Can compassion be taught ? A medical students ' compassion discourse

Background: Universities of Brighton, Surrey and the Brighton and Sussex Medical School responded to a regional bid to provide compassion awareness training to the local health care workforce. An appreciative inquiry methodology was used to develop a toolkit which included a number of different activities focussed on the following pillars. Appreciate (best of what has been), imagine (what might be), determine (what should be) and finally create (what will be). One of the toolkit resources focussed on seeking and celebrating acts of compassion. Methods: Following a cultivating compassion workshop, a group of medical students in their third year decided to use this activity from the Compassion toolkit to observe acts of compassion occurring within their clinical setting and reflected on the impact this activity had on them. Results: Themes deduced from the 34 acts of compassion witnessed included; team compassion, patient-centred compassion, peer to peer compassion and patient to patient compassion. Students’ reflections about undertaking this activity were thematically analysed and emerging themes included self compassion, confidence about talking about compassion, changes in behaviour and finally how could compassion be taught at medical school. Conclusion: This study generated discussions on what was the difference between acts of compassion and normal human behaviour and the “hidden curriculum” of health professionals’ behaviour. Students realised the importance of compassion and yet the absence of that word within their own curriculum. This small pilot study made it possible to consider how compassion can be taught within the undergraduate curriculum, simply by empowering students to open their eyes and witness compassionate acts. The medical students were able to see compassionate behaviour that they wished to model and that would support them once qualified.


Introduction
Compassion is an essential component of healthcare and in recent years there has been a drive to increase compassion awareness 1 within healthcare workers as a consequence of serious omissions in compassionate care 2 .Data from the Leadership in Compassionate Care Programme 3 showed that training on compassion could impact on practice through developing leaders.In 2014 the Universities of Brighton, Surrey and Brighton and Sussex Medical School received a regional grant to provide compassion training to the local healthcare workforce 4 .The Cultivating Compassion Project developed a toolkit for use within the 'train the trainers' workshops, as evidence based toolkits 5 are known to be important factors in enabling peer-educators to facilitate learning.The design of the activities in the toolkit reflected the appreciative inquiry approach 6 with activities centred on the following pillars; appreciate (best of what has been), imagine (what might be), determine (what should be) and finally create (what will be).Within the toolkit there are many available resources/activities including compassion pledges, digital stories and quotes as shown in Box 1.
Box 1.The Toolkit 1) Compassion Indicators -A list of compassion indicators that can be used for generating discussion around compassion.These were generated by NHS staff.
2) Compassion Pledges -A way of demonstrating the value of compassion through individual or team commitments (pledges) to change something in practice.
3) Digital Stories -Short 3 minute digital stories that aim to stimulate discussion on compassionate care, based on true experiences.4) Group Activities -various activities including emotional touchstones (something that keeps you focused on what is important to you).5) Quotes -Quotes relating to compassion which can be pinned up on a notice board in a clinical area to stimulate discussion on compassion.6) Seek and Celebrate -To encourage healthcare professionals to seek out and celebrate the good compassionate practice in our everyday working lives.
Following a Cultivating Compassion workshop, two Year 3 medical students decided that they wished to use the "Seek and Celebrate" activity whilst on their clinical placements and asked five other students to join them in using this activity.The students did not record any patient or staff identifying information.

Study Design
Seven medical students were instructed to note any acts of compassion observed whilst going about their daily activities in their clinical placements.This included A&E, the acute medical unit, clinical wards, theatres and the outpatient department.Compassionate acts were not defined to the group.Students were asked to note down anything they saw that might constitute an act of compassion to them individually.They recorded what they had observed, who carried out the act of compassion, and to whom it was aimed at and how it made them feel as an observer.The acts were regularly uploaded onto a private "Whatsapp" group in which all students were a part of.All students could see each others witnessed acts of compassion and so discussion was generated.The data was collected over a three week period.Students were reminded of the need for confidentiality and not to include information that could lead to person identification.Additionally, the students were asked to formally reflect on their experience in taking part in the study and consider specific areas as noted below: How did witnessing the acts of compassion make them feel and impact on their practice?What were their views about teaching compassion in the work place or medical school environment?
The seven students were asked to give a written response via email about their experience of taking part in this pilot study and include responses to the above posed questions.

Data Collection
Qualitative analysis of the acts of compassion recorded via the Whatsapp platform and of the students' views to the above questions was undertaken by the researchers.This qualitative data was analysed using thematic analysis which is a rigorous inductive method of analysis which involves the systematic generation and refinement of categories to themes and sub-themes 7 .The process has the flexibility to validly represent patterns found in participants' accounts whilst facilitating a reflexive awareness of the researchers own biases and assumptions.Emerging themes were then sought and agreed upon by the authors.
Ethical approval had been gained for the Cultivating Compassion Project that included the use of the toolkit and its dissemination within clinical settings (ID FREGC-14-026.R1).

Results
Overall, 34 acts of compassion were witnessed in the various clinical settings.Four major themes emerged from the data, team compassion, patient-centred compassion, peer compassion and patient to patient compassion.

Team compassion
As might be expected, in an environment where teamwork has a key role, team compassion was the most popular theme under which 14 acts of compassion were recorded.The acts of compassion were not only witnessed within a particular profession, for example, nurses showing compassion to other nurses, but also across professions (the multi-disciplinary team) for example nurses showing compassion to doctors and hospital volunteers.
"I over-heard a conversation between two nurses where one offered to cancel her holiday leave so that the other could have the time off instead" (Respiratory ward) "A nurse sister noticed that a young volunteer was upset by a patient's plight and allowed her some time to go and sit down and offered to talk" "A doctor bought in biscuits to have in the office for all to share.""A consultant noticed a member of the team was in pain from standing for a long time on a ward round and grabbed a chair to let them sit down."

Patient-centred compassion
It was surprising that only a total of 9 acts of compassion were recorded under this theme but this could have reflected the difficulty that students had in deciding what qualified as an act of compassion rather than expected clinical practice.
"A nurse brought in a book for a patient from home.She had been talking to him about the author the day before."(Cardiology medical ward) "I witnessed a medical student help get a patient comfortable in bed.The patient was grateful and looked much more comfortable."(A&E) "A Consultant Anaesthetist saw that a patient had split their drink on the table.He went out of his way to find a cloth and tidied it up for them."(Cardiac Surgical Ward)

Peer compassion
Very few medical students recorded acts of compassion seen between themselves, in fact only 2 acts of peer compassion were recorded.This may have been because students are not compassionate with themselves or because they felt that the recording of this behaviour was not part of the study.
"A student kindly swapped her surgery session for mine, despite having to re-organise her timetable.I really appreciated this." (Vascular ward) "One medical student helped another when they felt faint in the theatre room.She helped her to the ground safely and then got a creme egg and a cup of water."

Patient to patient compassion
As the students were observing compassionate care within their clinical placement it was noted that care extended between patients.This was a surprising findings as it is unusual to consider patients as care givers within a hospital.A total of 3 acts of compassion were recorded under this theme.
"After I clerked a patient this morning, the lady in the bed beside her started crying and thought she was going to be taken away to court (she has dementia).The patient who I had clerked went up to her and started chatting to her and reassuring her and spent time with her.The patient calmed down and appeared less distressed" "I saw a patient go and get a cup of water for another elderly patient attending the same clinic.The 90yr old patient appreciated this kind gesture as it had been a long afternoon of waiting" (Haematuria Clinic) Impact of observing the acts of compassion on the students.The students recognised that self-compassion is extremely important and that students, like other healthcare professionals, need to take care of themselves as well as the patients in order to avoid burnout. 8For some of the students, being part of this study acted as a coping mechanism, relieving stress and strengthening resilience.Students commented on the kindness seen between team members and this made them feel less anxious about their first qualified post.
"I felt really happy, and it cheered me up.Watching the act of compassion was probably nearly as good as personally receiving it" P6 "witnessing the acts of compassion made me feel good and I would have a more positive outlook to the day" P3 "I think it has changed my opinion of working relationships and I do understand the NHS working as a team a lot more now" P5 Confidence in talking about compassionate care in their placements: Having taken part in the study, the students felt that seeking and observing acts of compassion made them feel more confident in themselves.The students' confidence to discuss compassion with their peers increased throughout the study period.
"I appreciate the small things and I have the confidence to tell the person carrying out the act of compassion what I think -'that was a really lovely thing you did for that person" P6 "Since the study I have definitely felt able to express my feelings more when on the wards" P5 Changing behaviour: Through observing compassionate acts, the students were positively influenced and this prompted a change in their practice.The students became more aware of compassionate care and furthermore this made them become more compassionate whilst on their placements.
"I am also enthused to be more compassionate whilst in the healthcare environment" P6 "Witnessing these acts also made me think actively about my own behaviour and the little things that I can bring to my work/study environment that will make a positive difference to my colleagues on a daily basis" P2 "during the time we were looking for the acts I was more conscious about my behaviour towards colleagues and patients" P1

Teaching compassion:
The students reflected on the positive aspects of taking part in the study.They suggested that their fellow students would also benefit from exercises in cultivating compassion.This led to discussion and ideas of how compassion can be taught within the medical school environment.
"I think there is a huge benefit to be made by highlighting compassion early in medical school training, before students hit the wards.I like the 'reflection' style when witnessing encounters."P5 "perhaps students could write down little acts of compassion in a log book" P3 "an awareness of its importance and place in healthcare would make me more likely to put into practice "P4

Discussion
This study is particularly interesting because the idea of encouraging medical students to actively seek out acts of compassion during their clinical placements is novel.The acts of compassion witnessed during this three week study fell under four themes; team compassion, patient-centred compassion, peer compassion and patient to patient compassion.Much discussion was generated between the medical students after having shared their individual witnessed acts of compassion.After having completed the three-week observational study, the medical students discussed the difficulty between deciding what were acts of compassion and what was 'normal behaviour'.They also started to see the "hidden curriculum" of health professionals' behaviour in the workforce, realising the importance of compassion and yet the absence of that word within their own curriculum.Students felt confident to thank individuals undertaking compassionate care and even to challenge when there was not compassionate care.Acknowledging compassionate care in this manner was a positive effect and encouraged those students to perform more compassionate behaviour. 9 Compassion can be defined as the feeling that occurs when you are subjected to another's suffering and feel motivated to relieve that suffering.Not only has compassion been described to relieve suffering in the present but it has also been referred to as 'a source of renewable energy' that sustains both the giver and the receiver and is a source of healing.The students in this study believed that determining an act of compassion was unique to the person witnessing it.The specific situation at hand, the people involved and the emotive responses stirred up in each person involved were key factors in making a decision between whether an act was compassionate or simply 'normal human behaviour' i.e. something you would expect of a person in that situation.Students agreed that they expected healthcare professionals to have a natural, subconscious ability to show compassion towards others due to the nature of their career choice and this may have influenced their observations.Furthermore, students recognised that the healthcare hierarchy and job roles also played a part in the decision making process.For example, a care assistant helping to brush a patients hair is normal behaviour, however if a doctor was witnessed doing this, it would be noted as an act of compassion, as it was thought to be beyond their call of duty.Students also recognised that when they felt like 'part of the team' and team spirit and morale were high, showing compassion towards each other and towards patients was much more common.This concept has already been acknowledged in the literature, stating that a supportive environment is essential to fostering kindness and compassion in the workplace.Additionally, showing compassion can have the potential to rekindle any 'lost passion' for a healthcare profession.Carrying out a simple act of compassion in a healthcare setting can be the most satisfying thing one can do in a week's work.The exceptional feeling of happiness triggered by showing compassion can put work-caused stress, worry and tiredness into perspective.Although those working in the healthcare system are educated professionals, they are first and foremost human-beings capable of showing compassion.Looking for opportunities to perform an unexpected act of compassion can help one to cope and simultaneously also help others around them to cope as well.
As consequence of this study, students felt that compassion awareness should and could be introduced as a compulsory element of the medical school curriculum both as a therapeutic tool for supporting students in the clinical environment and to improve the quality of patient care.They thought that it could be used to prevent burnt out and develop resilience within students.They noted that teaching compassion within a lecture format was difficult and thought that it could be as simple as asking students to record acts of compassion seen on their placements within their clinical log books combined with reflection on how these acts had made them feel.Students believed this teaching intervention should be introduced from their first clinical encounter developing students into more compassionate doctors.
It is important to recognise the limitation of this pilot study due to small numbers of students involved.

Conclusion
This small pilot study made it possible to consider how compassion can be taught within the medical undergraduate curriculum, simply by empowering students to open their eyes and witness compassionate acts that are occurring daily.The medical students were able to see behaviour that they wished to model and that the act of seeing and recording these behaviours made them feel part of a community of practice that would support them as junior doctors.This pilot study is being rolled out to include other health care students such as physiotherapists, occupational therapists and nursing students.

Take Home Messages
A simple activity such as recording acts of compassion seen with the clinical placement can have a profound effect on compassionate behaviour.Using examples within clinical context can be more powerful than teaching compassion within didatic sessions within the undergraduate curriculum.Open your students' eyes.

Notes On Contributors
Victoria Cathie and Katie Whan: Year 3 medical students who attended the cultivating compassion workshop and implemented the toolkit activity 'Seek and Celebrate' activity with their clinical placements.Set up the whatsapp platform and recruited five other year 3 medical students to use the toolkit activity.They both collated the findings of the experience with the other 5 students.Together with the other authors qualitatively analysed the data and helped with the writing of this manuscript.Victoria Cathie is now a newly qualified Foundation doctor from Brighton and Sussex Medical School and Katie Whan is in her 4th Year at medical school having undertaken an Intercalated Degree.