Lessons from Malawi: An overview of compassionate care, barriers and what helps embed quality care in nursing and midwifery practice. Image Elizabeth Mbawa, awarded ‘Best Midwife 2020’, by nursing colleagues at\nEthel Muntharika Clinic, Malawi during a dissemination workshop for the Compassionate Care Research Project held in March 2020. What is ‘Compassionate Care’? Why does it matter? Compassionate Care is at the heart of all nursing and midwifery practice. It is care that is rooted in relationships and positive interactions. To deliver quality care requires emotional labour. Health practitioners manage their own emotions so that how they feel as caregivers does not affect the quality of the care they are providing. Caring is “the mental, emotional and physical effort involved in looking after, responding to, and supporting others.” (Baines C., Evans P. & Neysmith S.N. (eds.) (1991) Women's Caring: Feminist Perspectives on Social Welfare, Toronto: McClelland and Stewart, p11.) “Nurses have to work emotionally on themselves in order to appear to care, irrespective of how they personally feel about themselves, individual patients, their conditions and circumstances.” (Smith, P. (2012) The Emotional Labour of Nursing Revisited: Can nurse still care? Second Edition Basingstoke: Palgrave Macmillan. p184.) “The nurse provides a stable environment which alleviates some of the strangeness, anxiety and uncertainty inseparable from illness.” (William, G.W. 1963. Illness and Personality. The American Journal of Nursing. 63, 6, p87.) Healthcare workers engage with ‘suffering others’. Compassion is essential for patients and for staff. Without it, ethical practice is compromised, patients get poor care and there is a greater burden on health professionals. Learning and Leadership around the World Nurses and midwives play a crucial role in our communities and healthcare settings. Yet, as previous research has highlighted, compassion is not always embedded in how health care is delivered. This impacts the quality of care people receive. Three studies are noted here: Between Caring and Curing In 2001, Michael Kottow drew attention to the ways care and cure are inextricably interwoven in the article ‘Between Caring and Curing’ published in Nursing Philosophy. In it he highlighted how ethical considerations underpin all moments of ‘clinical encounter’. Given the impact of this work, all acts of cure require care and compassion. In the article, Kottow writes “Any human act which concerns living beings, must be thoughtful and concerned, lest it be trivial, harmful, and destructive or even cruel.” Access the article here. Responsing to a Cultural Crisis In 2013, an article published in the Lancet highlighted what was called a ‘cultural crisis’ within a particular area of the UK: 'Mid Staffordshire scandal highlights NHS cultural crisis'. The Mid Staffordhsire case had far reaching repercussions for the nursing profession in particular and healthcare in general not only in England but globally. Sir Robert Francis’ inquiry drew attention to the conditions required to sustain compassionate care and what can go wrong when they are absent. The full article is available here. Empowering Nurses and Midwives In 2015, Paula Tibandebage and colleagues undertook research to answer the question 'Can managers empower nurse-midwives to improve maternal health care? A comparison of two resource-poor hospitals in Tanzania'. Their findings showed how even in resource poor environments, hospital management practices such as supportive supervision, clear leadership and participatory ward cultures were key to empowering frontline staff to improve maternal care. However structural constraints remained an issue beyond their control. The full article is available here. Strengthening Compassionate Leadership Leadership and compassionate care needs greater attention – so that care people receive from nurses and midwives is ethical, and so that healthcare workers themselves are supported in the demanding work they do. Nursing Now Challenge is a global programme championing leadership development for nurses and midwives around the world. The Edinburgh Global Nursing Initiative at the University of Edinburgh is working to elevate and strengthen the influence and impact of nurses, midwives and their communities around the world. The Global Compassion Initiative at the University of Edinburgh works to catalyse, enable and embed the evidence and practice of compassion within the University and across our relationships in the city and the world. “Compassion is relational. It shows itself in acts of care that enable flourishing in ourselves and others and alleviates suffering. It is more than an emotion and more than empathy. Compassion requires action.” Global Compassion Initiative University of Edinburgh Image Billboard of the National Organisation of Nurses and Midwives in Malawi (circa 2010) highlighting the valuable role of nurses and midwives in our communities. Insights from Malawi 'Malawi – the warm heart of Africa' Colleagues at Kamuzu University of Health Sciences (previously Kamuzu College of Nursing, University of Malawi) and Nursing Studies and the College of Medicine, University of Edinburgh have been working together since 2012 to better understand what prevents and enables compassionate care within nursing and midwifery practice in Malawi. Barriers to Compassionate Care The research shows four key factors that prevent compassionate practice. Most of these are organisational issues that negatively impact individual staff’s ability to deliver quality care. Severe staff shortages prevent health workers from attending to patient needs and result is staff being exhausted, with less capacity to interact with compassion. Lack of equipment and supplies: When resources are not easily available, health workers can spend time trying to source equipment or need to deliver less effective care. This impacts staff morale and their capacity to deliver care. Poor attitudes and disrespectful communication of some staff: Within a team, some staff treat patients harshly – not taking time to explain things clearly or recognise their suffering. Unsupportive leaders create huge barriers to compassionate care when they fail to do effective supervision or model supportive behaviour on the ward. Read the research: Factors Militating against the Delivery of Compassionate Care: A Malawian Perspective. What helps Embed Compassionate Care? Nurses can – and do – still care It is essential that these barriers (noted above) are addressed. To do this, leaders must build capacity for ethical practice and compassionate care, and create an environment where compassionate care is possible, including: Through reflection and mentoring, build awareness of what quality care looks like so that all staff recognise and can model compassionate care in their relationships with patients and each other, remembering our care is not just physical, it is mental and emotional too. Celebrate people who are demonstrating compassionate care. Given how challenging the work environment is, staff appreciate recognition for quality care. Make this a regular feature. Require leaders to model compassionate care – including in how they support staff. Nurture strong teams. Compassionate care is more likely when teams are positive, collaborative places where staff can ask for, and get the support they need from colleagues and managers. Download the resource below for more ideas and practical tips for strengthening compassion in healthcare settings. A Quick Guide for Health Workers and Managers This resource presents key insights about embedding compassionate care within your own practice, ward or workplace. It is also a useful reference point for anyone managing and/or setting care standards for nurses and midwives. Document Embedding Compassionate Care (Resource) (4.07 MB / PDF) Document Embedding Compassionate Care (Slide Deck) (603.85 KB / PDF) Publications Msiska G, Munkhadya T, Munkhadya B et al (2021) Ethical concerns in maternal and child healthcare in Malawi. Clinical Ethics. First published online: July 22, 2021 Simwaka, A., Kabuluzi, E., Munkhondya, B., Ngoma, L., Kunkeyani, H., Munkhondya, T. E. M., & Msiska, G. (2020). Mixed perceptions of women on care in maternal and child healthcare settings in Lilongwe, Malawi International Journal of Africa Nursing Sciences, 13, 100259 Msiska, G., Simwaka, A., Munkhondya, B., Kabuluzi, E. & Munkhondya, T.E. (2018).Factors Militating against the Delivery of Compassionate Care: A Malawian Perspective. Open Journal of Nursing, 2018, 8, 889-904. Msiska, G., Smith, P. and Fawcett, T. (2014) Emotive Responses to Ethical Challenges in Caring: A Malawian Perspective. Nursing Ethics , 21, 97-107. Msiska, G., Smith, P. ,Fawcett, T. and Nyasulu, BM (2014) Emotional labour and compassionate care: what’s the relationship? Nurse Education Today, 34, 1246-1252 Smith, P. (2012). The emotional labour of nursing revisited: Can nurses still care?. Basingstoke: Palgrave Macmillan Funding and Acknowledgements Gladys Msiska has been leading initiatives to understand and embed compassionate care in Malawian health settings and education since 2016. Gladys Msiska is a Senior Lecturer (Nursing) at Kamuzu University of Health Sciences (Malawi). Her work builds on and develops Pam Smith’s work and research on the ‘emotional labour’ of nursing (Smith 1992, 2012). Pam Smith is Professor Emerita and former Head of Nursing Studies at the University Edinburgh. Gladys and Pam have worked collaboratively for over ten years, with colleagues in both Malawi and the UK. http://malawi.mvm.ed.ac.uk/projects A range of research and dissemination projects have been enabled with support from Norwegian Programme for Capacity Development in Higher Education and Research for Development (NORHED) and the Scottish Government International Development Fund. In 2019, funding was secured from the University of Edinburgh ‘Lower-Middle Income Countries (LMIC) Partnership Fund’ to support the project “Embedding compassionate care in nursing and midwifery practice in Kamuzu Central and Bwaila Hospitals: A Case Study Approach”. The purpose of the project was to organise workshops with frontline practitioners and senior stakeholders to disseminate research findings and gain insights on how to embed compassion in health care settings in Malawi. Image Comas Kapuyanyika, awarded ‘Best Nurse, Paediatric Ward 2020’, by nursing colleagues during a dissemination workshop for the Compassionate Care Research Project held in Malawi, March 2020. Timeline This timeline represents activities that have deepened our understanding of compassionate care: 2010-2016 Professors David Dewhurst, Liz Grant, Pam Smith and Dr Gladys Msiska worked on e-learning projects to develop and deliver Bachelors’ and Masters’ nursing programmes. Content included compassionate care workshops and an online Person Centred Care course. (http://malawi.mvm.ed.ac.uk/projects). Read more in the feature box titled 'Strengthening Online Learning' on our 'Programmes and Activity' page. 2012 Second Edition of Pam Smith’s book ‘The Emotional Labour of Nursing Revisited: Can Nurses still Care?’ published by Palgrave Macmillan 2012 Gladys Msiska awarded a PhD by Nursing Studies, University of Edinburgh on “Exploring the clinical learning experience: voices of Malawian undergraduate student nurses.” Supervisors: Professors Pam Smith and Tonks Fawcett 2016 Nursing Studies, University of Edinburgh 60th anniversary - research with Malawi featured e-learning projects funded by the Scottish Government International Development Fund with Professor David Dewhurst, College of Medicine and Veterinary Medicine (MVM) and Professor Liz Grant, Usher Institute and Global Health Academy, MVM, University of Edinburgh (https://www.ed.ac.uk/edit-magazine/editions/issue-3/history-makers-nursing-ambition) 2016-2020 The Compassionate Care Study funded by Norwegian Programme for Capacity Development in Higher Education and Research for Development (NORHED) to explore the perspectives of midwives and nurses, as well as those receiving care (mothers on discharge from a health facility) 2020 Dissemination workshops in Malawi with nurses, midwives and senior stakeholders to share research findings and explore ways to embed compassionate care in nursing and midwifery practice. 2021 Compassionate Care Resource developed and launched. Download the Compassionate Care Resource and Slide Deck Document Embedding Compassionate Care (Resource) (4.07 MB / PDF) Document Embedding Compassionate Care (Slide Deck) (603.85 KB / PDF)
