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2014, Vol. 18, No. 1 45
Dorothy J. Dunn, PhD, RNP, FNP-BC, AHN-BC
Northern Arizona University
Dawn Rivas MS, RN
Northern Arizona University
Keywords: theory of compassion energy, compassion satisfaction, caring, caregiving
Introduction Rogers (1970) described nursing as a humanistic science dedicated to compassionate concern for maintaining and promoting health, preventing illness, and caring for and rehabilitating the sick and disabled (p. vii). Nurses confronted with high intellectual, emotional, and physical demands are at risk for physical complaints, compassion fatigue, and burnout (van den Tooren & de Jonge, 2008). Yet nurses desire to care with compassion. Lavinia Dock, Lillian Wald, and Annie Goodrich considered compassion not only as the essence of nursing, but as an inherent quality a nurse should possess (Hamilton, 1994). Prior investigations convey that nurses experience time pressure as they attempt to provide compassionate care. Compassion is believed to be a nursing quality that impacts patient care, and studies indicate
that nurses do not have the time to provide compassionate care they desire to provide (Abendroth & Flannery, 2006; Cowin & Hengstberger-Sims, 2005; Sabo, 2006). Nursing is more demanding and multifaceted than it has ever been. The demand on nursing continues to increase due to patient acuity, changes in reimbursement, access to care, and technology (Christmas, 2008). Research to describe compassion among nurses is challenging and there is minimal literature linking compassion and nursing.
Literature Review Compassionate caring is identified as nursing’s most precious asset while nursing research and discourse regarding compassion is scarce. Compassion is described in nursing scholarship yet not widely promoted in the context of everyday nursing. In everyday practice, it is necessary to identify, understand, and internalize the meaning of compassion. The next step
would be to “exercise compassion in nursing practice every day” (Shantz, 2007, p. 54). Compassion can be understood from a number of different perspectives. This distinctive affective state arises from witnessing another’s suffering which then motivates a subsequent desire to help. The Buddhist approach focuses on intentional sensitivity to suffering and commitment to relieve it. In the Buddhist traditions, intentionality and motivation are central and compassion is not seen as an emotion. Buddhist traditions colocate compassion with motivational constructs such as lovingkindness, sympathetic joy, and equanimity. In the conceptualization of compassion, it can be understood as an attention and intention toward alleviating interpersonal distress (HHDL, 2001). Gilbert (2010) conceptualizes compassion in evolutionary terms, focusing on the interplay between threat, motivational, and soothing systems. In this definition of compassion, there is a capacity to cooperate and engage in kinship caring with the formation of attachment. Therefore, compassion is understood as an evolved motivational system designed to regulate negative affect through attuning to the feelings of self and others, thereby expressing and communicating feelings of warmth and safeness. Lundberg and Boonprasabhai’s (2001) ethnographic study defined compassion as giving care from the heart, valuing people, respect, trust, and loving concern. Experiencing compassion, the nurse seeks to know and understand interconnectedness to others in order to alleviate suffering and celebrate joy (Fox, 1979; Roach, 2002). Roach (2002) defined compassion as a way of living born out of an awareness of one’s relationship to all living creatures.
Abstract Compassion in caregiving is a quality which nurses are expected to possess. Little is known in the professional literature that addresses the essences of compassion as experienced by nurses. The purpose of this study was to explore the meaning of compassion in nursing practice. In this exploratory, qualitative secondary analysis study, grounded in hermeneutic phenomenology, textual data were obtained from an original study that revealed that intentional compassion energy (ICE) is what keeps nurses in nursing. This research study examined the archival data and de-identified anonymous text to understand the experience of compassion in nursing practice, and describes the usefulness, experience, and meaning of compassion in nursing practice through the lens of the theory of compassion energy. The findings revealed the emotional connection of caring for another who is suffering with the intention to care compassionately as the grounding of nursing practice. Compassion becomes the energy for caring and supports the relational process in connection between the nurse (caregiver) and patient (care recipient). The overall meaning of how nurses experience compassion was interpreted from 3 relational themes: Compassion as Emotion, Transforming the Compassion Occasion, and Connecting with Grace.
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Compassion involves a simple, unpretentious presence with the other. Kornfield (2002) described compassion as arising naturally with the ability to discover the capacity to bear witness to, suffer with, and hold dear the sorrow and beauties of the world (p. 103). Compassion is a sense of shared suffering, most often combined with the desire to alleviate such suffering. Nowen (1983) informed us that compassion means to suffer with and involves us in going where it hurts, to be weak with the weak, vulnerable with the vulnerable, powerless with the powerless, in that we can be fully immersed in the condition of being human. Suffering seems to call forth a natural human tendency to distance one’s self from exposure to vulnerability (Johnston, 2007). A nurse’s lack of presence may result in an inability to share suffering or demonstrate compassion and may indicate avoidance behavior. Compassionate acts are generally considered those which take into account the suffering of others and attempt to alleviate the suffering as if it were one’s own. In this sense, compassion differs from other forms of helpful or humane behavior in that its focus is primarily on the alleviation of suffering. Acts of kindness which seek primarily to confirm compassion rather than identify existing suffering are classified as acts of altruism, being defined as the type of behavior which seeks to benefit others by reducing their suffering. Caring, sympathy, and empathy are found generously within nursing literature, implying that these words are being used interchangeably with compassion. Sympathy is the ability to feel for the other. Our mirror neurons enable us to feel by watching another’s experience. Empathy is the ability to imagine, share, and understand feelings of the other, while pity connotes condescension, implying separateness by feeling sorry for another (Fox, 1979). Compassion is a rich energy source that gives the caregiver strength from a shared weakness or shared joy (Dunn, 2012).
Theoretical Framework When caregivers such as nurses engage with another from a place of compassion, the caring occasion becomes energized and focused on meeting the needs of the care recipient which in turn energizes the nurse (caregiver) and patient (care recipient). The dynamism associated with this dyadic encounter is linked with positive outcomes for both the nurse and the patient. Compassion energy is conceptualized as the intention, uniqueness, and patterning of individuals as well as the transformation of compassion, promoting health and well- being through positive mutual change. The process of creating a useful conceptual meaning is a way of creating meaning rather than assigning a definition. The theory of compassion energy was developed through a caring concept clarification synthesis process. Among this process, theoretical ideas, direct observation, and personal experience were studied in order to build a conceptual framework called compassion energy. The theory of compassion energy was explored through a caring concept clarification synthesis process within the theories of Boykin and Schoenhofer’s Nursing As Caring and Rogers’ Science of Unitary Human Beings (SUHB). The theory of nursing as caring describes that the person knowingly participates in nurturing relationships with caring others in the moment (Boykin & Schoenhofer, 2001). Caring is a quality of participating knowingly in human-environment field patterning (Smith, 1999). Rogers SUHB describes human beings as unitary or irreducible, in mutual process with an environment that is coextensive with the universe, participating knowingly in patterning, and ever-evolving through expanding consciousness (Rogers, 1970). The three attributes that developed from this process and make up the theory of compassion energy are compassionate presence, patterned nurturance, and intentionally knowing the other and self (Dunn, 2009). The compassionate nurse seeks to know and understand their
interconnectedness with the patient, and in this moment of mutuality, the nurse is able to desire to alleviate suffering or celebrate joy. When the nurse answers the call from the patient with compassion and with the intent to alleviate suffering or celebrate joy, a mutual processing of energy occurs. This energy transforms the nurse and patient to a higher level of consciousness (Dunn, 2009; Rogers, 1970). Therefore, the theory of compassion energy is the regeneration of the nurse’s capacity to foster interconnectedness when the nurse activates the intention to care for another. Rogers (1970) asserts that when one person interacts with another there is an integration of energy fields, both the nurse and patient become the other’s environment. Nurses caring for the patient experience this energy and their compassionate caring patterning are enhanced. Nurses initiate the experience of compassion energy when they answer the call of another with the intent to alleviate suffering or celebrate joy. Energy is exchanged via compassionate presence thereby compassion becomes the energy for caring.
Method In this exploratory qualitative secondary analysis grounded in hermeneutic phenomenology, textual data were obtained from an original study about what keeps nurses in nursing. The original study was administered in 2009 to eight registered nurse participants. Four relational themes were interpreted, practicing from inner core beliefs, understanding the other from within, making a difference, and nursing as an evolving process. The synthesis of these four relational themes described a constitutive pattern, intentional compassion energy. The relational theme, understanding the other from within, was further synthesized as compassion. The compassion data were the source for this secondary analysis. This secondary analysis allowed content which was not fully addressed in the original study and allowed for the extension of the theme compassion. The data were examined using
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Transforming the Compassion Occasion The researchers interpreted transforming the compassion occasion as the opportunity to provide space and time for a caring presence. Spending the time, to be there, to be present, is about noticing what is going on with the patient during the compassion occasion: It’s painful for us too, we don’t like to see somebody suffer like that, you feel very helpless. All the bronchodilators, all the respiratory treatments will not help a patient the way your presence will. Transforming the compassion occasion as it changes overtime was interpreted as the compassion occasion.
Connecting with Grace The researchers interpreted connecting with grace as connecting with lovingkindness, dignity, giving, presence, and relationship: I think that recognizing that grace in people is really critical because it is the part of where you meet the person. I don’t know how else to express it. It’s just being in touch with them. Connecting with grace is the theme that was described and interpreted as compassion. The overall meaning of the experience of compassion in nursing practice was interpreted from the three relational themes: compassion as emotion, transforming the compassion occasion, and connecting with grace. The overall meaning is described as a constitutive pattern that the researchers named transforming compassion satisfaction. Compassion satisfaction is about the pleasure you derive from being able to do your work. For example, you may feel like it is a pleasure to help others through what you do at work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society through your work with people who need care (Stamm, 2005). This study may contribute to understanding the importance of compassion in nursing care of another. Interpretive
phenomenology provided the opening to discover the experience of compassion in nursing practice.
Discussion Four study limitations can be identified. First, the text used for this secondary analysis was transcribed from participants of the original study who were from the same educational program. Second, most were White. Third, no participants were men. Lastly, the view was from nurses alone, not the dyad of nurse-patient relationship. Experiencing compassion, the nurse seeks to know and understand interconnectedness to others. Compassion can be thought of as an instrument that supports the evolving nursing process. In this context, a relational process in which nurses identify with suffering and emotions that are experienced become meaningful encounters known as transforming compassion satisfaction. The meaning of compassion, nurturance, energy, caring theory, and intentionality, which combined, comprises the concept of compassion energy. Essentially, compassion energy is experienced by conveying the essence and critical nature of nursing through a mindful, authentic presence that exudes a therapeutic energy which transforms the caring interaction and evokes compassion satisfaction. Many nurses use a default setting to protect themselves from the experience of the patient by distancing self from the perceived vulnerability of suffering. However, in distancing self from the patient the caring interactions is nonexistent and becomes a technical task devoid of healing potential. When nurses engage with the patient from a place of caring, compassion, and presence, the moment becomes energized and focused on meeting the needs of the patient which in turn energizes the nurse. The dynamism associated with this dyadic encounter is linked with positive outcomes for both nurse and patient. The nursing situation is an interactive qualitative place to dwell and study the
dynamic and evolving energetic process of compassion. Nursing practice enhances an intimate relationship with patients through the intention to make a difference. This allows the nurse professional and personal satisfaction, known as compassion satisfaction. Perhaps the next step is to develop measurements aligned for self- report such as intentional, attentional, and behavioral components of compassion. In addition, future research could explore the question, can compassion be learned? Then, nurses as caregivers may overcome the tendency to care at a distance by focusing on compassionate care rather than on the tasks to get done. The importance of calls for nurses to practice with compassion and providing compassionate care is cited as a principle of conduct for professional behaviors (American Nurses Association, 2010).
Conclusion The authors argue that in the act of understanding and nurturing self-generated vigor, as compassion energy, the nurse will find meaning in caring for self and other. Emotional encounters can be very destabilizing, but nurses need to embrace these encounters in order to truly care for the individuals they serve. This study advances nursing knowledge by linking theory to practice and by describing and defining compassion while gaining knowledge about the benefit of compassion as a vehicle for caring for self with self- compassion and caring for another. This secondary analysis provided the opportunity to discover the experience of compassion in nursing practice and the implications for further research, practice, and education. The findings revealed the emotional connection to caring for another who is suffering with the intention to care compassionately as the grounding of nursing practice. The compassionate nurse is able to recognize and empathize with the patient in distress, feel some connection toward the patient, feel both positive and negative affect, and be motivated to reduce or
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alleviate that suffering. Positive emotions are love or concern, and negative emotions are upset or distress about the suffering of another. Compassion becomes the energy for caring and supports the relational process in connection between the nurse and patient, allowing for a balance of energy between positive and negative emotions. The researcher’s goal is to promote an empirical approach to this topic with the perspective of enriching our understanding of the compassion phenomena, but also lead to new strategies for improving compassion satisfaction in the context of nurse-patient relationships. Compassion is one of the essences of care. The nurse compassionately nurtures the patient. Compassion is regarded as an active, positive emotion with volitional qualities. When the call is heard by the nurse, the response is with compassionate intention in the context of the nursing situation (Boykin & Schoenhofer 2001; Paterson & Zderad, 1988). This study revealed that caring for another with compassion yields a transformation in compassion satisfaction.
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