Developing compassion in nursing students through engaging with a lived experience

Helen Bingham Tara Malone   About the authors: Helen Bingham, RN, MN, is a senior nursing lecturer at the Western Institute of Technology Taranaki. Her correspondence address is [email protected] Tara Malone, RN, PGCertEd, is a senior nursing lecturer at the Western Institute of Technology Taranaki. This article was accepted for publication in May 2022.	ABSTRACT Aim: The aim of this study was to understand if an educational intervention, in which people with experience of mental illness and addiction shared their stories with nursing students, resulted in those students expressing empathy and compassion. Background: An educational intervention was incorporated into the teaching and learning of mental health and addictions concepts in the bachelor of nursing curriculum, based on the principles of narrative learning. In a series of workshops, small groups of second-year nursing students interacted face-to-face with people who had experienced mental illness and/or addiction and listened to their stories. This was facilitated through a partnership with non-government organisation Yellow Brick Road. Methodology: This study used qualitative descriptive research. Convenience sampling was used to recruit study participants, who were undergraduate nursing students enrolled in their second year of a bachelor of nursing programme. Data was gathered from self-report statements written by the students, following their experience of each of five workshops. Content analysis was used to identify themes and patterns. Findings: Results indicated a significant number of the nursing students expressed empathy and compassion after listening to the narrative of a person with a lived experience of mental illness and/or addiction. Conclusion: This educational intervention resulted in nursing students expressing empathy and compassion. This type of learning could contribute to the ongoing development of students’ nursing practice by making them more empathetic and compassionate towards people who have experienced mental illness and addiction.
KEYWORDS nursing students, undergraduate, education, mental health, empathy, compassion, lived experience

INTRODUCTION

CHANGE IS AFOOT FOR undergraduate nursing curricula in New Zealand’s polytechnic sector, with one bachelor of nursing curriculum being developed, to be implemented across all nursing schools, under the Te Pūkenga umbrella (Brinkman, 2021). Now is the time to strategically consider how and when the teaching and learning of mental health and addictions concepts are delivered in the curriculum. This should include consideration of whether current undergraduate nursing curricula adequately prepare nursing students for practice, not only for the mental health and addictions specialty settings, but also for using mental health and addictions skillsets across all clinical settings. The World Health Organization [WHO] (2019) suggests that mental health and addictions assessment and delivery of care needs to take place more in primary health care. The He Ara Oranga report notes that mental health and addiction issues are present in all health-care settings, and recommends strengthening mental health and addiction capacity in the primary health sector, and across non-specialist settings (New Zealand Government, 2018). This includes health promotion and prevention, to avert escalation of mental health and addiction issues (Australian Government Department of Health, 2019).

There is ongoing debate about the education undergraduate nurses receive, with particular concern about the mental health and addictions content, and the priority of these concepts within curricula (Spence et al., 2012). Learning experiences that increase empathy and compassion in nursing students toward those who experience mental illness and addiction is essential. These positive qualities improve both nurses’ interpersonal skills and outcomes for those whom the nurses encounter (Marcysiak et al., 2014). Exposing nursing students to those who have experienced mental illness and addiction, particularly during meaningful face-to-face interactions, is essential (Corrigan, 2012; Happell et al., 2014b). This is seen as an effective strategy to influence nursing students’ attitudes, making them more empathetic and compassionate toward those who experience mental illness and addiction (Ironside, 2015; Martin, 2000). This research was undertaken to see if an educational intervention developed the expression of empathy and compassion by nursing students towards those with mental health and addiction experiences. A timely question for nurse academics and curriculum developers to consider is:

“Does current mental health and addictions teaching and learning within bachelor of nursing curricula, strategically prepare nursing students to develop the attitudes and skillset required to meet the holistic needs of the communities they serve?”

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BACKGROUND

The education of nursing students should provide opportunities for them to develop the nurturing qualities of empathy and compassion, so they can provide safe and effective person-centred care (Francis, 2013). Public scrutiny of health care often discusses nursing qualities that those receiving care consider to be missing. Recipients of care consider that nurses, along with having knowledge and sound technique, need to be empathic and compassionate (Blomberg et al., 2016). Those receiving care are often not able to describe empathy, but are able to decide if they have experienced an empathic approach (Brunero et al., 2010). Having the ability to care is a valued attribute for a nurse, and caring is seen to be the core business of nursing (Shields, 2014).

It is interesting to note that empathy has two components – firstly the cognitive perspective, and secondly, the affective aspect, often described as compassion (Dal Santo, 2014). Compassion is an affective reaction to a person’s experience (Marcysiak et al., 2014), an attitude towards another that is focused on concerned caring and tenderness. This enables the development of a supportive helping relationship, based on an understanding of others, which is essential to providing person-centred care (Teofilo et al., 2019).

Despite empathy being a concept with many dimensions, this study concentrates on cognitive empathy – the ability to comprehend what another person is feeling and experiencing and to be able to understand those feelings. This underpins the willingness to respond appropriately to the other person’s needs (Hatfield et al, 2011). Empathy is an important part of nursing practice, and is an essential skill for forming caring relationships that are vital to the provision of quality nursing care (Reynolds et al., 1999).

Nursing students often hold attitudes and views that lead to stigmatising beliefs about those who experience mental illness and addiction (Corrigan et al., 2012; Fokuo et al., 2016). When stigmatising beliefs are dominant in a nursing student, the student is more focused on the self, which can decrease their ability to empathise (Delgado et al., 2021). Students can experience a decrease in stigmatising beliefs and discriminating behaviours when listening to the stories of people with a lived experience (Bingham & O’Brien, 2017). Therefore, if students are exposed to the stories of those with a lived experience of mental illness and addiction, they could subsequently feel concern (Low et al., 2015). With empathy and compassion being essential to caring, there is a complex interplay between the need to develop expert nursing practice, alongside the need for interpersonal sensitivity to develop therapeutic relationships (Richardson et al., 2015). Having those with experience of illness share their narratives of these experiences is a helpful education tool for developing empathy (Ferri et al., 2019).

Educational interventions that focus on developing empathy often involve vulnerable populations (Levett-Jones et al., 2019). The intervention used in this study does this, using those with a lived experience as expert-patient teachers to help the students experience their innate empathy (Ferri et al., 2019). Using those with lived experience as part of nursing education encourages students to reflect on what a person receiving care requires, which helps develop their cognitive empathy (Ferri et al., 2019).

A narrative consists of a person sharing their journey through time, through which the listener should glean the essential elements of the story. The sharing of the narrative allows the storyteller to clarify and reflect on their story as they tell it. It provides an opportunity for the teller to clarify, reframe and understand their current behaviours, in relation to their past (Freshwater & Holloway, 2015). Listening to patients’ stories allows the nurse to gain a deep understanding and sense of another’s suffering, in particular in relation to an illness; this, in turn, has a positive effect on patient outcomes (Freshwater & Holloway, 2015). Hearing real-life stories, in preparation for a mental health clinical placement, helps students make sense of how mental illnesses may affect a person. It enables them to reflect on their potential nursing actions in mental health practice (Treloar et al., 2017).

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STUDY SETTING

The study participants consisted of a cohort of second-year nursing students from a nursing school in New Zealand. Ages ranged from 18 to 50 years; two were male, and the rest female. Ethnic backgrounds varied, with the majority being European New Zealanders (n = 19) and the next highest group identifying as Māori (n = 9). Five workshops were held over five weeks of learning, each based on a specific topic related to mental illness and addiction. At the workshops, small groups of six to eight students interacted with people with experience of mental illness and/or addiction, and with whānau members who have supported people with these experiences.

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AIM

The aim of this study was to understand if an educational intervention, based on face-to-face sharing of narratives by those with a lived experience of mental illness and addiction, resulted in nursing students expressing empathy and compassion.

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METHODOLOGY

A qualitative, descriptive research design, described by Sandelowski (2000), was used to undertake this study (Borbasi et al. 2019). When choosing methodology for a research study, consideration needs to be given to the nature of the knowledge being sought to answer the hypothesis. The aim of this research study was to consider the behaviour of the students through their expression of language; therefore, a social science perspective was needed (Oliver, 2010). Descriptive research allows the researcher to explore the frequency with which a particular phenomenon occurs, in this case an expression of empathy and/or compassion (Polit & Beck, 2014). It is a methodology often used in nursing and social science research (Kim et al., 2017).

Quantitative research is often considered a superior scientific method to qualitative research (Shuval et al., 2011). However this study needed a method that fit with nursing philosophies, as the data is descriptive and takes place in a real-life setting (Welford et al., 2011). Content analysis was used to analyse themes and patterns that emerged, consistent with a descriptive qualitative study (Polit & Beck, 2014). Educators need to take responsibility and ensure that educational interventions do what they are intended to do. Therefore, it was important to understand if there was an empathetic and/or compassionate response (Levett-Jones et al., 2019).

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METHOD

To ascertain the language used in conjunction with the key terms “empathy” and “compassion”, as they are defined in the literature, a search string was created using (compassion*) AND (empath*) AND (other) to generate a literature search. The search parameters were literature that was: no older than 10 years, written in English, a peer-reviewed journal article, and relevant to the discipline of nursing. This resulted in 46 journal articles, from which 12 were selected, by reviewing the title and abstract.

Data collection took place after each of the five workshops, with the nursing students writing self-reporting statements, using free text, about how they experienced the education intervention in relationship to their development as a nurse. Data were collected anonymously. The language used by the students was examined using content analysis (Polit & Beck, 2014), and was subsequently coded manually as it correlated with the subcategories of empathy and compassion found in the literature.

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ETHICS

Ethics approval for this study was granted by the Western Institute of Technology Taranaki research committee, which identified it as low risk. This research was considered to be non-interventional. However, all participants were from the second-year cohort of the bachelor of nursing, whom the researchers were teaching, therefore the risk of coercion was acknowledged. The design of the research project was clearly explained to potential participants, including that data collection was anonymous, and participation was not compulsory. Steps were taken to maintain anonymity, so the researchers were not aware who participated, and who did not.

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EDUCATIONAL INTERVENTION

The design of this educational intervention addressed the need to widen nursing students’ view of the patient experience, to expand and deepen their knowledge, while building their capacity for empathy and compassion, within the constraints of the curriculum. Narrative as a pedagogy can engage nursing students in critical thinking by triggering personal reflection and making connections between textbook knowledge and learning in the real world. It also encourages them to look beneath the surface to understand a person’s story in a social context, that has personal consequences (Brady et al., 2016). Learning facilitated through listening to narratives results in a different way of thinking; personal assumptions are challenged and the ability to consider situations more widely is developed, especially for younger learners with less life experience (Morrison, 2010).

The educational intervention was designed with the understanding that patients can be expert teachers, and telling their illness stories has an effect on the empathic response of nursing students (Ferri et al., 2019). A specific mental health and addictions concept was explored during each of the five workshops – depression; psychosis, including schizophrenia; bipolar affective disorder; addictions; and suicide and self-harm. In preparation for each workshop, students were given information about the mental health concept that each particular workshop focused on. Two hours were set aside for each workshop, which involved a face-to-face interaction between a small group of nursing students, and either a person with experience of mental illness or addiction, or a whānau member who had supported someone with such experience.

Before the workshops, each group of six to eight students were asked to develop potential questions, and organise seating, greetings and karakia. All students were expected to take an active part. Participants from Yellow Brick Road (an organisation which supports families who have a member suffering mental distress) had two rotations through the small groups, which resulted in each small group having the opportunity to listen to the illness story of someone with a lived experience of mental illness or addiction, and a whānau member, who had supported someone with a lived experience of mental illness or addiction.

After each workshop, each group of students reflected on their learning. Key points from the group discussions were then shared with the whole cohort, and the workshop concluded with the students being invited to self-report anonymously, what they felt they had learned about being a nurse, in relation to those who experience mental illness and addiction. These self-reports were collected and formed the data used to understand if the learning experience had resulted in an empathetic and/or compassionate response.

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RESULTS

Data collected from the five workshops were connected to the individual mental health and addictions concepts being explored by the students. The cohort size was the number of students enrolled in the course, with the participant number representing those that attended each workshop. Workshops were run over five weeks with all of those attending choosing to take part in the study and provide data. This was deduced from the total number of self-reports collected. The data collection numbers, while not large, are a high proportion of those who could have participated (see Table 1 below).

Table 1: Cohort size and number of students who participated in each workshop

Case-based concept	Depression	Psychosis	BPAD#	AOD*	Suicide
Cohort size	39	39	39	36	36
Participant number	37	37	36	35	31
Total number of self-reports collected	37	37	36	35	31

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FINDINGS AND RESULTS

Table 2 shows a selection of self-reported statements from the students, which relate to key words consistently identified from the literature as being connected to compassion.

Table 2: Examples of language used that demonstrated compassion

Language indicating compassion	Nursing students’ self-report statements
Empathy	“The biggest thing for me is to understand and support the person by giving them hope.”   “Empathy of the nurse has a large impact on recovery.”   “The best thing a nurse can do is be nonjudgmental.”
Caring	“Taking time to really care, not just do assessments.”
Respectful	“As a nurse, bring present, not just doing tasks.”   “All patients deserve respect no matter how they got to where they are.”   “Ask the patient how they would like to be treated.”   “Treat patients as people, not labels.”
Self-aware	“As student nurses, we have the opportunity to make a change . . . to change discriminatory behaviours.”   “Nurses should spend more face-to-face time with patients.”   “You don’t have to be perfect, just present.”   “As nurses, being genuinely empathetic and compassionate and truly listening to our patients is one of the most valuable tools to build therapeutic relationships, trust and provide a sense of comfort for the patient.”
Validating	“Listen to the patient when they are talking about themselves because they know their bodies best.”   “Patients need to be listened to and treated with compassion.”
Active listening	“As nurses, being genuinely empathetic and compassionate and truly listening to our patients is one of the most valuable tools to build therapeutic relationships, trust and provide a sense of comfort for the patient.”   “The importance of listening and allowing the client to speak.”   “Importance of health-care professionals listening and understanding.”

The findings are outlined in tables 3 and 4, and are presented in two sections, under the headings “empathy” and “compassion”.

Table 3

Empathy subcategories	Number of self-reports in which this was expressed
Empathy	10
Listen with understanding	76
Feeling with	9
Self-aware	33
Validates	11
Allows opportunity to express needs	2
Total number of self-reports in which empathy was expressed	141 = 80.1% of total number of self-reports

Table 4

Compassion subcategories	Number of self-reports in which this was expressed
Compassion	11
Person-centred	22
Connection, open, approachable	14
Caring	2
Intelligent kindness	1
Respectful	6
Emotional intelligence	12
Non-judgmental attitude	50
Total number of self-reports in which compassion was expressed	118 = 67% of total number of self-reports

The content of the data was analysed based on key words identified in the literature that defined empathy and compassion. Results indicate a significant number of students expressed empathy and compassion, following the educational intervention.

“Empathy” was identified by the following language: using the word “empathy”, listening with understanding, feeling with, self-aware, validating, allows opportunity to express needs.

“Compassion” was identified by the following language: the desire to alleviate another’s distress; compassion; person-centred; connecting; open; approachable; caring; intelligent kindness; respectful; emotional intelligence; non-judgmental attitude.

Empathy

Data from all five workshops are combined and represented in Table 3. The key words identified by the authors from the literature are shown, along with the number of self-reports in which these were expressed listed in numerical form. “Listening with understanding” was noted as the top occurrence, as an expression of empathy. Overall, there appeared to be a significant number of times empathy was expressed following the five workshops, with 80 per cent of the self-reports showing students expressed empathy towards those with mental health and addiction experiences.

Compassion

The key words identified by the authors from the literature that express compassion are shown in Table 4, with the number of self-reports which express these listed in numerical form. “Being non-judgmental” occurred most often as an expression of compassion. Overall, there appeared to be a significant number of times compassion was expressed by the students following the five workshops. However, as empathy is considered to be a part of the development of compassion, the lower number of times compassion was expressed (67 per cent), compared to empathy (80 per cent), showed the students could still be developing compassion. On the other hand, the results might indicate compassion fatigue (Jack, 2017).

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DISCUSSION

Furnishing empathy and compassion is core business for nurses, particularly those caring for people who experience mental illness (Gerace, 2020). While there are a number of studies that have considered empathy, there are few that have examined the development of empathy in nursing students (Levett-Jones et al., 2019). This study has attempted to understand whether an educational intervention, using patients as expert teachers sharing narratives, triggers empathic or compassionate responses in nursing students. It is interesting to note that while the academic world finds compassion difficult to measure, the recipients of care can detect such qualities in nurses’ behaviour (Blomberg et al., 2016).

The findings of this study support the assumption that the educational intervention results in an expression of empathy and compassion. However the data collected shows a higher expression of empathy. This may be due to the underdevelopment of compassion in second-year undergraduates, because they tend to be young with limited life experience. However it may also indicate compassion fatigue, which has been reported to occur as the student advances through their training (Jack, 2017).

The feedback language observed in the data (Table 2) does nonetheless explicitly indicate powerful expressions of compassion, which correlate with how it was discussed or defined in the literature. The values and beliefs of the nursing students are also evident in the language used, along with the notion that those with a lived experience were ordinary people, just like themselves. Compassion is the result of cognitive empathy, that sets the tone of the compassionate relationship between the undergraduate nurse and the patient (Tan et al., 2021).

Nurse academics who set curricula need to understand that mental health and addiction teaching and learning should be part of a broader holistic understanding of who a person is, in the context of their own life story. This study suggests that through experiencing narrative learning, nursing students will become better listeners, who are more attentive to people’s needs. Thus they are moving from a biomedical model to a more holistic psychosocial model of thinking and caring (Happell et al., 2014a). The language used in the students’ self-report statements (Table 2) indicates an understanding of what it might be like to “walk in another person’s shoes”, allowing the students to gain an understanding of the feelings, perspectives, experiences and needs of another person (Levett-Jones et al. 2019).

The results indicate that the use of narrative as a teaching and learning pedagogy, using patients as expert teachers, can facilitate the development of empathy and compassion in nursing students, leading to real changes in their understanding of people’s lives (Happell et al., 2015). This is an important finding, as empathic relationships, built on trust, are core to effective nurse-patient relationships (Gerace et al., 2018). The literature suggests there is a generalised lack of empathy among nursing students, resulting in compromised patient outcomes (Levett-Jones et al., 2019). Furthermore, Trzeciak et al., (2017) state there is an overall lack of compassionate patient care, highlighting the need to address the issue, given the positive impact compassionate care has on patient outcomes.

The findings also add weight to the importance of the learning that can take place when partnerships are developed between nurse academics and those who have a lived experience -– those who are experts on their own life story. The language used in some of the student self-reports (Table 2) also indicates that listening to the narratives led them to have a sense of “knowing the patient”. The literature suggests that when the nurse “knows” the patient, as they exist in their own life story, therapeutic relationships are formed, and safe and effective nursing decisions about care are made (Johansson & Martensson, 2019).

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RECOMMENDATIONS

The use of narratives from those with lived experience, in the role of expert-patient teachers, to develop empathy and compassion is about making human connections during experiential learning. This often leads students to an emotional state which increases their innate capacity to empathise and be compassionate, which is shown in our data. An educational intervention such as this could be included in nursing curricula to encourage experiences of empathy and compassion in nursing students.

Further research could be done, using pre- and post- data collection, to measure nursing students’ attitudinal changes towards those who have experienced mental illness and/or addictions. Data would be collected before and after the educational intervention. Data for this study were collected about the responses of empathy and compassion at the time of the experience, whereas pre- and post- data would help establish if there were a change in levels of empathy or compassion. There is also scope to explore and understand how students move from empathy towards compassion.

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CONCLUSION

Contemporary mental health and addictions teaching and learning practices should include the expert knowledge of those with lived experience. Although people with a lived experience have been used in undergraduate curricula for a number of years, it is mostly in the capacity of face-to-face teaching of a whole class, in curriculum development, or for assessment (Happell et al., 2015). The intervention in this study allows for an intimate experience, where the sharing of the narrative between the lived-experience participants and the nursing students has the capacity to positively influence the values and beliefs of the students (Corrigan, 2011). This could lead to delivery of care that is more compassionate, which meets the needs of those receiving the care, regardless of the health-care setting.

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LIMITATIONS

This study used one small cohort from one nursing school. The study would have been made more credible by using a reliable tool to collect data. Using focus groups, or structured/semi-structured interviews, would also have provided more rich data, and would have added to the credibility of the data collection by allowing for triangulation. A quantitative approach ideally has pre- and post-testing, therefore a validated tool to measure empathy would have been required. This study, however, did not intend to measure the levels of empathy and/or compassion that the undergraduate nurses had, as this was part of the second year of learning, and other learning activities, that potentially influence empathy and/or compassion, had also been experienced by the study group (Levett- Jones et al., 2019).

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ACKNOWLEDGMENTS

The authors would like to acknowledge personnel from Yellow Brick Road (trading as Supporting Families NZ) who helped develop our idea into an education intervention that supports the learning of nursing students. We are grateful to those people who shared their lived experiences in the classroom. Without you, this powerful way of learning would not be possible.

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