Compassionate Practices for Nurse Managers in Colombia *

Objective: To recognize compassionate practices and the obstacles to their use by nurse managers in Colombia. Method: This is a mixed cross-sectional, descriptive, exploratory, international study with an online survey administered in 17 countries. Data were extracted from Colombia with a sample of 69 nurse managers. Quantitative data were analyzed with descriptive statistics, and qualitative data were processed using the Nvivo software and thematic analysis. Results: 90 % women, mainly from a hospital setting (40 %). Compassionate practices in administrative nursing involve four categories: Listening; supporting and recognizing staff individuality; defining compassion practices, needs, and benefits; receiving compassion and complementary views of compassion and administration where the influence of cultural and organizational patterns become obstacles to compassion. Conclusion: For nursing, compassion demonstrates the intentional ability to recognize the singularity of someone else’s suffering, understand their needs, offer support, and find solutions based on an understanding of what being human means. These aspects require significant changes at the organizational and health legislation levels to mitigate the obstacles to compassion.


Introduction
Compassion has been understood as people's intrinsic and extrinsic experiences harmonized with understanding and comprehension. It includes the desire and empathic response that arises from other people's suffering to relieve it (1) until reaching a degree of synchrony with patients and the commitment to help them (2,3). However, this study is based on the ideas of other authors, who have defined compassion as a construct that implies a deep awareness of one's and others' suffering and the willingness to relieve it (4,5).
From this perspective, it is necessary to improve professional excellence and safeguard ethical virtues such as respect, sincerity, compassion, and selflessness (6). These practices focus on equitable treatment, closeness, and individualization of care plans as indicators of institutional quality (7) and aspects investigated in educational and health settings (8)(9)(10).
Moral distress has been found in nursing professionals in general due to low self-compassion and compassion on their end and the healthcare organization processes, as they frequently face dilemmas such as meeting patients' needs, following work rules, and having conflicts with other hierarchical members of the healthcare organization (11,12).
Recent studies with nurses from different parts of the world show the perceptions of compassion, the actions in which they materialize it, and its effects (13)(14)(15)(16)(17). In addition, reflections have been drawn on leadership strengthened by compassion, which can lead to job satisfaction, improve organizational sustainability, mitigate harm, reduce costs, and allow progress in comprehensive health quality processes (15,18,19).
The need to delve into the compassion phenomenon in nurse managers stems from a preliminary study carried out in fifteen countries, including Colombia, which revealed, among other issues, the lack of compassion of managers (15,16,20). Likewise, other studies have shown that an organizational climate with a high division in objectives, concrete tasks, and a scarce treatment in empathy and compassion leads to moral distress, affecting one's well-being, that of the group in their charge, and the environment (21,22). This study reports the compassion practices and the obstacles nurse managers in Colombia face regarding compassion.

Method Design and participants
A mixed, cross-sectional, descriptive, exploratory study was carried out with an online survey. It was conducted within the framework of the international study led by Professor Irena Papadopou-los of Middlesex University, UK, and coordinated by Dr. Magdeline Aagard, Walden University, USA; seventeen countries participated in the study (23). The research was conducted from 2018 to May 2020. The Colombian sample consisted of 69 nurses out of 89, with 20 participants excluded because they failed to complete the online questionnaire.
The participants were invited through social networks in the nursing area, and a direct invitation was made to managers from different cities nationwide. The inclusion criteria were as follows: Having a nursing degree and managerial responsibilities, hospital unit supervision, area supervision, sub-direction or nursing direction, responsibility for care centers, and responsibility for nursing teaching units, schools, or faculties when answering the questionnaire. Nursing students or nurses who had previous managerial or administrative experience and were not performing this activity at the study time were excluded.

Instruments
The questions of the online questionnaire were previously tested among the international team members to detect possible issues with the translation and improve question clarity and the survey flow. The collaborating research teams from Spain and Chile carried out the translation and cultural adaptation processes of the questionnaire into Spanish, following the methodology proposed by the World Health Organization (24). The Colombian team contributed to the cultural adjustment process by omitting the term midwife, as it does not exist as a profession in Colombia.
The questionnaire consisted of twenty-six items, with nine sociodemographic, eight dichotomous or multiple choice, and nine open-ended questions, which enabled collecting nurse managers' perspectives on compassion and ideas regarding barriers, enablers, advantages, and practical manifestations of a compassionate administrator.

Data analysis
The online data were collected using the Qualtrics survey software by the Middlesex University team from England, who sent the data from the participants in Colombia. The quantitative data were processed with descriptive statistics, and the open-ended questions were processed qualitatively and initially categorized in the Nvivo program. Then, the thematic analysis was carried out considering Braun and Clarke's proposal (25), identifying inductive, central themes in the texts and constructing categories based on the content found. The categories were discussed and extracted by consensus with the Colombian research team in different discussion sessions, in addition to revalidating categories and defining dimensions for the main themes.
In addition, the criteria in qualitative research were considered, such as auditability, as the study has complete digital documentation that enables the route followed in the research to be known and the information obtained for contrasting. To achieve greater credibility, the researchers held several meetings to discuss the data collected, considering the textual transcriptions of the information collected in the open-ended questions. The transferability is given by the complete description of the participants' characteristics and the presentation of the participants' typical responses and data representativeness.

Ethical aspects
The study contemplated the international normative ethical criteria of the declaration of Helsinki and the national criteria outlined in Resolution 8430 of 1993. The study received the approval of Middlesex University, England, and the ethics committee of the Nursing College of the Universidad Nacional de Colombia (FE-UN), which endorsed the English committee's decision. Participants were asked for their approval to participate in the study before filling out the form and were informed that they could stop filling out the questionnaire at any time.

Results
This section initially presents the participants' sociodemographic description, followed by a description of the categories that emerged, containing the descriptive data.

Sociodemographic description
The study participants were 90 % female, 79 % held some postgraduate education, and 42 % had more than eleven years of experience. The work settings were mostly hospital (40 %), home care (29 %), and higher education for nursing education (31 %). The number of nurse managers with more than 51 employees was 29 %, one to five 25 %, 21 to 50 22 %, six to ten 15 %, and 11 to 20 10 %.

Listening to staff, advocating for them, and recognizing individual characteristics
A total of 58 % of nurse managers reported not having time to listen to their staff; however, 88 % reported advocating for and defending them. How they defend and advocate for their reports are described in three components: 1. Defending entails the actions of advocating for the workers' rights and compliance regarding the exact and diligent fulfillment of what is established in order, prescription, or regulation.

2.
Claiming entails the actions of promoting appropriate and fair working conditions, as well as listening to workers. 3. Recognition acknowledges the value of work and workers as integral human beings and their abilities.
In their role as managers, 84 % of them consider the individual and cultural characteristics of the employees in their charge, framed in two components: 1. Putting oneself in someone else's place implies understanding and adapting administrative processes to respond to individuality, such as rotation tables and services, and understanding and negotiating regional manifestations, i.e., staff beliefs, languages, and behaviors in the work environment.
I try to ask my colleagues how they feel and how they are doing in their activities and try to solve problems together. (CO006, Q15) Other actions are related to defending and advocating against the stigmatization of any staff member's cultural diversity.

2.
Personalizing/individualizing is related to being aware of their personnel's human and cultural diversity without discriminating. Individual, gender, age, and cultural characteristics must be known; health problems, abilities, skills, socioeconomic and family contexts, and needs must be recognized.

Defining the practice of compassion, its necessity, and benefits
The nurse managers' perspectives on compassion evidenced a higher-order theme defined as conscious and intentional in nature and five components that describe it: Eighty-eight percent of the nurse managers state that they advocate for their staff and defend their rights in practice. They describe this in three components: 1. Advocating for workers' rights and compliance with regulations.

2.
Claiming by promoting appropriate and fair working conditions and actively listening to workers.

3.
Recognizing and valuing workers as integral human beings, including their skills as workers.
These findings show the intentional capability to recognize the singularity of someone else's suffering, the understanding of their needs, and the importance of offering support and finding solutions based on understanding what it means to be human. These findings have been reported in a previous study with Colombian nurses (16).
The nurse managers' compassionate actions and behaviors are described in four components: 1. Respect for others: Interpersonal relationships of consideration and interest are consolidated and centered on listening to employees, which strengthens assertive communication, balances successes and failures, and demonstrates more empathy than compassion.
Listening to the problematic situations that prevent them from performing at their best. (CO004, Q13) 2. Creating a supportive environment means identifying the needs and strengths and individualizing the administrative aspects to favor the staff. Time is granted to get to know the personnel, listen to them, and support them in the solutions with resource management, orientation, training, or advocacy for workers.
Time is offered when employees need it and request leaves of absence or breaks.
When there is flexibility in dealing with personal situations and when absences are authorized without disciplinary processes. (CO009, Q33)

Regarding this component, the risk of leniency and irresponsibility towards requests for time is identified as a liability:
Trying to take advantage of such compassion most of the time to impede their work, lying, and neglecting their responsibilities. The benefits of providing compassion to staff are represented in three components: 1. Achieving better results in the work environment with a supportive/collaborative work team and appropriate communication and interpersonal relationships. It promotes physical and mental occupational health and personal and job satisfaction and recognition.
Staff who work with pleasure, with a harmonic working relationship, is essential for the group to do their best, providing quality and efficient care. (CO003, Q32) 2. To favor humanization by recognizing workers as human beings who suffer and face problems and promoting the identification of workers' and users' particularities. Promoting respect for Human Rights benefits the interconnection with others, and the administrator becomes a compassionate role model.
If they are treated with compassion, they will treat their assistants and patients with compassion. (CO001, Q16) 3. To create a collective construct that recognizes and accepts cultural diversity and particularity. It generates empowerment and promotes conflict resolution and proposals for improvement. In addition, there is solidarity toward co-workers' suffering, perceiving the administrator's support, trust, and solidarity. of staff, managers, supervisors, colleagues, work team, subordinates, students, other professionals, patients, or family members.

From my colleagues, co-workers, and bosses. (CO005, Q16)
The importance of compassion lies in three components: 1. Having a better work environment: Given that it contributes to solving difficulties or problems, organizing support for the work, expressing positive feelings and actions, and favoring humanized attention.
It is to become familiar with and understand the problems or needs of others. (CO002, Q48) 3. Retributing and transforming the environment: Whether at work, personally, or as a way of providing care.
Because I feel that I am not alone, but I have a team that, As I support them when they need it, they retribute that to me when I need it. It allows me to realize that they treat users with the same compassion. (CO002, Q6)

Complementary views when discussing compassion and administration
The nurse managers emphasized two core components when talking about compassion and administration: 1. Compassion, necessity, and opportunity: These aspects involve experience and time, development of human qualities, growth to foster capabilities and reciprocity, improvement of relationships and communication, the creation of a culture of change focused on the search for peace, justice, and a pleasant and constantly supportive life. This component also involves the transformation of an organizational climate in which teamwork, focused on the multiple benefits to the health system and impacting the user, requires stimulating challenges and productivity.

Nursing interventions are limited by institutional schedules and the different administrative tasks, nursing notes, and requests.
(CO003, Q18) The challenge involves breaking hegemonic management paradigms and a new way of managing human resources detached from the fear of losing leadership and authority or being a compassionate administrator. Others may think that a preferential stance is being taken towards certain members of the work team or the person in question.
They may think that they have the freedom to take on responsibilities that are not theirs, or to undermine their work, crossing the sphere from trust to disrespect. (CO002, Q6) 2. Barriers to compassion: These are visible from extrinsic factors, such as the non-existence of compassion in the Colombian system. The subject is not discussed, and there are no institutional stimuli; some regulations do not favor compassion. Additionally, it is not taught as a subject in the undergraduate program.
The mechanization of health systems in Colombia and the high restriction on nurses' work. (CO005, Q21) Intrinsic factors highlight the lack of skills and an instrumental view of the role associated with -"they see me as a machine"-.
Dilemmas are at play that glimpse whether being compassionate is positive or not, as it coexists with the fear of abuse and deception. In addition, stereotypes exist around the idea that administration is incompatible with compassion, and there are different perspectives of what administration is and what compassion is. Likewise, the non-existence of compassion among colleagues is raised.

The vast number of activities prevent closer attention to details regarding people's feelings. (CO005, Q37)
Furthermore, three components that prevent nurses from providing compassion were identified: 1. The health system is a source of factors related to over-productivity and minimal resources. It implies authoritarianism and the mechanization of human beings, privileging technology that results in depersonalizing, lack of time for interaction with the team and patients, work overload due to personnel shortage, and undervaluation of nursing work.

Lack of time for quality interactions
When staff requires urgent support, they are addressed personally, and the situation is resolved, but there is no room for feedback or follow-up, given the time constraints. (CO001, Q11) 3. The administrator's authoritarian leadership culture begins with selecting someone with a strong personality. From the academy, authoritarian leadership roles are molded; beliefs regarding leadership as a superior power, demands, and vertical relationships are fostered, creating a hierarchy of rivalry where human beings are rendered invisible. A compassionate leader is perceived as fragile, insecure, or as someone afraid and lacking training or experience in the decision-making process.
The invisibilization of human beings, the health system, and the selfish pursuit of one's goals. (CO004, Q22) In the organizational culture, work demands and compliance with standards take precedence over people. Managers are faced with demands and dilemmas in their professional practice, which places the practice of compassion in the background.

Discussion
This study provides a glimpse of compassion in the practice of nurse managers as a conscious action that includes individualizing the suffering of others and devoting time to being present with actions that promote equality and equity in the face of human needs. These findings are like those of previous studies with Colombian nurses in the framework of international studies (16,23), which indicates that nurses in the care and administrative roles share similar notions on the compassion construct. In addition, they are close to the theoretical ideas addressed by other authors (1)(2)(3)(4)(5) in that they coincide with a conscious and intentional behavioral approach that recognizes suffering and the need to contribute to alleviating it.
The compassion displayed by nurse managers is materialized in the appropriation of their employees' particular needs and empathy according to cultural characteristics, and the recognition of diversity can be perceived. This idea reaffirms the relevance of a culturally compassionate competence reported in the literature (23,26,27), representing an understanding of other people's suffering and the desire to alleviate it, considering the conditions and cultural background.
Human behaviors are described as the nurse managers' intention, among which respect for their co-workers stands out. It is strengthened through communication that prioritizes active listening and leads to a work environment of constant support and harmony, advocating to solve situations of their reports regarding the needs that may arise. These indicators have been theorized and studied in the cycles of positive interaction between supervisors and subordinates (22), resulting in higher work performance and increased positive emotions, loyalty, and organizational commitment (23).
The benefits of providing compassion to the staff are evidenced by favoring humanization, achieving common goals, and establishing a constant climate of collective construction that welcomes employees' suffering and needs. In other studies on compassionate practice in nursing (23,(26)(27)(28), these benefits have been considered strategies that reduce burnout, nurses' loyalty within hospital organizations, and improve their quality of life and mental health.
For nurse managers, it is vital to receive compassion both from the work team, their superiors, and users. This finding has been documented in other reports that indicate the need for a comprehensive institutional care design that promotes bidirectional compassion and counteracts current practices focused on instrumentalization and production (29).
In the constraints to compassion, intrinsic factors were identified that reflect a duality between assuming a compassionate approach and the fear or distrust of being deceived. There are fears regarding social imaginaries about the administrative role, as they may be incompatible with compassionate practices.
These factors have been reported in other studies (11,12,17,18). They are potentially influential in reducing compassion levels and leading to moral distress, given that, as reported in the international study with nurse managers (17), compassionate practice is considered highly demanding and causes more stress. For this purpose, other studies have recommended implementing strategies that improve well-being and relational leadership (23,30).
The inexistence of compassion from extrinsic factors reflects a lack of organizational stimuli and a Colombian health system that fails to contemplate compassionate practices. It is an entirely invisible issue, as institutions fail to consider stimuli or regulations that favor compassion; to these aspects, undergraduate training is also added, disregarding this competence. These findings have been made visible in other studies, both in Latin America and worldwide (17,23,31). These studies reiterate the relevance of a renewal in healthcare that needs to be claimed with integral humanization from compassionate practices, including a change in the triad: the health system, the organizational level, and personnel transformation.

Conclusions
The study shows that Colombian nurse managers perceive compassion as that intentional ability to recognize the particularity of someone else's suffering, understand their needs, offer support, and find solutions based on understanding what being human means.
The practice of compassion favors the recognition of the rights of others as workers and their defense as human beings who suffer, face problems, and need support; therefore, with this practice, changes in the human resource management paradigms are proposed when the fear or belief of losing leadership and authority for being compassionate exists.
For nurse managers and their work teams, it is crucial to establish the connection between offering and receiving compassion; in this way, better results can be obtained, making possible a collective construction that enables improvement in the work environment, barriers are minimized, and an environment of continuous retribution and transformation prevails.
In addition, it is necessary to adapt current health policies to adjust nurse managers' compassionate practices in health institutions, as the lack of time, work overload, and the authoritarian organizational culture of surveillance and control prevent them from exercising efficient and humane leadership.

Conflicts of interest:
None declared.