Compassion for others, self-compassion, quality of life and mental well-being measures and their association with compassion fatigue and burnout in student midwives: A quantitative survey

Highlights

• Student midwives may benefit from being kinder to themselves in times of suffering.

• High self-compassion scores were linked with fewer symptoms of compassion fatigue.

• Over half of the sample reported above average scores for burnout.

• Cultivating self-compassion may help student midwives face the rigours of education.

• Self-judgement scores were linked with reduced well-being.

Abstract

Background

compassion fatigue and burnout can impact on the performance of midwives, with this quantitative paper exploring the relationship between self-compassion, burnout, compassion fatigue, self-judgement, self-kindness, compassion for others, professional quality of life and well-being of student midwives.

Method

a quantitative survey measured relationships using questionnaires: (1) Professional Quality of Life Scale; (2) Self-Compassion Scale; (3) Short Warwick and Edinburgh Mental Well-being Scale; (4) Compassion For Others Scale.

Participants

a purposive and convenience sample of student midwives (n=103) studying at university participated in the study.

Results

just over half of the sample reported above average scores for burnout. The results indicate that student midwives who report higher scores on the self-judgement sub-scale are less compassionate towards both themselves and others, have reduced well-being, and report greater burnout and compassion fatigue. Student midwives who report high on measures of self-compassion and well-being report less compassion fatigue and burnout.

Conclusion

student midwives may find benefit from ‘being kinder to self’ in times of suffering, which could potentially help them to prepare for the emotional demands of practice and study.

Implications

developing, creating and cultivating environments that foster compassionate care for self and others may play a significant role in helping midwives face the rigours of education and clinical practice during their degree programme.

Introduction

The journey to become a midwife involves demanding workloads, challenging placements, and witnessing of traumatic events, with subsequent stress sometimes affecting compassion fatigue and burnout. Examples include, working with women who experience perinatal bereavement (Hollins Martin and Forrest, 2013, Hollins Martin et al., 2013, Hollins Martin et al., 2014), those who relinquish their baby for adoption (Mander, 2000), or traumatic birth (Leinweber and Rowe, 2010; Mollart, 2013; Sheen et al., 2014). In acknowledgement of such stressors, the British Medical Association (BMA, 2011) and the Nursing and Midwifery Council (NMC, 2015) recommend that a key element of health provision is to cultivate an environment that fosters compassionate care.

In an effort to explore this topic, a literature search was undertaken to find out what was already known about compassion in midwifery practice. A narrative review provided an overview which informed that some worries in relation to compassion and midwives in fact exist. Brettle and Grant׳s (2004) search strategy guidelines were followed, with key words including: compassion, midwives, midwifery, stress, compassion fatigue, burnout, and self-compassion. Databases explored included MEDLINE (R), PsychINFO, PsycARTICLES Full Text and PsycEXTRAand CINAHL. As the authors wished to include both quantitative and qualitative methods, a strict hierarchy of evidence was not applied. The motivation was simply to capture a wide variety of literature relevant to the area of interest. What follows is an appraisal of aspects of compassion to underpin the value of conducting the study.

Religious scholars perceive that compassion involves being charitable towards others (Barad, 2007). In contrast, the psychological sciences view compassion as recognising own or another׳s distress, and making an attempt to alleviate it (Gilbert, 2009). Empathy, distress tolerance, and kindness are key attributes of compassion, with self-compassion associated with reduced self-criticism, blame and worry (Neff, 2003, Gilbert et al., 2004; Gilbert and Procter, 2006). Self-compassion has its roots in Buddhist teachings, with research substantiating its link with psychological well-being (e.g., Neff, 2003; Neff et al., 2005; Leary et al., 2007; Hutcherson et al., 2008; Lutz et al., 2008; Gilbert, 2009; Kelly et al., 2009; 2010; Beaumont et al., 2012; Germer and Siegel, 2012; Beaumont and Hollins Martin, 2013, Beaumont and Hollins Martin, 2015). Mindfulness, empathy and loving kindness are factors that cultivate self-compassion and promote self-care and well-being (Raab, 2014).

Much debate has surrounded difficulties with health care professionals delivering compassionate care in health care settings (Care Quality Commission, 2011, Brown et al., 2013, Crawford et al., 2013, Crawford et al., 2014). High levels of self-compassion and compassion for others has been linked with lower levels of compassion fatigue and burnout (Figley, 2002; Beaumont et al., in press). Additionally, higher levels of self-compassion post-therapy has been linked to reduced trauma symptoms (Beaumont et al., 2012; 2013), improved mood (Gilbert and Procter, 2006), and a reduction in symptoms of psychosis (Mayhew and Gilbert, 2008, Braehler et al., 2012). Self-compassion exercises have been shown to reduce cortisol levels and increase heart-rate variability, which are linked with an ability to self-soothe when stressed (Rockliff, et al., 2008). Individuals who score:

• High on self-compassion are equally kind to others (Neff, 2003)

• Low on self-compassion are kinder to others than self (Neff, 2003, Neff and Germer, 2012)

As such, self-compassionate midwives are more likely to present with greater empathy for a childbearing woman׳s suffering through their appreciation of shared unity of pain (Şenyuva et al., 2014). A positive correlation between self-compassion and emotional intelligence was identified in nurses (n=135) (Heffernan et al., 2010), with an absence of self-compassion rendering carers less able to convey authentic compassion towards patients. Although participant numbers in the Heffernan et al. (2010) study are small, results indicate the worth of further exploration, particularly into the area of compassion fatigue and burnout in midwives.

Compassion fatigue is personal suffering that results from stress experienced through working with trauma (secondary traumatic stress) (Figley, 1995), or the reality of practice being mismatched to beliefs about care (Blomberg and Sahlberg-Blom, 2007). Compassion fatigue has been diagnosed in doctors (Joinson, 1992, Pfifferling and Gilley, 2000, Benson and Macgraith, 2005), nurses (Sabo, 2006), and midwives (Leinweber and Rowe, 2010). Experiencing, high levels of empathic relationships with childbearing women can place midwives/student midwives at risk of secondary traumatic stress (Leinweber and Rowe, 2010, Davies et al., 2015). Symptoms of compassion fatigue include (Figley, 1995):

• Lack of empathy/sympathy

• Irritability/anger

• Hyper-arousal

• Intrusive thoughts,

• Anxiety

• Increased alcohol consumption

• Trepidation of working with some patients

Women are more at risk of developing compassion fatigue than men (Sprang et al., 2007).

In contrast to compassion fatigue, burnout is the physical and emotional exhaustion that occurs in practitioners from working in stressful environments (Figley, 1995). Maslach and Leiter, 1997, Maslach and Leiter, 2008 propose three dimensions of burnout, which include: (1) exhaustion, (2) cynicism, and (3) inefficacy. In relation to exhaustion, out of (n=56) midwives, 60.7% were found to be experiencing high levels of exhaustion and 30.3% burnout (Mollart et al., 2013). A further study reported that 56% of nurses working in acute medicine, and 20% in Accident and Emergency reported emotional exhaustion (Gillespie and Melby, 2003a, Gillespie and Melby, 2003). The authors conclude that regular encounters of work related stress may cause nurses to lose their ability to respond empathically to their patients. One limitation of these studies is the small participant numbers. Nonetheless, they indicate a problem worthy of further exploration. Using a larger sample size, Bakker et al. (1996) reported an association between increased workload and burnout in Dutch midwives (n=200), concluding that implementation of policies to reduce burnout should be employed.

Together, burnout and compassion fatigue reduce attention, concentration, ability to communicate, and they contribute towards development of heart disease, mental health problems, and obesity (Miller et al., 1988, Spickard et al., 2002). Also, exposure to continual change, cutbacks, increased workloads, and pressure to meet NHS targets augment pre-existing stress in midwives (Kirkham, 2007, Todd et al., 1998; Iles, 2011, Kirkham, 2007, Todd et al., 1998), with workplace settings, personal trauma, and role type all influencing potential for the midwife to develop compassion fatigue and burnout (Ray et al., 2013, Sheen et al., 2014). Continuous exposure to distressing situations and lack of control can increase student midwives susceptibility to developing compassion fatigue and burnout (Abendorth and Flannery, 2006), with Yoshida and Sandall (2013) arguing that effective team-work, managerial support, job control and job satisfaction are key factors in relation to predicting burnout in midwives (Yoshida and Sandall, 2013). When faced with stressors, some student midwives smoke to excess, consume more alcohol, or comfort eat, whilst others implement positive approaches towards health, such as implementing mindfulness, writing diaries, or seeking help (Davies and Coldridge, 2015).

Clearly, a combination of factors can lead to compassion fatigue and burnout in student midwives, with point made that when a student midwife׳s threat system is in a persistent state of activation, compassion may be hindered (Gilbert, 2009). A compounding problem is that compassion fatigue and burnout are strongly associated with anxiety and depression in nurses (Hegney et al., 2013), with mental well-being a significant predictor of staff turnover (Brunetto et al, 2013). In essence, the optimal aim of midwifery lecturing staff and clinical mentors is for student midwives to be high on compassion and low on burnout and fatigue.

Evidence has shown that working in stressful environments can cause student midwives to overlook their own emotional and psychological needs. In addition, student midwives are set stressful challenges by higher education institutions (Robotham and Julian, 2006), which have potential to impact upon academic performance and mental health (Andrews and Wilding, 2004, Figley, 1995). The literature review has highlighted a lack of research that has explored the impact of secondary traumatic stress and burnout in midwives, with little known about relationships between self-compassion, compassion for others, and quality of professional life in student midwives. In response, the aim of the present study was to examine self-compassion, self-kindness, self-judgement and their effects upon compassion for others, well-being, compassion fatigue and burnout in student midwives.