Mark Durkin

Introduction Compassion is an important part of nursing practice and the way in which care is delivered to patients. A number of high profile reports have highlighted the consequences of the failure to demonstrate compassionate care, with others calling for the introduction of compassion into nurse training.
Background The recent reports into compassion recommend a need to create education programmes for nursing students so that they can continue to show compassionate care in practice. However, while the general literature explains the background to compassion and various ways in which this virtue can be demonstrated, it is not clear what type of training has been developed for nursing students or how effective such programmes are at teaching compassion.
Aims and objectives The aim of the study was to develop a model of learning that would help nursing students understand and demonstrate the practical and emotional elements of compassion in practice. An additional aim was that the Measure Explore Try Apply (META) model would help bridge the gap between education and practice by preparing nursing students for compassion in the workplace. The main objectives were; (1) to investigate the characteristics of compassion in nursing, how compassion is taught and measured, (2) explore and validate these findings further with a series of stakeholder groups, (3) use the results of the study to create a compassion strengths model for nurses’ compassion, (4) using the compassion strengths model as a foundation develop a psychometric scale and online learning intervention to measure and teach compassion strengths, and (5) validate both interventions with a cohort of nursing students, and assess them for their individual and combined effectiveness in relation to the META model.
Methods A systematic review of the literature highlighted a dearth of empirical research to support the identification of teaching and measurement of the characteristics of a compassionate nurse. As the study aimed to develop a new psychometric questionnaire, and an online scenario based learning course to help teach nursing students about compassion, a mixed methods approach underpinned by pragmatism was used. A variety of methods were included in the design of the studies. Directed content, and thematic analysis were used to explore the qualitative data. In addition, classic scale development statistics and confirmatory factor analysis methods were used to analyse the quantitative data.
Findings Two major findings from this study were the development of the META model and Compassion Strengths model to support nursing students in the understanding and demonstration of compassion in practice. The Compassion Strengths model suggests that compassion is a multifaceted concept comprised of eight strengths, (1) Character, (2) Self-care, (3) Communication, (4) Connection, (5) Engagement, (6) Competence, (7) Interpersonal skills, and (8) Empathy, which are key factors in the development of a compassionate nurse. The META model proposes that nursing students can first Measure themselves on their own unique compassion strengths. Next, using the online course they can access and Explore information about each of the compassion strengths to increase their knowledge and understanding of compassion. Then, Try out what they have learned through a series of reflective scenarios. Last, students can take what they have learned and Apply it to their practice. Nursing students who engaged in the META model using the compassion strengths as a framework, developed a new understanding of how to demonstrate compassion that they were able to implement into their clinical practice with patients.
Conclusion The META model, and Compassion Strengths model are two novel approaches to teaching compassion in nursing. While nursing curricula undoubtedly cover some of the compassion strengths included in this research, this study provides further empirical evidence for their importance and ways in which they can be implemented into nurse education and practice using the META model. The findings can be used to explore new avenues in the pursuit of producing nursing students with the strengths of compassion along their educational journey. The META model adds a unique contribution to knowledge. It is a novel approach to teaching that can be used as a learning tool to help students improve on specific compassion skills and help track progress over time.
The results of this will not only have a positive impact on their own health and wellbeing, but that of their patients too. While this study explored the impact of both models on nursing students, the research could be applied to other healthcare students and professionals.

Despite considerable research and rhetoric on the importance of compassion in nursing, progress has been hindered by the lack of an adequate psychometric instrument to measure its multidimensional nature. This paper reports several studies conducted over three stages, to develop and validate a new instrument to measure nurses’ compassion strengths. A purposive sample of UK pre-registered nursing students studying at a University took part in this study. The eight indicators highlight the multidimensional nature of compassion. The Bolton Compassion Strengths Indicators (BCSIs) demonstrated robust psychometric properties and could provide the means by which nursing students can empower themselves, as they strive to develop their professional identity as compassionate practitioners. This new measure will also help other researchers and educators who wish to study the development of compassion strengths in nursing.

AIMS:
To explore stakeholder perspectives of compassion in nursing.
BACKGROUND:
Studies show that nurses' compassion can be characterized by 11 characteristics. A growing body of research illustrates how courses aimed at teaching nursing students about compassion can be effective. Including the views of key stakeholders in the design of these programmes is recommended, yet the number of studies that have explored this are limited.
DESIGN:
This study used a qualitative exploratory design, applying a directed content and thematic analysis to the data.
METHODS:
Key stakeholders (N = 34), including nurse educators, nursing students, registered nurses and service user/patients, were recruited between September 2016 - July 2017. Focus groups and semi-structured one-to-one interviews were conducted. Data were transcribed verbatim. Directed content analysis and thematic analysis were applied to transcripts to address two separate research questions.
RESULTS:
In relation to question 1, 'What are the characteristics of a compassionate nurse'? eight themes: (a) character; (b) self-care; (c) connection; (d) empathy; (e) interpersonal skills; (f) communication; (g) competence; and (h) engagement, emerged from the content analysis. For question 2, 'How can compassion be taught to nursing students'? there were five separate themes that emerged from the thematic analysis: (a) beliefs about teaching compassion; (b) motivation; (c) the 5 W's needed to teach compassion to nursing students; (d) barriers to compassion in practice; and (e) compassion requires strength CONCLUSION: The findings of this research support previous research into compassion in nursing. The Compassion Strengths model may serve as a framework for nursing students and nurses' compassionate practice. This may also assist nurses internationally to develop further research in this vital area.

Compassion has global implications for nursing care. However, failure to provide compassionate care is reported by patients. Nursing and nurse education have been scrutinized about the impact training can have on student's compassion. Furthermore, there is a paucity of standardised measures to assess levels of nurses' compassion. To identify (1) the qualities of a compassionate nurse, (2) how compassion is taught to nursing students, and (3) the instruments used to measure compassion in nursing. Systematic literature review. CINHAL, EBSCO, SCOPUS, PubMed, Ovid Nursing. A systematic review of published research was conducted with. No limitations in the search timeframe were used. Articles were included if they were (1) nurses (2) nursing students (3) educators and (4) patient groups, (5) written in English. Articles that were, peer reviewed, research articles, or articles grounded in evidence based practice were also included. Fourteen studies (6 UK, 3 USA, 2 Canada, 1 Korea, 1 Thailand, and 1 Netherlands) identified eleven characteristics of a compassionate nurse. Two UK and one Australian study investigated teaching compassion to nursing students. Four articles reported on instruments used to measure compassion in nursing. Three were American, and one Korean. This review identified only 21 papers overall. Several qualities of a compassionate nurse were found. In addition, few studies have explored how compassion is taught to nursing students. Also, there are a limited number of instruments for measuring compassion in nursing. More research is needed in nurse education to develop a teaching approach and psychometric measure for nurses' compassion.

This paper reports on the development and evaluation of an online scenario based compassion intervention for nursing students. Reports suggest that nursing education programmes should include simulation based learning, and be developed using service users to help teach nursing students about compassionate care, and what it actually feels like to be the patient. In addition, many of the problems arise in hospital environments that are under immense pressure, both financially and to perform well with limited resources. The complex and resource constrained practice environment shapes how people act This underlines an additional need to include educational programs that can prepare nursing students for the reality of practice. In an attempt to address this, previous studies have used both simulation and online teaching environments to teach nursing students about empathy and compassion. Although results showed improvements in the delivery of empathy, confidence and understanding of compassion, very few, if any, have explored the effectiveness of online scenarios as a teaching intervention for nursing student’s compassion. To address this gap, eight nurse – patient scenarios, based on real life clinical experiences, were recorded and developed further with additional theoretical information in Articulate software package. A sample of nurse educators and nursing students participated in a short pilot study aimed at evaluating the experience and understanding of compassion from those using the intervention. The findings from the study are presented and the implication for nurse education discussed.

Compassion in nursing is an important moral virtue that forms the basis of ethical guidelines for practice (Dietze & Orb, 2000; Armstrong, 2000). However, identified compassion failures (UK) (Francis, 2013) have led to a renewed interest in championing it across nurse education programs. Debate exists as to whether compassion is an innate quality or something that can actually be taught (Bray et al, 2014; Johnson, 2013). Some argue that it can be taught combined with reflective practice, and should be even though evidence exists of it being overlooked in preregistration education (Benbow, 2016; Bramley & Matiti, 2014; Sinclair et al., 2010).
This paper reports on the design considerations for a self-evaluation online tool (built using Articulate) incorporating a compassionate strengths scale and patient case scenarios to assist nursing students in developing their strengths of compassion. The compassion strengths scale is employed as a tool for learners to self-evaluate areas where their compassion is strong and areas where development can occur. In this way it focus on what learners have rather than a deficit approach to build on the strong qualities and grow in areas where it is less so. A reference group of students also inform the content development and evaluate the functionality of the tool. The design is research informed (primary research) and pedagogically designed around a reflective model and collaboratively developed with academic, student and patient group contributions.
The purpose of the tool is to be used as an online curriculum intervention blended with classroom teaching content. Compassion is relevant all nursing practice and the tool is designed to include discipline specific case examples. It facilitates accessible education at a time place and pace according to learner requirements working in practice alongside their learning. The tool supports student’s development of lifelong learning and reflective self-evaluation of their compassion strengths. Overall the design is a unique approach employing content creation software to champion compassion education in nursing practice that could also be a basis for developing an Interprofessional learning approach with a wider stakeholder group

Purpose: This study examines pre and post outcome measures following a course of Compassionate Mind Training (CMT). Participants were students enrolled on a Post Graduate Diploma in Cognitive Behavioural Psychotherapy (CBP). The aim of the research was to explore whether the training would increase self-compassion, compassion for others and dispositional empathy.
Method: Twenty-one participants who had enrolled on the CBP programme took part in the study. Data were collected using the Self-Compassion Scale, Interpersonal Reactivity Index and the Compassion for Others Scale.
Findings: Results reveal an overall statistically significant increase in self-compassion scores and statistically significant reduction in self-critical judgement scores post training. There was no statistically significant difference post training on the Interpersonal Reactivity Index or the Compassion for Others Scale.
Research limitations/implications: CMT training may help students develop healthy coping strategies, which they can use to balance their affect regulation systems when faced with organisational, placement, client, academic and personal demands. Further research using a larger sample size is needed to examine whether cultivating compassion whilst on training can help students build resilience and provide a barrier against empathic distress fatigue, compassion fatigue, and burnout.
Practical Implications: Incorporating CMT into psychotherapy training may bring changes in student levels of self-compassion and self-critical judgment.
Originality/value of the paper: This inaugural study examines whether incorporating CMT into a CBP programme impacts on students levels of compassion, dispositional empathy and selfcritical judgement. The findings from this preliminary study suggest the potential benefits of training students in compassion focused practices.

Background - Compassion fatigue and burnout can impact on performance of nurses. This paper explores the relationship between self-compassion, self-judgement, self-kindness, compassion, professional quality of life, and wellbeing among community nurses.
Aim - To measure associations between self-compassion, compassion fatigue, wellbeing, and burnout in community nurses.
Method - Quantitative data were collected using standardised psychometric questionnaires: (1) Professional Quality of Life Scale; (2) Self-Compassion Scale; (3) short Warwick Edinburgh Mental Wellbeing Scale; (4) Compassion For Others Scale, used to measure relationships between self-compassion, compassion fatigue, wellbeing, and burnout.
Participants - A cross sectional sample of registered community nurses (n = 37) studying for a postgraduate diploma at a University in the North of England took part in this study.
Results - Results show that community nurses who score high on measures of self-compassion and wellbeing, also report less burnout. Greater compassion satisfaction was also positively associated with compassion for others, and wellbeing, whilst also being negatively correlated with burnout.
Conclusion - High levels of self-compassion were linked with lower levels of burnout. Furthermore when community nurses have greater compassion satisfaction they also report more compassion for others, increased wellbeing, and less burnout. The implications of this are discussed alongside suggestions for the promotion of greater compassion.

Background - compassion fatigue and burnout can impact on the performance of midwives, with this quantitative paper exploring the relationship between self-compassion, burnout, compassion fatigue, self-judgement, self-kindness, compassion for others, professional quality of life and well-being of student midwives.
Method - a quantitative survey measured relationships using questionnaires: (1) Professional Quality of Life Scale; (2) Self-Compassion Scale; (3) Short Warwick and Edinburgh Mental Well-being Scale; (4) Compassion For Others Scale.
Participants - a purposive and convenience sample of student midwives (n=103) studying at university participated in the study.
Results - just over half of the sample reported above average scores for burnout. The results indicate that student midwives who report higher scores on the self-judgement sub-scale are less compassionate towards both themselves and others, have reduced well-being, and report greater burnout and compassion fatigue. Student midwives who report high on measures of self-compassion and well-being report less compassion fatigue and burnout.
Conclusion - student midwives may find benefit from ‘being kinder to self’ in times of suffering, which could potentially help them to prepare for the emotional demands of practice and study.
Implications - developing, creating and cultivating environments that foster compassionate care for self and others may play a significant role in helping midwives face the rigours of education and clinical practice during their degree programme.

Background - Prolonged deficiency in self-care strategies puts counsellors and psychotherapists at risk of burnout and compassion fatigue.
Aim - To measure associations between self-compassion, compassion fatigue, well-being and burnout in student counsellors and student cognitive behavioural psychotherapists.
Method - A quantitative survey using four validated data collection instruments: (1) Professional Quality of Life Scale; (2) Self-Compassion Scale; (3) short Warwick and Edinburgh Mental Well-being Scale; (4) Compassion For Others scale, was used to measure relationships between self-compassion, compassion fatigue, well-being and burnout.
Participants - A mixed sample of student counsellors and student cognitive behavioural psychotherapists (n = 54) in their final year of study.
Results - This preliminary study shows that student counsellors and student cognitive behavioural psychotherapists who reported high on measures of self-compassion and well-being also reported less compassion fatigue and burnout.
Implications for practice - Compassion fatigue and burnout are found in many modern-day, highly stressful healthcare professions. The practice of self-compassion could help student practitioners manage these symptoms and subsequently improve their professional quality of life.