Caring about caring: Developing a model to implement compassionate relationship centred care in an older people care setting

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    International Journal of Nursing Studies 50 (2013) 12471258

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    ring about caring: Developing a model to implementmpassionate relationship centred care in an older peoplere setting

    linda Dewar a,*, Mike Nolan b

    ulty of Education, Health and Social Sciences, Hamilton Campus, Caird Building (Room 2.3), Almada Street, Hamilton ML3 0JB, United


    iversity of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AUU, United Kingdom

    What is already known about the topic?

    Relational knowledge is important in delivering highquality care particularly in care settings for olderpeople.

    T I C L E I N F O

    le history:

    ived 28 June 2012

    ived in revised form 18 November 2012

    pted 27 January 2013


    reciative inquiry


    ng conversations


    r people

    tionship-centred care

    A B S T R A C T

    Aim: This study actively involved older people, staff and relatives in agreeing a definition

    of compassionate relationship-centred care and identifying strategies to promote such

    care in acute hospital settings for older people. It was a major component of a three year

    programme (the Leadership in Compassionate Care Programme, LCCP) seeking to integrate

    compassionate care across practice and educational environments.

    Background: Compassionate caring and promoting dignity are key priorities for policy,

    practice and research worldwide, being central to the quality of care for patients and

    families, and job satisfaction for staff. Therapeutic relationships are essential to achieving

    excellence in care but little is known about how to develop and sustain such relationships

    in a culture that increasingly focuses on throughput and rapid turnover.

    Approach and methods: The study used appreciative inquiry and a range of methods

    including participant observation, interviews, story telling and group discussions to

    actively engage older people, relatives and staff. A process of immersion crystallization

    was used to analyze data with staff as co-analysts.

    Findings: The study adds considerably to the conceptualization of compassionate,

    relationship-centred care and provides a model to aid staff deliver such care in practice,

    based on appreciative caring conversations that enable all parties to gain two forms of

    person and relational knowledge about who people are and what matters to them and

    how people feel about their experience. Such knowledge enables staff, patients and carers to

    work together to shape the way things are done. The study generated a model called the 7

    Cs that captures in detail the factors necessary to promote appreciative caring


    Conclusions and implications: The study demonstrates that engaging in appreciative caring

    conversations promotes compassionate, relationship-centred care but that these

    conversations involve practitioners taking risks. Such relational practices must therefore

    be valued and accorded status. Staff require appropriate support, facilitation and strong

    leadership if these practices are to flourish.

    2013 Elsevier Ltd. All rights reserved.

    Corresponding author. Tel.: +44 7511106411.

    E-mail addresses: (B. Dewar), (M. Nolan).

    Contents lists available at SciVerse ScienceDirect

    International Journal of Nursing Studies

    journal homepage:

    0-7489/$ see front matter 2013 Elsevier Ltd. All rights reserved.://

  • B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 124712581248

    The type of relational processes and practices thatsupport compassion and caring require the developmentof skilled interpersonal relationships.

    What this paper adds

    A new practice model for compassionate relationship-centred care that helps to clarify both the meaning ofcompassion and how it can be achieved in everydaypractice with patients, relatives and staff. Central to the model is the articulation of caring

    conversations that represent an advanced and highlyskilful form of relational practice.

    1. Introduction: compassion, a concept looking for adefinition

    Concerns about standards of hospital care for olderpeople have been apparent for decades (Norton et al.,1962; Townsend, 1966; Robb, 1967) and recent interna-tional literature suggests that rather than being amelio-rated these concerns are being exacerbated as levels offrailty and acuity rise (Clarfield et al., 2001; Youngson,2008; Edvardsson et al., 2010). Therefore as Clarfield et al.(2001) rightly assert, this is now an internationalproblem. This paper describes the development of amodel of compassionate relationship-centred care, thatwhilst developed in the UK has global relevance.

    Despite over a decade of effort to improve the care ofolder people in the UK (Davies et al., 2007; HAS, 2000,1998; DoH, 2001, 2006; Nolan et al., 2001) several recenthigh profile reports indicate that unacceptable standardsof hospital care for older people remain prevalent(Abraham, 2011; Care Quality Commission, 2011; Nichol-son and Oliver, 2012; Tadd et al., 2011). Consequently,considerable policy and practice attention has been givento promoting dignity and models of practice that arecentred around relationships (Darzi, 2008; DoH, 2009,2012; Goodrich and Cornwell, 2008; Scottish Government,2011), with compassion being identified as a core valueunderpinning the National Health Service in the UK (DoH,2009).

    Yet what compassion means in this context and how itcan be achieved in everyday practice is far from clear.Without greater clarity compassion is likely remain littlemore than a rhetorical and political device which tripseasily off the tongue but remains elusive, particularly in ahealth care culture that is dominated by productivity,efficiency and effectiveness, and promotes quick fixsolutions to the caring problem (Finfgeld-Connett,2008; Goodrich and Cornwell, 2008; Watson, 2006;Youngson, 2008). The current focus on metrics (Pattersonet al., 2011) has spawned a plethora of tools to measurethe caring dimensions of practice (Watson, 2006, 2009)and whilst these go some way towards identifying thoseaspects of care that matter to people, they fail to capturethe complex relational practices necessary to achievecompassion (Parker, 2008; Williams et al., 2009). Further-more, although recent initiatives in the UK such asReleasing Time to Care (NHS Centre for Improvement

    Schwartz rounds (Goodrich and Cornwell, 2008) tacitlyacknowledge the importance of caring they do notnecessarily support frontline staff to develop sustainablereal time strategies to ensure high quality care in day-to-day practice.

    Making explicit what compassion comprises of andhow it can be realized is challenging due to its largelyinvisible nature (Liaschenko and Fisher, 1999). Writing ofhealth care in the US these authors stress the importance ofrelational knowledge to ensuring high quality care.Others in the UK have started to identify the relationalpractices necessary to achieving compassionate care(Parker, 2008; Williams et al., 2009; Smith et al., 2010).This paper describes a study that more fully articulates thetypes of relational knowledge that underpins compassionfrom the perspectives of older people, relatives and staffand considers how such knowledge is generated and usedin practice in the form of appreciative caring conversations(Dewar, 2011). It presents the most comprehensive modelyet developed of the behaviours staff need to engage in toencourage such conversations. It begins with a briefconsideration of a systematic narrative synthesis thatdelineated the key dimensions of compassion beforeconsidering the background to the study on which thispaper is based.

    2. Compassion: we know what we say but what do wemean?

    Prior to the empirical work, a comprehensive narrativesynthesis of the extant literature on compassionate careusing the key terms caring, compassionate care, dignity,relationship-centred and person centred care, was under-taken (see Dewar, 2011 for a full account). A pragmatic andinclusive approach was adopted with Medline, CINAHL,PsycLit and Index to Theses being the principal sourcesused to identify policy documents, theoretical and researchliterature, discussion and opinion pieces and newscommentary. Over 500 items were obtained for reviewand critical appraisal.

    The resultant synthesis revealed that consensus as to adefinition of compassion was lacking and that there was nocomprehensive model indicating how it could be achievedin practice. However, key attributes were identifiedincluding: recognizing vulnerability and suffering; relatingto the needs of others; preserving integrity and acknowl-edging the person behind the illness (Dewar, 2011). Inessence therefore compassion primarily involves anawareness of anothers feelings, an appreciation of howthey are affected by their experiences and interacting withthem in a meaningful way (Dewar et al., 2011). Therefore,compassion can be considered as having four essentialcharacteristics:

    1. a relationship based on empathy, emotional support andefforts to understand and relieve a persons distress,suffering or concerns;

    2. effective interactions between participants, over timeand across settings;

    3. staff, patients and families being active participants in

    and Innovation, 2011) and internationally, such as

    decision making; and

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    B. Dewar, M. Nolan / International Journal of Nursing Studies 50 (2013) 12471258 1249

    ontextualized knowledge of the patient and familyoth individually and as members of a network ofelationships.Adapted from Lown et al. (2011).The relational processes and practices that support

    passion require the development of skilled interper-al relationships (Cash, 2007; Congressi, 2006; Criggerl., 2006; Dewar et al., 2010; Jull, 2001; Kanov et al.,4; Kim and Flaskerud, 2007; Macleod and McPherson,7; Milner, 2003; Peters, 2005, 2006; Schantz, 2007;ultz et al., 2007; Torjuul et al., 2007; Von Dietze and, 2000; Youngson, 2008). However, what is absent from

    extant literature is a model that articulates how suchtionships can be established and enabled to flourish inctice.Current models of person and relationship-centred caress the importance of knowing the person in order toieve a human connection often defined as being with

    patient (Dewing, 2004). However, as Dewing (2004)es this highly skilled activity requires specific inter-sonal competences rather than technical expertisehultz et al., 2007). We need to understand how sucherpersonal competence can be understood (Doane,2). That was one of the primary aims of the present

    dy.To do so the study, as with others, recognized theessity of actively involving staff, patients and families inloring the intricacies of compassionate care in daily care

    own Wilson, 2009; Dewing, 2004; Koloroutis, 2004;Cormack, 2003, 2004; Meyer and Owen, 2008; Nolanal., 2004; Tresolini et al., 1994; Watson, 2006) andpted an appreciative inquiry approach to achieve this. The study was a core element of a comprehensivegramme called the Leadership in Compassionate Caregramme (LCCP), a three-year action research projectertaken by Edinburgh Napier University and NHS

    hian with the goal of establishing compassionate carean integral aspect of all nursing practice (Edinburghier University and NHS Lothian, 2012). The first author

    s a member of the LCCP research team. The study that thiser reports took place between January 2008 and January9 on a 24 bedded mixed-sex ward for older people.

    Design/research approach

    In recognition of the high quality of care it provided thet in question was awarded beacon ward status in theP programme and it was important that the metho-

    ogy adopted built on what was currently working well.reciative inquiry (AI) starts by exploring what people

    ue in what they do and how this can be built on rathern focusing on problems (Cooperrider et al., 2003;perrider and Whitney, 2000; Kowalski, 2008; Reed,7). In this study AI was combined with action researchensure an emphasis on developing and evaluatingctice change. A collaborative approach, which focusedreal time feedback, and reflection and evaluation onitive attributes to develop practice, were central to thethodology (Dewar and Mackay, 2010; Egan and Lan-ter, 2005; Kavanagh et al., 2008). The four principles for

    and collaborative (Cooperrider and Srivastva, 1987). Theseprinciples were woven into all aspects of the study. AItypically involves a number of phases described in Table 1.The basic process of AI is to begin with a groundedexploration using a range of methods to identify the bestof what is (discovery phase), subsequently visioning anddebating with a range of stakeholders articulates whatmight be (dream phase), followed by working together todevelop what could be (design phase) and finallycollectively experimenting with what can be (destinyphase) (Moore, 2008). In the design phase, cycles of changeare developed which are then implemented and evaluatedin the destiny phase. In addition the principles ofrelationship-centred inquiry and action research wereapplied which included: understanding what was happen-ing and developing practice with all key stakeholders, andworking in democratic and participative ways to supportpeople to develop practice. The first author acted as anappreciative inquirer working on the ward for one yearapproximately two days a week. The challenges andbenefits to using this approach are described more fullyelsewhere (Dewar, 2011).

    3. Participants

    A range of staff including registered nurses, non-registered care staff, allied health care professionals andmedical staff (n = 35 i.e. 85% of staff), patients (n = 10) andfamilies (n = 12) took part in the study. Staff were asked toinvite patients and families to take part and deciding who toinclude was pragmatic based on factors such as, how wellpatients were at the time and whether the lead author waspresent on the ward that day. The sampling is therefore bestdescribed therefore as purposive (Creswell, 2003).

    4. Ethical considerations

    The research was approved by the University EthicsCommittee. Due to its emergent design ongoing processconsent was used whereby consent was continuallyrenegotiated (Dewing, 2007; Winter and Munn-Giddings,2001). Where participants were from potentially vulner-able groups (e.g. those with a serious or terminal illness)discussion took place with both the health care profes-sionals involved in the...


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