By Professor Michael West
Countries around the world face a healthcare workforce crisis with widespread shortages of people trained to deliver high quality, compassionate care. The World Health Organization estimates that by 2030, an additional 40 million healthcare professionals will be needed. Meanwhile, in most countries healthcare staff are experiencing high levels of stress and burnout, resulting in ill health and many leaving their professions. The pandemic exacerbated these problems and caused worsening mental ill health and long-term physical ill-health consequences for many. Aging populations in many countries of the world, produce additional pressures on healthcare systems and staff. Our challenge globally in this context is how to create the conditions where we can provide high quality, compassionate care for patients and high quality, compassionate support for healthcare staff.
This requires that we develop and sustain compassionate cultures throughout healthcare. Why? Because compassion is the most powerful intervention in healthcare, as shown by hundreds of studies internationally. Evidence of its effects include speed of post-surgical recovery, longevity of patients diagnosed with lung cancer, outcomes in long term disorders such as HIV and diabetes, and better results in the treatment of mental health problems. There are also significant associated cost savings. Moreover, the evidence shows that being compassionate affects the wellbeing of healthcare staff resulting in lower levels of anxiety, stress, and depression. When we are compassionate to others, both they and we benefit. There are major benefits of compassion, not only in individual interactions with patients, but also in the cultures of healthcare provider organisations.
For example, Berkshire Health, a British healthcare organization focused on mental health, community health and those with learning disabilities, has been retraining all its staff in compassionate leadership for the last five years. They now have highest levels of staff engagement and lowest levels of staff stress of any organisation in the English National Health Service. The care they provide, and their financial performance are both rated as outstanding by the national audit body.
How then do we create the conditions in healthcare organisations where staff will be (even more) compassionate to patients, each other, and themselves – how do we develop compassionate cultures. Culture is a consequence of the behaviours of everyone in our organisation – every interaction every day is an opportunity for us to shape the culture. But the role of leaders is particularly powerful. The last 100 years of research on organisational culture shows that leadership is the most important factor in shaping organisational culture. What leaders pay attention to and model in their behaviours tells us what it is they value and by extension what we should value.
Leaders in healthcare must recognise that compassion is the core work value (if not life value) of virtually all of those who work in healthcare. They are called to their professions by a desire to help alleviate the suffering of others. To the extent that leaders mirror this core value, those working in healthcare will be more engaged and less likely to quit, even in stressful working environments. So, leaders must embody the four behaviours of compassion in their leadership – attending, understanding, empathising, and helping.
Compassionate leadership therefore requires four key behaviours.
- Attending: This means leaders having the courage to be present with those they lead. Being present means being here and now with those we lead and letting go of other distractions. We don’t have to try to be present but we do have to let go of the distractions that interfere with our presence. Being present with those we lead enables the other element of attending – listening or listening with fascination. Listening is the most important leadership skill and compassionate leaders take time to listen to the challenges, obstacles, frustrations, and harms colleagues experience as well as listening to accounts of their successes and joys. This means listening (for example) to maternity staff telling you there are not enough qualified midwives in the maternity unit to deliver safe care for mothers and families. Attending provides a powerful base for the other three behaviours constituting compassionate leadership and is a prerequisite for understanding.
- Understanding is having the courage as a leader to be curious and explore and understand the situations those we lead are struggling with. It implies valuing and exploring conflicting perspectives rather than leaders simply imposing their own understanding, especially if from some remote, hierarchical position. For example, when healthcare staff are struggling to meet the targets they have imposed on them, in relation to waiting times in the emergency room, leaders may need to understand how chronic work overload affects cognitive functioning, the ability to improve quality and the capacity for helping others. Attending and understanding create the conditions for empathising.
- Empathising involves mirroring and feeling colleagues’ distress, frustration, joy, etc, without being overwhelmed by these emotions and becoming unable to help. Virtually all of us as humans are hard wired to empathise – to put ourselves in the other’s position and feel with them. Leaders must have the courage to empathise, for example, with the nurse on her third thirteen-hour night shift in a row, who is exhausted and depleted. She has not had time to take her rest break, feels guilty because she could not spend sufficient time with an elderly patient in distress, and now she feels afraid to drive home in her exhausted state. Empathising as leaders gives us the motivation for the fourth, critical element of compassionate leadership – having the intention to help.
- Helping or the intention to help is fundamental to compassionate leadership. Indeed, compassionate leadership can be understood as more a motivation than an emotional orientation – the motivation to help those we lead. Helping those we lead to do their jobs more effectively is the key task of leadership. This involves taking thoughtful and intelligent action to support individuals and teams by helping them ensure they have clear direction for their work; helping them to remove the obstacles that get in the way of doing their work effectively (e.g., chronic excessive workloads, conflicts between departments, unnecessary bureaucracy) and providing the resources people and services they need (e.g., staff, equipment, training).
We have known for sixty years or more that these four behaviours are fundamental to effective leadership. The same four behaviours that constitute compassion underpin effective leadership because they are the basic human behaviours that enable us to connect with each other and build a sense of trust and belonging – an antidote to stress and loneliness for health care workers and leaders. And these are behaviours that can be practised in all our interactions – not only in leadership contexts.
In Wales, national leaders are convinced by the evidence and have committed to developing compassionate leadership across all of health and social care within ten years, developing the resources and supports to enable this (About Gwella – Gwella HEIW Leadership Portal for Wales). This includes compassionate leadership training, and compassionate systems, structures, policies, strategies, teamwork, and cultures. They, along with others such as the Irish Health Service Executive, are working with The Global Compassion Coalition to support the development of compassionate leadership in healthcare worldwide (Healthcare – Global Compassion Coalition). Initiatives in many healthcare organisations around the world are combining to create a social movement for compassionate leadership in healthcare. Compassionate leadership is also a key element of the World Health Organisation’s strategy for primary care. This is evidence-based practice rather than ideology. International data, gathered over the last twenty years, shows that compassionate leadership has wide-ranging benefits not only for patients but also for staff and organizations:
- Compassionate leadership increases staff engagement and satisfaction, resulting in better outcomes for organisations including improved quality of patient care and financial performance.
- Compassionate leadership is associated with the more effective organisational changes such as mergers, mitigating the negative effects on staff wellbeing and morale.
- People who work in supportive teams with compassionate team leadership and clear goals have dramatically lower levels of stress.
- In hospitals where staff report the absence of such leadership, staff also report higher levels of work overload, less influence over decision-making and less quality improvement.
- Where compassionate leadership is missing, care quality and financial performance are both worse than in those organisations with higher levels of compassionate leadership.
- Staff who are treated with compassion are better able to direct their support and care giving to others. This results in higher-quality care and higher levels of patient satisfaction.
- Where staff generally report the absence of such leadership there are lower levels of patient satisfaction, poorer care quality and higher levels of avoidable patient mortality.
Compassionate leadership is not some soft cushions, scented candles approach to leadership, however. Compassion involves leaning towards pain and difficulty. Compassionate leadership therefore involves leaning in to dealing with difficult behaviours (aggression, discrimination, harassment, poor performance) and doing so with compassion – attending, seeking to understand, empathising, and helping, perhaps using coaching models and agreeing clear objectives for behavioural change with those involved. It involves having difficult conversations and giving clear and constructive negative feedback. It involves dealing openly and courageously with conflicts, particularly the damaging chronic interpersonal conflicts that so jeopardise health care team effectiveness and thereby patient safety. Compassionate leadership requires courage and wisdom in equal measure to transform the cultures of health care organisations so that they can deliver better health care and outcomes for those we serve.
There is increasing evidence that the ability of leaders to adopt these behaviours depends on their having the courage to practice self-compassion. Moreover, where leaders practice self-compassion, those they lead go on to provide better quality and more compassionate care to patients. Leadership self-compassion is being present with ourselves– knowing when I am feeling overwhelmed, anxious, angry, hurt, ashamed or inadequate. Self-compassion requires we accept rather than reject such feelings in order that we can cultivate curiosity about them and understand them. Rejecting or denying our feelings distances us from ourselves and therefore hinders our ability to connect authentically with others. Self-compassion is asking:
- What am I feeling,?
- What do I need?
- How can I get those needs met?
This is not narcissistic, self-indulgence but caring for ourselves in the same way we would care for a dear friend who was suffering. After all, each of us is as deserving of love as every other human being on the planet. When we connect deeply, courageously, authentically, and compassionately with ourselves, it enables us as leaders to connect more deeply, courageously, authentically, and compassionately with all of those we lead, indeed with all of those we interact with in our lives.
Compassionate leadership must be at the heart of local, regional, and national healthcare efforts to nurture cultures that provide high-quality, continually improving, and compassionate care for patients and staff. Leaders must have the courage to shift from traditional hierarchical leadership approaches to compassionate leadership. This requires a sustained shift in mindset and behaviours by leaders in health and care (and other public sectors) to deliver and sustain this culture change. For the sake of patients, service users, staff and communities, such sustained courage and commitment to developing compassionate leadership is essential.
Michael West is Senior Visiting Fellow at The King’s Fund, London, and Professor of Organizational Psychology at Lancaster University. His latest book is Compassionate Leadership: Sustaining Wisdom, Humanity and Presence in Health and Social Care.
