What is blocking the hose? Compassion in perinatal care.

There was a helpful discussion on one of our professional forums recently about compassion, and what gets in its way. ‘Compassion fatigue,’ the theory goes, doesn’t exist. When professionals feel burnt-out, the motivation to care remains, but it gets obstructed. It’s like compassion is water flowing through a hose: the tap remains open, but the hose gets blocked. Turning up the pressure won’t help, until the hose is untangled and the kinks removed.

It’s like compassion is water flowing through a hose: the tap remains open, but the hose gets blocked.

It really made us think about the situation we find ourselves in, in the perinatal system. There’s a lot of anger about the fact that people ‘just need to be kind, how hard can it be?!’. A sense of moral failing that people are sometimes behaving in ways that aren’t compassionate and that when we hear these stories, it feels far from how we ourselves imagine we would act. There is a call for ‘more kindness, more civility, more compassion.’ This is a call to ‘open the tap and turn up the hose.’

But often the tone of these conversations reveals something of the challenge itself. What would it take to pay attention not just to the tap and how much care people are putting into the system, but also to the state of the hose itself and how might be slowing down the flow of compassion through it?

When things work well, compassion flows freely through the hose. Some things will turn the tap up or down – but we have never met a healthcare professional who didn’t have a good water supply! No one would keep coming to work in these really challenging fields without it.

So what gets in the way of the flow? Sometimes these are really temporary twists in the hose. A family might behave aggressively and we find the hose gets a bit kinked – it’s hard for our compassion to flow. Usually, we’ll have a brew and a debrief, straighten out the hose and the water flows freely again.

But the hose of perinatal care has taken some serious battering in recent years. Covid stretched this hose way further than it was designed for – people were scared to come to work, patients were scared to be there, and the hose wore thin. The rubber perished.

The work itself is increasingly high stakes – higher risk pregnancies, poorlier babies, perilous staffing levels and interactions with parents who are more likely to ask questions and feel in conflict with teams (understandably, given all the same challenges!) have bent and twisted and knotted the hose over and over again.

And more recently, people have tried to step in. They’ve tried to direct the water – putting a finger over the end of the hose to push the water in a certain direction – but building up pressure in the hose as a result.

They’ve been anxious about the task at hand and desperate to protect babies and families and so they’ve worn really big, steel toe capped boots of scrutiny, regulation and fault finding. But unfortunately, at times they have trodden firmly on the hose. Shaming and criticising people for personal failings is a surefire way to crush the flow of compassion.

Or maybe there are stories that are told in the organisation about the permissibility of compassion for ourselves and each other. Some of these stories are voiced and visible, some are below the surface: "if I slow down and connect, it will overwhelm me." "If we really listen to how our staff feel and what they need we might not be able to tolerate what we hear." "If we offer too much we might create a dependency." These stories often originate a long way back, and are usually born of fear. They twist and kink and knot the hose.

What is the consequence when the hose gets blocked? The tap is still running, but the flow of compassion slows and pressure starts to build. If this goes on, the hose might not be able to contain this pressure, and could burst. How often have you, or a colleague felt that way, lately?

What gets in the way of the flow?

We keep emphasising the need to turn up the taps. ‘Have more compassion!’ we say. And then we block the flow – and gradually the hose starts to erode and split. We wrap it in gaffer tape: ‘wellbeing initiatives’, baskets of fruit. We pay for ‘hose reinforcers’: brief therapy offers for staff who have burst. But still the kinks and the pressure continue to build. Eventually, there’s a crack so big that the hose is out of action, and suddenly there is no way to bring compassion to patients at all.

So. We have a dilemma. We need our patients to experience more compassion as a baseline, the findings on that are clear. But what helps to build a hose through which it flows freely? How do we:

• Build the capacity of our teams to understand what impacts their flow of care and compassion, so they are better able to strengthen and direct it?

• Create spaces for staff to think with others, to help untangle the hose when it gets twisted, or unblock it when there is an obstruction?

• Get out of the way? Finding compassionate, safe ways to assure and improve our services that take account of all the humans within them.

We absolutely need to improve compassionate flow, but unless we turn to the source of the problem, we will simply shame and erode individuals and teams further until there is no way to access that source of compassion at all.

Safe, effective perinatal care relies on the humans at the heart of it far more than the systems that regulate it. How do we tend to the flow of compassion?

Thanks for reading.