GRACE: a tool for providing compassionate care.

There is little argument that nursing is grounded in high clinical acumen and competence. You probably see that it abundantly clear that it is also deeply entwined with the cultivation and delivery of compassionate caregiving.

The compassionate nurse is not only caring for, but also caring about.

Much has been written recently around compassion and the nurse.
There is a great deal of pressure on our profession to be seen to be generating it in abundance, despite the working environment becoming increasingly acidic and challenging to this very experience.

In an article for the Journal of Nursing Education and Practice, Joan Halifax Roshi, a Zen teacher and anthropologist, discusses a tool she has developed  to assist  in cultivating compassion in nurse/patient interactions.

GRACE.

Gather your attention. A reminder to pause and ground yourself with attention to your breath or to a particular sensation. To reallocate your attentional resources for a moment away from the patient and into your subjective experience in order to open a focused space.

Recalling Intention. Joan describes this as recalling the “essential intention of the nurse’s mission, which is to protect and preserve the well-being and integrity of the patient”.

Attunment to self and other. Often we see our patient through a screen of perceptual, affective and cognitive biases. By using metacognition (thinking about our thinking) we can acknowledging these biases and try to see the patient with fresh eyes. Thus, we produce a shift in our attitude and behaviour towards them.

Considering what will serve. Deciding on response rather than reaction.
A diagnostic process assisted by intuition and heuristics. “The discernment process might take time; it certainly requires attentional and affective balance, a deep sense of moral grounding and an ethical imperative, as well as an unbiased attunement into the patient’s experience and needs”

Enacting, Ending. Engage or apply a compassionate action and then bring that action to a close or letting it go.

An example of GRACE in action:

Gather your attention:

Pause, breathe in, give yourself time to get grounded by gathering your attention.
Invite yourself to be present and embodied, by sensing into a place of stability in your body.
You can focus your attention on the breath, for example, or on a neutral part of the body, like the soles of your feet or your hands as they rest on each other.
You can use this moment of grounding to interrupt your assumptions and expectations.

Recall your intention:

Remember what your service to the patient is really about: to relieve the individual’s suffering and to act with integrity and preserve the integrity of the other.
Recall the felt-sense of why you have chosen to relieve the suffering of others and to serve in this way. This “touch in” can happen in a moment.
Your motivation keeps you on track, morally grounded, and connected to the patient and to your highest values.

Attune by checking in with yourself, then the patient:

First notice what’s going on in your own mind and body. Then sense into the experience of your patient. This is an active process of bearing witness and inquiry, first involving yourself, then the patient.
Give attention to your own somatic state, what the body is experiencing at this moment. Shift your attention to your affective stream, and what emotions are present for you. Then shift to your cognitive stream, and notice what thoughts are present. Your sense of and insight into your internal experience can help you regulate biases that might be present in your perception of and attitude toward your patient.
Now, sense into what the patient might be experiencing. Sense without judgment. Sense into not only what the patient is experiencing but also how they might be seeing their situation, and experiencing you.
Open a space in which the encounter can unfold, in which you are present for whatever may arise, in yourself and in your patient. How you notice the patient, how you acknowledge your patient, how your patient notices you and acknowledges you, all constitute a kind of mutual exchange. The richer you make this mutual exchange, the more there is the capacity for unfolding.

Consider what will really serve your patient by being truly present with your patient and letting insights arise.

As the encounter with the patient unfolds, notice what the patient might be offering in this moment. What are you sensing, seeing, learning? Ask yourself: What will really serve here?
Draw on your expertise, knowledge, and experience, and at the same time, be open to seeing things in a fresh way.
This is a diagnostic step, and as well, the insights you have may fall outside of a medical category. Don’t jump to conclusions too quickly.

Engage, enact ethically, and then end the interaction: allow for emergence of the next step.

Engage and enact: Compassionate action emerges from the sense of openness, connectedness, and discernment you have created. This action might be a recommendation, an open question about values, or even a proposal for how to spend the remaining time with this patient.
You co-create with the patient a dynamic, morally grounded situation, characterized by mutuality, trust, and consistent with your values and ethics; you draw on your professional expertise, intuition, and insight, and you
look for common ground consistent with your values and supportive of mutual integrity.
What emerges is principled compassion: mutual, respectful of all persons involved, and as well practical and actionable. These aspirations may not always be realized; there may be deeply rooted conflicts in goals and values that must be addressed from this place of stability and discernment.

End: Mark the end of the interaction with your patient; release, let go, breathe out.
Explicitly recognize internally when the encounter is over, so that you can move cleanly to the next patient or task; this recognition can be marked by attention to your out-breath.
While the next step might be more than you expected would be possible or disappointingly small, notice that, acknowledge your work. Without acknowledging your own work, it will be difficult to let go of this encounter and move on.

The full article is available for free download in pdf formG.R.A.C.E. for nurses: Cultivating compassion in nurse/patient interactions.

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