Distress in working on dementia wards – A threat to compassionate care: A grounded theory study

Abstract

Objectives

Nurses and health care workers are under increasing scrutiny from the general public and other professionals over their capacity for compassion. For example, in the UK, recruitment of nurses includes assessment of compassion through ‘Values Based Recruitment’. However, compassionate care can be hindered when working in very challenging and pressurised environments. The study aimed to explore the experiences of managing work pressures in front-line NHS staff caring for older adults with dementia. One aspect of the analysis was to explore the factors that facilitate or hinder self-compassion and mindfulness, since these ways of responding to extreme pressure are likely to facilitate compassion towards others.

Method

Ten front-line staff (a mixture of nurses and Health Care Assistants) from three inpatient dementia wards took part in qualitative interviews which were then analysed using constructivist grounded theory methods.

Results

A theoretical framework was generated which highlighted the role of structural and interpersonal types of work pressure on individual responses and ways of managing pressure. A range of helpful and unhelpful strategies were employed and although many participants appreciated the importance of taking time to process and reflect on difficult emotions and experiences during work, there were significant structural and personal barriers to practicing mindfulness and self-compassion more fully. A sense of professionalism along with various organisational factors meant that much processing of difficult emotions had to take place largely out of work hours.

Conclusions

Recruiting staff with high levels of compassion and training compassion to existing staff are not likely to significantly improve compassionate care alone in the context of extremely challenging work environments. Rather, organisational changes need to be made to model and reward self-compassion; staff training should focus on self-compassion and mindfulness, without which compassion to others is hindered. Strong professional values which may instil in care staff a belief in not displaying emotions at work should be considered carefully by professional bodies in order to provide guidance from pre-qualification onwards about how to balance professional conduct with appropriate expression of emotion in response to extreme situations.

Introduction

There are an estimated 44.4 million people living with dementia worldwide (Alzheimer's Disease International, n.d.) with the majority (62%) living in developing countries. In the UK 850,000 people are living with dementia (Alzheimer's Society, 2015), posing one of the most significant challenges for UK health services.

Dementia care has been under scrutiny in the UK press and in government and policy circles. The ‘systemic failings’ identified in Mid-Staffordshire by the Francis Report (an independent public inquiry) affected many people with dementia in the hospitals concerned, with issues around the lack of compassionate care applying particularly to this population. Following the Francis Report, there has been a push towards ‘compassionate care’ in the UK National Health Service (NHS) with NHS Trusts investing in both internal and external bodies to train staff to increase their levels of compassion. Training providers commissioned by the NHS are now required to adopt ‘Values Based Recruitment’, “an approach which attracts and recruits students, trainees and employees on the basis that their individual values and behaviours align with the values of the NHS Constitution” (Health Education England, n.d.). Those values are putting patients first, valuing every person, a commitment to quality care, striving to improve lives, inclusion and compassion (Health Education England, 2014). However, the conceptualisation of compassion as a trait, which is either present or absent in an individual, is contrary to evidence that both nurses (Smith, 1995) and doctors (Shapiro, 2008) tend to begin their training with good levels of compassion but that this diminishes either during the course of training or in the early years after qualifying (Maben et al., 2007). It is therefore important “to understand what interferes with learners’ impulses and desires to express empathy towards patients” (Shapiro, 2008). One likely hindrance is the nature of the work environment itself.

Front-line staff working with older adults with dementia often work for long hours in stressful, challenging environments (Deutschman, 2000). Research suggests that staff working in older adult inpatient services are exposed to different types of stressors compared to those in outpatient and community services (Pinner et al., 2011). Caring for older adults with dementia can be exceptionally stressful due to the behavioural and psychological symptoms of dementia which can sometimes result in abusive behaviour towards staff (Beck and Shue, 1994). For staff working with older adults with dementia, client aggression and threat appraisal have been significantly associated with staff work stress (Rodney, 2000). The management of these behaviours in particular and subsequent staff distress represents a significant part of the workload for older adult services (Lawler, 2002).

A small body of research has examined the ways in which front line staff working with dementia clients experience and respond to work pressure. These have measured stress and coping alongside other variables such as attachment and self-efficacy (Kokkonen et al., 2014) aggression, personality, cognitive appraisal and coping (Rodney, 2000) and turnover (Margallo-Lana et al., 2001). Qualitative approaches have also been used to explore the experience of work-stress and coping by means of participant interview (Clinton et al., 1995) and focus groups (Edberg et al., 2008). Kokkonen et al. (2014) found that attachment insecurity, low self-efficacy and staff attitudes (pessimism) were associated with burnout and that a person centred approach was associated with a greater sense of achievement at work. Similarly, Margallo-Lana et al. (2001) found that positive coping strategies protected against psychological distress, with dementia care nurses being more likely to use positive coping strategies than care assistants. Rodney (2000) found that primary threat appraisal (perceiving the possibility of aggressive behaviour as a threat) was linked to increased stress. Using more qualitative approaches, Edberg et al. (2008) found that a primary driver among dementia care staff was ‘a desire to do the best for the residents to alleviate their suffering and enhance their quality of life’. They describe this however as also the primary source of strain because nurses wanted to do much more than they actually could but were prevented by many factors including environment and challenges associated with caring for people with dementia. Clinton et al. (1995), using a repertory grid approach, found that nurses were aware of stressors in their work and had developed coping behaviours to respond to them. Factor analysis of 30 grids identified 92 stressors, of which client behaviours were the most frequently cited sources of stress with aspects of the organisation, work and the characteristics of clients next most frequent. Even the more qualitative approaches to this area have clearly been underpinned by a ‘coping styles’ approach based on socio-cognitive models. The present study similarly examines responses to work pressure but attempts to look at the data without assuming a coping styles model. In particular the analysis seeks to explore whether self-compassion and mindfulness can be observed in staff strategies for managing work pressure in dementia care and what factors appear to facilitate or hinder use of these techniques, since these strategies are likely to be required in order for nurses to maintain compassion towards patients (Raab, 2014).

Neff et al. (2007) argue that both self-compassion and mindfulness offer a buffer to the harmful effects of stress. Neff (2003) describes self-compassion as an emotionally positive self-attitude that should protect against the negative consequences of self-judgement, isolation and rumination; it is closely related to, and informed by the construct of mindfulness but also incorporates self-kindness and a sense of common humanity. Mindfulness is defined for present purposes as a “moment-to-moment, non-judgmental awareness, cultivated by paying attention in a specific way, that is, in the present moment, and as non-reactively, as non-judgmentally, and as openheartedly as possible” (Kabat-Zinn, 2005, p. 108). Working in a highly demanding occupational environment such as the current NHS, particularly in dementia wards, is likely to pose numerous barriers to self-compassion and mindfulness.

In spite of a wealth of evidence concerning the need for a whole system approach (see Crawford et al., 2014), nurses and health care workers are pressured to meet expectations of both the general public and other professionals to demonstrate compassion despite increasing work pressures (Ashker et al., 2012). Different people, of course, respond differently to challenging work environments. There is evidence that training in managing work pressures using coping style approaches, as well as more contemporary mindfulness-based approaches, can reduce stress (Shapiro and Carlson, 2009). However, it is unclear whether staff intuitively use techniques akin to mindfulness or self-compassion to manage work pressures. With the current emphasis on recruiting staff with high levels of compassion or ‘training’ staff to be more compassionate, little focus has been placed on the structural and interpersonal barriers and facilitators to staff drawing upon their existing capacity for self-compassion, mindfulness and ultimately compassion to others. A focus on training compassion and Values Based Recruitment may therefore be misguided without a greater understanding of what may prevent or hinder the practices of self-compassion and mindfulness.

The study aimed to explore the experiences of managing work pressures in front-line NHS staff caring for older adults with dementia. One aspect of the analysis was to explore the factors that facilitate or hinder self-compassion and mindfulness, since these ways of responding to extreme pressure are likely to facilitate compassion towards others.