International Journal of Nursing Studies 101 (2020) 103436

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International Journal of Nursing Studies

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Needing permission: The experience of self-care and self-compassion

in nursing: A constructivist grounded theory study
Hannah Andrews a,∗, Stephanie Tierney b, Kate Seers c
a
Mental Health and Wellbeing, Senate House, University of Warwick, Coventry CV4 7AL, United Kingdom
b
Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
c
Warwick Research in Nursing, Warwick Medical School, University of Warwick, United Kingdom

article info abstract

Article history: Background: Healthcare is delivered in a culture of ongoing change, with many nurses highlighting the
Received 2 April 2019 impact of this on their own wellbeing. However, there is a dearth of literature focusing on how nurses
Received in revised form 17 September
care for themselves as they try to provide compassionate care in a challenging job.
2019
Accepted 18 September 2019 Objectives: This study explored nurses’ experience of self-care and self-compassion and how this may
relate to compassionate care giving towards patients.
Keywords:
Design: A constructivist grounded theory approach was used to develop a theoretical understanding of
Compassion
nurses’ experience.
Compassionate care
Nursing Settings: This study included participants from two National Health Service (NHS) Trusts within the
Self-care United Kingdom (UK).
Self-compassion
Participants: Purposive and theoretical sampling were used to recruit general, mental health and learning
disability nurses, at different levels of seniority.
Method: Between September 2015 and March 2016 semi-structured interviews were conducted. Analysis
was completed in line with the process set out within constructivist grounded theory. Using constant
comparison and memo writing, analysis moved from initial coding to focused coding, through to theoret-
ical coding, resulting in the production of core concepts and categories, and theory development.
Results: Thirty participants were included in the study. Three concepts were derived from the data: (1)
‘Hardwired to be caregivers’ – vocation versus role, (2) needing a stable base, (3) Managing the emo-
tions of caring. All three concepts linked to a core process: needing permission to self-care and be
self-compassionate. Nurses needed permission from others and from themselves to be self-caring and
self-compassionate. An inability to do this affected their wellbeing and compassionate care giving to oth-
ers. Interviewees described how they struggled particularly with self-compassion. Helping nurses to be
proactively more self-caring and self-compassionate may increase their ability to manage emotions and
prevent some of the negative consequences of nursing such as burnout and compassion fatigue. A con-
ceptual framework is proposed which identifies that formal permission (e.g., within nursing guidance)
may be necessary for some nurses to look after themselves.
Conclusion: Findings identified the need for permission as key in enabling nurses to self-care and be self-
compassionate, which may facilitate them to address patients’ needs. The study highlights the importance
of self-care and self-compassion within nursing education and nursing guidance.
© 2019 Elsevier Ltd. All rights reserved.

∗
Corresponding author.
E-mail address: [email protected] (H. Andrews).
Social media: (H. Andrews)

https://doi.org/10.1016/j.ijnurstu.2019.103436
0020-7489/© 2019 Elsevier Ltd. All rights reserved.
2 H. Andrews, S. Tierney and K. Seers / International Journal of Nursing Studies 101 (2020) 103436

What is already known about the topic? to deal with their own internal processes and emotions or to cope
with the environment in which they work.
• There has been a focus on compassionate care giving, but little Compassion in healthcare has been an area of debate in recent
is known about how nurses care for themselves. years on an international scale (Sinclair et al., 2017). At the same
• The ability to apply self-care and self-compassion may reduce time, self-compassion as a concept has been discussed through the
levels of compassion fatigue, burnout and vicarious traumatisa- work of people like Neff (2003) and Gilbert, 2010; Webber et al.,
tion and foster resilience. 2013. Increasing compassion for oneself and others is thought to
• Self-compassion is positively associated with wellbeing and life decrease stress, improve staff wellbeing and patient care (Lamothe
satisfaction. et al., 2014), whilst also maintaining organisational commitment
• It is unclear how nurses perceive and experience their own self- (Lilius et al., 2008).
care and self-compassion in a role that can be both physically The term compassion and the concept of compassionate
and emotionally demanding. care have been embedded within international nursing policy
(American Nurses Association (ANA), 2011; Curtis, 2013; Canadian
What this paper adds Nurses association (CAN), 2008; DoH, 2009; DoH, 2012; Nursing &
Midwifery Council (NMC), 2015; Sinclair et al., 2017). There has
• Nurses require permission to be self-caring and self- been a rising focus on compassionate care giving but little about
compassionate and can take the form of giving permission how health professionals care for themselves. In a role that ex-
to the self through the process of taking ownership and re- poses them to difficult situations, such as death, illness, dete-
sponsibility for his or her own wellbeing, or receiving more rioration, and ethical dilemmas, which can lead to distress and
formal permission from another. conflicted feelings (Davidhizar, 1993; McAllister and McKinnon,
• Many factors can facilitate or impede such permission, includ- 2009), it has been suggested that to provide compassionate care,
ing identity, early experience, feeling safe, living with uncer- nurses need to be self-compassionate (Mills et al., 2014). Lit-
tainty and managing the emotions of caring. erature on fostering resilience and preventing burnout among
• Nursing guidance, policies, reports, the media and nursing col- healthcare professionals exists (Durkin et al. Carson, 2016; Friborg,
leagues instilled the notion that patients take priority. Whilst et al., 2003; Marsh, 1996; McAllister and McKinnon, 2009;
this was important for the role of a nurse, it was often inter- Newman, 2003; Skovholt and Trotter-Mathison, 2011), which has
preted in isolation, without consideration of the nurse’s own overlaps with self-care and self-compassion. However, it does not
needs, which were pushed aside in favour of others. fully explore these concepts and how they are experienced, al-
• Participants held a good understanding of self-care and the though it highlights that nurses may be required to foster self-care
facets it encompassed and what it entailed for them. However, abilities to remain resilient in their work (Delgado et al., 2017).
the tendency was to use self-care as a reactive coping strat- An ability to be self-caring and self-compassionate may re-
egy rather than as a proactive, preventative measure. If nurses duce levels of compassion fatigue, burnout and vicarious trau-
are able to manage the emotions of caring by being self-aware matisation, whilst improving staff retention and engagement, and
and recognising when they need to apply self-care and self- job satisfaction (Abaci and Arda, 2013; Dominguez-Gomez et al.,
compassion, then they may feel more able to offer compassion- 2009; Elwood et al., 2011; Maslach, 2003; Newall and MacNeil,
ate care to others. 2010; Sabin-Farrell and Turpin, 2003). Within the existing liter-
ature, self-compassion has been associated positively with well-
1. Introduction being, life satisfaction, emotional intelligence and effective coping
strategies (Barnard and Curry, 2011; Durkin et al., 2016; Heffernan
The focus of this paper centres around three terms: self- et al., 2010; Reyes, 2012; Senyuva et al., 2013; Zessin et al., 2015).
care, self-compassion and compassionate care. Self-care is de- However, it is not known how self-compassion and self-care are
fined within existing literature as the process of taking steps to experienced in everyday nursing practice, how they can be culti-
and engagement in activities to establish and maintain health vated, and the barriers to their use by nurses. The literature pro-
(World Health Organisation, 1983; Department of Health, 2005; poses a link between self-care, self-compassion and compassionate
Lee and Miller, 2013; Webber et al., 2013). Literature defines self- care giving (Dewar et al., 2014; Gustin and Wagner, 2013; Mills et
compassion as the ability to turn compassion inwards, to be kind al., 2014), but only a limited amount of research has explored self-
to the self, and to acknowledge our humanity, imperfection and compassion and self-care in nursing (Blum, 2014; Mills et al., 2018)
fragility (Heffernan et al., 2010; Neff, 2003; Lindstrom, 2014). and how these elements influence the delivery of compassionate
Whilst these two terms are inward facing, compassionate care is care. A greater understanding of these areas will support nurses to
outward facing (with patients as a focus). It is defined within cur- care for themselves whilst providing quality, compassionate care
rent literature as a collaboration and relational process of care, for patients.
achieved by entering into the patient journey in order to relieve To explore these ideas and to develop a model to inform nurs-
suffering (Fox, 1990; Nussbaum, 1996; Von Dietz and Orb, 20 0 0; ing practice, a Grounded Theory study was conducted. This study
Frank, 2004; Cozens and Cornwell, 2009; Dewar et al., 2014). stemmed from a perceived need by the authors, who have a back-
Nurses tend to be closely associated with compassion in health- ground in nursing/and or compassion in healthcare, to look at self-
care (Bivins et al., 2017). They spend large amounts of time with care and self-compassion as experienced by nurses and how they
patients and are involved in basic and complex (sometimes inti- relate to, and may influence, the provision of compassionate care
mate) care processes. In practice, they deal with multiple stres- for others. The final conceptual framework proposes that nurses
sors simultaneously, in increasingly complex environments (Crary, require permission (internal and external) in order to self-care and
2013). Literature spanning a range of countries suggest that nurses offer themselves compassion.
appear to be under pressure to deliver care and meet targets in
organisations undergoing substantial change, resulting in increas- 2. The study
ing levels of stress, burnout and attrition from the profession
(Lavoie-Tremblay et al., 2008; Boyle, 2011; Rudman and Gustavs- This study explored nurses’ personal experiences of self-care
son, 2011; Li et al., 2014). It is unclear whether nurses can utilise and self-compassion in practice. It resulted in the production of
self-care and self-compassion when facing these pressures in order a conceptual framework for use within nursing education, nursing
 H. Andrews, S. Tierney and K. Seers / International Journal of Nursing Studies 101 (2020) 103436 3

Table 1 Additional topics were added to follow lines of enquiry as the

Examples from topic guide.
research evolved. These included motivations for going into nurs-
• What do you understand by the term self-compassion? ing, nursing identity, impact of leadership, professional persona,
• How able are you to care for yourself during times of stress? impact of caring for patients, responsibility and permission.
• What happens regarding self-care within your workplace?
◦ Is there anything that facilitates self-care?
2.5. Ethical considerations
• What are your thoughts regarding providing compassion to your patients?

Approval to conduct the study was sought from the University

ethics committee and from relevant NHS Research and Develop-
guidance for safe and effective practice, nursing policy and nursing
ment departments.
practice.
McCosker et al. (2001) highlight that consideration must be
taken by the researcher if sensitive phenomenon is being re-
2.1. Aims
searched. This was recognised within the participant information
sheet and participants advised that support be sought if needed.
The study sought to explore:
Distress was expressed during some interviews (n = =5) as partic-
– What are nurses’ experiences of self-care and self-compassion? ipants acknowledged that they were not able to care for them-
– How do these experiences relate to compassionate care giving? selves, remembered difficult experiences, felt they had been mis-
treated by their organisation or expressed sadness at changes
2.2. Design within the NHS. These issues were dealt with in the room and a
follow up email. Many of the participants, not just those who had
A constructivist grounded theory approach was adopted, guided experienced distress, reflected that they found the process of talk-
by the work of Charmaz (2014). Charmaz (2014) proposes the no- ing during the interview to be cathartic, adding it had caused them
tion of theory generation, with Grounded Theory methods being to think about how to care for themselves more in the future.
used flexibly in order to recognise the role of the researcher and
the ways in which theories are developed within the context of 2.6. Data analysis
social and power relations. The interpretive nature of Charmaz’s
approach allows for the role of the nurse researcher, taking their Initial coding allowed for familiarisation with the data. This en-
personal and professional experience into account, alongside the tailed line-by-line coding to become aware of potential categories
existing knowledge informing the field of enquiry. and processes (Charmaz, 2006), with initial codes being grounded
in the data. Focused coding was then used to identify emerging
2.3. Sample/participants core categories, remaining grounded in the data to some extent,
but involving some clustering of ideas. The last stage of coding,
It was anticipated that the findings would have wider relevance theoretical coding then enabled the saturation of the core cate-
if data were collected from more than one clinical setting and gories identified during focused coding, with the use of constant
spanned a variety of nursing specialties (Williams, 2002). There- comparison allowing the analysis to become much more analyt-
fore, two National Health Service (NHS) Trusts were used for re- ical and interpretive, in order to advance towards concepts and
cruitment. an emerging theory. Charmaz (2014) states that theoretical codes
Initially, a recruitment poster was sent via email to the research are used to theorize the data and focused codes help to tell a co-
departments and nurse leaders situated in both NHS trusts. When herent, analytical story. Within this study theoretical coding clar-
nurses expressed an interest, they were sent the participant infor- ified and sharpened the analysis, enabling the move from initial
mation sheet and consent form. Fifty-three nurses expressed an coding through to the final core process and development of the
interest; 30 were recruited, consented and interviewed. The re- conceptual framework. Memo writing was utilised throughout to
maining 23 did not respond to further correspondence or found help with this process, by focusing on any coding changes or mod-
it difficult to arrange a time to meet. Purposive sampling was em- ifications, any explanations, reflections, ideas for theoretical sam-
ployed in this initial stage of recruitment, to ensure participants pling or any links to the existing literature (Pidgeon and Henwood,
were chosen based on the qualities and variables they possessed 1996). An example memo can be found in Box 1:
and to find people who could shed light on the topic of inter-
est through knowledge or experience (Bernard, 2002; Etikan et al., Box 1. Memo – ‘Halcyon days of nursing’
2016). Theoretical sampling, as suggested by Charmaz (2014), was
used as the study progressed, with participants asked to identify ‘Halcyon days of nursing’ – 22.03.16
suitable colleagues who could enrich the emerging theory. For ex- Participant DQ2 spoke about the ‘halcyon days of nursing’,
ample, it became apparent from the data that it would be useful to during the 1980’s, 1990’s and early 20 0 0’s. On further discus-
sample nurse leaders and newly qualified nurses to expand some sion the changing NHS and culture was blamed on the move
of the emerging categories and to follow-up leads within the data. to a more business-like model.
Data collection ceased after 30 nurses were interviewed as data Many of the participants reflected the changing face of
saturation was reached. the NHS and nursing in general with many reasons for the
changes being cited, including the above. Other changes fea-
tured the change in nurse training, negative healthcare en-
2.4. Data collection
quiries with lessons learnt, changing management structures,
more experienced staff leaving ward-based environments, a
Data were collected via semi-structured interviews, which took more threat focused environment and the constant restruc-
place in a clinical setting (n = 27), in a university office (n = 2) turing.
or in a participant’s home (n = 1). Data were collected between This will require further exploration as to whether there
September 2015 and March 2016. All interviews were conducted is any research looking at the changes in nursing or whether
by the lead author, lasted an average of one hour, and were audio it is a more narrative experience at present. It seems to be a
recorded and transcribed verbatim. Table 1 provides examples of recurring theme throughout the data.
the questions asked during the interviews.
4 H. Andrews, S. Tierney and K. Seers / International Journal of Nursing Studies 101 (2020) 103436

Table 2
Example of how analysis moved from raw data to concepts (moving from surface level description and summarizing towards
interpretation and a broader conceptual understanding).

2.7. Study rigour

A link has also been made around not being able to
have fun at work anymore (participant RGN12). Why did this Rigour was demonstrated by the application of four criteria
change? Have rules and guidance changed so much that staff for trustworthiness proposed by Charmaz (2006, p182): Credibil-
feel unable to experience or have fun anymore. Is this reality ity; Resonance; Originality; and Usefulness. The use of Grounded
or perception? Theory and following its guidelines enhanced the credibility of the
‘we gave ourselves permission to have fun and we don’t do
current research. Polit and Beck (2008) identify triangulation as a
that anymore (no) and I don’t think we’re good at doing that
with our teams as well’ (RGN12) way of improving credibility. Within this research, data were col-
lected from a range of sources, from interviewees working in dif-
ferent nursing disciplines, over two NHS trusts. Triangulation was
also achieved through the process of discussing the data as a team.
Resonance was demonstrated using two approaches. Firstly,
Table 2 highlights how analysis moved from raw data to a more theoretical saturation was reached after interviewing 30 partici-
conceptual understanding of what interviewees had discussed. pants, whereby no new data or leads were arising and categories
Each transcript was stored within NVIVO, which supported data were sufficiently dense. Secondly, member checking was utilised.
analysis. NVIVO was used following coding on paper in an attempt Sandelowski (1993) identifies the twofold purpose of member
to manage the vast array of collected data. NVIVO provided an au- checking as gaining feedback from participants pertaining to the
dit trail, adding rigour to the analysis process. interpretation of the data collected and allowing participants ac-
 H. Andrews, S. Tierney and K. Seers / International Journal of Nursing Studies 101 (2020) 103436 5

Table 3 good nurses. So I think we are already in a sense hardwired to be,

Participant characteristics.
to be givers (ok), rather than looking after ourselves more’ (RGN6)
Participant discipline Years Role
and number qualified The journey to being a nurse appeared to be an important con-
cept when looking at permission to apply and accept self-care and
RGN1 11 Non-clinical role
self-compassion. Nursing identity incorporated ideas of character,
RGN2 29 Senior clinical role
RGN3 39 Non-clinical role sense of self and compassion as an inbuilt trait.
RGN4 36 Clinical role
RGN5 9 Clinical role (trained outside of UK)
‘you’ve got to be erm you know a certain character, a certain per-
RGN6 32 Clinical role sonality erm it’s such a rewarding job but it’s a hard job, it’s hard
RGN7 29 Clinical role work you know, harder than it’s ever been’ (RGN14)
RGN8 12 Clinical role
RGN9 17 Clinical role (trained outside of UK) ‘my view is that you’re born a compassionate individual or you’re
RGN10 40 Senior clinical role not but there are some situations that people are put in that re-
RGN11 11 Senior clinical role duce that level of compassion, their ability to display it’ (RGN12)
RGN12 30 Senior clinical role
RGN13 7 Senior clinical Role For each nurse this is likely to be different, shaped by early in-
RGN14 29 Senior clinical role
fluences, experiences and role models. Hence, individuals will have
RMN1 3 Community clinical role varying ideas about ‘being a nurse’. Some viewed it as a voca-
RMN2 1 Community clinical role
RMN3 6 Community clinical role
tion and others more as a profession or a role. There appeared
RMN4 5 Clinical role to be a link between the notion of nursing as a vocation, which
RMN5 31 Senior clinical role brings with it an element of self-sacrifice, making self-care and
RMN6 28 Senior clinical role self-compassion more difficult.
RMN7 4 Community clinical role
RMN8 8 Community clinical role ‘a lot of people say, ‘oh nursing is what I do’, but a nurse is who I
RMN9 15 Community clinical role am and when I’m not at work I feel a bit lost’ (RGN11)
RMN10 28 Community clinical role
RMN11 19 Senior clinical role ‘I think that sometimes people think that because you’re a nurse
RMN12 31 Senior clinical role
and that’s what you do for your job that you’re always your job
RMN13 16 Senior clinical role
and you’re always a nurse’ (RMN7)
RNMH 7 Community clinical role
DQ1 33 Senior clinical role A contrasting viewpoint appeared to be that if nursing is re-
DQ2 31 Senior clinical role garded as a profession, a job or role, then self-compassion and
self-care could be more accessible and acceptable. However, data
suggested a lack of clear distinction between nursing as a role or
cess to their data. Birt et al. (2016) suggest that ‘within a construc- identity, with nurses often changing their viewpoints as their ca-
tivist epistemology, it can be used as a way of enabling participants reers and experience progressed, or if events occurred that caused
to reconstruct their narrative through deleting extracts they feel no them to question their loyalty to the profession or organisation.
longer represent their experience, or that they feel presents them
in a negative way’ (p1803). Throughout interviews, paraphrasing 3.1.2. Needing a stable base
and summarising were employed to check the interviewer’s un- Data suggested that nurses need to feel safe and secure
derstanding of what the participant was saying. Each participant in themselves and their workplace to be self-caring and self-
was sent their transcript to review. All were happy with their tran- compassionate.
scripts, with no data being removed aside from a couple of words,
‘you have to feel contained don’t you as an individual and as a
which they felt could impact anonymity.
team and everything else, because of, you know if one, if you start
3. Findings to not feel that, then it starts to spread out to everything else
doesn’t it’ (RMN3)
Table 3 provides an overview of the characteristics of nurses A number of factors can get in the way of a stable base, such as
recruited based on their discipline, years of experience and role; the working environment, jobs being at risk and having effective,
6 were male and 24 females. The blue lines split the groups into clearly defined leadership.
those who were Registered General Nurses (RGN), Registered Men-
tal Health Nurses (RMN), Registered Learning Disability Nurses ‘brilliant practitioners that were competent people would be com-
(RNMH) and those who were Dual Qualified (DQ). ing in, in tears hiding in our recovery rooms and sort of saying ‘oh
god I’ve got to go back’…I don’t think they’re necessarily better or
3.1. The concepts any worse than any other trust but I think they just do not value
the resource they have and that’s pretty apparent because we can’t
The core concept to emerge from the data analysis was “Need- retain people’ (RMN12)
ing Permission” to be self-compassionate and self-caring. This core ‘the best wards I’ve worked on is where you have really good nurse
concept (which is described in more detail below) was informed managers who recognise that terrible things happen and that
by three concepts: Hardwired to be caregivers; Needing a stable sometimes staff need time out to actually process that’ (RGN6)
base; and Managing the emotions of caring.
The effects of increased pressure in the workplace, a business-
3.1.1. ‘Hardwired to be caregivers’ – vocation versus role orientated approach to healthcare delivery and a broken system
The notion of ‘Hardwired’ refers to the innate need to nurse, appeared to have a de-stabilising effect; nurses could end up feel-
motivations to enter nursing and how they fit with identity. ing like ‘automatons’ rather than professional carers, with technical
skills more highly valued compared to relational ones.
‘you’ve attracted people who are of that mind set, you want to
care for others, you are essentially carers, otherwise you wouldn’t ‘Mental Health nursing used to be about a dynamic process re-
do the job. The nurses that aren’t that way inclined tend not to be sponding to the environment through visibility, engagement, pres-
6 H. Andrews, S. Tierney and K. Seers / International Journal of Nursing Studies 101 (2020) 103436

ence and now like I say automaton is that the priority is that self-compassion were being used proactively in order to cope with
you’ve got to well I don’t know you’ve got to do your paperwork’ negative effects of nursing, or reactively (when self-care and self-
(DQ2) compassion were only accessed when nurses were already strug-
gling).
Data analysis showed how the changing NHS and public per-
ceptions could interfere with a nurse’s ability to feel safe and se- 3.1.4. Core concept: needing permission
cure. As mentioned above, interviewees described how permission
‘If I said to people when I first started I’m a nurse I would have for self-compassion was needed from themselves and from others.
been perceived as an angel, you’re absolutely wonderful, I don’t Permission may be given to the self by looking at the need to take
know how we could manage without you …public perception has ownership for one’s own wellbeing. A barrier to doing this was re-
changed very much so we’re perhaps not seen as these, you know lated, by interviewees, to how self-compassion was perceived; it
these wonderful beings as we once were, we’re seen as maybe hu- could be viewed as a weakness and, therefore, potentially prob-
man beings that are fallible’ (DQ1) lematic.
‘I think as a profession in general we are very very bad at giving
3.1.3. Managing the emotions of caring ourselves permission to look after ourselves…I was gonna say in
Participants wanted and needed to care for others to feel val- the past but even now it is seen as a weakness, which is very sad…
ued. It was proposed that patients come first, a notion instilled you are expected to push yourself to do things and I think it is
through nursing guidance and expectations of their workplace, about giving people permission to, just to look after themselves’
which was also an internal driver. However, whether this should (RGN2)
be to the detriment of oneself was questioned.
Conversely, an ability to be self-compassionate was depicted as
‘I always would put my patients first but actually if I’ve got no a skill; if learnt it had the potential to be protective and beneficial.
self-compassion for myself and I’m not looking after myself I can’t Hence, rather than being seen as a soft skill, it has power and can
give my patients a hundred per cent so it works both ways really’ transform experiences of caregiving. There also appeared a need to
(RGN14) understand the meaning and potential rewards of self-compassion,
which again called for an acknowledgement of nurses’ humanity,
‘I think people can probably provide compassionate care, the prob-
by self and others, alongside their professional role.
lem is their own wellbeing may suffer because, because they’re not
able to be self-compassionate or self-caring so that their compas- ‘we have to maintain a professional status I totally get that but
sion may be almost too great if you like in terms of looking after actually we’re only human and if something very very difficult and
people and not looking after themselves’ (RGN4) emotive is happening obviously you can’t lose it and be in floods
of tears…but I think it’s perfectly acceptable to show that you’re
Participants acknowledged that nursing could be difficult, re-
feeling that’ (RGN14)
quiring them to develop coping strategies in order to manage.
This included ‘turning a page’ and becoming hardened through re- ‘the self-compassion it has to be allowed, you have to allow it,
peated exposure or closing off. you’re allowing yourself to feel it, but you also have to hope that
your managers, your colleagues have room for that as well, have
‘so you’ve got all these things going on and real horrible things
room for you to feel it, recognise that they need it too’ (RGN4)
erm you know real significant self-harm and traumas that children
go through and you’re just like ‘ok right what’s happened now, Numerous barriers to self-care and self-compassion were re-
oh someone’s been raped, oh what’s happened now oh there’s a called by participants that were internal (e.g., nursing identity and
suicide and you’re like ok next thing lets go see’ and sometimes we character) or more external (e.g., the environment, targets related
just get a bit hardened to that (mmm) and then when it catches to care-giving expected by organisations). As a consequence, per-
all up on you and you think oh no this is awful, this has happened mission from another in attending to their needs was proposed.
in one day, it’s not very nice’ (RMN8) Participants mentioned the importance of formal and informal
permission to be able to challenge practice, to go off sick, and
Interviewees proposed that nurses are sometimes viewed as a to lessen the guilt of being away from work. There was a sense
resource rather than as human beings who can become exhausted that this was process and policy driven, which may not be flexible
when overwhelmed or placed under pressure, with burnout occur- enough to respond to varying professional or personal situations,
ring when there is an inability to cope. acting as a potential barrier.
‘you know it’s tragic, you do walk on wards and find nurses who ‘nurses in particular have this thing that you plough on, you know
burst into tears when you ask them about things and it happens ‘what are you upset for’, you plough on (yeah) and I do have con-
and they’re getting themselves so stressed out and we don’t, we cerns when the quest for personal resilience and you know sort
don’t teach them to look after themselves, we don’t teach them of ends up looking like ‘well each person for themselves’…I think
how to recognise when things are going wrong for themselves. We organisations do and should have a duty to take responsibility for
teach them to recognise it in the patients (mmm) but not in them- staff’ (RMN1)
selves or in their colleagues’ (RGN2)
‘it can’t just be about you as an individual having to take respon-
If participants were overwhelmed, burnt out or unable to apply sibility, yes of course we’ve all got to look after ourselves, we’ve all
self-care or self-compassion, there was a risk of ‘thinner care’. got responsibility for our own health and wellbeing but I think as
‘it certainly makes the care that they give thinner or so it can an organisation we work for we’re meant to be a caring organisa-
seem, coz they’re spreading themselves so thin and I think it’s valu- tion, that says it all to me. If you can’t care for your staff who can
able that we look after ourselves’ (RNMH) you care for’ (RMN11)

Findings suggest that to manage the emotions of caring, an el- 3.2. Conceptual framework
ement of permission to be self-caring and self-compassionate was
required. However, balancing compassion towards the self and oth- Fig. 1 depicts the final conceptual framework constructed
ers was called for, as was an awareness of whether self-care and through the data analysis. It provides a visual representation of
 H. Andrews, S. Tierney and K. Seers / International Journal of Nursing Studies 101 (2020) 103436 7

Fig. 1. Needing permission – conceptual framework.

a process that may be used to inform policy, practice and educa- 4. Discussion and implications
tion. The need for permission appeared to be central so partici-
pants felt able to be self-caring and self-compassionate. For some Due to the dearth of existing knowledge relating specifically
it was about giving themselves permission (internal) and for others to self-care and self-compassion in nursing, originality and useful-
it was about receiving permission (i.e., from their manager or more ness of the study were demonstrated by offering novel insights and
globally from their organisation). It could also be a combination of the development of new concepts and a conceptual framework.
the two. Data suggested that if self-care and self-compassion were These findings and new insights have implications for future nurs-
more understood and embedded within nursing education and the ing practice, education and policy.
workplace culture, this would serve as a form of permission. Fur- The conceptual framework presented above situates permission
thermore, a nurse’s wellbeing and need to care for the self have to as central in enabling nurses to care for themselves; this links to
be acknowledged by society and patients so nurses feel they have the management of emotions that can transpire from caring for
been given permission. others. Previous literature and research have not addressed this
The concept ‘Hardwired to be caregivers’ noted the impact concept of permission, focusing instead on the difficulties of ap-
of nursing identity and sense of self, with this often influencing plying self-care and self-compassion due to embarrassment, guilt
whether self-care and self-compassion were viewed as acceptable and fear of being viewed as selfish (Mills et al., 2014). Literature
when patient care was perceived as the priority. How identity was has also focused on fostering resilience and burnout (Delgado et
viewed appeared to impact upon acceptability of caring for the al., 2017; Durkin et al., 2016; Friborg et al., 2003; Marsh, 1996;
self. McAllister and McKinnon, 2009; Newman, 2003; Skovholt and
The need for a stable base within a culture of change was ex- Trotter-Mathison, 2011), but has not sought to draw out and in-
plored, with participants identifying that if they felt safe and se- terpret the specific meaning of self-care and self-compassion for
cure, whether this comes from the self or the environment in nurses.
which they work, then permission to care for the self was present. The existing literature focuses on instilling self-care within pa-
They acknowledged that when feeling destabilised, uncertain or tients (Orem, 1981, Orem, 1985; Webber et al., 2013; Davidhizar,
unsafe, they were less likely to care for themselves and more 1993; Richards, 2013) as opposed to such activity for healthcare
likely to experience negative emotions, with this impacting on staff. These ideas, alongside nursing guidance, may contribute to a
their overall wellbeing and their ability to provide compassionate belief that nurses’ self-care and wellbeing are not priorities. Par-
care. ticipants showed a lack of awareness of how ignoring their own
Having permission, and being able to be self-caring and self- needs may jeopardise their primary aim of caring for others, but
compassionate, appeared from the data to link to managing emo- acknowledged a frustration that they were not able or not permit-
tions that could affect compassionate care giving. There was a ted to care for themselves alongside caring for their patients. This
sense that to care for others, you must care for yourself; however, point has not been previously raised within the existing literature.
this was not seen as an easy process. Self-care and self-compassion Findings within this study highlighted that nurses live with
tended to be viewed as coping strategies that were only used when uncertainty due to the constant change within the NHS, com-
participants were ‘close to the edge’, ‘burning out’ or ‘becoming pounded by portrayals of nursing within the media following neg-
overwhelmed’ with caring. Yet participants acknowledged that self- ative healthcare inquiries (CIPOLD, Bubb, 2014; DoH, 2013; Francis,
care and self-compassion could be employed more proactively by 2013; Kirkup, 2015). The changes discussed within the data focused
taking time to reflect on their needs, accepting their humanity on service restructuring, poor staffing levels and jobs being at risk,
and being kind to themselves. Data suggested that if participants which all seemed to have a de-stabilising effect and ultimately im-
were able to self-care and be self-compassionate, this would posi- pacted on nurses’ ability to be self-caring and self-compassionate.
tively impact their own wellbeing and prevent them from deliver- These challenges are also experienced by nurses in other countries
ing ‘thinner’ care, thereby enabling them to offer the compassion- and, therefore, findings from this study are likely to have meaning
ate care that they wanted to provide.
8 H. Andrews, S. Tierney and K. Seers / International Journal of Nursing Studies 101 (2020) 103436

for nursing outside of the NHS (Jourdain and Chenevert, 2010; Li similarities or differences in their experiences and the meaning of
et al., 2011). self-care and self-compassion to them. There was a lack of data re-
Participants identified a holistic approach to self-care, resonat- lated to positive recollections of self-care and self-compassion. This
ing with definitions of this term in the literature (World Health could signify that interviewees had a particular experience or story
Organisation, 1983; Department of Health, 2005; Lee and Miller, to tell relating to the topic of interest, or positive experiences were
2013). However, whilst existing literature has focused on prevent- fewer or harder to access. Sampling from other geographical loca-
ing ill health, findings from this study suggested nurses could tions might further enhance our understanding of the phenomena
recognise when they were unwell and needed to actively address explored in this study.
this, but felt unable to act on warning signs and early stages of
illness because they did not have the internal and/or external per-
mission to be proactive. Hence, self-care was often used reactively, 4.2. Practice implications
rather than as a preventative measure as suggested by Webber et
al., (2013), who proposed that self-care should be used to avert dis- 4.2.1. Nursing practice and policy
ease and illness. Reflective practice is used internationally within Within nursing policy and guidance (ANA, 2011; CAN, 2008;
nursing education as a tool to embed these core ideas around NMC, 2015), there is a focus on caring for patients, but little em-
recognition of impact (Oelofsen, 2012; Ruth-Sahd, 2003), enabling phasis has been placed on the care of staff. As this study has
nurses to reflect on the impact of their everyday practice, and highlighted, active engagement in self-care and self-compassion is
therefore may be used as a means of giving themselves permission required; even if recognised within nursing policy and practice,
to care for themselves. adequate provision, formal acknowledgement and legitimisation
Interventions proposed within existing literature to help nurses appear necessary for it to occur. The ability to self-care and be
manage the emotions of caring and to enhance wellbeing are su- self-compassionate should be embedded within nursing culture to
pervision (Lyth, 20 0 0; Edwards et al., 20 05; White and Winstanley, enable nurses to use these approaches continuously rather than in
2010; Koivu et al., 2012; Buus et al., 2013), focusing on safety and a reactive manner in response to difficult situations. If given this
reflexivity, staying professional and managing feelings. Schwartz permission, it may make caring for the self a part of nurses’ duty
rounds (George, 2016; Goodrich, 2016) can enable staff to reflect of care.
upon thoughts and feelings related to their job in a safe envi- Receiving permission to care for themselves from early on
ronment during protected time. Likewise, mindfulness (Grossman within their nursing career may aid in facilitating its acceptability
et al., 2004; Pipe et al., 2009; Hoffman et al., 2010; Cunningham in everyday practice. Alongside these early key messages, nurses
et al., 2013; Halm, 2017) can reduce negative psychological states need to feel safe and secure at work, requiring a stable base to
such as stress, anxiety and depression, whilst also improving self- cope with and manage day to day distress associated with their
awareness and nurturing skills. These interventions and models role. Feeling supported and valued and having effective leadership
have proven useful to nurses but may not be available or acces- were cited as key facilitators to achieving a stable base. West and
sible in every setting. The conceptual framework depicted within Bailey (2019) suggest effective leadership should incorporate com-
this study calls for permission for nurses to care for themselves passion, with a strong commitment to the team and a clear sense
both proactively and reactively; adopting some of these interven- of purpose. Alongside a recognition of key healthcare challenges
tions within healthcare organisations may show that the emotional and wellbeing needs of staff within this (C de Zulueta, 2016), and
impact of caring is recognised and warrants attention by individual responsibility for collective leadership within organisations (West
practitioners and teams. et al., 2014).
Identity and motivations to nurse were key ideas within the
interview data when thinking about permission to care and be 4.2.2. Nursing research
self-compassionate. A focus on others, referred to by interviewees Although this study has added to the dearth of literature re-
and in the existing literature, is key to society’s construction of lated to the topic of interest, there are areas for further research.
nursing and the notion of patients coming first (DoH, 2009, 2015; For example, research suggests that self-care and self-compassion
NMC, 2015). Embedding the ideas of self-care and self-compassion may have a positive impact within nursing (Heffernan et al., 2010;
early on in nursing may be important in nurses’ receptiveness to Reyes, 2012), yet how this is achieved is unclear. Qualitative re-
these activities as a means of keeping well and their ability to search has provided an insight into experience and meaning. Fur-
continue interacting with patients as desired. Current literature ther mixed method research may be useful, so that alongside
identifies the need for more focus on student and newly qual- experience, relationships can also be tested (e.g., influence of en-
ified nurses in dealing with the realities and challenges of this gagement in self-care on compassion fatigue and burnout). Re-
profession (Allcock and Standen, 2001; Freshwater and Stickley, search with other healthcare professionals could explore similar-
20 05; Hunter and Deery, 20 05; Jack and Wibberley, 2014; Lavoie- ities and differences to those outlined above and further develop
Tremblay et al., 2008; Maben and Macleod Clark, 1998; Maben et the study’s conceptual framework, establishing whether it has res-
al., 2007; Msiska et al., 2014; Rudman and Gustavsson, 2011). The onance beyond nursing.
findings of this study provide knowledge in how to care for the
nursing workforce in a proactive way.
4.2.3. Nursing education
4.1. Strengths and limitations Nurse training did not seem adequate in enabling individuals
to be self-caring and self-compassionate. Findings suggested that
There was a dearth of literature related to the field of in- nursing identity played a key role in accepting permission to self-
quiry; hence, the research offers new and significant knowledge care and be self-compassionate. This often developed before but
that could (a) influence nursing practice and policy, (b) underpin also during nurse training. Therefore, if the concepts within this
further research and (c) impact upon nursing education. Partici- study were embedded into nursing education, nurses may feel able
pants reflected on the importance of the research; the eagerness to care for themselves from early on in their careers. This may pro-
and ease of recruitment highlighted that it was a topic of interest. tect them from the more negative effects of caring such as burnout
If the study were to be repeated it would be interesting to sam- and compassion fatigue. It could also enable them to be positive
ple children and young people’s nurses (RNCs) to ascertain any role models to future nurses.
 H. Andrews, S. Tierney and K. Seers / International Journal of Nursing Studies 101 (2020) 103436 9

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Elwood, L.S., Mott, J., Lohr, J.M., Galovski, T.E., 2011. Secondary trauma symptoms
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