Compassion in Healthcare Systems and Nurturing Staff Well-being Amidst Strain

Dr JP Corrigan, Consultant Clinical Psychologist

Dr Jane Gilsenan, Clinical Psychologist.

Contact: john.corrigan@belfasttrust.hscni.net

As the Compassion Focused Therapy (CFT) approach has gone from strength to strength in recent years, new avenues for clinical and research application have become more apparent. Whilst still in its infancy, one such area is the application of this approach to staff wellbeing. For context, it is likely that the Covid-19 pandemic and the noted high levels of mental health symptoms in occupational contexts has driven the need for a wider suite of interventions that meet the needs of individual and teams of staff. 

We have been working clinically within an Occupational Health service in a large healthcare Trust for the past number of years with interests in developing the CFT approach in this domain. Given our experience and interests, we have taken the opportunity to outline both the challenges and the opportunities for working clinically in this area when applying a CFT approach to clients and services.

Applying CFT clinically in this setting – the challenges

A systemically informed formulation of compassion in healthcare

 

In order to appreciate the challenges within this work, we should first make clear the source of one particular difficulty when offering psychological therapies in an organizational context. 

Large healthcare organisational systems, particularly those that are publicly (under)funded, are often poorly resourced and find great difficulty in providing a satisfactory level of patient care. This is well documented and is all too often the focus of media attention. 

By contrast, the staff working within these systems typically hold a strong sense of value for the quality of care provided and will go to great lengths to offer high quality services.

Compassion Focused Therapy

Formulaically speaking, this tension often results in higher levels of self-sacrifice behaviours by individual staff, and staff teams work over and beyond their remit to meet patient needs. We hypothesise that the larger system comes to rely on this level of output from staff members and may even inadvertently reinforce self-sacrificing behaviours through various mechanisms such as offering overtime work and incentive systems, as well as implicit narratives regarding particularly self-sacrificing individuals, such as “we couldn’t cope without you.” 

This invites other staff in a team to then behave in a similar way and models a self-sacrificing approach to patient care. Perhaps of equal concern are staff members who resultantly feel that they are insufficient or inadequate if they cannot perform to the same level of those around them. This also predisposes staff to a level of moral distress across a team; in that they cannot provide a sustainable level of care to their patients. They may then compare themselves to busier or idealised colleagues and further infer something deficient in themselves. 

In the CFT model of emotion regulation, our formulation suggests that a heightened drive system is positively reinforced in staff members through a range of mechanisms and simultaneously primes an overactive threat system, as ultimately the staff members cannot sustain such a high level of under resourced working. The inability to establish or maintain a high level of self-sacrifice gives rise to feelings of inadequacy, distress, or shame responses. 

Efforts of course can be made to promote ‘self-care’ (a term which can cause a range of reactions), but these are often ineffective against the high level of oscillation between drive behaviours (e.g. self-sacrificing) and threat responses (feeling inadequate in the role or moral distress) in the face of caring for sick patients. It should be noted that these emotional responses are also clearly linked to present workplace stressors, but an added layer of complexity is also present in terms of the staff member’s own personal history, attachment and coping styles, etc.

The ‘knee-jerk’ clinical reaction

compassion in healthcare leave job

Unfortunately, to address this, we have encountered many clinicians who have dealt with this impasse by advising the client that leaving their job may be the most viable option. This at first glance appears to be underpinned by contextualising these decisions within a CFT formulation and rationale, i.e. by leaving the job, the client reduces their exposure to perpetuating factors of poor mental health, exercises compassion for themselves as an individual, and thus opens up more opportunity to recover from symptoms. This analysis is hugely problematic and often leads to a further dilemma; the client is then faced with a decision that precipitates feelings of shame and guilt at the prospect of abandoning patients and colleagues. 

Indeed, we have at times clinically observed phenomena associated with survivor guilt in those clients who take such action. We suggest this is a messy recourse, fraught with wide ranging implications for the client. Often, a clinician’s guidance for a staff member to leave their job is a response to an overactive threat system, possibly within both patient and therapist as an attempt to survive, but does not in itself teach the client anything about compassionate self-regulation.

The therapist’s own process

Should the client decide to stay in their role and work therapeutically on their threat response in therapy, a range of clinical challenges arise. Initially, the therapist can find it difficult to make meaningful steps forward when the client remains in work, as the therapist can come to believe that they should challenge the status-quo within the organisation and break down underlying perceptions that the client should continue to work long hours in poor conditions. Trying to challenge such ingrained narratives in large organisations is often not fruitful and actually creates a tension for the client, i.e. do I listen to my struggling colleagues or my therapist? Dynamically, this may lead to a client perception that the therapist does not truly understand their difficulty and may even lead to therapy drop-out. 

Secondly, we often encounter staff members who have been unable to bare the conflicts outlined in this formulation and take a period of sickness absence in order to devote time to therapeutic support. This can be more helpful for therapeutic processes as the client now has separation from drive-provoking narratives. In this instance, the therapist must then focus with their client on feelings of shame and guilt regarding not being in work. Physically, the client is temporarily removed from the situation, however, psychologically remains tethered to it through unhelpful behaviours such as keeping an eye on their emails, reading group messages, or even subliminally through discussing aspects of work with their colleagues outside of working hours when meeting socially.  In our experience, this distress about being out of work temporarily often passes within a relatively quick period of time, allowing therapeutic work to progress.

Applying CFT clinically in this setting – the opportunities

On an individual level, the initial application of CFT typically involves exploring the three-system model with clients, particularly their overactive and imbalanced drive and threat systems, contrasted with their often limited or maladaptive soothe system. Supporting clients with accessing this soothing inner network can often prove to be a lengthier process than anticipated during therapy sessions. 

When clients present with chronic burnout or anxiety stemming from work-related stressors, the journey toward tapping into a more functional soothe system and cultivating a compassionate self that can access this, can evoke inner conflicts and feelings of unfamiliarity or discomfort.  Nevertheless, when clients become receptive to the model, it holds potential for therapeutic exploration and growth.

three system model compassion focused therapy

Healthcare professionals often resonate with this approach due its relevance to their work environment and the unique stressors they face. For example, safe-place imagery has been a valuable tool for clients who experience workplace-trauma and encounter triggers in the workplace. Addressing self-criticism in a work context may also help clients recognise and respond in a kinder way to self-critical parts of themselves, fostering a gentler inner dialogue. Further, incorporating soothing rhythm breathing as a quick self-regulation strategy in the workplace, can facilitate regulation and aligns clients with a slower, more conducive pace, amidst high-pressure ward environments. Hence, this approach sets a client up for longevity and adaptability through an internal soothe system that works effectively and helps them separate from unsustainable narratives that fuel the drive-threat interplay.

Values based approach – metaphor

When self-criticism and unwanted emotions surface in therapy, such as feelings of inadequacy stemming from the inability to provide optimal care for patients and compounded beliefs around excessive responsibility, therapeutic metaphors can often shed light into the realities of operating within an under-resourced system. One such metaphor approach that we have used clinically, is to draw parallels between healthcare environments where care provision is not optimal but does not lead to a caring professional entering into self-attack.

Developing countries, where resources, staffing, and medical care are scarce, can offer insight. Discussing these environments with clients can promote realisation that a single healthcare professional or team is not responsible for sub-optimal care, thus loosening excessive beliefs around responsibility. In addition, this fosters a more compassionate self-view, encouraging clients to embrace their limitations with understanding and empathy. 

This perspective shift can potentially steer away from the self-blame and guilt-driven narrative of ‘it’s my fault,’ ‘we should be doing more,’ and the associated distress with limited care, towards a more balanced view. By holding in mind the idea of a staff member working in a developing world and embodying this philosophy, clients can free themselves from excessive feelings of responsibility to provide in an overstretched system and the associated moral distress that comes with this.

Working systemically – involving managers and systems leaders

To foster individual-level change, establishing systemic frameworks within the Compassion Focused Therapy (CFT) approach is important. This involves an array of strategies, often entailing collaboration with managerial or more senior staff members. It can involve consultation with managers, compassionate formulation-orientated report writing to managers, training workshops on compassionate practices, and group / 1.1. CFT based interventions. Additionally, offering recommendations and adjustments to managers, often aiming to restore balance within the emotional regulation systems of our clients. For instance, suggesting a review of job duties or implementing additional supervision can help mitigate an overactive drive system.

There is a need to target both the ‘bottom-up’ work with clients and a ‘top-down’ approach, where staff at a more senior and managerial level acknowledge the benefits of fostering compassion within teams. We’ve discovered that when managers adopt a compassionate perspective and prioritize staff wellbeing, relationships are strengthened, staff feel less threat, transferring this ethos to frontline staff can open avenues for more impactful therapeutic progress.

Implementing this top-down strategy presents its challenges for several reasons, one of which is the potential resistance from higher-level staff who may be contending with their own sources of distress. In a system driven by box-ticking, pressure and targets, staff at a managerial level may find it incongruent to take time to address their own well-being, feeling it’s not aligned with their leadership responsibilities. As clinicians, this encourages us to take a therapeutic approach to the whole system, as opposed to a critical or blaming approach to management.

Population level intervention – current CFT research program

Compassion Focused Therapy

In our efforts to integrate Compassion Focused Therapy principles into staff well-being initiatives, we have been developing a research program with Dr Chris Irons to expand our work. This program has aimed to explore the delivery, feasibility, and effectiveness of applying an online brief compassion-focused therapy intervention across various healthcare populations.

Our initial study focused on assessing the feasibility of implementing this intervention within an ICU nursing population during the COVID-19 pandemic. We explored key constructs such as self-compassion, compassion satisfaction, burnout, trauma, and the CFT emotional regulation systems. Our findings suggested that whilst the online intervention holds potential for promoting well-being among ICU nurses, its effectiveness may be contingent upon a pre-existing level of self-compassion among participants.

We later expanded the intervention to a broader population of nurses and observed positive impacts on mental health symptoms, emotional exhaustion, fears of self-compassion, and feelings of inadequacy. Our findings concluded that CFT via an online format is a potentially feasible intervention for nursing populations and can be delivered at scale. However, it is important to note that dropout rates were fairly high, which was anticipated given the challenges noted throughout this article, and additional trial research illustrating that drop out is a common occurrence in healthcare population research.

Qualitative feedback from the study also highlighted emotions which arose for clients during engagement to the CFT intervention. Notably, guilt for prioritizing self-care, again reflecting the sense of duty pervasive in healthcare professionals. Participants also reflected on the inherent challenges within their nursing careers, acknowledging the pervasive stress inherent in a high-pressure system.

The next stage of this research programme involves extending the intervention to a help-seeking population, specifically individuals accessing the Occupational Health Service due to mental health symptoms and workplace burnout. By integrating the intervention into the service, we aim to make compassion-focused interventions more incorporated into service delivery, thereby enhancing accessibility on a broader scale.

Final reflection

We hope that our reflections offer some insight into the nature of providing compassionate interventions within a strained system. Despite the acknowledged challenges, the opportunity to support individuals who provide an essential service, and offering psychological input aligned with Compassion Focused Therapy principles is a really rewarding aspect of the work.

JP & Jane 

Papers of interest:

Corrigan, J. P., Dympna Browne, Jane Gilsenan, and Chris Irons. “Evaluating a brief online compassion‐focused intervention for intensive care nurses.” Nursing in Critical Care (2022). https://doi.org/10.1111/nicc.12860

Drobinska, K., Oakley, D., Way, C., & Jackson, M. (2022). “You Forget to Apply It to Staff”: A Compassion-Focused Group for Mental Health Inpatient Staff. An Exploration of the Barriers to Attendance. Issues in Mental Health Nursing43(9), 798-807. https://doi.org/10.1080/01612840.2022.2074177  

McBride, L., Dempsey, C., Corrigan, J (2023). “Learning from Covid-19; Lessons for Healthcare Staff Wellbeing.” Clinical Psychology Forum 362. https://doi.org/10.53841/bpscpf.2023.1.362.48

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