1. Oxford Brookes University, Faculty of Health and Life sciences, Jack straw's Lane, Marston Road, Oxford, OX3 0FL, England
2. Buckinghamshire New University, Nursing and Allied Health, Uxbridge Campus, 106 Oxford Rd, Uxbridge UB8 1NA, England
Academic Editor: Steven K. H. Aung
Special Issue: How Compassion Benefits in the Healing Process
Received: March 07, 2019 | Accepted: June 05, 2019 | Published: June 13, 2019
OBM Integrative and Complementary Medicine 2019, Volume 4, Issue 2, doi:10.21926/obm.icm.1902036
Recommended citation: Ramluggun P, Nathoo S. Compassion in Preregistration Nurse Education: An Integrated Review. OBM Integrative and Complementary Medicine 2019;4(2):18; doi:10.21926/obm.icm.1902036.
© 2019 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
The evolving, dynamic and challenging healthcare landscape requires that the art and science of nursing equip preregistration nursing students with the knowledge and skills to positively respond to these changes. Central to these students’ ability to demonstrate competence in the fundamentals of nursing care are core nursing attributes to meaningfully engage and attend to patients’ in delivering compassionate care and meeting their needs. The literature identifies the process of delivering compassionate care as a human dimension of caring that is complex and multifaceted. This paper discusses the concept of compassion in preregistration nursing education and explores the associated challenges around how compassionate care contributes towards quality care and the healing process.
There is a plethora of definitions of compassion with different interpretations, but the consensus is that it is an important trait in healthcare practice which is indisputably supported by several authors [1,2,3,4,5]. Compassion has been defined as ‘sympathetic pity and concern for the sufferings or misfortunes of others’ (p. 232)  and motivated by the very appreciation of a person’s pain . Three dimensions to its meaning have been postulated which comprise of understanding the person, recognising their suffering and thereafter attempting to alleviate their suffering [5,8]. These dimensions underline the relational nature of compassion and interpersonal processes involved .
2. Compassion in Healthcare
It is widely accepted that compassionate care is integral to healthcare practice and requires an inter-professional approach  as collaborative working is central to delivering quality care . It has been given increasing prominence in national and international healthcare policies [11,12] and has been described as ‘intelligent kindness’  which is fundamental to how patients perceive their care . It is at the core of the patient-healthcare worker therapeutic engagement and the intricacies of compassionate care are opened to various interpretations which can range from a smile  to being there for the patients, talking to them, holding their hands, reassuring and comforting them . Cole-King & Gilbert  suggest that “compassionate care can enhance staff efficiency, help elicit better staff information, inform treatment plan and lead to better recovery and increase satisfaction” thereby, enhancing the healing process .
Improving patients’ experiences by providing high quality compassionate care and treatment is at the core of the Compassion in Practice Strategy in England . The provision of holistic compassionate care which also considers the patient’s other needs aside the specific problem and encourages their active engagement in their treatment enhances patients’ experiences  and attention to detail can also lead to the improvement of quality care . Even though seemingly unassuming, at times, intangible during transient patients’ contacts, simple compassionate actions such as a reassuring look and therapeutic touch forms part of the complex process of compassionate care which are not easy to capture and quantify in the overall healing process . Nevertheless, in quantifying the significance of the relational aspect of compassion, hormonal determinants such as oxytocin has been identified as biological mediators in forming close relationship in caring and so the others in neurophysiology . Hence, compassion has far reaching benefits for patients.
Whilst exploring the perspectives of compassion amongst preregistration nursing students, clinical mentors and nurse educators, participants argue that treating patients with compassion, making them feel relaxed can enhance their holistic wellbeing and hence positively impact on safe discharge . But, compassion in healthcare is not restricted to patients care but also a compassionate workplace where both patients and staff experience ‘thoughtful, caring and empathetic actions’ and ‘positive care experiences whether they are delivering or receiving care’ (p. 4) .
3. Compassion in Nursing
Nursing ‘encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles’ (p. 1) .
The above definition underlines the wide-ranging roles within the scope of nursing practice following registration in delivering and influencing responsive patient centred care that meet the needs of patients as individuals, their families and carers. Those with expert knowledge base and advance skillset such as Advanced Nurse Practitioners are involved in even more complex decisions which were once considered to be within the realm of the medical profession.
Compassion is not simply a nursing issue, but as the single largest healthcare professional workforce, spending more time with patients and attending to their more intimate aspects of care than other health-care professionals , nurses play a vital role in positively influencing patients’ affective aspects of their care. A fundamental element of every nurse’s role is to deliver care with compassion  which is embedded in the Nursing and Midwifery Council professional standards and code of practice [24,25]. Nursing care provided with compassion not only reduces complaints , but it positively impacts on quality care .
One of the main themes that emerged from Bradshaw’s historical analysis is the “character of the nurse” (p. 1798) . Bradshaw argued that compassion is one of the main traits that gave the nursing profession its caring philosophy . It is recognised as being central to the nurse-patient relationship . It is also purported that compassion enhances the element of trust and relationships with clients through emotion, by entering their world, recognising the suffering they go through to relieve it . A pertinent characteristic of compassion is that it is “a virtue to be cultivated as an aspect of individual character” . This has implications for the selection and recruitment process of the most suitable applicants for the preregistration nursing programme.
4. Compassion and Recruitment Practices
Applicants’ altruistic motivation to help others in choosing nursing as a career is evident  but equally important is the evidence of compassion and caring attitudes which is sought during recruitment activities such as group activities and/or one to one interview with applicants . In creating a caring and compassionate culture one of the recommended schemes was to screen for compassion at the selection point to the preregistration nursing programme [31,32].
There are tools that can be used to measure compassion, such as the Pommier’s compassion scale. Pommier’s offers a compassion scale which measures how one would act towards someone else . Six aspects for compassion, namely, ‘kindness versus indifference, common humanity versus separation and mindfulness versus disengagement’ are used to calculate the degree of compassionate (p. 262) . While this self-reporting tool is relatively easy to use, it is not as quick to complete and is subject to the common weakness such as social desirability bias of self-reports. The CCAT (Compassionate Care Assessment Tool) was developed by Burnell & Agan . In their study, four subscales: meaningful connection, patient expectations, caring attributes and capable practitioner were used by inpatients to rate nurses’ level of compassion. However, it is another time-consuming tool which mainly focuses on an inpatient context.
With the selection methods coming under increasing scrutiny due to reported cases of declining quality of care  and rising attrition rate , Approved Education Institutes (AEIs) endeavour to select the best applicants for the preregistration nursing programme. The admission to the programme is in line with the UK Regulatory Body’s Guidance which requires that all student nurses to be of good health and character to be capable of delivering safe and effective practice [24,25]. However, the most effective ways to assess the character of applicants has been subject to debate in appraising their virtues, beliefs and values. Which aspects of these characteristics are expected to be sought during recruitment or can be taught in their programme are also questionable.
Nevertheless, in assuring that the best judgements are made on an applicants’ character, AEIs in the UK generally work in partnership with their healthcare placement providers and service users  using a value-based recruitment process such as the Values Based Recruitment Framework  in ensuring that applicants’ values are aligned with that of the NHS constitution. Service users’ involvement in the selection and recruitment process at the interview is important as they offer their perspectives on applicants’ compassionate and caring aptitudes . These personal characteristics as a prerequisite to enrolling on the preregistration nursing programmes were found to be unchanged for students on completion of their programme .
Nonetheless, it must be noted that the recruitment methods such as interviews are not impervious, and there is scope for admission to the programme to be enhanced in selecting competent applicants with academic credentials and value-based qualities able to stand the rigour of the programme with potential to become an all rounded professional . There is no standardised compassionate scale that is used consistently across the NHS  or AEIs for recruiting applicants to the preregistration nursing programmes. Hence, there is scope for further empirical research on developing an effective standardised predictive mechanism that can accurately capture the aptitude for compassion in applicants.
5. Compassion in Nursing Education
In addition to assessing the applicants’ virtuous intent to join the nursing profession, their preparedness to practice compassionately has been integrated in nursing theory and practice in the last decade [24,25,41]. However, following several national reports [32,42,43] which underscored the need for care to be more patient-centred and compassionate led to a review of how nursing students are being educated especially mentoring models in practice . Hence, the resurgence in the human dimension of care and a renewed call to embrace compassion as a guiding principle for healthcare practices .
Key reports on nursing education , the vision and strategy for compassion in practice  in raising standards to put patients first  have highlighted the lack of compassion in nursing care. Subsequently, the role played by AEIs in preparing students to practice compassion in clinical settings [1,12,48,49,50] including teaching and assessment approaches for compassion [51,52] have received much attention.
Whether compassion is an innate virtue or can be instilled through teaching has been subject to debate [53,54,55]. Nathoo’s study posits that compassionate care can to be taught , learnt and nurtured, a point supported by Lown and Fotaki [56,57]. Participants in Nathoo’s studies suggest that nurses should at least have the basic aptitude of being respectful and caring to show compassion in the first instance . However, Curtis argues how nursing students’ compassionate practice can be sustained through their programme and as registered nurses needs more clarity . Francis suggested that gaining experiential knowledge by working in the care sector as a nurse assistant under supervision and preferably in the care of older people attending to their basic needs before enrolling on nurse education programmes, would better prepare nursing students in giving person-centred care .
In preregistration nursing education the curricula programme is underpinned by compassion as a core value as encapsulated in the six fundamental values (Care, Compassion, Competence, Communication, Courage and Commitment) commonly known as the 6 Cs to support healthcare staff deliver excellent care . However, how such a programme informs and shapes students’ understanding, and experience of compassion is not well known . Furthermore, whether compassion can be measured effectively and meaningfully in nursing education is unclear as empirical studies measuring the level of compassion at the different progression point of the preregistration programme is lacking.
A study which explored the meaning of compassion amongst nursing students reported that students experience compassion in terms of support, guidance and advocating for the patients but it can also be a concept difficult to engage with, leaving them feeling vulnerable and inadequate in their practice . This study advocated exploring creative ways such as poetry writing in teaching and learning on compassion to understand how students experience of compassion and to meaningfully engage them in the delivery compassionate care . Furthermore, an online format for teaching and evaluating compassion nursing students using dignity and respect as core elements has also been suggested .
Preregistration nursing students have reported concerns about their ability to engage in compassionate care and maintaining this practice in their progression to new registrants . Their ability to manage aspiring professional ideals against the constraints of the reality of practice in providing compassionate care has also been reported . Hence, it is also important to foster an open culture that provides a safe space for a frank discussion on how to respond to the challenges around compassion in their practice . Developing core skills such as communication, being empathetic, displaying respectful behaviours and understanding emotional connection paramount to providing individualised care have been suggested in enabling students to engage in compassionate practice [17,23,64; 65].
6. Respect and Cultural Competency
Truly compassionate care is skilled, competent, value-based care that respects individual dignity. Its delivery requires the ‘highest levels of skills and professionalism’ (p. 3) . Respecting patients and their dignity are a fundamental aspect of nursing care and is enshrined in the UK nursing Code of Practice [24,25]. Valuing as well as respecting patients whilst enhancing compassionate care is important . Respecting the individual dignity of the patient when providing care is widely linked to their satisfaction and adherence to advice for their care . In practice, being respectful is also demonstrated by taking time to listen to the patient, adopting a non-judgemental attitude by respecting their point of views , validating their feelings and providing informational care . In exploring the final year nursing students’ understanding and experiences of respect towards patients, Clucas and Chapman underlined the importance of socialising them into the norms of their profession as they approach their registration . Their study reported nursing students’ lack of an integrated understanding of respect and perceived barriers to respectful behaviours. It also highlighted the students’ concerns for the barriers such as work overload and time pressures may adversely impact on their respectful care ideals .
Moreover, a deficiency of cultural competence can be another barrier to respecting the patients’ values, needs and preferences in providing compassionate care in a multicultural country by a culturally diverse healthcare workforce. The importance of culturally competent compassion by responding to patients’ suffering in a culturally appropriate way that considers patients’ cultural backgrounds has been underlined . However, this important factor has not received much attention except for the cursory reference in the Willis Report on nursing education  hereafter, the need to address cultural competence in preregistration nursing education .
To cultivate compassionate care, communicating effectively is vital [3,50,60,72,73]. As a foundation of good nursing care and one of values of the 6 Cs that underpin care , communication in compassionate care involves ‘real dialogue’ (p. 3) . This consists of honesty and showing genuine interest to patients’ concerns. Yet, lack of communication has been reported as one of the main reasons for patients’ complaints  and features inconsistently in healthcare culture . Such inability to communicate between the many organisations in sharing information of concerns has been labelled as problematic . The theory of communication, which is based on nursing, psychological and social theories is a fundamental part of the nursing curriculum programme . In their education nursing students are taught communication skills, when caring for patients. However, there are a growing number of complaints due to poor communication , pointing to the need to further improve nurses’ communication skills to establish effective, compassionate and caring relationship.
Furthermore, in communication, listening is acknowledged as an indispensable ingredient of nursing practice and the very basis of all significant interpersonal relationships, be it nurse/patient or nurse/nurse . Being listened to, has been associated with feelings of being valued and connected, cared for with compassion and involvement with others [1,78]. In their study, Bray et al. provided health professionals and nursing students an understanding of how compassionate care could be demonstrated, and participants were required to categorise the ones they felt were most significant. The actions that were the highest rated to promote compassionate care were to “actively listen to patients”, (p. 482) .
Bray et al. argued that “active listening, attentiveness and understanding a patient's individual needs” were branded as paramount in delivering compassionate care (p.487) . The individual skills, such as awareness (being attentive to what is happening or carefully noticing distress on patient’s face), emotional response (being warm and caring) and being respectful can contribute to enhancing compassionate care . In cultivating a culture of compassion, nurses’ emphatic abilities to connect with their patients and the cognitive ability to respond with the emotional intelligence that entails understanding and facilitating emotion  when managing emotionally intense situations in caring for their patients are paramount.
It is claimed that empathy is important in the delivery of compassionate care [2,26,50] and several studies propose that the more empathy the better . Conceptually, empathy and compassion share common elements such as warmth, kindness and person centredness which have been used interchangeably in the literature [81,82]. Fernando and Consedine (p.388) , debate that “empathy is necessary to be compassionate, but one can be empathetic without being compassionate.” Therefore, this suggests that one can have a good understanding of how it feels to be in someone else’s shoes without actively wanting to help.
Making someone feel comfortable by treating them the way that one would want to be treated is an important element in showing compassion [1,3,83] and “acting with warmth and empathy was selected as the most important attribute of compassion for both qualified and unqualified health professionals” (p. 482) .
Dietze and Orb (p. 168)  state that “an empathic relationship is one where a nurse is professionally detached from a patient”, which implies that empathy is feeling for someone else, but without evoking a personal emotional response in the nurse . This “golden rule” for giving compassionate care is to ‘always assess the needs of someone in need and act upon those needs’ (p. 2) . The motivation and desire to act to relieve the suffering the patient has been identified as the moral dimension of empathy . Van der Cingel also suggests that empathy can have its downside as treating someone the way that one wishes to be treated can have unwanted consequences . Rogers, the founder of humanistic psychology cautioned about the risk of over identifying with the patient which can be at the detriment of losing objective perspective of the therapeutic process .
Adopting Irving’s three-dimensional model (cognitive, affective and behavioural) of empathy , nursing students need to be well equipped with the emphatic ability to care for their patients. This means being skilled in subjectively experience the patients’ feelings, understanding their world and communicating this understanding to the patients while keeping an objective stance. This skill can be developed and fostered in the students’ early stages of their studies through experiential education such as reflection . However, the emphatic concern which is crucial to the development of the therapeutic relationship can result in emphatic distress amongst students if they are not equipped to manage the emotional demands of their practice .
9. Emotional Intelligence & Self-Compassion
Compassion requires emotional connection and interpersonal skills to be thoughtful of others’ views [2,3] and requires personal commitment, quality time in developing a positive interpersonal relationship with patients .This personal commitment needs the emotional intelligence of nurses to know their own feelings and of other people’s, to differentiate between those feelings and identify them appropriately to help them in the way they think and act . However, although emotional intelligence has been associated with positively relating to others , it has also attracted much criticism as it is defined and measured in different ways depending on whether it is viewed as a personality trait or a skill. Hence, there are validity and reliability issues in how it is measured with self-report measures being viewed as less robust than psychometric measurement. So, an eclectic approach to measurement that combines the personality questionnaire and aptitude test including observation would be more suitable.
Furthermore, Cadman & Brewer argue as an emotionally intelligent person, being aware of one’s boundaries and those of the patients are paramount and fundamental in providing holistic care . However, in addition to managing boundaries nurses also must manage the intense emotions engendered by constant exposure to patients’ suffering in a highly distressing practice environment . The emotional labour has positive influences when delivering care with compassion because this gives health care workers a sense of job satisfaction [14,96]. Nevertheless, if the emotional demands are not properly regulated and balanced with protective factors such as self-compassion, they may result in compassion fatigue [97,98]. Compassion fatigue in nursing has been described as the loss of the nurturing ability towards oneself  due to physical and mental exhaustion. Hence, the emotional intelligence to be aware of others’ feelings, having the tacit understanding of competing healthcare, personal and patients’ values and the resilience to master these challenges are important developmental skills for preregistration nursing students [64,90]. Szeles argues that the evidence on measuring nursing students’ ability for emotional intelligence is lacking and proposes peer coaching as a strategy to develop emotional intelligence for self-compassion for these students .
Self-compassion has been described as compassion directed inwards, a self-recognition and connection to one’s own feelings in face of others’ sufferings . Evolving evidence suggests that self-compassion is concomitant in providing compassionate care, and as having positive influence on patient care outcomes . It has been associated to emotional intelligence acting as a buffer in preventing compassion fatigue and promoting compassionate care . The beneficial effects of self-compassion amongst nursing students have been reported [103,104] but the degree to which nurses balance and extend the compassionate care to their patients to themselves has not received much attention . Additionally, nursing students experience more academic stress, fears and anxieties in managing the demands of their educational programme than other healthcare programmes . A raised risk of suicide in healthcare professionals especially nurses have been reported  with recommendation that improving emotional coping skills should be included in the curricular programme as one of the strategies to prevent suicidal ideation amongst students . As students and registered nurses play a pivotal role in caring for patients, self-compassion can be of help in maintaining and preserving a positive mental health by being aware of their own vulnerabilities and being kind and caring to themselves . Nevertheless, more evidence specifically examining self-compassion in nursing students are needed.
10. Work Environment and Care Transformation
A compassionate working environment is a prerequisite for the delivery of compassionate care [110,111,112]. However, a conflicting personal and professional ethics in a system driven culture can set professionals aspiring compassionate ideals at odds with the organisational goals and policies . During and after completing their training empathetic and caring nurses tend to absorb the stresses of those in their care which may lead to compassion fatigue and emotional burden . This can lead to emotional detachment and burnout resulting in a reduced disposition to appreciate and tolerate patients’ and colleagues’ emotions . The national framework on ‘developing people and improving care’ highlighted the need for compassionate leadership at all level in the NHS .
Several factors have been identified which can constrain and mitigate against compassionate care. This ranges from the organisational culture, high staff and patient turnover, negative attitudes to some patients with complex care who are labelled as challenging, poor leadership to the changing role of the nurse. Christiansen et al. (p.835)  argued that ‘being approachable and non-judgemental” were some of the enablers but inadequate time spent with patients and pressures of work were some of the major difficulties to delivering compassionate care. The erosion of compassion has been linked to poor skill mix, targets, overcrowded wards, the high nurses’ workload and paper work, red tape, which takes time and energy , a view substantiated by Chirkov et al. and Georges [117,118]. To address the nursing staffing level, a paper put forward by The Chief Nursing Officer for England sets out guidance on care staffing capacity and capability  but there is currently no safe staffing law in England to ensure appropriate nurse staffing levels. Scotland is leading the way in the UK for improving the scrutiny of the delivery and monitoring of safe staffing levels in health and social care services by the passing the safe staffing law in May 2019.
It is considered that many nursing students join the profession because they want to improve healthcare  and their learning experience in practice is central to their professional development as a nurse . Hence, it important to ensure that adequate resources are available for nursing students’ learning in practice. To address the mentoring shortage and concerns for placement capacity, the roles of mentors and sign off mentors have been replaced by practice assessors and practice supervisors and all registered nurses will be expected to supervise students learning under the revised NMC (2018) Standards for Students Supervision and Assessment .
It has been argued that there is a mismatch in the patients values such as respect, rights and choices to the service quality standards which can potentially create a ‘value gap’ which is challenging for nurses to manage (p. 2718) . Nursing students dispute that there is a conflict between nursing practice (meeting targets and task centred- activities) and the professional ideals of taking the time to demonstrate compassionate care, spending time with patients and person-centred care . The emulation of negative role models in training and disillusionment in new registrants to reconcile the dissonance between their espoused ideals instilled in their training  and the working conditions are contributing to nurses leaving the profession . Therefore, in addition to initiatives to improve retention before and after their registration, it is important that the students are equipped and supported during their training on how to manage any tension in their ability to challenge poor practice and manage competing commitments in working environments that structurally may mitigate against the capacity for compassionate care .
Furthermore, the provision of quality and compassionate care is also impacted by the changing health needs. Considering the changing role of registered nurses in meeting an ageing population with more complex clinical needs in the UK compounded by an ageing workforce, several documents have outlined the major trends for health and social care and workforce challenges namely the Five Forward View , Health Care Workforce in England  and Scotland’s 2020 Vision for Health and Social Care, (2011) .The required contemporary knowledge and skills for the advances in science and technology in the digital health age have subsequently engendered changes to the nursing roles. As argued by Wiljer et al.  the integration of digital health in the promotion of compassion and the potential inadvertent consequences of technology on compassionate care has not received much consideration.
The ‘professional socialisation and doctrinal conversion’, has seen a shift from nursing as a vocation to a profession (p.467) , and nursing students studying for a degree. New routes to nursing have been created such as nursing apprenticeship and regulated roles in the nursing team like Nursing Associates have been developed and being trained to fill the identified skills gap between care workers and registered nurses . The NMC (2018) preregistration education standards, requires registered nurses to be proficient in advanced skills previously undertaken by junior doctors, such as cannulation, implying that more fundamental nursing care work is passed down to other healthcare workers . The nursing curricula which reflects these technical skills [24,25] has been criticised for moving away from the compassionate and basic nursing care  to more technical skills and subsequently squeezing compassion out of nursing programme with suggestions that it can leave patients to perceive qualified nurses as less compassionate because of the technical aspect of the profession [9,132]. However, Aiken et al. dispute that high levels of education have a positive outcome on quality of care interactions and patient mortality .
Compassion is recognised as a fundamental human dimension of care which is integral to patient care. Every effort should be concentrated on how the fundamental principles of compassion can be firmly anchored at the heart of contemporary nursing practice in the recruitment and education of neophyte nursing students. AEI’s and placement providers have a collective responsibility in preparing these students as compassionate nurses from admission to the programme to the provision of learning experiences that prepare them in delivering humanistic standards of care. Exposure to learning experiences in inspiring and healthy practice environment and creative teaching methods which provides the gateways to understanding and valuing the patients’ needs and preferences by not losing sight of the person in the patient are imperatives to sustain nursing students’ growth into compassionate practitioners. The ability to thrive despite adversity in challenging practice learning situations in judiciously and empathetically managing interpersonal relationship by cultivating a culture of self-compassion are also important for nursing students. In their duty of care towards these students ‘health, well-being and safety, AEIs also have a responsibility to examine how to deliver a preregistration nursing education programme designed to be more compassionate to these learners.
The authors would like to thank Mike Anjoyeb (Senior Lecturer at Bucks New University) for his contribution in critically reviewing the manuscript.
Both authors have drafted the work and revised it critically in keeping with important intellectual content and have agreed to be accountable for all aspects of the work and have approved the final version to be published.
The authors have declared that no competing interests exist.
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