Teaching empathy and resilience to undergraduate nursing students: A call to action in the context of Covid-19.

Introduction

There is a compelling narrative in research, practice, and education that resilience is an important component in an individual's ability to cope with clinical nursing practice (for example, Taylor, 2019). The need for compassion in practice is emphasised (NHS England, 2019) with (in our view) the implication that nursing often lacks this attribute. Patients justifiably expect to be cared for with competence, kindness, and compassion, and the opportunity to demonstrate these qualities is what attracts many to nursing. But when nursing students and nurses are exhausted and burnt-out, it is unlikely that they can care compassionately for others.

In addition to the challenges of healthcare practice that student nurses may experience in ‘usual’ times, the advent of the Covid-19 pandemic brings with it a new reality. Student nurses are at the frontline of healthcare practice with, in some countries, changes in regulatory practices that enable students to appropriately use their knowledge and skills in ways that go beyond what was previously the norm (NMC, 2020).

To spark debate about these ‘contemporary issues’, we present a series of three papers for different audiences (i.e., nurse educators; front-line nurses; health system leaders and managers) to explain the relevance of empathic healthcare cultures and constructs such as empathy, emotion regulation, compassion, and self-care to sustain wellbeing, resilience and effectiveness in these volatile times. In this first paper in the series, we discuss theory of emotion regulation and the ways in which nurse education can support its development in student nurses to support the development of resilience.

In this paper we explain how empathic healthcare cultures and constructs such as empathy, emotion regulation, compassion and self-care are relevant to sustaining wellbeing, resilience and effectiveness. We suggest that student nurses need to be supported to learn to better regulate their emotions through self-care practices to prevent distress and burnout, particularly within the context of this global pandemic. This article seeks to address the dissonance that we believe exists: between the ideal scenario that negates the need for individual resilience, and the reality of clinical practice where resilience is required, with some practical strategies that nurse educators can implement to address the challenges. We assert that nurse education needs to place an emphasis on the development of emotion regulation which will go some way towards supporting the development of resilience in student nurses. In these unprecedented times, it is more urgent than ever to support students to develop emotion regulation.

We believe that we should be educating nurses to become capable of resilience, of avoiding burnout by developing emotion regulation, and who are also able to become the future practitioners who build organisational empathy. With regards to the latter, we believe that there must be a ‘tipping point’ at which many practitioners (a critical mass) who have these skills can make a difference to the critical organisational culture issues leading to sustainable organisational empathy. We are referring to factors that are identified within the NHS staff survey (NHS England, 2018) such as inadequate staffing levels, experience of discrimination, feeling unwell as a result of work, working additional unpaid hours, management taking an interest in staff health and wellbeing. The evidence is clear that organisational empathy and direct managerial involvement in the wellbeing of staff correlates with “a positive effect on patient satisfaction and health outcomes” (West et al., 2017 p.3). Even though as we write we are in the midst of the Covid-19 crisis, we strongly assert that we should debate these issues as part of the learning from the crisis that will, we hope, impact positively on the culture of healthcare practice.

This article underscores the crucial role of nurse educators in the education and development of nursing students to enable them to work effectively and to thrive in volatile contemporary healthcare environments. To meet this call to action, curricula must be evidence-based and address a range of current topics including those identified in Box 1 .

Alt-text: Box 1

Background

There is a crisis in the NHS workforce supply in the UK (Bungeroth and Fennell, 2018; Buchan et al., 2019). The NHS 10 Year Plan confirms that workforce growth has not kept up with workforce requirements, and that staff are “feeling the strain” (p.78) in part due to the large numbers of vacancies. Whilst the plan identifies the perceived need to “strengthen and support good, compassionate and diverse leadership” (p.79), it does not clearly acknowledge the level of challenge that staff are dealing with every day and nor does it put forward, in our view, innovative policy solutions that have the capacity to directly address these challenges. What we have seen as a response to the Covid-19 pandemic is rapid recruitment to healthcare posts and increasing numbers of hospital beds: not planned as part of a sustainable response to growing demand pre-Covid-19, but a reaction to the urgency of the situation.

What we also see, in the context of Covid-19 are student nurses being asked to work in clinical settings where they might have fears about the lack of personal protective equipment, being exposed to the virus themselves, and potentially ‘bringing it home’ and exposing family. Students are being asked to cope with an adapted reality, and a changing concept of ‘placement’ in these current circumstances. All this alongside the continuing challenges that impact on the culture of healthcare.

We argue that if we want to truly transform the culture of healthcare, we need to build a critical mass of nursing students who will go on to be the qualified staff who will make a difference and be able to build organisational empathy (a concept that we discuss later). As West et al. (2017) wisely assert, our staff are our greatest resource, and we need compassionate, collective leadership to enhance the individual and organisational experiences of healthcare practice. With empathy at the heart of their description of compassionate leadership, and the notion of “leadership of all, by all, for all” (p.9), we argue that student nurses must be prepared for the current realities of practice, and for making the changes that will impact on both the experience of work, and the outcomes for patients. A 2005 study (Maben et al., 2005) identified the disparities between the values, ideals and expectations that newly qualified nurses have, and the realities of their professional experience. Published 15 years ago, the problems that emerged from the study seem achingly familiar: structural and organisational constraints that prevent the enactment of these ideals.

Definitions

This section explores resilience, empathy, organisational empathy, emotion regulation, and burnout with the aim of developing an argument that empathic distress can undermine resilience and lead to ‘burnout’ resulting in sub-optimal patient care and detached staff. The purpose of this exploration is to set out the need for education in these areas for nursing students.

Resilience is defined as “the ability of an individual to adjust to adversity, maintain equilibrium, retain some sense of control over their environment, and continue to move on in a positive manner” (Jackson et al., 2007, p.3). As Jackson et al. (p.4) go on to say, nurses “bear witness to” all sorts of situations and experiences that go beyond the norms of everyday life and they therefore have the potential for empathic distress which, we assert, can in part undermine resilience and can lead to burnout and organisational ineffectiveness.

Empathy is defined as the ability to ‘feel with’ others when we are exposed to others' experiences whilst recognising that those feelings belong to another (Singer and Klimecki, 2014). “Empathy is as critical to quality patient care as it is to the wellbeing of professionals who deliver that care” (Ekman and Krasner, 2017 p. 172). Riess (2018) explains that empathy has three distinct components: affective (emotional) empathy – the ability to share the emotions of others; cognitive empathy – the ability to understand the emotions of others whilst appreciating that those emotions may be different from their own (also known as Theory of Mind); finally, empathic concern - “the inner motivation to respond and care about another person's welfare” (p.24). We understand this latter action as compassion. Empathic capacity is not a static state – it fluctuates. Mastering empathy is a vital ingredient for teamwork, collaboration, accommodating difference and diversity and ultimately safe patient care. For more information and a lengthy discussion on the associated social neuroscience evidence please see Hofmeyer et al., 2019, and Singer and Klimecki, 2014.

There is little in the literature about organisational empathy, although it is a term that in business sometimes refers to the psychology of working with people. When we talk about ‘organisational empathy’, we are conceptualising this as the ability of the organisation to understand what, in this case, can make the working lives of the staff better (Nichols and Ojala, 2009). Whilst of course the organisation itself is not a sentient being, it is made up of people and our argument is that we should work towards a greater understanding of the lived experience of the workforce, in other words the empathic organisation.

In order for empathy to be enacted well, the individual must be capable of emotion regulation which is the ability to tolerate difficult emotions when confronted with someone else's suffering without becoming overwhelmed by those emotions. If we over-identify with another person's suffering we may feel the need to get away from the situation, avoid the person, or reduce our awareness of their distress preventing a compassionate response, and potentially leading to empathic distress fatigue (Singer and Klimecki, 2014). The term ‘compassion fatigue’ has been used in the nursing literature to refer to this condition. Using Functional Magnetic Resonance Imaging (fMRI), neuroscientists have shown that inadequate emotion regulation (i.e. blurring of the ‘self-other’ distinction) means clinicians can experience the distress of others and typically withdraw to emotionally protect themselves. Subsequently this can lead to what is commonly termed ‘burnout’.

Burnout has been described as “the loss of the ability to care” (Schwenk, 2018, p.1543). The World Health Organisation (WHO, 2019) defined burnout as: “a syndrome resulting from chronic work stress that has not been successfully managed. Burnout is characterised by three dimensions:

feelings of energy depletion or exhaustion;

increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and

reduced professional efficacy.”

We argue that the development of resilience strategies enhances the ability to be empathic, in part therefore preventing empathic distress and burnout. Going back to our earlier discussion on organisational empathy, in order to lead to sustainable change within the healthcare system, the empathic organisation can make systemic changes that will address the causes of burnout in the culture and will increase individual resilience. To achieve the latter, awareness and understanding of the relevant theory is required, alongside leadership that is willing to make those changes. This is where education comes in.

Purpose of nurse education: what can it offer?

Whilst in the UK and elsewhere there is an educational emphasis on the demonstration of resilience, effective communication, and managing relationships, we believe that there is possibly a gap in that emphasis: the need for education that supports the development of emotion regulation incorporating a highly-developed sense of self and other (personal and professional boundaries). The aim here is to, in part, develop resilience for the realities of practice alongside a desire to change the status quo (leadership) and to be part of a new commonly held approach to developing organisational empathy.

Nurse educators have a critical role to educate and develop nursing students to be primed to work in contemporary healthcare environments, and in circumstances beyond what we might have understood to be possible in light of this current pandemic. This means that curricula need to address all the areas we defined above. Box 1 provides an overview of some of the areas that we believe should be covered within curricula. We acknowledge that, in the context of the current pandemic, it might feel more challenging to consider how education can address empathy. However, we assert that it is more important than ever and will continue to be so when the pandemic is over.

Educators need to consider how to educate in this area, as well as what is taught or learned. The following list is not exhaustive but provides examples:

Empowering the other person to take action by, for example, using coaching

Using reflection and critical analysis as part of a process of understanding experiences in practice

Peer to peer learning and support with a focus on experiences

Student-guided learning to enable the learning to be focused on important experiences

Facilitative techniques

Honest, curious conversations that open up the issues safely

Role play and other interactive learning techniques

Service user involvement with structured feedback and feedforward

Role modelling

The central point here is the importance of good communication, so we need to teach within a framework of affective and cognitive empathy. Teaching and using the evidence-base (e.g. the neuroscience) is vital so that the perception of the importance of this work is articulated through that evidence-base.

Discussion

Do we really expect students to ‘walk in another's shoes’? To really understand what it is like for any individual in any challenging situation? We don't need to do this to be useful as practitioners especially when we think about the situations that students will be working in as they try to manage the many emotional and practical challenges of Covid-19. And this is our over-riding point: that it is so important to create ways of being that enable empathy but ensure othering so that distress and burnout do not occur.

Awareness of the current evidence that demonstrates that the symptoms of burnout build up over time is crucial for students and qualified nurses to understand so that it is possible that this ‘secret issue’ can be identified early perhaps by others around those affected. This is why staff need to be educated about the current evidence and the strategies to promote ‘routine self-care’ and ‘urgent self-care’ when a major emotional disruption occurs that can trigger distress, withdrawal, exhaustion, and reduced efficacy (burnout symptoms).

We need students to feel the impact of empathic actions and of the empathic organisation. We are saying that if educators facilitate learning that models these ways of being, students will see and feel the differences to their own experiences. We are also asserting that, whilst each person does have a responsibility for self-care, it is the organisation that, as a collective, can make transformative differences through organisational empowerment and associated actions. Again, developing students who have this understanding and the leadership skills will lead eventually to a critical mass within organisations who actually can make that difference.

It is important to acknowledge that additional interventions may be needed depending on other issues in an individual student's life and, whilst we are promoting an embedded curriculum approach that incorporates self-awareness and self-care strategies, there will be times when professional therapy or support is required.

Conclusion

We have made the case that education plays a vital role in developing students' ability to work well and remain resilient in challenging healthcare environments, including in the context of a global pandemic. The evidence-based approach that we propose is extensive but, we believe, can be embedded within existing curricula. Yes, there is new knowledge but much of what we have described relates to how this knowledge is conveyed.

Resilient nurses will not only remain in the nursing workforce but will also provide higher-quality patient care (West et al., 2017). We make the case for change and hope to open up debate about how best to do this.

Credit author statement

Ruth Taylor: Conceptualisation, writing – original.

Annette Thomas-Gregory: Writing – review and editing.

Anne Hofmeyer: Conceptualisation, writing – review and editing.

Funding source

Not applicable.

Ethical approval

Not applicable.

Declaration of competing interest

Not applicable.

The individual

The organisation, and the individual's role in that organisation

• Strategies for resilience • Neuroscience – empathy, empathic distress, emotion regulation, self-regulation techniques, compassion, burnout • Professional (and emotional) boundaries • Empathic communications, increasing emotional awareness, self-awareness, self-reflection, how to perceive others' emotions, and other empathy skills • Self-care practices and self-compassion to maintain wellbeing including self-care care plans to improve physical, psychological, or spiritual wellbeing • Planning for self-care • Curious conversations i.e. those conversations to which we go openly and with curiosity so as to understand another's perspective or experience • ‘Straightforward’ language for honest interactions One example of a range of impressive resources that can help some of this learning is the ‘Virtual Empathy Museum’ website with its evidence-based resources:https://theempathyinitiative.org/virtual-empathy-museum

• The context of healthcare practice including the challenges • Organisational empathy and leadership (compassionate, collective) • Approaches to listening to the organisation • How to be part of the change • Ways of being together in an empathic ‘zone’ • Strategies to address workplace issues identified through listening and empathic/curious conversations e.g. buddy systems