Developing Skills and Becoming More Mindful
Having considered ‘Compassion in Healthcare’ in Part I of this book, Part II presents practical steps towards operating from a place of safe, secure grounding to become more compassionate towards ourselves and others when confronted with suffering. This part of the book includes practical exercises that the reader can carry out to develop skills that promote mindful, compassionate healthcare. These techniques enhance the individual’s ability to reduce burnout and overwhelm, and to make decisions from a place of awareness, mindfulness, and compassion.
These chapters are based on the premise that caring for yourself and others in a compassionate way will result in better outcomes for you and the people you care for. The ripple effect of this is important to remember. We are inter-connected beings, and this is especially evident in health systems which are designed to care, cure, and connect. Healthcare is a very human endeavour, and compassion is a quality we can develop as humans when reaching out to each other at times of difficulty, times of challenge, and – hopefully – times of healing.
The sequence of chapters and exercises in Part II is important, as we seek to build a skill-set that helps us to become more aware, cope better with distress, deepen compassion in our workplaces, and work more compassionately with each other. We develop mindful awareness first, so that we are more likely to respond to events thoughtfully, rather than automatically or habitually, as outlined in this chapter.
Following this chapter, we will explore how to cultivate compassion towards ourselves and other people (Chapter 11), how to build our skills for developing resilience (Chapter 12), and how to implement strategies for more compassionate health systems (Chapter 13). The Conclusions chapter will present overall conclusions from the book as a whole and articulate a call to action to create conditions that support more compassion in healthcare.
Awareness, Reacting, and Responding
Most of the time, we react to events around us without much conscious thought. We use cognitive and behavioural shortcuts that generally serve us well. We do not think through each routine action from beginning to end every time that we do it. We use experience, hunches, and guesses to cut corners and move forward briskly. We brew cups of tea, leave the house, and take routine decisions at work each day without much conscious thought and without re-analysing each step every time. We do these things automatically, barely aware that we are doing them at all, and certainly without questioning each step.
Staying on autopilot as we move through the day helps us to make decisions quickly and navigate recurring situations efficiently. In most of our lives, each day is pretty similar to the previous one, so it is usually best to do today what we did yesterday. After all, we survived yesterday, so that is presumably our best chance of surviving today. For evolutionary reasons, we have a negative bias in decision-making: avoiding risk keeps us safe, and autopilot is risk-averse.
Despite its benefits, however, staying on autopilot all the time means never doing anything differently. This can prevent us from living in a more open, connected way. It can keep us from responding thoughtfully to certain events, as we simply react immediately to all of them. Autopilot can limit our horizons and close our minds to the possibilities of change, growth, and renewal in the world.
The first step to break out of autopilot is to become aware of the habitual. Is your instinctive reaction to most external events to become defensive, to lock down, to say ‘No’? Healthcare professionals tend to perfectionism, second-guessing ourselves to prevent mistakes and help fix things. Responding thoughtfully, rather than just reacting, or repeating the behaviours of the past, means making space for a more creative response to arise. To achieve this, awareness is the first step in breaking out of autopilot.
Awareness is the quality of knowing and understanding that something is happening or exists. It means bringing your 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 for navigating new situations, and diminish the attention we pay to what our bodies and minds are telling us in the moment.
Deepening our awareness involves developing mindfulness, which means paying careful attention to the present moment, simply and directly, rather than being distracted by our thoughts, judgements, or interpretations (Kabat-Zinn, Reference Kabat-Zinn2013). For example, when we first learn how to ride a bicycle or drive a car, we concentrate deeply and maintain awareness because this is a novel activity which often involves a degree of anxiety. Once we become accustomed to cycling or driving, however, the steps involved become habitual, we lose awareness, and our actions are automatic. We can even arrive home without being aware of anything we saw along the way.
Awareness involves paying attention. We develop good foundations for awareness by slowing down, doing one thing at a time, moving our bodies slowly, watching our screen use, and maintaining sleep hygiene. Much like training a physical muscle, training our awareness muscle involves practising over and over again. As we do this, it is important to maintain some self-compassion because, as we seek to develop awareness, we lose concentration, we become unaware, thoughts creep in, and we get distracted. That is fine. We are all human and that is what our minds do. So, for each of the exercises described here, the more we practice, the easier they become. In time, we overlook moments of distraction and simply try again.
Traditionally there are four components or foundations of mindfulness. This framework allows us to develop awareness of all aspects of our experience. These components 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. We will consider each component in turn, with particular emphasis on the first two.
(a) Mindfulness of the Body
Mindfulness of the body includes awareness of the body itself, the form of the body, how and where the body is in the world, and processes of the body, such as breathing, sensing, and performing daily activities. The body is used as a means to develop concentration by focusing on, for example, the rise and fall of the stomach or chest when breathing.
The body is the first foundation of mindfulness. By becoming familiar with our own body and how it feels in the resting state, we are better able to identify changes in sensations when we experience particular mental states or emotions. The better we are at recognising how we habitually respond, the earlier we can identify habitual mental states, and the more likely we are to act rather than react.
We may all be familiar with the scenario where we have an appointment with a patient whom we find challenging. If we are unaware of our feelings, it is easy to slip into speaking brusquely or demonstrating irritability non-verbally. This is recognised by the patient who might respond in a similar way or withdraw from the conversation or consultation. If we become familiar with how our bodies habitually react, we are better able to identify those feelings and engage in creative responses. These include pausing and allowing feelings of frustration in our bodies to rise, crescendo, and pass, or actively focusing on noticing the breath, or engaging the parasympathetic nervous system by deliberately slowing the out-breath.
With mindfulness of the body, we become more aware of where we are and what we are doing: our feet in contact with the floor, our posture, our stance, our movement, our stillness. We become more aware of internal sensations within the body: heat rising, the thumping of our hearts, the chest rising and falling, our breath shifting. We become more aware of our senses: noises around and within us, what we can see, touch, taste, and smell. Ideally, as we become more aware of sounds, sights, and other perceptions, we do not interpret them or ascribe meaning. We allow them to be as they are. We allow ourselves to be as we are.
As we practice mindfulness of the body, we become more aware of patterns that indicate particular mental states to us. Most of us spend a lot of time in our heads and are often disconnected from the body, but the more in tune we are with our physical bodies, the more grounded and present we become. If we notice habitual contraction or tension in our muscles, we can bring awareness to these areas of the body. By doing so, they will naturally soften.
For example, this is a familiar sequence of events for many people:
I have noticed that when I feel irritated, and just before the irritation changes to outright anger, there is a sensation of heat rising from the centre of my chest up into my jaw and cheeks, which feel tighter, hotter, and even painful. This sensation is followed swiftly by pressure in my temples and tightened, tense jaws. When I consciously slow my breathing down and bring attention to my feet on the floor, my hand, or another part of my body, the heat and tightness subside, and eventually disappear.
The Three-Step Breathing Space is a useful, short exercise that can help us to step out of autopilot and into the present moment in this way. There are three stages to this practice, each involving focusing your attention for one minute. Step One involves focusing your attention on what is actually happening at that moment, rather than how you interpret events. Step Two involves gathering and focusing your attention on the direct feeling of your breath entering and leaving your body, for one full minute. Finally, Step Three involves widening your attention back out into the world again.
The Body Scan is another useful mindfulness practice that can support you to become more familiar with your body in its resting state (see Box 10.1). It is important to note that mindfulness of the body can bring up painful memories or associations, especially for people with a history of trauma. There are, however, approaches and techniques which are sensitive to trauma (Treleaven, Reference Treleaven2018). If it is not comfortable for you to focus on the breath, for example, many of the exercises we suggest can be adapted to focus on the feeling of your feet on the floor or on sounds or on other direct experiences in the moment, rather than the breath.
This body scan assumes that you are in the sitting position, but it can be adapted for lying down, or what ever position is most appropriate for you.
I invite you to close your eyes if you wish. Otherwise, rest your eyes gently on a point in front of you with a soft gaze.
When you are ready, take a few gentle purposeful breaths in and out, and then bring your attention to how you are sitting.
Become aware of your feet on the floor, your rear on the chair, your back pressed against whatever you are sitting on.
Allow your feet to press into the floor, grounding yourself, connecting with the earth. Allow your body, your spine, and your neck to lengthen, almost as if there was a string on the top of your head connecting you with the sky.
Breathe gently for a few moments as you are aware of this connection between your body and the earth, and your body and the sky.
When you are ready, you can place a hand on your stomach. Become aware of your breath and the rise and fall of your stomach as you breathe in and out. Allow the breath to lengthen and gently move your attention up to your chest to become aware of your ribs rising and falling as you breathe in and out.
Bring your attention to your back and notice how that, too, rises and falls as you breathe in and out.
Then, gently scan your body all the way from the feet up through the legs, the knees, the thighs, the pelvis, the stomach, your lower back, your upper back, your shoulders, your neck, and into your head.
Are there any areas where there is tension or holding? If so, bring your attention to those areas. Particularly, we can notice tension in the shoulders, in the jaw, around the eyes, or in the thighs. And by gently bringing your attention to this area, the effect of your awareness is to soften the tension. Spend a few moments gently breathing in and out, resting your awareness on this area.
When you are ready you can bring your attention back to your hands on your lap, rising and falling with your breath, or the feeling of your feet on the floor, with the sensation of pressure there.
When you are ready, start to move gently in your chair, open your eyes or refocus them. Bring your attention back into the awareness of your everyday world, carrying with you the grounding that you experienced during this body scan.
Other ways to develop mindfulness of the body are to focus attention on one particular aspect of the body (such as mindfulness of the senses) or to focus on movement. Many people find sitting still difficult, so moving the body mindfully is another way to meditate and become more aware of our bodies. Formal movement practices include yoga, Qi Gong and Tai Chi. Dancing can be a lighter way to be more embodied, but it is likely that most health professionals will find mindful walking to be a more convenient practice, even at work.
Mindful walking involves walking slowly and deliberately, usually within a small area. The intention is to become more aware of the body, rather than getting from A to B. The practice involves planting each foot on the ground with care and noticing the sensations as you do so: the heel, the sole, and the ball of the foot, each making contact with the ground, and the other foot beginning the same process before the first foot rises. It is helpful to keep a loose focus, breathing gently in and out, allowing the mind to empty, and focusing on the feeling of the movement rather than the environment. When thoughts come into the mind, we try to notice them with kindness, let them subside, and bring the attention back to the direct sensation of the feet on the ground.
(b) Mindfulness of Feelings or Feeling-Tone
Mindfulness of feelings, also described as feeling-tone, does not refer to emotions, but to the bare tone of each experience, that is, whether each experience feels pleasant, unpleasant, or neutral. When we have an experience, such as hearing a noise or seeing something, the feeling-tone is the first thing that is consciously evoked in us, as we become immediately aware of whether we experience this event as pleasant, unpleasant, or neutral.
For most of us, hearing a drill beside us while walking to work evokes a feeling-tone that is unpleasant. We can stop there and notice that the feeling-tone is unpleasant or (more likely) we can cascade into a story: ‘I dislike that noise. It is so unpleasant that I cannot hear my music on my headphones. My walk into work is horrible. I wish I was somewhere else.’ This story leads us to feel miserable, but by being mindful of the feeling-tone, perhaps by consciously saying the word ‘unpleasant’ to ourselves, our response can be more proportionate, more transient, and less distressing overall.
Mindfulness of feeling-tone is a useful exercise that can be done as part of a body scan (see Box 10.1) or, more quickly, as part of everyday life (see Box 10.2). Standing in a queue for lunch, for example, you can become aware of a sensation of churning in your stomach. Rather than jumping straight to label this as ‘hunger’ or ‘anxiety’, ask yourself what the feeling-tone is. By tuning into the sensation itself, rather than our interpretation of it, we can become better aware of what is going on.
This exercise has the effect of grounding us in our bodies and in our environment, but it also makes us more aware of the immediate tone of feeling as it arises, rather than the emotions or interpretations we can overlay on these feeling-tones.
Set a timer for a minute.
Scan your body for ‘pleasant’ sensations and say them aloud or to yourself.
Do the same for parts of your body or sensations that feel ‘unpleasant’.
Then, do the same for areas or sensations that are ‘neutral’ or have no feeling-tone.
What do you notice? Are there sensations which you were not aware of before? Was it easier to list pleasant or unpleasant sensations? What was it like to notice aspects with no real feeling-tone, neutral sensations?
You can repeat this exercise for aspects of your environment.
This is true for all sensations, such as loud or unpleasant noises or over-bright lights. We can become overwhelmed by the presence of such stimuli, but they can fade into the background if we pause to ask ourselves what we are actually feeling (e.g., ‘unpleasant feeling-tone’), rather than developing a habitual storyline, such as: ‘I hate this noise. What is it? It is a leaf blower. When will it end? I am never going to get this report written because of this noise. I might as well give up now. It is hopeless.’
(c) Mindfulness of States of Mind or Emotions
Mindfulness of states of mind sees the mind as a stream of temporary experiences which arise and pass, both fuelled and coloured by emotions. As is the case with immediate feeling-tones, it is not helpful to push away or resist unhelpful or negative emotions when they appear. These emotions often dissolve once we bring awareness to them and label them, rather than amplifying them, judging them, or interpreting them into stories about our lives. Just as these emotions arise, they also dissipate, provided we do not cling to them.
Negative emotions are a feature of everyday life. We might feel sadness or anger at an injustice, or irritation or frustration towards another person. If we add a secondary story to the emotion, this adds fuel to it, prolongs it, or even deepens it. If we pause and resist getting caught up in the emotion, it will pass quicker. No emotion lasts. Each emotion has an arising, a peak, and a dissipation. The key is to allow this process to happen. We can use various techniques to resist getting drawn in, such as grounding our thoughts in our bodies, practising mindfulness of the senses, or doing breathing exercises to activate the parasympathetic nervous system and down-regulate the sympathetic nervous system. These techniques help to take us out of our minds and into the present moment.
(d) Mindfulness of Thoughts
Most of the time we are not aware of our stream of thoughts. Thoughts, like emotions, are temporary. They come and go. It is our tendency to get caught up in them and allow them to proliferate that causes difficulty. The human mind naturally has thoughts bubbling into existence virtually all of the time. Habitually, we focus on particular thoughts and create stories around them. An alternative approach is to notice this tendency, label it in our minds as ‘thoughts’ or ‘thinking’, and then return the focus to awareness of thoughts as thoughts, rather than anything more than that. Thoughts are not facts.
Becoming more aware of our thoughts in this way allows us to realise when we have slipped into a daydream or a proliferation of thoughts. Awareness acts as an anchor bringing us back to the present moment. A helpful metaphor is the ‘train of thought’, where the train is our stream of thoughts, and we can either stand on a bridge above the train observing it, or we can jump down onto one of the carriages and get carried away. The goal of mindfulness of thoughts is not to avoid thoughts (which is impossible), but to allow the thoughts to arise and to pass. This helps us avoid getting too caught up in them or adding to them with various interpretations and mental proliferations which distract us from the present moment awareness that mindfulness seeks to cultivate.
Conclusions
Awareness and mindfulness are foundational tools for supporting self-compassion and compassion towards other people. We develop mindful awareness so that we are more likely to respond to events thoughtfully, rather than automatically or habitually. When we are mindful, we observe our emotions, thoughts, and sensations without judgment, as best we can in the circumstances. This, in turn, opens the door to recognising our own struggles and efforts to navigate various situations, thus fostering self-compassion. This is a very useful skill in fast-moving, stressful healthcare environments which often make mindful awareness difficult and commonly present deep challenges to our sense of self-compassion.
As we become more compassionate towards ourselves, we are better equipped to extend this compassion to other people. By practising mindfulness, we become more attuned to the situations and feelings of those around us. Rather than reacting to ourselves and to them impulsively or with indifference, mindfulness helps us to pause, consider the situation, and build deeper connections. Mindful awareness promotes thoughtful responses rather than automatic or unthinking reactions to events. It also provides the mental space and emotional awareness necessary to nurture more compassion for patients, their families, our colleagues, and the many other people we encounter as healthcare professionals, as well as our own families and friends.
In Chapter 11, we will explore how to cultivate compassion towards ourselves and other people, rooted in the common humanity that underpins mindfulness. Chapter 12 will explore skills for developing resilience. Chapter 13 will outline strategies for building more compassionate health systems. The Conclusions chapter will present overall conclusions from the book as a whole and articulate a call to action to create conditions that systematically support greater compassion in healthcare.
Compassion for Ourselves and Other People
The previous chapter focused on the development of awareness and mindfulness. It outlined four components or foundations of mindfulness: (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. That chapter presented exercises and guidance for developing deeper awareness and mindfulness in day-to-day life, especially mindfulness of the body and mindfulness of feelings or feeling-tone. These approaches are especially useful for healthcare professionals.
As we cultivate these mindfulness skills, or after we do so, the next step is to develop and deepen our compassion skills, both for ourselves and for others. We cannot look after other people compassionately without strengthening self-compassion at the same time. 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 outlined in Part I of this book, and which build on the awareness and mindfulness skills explored in Chapter 10 (‘Mindfulness and Awareness’).
Following the current chapter, we will explore how to improve our skills for developing resilience (Chapter 12), and ways to implement strategies for more compassionate health systems overall (Chapter 13). The Conclusions chapter will present take-home messages from the book as a whole and articulate a call to create better conditions for compassion in healthcare.
But first: how can we develop and deepen compassion for ourselves?
Developing Self-Compassion
Healthcare workers who look after other people can experience burnout if they do not operate from a place of self-compassion and resilience. Low self-compassion is associated with symptoms of depression, anxiety, and stress (MacBeth and Gumley, Reference MacBeth and Gumley2012). Conversely, high levels of self-compassion are associated with psychological well-being (Germer and Neff, Reference Germer and Neff2019). Clearly, self-compassion is a crucial element of wellbeing for everyone, including healthcare workers.
As we discussed in Chapter 8 (‘Self-Compassion’), Neff and colleagues conceptualise self-compassion as a balance between increased positive and reduced negative self-responding to personal struggle (Neff et al., Reference Neff, Long and Knox2018). This involves three key elements: (a) being supportive to oneself, rather than harsh and judgemental; (b) recognising that difficulties constitute a normal part of a human life, rather than feeling isolated from others as a result of one’s experiences; and (c) keeping personal suffering in rational awareness, rather than becoming fully absorbed by one’s problems (Neff, Reference Neff2003a; Neff, Reference Neff2003b).Footnote 1 These elements constitute a solid basis for deepening our self-compassion, as demonstrated in Box 11.1.
Become aware of your contact with the ground beneath you, such as your feet or shoes on the floor. Be aware of your rear and your back against the chair or a wall, if you are leaning against one. Bring your attention to those places and rest it there.
Breathe in and out gently for a moment. Place your hand over your heart if that feels comfortable for you, or on your belly, or cup one hand with another, or place one hand on your cheek or any place you feel comfortable with resting a soothing hand. If you find bodily touch difficult, imagine that you are holding something warm and soft, like a family pet.
Allow your attention to move from the body to your thoughts. Picture a time that felt difficult to you, but not too difficult – a time when you were significantly challenged, but not overwhelmed. This can relate to something that just happened or to another moderately difficult time in your life.
Allow the recollection of that difficult experience to fill your mind but try not to get caught up in thoughts about it or interpretations. Again and again, bring your attention back to the body where direct emotions associated with the event are arising, rather than thoughts about it.
Perhaps you notice your cheeks burning, or there is a prickling of tears behind your eyes, or a tightness in your belly or chest.
Breathe slowly and gently while keeping your soothing hand on your heart or over your other hand, wherever you have it resting. Whisper to yourself or say in your mind: ‘That was tough. Anyone in that position would find it tough.’
If you find it difficult to say those words to yourself, imagine that a good friend or wise person whom you respect is saying those words to you. If you find that too hard, imagine that you are saying those words to someone else you care about.
As you breathe gently in and out, allow the bodily sensations that arose when you recalled the tough situation to keep arising for as long as they take.
Then, observe as these feelings fall away, becoming softer and less intense as time passes, and maybe even fading away completely.
When you are ready, you can bring your attention back to the places where your feet and body are in contact with the floor or chair. Remove your hand from the comforting position.
Exhale slowly and return to the world around you, carrying the sense of care that you just experienced with you into the rest of your day.
Becoming aware of each aspect of our entire experience means that we can respond to whatever is arising from a place of awareness rather than reactivity. Self-warmth and kindness to the self can be challenging for people who experience a great deal of shame or self-criticism or have perfectionist and exacting standards for themselves (as many healthcare professionals do). ‘Compassionate mind training’ can help significantly with this issue (e.g., Gilbert and Procter, Reference Gilbert and Procter2006; Gilbert, Reference Gilbert2020).
Other useful exercises include the ‘amygdala hug’. How often are you aware of resting your head in your hands? Perhaps, when tired, you might even cup your chin on your hand or hands, or place one or both hands over your forehead or temples. This is a movement we do naturally and unconsciously. It is soothing and has the advantage of not being perceptible to others as a gesture of self-care. The ‘amygdala hug’ can be done by placing both hands cupped around the temples, or by placing one hand over the back of the head where the top of the neck meets the base of the skull and the other hand over the front of the forehead. This activates the body’s ‘soothing system’.
Various short breathing practices can also ground us in the present moment and create conditions for greater self-compassion. Many of these exercises can be done in healthcare settings; for example, before a busy clinic, in advance of a potentially challenging meeting, or to regulate oneself after a difficult experience. These practices combine awareness and mindfulness with a gentle, soothing, compassionate approach to ourselves and our experiences, as demonstrated in Boxes 11.2 and 11.3.
Imagine, or physically draw with your finger in the air, a box shaped by your inspiration (in-breath) and exhalation (out-breath).
Breathe in for four seconds, if that is comfortable for you, imagining or drawing one side of the square in the air as you do so.
Breathe out for four seconds, imagining or drawing the next side of the square in the air as you do so.
The length of the in-breath and the out-breath should be approximately the same, if that is comfortable for you.
Continue this for at least one minute or longer, if possible, imagining or drawing boxes in the air as you do so.
This is a variation on Box Breathing with greater focus on soothing and self-compassion.
For Rectangle Breathing, the exhalation is longer than the inspiration, at a ratio of approximately six seconds for the exhalation and three seconds for the inspiration (or whatever similar duration is comfortable for you, as long as the out-breath lasts longer than the in-breath).
The longer exhalation activates the parasympathetic nervous system, which prioritises ‘rest and digest’, and is experienced as soothing and self-compassionate.
Continue this practice for at least one minute or longer if possible, imagining or drawing rectangles in the air as you breathe in and out.
Another variation on these short breathing practices is to add a pause or to hold the breath briefly in between the inspiration and exhalation, if that feels appropriate and supportive for you.
Developing Compassion for Other People in Our Lives
As humans, we are interconnected creatures. Building compassion for other people rests on realising that other people are deeply similar to us, with the same problems and possibilities, the same dreams and disappointments. So, the next step in our sequence is to build on our mindfulness practices and self-compassion skills to translate this interconnectedness into greater compassion for other people in our day-to-day lives.
As healthcare professionals, it is expected that we have compassion for other people as part of our jobs. It is likely that many of us chose our careers because we want to help people at times of difficulty and uncertainty. In Part I of this book, we saw how operating from this compassionate perspective, rather than an overly empathic one, can enhance resilience and joy when working in healthcare (Chapter 3: ‘What Compassion Is Not’; Chapter 5: ‘Compassion in Healthcare’; Chapter 7: ‘Resilience and Compassion’). This section of the book now goes through some practical exercises for further developing our compassion skillset for different people.
It is part of our evolutionary make-up to see other people as ‘other’ or even as a threat. We can spend a great deal of time in this threat-based or drive-based system, with our sympathetic nervous systems at full blast, operating on adrenaline and cortisol. At such times, it is no wonder that we feel exhausted: we can see other people’s actions as obstructive, inconvenient, or, at best, thoughtless; for example, a team member who is constantly late, or a patient who raises a complex issue only at the very end of the consultation, when their hand is on the door-handle apparently ready to leave.
To generate more compassion in these situations, it is useful to start by reminding ourselves that other people are living human beings just like us. They want to be happy and do not want to suffer. They are just as rational and irrational as we are. Their actions in the course of seeking happiness and avoiding suffering might prove inconvenient or upsetting for us, or clearly deleterious for themselves, but once we accept that they have the same motivations as we do, and think and feel similarly, their behaviour can make more sense.
This realisation that other people are living lives which are just as vivid and complicated, rich and complex as our own has been termed ‘sonder’ (Koenig, Reference Koenig2021; Bowman, Reference Bowman2015). With this idea in mind, many of the exercises for developing compassion involve story-telling and narrative that enable us to realise this common humanity. We are at the centre of our own story, with all our surrounding characters, but every other person is at the centre of their own story too, and we might or might not be a surrounding character in their world.
A number of exercises can help us to deepen this sense of common humanity, tempered with humility, and appreciate more profoundly the feeling of sonder and how interconnected we truly are, as demonstrated in Box 11.4.
Imagine that it is Thursday morning. You are a hospital consultant (senior clinician) and your busy outpatient clinic is about to take place. As usual, the clinic is overbooked. It always runs late. You depend on having a full team present to keep the clinic flowing smoothly. When someone is on leave or sick, you depend on everyone else pulling together to pick up the slack. Your registrar (junior hospital doctor or resident) started with the team a month ago. They seem competent and knowledgeable, but they are always late.
On this particular Thursday morning, you walk into the clinic ready to start and notice that the charts are piled high, and the list is full. Extra patients have been added in at the last moment. Your registrar is not here. You see one patient, who is upset and takes longer than scheduled. Eventually, you are ready to see your second patient. There is still no sign of your registrar, so you simply carry on.
As you collect your third patient’s chart, your registrar runs into the clinic. They hurriedly throw their coat into a room and grab a chart, calling in the patient at the same time. Your levels of irritation rise; that is not very professional behaviour – being late and being discourteous.
Later in the morning, when the registrar knocks on your door with a query, your irritation bubbles over and you speak sharply to them. They apologise for interrupting. You ask them to come to see you at the end of the clinic.
At the end of the long morning, you are aware that you have a ward round to do in the main hospital and there will be no time for lunch, so your irritation has reached boiling point. You chastise the registrar for being late repeatedly and being discourteous to patients and staff. Your registrar apologises and says they will do their best not to let it happen again. You are not optimistic, but you end the meeting. You still feel just as annoyed as you did before the meeting, and maybe more so.
For this exercise, reflect on the feelings that this scenario evokes. Does it feel familiar? Have you found yourself in similar situations? Do you feel tension in your body or mind as you imagine such a meeting? Where is that tension located: shoulders, hands, stomach? What else do you feel in your body? Are there emotions, too?
Now, imagine what might be happening in the life of the registrar. They might dislike their job, and being late is a manifestation of that. Perhaps they regret choosing medicine as a career but are struggling to admit this to themselves because of what it means for their life. Perhaps the registrar lives at a great distance from the hospital and finds it hard to get there on time on public transport. Perhaps they are the carer for a relative or a child with disability and must ensure those needs are met before they leave the house. Perhaps they have an illness themselves and are just about managing to make it to work at all.
The point is that we do not know what is happening in other people’s lives. Ideally, we would operate from a place of assuming that each person tries their best and, just like us, wants to be happy and not to suffer. Too often, we attribute other people’s apparent shortcomings to their characters or lack of effort, rather than their circumstances. Perhaps they are doing very well in exceptionally challenging circumstances of which we know nothing. Perhaps we are the problem for them, just as they appear to be the problem for us.
Taking this perspective, rooted in common humanity, we are less likely to respond with irritation in these situations. We can show interest and compassion, and ask the person to explain the issue to us. That compassionate gesture alone can soften barriers, reduce annoyance, and reflect the common humanity that we share.
Other exercises focus on seeing the world through different lenses or from different perspectives (Burgess-Auburn, Reference Burgess-Auburn2022; pp. 37–8). These practices reveal our assumptions about the way we approach the world, help us to imagine the perspectives of different people, and deepen our sense of compassion towards people whom we find challenging or difficult.
Developing Compassion for Everyone
So far in this chapter, we have discussed ways to deepen self-compassion and how to increase understanding of, and compassion for, other people in our lives (e.g., colleagues at work). The vast majority of people in the world, however, are largely unknown to us, or we see them just a small number of times for a specific reason. What about them? Can we develop compassion for those people? Is it important that we do so?
We perceive many people as ‘other’ because we know virtually nothing about them. We might have impressions of them which are rooted in our assumptions about what they do, how they behave in the moment when we see them, or the extremely limited amount of information we have about them. We might feel overall positive, overall negative, or neutral towards any given person whom we see just a small number of times or for a specific reason, but these positions are often based on assumptions and bias, rather than knowledge or engagement with the person.
One way to reflect on this is to bring to mind a busy outpatient clinic as you scan the list of patients who are yet to be seen. Some are new patients, so their names on a list should evoke no response. These should be neutral names, but they might well evoke a negative response anyway, owing solely to the length of the list: why are there so many patients to be seen today? Who scheduled this over-filled clinic?
It is easy to feel irritated by the names, but that response has nothing to do with the specific individuals who are waiting to be seen, and everything to do with my situation, facing a busy clinic and general organisational dysfunction. And yet, it is easy to transfer this negativity to the patient, through irritability or impatience as the clinic stretches through the morning, into the afternoon, and even into the evening.
The names of other patients on the clinic list might be familiar and evoke a positive response; for example, a person who responded well to treatment and is attending for follow-up, or a patient for whom we have good news or a reassuring test result. We look forward to these encounters.
Finally, the names of some patients might evoke a negative response, especially those whose medical problems are proving difficult to resolve, or those with complex health histories and multiple comorbidities. As you imagine these difficult encounters, allow your awareness to rest on your internal bodily sensations. Perhaps you notice that your heart rate is rising, or your breathing is faster or shallower than usual. You might have a feeling of anxiety in the pit of your stomach. You might be aware that your patients notice when these physiological changes manifest as irritation and impatience. This contrasts with the patients towards whom you have a positive response, who might notice your friendliness and are more likely to engage with you and trust you.
We can use these categories that ‘other’ people fall into – overall positive, overall negative, or neutral – to work with our ways of being with other people. Like us, other people want to be happy and do not want to suffer. Holding this as true, we can accept that humans are mostly alike. It is impossible for us to fully know what other people are experiencing in a given moment, just as it is impossible for them to fully know what we are going through. Therefore, by focusing on common humanity, we can 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 this kind of understanding and 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 will conclude with an exercise that focuses on generating feelings of compassion towards others by encouraging mindfulness of our connection with all beings and with the planet as a whole.
In this exercise, we bring awareness to the idea that everyone has a complex, rich, and vivid life, just as we do. When we keep this connection and common humanity to the front of our minds, it reminds us that we are not solitary, isolated beings living separately, but part of connected, living, breathing networks. This helps us when we meet with people in the course of our everyday lives. No matter how they act towards us, or what feelings they evoke in us, we can take it less personally and act in a kindly, compassionate way.
This practice involves moving through a sequence of stages of well-wishing towards yourself, towards a good friend (a person towards whom you have a positive reaction), towards someone you do not know very well (a neutral person), and towards someone you find difficult (a person towards whom you have a negative reaction). In the last stage, we equalise the well-wishing between all four and then spread it out to the entire world, starting locally and eventually encompassing all beings. This is a powerful imaginative practice that can change how we feel about ourselves and others.
Traditionally, this exercise starts with generating feelings of warmth and kindness towards ourselves (described here as well-wishing). This can be challenging, especially for people who do not usually feel a sense of love or kindness towards themselves.
Another way to start this practice is to generate feelings of warmth and kindness by doing something called ‘gladdening the heart’. You might be familiar with a time that you felt a warm feeling spontaneously arise in the centre of your chest in response to something. It could be a beautiful scene in nature, a much-loved animal or family pet, hearing a particular piece of music, seeing a loved one after time apart, or the warmth of a hug from your child. To start this exercise, it can be helpful to ‘gladden your heart’ by recalling that event again. From there, you can spread this feeling of warmth and well-wishing to yourself, to your good friend, to the neutral person, to the person you find difficult, and outwards to all beings, as demonstrated in Box 11.5.
Start by finding a comfortable position, seated, lying down, or whatever is most suitable for you. Allow your body to relax as best as possible, releasing any tension. Gently close your eyes if you wish, and take a few deep breaths, feeling the inhale and exhale calming your mind and body. As you settle in, focus on the natural rhythm of your breathing. Let it guide you into a state of ease.
First, focus your attention on yourself. Direct kindness and well wishes towards yourself, remembering that you are deserving of care and love. Silently say this phrase: ‘May I be happy.’ If it feels difficult to offer yourself these kind wishes, simply notice this, without judgement, as best you can. Continue to breathe gently and allow the words to sink in, to whatever extent is possible.
Second, bring to mind someone about whom you feel generally positive. This could be a close friend, a family member, or even a pet. Picture this person or being in your mind’s eye and notice the warmth that arises in your heart and throughout your body as you think of them. Silently repeat this phrase, offering them well-wishes: ‘May you be happy.’ Allow your feelings of love and kindness to grow naturally. Imagine that your words are like a warm light, embracing this person and filling them with peace.
Third, extend your well wishes and loving-kindness to a neutral person, someone you encounter regularly but do not know well, like a colleague or a neighbour. Repeat the phrase: ‘May you be happy.’ Notice any reactions in your mind and body.
Fourth, bring to mind someone about whom you feel generally negative. This might be a colleague who seems to create problems at work or a family member whom you often find difficult. Picture this person in your mind’s eye and notice what arises in the body as you do so. Silently repeat the phrase, offering them kindness and well-wishes: ‘May you be happy.’
Finally, focus on equalising the well-wishing between all four of these people or beings, including yourself. Then, spread it out to the entire world, starting locally and eventually encompassing all beings. Picture the earth bathed in kindness, compassion, and good wishes. Silently repeat to yourself: ‘May all beings be happy.’
When you are ready, take a deep breath, and gently open your eyes if they have been closed. Try to take this sense of compassion with you into the rest of your day.
Resilience in Healthcare Settings
As we discussed in Chapter 7 (‘Resilience and Compassion’), resilience is ‘the ability to cope with adversity and to adapt to major life events’ (Jeamjitvibool et al., Reference Jeamjitvibool, Duangchan, Mousa and Mahikul2022; p. 2). Resilience ‘varies widely from person to person and depends on environmental as well as personal factors’ (p. 2). Resilience changes over time and is amenable to modification, adaptation, and enhancement. Resilience can be seen as a skill which it is possible to develop through careful effort and sustained attention.
Chapter 7 noted 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 provision of resources. These matters have an enormous influence on individual experiences, attitudes, and behaviour, as well as the levels of resilience that are required and accessible in the workplace. Systemic challenges can include competing system demands, time constraints, inadequate resources, communication issues, poor emotional connections with the broader healthcare system, and the perception or reality of staff not being valued for the care that they provide.
It is likely that these themes will resonate with many people who work in large healthcare systems where organisational challenges can loom large, often distracting focus from day-to-day patient care. Chapter 7 concluded by indicating that mindfulness and meditation can help in navigating some of the challenges outlined and in building appropriate levels of resilience among healthcare staff.
The present chapter continues this discussion by exploring the relevance of resilience among healthcare workers during the Covid-19 pandemic (which occurred from 2020 onwards); outlining positive behaviours that promote individual physical health, mental health, and resilience; presenting a guided practice focusing on resilience and inner solidity; and drawing together the key themes of resilience, equanimity, and compassion towards the end of the chapter. The following chapter is devoted to ‘Building Compassionate Health Systems’ (Chapter 13) and looks at systemic factors that promote qualities such as mindfulness, awareness, resilience, and compassion in healthcare organisations.
At the outset, it is important to acknowledge that the term ‘resilience’ can be overused and misused. For example, the concept of individual resilience is sometimes invoked in order to place undue responsibility on individuals who experience stress, when the primary problem lies with systems of care or bureaucracies that place unreasonable demands on individual workers in the first place. Too often, employees are advised to attend resilience training, mindfulness classes, or compassion programmes solely so that managers do not have to deal with the fact that their policies and workplaces need to change. From this perspective, individual resilience is not always about coping with difficult situations. Sometimes, resilience means standing up against inappropriate demands and realising that the primary problem lies with the system and not with the individual, regardless of their level of individual resilience. The goal should be to create systems of care that care for all, without placing undue pressure on individual resources or individual resilience.
Resilience among Healthcare Workers During the Covid-19 Pandemic
The Covid-19 pandemic presented substantial challenges to the physical and mental health of many people, including healthcare workers. It was a significant test of resilience for populations as a whole and especially for frontline workers (such as clinical staff) who often operated in conditions of uncertainty and risk.
When the outbreak commenced in 2020, there was widespread concern about the impact of the virus and associated public health restrictions on mental health. Evidence soon showed that the combined effect of the Covid-19 pandemic and associated restrictions was that approximately one person in every five in the general population had significantly increased psychological distress (e.g., anxiety, depression) (Kelly, Reference Kelly2020). Particular risk factors included being female and living alone.
Rates of significant psychological distress among healthcare workers were approximately double those in the general population (Kelly, Reference Kelly2020; Liu et al., Reference Liu, Hou and Gu2022). To mitigate these effects, healthcare staff required several forms of practical support as a matter of urgency during the pandemic: careful rostering, the ability to take leave, and organisational support from employers. When necessary, they also required ‘psychological first aid’ to assist with managing risks that were both known and unknown, and challenges that deepened by the week. How did levels of resilience help in navigating these circumstances?
In 2022, Jeamjitvibool and colleagues published ‘a systematic review and meta-analysis’ of ‘the association between resilience and psychological distress during the COVID-19 pandemic’ (Jeamjitvibool et al., Reference Jeamjitvibool, Duangchan, Mousa and Mahikul2022). This research group found that, ‘during the pandemic, the higher an individual’s resilience, the lower the psychological distress. The results indicate that resilience is essential in promoting a person’s positive mental health and reducing negative consequences’ (p. 11):
This study’s findings shed light on the need to develop interventions for enhancing resilience among healthcare providers, the general population, and patients to decrease the long-term impacts of psychological distress. In clinical practice, these populations should receive psychosocial support during health emergencies such as COVID-19 and other infectious disease outbreaks. As an example, they could be provided with consultations with a psychologist to promote their resilience and reduce their psychological burden. Where healthcare providers are concerned, this approach might also reduce turnover rates and thus benefit the overall healthcare system.
During the pandemic, many healthcare professionals, other frontline workers, and members of the public demonstrated enormous resilience (Kelly, Reference Kelly2023). A sense of pride in their work likely boosted resilience among healthcare workers. In 2023, Hughes Spence and colleagues published ‘a narrative inquiry into healthcare staff resilience and the sustainability of Quality Improvement implementation efforts during Covid-19’ (Hughes Spence et al., Reference Hughes Spence, Khurshid, Flynn, Fitzsimons and Brún A2023). This group found that ‘the pride healthcare staff took from working throughout the Covid-19 pandemic was evident amongst the participants, alongside their resilience’ (p. 8):
The objective of this study was to explore the sustainability and resilience of not only the changes implemented by healthcare staff during Covid-19 in Ireland, but the resilience of the healthcare staff themselves through the various waves of Covid-19. Through using a narrative approach, four key themes were evident from the data: (i) From fear to exhaustion; (ii) maintaining person-centred approaches to care; (iii) Covid as a medium for change and; (iv) staff pride, resilience and appetite for [Quality Improvement].
Notwithstanding this and similar evidence of resilience, it is clear that many healthcare workers suffered deeply during the pandemic. It is also apparent that resilience was a key element in reducing such distress and managing uncertainty, but that resilience is best cultivated before such emergencies take place, as well as during them. With this in mind, there is a particular need for research ‘to look at ways in which resilient healthcare can be facilitated and supported in different practice settings, for example through the development of collaborative learning tools’ (Lyng et al., Reference Lyng, Macrae and Guise2022; p. 13).
Consistent with this observation, there is, over recent years, a growing literature on topics such as burnout and compassion fatigue among various healthcare workers (e.g., Sweileh, Reference Sweileh2020; Baqeas et al., Reference Baqeas, Davis and Copnell2021). But what can be done now to improve matters and boost resilience among healthcare workers? How can we use our current knowledge today to improve resilience, reduce burnout, and hopefully increase compassion in healthcare?
The remainder of this chapter focuses on individual-level actions to improve resilience and, thus, capacity for compassion, while the following chapter looks at system-wide factors and interventions that are needed at the level of organisations for greater compassion (Chapter 13: ‘Building Compassionate Health Systems’). For now, we start with positive behaviours that promote individual physical health, mental health, and resilience, followed by a guided imaginative practice focusing on resilience and inner solidity. The chapter will then conclude by drawing together its key themes of resilience, equanimity, and compassion in healthcare.
Building Physical and Mental Resilience as a Solid Basis for Compassion
Resilience and self-compassion find many of their roots in self-care. We cannot care for others unless we care for ourselves, so it is essential that healthcare workers pay attention to both physical and mental health. This includes actively considering levels of physical exercise, sleep patterns, dietary habits, and 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 form the foundations for resilience and compassion.
Regular, moderate physical exercise enhances both physical health and mental wellbeing (Kelly, Reference Kelly2021). Humans were designed to move, so we function best when we have regular exercise as part of our lives. Most adults need to be physically active every day. Each week, we need at least 150 minutes of moderate intensity activity or 75 minutes of vigorous activity. We should also do some strengthening activities that work all our major muscles (legs, hips, back, abdomen, chest, arms, and shoulders) two or three days each week. Popular activities include running, cycling, swimming, brisk walking, various other sports, any other vigorous activities, and even energetic forms of dance. The key to establishing a regular exercise habit is that our chosen activities should be convenient, local, sustainable, and (ideally) enjoyable.
Sleep is also important for wellbeing. Most adults should aim to sleep for between seven and nine hours in every 24 hours. We can support good sleep hygiene by exercising in the morning (ideally outside); avoiding naps during the day (which can be challenging for shift workers); avoiding stimulants in the hours before sleeping (e.g., coffee, alcohol, cigarettes, sugar); enriching our diets with foods that contain tryptophan (e.g., chicken, turkey, milk, dairy, nuts, seeds); easing ourselves into sleep in the evening (i.e., dim lights, avoiding alcohol and screens, winding down gently); and keeping our bedrooms dark, cool, comfortable, and free of distractions (especially screens). Sleep merits more attention than we routinely give it. Good sleep is a valuable, free resource for wellbeing that most of us could mine more deeply.
From a dietary perspective, it is important to maintain a balanced diet in accordance with relevant guidance (Kelly, Reference Kelly2021). It helps if we de-link food from emotions, meanings, and self-esteem, and see food for precisely what it is: simply food. Certain nutrients, such as vitamin B12, can help with brain health, but a generally balanced diet will usually deliver all that our bodies need for physical and mental wellbeing. Eating is a routine behaviour, so it is wise to harness the power of habit to improve our eating patterns, and rationalise our ideas about food and weight. Radical diets do not work: they are unsustainable, unrealistic, and frequently ridiculous. Moderation and sustainability are the keys to positive eating and to reaping the benefits of good food for our bodies and minds.
Attending to our levels of exercise, sleep patterns, and dietary habits is an act of radical self-compassion which boosts health, enhances resilience, and empowers us to provide compassionate care to our patients and their families. It is also important that we pay specific attention to our mental wellbeing, even when everything seems to be going smoothly in our lives. Those are the times when we can really consolidate our psychological health, deepen our resilience, and resource ourselves for our challenging roles in healthcare.
In general, mental health improves when we realise that, too often, we equate activity with value, and frequently this is not the case. We inadvertently clutter our lives with unnecessary tasks and unneeded physical objects that weigh us down rather than move us forward. It is helpful if we consciously identify those aspects of our lives that truly help us to cultivate wellbeing, deliver value, and align with our intentions. To do this, we need to create mental space to maintain a calm focus on what matters. Specific techniques such as meditation and mindfulness can be useful as part of this broader commitment to conscious, value-based living. We can move away from unneeded activities and unnecessary objects, and towards our valued goals, once we identify them in this way.
Connecting with other people in a conscious and judicious way also helps with mental health. The first step is connecting better with ourselves by taking time to become more aware of our thoughts, moods, and emotions. As always, compassion for others starts with compassion for ourselves. This approach provides a solid basis for us to deepen, renew, and enrich the relationships we already have with partners, family members, friends, and colleagues. Being part of something bigger also matters deeply: families, book clubs, work groups, political movements. Reaching out is important because a growing sense of belonging nourishes our minds, even if we never explicitly draw on the support that certain groups or relationships offer. Finally, while connections matter deeply, it is also useful to disconnect at times, and to be alone: reading, walking, or simply being. For good mental health, we need both time together and time apart.
Most of us need to work harder on disconnecting from our devices: smartphones, laptops, and computers. This can be difficult, but small steps work best: leaving the phone in the kitchen at nighttime, minimising work emails outside working hours, and being compassionate with ourselves when we overuse our phones. We are human, social media is addictive, and change takes time. Minimising the negative impact of technology in our lives means making sustainable improvements to our habits. Radical change rarely works; incremental steps often do.
Once we have prioritised physical and mental health, and once we see this prioritisation as an act of radical self-compassion, what else can we do to boost our resilience and solidify the foundations for greater compassion towards other people and ourselves?
Cultivating Inner Solidity: Guided Imaginative Practice
Often, we lose sight of the resilience that we already possess. We forget the times when we were solid, strong, and compassionate in circumstances that were deeply challenging at the time. This is a pity. We are resourceful beings with extraordinary levels of adaptability. Too often, our previous strength moves to the back of our minds, and we are beset by the doubts, anxieties, and fears of the present moment. This guided resilience practice seeks to remind us of our core strength and re-connect us to the resilience that we already possess but do not always recognise when we need it, as seen in Box 12.1.
Find a comfortable, quiet place to sit or lie down. Close your eyes if that is suitable for you. Allow yourself to settle into the moment. Take a slow, deep breath in through your nose and fill your lungs completely. Hold the breath for a moment, and then gently exhale through your mouth, releasing any tension you are holding. Let your shoulders relax and let your body sink into the chair or ground beneath you. Take two more deep breaths, letting go of any stress each time you exhale.
Bring your attention to the present moment. Notice how your body feels right now. Notice where you feel relaxed. Notice where you might feel discomfort or tension in your body. Try your best to observe these sensations without judgment. This is your body in this moment, so it is alright to feel whatever you are feeling.
Next, bring to mind a recent challenge that you faced. It could be something small or something significant, whichever naturally comes to mind. As you recall this situation, notice the emotions that arise within you. You might feel frustration, fear, sadness, or something else entirely. Whatever arises, try to just observe it. Try to let the feelings come without seeking to change them.
Now, imagine that you are watching this situation from a distance, as if you were a witness, rather than in the situation yourself. What do you feel now? What emotions arise? What body sensations are present? Try to simply acknowledge your response without interpreting it and without judging yourself, as best you can.
Take a moment to reflect on how you handled various difficulties in the past. Recall a time when you were proud of how you responded to a challenging situation. Maybe you remained calm under pressure, adapted to unanticipated changes, or persevered through adversity. As you remember this event, allow the feelings of capability, strength, and resilience to fill you. Let those positive emotions move through your body and mind. Notice how they affect you. Notice how you feel.
Next, picture this inner strength as a glowing light within you. It might be in your chest, your stomach, or wherever you feel the most grounded. As you inhale, see this light growing brighter and stronger, expanding with each inhalation. With each exhalation, feel yourself releasing any tension, doubt, or fear that might have been holding you back.
Now, return your attention to the recent challenge that you brought to mind. But this time, picture yourself approaching it with this inner strength glowing brightly. How does it feel to face this situation with patience, confidence, and resilience? Imagine yourself responding calmly, making reflective decisions, and remaining grounded even in these difficult circumstances. Remind yourself that you are able to handle this challenge, just as you dealt with similar situations in the past.
Repeat silently to yourself: ‘I am calm. I am strong. I am resilient.’ Let these words settle into your body and mind, becoming part of your inner dialogue.
Take three more deep breaths, letting the feelings of confidence, strength, and resilience grow with each inhalation. Remind yourself that this strength is always within you, ready to be accessed whenever you require it. You have faced difficulties before, and you will face challenges again – but each time, you grow more confident, more resilient, and wiser.
When you are ready, gently bring your awareness back to the room you are in. Gradually, move your fingers and toes, take one last deep breath, and softly open your eyes, if they have been closed.
Try to carry this sense of inner strength with you throughout the day, knowing that resilience is a part of who you are, it is always available to you, and it will support you whenever you need it.
Resilience, Equanimity, and Compassion
So far, this chapter has explored relevant learnings from the Covid-19 pandemic in relation to resilience among healthcare workers. We noted that we cannot care for others, or become more resilient, unless we care for ourselves in the first instance. As a result, it is important that healthcare workers (and others) optimise our levels of physical exercise, develop positive sleep patterns, and improve our dietary habits, as best as possible.
Physical and mental health are intimately related to each other, so both require attention. Specific steps to improve mental health include seeking to maintain a calm focus on what matters (e.g., using meditation and mindfulness to deepen a commitment to conscious, value-based living), connecting with other people in a deliberate and judicious way (as well as disconnecting from family, friends, and colleagues when needed), and working harder to spend more time away from our devices (especially smartphones). Self-compassion also means forgiving ourselves when our best efforts falter, and simply trying again. Change takes time.
The guided resilience practice in the previous section of this chapter sought to remind us explicitly of our core strength and to connect us with the resilience that we already possess but do not always access when we need it. We are stronger than we give ourselves credit for.
The overall message from this chapter is that self-care is an act of radical self-compassion, is the basis of compassion for other people, and is a vital foundation for resilience. This is especially true when our jobs require a significant amount of compassion on a day-to-day basis. As Maddox and Barreto emphasise:
Staff need to be nourished, valued and compassionately cared for in order to be able to care compassionately for the patients they look after. They need the same elements of compassion as those which they seek to provide.
As individual healthcare workers, we can facilitate this process by building our own resilience (as best as is possible and reasonable in our circumstances), providing compassion to ourselves (through conscious, deliberate acts of self-care), and seeking to extend that compassion to other people, including our patients, their families, and our colleagues, as well as our own families and friends. These are challenging tasks, but they lie at the heart of healthcare.
In addition, it can be useful for healthcare workers to distinguish ‘safety’ from ‘safeness’, which is important because safety and safeness have different meanings and operate through different physiological systems:
Threat-defending and safety checking and seeking are regulated primarily through evolved threat processing systems that monitor the nature, presence, controllability and/or absence of threat (e.g., amygdala and sympathetic nervous system). Safeness uses different monitoring systems via different psychophysiological systems (e.g., prefrontal cortex, parasympathetic system) for the presence of internal and external resources that support threat-coping, risk-taking, resource exploration. Creating brain states that recruit safeness processing can impact how standard evidence-based therapies (e.g., exposure, distress tolerance and reappraisal) are experienced and produce long-term change.
In healthcare, there can sometimes be a relatively excessive focus on safety and a consequent lack of focus on safeness, especially in environments where staff do not feel supported by management. In mental health services, for example, staff who especially fear criticism can become risk averse and inadvertently add to patients’ feelings of emotional turmoil and lack of safety (Veale et al., Reference Veale, Robins, Thomson and Gilbert2023). Focusing on safeness and resources for compassionate care, rather than safety, can help to address this.
Equanimity is another important value throughout this process, as we seek to remain calm in the midst of the uncertainties of clinical decision-making and to navigate the vagaries of large healthcare systems in which many of us operate (Kelly and Feeney, Reference Kelly and Feeney2006; see also Chapter 2 of this book: ‘Background to Compassionate Healthcare’). It is not always easy to maintain balance and composure in these high-pressure environments, especially when faced with emotionally charged clinical scenarios. Consciously seeking to maintain equanimity can help with effective engagement with patients, clear thinking, better decisions, and optimal outcomes. Often, there is no definitive right answer to these clinical dilemmas, only the best provisional answer that can be generated at a given moment, to be reconsidered later.
Overall, a sense of equanimity promotes resilience. It allows us to optimise the balance between professional detachment and interpersonal engagement, which is so essential for effective, sustainable clinical practice. Equanimity also fosters a stable, thoughtful approach to healthcare, promoting compassion, benefiting patients, and supporting staff during challenging times. Resilience is a key factor in these situations too, including resilience at the individual level and resilience at the levels of teams, organisations, and entire health systems.
The next chapter explores systemic factors that can shape levels of equanimity, resilience, and compassion in healthcare. Both levels are important: resilience and compassion at the level of individual healthcare workers, and resilience and compassion at the level of organisations.
Compassion in Health Systems
The value of compassion in healthcare is both proven and undeniable. The various components of compassion offer benefits that are at once physical and psychological (Shea et al., Reference Shea, Wynyard, Lionis, S Shea, Wynyard and Lionis2014a). Most healthcare professionals are profoundly aware of this, often based on our own experiences of receiving compassion from others, our recollections of witnessing compassionate care in our workplaces, and our deeply human awareness of the intrinsic healing that compassion commonly brings.
Despite this, we sometimes struggle to translate our compassionate intentions into care that is always truly compassionate. There are many reasons for this, operating at several levels. So far, Part II of this book has focused chiefly on individual-level factors relating to compassion, and how to optimise these by ‘Cultivating Mindfulness and Awareness’ (Chapter 10), ‘Deepening Compassion’ (Chapter 11), and ‘Developing Resilience’ (Chapter 12). These are important undertakings for many reasons: strengthening our own awareness and resilience, increasing compassion in the care we provide, and delivering better outcomes for all stakeholders in the health system.
Our efforts as individuals and teams, however, always occur in specific contexts. For clinical professionals, that context is often a healthcare organisation such as an acute hospital, public health system, or other healthcare provider. While many of these organisations have compassion as a stated value, systemic factors sometimes impede the attainment of compassion. This is especially true in larger organisations which have become bureaucratic, depersonalised, and – at times – apparently lacking in compassion. This is not necessarily a reflection on the managers of such healthcare organisations, but rather a consequence of the mass systematisation of healthcare services. Sometimes, organisational efficiency appears to come at the cost of humane, compassionate care. This need not be the case.
Against this background, this final chapter in our book looks at systemic factors in healthcare systems and how these can promote qualities such as mindfulness, awareness, resilience, and compassion. The chapter starts by looking at the components of compassionate leadership in healthcare organisations, moves on to the topic of resilience in health systems (especially in the context of sustaining compassion), and then outlines specific approaches that healthcare professionals can take to increase compassion across the services in which we work. Finally, relevant conclusions are presented at the end of the chapter.
Compassionate Leadership in Healthcare Organisations
What does compassionate leadership in healthcare look like? It is easy to suggest that we should be more compassionate as we provide care and as we shape health services at the managerial level, but is there a way to systematise compassion at the level of organisations? Or is the very idea of ‘operationalising’ a value like compassion contrary to its essential nature? Is compassion too personal and too relational to form part of standard operating procedures or to be made into a mandatory feature of care and management?
When considering compassionate leadership and designing compassionate health systems, it is useful to think not about systematising compassion as such, but rather about how we create circumstances in which compassion is not inhibited but is rewarded and promoted. Can we design workplaces and work processes that facilitate compassion, that acknowledge compassionate care, that reward it, and that actively encourage compassion to flourish?
This is indeed possible, and a growing evidence base provides more detail on what it involves. In 2024, Östergård and colleagues published ‘a mixed-methods systematic review’ of ‘health-care leaders’ and professionals’ experiences and perceptions of compassionate leadership’ (Östergård et al., Reference Östergård, Kuha and Kanste2024). The purpose of their study was ‘to identify and synthesise the best evidence on health-care leaders’ and professionals’ experiences and perceptions of compassionate leadership’:
Ten studies were included in the review (five qualitative and five quantitative). The thematic analysis identified seven analytical themes as follows: treating professionals as individuals with an empathetic and understanding approach; building a culture for open and safe communication; being there for professionals; giving all-encompassing support; showing the way as a leader and as a strong professional; building circumstances for efficient work and better well-being; and growing into a compassionate leader.
The authors concluded that ‘compassionate leadership can possibly address human resource-related challenges, such as health-care professionals’ burnout, turnover and the lack of patient safety. It should be taken into consideration by health-care leaders, their education and health-care organisations when developing their effectiveness’ (p. 49).
It is interesting that the themes identified in the research emphasise ‘treating professionals as individuals’, ‘open and safe communication’, and ‘being there for professionals’. These are not expensive solutions. They are not technology-based or highly complex. They do not require high levels of investment, apart from time and commitment to make compassion a reality through thoughtful interpersonal interactions. These are very human values which accurately reflect the deeply relational nature of compassion. They also tap into compassion’s potential to unlock potential in other people – and in ourselves – through good communication and collegiality.
Listening is central to this process, both listening to staff and listening to patients (Frampton and Goodrich, Reference Frampton, Goodrich, Shea, Wynyard and Lionis2014). Listening fosters collaboration, mutual respect, and better care. Listening creates an environment in which everyone’s ideas and perspectives are valued. It promotes trust and encourages open dialogue, which are both essential for innovation, problem-solving, and collaboration. When individuals feel heard, they are more invested in the tasks at hand, leading to a more inclusive and creative team atmosphere and greater compassion in care.
In addition, listening strengthens relationships by showing interest and understanding, even when diverse views are expressed. Listening helps to identify potential conflicts early, address them before they escalate, and cement the vital working relationships which form the basis of compassionate care. Ultimately, listening is not just a passive activity but a critical component of successful teamwork that helps teams to cohere, focus on the outcomes that matter, and keep core human values, such as compassion, at the heart of healthcare.
Resilience in Health Systems
Many of the difficulties with compassion in healthcare relate not to generating compassion in the first instance, but to sustaining it in the face of challenges and complexities. Most of us seek to be compassionate, but we are worn down by bureaucracy, workloads, and the emotional intensity of the illnesses we encounter at work. Many of us start the day with plenty of compassion, but by lunchtime we are struggling to survive. What can we do, as individual clinicians and as organisational managers, to sustain compassion in these challenging circumstances?
This question brings us back to resilience, which we explored in Chapter 7 of this book (‘Resilience and Compassion’) and Chapter 12 (‘Developing Resilience’). Those chapters looked at the value and limits of resilience at the level of individual healthcare workers. But is there a research base to help us promote resilience not only at the individual level, but at the level of organisations and work cultures, too? Individual resilience is clearly relevant to our organisations, but what about the settings in which individual resilience operates and is, too often, tested beyond its limits? What does the research say about resilience in the organisational context?
In 2022, Lyng and colleagues explored ‘capacities for resilience in healthcare’ through ‘a qualitative study across different healthcare contexts’ (Lyng et al., Reference Lyng, Macrae and Guise2022). Their aim was ‘to contribute to this discussion by synthesizing knowledge and experiences from studies in different healthcare contexts and levels to provide holistic understanding of capacities for resilience in healthcare’:
Ten different capacities for resilience in healthcare emerged from the dataset, presented here according to those with the most identified instances to those with the least: Structure, Learning, Alignment, Coordination, Leadership, Risk awareness, Involvement, Competence, Facilitators and Communication. All resilience capacities are interdependent, so effort should not be directed at achieving success according to improving just a single capacity but rather at being equally aware of the importance and interrelatedness of all the resilience in healthcare capacities.
The authors emphasised ‘that all resilience capacities are associated with contextualization, or collaboration, or both’ (p. 1). These two factors are clearly essential for building resilient healthcare organisations in which compassion can be sustained over time; that is, ‘contextualization’ and ‘collaboration’:
Our study indicates that efforts to understand or translate resilience capacities into practice need to provide appropriate levels of collaboration and contextualization for intervention activities and for everyday practice. What is clear from our framework is that these translation efforts should involve tailored intervention activities, and material based on this new knowledge about the key role of the collaboration-contextualization dimensions for each resilience capacity. The framework and the inductively arrived resilience capacities constitute a sound basis that will support future resilience learning tools and interventions.
These two values, ‘contextualization’ and ‘collaboration’ are highly consistent with the third ‘c’ that concerns us throughout this book: compassion. By promoting resilience, ‘contextualization’ and ‘collaboration’ can help to sustain compassion when it is tested by circumstances, by fatigue, and by the sheer complexity of providing clinical care day after day, month after month, year after year.
Critically, such resilience depends not only on resilience at the level of individual healthcare workers, but also on organisational context, which can be improved by working on the ‘ten different capacities for resilience in healthcare’ identified by Lyng and colleagues: ‘Structure, Learning, Alignment, Coordination, Leadership, Risk awareness, Involvement, Competence, Facilitators and Communication’ (Lyng et al., Reference Lyng, Macrae and Guise2022; p. 1).
In the next section of this chapter, specific actions are outlined to try to optimise the organisational context for greater compassion in healthcare systems.
Building Compassionate Contexts and Cultures in Healthcare Organisations
So far in this chapter, we have looked at the components of compassionate leadership in healthcare organisations and examined resilience in healthcare systems, especially in the context of sustaining compassionate care. This can be especially complex in the face of the sustained challenges presented by illness, its treatment, and people’s varied expectations and experiences of care.
Against this background, what can we do to build compassionate contexts and compassionate cultures in healthcare organisations? Here are seven steps that can help healthcare professionals to increase compassion across the healthcare systems in which we work:
(a) The first step is to lead by example. The importance of this cannot be overstated. We encourage compassionate behaviour in other people by behaving compassionately ourselves. This applies to our work when directly providing care, our interactions with colleagues and other team members on the corridor, and our decisions in any management roles we occupy. If we seek to demonstrate respect, kindness, and compassion in all our interactions, no matter how minor, this has a ripple effect around us and beyond us. Compassion is not a zero-sum game. Demonstrating compassion does not use up a finite supply of compassion. Compassion breeds compassion. Compassion spreads organically across teams, departments, and organisations. We lead best when we lead by example. If we seek to create compassionate cultures within our organisations, this means leading through compassion.
(b) The second step is to actively support the wellbeing of colleagues and any staff we manage. Sometimes, the steps that managers can take here are simple, practical ones, but these can be the most impactful ways to demonstrate compassion. These measures might include offering flexible work arrangements, implementing more considerate rostering practices, increasing flexibility in scheduling, and ensuring fair dispute resolution. All these measures can help to reduce burnout and allow healthcare professionals to balance our work and personal lives more effectively. It is also useful to explicitly prioritise the emotional health of clinical staff through wellness supports, counselling services, and stress management resources when they are needed. Happy people have more capacity for awareness, resilience, and compassion. At individual level, these values are further supported by active listening, emotional intelligence, and treating other people as we wish to be treated ourselves. Supporting staff wellbeing means supporting compassion.
(c) The third step is to foster open communication within our organisations. This applies at both the individual level and the level of organisational culture and context. It is essential that we create spaces in which staff feel safe sharing concerns or discussing challenges without fear of judgement or repercussions. This atmosphere creates a solid basis for awareness, resilience, and compassionate care. Listening is the bedrock of open communication. Even if you have a great deal to say yourself, it is important to listen to the views of others and engage with their perspectives. Active listening fosters connection, engagement, and dialogue. If you want to be heard, listen. If you want to create a culture of compassion, communicate.
(d) The fourth step is to ensure that open communication includes patients and their families whenever this is possible. This means involving patients and their families in decision-making processes, valuing their perspectives, and making sure that their emotional needs are met in an open, authentic way. This generally involves spending time with people and simply being there for them. Compassion is not a high-tech intervention. Compassion is a very human intervention which is often best achieved through quiet presence and attentive awareness. This helps not only at the level of the individual but also at the level of organisational culture. Patient-centred care requires communication that is open, available, and informed by compassionate intent.
(e) The fifth step in creating compassionate healthcare organisations builds on the first four steps; that is to say, (a) leading by example to promote compassionate behaviour; (b) supporting the well-being of colleagues and any staff we manage; (c) fostering open communication across clinical and managerial teams; and (d) including patients and families in decision-making and valuing their perspectives. The fifth step is to promote teamwork and collaboration that are inclusive, adaptive, and resilient. This means building strong, supportive teams in which members rely on each other, support each other with kindness, and experience a sense of belonging and shared purpose. Such teams constitute a solid basis for awareness, resilience, and compassion. Generating this kind of teamwork is both an individual endeavour and a collaborative one. Teams flourish in organisational cultures that are open, largely blame-free, and centred on learning from experience. Thriving teams are better placed to provide compassionate care.
(f) The sixth step is to recognise and reward compassion. Many healthcare workers are quietly compassionate, offering extraordinary levels of kindness and support to patients and their families without seeking any recognition. The work is its own reward. While it is important to respect this, it is also useful to acknowledge and celebrate compassionate acts when appropriate in order to reinforce the importance of kindness in care. This might involve formal recognition programmes or organisational awards, but it might also mean a quiet word with an individual staff member. This can be a very powerful intervention by a colleague or manager: ‘I noticed the time you spent with that patient the other day. I know it made all the difference to them. Thank you for all you do.’
(g) Finally, do not forget the centrality of self-compassion. Organisational compassion will falter if managers and staff are too self-judgemental, too self-critical, or too demeaning of their own efforts. Healthcare is challenging. Outcomes are not always what we would like them to be. Sometimes, sitting with pain and loss is inevitable. In these situations, organisational cultures support self-compassion through open communication, realistic expectation management, and robust teamwork that promotes awareness, resilience, and solidarity. We are human. We care best when we care together and when we care for each other.
Compassionate Leadership and Collectivity in Healthcare Organisations
This chapter set out to examine the themes of compassionate leadership in healthcare organisations, resilience in health systems, and approaches that healthcare professionals can take to increase compassion across the healthcare services in which we work. The latter were summarised into seven key steps that clinical staff can implement, not necessarily in sequence, but in parallel with each other, in order to promote compassionate cultures in healthcare systems.
These steps are: (a) leading by example to promote compassionate behaviour for better care; (b) supporting the well-being of colleagues and any 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: healthcare is challenging, we are all human, and self-compassion is the basis of compassion for others.
It is not always easy to keep these steps to the forefront of our minds as we operate within, and shape, our organisational contexts and cultures. There are many reasons why clinical care can be less than compassionate, ranging from local issues to broader social factors that shape the environment within which healthcare is delivered (Iles, Reference Iles, Shea, Wynyard and Lionis2014). Despite these challenges, compassionate care can be supported by drawing on existing skills, accumulated knowledge, and personal experiences of compassion (Adamson and Smith, Reference Adamson, Smith, S Shea, Wynyard and Lionis2014). In this book, we have argued that there is a strong evidence-base informing compassionate care (Part I of the book) and this evidence-base can be operationalised at the individual level by ‘Cultivating Mindfulness and Awareness’ (Chapter 10), ‘Deepening Compassion’ (Chapter 11), and ‘Developing Resilience’ (Chapter 12).
This final chapter in this book moved to the collective and organisational levels, focusing on teams, cultures, contexts, and health systems. These are important because compassionate leadership in health and social care needs to be inclusive and collective, and usually involves collaboration across boundaries (West, Reference West2021). These values are also essential to the provision of health services at the individual level, so it makes sense that they inform compassionate leadership at the level of organisations too. This can be especially challenging in high-stress scenarios like healthcare, which invariably involve multiple actors, diverse emotions, and managing uncertainty. But these complications also make compassion even more important in these settings.
As a result of these factors, building leadership for compassionate care means explicitly acknowledging and taking account of the challenges and difficulties of a context that routinely involves anxiety-provoking situations (De Zulueta, Reference De Zulueta2016). This means providing the requisite training, supplying supports for wellbeing, maintaining optimal levels of trust and connection, and sharing workloads, skills, and knowledge across silos. It also requires an atmosphere that facilitates experimentation, reflection, and learning from errors, which is why this chapter has focused on organisational cultures and contexts.
Finally, as mentioned above and in Chapter 8 (‘Self-Compassion’), self-compassion is always central. Without self-compassion, it is difficult to generate compassion for other people or to grow compassionate organisations. Self-compassion is essential for compassionate leadership in health and social care because our relationship with ourselves forms the foundation of our relationships with other people (West, Reference West2021). Being compassionate towards ourselves enables and empowers us to be compassionate towards others. At the organisational level, self-compassion helps us to build compassionate health systems which deliver better outcomes for the benefit of all. That is true compassion.
Conclusions
Compassion is not a static value. It is essential that the concept of compassion, along with other similar values, is continually re-formulated in the context of the specific skills and duties associated with different roles in healthcare organisations (Pedersen and Roelsgaard Obling, Reference Pedersen and Roelsgaard Obling2019). Change is constant, one size does not fit all, and some of the requirements for compassionate care evolve over time.
In addition, it is important that we recognise our personal limits, especially in the context of large organisations that can appear to lack compassion at the level of the overall system. Sometimes, we cannot have an immediate systemic impact to increase compassion in our organisations, so we need to focus on achievable goals at our level, at least for now (Kislik, Reference Kislik2022). With this in mind, it is always important to acknowledge the accomplishments of colleagues through appropriate accountability and to support them through advocacy and awareness.
Östergård and colleagues, in their ‘mixed-methods systematic review’ of ‘health-care leaders’ and professionals’ experiences and perceptions of compassionate leadership’, conclude ‘that compassionate leadership has a broad and diverse entirety, and it diverges from other leadership styles by emphasising compassion’:
Compassionate leadership is comprehensive, and it involves many aspects that need to be taken into consideration in health care. Compassionate leadership was experienced through many aspects, from empathy to enhanced work circumstances. A compassionate leader is there for others and works as an example. Compassionate leadership can also be exhausting, and leaders should know their own limitations. This could be addressed with self-help abilities, as they have a significant impact on becoming compassionate leaders.
In the end, compassion matters deeply both at the level of individual care and at the level of healthcare organisations (Shea et al., Reference Shea, Wynyard, Lionis, Shea, Wynyard and Lionis2014b). At all times, however, compassion remains a very human value, which means it has added resonance in the deeply human contexts of illness, treatment, and outcomes.
The central argument of this book is that we can enhance compassion in healthcare through conscious effort. To summarise very briefly: we care as best as possible when we are as aware as possible, as mindful as possible, as resilient as possible, as compassionate as possible, and as supported by our organisations as is possible.
We can only do what is possible, but compassion extends the limits of the possible. And that, surely, is the essence of good medicine.
Compassion in Healthcare
At the start of this Handbook of Compassion in Healthcare: A Practical Approach, we outlined why we wrote this book. We noted that, 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 families, although magical and therapeutic at the time, also highlight the uncertainty or even the darkness that surrounds those moments.
Too often, compassion is notable by its absence. Staff struggle to make sense of healthcare systems that seem to value neither ‘health’ nor ‘care’. This is a difficult position for clinical professionals. It is not as if we do not feel compassion. We do. The problem lies in sustaining compassion during challenging circumstances, translating the compassion we feel into compassionate healthcare, and supporting our colleagues in developing health systems that routinely facilitate and promote compassion.
We argued that the first step lies in recognising that, while we do not have full control over the shape of the healthcare systems we work in, or indeed the societies we live in, we can control how we navigate these contexts, how we respond to them, and how we seek to be in the world. Sometimes, we need to accept imperfection and to work within systems that are less than compassionate, simply doing our best for our patients and their families in the given circumstances. Healthcare cannot wait. Not every day can bring a revolution.
At the same time, while compromise and acceptance can be practical and necessary on a day-to-day basis, we also need to take action to change non-compassionate systems from within. We might accept certain problems or limitations in order to deal with the pressing problems of today, but we should also advocate for change in the longer term. This means leveraging any management roles we have to prioritise compassion or, at least, to minimise non-compassionate elements of healthcare systems. Each day, healthcare workers use their common humanity to soften the hard edges of large healthcare organisations as they deliver care to individuals, but how about changing the system itself? Not every day can bring a revolution, but some days can.
Compassion is central to much of this, especially in health and social care. That is why we wrote this book, to try to make compassionate care a clinical reality for everyone: patients, families, and healthcare professionals who constantly seek to do better and more. We have sought to approach this from the perspective of day-to-day clinical care, but also from a longer-term perspective. We operate the health system, so why don’t we change it, too?
Combining Evidence with Practical Strategies
As healthcare professionals who operate in the world of evidence-based medicine, we divided this book into two parts to reflect both the concepts and the evidence underpinning compassion in healthcare (Part I) and practical approaches to compassionate care on a day-to-day basis in clinical settings (Part II). Both kinds of knowledge are needed: awareness of theory and evidence on the one hand, and pragmatic strategies for implementation on the other.
Part I of the book commenced by asking: ‘What Is Compassion?’ (Chapter 1). This was followed by an exploration of the ‘Background to Compassionate Healthcare’ (Chapter 2) and discussions of ‘What Compassion Is Not’ (Chapter 3), ‘Medical Professionalism and Compassion’ (Chapter 4), and ‘Compassion in Healthcare’ (Chapter 5). Chapter 6 examined ‘Neuroscience and Compassion’; Chapter 7 was devoted to ‘Resilience and Compassion’, and Chapter 8 focused on ‘Self-Compassion’, which is fundamental to all compassion, both for ourselves and for others. Part I concluded with a consideration of ‘Compassion-Based Therapies’ (Chapter 9).
Building on the theoretical and research foundations of Part I, Part II of the book presented practical steps towards operating from a place of safe, secure grounding to become more compassionate towards ourselves and others. This is especially important when we are confronted with suffering and seek to deliver services to alleviate that pain. To assist with these tasks, Chapter 10 focused on ‘Cultivating Mindfulness and Awareness’, Chapter 11 examined ‘Deepening Compassion’ towards ourselves and others, and Chapter 12 outlined approaches to ‘Developing Resilience’, which is essential for establishing and maintaining compassion in high-stress situations.
Chapter 13 shifted focus from individual clinical professionals to the systems of care in which many of us work, seeking ways to shape more ‘Compassionate Health Systems’ overall. This chapter examined 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 operate. These steps include: (1) leading by example to promote compassionate behaviour for better care; (2) supporting the well-being of colleagues and staff we manage; (3) fostering open communication across clinical and managerial teams; (4) including patients and families in decision-making and valuing their perspectives; (5) promoting teamwork and collaboration that are inclusive, adaptive, and resilient; (6) recognising and rewarding compassionate care, both formally and informally; and (7) making self-compassion a key organisational value: healthcare is challenging, we are all human, and self-compassion is the basis of compassion for others.
In structuring our book in this way, we sought to combine research evidence with pragmatic suggestions, and to balance theoretical considerations with as much guidance about implementation as we felt was possible. We hope that at least some of this material resonates with readers.
Compassion Matters
As we have noted, there are many reasons why compassion is mentioned in medical graduate profiles, ethical guidance documents, interviews with patients, reports on health services, and everywhere that healthcare is discussed in truly human terms. Compassion matters. Sometimes, compassion matters more than anything else, but it always matters at least to a certain extent. There is no situation that is not improved by more compassion, both towards ourselves and towards other people.
There already is a great deal of compassion evident in our health services. 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.
As healthcare professionals, we are not for a moment suggesting that current health systems are entirely lacking in compassion. This is clearly not the case. All around the world, health services are operated by staff who seek to be professional, caring, and compassionate at all times. However, it is also 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 focus on compassion. Many services do well, but most could do better.
Health systems are operated by people, for people. Compassion is central to this process, and always should be.
With this in mind, compassion can be the value that improves health services on the ground, enhances their tone and function, and optimises outcomes for patients and their families. Compassion can make our fundamental caring impulses more apparent, more effective, and more human. Compassion helps us to connect better and more.
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