Sustaining compassion across long periods of time is an essential part of a midwife's role, with stress experienced from continual exposure to traumatic events potentially resulting in emotional fallout. As a consequence, midwives may experience symptoms of empathic distress fatigue (Klimecki and Singer, 2012), compassion fatigue (Sabo, 2006), secondary trauma (Leinweber and Rowe, 2010), and burnout—all of which can have an impact on the level of compassion the individual is able to show towards him/herself and others (Figley, 1995; 2002). Introducing student midwives to interventions that aim to promote self-compassion is, therefore, vital; this may furnish them with some of the coping strategies needed to manage emotional distress. The aim of this article is to explore an intervention designed to increase student midwives' levels of compassion for themselves and reduce levels of self-criticism.
Empathic distress fatigue is the consequence of emotional, psychological, physical, spiritual and occupational exhaustion, and according to Klimecki and Singer (2012) it is the cause of burnout and compassion fatigue. Compassion fatigue was a term first coined by Joinson (1992) and is a form of burnout that can have a negative effect on health professionals who bear witness to suffering. Klimecki and Singer (2012) suggest that compassion fatigue is a result of placing the needs of other people above one's own and can lead to emotional, physical and psychological damage. Compassion fatigue may be prevented by using exercises that activate the neural pathways associated with compassion, empathic concern, positive feelings and altruistic behaviour (Klimecki and Singer, 2012).
Richards (2013) argues that health professions should expect clinicians to nurture their own wellbeing; therefore, examining interventions that aim to promote self-care and cultivate self-compassion warrants consideration. Compassion can be defined as a quality that ‘aims to nurture, look after, teach, guide, mentor, soothe, protect, offer feelings of acceptance and belonging’ (Gilbert, 2005: 127). These factors are important because work-related stress has been shown to have an impact on health professionals' concentration levels and ability to communicate effectively (Raab, 2014). This article explores an intervention that could potentially equip midwifery students with the psychological tools required to cope with organisational, personal, academic and placement demands. Compassionate mind training (CMT) may enhance levels of compassion, reduce self-criticism, and help prepare student midwives to face the challenges of academic and organisational pressures, traumatic childbirth (Leinweber and Rowe, 2010; Mollart et al, 2013; Sheen et al, 2014) and stillbirth (Hollins Martin and Forrest, 2013; Hollins Martin et al, 2013; 2014).
Background
A literature review was conducted (Box 1) to examine what research has already addressed in relation to self-compassion, compassion for others, empathic distress fatigue, compassion fatigue, and burnout in the health professions. From the body of literature it was identified that patient dissatisfaction (Vahey et al, 2004), insufficient training, shortage of personnel and lack of support from colleagues are all linked to staff burnout (Shanafelt et al, 2002). Continued absence of self-care strategies can put midwives at risk of burnout (Miller et al, 1988) and compassion fatigue (Figley, 2002), and can create a tendency to be more self-judgemental (Beaumont et al, 2016a). Van Mol et al (2015) conducted a systematic review to examine the literature connected to emotional suffering among health care practitioners. The authors concluded that the true scale of emotional distress among practitioners was uncertain, with prevalence rates ranging from 7.3–40% for compassion fatigue and 0–70% for burnout. In response, they suggest that policy makers introduce practitioners to interventions that help prevent the negative consequences of emotional distress. This sentiment is echoed by Raab (2014), who conducted a literature review which concluded that further research focusing on cultivating self-compassion among health-care practitioners is warranted. Enhancing levels of self-compassion may have the potential to reduce stress-related symptoms and improve levels of compassion in student midwives.
Links between self-compassion, compassion for others, wellbeing, compassion fatigue and burnout have already been explored by Beaumont et al (2016a). In a quantitative survey, Beaumont et al (2016a) examined the relationships between wellbeing, self-compassion, compassion for others, compassion fatigue and burnout in student midwives (n = 103). The authors found that just over 50% of the sample reported scores that were above average for burnout. In addition, participants who reported higher levels of self-judgement also reported lower levels of self-compassion and compassion for others, and an increase in symptoms associated with burnout and compassion fatigue. The authors concluded that students wanting a career in midwifery may benefit from learning to be ‘kinder to self’ when faced with challenging circumstances. To augment these findings, studies by Mollart et al (2013) found that 60% of midwives (n = 56) reported symptoms of emotional exhaustion that were categorised as moderate to high. Yoshida and Sandall (2013) also found that 50% of practising midwives reported symptoms of burnout. In response to these findings, this article will examine the possible benefits of incorporating CMT into undergraduate midwifery education programmes.
Organisational demands
The Nursing and Midwifery Council (NMC, 2015) recognises the importance of working in environments that foster compassionate care. Maben et al (2010) reported that some nurses felt disillusioned with their role, and experienced feelings of frustration and symptoms of burnout, within just 2 years of commencing their career. This highlights the relevance of considering an intervention that develops compassion. The working environment can affect all health professionals, with newly qualified staff sometimes facing organisational obstacles that have a negative impact on their performance (Bjerknes and Bjørk, 2012). Compassion inhibitors in the working environment include stress and workplace threats that compel individuals to focus on self-defence mechanisms, which can lead to judgement errors and, ultimately, compassion fatigue (Figley, 1995; 2002; Crawford et al, 2014). To compound such situations, bureaucratic organisations and staff shortages inhibit the capacity of staff to function compassionately (Brown et al, 2014).
Research has also been conducted to examine the stressors experienced by staff during the processes of delivering bereavement care. Peer support has been found to be one variable that affects the midwife's experience of delivering bereavement care (Kirkham, 1999; Mander, 2006). Stress may initially manifest itself in the form of an increase in sickness absence, or through a rise in errors in the workplace. Educators, peers and team leaders must be vigilant to recognise when a student midwife is not coping well with a bereavement situation or an adverse event. Causes of stress or stressors fall into two categories: external and internal.
External stressors
External stressors consist of physical stimuli in the person's environment, such as uncomfortable hot or cold temperatures. Alternatively, external stimuli may include an abusive colleague, or being given too much work to cope with during a given time period.
Internal stressors
Internal stressors consist of stimuli within the person's body, such as infection, inflammation, lack of sleep, hunger or thirst. Alternatively, internal stimuli may be psychological in origin, e.g. experiencing worrying thoughts, nightmares or anxiety. The working environment is capable of producing both acute and chronic stressors. Other causes of stress and trauma at work include (Hollins Martin and Forrest, 2013; Hollins Martin et al, 2016):
When a professional recognises signs of stress and trauma in him/herself or a staff member, it is that individual's duty to do something about it. Maternity unit managers, lecturers and supervisors should take responsibility for continuing to provide support to colleagues while they gain experience in all areas of practice. Midwifery educators should consider the variety of acute stress responses that may lead to symptoms of trauma, and offer interventions to student midwives to support them with such challenges (Davies and Coldridge, 2015). Self-compassion has been shown to include a healthier reaction to stress (Leary et al, 2007). These factors provide a rationale for creating a more compassionate environment for students on the undergraduate midwifery programmes.
‘Developing an intervention that cultivates compassion could improve students' ability to cope with distress through reducing levels of self-critical judgement and self-attack’
Creating and cultivating environments that foster compassion could help student midwives cope with placement and educational demands (Beaumont, 2016). Wiklund Gustin and Wagner (2013) found that nurse lecturers who cultivated self-compassion presented with improved compassion for others. This makes the idea of developing self-compassion in student midwives a promising solution for stress reduction, and it also has the potential to increase the effectiveness of maternity care provision.
Benefits of self-compassion
Increasing self-compassion and reducing self-criticism may work towards protecting student midwives from a variety of stress-related illnesses, including empathic distress fatigue, burnout and compassion fatigue. Klimecki et al (2013) demonstrated that compassion training led to a significant improvement in positive emotions when faced with the suffering of others. It has been found that individuals who report high self-compassion scores experience improved relationships and report lower levels of self-criticism (Neff and Beretvas, 2013), and self-compassion has been shown to include a healthier reaction to stress (Leary et al, 2007). Developing an intervention that cultivates compassion could, therefore, improve students' ability to cope with distress through reducing levels of self-critical judgement and self-attack.
The act of self-compassion includes reacting to self-suffering with a non-judgemental attitude, kindness and understanding (Neff, 2003). Neff (2003) proposes that there are three elements of self-compassion:
Compassionate mind training and compassion-focused therapy
CMT and compassion-focused therapy (CFT) were developed by Professor Paul Gilbert to help clinical populations who experienced high levels of self-criticism and shame to reduce negative emotional responses. CFT describes the process and theory of Gilbert's (2009) model, whereas CMT refers to the specific interventions used to trigger the affiliative self-soothing system. The model offers an evolutionary and neuroscientific approach that explores how the evolution of affiliative emotions regulate threat-processing and motivational systems (e.g. to help others, improve status, care for family, or seek out partners).
Compassion as a flow
A continuous and external flow of compassion, in the absence of self-compassion, can lead to burnout (Gilbert and Choden, 2013). Com passion is classified as flowing in three distinct ways (Gilbert, 2014):
Exercises that assist internal and external compassion have shown to be beneficial in clinical populations (Gilbert and Procter, 2006; Mayhew and Gilbert, 2008; Beaumont et al, 2012; Beaumont and Hollins Martin 2013; 2015) and, as such, could assemble part of a strategy that attempts to improve compassionate care in student midwives.
Rationale for developing CMT for student midwives
Placement stressors, trauma, academic demands, staff absences and organisational issues can all take their toll on midwifery students (Chang et al, 2005; McNeely, 2005; Sheen et al, 2014). In place of blaming individuals for their lack of compas sionate care, we could instead offer interventions which are designed to develop greater compassion. Such activities are devised to help build emotional resilience through an individual feeling ‘cared for’ within an organisation. Cultivating self-compassion could help student midwives deal with distress and trauma in the workplace, with CMT using a variety of breathing, postural, and imaginal interventions. During the process, acting techniques (experiencing what it would be like to be a compassionate self), and recall of experiences of giving and receiving compassion are also examined.
CMT implementation strategy for student midwives
Given that CMT has been found useful for helping people experiencing primary trauma, a CMT teaching programme has been designed to explore whether it can help student midwives (who bear witness to the trauma of others) develop self-compassion, build resilience and reduce self-criticism. The teaching programme devised aims to help student midwives cope with organisational, placement, personal, and academic demands through cultivating compassion (Figure 1).
Data collection and ethical considerations
Data will be collected pre-and post-CMT and its effectiveness will be measured using qualitative and quantitative methods. Qualitative data will be collected via a focus group and quantitative data collected using the Self-Compassion Scale (Neff, 2003), Professional Quality of Life Scale (Stamm, 2009), Short Warwick–Edinburgh Mental Well-being Scale (Tennant et al, 2007) and the Compassion For Others Scale (Pommier, 2011). Ethical approval will be sought from the university ethics committee before the sessions are incorporated into the student midwifery curriculum.
Implementation
Table 1 offers an implementation strategy outlining the interventions that will be added to each year of the midwifery curriculum. Students will be offered additional support, practice and reflection sessions which they can choose to attend if they wish.
| Session number | Outline of the additions to the curriculum |
|---|---|
| 1. Psycho-education: Key elements of CMT (introduced in year 1 of the curriculum) |
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| 2. Psycho-education and developing the compassionate self (introduced in year 1 of the curriculum) |
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| 3. Formulation: Understanding yourself (introduced in year 2 of the curriculum) |
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| 4. Cultivating and building compassionate capacities (introduced in year 2 of the curriculum) |
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| 5. Building compassionate capacity using behavioural practices (introduced in year 3 of the curriculum) |
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| 6. Using the compassionate mind to engage with difficulties (introduced in year 3 of the curriculum) |
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Student midwives will initially be introduced to the core theoretical elements of Gilbert's (2009) model. This approach will include exploration of the evolved nature of the human mind, how sense of self is created through an interaction between genetics and social experience, and how shame and self-criticism can have an impact on levels of compassion. A variety of experiential exercises to cultivate distinctive aspects of compassion will be utilised, which follow a series of defined steps.
Step 1: Psycho-education: key elements of CFT
Students will be introduced to the theoretical components of the compassionate mind model, alongside a critical exploration of how a ‘sense of self’ is created, through:
Threat and protection system
The TPS alerts and directs attention to aspects that an individual perceives as threatening, and prompts the body into action. The TPS creates ‘better safe than sorry’ scenarios that focus on the negative. For example, the person imagines in their mind ‘worst case’ scenarios and their catastrophic consequences. Self-critical or shame-prone individuals are sensitised towards having a dominating threat system (Gilbert, 2009); for example, a midwife engaged in an unexplained stillbirth who blames him/herself for the unfortunate outcome. In turn, this could cause stress to the extent that the midwife imagines being publicly shamed and struck off the register.
Drive system
The drive system is linked to doing, wanting, achieving, avoiding rejection, and consuming activities (Depue and Morrone-Strupinsky, 2005). It evolved to motivate animals to find food and shelter, and seek out sexual partners. The drive system down-regulates negative emotions from the threat system. That is, when a person engages their drive system (e.g. to win a competition, pass an exam, or gain an award), they experience positive emotions (e.g. excitement, joy, elation) that act as reinforcers for repeating behaviour.
The content, soothing/affiliative system
The soothing/affiliative system is associated with a number of physiological responses, such as physical calming, attachment, caring and interpersonal connection (Depue and Morrone-Strupinsky, 2005). The soothing/affiliative system is associated with social connection, affection and kindness, and is responsible for reducing threat responses to feared stimuli and for activating feelings of safety, bonding and trust. In distressing events, being in receipt of compassion generates security within the group. Hence, activities that engage the soothing/affiliative system increase self-compassion and feelings of safeness, and help to regulate the affect-regulation system in response to threat (e.g. self-criticism).
In a nutshell, the aim of CMT is to balance the three systems, build the soothing/affiliative system, and understand how the three systems affect one another. Cultivating a compassionate mind involves being prepared to change, having wisdom about how to take effective action (Gilbert, 2014), and having a caring motivation to develop a variety of key attributes and skills linked to compassion. Gilbert (2009) refers to the first psychology of compassion, which involves:
The second psychology of compassion includes acknowledging, knowing, and finding out what to do when suffering is experienced (Gilbert, 2014).
The two psychologies of compassion are action-focused and include a desire to acquire skills that attempt to alleviate suffering. For example, skills training involves the person learning to direct attention, behave, reason, and respond to feelings and sensations with compassion (Table 2).
| First psychology of compassion (compassionate attributes) | Second psychology of compassion (compassionate skills) |
|---|---|
| Care for wellbeing: Developing a caring motivation to notice and turn toward suffering with a wish to alleviate distress | Attention: Learning how to notice that our attention can be directed by us (what we focus on expands). This is linked to mindfulness, being in the present moment without judging or criticising |
| Sensitivity to distress: Learning to recognise and be attentive to one's own and other people's distress | Reasoning: Learning to reason in ways that are helpful (exploration of cognitive processes with a focus on ‘what will be genuinely helpful right now’) |
| Sympathy: The ability to be emotionally moved by feelings of distress rather than feeling dissociated from it | Behaviour: Behaving in ways that are helpful (facing fears, reducing safety behaviours, acts of gratitude, compassionate letter writing, doing helpful things for self or others) |
| Distress tolerance: Using the compassionate mind to tolerate difficult emotions by moving toward suffering rather than avoiding suffering | Sensory: Using breathing practices, vocal tones, facial and body postures to generate physical states, which are conducive to affect regulation and compassion |
| Empathy: Seeing the world through the eyes of another and understanding our own emotions, which can involve taking the perspective of our different parts (angry self, sad self, compassionate self, critical self) | Feeling: Learning to pay attention to, and compassionately respond to, the different emotions we feel |
| Non-judgement: The process involves acceptance and non-judgement. Individuals are taught techniques that aim to help them become more aware of and let go of self-attacking and self-criticism | Imagery: Using imagery and meditation exercises to stimulate the soothing systems |
Step 2: Compassion in midwifery
The education provided in step 1 will be strengthened by discussions regarding symptoms of empathic distress fatigue, compassion fatigue, (secondary/vicarious trauma), burnout, and occupational stress—all of which can have an impact on the performance of midwifery staff. Discussions will include examination of how trauma experiences in the workplace (e.g. traumatic childbirth, stillbirth, lack of support) have an impact on staff well being. Students' beliefs surrounding com passionate thinking and compassionate behaviour (e.g. what constitutes self-compassion vs self-critical behaviour and thinking) will be explored, and a critical appraisal of helpful and unhelpful behaviours in the workplace examined. Students will discuss stress-coping strategies, and role-play exercises will be used to help equip students with the necessary tools to face workplace stressors. Students will recall memories of giving and receiving compassion.
Step 3: Formulation
The reflections in step 2 will be reinforced through learning about early life experiences and how to create coping strategies to self-soothe, drive forward, and defend against threat. Self-awareness will be bolstered through exploring interactions students have with their own ‘self’; for example, what tone of voice is used when a mistake is made, what fears are learnt in childhood, and what helpful and unhelpful strategies are used to regulate emotions and interactions with others. Fears, blocks and barriers to compassion will be examined.
Step 4: Cultivating and building compassionate capacities
Participants will be introduced to a variety of interventions, such as breathing and imagery techniques that create safeness and calm. Exercises designed to help student midwives experience ‘compassion as a flow’ will be introduced. In addition, mindfulness and focused attention will be taught, to direct attention towards being in the present moment without judgement or criticism. Breathing exercises—including soothing rhythm breathing (SRB), which moderates heart rate variability and is linked to positive health outcomes—will be incorporated into training. SRB engages the soothing-affiliative system and produces feelings of calm. Creating a safe place using guided imagery interventions will help student midwives create a sense of safety and calm. In addition, compassion-focused imagery exercises will be taught, which stimulate the soothing system. Participants will create in their mind, or through art, an image of their ideal compassionate other. The image created requires that the person uses a compassionate, non-judgemental approach (Gilbert, 2009; 2014).
Step 5: Building compassionate capacity using behavioural practices
The compassionate qualities cultivated in step 4 will be used to challenge unhelpful behaviours and self-critical thoughts; for example, a student midwife criticising his/her ability to cope when a childbearing woman experiences an adversity, such as an infant abnormality.
The skills acquired in these steps will be used to explore helpful alternative assertive behaviours. Student midwives will also be introduced to creative ways of developing self-compassion, through use of acting and art to depict the ‘bully within’ and the ‘compassionate self’.
Step 6: Using the compassionate mind to engage with difficulties
Participants will use their compassionate mind to engage with self-criticism, organisational pressures, and trauma memories. Discussions about sad, angry or anxious parts, which respond simultaneously in a situation, will take place—for example, a student midwife may simul taneously experience sadness about leaving university, anxiety about commencing a new role, and joy at successfully completing the course. In contrast, participants will also explore how to engage with compassion to help self-criticism, which involves employing the compassionate part of themselves and directing compassionate attributes (such as empathy, distress tolerance and non-judgement) to self-critical parts.
Conclusion
‘As compassionate mind training has proven effective in treating symptoms of trauma in clinical populations, it has shown potential to benefit midwives who bear witness to trauma’
While many students face similar challenges, student midwives face a set of distinctive emotional challenges that can test their confidence, knowledge and capacity. Student midwives work with women and families who, at times, experience high levels of distress. Being part of these traumatic experiences, if not well managed, can propagate emotional fallout. In this instance, we are talking about experiencing symptomology of secondary traumatic stress and burnout. Given the evidence that health-care educators' levels of self-compassion improved, and self-critical judgement reduced, post-CMT training (Beaumont et al, 2016b), and because CMT has proven effective in treating symptoms of trauma in clinical populations (Beaumont et al, 2012; Beaumont and Hollins Martin, 2013; 2015), it has shown potential to benefit midwives who bear witness to trauma. As such, the authors recommend that CMT be incorporated into a midwifery undergraduate degree programme, and its effectiveness measured. In the current climate, it is timely and appropriate for midwifery educators to explore concepts of compassion in greater depth.