This chapter focuses on systemic factors in healthcare systems and how these can promote qualities such as mindfulness, awareness, resilience, and compassion. Too often, health systems do not promote these values at the organisational level despite the best efforts of individual healthcare workers. With attention and awareness, however, this can be remedied. This chapter examines the themes of compassionate leadership in healthcare organisations, resilience in these settings, and specific approaches that healthcare professionals can take to increase compassion across the healthcare systems in which we work. These steps include: (a) leading by example to promote compassionate behaviour for better care; (b) supporting the well-being of colleagues and staff we manage; (c) fostering open communication across clinical and managerial teams; (d) including patients and families in decision-making and valuing their perspectives; (e) promoting teamwork and collaboration that are inclusive, adaptive, and resilient; (f) recognising and rewarding compassionate care, both formally and informally; and (g) making self-compassion a key organisational value: health care is challenging, we are all human, and self-compassion is the basis of compassion for others.

This chapter focuses on resilience and compassion, starting by examining the relevance of resilience in healthcare, especially during the Covid-19 pandemic. The chapter notes that while a certain amount of resilience is helpful and even essential, resilience depends on not only the personal characteristics of each healthcare worker, but also the conditions in which they work. Relevant factors include the structure and function of teams, models of organisation, quality of leadership, and resources. These matters have an enormous influence on individual experiences, attitudes, and behaviour, and on the levels of resilience that are required and accessible in the workplace, as well as compassion. This chapter considers the concepts of ‘compassion fatigue’ and ‘burnout’, and outlines barriers to, and facilitators of, compassionate care. Systemic challenges include competing system demands, time constraints, inadequate resources, communication issues, poor emotional connections with the broader healthcare system, and the perception and/or reality of staff not being valued for the care they provide. These are themes that resonate with many people who work in large healthcare systems where organisational challenges loom large, often distracting focus from day-to-day patient care. This chapter also examines the roles of mindfulness and meditation in navigating these challenges.

Certain skills support compassion and help us to develop and sustain compassion even in circumstances that are far from ideal. Against this background, recent decades have seen a remarkable growth of research in this field. There is, in particular, a welcome flourishing in the area of compassion studies and compassion-based therapies, which form the focus of this chapter. Paul Gilbert, in particular, has developed compassion-focused therapy (CFT) which is outlined further by the Compassionate Mind Foundation and available in many countries around the world, as well as online. The Compassionate Mind Foundation advances an evolutionary and bio-psycho-social informed approach to compassion, and this forms the basis of CFT and ‘Compassionate Mind Training’. This chapter starts by exploring the origins of CFT and key attributes for the cultivation of compassion, before considering compassion and shame in clinical contexts. Shame can be an especially powerful emotion with a profound effect on health-related behaviour. Compassion can be a valuable way to address this issue. This chapter examines CFT in practice and notes the growing evidence base to support its use. The chapter concludes with further reflections on compassion and self-compassion as key skills and vital resources in healthcare.

In theory, compassion lies at the heart of all healthcare. There are, however, many reasons for the erosion of compassion in day-to-day clinical practice: increased demand on services, limited resources, large caseloads, insufficient time to spend with each patient, and a consequent transactional rather than relational approach to each person. Systemic focus on efficiency and throughput can also impede the cultivation of compassion, empathy, understanding, and addressing the individual needs and concerns of each patient and their family. Growing reliance on technology and electronic health records can further depersonalise patient interactions and reduce compassion, despite the many benefits of such technologies. This chapter outlines these and other factors which tend to diminish compassion, reflects on the relevance of overarching values in medical education, focuses especially on the meaning of ‘equanimity’ in this context, and overviews the place accorded to compassion in guides to professional ethics and codes of practice. The role of health systems in limiting compassion and empathy is balanced by evidence supporting the importance and possibilities of compassionate care, especially during times of emergency such as the Covid-19 pandemic in the early 2020s.

Despite its expanding presence in codes of practice and ethical guidance for healthcare professionals, there is limited research into the precise components of compassion in clinical settings. This chapter continues the exploration of compassion in healthcare by noting occasional confusion surrounding the term ‘compassion’, and the distress that an absence of compassion can cause for patients, families, and staff. The chapter examines research that seeks to define compassionate healthcare and delineate its constituent elements. Patients experience compassionate care when healthcare providers are emotionally present, communicate effectively, enter into their experience, and display understanding and kindness. Listening and paying close attention are the most dominant features of compassionate care, along with following‐up and running tests, continuity, holistic care, and respecting preferences. Other factors include honesty and kindness, as well as specific behaviours such as smiling. These are simple ways to demonstrate the compassion that healthcare workers routinely feel but sometimes do not convey clearly, owing to challenging circumstances. The chapter concludes with considerations of cultural and ethnic factors, as well as the importance of engagement, mindful awareness, and emotional intelligence in generating and deepening compassionate practice.

Awareness is the quality of knowing and understanding that something is happening or exists. It means bringing conscious attention to whatever is arising, with as little judgement as possible. On a subconscious level, we respond to what is happening in the moment by applying existing information in our brains to the external event. This response is often habitual or unaware, as we tread well-worn grooves in our brains and follow heuristics which help us to manage the vast amount of information that comes our way every moment. These cognitive shortcuts can be helpful, but they can limit our understanding, undermine our confidence in new situations, and diminish the attention we pay to what our bodies and minds tell us. Deepening awareness involves developing mindfulness, which means paying careful attention to the present moment, simply and directly, rather than being distracted by thoughts, judgements, or interpretations. Traditionally, there are four components or foundations of mindfulness. This framework allows us to develop awareness of all aspects of our experience. These are: (a) mindfulness of the body; (b) mindfulness of feelings or feeling-tone; (c) mindfulness of states of mind or emotions, and (d) mindfulness of thoughts. This chapter offers exercises and guidance for developing deeper awareness and mindfulness in day-to-day life.

A growing literature examines the relationship between compassion and various aspects of nervous system function, especially the brain. The chapter starts by outlining neuroimaging studies of compassion and then examines the topic of empathy and the brain, noting evidence that observing another person’s emotional state activates parts of the neuronal network that are also involved in processing that same state in oneself. Research suggests that multiple areas within the brain are involved in compassion and compassion training, with some regions more strongly implicated than others. Finally, relevant conclusions are presented and potential directions for future work outlined. Overall, research into the neuroscience of compassion supports the idea that compassion can be cultivated deliberately through training. There is evidence that activities such as compassion training and meditation can increase positive affect, boost resilience, facilitate altruistic behaviour, and possibly even assist with equanimity. These ideas are underpinned by growing neuroscientific evidence of impact on the brain. These valuable findings underscore the importance of developing compassion as a skill and fundamental attribute for healthcare workers across all settings.

This chapter explores why we decided to write this book about compassion in healthcare. Despite choosing our professions in order to help others, many healthcare professionals feel chronically tired, emotionally drained, deeply heart-sore, and ultimately burnt-out. Too often, moments of connection with patients and their families, although magical at the time, also highlight the uncertainties and even the darkness that surrounds them. Commonly, staff struggle to make sense of healthcare systems that seem to value neither ‘health’ nor ‘care’. The message of this book is that we can do better. Perhaps the first step in resolving these matters lies in recognising that while we do not have full control over the shape of the healthcare systems within which we work, or indeed the societies in which we live, we can control how we navigate these contexts, how we respond to them, and how we seek to be in the world. In parallel, we can also seek to change health systems in the direction of more compassionate care. Compassion is always essential in these processes, especially in the settings of health and social care. That is why we wrote this book: to try to make compassionate care a day-to-day clinical reality for everyone: patients, families, and healthcare professionals who constantly seek to do more and better.

This chapter examines the formal relationship between medical professionalism and compassion, looking at codes of ethics and practice guidelines, chiefly for medical professionals but also with reference to other healthcare workers. The chapter starts by exploring the importance accorded to compassion in ethical guidance for doctors in the United Kingdom (UK), Ireland, the United States, Australia, and New Zealand. It then examines guidance specifically aimed at psychiatrists, including documents published by the Royal College of Psychiatrists in the UK, the College of Psychiatrists of Ireland, and the American Psychiatric Association. Many of these guides emphasise the importance of compassion and related values, with the Royal College of Psychiatrists providing particularly detailed suggestions about building and sustaining compassion in mental healthcare. Compassion and related values also feature commonly in codes of practice and ethical guidance for other clinical professionals, such as nurses, midwives, social workers, occupational therapists, and others. This chapter concludes that, taken together, these statements of practice values and ethical principles reflect a welcome and growing emphasis on compassion in guidance for healthcare professionals across many clinical domains.

The literature about values in healthcare contains many terms which are sometimes used interchangeably. These terms include ‘compassion’, ‘sympathy’, ‘empathy’, ‘kindness’, ‘communication skills’, and various other words which are intended to denote a caring, understanding attitude towards healthcare provision. Confusion between these terms adds significantly to the apparent heterogeneity of research in this area and raises the worrying possibility that some writing on this topic uses these terms interchangeably. This chapter starts by exploring specific terms which are often used as synonyms for ‘compassion’, such as ‘sympathy’, ‘empathy’, ‘kindness’, and ‘communication skills’, and then focuses on two of the so-called ‘near enemies’ of compassion: pity and ‘horrified anxiety’. We may be trying to cultivate compassion, but, at times, emotions can arise that may be mistaken for compassion and can have negative effects. Clarity about concepts and terms can help to understand their significance, their importance in healthcare provision, and ways in which they support, as well as differ from, compassion. Overall, this chapter echoes the main arguments of this book by emphasising that compassionate healthcare requires an all-of-system approach, rather than isolated changes, paper exercises, or tinkering around the edges. Reflecting on terminology can help greatly in this process.

The purpose of this ‘Handbook of Compassion in Healthcare: A Practical Approach’ is to help make compassionate care a day-to-day clinical reality for everyone: patients, families, and healthcare professionals. We do not suggest that current health systems are entirely lacking in compassion. All around the world, clinical care is provided by staff who seek to be professional, compassionate, and patient-centered at all times. The very existence of health centres, doctors’ surgeries, outpatient clinics, acute hospitals, daycare centres, dental practices, physiotherapy centres, and many other healthcare facilities is a testament to basic human compassion, to society’s commitment to help the afflicted, and to our fundamental desire to support each other in times of difficulty. We care. At the same time, it is clear that healthcare settings vary widely in relation to compassion, with some already excelling in compassionate care, but others in need of a more conscious or sustained focus on compassion. Many services do well, but most could do better. Improvement is always possible. Health systems are operated by people, for people. Compassion matters deeply. Compassion can be the key value that improves services further and makes our fundamental caring impulses more apparent, more effective, and more human. Always and everywhere, compassion matters.

This chapter explores the concepts of self-compassion and moral injury, and ways of navigating complex healthcare roles with self-awareness, kindness, and greater compassion. Self-compassion involves recognising our suffering, being moved by it, and offering kindness and understanding towards ourselves. Human beings can be our own worst enemies and toughest critics. Cultivating self-compassion helps to address this tendency, increase resilience, and empower us to show greater compassion towards others. Moral injury stems from situations in which a person must make choices that go against their core values and can corrode compassion. There are many kinds of moral injury, ranging from a single large, conflictual decision to a sustained pattern of smaller but still conflictual decisions that arise on a day-to-day basis. The latter is common in large healthcare systems owing to rapid decision-making, inadequate resources, outsized expectations of healthcare providers, and working conditions that are often not conducive to clear thought: long hours, sleep deprivation, inadequate personal support, and lack of compassion for staff. This chapter examines how to manage the risk of moral injury in these situations, how to boost self-care for staff, and the importance of self-compassion when managing or living with difficult experiences or situations, especially on a recurring basis.

At its heart, compassion is the feeling of being motivated to act in the presence of suffering. From a psychological perspective, the construct is conceived as having two dimensions: state and trait. The compassionate state reflects the feeling of compassion or having a compassionate response in the moment, while a compassionate trait is more stable, reflecting a general tendency towards compassion or towards feeling and responding compassionately most of the time. For people who are expected or required to be compassionate in their everyday life or work, compassion requires sustained courage and a continued willingness to engage with suffering, rather than avoid it. This chapter explores compassion from psychological, evolutionary, and physiological viewpoints. Despite a useful and growing literature in this area, a precise definition of compassion in practice can remain elusive. The meaning of compassion is not written in stone; it flows. As a result, what the concept means in healthcare, and how it works in practice, are, perhaps, made most tangible through providing compassionate care to patients, interacting with families, discussing compassion with colleagues, and teaching students about compassionate healthcare. If compassion is defined flexibly and understood wisely, it can shape care in positive ways, improve outcomes, and change lives.

This chapter looks at ways of building personal resilience as a foundation for compassion. The chapter starts by presenting relevant learnings about resilience from the Covid-19 pandemic; outlines positive behaviours that promote individual physical health, mental health, and resilience; presents a guided imaginative practice focusing on resilience and inner solidity, and, finally, draws together key themes of resilience, equanimity, and compassion towards the end of the chapter. The overall message is that self-care is (a) an act of radical self-compassion, (b) the basis of compassion for other people, and (c) a vital foundation for resilience, among other qualities. We cannot care for others, or become more resilient, unless we care for ourselves, so it is essential that healthcare workers pay attention to their physical and mental health. This includes optimising levels of physical exercise, sleep patterns, and dietary habits, as best as possible. It also includes specific steps to improve mental health, both in our own lives and in relationship with other people. Physical and mental health are intimately related with each other. Both are vital foundations for learning greater resilience and cultivating deeper compassion for ourselves, our patients, their families, and our colleagues in the healthcare professions.

As we cultivate mindfulness, we can develop and deepen our compassion skills, both for ourselves and for others. Without self-compassion, we will struggle to look after other people compassionately. This chapter explores ways to build self-compassion and how to extend this compassion to other people in our lives. This includes our patients, their families, and our colleagues, as well as our own families and circles of friends. These are important tasks that find their roots in the theoretical and research foundations of compassion, and build on the awareness skills that we develop through mindfulness practice. This chapter presents exercises for deepening self-compassion, growing compassion for other people in our lives, and extending that compassion to everyone. By focusing on common humanity, we move towards a more stable, engaged response to other people, less informed by our own situation and more informed by theirs, less shaped by our judgements about them and more shaped by what we can achieve together. Developing compassion for everyone can be challenging, especially for people whom we anticipate will be difficult, but, with awareness, we can move in the right direction. This chapter concludes with an exercise that focuses on generating feelings of compassion towards other people by encouraging mindfulness of our connection with all beings and the planet as a whole.