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In order to understand compassionate practice, what a nurse does and the ethical principles, ideals and values on which nursing is founded need to be considered. A definition for nursing developed by the RCN in 2003, states that nursing is:

‘The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover heaith, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.’ (RCN, 2003:3)

This definition was later enhanced with the publication of The Eight Principles of Nursing Practice’ (RCN, 2010) where the first principle states that nurses should treat everyone in their care ‘with dignity and humanity - they understand their individual needs, show compassion and sensitivity, and provide care in a way that respects ali people equally’

(RCN, 2010:3) Dignity has become a primary focus for enhancing the patient care experience, as demonstrated by the launch of the UK Dignity Campaign (DH and RCN, 2008). This campaign was designed to improve the understanding of promoting dignity in health and social care, using education and initiatives such as Dignity Champions in practice (Dignity in Care Network, 2008). In a speech by Alan Johnson, former UK Secretary of State, he described what a modern compassionate health service involves:

‘Keeping curtains closed during examinations, helping patients at mealtimes, explaining their condition and illness clearly to them, taking time to listen to their concerns, to talk through difficult decisions, simply being polite and respectful’. (DH, 2009a)

It can be argued that compassion, dignity, and respect are all descriptors of quality within nursing practice, elements that add up to improve the patient’s experience of nursing care (Gallagher, 2007). As UK nursing services have become more and more regulated and ‘outputs measured’ to justify costs, so the need for demonstrating the quality of nursing care has become more important. A component of nursing output is measured through the ‘patient experience’ of their care. Due to the complexity of suffering and it encompassing more than physical but also emotional facets, the quality of compassionate nursing is difficult to measure. High quality nursing involves taking time to understand what individual patients want and need, and is not just the speed of answering call bells, reducing infection rates, or the measurement and management of patient risk; yet it tends to be these things that are monitored by most NHS Trusts (South East Coast NHS, 2011).

The RCN (2010) first principle states that nurses should ‘show’ compassion, a phrase that could be interpreted as demonstrate compassion through behaviour and not necessarily ‘feel’ compassion. This apparent dissociation between behaviours and emotions or values is interesting to note. Nursing is a profession that has enormous breadth of scope as already discussed in Chapter Two. Perhaps this breath of scope creates its own complexity when defining the expectation of nursing practice, a complexity that makes it difficult to capture appropriate quality indicators for every role. Dissociating emotions and values from behaviours could be a means to maintain a diverse approach to caring practices, enabling

local interpretation of what nursing requires. However, this further increases the complexity of practice expectations, understanding of the RN role, and therefore what is required for appropriate professional preparation.

Evident within DH and NMC guidance are the four fundamental ethical principles on which all values in nursing are based: non-maleficence: to protect the patient from harm by minimising risk and complications; beneficence: to provide the care required to maximise people’s health; autonomy: to work in partnership with people so they receive care based on their individual needs and preferences; and justice: to respect all people and not discriminate between them in the provision of care (Beauchamp and Childress, 1994). These are noble intentions for the practice of UK nursing but it is not always clear how realistic such expectations are within the day to day, target driven, financially stretched, workplace demands of NHS healthcare provision (Smith, 2012). Despite having an ethical framework and being aware of nursing values within The Code (NMC, 2008), nurses are not always able provide all the care patients need for a variety of reasons, and when nurses’ values are compromised the nurses can suffer moral distress (Corley, 2002); a concept explored later in this chapter.

Many educationalists have explored nursing values. Benner (2000), explained that understanding nursing values allowed identification of ‘good nursing’ practice and nursing values embodied what it was to be human and live in inter-dependence with other humans. She went on to emphasise the importance of education for nursing values:

‘The schooling of nurses should encourage and not thwart the ability to see and respond to the other. Knowledge, skill, virtues (habits of thought and action) enable the nurse to perceive needs, threats and opportunities in the patient/family situation and to respond to them. The community of practitioners teach one another and create a level of attentiveness and knowledge that would be impossible to develop in isolation’. (Benner, 2000:5)

Benner’s comments are particularly pertinent to the professional socialisation of student nurses in compassionate practice. The student nurses’ education and experiences in both classroom and practice settings shape their profession-specific moral identity. Being a nurse

is a moral endeavour because every decision has an ethical or moral dimension (Corley, 2002). According to occupational socialisation research by Melia (1987), student nurses have to internalise the values, norms and attitudes of their professional identity in order to ‘become’ a nurse. Being a ‘good nurse’ is something students aspire to but this requires identification of what a good nurse is and what a good nurse does (Melia, 1987). Many studies have identified components of the patients’ view of what a good nurse is (Smith and Godfrey, 2002; Nolan et al., 2004; Gallagher 2007) and most share similar findings; that a ‘good nurse’ has specific personal virtues, values and characteristics such as respectfulness, kindness, honesty, patience; and the knowledge and skills that enable the nurse to provide competent care within a professional relationship with the patient, that enhances the patient’s well-being. From recent consultations with the UK public, the ethical expectation on nurses for compassion has been added to this list (DH, 2010a).

Caring is an ethical endeavour for nurses, as explained by the feminist philosopher Nel Nodding (1984). She explains that caring requires nurses to enter into a ‘real’ relationship with their patients and that for nurses to truly become one with the experiences of others, they need a prolonged personal relationship. Nodding distinguishes ‘natural caring’, such as that seen between parent and child, with ‘ethical caring’ where the care is recognised and evaluated in relation to its impact upon others (Nodding, 1984:83). From such discussions it can be seen that nursing is engagement in ethical caring and so nurses see a vision of their best self in the nursing ideal, a person who maintains and enhances the caring relationship. This ideal or expectation of ethical caring is evident within many codes of professional behaviour and conduct around the world (NMC, 2008; CNA, 2008; ANA, 2011), demonstrating an international emphasis on the importance of caring relationships within nursing.