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Introduction

Sound leadership is an essential component in ensuring compassionate nursing behaviours.

Paulson (2004), Sabo (2006) and Sanghavi (2006) conceptualise compassion as a way in which people relate to each other, not necessarily what people do for each other, but what they choose to do together implying a sense of reciprocity and interdependence. It is challenging to measure which aspects of care comprise compassion as the nature of the caring work is often invisible. When less tangible aspects of care get missed, patient care suffers (Commissioning Board Chief Nursing Officer, 2012). When compassion is present, patient care improves (Allan et al, 2015).

Understanding the concept of compassion has significant implications for its recognition, promotion and assessment in practice. Compassion has been defined as ‘a deep awareness of the suffering of another coupled with a wish to relieve it’ (Chochinov, 2007, p.184) and ‘a deep feeling of connectedness with the experience of human suffering that evokes a moral response to the recognised suffering resulting in caring that brings comfort to the sufferer’

(Peters, 2006, p.39). Dewar (2013) views compassion as a response to vulnerability in others. In a community setting where many elderly, vulnerable people receive nursing care, it is clear that enormous damage can occur when compassion is not present. The Francis

(2013) and Keogh (2013) Reports suggest that to be able to sustain the future, NHS organisations must have the right leadership not only to deliver compassionate and quality care for patients but to also remain financially viable. Francis (2013) recommendations

(numbers 195-198) identify the importance for nurse compassionate leadership training to be delivered at every level from nursing student to director with a vision of having every clinical staff with a degree of leadership ability throughout the NHS. The Kings Fund (2011), a report on the future of leadership and management in the NHS, also supports this by linking quality of leadership to quality of healthcare organisations. However, leadership training has been taught in various ways over many years and there is scepticism whether leadership training on its own is enough to sustain compassionate care on a day-to-day basis. Since

1 organisations rely upon their leaders to provide clear direction to their staff, it is important to gain a sense of how compassionate leadership is perceived. The study presented here sought the views of community health care organisation leaders within one NHS Trust to inform future service development.

Literature review

The need for compassionate leadership

De Zulueta’s (2016) integrative review of compassionate leadership identifies the need to model and harness positive adaptive responses to challenges that threaten quality care. De

Zulueta suggests that authentic or transformational leadership styles are compatible with compassionate leadership. Arguably, the transactional leadership model is potentially incompatible with delivering compassionate care because barriers like bureaucracy and burnout reduce compassion (De Zulueta, 2016). The Francis Report (2013), the Keogh

Report (2013), the Cavendish (2013) and Berwick Reviews (2013) highlighted multiple factors that led to health and social care workers and managers to lose compassion.

Examples include staff being so institutionalised that poor care did not register; others were frightened to raise concerns in case of reprisals. Improved support for compassionate caring, committed care and stronger healthcare compassionate leadership has been advocated by

NHS England (2014). The Department of Health (2014), Health Education England and

Public Health England, Trust Development Authority, Care Quality Commission (CQC),

Monitor and the Nursing Midwifery Council are committed to delivering the strategy. In 2012, core values in the form of the 6Cs – Care, Compassion, Competence, Communication,

Courage and Commitment – were introduced (Commissioning Board Chief Nursing Officer,

2012). These values are being embedded across healthcare as relevant to all health and social care workers to allow an approach to care that is motivated by compassion.

Strengthening compassionate leadership will enable the delivery of compassionate care and contribute to creating the right environment to patients, carers, staff and colleagues ensuring

2 high quality care and a positive patient experience for patients and staff (Commissioning

Board Chief Nursing Officer, 2012). Compassionate leadership is multi-faceted requiring different interventions to target different levels of the organisation by stopping compassion- killers and encouraging practices to help reconnect with values and behaviours of compassionate care. Embedding compassionate leadership requires engagement across organisations (Cummings and Bennett, 2012). Genuine leadership can be developed by involving staff and patients (Dewar and Nolan, 2013). Reflective, proactive managers can shape the cultural climate in which compassionate relationship-centred care can flourish

(Leicester, 2009; The Kings Fund, 2013). Delivery of compassionate care requires a compassionate environment, where staff attend to their own emotional health and the wellbeing of the team (Goodrich, 2012).

Emotionally intelligent leaders help to promote compassionate relationships between peers and build resilience among staff by allowing staff to process emotional and physical challenges encountered at their work (Dewar, 2013). Several strategies are evolving to support hospital-based leaders in this venture (Kings Fund, 2013; NHS England, 2014).

However, there is a gap in knowledge around community settings (NHS England, 2016) which this study was designed to help address. The aim of this study, completed for an MA

Practice Education, was to understand how leaders (senior staff) within one Community

NHS Trust perceive compassionate leadership and its importance in the community.

Methodology

Smith, Flowers and Larkin’s (2010) interpretative phenomenological analysis was employed to explore the perceptions of compassionate leadership within a community setting. The researcher was already a member of the organisation so had access to the organisation leaders.

3 Participants (n = 11) had compassionate leadership as a key aspect of their job role.

Purposive sampling was used and after the initial participants’ were recruited the researcher introduced a snowballing approach whereby those already recruited assisted the researcher in finding further participants’ who meet the selection criteria. Information about the study was given to potential participants by email or in person. Participants included the Chief

Nurse, Deputy Chief Nurse and Compassion-in-Care Lead.

Semi-structured face-to-face interviews with a semi-structured interview schedule were conducted and transcribed. A pilot interview was conducted with one of the leaders in the organisation prior to the main interviews. Participants were asked (1) What is your understanding of compassionate leadership? (2) Why is compassionate leadership important

(in the community setting)? These questions were sent to participants prior to the interview to allow more thoughtful responses and enable good discussions. Interviews lasted between

30-50 minutes. The basic form of IPA analysis following a series of steps as recommended by Smith et al. (2010, pp.83-84) for new or novice IPA researchers was employed. Repeated engagement with transcripts and audio files allowed deepening understanding of participants’ lived experiences of compassionate leadership thereby ensuring that anything that mattered to the participant was captured and understood. Two main themes were identified. For quality assurance, transcripts were emailed to individual participants to ensure that their views were not misrepresented. The dissertation supervisor, an experienced researcher, analysed two transcripts for comparison.

Ethical approval was obtained for the study from the School of Health and Social Care Ethics

Committee at London South Bank University. Also, the Research and Development department at the community NHS Trust within which the lead researcher is employed authorised the study. Written consent was taken prior to commencing interviews which all took place on Trust premises. Participants’ were assured of their anonymity. If bad practices, concerns about the safety of others or criminal activity had been identified, these would have been acted upon. Participants’ were given the option to opt out at any point.

4 Findings

Two major themes emerged: Leading with the head and heart; and Being treated but not cared for. The findings are presented with illustrative participant quotes.

Leading with the head and the heart

All participants (P1-P11) perceived that compassionate leadership is about leading with the head and the heart, so it’s about having a balance of leading with kindness (being ‘pink and fluffy’ – P10) but also with honesty, consistency and courage to challenge behaviours which are not compassionate towards patients.

‘…my understanding of compassionate leadership is a leader who

demonstrates care and compassion and role modelling in their leadership

style, so it's somebody that leads with their head and their heart.’ (P4)

Table 1 provides an overview of the leadership styles identifiable from each participant’s interview and why they consider compassionate leadership important in the community setting.

One participant referred to a novel concept of ‘gritty compassion’:

‘…as a leader you have to be able to demonstrate that you have a leadership

style that’s in touch with reality and that you care even though you have to be

courageous in your leadership styles so I call compassionate leadership,

‘gritty compassion’. So sometimes a compassionate style of leadership is not

always the kind, caring, fluffy leadership style, it’s one that’s honest and

courageous in their conversation and treats people very much throughout the

organisation they would want to be treated themselves.’ (P4)

Another stated:

5 ‘…I see compassionate leadership as a really solid, strong way of leading…

it’s more about people and working with them as opposed to what to do to

them.’ (P10)

Participants’ also felt that compassionate leadership is values driven, seeing people as human being and if they are treated in this manner then they will reciprocate these behaviours and treat patients in a similar way.

…It is very values-driven, it’s very kind, caring, communicates appropriately,

openly but in a very honest style. (P4)

…compassionate leadership is about leading people in a transformational

way, which values them as human beings, values what they do, and supports

them to move forward. If you treat people with respect and compassion, then

they will treat patients with respect and compassion.’ (P10)

Participants’ identified that for compassionate leadership to work it needs to involve the ability of the leader to consider the needs of the organisation, the team and themselves (Co-

Pasion) to align into a meaningful relationship working towards a common goal.

‘…it’s the ability of the leader to position himself or herself in any team

situation where they are taking the needs and passions and ideas and values

of the organisation into account, and the needs, passions, ideas and agendas

of the team into account and somehow able to bridge those two agendas.’

(P6)

…is achieved in a way that it is in the best interest of everybody, the patient,

the staff and the organisation and I think that’s by being a collective. (P2)

Participants’ also identified the general traits a compassionate leader as identified below

6 ‘…the behaviours required for compassionate leadership are those that are

consistent…if you are never sure what mood your boss is going to be in, that

makes you very insecure, insecurity leads to mistakes and leads to [a] poor

functioning organisation.’ (P11)

‘…emotional literacy is a key part and I think compassion comes from

emotional literacy, so if you are aware of yourself, and the impact that you

have on others and are aware of others and their needs, it is easier to be

compassionate.’ (P7)

Role modelling and leading by example was an important aspect of compassionate leadership

…role modelling, that’s the only way that will happen…if you want an

organisation to adopt compassionate leadership you need a set of leaders

who are all willing to sign up to the tenets of compassionate leadership.’ (P7)

Being treated but not cared for

There was also a common theme with participants’ in terms of thinking beyond the procedures of treating people like commodities to be transacted but to lead with emotions and feelings to those around us whilst not losing sight of those we are caring for.

‘…very simply I would define it as the difference in someone feeling treated

and cared for and I think that those same principles, that when we talk about

compassionate leadership, about the way that we as leaders communicate,

interact, respond, treat our staff as well.’ (P5)

‘…I had this massive heart attack and I said to the cardiologist, is there any

way I can have somebody to help me manage my emotional reaction to this,

[be]cause I was scared, depressed and anxious and I didn’t know if I would

7 ever work again and he said that's not a cardiologist job. And I thought that

was just the most uncompassionate response.’ (P8)

Participants’ also identified that by focussing on leadership that looked at productivity rather than care desensitised care givers.

‘…majority of people who come into healthcare come in because of an innate,

inherent wish to care for others, truly caring for somebody not just treating

them. I think that sometimes that is almost knocked out of people during their

professional career, because of culture, the climate, the expectations that are

set, and so their behaviours change.’ (P5)

‘…I think you can lose compassion from three angles, one is just being

overloaded, the other one is secondary traumatisation, feeling your patient

group too much and the third is deciding to move on.’ (P6)

However others stated that some people just have no compassion.

‘…I think there are people in the world without compassion...some people just

seem to have a natural ability to show compassion, some people just seem to

struggle.’ (P6)

…I can identify a very small number of people that I’ve worked with and

managed, that I don’t believe have the ability to work with compassion, it's

just not there, and I don’t believe any amount of role modelling, education,

development, reflective practice for a very small minority of people has any

impact on their ability to work with compassion. (P5).

Participants’ also highlighted command and control approaches used by executive leadership and political influences that impacts on compassionate leadership and how these influences can filter to the frontline staff and ultimately affecting the basic care needs for patients.

8 ‘…if you are joyful and happy at your place of work it is much easier to be

compassionate than if you are stressed and angry.’ (P8)

‘…we have got some individuals…that will clearly role model compassionate

care but …we have some that are not, or using that tokenism.’ (P1)

‘…I do not feel our current government are particularly compassionate in their

policies or their procedures and I think that filters down into public services,

so at my level we have to try even harder to make sure that we are

compassionate leaders even though we are not getting that from up above.’

(P10)

Discussion

The findings of this research showed a high consistency of participants’ understanding that a compassionate leader should lead with their head and their heart, thus recognising that both cognitive and affective domains need to be engaged (Mascaro et al, 2015). Participants explained this by describing the characteristics of what that leader should demonstrate in their everyday practice. Paying attention to the small but significant ways in which we treat each other with kindness and as human beings is where compassionate leadership was most effective. This notion is supported by Bramley and Matiti, (2014) and Perry (2009).

However, Dewar (2013) stated that these characteristics can be difficult to quantify and measure. Although the term ‘compassion’ and its characteristics are deemed to be essential and underpin the healthcare profession, its application in a measurable manner is still unclear on how it will work under the current target-driven NHS. This might be the reason the concept of ‘Gritty compassion’ emerged as a leadership style in the interviews. This implies putting conditions upon when compassion should be shown. While moving away from the command and control towards shared goals and vision approaches (Avolio and Luthans,

2006), a ‘gritty’ leader is said to be one who is vision driven, passionate, down to earth, resilient and a doer who creates success across multiple bottom lines (Stoltz, 2015). Meeting

9 targets may be prioritised over time for kindness. Such heroic leadership styles can lead to staff burn-out if sustained for a long time (Stolz, 2015) because allowing people to show distress and anxiety becomes seen as culturally unacceptable.

The Five Year Forward View (NHS England, 2014) which aims to eradicate a £30bn deficit by 2020-2021 is placing NHS leaders and staff under great pressure. The turnover of Trust

Chief Executives (CEO) across the NHS is unsettling. 7% of all CEO positions were reported as unfilled; increasing to 17% for trust in special measure and the average tenure was 700 days. This paints a picture of frequent arrivals and departures of ‘heroic leaders’ resulting in unsettled teams and initiative fatigue (The Kings Fund, 2014). Participants reported a general NHS culture of hard-nosed chief executives implementing tough decisions in a less compassionate manner to achieve targets leaving the workforce fatigued and demotivated who then filter similar behaviours to patients. This culture might in turn affect understandings of compassionate leadership such that a ‘gritty’ version develops. Leaders whose primary focus is upon delivering success across multiple ‘bottom lines’ or healthcare metrics, are now required to also lead for compassion. Consequently, in the mind of heroic leaders, compassion could be reduced to ‘another’ target which, arguably, may be traded against other metrics for success. A ‘slippery slope’ might result whereby the placing of restrictions upon compassion lead to loss of compassion.

Dewar and Christley (2013) identified that when healthcare workers struggle to cope with the work environment this creates disconnect between their desire to provide high-quality compassionate care and their ability to meet this demand. Participants’ indicated that compassion is compromised when money is tight especially when leaders have other competing priorities. Dixon-Woods et al (2014) reported that NHS staff often feel overwhelmed by tasks and unclear about the constantly changing priorities which results in stress, inefficiency and poor quality care. When organisations focus on productivity using command and control leadership styles to drive target-driven culture this leads to limited success (Ham, 2014). It requires a strong compassionate leader to re-focus and establish

10 clear, aligned and challenging objectives are embedded across all levels of the organisation in order to deliver high quality care (West, 2013).

Primary care is particularly vulnerable to care being given with a task-oriented, not compassionate, focus. Edwards (2014) stated that the Transforming Community Service

Programme launched in 2008 did no such thing and community services have been left neglected and poorly understood with loss of direction. Equally, the Our health, Our care,

Our say programme with the aim of bringing care closer to home was a damp squib according to Edwards (2014) resulting in community services being a dumping ground of the growing and aging population receiving more rhetorical support rather than actual support.

Given the challenges of providing effective community services, it is commendable how the participants in this study were all passionate advocates for developing a compassionate workforce.

Participants saw reflection as key to developing emotional literacy which is a major factor of establishing compassion. This process of being able to attune to your feelings and experience and those of others through openness and connectivity has previously been described (Dewar, 2013). Gilbert (2013) also suggests that the capacity for humans to demonstrate compassion is multi-faceted which includes emotional awareness to see when others need help which then drives how you emotionally respond, connect and act on behalf of the other person. For staff to be attentive, feel empathy and take emotional intelligent action for patients, they need a positive atmosphere, support and resources to deliver high- quality care (West et al, 2014). This explains why role-modelling compassionate behaviours was championed by participants. The organisation where this study took place has appointed a Compassion in Care Co-coordinator who is utilising appreciative enquiry (Wyn

Roberts and Machon, 2015) and the 6Cs by focussing on improving patient care through shared leadership with frontline staff. However, for these initiatives to be sustained, participants’ indicated the need for the support of executive leaders. If staff do not feel engaged and supported they can burn out. Healthcare providers who are exposed to

11 prolonged, continuous, and intense contact with patients and families undergoing pain and suffering can lead to them having compassion fatigue and become desensitised (Coetzee and Klopper, 2009; Stamm, 2010). Compassion fatigue leads to diminished caring relationships with patients or family members (Coetzee and Klopper, 2009). In community settings where lone working is the norm across multiple locations, participants indicated that the critical eye of spotting poor care is lacking so leaders need to be mindful and continually motivate community staff. Team working in the community was seen as an important factor by participants for supporting staff and having compassionate leaders to ensure that staff wellbeing is being upheld and patients and families feel cared for, not merely ‘treated’.

Limitations

The type of sampling used could be argued to be non-representative by some researchers but, since the aim of the research was to explore a phenomenon of interest (Saunders et al,

2009) it was appropriate. Parahoo (2006) suggests that one advantage is that the researcher can decide not to interview anymore once a saturation point has been reached.

Only one community organisation was involved so the eleven participants cannot be seen as representative of all organisation leaders but data saturation appeared to have been achieved.

Conclusion

This study provides evidence that leading and caring with compassion is particularly important within the community setting where many staff are lone workers visiting people’s homes alone. Community organisations should commit to training of compassionate leaders who lead with their heads and their hearts and ensure that patients, clients and families feel cared for not merely treated. Participants’ identified role modelling; reflection, action learning, mindfulness, emotional intelligence and compassionate in care projects as useful education strategies. Ways to measure the impact of compassionate leadership within community settings need developing to support future educational developments relating to

12 compassionate caring. Sadly, participants in this study identified that some individuals lack compassion and no amount of support or education of promoting compassion will ever make a difference (Gilbert, 2013). Further research is necessary to identify how to address this phenomenon either through improved compassionate leadership or through employee selection processes.

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