The ‘Compassionate and Professional Midwife’ module was implemented in September 2015 at Nottingham University as part of the Nursing Midwifery Council (NMC) revalidation process. The innovative compassion module derived from a newly developed values-based curriculum. The impetus to teach compassion came from a high-profile report (Francis, 2013) that suggested that compassion was lacking in healthcare, and recommended that compassion should be a central tenet of care delivery. This led to the Department of Health and Social Care's (DHSC) Compassion in Practice policy (2012) to develop a culture of compassion among healthcare staff, and a vision of the values needed in the NHS was enacted to improve care for all. These are known as ‘The Six C's’ (compassion, commitment, care, courage, communication and competence) (DHSC, 2012), and are supported by a revised edition of the Code (NMC, 2015). This implies that, rather than being an implicit value that midwives possess, compassion needs to be taught and examined among health professionals. Midwifery educators should therefore educate their students about the ‘Six Cs’; however, there does not seem to be a precedent in the literature (and specifically relating to midwifery) to suggest how to teach compassion. The aim of this article is to provide a critical reflection on the experiences of developing a compassion module in pre-registration midwifery education.
Before commencing module design, it was necessary to provide a definition of compassion in a midwifery context, as until this concept was understood, the supporting pedagogy would have been difficult to establish. The term ‘compassion’ is derived from the Latin and means ‘to suffer with’ (Davenport, 2015); however, there are issues with this definition for midwifery. A comprehensive narrative synthesis of more than 500 nursing studies on compassionate care (Dewar, 2011) revealed that there was no consensus of what form compassionate care should take, and no comprehensive model of how it may be achieved in healthcare. The research revealed the key attributes of compassion were (Dewar, 2011):
Defining compassion in midwifery
Nursing and midwifery are two distinct professions, and while they have many commonalities, they are different enough to need separate definitions of compassion. While women experiencing childbirth may be vulnerable, and midwives relate to women's individual needs, the words ‘illness’, and ‘suffering’ do not easily resonate with midwifery care. Pregnancy is not synonymous with illness, and those accessing maternity care are referred to as ‘women’, as opposed to ‘patients’ (DHSC, 2017). Although some women may have pre-existing medical conditions that worsen during pregnancy and in the postnatal period (Larkin et al, 2009), most women remain healthy during and after pregnancy (DHSC, 2017). Compassion also involves the recognition of suffering, but in midwifery, generalisations of suffering cannot be made: some women may ‘suffer’ with the pain of contractions, for example, but other women may not.
Consequently there is still a lack of an agreed definition of compassion in healthcare. Bray et al (2014) surveyed 155 qualified health professionals and 197 pre-registration students studying Health and Social Care, and found compassion to encompass acting with warmth and empathy, treating people as individuals and ‘acting in a way that you would like others to act towards you’. Bray et al (2014) suggested that compassion could only be displayed during contact with patients, a view that does not necessarily fit with midwifery, where compassion should be shown to women and their families but also colleagues and students. Certainly, experience shows that when compassion is deficient in a midwife or student, it is easy to recognise, arguably easier than trying to define what the value actually is.
Clift and Steel (2015) asked 280 frontline multi-faith and multicultural healthcare staff what compassion meant to them, and to describe an example of where they had shown compassion. Findings suggested that compassion involved communication, helping, caring, empathy, kindness, listening, sympathy, and understanding.
Developing the module
The aforementioned literature (Bray et al, 2014; Clift and Steel, 2015) informed key themes that were used to develop the teaching sessions within the module, namely:
The module's aim was then created, which was to examine how professional and personal attributes could support the development of emotionally intelligent, resilient midwives and the provision of compassionate and holistic evidence-based care. The following learning outcomes were then agreed:
These learning outcomes are tested by assessment, whereby students answer one of three questions with a 3000-word essay. Students also complete an online evaluation, which has consistently found that students value being taught about compassion, particularly as the first module before their clinical placement.
Midwifery education has two perspectives: theory and practice, and full-time students spend equal time in both university and clinical practice during their course (NMC, 2009). As a practice-based discipline, midwifery requires the synthesis of both explicit (theoretical) and tacit (practical) knowledge (Polyani, 1966), which can be challenging, given that higher education institutions and practice settings exist separately from each other.
Aligning both the tacit and explicit knowledge needed to teach compassion was considered during the module's development. As communication is needed to deliver compassionate care (Clift and Steele, 2015), the theory of communication is taught during the compassion module and then put into action by students during interactions with women and alongside their midwife mentor in clinical practice. The university is then responsible for assessing the student's knowledge of communication through completion of the module's summative assignment, and mentors grade the students on communication skills demonstrated in practice during the two summative practice assessments that take place at the end of each teaching period.
Legitimate Peripheral Participation
Lave and Wenger's (1991) social practice theory of learning, Legitimate Peripheral Participation (LPP) was also used to consider how compassion might be consolidated by students in practice. LPP is based on a framework of co-participation in the sociocultural practices of a community and closely resonates with student midwives and the shared partnership between the university, educator and mentor. LPP postulates that learners (student midwives) participate in communities of practitioners (mentors), and full participation in the sociocultural practices of the community is required to master knowledge and skills (Lave and Wenger, 1991). LPP differentiates between a teaching curriculum, constructed for the instruction of ‘newcomers’ (in this case the themes of compassion taught to students), and a learning curriculum, which consists of situated opportunities, such as caring for women in clinical practice (Lave and Wenger, 1991). Therefore, compassion is learned both in university and clinical practice, with each informing the other.
However, there are complexities with this theory. Given the view that compassion is not always displayed in healthcare (Francis, 2013), LPP could result in the theory of compassion being taught to student midwives, but not being applied or valued in practice. A Royal College of Midwives' (RCM) (2016) survey revealed that the most cited reason for midwives leaving the profession were that they were dissatisied at being unable to give women the compassionate care they wanted to due to funding and resource constraints. Therefore, there are challenges for students as disillusioned or overworked mentors may not feel able to demonstrate compassion, which may leave compassionate practice lacking or unappreciated.
Most learning in midwifery takes place in the cognitive, psychomotor and affective domains (Bloom and Krathwohl, 2001). Herbst et al (2010) consider learning in the affective domain the most challenging, as it requires a personal behaviour change. Learning about compassion requires the delivery of cognitive information (taught in the university) and psychomotor skills (learned in clinical practice), which would then elicit a behaviour change (affective response) (Herbst et al, 2010). Learning compassion may then take place as all three domains are engaged through the acquisition of new knowledge, experience and perspectives.
Reflections from developing a compassion module
This article has sought to share how the compassion module was developed at the University of Nottingham. While there is an increasing requirement and expectation to base pre-registration programmes on The ‘six Cs’— and on compassion in particular—there is very little published in relation to if and how this is being achieved in midwifery education. It is difficult to gauge if this reflects a lack of activity, or a delay in sharing and evaluating existing practice. Without the opportunity to share experiences and present different models for peer review, there is a risk that compassion will remain rhetoric, undefined and not understood in terms of application to real-life practice.
Educators should be encouraged to share examples of successful teaching about compassion, so that future research studies can start to consider students' learning, and what differences this makes to outcomes for women accessing maternity services in the longer term.