Allie Tran, who works in UVA Medical Center’s Intensive Care Unit, followed in her mother’s footsteps when she became a nurse. Photo: John Robinson
When Dorrie Fontaine became dean of UVA’s School of Nursing in 2008, a subtle shift in how nurses were taught to tackle tough situations—the death of a young patient, a family pushing back on end-of-life decisions—was already under way.
Toward the end of her tenure, former Dean Jeannette Lancaster partnered with philanthropist Tussi Kluge to create a resiliency elective course for nurses, designed to help them deal with the most emotionally taxing aspects of health care with mindfulness techniques like meditation and yoga.
Since her arrival, Fontaine has built on that idea with the Compassionate Care and Empathetic Leadership Initiative. It’s a long title for a simple concept: Give nurses the tools to take on the challenge of facing illness and death on a daily basis, and they’ll be better prepared to help patients and families do the same. Better health care relationships, better health care.
At the heart of the initiative is the idea that compassion can be taught. Nursing students keep journals reflecting on their experiences, practice tough conversations with simulated patient encounters, and attend workshops and retreats where they learn techniques to clear their minds.
The initiative has spread beyond the nursing school, said Fontaine. Medical Center staff have found ways to bring moments of peace into the hectic hospital environment, like the nurse who instituted a practice of taking a 45-second silent pause in the wake of every E.R. death to honor the patient who passed away.
So far, the implementation has been piecemeal, but Fontaine said she’s working with the Curry School of Education to build the practice of teaching compassion into the curriculum. We sat down with Fontaine and later with Rebecca Kneedler, the Curry School’s associate dean for academic partnerships and international initiatives, to talk about the process of making mindfulness part of medical care.
C-VILLE: Did you have pushback from people who thought this approach was too…New-Age-y?
DF: I had a couple faculty members who felt like I was pushing religion—which is O.K. Now they’re on board. I’m very patient.
The way you deal with it is you fight science with science. Susan Bauer-Wu, the new Kluge Endowed Professor in Contemplative End of Life Care, got big money from the National Institutes of Health to show that mindful meditation programs for people who are having bone marrow transplants help in their quality of life, and it helps their families. She’s a trained scientist who’s doing this work. Mindful practices are getting mainstreamed now.
RK: We struggle with that. It is so easy to dismiss and demean this approach. I think that that’s why it’s really important that we bring the science to it. If you’re going to bring it into the university setting, then you have to approach it with the same language and rules about rigor and empirical evidence. But it’s there.
C-VILLE: Showing patients and nurses meditation techniques is one thing. Can you really teach someone to be more compassionate?
DF: We can teach it, and we’re wrong not to teach it. We’re reclaiming the soul of health care. It’s why people come into the field. There are so many physicians and nurses who are just sad right now, because they’re not able to give the care they want.
But when we teach compassion, people are going, ‘Yes.’ It’s very hard to be angry or upset at somebody if you put yourself in their shoes. That’s a big first step to amplify compassion.
C-VILLE: So how do you teach it?
RK: We want to help our students to just be present. Try to forget the garbage from the past and the anxiety from the future. The power of bringing that to a struggling learner, a patient, your spouse, your mother-in-law, anybody—it’s overwhelming. We’re always told, ‘Pay attention, pay attention, pay attention.’ But we’re never given any tools to do that.
DF: You have to role model compassion. You have to be aware of what’s going on around you, and that’s what we’re teaching our students—to stop, observe, and think. Understand when somebody gets upset, and ask what’s behind it. Listen and be thoughtful, even when you don’t feel like it.
C-VILLE: What do you want to see as you implement this program?
DF: I would really like to see it improve the lives of our students and faculty and the University as a whole. With so much focus on mindful practices in Charlottesville and with the Contemplative Sciences Center here, we’re like ground zero for this kind of approach. There’s probably not one university like ours—with a law school, with an education school, a nursing school—where it’s all coming together.
And now we’re asking, if it’s a national model, how do we scale it up? How do we help others implement this? If it really works, we need to demonstrate that and replicate it. Sometimes you just have to keep talking about things.
Notes from the front lines
Nurses weigh in on why the Compassionate Care Initiative matters
Sue Kiley has a Ph.D. in cell biology, and studied influenza vaccines, H.I.V., cancer, and pediatric kidney disease for 30 years before she decided to return to school for her MS in nursing. She made the switch, she said, because she wanted the chance to make a daily difference in peoples’ lives. “It takes a very long time for bench research to be translated to bedside medicine,” she said. She’s now an intensive care nurse.
“For new graduate nurses like myself, there are so many skills to master and tasks that must be performed each shift, it is easy to mechanically work through the day without allowing yourself to feel the emotions in your patients’ rooms or take the time to listen. This is the difficult part of health care; several patients to care for, with too much to do in too little time.
“Finding ways to incorporate compassion and empathy into daily practice is still a work-in-progress for me, but it is absolutely essential to the joy I find in the work I do. During physical assessment, I might comfort a patient with the gentle squeeze of a hand after assessing strength of arms and hands, or a quick hand or foot massage after pulse checks. It’s the small gestures that provide comfort and connection to another human being.
“Compassionate care includes listening to the patient and family, appreciating their needs and/or answering their questions, even if it means I must pick up the threads of the conversation later in the day after I’ve had time to find needed support, answers, or explanations.
“I find listening with empathy is never more important than when a family is facing end-of-life decisions for a loved one. When I ask the right questions, encouraging dialogue among family members, and seek the support of chaplains, social workers, and the palliative care team, I can help turn a difficult and scary time into a peaceful end that provides closure for all who witness it, including me and other health care professionals.”
Allie Tran, 24, entered nursing school at UVA straight out of high school, knowing it was a career that would allow her to have a direct impact on people’s lives. (“My backup plan was to be an engineer or mathematician,” she said.) She’s now spent six years in Charlottesville—four as an undergrad and two at UVA Medical Center, where she’s now a charge nurse in the Medical Intensive Care Unit.
“When I met John (I’ve changed his name), a gentleman in his 80s, he had chronic obstructive pulmonary disease and lung cancer from years of smoking, as well as diabetes, kidney disease, and problems with his heart. When his daughter brought him to the hospital, his respiratory status was getting worse; he needed a breathing tube and mechanical ventilation to stay alive, but it was unlikely that he would ever leave the hospital once that was done.
“John had moments of lucidness in which he would tell staff about how he had had enough of the hospital and how he just wanted to go home. He said he did not want to be intubated. But because of his delirium, he didn’t have the capacity to make this decision himself, and we had to rely on his daughters to make it for him. They said he never wanted the breathing tube, but that they did not want him to die either. John ended up being intubated, and had to be restrained and sedated so he wouldn’t pull out the lines and tubes that were keeping him alive.
“I didn’t realize it then, but I found myself caught in an ethical dilemma. I felt like we were acting against John’s wishes, giving him medications and restraints so he could tolerate what he didn’t want in the first place. I felt like he relied on them to speak for him when he couldn’t, and they let him down.
“It took an emotional toll on me, but I didn’t want to accept it. My mentor, however, recognized this and encouraged me to talk about my feelings. I was resistant. ‘My feelings? What? No, I’m fine. I don’t need to talk about my feelings.’
“But I wasn’t fine.
“Eventually, I realized I was really upset with the family, and that I disagreed with their decision. After a few days of frustration, tears, and talking to my mentor and parents, I was better able to understand that their decision was one of desperation—they weren’t ready to say goodbye to their father.
“The next time I saw them, I was more at peace. I was able to move forward and re-focus attention on what was most important: how we could best care for John now. Soon, his daughters began to accept that he was very ill and had been through enough, and they were ready to honor his wishes. The breathing tube was taken out and John died peacefully in the ICU, with his family at his bedside.
“In health care, there is a push to work harder and faster, to get more done and see more patients. Taking the time to stop and pause is sometimes discouraged; it ‘slows you down’ when there is work that needs to be done. And yet, we take care of patients at their sickest and are reminded daily of the mortality of humans—this is an extremely personal, emotional, and spiritual experience. How do we balance the two?
“Finding that balance was difficult for me in the beginning, but I’ve come to find that taking the time to pause and be mindful of my own emotions and those of others has been key to my practice and my resilience as a nurse. The more I practiced this mindfulness, the more I recognized my anxiety and frustration towards situations involving death and dying. It has helped me to approach the suffering we see every day with the compassion and presence that our patients and their loved ones deserve.”