programmes and resources may help health professionals cope with job stress in a way that increases wellbeing and reduces compassion fatigue and burnout. Research has demonstrated that self-compassion training programmes significantly increased compassion satisfaction and feelings of personal accomplishment, allowing participants to retain a sense of meaning and value in their work (Neff et al, 2020). The proactive support of resilience development though self-compassion has the potential to prevent compassion fatigue within a workforce with care at its heart.
- Over the past couple of years there has been increasing interest in the psychological and emotional burden experienced by nurses, particularly after the COVID-19 pandemic
- Within the literature, self-compassion training has been highlighted as a way to enable nurses to deal with the stress and emotional impact of the job
- A self-compassion course was created by the authors to support and enhance the wellbeing of the nursing workforce
CPD reflective questions
- Think about what compassion means to you
- Take a moment to consider how you speak to yourself. Is it in a positive or negative tone or is it a mixture of both?
- What do you think the key challenges are for healthcare workers when accessing training such as self-compassion or compassionate minds training?