The Transformational Ways of Being: Self-Compassion, Compassion & Resilience in Healthcare
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Vol. 3, No. 2
September 2021
The Transformational Ways of Being: Self-
Compassion, Compassion & Resilience in Healthcare
Michelle R. Peck,
Graduate Studies, Cizik School of Nursing at UTHealth
Abstract: Since it is impossible to separate adversity from healthcare, especially during pandemics,
compassion and resilience are required now, more than ever, to protect, recover, sustain, and grow the
healthcare workforce. Unfortunately, in modern-day healthcare and training programs, ways of doing
are predominant, and many missed opportunities remain for ways of being, such as resiliency and
compassion. Consequently, healthcare trainees, workers, educators, and leaders should learn to (1)
differentiate between sympathy, empathy, compassion, and resilience, (2) embrace self-compassion and
resiliency for self-care, and (3) foster resilience and compassion when caring for another. Therefore, this
paper describes recent research findings to differentiate and describe the impacts of sympathy, empathy,
compassion, and resiliency and provides storytelling scripts to further illuminate these findings.
Furthermore, discussions in healthcare about workforce training, retention, distress, and well-being
should include how we teach and foster (and fail to teach and foster) resilience and compassion.
Keywords: self-compassion, compassion, resilience, sympathy, empathy
The Ways of Being the misconceptions about fostering compassion
and resilience in healthcare and training
Since pandemics can negatively impact the programs. For example, a scoping review of the
physical and psychological health of the healthcare literature found inherent struggles in
healthcare workforce, the ways of being, such distinguishing compassion from empathy and a
as compassion and resilience, are required now limited empirical understanding of compassion
more than ever. However, a literature review on (Sinclair, Beamer et al., 2017). In addition, a
compassion by Perez-Bret et al. (2016) found common counterargument to teaching and
that many healthcare workers prioritize learning compassion is the fear of compassion
treatments over the quality of relations. Also, fatigue. Hofmeyer et al. (2020) reported that if
resilience for healthcare workers has been compassion fatigue remains a dominant topic
elusive (Epstein & Marshall, 2017).
in educational initiatives and the nursing
Compounding the necessity for compassion and literature, compassion will continue to make
resilience in healthcare, are the many missed
no sense.
opportunities in training programs. For
example, a literature review by Younas and The Caring Journey in Healthcare
Maddigan (2019) found a lack of attention in
The caring journey in healthcare has a path
compassion from nursing schools despite
leading toward affirmation, compassion, and
repeated calls to nurture compassion in
resilience. As a nurse practitioner, consultant,
students. Similarly, Patel et al. (2019) described
and nursing instructor in higher education for
missed opportunities for physician empathy and
over ten years, I have seen and personally
compassion in a literature review on training in
experienced great joys and suffering.
medical education.
Fortunately, long ago, I learned that whatever is
Intensifying the missed opportunities for
affirmed has the potential to grow. For
teaching and practicing these ways of being are
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CSHR Vol. 3, No. 2 September 2021
51THE TRANSFORMATIONAL WAYS OF BEING
example, “if you water the weeds, they will can counteract the multitude of compassion
grow and expand; however, you can choose to barriers built into the system.
water the fruit trees, vegetables, and flowers. Goldberg’s (2020) summary of
Even if a weed or two remains, paying attention neuroscience and social research described
to the abundance of the garden will override the several compassion barriers in healthcare
existence of the weeds" (Miller-Karas, 2015, p. delivery:
32). Unfortunately, the path toward self-
• decreased patient face-to-face time,
compassion, compassion, and resilience is less
traveled in healthcare. But when coupled with • increased documentation needs,
courage and the proper resources, compassion
and resilience are where solutions and • lack of autonomy, and
transformation await. • electronic medical record systems.
Several years ago, after being trained in
two compassion and resilience programs, I Furthermore, Goldberg (2020) described
grew my caring abilities tremendously. After that without activation of the neural
accessing my newfound talents, I helped compassion pathways, clinicians may “feel
trainees, healthcare workers, and support group ineffective (not inefficient) and may begin to
facilitators learn these ways of being and experience burnout" (p. S5). Additionally,
witnessed many benefits: Fernando and Consedine (2014) described four
distinct barriers to compassion in physicians:
• Nursing students trained in compassion
• complex clinical situations,
and resilience found these ways of being
“a more caring way of caring,” and many • burnout or overload,
described healed personal relationships
and newfound peace and joy. • difficult patients or families, and
• external distractions.
• After a series of resilience webinars with
healthcare workers in spring 2021, over The Path of Emotional Contagion
90% (N=179) responded positively (either
a lot or some) to the question: “How much Compassion is considered both prevention and
remedy for the psychological consequences of
will information from this session help
you improve your facility's COVID-19 empathetic distress. Sinclair, Norris et al.
(2016) reported that “compassion seems to
related practices?”
reside between objective and affective
• Peer-support group participants (being understanding oriented to another (empathy)
trained to host virtual peer-support groups) and subjective responses oriented to the self,
shift from suffering to discovering rooted in pity toward another (sympathy)” (p.
personal solutions in every group. 2). Moreover, a study by Sinclair, Beamer et
al. (2017) with cancer patients found that
I have used virtual and in-person peer-
“patients distinguished and preferred
support groups for compassion and resilience
compassion to empathy…and they identified
training and find them equally compelling.
sympathy as a largely distinct and unhelpful
Accessing the energy of connection in a
construct based on pity and a lack of
group setting for training is powerful.
understanding” (p. 440). Furthermore, Singer
Miller-Karas (2015) described these types of
and Klimecki (2014) clarified that in empathy,
group dynamics as, “resiliency can be
there is a feeling with someone, but when there
contagious because when we shift a whole
is no self-other distinction, “we speak of
group’s awareness of the inherent wisdom of
emotion contagion” (p. 875).
the body, there is an improvement in well-
Hofmeyer et al. (2020) described that if
being” (p. 153). Buddy systems, end of shift
the knowledge gap about compassion fatigue
huddles, and peer-support groups can foster
prevails in education and research, healthcare
compassion and resilience in healthcare, which
leaders will not address workforce distress or
CSHR Vol. 3, No. 2 September 2021
52THE TRANSFORMATIONAL WAYS OF BEING
strengthen cultures. There is no empirical Hofmeyer et al. (2020) reported, “few nurses
validation for compassion fatigue, and studies understand that self-care is not selfish” (p. 235).
using functional magnetic resonance imaging However, self-care practices are imperative for
found that compassion fatigue should be re- fostering resilience, and self-compassion is
labeled as “empathic distress fatigue” essential for self-care.
(Hofmeyer, et al., 2020, p. 232). Singer and Fortunately, recent research provides
Klimecki (2014) conducted a series of studies components of self-care and self-compassion
with participants exposed to the suffering of and their great benefits. Gilbert (2014)
others and found two possible emotional described the compassion we feel flows from
reactions: three directions:
• empathic distress - associated with with- • directed to ourselves in self-compassion,
drawal, negative feelings (chronic
• for others, and
exposures likely for adverse health
outcomes), or • from others to ourselves.
• compassion - “based on positive, other- Moreover, self-criticism disrupts the
oriented feelings and the activation of capacity for activating the inner affiliative
prosocial motivation and behavior” (p. systems essential for well-being and the
878). regulation of emotions (Gilbert, 2014).
Additionally, Neff (2003, p. 85) described a
Without emotional regulation skills (the
remedy for self-criticism as self-compassion:
capacity to remain clear about the self-other
distinction), we can absorb another’s negative • Self-kindness – being kind and under-
emotion or pain, called empathic distress standing toward oneself during instances
fatigue (Singer & Klimecki, 2014). of failure or pain rather than being self-
Furthermore, Singer and Klimecki (2014) critical,
clarified that compassion is “feeling for and not
feeling with the other” (p. R875). Finally, • Common humanity – perceiving experi-
Hofmeyer el al. (2020) described that com- ences as shared human experiences rather
passion training does not focus on reducing or than as isolated or separated, and
removing negative emotions but instead on • Mindfulness – holding painful feelings
increasing brain activation in areas associated or thoughts in balance rather than over-
with positive emotions; therefore, compassion identifying.
is “a protective factor to empathic distress” (p.
235). While barriers to self-care and self-
compassion exist, learning about the health
The Path of Self-Compassion benefits and adopting simple practices helps.
Wei et al. (2021) recommended unifying the For example, Hategan et al. (2020) reported
Human Caring Theory with research-informed that one barrier against self-compassion is a
neuroscience and psychological evidence to concern about performance because fear of
build resilience strategies in healthcare. When failure is often used as a motivator. However,
I learned Human Caring Theory, I discovered in this instance, self-compassion can replace the
changes that I needed to make in my caring. fear of failure by shifting the motivator toward
First, in Human Caring Theory, self-care is achieving goals. Then, compassion neural
foundational and comes before caring for networks can activate to protect from stressors
others. Yet, I was always caring for others first (Vachon et al., 2016). A question also arises
and myself second. Unfortunately, I am not about individual and organizational roles in
alone in this mid-career awakening. For self-care. A recent study by Mills et al. (2018)
example, Newell (2018) described that it is rare with palliative care workers helped to address
to find actual self-care content after reviewing this question. They defined self-care as a
countless social work textbooks. Moreover, “proactive and personalized approach to the
promotion of health and well-being through a
CSHR Vol. 3, No. 2 September 2021
53THE TRANSFORMATIONAL WAYS OF BEING
variety of strategies, in both personal and • the clinicians' vulnerable role in engaging
professional settings, to support capacity for in suffering.
compassionate care of patients and their
A literature review by Younas and
families” (p. 11). Importantly, they also found
Maddigan (2019) found several direct
that harmony between professional and
indicators of compassionate care, which
personal roles was effective self-care and
included, “recognizing, accepting, and
shared responsibility:
alleviating patients’ suffering” (p. 1621). In
• between palliative care workers and the addition, a scoping review of compassion in
services in which they work, clinical care concluded that compassion could
be nurtured over time (Sinclair, Norris et al.,
• with staff support, and
2016). During my compassion training, I
• with workplace cultures (Mills et al., learned to witness another’s expressions using
2018). nonjudgement and compassion, and when
coupled with resiliency, my caring of self and
The Path of Compassion others transformed.
An extensive literature review by Perez-Bret et
The Connected Path: Resilience &
al. (2016) defined compassion as “the
Compassion
sensitivity shown to understand another
person’s suffering, combined with a willingness Singer and Klimecki (2014) described that
to help and to promote the well-being of that “compassion training promotes not only
person, to find a solution to their situation” (p. prosocial behavior but also augments positive
605). In addition, a literature review by Strauss affect and resilience, which in turn fosters
et al. (2016) defined “compassion as a better coping with stressful situations” (p. 878).
cognitive, affective, and behavioral process While there are many definitions of resilience,
consisting of the following five elements that they embrace similar components. For example,
refer to both self-and other-compassion: a literature review by Venegas et al. (2019)
described resilience as “the act of coping,
• recognizing suffering,
adapting, and thriving from an adverse event
• understanding the universality of suffering that arises from the complex interplay between
in human experience, individual, environmental, and socio-cultural
factors" (p. 2). In addition, Pangallo et al.
• feeling empathy for the person suffering (2016) described three conceptual components
and connecting with the distress, of resilience:
• tolerating uncomfortable feelings aroused • presence of significant stress carrying a
in response to the suffering person so threat of negative outcomes,
remaining open to and accepting of the
person suffering; and • environmental and individual resources
helping a positive adaptation, and
• motivation to act/acting to alleviate
suffering” (p. 19). • adjustment (based on developmental stage).
Additionally, Sinclair, Norris et al. (2016) For resilience, “the more the skills are
described how compassion differs from used, the more likely they are to develop into
empathy: integrated neural networks of resilience…then
the less we use those unhealthy paths, the more
• psychological and spiritual motivators, likely they will become obsolete” (Miller-
• predication in suffering, Karas, 2015, p. 16). An example of
incorporating resilience training in healthcare
• reciprocal and experiential nature, by Malik et al. (2021) was a well-being support
• orientation towards action, and hospital-based rounding program that provided
Psychological First Aid (PFA) to frontline
CSHR Vol. 3, No. 2 September 2021
54THE TRANSFORMATIONAL WAYS OF BEING
healthcare workers. Everly (2020) described Furthermore, discussions in healthcare about
PFA as “a psychological intervention that can workforce training, retention, distress, and well-
be easily and quickly taught to enhance the being should consider how we teach and foster
peer communication experience whether in an (or fail to teach and foster) resilience and
informal exchange or a more formal peer to compassion.
peer support intervention in institutions that
have more formalized peer support teams" (pp. References
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frontline staff engaged in the support program resilience: Cultivating compassion and
fostered resilience, self-efficacy, and emotional gratitude. Journal of Pain and Symptom
support. Management, 53(2), 309-310.
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Storytelling as Powerful Tool
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(2021) found storytelling as a powerful tool for to support healthcare professionals. Journal
“illuminating contextual data, thus facilitating of Patient Safety and Risk Management,
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story, you should adapt it each time for your Gonzales, K. A. M., Vidot, D. C., &
audience. Two storytelling scripts describing Johnson, L. P. (2021). What Anansi did for
the transformational path towards self- us: Storytelling’s value in equitably
compassion, compassion, and resilience in exploring public health. Health Education
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1
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Fernando, A. T., & Consedine, N. S. (2014).
using a version of Cantril’s ladder, a
Development and initial psychometric
Well-being in the Nation measure for the
properties of the Barriers to Physician
well-being of people (Saha et al., 2020).
Compassion Questionnaire. Postgraduate
• The Resilient Compassionate Symphony Medical Journal, 90(1065), 388-395.
describes the caring journey leading to https://doi.org/10.1136/postgradmedj-2013-
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55THE TRANSFORMATIONAL WAYS OF BEING
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56THE TRANSFORMATIONAL WAYS OF BEING
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57THE TRANSFORMATIONAL WAYS OF BEING
APPENDIX
The Connected Path: Compassion & Resilience Storytelling Script
You are walking through the woods on a winding path. Just when you start
thinking about the perfect weather, you notice a giant ladder leaning up
against a steep mountain. There are ten steps. At the top is step ten,
The Giant Ladder
representing the worst possible life, and at the bottom is step zero, meaning
the best possible life. Today, you enjoy being in harmony with nature,
and you enjoy being at the bottom of the ladder.
Path of Sympathy As you enjoy being at the bottom of the ladder, someone suddenly walks
Turning to self & holding up, climbs the ladder, and sits down on step eight. You think, “wow, I feel
pity toward the pity, that must be awful,” and say something along the lines of “I’m so
misfortune of another sorry.” Luckily, you pull out a sympathy card from your pocket, toss it up to
them, and walk away.
You again follow the winding path, but instead of feeling in harmony with
Path of Affirmation, Self- nature, negative thoughts like “I should have done more, I never help
Compassion enough” start to ruminate. As you hold your hand on your heart, you
appreciate the warmth—you focus on your breath as it flows in and out of
Turning to self & holding your heart area. Then you talk to yourself, just like you are talking to your
loving-kindness best friend, “under these abnormal circumstances, I did my best, I am
grateful.”
Now, after an hour or more, you find yourself back on the winding path,
looking up the ladder. This time, you decide to climb up and share a seat
on step eight. Two choices suddenly appear:
Path of Empathy
Turning to another & The first choice: As you offer support, feeling with them, “I am here with
feeling with or for you, I feel your sadness,” you start to notice the coldness and relate to the
another darkness and gloominess. Then, as negative emotions begin to prevail, you
climb down and follow the empathetic distress path.
The second choice: As you feel for them, “I am here for you,” you use
emotion regulation, turn positive feelings toward them and follow the path
of compassion.
Path of Empathetic Distress After following the muddied path, fatigue, withdrawal, and negative
Turning to another & no feelings build. Finally, with repeated turns down the muddied path, adverse
self-other distinction health-related symptoms appear.
Path of Compassion As you show sensitivity to their suffering, you hold positive feelings,
nonjudgement, and a willingness to help. As you promote well-being, you
Turning to another & both explore solutions, such as “what can I do to improve your situation”
holding positive feelings and explore options such as climbing down the ladder.
Path of Compassion &
You have all the benefits from the path of compassion, plus you have a
Resilience
Resilience bag that is as light as your breath. Each time you find stress,
threat, or pain along the caring journey, you reach inside your bag, pull out
Inner flexibility/connection a resource, then positively adapt and adjust.
Note: means compassion neural networks activate to protect you from stressors & empathic
distress.
CSHR Vol. 3, No. 2 September 2021
58THE TRANSFORMATIONAL WAYS OF BEING
The Resilient Compassionate Symphony Story telling Script
In this world, we arrive in wholeness and perfect vibration.
Just like a violin’s beautiful melody.
But life plays us all.
And we fall in and out of tune.
Overtightening can break our strings, but our strings tune to resilience as we
learn to let go gently.
Remembering our perfect vibration takes practice.
By practicing, you tune back, again and again.
By practicing gratitude, surrender, forgiveness, and compassion starts to play.
And as compassion plays, connections grow and stay.
Good vibes harmonize; now a symphony is played.
The Resilient Compassionate Symphony resonates with the same vibration
from which we all are made.
The Resilient Compassionate Symphony lingers on after life’s played.
Dedicated to Dr. George S. Everly, Jr.
CSHR Vol. 3, No. 2 September 2021
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