Kindness is a delicate thing – as soon as you try to ‘operationalise’ it, or scale it up, something of its essence is lost. It brings to mind an image of a wild animal being brought into captivity. In an older people’s ward a terminally ill man commented that he appreciated a nurse making him a hot chocolate after she’d finished her shift. He felt that she went out of her way to be kind to him, he felt that he mattered, and he was touched – “She sort of broke the rules for me.” The well-intentioned ward manager responded to this by introducing a ‘hot chocolate round’ as part of the routine care on the ward; it became part of the ‘machinery’ of care rather than an act of spontaneous kindness.
Health care is a calling to so many people who are led by an instinctual, natural kindness. We believe that the act of caring is an invitation to engage with distress, disease and death, which in itself carries a necessary emotional cost. Caring cannot work in relieving pain and suffering unless the person being cared for can see an impact on the carer. This connection is the psychological and spiritual basis of transformation in suffering. Touching and being touched by the heart and mind of another creates the connection that enables relief and comfort. This happens from the cradle to the grave as all of us seek recognition and understanding in the responses of others. It is part of our common humanity.
Organisations can become structured to protect staff from some of the painful realities of people’s lives. For example, an emphasis on checklists of questions can bring apparent structure and certainty, rather than connecting with patients on an equal human level and responding to whatever comes up. A perceived need for staff to have a sense of detachment (often described as ‘being professional’) carries a risk of disengagement from the feelings necessary to build compassionate relationships with patients and colleagues. Part of professionalism is an intention to ensure that individual preferences and personal connections don’t cloud the process of objective, equitable decision-making. However, this emotional detachment can be at the heart of systemic care failings.
To care, we need to feel, but feelings can sometimes invite us down unhelpful paths. Feelings without thought can mean that sometimes we react in a totally inappropriate way, without consideration for others. The solution is to bring conscious awareness to feelings so that we can be aware of the emotion before we act and consider whether this is the best way to respond to the situation. This is a skill that people can learn and develop.
At a local level, reflective practice sessions or mindfulness groups might offer protected spaces for thinking and being, and not ‘doing’ all the time – spaces where our own and others’ vulnerabilities can be acknowledged and embraced. Feelings can be combined with thoughts. Individuals and teams are increasingly encouraged to reflect on what matters to them, as a way to reconnect with core values. Our experience is that sessions like these can be useful but are tough to set up and maintain. Also, they can have much in common with the way that individual therapy functions as a sticking-plaster for wider social issues. We must consider the ecology of the whole health-care system.
To care is an interpersonal matter that involves empathy, warmth and genuineness. These vital human qualities are the easiest things to experience subjectively, but in a health-care system that values objective outcomes the spiritual essence of care can become lost or diluted. Care can only be as good as the mental state of the carer, and the mental state of the carer depends in turn on the support and nourishment of the working environment.
Carers need nurturing relationships with other people so that their own energy can be constantly replenished. For this to happen, the needs of caregivers have to be recognised and the working environment has to be designed to meet them, in line with fundamental psychological needs.
What we call a ‘psychologically safe’ health-care environment is one in which everyone feels a sense of involvement; an environment where conversations routinely happen whose purpose is to talk through difficult feelings so that people feel refreshed and re-energised to carry on; an environment where not only the patients feel remembered and held in mind, but also the staff. One of the most practical steps, therefore, in ensuring good-quality care is to care for the care staff as human beings too. Simple behaviours that create psychological safety include conversational turn-taking, empathy and a freedom to “say what I think without fear”. We must be able to talk about what is messy or sad with openness, to embrace hard conversations with colleagues (for example in team meetings) with whom we are having difficulty. We acknowledge that these behaviours require some time, and that health care is fast-paced and highly pressured. We lose so much when our focus is on efficiency and protocols.
Care can only be as effective as the state of mind of those providing it. This means limiting the factors that expend emotional energy, and bolstering those who supply it. This task cannot be left to self-care or individual ‘resilience’: it requires the whole organisation to provide a system of sustaining supportive relationships.
If patients feel heard, cared for, engaged with on a human level, they are more likely to feel that they had a positive experience of health care and perhaps will feel more supported to self-manage and be more in control of their health. This becomes more possible, we believe, if carers are maintained in a state of mind where there is the energy, focus and time to really engage with patients. This means that we cannot care for patients unless we also care for their carers. In human health, the most powerful factor is caring relationships. By honouring those relationships, we will optimise health outcomes, enable more compassionate work environments, and genuinely improve efficiency.
FUNDAMENTAL PSYCHOLOGICAL NEEDS
As we see it, the top five universal psychological and spiritual needs of the human condition can be simplified as follows:
To be loved
To be heard
To belong
To make a difference
To have meaning and purpose
These universal needs apply equally to all of us whether we are giving care or receiving it, and should be held in mind in the development and delivery of health care.
