Building Cultures of Caring

Burnout, compassion fatigue, vicarious traumatization, secondary traumatization, second victim syndrome, moral injury―we describe the costs of caring, the suffering of clinicians and staff, with these terms. Caring for others can seem like an endless task. There’s so much suffering in the world. It was already tough working in healthcare and it’s only bcome more challenging with the pandemic, social justice issues, climate change, natural disasters, deaths from gun violence, anti-science propaganda, the overturning of Roe v. Wade in the U.S., and political divisions. How can we care for others when it is increasingly challenging to care for even ourselves? 

During the pandemic and the events of the last few years, I’ve found myself struggling sometimes to care for myself. I know I should do more self-care. I’m board certified in holistic & integrative medicine, I teach Whole Health with the national VA Office of Patient Centered Care & Cultural Transformation, I have a skill set of self-care modalities―yoga, meditation, and mindfulness. But sometimes, I just don’t care enough to care. I don’t care enough to care for myself. The pressure of having an active self-care program can seem just like one more thing I’m trying to accomplish each day, one more protocol I’m trying to manage. It feels like the burden of care for self and others falls primarily on clinicians rather than being borne by institutions. When I can’t care for myself, it’s more difficult to care for others, and it’s a struggle to care about my job. 

Lately, I’ve been wondering about caring―what is it? Is there a way of cultivating caring so that it sustains and supports us rather than depletes us? What if our view of ourselves as separate individuals processing patients through protocols is what leads to burnout? Is there a way to bring more heart and soul into our work, rather than feeling our hearts are empty and that we are gradually losing our souls in our work? Is there a way to cultivate caring and compassion that fuels and replenishes us while we care for others?  

Maybe caring is a state of being rather than a commodity or transaction. Lewis Hyde has written about the distinction between gift economies (where gifts are circulated) and capitalist economies (where objects and services are commodified and accumulated―similar to much of the work of diagnosing, billing, coding, and documenting in healthcare). Could part of burnout be alienation from our work in which we do not derive the intrinsic benefits of circulating the gift of caring? Gift economies teach us interconnection, rather than separation as individual units of productivity and objectification.  

Hyde wrote in “The Gift,” “a circulation of gifts nourishes those parts of our spirit that are not entirely personal . . . although these wider spirits are a part of us, they are not ‘ours’; they are endowments bestowed upon us. To feed them by giving away the increase they have brought us is to accept that our participation in them brings with it an obligation to preserve their vitality.” What if we could cultivate a gift economy of caring in which giving it away increased our capacity for caring and compassion?  

The Buddhist concept of lovingkindness (metta) involves a cultivation of caring through giving away lovingkindness to others. As Sharon Salzberg wrote in “Lovingkindness: The Revolutionary Art of Happiness,” “giving is a way of stating our interconnectedness.” Thus, when we give caring and lovingkindness to others, we are receiving it as well because we are all interconnected. Salzberg tells us that, “The Buddha taught that if the heart is full of love and compassion, which is an inner state, the outer manifestation is care and connectedness . . . they are both aspects of the same radiance.” 

Maybe you’ve felt this sense of being nurtured and sustained by your own caring. This is different than realizing you can upcode your billing documentation to get more RVUs (Relative Value Units); instead, it is an increase in a different kind of RVU (Relational Value Units). Connection is its own reward and sustains us, even in trying situations and circumstances. It’s the alienation, separation, and isolation that weigh on us, where we are going through the motions of our work without feeling able to take time to care.  

What if caring is like the flow states that Mihaly Csikszentmihalyi describes in which there is “a sense of deep enjoyment that is so rewarding people feel that expending a great deal of energy is worthwhile simply to be able to feel it.” Further, he writes that it is through active engagement and striving that we sometimes reach flow states. “The best moments in our lives, are not the passive, receptive, relaxing times—although such experiences can also be enjoyable, if we have worked hard to attain them. The best moments usually occur when a person’s body or mind is stretched to its limits in a voluntary effort to accomplish something difficult and worthwhile. Optimal experience is thus something we make happen.” 

What if we could transform the culture of healthcare so that everyone was cultivating caring: patients, clinicians, staff, and leadership? Drs. Trzeciak and Mazzarelli, after an extensive literature review of compassion in healthcare, concluded in “Compassionomics,” that, “Compassion matters―for patients, for patient care, and for those who care for patients…Compassionate care belongs in the domain of evidence-based medicine.” 

If compassion is evidence-based, why aren’t we doing more to enhance compassion in our institutions? Dr. Danielle Ofri points out that “The Business of Health Care Depends on Exploiting Doctors and Nurses” as our professionalism demands that we always try to put patients first despite the system exploiting our caring as an “infinite and free” commodity. When we leave it up to individuals to care for themselves in their free time so that they can do their jobs at work, it’s a set up for burnout. We need caring throughout the systems and institutions we work in. If we want caring and compassion as an “output,” we need caring and compassion as an “input.” We need to build a culture of caring.  

Christopher Germer and Kristin Neff have studied self-compassion and developed the Mindfulness Self-Compassion program through the Center for Mindful Self-Compassion. They speak of a “caring force” that can be developed through the practice of three interrelated elements of self-compassion: mindfulness, recognizing our common humanity, and kindness. This is another evidence-based approach to teaching compassion. We have many tools for teaching and sustaining compassion, we just have not built them into our daily practices in institutions.  

The component of common humanity in self-compassion dovetails with Salzberg’s statement that giving is a way of stating our interconnectedness. Many spiritual traditions point beyond interconnectedness to unity, or non-dualism, in which we are not only interconnected, but are actually One, not two. This is a state of radical non-separateness.  

Salzberg writes, “With this understanding, the interconnectedness of all that lives becomes very clear. We see that nothing is stagnant and nothing is fully separate, that who we are, what we are, is intimately woven into the nature of life itself. Out of this sense of connection, love and compassion arise.” 

Perhaps burnout is a symptom of a larger problem. Perhaps we’ve cut ourselves off from a root of support in our work, we have lost touch with a spiritual and humanistic dimension of who we are and that when one suffers, all suffer. We have lost touch with our interconnection, our non-duality. What did Mother Teresa, Mahatma Gandhi, and Martin Luther King Jr. draw upon when working with the immense suffering in the world? Gandhi spoke of satyagraha as “the Force which is born of Truth and Love,” and Dr. King, spoke of this as “soul force.” Perhaps we should consider developing some kind of non-dual medicine, some kind of practice of non-separation in our healing work.  

Building a culture of caring would require us all to engage in cultivating caring at individual, clinical, team, and organizational levels. It would mean that caring is valued in clinical encounters and within the institutional structure. It would mean being cared for while we are caring for others. In this sense, caring is not something that clinicians “do to” patients, rather caring is a cultural value for all interpersonal interactions within the institution. This would be part of our daily work, cultivating compassion, practicing caring. 

Perhaps if we were to view caring as a spiritual, mystical, or humanistic state of being, we could cultivate caring through individual practice, through supportive processes in teams, and institutions would support our growth as healers as well as technicians, protocol managers, and data entry clerks.  

Here are some ideas we can try to build a culture of caring: 

1. Practice mindful self-compassion: be kind to ourselves and recognize our common humanity with others.  

2. Practice lovingkindness: extend compassion to ourselves, our colleagues, and our patients. 

3. View our self-care practices (such as meditation, reflection, and physical exercise) as a way to be able to continue cultivating connections and caring for ourselves and others. 

4. Develop seminars, grand rounds, and work groups focusing on the evidence-base of compassion and integrating mind-body-spirit practices. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.