The Francis (2013) inquiry recommendations set out improvements required to NHS care, which included a renewed focus on compassion and compassionate care. This prompted increased emphasis on compassion to underscore all areas of healthcare. The Nursing and Midwifery Council (NMC, 2018) code stipulates that care must be compassionate, highlighting the importance of the value to midwives providing care and those supporting student learning. Arguably, this should prompt midwifery educators to consider how future midwives should be educated about and for compassion. Moreover, learning about and for compassion in midwifery education is far from clear. There is little published work about how compassion might be taught and how it may be learned.
Research into how to educate student midwives about compassion may alleviate some of the challenges that educators currently face when deciding how to support students in developing the skills, knowledge and attitudes conducive to showing compassion. Furthermore, sharing that research may help to ensure that concerns about compassion underpinning healthcare will amount to more than simple rhetoric (Pearson, 2018).
At the author's university in 2015, a new values-based curriculum was introduced, which included a module focused on compassion in response to the Francis (2013) recommendations. This was the first module that students studied upon commencement of their pre-registration midwifery education. Students' formal study about compassion presented a research opportunity, which was undertaken as part of a professional education doctorate.
The aims of this research were to investigate student midwives' perspectives of compassion and the impact that the taught theory and clinical practice elements of their education had on their learning. This study aimed to explore and understand how theory and practice worked together to facilitate student midwives' learning about compassion during undergraduate midwifery education. The overarching question for the research was what and how do student midwives learn about compassion in an undergraduate midwifery course?
Defining compassion
The word compassion has been in use since at least the 14th century and the etymology of the word emerges from the Latin, ‘com’, which means together with, and ‘pati’, which is suffer; in other words, it means to ‘suffer with’ (Thompson, 1995). Suffering may be a term that has a different meaning according to a person's culture, background and value-beliefs (Saunders, 2015), which adds to the lack of universality in defining compassion. A full definition of compassion perhaps includes considerations other than just the alleviation of suffering. The absence of suffering in relation to compassion may be seen in the Department of Health and Social Care's (DHSC, 2012) compassion in practice vision. It defines compassion as ‘how care is given through relationships based on empathy, respect and dignity - it can also be described as intelligent kindness, and is central to how people perceive their care’ (DHSC, 2012).
The term relationships in the DHSC (2012) definition resonates with the association that midwives engage with women and their families. Both respect and dignity are important aspects that midwives must display for those in their care (NMC, 2018). In the DHSC (2012) definition, ‘intelligent kindness’, first cited by Ballatt and Campling (2011), expresses the positive values that should define healthcare and not the negativity that has unfortunately often been associated with care in recent years (Francis, 2013).
Compassion is a complex construct, which is multilayered and its definitions appear to have evolved over time. It is agreed that compassion should underscore healthcare. What is less clear is how to educate future midwives about compassion. The literature reveals that a number of researchers in nursing and medicine have set out to better understand what might be useful when educating healthcare professionals about compassion. The midwifery profession has yet to substantially add to this discourse.
Methods
A mixed-methods design was used for this study (Tashakkori and Teddlie, 2003). Mixing positivism and intepretivism by adopting a quantitative approach allowed for scope and scale, while the qualitative data offered depth, breadth and allowed the participants' perspectives of compassion to inform the research.
Design
There were three phases to this study. The first comprised a free writing exercise framed around set questions and was carried out with students new to the course, who were yet to undertake the compassion module.
The second phase included self-completion questionnaires that were administered to students in all years of the course. The possible responses that students could choose to signal a change or otherwise to their understanding about compassion, having been taught about the value and clinical placement attendance were ‘yes a lot’, ‘yes a bit’, ‘not much’ or ‘not at all’. The third phase consisted of three focus groups and semi-structured interviews with students in years one, two and three.
Participants
The participants were students at the researcher's university, potentially raising issues of the researcher being known to the students and reflexivity. The reason for researching students locally was that a seminal module about compassion had been introduced into midwifery education at the university (Pearson, 2018). Consequently, it seemed reasonable that data should be collected from students who were about to or had already been taught about compassion. Therefore, it was not possible to extrapolate whether being known to the students had a bearing upon or made a difference to the responses they provided during the data collection. This is a limitation of the research.
The methods, participant numbers and response rates are set out in Table 1. In phase one, participants were anonymised by assigning them a number. In phase two, participants were assigned a year, followed by a number. In the final phase, participants were categorised using symbols and a number. These codes are also used to identify the illustrative quotations in the results.
Table 1. Participants and response rates
| Year | Phase 1: free writing exercise | Phase 2: self-completion questionnaires | Phase 3: focus groups, semi-structured interviews |
|---|---|---|---|
| 1 | Participants: 24/24 (100%) | Questionnaires distributed: 24, returned: 22 (92%) | 6 participants |
| 2 | - | Questionnaires distributed: 33, returned: 30 (91%) | 4 participants |
| 3 | - | Questionnaires distributed: 29, returned: 29 (100%) | 6 participants |
| Total | 24 | 81 | 16 |
Data analysis
The qualitative data were analysed by the researcher using the principles of thematic analysis (Braun and Clarke, 2006). Free writing data were read and re-read, and recurring words and their co-location to others were noted. Finally, the data were analysed by considering interrelating themes and categories.
The phase two questionnaires generated both quantitative and qualitative data, which were dealt with separately. The qualitative data were subjected to thematic analysis. The quantitative data are summarised in Table 2.
Table 2. Response to questions by age group
| Age (years) | Response | n (%) | Response | n (%) | Response | n (%) |
|---|---|---|---|---|---|---|
| Did taking a module about compassion change your understanding of it? (Q3) | Did studying compassion help prepare you for practice? (Q4) | How did you think working in practice changed your understanding of compassion? (Q5) | ||||
| 18–24 | Yes, a lot | 6 (13.6) | Yes, a lot | 13 (29.5) | Yes, a lot | 15 (34.1) |
| Yes, a bit | 23 (52.3) | Yes, a bit | 20 (45.5) | Yes, a bit | 17 (38.6) | |
| Not much | 9 (20.5) | Not much | 6 (13.6) | Not much | 9 (20.5) | |
| Not at all | 5 (11.4) | Not at all | 4 (9.1) | Not at all | 2 (4.5) | |
| No response | 1 (2.3) | No response | 1 (2.3) | No response | 1 (2.3) | |
| Total | 44 (100.0) | Total | 44 (100.0) | Total | 44 (100.0) | |
| 25–34 | Yes, a lot | 13 (48.1) | Yes, a lot | 13 (48.1) | Yes, a lot | 15 (55.6) |
| Yes, a bit | 10 (37.0) | Yes, a bit | 12 (44.4) | Yes, a bit | 9 (33.3) | |
| Not much | 3 (11.1) | Not much | 2 (7.4) | Not much | 2 (7.4) | |
| Not at all | 0 (0.0) | Not at all | 0 (0.0) | Not at all | 0 (0.0) | |
| No response | 1 (3.7) | No response | 0 (0.0) | No response | 1 (3.7) | |
| Total | 27 (100.0) | Total | 27 (100.0) | Total | 27 (100.0) | |
| 35–44 | Yes, a lot | 3 (42.9) | Yes, a lot | 3 (42.9) | Yes, a lot | 2 (28.6) |
| Yes, a bit | 4 (57.1) | Yes, a bit | 4 (57.1) | Yes, a bit | 3 (42.9) | |
| Not much | 0 (0.0) | Not much | 0 (0.0) | Not much | 1 (14.3) | |
| Not at all | 0 (0.0) | Not at all | 0 (0.0) | Not at all | 0 (0.0) | |
| No response | 0 (0.0) | No response | 0 (0.0) | No response | 0 (0.0) | |
| Total | 7 (100.0) | Total | 7 (100.0) | Total | 7 (100.0) | |
| 45–54 | Yes, a lot | 1 (33.3) | Yes, a lot | 1 (33.3) | Yes, a lot | 1 (33.3) |
| Yes, a bit | 2 (66.7) | Yes, a bit | 2 (66.7) | Yes, a bit | 2 (66.7) | |
| Not much | 0 (0.0) | Not much | 0 (0.0) | Not much | 0 (0.0) | |
| Not at all | 0 (0.0) | Not at all | 0 (0.0) | Not at all | 0 (0.0) | |
| No response | 0 (0.0) | No response | 0 (0.0) | No response | 0 (0.0) | |
| Total | 3 (100.0) | Total | 3 (100.0) | Total | 3 (100.0) | |
The phase three focus group voice recordings were downloaded and transcribed by the researcher. These data were analysed using thematic analysis.
Ethical considerations
The university's code of ethical conduct was adhered to and the study received ethical approval from the university ethics committee (reference number: 2017/107). Participants were informed about the nature of the study and were able to withdraw at any time. Participants consented to take part by reading an information sheet and providing written consent for phase one and three of the research. By completing and submitting the self-completion questionnaires in phase two, consent was implied. The participants were not offered incentives for taking part in the research.
Results and discussion
All year groups completed the questionnaires (n=81), and the quantitative data are presented in Table 2. Three overarching themes emerged from qualitative data analysis: ‘pre-course life experiences influenced perspectives about compassion’, ‘formal teaching about compassion’ and ‘learning during clinical practice’. The themes were not entirely distinct from one another. This reflects that like other deep learning (Biggs and Tang, 2011), learning about compassion is recursive. Students bring their pre-professional life experience to the classroom and to clinical practice; they will continue to learn both formally and informally, depending on the situations they find themselves in. Each individual arrives at the course with different ideas and experiences of compassion. The professional education issue is how to get every student on the course to at least the minimum threshold level of understanding and practice of compassion that is expected, as per the professional expectations and standards (NMC, 2018; 2019).
Life experiences
As student midwives began their midwifery course, their experiences of compassion were both highly individual and diverse.
‘Compassion is giving mothers and families the best possible care, which includes explaining procedures and keeping them informed.’
(Participant 1)
This perhaps suggests students had started to think how compassion might fit with their new role as a student midwife.
‘Compassion is the ability to share feelings and emotions of someone else's situation. It is to treat people how you would like to be treated.’
(Participant 12)
Students had included the emotional aspects of midwifery care in their thinking. Such differences in student perspectives about compassion as they started their midwifery education suggested that the task ahead for their teachers would be in reconciling different views and linking them to better understanding of how to be a compassionate midwife.
The finding that life experiences influence an individual's understanding of compassion agrees with work by a number of academics who have argued that ‘foundational influences’, such as how individuals are parented, are necessary to the understanding of being compassionate (Pence, 1983; Bryman, 2004; Wear and Zarconi, 2007; Gilbert, 2009). If an individual's upbringing is within a safe and supportive setting, compared with one that is not, this may offer individual contrasting perspectives about compassion. Such foundational influences may lead to either the presence or absence of compassionate behaviours (Gilbert, 2009). Furthermore, compassionate behaviours may be improved in those who have experienced past difficulties, which some believe increases their prosocial attitudes, including compassion towards others who may also be facing difficulty (Vollhardt and Staub, 2011).
Additionally, Wenger (1998) proposes that ‘learning as experience’ (here compassion) is not found inside the pages of dictionaries, it is in the ‘experiences of everyday life’. This suggests that the sample group's experiences of compassion would be diverse. In fact, a midwifery cohort will always include students with diverse former life experiences, which may help them to consider the importance of compassion when providing care to service users. For all students, being taught about compassion is also an important consideration.
Formal teaching about compassion
Renegotiating the meaning of compassion and building on students' pre-course life experiences began with formal teaching about compassion during the taught module (Pearson, 2018). The two sub-themes were empathy and communication skills.
Empathy
Those recalling empathy from the module content explained how it had been useful to their understanding.
‘I think it developed my empathy a lot more because I was able to sort of say “well, why do you think she acts that way?” You know, it could be causing that behaviour’.
(=*2)
‘I don't think that my compassion has changed. I think that it's my level of empathy, so my ability to be empathetic and think about why that person is that way, or why they're acting that way.’
(=*3)
Communication skills
The importance of communication skills needed for being compassionate were acknowledged by students in all years. Studying about compassion had helped some students' understanding. One student said that learning about compassion heightened their awareness of the need for communication in compassion (Year 1; S10).
‘Always listen and be present with the woman.’
(Year 1: S1)
Given that this student had only been in practice for 6 weeks, they may have drawn upon their pre-course experiences to inform their thinking about compassion.
‘I was more aware of my bodily actions and what I was saying. It helped with communication skills.’
(Year 1; S1)
Non-verbal ideas around communication taught during the module were important. One student said the module content had: ‘made me stop, and think and listen before talking or acting’ (Year 1; S3).
Learning about and practising being compassionate in clinical practice
Role modelling
Interactions with mentors in practice had, according to some students, impacted their experiences of compassion. When some students told their mentors about the compassion module, some mentors thought it odd that students needed to be taught about the value. Students considered mentors who did not see value in learning about compassion as non-compassionate individuals. One student said some mentors did not think that students needed to be taught about compassion, which made her think ‘you need to go and do that module’ (=#2).
Therefore, practice experiences and mentors as role models had led students to think of ‘what to do’ and ‘what not to do’ regarding compassionate behaviours during their practice placements. Teaching students about the ideas associated with compassion (Pearson, 2018) prior to the practice placement seemingly supported their learning.
Others have also sought to illuminate the evidence that supports student learning when considering compassion (Younas and Maddigan, 2019). Drawing upon 29 literature sources, Younas and Maddigan's (2019) critical review intended to develop strategic policy direction to foster compassion in future nursing students and advance the pre-registration nursing curricula. Directions for the future nursing curriculum were threefold, including that nursing curricula should allocate teaching-learning strategies targeting learning in the affective domain, use reflection, including reflective thinking, in students to cultivate excellence in clinical practice and incorporate information that can be assessed to elicit students' understanding and expression throughout the nursing curriculum (Younas and Maddigan, 2019). All 29 reviewed sources were nursing focused, further illuminating that midwifery perspectives are largely absent from educational literature about compassion.
Barriers to compassion
All year groups described barriers in practice that served to impede compassion. There were differences across the three year groups, for example, a year one student commented in phase two that lack of compassion lay with the individual midwife (year 1; S21), a year two student's comments were about the hospital ward's pressures (year 2; S22) and a year three student considered that when compassion was lacking it was the institution's fault (year 3; S9).
Lack of compassion being down to an individual has some resonance with Clift and Steele's (2015) research. Their participants also suggested that personal characteristics, such as those who do not value compassion, can hinder compassion. Wenger (1998) suggests that individuals ‘hold the key to transformation… that has a real effect on people's lives’. To some extent, where compassion is concerned, the macro structures in healthcare may be more complex to change and control than individuals.
Year two students suggested that barriers to compassion existed at the ward level. For example, one student described a mentor had given care to a woman on the ward and observed that the interaction was, in her opinion, ‘lacking in compassion’ (=*3). Another stated that during an interaction with a woman, the mentor had ‘turned toward the computer’ (=*1). Students described that, for them, this showed a lack of compassion. Moreover, it would prevent a woman from feeling connected with and perhaps make her feel unable to confide in the midwife.
Regarding one student's comment that the ‘institution’ (year 3; S9) posed a barrier to compassion, Wenger's notion (1998) that a community of practice, like midwifery, develops in a larger institutional context with specific resources and constraints may be useful to consider. He goes on to suggest that the institution can ‘shape conditions outside the control of its members’ (Wenger, 1998). It is up to the community of practice to overcome barriers in the environment and to make it their ‘enterprise’ (Wenger, 1998). Therefore, compassion has to be important to all members of a community of practice, if the barriers preventing it are to be overcome, including individual, ward and institutional challenges (Royal College of Midwives, 2016). The challenges faced by maternity services are multi-factorial and these may in turn impact student learning in practice. During care delivery, short staffing levels and high numbers of women to care for lead to pressures on midwives' time, which is a requisite of giving compassionate care (Kirkham, 2015).
These concerns may have an impact on student learning, as they may often witness disillusioned, overworked midwives (Kirkham, 2015). Teaching those who are newly entering the midwifery profession about the importance of compassion has the potential to improve the individual, ward-level and institutional appreciation for compassionate care and kindness in the future.
Limitations
This is an original and much needed study that may benefit the midwifery community and beyond. However, there are limitations. The quantitative data were not subjected to any statistical tests. The aim was to show any reported difference to the sample group's understanding about compassion following the teaching and clinical practice placements. This may be considered a research limitation. The qualitative methodology has not resulted in a definitive truth; there are no right or wrong answers.
Conclusions
Compassion is an important value for midwifery care. However, there is little published research to support what form educating student midwives about compassion should take. This research has revealed that students begin their midwifery education with differing perspectives about compassion and this is dependent on their previous life experiences. Teaching students about ideas associated with compassion at the commencement of their midwifery education supports their learning and this is further consolidated in clinical practice. Therefore, formal teaching about compassion should take place at the commencement of students' midwifery education.
Key points
- There is very little published research about how we may teach student midwives about compassion.
- Student midwives' perspectives developed about compassion during their midwifery education and practice placements may help to inform the discourse around compassionate care.
- Formally teaching student midwives about compassion at the start of their midwifery education increases their understanding of the value.
- Formally learning about compassion supports students in being able to observe when the value is present or absent during the delivery of clinical midwifery care.
CPD reflective questions
- How might you define compassion in maternity care?
- How do you think that compassion is learned?
- How would you assess if a learner is providing compassionate care?
- As a role model to your student learners, what might you need to consider about compassion?