Exploring how mindfulness and self-compassion can enhance compassionate care
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Caroline Barratt Lecturer, University of Essex, Colchester, England

Research suggests that the development of mindfulness and self-compassion may help to improve the well-being and resilience of professionals and students in the healthcare setting. This is reflected in the growth of mindfulness training for these individuals. Mindfulness is an important aspect of self-compassion, and healthcare professionals should be aware of the need to care for themselves when caring for others. This article explores the concepts of mindfulness and self-compassion and their relationship with, and ability to enhance, compassionate care.

Nursing Standard. 31, 21, 55-63. doi: 10.7748/ns.2017.e10671

Correspondence

barrattc@essex.ac.uk

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Conflict of interest

None declared

Received: 23 August 2016

Accepted: 04 November 2016

Published: 18 January 2017

Aims and intended learning outcomes

This article aims to explore the concepts of mindfulness and self-compassion, particularly in relation to compassionate care. After reading this article and completing the time out activities you should be able to:

  • » Describe the concepts of mindfulness and self-compassion.

  • » Identify what distracts you during caregiving and what might contribute to care that is perceived to be uncompassionate.

  • » Understand how mindfulness and self-compassion relate to compassionate care, and reflect on this based on your experience.

  • » Develop mindfulness and self-compassion through the use of reflection.

Relevance to The Code

Nurses are encouraged to apply the four themes of The Code: Professional Standards or Practice and Behaviour for Nurses and Midwives to their professional practice (Nursing and Midwifery Council (NMC) 2015). The themes are: Prioritise people, Practise effectively, Preserve safety, and Promote professionalism and trust. This article relates to The Code in the following ways:

  • » The relationship between mindfulness and providing compassionate care to patients is discussed. This relates to the theme of prioritising people, which states that people must be treated with kindness, respect and compassion.

  • » Nurses should be aware of how their behaviour can affect and influence the behaviour of others. This awareness can be enhanced through mindfulness practice.

  • » An important component of mindfulness is reflection, which The Code states is important in improving nurses’ practice and performance.

Introduction

Discussion on how to develop and enhance compassionate care among healthcare professionals, particularly nurses is increasing. Incidents of suboptimal care, such as those raised in the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013) have received significant media attention, emphasising concerns about the quality of care in the NHS. At the same time, healthcare professionals are under increasing pressure to produce specific outcomes and demonstrate recovery rates. This can lead to the depersonalisation of patients, since healthcare professionals may be unable to focus fully on the person they are caring for, while attempting to complete tasks and paperwork (Ballat and Campling 2011). Therefore, it is essential to identify ways to enable healthcare professionals to deliver compassionate care in a challenging working environment. Before the concepts of mindfulness and self-compassion are explored in depth, an overview of the research in this area is provided. The reader may wish to return to this information once the relevant concepts have been defined to enhance their understanding of the effects of these practices in the healthcare setting.

Key Point

The popularity of mindfulness practice has grown rapidly, and it is becoming common in clinical treatment, as well as in staff development and support. Although evidence of how mindfulness practice can benefit healthcare professionals is not yet robust, there is compelling evidence to suggest that the development of mindfulness can help to protect healthcare professionals and students from burnout and stress, while improving their resilience

The popularity of mindfulness practice has grown rapidly, and it is becoming common in clinical treatment, as well as in staff development and support. Although evidence of how mindfulness practice can benefit healthcare professionals is not yet robust, there is compelling evidence to suggest that the development of mindfulness can help to protect healthcare professionals and students from burnout and stress, while improving their resilience (Shapiro et al 2005, Newsome et al 2012, Gockel et al 2013, Horner et al 2014, Craigie et al 2016). Gauthier et al (2014) found that mindfulness practice of five minutes at the beginning of each shift led to a measurable reduction in the stress levels of nurses in paediatric intensive care units. For students training to be healthcare professionals, mindfulness practice has been associated with improved patient care (Shapiro et al 1998, Shields 2011, Warnecke et al 2011). Nursing literature, such as Watson’s human caring theory (Sitzman and Watson 2014) and Parse’s concept of ‘true presence’ (Palmieri and Kiteley 2012) have also drawn on the concept of mindfulness as a mechanism for improving connection with patients and quality of care.

The relationship between mindfulness and compassion has been explored, reflecting the ethical and social dimension of mindfulness emphasised in traditional Buddhist mindfulness teaching (Stanley 2013). In particular, mindfulness has been identified as an important aspect of self-compassion, since by becoming aware of their experience, individuals can learn to identify and address harsh or critical self-talk, and to respond appropriately (Neff 2003, Gilbert and Choden 2013). A meta-analysis of 20 samples from 14 studies found a strong association between self-compassion and psychopathology, with higher levels of compassion associated with lower levels of mental health symptoms (Macbeth and Gumley 2012). Research on self-compassion and relationships with others suggests that, in increasing a sense of connection with others, the development of self-compassion is more important than practising mindfulness alone (Birnie et al 2010, Neff and Germer 2013, Neff and Pommier 2013, Boellinghaus et al 2014).

It is important to note that research has paid little attention to the potential adverse effects of mindfulness practice, in particular meditation, despite emerging evidence that participants occasionally experience negative outcomes, such as depersonalisation or emotional distress (Farias and Wikholm 2015). Furthermore, although the evidence of the positive effects of mindfulness and self-compassion on the resilience and mental health of healthcare professionals is becoming established, there is less research examining their effects on emotional competence, or the extent to which they affect professional practice and compassionate care (Regehr et al 2014, Smith 2014, Lamothe et al 2016). In addition, the ability of healthcare professionals to effectively care for themselves and for others is contingent on a variety of factors, some of which are outside their control, such as funding and staffing levels. Mindfulness and self-compassion are not a panacea for the complex and demanding challenges individuals may experience in healthcare settings. However, the author’s experience of using these practices with healthcare professionals suggests that they may be useful and supportive for those who wish to engage in them.

The time out activities in this article are appropriate for individuals with no experience of mindfulness practice, and do not include prolonged meditation. When undertaking these activities, it is important that readers take note of their well-being and stop if they experience any difficulties. If readers wish to further develop their mindfulness practice after reading this article, it is recommended that they do so with an experienced teacher.

Mindfulness and nursing

There are several definitions of mindfulness. Kabat-Zinn (1990) stated that the aim of mindfulness practice is to develop a non-judgemental awareness of the present moment. He emphasised the importance of being present in an experience without getting caught up in constant ‘mental busyness’. Furthermore, he stated that an attitude of openness, acceptance and patience is important to develop mindfulness; otherwise, it is unlikely that an individual will achieve the necessary depth of experience that enables mindfulness to be better understood.

Young (2013) suggested a three-component model of mindfulness, known as the CCE paradigm. This is comprised of three skills that contribute to, and are developed through, mindfulness practice:

  • » Concentration: by starting to notice where attention is placed, it is possible for individuals to become aware of the ability, or lack of ability, to concentrate on what is relevant in a particular moment, and to notice that effectiveness increases as concentration increases.

  • » Sensory clarity: being able to perceive sensory experience directly, without getting caught up in thoughts and judgement about the experience. This creates the ‘mental space’ to enable effective responses, instead of repeating reactive habits, such as becoming angry and responding abruptly to someone.

  • » Equanimity: a state of internal balance in which there is no fighting against or suppression of experience, but there is also no strong identification with it. In response to an unpleasant experience, for example receiving criticism from a loved one, an individual may attempt to suppress or deny the experience, which can prolong distress and further alienate the person who made the criticism. If an experience is pleasant, for example going on holiday, an individual may attempt to cling to that experience on returning to work, resulting in a state of perpetual desire for an experience that is no longer available. This causes tension in the body and mind. Equanimity involves accepting the continually changing nature of experiences, from pleasant to unpleasant, while neither resisting nor clinging to these experiences.

While it is useful to consider the skills and attitudes that underpin mindfulness, it is important to note that concentration, sensory clarity and equanimity are not prerequisites for mindfulness practice. As the individual begins to develop mindfulness, they become aware of how distracted they are and how caught up they may be in their mental dialogue. This increased awareness is an important stage in becoming mindful.

Hanh (1987) provided an example of what is meant by being mindful of a particular activity and how it can alter the experience of being alive: ‘If, while washing dishes, we think only of the cup of tea that awaits us, thus hurrying to get the dishes out of the way as if they were a nuisance, then we are not “washing the dishes to wash the dishes.” What’s more, we are not alive during the time we are washing the dishes. In fact, we are completely incapable of realising the miracle of life while standing at the sink. If we can’t wash the dishes, the chances are we won’t be able to drink our tea either. While drinking the cup of tea, we will only be thinking of other things, barely aware of the cup in our hands. Thus we are sucked away into the future and we are incapable of actually living one minute of life.’

Key Point

While it is useful to consider the skills and attitudes that underpin mindfulness, it is important to note that concentration, sensory clarity and equanimity are not prerequisites for mindfulness practice. As the individual begins to develop mindfulness, they become aware of how distracted they are and how caught up they may be in their mental dialogue. This increased awareness is an important stage in becoming mindful

Key Point

Mindfulness practice can help to increase the ability of healthcare professionals to engage effectively with patients and to be fully present throughout these interactions, enabling dialogue, compassion and an accurate assessment of the patients’ needs. Mindfulness practices serve to stabilise attention, giving healthcare professionals the mental space to better connect with the person in front of them, instead of only completing the task at hand; for example, taking someone’s temperature while thinking about the next job they have to do, when it will be time for lunch or what they are going to make for dinner

Time out 1

Choose one activity that you do at least once a day, for example washing up, cleaning your teeth, showering or washing your hands. For one week, commit to undertaking this activity mindfully, with your full attention; noticing the sensory experience of carrying out the task instead of getting caught up with your thoughts or rumination.

Write down what you noticed while doing this. You may find it useful to reflect on the three components of mindfulness:

» Concentration: could you identify what it was important to pay attention to during the activity? How easy was it to concentrate on that aspect of the experience?

» Sensory clarity: were you able to observe your experience as it was or did you notice that judgement arose in your mind about your experience or performance? Did your mind fill with thoughts about different things that distracted you from the sensory experience?

» Equanimity: did you become frustrated or want the experience to be over? Did you start to cling to a positive aspect of your experience? To what extent could you be open and accepting of what was happening?

Relevance of mindfulness for nurses

Mindfulness practice is relevant for nurses because of the effect it can have on them as individuals. Research suggests that mindfulness practice can lead to improved well-being and reduced levels of stress and burnout. Cohen-Katz et al (2005) illustrated the effect on nurses of mindfulness-based stress reduction, which is an eight-week mindfulness programme developed by Jon Kabat-Zinn. It includes one class of up to two and a half hours each week, one silent mindfulness day, and practice at home of approximately 30-40 minutes, six days a week (Santorelli 2014). One participant in Cohen-Katz et al’s (2005) study stated: ‘I used to stand by the microwave, impatient that the food hasn’t cooked fast enough. Now I can step back when I start to do that, laugh and then slow down.’

In a review of how mindfulness training effects nursing and midwifery practice, Hunter (2016) found that mindfulness practice led to feelings of peace and calm, which gave nurses and midwives a sense of space and a greater feeling of agency, and reduced their sense of being potentially overwhelmed. The theme of ‘changing perspective’ was identified as an outcome of mindfulness practice in four of the five articles reviewed. Nurses and midwives reported that mindfulness helped them to take a step back, to recognise what was important and to develop a greater sense of acceptance, enabling them to let go of what they no longer considered important. This reflects the developing equanimity that Young (2013) identified as an important component of mindfulness.

Mindfulness practice can help to increase the ability of healthcare professionals to engage effectively with patients and to be fully present throughout these interactions, enabling dialogue, compassion and an accurate assessment of the patients’ needs. Mindfulness practices serve to stabilise attention, giving healthcare professionals the mental space to better connect with the person in front of them, instead of only completing the task at hand; for example, taking someone’s temperature while thinking about the next job they have to do, when it will be time for lunch or what they are going to make for dinner. One participant in Cohen-Katz et al’s (2005) study reflected this ability to develop concentration, stating that: ‘I’ve learned to do one day at a time, one duty at a time, one thing at a time.’

Overall, it is difficult for healthcare professionals to provide compassionate care when they are not ‘present’ and aware of their internal experience, because without this, it is not possible to notice when they have become distracted. Hunter (2016) found that an outcome of mindfulness training was improved ability to care. This was because mindfulness training resulted in the ability to focus effectively on patients, which improved the quality of the healthcare professionals’ interaction with them, for example by listening in depth and allowing others to speak.

Hunter (2016) also emphasised that those trained in mindfulness reported being more aware of, and attentive to, patients and colleagues, potentially contributing to a harmonious and supportive working environment. In addition, research on mindfulness training for staff in organisations has suggested that it may contribute to organisational change, since it would ‘increase the motivation to act in ways that are congruent with values’ (Leonard 2016). It is possible that the effect of mindfulness training in organisations may be greater than that experienced at the individual level.

Time out 2

The first step in developing mindfulness is becoming aware of how distracted you often are. When caring for patients, start to become aware of where your attention is and to what extent you are ‘present’ with the person you are caring for. At the end of your shift, write down what distracts you and draws your attention away from providing care. You may wish to consider:

» Sensory experience: smells, sounds, pain and hunger.

» Emotions: such as those arising that might make it difficult to focus and be present.

» Thoughts: ‘mental chatter’ about issues that you are not immediately concerned with, planning for what is next, or making judgements about the situation.

Developing mindfulness

There are several ways to develop mindfulness. There are two main groups of mindfulness practices: informal practices, which individuals engage in during daily life activities, and those that require time out or away from daily life activities, also referred to as ‘formal’ meditation practice. However, there are common features of all mindfulness practices. Germer (2009) described three such features:

  • » Stop: cease what is being done, or at least slow down.

  • » Observe: become aware of the immediate experience.

  • » Return: constantly return to the point of focus.

Key Point

Taking steps to ensure one’s own well-being is not a selfish act, especially for those in caring roles. There are several metaphors used to describe the interrelationship between caring for others and caring for oneself. For example, that the heart has to pump blood to itself first before it can circulate it around the body. Healthcare professionals should be reassured that being compassionate towards themselves is an important aspect of being able to deliver sustained compassionate care

Informal practices include individuals choosing a daily activity that will be completed mindfully, and the use of mindfulness cues, which involves choosing a particular event, such as washing hands, turning the key in the car ignition, or opening the front door, to be in the moment and become aware of their internal and external experience. While informal practices can be helpful, meditation is considered an important component of mindfulness practice because it can change how people perceive their thoughts and their mental functioning (Williams and Penman 2011). While interventions such as mindfulness-based stress reduction advocate approximately 40 minutes of formal practice each day (Santorelli 2014), there is debate about the optimum duration of such practice, with some studies suggesting that regular meditation periods of five minutes are beneficial (Gauthier et al 2014, Strauss et al 2015).

Self-compassion and caring for others

Self-compassion can be a difficult concept to understand and practise, particularly when healthcare professionals have been trained to focus on caring compassionately for others. Training for healthcare professionals has often neglected or actively excluded the subjective experience of the caregiver. While this may be beginning to change (Barratt 2016), the author observed on a course they taught about developing compassion that healthcare professionals appear to have little patience for their own weaknesses, and little need for self-compassion and compassion from others. Halifax (2008) discussed the need to ‘see my own limits with compassion’, becoming a recipient of the compassion that is readily extended to others, while the Dalai Lama (n.d.) emphasised the importance of self-compassion: ‘For someone to develop genuine compassion towards others, first he or she must have a basis upon which to cultivate compassion, and that basis is the ability to connect to one’s own feelings and to care for one’s own welfare… caring for others requires caring for oneself.’

Therefore, taking steps to ensure one’s own well-being is not a selfish act, especially for those in caring roles. There are several metaphors used to describe the interrelationship between caring for others and caring for oneself. For example, that the heart has to pump blood to itself first before it can circulate it around the body. Healthcare professionals should be reassured that being compassionate towards themselves is an important aspect of being able to deliver sustained compassionate care.

Time out 3

Consider how easy you find it to accept that self-compassion is an important aspect of compassionate care. Reflect on how it feels to think about putting yourself before others. You may find it useful to list some of these feelings and review them, or to discuss this with a colleague.

Developing self-compassion

Neff (2003) described three components of self-compassion: mindfulness, self-kindness and common humanity. By developing mindfulness, feelings and emotions can be explored with greater openness, curiosity and acceptance. Emotions can be better observed and experienced, increasing an individual’s ability to respond appropriately. Therefore, mindfulness is a crucial component of self-compassion. However, Gilbert and Choden (2013) observed that while mindfulness and compassion are linked, they have different effects on the brain. As such, these concepts are not synonymous, and both should be attended to for personal transformation to occur. For self-compassion to arise, awareness should be combined with kindness and the development of warmth and understanding, rather than harsh judgement or criticism.

The last component of self-compassion is common humanity, which prevents self-compassion from becoming self-pity or self-indulgence. Common humanity is the recognition that, while life experience is ultimately unique and individual, others share similar life experiences. This recognition of shared experience can alleviate feelings of shame and isolation that may arise during difficulties, thus contributing to self-compassion.

There are several ways to foster self-compassion. Germer (2009) suggested five different pathways through which self-compassion can be developed. These pathways are shown in Table 1.

Table 1

Five pathways to develop self-compassion

PathwayMechanismExamples
PhysicalThrough the bodyRelaxation, exercise, nutritious food, avoiding substances that harm the body, soothing touch.
MentalAllowing your thoughtsMeditation, mantra, visualisation, kind self-talk.
EmotionalBefriending your feelingsDeveloping acceptance of emotions, engaging in enjoyable activities, loving-kindness meditation, forgiveness.
RelationalConnecting with othersPractising generosity to others, expressing kindness and love to others, deepening friendships.
SpiritualNourishing your spiritTime in nature, spending time with loved ones, seeing the beautiful in our daily lives, identifying what we most value and finding ways to include more of that in our lives.
(Adapted from Germer 2009)

As well as engaging in positive activities to increase self-compassion, it is important to become aware of negative cycles of thought and self-talk that are unkind and potentially destructive. Gilbert and Choden (2013) observed that critical and negative views of the self are associated with mental health problems, and that these views contribute to feelings of threat such as anxiety, as well as hindering self-compassion. Although wanting to achieve success and reach high standards is not bad in itself, it can become detrimental if any failure to achieve these goals is met with self-recrimination and self-accusation (Neff 2011). Learning to self-talk in positive ways can help to counteract accusing internal voices. Changing self-talk is not about rejecting responsibility, or letting ourselves ‘off the hook’. Instead, it is about appraising the situation in a way that is fairer and more compassionate.

Time out 4

Over 48 hours, note what you say to yourself in your head and what effect this has on you and include the language you are using. Write down what you have observed and how you think your self-talk might affect you.

Identify positive phrases that you might use to replace the negative ones. For example, instead of saying ‘I’m useless, I’m just not good at my job’, which is an unhelpful universal judgement, an alternative might be to say ‘that did not go well on this occasion and I feel upset by what has happened’ or thinking about what can be done to look after yourself and what you could do differently in future.

Mindfulness, self-compassion and compassionate care

Having explored mindfulness and self-compassion and their relevance to healthcare, this article will now explore how these concepts are linked to compassionate care. Defining compassion is complex, and it is challenging to distinguish it from similar terms, such as kindness and empathy. Strauss et al (2016) reviewed various definitions of compassion, and proposed that this concept has five elements:

  • 1. Recognising suffering.

  • 2. Understanding the universality of suffering in human experience.

  • 3. Feeling empathy for the person who is suffering and connecting with the distress (emotional resonance).

  • 4. Tolerating uncomfortable feelings aroused in response to the person who is suffering, such as distress, anger or fear, thus remaining open to and accepting of the suffering person.

  • 5. Motivation to act or acting to alleviate suffering.

Strauss et al’s (2016) definition of compassion incorporates aspects of mindfulness and self-compassion. For example, the first element of recognising suffering requires awareness of the self and others, which can be fostered through mindfulness practice. It requires individuals to develop focused attention that enables engagement with others and an accurate assessment of their experience. The second element draws on the common humanity aspect of Neff’s (2003) definition of self-compassion, which recognises the connection between individuals’ suffering. Elements three and four require mindfulness and self-compassion to enable an individual to connect with another person’s suffering without becoming overwhelmed by it and rendered unable to help. Noticing their internal responses to the experience and the challenging emotions that arise can enable an individual to identify appropriate responses. The fifth element of motivation relates to the intentions associated with an individual’s actions. Developing mindfulness can help sustain a connection to the underlying values that motivate professional practice.

While the capacity of healthcare professionals to care compassionately depends on the individual, this is conditioned by a range of complex institutional, contextual factors that may inhibit compassionate care (McConnell 2015, McPherson et al 2016). Therefore, individual healthcare professionals alone are not responsible for establishing a culture of compassionate care. Training in mindfulness and self-compassion should be considered one aspect of wider institutional strategies to improve support for staff and the quality of care for patients.

Key Point

While the capacity of healthcare professionals to care compassionately depends on the individual, this is conditioned by a range of complex institutional, contextual factors that may inhibit compassionate care (McConnell 2015, McPherson et al 2016). Therefore, individual healthcare professionals alone are not responsible for establishing a culture of compassionate care.

Training in mindfulness and self-compassion should be considered one aspect of wider institutional strategies to improve support for staff and the quality of care for patients

Conclusion

There are important links between the concepts of mindfulness, self-compassion and compassionate care. The popularity of mindfulness has grown rapidly, leading to an increase in the availability of mindfulness training. Evidence has suggested this may benefit healthcare professionals and students by providing protection from burnout and stress, while improving resilience and enhancing patient care. Self-compassion is an important component of mindfulness, and healthcare professionals should be aware of the relationship between caring for others and caring for oneself in providing sustained compassionate care. Developing mindfulness and self-compassion is challenging and requires ongoing effort; however, for many people who engage in these practices, they are worthwhile.

Time out 5

Spend 10 minutes reflecting on what you have learned from reading this article and completing the time out activities. Think about the following:

» What effect have the time out activities had on you? What have you observed as a result of completing them?

» How has your understanding of mindfulness and self-compassion changed?

» Have you noticed any areas of your work that have been influenced by reading this article?

Identify three actions you intend to take to explore mindfulness and self-compassion further. For example, purchasing one of the books in the reference list of this article or finding out about mindfulness training offered at work. Write down these actions and put them somewhere you are likely to see them regularly until you have completed them.

Time out 6

Nurses are encouraged to relate the four themes of The Code (NMC 2015) to their professional practice. Consider how enhancing self-compassion and compassionate care relates to The Code.

Time out 7

Now that you have completed the article, you might like to write a reflective account as part of your revalidation.

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