Compassionate care is defined as ‘a deep feeling of connectedness with the experience of human suffering that requires personal knowing of the suffering of others’ (Peters, 2006: 38). Dewar et al (2011) conceptualised compassionate care in terms of the relationship that exists between vulnerable human beings that must be nurtured so that one person perceives the vulnerability of the other person and responds to it in a meaningful way.
Effective leadership is vital to the delivery of safe, high-quality, and compassionate health care. In contrast, the lack of compassionate leadership has a negative impact on healthcare outcomes and quality (McSherry and Pearce, 2016). This was highlighted in two key reports in the UK, namely Kirkup's (2015)Report of the Morecambe Bay Investigation and the Report of the Mid Staffordshire NHS Foundation Trust Inquiry (Francis, 2013). Within these reports, the failure of several nursing leaders in their role and responsibility to care was identified as one of the key contributors to detrimental, neglectful and systemic failures to safeguard a culture of safety, quality and compassion (McSherry and Pearce, 2016). Therefore, the importance of promoting patient-centred compassionate leadership in health care was emphasised (Francis, 2013; Kirkup, 2015).
Literature review
Coffey et al (in press) conducted a mixed-method systematic review to summarise evidence from 15 studies aimed at preparing nurses to lead on and/or deliver compassionate care. Studies reviewed were published between January 2007 and February 2018 and sourced from four electronic databases: CINAHL, Medline, PsycINFO, and SocINDEX. The methodological quality of the included studies and the risk of bias per study outcome were measured and varied between weak and strong.
It was found that training and educating nurses and midwives to become leaders in compassionate care delivery yields positive patient outcomes (Coffey et al, in press). For instance, in a pilot pre- and post-test study, Day (2014) explored the impact of a number of aspects:
It was found that the incidence of pressure ulcers and falls dropped to zero and the overall experience of patients was improved at 3 months post-test (Day, 2014). Another intervention that yielded positive patient outcomes was delivered in the form of emotional touchpoints (ie coming into hospital, going for tests, mealtimes, and so on) and associated negative and positive emotional words (Dewar et al, 2010). These were written on cards that were distributed to patients (n=16) and their relatives (n=12). Participants reported that the touchpoints enabled them to get in touch with the positive and negative aspects of their experiences and strengthen their relationships (Dewar et al, 2010).
Compassionate care leadership education was also found to impact positively on nurses. Overall, there was a consensus across the reviewed studies regarding the positive role of compassionate care leadership education in increasing nurses' sense of pride and ability to reflect on practice, handle challenging situations, and gain confidence to lead compassionately (Coffey et al, in press). Positive outcomes were linked to various factors, such as involving nurses from all levels in compassionate care leadership education (Bridges et al, 2017), and promoting a culture of compassionate care within healthcare organisations (O'Driscoll et al, 2018). This helped increase nurses' commitment to offer compassionate care, gave them a positive outlook regarding their role as leaders, and contributed to improving the patient experience (Zubairu et al, 2017). For instance, Dewar and Cook (2014) found that nurses who attended a 12-month leadership programme on compassionate care delivery reported that nurses gained heightened self-awareness, better relationships with colleagues, and greater ability to reflect on practice. Similarly, Masterson et al (2014) found that a compassionate care programme titled ‘Enabling Compassionate Care in Practice’ successfully increased nurses' knowledge, understanding, and application of the 6Cs (care, compassion, courage, competence, communication, and commitment).
The Leaders for Compassionate Care Programme
In England, the Department of Health (2015) stressed the importance of compassionate care leadership, education, and training. Similarly, the Health Services Executive (2015), which is the main provider of public health and social care services in Ireland, has care and compassion embedded in its core values and emphasises the need to facilitate nursing and midwifery leaders to serve as advocates for compassionate care delivery (National Leadership and Innovation Centre for Nursing and Midwifery, 2017). As a result, the ‘Leaders for Compassionate Care Programme’ (LCCP) was implemented.
The LCCP was a development programme for nursing and midwifery leaders facilitated by the Florence Nightingale Foundation in the UK and launched in Ireland in July 2015. This programme provided experienced and front-line nursing and midwifery leaders with time away from their organisations where, together with other leaders from a wide range of services and specialties, they participated in their own and each other's leadership development (Florence Nightingale Foundation, 2015). The LCCP provided several opportunities for leaders to learn about patient-focused quality improvement and compassionate leadership. The goal was to empower leaders while supporting their teams in delivering high-quality and compassionate patient-centred care. The LCCP was offered over 3 days, grounded in experiential learning, and highly interactive. On the first day, leaders were introduced to each other and to the facilitators. The first session explored what ‘leading for compassionate care’ meant to the leaders and aimed to elicit responsibilities and challenges faced in everyday practice. The second session was conducted in groups and aimed to explore the concepts of presence and personal impact. The first day included three plenary sessions that discussed topics emerging from the conversations and linked leadership to compassionate care delivery.
During the second day, leaders were divided into two groups; one was introduced to quality improvement and equipped with tools and techniques to improve patient care and the other to co-consulting in order to build their leadership practice experience and get to know their learning partners. This was followed by the administration of the Myers Briggs Type Indicator personality inventory and a plenary session discussing the programme and arrangements for the third day.
The third and final day took place 6–8 weeks following the first 2 days. This day began with a postcard exercise, whereby various images were displayed on cards and leaders were asked to select two; the first card to symbolise what had been going on for the leaders since the first day of the LCCP and the second card what they hoped to gain from the third day. This was followed by an informal session on managing change during which leaders shared examples of changes that they have implemented following the LCCP and discussed the impact of the LCCP on their clinical practice.
The evaluation
This study measured the perceptions of nursing and midwifery leaders regarding the impact of the LCCP on their personal development, learning experience, service and care delivery, programme quality, and satisfaction with the programme. Six programmes (each with approximately 30 nursing and midwifery leaders) were delivered between October 2015 and July 2016. Participants were recruited directly through the seven geographically dispersed Hospital Group Chief Directors of Nursing and Midwifery in Ireland (National Leadership and Innovation Centre for Nursing and Midwifery, 2015). All the leaders who completed the 3 days of the LCCP (n=168) were invited to participate in this study.
A cross-sectional descriptive survey incorporating a modified retrospective pre-test design was used (Allen and Nimon, 2007). This was deemed most appropriate to determine the participants' perceptions and experiences of the programme. In addition, this design has utility when pre-test data are not available to assess change at post-test (Hill and Betz, 2005).
Ethical approval to conduct the study was obtained from the Clinical Research Ethics Committee and participants provided written informed consent. Data were collected between November 2016 and March 2017. Participants were provided with the option of either returning the questionnaire by post or responding via the web-based survey platform SurveyMonkey. This strategy is known to yield higher response rates (Funkhouser et al, 2017). Postal surveys, web-based surveys, and two e-mail reminders were sent by the organisation that offered the LCCP, rather than the researchers. This approach was an attempt to maintain participant confidentiality and minimise intrusion. Fifty-four electronic and 25 postal surveys were completed, yielding a sample size of 79 participants (47% response rate).
Data were collected using a structured questionnaire that was developed based on instruments previously used to evaluate the impact of educational programmes for nurses (Drennan, 2012; Hyde et al, 2016). Participants' demographic and professional data were gathered using six items. The Leaders for Compassionate Care Outcomes Evaluation Questionnaire (LCCOEQ) contained 35 items based on course content that measured outcomes related to four domains of leadership practice: understanding of context, introduction to skills in quality improvement and management of change, personal development, and relational development. The Leaders in Compassionate Care Experience Questionnaire (LCCEQ) contained 34 items and measured the participants' experiences and satisfaction with course organisation, teaching, and workload. LCCEQ was developed based on the Course Experience Questionnaire (Byrne and Flood, 2003).
Data were entered into IBM SPSS Statistics and analysed using descriptive and inferential statistics. Data from LCCOEQ were not normally distributed; therefore, the Wilcoxon signed-rank test was used to compare the participants' scores before and after the programme. The Bonferroni correction 0.25 was used as the critical level of significance to prevent against the possibility of a type 1 error (a=0.25). The items comprising the LCCEQ were summated into eight scales measuring participants' experiences of good teaching, appropriate assessment, preparation to lead compassionate care, workload, teaching support, programme organisation, infrastructure, and satisfaction. In order to interpret and standardise scores across the LCCEQ, the mean item scores were based on a linear transformation and were re-coded to range from 0 to 100, with higher scores indicating greater satisfaction.
Participant characteristics
All but one participant were female. The mean age of participants was 46.09 years (SD=6.9). Participants reported that, on average, they had been qualified as nurses/midwives for 23.52 years (SD=7.5). The majority of participants were clinical nurse and midwife managers (93%, n=73). Participant characteristics are presented in Table 1.
| Characteristic | n (%) |
|---|---|
| Age (years) | |
| Range | 32–60 |
| Mean (SD) | 46.09 (6.9) |
| Gender | |
| Female | 78 (99) |
| Male | 1 (1) |
| Education | |
| Certificate | 12 (15) |
| Diploma | 8 (10) |
| Higher/postgraduate diploma | 29 (37) |
| Bachelor's degree | 12 (15) |
| Master's degree | 15 (19) |
| Other | 3 (4) |
| Years qualified | |
| Range | 8–40 |
| Mean (SD) | 23.52 (7.5) |
| Current role | |
| Clinical nurse/midwife manager | 73 (93) |
| Clinical nurse/midwife specialist | 3 (4) |
| Assistant director of nursing/midwifery | 2 (3) |
| Advanced nurse/midwife practitioner | 1 (1) |
| Clinical area | |
| Obstetrics and gynaecology | 15 (19) |
| Surgical | 11 (14) |
| Medical | 9 (11) |
| Haematology/oncology | 7 (9) |
| Emergency care | 6 (8) |
| Orthopaedics | 5 (6) |
| Others | 26 (33) |
Personal development, learning experience, service and care delivery
Out of a maximum score of 7, participants' perceived ability to show respect in their interactions with people increased significantly following the programme (mean before 5.86, SD=1.25 versus mean after 6.78, SD=0.44; P≤0.001). In addition, their perceived ability to demonstrate consideration and empathy in communicating and interacting with people showed a significant increase after the programme (mean before 5.56, SD=1.30 versus mean after 6.63, SD=0.74; P≤0.001). Participants made significant gains in all items related to the development of leadership capabilities. Of particular note was the high level of change that participants perceived in relation to developing and understanding themselves as leaders; this was one of the lowest rated capabilities before the programme (mean 3.96, SD=1.31), but increased significantly afterwards (mean 6.22, SD=1.02; P≤0.001).
The development of leadership capabilities was also highly evident in the participants' perceived ability to apply leadership for quality improvement in practice (mean before 4.43, SD=1.40 versus mean after 5.91, SD=1.23; P≤0.001) and implement leadership interventions that are effective and grounded in best practice (mean before 4.47, SD=1.44 versus mean after 5.96, SD=1.25; P≤0.001).
Quality and satisfaction with the programme
Over 90% of participants agreed that they were able to apply what they had learnt on the programme in practice. Moreover, over 80% of participants reported that the programme had increased their motivation to lead on compassionate care, enhanced their ability to work as members of the multidisciplinary team, and equipped them with the skills needed to deliver compassionate care. The highest levels of satisfaction related to the support received from the programme facilitators; this was particularly the case in relation to linking theory to practice, communicating effectively, encouraging group work, and fostering critical thinking (>90%). Moreover, most participants agreed that the programme facilitators were good at explaining content (96.2%) and made the subject interesting (96.2%).
| Item | Before programme Mean (SD)* | After programme Mean (SD) | P value† |
|---|---|---|---|
| 1. Ability to show respect in my interaction with people | 5.86 (1.25) | 6.78 (0.44) | ≤0.001 |
| 2. Ability to demonstrate consideration and empathy in my communication and interaction with people | 5.56 (1.30) | 6.63 (0.74) | ≤0.001 |
| 3. Ability to be open in my communication with people | 4.81 (1.27) | 6.35 (0.89) | ≤0.001 |
| 4. Ability to recognise the fundamental worth of people | 5.47 (1.40) | 6.51 (0.86) | ≤0.001 |
| 5. Ability to assume authority | 4.43 (1.68) | 6.18 (1.01) | ≤0.001 |
| 6. Ability to develop and use skills to support peer learning | 4.46 (1.43) | 6.00 (1.21) | ≤0.001 |
| 7. Ability to develop and use skills to support problem solving | 4.48 (1.30) | 6.05 (1.12) | ≤0.001 |
| 8. Understanding myself as a leader | 3.96 (1.31) | 6.22 (1.02) | ≤0.001 |
| 9. Ability to work effectively in teams | 5.44 (1.19) | 6.46 (0.84) | ≤0.001 |
| 10. Ability to support change in practice | 4.90 (1.52) | 6.16 (1.16) | ≤0.001 |
| 11. Ability to apply leadership for quality improvement in practice | 4.43 (1.40) | 5.91 (1.23) | ≤0.001 |
| 12. Ability to support staff in leading compassionate care in practice | 4.77 (1.41) | 6.19 (1.12) | ≤0.001 |
| 13. Ability to reflect on the outcome of my individual actions | 4.51 (1.31) | 6.18 (1.01) | ≤0.001 |
| 14. Ability to implement leadership interventions which are effective and grounded in best practice | 4.47 (1.44) | 5.96 (1.25) | ≤0.001 |
| 15. Ability to promote multidisciplinary learning about leading change to improve overall quality of patient care | 4.57 (1.43) | 5.81 (1.44) | ≤0.001 |
| 16. Ability to promote cross-organisational learning about leading change to improve overall quality of patient care | 4.00 (1.52) | 5.46 (1.48) | ≤0.001 |
| 17. Understanding of the existence of individual learning styles and preferences | 3.94 (1.64) | 6.00 (1.21) | ≤0.001 |
| 18. An understanding that creative solutions and ideas emerge rather than being imposed from on high | 4.28 (1.61) | 5.91 (1.19) | ≤0.001 |
| 19. The ability to build trust with patients | 5.87 (1.21) | 6.47 (0.88) | ≤0.001 |
| 20. Understanding of different models of leadership particularly those that relate to quality, sustainable change and improvement | 4.03 (1.70) | 5.85 (1.26) | ≤0.001 |
| 21. The ability to enable staff to find their own way forward and their own solutions to problems as they arise | 4.24 (1.44) | 6.11 (1.05) | ≤0.001 |
| 22. An understanding of effective communication | 5.06 (1.45) | 6.33 (0.97) | ≤0.001 |
| 23. Ability to help a colleague learn more about a work issue that they find problematic so that they can think about how they might behave differently | 4.41 (1.34) | 6.06 (1.18) | ≤0.001 |
| 24. Ability to develop a relationship designed to help another explore what is problematic without telling them what to do | 3.90 (1.46) | 5.81 (1.20) | ≤0.001 |
| 25. Understanding of the concepts of care and compassion | 4.91 (1.48) | 6.34 (0.96) | ≤0.001 |
| 26. Ability to remain calm in potentially stressful or distressing situations | 5.33 (1.32) | 6.16 (1.03) | ≤0.001 |
| 27. Ability to manage staff conflict | 4.20 (1.30) | 5.76 (1.14) | ≤0.001 |
| 28. Ability to deal with difficult situations | 4.76 (1.32) | 5.92 (1.18) | ≤0.001 |
| 29. Ability to seek ideas and listen to different perspectives | 4.86 (1.27) | 6.05 (1.10) | ≤0.001 |
| 30. Ability to let staff sort out issues themselves rather than feeling the need to take the lead | 4.37 (1.57) | 5.89 (1.19) | ≤0.001 |
| 31. Ability to come up with ideas for change | 4.56 (1.42) | 5.84 (1.18) | ≤0.001 |
| 32. An understanding that healthcare systems are characterised by complexity, uncertainty and ambiguity | 4.56 (1.60) | 5.87 (1.23) | ≤0.001 |
| 33. Ability to consider the opportunities and challenges to providing care that is compassionate within your practice setting | 4.76 (1.50) | 6.06 (1.08) | ≤0.001 |
| 34. Ability to be patient, tactful and non-judgemental | 5.09 (1.37) | 6.24 (1.00) | ≤0.001 |
| 35. Ability to demonstrate a sensitive and compassionate approach to people | 5.65 (1.22) | 6.52 (0.78) | ≤0.001 |
| Scale | Min–Max* | Mean (SD) |
|---|---|---|
| Good teaching | 25–100 | 82.27 (14.45) |
| Teaching support | 37.50–100 | 81.54 (13.94) |
| Preparation to lead compassionate care | 25–100 | 77.16 (16.96) |
| Appropriate assessment | 8.33–100 | 74.57 (16.60) |
| Workload | 43.75–100 | 73.64 (12.49) |
| Organisation of the programme | 37–100 | 73.58 (15.85) |
| Infrastructure | 25–100 | 70.89 (16.95) |
| Overall satisfaction | 25–100 | 80.54 (18.21) |
The vast majority of participants agreed that the programme used problem-solving approaches as opposed to rote recall or memorisation of facts. Although there were relatively high levels of satisfaction with the programme workload, responses in this domain were not as high as in the other domains. In addition, 76% of participants agreed that they had received helpful feedback from the facilitators.
Overall, 96% of participants agreed that they enjoyed the programme and 88% reported that they felt confident to lead in compassionate care delivery. However, agreement was below 80% for the statement: ‘I have changed my attitude towards my work as a consequence of the programme’, with 76% in agreement.
The mean scale scores on the LCCEQ indicated that participants were highly satisfied with:
Discussion
The LCCP and subsequent evaluation aimed to address major causes of failure in care, namely the lack of compassionate care delivery and lack of nursing leadership (Francis, 2013). Moreover, the LCCP and findings from the present study helped meet several nursing recommendations from the Francis (2013) inquiry. These include: building a ‘culture of compassion and caring in nurse recruitment, training and education’(Francis, 2013:76), increasing the ‘focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory’ (Francis, 2013:105), and including leadership training as part of the ‘training and continuing professional development for nurses’ (Francis, 2013: 106).
Overall, positive and significant changes were reported following participation in the LCCP. These related to the participants' understanding of compassionate care delivery, preparedness to act as compassionate care leaders, and acquisition of new problem-solving skills. Moreover, participants were satisfied with the organisation of the programme, the competence of programme facilitators, teaching support, and workload.
Participants were predominantly in managerial roles and had extensive clinical experience. Enabling clinical leaders to undertake programmes such as the LCCP has been identified as a crucial step in adopting and sustaining change and fostering patient centredness (Luxford et al, 2011; MacArthur et al, 2017). In fact, participants in the present study reported an increase in their ability to implement change and support their staff while offering compassionate and patient-centred care. Nevertheless, Burston et al (2011) recommended a hybrid model of change involving both top-down and bottom-up leadership. Similarly, Francis (2013: 76) stressed that offering training and continuing professional development opportunities for nurses ‘should apply at all levels, from student to director’. In fact, Bridges et al (2017) found that involving nurses from all levels in compassionate care leadership education yielded a number of positive clinical outcomes. This highlights the importance of involving both, junior and senior nursing staff in initiatives such as the LCCP in the future.
Participants reported gaining abilities and building understandings in several areas. Of note was the change that occurred in their understanding of themselves as leaders, implementing change, assuming authority, and supporting peer learning. The LCCP also positively affected the participants' perceived relationship with patients and their families. Participants also reported that their perceived abilities to demonstrate consideration and empathy in interactions with patients and to build trust with patients and their relatives increased significantly following the programme. These findings echo those in a study conducted by MacArthur et al (2017) who evaluated the impact of a 3-year initiative aimed at embedding compassionate care in clinical practice. It was found that wards that adopted the programme reported an increase in caring conversations among the staff and between the staff, patients, and their relatives. Moreover, the 3-year programme was successful in eliciting the views of patients and their families, which is key to promoting holistic and person-centred care (MacArthur et al, 2017).
In the evaluation presented here, participants were highly satisfied with their experience of the LCCP; this was particularly the case in relation to programme layout and the support offered by the facilitators. Teaching support was also highly rated, with the use of approaches that facilitated critical thinking, reflection, and linking theory to practice. The role of professional education and training in developing compassionate practitioners had been highlighted in the literature on compassionate care education (Straughair, 2012a; 2012b; Bray et al, 2014; Lown, 2014). For instance, a study exploring health professionals' understanding of compassion and the role of health professionals as compassionate care educators found that education plays a key role in developing compassionate practitioners and promoting compassionate care delivery (Bray et al, 2014). Similarly, Lown (2014) identified ‘teaching compassion’ as an essential commitment to fostering compassionate care in healthcare organisations and Straughair (2012a; 2012b) highlighted the importance of educators as role models for compassionate care delivery. The role of educators in fostering compassionate care was also highlighted at undergraduate level and among novice nurses (Smith et al, 2014; Coffey et al, in press).
In this evaluation, high levels of satisfaction were evident in the preparation to lead compassionate care in practice, including the development of knowledge, skills and competencies to deliver compassionate care, the ability to apply what was learnt during the programme to practice, and motivation to deliver compassionate care. Similarly, a 12-month compassionate care leadership programme helped nurses influence clinical decision-making and enabled them to discuss tough issues (Dewar and Cook 2014). The LCCP also reportedly helped participants engage in compassionate conversations, build better work relationships, and reflect on their clinical practice. Another area of greatest growth in the findings here was the change in the participants' understanding of themselves as leaders and their level of confidence. Similarly, a programme titled ‘Enabling Compassionate Care in Practice’ was successful in increasing nurses' courage and confidence to lead and to make positive changes in clinical practice (Masterson et al, 2014).
This study has some limitations; non-probability convenience sampling was used to recruit participants. Despite being commonly used in the nursing literature (Grove et al, 2015), this sampling strategy is known to increase the risk of self-selection bias. Furthermore, despite using electronic and postal surveys with multiple reminders, approximately half of the nursing and midwifery leaders who undertook the LCCP participated in this study, compromising the generalisability of findings. Finally, a retrospective pre-test approach was used to rate the participants' understandings and abilities before and after the programme. Therefore, a longitudinal study and/or a pre-post study would help enhance rigour. In addition, it is worth considering conducting a randomised controlled trial in order to evaluate the impact of the LCCP in comparison with no programme and/or alternative programme(s).
Further research is recommended using a longitudinal 360-degree research methodology to explore the long-term impact of the LCCP on leaders, healthcare organisations and patients. This research should also include outcomes for services and service users in different healthcare settings using valid and reliable instruments and sample sizes to enhance generalisability. This could be achieved through using pre-existing frameworks for programme evaluation. An example is the Kirkpatrick (1976) model that uses four levels of programme evaluation as follows:
This model proved effective in a number of nursing contexts including problem-based education (Clark et al, 2013), simulation (Coffman et al, 2015), and cardiopulmonary resuscitation training (Dorri et al, 2016).
The organisation of future leaders in compassionate care programmes should reflect the work situation of nursing and midwifery leaders and their practical concerns in relation to programme delivery and layout. Moreover, given the positive outcomes achieved, high-level management (ie directors and chief directors of nursing and midwifery) is encouraged to build an infrastructure that supports nurses and midwives from all levels to avail of programmes such as the LCCP periodically.
Conclusion
This study illustrates the role of programmes such as the LCCP in enabling nurses to lead change and better understand themselves, peers, patients and their families. Overall, participants were highly satisfied with the organisation, delivery and outcomes of the programme. In particular, leadership capabilities were highly developed and resulted in participants reporting that they had developed the ability to apply these capabilities in clinical practice. Study findings highlight the need to conduct a longitudinal study to capture the long-term impact of the LCCP, compare outcomes from the LCCP with those from other programmes, evaluate the impact of the LCCP on healthcare organisations and patient outcomes, and promote a culture and infrastructure that support nurses and midwives from all levels to avail themselves of programmes like the LCCP.