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Perceptions of compassion in nursing care vary among both patients and nurses. Therapeutic touch and facial expression are powerful non-verbal communication tools used to convey compassion, but both have been negatively affected by social distancing and the use of personal protective equipment during the coronavirus pandemic. Being unable to relieve people’s suffering using these instinctive methods may result in nurses having low levels of compassion satisfaction and, ultimately, compassion fatigue. This poses a challenge to the profession: it must develop alternative ways of conveying compassion.
Citation: Brown A (2020) Will Covid-19 affect the delivery of compassionate nursing care? Nursing Times [online]; 116: 10, 32-35.
Author: Annemarie Brown is lecturer in BSc Adult Nursing, University of Essex, Southend.
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he importance of compassion in nursing practice has been acknowledged in a range of publications in recent years, including: a report into complaints about the standard of NHS care provided to older people by the Parliamentary and Health Service Ombudsman (2011), Compassion in Practice, the strategy for nursing often referred to as the 6Cs (Department of Health, 2012); and the report into care failings at Mid Staffordshire NHS Foundation Trust (Francis, 2013). The use of touch – an integral part of nursing care for task-focused purposes – is also often used by nurses to convey compassion, as is facial expression, an important non-verbal means of communication. The need for social distancing and personal protective equipment (PPE) during the coronavirus pandemic may make it difficult for nurses to use therapeutic touch and facial expression to show compassion, and this is likely to continue for the foreseeable future.
This article explores the meaning of compassion from the perspectives of both nurses and patients, and how social distancing and the need for PPE may negatively affect nurses’ ability to deliver compassionate care.
What is compassion?
Cambridge Dictionary defines compassion as “a strong feeling of sympathy and sadness for the suffering or bad luck of others and a wish to help them” (Bit.ly/CamCompassion). In relation to nursing, Dewar (2011) defines it as “…the way in which we relate to other human beings when they are vulnerable. It has to be nurtured and supported. It involves noticing another person’s vulnerability, experiencing an emotional reaction to this, and acting in some way with the person, in a way that is meaningful for people. It is defined by the people who give and receive it, and therefore interpersonal processes that capture what it means to people are an important element of its promotion”.
“Nurses may want to comfort a relative but feel unable to embrace them or even place a hand on theirs to demonstrate compassion”
Nurses’ perceptions of compassionate care
Papadopolous et al (2016) found that nurses define compassion as a “deep awareness of the suffering of others and the wish to alleviate it”. Tehranineshat et al (2019) have explored compassion from the nurse perspective and described it thematically, for example as:
- Effective communication – kindness, feeling of integration, building trust and verbal and non-verbal communication skills;
- Professionalism – clinical proficiency, evidence-based care, intuition in diagnosing problems, time management in clinical practice;
- Continuous comprehensive care – adherence to moral values, meeting holistic needs, providing psychological and emotional support to the patient and family, managing the physical environment, care education.
Sacco and Copel (2018) conducted a concept analysis of compassion satisfaction with a focus on compassion fatigue; they outlined assumptions that underpin the desire to deliver compassionate nursing care (Box 1).
Box 1. Assumptions underpinning the desire to deliver compassionate nursing care
- The nurse must wish to have a caring relationship with patients and their families, which, in turn, will greatly benefit all parties
- By meeting the needs of both patients and families, the nurse will experience positive feelings of fulfilment and a sense of worth
- The environment in which the caring occurs can influence the nurse, particularly if there is repeated exposure to traumatic events
- An empathetic connection develops, which, in turn, develops compassion, altruism, sympathy and understanding
The questions of whether compassion can be taught, whether it is an intrinsic and natural personality trait, and how nurses demonstrate compassion have been discussed by several authors – such as Su et al (2020), Tehranineshat et al (2019), Papadopoulos et al (2016), Bramley and Matiti (2014) – and continue to be debated.
In a study by Papadopolous et al (2016), it was found that 69.6% of nurse participants thought compassion was very important in nursing and more than half (59.6%) argued that compassion could be taught; however, only 26.8% reported that the correct amount and level of teaching is provided. The majority of participants (82.6%) believed their patients preferred knowledgeable nurses with good interpersonal skills over knowledgeable nurses with good technical or management skills. Only 4.3% (n=1,323) of participants noted that they had received compassion from their managers. Papadopolous et al (2016) suggested there is a relationship between nurses’ own experiences of receiving compassion and their delivery of compassionate care to patients. Other authors concur that if nurses experience compassion at work they are more likely to be compassionate to their colleagues and patients (Su et al, 2020; Frampton and Goodrich, 2014).
Patients’ perceptions of compassionate nursing care
Bramley and Matiti (2014) conducted a study to explore patients’ experiences of receiving compassionate nursing care and to understand their views on how a perceived lack of compassion in nursing can be addressed. In total, 10 patients participated in the study; the main themes to emerge were:
- What is compassion? – knowing me and giving me your time;
- Understanding the impact of compassion – how it feels in my shoes;
- Being more compassionate – communication and the essence of nursing.
The participants were undecided as to whether compassion could be taught or whether it was a personality characteristic. However, it was clear from the data analysis that patients felt it was not the amount of time nurses spent with them that defined compassion, but rather gestures – irrespective of how fleeting they were – that demonstrated a compassionate connection. This is illustrated in a quotation from one participant:
“Well, they look or touch and feel and put their hands on your shoulders. Well… you know, people, they respond to that… it makes you feel like a human being. I know they are busy, but the small things show they care”
(Bramley and Matiti, 2014).
It is clear that people perceive compassion in nursing in a variety of ways; however, two common themes are threaded throughout the nursing definitions:
- Awareness of distress;
- The act of moving from feelings, such as empathy and sympathy, towards a desire to act to relieve the distress (McCaffrey and McConnell, 2015).
From the perspective of participants in Bramley and Matiti’s (2014) study, touch was viewed as therapeutic and associated with compassionate nursing care.
Touch and nursing care
Touching patients is an integral part of delivering nursing care. Pedrazza et al (2018) defined three types of touch nurses use:
- Touch for task-orientated contact;
- Touch to promote physical comfort;
- Touch to provide emotional containment.
The benefits and social meaning of touch have been studied since the mid-1950s and studies have found that, in general, patients have a greater need for touch during illness or psychological distress (Dewever, 1977; Burton and Heller, 1964). Since 1990, researchers have attempted to explore the meaning of touch in terms of its social and psychological effects, which include support, such as helping patients cope with their illness (Bottorff, 1993), and comfort, reassurance and encouragement (Adomat and Killingworth 1994). It has also been proposed that some patients may have an increased need for touch due to the isolation and separation from their families caused by severe or terminal illness, age or chronic pain (Estabrooks, 1989; El-Kafass, 1983).
Touching is a powerful tool for non-verbal communication and can be comforting, as long as it is used appropriately and received positively by the person being touched (Fry et al, 2013; Van der Cingel, 2011; Davidhizar and Giger, 1997; Hollinger and Buschmann, 1993). Routasalo (1999) suggested that touch is an essential part of caregiving and an excellent way of communicating the following:
Kübler-Ross (2008) found that gentle hand pressure was the most effective form of communication with dying patients.
Covid-19 and the use of touch
The coronavirus pandemic will, in all probability, have already influenced the way health professionals use touch to demonstrate compassion and caring. For example, nurses may want to comfort a grieving relative but feel unable to embrace or comfort them, place a hand on theirs to demonstrate compassion or to put their arms around a patient who has just received a terminal diagnosis and is clearly distressed.
The examples of relatives being unable to touch or say goodbye to their loved ones during the response to Covid-19 reinforces the distress caused when the need to comfort is not fulfilled (Pattison, 2020). These gestures and expressions of compassion may well have been instinctive and spontaneous in the past but, in many clinical settings, they can now no longer happen due to the need for social distancing and PPE (Pattison, 2020).
Avoidance of use of touch
Not all nurses are comfortable using touch to communicate compassion; touching patients implies closeness and intimacy, and some nurses are uncomfortable engaging in this (Edvardsson et al, 2003). Maslach et al (2001) suggested that nurses who feel stressed due to their workload or the nature of their work may wish to distance themselves emotionally and cognitively from their work and may avoid touching as a coping mechanism.
Adomat and Killingworth (1994) found that nurses in intensive care units engaged in mechanical task-orientated touch as a result of organisational pressures. Other nurses may feel uncomfortable and under pressure to use therapeutic touch when it is not a natural instinct, particularly when caring for patients whose behaviour is difficult or offensive (Connor and Howett, 2009; Gleeson and Timmins, 2005; Kruijver et al, 2000).
Pedrazza et al (2018) hypothesised that the type of touch a nurse uses when caring for patients is related to attachment theory, which seeks to explain how secure, anxious and avoidant attachment styles can affect human interactions differently (Mikulincer and Shaver, 2007). They found that:
- Nurses who were insecure or worried tended to use task-focused touch;
- Nurses with secure attachment felt confident in their own ability to maintain relationships, comfort and cope with another’s stress, pain or fear when expressed to them, and used therapeutic touch to convey compassion and caring.
Pedrazza et al (2018) suggested that therapeutic use of touch is a skill learned over time and by role modelling.
“The face is the richest tool in social communication but this channel of communication breaks down if the parties are a distance apart or their faces are concealed”
Impact of PPE on professionals and patients
The use of PPE, particularly face masks and gloves, may form a further barrier to communication and expressing compassion. Jack and Schyns (2015) suggested that the face is the richest, most powerful tool in social communication; it allows a person to interpret other people’s emotions such as happiness, surprise, fear, disgust and anger, through a complex process of sending and decoding signals. However, this channel of communication breaks down if the parties are a distance apart or their faces are concealed.
Wong et al (2013) conducted a study in primary care to determine whether doctors wearing face masks affected patients’ perceptions of the doctors’ empathy, enablement and satisfaction with the care received. Patients perceived the doctors as lacking empathy and felt the face masks had a negative impact on the doctor–patient relationship. This study was conducted in Hong Kong, where face masks are worn routinely, but its findings are likely to be applicable in the UK during the pandemic, and may even have a more profound effect given that patients in the UK are less accustomed to seeing health professionals in masks. Across the UK, NHS and care workers are being given clear face masks to help them communicate with people with certain conditions like hearing loss, autism and dementia.
In response to a growing body of literature suggesting an overuse of non-sterile gloves in hospitals when there was no exposure to blood and bodily fluids (BBF) (Loveday et al, 2014a; Loveday et al, 2014b; Fuller et al, 2011; Synder et al, 2008; Flores and Pevalin, 2006; Girou et al, 2004), Wilson et al (2017) explored the attitudes of members of the public and final-year student nurses about the use of non-sterile clinical gloves by healthcare staff. When members of the public were asked about the procedures and activities for which they would like healthcare staff to wear gloves, they indicated things such as changing wound dressings, taking blood samples and help with toileting. However, these respondents admitted to being uncomfortable with healthcare staff wearing gloves to undertake personal tasks, such as helping them walk to the toilet, get dressed or eat, or when pushing wheelchairs and serving beverages. In terms of personal care, the majority of respondents said they would prefer healthcare staff to wear gloves, particularly for washing intimate areas.
Interestingly, the survey demonstrated that almost all student nurses would routinely wear gloves to wash adult patients, yet only a quarter would wear them to wash a baby (Wilson et al, 2017). It is not necessary to wear gloves for washing patients unless there is a risk of exposure to BBF. Babies’ skin is almost inevitably contaminated with BBF, yet the study suggested that BBF from babies was perceived to carry a lower risk than that from adults, with respondents much more likely to use gloves to change an incontinence pad than a baby’s nappy (Wilson et al, 2017).
Student nurses in Wilson et al’s (2017) study felt that patients preferred to see them wearing gloves as they not only conferred a sense of hygiene, but also provided an emotional barrier against “intimacy” – for example, when washing genital areas.
A large proportion of the members of the public commented that gloves were:
- Often not changed between tasks or patients;
- Used to protect the worker rather than the patient;
- Often used instead of hand hygiene (Wilson et al, 2017).
The student nurses, however, acknowledged that glove use interfered with “therapeutic touch” and could make patients feel they were somehow “dirty” or contagious.
In conclusion, Wilson et al (2017) agreed with Whitby et al (2006), who suggested that hand hygiene – and the wearing of gloves, in particular – was a ritualised behaviour performed for self-protection, as opposed to protecting the patient and was strongly influenced by emotional perceptions about what was “dirty” and what was “clean”. As the wearing of gloves will become routine in the wake of Covid-19, it will be interesting to discover whether the attitudes of both patients and health professionals will change.
The coronavirus pandemic has changed the way we interact with, and provide compassionate nursing care to, patients – and it will do so for the foreseeable future. Some nurses already employ alternative ways of demonstrating compassion, such as verbally rather than through touch, gestures or facial expression. For some, however, witnessing a person’s distress and being unable to relieve it by using therapeutic touch or compassionate gestures may result in low levels of compassion satisfaction and, ultimately, compassion fatigue. Increasing nurses’ feeling of compassion satisfaction promotes the wellbeing of the individual nurse and provides a positive beneﬁt for patients and service users. With the need for social distancing and PPE, the profession must develop new ways of showing compassionate nursing care that are acceptable to both nurses and patients.
- Perceptions of compassionate nursing care differ, but therapeutic touch and facial expression are powerful tools
- Nurses who experience compassion at work are more likely to be compassionate to their colleagues and patients
- Social distancing and personal protective equipment make it difficult for nurses to use touch and facial expression to show compassion
- Being unable to relieve people’s distress may result in compassion fatigue and, consequently, have a negative impact on both nurses
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