Transcript Slide 1

WHAT DOES ‘CARE’ MEAN
IN HEALTH CARE
AND WHAT CAN WE DO TO
IMPROVE IT?
Dr. Justin Brophy
FRCPsych
Before we begin:
Dimensions of Care
Attentiveness
- Compassion
Right Intention
Interconnection
LET’S LOOK AT THE
PROBLEMS AROUND
COMPASSION
Some Basics
Empathy is the emotional response to
others
Compassion involves an authentic
desire to help.
a capacity to meet pain with "kindness, empathy, equanimity and
patience",
both in ourselves and in others.
5
“There is no compassion left in the NHS”
the Francis report
at Stafford Hospital identified
a lack of compassion
as being amongst the major causes of
negligence.
6
“Recent scandals”
5
At Winterbourne View,
vulnerable people
were mocked
and even tortured
by staff
7
Public & Media - “Too posh to wash.”
“university trained nurses lack
compassion
The prime minister seems to agree,
“nurses should
serve their time as care assistants
before they even start their training”.
saying that "nurses should be hired and promoted on the basis of having compassion
as a vocation and not just academic qualification".
8
According to a new national survey,
Compassion is Missing in
American Health Care
Schwartz Center for Compassionate Healthcare
By RICK NAUERT PHD Senior News Editor
September 9, 2011
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Competing tensions
Caring
Careful
Individualised
Person focused
Experience focus
Standardized
Task Focus
Outcome focus
Standardised
Risk - Safety focus
Spontaneous / Flexible
Satisfaction focus
As the Francis report notes:
“services can be time-pressured,
accounts-driven, and job-threatening,
whereas compassion grows in
compassionate, supportive
environment”

The Guardian, Monday 1 April 2013
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THE CONTRARY VIEW…………
Ebola volunteers
Ryanair example
There are effective, ways of
ensuring that crucial tasks
are undertaken,
without relying on compassion
 “It’s dangerous to rely on compassion as the motivation” to ensure that
essential tasks are carried out......says the medical ethicist Anna Smajdor, “
 http://www.bbc.com/news/magazine-22773043
“Lack of compassion has also become the
new stick to beat the much-beaten NHS with.”
"The effort to become more
empathetic
will only increase resentment
and your sense of burnout“
‘Compassionate care' has become a new healthcare buzz-phrase, Threat
and fear basically inhibit compassion and negatively impact on these
systems. While it is very seductive to believe that you can threaten
people into becoming compassionate, all the evidence is you cannot
and that you will make things worse.
The Guardian, Monday 1 April 2013 20.59 BST
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Peter Carter, head of the Royal College of Nursing
Nurses have been scapegoats in
scandals
when the main problem is
understaffing,
the recommendations that tend to get implemented
are the ones . . . that don’t have resource implications
http://www.bmj.com/content/348/bmj.g126
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And we know
Selflessness and continually giving
will provide a fast-track to
burn-out,
personal health problems,
emotional anguish,
and mental weariness.
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The most compassionate
are often the most impaired
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The ‘Kindness Paradox’
We frequently work under conditions
no other workforce would tolerate
Why?
Compassion binds us
- but also blinds us
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WHY IS CARE LIKE THIS?
Those lacking compassion
Some Frankly Uncaring
Detached
Indifferent
Intentionally so
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Physicians, trained as biomedical scientists,
have focused on the diagnosis, treatment, and prevention of disease.3 In the process
,
cure,
not care,
became the primary purpose
of medicine 4,5
 Ann Fam Med. May 2005; 3(3): 255–262
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Care has become Sub-contracted
BMJ 2014
Most valued
Least valued
- Professional
- Carer
Inhibitors of compassion
Personal
Fatigue
Stress
Over-exposure
Excess Demand
Depression
Injustice
Injury
Tyranny/Bullying/Abuse
Systemic Inhibitors of Compassion
Fear
Oppression
Blame
Shame
System mistrust

“Threat and fear basically inhibit
compassion and negatively impact
on these systems.

While it is very seductive to believe
that you can threaten people into
becoming compassionate,

all the evidence is you cannot and
that you will make things worse”
Larger Stage of Shame
Public hearings
Public Reports
Media coverage
Internet diffusion
Personal Images
Legal & Regulatory
Unforgotten
Effects all grades of offenders
 100 GMC suicides
Contextual inhibitors of compassion
Contextual
Pay cuts & pay differentials
Agency staff
Turnover on units
Hostile Discourse
No Right of rebuttal / challenge
Ingratitude
Lack of time is another major
impediment to compassion

An elegant experiment from 1973
 observed the behaviour of 40 theology students in a situation inspired by the Good
Samaritan parable.
 Students walking between two buildings, on their way to give a talk, encountered a
shabbily dressed person slumped by the side of the road.
 Students in a hurry to reach their destination were more likely to pass by without
stopping.

The time pressure students were under was the only factor that significantly influenced whether
they helped.
 Individual character traits, religious identification, and the topic of the talk they were
about to give had no effect, even when the topic of the talk was the story of the Good
Samaritan.
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NHS Staff Survey Conclusion
 When staff feel too much work pressure,
 Experience aggression or discrimination
 – either physical violence or bullying, harassment or abuse – from
patients, members of the public or colleagues,
 outcomes are generally worse.
 www.gov.uk/government/uploads/system/uploads/attachment_da
ta/file/215455/dh_129656.pdf
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REASONS FOR DECLINE :
INDIVIDUALS
Reasons for decline

Meta-analyses show
 that clinicians' distress
is a key determinant of empathy
decline



those who are more sensitive,
those who have difficulties regulating their negative emotions.
Or those with overly suppressed pain responses and insufficient
emotional arousal
Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents.
Acad Med 2011;86:996-1009.
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Reasons for decline
 This exaggerated distress reaction
 may lead to emotional
exhaustion, detachment
 and a low sense of accomplishment
Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of
studies with medical students and residents.
Acad Med 2011;86:996-1009.

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Fear of being Compassionate

Fear of compassion,

both towards others and towards ourselves, is one of the factors identified as getting in
the way of being able to be compassionate.
 Fear of being
 overwhelmed, of becoming too upset
 and not able to recover…
 or being helpless to change anything
 of being too soft, too gullible
 Of managing hard decisions
 Of losing professional objectivity
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Tricky Challenges
managing angry or dissatisfied patients,
de-escalate volatile encounters,
deliver bad news,
Enlisting patients into their own treatment,
and engage de-motivated others
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RECOGNISING THE SIGNS
Burnout
-only the best!
various studies have shown that
40% to 60% of US physicians are
experiencing symptoms of
burnout
extra effort often increases risk
for burnout, secondary trauma, and poor well-being
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Accessing mechanisms of support?
Sick note?
Avenues of recovery?
3 Months ‘sick’ leave
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Being or becoming un-compassionate
Frankly Uncaring
 Detachment
 Indifference
 Intentionally so
Becoming uncaring
 Burned out
 Wounded
 Inexperienced
 Depressed
Compassion becomes un-learned
House of God
Penguins jumping off ice
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WHY SHOULD WE BOTHER?
CAREFULNESS AND
COMPASSION ARE CONNECTED
AND SYNERGISTIC
“Strong evidence that
compassionate care
improves health outcomes
and quality of life,
increases patient satisfaction,
and lowers health care costs.”
Its not about the feeling.........
its about the outcome!
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Empathic communication is associated with
increased adherence to treatment,
and fewer malpractice complaints [1].
greater agency in addressing problems
such as cancer[11].
Patients' perceptions of empathy are positively related to more favourable
health outcomes [2-4].
Neumann M, Edelhäuser F, Tauschel D et al.
Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med 2011;86:996-1009.
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“one relatively consistent finding
physicians who adopt a warm,
friendly, and reassuring manner
are more effective
than those who keep consultations formal
and do not offer reassurance.
 The Lancet, Volume 357, Issue 9258, Pages 757 - 762, 10 March
2001
Positive engagement
 has significant associations with better
 patient mortality,
 infection rates,
 annual Health Check scores,
 staff absenteeism and turnover
 outcomes for that trust
 NHS Staff survey

://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215455/dh_129656.pd
f
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Detached concern is no longer tenable
teaching and practice of “detached concern”,
a process where physicians establish a certain emotional distance from their
patients in order to maintain objectivity is not supported by the literature
negative emotions
do not necessarily lead to emotional
turmoil [11].
Affective engagement
improves cognitive accuracy
as well as affective understanding [12]. [14].
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The Psycho-Biological basis for the positive
effects of Compassion
Oxytocin
Endogenous opioids
Psychoneuroimmunolology
Epigenetic effects
+ve Pressor and cardiac effects

Mood effects
Anxiolysis – reduced fear
Recruitment of Coping strategies
Health promoting behaviour
Cognitive and meta-cognitive
changes

“Compassion, both given and
received, is rooted in affiliative
emotion systems. It has major
impacts on a range of
physiological and psychological
processes, including immune,
cardiovascular stress and
recovery processes that
significantly affect outcomes”.
Indeed, perceived controllability
over a stressor is associated
with prefrontal cortex mediated
regulation of limbic (amygdala
and hypothalamus) and
brainstem (dorsal raphe
nucleus) structures associated
with neuroendocrine and
autonomic nervous system
reactivity[45].
This provides a direct pathway
through which the perception of
one's ability to control aspects of
his/her disease is capable of
regulating physiological
processes ranging from glucose
metabolism and blood pressure
to immunomodulation and
neurogenesis [46].
In addition to improving patient outcomes,
clinical empathy is associated with increased overall
well-being for the physician [5].
decreased burnout, personal distress,
depression and anxiety,
along with increased life satisfaction and
psychological well-being [6, 7].
Neumann M, Edelhäuser F, Tauschel D et al.
Empathy decline and its reasons: a systematic review of studies with medical students and
residents. Acad Med 2011;86:996-1009
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WHERE DOES THAT LEAVE US?
Fundamentally
Compassion is a
one to one transaction
Each time - every time
It is always required of the
individual
to the individual
regardless of the context
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“PHYSICIAN HEAL THYSELF”.............
.....................BUT NOT BY THYSELF!
WHAT ABOUT COMPASSION ?
Let go of the toxic bits
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Peter Carter, head of the Royal College of Nursing
certainly does not believe that
“compassion” can be taught
—as
much of the reporting of the Francis
report seemed to imply.
http://www.bmj.com/content/348/bmj.g126
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I disagree..........
It’s a competency that can be
grown, developed & recovered
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What is the minimum quantum ?
Eye contact
Personalised interactions
Framing Statements
Be less judgemental
Signpost sources
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General Measures – Being Caring
Basic Heart support





Understand your role in care of suffering
Protect & Renew your ideals
Refill the tanks - Take an occasional ‘care pause’
Keep good company
Avoid the angry trap
 “Little by little, your frustrations mount”.




Limit commitments but commit to work
Stay close to patients / mission
Tend your own needs too
Preserve personal and collegial relationships
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Can we learn compassion?
Or is it something innate that we either have or don't have?
Recent research by Jazaieri and colleagues
programmes based on mindfulness
meditation
are associated with
reduced fear of compassion
and a more compassionate attitude

This is a guest post by Dr Lucy Maddox, NHS Clinical Psychologist, lecturer and BSA media fellow. You can read more
from Lucy on her blog, Psychology Magpie, and on Twitter @Lucy_Maddox.
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A word about Mindfulness
For Compassion
Dissolution of narrow and isolated sense of self
Emotional awareness and stabilisation
Less Judgemental
Self acceptance
Less anxiety / depression
Letting go – forgiveness
Liberates joy / bliss / love
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Mental wellbeing
Yourmentalhealth.ie
#littlethings
Headspace App
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AT A SYSTEMS LEVEL……
NHS Staff survey
 Conclusion
 Having a safe working
environment is critical
 https://www.gov.uk/government/uploads/system/upload
s/attachment_data/file/215455/dh_129656.pdf
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Compassion as Core Value
Not so lean
That we carry no slack
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Dov Seidman said that
“the last era of management
was about how much performance we could
extract from people.
The next is all about how much humanity we
can experience”.
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There are an awful lot of Penguins
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The way it will succeed.....
Small peer led teamwork informed by
compassion recovery and maintenance
approaches eg Bailint groups etc
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LAST WORDS
Recovering our personal value
in kindness – it doesn’t matter
in ourselves - we don’t matter
in the context - It doesn’t matter to
anyone
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Healing = care of suffering
Our work
Our gift
Our profession
Our reward

“The secret of the care of the patient,” Peabody noted, “is caring for
the patient.”
 Peabody FW. The care of the patient. JAMA. 1927;88:877–882
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Resources Compassion

Recent research by Jazaieri and colleagues suggests that compassion cultivation programmes, based on
mindfulness meditation, are associated with reduced fear of compassion and a more compassionate attitude
towards oneself.

https://compassionateaction.org/global-compassion-movement

http://greatergood.berkeley.edu/article/item/sustaining_compassion_in_health_care

http://www.tibet.emory.edu/cbct/index.html#CBCT

Look at the Cleveland clinic empathy series on youtube

The Art and Science of Medicine: Guidelines for the Human Physician. Göttingen: Hogrefe Publishing; 2011.

HBR Blog Network How to Spread Empathy in Health Care

Social network scientists have shown that emotions and values can spread in a community with the same
patterns as infectious diseases –”compassion cannot be taught, but it can be caught”

The Center for Compassion and Altruism Research and Education (CCARE) at Stanford University

http://www.psychologicalscience.org/index.php/publications/observer/2013/may-june-13/the-compassionatemind.htm

http://www.visimobile.com/wp-content/uploads/2014/03/Transforming-Care-at-the-Bedside.pdf

Compassion and Healing in Medicine and Society: On the Nature and Use of Attachment Solutions to
Separation Challenges By Gregory L. Fricchione. Johns Hopkins University Press. 2011

Biol Res Nurs. 2012 Oct;14(4):419-30. Epub 2012 Jul 6. The biology of caring: researching the healing effects
of stress response regulation through relational engagement.Zender R1, Olshansky E.

Karen Armstrong 12 steps to a compassionate life

Patient Experience: Are We Overlooking a Crucial Element? Medscape. Oct 31, 2014.
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Comments welcome
THANK YOU
[email protected]
Synergy
Carefulness
↕
Compassion
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LET’S LOOK AT THE PROBLEM OF
ATTENTIVENESS IN THE AGE OF
DISTRACTION
Personal Obstacles to Attentiveness
Stress
Distraction
Fatigue
Perfectionism
Carelessness
Overload
Noise
Conflict
Hangovers etc
Time & Boundaries encroachment
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Contextual Obstacles to Carefulness
- The age of performance
Crowding
Environment
Regulatory excess
Bureaucracy
Performance &
Time pressure
Sectoral change
Ignored problems
Multitasking
http://enlivenwellnessworks.com/wp-content/uploads/2013/10/8036438_l.jpg
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How Multitasking Affects Mental Health
“Inability to focus well on one activity.”
leading to
“Impatience and lack of empathy for
others
who are often seen as getting in the
way.”
-attention switching is difficult

How Multitasking Affects Mental Health

By Rheyanne Weaver

Published January 07, 2012 EmpowHER
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Being Too Careful is also a problem
Scrupulous
Risk averse
Anxious
Mistrustful
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BECOMING MORE ATTENTIVE
Let go of the toxic bits
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What is the minimum quantum of safe
practice ?
3 Checks
Take personal responsibility
Recording
If in doubt don’t proceed
Consult and confer
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General Measures – Being Careful
Basic Head support











Beware fatigue - Protect sleep
Protect health
De-clutter work practices - Don’t Multitask
Develop +ve rituals / habits
Manage other’s access
Take regular ‘attentional pauses’
Analyse and fix your weak points
Don’t rely on stimulants - take Tea!
Practicing mindfulness, Fun Exercise etc
Supervise & review
Individualise improvement & Localise the focus
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Use Focus techniques
http://learningfundamentals.com.au/wp-content/uploads/Focus-mindmap-for-web.jpg96
A word about Mindfulness
For Attentiveness
Clarity
Calm
Energising
Short term focus → sustained clarity
Perceptual shift
Discernment
More Intuitive
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Resources Attention








Focus
Focus Manifesto focusmanifesto.s3.amazonaws.com/FocusFree.pdf
For the Mindmap go to http://learningfundamentals.com.au/wpcontent/uploads/Focus-mindmap-for-web.jpg
Mindfulness
Meditation Society of Australia
Mindful awareness UCLA http://marc.ucla.edu/body.cfm?id=107
Mindfulness Meditation app
Lifestyle
Sleep genius App also Relax and Sleep Well App
Life Goals App also Get it done App IOS only
Recharge App

Resilience Healthcare http://resiliencehealthcarelearningnetwork.ca/



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