Compassionomics

  More data on the time required to make a compassionate connection with patients is available from the experience of Christy Dempsey, chief nursing officer at Press Ganey, Inc. A patient experience thought leader, Dempsey is the author of the book The Antidote to Suffering: How Compassionate Connected Care Can Improve Safety, Quality, and Experience.325

  In Dempsey’s thirty years of personal experience in health care, both at the bedside as well as working with groups of health care providers to improve their ability to connect compassionately with their patients, she has found that a meaningful compassion connection takes, on average, 56 seconds (and she reports that it almost never exceeds two minutes).

  The Perception Problem

  Given a plethora of data that the time required to show meaningful compassion to a patient is, on average, less than a minute, could it be that health care providers’ belief that they do not have time for compassion is all “in their heads”?

  Compassion Takes Less than 60 Seconds

  Bylund et al324 32 seconds

  Bensing et al174,175 38 seconds

  Fogarty et al97 40 seconds

  Roter et al185 54 seconds

  Dempsey325 56 seconds

  Studies show that demonstrating compassion to patients takes less than one minute. The median value based off these five studies is 40 seconds.

  Perhaps it’s not really about actual time, but rather about their perception of time.

  Think back to the “good Samaritan” study from Princeton University that you learned about in Chapter 1.24 That was the research on seminarians (i.e., students studying to be pastors of a church) where just 40 percent of the seminarians stopped to help a person in obvious distress…someone disheveled, moaning, and lying in an alley.

  You will recall that the person in distress was a “confederate” (i.e., an actor who was part of the research study). You will also recall that hearing a lecture about the Good Samaritan parable from the Bible right before encountering the person in distress had no effect on whether or not the seminarian stopped to help.

  But you haven’t heard the rest of the story yet. We explained that half the seminarians were randomly assigned to hear a lecture on the Good Samaritan parable, to see if that would make a difference in helping behavior. And that it did not.

  But the seminarians were also randomized in one other way. All of the seminarians were instructed to go to another nearby building on campus for their next assignment. In doing so, they would have to walk right past the person in distress lying in the alley.

  But here was the next level of experimental randomization: Half of the seminarians were randomly told that they did not need to rush. In this experimental study, the researchers called this the “no hurry condition.” The other half of the seminarians were given the exact same instructions about which building to go to next, but with a twist.

  Instead of being told not to rush, these seminarians were told that they were already late for their next assignment, and they needed to hurry. The researchers called this the “hurry condition.” (Of course, the seminarians were not really late for anything at all; they were just made to believe they were in a hurry.)

  What the researchers found was that seminarians who believed they were in a hurry to reach their destination were significantly more likely to pass by the person in distress without stopping. Compared to seminarians who believed they were in a hurry, the proportion of seminarians in the “no hurry” group that stopped to offer meaningful help was six times higher. Specifically, 63 percent of the “no hurry” group stopped to help, but just 10 percent stopped to help among those in a hurry.

  Further analyses even took into account multiple other factors beyond whether or not they heard the lecture on the Good Samaritan parable. Researchers considered the seminarians’ personal attributes—including their degree of “religiosity”—and found that believing to be in a hurry was the only factor that predicted whether or not they stopped to help a person in need. And the seminarians weren’t really even late for anything…they just thought they were.

  Researchers found that believing to be in a hurry was the only factor that predicted whether or not participants stopped to help a person in need.

  So you’ve seen that 56 percent of physicians believe they don’t have enough time for compassion. And that it really only takes forty seconds or so. Is it possible that this disconnect—a perception problem by health care providers—is a major contributor to the compassion crisis that we have in health care today?

  A Virtuous Cycle

  In a fascinating series of experiments from The Wharton School at the University of Pennsylvania published in the journal Psychological Science, researchers examined a person’s perception of “time affluence.” Time affluence is the perception of having plenty of time, not being in a rush, and thus a willingness to donate more time to others.326 This research sought to examine the determinants of time affluence, and specifically how the ways that people use their time makes them feel about the time that they have.

  What the researchers found was surprising, and perhaps counterintuitive. Although the objective amount of time people have cannot be increased—after all, there are only 24 hours in a day—this research demonstrated that people’s subjective sense of time affluence (i.e., the perception that that they have plenty of time) can actually be increased. Their solution to the common problem of feeling that one does not have enough time? Give some of it away!

  In a series of experiments, these researchers compared the effects of four things on people’s perception of their time affluence: (1) spending time helping other people, (2) spending time on oneself, (3) wasting time, and (4) gaining an unexpected windfall of “free” time. What they found was that spending time helping others actually increases one’s perception of time affluence.

  In fact, spending time helping others had a statistically significant larger boost in perception of time affluence compared to self-focused time, wasting time, or gaining more free time. The researchers concluded that the mechanism by which giving time to others raises one’s perception of time affluence is driven by an elevated sense of purpose and self-efficacy in helping others. That is, the positive emotions associated with making a difference for others changes how people feel about the time that they have.

  So what does this have to do with compassionomics?

  The answer: Everything.

  The research is quite clear that giving time actually gives you time.

  Given that research shows 56 percent of health care providers believe that they do not have enough time for compassion, it is quite possible (based on this rigorous research from the University of Pennsylvania) that spending a little more time on compassion for patients will change health care providers’ experience in a way that makes them feel like they actually have more time for compassion.323, 326

  It’s a virtuous cycle. The data are quite clear here…giving time away actually gives you time!

  Maybe when we consider how much time we have to show others compassion, we should make the next leap in our thinking: Compassion doesn’t necessarily take any extra time at all.

  Dr. Robin Youngson, co-founder of the Australian organization Hearts in Healthcare and author of the book Time to Care: How to Love Your Patients and Your Job, relates a story of a patient admitted to the hospital due to a serious illness who is awakened in the wee hours of the morning by a nurse coming in to his hospital room to administer his next dose of intravenous medication.327, 328

  The nurse loudly opens the door with a bang, abruptly turns on the lights, and roughly pulls back the sheets of the patient’s bed to check his wrist band identification. After she finishes giving the dose of medication, she marches out the room…leaving the lights on.

  “There is no possibility of rest in this place,” mutters the patient.

  Contrast this experience with the next night, when a different nurse is on duty and takes a totally different approach to the same task with the same pati
ent. She tiptoes quietly into the room and uses a flashlight so that she doesn’t have to turn on the overhead room lights. She gently checks his wrist band identification, and quietly administers his medication before tiptoeing out of the room. The patient never wakes up.

  Which nurse was compassionate? How much extra time did it take?

  The point of Youngson’s story is that when health care providers are doing their necessary clinical tasks, they can do so with an approach of compassion or with what he calls “brusque efficiency.” They can either greet patients with warmth and engage them in conversations about their needs, or alternatively, they can ensure their patients know just how busy they are (or how busy they think they are). 328

  Each option actually takes exactly the same amount of time.

  CHAPTER 9:

  Nature versus Nurture: Can We Learn Compassion?

  “One of the most powerful forces in human nature is our belief that change is possible.”

  —Shawn Achor

  It is likely that your junior high school biology teacher once asked you—between teaching you how to dissect a frog and mount a glass slide onto a microscope—whether you could roll your tongue. Tongue rolling is the ability to roll the lateral edges of the tongue upwards into a tube.

  Then you likely learned that some people have the genetic ability to roll their tongue while others do not. Ever since the prominent geneticist Alfred Sturtevant published the article “A New Inherited Character in Man” in 1940, biology teachers have used this example to demonstrate basic genetic principles as well as give a solid example of “nature” in the “nature versus nurture” explanation of human traits.329, 330

  But what about compassion? Is that something that falls squarely in the “nature” category? Something similar to Sturtevant’s description of tongue rolling: you either have it or you don’t? Or is it something that can be “nurtured?” In other words, can we train people in this powerful intervention? Can compassion for others actually be learned?

  Some people feel intuitively (and quite strongly) that the answer is “no.” They believe that compassion for others cannot be learned. They scoff at the suggestion that one can be taught to be compassionate.

  In fact, they would probably tell you that some people are just “wired” for compassion, while others simply are not. Or that compassion is something intrinsic that one is born with—it’s in the fabric of who you are—and you cannot pick it up along the way. They might also believe that people without compassion cannot change their character—the old idea that “a leopard never changes its spots.”

  In fact, some people believe this about themselves. You will recall from Chapter 1 that an important reason why health care providers sometimes fail to treat patients with compassion is a belief that it is not in their nature (e.g., “I’m not a ‘touchy-feely’ person”).

  The problem with this kind of thinking is that it is not supported by the available evidence. Science tells a different story. The preponderance of data in the scientific literature shows quite clearly that compassionate behaviors can, in fact, be learned. This includes compassionate behaviors towards patients by health care providers.

  The scientific literature clearly shows that compassionate behaviors can be learned.

  Therein lies a key distinction: It’s all about behaviors. Whether or not a health care provider can be taught to care more for others in his or her own mind is a separate (perhaps more philosophical) question. But what matters from the patient perspective is what a patient experiences. That is shaped almost entirely by the behaviors that health care providers display toward them. So, for our purposes, the main question is: Can a health care provider learn compassionate behaviors?

  The answer, you will see, is a resounding yes.

  Be Intentional

  Implicit in the idea of behaving in a compassionate way is the concept of “emotional labor,” which we briefly touched on in Chapter 1. Emotional labor is the management of one’s emotions (both one’s experienced emotions as well as one’s displayed emotions) to present a certain image.56

  For decades, researchers in management and organizational behavior have been studying emotional labor by service workers across all types of service industries. For health care providers, emotional labor includes the expectation of compassionate behaviors toward patients, even if those providers aren’t actually feeling an emotional connection with the patient in that particular moment. (A word of caution here: Please resist the temptation to trivialize emotional labor as “faking it.” It goes much deeper than that, as you’ll see in a moment.)

  Compassion makes you a better healer. Period.

  If you are a health care provider, implicit in emotional labor is the recognition that your patients are counting on you. In earlier chapters, you saw a tidal wave of data that demonstrated that compassion is an essential ingredient for optimal health outcomes and quality of care. Compassion makes you a better healer. Period.

  Therefore, you have a responsibility. Everyone has bad days, of course. Maybe your own life circumstances at the present time are not what you intended, or ever expected. But when there are patients in front of you who need your compassion, it is your responsibility to find a way to show it to them.

  Renowned University of Houston researcher Dr. Brené Brown reminds us that “Compassion…is a commitment. It’s not something we have or we don’t have—it’s something we choose to practice.”331

  So it’s a conscious decision. Being intentional about compassion is not only allowable; it’s necessary. Without question, people in health care (and all helping professions, for that matter) will not always feel like being compassionate. In those instances, it’s not only okay to “dig deep” and force oneself to muster compassionate behaviors, it’s essential.

  What does that look like exactly? A classic paper published in JAMA explains the different types—or layers, really—of emotional labor as they pertain to health care providers.56 For example, one is called “deep acting.” This is when health care providers intentionally generate compassionate emotional and cognitive reactions in themselves before and during interactions with patients who are in need of compassion. You can think of it as analogous to the famous “method acting” tradition used by some stage and screen actors.

  But let’s be clear: There is no “faking it” here. The compassionate feelings are 100 percent genuine and sincere; they are just the product of being intentional. They are feelings generated by health care providers within themselves…explicitly for patients’ benefit.

  Anyone who has small children at home does this quite frequently. No matter how stressed, tired, overworked or overwhelmed caring parents become, they almost always summon up the necessary energy with their children. They offer a consistent message of love, understanding, and hope when speaking to them, especially when their kids are frightened or upset.

  People intentionally put on a different face with their children to connect with them in those moments. It’s because parents take the responsibility of how their kids respond to their words and behaviors very seriously. Parents understand that their interactions make an imprint on them.

  The energy it takes for a parent to push worries—work stress, paying the bills, etc.—to the back of the mind in favor of a positive, nurturing message about why doing your homework or being kind to others is important sometimes requires emotional labor. It’s not always easy if you’re feeling completely stressed in the moment. But you do it anyway, because that’s what parents do.

  It’s a form of “deep acting,” really. And yet, the sentiments and caring that those parents summon up within them are 100 percent genuine and sincere.

  The other type of emotional labor in health care described in the JAMA paper is called “surface acting.”56 This is when a health care provider shows compassionate behaviors toward the patient, but without consistent emotional and cognitive reactions. When it comes to surface acting, the outward compassionate behaviors are there, but the
health care provider is not actually feeling it on the inside. So this is kind of like faking it.

  Compassionate behaviors are a health care provider’s responsibility.

  The JAMA authors suggest that although deep acting is preferred, it is okay for health care providers to rely on surface acting in those situations when an emotional understanding and connection are impossible. What’s key to remember is that, in either case, compassionate behaviors are a health care provider’s responsibility.

  Engaging in emotional labor, in a meaningful way, can also begin to transform how a health care provider feels about his or her patients. In other words, treating patients with compassion by being very intentional—through emotional labor—may result in a health care provider actually feeling more compassion for patients.

  Some might consider this to be a “fake it ‘til you make it” approach. But remember that many prominent thinkers throughout history have attested to the fact that making a habit of altruistic behaviors can transform oneself from the inside.

  The literary giant and theologian C.S. Lewis observed that: “When you are behaving as if you loved someone, you will presently come to love him.” Mahatma Gandhi taught that “Compassion is a muscle that gets stronger with use.” In Nicomachean Ethics, Aristotle wrote: “Virtues are formed in man by his doing the actions.”

  Emotional labor—and specifically compassionate behaviors towards others—can, in fact, make one more compassionate which, in turn, yields more compassionate behaviors. So giving patients your forty seconds of compassion will not only make you feel like you have more time to give (see the section on time affluence in Chapter 8) but also it will make you feel more compassion.