Promoting Workplace Mental Health for Hospital Social Workers Using Compassionate Mind Training

Patricia LH Tay , Eva LK Kerk , Mandy MY Lau , Soon-Noi Goh ^*

1. Medical Social Services, Changi General Hospital, Singapore

* Correspondence: Soon-Noi Goh

Academic Editor: Syd Hiskey

Collection: Compassion Focused Therapy (CFT) – Advances and Innovations

Received: April 30, 2024 | Accepted: October 21, 2024 | Published: November 04, 2024

OBM Integrative and Complementary Medicine 2024, Volume 9, Issue 4, doi:10.21926/obm.icm.2404064

Recommended citation: Tay PL, Kerk EL, Lau MM, Goh SN. Promoting Workplace Mental Health for Hospital Social Workers Using Compassionate Mind Training. OBM Integrative and Complementary Medicine 2024; 9(4): 064; doi:10.21926/obm.icm.2404064.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

The attrition of Allied Health Professionals in the public healthcare sector in Singapore has increased from 8.9% in 2018 to 11.6% in 2022 [1]. Junior staff might find it hard to cope with the inevitable stressors and increasingly challenging practice context and navigate with limited resources. For social workers, they are at risk of leaving the profession if they are unprepared to address the psychological and emotional challenges of their practice [2]. Staff with many years of experience are similarly not spared. Years of having to deal with the intense demands of the job, resulting in vicarious trauma [3], bereavement overload, high workload and high pace work environment and accountability, also put them at risk of empathy fatigue. This is further exacerbated by the pandemic climate and waves of COVID-19 infections which constantly affect staff both personally and professionally.

Goh and colleagues [4] observed that the shifts in the work environment that social workers experienced during the pandemic had profound effects on their professional quality of life, encompassing both positive and negative outcomes. They highlighted the significance of recognizing the roles of resilience, social support, and workplace support in improving the well-being of social work professionals. Notably, it is crucial to identify those salient factors that could potentially reduce empathy fatigue and enhance satisfaction, such as possessing a longer length of work experience and higher levels of training [5]. Therefore, preventive information on the risks of empathy fatigue and the benefits of compassion satisfaction and self-care should be infused into social work education curricula and integrated into efforts to promote workplace mental health for professional staff [6].

Understanding the complexities of empathy and its impact is essential for managing the dynamics of emotional bonds. Empathy refers to one’s ability to recognize, understand and resonate with the emotional states. Specifically, we can feel happy when we share the joy of others, but we can also feel distress when we empathize and share the experience of suffering with others. This form of shared distress is often prevalent among helping professionals [7]. It is not unusual for healthcare professionals to describe it as compassion fatigue and burnout. However, research has shown that compassion does not fatigue and empathy fatigues [8]. Functional magnetic resonance imaging studies also show that the debilitating condition described as compassion fatigue should be called empathic distress fatigue [9]. As such, being overwhelmed by the excessive shared sufferings of others can lead to the development of empathic distress fatigue.

Empathic distress is characterized by a solid aversive and self-oriented response to the suffering of others, accompanied by a desire to withdraw from a situation to protect oneself from developing excessive negative emotions [7]. To prevent the overwhelming sharing of suffering and its impact on personal distress, research has shown that empathic distress can be reversed by responding to the suffering of others with compassion [10].

According to Gilbert [11], compassion is a sensitivity towards the suffering of self and others, with a commitment to strive to alleviate or prevent it. Psychologically, it involves two aspects of compassion. The first consists of the ability to notice, turn towards, and engage with suffering, which opens the door for a choice and to face it with courage without pulling back. Embracing this compassionate stance and enhancing a sense of sustainable well-being with practice can help hospital social workers stay fully present even when there is significant distress and suffering [12]. The second aspect of compassion involves the motivation to relieve or prevent the cause of suffering. Motivation differs from feeling, implying intentional and focused behavioral components [13]. Frequently, the work of hospital social workers requires a beneficence presence which involves a compassionate stance towards purposeful and present-oriented observation and assessments.

In recent years, there has been a surge in research, literature, and training on compassion-based approaches. One prominent exemplar of such an approach is “Compassion Focused Therapy (CFT)” established by Gilbert [11]. The core of CFT is the flow of life and CFT posits that our minds are designed for us, not by us, through evolution. CFT applies principles of compassion from an evolutional and neurobiological approach. Most importantly, the key lies in effectively managing the suffering that arises from our tricky brains. Through compassion training, hospital social workers can continue to feel empathy towards one’s suffering while developing the capacity to feel positive emotions without distress [14]. This results in an enhanced ability to tolerate distress, maintain focus and clarity to discern clinical interventions and increase resiliency. Training and insight on the flow of compassion may enable hospital social workers to strengthen their overall capacity to attend to themselves and others with compassion and be comfortable to receive compassion from others.

Using compassion-based approaches [15] to work with clients in diverse populations has been widely supported through recent research due to the capacity-building effect for clinicians and clients alike to tolerate distress. Given the emotional demands of clinical practice faced by healthcare professionals and the potentially harmful impact of self-criticism on their ability to maintain compassionate care for others, training to cultivate compassion to deal with suffering may be helpful for healthcare clinicians to develop more excellent self-care and emotional resilience [16]. The results of a series of meta-analyses of the efficacy of CFT across six databases [17] showed that CFT has been effective in reducing overall adverse mental health outcomes and improving compassion for self and others in both clinical and non-clinical populations. Compassionate Mind Training (CMT) is an intervention that can be used in clinical settings to help healthcare professionals who self-reported a high level of shame and self-criticism to develop compassion [18]. CMT uses breathing practices, friendly voice tones, facial and body expressions, and imagery practices that focus on activating and developing soothing-affiliative processing systems, helping to soothe and calm individuals when they are stressed [19]. Research has also shown that the use of CMT has helped promote mental health resilience in healthcare workers with improved self-reported mindfulness, self-compassion, and compassion towards others [20].

1.1 The Journey of Initiating the Current CMT Programme

Before the implementation of this CMT program, two hospital social workers from an acute care general hospital in Singapore, each with more than 5 and 20 years of experience respectively, completed a 3-day training in Compassion Focused Therapy (CFT) by trainer Dr Stan Steindl, a practicing clinical psychologist.

The two staff discovered that the experiential and reflective exercises of the training helped them dwell deeply into their inner selves and explore the impact of their internal beliefs on their self-perceptions. They realized that while compassion could be easily understood on a cognitive level, embracing it as part of one’s life required a deep appreciation of its benefits, constant awareness, and mindful practice. They reflected on their main learnings, curated the training materials, developed an abridged version, and integrated it as part of the mandatory internal training and development program for all staff in the department. It was deemed integral to obtain participant buy-in through reflective, experiential, and interactive exercises in developing the current abridged CMT training.

1.2 Aim of the Abridged CMT Training

The objectives of the abridged CMT training for participants include:

1. To gain awareness of self in self-compassion.
2. Self-compassion exercises should be applied to the self to regulate one's own emotions and gain mindfulness.
3. To develop compassionate resilience through Compassionate Mind Training, where the three flows of compassion are practiced.

2. Methods

2.1 The Development of the Abridged CMT Training

The abridged CMT training was implemented from February 2023 to April 2023. Several significant CMT components were identified as essential training elements and explored in depth during sessions through discussions and reflection of personal experiences.

2.2 Component 1: Definition of Compassion

Compassion is characterized by feelings of warmth and emotions one experiences when one feels concern and care for another’s suffering and a strong desire to improve the other’s well-being [11].

Whether compassion came from nurture or nature was commonly raised during sessions. There was a consensus that it is more natural, but compassion could also be taught through training and practice. Some participants found the second part of the definition, “commitment to alleviate and prevent it,,” to be profound and difficult to resonate with consistently. Exploration of what commitment to alleviate and prevent also meant being present-oriented and making the best efforts.

2.3 Component 2: Compassionate Resilience

Professionals engaging in providing social work services with compassion increase satisfaction and engagement. However, over time, for a variety of reasons, helping professionals may start showing symptoms of empathic distress and fatigue, secondary trauma, and burnout, all of which negatively impact the quality of care delivered and the level of compassion offered to others and themselves [21]. Providing a continuous external flow of compassion without self-compassion can lead to depletion and burnout.

2.4 Component 3: Compassionate Mind Training

Social workers can benefit from compassionate mind training, where they are introduced to core theoretical elements of CFT, including the three circles model of emotions, compassionate mind, three flows of compassion, and working with shame. Various experiential exercises designed to cultivate different aspects of compassion were introduced and practiced during the workshop.

Strategies for cultivating the competencies of compassionate engagement were introduced to participants. For example, participants were encouraged to find their processes for engaging and disengaging from distressing situations to enhance distress tolerance. To better care for their well-being, participants were encouraged to show small acts of kindness to themselves (e.g., practicing relaxation activities to de-stress) and others (e.g., buying food for colleagues engaged in meetings or seeing patients). The workshop emphasized the importance of applying compassion for oneself, loved ones, and even strangers to have a healthy and happy life. It was encouraging to hear from participants’ sharing that this workshop enabled them to be more supportive of others, cultivate higher tolerance for others’ mistakes and weaknesses, and reach out to colleagues in need. Participants also discussed and shared their difficulties in receiving care, kindness, and support from others during distress. With these insights and awareness, participants brainstormed specific simple and practical strategies that could help them cultivate compassion for others, receive compassion from others, and have self-compassion.

2.5 Three Circles Model of Emotions

Compassionate mind training is about learning to bring balance to our three different types of emotion regulation systems - namely, the system that focuses on threats and self-protection, the incentive/resource-seeking system that concentrates on wants and achievements, and the soothing/contentment system that focuses on safeness and connectedness. By bringing balance to these, patterns of brain activity will emerge that create states of well-being, pro-social values, and behaviors [11].

During the session, the participants indicated that they needed to be more intentional and purposeful in engaging in “content, safe, soothed” drive, while the threat-focused drive might be activated more naturally in their daily routine. The threat-focused drive is designed to keep us safe for our survival. Subsequently, when faced with challenging situations, it activates our fight/flight responses, including freeze and deactivation, which can be associated with a sense of defeat, helplessness, and despair [22]. However, when the threat system is activated over a prolonged period, it can affect our ability to be receptive to opportunities for healing, sharing pain, and receiving support from others. Similarly, our “survival instinct” can also trigger the incentive & resource-focused drive to ensure our well-being by constantly seeking to acquire resources to overcome challenges.

Incentive & resource-focused drive could also be intentionally engaged to increase drive, excitement, vitality, and satisfaction. They became aware of the constant interplay of the circles model of emotions, the triggers of the day-to-day experiences and building the repertoire of coping skills and strategies could all contribute to helping them in emotional regulation and building emotional resiliency.

It has been observed that the three circles model of emotions allowed participants to express themselves more effectively, to help them to understand and manage their stress levels and reactions to protect themselves against burnout.

2.6 The Three Flows of Compassion

Embracing the three flows of compassion encourages us to be more open and responsive to compassion and support from others, increasing our ability to deal with our distress and trauma in the workplace and enhancing our ability to deliver compassionate care to others. Helping professionals may be more comfortable offering compassion to others than themselves and find it difficult to receive care and compassion from others; cultivating the three flows of compassion provides a more sustainable approach [21]. The three flows are mainly:

1. Compassion for others (compassion flowing out) refers to the experience of compassion in the self and directing this compassion towards others.
2. Compassion from others (compassion flowing in) refers to the experience of receiving and accepting compassion from other people.
3. Compassion from ourselves to ourselves (self-compassion), where we attend to ourselves with sensitivity and understanding to support and care for ourselves.

2.7 Component 4: Working with Shame

Shame is a powerful, self-conscious, and socially focused emotion. It can easily pull individuals into a ruminative self-critical style, thereby increasing susceptibility to various difficulties [23]. People with high levels of shame and self-criticism can have enormous difficulty being kind to themselves, feeling self-warmth, or being self-compassionate, which hinders achieving contentment, well-being, and self-compassion [24]. Additionally, shame impacts our threat -defending and safety checking and seeking where one becomes constantly alert to monitor the nature, presence, controllability and/or presence of threats internally and externally. This is primarily regulated through evolved threat processing systems, which might potentially lead to mental health conditions [22]. Safeness uses different monitoring systems via different psychological systems for the presence of internal and external resources that support threat-coping, risk-taking, and resource exploration [22].

Guilt is a response to a specific event or behavior, where one may feel regret as they feel a sense of responsibility for the outcome or against their beliefs. It has a role in shaping behavior but not necessarily in self-defeating ways, as typical of the same effect. Compassionate Mind Training focuses on developing abilities to generate feelings of self-reassurance, warmth, and self-soothing to increase one’s safeness that can help participants regulate their own emotions and gain mindfulness to develop self-compassion competency, which in turn helps mitigate the harmful effects of shame and guilt.

Participants identified their personal shame experiences, which negatively impacted their self-perception. For example, one participant who was constantly driven to a high level of achievement might have an inner world filled with negative thoughts about self that focused on not being able to meet up with expectations or that sense of being lacking in some way. Participants identified that these shameful experiences were rooted in culture, societal norms and expectations, making it hard for them to be self-compassionate.

Participants acknowledged the importance of helping themselves cultivate a feeling of being safe within themselves by using compassionate reframing through positive self-talk or self-perceptions, thereby building self-compassion, which helps reduce the painful adverse effects of traumatic shame memories on their psychological well-being.

3. Results

3.1 Participants

As part of the department's effort to build compassionate resilience, the Head of the Department of Medical Social Services mooted and supported the provision of this abridged training program for all staff. A total of 60 participants, including hospital social workers who are degree holders in social work and nonsocial work trained assistants (SWAs) working at a hospital in Singapore, participated in this CMT program. Of these 60 participants, 76.7% were females, while 23.3% were males. 46.7% were junior MSWs 35% were senior-level MSWs, and 18.3% were SWAs. To allow for a safe space for participants to share freely and avoid hierarchical pressure, each group size was considered minor, and the staff was grouped according to seniority and years of experience.

3.2 Format and Sessions

Considering the nature of hospital social work, which is fast-paced and high volume, the training program was designed to be short yet have a workshop style to allow for more experiential learning and interaction. The first session was conducted with senior staff, and their feedback was obtained to finetune the program further. Special efforts were also made to ensure a conducive environment with aromatherapy, soft music, simple snacks, and beverages. In total, 6 sessions were conducted throughout the 3-month implementation. Each session was initially planned for 2.5 hours but subsequently changed to 3 hours. During the first session, specific discussions took much longer than expected, resulting in the session being overrun. As such, trainers made changes to session duration, content, and activities to meet better the needs of participants, as well as being intentional and mindful about time management. Participants who could not attend the training at their allocated training slot were arranged to join other groups on other days.

3.3 Feedback Collection

Feedback was collected within three time points 1) pre-workshop, 2) post-workshop, and 3) follow-up email within 3 months of post-workshop. Participants were invited to complete the self-administered questionnaire related to pre-and post-criticizing/attacking and self-reassuring scales before and after the workshops and 3-month post-session questionnaires. Materials were also given to participants to practice during their own time.

3.4 Measures

To collect the feedback on the CMT training, several measurement tools were adopted in this programme:

3.4.1 The FSCRS Scale

The Forms of Self-Criticizing/Attacking & Self-Reassuring scale (FSCRS) developed by [25] were administered to the participants to measure self-criticism and their ability to be self-reassured. It is a 22-item scale that measures different ways people think and feel about themselves when things go wrong. The items are made up of three components, there are two forms of self-criticalness: inadequate self, which focuses on a sense of personal inadequacy, and hated self, which measures the desire to hurt oneself, and one form of self-reassured, which is the ability to remind oneself of positive things about oneself.

Three months later, participants were invited to provide feedback on using CFT concepts in their daily work. The questions included:

1. What are some of the CFT concepts (three-circle model of emotions, compassionate mind skills/attributes, 3 flows of compassion) that you have applied?
2. Which experiential activities (soothing rhythm breathing, safe place imagery, compassionate friend) have you been practicing?
3. What are some of the barriers/difficulties that prevent you from using CFT concepts/activities?

3.5 Shifts in Reassured Self, Hated Self and Inadequate-Self Scores

In this study, participants were asked to rate the FSCRS to measure their self-criticism levels and ability to self-assess. Descriptive statistics, including mean and standard deviation, were employed to analyze the score variation between pre- and post-workshops. Results showed shifts in the scores across all FSCRS domains from pre-workshop to post-workshop (see Figure 1). Notably, participants scored higher in Reassured self in post-workshop (M = 25.58, SD = 4.75) than in pre-workshop (M = 22.28, SD = 4.36). In contrast, Hated-self scores decreased from pre-workshop (M = 1.55, SD = 2.27) to post-workshop (M = 0.61, SD = 1.20). Additionally, participants reported lower scores of inadequate self in post-workshop (M = 10.87, SD = 7.28) than in pre-workshop (M = 11.93, SD = 6.10). These findings suggest that the CMT training may have some potential positive impact on influencing participants’ self-perception in self-reassurance and self-criticism.

Figure 1 FSCRS Scores for Self-Criticizing/Attacking and Self-Reassuring Scales.

However, it is essential to highlight that this study primarily depended on descriptive statistics without using inferential analysis. Consequently, while the observed changes in the levels of self-reassurance and self-criticism are noteworthy, one must be cautious during the data interpretation. The absence of paired t-tests, due to the omission of each participant’s identifiers to alleviate pressure and safeguard participants’ confidentiality, thereby constrains the capacity to draw the statistical conclusion regarding the effectiveness of this workshop.

3.6 Post Session: Learning Objectives Met

During the post-workshop stage, participants’ feedback on the overall workshop was collected and analyzed using a Likert scale. It is noted that most participants perceived benefits from the current CMT workshop, specifically in gaining awareness of self-compassion and the application of CFT concepts and knowledge/skills (see Figure 2). In particular, over 95% of participants agreed or strongly agreed that they experienced positive outcomes from the training, while only 2% of them expressed disagreement on the benefits of this workshop. For illustration, one staff member confidently shared that the practical exercises and techniques such as mindfulness, breathing exercises, and setting compassionate intentions to self and others are not foreign to her as she has been practicing them for some time. Still, she often struggled to find the time to execute the concept. Additionally, other participants agreed (63.3%) and strongly agreed (32.7%) on gaining self-awareness of self in self-compassion. Furthermore, 57.1% of MSWs and 38.8% strongly agreed that they could apply self-compassion exercises to regulate their emotions and achieve mindfulness. Apart from this, 95% of participants echoed that CMT training could help them develop self-compassion competency and apply CFT concepts for personal and professional self. Overall, the learning objectives of the CMT training were successfully attained.

Figure 2 Agreement Levels on Learning Objectives Addressed by CMT Training.

3.7 CFT Concepts Applied by Participants: A 3-Month Review

To understand the lasting impact of the application of the CFT concept, a post-session questionnaire was administered 2-3 months after the workshop. Among various CFT concepts, it is noted that most participants (63.2%) consistently applied compassion, mind skills, and attributes. In contrast, fewer participants continued to practice the three-circles model of emotions (31.6%) and the 3 Flows of Compassion (31.6%) (see Figure 3).

Figure 3 Participants’ Utilization of CFT Concepts in Daily Practices.

On top of the skills applied, participants were also asked for the types of experiential activities they had been practicing (see Figure 4). Compared to the activities of Safe Place Imagery (18.4%) and Compassionate Friend (23.7%), a large proportion of participants reported that they had been practicing soothing rhythm breathing (84.2%). It is an encouraging result, showing that the training could contribute to the enduring effect, particularly for hospital social workers who continued to practice the CFT concepts actively for a few months after implementing the CMT training.

Figure 4 Participants’ Continued Practices in Experiential Activities.

Lastly, to improve the future CMT workshop further, the team attempted to gather feedback from the participants on the perceived barriers and challenges in applying the CFT approach (see Figure 5). Participants identified various barriers to the CFT application, including lack of time, a need for conscious effort, being overwhelmed at work, failure to recall concepts, or the absence of urgent needs driven by a positive mindset. Notably, the most cited barrier to applying the CMT approach was a lack of time (47.4%), indicating that time constraints are a significant factor that we may need to prioritize and address in the future development of an effective CFT program. While it is not uncommon to identify time constraints as a challenge to compassion practice, it is also crucial to emphasize that “compassion could happen in a moment and therefore was affected by, but not contingent on time” [26].

Figure 5 Perceived Barriers and Challenges in Application of CMT.

4. Discussion

Throughout the entire journey of conceptualization, development, implementation, and follow-up sessions, the facilitators generated a series of reflections on the current CMT program. The following points are the observations and reflections by session facilitators and participants’ feedback. These CFT key concepts were fundamental; participants found them relevant to increasing self-awareness and building compassion.

4.1 Building Awareness via the FSCRS Scale

In this workshop, the FSCRS scale was applied to measure participants’ perceptions of their abilities regarding self-criticism and self-assurance. Surprisingly, during the self-administration of the scale, participants unintentionally found it helpful in creating awareness and reflection on themselves of where they were in self-compassion. Hence, the scale can be a tool for hospital social workers to use periodically in their self-reflection. While it's normal to feel inadequate in some ways, participants can consider the impact on self-perception and sense of shame, which may increase Hated Self. Most participants have low self-hate and feel confident about their ability to assure themselves when distressed.

4.2 Impact of CMT Training on Self-Perception

The findings indicating an increase in reassured-self scores alongside the decreases in hated-self scores and inadequate-self scores suggest that CMT training appears to promote specific enhancements in the abilities of hospital social workers regarding self-reassurance and self-criticism. These improved scores further highlight the significance of incorporating self-compassion training into workplace practices to enhance the well-being of social workers in hospital settings.

The shifts in scores could be related to the previous research’s findings that indicate self-compassion training may improve self-compassion and a range of work-related well-being outcomes among employed individuals [27]. In addition, CMT could cultivate self-compassion and diminish self-criticism among healthcare professionals [28]. More specifically, it aided these healthcare professionals in building the capacity to soothe themselves, stepping back to reflect and confront the struggles more compassionately. Additionally, it assisted them in transforming their self-talk from critical to compassionate, boosting their inner warmth and kindness in the face of personal obstacles.

Although these findings show some potential positive impact of CMT on improving the levels of self-assurance and self-criticism of social work practitioners, it is crucial to interpret the results with caution. The existing data cannot distinguish the individual pretest and posttest scores for each participant, hindering the application of repeated measures design and paired t-tests in this study. Therefore, future research should incorporate a within-subjects design with paired t-tests while employing alternative methodologies to capture unique identifiers to measure each individual’s scores in pretest and posttest workshops, ultimately enabling participant matching. Moreover, future studies will necessitate more precise measurements to allow thorough investigations and a robust understanding of the impact of the CMT intervention.

4.3 Cultivating a Compassionate Motivation

Most participants resonated with this point and its relevancy in integrating it into personal and professional practice. Staff who have longer working years may experience repeated exposure to traumatized clients and thus, they are more susceptible to compassion fatigue [29]. As such, staff may find it helpful to remind themselves to be more mindful about maintaining a compassionate motivation and the impact on self and practice.

4.4 Insights for Future CMT Programme

Participants applied and internalized best the concept of compassionate mind skills and attributes through experiential learning. Experiential learning can motivate learners to reflect on their experiences to transform and create new skills, attitudes, and ways of thinking [30]. As such, future programs should adopt experiential learning as a learning approach to deliver the CFT concepts. The three-circle model of emotions is less practiced and applied, which may be related to the absence of visual reminders. As such, more efforts can be made to include more visual cues to help participants quickly grasp what is being discussed and taught.

Cultivating compassion in healthcare culture is also integral to providing and promoting compassion training as early as possible to support staff to better cope with occupational stress and encourage prosocial behavior that can augment positive affect and resilience for better dealing with stressful situations [7].

Regarding the entire format and operation, participants stated that the workshop duration was suitable as a basic introduction to CFT. Considering the hectic schedule of hospital social workers, the program may not be able to be designed as a long session. The main objective was to help staff gain awareness of the importance of compassion and integration into their personal and professional self in this short, experiential, and relatable program.

To better assess and evaluate future CMT program and their impact on the changes in the flow of compassion experienced by participants, both Compassion Engagement and Action Scales invite participants to record how they respond when confronted by their suffering, the suffering of others or the experience compassion from others [31] and Fears of Compassion Scale [32] will be used.

4.5 Barriers to Compassion Practices

The findings also revealed several critical barriers to practicing compassion, including time constraints, being overwhelmed at work, a need to be intentional in practicing compassion, and difficulty recalling CFT concepts. Bearing in mind our tricky brain, it is also expected and natural to continue to experience distress and suffering, particularly in fast-paced and highly stressful environments. Adopting a compassionate lens is not an instinctive reaction. Instead, it requires ongoing efforts, practice, and the progressive cultivation of behaviors.

Therefore, developing self-awareness and being more intentional about nurturing compassion are essential steps in this journey.

Both systemic support and individual interventions are essential to overcome the barriers to compassion and to strengthen compassionate practices [26].

4.6 Trainers Reflections

The two trainers debriefed after every session to reflect on their observations. They noted the participants enjoyed the experiential activities (soothing rhythm breathing, safe place imagery and compassionate friend) and the three flows of compassion activity that required them to list down some of the simple, specific, and practical strategies that would enable them to practice the concept on the flow of compassion back in their personal and professional life. During the three flows of compassion activity, where participants were asked to list down some of the ways that they could show compassion to self, compassion to others, and receive compassion from others, it was noted that more time was often spent on brainstorming ways that enabling them to receive compassion from others. Trainers drew the participants’ attention to their difficulty to receive care, kindness and support from others and then discussed the plausible reasons with them. Trainers would then share their own ways, allowing them to receive compassion from others, such as sharing their struggles with friends and family. This sharing between and among trains and participants helped participants come to an awareness that this was something they could do as well.

5. Recommendations

Based on the insights mentioned above gained from the participants and trainers, some recommendations are made for the future development of CFT approach and related programs as follows:

5.1 Building a Compassionate Mindset in the Clinical Work

Cultivating a compassionate mindset in daily clinical work is one of the significant insights from this program evaluation. To build the compassion mindset, some further strategies, including imagination, compassion writing, traditional martial art practice [33], and the G.R.A.C.E process [34], can be built in future training programs.

a) Imagination

When it comes to building self-compassion, imagination is one of the most potent resources one can readily have access to. Compassionate imagery exercises can be explored in depth to offer an experience of connectedness and acceptance where one can learn to self-soothe and create compassionate brain states. This exercise can be as simple as spending five minutes a day.

b) Compassion writing

Compassion writing in the form of journal writing [35] can also be explored to help individuals identify their self-critical thoughts and write them down or articulate them to express them. Validation and recognizing the root causes of these thoughts will allow individuals to be gentle and kind to themselves and others to heal.

c) Martial Arts-informed Compassionate Mind Training

The practice of Martial arts-informed CMT [33] for healthcare workers is designed to help build competencies in compassionate engagement and action, which translates into greater motivation, sensitivity, attunement, distress tolerance and responsiveness at a deeply embodied level. The physical and mental discipline acquired in martial arts can help one develop a mind-body connection, self-compassion, emotional regulation, and resilience. Therefore, introducing martial arts workshops or activities to the department can be considered to build interest, develop awareness, and, ultimately, improve personal development.

d) G.R.A.C.E process

The acronym G.R.A.C.E. stands for gathering attention, recalling intention, attuning to oneself and others, considering what will serve, and engaging and ending with presence. This framework helps healthcare workers cultivate compassion in a fast-paced setting, focusing on self-awareness and emotional regulation. It has been found to enable healthcare workers to respond more compassionately and with greater clarity and ethical grounding in their interactions with patients, family caregivers and fellow healthcare professionals when dealing with complex clinical situations.

5.2 Integrating CMT into Clinical Supervision

Supervisors are encouraged to incorporate regular discussions and exercises during clinical supervision that focus on cultivating self-compassion and compassion towards patients, conduct case discussions with a compassionate lens, and explore personal reactions. This will help provide a safe space for staff to learn, reflect, and practice their new skills or theories, and it will enable supervisees to feel heard and ask sensitive questions.

5.3 Direction for Education and Future Research

Given the current positive outcomes of this CMT workshop, CMT basic training can be promoted and implemented for all new hires as part of the required elements in the orientation program for new hires. Meanwhile, those successful factors could be continually advocated in future trainings.

Longitudinal research can be considered to measure the effectiveness of CMT program in improving the well-being of social work professionals. By tracking changes over time, trainers can determine the impact of CMT concepts and a set of enabling factors.

The department can use various platforms, such as team building meetings and weekly roll calls for CMT activities. Some activities include writing a self-compassion letter (where pen, paper and envelopes are given to participants), and taking a self-compassion break (small snacks can be provided).

Regular reminders, for example, through emails entailing tips and monthly staff features (sharing with other colleagues what they do to promote their own wellness and well-being).

5.4 Development of Compassionate Care in Organizational Level

In support of the hospital’s vision that values compassion in the workplace, continuous efforts have been made to reinforce the development of a compassionate stance at individual and interpersonal levels. Research has also shown that with a positive workplace where hospital staff felt supported by their employers and co-workers, they are more likely to facilitate compassionate care [36]. As such, there is also consideration to extend this CMT program to other hospital staff for building more vital awareness and a culture of compassion.

6. Limitations

Due to challenges arising from logistic and workforce constraints, it was difficult to keep to the group size and grouping according to years of working experience and seniority, for example, a few of the support staff SWAs joined the MSW groups while a couple of senior MSWs join the junior MSW groups. The diversity in the groups has some impact on interactional dynamics. Similar workshops conducted in the future for new hires may not have homogeneous groups either. Careful planning on group composition will be required. Facilitators may require training to improve their skills in managing different group dynamics.

As post-workshop results were collected anonymously across all groups, it is not possible to evaluate the impact of the training on different groups based on years of experience or seniority. Information on their years of experience and job scope will be collected for future sessions to enable comparisons between groups. In addition, Compassion Engage and Action Scales [31] and Fears of Compassion Scale [32] will be used during workshops to measure the impact of the training on participants over time.

7. Conclusion

The program results showed that CMT workshop helped participants gain self-awareness and be more mindful and purposeful in developing self-compassion, which is integral in mitigating the impact of empathy distress and fatigue. The CMT workshop sent the participants a clear message that self-care or developing self-compassion is a shared responsibility between the individual social worker, the department, and the organization through conscious practice, ongoing training, and allowing safe space for such practices. It is also integral for social workers to understand secondary trauma and gain awareness of internal barriers to self-compassion and self-care.

A compassionate work climate and supportive work measures can help staff cope with a pandemic and the day-to-day healthcare setting and improve their professional quality of life [4]. Creating a culture of compassion in the workplace through CMT helps build a sense of psychological safety that leads to positive ripple effects in the mental health of persons working in helping professions or in stressful environments.

Appendix

Instruments

One measure scale was given to participants before and after training.

Forms of self-criticizing/attacking & self-reassuring scale (FSCRS) [26]. This scale was developed to measure self-criticism and the ability to be self-reassured. It is a 22-item scale measuring different ways people think and feel about themselves when things go wrong.

The items comprise three components: two forms of self-criticalness and 1 form of self-reassurance.

• Inadequate Self (IS), which focuses on personal inadequacy (I am quickly disappointed with myself), scores 0-36.
• Hated Self (HS), which focuses more on disgust and anger with the self (I have become so angry that I want to hurt or injure myself), scores from 0-20.
• Reassured self (RS), which focuses more on thoughts of self-reassurance (I can remind myself of positive things about myself), scores from 0-32.

Post-session evaluation form via Survey Monkey

1. Please indicate how much you agree or disagree about how well the following learning objectives were addressed during today’s training:

• I can gain awareness of myself in self-compassion.
• I can apply self-compassion exercises to regulate my emotions and gain mindfulness.
• I can develop self-compassion competency.
• I can use CFT concepts for my personal and professional self.

2. The objectives of the training were clearly defined.

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

3. Participation and interaction were encouraged.

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

4. This training experience will be helpful in my area of work.

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

5. The training objectives were met.

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

6. The content was organized and easy to follow.

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

7. The time allotted for the training was sufficient.

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

Author Contributions

Ms Patricia Tay and Ms Eva Kerk have initiated and led the current compassion mind training (CMT) group. The design of intervention was reviewed by Dr Soon-Noi Goh while Ms Patricia and Ms Eva delivered the CMT group to the participants and conducted the data collection. Ms Patricia and Ms Eva wrote the initial manuscript, with continual feedback and contributions from Dr Soon-Noi Goh and Dr Mandy Lau for the conceptualization, proofreading, revision of the language usage and approval for the final manuscript.

Funding

No funding received for this project but tapped on existing resources in the department.

Competing Interests

The authors have declared that no competing interests exist.