Hermeneutic phenomenological research on how nurse educators make meaning of compassion and understand its role in their professional practice

Background: In the United Kingdom (UK), whilst nurse educators are responsible for developing compassion through providing high quality education, there is limited literature exploring how their lived experience of compassion is interpreted in nurse education. Objectives: To explore how nurse educators make meaning of compassion through their lived experiences in the UK. Design: Hermeneutic phenomenology. Setting: A UK school of nursing. Participants: Purposeful sampling was used to recruit twelve nurse educators. Method: Semi-structured interviews were used to explore participant experiences of compassion. Data analysis involved crafting stories and was interpreted by applying Heideggerian and Gadamerian philosophical notions to surface meanings of everyday experiences. Findings: The phenomenological themes identified nurse educators interpreted compassion through Being-with is Care ; settling their colliding worlds of nursing practice and nurse education, and balancing Kairos or ‘felt ’ time with negotiated time for compassion in nurse education. Conclusion: This research demonstrates that nurse educators share genuine concern for Being-with others that is interpreted as compassion. However, the emotional aspect of compassion is avoided in their professional practice as a means of protecting students and their own feelings of vulnerability. There are colliding views in understanding compassion. Emotional intelligence is identified as necessary to grasp ‘felt ’ moments or negotiate a time to Be-with that is interpreted as compassion. Training and support is necessary for nurse educators to understand and develop compassion in their professional practices.


Introduction
Compassion is the 'most precious asset of nursing' (Schantz, 2007, p.48) and a professional responsibility (Newham et al., 2019). As the world faced Covid-19, the centrality of compassion in nursing was reinforced by the United Kingdom Royal College of Nursing, stating 'nursing staff are revered for their heart and compassion that's a core part of our job' (Kinnair, 2020, p.3). The International Nursing Code of Ethics (2012) identifies compassion as a core value in nursing and thus a worldwide expectation that nursing is underpinned by compassion.
Whilst compassion is said to be at the heart of nursing, in the UK there are publicised examples of care without compassion, including neglect and abuse (Francis, 2013). In response, scholarly opinions argue that nurses are compassionate but the emotional fatigue felt by nurses and the humanistic aspects of care may go unnoticed (Ledoux, 2015). Such findings have also been found among student nurses who feel vulnerable in the context of compassion expectations within environments that are not conducive to compassionate practice (Curtis et al., 2012). In light of these concerns, nurse educators have been charged with the responsibility of enabling compassion in nursing through education (Willis, 2015). Published literature demonstrates the complexity of the concept of compassion (Straughair et al., 2019) and a gap in our understanding of how the lived experience of compassion is interpreted in the context of nurse education. The nature of students' concerns or challenges during education for compassionate practice may therefore not be understood and the lack of consensus in the meaning of compassion in education may lead to inconsistency of student and educator support.

Background literature
The Nursing and Midwifery Council standards for pre-registration nursing programmes (NMC, 2018) provide guidance that nursing values include compassion and underpin nurse education, but how compassion is incorporated into programmes is left to educators. The standards also suggest nurse educators engage in continuing professional development. However, it is not entirely clear what type of preparation and development nurse educators should access in order to educate for compassionate practice.
Whilst there is no single definition of compassion, a critical analysis of literature by McCaffrey and McConnell (2015, p.3008) indicate that compassion consists of two distinctive elements, 'an awareness of another's distress and the motivation to relieve it'. Whilst care is closely connected to compassion, it is important to have a clear focus on compassion as a distinct concept. For example, compassion is defined as relief of suffering whilst care has a broader definition in provision of what is required to maintain health or welfare. Hence, there are terms that include the concept of compassion such as 'compassionate care' (an adjective) or 'to care compassionately' (an adverb). It was not the intention to do a comparative study on care vs compassion, but rather to understand the meaning of compassion interpreted from nurse educators lived experiences. The role of emotions in compassion for nurse education adds to this complexity and Smith (2012) suggests that the everyday language of emotional labour incorporated in the discourse of compassion means the concept has become normalised and therefore the relational aspect of emotional work in nursing remains hidden. It is this normalised talk and tacit view that the research sought to uncover in nurse educators' stories to reveal their meaning of compassion.
Literature reveals diverse teaching practices for developing compassion in nursing students, such as using online protocols, reflection, positive role modelling and application of creative arts in the nursing curricula (Adamson and Dewar, 2015;Newham et al., 2019). There is no agreement on when or how compassion is best taught during the curriculum. In addition, there are arguments over whether compassion can be taught or is an innate human trait (Straughair et al., 2019).
There appears to be a deficit in research that explores how nurse educators regulate and manage their emotional experiences in their meaning making and facilitation of compassion. The research questions were therefore shaped by the gaps in the literature that seek meaning of compassion from nurse educators' modes of existence. The research was integral to understand how nurse educators interpret compassion through thinking about their own and others' emotions in the professional context, and in doing so, how this influences their education practice and the development of compassion in students.
The primary research question of the study was 'How do nurse educators make meaning of compassion and understand its role in their professional practice in a UK HEI?' and other secondary questions included: I) How do nurse educators make meaning of compassion?, II) What are nurse educators' lived experiences of compassion in a UK HEI? III) And How do nurse educators perceive the meanings of compassion are influencing their pedagogical practices in a UK HEI?

Nurse educators' meaning of compassion
Whilst there is existing literature that describes the significance of establishing effective relationships for compassion, it is mainly told from patients', carers' and student nurses' perspectives (Curtis et al., 2012;Straughair et al., 2019). Peters' (2006 phenomenological study offers some understanding of nurse educators' experience of compassion in the educational context, such as: human connectedness, reciprocity, empathy, recognition of suffering, kindness, caring and maintaining professional boundaries. However, it does not explain how these experiences are influencing their teaching practices nor does it explore the nurse educators' relationships with their peers and managers. There is a significant gap in current literature on exploring nurse educators' meaning of compassion revealed through their lived experiences.

Aim
The aim of this research was to illuminate the meaning of compassion through nurse educators' ways of being and to understand how their meaning of compassion might be informing their pedagogic practice.

Design
Hermeneutic phenomenology was the most fitting methodology for the research as it enabled thinking beyond concepts of compassion and to be attentive to meanings hidden in nurse educators' everyday experiences. Philosophical concepts that underpin hermeneutic phenomenology propounded by Heidegger (1962) and Gadamer (2004) were adapted and guided the research data collection and interpretive processes.

Data collection and participants
Twelve nurse educator participants were recruited from a UK school of nursing. The participants were Registered Nurses and had at least two years' experience in pre-registration nurse education. Pseudonyms protected their identity. The majority of the participants identified as female (9) with six participants in the age range 30-40 years, two were 41-50 years old and four were over 50 years old. Recruitment was through email invitation and included participation information to ensure informed consent.
The research took place in 2018-2019 using semi-structured interviews in one to one sitting together in person with the nurse educators to produce detailed contextual meanings of the phenomena. A loose interview guide was used following Gadamer's call for the conversation to have a 'spirit of its own…taking its own turn' and responding to the participants' cues (Smythe et al., 2008). Only one sitting was needed as hermeneutic phenomenology recognises that stories are never neutral or complete. The length of these sittings ranged from 47 min to 1 h and 39 min as the times were not pre-determined but rather came to a natural end. The interviewer was known by the participants and care was taken by the interviewer to recognise risk of 'informant bias' through reflexivity (Fleming, 2018).

Ethical considerations
Ethical approval was granted by the university's Research Ethics Committee and all ethical principles for conducting research were upheld.

Data analysis
The analytical process was iterative as participants recordings were repeatedly listened to, alongside re-reading of transcripts, to enable questioning of the meaning-making of compassion. Expert guidance by Smythe (2011) and Crowther et al. (2017) was used to craft stories that involved the ontic phase of knitting together significant words from the transcripts and the ontological phase that required an Interpretive Leap; requiring questions of the story in seeking deeper underlying meaning that connects to the philosophical perspectives of hermeneutic phenomenology. Heidegger was interested in the human 'way of being' and used the term 'Dasein' to denote 'being there' that is ontological. The capitalisation of the 'B' in 'Being' is used to emphasise this ontological way of existing (Wheeler, 2011) and is revealed in the participants' stories. The interpretive leap allowed imaginative thinking about notions such as Kairos that represents a time of possibility and is a mode of temporality (van Manen, 2018) that identified such felt experiences. The emergent meanings connected with ideas that were informed by the philosophical notions and their inter-relatedness uncovered significant themes. Prolonged engagement with the transcripts and reflexivity enabled trustworthiness of the findings.

Findings
The following phenomenological themes demonstrate the meaning of compassion: • Being-with is Care • A settling of the colliding worlds of nursing practice and nurse education • Unveiling the veiled dance of Kairos balanced with negotiated time for compassion in nurse education

Being-with is care
Nurse educators shared genuine concern for how they engaged with their peers, students and the university in their making meaning of compassion. As they talked about their engagement with others, their stories uncovered particular forms of Being-with one-another, revealed through authentic and inauthentic ways of Being that is interpreted as compassion or lack of compassion. According to Heidegger (1962), humans are already socialised in public practices and they can either choose to accept the norms and culture of society and exist inauthentically or face up to their anxiety and become an authentic self. Inauthentic Being is not always a deficient mode of existence (Heidegger, 1962) but in this research it is demonstrated when the participants followed unwritten rules of avoiding personal emotions on how compassion is taught: Ann seemed to appreciate the reasons behind the customary rule of not sharing personal stories in the classroom and although she went along with normative practices that are championed by others that relate to inauthentic existence (Heidegger, 1962), she was unsure if emotional avoidance was the best way to facilitate compassion. Similarly, another participant recognised that sharing personal stories about suffering could be upsetting for students and time-consuming and whilst the emotional aspects were avoided, she believed it is part of facilitating compassion: 'When we do death and dying, we don't go down the emotional side because the students might get upset, but I don't know if that's very healthy… In the third year we go into a much deeper level but we use scenarios, I think it's because we haven't got enough time'.
There was contemplation by some participants about their preparedness to facilitate the emotional aspect of compassion: 'We use case scenarios but I don't know if they really explore how they feel. Even though I am quite experienced I would be frightened because you don't know what you are going to unearth and how you are going to support them'. (Emma) The stories shared by Ann, Emma and Bird revealed that they understood the significance of emotions in making meaning of compassion but there were conflicting views on how they thought it should be facilitated that led to tensions between their authentic and inauthentic engagement with students.
The participants indicated that organisational norms and the nature of relationships with colleagues can sometimes constrain compassionate behaviours in Being-with: 'In the academic world you don't openly cry or express yourself. We are distant, we are educated, we are doing a job'. (Jason) Uncompassionate behaviours by colleagues were described as 'simply processing the rules or going through the motions' (Ann). Participants' experiences and interpretations of compassion varied in relation to the nature and depth of the relationships formed through Being-with their peers: Relationships and power dynamics within groups formed in the university seemed to influence the participants' expectation and interpretation of compassion. For example, although the participants expected managers to be compassionate, there was a supposition that professional boundaries curtailed how compassion was expressed: 'You have got those professional boundaries, they (managers), are not really concerned about your feelings…'.
The participants' stories implied that systems of managerial structure, power dynamics and organisational processes influenced how compassion is experienced by nurse educators. Regardless of Being-in a team or in positions of power, they expressed concern for how they existed with others in the university as Dasein is care (Heidegger, 1962). Opportunities for developing compassionate relationships with colleagues were problematic when working across differing sites and dealing with the everydayness of university life: 'I work across two sites which mean that I don't have deep compassionate relationships because I am hardly ever with my team. I always feel pushed and pulled as you might not see them all day'.
Although teams created opportunities for strengthening collegiality, the participants explained how it was compounded by the complexities of their work, the spatiality of working practice sites and the team's structure. van Manen's (1997) notion of the 'lived space' shows how working across various sites can affect our relations with others.
Whilst the challenges in forming close relationships with students were compounded by workload pressures the participants described times they chose to put aside busy schedules and Be-with: "Sometimes students will say 'Can I have a word with you?' and I put everything aside and sit and talk to them and find out what they are worried about on a one-to-one because often we are in groups that are massive".
Being-with-others described by the participants revealed an overall endeavour for care that is interpreted as compassion.

A settling of the colliding worlds of nursing practice and nurse education
The concept of 'worlds colliding' describes the different perspectives the participants held about compassion that arose from their background experiences as a nurse, educator or individual. Their jostling ideas on how they thought students should be supported were related to traditional social norms in nursing about emotion management, which involved emotional distancing: 'I can't help feeling that some students need to toughen up a bit…, man up or grow a pair… I have empathy for them but up to a point… you have to be careful cause you get landed with everything and that happened in nursing and then you burnout'.
As a man, Cameron seemed cautious about how much support he offered students and his experiences of the fear of 'burnout' in nursing influenced his measured approach to Being-with-students. Conversely, for some nurse educators challenging gender stereotypes was important as another male participant attempted to role model by openly sharing his emotions: 'Through sharing my experience perhaps they feel that this man is demonstrating an emotion, compassion,… I'm acting as a role model for them'.
Nursing roles seemed to conflict with academic roles and created tensions on how students were supported. Sandra recognised there is a risk of blurring of boundaries between Being-a-nurse and Being-aneducator that steered how she related to students:

'Some students come with complex mental health needs and I have to remind myself that I am not a mental health nurse to my students'.
(Sandra) Conversely, another participant used his mental health nursing's experience to understand students' difficulties but recognised the need for professional boundaries:

'As a mental health nurse, I'm thinking what's happened in their lives for them to get where they are struggling…But it's right to want professional boundaries…'.
(Matt) Heidegger's (1962, p.158) notion of 'leaping in' that takes care away from others and can lead to dependency versus 'leaping ahead' that involves empowerment of others, were identified in the participants' stories. Ella for example, thinks 'as nurses we can rush in as we try and fix things…' and uses her awareness to leap ahead and encouraged students to seek opportunities for problem-solving through 'reflecting and debriefing'. Similarly, leaping ahead is demonstrated in Bird's story as she recollects the time a student faced difficulties in practice: 'I sat with the student and she had a little cry and we had a chat about it… I think that there was a lot of learning for the student… it's about helping her to grow'.
Contrastingly, the risk of students' failing seemed to cause underlying anxiety for some participants and led to acts of leaping in: 'I know how difficult it is for the university to lose 3rd year students…they are now down to their last attempt. So I took charge and supported them to submit their assignment and prevent them failing'. (Matt) Colliding views over the practical acts of 'caring for' and the emotional aspects of 'caring about' featured in the participants pedagogical practices. For instance, Bird indicated that the curriculum divides and prioritises the practical tasks of 'caring for' from the emotional aspects of 'caring about' where the first year focuses mainly on the skills: 'In the first year when we teach about death, it's just about the skills and we don't go down the emotional side…it's very task-orientated… in the third year we would go into it in a much deeper level'. (Bird) Contrastingly, another participant thinks that compassion is intertwined with the technical skills and is threaded throughout the curriculum: 'compassion should run through your teaching like a running stitch… In all of my teaching I try and teach a narrative…instead of it being a boring brown thread it becomes more like a golden vibrant... more of a dimension'. (Dani) The stories uncovered a jostling of ideas between the techne and phronesis in terms of how it was interpreted and positioned in nurse education. Whilst the participants held contrasting perspectives on how compassion is interpreted, there was a settling of their colliding worlds evident through efforts to empower others by engaging in caring conversations because they understood compassion is significant and accepted responsibility for developing it in nurse education.
Unveiling the veiled dance of Kairos balanced with negotiated time for compassion in nurse education.
The meaning of compassion in this research is uncovered in felt moments (Kairos), and therefore can be missed but can be reignited through planned times for compassion. The metaphoric veil is applied from reflections of Oscar Wilde's play, 'Salome Dance of the Seven Veils' and describes the ambiguous nature of Salome's dance that aligns with the participants' stories which hinted to special moments captured, lost or balanced and re-instated in the intangible dance that is compassion. There were times compassion was interpreted through Being-in-themoment: 'It was stopping in the here-and-now, of recognising that I had become upset and listening, the conversation was like coaching me'. (Sandra) Conversely, the following participant talked about when felt moments of suffering were not grasped by their colleagues: 'After my mother passed away I spoke to some of my colleagues saying how close I was with my mum. I didn't expect them to hug me and cry but none of them came'. (Jason) Whilst Sandra interpreted her colleague's awareness to relieve her distress at her time of need as compassion, Jason interpreted the experiences of feeling ignored as a lack of compassion.
The findings revealed that it is not always possible or practical to deal with individuals' needs immediately but it can be balanced with a negotiated time for compassionate practices: 'I made the time to meet up with this student and mentor and we had been back and forth with different dates and times that didn't suit. Eventually we came up with a date as I want to be there to support the student…'. (Bird) Whilst felt moments for compassion with others were not always grasped or recognised, there was a moral endeavour to seek out or plan opportunities to Be-with others that was interpreted as compassion. Compassion is interpreted through a fusion of horizons (Gadamer, 2004) revealed through reflexive poetry, created from the voices of the nurse educator's data (Fig. 1).

Discussion
The data demonstrates that nurse educators place great importance in forming meaningful relationships through Being-with their students, peers, managers and the university. They make meaning of compassion through their and others' modes of existence that are interpreted as authentic and inauthentic, and communicated through acts, feelings, attitudes and behaviours. The research findings support existing understanding of nursing practice and nurse education which convey 'caring for' patients through practical acts and 'caring about' others through emotional and relational facilitation is interpreted as compassion (Curtis et al., 2012). The research extends understanding and reveals that owing to the complexity of the emotions in compassion, nurse educators use emotional distancing as a safeguarding measure during their interactions and teaching practices. There are parallels with the study by Peters (2006) who found that although nurse educators acknowledged students' feelings, the emotional aspects of compassion were not made explicit in the curriculum. In addition, the stories identify that nurse educators do not feel knowledgably prepared for facilitating the emotional aspects of compassion and this exposes their vulnerability. The emotional distancing used by nurse educators can be related Hochschild's (1983) theory on emotional labour who explained that 'surface acting' or suppression of emotions is used in challenging emotional situations but there is evidence it can lead to emotional fatigue and burn out.
In addition, the colliding worlds of nursing practice and education lead to irregularities in pedagogical practices for facilitating compassion as emotional aspects are delayed or developed through theoretical and abstract knowledge and technical skills are prioritised over human relational issues. These pedagogical inconsistencies have implications for nurse education, as the literature demonstrates student nurses could already be at risk of emotional fatigue as early as in their first year (Jack, 2017). Further disruptions in teaching practices and ways of Being in the university that stem from nursing practice are exampled in the research by emotional avoidance for fear of burnout, supporting students as patients or as learners, conflicted behaviour due to gendered norms, tensions over maintaining professional boundaries and jostling between empowering others or taking control. The pedagogical focus on technical tasks revealed in this research compares with Smith's (2012) ethnographic study who illustrated it's easier to divide the technical skills from emotional care, and the grounded theory research by Straughair et al. (2019) who confirmed that scientific, technical knowledge is prioritised over humanistic values in contemporary nursing.
Nurse educators understand compassion is significant to nursing practice and accept professional responsibility for developing it through education. Therefore, attempts to settle their colliding worlds are evident in their openness to each other's interpretation of compassion. Nevertheless, ambiguity in the educational standards (NMC, 2018) adds to colliding opinions on how humanistic values are interpreted. The curriculum projects the ideals of compassion espoused by the profession's educational standards but the students are socialised into managing their emotions through surface acting, role modelled by nurse educators. The data supports previous research that a mismatch exists between teaching professional ideals for compassion and the socialisation processes that constrains development of compassionate practice (Curtis et al., 2012).
Paradoxically, in the research findings a tacit knowing was gleaned from the nurse educators' concern for Being-with others, as they understood emotions management is necessary for compassion. It urged nurse educators to think about their own and others' feelings and at times they chose to grasp opportune moments, adapt pedagogical rules, take time to Be-with necessary for compassionate practice. The findings highlight that due to increasing performative pressures, there are limited opportunities for nurse educators to develop their skills for teaching compassion or strengthen relationships in the university, echoing findings in other studies that nurse educators feel disempowered to provide emotional support for students due to increasing work pressures, limited time and resources (Braine and Parnell, 2011). Nevertheless, when nurse educators are able to reflect on their pedagogical practice, it develops their emotional intelligence for authentic evaluative judgements necessary for compassionate practice. Their authentic concern for how they interact with others is juxtaposed with their angst caused by the marketisation of university activity.
There is an underlying assumption by nurse educators that the university expects professional behaviour comprising the containment of distressing emotions. Although the nurse educators echoed the need to maintain professional boundaries for compassion, they were conflicted on the demarcations of these boundaries that were complicated by professional identity as nurse and an educator.
The research demonstrates that the felt time for compassion is ephemeral, sometimes grasped at opportune moments, missed or planned, and is balanced by personal and organisational conduits. The findings reveal that emotional intelligence enables reflecting in the now and grasping opportune moments for compassion or negotiating a mutually agreed time. It is clear that nurse educators are making meaning of compassion through navigating the contours of their personal, professional and organisational existence based on their concern for self and others. Importantly, it highlights how systems, processes and power structures in the university are influencing how nurse educators make meaning of compassion and their pedagogical practice.

Limitations and potential for future research
The researchers acknowledged the insider-researcher status as part of nurse educators' lifeworld and as such share experience of compassion that contribute to presuppositions. Whilst these presuppositions cannot be bracketed, they were made explicit through on-going reflexivity. An unexpected finding that was beyond the scope of this paper suggests that traditional gendered norms might be changing in nurse education. Further research is recommended to explore how gendered norms are influencing compassion in nursing practice and nurse education.

Implications for nurse education
The research highlights the 'joint responsibility' of the individual and the university to create opportunities for enabling compassionate relationships and ensure a shared meaning of the phenomenon is integrated in pedagogical practices. In addition, training and support is required to deliver a compassionate curriculum. Nurse educators value when there are opportunities to reflect together and develop emotional intelligence for compassionate relationships. Such safe spaces can be created alongside planned time for Being-with-others. The research demonstrates that leaders and nurse educators have shared responsibility to role model positive ways of Being-with-others.

Conclusion
This research provides a unique contribution to understanding how nurse educators value meaningful relationships and demonstrates that compassion is revealed through their careful concern for Being-withothers. In addition, it highlights that nurse educators do not feel prepared to educate for compassionate practice and so use emotional avoidance as a protective mechanism for dealing with the emotional aspects of compassion, thereby safeguarding themselves and their students from feelings of vulnerability. Nurse educators also have different perspectives on compassion and settle their differences through interpreting compassion pursued through their pedagogical practices. Essentially, this research has potential to bring about a change that draws attention to the significance of facilitating compassion when 'caring for' and 'caring about others'. Therefore, it highlights that compassion should be integrated in the technical and humanistic aspects of care and in the teaching of those components of nursing education. The research provides insight into nurse education, exposing how nurse educators seize opportune moments and negotiate times for compassion alongside meeting organisational demands. The findings from this research propose a change for clearer guidance from the NMC's pre-registration educational standards on how professional values are taught that can influence how local curriculum are developed to facilitate compassion.

Declaration of competing interest
None.