Figure 1: The conceptual model of the Compassionate Care Initiative
Juliet Trail and Tim Cunningham, University of Virginia, US
Since 2009, faculty at the University of Virginia (UVA) have made collective strides towards building a more compassionate university (Bauer-Wu & Fontaine, 2015). Rooted in contemplative practices, key units have helped to launch an array of interventions aimed to primarily support students and secondarily raise awareness and inspire transformation among faculty, administrators, staff, donors and other University leaders, inspiring countless graduates and employees of UVA as well as affiliated community members. Singer’s research on compassion puts into rigorous terms the complexities of this phenomena (Singer & Klimecki, 2014). Neff’s work on self-compassion, coupled with innovative research on the effects of Mindfulness-Based Stress Reduction by Davidson and Kabat-Zinn (Neff et al., 2018; Weng et al., 2018; Kabat-Zinn, 2011) have made a once-considered ‘soft topic’ more objective through empirical study. The charge by Halifax that “compassion is central to being fully human” (Halifax, 2018, p. 212) reinforces the fact that compassion is not simply to be dismissed as ‘soft’, but is instead essential. The implication for higher education then becomes: How do we model and teach compassion?
In this article, we will provide background on two sister organisations at UVA, the Compassionate Care Initiative and the Contemplative Sciences Center, complemented by four case studies of how we are infusing compassion into our university. We will discuss impacts of these interventions, challenges encountered, and concluding observations about how compassion may be made more sustainable in a large, public university in the United States.
The mission of the Compassionate Care Initiative (CCI) is to train learners to be their best selves:
[Its] purpose is to cultivate a resilient and compassionate healthcare workforce –locally, regionally, and nationally – through innovative educational and experiential programs. Our vision is to have safe and high functioning healthcare environments with healthy and happy healthcare professionals and where heart and humanness are valued and embodied. (Purpose & Vision, 2013)
The CCI was established in 2009 through the leadership and vision of Dorrie Fontaine, Dean of the UVA School of Nursing since 2008. Though housed in the Nursing School, the CCI offers free classes, workshops and lectures to any interested students and community members. Because of generous funding from individual donors, the CCI is able to offer the majority of its services and programs free of charge. These services include a quarterly speaker series featuring local and national community members sharing their work in regards to research, social activism, and contemplative practices with community audiences. Like the CCI’s sister organisation, the Contemplative Sciences Center (CSC), the CCI offers free drop-in classes, five days a week for any student, UVA employee, or community member who is interested in participating. These courses are taught by trained professionals in the following practices: Meditation (MBSR), Yoga (various forms), Tai-Chi, and Alexander Technique. Workshops include topics such as Narrative Medicine, self-defense, and the arts.
In addition to these programs, the CCI is developing nursing-focused curriculum for entire courses, such as ‘Mindful Leadership’ and ‘Wisdom in Nursing’, while its staff also consult with faculty on ways to include contemplative practices within the classroom – such as opening a class with a body-scan, or incorporation of narrative writing exercises with the intention of grounding and focusing the students. As of 2016, the CCI has begun research studies on the effects of some of the interventions it teaches to nursing and medical students to complement ongoing program evaluation of its many offerings.
All programs facilitated by the CCI reflect the simple conceptual model of the organisation (fig. 1). The cultivation of compassion is derived, at its source, from self-care practices (Alkema et al., 2012). The CCI considers self-care to be any of a series of specific actions taken to improve mental and physical health. What matters most about self-care is that the intention behind the action is one that leads to prosocial behaviors. Self-care then builds a sense of resilience (Shapiro et al., 2007). The CCI asserts that more resilient individuals, groups, or organisations are likely to have a higher capacity to make compassionate choices and thus provide more compassionate care (in hospital settings).
Figure 1: The conceptual model of the
Compassionate Care Initiative
Evidence suggests that when a health organisation encourages compassion, the hospital is more likely to have higher ratings (McClelland & Vogus, 2014). In essence, self-care builds resilience and resilient individuals are more apt to be aware of and available to provide compassionate responses. The CCI model is focused on caregivers, but it can also be applied to a broader range of students and future professionals. Two case studies focused on CCI programming will follow in the second section of this paper, to further demonstrate how the CCI, in partnership with the CSC, is building a more compassionate university.
Founded in 2012, the UVA Contemplative Sciences Center (CSC) pursues a mission to foster understanding, compassion, and resilience in individuals, communities, and institutions, through contemplative practices that integrate experiential learning, innovative research, and practical applications. As a pan-university center reporting to the Provost’s Office, the CSC partners with all 11 Schools of the University as well as other units that exist outside of the Schools, such as Student Affairs, Residential Life, the University Libraries, etc. The CSC was initially launched through a $12 million gift to the University for the express purpose of creating the pan-university Center, made by Paul Jones, a UVA alumnus, and his wife Sonia. The CSC is concerned with enabling flourishing within all individuals, across our campus and in the wider world, as well as exploring the role that contemplation – understood here as deep and wide-ranging reflection that integrates inner and outer work – can and should play in facilitating deep and diverse forms of learning that engender qualities such as wisdom, resilience, and compassion.
Academic instruction of UVA courses offers the CSC an opportunity to innovate the ways in which students at the undergraduate and graduate levels are instructed, through incorporation of contemplative pedagogy in a wide variety of ways (Newman, 2018). ‘Contemplation’ denotes a deep and profound attention directed to an object of study or focus. In practice, contemplative pedagogy aims to cultivate attention, emotional balance and the array of faculties required for insight and creativity (Zajonc, 2008). Examples of academic courses being taught by CSC employees include the Art & Science of Human Flourishing, Buddhism in the Modern World, Mindfulness & Compassion, and Meditation, Brain & Body – all of which are offered as three-credit, graded academic courses. Additionally, one-credit courses that focus primarily on the integration of contemplative practices into students’ daily lives are offered through a credit/no-credit (i.e. pass/fail) system in subjects such as Yoga, Mindfulness Meditation, Mindfulness in Nature, and Alexander Technique. Class cohort sizes vary from seminars of 20 to mid-sized classes or 60 and large-size classes of 200, intentionally attempting to impact a larger and wider array of students through mid- and large-size seminars that integrate active learning and contemplative practices within and beyond the class period. Additionally, CSC Faculty Development efforts help to extend the impact of the center across schools and disciplines through offering programs and series, such as a year-long Contemplative Faculty Learning Community, in which interested faculty from all disciplines can learn about and integrate contemplative and reflective pedagogies into their courses at the undergraduate and graduate levels.
Co-curricular programming of the center includes offering free, weekly drop-in contemplative programs across multiple locations on a recurring schedule six days a week that are open to students, faculty, staff and community members. Special events such as the CSC Speaker Series are also free and open to the university and local community, bringing national and international figures in the broad field of contemplation to the university to share cutting-edge research, to lead practices, and to add to the knowledge-base of wisdom, compassion, and reflection. Like the CCI, these events and co-curricular programs are funded almost exclusively through philanthropy of alumni and other interested CSC supporters, allowing these to be offered to university and community members free of charge.
Research partnerships and program evaluation projects of the CSC include internal assessment of CSC programs and courses, cross-school partnerships with other UVA entities, and inter-school partnerships with other universities pursuing similar contemplative research agendas. Further, a robust wing of the center is dedicated to scholarship and digital technologies, conducting research into topics related to the mission of the center with the aim of developing websites, publications, and other digital resources that can help to serve and inform the wider world, beyond the boundaries of the institution. Two case studies focused on the pedagogy and co-curricular programming of the CSC will be shared in the following section of this paper, to illustrate ways in which the CSC is helping to build a more compassionate institution.
The CCI has incorporated resilience retreats into the nursing curriculum for all undergraduate and master’s level students. These retreats are based on traditional MBSR training, which provides learners an opportunity to experience sitting and walking meditation. Practices of yoga, Shinrin-yoku (forest bathing—fig.2), narrative writing, radical listening (in dyads), and a silent meal are also incorporated into the experience.
Figure 2: Image of retreat participants, Shinrin-Yoku. Photo
Credit: Hannah Crosby, 2018
These CCI resilience retreats are offered in half-day or full-day format based on the course schedule of individual cohorts of participants. The best timing for these retreats in our nursing curriculum is to coincide them with the School’s ‘psychological care for patients’ training. All retreat participants are given a list of supporting literature for the topics covered that day. They are also asked to complete pre- and post-surveys that include basic quantitative and qualitative questions.
Retreat facilitators and CCI leadership evaluate retreats from semester-to-semester, to adjust content and respond to feedback by the students. Overwhelmingly, anecdotal feedback from the retreats has remained positive. Some examples of student feedback follow:
Thank you for making this kind of work/selfcare a priority. Having a school and/or workplace that cares for the health of the people is truly touching, and it makes me feel more included in the UVA society.
I think I came into this with a skeptical mind and possibly a closed mind to whether or not these strategies were going to help or work. This day was so much more than what I expected, and it was absolutely perfect timing for us as fourth years. Thank you so much for all the hard work and effort that went into this.
During the retreats, facilitators offer various forms of self-care and encourage participants to reflect on what types of self-care or contemplative practices might provide the most benefit to each of them, as individuals. To evaluate long-term aspects of adherence to self-care practices, a small cross-sectional survey was conducted in 2016 for nurses working in the hospital who are associated with the UVA School of Nursing, part of the UVA Health System. Of the nurses who completed the survey (n=391), 108 nurses had studied at UVA and had exposure to CCI retreats. Chi-squared distributions showed no significant differences between groups. Ordinary least squared regression analyses suggested that graduates of the UVA School of Nursing practiced meditation more frequently than nurses who had trained at other schools – 4-6 days per week as compared to 2-3 days per week (p.≤0.05). What is more, nurses who studied at UVA reported using meditation (p ≤ 0.001), exercise (p≤0.01), writing (p≤0.01), yoga (p≤0.05), and breathing exercises (p≤0.05) more than nurses that trained at other schools (Cunningham, Kurotsuchi-Inkelas, & Trail, unpublished data). There is thus a small amount of evidence gathered in this initial impact study suggesting that students continue the self-care practices taught by the CCI in ways that can continue to support their growth as resilient and compassionate professionals. However, these findings merit more in-depth program evaluation before we can assert that there is a direct correlation between CCI training and the continuation of a self-care practice.
Another pillar of CCI programming is its Ambassadors. This program thrives due to the presence and support of clinical practitioners, faculty and students who work around our campus, encouraging contemplative practices. Every month, the CCI hosts a think-tank-style meeting for members of the three aforementioned groups. During these meetings, participants share ideas about ways to build a more contemplative community and to encourage compassion-building practices. The ambassador meetings also allow them to provide support for one another. The CCI provides minimal seed-funding for small Ambassador projects; the most significant projects have arisen from the creativity of the groups’ members.
A few such initiatives inspired by the ambassador groups include: ‘The Pause’, Resilience Rooms for clinicians, and a Compassion Cart Program. ‘The Pause’ is a practice that has gained popularity beyond our university and is now being used in health systems on four continents (Ducar & Cunningham, in press). It is a practice that was originated by an emergency nurse and lecturer at the UVA School of Nursing. It occurs when a patient dies in a hospital setting and a member of the care team asks for everyone to pause in silence for a few seconds to honor the life of the deceased patient while also honoring the efforts made by the entire team (Bartels, 2014). This practice is now included in CCI-based curriculum on end-of-life care as well as general self-care.
Many CCI Ambassadors are nurses and physicians at the UVA Health System; they welcome students to shadow their work as they incorporate contemplative practices into their clinical care. Two pediatric nurses worked with the CCI ambassadors to design, fund and implement a ‘Resilience Room’ on UVA’s pediatric intensive care unit. This room is a small space, only accessible to hospital staff and designed to provide a quiet place for caregivers to find repose and rest (even if for a few minutes) after facing challenging or traumatic events in the intensive care unit. Fitted with comfortable places to sit, yoga mats, a mirror, tissues and contemplative readings, this room is designed to help caregivers recharge. The popularity of this space has grown such that other units in the health system are adopting the same model.
The third example of an intervention arising from the CCI ambassadors was a collaboration between a nursing student and clinical nurse. They decided to build a rolling cart equipped with ‘feel-good’ objects: teas, snacks, cards with words of support, small art projects, etc. This ‘Compassion Cart’ is taken through the hospital – often accompanied by a therapy dog – and staff in the hospital are offered a few minutes to enjoy these quiet comforts. From a pedagogical point of view, the Compassion Cart, Resilience Rooms and integration of ‘The Pause’ are all programs that come from grass-roots development models. They also are taught in the CCI curriculum. Additionally, other students with any association to the UVA Health System (nursing, pre-medical, chaplaincy, social work, or just shadowing professionals for a day) are invited to participate in and learn about them.
It is through integration of contemplative practices within and outside of the classroom, coupled with engagement between students and professionals, that makes the pedagogy of the CCI complex but also realistic to meet the current needs of students and professionals. The CCI also has the opportunity to share support from the CSC as both work to develop broad programming that supports the greater student body at UVA as well as faculty and staff from all sectors of the institution.
Contemplative pedagogy can empower students to integrate their own experience into the theoretical material they are being taught via problem-solving, engendering students' sense of connection to and compassion for others; and encourages inquiry into the meaning and purpose of individual and collective lives (Barbezat & Bush, 2013). The pedagogy of contemplation also considers how to integrate theoretical understanding, that typically utilises third-person data and ways of knowing (e.g. from textbooks and scientific/empirical studies), with critical first-person approaches in which learners engage directly with material to explore and validate their understandings via their own, direct experiences (Roth, 2014). Contemplative practices can include: meditation, deep listening, reflective writing, improvisation, dialog, mind-body practices (e.g., yoga, walking meditation), rituals based in cultural and/or religious traditions, and contemplative social justice activity such as bearing witness, vigils, directed social action, etc. (‘Tree of Contemplative Practices’, C-MIND). At UVA, the 3-credit, graded academic course ‘Mindfulness & Compassion: Towards Living Fully, Personally & Professionally,’ embodies these principles of contemplative pedagogy. Further, it prioritises compassion in the course title and organisation of course content to pursue half of a semester (roughly 8-weeks) of study and practice dedicated to mindfulness and half of a semester (another 8-weeks) dedicated to compassion.
This course has been offered annually since the 2012-13 academic year and is cross-listed in the School of Nursing and the Department of Religious Studies of UVA’s College of Arts & Sciences. Initially developed by Dorothe Bach, Associate Director of the UVA Center for Teaching Excellence, and Susan Bauer-Wu, then the UVA Director of the Compassionate Care Initiative, the course has been taught in subsequent years jointly and individually by Bauer-Wu, Bach and Juliet Trail, Director of Education for the Contemplative Sciences Center. Nursing students can register via their home school, while students from the other undergraduate schools of UVA can register under the Religious Studies course code. The learning environment offers an opportunity for students from across years and across disciplines to enroll together. The course is capped at 22 undergraduates and requires application by essay for enrollment, typically running a wait list of more than eighty students. Efforts are underway to expand the number of sections offered in future years, to better meet this demand.
During the unfolding of the semester, students and instructor(s) of the course embark upon a journey of discovery together. Each week is dedicated to exploration of a single topic via humanistic readings, scientific and empirical studies on the subject, and critical first-person discovery through integration of both formal and informal contemplative practices within the classroom and as daily homework. The weekly concepts explored in this manner include: awareness, (un)pleasant, stress reactivity, gratitude, skillful habits, communication, compassion, self-compassion, forgiveness, and sympathetic joy. In addition to the single, weekly class session of 2.5 hours, students also participate in a full-day weekend retreat after the tenth week of term. Examples of contemplative practices incorporated into the learning experience include sitting and walking meditation, mindful eating, body scan, loving-kindness meditation, self-forgiveness practice, self-compassion break, compassion meditation, and informal practices such as maintaining logs of pleasant or unpleasant experiences, gratitude journaling, tracking one’s amount of cellphone usage within a week’s span, performing random acts of kindness or random acts of social justice, etc. Reflective writing is woven extensively through the course, to enable students to investigate and cultivate an articulate, thoughtful awareness of their own experiences and to enhance their capacity for deep learning. It is supportive of the students’ learning experience to provide multiple forums for discovery and synthesising, as they integrate readings from across the humanities and the sciences alongside first-person investigations via personal practice. Weekly blogs, deep listening and other dialogic activities, frequent small or full group discussions, reflection papers, and a summative community-impact project are incorporated into the course to assess student progress and aid their learning journey.
Consideration of individual, interpersonal, and societal dimensions of concepts is woven throughout the course, particularly as the course turns towards compassion and discussions of prosocial behaviour during the second half of the semester. As a critical pedagogy, contemplative practices in the learning experience have potential to support students in making a move from wordless, embodied, previously un-articulated knowledge to a world of words, a shift that can empower students from highly diverse backgrounds and life experiences (Busch, 2014). Contemplative pedagogy can also aid students in the identification and disruption of social oppressions within their everyday lives (Wray & Batada, 2017). Grappling with complex issues such as forgiveness of self and of others, or feeling sympathetic joy in the midst of times when one is personally struggling, or working to silence the inner critic through practice of self-compassion, or endeavouring to serve others in a compassionate way through a small-group, community-impact project all help to surface and disrupt typical and/or habitual relationships that the student may hold to him/herself, to the social circles among fellow students, to interpersonal relating to ‘others’ of all ages and types, and to wider groups, communities, or societies. In this way, Mindfulness & Compassion seeks to empower students, through a rigorous academic course, to consider personal and prosocial dimensions of their own knowledge and capacity for action in the world. This journey can be joyous, challenging, and profound, as illustrated in these comments from one student’s final reflection assignment:
The power of perspective, of being able to see and experience things not as they are known to be, but as they are, still amazes me. It is a perspective that I hope to carry with me for the rest of my life. I’ve come to realize that there is infinite possibility and potential in things, and that nothing really is for certain…Beyond this discomfort lies a sense of freedom that I think I am beginning to touch. I am curious to explore, to discover, and to learn. I am excited to use this freedom to see and live, to create my own story. I will embrace fear. I will work together with my inner enemy. I will not make myself small. I will blossom, like an orchid in the middle of a densely packed flower bed, absorbing all the sunlight, never hiding from the rain. Here. Present. Living.
Efforts to transform the culture of a college or university are enhanced by innovations to pedagogy and curricula. However, institutional culture change should also consider how to impact the activities and operations of the institution beyond the classroom, rehearsal studio, and laboratory. For students, they enroll to complete a course of study or degree as well as joining organisations, making friends, and forming connections socially and with mentors, thus building a full life that does not stop outside of classroom hours. Co-curricular programming of the center allows CSC to partner with units like Intramural-Recreation (IM-Rec) Sports to offer more than twenty yoga classes per week on a six-days-a-week recurring schedule every semester, or with the University Libraries to operate a Contemplative Drop-In Studio in Clemons Library that offers an additional fifteen or more programs per week in topics including Mindfulness Meditation, Contemplation and Art, Tai Chi, Qigong, Restorative Yin Yoga, Alexander Technique, and Desk Yoga for Students and Professionals. These recurring programs are further complemented by stand-alone events and shorter series, including a CSC Speaker Series bringing in national and international guests to present on research and practice, and a Rotunda Contemplative Practice Series in which guests from the local and regional area provide short, weekly talks accompanied by an opportunity to practice from an array of contemplative traditions and modalities.
These co-curricular classes, talks, and practice sessions help to broaden awareness across the University, demystifying and expanding upon people’s prior knowledge or assumptions about what might constitute ‘contemplation’, ‘mindfulness’, or ‘compassion’. Being free and open to the public enables individuals to explore freely without obligation or pressure to attend regularly. However, the recurrence of weekly offerings every semester helps to reinforce that more regular practice is possible, and helpful, to those who wish to more fully and deeply experience and cultivate compassion, resilience, and flourishing. To illustrate the scale at which these activities are now impacting the university, in the prior three academic terms: 2,820 people attended CSC Summer 2018 programming (including among that number 1,719 parents at Parents Orientation breakout sessions dedicated to Student Flourishing); in the Spring semester 5,337 attended recurring or stand-alone classes, programs, and events (including 3,371 just at the weekly yoga classes offered at the UVA gyms in partnership with IM-Rec Sports); and in Fall 2017 semester another 4,843 people participated (including here at least 91 faculty and 240 staff members, with the rest being primarily UVA students). Impact cannot be determined by quantification alone, however. To that end, the center has embarked upon an in-depth research study launched in the 2018-19 academic year to better track the motivations and experiences of participants across the many different recurring CSC co-curricular programs. Results from this study will support efforts in ongoing program improvement and will provide further insight into the effectiveness and impact of this work upon the university community.
Both the CSC and the CCI have faced challenges in building our programs and outreach. The ongoing search for funding for any academic endeavor can be daunting. As mentioned previously, both organisations have relied primarily upon philanthropy from interested alumni, donors and foundations to garner financial support for staffing and programming. Research and program funding via grants provide a second strand of support. Long-term financial security and diversification of funding streams remain a work in progress. A second challenge for us is that compassion, in our community and in wider academic circles, has often been regarded as a ‘soft’ skill. Prior to this decade, much research on compassion remained anecdotal and qualitative, thus carrying less weight in some disciplines. Shifts to larger-scale studies and implementation of methodologies such as randomised controlled trials on contemplative topics help to amass evidence on the effectiveness of this work, reversing earlier trends that dismissed or trivialised such endeavors. Another barrier encountered at our university over the past decade has been countering an assumption that meditation (and related) practices would be, necessarily, religious in nature. As the flagship public university for the Commonwealth of Virginia, it is absolutely fundamental that the contemplative and compassionate practices presented are secular in nature. Over the past decade, both units have worked to continuously improve clear and effective communication within our community regarding our missions and our programs to proactively address concerns regarding the secular nature of the practices offered, as well as to host thoughtful and informed events about the religious traditions which have helped to establish and refine contemplative practices through the course human history.
What does it take to shift the culture of a university? This is an important and unresolved question facing professionals from across sectors of higher education (Kezar & Lester, 2011). At the University of Virginia, the CCI and CSC collaborate within a shared mission to discover answers to this question, in the context of building a more compassionate university. Each unit works to clearly define the ways in which we use terminology such as self-care, resilience, flourishing, and compassion. We pursue distinct strategies to cultivate these principles across our constituencies. Organisational culture emerges from the totality of activities and relationships held by the members of an institution. We therefore work at UVA to transform an array of endeavors that take place at our institution, including: classroom pedagogy, the curricula of degree programs such as the Bachelor’s of Nursing, retreats providing deep experiences into contemplative and compassionate practices, mentorship as offered by Student, Faculty, and Clinical Ambassadors, and through a robust co-curricular domain that includes recurring and stand-alone programs and events utilising local expertise and also bringing in thought leaders in the fields of contemplation and compassion from across the nation and around the world.
Both the CCI and the CSC are engaged in ongoing research studies that focus on the pedagogy, training, and programming that each unit is providing, towards assessing our impact and continuously improving our offerings. It will be helpful for all such institutions engaged in efforts to build more compassionate institutions to increasingly gather and share the results of such studies, so that best practices are established and lessons-learned shared. Just as these two centers collaborate actively to impact the life of our home institution, individuals and groups engaged in the work of compassion must come together to inspire, inform, and mutually-enable the effective creation of more compassionate institutions across all sectors of higher education. Our care for constituents on our home campuses helps inspire us to spread compassion to those closer to us; however, our work is not complete until we have gathered as members of larger networks of individuals and institutions who are dedicated to pursue this common purpose. Ultimately, we hope to serve not only the constituencies of our own university, but also to help bring more compassion into the lives of peoples from across nations and around the world.
Juliet Trail, PhD, is Director of Education for the UVA Contemplative Sciences Center and Research Scientist, Center for Advanced Study of Teaching and Learning in Higher Education, Curry School of Education. Her doctoral work established a grounded theory of Network Enablers, defined as highly-empowering higher education professionals (UVA, 2016). https://www.uvacontemplation.org/
Tim Cunningham, DrPH, RN, is Director of the Compassionate Care Initiative at the UVA School of Nursing. His research focuses on resilience and compassion in healthcare. He completed his Doctorate of Public Health at Columbia University and specialised in psychosocial support during humanitarian responses. Cunningham is an emergency nurse. https://cci.nursing.virginia.edu/