Andy Bradley, Frameworks 4 Change

Published in JHH13.1 – Shaping the invisible

I founded Frameworks 4 Change 11 years ago as I felt so unsettled by the pervasive culture in health and social care which is driven more by the forces of competition and regulation than those of compassion and our shared humanity. Having spent part of my childhood living in a care home established by my parents (which operated as a compassionate community) I now realise I caught a glimpse of how good and kind we can be given the right conditions. We all matter and we all need to belong.We must join with each other to write a wiser, more collaborative and integrated story of health and care.This article is my attempt to summarise how our Frameworks 4 Change work developed, its impact and our direction of travel into the future.

Most participants felt strongly that compassion circles could be used to look after their own wellbeing Click To Tweet Compassion is not something abstract. The catastrophic failings of care revealed in the report on Mid Staffs and the Panorama exposé of shocking abuse at Winterbourne View provoked widespread calls for NHS and social care staff to be more compassionate. But I am convinced that speaking about compassion as if it were some disembodied abstract commodity may do more harm than good. For if those calling for a compassionate collective response are not themselves in a state of compassion this creates a fundamental problem. Apart from any other consideration, assuming a general lack of compassion among health and social care professionals and then exhorting them to do better is extremely damaging to morale.

Inclusive compassion

Why is the narrative about compassion so often about other people? A central problem in our understanding of how to cultivate compassion in our health and care system is that we project on to those using these services (that will include most of us eventually) that they are the ones at risk of a compassionate deficit. Why do we so often hear about a lack of compassion for patients but so little about compassion for the people whose job it is to serve them? In fact if compassion can’t flow from self to self and from others to self then it’s more like pity than compassion. In such a deficit model as this, where there can never be enough compassion to go round, any spare compassion and kindness remaining in the system has to be passed on to patients, and those providing the care will be left out.

The development of compassion circles

Since its inception in 2004, Frameworks 4 Change has engaged in an ongoing enquiry into compassion in health and social care, and the conditions that allow it to flow. I was fortunate to spend part of my child[1]hood living in what I now think of as a compassionate community (a care home), which was home to both my family and older people living with dementia and in need of care and support. Having spent 15 years working in health and social care environments in care and support roles and then as a leader I realised there was a gap between the culture and practice I grew up with, and the current pervasive culture in health and social care.

In our ongoing enquiry we use Professor Paul Gilbert’s definition of compassion. He views compassion ‘as a sensitivity to the suffering of self and others with a deep commitment to try to relieve and prevent it’. Compassion, he says requires courage and dedication. Courage allows one ‘to approach, understand and engage with suffering, to look into its causes; and working to acquire wisdom and skills to alleviate and prevent suffering requires dedication.

Our work is much influenced not only by Paul Gilbert’s Compassionate Mind Foundation, but also the writings of Nancy Kline (Time to Think), Jon Kabat-Zin (Full Catastrophe Living) and Charles Duhigg (Power of Habit). As our project evolved, it has centred around three questions:

1. What is it that activates a fierce commitment to self-compassion?
2. How can we systematically grow safe and soothing spaces for reflection on the inhibitors and facilitators of compassion?
3. How can we make more rapid progress in evolving systems that enable and encourage us to be more human with each other?

Compassion circles developed as a response to these questions. The first two-and-a-half-hour compassion circle took place in South Tyneside in June 2013. There, we provided a space for health and social care leaders to come together to talk about self-care, about blocks to compassion and ways of growing a more compassionate system. One of the senior NHS leaders at the meeting (whose work is centred upon kindness in teams) was in touch next day to suggest that a one-hour version of the compassion circle would have the potential to roll out nationally.

This led us to design a one-hour compassion circle for up to 12 participants. Our vision was for all health and social care workers never to be more than a month away from their next safe, compassionate ‘top up’ where they could reconnect with their meaning and purpose, have space to think about self-compassion and to focus on inhibitors and facilitators of compassion.

In these early days Professor of Psychology Steve Onyett, who energetically supported us (see note at end), had this to say after attending a training session for circle facilitators in Exeter:

Zimbardo (‘The Lucifer Effect’) argues that “If you want to change the person you’ve got to change the situation”. In this he is asserting the importance of culture: how we do things around here. I have recently explored the issue of cultures of compassion and how to prevent the tragedy of the failures of care in Mid Staffordshire happening again and again. In order to understand a culture we observe others and act in order to see how the system responds. We are hard-wired to do this very quickly. Compassion Circles have the potential to promote different ways of being by offering a space where I can witness the people around me, and myself in the process, when we are voicing our best values and hopes for the future.

Zimbardo highlights the chilling power of anonymity, citing research that shows how people can act in the most bestial ways when they are able to hide their identity (for example in military uniform). Compassion Circles encourage people to listen to themselves, focusing on what is being felt in the moment and to speak that truth. It encourages spontaneous expression of who I am being right now. In doing this it also counters one of the seven social processes that Zimbardo says “grease the slippery slope of evil”: the “de-individuation of self”.

Maxine Craig, former long-time leader of organisational development for South Tees Foundation Trust was one of the early adopters of compassion circle practice. She introduced it into the trust and, as part of NHS Change Day in 2014, also offered space for the practice in the Town Hall. Maxine reflected on how challenging it can be for people to think about self-compassion:

I come from a generation of healthcare professionals who were trained to “leave their emotions at the ward door”. Professionally socialised to believe that we, the nurses, were unimportant, that our patient’s needs were paramount and they were best served with kind[1]ness and compassion and technical expertise, which should always be on show, irrelevant of how you were actually feeling. We were taught that we should work hard, serve the patients, and that the work would be highly emotional but that we should be able to control that emotion and continue to care for others, putting our own needs to one side. Being authentic was not part of my initial training. The reward for this approach was that the honour of caring for others would sustain us. Now some of this is true and some of it we now understand better.

My work in the NHS will always be my calling, it is a true vocation for me, I came to make things better and the rewards of improving things, relieving suffering, fostering independence are indeed rewards without measure. However “leaving your emotions at the ward door” was possibly understandable as an instruction before we knew about such things as emotional labour, burn out and the importance of authenticity. What we now know changes things, the research into all these areas tells us that …

• to give our best we must be at our best
• and that means caring for ourselves, in order that we can care for others
• so if you do nothing else this week in your team, begin gently to ask the question “what could you do more of to care for yourself more deeply?”

Expect your colleagues to be quiet, a little uncomfortable, but please stick with it because in my experience it’s vital to the creation of great teams’.

Integrating compassion circles with other approaches

Relational intelligence

The Director of Patient Experience for the NHS in the South of England attended an open compassion circle in March 2014. At this time continuing healthcare (CHC) assessors were facing particularly high stress scenarios. They had a programme on communication skills whose lead trainer had previously led on design and training in an advanced communication skills course for cancer professionals.

Why do we hear about a lack of compassion for patients but so little about the people who serve them?

The patient experience team was wondering about the connections between compassionate practice (beginning with compassion for oneself) and a practitioner’s necessary ability to sustain their emotional connection and psycho[1]logical wellbeing despite being frequently involved with very difficult conversations. We therefore piloted a programme integrating a compassion circle into communication skills training, and this was well received by participants.

This programme for CHC teams, which continues to evolve, is now rolling out nationally. A report on the programme’s success invites a deeper enquiry into capacity-building. If, as this report implies, compassion is a process which supports practitioner resilience, good communication and better patient experience, circles could become more widely accepted as a way of supporting the growth of healthy compassionate organisations. Recognising the way the programme has evolved the work is now described as an ‘advanced relational skills programme’ and the trainers have developed a working definition of relational intelligence:

The skills, knowledge and experience required to relate effectively, both intra-personally (self-to-self) and interpersonally (self-to-other); this includes relationships at communal and societal levels as well as the less than conscious aspects of our relational patterns’

The trainers felt that this term captured the spirit and themes of the day: acknowledging the difficulties in our working relationships; becoming more aware of how we get stuck in unhelpful relational patterns; and practising how to relate in more intelligent and caring ways towards ourselves, our colleagues and service users.

Mindfulness in the evolution of compassionate organisations

A large mental health trust in the south which has been leading the way in implementing mindfulness-based approaches has paved the way for the development of a mindfulness centre. Psychologists and researchers from the centre were curious about compassion circle practice and how it might complement its already well-established mindfulness work for patients and staff.

Based on the feedback report from five compassion circles in the trust we evaluated participants’ attitudes towards the compassion circles.

All participants said they had a positive experience of the compassion circles. Satisfaction was rated high (mean = 7.71). Most participants felt strongly that compassion circles could be used to look after their own wellbeing (mean = 7.35), and the wellbeing of colleagues and clients (mean=7.16). But they were more moderate in rating the extent to which the circle helped them see the trust differently (mean = 5.99).

In our ongoing collaboration with senior leaders and the mindfulness centre, we have been presenting at conferences on leadership, mindfulness and culture change. Most recently senior leaders took part in a two[1]day programme (‘Engaging meetings’) aimed at transitioning compassion circles from being ‘pure’ practices of mindfulness, towards becoming integrated into the everyday business of running a large complex high pressure NHS trust. The aim of engaging meetings training is to help the emotional tone of compassion circles to cross over into organisational life and create the safe psychological conditions that enable healthier, more productive meetings to happen. Engaging meetings trainees are forming a community of practice. Responding to a question about the most useful aspects of the programme one of the participants said: ‘Bringing in humanity and vitality to de-humanised systems. Practicing ideas for how to run meetings differently – offering a different culture’.

Can compassion circles and related practices spread?

At times it feels as though there are only two problems with spreading the practice – the first is the word compassion and the second the word circle!

In our overstretched dehumanised health and care system, sitting together in a circle taking turns to think and being invited into an awareness of our own and each other’s needs is counter-cultural. Yet there are grounds for hope. As the general sense of crisis and of urgency around the need for cultural and systemic change grows, circle practice alongside mindfulness and advanced communication skills is finding a home inside the system. After attending a two-day compassionate practitioner programme, a care home manager decided to take matters into his own hands. Instead of the hour we usually set aside, he and the participants only needed 29 minutes to attain what he calls Ancient Wisdom.

The afternoon of the meeting was a busy one and staff entered the room flushed with their efforts and the stresses of the day. They were initially wary of the circular seating arrangement but all listened intently as I explained the format of the meeting and we concentrated on our breathing and clearing our minds of distractions. The silence was eventually broken by me informing the group of our question which was “How can we encourage others to be more compassionate”

The first responses to the question were that people were either compassionate or they were not, and that we could not teach people to be compassionate. Others felt that leading by example was important. Gradually as we went round the group, people began to recount influences and experiences that had affected them and instilled in them the importance of compassion for others. Tales of lost loved ones and people who had touched their lives in a meaningful way were told, some tearfully, some with deep affection but all contributed to the group’s understanding of the effect that compassion had had upon their attitude to others. The stories were incredibly moving and powerful.

On the second round of comments it became clear that the group had come to a unanimous answer to the question of how we encourage others to be more compassionate. The answer was that we must show others compassion ourselves. We all felt that it was the compassion that we had been shown in our own lives that had made us feel compassionately towards others.

We ended with a round of thanks and they left with smiles and a much more positive outlook towards their work. Two members of staff actually shook my hand and said that they had enjoyed listening to what others had said as well as being listened to themselves. All said that they were looking forward to the next meeting and inviting others to attend.

Reflecting on the meeting I was struck by the simplicity and beauty of the answer that the group had come to. I was also surprised at how it mirrored the message of so many ancient philosophies, religions and teachings.

 Ancient wisdom….. in 29 minutes.

Acknowledgements

Along with many of Professor Steve Onyett’s friends and family we were devastated to hear of his sudden death in September 2015. Steve died suddenly as a result of a cardiac arrest – he was cycling across Palestine to raising funds for Medical Aid for Palestine at the time. Steve was one of the most ardent advocates of compassion circles and his passion kept us going through times of adversity and criticism. Together with Steve’s partner we are thinking about future compassion circles being renamed Onyett circles in his memory and with the intention that his spirit lives on through the practice.

We are indebted to Professor Paul Gilbert and colleagues at the Compassionate Mind Foundation and to Jon Kabat-Zin and Nancy Kline for pioneering new approaches which help us to be human in this complex and frightening world of ours.

We acknowledge all of the inspiring people we have been privileged to work with in the health and care sector – your energy, courage and vision gives us the determination we need to carry on.

Please be in touch to discover more about compassion circles and our work.

andy@frameworks4change.co.uk