“The team needs to feel cared for”: staff perceptions of compassionate care, aids and barriers in adolescent mental health wards

Literature on cultivating compassion in healthcare systems, has identified a need for compassionate leadership to be present in order to foster conditions in which compassion can flourish [18], including conditions that improve patient care by enhancing supervisory support [19]. Staff wellbeing has been linked to better patient care [20], and factors that improve staff wellbeing may therefore indirectly influence levels of compassionate care.

The organisational psychology literature has highlighted the superior effect of wellbeing interventions that target multiple levels (work conditions as well as individual resilience) [20] over those that only target individuals. Potential factors that might improve both staff wellbeing and patient care include those relating to work motivation, such as “hygiene factors,” i.e. factors needed to prevent dissatisfaction (e.g. adequate supervision, work conditions and rewards), and motivating factors such as recognition and growth [21].

Additional factors linked to wellbeing include appropriate balance of work demands and individual control over how to fulfil those demands [22], adequate support including positive relationships at work [23] and staff opportunities for autonomy, relatedness and competence [24]. Factors known to help or hinder motivation have also been related to the creation of compassionate leadership and fostering of trust [25].

An important barrier to compassionate care is the stress experienced by health care professionals. Indeed, healthcare is widely acknowledged to be one of the most stressful work settings, with a report in the UK stating that approximately 40% of NHS staff had called in sick due to stress in the previous year [26]. These numbers are likely to be worse now, as the COVID-19 pandemic continues.

Stress can impair compassionate care for example by inducing compassion fatigue [27]. Compassion fatigue refers to emotional (and often physical) exhaustion and an associated reduction in ability to feel compassion [27]. It is distinct from burnout (exhaustion, hopelessness and a reduction in a sense of personal accomplishment, not necessarily associated with compassion) and from vicarious (or secondary) trauma (the triad of post-traumatic stress symptoms: avoidance, hyperarousal and intrusive thoughts, experienced in the wake of someone else’s description of a trauma) [28].

Although healthcare professionals are often highly compassionate, compassion fatigue is a particularly prevalent response to work stress in this population, possibly precisely because of how often compassion is required (and experienced) [27, 29]. Within healthcare settings, staff often have to cope with stressful and sometimes upsetting environments, tasks and interactions (e.g., in mental healthcare, helping an individual to dress their self-harm wounds, or in physical healthcare helping a patient to manage chronic pain, or delivery of a terminal diagnosis). How to manage these without experiencing compassion fatigue presents a challenge both to individuals engaged in the work and to supporting organisations.

Compassion fatigue impacts the ability of staff to provide compassionate care [20], as well as impacting service efficiency (through staff sickness or turnover) [30]. In addition, lower staff wellbeing is both a precursor to compassion fatigue, and a potential consequence, since compassion fatigue is associated with lower compassion satisfaction – the feeling of satisfaction from performing a caring role [31].

Models of how compassion fatigue develops differ in the extent to which they emphasize individual or organizational risk factors [29, 32], with the latter including factors such as poor resources and considerable patient demands. Empirical studies show an effect on compassion fatigue of both individual factors (e.g. staff history of trauma) and more systemic/organisational factors (e.g. level of support in working environment) [28]. It is therefore likely that individual, team, and organisational factors are important aids and barriers to compassionate care, but these are seldom explored from the staff’s perspective, consistent with a general paucity of studies grounded in individual healthcare providers’ experiences in specific settings.

Current knowledge about compassionate care is theoretically sophisticated but study of what compassionate care consists of, what aids it, and what hinders it is seldom rooted in lived experience. Theoretical models are yet to coalesce into an established consensus on what aids compassion and what acts as a barrier. We complement existing theoretical knowledge by examining what compassionate care means to staff working in inpatient CAMHS in the UK. We specifically focus on how these staff understand compassionate care, and what they perceive as aids or barriers to compassionate care.

Although the first author of this paper has lived experience working with children and adolescents in mental health services, our research started with a wider consultation with a broader range of clinicians, as well as (former) patients, to ensure our research questions and approach were relevant to the population in question. Stakeholders were selected through the first authors’ professional networks and a patient and public involvement network at Bath University, and were contacted by email or phone. Stakeholders included clinicians from a range of relevant disciplines (nursing, occupational therapy, medical, psychological, social work), mental health commissioners, and adults who had previously been patients on adolescent inpatient mental health wards. Exchanges ranged from one response to the original contact to emails/phone calls exchanged between author and stakeholder. Stakeholders were from London and the South West of the UK and were asked: (1) What does compassionate care mean to you? (2) What do you think would be useful to research in this area? (3) What in your opinion helps compassionate care to happen? (4) What in your opinion gets in the way of compassionate care?

The consulted stakeholders thought of compassionate care as an important, but as yet poorly understood, issue, deemed worthy of further research by all stakeholders consulted. The importance of empathy, kindness, and taking the perspective of another were all discussed as aspects of compassionate care. Some staff were interested in how patients feel during their first contact with CAMHS, hypothesising that the initial contact usually helps set the tone for therapy and recovery and wondering how important compassion might be at that stage. Others were interested in links between compassionate care and attachment theory, and also between compassionate care and staff burnout. Opportunities to reflect, to pay attention to self-care, and to relate theory to practice were all identified as important aids to compassionate care. Limited resources, including lack of time and poor staff relationships, were highlighted as barriers to compassionate care. Ex-patients were interested in whether patients noticed staff stress on the ward and whether patients had different views before and after admission of what compassionate care was like. A mix of people were interested in whether staff experiences with stress and compassion changed over time. All thought that different perspectives on compassionate care would be interesting to compare and that staff, if consulted, was likely to have useful ideas about what helped and hindered compassion on the ward. All were able to answer the questions meaningfully, and questions 1, 3 and 4 were used (in a modified form) as a basis for the subsequent focus groups.

We next conducted three focus groups with mental health professionals on three different adolescent mental health wards in the South of England (one focus group per ward). These focus groups did not include (former) patients, as our focus in this part of the study was primarily on mental health professionals.

All wards were UK NHS services and provided care to adolescents from 12 to 18 presenting with significant distress and a diagnosis of a mental health problem. These wards did not overlap with those who participated as stakeholders in the first phase of this research. Wards had given consent for staff recruitment. A senior team member on each ward helped facilitate information sharing and recruitment for the focus group. Care was taken that there was no suggestion of coercion and that all staff voluntarily participated. All staff were invited including care staff, domestic staff, and administrative staff, although the majority of attendees were clinical staff. Staff were informed about the study through an email and participant information sheet shared with all staff by the local senior team member and through posters and participant information sheets left in staff areas of these wards. Focus groups took place in staff meeting rooms on the ward site and staff were thanked for their time with a £10 online shopping voucher.

Between 10 and 12 participants attended each of the three focus groups, with a total of 35 participants. Full demographic information was not collected but verbal report and observation revealed that groups were attended by a mix of professionals, including nurses, doctors, and other healthcare professionals (e.g. occupational therapist). Nurses were the largest staff group, reflecting the staff mix on CAMHS wards in general.¹

Focus groups were moderated by the first author and followed a semi-structured interview schedule honed from initial stakeholder conversations. Groups lasted an hour, with three key questions: 1) What is compassionate care for you?; 2) What are, for you, aids to compassionate care?; And 3) What are, for you, barriers to compassionate care?

Group discussions were recorded and transcribed by an independent transcription service.

All transcripts were analysed together by the first author using thematic analysis [34], with data for each question analysed separately and then reviewed by the second author and by an additional postdoctoral qualitative researcher. Analyses were reflexive and informed by our own experiences as well as understanding of past research and theory. The first author has worked inpatient CAMHS settings whilst the second author and postdoctoral researcher have not.

The first author familiarised herself with the data by listening again to the recordings of the focus groups, which she had conducted, and reading and re-reading the transcripts. Raw data were reflexively coded by the first author by hand (using paper copies of the transcripts, highlighters and pen). Codes were noted in the margins and the relevant text was highlighted. Codes related to the participants’ expressions in the transcripts in both a very literal way relating to the semantic meaning of what the participant said and in some cases in a more inductive way, describing a latent meaning which seemed to be present. Codes were listed by the first author then checked by a post-doctorate researcher with expertise in qualitative analysis, and adapted in response to feedback.

Codes were assembled into initial candidate themes and sub-themes by the first author. Sub-themes were organised as clusters under each theme and the generation of sub-themes involved the interpretation of some participant experiences. Themes and sub-themes were first established in relation to each question, and then looked at overall in relation to the whole dataset. Initial themes and subthemes were then reviewed in collaboration with the second author and the qualitative expert advisor. This included consideration of whether themes or subthemes would be better conceptualised as a code, whether the themes were meaningful, useful and coherent, and whether there was enough data to support the themes. The overarching themes were mainly those that could be directly related to participants’ accounts, however, some elements of the themes drew on a priori knowledge of the first author from past theory and research (as highlighted in the introduction).Whether the data related to individual, group, or system-level experiences was also coded by the first author and reviewed by the second author. Themes, sub-themes, and naming of data as relating to individual, group or system-level experiences were modified as a result of discussions: the process was iterative. Themes were collaboratively defined and named, and a first draft of this paper produced. As a result of pre-publication peer review, themes and sub-themes were further revisited and themes were condensed further.

After analysis of focus group discussions, we created a survey to examine to what extent the sub-themes resonated with the experiences of CAMHs workers in other inpatient services. An online survey was created on Qualtrics and shared with all members of the Quality Network of Inpatient CAMHS (QNIC). This is a mailing list run by the Royal College of Psychiatry that staff working on inpatient mental health units for children and teenagers (from multiple professional disciplines) in the UK and Ireland can choose to join. Network members were invited to participate in the survey; anonymity and the voluntary nature of participation were stressed.

Data was collected for six weeks and three reminders were sent within this period. The survey received 36 responses. Nearly 70% of respondents worked in adolescent inpatient units. Of the 36, 25 (69.4%) worked on adolescent mental health wards, three (8.3%) worked on child wards, two (5.6%) worked on adolescent Psychiatric Intensive Care units, and six (16.7%) worked on other types of child and adolescent mental health wards. Roles were allied health professionals (AHP) (n = 12, 33.3%), nurses (n = 8, 22.2%), doctors (n = 5, 13.9%), Health Care Assistant (HCA) (n = 1, 2.8%) and other (n = 9, 25.0%); one participant did not provide information about their role.

Participants were asked how much they agreed that each of the sub-themes reflected their experiences in relation to each question. For example, participants were asked to what extent “active listening” was inherent to their understanding of compassionate care and to what extent they experienced “self-criticism” as a barrier to their ability to deliver compassionate care. Participants responded to these questions on a six-point Likert-type scale (from 0 = not at all important to 5 = extremely important). Participants were then asked whether they felt any factors were missing from the list presented, and if so, to describe these.

Themes and sub-themes are presented in Tables 1,2,3 and summarised with example quotes. There were no noteworthy differences across focus groups at different locations.

Responses to the first question (What is compassionate care?) were categorised into 6 themes with 18 sub-themes (see Table 1), including practical actions that demonstrate compassionate care and attitudes that staff hold as part of compassionate care. Overarching themes were: Emotional connection, sense of being valued, attention to the whole person, understanding, good communication, and practical help/resources. In all tables below, the level of system to which themes related is indicated by I, T, or O (individual, team and organisation).

Helping the patient to feel safe was described both as reassuring them through words and actions, and through staff modelling safety through their behaviour with each other: “They trust us ‘cause they see us look after each other” (Nurse, ward 1).

Sitting with difficult feelings was described by one nurse as “Sitting with them when they’re distressed and it doesn’t matter how distressed they get you’re still there.” One staff member related that those difficult feelings could even be brought up by receiving compassion, if this was an unfamiliar experience: “When they experience compassion it can sometimes bring up times when they might not have had that experience in the past. It can bring up a lot of painful feelings for them so being able to sit with them through that” (Nurse, ward 1).

Several ward staff also felt that the willingness to touch the patient, appropriately, was an important part of compassionate care. This could take different forms, either “touching a hand on the shoulder” (Nurse, ward 2) or getting down on the same level as a distressed patient and holding their hand, or offering to help plait patients’ hair: “That hands on approach that we care enough to do it” (Healthcare assistant, ward 2).

A sense of being valued was subdivided into sub-themes of prioritising patient care and having a non-judgemental attitude towards the patient. Prioritising patient care was common to staff’s understanding of compassionate care. One senior nurse spoke about prioritising face-to-face contact: “I spend a lot of time doing paperwork but if someone is in need of my care and my compassion then I make time for that” (Nurse, ward 1). Conversely, one staff member spoke about how prioritising patient care could take many forms, which were not all witnessed by the patient themselves but which did all involve providing compassionate care:

“It’s easy to get drawn into feeling that the only time we’re being compassionate is when we’re sat with somebody and soothing them… they don’t necessarily see my compassion when I’m shouting at a social worker down the phone because a placement hasn’t been found” (Nurse, ward 1).

Suspending judgement about young people’s behaviour was an important aspect recognised by several staff members: “Being non-judgemental, making sure that… if you’ve got your own beliefs not letting that affect your ability to care for the person that’s in front of you” (Nurse, ward 2).

Attending to the whole person included active listening, individualising care, spending time with the patient and working as a collective around the person. Many participants described qualities of active listening, and reasons for why this was so important for compassionate care, including the more practical seeking of patient views and the more emotional “responding to somebody’s feelings”. For example:

“Normally you try to reflect back what they’re saying or give a little summary if they’ve said an awful lot. So they know that you’ve heard what they’re trying to say. Or if you get it wrong they’ve got the opportunity to say no, no, not like this, it’s like this” (Nurse, ward 3).

Whilst ward rules and boundaries were viewed as important there was also a recognition that to provide compassionate care sometimes rules need to flex to accommodate individual needs. Sometimes this included flexing the rules to allow increased comfort, for example around letting young people have teddy bears with them through the day, or letting them “curl up under a blanket” if they were having a difficult time: “Tailoring care to individual circumstances… otherwise patients can merge into one big patient we’ve seen many many many times… to press pause a moment and think about that individual” (Nurse, ward 1).

To provide compassionate care, the importance of spending time with patients was emphasised, even when this was not always to do anything in particular, but more about sitting with someone: “Just staying in the room. Just sitting there quietly sometimes” (Nurse, ward 2).

Working as a collective around the young person with other staff members and the young person’s family was seen as an important aspect of compassionate care in the ward setting in order to bring in different aspects of their lives: “It really encapsulates everyone that’s involved in that person. If you’re all compassionate and work as a sort of collective…everybody including their folks, and carers, or social services… that big circle around them” (Nurse, ward 2).

Relatedly, seeing the staff team as one entity in which different team members could swap in and out of working with a young person was another strong theme: “Sometimes it’s recognising that actually, I’m not getting anywhere here, maybe someone else might be able to help” (Nurse, ward 3).

Being able to explain clearly what was going on and why, and to offer alternative options, was also felt to be an important part of what staff felt qualified as compassionate care. This included thinking about how to explain if something that the young person wanted to happen couldn’t happen: “If you can’t do what they’re asking explaining why and perhaps offering to do something slightly different” (Nurse, ward 3).

Staff spoke about the importance of showing you care, “being explicit that you care” (Nurse, ward 1). One nurse said: “I think it’s important to let them see that you care… okay you’re telling me to go away right now but actually I’m really worried about you and I care about you so I don’t want to leave you” (Nurse, ward 1).

Staff spoke about the importance of normalising distress, understanding and empathising with distress and wanting to help, as you would help anyone who was struggling. One nurse summed this up as helping patients to understand for themselves that: “You do things differently when you’re having a bad day” (Nurse, ward 1).

Staff emphasized the importance of openness about the impact of caring on themselves, even when this might involve more difficult conversations, for example letting a patient know that something they have done has made the staff member worried or concerned. This also related to authenticity. This was spoken about as an important aspect of care, so that patients weren’t receiving mixed message. In this sense, being compassionate involved “Being open, not saying one thing but actually they’re picking something else up” (Nurse, ward 1).

Several examples of practical help were given to illustrate compassionate care, both for patients (e.g. “helping them to put on their shoes” Nurse, ward 2, or “making them a cup of tea” Nurse, ward 3), and for family members (e.g. “offering them a box of tissues” Nurse, ward 3). The importance of “something small you can do to make them feel more comfortable” (Nurse, ward 3), often going beyond baseline clinical care, was a common theme, as shown by the following example:

“We had a parent who was in a wheelchair and really restricted mobility and I recognised that her young person’s gone for something to eat and I was on my way out to get some lunch, and I just stopped and said “is there anything I can get you?”, because I knew the likelihood was she couldn’t… She asked me to get her something and that was just such a little thing to do for somebody, but I thought ‘I’m really glad I did that because she’d have been really hungry’” (Nurse, ward 3).

Responses to the second question (i.e., what might aid or facilitate compassionate care) yielded six themes that were similar to those obtained in response to question one, with 18 sub-themes. However, this time, the 18 sub-themes involved individual factors related to the staff members and their ways of coping with work, team factors, and factors related to the organisation as a whole, including the actions of other members of the system, e.g. colleagues, senior management, and young people. Themes and sub-themes are summarised in Table 2.

Examples of feeling cared for at work were given by multiple ward staff. Being held in mind by the staff team as a new starter, having people notice if you are struggling, being able to talk to colleagues about professional and personal dilemmas, and having basic physical needs looked after by other staff, all were given as important examples of feeling looked after by colleagues through the stressful events of day-to-day ward life:

“You have a really rubbish hour and someone will have gone on their break and bring back the most doughnuts you’ve ever seen” (Nurse, ward 1).

Part of feeling cared for by a compassionate team was a feeling that other team members would be attuned to staff distress and act to do something about it, without a staff member necessarily needing to ask for help. For helping professionals used to caring for others this is perhaps particularly important: “We’re good at spotting when someone is struggling. I’d say we’re stronger at spotting when someone is struggling than we are at actually asking for help” (Nurse, ward 1).

Many staff members spoke about the importance of a strong connection with the wider staff team, which encompassed multiple practices of building and maintaining this connection, including small gestures such as smiling at each other in the corridor, and more difficult practices such as making sure repair happened after difficult conversations between staff: “Everyone’s going to fall out [staff]… but it’s what you do next to repair that is valuable” (Nurse, ward 1).

One staff member highlighted the important of handover as a way of facilitating this connection, encouraging an understanding of the events of the last shift better and promoting compassion for the staff and young people who may have been through some difficult experiences in that time. Another emphasised the idea of the ward as an entity involving multiple people – staff, patients, and families – and one where care is continual, even when the particular staff member is not on duty: “It’s something about being connected to the whole, ‘cause it’s 24/7” (Nurse, ward 1).

Establishing and maintaining connection with the patient was also seen as an aid to compassionate care. Some staff spoke about feeling that a patient had a particular resonance with them, as if “the patient tends to pick you” (Nurse, ward 2), whilst others found they felt more empathy for particular types of mental health difficulty: “I probably get on more with people who have psychosis rather than mood disorders. I find with mood disorders I probably end up going down in the ditch with that person whereas with psychosis I can stay there” (Nurse, ward 2). Knowing about an abusive history was spoken about as something that was likely to increase staff compassion for that young person for most staff.

Staff also saw team work as an aid to them remaining emotionally fit enough to care in a compassionate way. Teams were often described as acting “like a family” (Nurse, ward 1), with team members being supportive and taking time to give practical help when needed: “if something is going on on the wards, you’ll find everyone is down on the ward doing what we can” (Nurse, ward 1). Another participant stated: “We have those squabbles, but that’s okay because we all care about each other enough to make up afterwards and still continue to work together in a really collaborative and cohesive way” (Nurse, ward 1).

The importance of patients valuing work the staff had done was clear. Staff remembered being contacted by some patients years after having cared for them:

“Sometimes they write lovely letters about how much they feel that the ward has helped them or sometimes, even now, somebody who left about a year ago will phone up and say this is happening, or I just got my GCSE results or whatever. It’s lovely. You don’t want to keep them connected with us necessarily but at the same time you know your work has been valuable to them” (Nurse, ward 3).

This fitted with the idea of how important it was to celebrate successes, in order to keep staff feeling motivated to care compassionately. This related both to staff and patient successes, for example from small acknowledgements of a positive piece of work to opportunities in shift handover to speak about young people with optimism: “Looking at something positive that they’ve done and the way you speak about it… helps the staff when they go onto the ward… you’ve got more compassion when you’re dealing with them” (Nurse, ward 2).

Individual supervision from more senior colleagues was talked about in particular as something that was vital, in order to “see beyond” (Nurse, ward 1) what was going on and retain compassion: “Being able, through supervision, reflection and all these other things, to be able to see beyond perhaps what you’re faced with” (Nurse, ward 1).

Formulation, consisting of a shared understanding within the team (and with the patient and their family) of what is going on for the young person, was talked about as being important for staff to have a shared knowledge framework, but also as a way to grow and sustain compassion: “If you understand the reasons why someone’s behaving in a certain way that helps you feel more compassion” (Doctor, ward 2).

Authenticity and openness were named by some staff as important in promoting compassion because they enabled staff to relate more authentically to each other and to patients, and to appropriately feel their own feelings rather than “keeping a lid on everything”.

A senior nurse described: “I’ve named it with the young people only this morning. I’ve had three of them in a room and I’ve said ‘I’m really disappointed, I’m angry, I’m upset with the way you’ve treated this ward’, because it’s role modelling, we’re allowed feelings” (Nurse, ward 1).

Relatedly, holding a non-judgemental attitude towards oneself as a staff member was deemed important for staff to authentically cope with the difficulties of the role, accompanying the ability to be compassionate or to return to compassion if for a while it felt absent: “to be compassionate to yourself not only the patients” (Nurse, ward 3). One nurse said: “Thinking that’s okay sometimes to feel really angry, or bitter, or not feel that compassion. Not putting yourself down… just helps it come back again” (Doctor, ward 1).

Taking time off the ward in different ways was a prominent theme. One ward had renamed staff breaks as “patient safety breaks” (Nurse, ward 1) to emphasise the impact they had on patient care as well as staff wellbeing. Alongside this was a recognition that it was better to communicate to management if you were struggling to manage emotionally and take some time off the ward, if this was a possibility: “When you’re not quite right… have the afternoon at admin” (Nurse, ward 1).

Adequate staffing was one aspect of practical resource, and “Not being short staffed” (Nurse, ward 2) and “having time to check in with the children [patients]” (Nurse, ward 2) were seen as directly related. Thinking carefully about the number and role of the staff present on different shifts was also seen as important, as different times of day on the ward have different demands. For example, the early evening on CAMHS wards is a time routinely associated with increased risk incidents such as aggression or self-harm and is a time when there are fewer structured activities and fewer non-nursing staff. One ward introduced a twilight shift (between 4 pm and midnight) to increase staff at this time and found this reduced incidents. A manager spoke about the importance of having a higher level management presence on the ward at times:

“S--- higher level manager is here once a week so she’s always around if you ever feel like you need to go to a higher level…. That felt supportive and enables you to work better because you really feel listened to because the top people are out talking to you” (Nurse, ward 3).

Responses to the third question (i.e., what might be the barriers to compassionate care) again reflected six themes that were similar to those observed in response to the first and second question, this time subdivided into 19 sub-themes. These were again related to different levels of the system: individual factors, factors related to team relationships with other colleagues, and organisational factors. Themes and sub-themes are summarised in Table 3.

Constant change in the way services were run was highlighted by both managers and frontline staff as a barrier to being able to provide compassionate care, since staff were preoccupied by acclimatising to changes. Teams were described as particularly sensitive to any kind of change because of the amount of changes that had already occurred, in quick succession, and with a lack of consultation. “That one change is probably not going to be seen as a positive change because people are still disgruntled about everything else… you can’t plonk a house together… it’s brick by brick. One change at a time” (Nurse, ward 2).

Ward rules were seen as important. There was a sense from some staff that “blanket rules” (Nurse, ward 3) on the ward were unhelpful and acted as a barrier to more individualised care, which staff felt was intrinsic to compassionate care. Conversely, a lack of rules and boundaries was also seen as unhelpful:

“Lack of consequences for actions sometimes… I’m not saying we need to punish young people in CAMHS inpatient units but that feeling that they can do whatever they want and we don’t have any power to put a consequence in… and boundaries, that can then make it harder to remain compassionate” (Nurse, ward 1).

Lack of emotional connection also related both to a lack of connection with fellow team members and a lack of connection to the young people being cared for.

Staff generally did not feel a lack of connection with the wider team, but they did feel this was an important barrier when it did occur: “If somebody’s said something to you and you’ve taken it quite personally and critically and you’ve just had a big flop then… if you perceive somebody else being a bit mean to you that can really have an impact on your ability to be compassionate to others” (Nurse, ward 1).

When a lack of connection with a young person was perceived this was also seen as having a negative impact on compassion. Sometimes this related to specific aspects of patient presentation, and this was often related to young people continuing to hurt themselves or others: “It’s really difficult when someone keeps trying to hit you” (Nurse, ward 3). Staff also spoke about how feeling that they couldn’t ‘get through’ to a young person could block their ability to feel compassion as strongly: “some of them have got walls up” (Nurse, ward 2) A feeling that a patient didn’t need to be on the ward, perhaps because their behaviour was seen as less related to mental health problems, was also seen as a barrier to compassion: “If we feel that maybe they’re not poorly anymore then that’s harder to keep the compassion for them” (Nurse, ward 1).

The potential for staff traumatisation in events such as when restraints are used, was also highlighted as an important factor that could jeopardise connection with a patient and block compassion: “Things like restraints… you’re holding someone down who is screaming in your ear and it echoes right in there and it can stay there” (Nurse, ward 2).

Staff mentioned a sense that not feeling rewarded by the way that they were continually asked to do more by the organisation without full acknowledgment of what they were already doing could be wearing: “It just grinds slowly, slowly, slowly… we should have done this, or we should have done that” (Nurse, ward 2).

Poor working conditions for staff on the ward were seen as an important, and under-acknowledged, barrier to compassionate care: “the team has to feel looked after” (Nurse, ward 2). Staff referred, for example, to not being provided with tea, coffee, and milk, and having to bring their own if they were to have some during the day. This led to staff feeling undervalued (and to a wasteful amount of milk in the fridge) and added to a sense of exploitation: “Instead of telling me to be positive they should be giving me more money or free coffee” (Nurse, ward 2) There was a definite emphasis on how important is was for the team to feel looked after: “Getting those basic needs met and then you’re able to perform and give that 100% and be compassionate” (Nurse, ward 2).

Lack of attention to the whole staff member was a theme that related to the staff as a person with both personal and professional needs and aspects to their life. Staff acknowledged the impact of their personal life on their work persona, and the difficulty in maintaining compassion, “if you’re just having a really bad time personally” (Nurse, ward 1). Conversely, the impact that working in a CAMHS ward setting could have on home life was seen as a potential difficulty: “It’s difficult to have your life here and have your life there [home].” (Nurse, ward 3). This was seen as a something which could impact on staff’s feelings about work and patients, making them less able to be compassionate with young people.

A lack of openness in staff was related to a self-critical attitude which they identified, and which they then related to coping by hiding their true feelings (and being inauthentic). Staff spoke about failing to be compassionate with themselves: “We struggle to have compassion for ourselves… we need to call our own breaks ‘breaks for the patients’ because we just cannot accept that we could possibly need any care ourselves,” (Nurse, ward 1). Staff acknowledged that these strategies were risky: “Burnout happens really quickly when the inside doesn’t match the outside for some reason” (Nurse, ward 1).

Several staff acknowledged that they needed to be more deliberate about taking care of themselves and that often staff coped in unhelpful or counter-productive ways, like engaging in excessive drinking. As one team member said: “We’re human as well and we have our own mental health to look after… a lot of the time we don’t do it very well” (Nurse, ward 2).

Staff described the consequence of a lack of personal resource: Feeling “worn out” or “at your wits end” (Nurse, ward 3), as a barrier to compassionate care. This is often defined as one of the components of compassion fatigue, and was identified as something which led to a need for self-protection, but also as something that could result in feelings of guilt “after a while we will protect ourselves but we’ll feel bad” (Nurse, ward 3). One staff member stated: “It’s not that you don’t care, but it’s just where you’ve got to the point where you’ve got nothing left to give” (Nurse, ward 3).

Several physical features of the ward environment were described by staff as a barrier to being in a state of mind, in and outside of work, which is calm and compassionate. Alarms going off on the ward was one feature that seemed to particularly stress and stay with staff, even when they weren’t on shift: “I was at Lidl and I literally took a step [when an alarm went off] and my husband’s like What?… I just literally thought it was these alarms” (Nurse, ward 2).

Staff described their basic needs not being met at work, for example having time to eat, use the bathroom or rest, and this impacting on their ability to provide compassionate care: “things are so difficult when you’re so tired, when you need the toilet, when you’re hungry, it’s all the basic things isn’t it? They massively get in the way” (Nurse, ward 1).

The amount of bureaucracy, including forms that need to be filled in multiple times, was identified as a barrier affecting nurses in particular: “the amount of paperwork that qualified nurses are expected to do and the duplication of that frustrates me” (Nurse, ward 1). There was also a related theme about the impact on the team of the sorts of questions asked in fact-finding or incident-related paperwork: “I don’t know if the system always encourages us to be compassionate towards each other. I think the system and the paperwork is often about placing blame or saying that things need to be done…when actually it was a really hard shift and it could get done next shift” (Nurse, ward 2).

The trade-off between time spent completing paperwork and time spent with patients was a common theme: “If they [nurses] had less red tape they’d be able to spend more time [with patients]” (Nurse, ward 1). One healthcare assistant described having to reduce attendance at therapeutic groups “it’s just managing that one with the time” (Healthcare assistant, ward 1).

A lack of financial resources available to the service was highlighted as a practical barrier to being able to provide compassionate care, particularly when staff had to be creative to meet patient needs: “They’ve taken away the money [for activities with YP] at the weekends… our consultant used her own money to buy pizzas [for patients]” (Nurse, ward 2).

Short staffing was another example of a practical barrier to providing compassionate care: “We were short staffed for a bit and that was really hard… bouncing from one incident to another” (Nurse, ward 2).

Results from the survey (Supplementary Tables S1,S2,S3) indicated that all sub-themes listed were endorsed by at least one participant and the importance of compassion running throughout all levels of the organisation was highlighted by open comments, such as: “from board to ward, staff need compassion too.” Most sub-themes were rated as at least somewhat important or above (i.e. a rating of 2 or above on the 0–5 response scale) and seven were rated by all respondents as very or extremely important (a rating of 3 or above on the 0–5 scale). These were: Having a non-judgemental attitude and empathy as elements of compassionate care, and having the aids of respect for other points of view, feeling valued, teamwork, formulation, and adequate staffing resources. Five sub-themes were more weakly endorsed than the rest, with some staff voting them as not important at all. These were: Therapeutic touch as an element of compassionate care, authenticity as an aid to compassionate care and personal challenges, coping styles, and impact on home life as barriers to compassionate care.

When asked what factors might be missing from the list presented in the survey, some ideas were mentioned, but they all seemed to fit within existing overarching themes, though they did add detail. When commenting on what compassionate care consisted of, participants mentioned an understanding of the biology of stress and trauma and an understanding of the spirituality of young people being cared for. Both these factors can be seen to fit under the theme of ‘understanding,’ adding elements to what staff feel they must understand to provide compassionate care. For aids to compassionate care, participants mentioned the inclusion of families as an additional aid, which can be seen to relate to understanding, helping and communicating, and the recognition of team work difficulties was related to connecting with the team. For barriers to compassionate care, participants added lack of team conversations, especially about compassion, a culture of staff fear of complaints, a “double-edged” nature to teamwork and a tendency for staff to make assumptions about families. These can be seen as related to poor emotional connection within the system.