‘I didn’t feel like I was a doctor’: a qualitative interview study exploring the experiences and representations of healthcare professionals’ capacity to deliver compassionate care and to practice self-care during the Covid-19 pandemic

Abstract

Objective

The increased demand on healthcare professionals (HCPs) during the Coronavirus Disease (Covid-19) pandemic reduces opportunities for HCPs to deliver compassionate care to patients and to maintain self-care. This study explored how HCPs understand and experience compassionate working practices during the Covid-19 pandemic to better support HCPs’ wellbeing and to sustain quality of care.

Design

All nineteen participants worked as an HCP during the Covid-19 pandemic, resided in the United Kingdom (UK) and took part in individual semi-structured interviews.

Main outcome measures

Using a thematic analysis approach, we developed three themes: (a) The art of compassionate care: Feeling and action, (b) The impact of Covid-19 on compassionate care and (c) Suffering during Covid-19: The importance of self-compassion and self-care.

Results

Overall, the analysis illustrated the strong and negative impact that Covid-19 had on the ability to deliver compassionate care, resulting in moral injury and psychological and behavioural difficulties for HCPs, particularly in terms of self-care.

Conclusions

This research demonstrates an imperative need for organisations to better support HCPs’ health and wellbeing, through a self-care system that promotes self-compassionate and self-care practices.

Keywords:

• Covid-19
• healthcare professionals
• compassion
• self-compassion
• self-care
• moral injury

1. Introduction

Coronaviruses are a family of diseases that may result in disorders ranging from mild colds to severe illnesses. In December 2019, the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) caused an outbreak of Coronavirus Disease (Covid-19) in Wuhan, China which later spread around the World (Coccia, 2020a, 2020b; Elbarbary et al., 2020). The rapid increase in demand on health facilities and healthcare workers threatened to overstretch and possibly collapse the existing healthcare systems, requiring healthcare worldwide to change rapidly to accommodate the increase in demand (Akondi et al., 2020). In this research, we are outlining how coronaviruses exacerbated problems that were observed in healthcare settings prior to any pandemic, specifically the impact on healthcare professionals in delivering compassionate care to patients and in practicing self-care.

1.1. Compassionate care and self-compassion in healthcare

Compassion within healthcare is considered mandatory and is clearly outlined in both policy and legislation in the NHS in the UK (Department of Health, 2012, 2015; NHS, 2016; NHS Health Education, 2016; Scott, 2013). Quality of care is underpinned by the strategy ‘Compassion in Practice’. Compassion is defined as ‘delivering care with empathy, respect and dignity, treating people with kindness, empathising with what they are going through and supporting them emotionally and medically’ (Department of Health, 2012, 2015).

Even before the pressures of the Covid-19 pandemic, it had been suggested that it was perhaps an idealistic policy aim (Kneafsey et al., 2016; Richardson et al., 2015). Egan et al. (2019) discussed several costs, both physiological and emotional to HCPs that reflected barriers to providing compassionate care and the potential for a resulting lack in self-care (see also Egan et al., 2017). Barriers to providing compassionate care include time pressures and demanding workloads exacerbated by understaffing (Chadwick & Lown, 2016; Dean, 2017; Francis, 2013; Scammell, 2016; Strauss et al., 2016), with time also being a barrier to HCPs engaging in self-compassion and self-care.

Self-compassion is a mindful awareness of self, including treating oneself kindly and understanding one’s difficulties by acknowledging that such experiences are common amongst all humans. Neff (2011) described how self-compassion consists of three inter-related components: self-kindness (vs. self-judgment), common humanity (vs. isolation) and mindfulness (vs. over-identification). Research indicates that lower scores in self-compassion predict poorer self-care, health behaviours and wellbeing (e.g. Mantzios, 2014; Mantzios & Egan, 2017; Mantzios & Wilson, 2015a, 2015b; Phipps et al., 2015).

In the workplace, HCPs frequently disregard their own needs and give precedence to patient and colleagues needs which results in a lack of self-care (Egan et al., 2019). Self-neglect can consist of not having time to drink, resulting in reducing micturition or to eat (Longhurst, 2015), with food consumed typically being low nutrition and/or including high levels of fat, sugar and salt contributing to poorer health (Black, 2017). Overall, previous research outlines that stipulating and aspiring to build a compassionate health care service should address attending to the needs of carers and supporting them to care for themselves and one another (Egan et al., 2019); in essence proposing a self-care system that would enhance both self- and patient- care.

1.2. Impact of the pandemic on compassionate care, self-compassion and self-care

Within the UK, and throughout the world, during the Covid-19 pandemic, HCPs have worked under extraordinarily difficult clinical circumstances, particularly during the initial stages of the pandemic and in subsequent waves. One of the main documented issues contributing to unsafe workplace conditions was the problems with obtaining Personal Protective Equipment (PPE). This shortage resulted in poor self-care practices to preserve limited supplies, for example working extended hours without food or drink due to an unwillingness to remove and discard N95 respirators and risk contamination (Bourgault, 2020; Rathore et al., 2020; Shanafelt et al., 2020).

Understandably, the greatest concern reported by HCPs whilst working during the pandemic was fears of infection and infecting others (Jambunathan et al., 2020; Nguyen et al., 2021; Rathore et al., 2020; Sarma et al., 2020; Sockalingam et al., 2020); leading to panic, anxiety and depression for HCPs and their families (Amakiri et al., 2020; Murat et al., 2021; Ying et al., 2021; Zhang et al., 2020). Many HCPs have made sacrifices, isolating themselves from their families and loved ones to prevent virus transmission, particularly during the initial outbreak of Covid-19. Additionally, HCPs have reported that they have envisioned their own mortality, informing loved ones about their end-of-life wishes and their will (Bourgault, 2020). Fundamentally, these are actions of physical and psychological self-sacrifice that go far beyond the deficit of self-care previously described in literature (Egan et al., 2019). Such actions are in part the result of both self and others’ perceptions of what it means to be a ‘good’ HCP, with public responses such as the ‘clapping for NHS heroes’ that occurred in the UK reinforcing the notion that HCPs should meet these unrealistic expectations regardless of high personal costs.

HCPs have reported feelings of guilt and upset when they feel unable to provide a level of compassionate care that goes beyond medical needs and neglects the individual and emotional needs of patients (Egan et al., 2019). Many HCPs have experienced working in a different way during the Covid-19 pandemic, and some have witnessed multiple deaths in one shift for the first time in their career. They report a range of emotions including fear, anger, frustration, exhaustion, sadness, guilt, pride, determination and joy (Bourgault, 2020). Such emotions may be normal and expected, however, there is evidence of rising mental health problems amongst healthcare workers (Jambunathan et al., 2020; Keubo et al., 2021; Murat et al., 2021; Rathore et al., 2020; Shanafelt et al., 2020; Szambor et al., 2019; Zhang et al., 2020).

Since the onset of the Covid-19 pandemic, visits in hospitals have been highly restricted or suspended completely. HCPs have typically been the sole source of physical contact and in-person support for patients. HCPs have expressed the sadness they experience when patients are physically separated from their loved ones, and when patients have died without their loved ones being present (Bourgault, 2020). The imperative to provide quality compassionate care during this time is increased, but the previously highlighted barriers to providing such care are also intensified, with hospitals experiencing low staffing levels and increased demand. Under such conditions, it is likely that HCPs are not able to provide the levels of compassionate care they would wish to, and this may have a detrimental impact on their psychological and physical wellbeing, with HCPs prioritising patients’ needs over their own needs more so than usual. The ‘you before me’ attitude (Egan et al., 2019) which HCPs have demonstrated may be intensified during the Covid-19 pandemic, resulting in further self-neglect amongst HCPs. The current study sets out to explore how HCPs understand and experience compassionate care, self-compassion and self-care during the Covid-19 pandemic.

2. Method

2.1. Design

An interview study exploring how health care professionals understand compassionate care and self-care and how the pandemic impacted on delivery of compassionate care and capacity to care for oneself.

2.2. Participants

Nineteen participants (11 female) aged between 24—54 years from the UK were recruited through opportunity sampling through the researchers’ social and professional networks. Participants were doctors (11), nurses (7), health care assistants (1), with thirteen participants working within hospitals, five participants working within primary care, and one participant working within a Clinical Commissioning Group (CCG). Three participants reported being redeployed during the Covid-19 pandemic (please see Table 1 for an overview).

Table 1. Participant demographic information.

Pseudonym	Gender	Ethnicity	Occupation	Place of work	Redeployed	Years in profession
Ally	F	White British	Doctor	Hospital	Yes	25
Amy	F	White British	Advanced Nurse Practitioner	Hospital	No	6
Anna	F	White British	Nurse Acute Medical Unit	Hospital	No	6
Bruce	M	White British	GP Principle	Primary Care	No	16
Charlotte	F	Asian British	Doctor	Hospital	No	18
Corin	F	Indian	GP Partner	Primary Care	No	25
Kate	F	White British	Health Care Assistant	Hospital	Yes	1
Maz	M	Indian	Consultant Orthopaedics	Hospital	No	17
Rory	M	White British	GP	Primary Care	No	20
Sally	F	White British	Nurse	Hospital	No	7
Sam	F	Asian British	Doctor	Primary Care	No	8
Sarah	F	White British	Nurse ICU	Hospital	No	12
Sean	M	White British	Manager	CCG	Yes	26
Seth	M	Pakistani	Doctor	Primary Care	No	11
Jack	M	White British	Doctor Anaesthetist	Hospital	No	17
Ruth	F	White Asian	Nurse	Hospital	No	13
Meghan	F	White British	Nurse	Hospital	No	25
Robert	M	White British	Doctor	Hospital/Research	No	14
Alex	M	–	Nurse (Manager)	Hospital	No	–

2.3. Semi-structured interview

The semi-structured interviews explored how participants understood compassion in the workplace, investigating how the Covid-19 pandemic had impacted on experiences of compassionate care. The research team developed the interview schedule adapting questions regarding compassion and self-care from previous published literature investigating these topics with HCPs (Egan et al., 2019). The interviews focused upon the impact Covid-19 has had upon patient care, care for colleagues and care for self. Example questions included the experience of working while wearing PPE as this was highlighted in the literature as salient as a new experience for most HCPs, ‘(How) Did working in PPE change the way that you interacted with patients?’ and, ‘Did it (working in PPE) impact on delivering care?’ We investigated if and how self-compassion and self-care influenced health and lifestyle choices whilst working during the pandemic, as previous research has shown working long, irregular shifts in healthcare reduces capacity to engage in regular exercise and to prepare healthy meals, which may be seen as acts of self-care. Questions included, ‘Does work impact on your home life?’ (Relationships with other people? Mental health and wellbeing. Eating, exercise, time out for yourself?). To elicit more specifically whether and how participants’ practiced self-care and self-kindness, we also asked: ‘How do you show kindness to yourself?’ And ‘What kind of things do you do for self-care?’ Time and stress were identified from previous literature as impacting on self-care and were therefore included as questions, however due to the qualitative nature of this project; participants were free to identify other ways in which the pandemic has impacted delivering compassionate care and practicing self-compassion and self-care. Example questions that asked about the impact of time and stress included ‘Were you able to take care of your physical needs at work during this time?’ and, ‘Were you able to take care of your psychological needs at work during this time?’

Four researchers undertook the interviews, three were health psychologists with a particular interest in health and wellbeing of healthcare professionals all had previously worked in active healthcare roles, and one currently worked in the NHS. Interviews were conducted via video call used in line with self-distancing guidelines; video interviews outside of the workplace may also have allowed for participants to talk more freely about sensitive issues or perceived shortcomings in service provision. The duration of interviews lasted between 21 minutes − 1 hour 15 minutes (M = 53 minutes). Participants were assigned pseudonyms, participated voluntarily and were able to withdraw at any point.

2.4. Ethical approval

Ethical approval was obtained by the Business, Law and Social Sciences Ethics Committee at Birmingham City University (Connabeer/7487/R(C)/2020/Jun/BLSS FAEC) and the HRA and Health and Care Research Wales committee (20/HRA/2777), with HCPs providing written informed consent via email prior to the interview being conducted.

2.5. Analysis

Data collection continued until researchers considered that data saturation had been reached. Interview recordings were transcribed verbatim, a word for word reproduction of the interview (Poland, 1995) and analysed using thematic analysis following Braun and Clarke (2006) procedural steps. The research team analysed data using an experiential approach, utilising inductive reflexive thematic analysis. Thematic analysis allowed the researchers to explore how participants attached meaning to their experiences whilst also reflecting on the influence of wider social contexts and how these impact on the way in which people make meaning of experiences (Burr, 1998).

Four of the research team systematically coded data line by line using both semantic and latent coding (Braun & Clarke, 2006, 2012, 2014) reflecting what was interesting and relevant in that section of data. Following the initial coding, the researchers collaboratively revised the codes by discussing and reflecting on possible different meanings and perceptions of the data. This method allowed for different perceptions and theories to be challenged and integrated until a shared interpretation of the data was reached that represented how HCPs believed and understood the role of compassion and self-care during the Covid-19 pandemic.

Together the researchers grouped codes in a meaningful way to generate and refine themes which captured relevant aspects of data highlighting commonalities, differences and relationships between coded data. These collaborations ensured the consistency and agreement of codes and theme generation.

3. Results

Using a thematic analysis approach, we developed three themes from the data (Table 2). The first, ‘The art of compassionate care: Feeling and action’ discusses conceptualisations of compassion and highlights the dynamic nature of compassion. Theme two, ‘The impact of Covid-19 on compassionate care?’ elucidates on the multiple detrimental ways in which Covid-19 impacted clinical care and practices and explores how HCPs felt about this. In the final theme, ‘Suffering during Covid-19, the importance of self-compassion and self-care’, the impact on health and wellbeing of working during Covid-19 is examined and use of coping behaviours is explored.

Table 2. Themes and codes constructed from data.

Theme	Codes
The art of compassionate care: feeling and action	Compassion is going beyond duty Compassion is Active/Action Workplace compassion is essential Compassion is part of who you are (ingrained) Compassion is a feeling before action To be compassionate is to be vulnerable ‘Fake’ compassion Compassion can be given contrary to one’s own beliefs/emotions
The impact of Covid-19 on compassionate care	Compassion has a cost (you before me) Compassionate care takes effort/time Concealing one’s own feelings for the care of others No room for self-compassion at work Self-compassion is not as important as compassion for others Impact of Covid on clinical practice PPE impact on clinical practice PPE resources Inadequate protection Impact of COVID on patient treatment decisions Impact of COVID on patient wellbeing.
Suffering during Covid-19: The importance of self-compassion and self-care	Impact of Covid on patient care Suffering at home, vs work. Playing down own suffering (and therefore self-compassion is not enacted) Seeing relatives suffering Personal suffering Health vulnerability Adapting to increased levels of suffering. Variation in degrees of patient unwellness Self-judgment

3.1. The art of compassionate care: feeling and action

All participants upheld the need for compassion in the workplace; compassion to patients, to relatives and to colleagues, it was considered a mainstay of working life in healthcare facilitating quality patient care:

Kate [pg 2]: Well, to me compassion is the centre of the job that I do really. I mean, I don’t feel like you can do the job unless you have compassion

Compassion was seen to not only be an essential part of delivering high quality healthcare but was expressed by others such as Ruth, who worked as a nurse, to be even more important than medical skills and competency in identifying when there is a problem with patients:

Ruth [pg 4]: Well I think it’s a fundamental thing of being a nurse, I think yes definitely. I think it’s the most important thing, I don’t think there’s anything more important than that.

While everyone readily offered that compassion was important, conceptualisations and definitions varied, here Sally, a midwife, defines compassion as an innate desire and ability to care for others, which influences the decision to work in healthcare:

Sally [pg 3]: Err, I think it’s just in our human nature to care for others, erm, particularly if we go in to a caring position, that must be in our nature to want to do those things because it’s not a very glamorous job so it’s got to be….

Sam considers that being a doctor forms part of his personal identity that is more than an occupational identity:

Sam [pg 6] I know as a doctor a career isn’t just a career, it sort of becomes ingrained in you, it’s part of you, you know.

Participants considered compassion to be a dynamic entity, something that could be changed though experiences, learned from others and through personal development. Maz, a hospital doctor explains that although communication was part of medical training, compassion was not explicitly taught and that he learned ‘on the job’:

Maz [pg 3]: Erm so I think you learn, no-one sat with me ‘this is compassion’. Erm so I think it is kind of a learnt behaviour by probably watching other people

This was echoed by many others who described learning how to respond compassionately to patients through watching others. Participants described and understood compassion as comprising both a feeling and an action, whereby feeling compassion for a person prompted a compassionate way of acting towards them. Kate, a student nurse who was redeployed to work with Covid patients, explains:

Kate [pg 3]: I think you’ve got to have the…the feelings in order to enact…to act on it. Erm, if you don’t have the feeling there then you’re not really thinking about what to do.

One widely expressed view was that compassion necessitated putting yourself in another’s shoes. This, in effect, is describing a method (necessary first step) of accessing a means to feel, and then act with compassion in a way that is personalised to the needs of others:

Seth [pg 4] I think compassion is about understanding things from the other person’s point of view, and transporting yourself into somebody else’s mind, and realising all the things that something means to them

The necessity of responding compassionately to patients, meant that if compassionate feelings were not felt, compassionate action was still required. At these times, participants described this as faking compassion. Sarah is an experienced ICU nurse who refers to her ability to ‘say’ and ‘do’ compassionate actions without needing to feel authentic compassion:

Sarah [pg 4]: So I-I-I’ve had many times when I’ve just thought “I really, really, really don’t like you as a human being, but you’re going through something that’s really terrible so now I’m going to pretend I like you and I’m going to pretend to feel something for you because I can say all those words and I can do all those things. But it’s not the same.”

This is interesting, as if the action is compassionate but the feeling is not, it was widely understood not to be authentic compassion. The cost to staff of acting compassionately while not feeling authentic compassionate feelings delineates an additional cognitive effort or demand. Sally (a midwife) explains it as both a physical and emotional additional demand:

Sally [pg 12]: it just makes it harder to… it just makes it physically and emotionally draining but I’m still providing the same level of compassion and kindness but it’s just taking it out of me instead.

As well as being a feeling and an action, participants also described compassion as being a collective ethos, and one which may differ between workplaces and roles. Here we see compassion not just as an individual expression, but as something over which one individual has less agency and influence:

Kate [pg 12]: the ward I came from because there seems to be an…a lack of compassion as whole on the ward. So, I remember this woman was told she had coronavirus and then they just shut the curtains on her and walked away.

Several people readily described times when they saw and experienced what they perceived to be a lack of compassion to patients and to colleagues. These were either individual uncompassionate responses, organisational lack of compassion or as a consequence of changed working practices due to the Covid-19 pandemic. This was described as very painful to see and difficult to be a part of, and this will be explored more in the next theme.

3.2. The impact of Covid-19 on compassionate care

The Covid-19 pandemic has impacted people in clinical settings in a multitude of ways. Participants spoke of the effect on patient care, relatives’ experiences, clinical practices, patient treatment decisions and on their own health and wellbeing. The discourse was framed in terms of a negative impact, with few exceptions. Sarah, an experienced ITU nurse, described how care practices for patients changed, with less time for personal care of patients, but more concerning for Sarah and others, was not being able to protect patients from distress. She talked passionately and with regret about how patients had witnessed and experienced things from which they would usually have been shielded: Sarah overhead this patient talking to their wife on the phone:

Sarah [pg 2]: “They are all dying around me, I’m going to die.” He watched it all, he watched, he witnessed it all and then, erm, the day…the–the–the patient who’s…to…er, people the other side of him also died and so he’d seen all of this, erm, he didn’t die, he didn’t…he was never even sedated or ventilated. I’m absolutely sure he’s got PTSD now just from everything that he saw.

Here, we understand that circumstances did not allow for this patient to be cared for in a truly compassionate manner, which negatively impacted both the patient and those who felt responsible for his emotional wellbeing. Sarah repeats ‘he watched’ and then reiterates with ‘he witnessed’, language that emphasises that the patient keenly observed these traumatic events when they should not have done so. Others who were not working directly with Covid patients also experienced a self-perceived deficit in compassionate care to patients. Sally, a midwife, felt that she could not offer the level of care that she wanted to for several Covid-related reasons.:

Sally [pg 6]: I could tell that she was worried about the contact. So, then I… I just kept a distance. Even though she didn’t outright say it, but then again I still felt guilty that I probably was providing what I would say was minimum care to her compared to somebody else.

This effort on Sally’s part to allay the fears of the patient was compassionate but left Sally with difficult feelings of guilt. Compassionate care is often perceived as synonymous with high quality care. In Sally’s experience, we see that the pandemic resulted in HCPs having to find a balance between acting with compassion and upholding their duty as clinical professionals resulting in emotional distress. Sally went on to talk about caring for women who were unable to have their birth partner with them, blurring the lines between midwife and birth partner, with women needing more than Sally felt practically able to give, and this added to her feelings of guilt:

Sally [pg 13]: I’ve got so much work clinically to do that I can’t do all those other little things that a birth partner would do as well, like holding their hand continuously, I can’t hold their hand all the time even if they might want me to, because I’ve got to do other things.

Sarah also talked about issues with resources and how decisions were made around best use of limited resources. While Sarah was not responsible for such decisions, and did not feel that the decisions necessarily affected the ultimate clinical outcome for individual patients, she felt keenly that there have been compromises in the usual working ethos of the ICU during the Covid-19 and that this had a negative impact on her wellbeing:

Sarah [pg 7]: That was really hard for us because we knew if we put that person on a filter, we might get the kidneys back, the likelihood is they still wouldn’t have survived but we-we would have tried all the things we normally try and that was the whole point in Covid is it wasn’t…it was unprecedented, it was completely un… There was nothing normal.

Many participants talked about how the necessity of wearing personal protective equipment affected the delivery of compassionate care to patients and relatives. Barriers in communication were one of the most frequent issues raised, with the most vulnerable patients being particularly affected. Corin, a General Practitioner, describes the difficulties of showing compassion while wearing PPE:

Corin [pg 7]: I think it is difficult for patients because they’re not, not understanding my body language because they can’t read my face. I think showing compassion is very different and wearing PPE, it’s very, very, difficult showing (compassion), wearing that PPE.

While the wearing of PPE was a shared challenge, it was the lack of adequate personal protective equipment (PPE) which was a strong and enduring concern for most participants, and this impacted in many ways. Most of the participants felt a degree of mistrust in the guidance given, Bruce a GP, expressed that protection of staff was not the primary rationale in informing PPE guidance

Bruce [pg 8]: And we have as a practice provided equipment [PPE] that is over and above NHS England’s recommendations because we do not trust them and noted that the timing of the reduction of their recommendations matched very well with the stated shortfall.

Lack of trust was a very strong theme that emerged; people did not feel that they or their colleagues were being taken care of compassionately, Sarah describes feeling expendable as a worker and as a person:

Sarah [pg 12]: “You can go in there because there’s more coming up behind you. You know, we’ve got loads of-loads of nurses, so you go in there and it’ll be fine and then if you get sick it’s fine ‘cause we’ve got other people coming in behind you so it’s not a problem.” It-it…I tell you what that’s it’s it felt like we were going into war and a lot of the time we would say “Right here we go, we’re on the frontline we’re going in there to fight this fight.”

Inadequate PPE contributed to a perceived lack of care and compassion for frontline workers from those ‘higher up’ in the organisation and participants talked in detail about how they experienced this and how they suffered consequently. The experience of suffering is explored in more detail in the next theme.

3.3. ‘Suffering during covid-19: the importance of self-compassion and self-care’

Participants spoke of experiencing suffering in a multitude of ways. They described their own personal sufferance, how they witnessed colleagues, patients and patients’ relatives suffer and they talked about the ways in which they tried to cope with this. Many participants described feeling fear and anxiety never previously experienced at work, largely centred on fear of contracting Covid and exacerbated by concerns over inadequate PPE:

Sally [pg 6]: At the beginning I did feel really anxious about going to work. Erm, I thought that at least one staff member was gonna get seriously ill and die and I was waiting for like impending… I had impending doom feeling.

Participants articulated experiencing recurring worry and fear over their own safety and the potential for imminent danger. Here, Sarah, an experienced ICU nurse, explains:

Sarah [pg 8]: So for the first maybe two or three weeks every time I put the PPE on, I thought “Oh, has that germ got my name on it this time am I gonna get it this time? Is this gonna be me this time?” Erm and that…so from that point of view it’s really, really frightening.

Many participants spoke about the significant increase in physical and emotional demands they faced at work whilst caring for patients with Covid-19 that affected their ability to ‘switch off’. Witnessing patients and colleagues suffering often intensified their own anxieties around whether they would contract Covid-19:

Rory [pg 22]: you’re not sleeping ‘cause I’m knackered all the time […] you’ve gotta go home, get into bed and think am I gonna wake up, you know, with a temperature, coughing and, and, and I, I see people with…and it’s awful

Concerns about causing suffering to family members comprised an additional fear for many people, for some this was thoughts of dying and leaving children or partners bereft:

Corin [pg 16]: it was my fear that I might get Covid and then pass it onto my husband and that’s what, what was the fear factor that we would both die, and the children would have nobody.  Or of passing the virus on to others, particularly more vulnerable family members created an additional level of suffering

Reduced opportunities to engage in self-care actions while at work compounded the suffering. Several people discussed the difficulties in taking usual breaks. It was apparent that the nature of the work made greater than usual emotional demands and that patient needs were consistently prioritised over their own needs:

Sarah [p11]: Well, on one of my shifts I had three of my, erm, patients die, I couldn’t leave because my patients were dying so, erm, so on that shift that was very difficult, erm, to get out

Prioritising consideration of other factors over one’s own needs was not confined to concern for patients and colleagues. Worries over availability and cost of PPE also influenced self-care decisions. Sean speaks directly of this:

Sean [pg 13]: you’ve done four- or five-hours and you’re walking past water machines, but you can’t take your mask off because you’re in a COVID sealed area um and you’re really thirsty. [laughs]. But then equally you come out for breaks, you can’t load yourself with water. Because actually you know that you’ve got to go in and just do another four or five hours or whatever. erm and you know you don’t want to, after three hours, say look I need to go for a pee, because you’re actually throwing about £15 worth of PPE away.

Overall participants’ narratives highlighted a prioritisation of other factors, including patients, colleagues, relatives, and concerns over PPE, all of which consistently overrode attention to self-needs. The idea of caring for oneself at work as a priority was noticeably absent and there was, rather, a perceived expectation to just ‘get on with it’ which was painfully experienced by Kate (who was redeployed to work as a health care assistant) when she attempted to use mindfulness at work as a self-care technique to reduce her anxiety:

Kate [pg 18]: I found it most helpful to just take a step back from what was making me stressed……and then it was taking like two minutes to do a bit of mindfulness. Do some breathing. And then go back into the situation where, erm…you know, that I found stressful….But I got pulled a few weeks ago, saying that I was off the ward too much

The dual responsibility of caring for patients and caring for staff often placed additional demands on participants within managerial and clinical roles. Alex discussed prioritising and committing himself to the care of others as a way to bury one’s own personal suffering:

Alex [pg 7]: So, that was probably the most challenging, was dedicating myself to my job, dedicating myself to my patients and my staff, and then at the back of my head, always having this kind of problem.

Many participants found that the experiences of working during Covid had a major detrimental impact on their health and wellbeing with health behaviours, for example disrupting eating and sleeping behaviours:

Amy [pg 15]: I definitely think my stress level has been a lot worse, erm, initially I found it really hard to sleep as well. I was really struggling in sleeping which working nights is never a good…a good thing, but you’ve got to sleep. Erm, I found I was quite tearful, but then nothing in particular would set me off…

While many participants spoke about how working during the pandemic significantly impacted their psychological wellbeing, Sam discussed the challenges of disclosing personal suffering as a healthcare professional due to the expectations of HCPs being highly resilient in the face of adversity:

Sam [pg 10]: I just think erm, I think as a doctor to admit that you’re struggling is a big thing in itself because you’re seen as being erm well you’re meant to be sort of immortal and don’t get ill if you’re a doctor.

For many participants their decision to work in healthcare was due to their innate drive to help people in their time of need. Yet working during the pandemic, participants expressed feeling helpless in the face of patient’s suffering, knowing that for some patients, any medical intervention would likely be ineffective, and this resulted in feelings of psychological distress. Participants strongly perceived that there was an expectation for them to ‘just get on with it’, with little regard of how the unprecedented situation affected their own wellbeing:

Amy [pg 10]: I think there was an expectation that you would just get on with it, that was your role as a nurse, whereas I think for a lot of people when they sign up to do nursing or be a doctor no-one really ever thought a situation like this would happen, so.

Participant’s feelings of helplessness were intensified when they were unable to help patients from either a medical or compassionate care perspective. Ruth highlights the psychological impact of feeling helpless:

Ruth [pg 9]: If you had a comorbidity, heart failure or CPD you were just going to die, and when you’re coming up with that every day, day in and day out and thinking okay, no one’s going to get better from this, we’re trying, we’ll keep trying. This one, this one we’re going to… this time we’re going to make them better and they’d still die. No, this time, this time it’s going to work, we’re going to get treatment early and every single time it was still like you still failed. It was draining, it’s just draining.

Sam expressed how much Covid changed the essence of her work, it not only took away her ability to care for patients in a way that she wanted, but also shattered her self-identity as a doctor who saved lives:

Sam [pg 5]: I don’t know like yeah I didn’t feel like I was a doctor, I felt like I was just letting people die, but managing their death and you sort of, you know, prior to Covid I would, a lot of these people I would’ve said let’s [….] to give you a chance

Overall, participants’ narratives highlighted the all-compassing detrimental impact that Covid had on the experience of delivering and receiving compassionate care from both patient’s and carer perspective. These experiences resulted in an increase in negative symptoms in mental and physical health and a reduced ability to engage in coping behaviours to alleviate such symptoms. The extent of the suffering witnessed and experienced was clearly expressed by every participant. They dreaded the thought of subsequent waves of Covid and most of them anticipated that they and others would suffer serious detrimental consequences of what they had experienced, for a long time to come.

4. Discussion

The present research extends our previous work on compassion in healthcare delivery (Egan et al., 2019); we set out to explore HCPs’ experiences of compassionate working during Covid-19. Our focus on developing a deeper knowledge of how people understand and enact compassionate working practices, drew on perspectives that are largely absent from the literature. Our research included HCPs from a broad range of professional backgrounds including healthcare assistants, nurses, GPs (Primary care) and doctors (secondary care). This gave a diverse spectrum of experiences from people with differing roles and responsibilities for patient and staff care.

Overall, the thematic analysis process highlighted compassion to be a vital and necessary part of quality care and a skill that can be developed and enhanced through learning and experience. Analysis revealed the strong and negative impact that Covid-19 had on the ability to deliver compassionate care, resulting in psychological and behavioural difficulties for HCPs, particularly in terms of self-care. There was thematic consistency across all participants who expressed that they had lived through suffering in ways that they had never previously experienced. An expressed lack of trust that they were being cared for by those in positions of power compounded this suffering. These findings support and extend previous findings (Egan et al., 2019) and provide an insight into the kind of organisational support needed for HCPs to address the emotional, psychological and physical repercussions of working at times of heightened adversity.

The present research introduces a novel conceptualisation of compassion, where participants understood it to be a dynamic entity comprising both feelings and actions, which did not always occur concurrently. Not feeling compassion, but still behaving in a compassionate manner was an accepted challenge of the job requiring additional effort from people. Feeling compassion and not being able to act on it presented a much greater challenge and this experience was highly evident within the data. Egan et al. (2019) have previously highlighted the difficulties that this presents to HCPs and the concern for their health and wellbeing. Previously, time pressures and heavy workload due to understaffing have been flagged as seriously impeding the ability to provide compassionate care (e.g. Black, 2017) and these factors were magnified in the present study. Most people reported not having the time or staff ratio to care in the way that they wished. This impact was perceived as an inevitable and unavoidable consequence of the pandemic and participants largely accepted it as such. Practicing acceptance can be an adaptive response in the face of situations that are difficult and unchangeable and Covid-19 resulting in an increased workload was certainly such a situation. Of all the difficulties of working during Covid-19, working harder was not considered the most challenging or most difficult to accept, but rather the tough clinical decisions that they had to make throughout those challenging times.

Clinical decisions that were understood as being made based on resources, rather than clinical need, resulting in a perceived failure to deliver usual care, was one such significant challenge. This has several implications for the mental health and wellbeing of workers, including an increased likelihood of experiencing moral injury. ‘Moral injury involves a deeper emotional wound and is unique to those who bear witness to intense human suffering and cruelty’ (Gibbons et al., 2013, p. 248). While the concept was originally conceived and researched in military literature (Shay, 2014), it has become apparent for healthcare professionals (Mantri et al., 2020), and more so during the Covid-19 pandemic (Williams et al., 2020). Moral injury has been associated with sadness, frustration, anger and outrage, as well as posttraumatic stress disorder (PTSD), depression and long-term increases in guilt and shame (Lancaster & Erbes, 2017; Litz et al., 2009; Schorr et al., 2018; Schrøder et al., 2017; Stein et al., 2012). Litz et al. (2009) proposed a way forward to overcome moral injury to be forgiveness and compassion, which entails appropriate leadership and corresponding institutional and population responses.

While some participants talked about experiencing compassionate leadership at local management levels, this frequently did not extend to feeling cared for by higher levels of management, the wider NHS organisation or indeed the public. Instead, working on the ‘frontline’ during a pandemic (Fernandez & Shaw, 2020)—a fundamentally known expression in war literature—as well as being labelled a ‘hero’, are both linguistically convoluted phrases that created a certain expectation of self-sacrifice to save others’ lives. Failing to live up to those expectations can have severe and enduring negative consequences for HCPs. Being unable, or declining to work on the frontline, witnessing unprecedented levels of suffering and dying without being able to alleviate such suffering, being unable to care compassionately for people, failing to save lives and losing the battle against Covid-19, were all common experiences for HCPs. Such experiences lead to feelings of guilt and shame, hopelessness and helplessness; all manifestations of moral injury that have serious implications for the health and wellbeing of HCPs.

The forgiveness and compassion that HCPs need, can be found in literature that proposes compassion-based interventions emphasising compassion for oneself; that is, self-compassion. Self-compassion has been negatively associated with shame and anger (Siwik et al., 2021), self-critical thinking (Arimitsu & Hofmann, 2015), hopelessness isolation (Hawkley & Cacioppo, 2007) and rumination (Moberly & Watkins, 2008) while self-compassion positively associates with forgiveness (Wu et al., 2019). The dynamic nature of compassion means that we can support and enhance self-compassion over the lifespan of professional lives of workers and, thus, enhance compassionate care. Proactive support is needed, particularly as symptoms of PTSD can include denial and avoidance of having negative feelings about the events (of Covid-19). This proposal is not new, Egan et al. (2017; 2019) made such proposals pre-pandemic, with an emphasis on the urgency of interventions and compassionate responses to health care workers. Covid-19 and any future implications of epidemic and pandemic threats increases this imperative.

While aiming to identify solutions, the perceived gap between management and frontline staff, ‘them and us’, has further implications for post pandemic working relationships within healthcare. Covid-19 highlights and exacerbates existing issues which are raised in the NHS staff survey 2020, where only one third of staff said that their trust takes positive action on health and wellbeing, nearly half (44%) reported feeling unwell due to work related stress and one third were considering leaving their current role. Plans to improve staff wellbeing are laid out in the NHS People Plan 20/21, including growing the workforce, training workers and working differently. However, lack of government funding commitments to meet these proposals, pay disputes and the impact of new immigration rules on recruitment cause concerns and inevitably further stretch the wellbeing resources of HCPs.

5. Conclusions and recommendations

Compassionate care is at the heart of the NHS, enshrined in training and professional standards and expectations. The question here is whether this trains people to feel more compassion or is the focus on training people to appear more compassionate and to behave more compassionately? These are indeed important skills as identified in the present research, where acting with compassion in the absence of feeling compassion is often necessary and challenging. To enhance authentic feelings of compassion, people need to be treated with compassion, to experience kindness and care in an authentic way from others at all levels in the workplace. Developing and extending compassionate care towards healthcare workers must also include an imperative for organisations to support HCPs in promoting self-compassionate and self-caring practices, extending the use of Schwartz rounds, destigmatising access to support and introducing specific self-compassionate interventions and training. These should also be extended to those working in primary care and in social care. Whilst so many healthcare workers feel uncared for by their organisations, the current problems with poor health and wellbeing of staff and of recruitment and retention issues within the NHS are likely to remain unless immediate action is taken.

Compliance with ethical standards

The study was approved by the HRA and Health and Care Research Wales committee (20/HRA/2777) and the Ethical Review Board of the University and was in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments. This article does not contain any studies with animals.

Consent to participate

Informed consent was obtained from all individual participants in the study.

Consent to publish

Informed consent to published findings was obtained from all individual participants.

Acknowledgements

With grateful acknowledgment to the health care professionals who gave their time to talk to us when they were under immense pressure. Also thanks to Staffordshire and Stoke-on-Trent CCG for supporting the aims of this work.

Disclosure statement

All authors declare that they have no conflicts of interest.

Data availability statement

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Additional information

Funding

The preparation of this manuscript was not supported by any funding bodies.