Constrained compassion: an ethnography exploring compassion in the hospital ward setting

Ethnography; Compassion; Compassionate care; Nursing A series of healthcare scandals over the last 15 years in the United Kingdom (UK) National Health Service (NHS) generated a vigorous public and professional debate. Within this debate, care failures were framed as a ‘lack of compassion’ and, specifically, a lack of compassion in contemporary nursing. The healthcare policy response was to rapidly implement a values-based strategy that aimed to ‘embed the principles of compassion and caring’ (DoH, 2014) in healthcare staff. The strategy progressed, despite evidence suggesting that healthcare professionals valued compassionate care (Maben et al., 2007b, Newton et al., 2009, Glazer and Beehr, 2002). Significant changes were made to nursing recruitment, regulation and education, with the explicit intention of prioritising compassion. The research response to the NHS care standards debate has also focused predominantly on the values of NHS staff, and has inadequately represented the contextual contingencies of practice. This study aimed to develop an empirically informed descriptive and explanatory understanding of compassion in a healthcare setting. The objectives were to examine the key elements of the phenomenon and how participants constructed and enacted compassion. The study was a constructionist ethnographic design set in one NHS hospital ward. Participants included various staff groups, patients and relatives. Fieldwork lasted one year and included over 150 hours of participant observation, 70 informal interviews and 30 recorded interviews. Analysis involved thick description of ward life, and thematic, key-event and deviant-case analysis. Theories of compassion, psychological research and a sociological perspective were employed as analytic lenses. Themes included contextualised compassion, compromised compassion, receiving compassion, and the role of threat and safety. I found compassion in the ward setting was constrained by a tangle of micro- and macro-level contingencies which shape the experience of giving, and receiving, compassionate care. The contingencies of the clinical context were frustrating to staff and patients and led to an inconsistent quality of care. All actors contributed to the dynamics of compassion on the ward. I found that staff valued compassion as an aspect of their care, and for some it was part of their identity and gave meaning to their work. Patients also valued compassionate care, felt comforted by it, and responded positively, which in turn was uplifting for staff. Unexpectedly, some patients struggled to recognise, trust or feel relieved from compassionate care. I found that a sense of threat dominated the ward culture, which was evident in the language and practices of staff, and could inhibit their capacity to engage compassionately with others. However, when the organisation provided positive practical support, compassionate care often flourished. This study contributes the notion of ‘constrained compassion’ as a descriptive and explanatory framework for understanding the phenomenon in the ward setting, and evidences that threat and safety, compromise and cost are inherent in its enactment. It demonstrates that theoretically-informed compassion research can be beneficial, and highlights the value of cross-disciplinary approaches to compassion scholarship. The study also demonstrates the strengths and limitations of process- and values-based theories of compassion and argues that conceptualising compassion as a context-dependent process can broaden the possibilities of future nursing research. In terms of policy, this study argues that healthcare strategies must take a broader, research-based approach. Furthermore, it recommends the urgent acknowledgement and investigation of the contextual barriers to care. Embedding positive, practical and pastoral staff support within organisations should be a priority. Rather than aiming for ‘compassionate staff,’ healthcare organisations may benefit from making multidisciplinary efforts towards developing compassionate healthcare environments