Contribution from 2020health’s report ‘Too posh to wash? Reflections on the future of nursing?’
By Harry Cayton, Chief Executive, Professional Standards Authority and Douglas Bilton, Research and Knowledge Manager, Professional Standards Authority
The alleged absence of compassion in nursing care is a common theme in recent healthcare scandals, and is one of the themes of this book. In parallel, the importance of compassion is also stressed; as one paper put it, ‘quality of care includes the quality of caring. This means how personal care is – the compassion, dignity and respect with which patients are treated’ (Department of Health, 2010). The regulators of health professionals set the standards of conduct and behaviour which their registrants must demonstrate in their day to day work. Yet the task of articulating and explaining to registrants what is meant by compassionate care is difficult territory. Clearly, health professionals cannot ‘suffer with’ their ‘suffering’ patient – the literal meanings of compassion and patient. Such an effort of empathy would be both exhausting and distracting from the professional task in hand. Equally undesirable would be a lack of any emotional engagement; a glacial distance would be both obvious and repellent to most patients. How can regulators define an optimum state between the two extremes?
A further difficulty is that compassion implies an intimacy which sits uneasily with health professionals’ obligations to preserve clear personal and sexual boundaries between themselves and their patients. While some patients welcome an openly compassionate and expressive approach, others do not wish to engage at this level with health professionals at all, preferring greater distance to be preserved. The challenge to professionals and their regulators is to explore the latitude involved – the extent to which they should amend their behaviour according to the individual before them and the ways in which they should be constant.
But these observations assume that professionals’ compassion is a given; what if compassion is only sporadically present, or entirely absent? Can regulators promote compassion in the sense of instilling it where it is lacking? There is some research evidence that suggests that teaching or inducing compassion is possible. One study found that meditation could heighten activity in the area of the brain associated with compassion (Lutz et al, 2008). Other research found that working in an environment which is demonstrably compassionate and encourages students to pursue cases in which they become interested and involved encourages and promotes compassion (Pence, 1983).
However, what is evident from both studies is that inducing or eliciting compassion is no small undertaking.
A more pragmatic approach for regulators would be to concern themselves with defining compassionate conduct, rather than trying to ensure and influence internal motivations. Conduct and behaviour can be measured, evaluated and assessed taking into account the circumstances in which it took place. Regulators can promote examples and guidance on what constitutes acceptably compassionate behaviour.
The next challenge is how regulators can convey their standards effectively to their registrants. How do they know that their guidance is changing behaviour for the better? A study that we commissioned in 2011(Quick, 2011) showed that little is known about the specific influence of regulators on the behaviour of their registrants. This is not to say that there is no influence, but that the nature and strength of the influence is an unknown quantity.
What is clear however is that individual professionals are subject to numerous influences on their behaviour, arising both from within themselves and in their working environment. Some of the most potent influences on behaviour are those which arise close to where they work – the teams and workplaces of everyday life. The study also highlighted the underuse of behavioural theory in understanding regulation’s influence.
At the Professional Standards Authority we have begun to try to address the absence of knowledge in this area, in order to better understand how regulators can more effectively promote compassionate conduct, as well as the other standards they define. Building on the findings of the 2011 study, we are undertaking a further review to explore the potential of the behavioural sciences to help us understand how registrants relate to the standards that their regulators set, and what influences compliance.
By pursuing this line of enquiry, we hope to be able to promote new ways for regulators’ standards to be communicated, received, processed, internalised and acted upon. This would be to the benefit of all; to patients, who would enjoy more consistent standards of compassionate conduct; to health professionals, through better and more effective engagement with their regulator; and to regulators, if it meant that less cases of alleged unfitness to practise needed to be heard, the most expensive of the regulatory functions.
Finally, regulators also need to be wise enough to regulate with compassion; to treat regulated professionals with sensitivity and care, in particular those facing allegations of unfitness to practise. The daily pressures of work are stressful; much more so having your fitness to practise called into question, assessed, tested and possibly found wanting.
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Department of Health, 2010, Transparency in Outcomes – a framework for the NHS
Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson R, 2008, Regulation of the Neural Circuitry of Emotion by Compassion Meditation: Effects of Meditative Expertise. PLoS ONE, 3 (3): e1897
Pence, G, 1983, Can compassion be taught? Journal of Medical Ethics, 9,189-191
Quick O, 2011, ‘A scoping study on the effects of health professional regulation on those regulated’, Council for Healthcare Regulatory Excellence