In search of compassion: a new taxonomy of compassionate physician behaviours

Communication strategies for expressing empathy during family-clinician conversations in the intensive care unit: A mixed methods study

OBJECTIVES

To explore communication strategies intensive care clinicians and patients' family members prefer for expressing empathy during family-clinician conversations.

RESEARCH METHODOLOGY/DESIGN

Mixed-methods survey study.

SETTING

Two medical ICUs of a German academic tertiary care hospital.

MAIN OUTCOME MEASURES

Using a self-developed online survey with closed and open-ended questions with free-text options, the participants' preferences of communication strategies for expressing empathy were investigated. Quantifiable similarities and differences were determined by statistical analysis. Qualitative themes were derived at by directed content analysis.

FINDINGS

The responses of 94 family members, 42 nurses, and 28 physicians were analysed (response rate: 45.3 %). Four communication strategies were deduced: (1) reassuring the families that the intensive care unit team will not abandon neither them nor the patient, (2) acknowledging emotions and offering support, (3) saying that the families are welcome and cared for in the intensive care unit, (4) providing understandable information. In comparison, the families considered an expression of nonabandonment as more empathic than the physicians did (p =.031,r = 0.240), and those expressions focussing solely on the family members' well-being (p =.012,r = 0.228) or comprising evaluative wording ("good", "normal") (p =.017,r = 0.242) as less empathic than the nurses did. Unanimously advocated nonverbal communication strategies included to listen attentively and to avoid interrupting as well as being approachable and honest.

CONCLUSION

The participants' preferences supported expert recommendations and highlighted that it is not only important what the clinicians say but also how they say it. Further research is needed to elucidate ways of successfully expressing empathy during family-clinician conversations in the intensive care unit.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care unit clinicians are encouraged to practice active listening and to express their caring and nonabandonment. It is further suggested to reflect on and adjust pertinent nonverbal behaviours and relational aspects of their communication, as applicable.

Compassionate care during the COVID-19 pandemic

BACKGROUND

There was a substantial documented call for healthcare professionals to provide compassionate care during the COVID-19 pandemic and significant criticism voiced when it was lacking. This study aimed to explore perspectives on compassionate care among healthcare professionals providing care during the COVID-19 pandemic. The study focuses on healthcare professionals who participated in a wide range of COVID-19 measures, including testing, quarantine, diagnosis, and care provision (patients with COVID-19 or patients with other illnesses and comorbid with COVID-19).

METHODS

A qualitative design with an interpretative phenomenological analysis approach was used. Twenty frontline healthcare professionals (15 nurses and five physicians) who had worked in COVID-19 facilities in China were interviewed individually.

RESULTS

Participants stated that a commitment to 'offering oneself' and 'balancing the advantages/disadvantages' in providing care during the pandemic were key to alleviate population-level suffering. On a personal level, they described a desire for obtaining 'mutual support' and improving 'professional competencies' to safeguard their physical and mental well-being. Two professional competencies were notable: coping with grief and implementing infection control across the organization. Additionally, they emphasized the importance of receiving support from the health care organization, the public, and leaders in creating an 'environment conducive to fostering compassionate care.'

CONCLUSION

Healthcare professionals recognized the centrality of compassionate care during the pandemic which entailed a commitment to offering themselves, the balancing of advantages and disadvantages in order to find the best solution, as well as the need to safeguard themselves using professional competencies. Such findings can enrich the contemporary understanding of compassion, including when it is lacking. Support from the healthcare organization, the public, and leadership were crucial in fostering compassionate care in healthcare professionals during the pandemic and in moving the field forward in the future.

Transpersonal Caritas Relationship: A new concept from the unitary caring science framework of Jean Watson

Objective

To analyze deeply the concept of the transpersonal caring relationship as the core of the theory of Caring Science proposed by Jean Watson. To present a historical evolution and to introduce the Transpersonal Caritas Relationship construct.

Methods

Methodological Study to support the central concept measured by the Watson Caritas patient instrument. We designed a focus group with four nursing scholars to develop the "Transpersonal Caritas Relationship" construct. We recount the history of the concept of the transpersonal caring relationship, then analyze this concept in terms of Watson's theory. We reviewed the concept with Dr. Jean Watson, presented her with the construct, and discussed our considerations.

Results

This article introduces a transitional adaptation of the concept of transpersonal relationship to Caritas' transpersonal relationship. Transpersonal Caritas Relationship is the foundation of evolved Caritas nursing, recognizing that mutual caring affects the universal field we all belong to Caritas' consciousness and action affect the energy field when the nurse relates with the other, making it possible to awaken the compassionate heart, which is the foundation of Evolved Caritas Nursing Universal love and in this way evolve to the Caritas consciousness that allows recognizing the other with loving kindness in the practice of careful. This is the proposed central concept measured in the caring approach using the Watson Caritas Patient.

Conclusion

This article introduces a transitional adaptation of the concept of transpersonal relationship to the Caritas transpersonal relationship, which is the foundation of Caritas Evolved Nursing.

More than a feeling? What does compassion in healthcare 'look like' to patients?

OBJECTIVE

Compassion is important to patients and their families, predicts positive patient and practitioner outcomes, and is a professional requirement of physicians around the globe. Yet, despite the value placed on compassion, the empirical study of compassion remains in its infancy and little is known regarding what compassion 'looks like' to patients. The current study addresses limitations in prior work by asking patients what physicians do that helps them feel cared for.

METHODS

Topic modelling analysis was employed to identify empirical commonalities in the text responses of 767 patients describing physician behaviours that led to their feeling cared for.

RESULTS

Descriptively, seven meaningful groupings of physician actions experienced as compassion emerged: listening and paying attention (71% of responses), following-up and running tests (11%), continuity and holistic care (8%), respecting preferences (4%), genuine understanding (2%), body language and empathy (2%) and counselling and advocacy (1%).

CONCLUSION

These findings supplement prior work by identifying concrete actions that are experienced as caring by patients. These early data may provide clinicians with useful information to enhance their ability to customize care, strengthen patient-physician relationships and, ultimately, practice medicine in a way that is experienced as compassionate by patients.

PUBLIC CONTRIBUTION

This study involves the analysis of data provided by a diverse sample of patients from the general community population of New Zealand.

What is the Most Valid and Reliable Compassion Measure in Healthcare? An Updated Comprehensive and Critical Review

Our previous review of compassion measures in healthcare between 1985 and 2016 concluded that no available measure assessed compassion in healthcare in a comprehensive or methodologically rigorous fashion. The present study provided a comparative review of the design and psychometric properties of recently updated or newly published compassion measures. The search strategy of our previous review was replicated. PubMed, MEDLINE, CINAHL, and PsycINFO databases and grey literature were searched to identify studies that reported information on instruments that measure compassion or compassionate care in clinicians, physicians, nurses, healthcare students, and patients. Textual qualitative descriptions of included studies were prepared. Instruments were evaluated using the Evaluating Measures of Patient-Reported Outcomes (EMPRO) tool. Measures that underwent additional testing since our last review included the Compassion Competence Scale (CCS), the Compassionate Care Assessment Tool (CCAT)^©, and the Schwartz Center Compassionate Care Scale (SCCCS)™. New compassion measures included the Sussex-Oxford Compassion for Others Scale (SOCS-O), a self-report measure of compassion for others; the Bolton Compassion Strengths Indicators (BSCI), a self-report measure of the characteristics (strengths) associated with a compassionate nurse; a five-item Tool to Measure Patient Assessment of Clinician Compassion (TMPACC); and the Sinclair Compassion Questionnaire (SCQ). The SCQ was the only measure that adhered to measure development guidelines, established initial construct validity by first defining the concept of interest, and included the patient perspective across all stages of development. The SCQ had the highest EMPRO overall score at 58.1, almost 9 points higher than any other compassion measure, and achieved perfect EMPRO subscale scores for internal consistency, reliability, validity, and respondent burden, which were up to 43 points higher than any other compassion measure. These findings establish the SCQ as the ‘gold standard’ compassion measure, providing an empirical basis for evaluations of compassion in routine care.

Effect of an Intensive Mindful Practice Workshop on Patient-Centered Compassionate Care, Clinician Well-Being, Work Engagement, and Teamwork

INTRODUCTION

Mindfulness-based interventions for health professionals have been linked to improvements in burnout, well-being, empathy, communication, patient-centered care, and patient safety, but the optimal formats and intensity of training have been difficult to determine because of the paucity of studies and the heterogeneity of programs. A 4-days residential "Mindful Practice" workshop for physicians and medical educators featuring contemplative practices, personal narratives, and appreciative dialogs about challenging experiences may hold promise in improving participants' well-being while also improving compassionate care, job satisfaction, work engagement, and teamwork.

METHODS

We collected baseline and 2-month follow-up data during four workshops conducted in 2018 to 2019 at conference centers in the United States and Europe. Primary outcomes were burnout, work-related distress, job satisfaction, work engagement, patient-centered compassionate care, and teamwork.

RESULTS

Eighty-five of 120 participants (71%) completed both surveys (mean age was 49.3 and 68.2% female). There were improvements (P < .01) in two of three burnout components (emotional exhaustion and depersonalization), work-related distress, job satisfaction, patient-centered compassionate care, work engagement and meaning, teamwork, well-being, positive emotion, mindfulness, somatic symptoms, and spirituality. Effect sizes (standardized mean difference of change) ranged from 0.25 to 0.61. With Bonferroni adjustments (P < .0031), teamwork, general well-being, and mindfulness became nonsignificant.

DISCUSSION

An intensive, multiday, mindfulness-based workshop for physicians had clinically significant positive effects on clinician well-being, quality of interpersonal care and work satisfaction, and meaning and engagement, all important indicators of improved health and sustainability of the health care workforce. Future iterations of the program should increase the focus on teamwork.

Compassion, communication, and the perception of control: a mixed methods study to investigate patients' perspectives on clinical practices for alleviating distress and promoting empowerment during awake craniotomies

PURPOSE

To inquire into clinical practices perceived to mitigate patients' intraoperative distress during awake craniotomies.

METHODS

This mixed-methods study involved administration of Amsterdam Preoperative Anxiety and Information Scale and PTSD Checklist prior to the awake craniotomy to evaluate anxiety and information-seeking related to the procedure and symptoms of PTSD. Generalized Anxiety Disorder Scale and Depression Module of the Patient Health Questionnaire were administered before and after the procedure to evaluate generalized anxiety and depression. Patient interviews were conducted 2-weeks postprocedure and included a novel set of patient experience scales to assess patients' recollection of intraoperative pain, overall distress, anxiety, distress due to noise, perception of empowerment, perception of being well-prepared, overall satisfaction with anaesthesia management, and overall satisfaction with the procedure. Qualitative data were analysed using conventional content analysis.

RESULTS

Participants (n = 14) had undergone an awake craniotomy for tissue resection due to primary brain tumours or medically-refractory focal epilepsy. Validated self-report questionnaires demonstrated reduced levels of generalized anxiety (pre mean = 8.66; SD = 6.41; post mean= 4.36; SD = 4.24) following the awake craniotomy. Postprocedure interviews revealed very high satisfaction with the awake craniotomy and anaesthesia management and minimal levels of intraoperative pain, anxiety, and distress. The most stressful aspects of the procedure included global recognition of medical diagnosis, anxiety provoked by unfamiliar sights, sounds, and sensations, a perception of a lack of information or misinformation, and long periods of immobility. Important factors in alleviating intraoperative distress included the medical team's ability to promote patient perceptions of control, establish compassionate relationships, address unfamiliar intraoperative sensations, and deliver effective anaesthesia management.

CONCLUSION

Compassion, communication, and patient perception of control were critical in mitigating intraoperative distress. Clinical practice recommendations with implications for all clinicians involved in patient care during awake craniotomies are provided. Use of these interventions and strategies to reduce distress are important to holistic patient care and patient experiences of care and may improve the likelihood of optimal brain mapping procedures to improve clinical outcomes during awake craniotomies.

Communication between neonatologists and parents when prognosis is uncertain

OBJECTIVE

When an infant's prognosis is uncertain, communication between neonatologists and parents surrounding goals of care and decision-making can be challenging. This qualitative study explored communication between neonatologists and parents to discover qualities which may enhance or impede parent-clinician partnership under such difficult circumstances.

STUDY DESIGN

Guided by the National Cancer Institute (NCI) Patient Centered Communication framework, semi-structured individual interviews were conducted and analyzed regarding neonatologist and parent perceptions of their communication. Subjects consisted of nine dyads of neonatologists and English-speaking parents whose infant had an uncertain prognosis.

RESULTS

Parents were overall satisfied with neonatologists' communications concerning their infant's uncertain trajectory. Nonetheless, both experienced challenges and distress during communication, impeding collaboration and engagement.

CONCLUSIONS

Families and neonatologists value principles of patient centered communication but report challenges implementing this practice. Incorporating a multidisciplinary approach in settings of prognostic uncertainty to foster patient centered communication, may enhance communication surrounding NICU care.

Patient-Clinician Communication Issues in Palliative Care for Patients With Advanced Cancer

The delivery of palliative care to patients with advanced cancer and their families, whether done by oncology clinicians or palliative care clinicians, requires patient-centered communication. Excellent communication can introduce patients and families to palliative care in a nonthreatening way, build patient trust, enable symptom control, strengthen coping, and guide decision making. This review covers deficiencies in the current state of communication, patient preferences for communication about palliative care topics, best practices for communication, and the roles of education and system intervention. Communication is a two-way, relational process that is influenced by context, culture, words, and gestures, and it is one of the most important ways that clinicians influence the quality of medical care that patients and their families receive.

Compassion in the Clinical Context: Constrained, Distributed, and Adaptive

BACKGROUND

Compassion is intrinsically situated within particular contexts and how these contexts can shape compassion has not been well-described.

OBJECTIVE

The purpose of the study was to describe how individual and contextual challenges can impact compassion within critical care and palliative care settings.

DESIGN

This qualitative study adopted phenomenology and autoethnography to inform data collection, and principles of activity theory and realist inquiry for data interpretation.

PARTICIPANTS

Five clinicians who work in critical care (n = 3) and palliative care (n = 3) participated in the study.

APPROACH

Qualitative data were obtained from ethnographic observations, interviews, and focus groups. Participants observed and recorded field notes (n = 53) on instances of suffering and compassion in their workplace settings. At the end of the study period, they participated in a focus group or individual interview to reflect on their experiences. Data was analyzed using constructivist grounded theory techniques and iteratively synthesized through group discussion and model building.

KEY RESULTS

The findings reflected four phenomena associated with compassion in context: individual gaps and lapses in compassion, relational challenges, contextual constraints on compassion, and distributed compassion. Individual gaps and lapses in compassion involved inattention, intention vs. perception, personal capacity, and personal toll. Relational challenges included receptivity, fragmentation, and lack of shared understanding. Contextual constraints consisted of situational pressures, the clinical environment, gaps in education, and organizational culture. The distribution of compassion within teams and how teams adapt their behaviors in response to perceived needs for greater compassion modulated these challenges.

CONCLUSIONS

The study illustrates the many ways in which compassion can be shaped by context and highlights the role of teamwork in identifying gaps and lapses in compassion and responding in a way that supports patients, families, and colleagues.

Compassionate Care in Healthcare Systems: A Systematic Review

BACKGROUND

In spite of emphasis on patient-centered cares and promotion of their quality, shortcomings have been seen in health systems due to lack of compassion.

PURPOSE

The aim of the present study was to determine the definition, fields, facilitating and inhibiting factors of compassionate care in healthcare systems and the interventions designed to promote it.

METHODS

This study was conducted through narrative synthesis which is supposed to do systematic and synthesized review. Searching was done in English databases including Pub Med, CINAHL, Google Scholar, Web of Science, and Cochrane library, Ovid, Science Direct, WILEY by using keywords of Compassionate Care, Delivery of Health Care, Healthcare Systems, Compassion and Health Care Providers from 1987 to 2017.

RESULTS

Compassionate care has some dimensions including ethical, professional, effective communication, human, spiritual/religious and getting involve with patients. Facilitating and inhibiting factors consisted of the nurse's personal characteristics, patients' behavior and organizational factors included workload, role model, and value of compassionate care in healthcare systems. Educational interventions such as providing feedback and reorienting have been mostly used to improve the compassionate care.

CONCLUSIONS

Although compassionate care has been known as the main element of improving services quality in health care system, it has been studied restrictively from the viewpoints of the patients and all personnel in healthcare systems. The improvement of compassionate care through education cannot remove completely the gap between theory and practice, because it seems that clinical environment and organizational values of healthcare system are the largest facilitating and inhibiting factors for filling this gap. Therefore, it is necessary to take measures for promoting organizational culture.

Contraste de perspectivas y experiencias sobre compasión de enfermeras colombianas con 14 países

Se exploraron puntos de vista y experiencias sobre compasión en la práctica de enfermeras colombianas y contrasta con los otros 14 países participantes del estudio internacional online. El estudio transversal exploratorio con survey internacional online con 10 preguntas (abiertas y cerradas), contó con 1323 enfermeras, 103 fueron de Colombia. Datos cuantitativos colombianos fueron analizados en Excel y los cualitativos en el programa Nvivo con análisis temático y consenso entre investigadores. La muestra colombiana contó con 83,5% docentes y eligieron la definición de compasión como la “conciencia profunda de sufrimiento de los otros y el deseo de aliviar ese sufrimiento” (84,3%). Piensan que la compasión puede ser enseñada (64,1%) pero no es impartida (45,1%) y es influenciada por la experiencia personal (38,2%) y los valores culturales (37,3%).  Los relatos de Colombia revelan barreras sociopolíticos, organizacionales y educativos para la atención compasiva. Perciben compasión de sus pacientes (84,7%), escasa compasión entre colegas (14,3%) y casi nula compasión por parte de los gerentes (1%). Sin embargo, emerge la naturaleza consciente e intencional de la compasión y el esfuerzo de enfermería por desarrollarla en cinco componentes: particularizar, invertir tiempo, estar presente, ir más allá y la defensa/abogacia. Se hacen evidentes algunas variaciones culturales de la compasión y formas de promoverla en un ejercicio profesional cada vez más transcultural.

Understanding compassion for people with dementia in medical and nursing students

BACKGROUND

Compassion is an essential component of good quality care. Compassion towards people with dementia in health systems is often suboptimal, which can have negative impacts on clinical outcomes and patient experience. Attitudes are formed early in training and the literature on healthcare student compassion towards those with dementia is limited. This study aimed to understand how undergraduate medical and nursing students understand compassion towards people with dementia and factors influencing the delivery of compassionate care.

METHODS

Nine individual in-depth interviews and two focus groups were undertaken with 23 medical and nursing students. A topic guide was developed, and transcripts were analysed using thematic analysis.

RESULTS

The analysis identified three themes which students used to define compassion: (i) connection, (ii) care, and (iii) respect. Three factors were identified as being either facilitators or barriers to delivering compassionate care to people with dementia: (i) patient factors, (ii) student factors, and (iii) connection. Patient factors related to the presence of behaviours which might be challenging to manage. Student factors included student exposure to dementia, as well as student knowledge and skills. Connection focussed on whether there was an awareness and understanding of the person behind the diagnosis.

CONCLUSION

Undergraduate healthcare students are the future workforce for patients with dementia, and understanding how compassion develops within them is important. We found medical and nursing students had a broad understanding of compassion, and identified factors influence their compassion towards people with dementia. These novel data can be used to shape healthcare education programmes aimed at improving dementia care.

Implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings: a pilot RCT and feasibility study

Background

Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable.

Objectives

To assess the feasibility of implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings and to evaluate its impact on patient care.

Design

Pilot cluster randomised trial (CRT) and associated process and economic evaluations.

Setting

Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n = 4) or control (n = 2).

Participants

Patients (n = 639), staff (n = 211) and visitors (n = 188).

Intervention

CLECC is a workplace educational intervention focused on developing sustainable leadership and work team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. The control setting involved no planned staff team-based educational activity.

Main outcome measures

Quality of Interaction Schedule (QuIS) for staff–patient interactions, patient-reported evaluations of emotional care in hospital (PEECH) and nurse-reported empathy (as assessed via the Jefferson Scale of Empathy).

Data sources

Structured observations of staff–patient interactions; patient, visitor and staff questionnaires and qualitative interviews; and qualitative observations of CLECC activities.

Results

The pilot CRT proceeded as planned and randomisation was acceptable to teams. There was evidence of potential contamination between wards in the same hospital. QuIS performed well, achieving a 93% recruitment rate, with 25% of the patient sample cognitively impaired. At follow-up there were more positive (78% vs. 74%) and fewer negative (8% vs. 11%) QuIS ratings for intervention wards than for control wards. In total, 63% of intervention ward patients achieved the lowest possible (i.e. more negative) scores on the PEECH connection subscale, compared with 79% of control group patients. These differences, although supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: the CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. Strong evidence of good staff participation was found in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: the costs associated with using CLECC were identified and it is recommend that an impact inventory be used in any future study.

Limitations

Findings are not generalisable outside hospital nursing teams, and this feasibility work is not powered to detect differences attributable to the CLECC intervention.

Conclusions

Use of the experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research, but further validation is required. Further development of the CLECC intervention should focus on ensuring that it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers. Funding is being sought for a more definitive evaluation.

Trial registration

Current Controlled Trials ISRCTN16789770.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 33. See the NIHR Journals Library website for further project information. The systematic review reported inChapter 2was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, the University of Örebro and the Karolinska Institutet.

Ethological observations of social behavior in the operating room

Operating rooms (ORs) are inhabited by hierarchical, mixed-gender clinical teams that are often prone to conflict. In evolutionary terms, one expects more within- than between-gender rivalries, especially since the OR is a place where all sorts of social interactions occur, not merely technical communications. To document the full range of behavior, the present study used ethological observation techniques, recording live all social behavior by the team. Using an ethogram, 6,348 spontaneous social interactions and nontechnical communications were timestamped during 200 surgical procedures. Cooperation sequences (59.0%) were more frequent than conflict sequences (2.8%), which ranged from constructive differences of opinion to discord and distraction that could jeopardize patient safety. Behavior varied by clinical role and with the gender composition in the OR. Conflict was initiated mostly down the hierarchy between individuals several ranks apart. Cooperation tended to increase with a rising proportion of females in the OR, but the most pronounced effect concerned the interaction between both genders. If the attending surgeon's gender differed from that of the majority of other personnel in the OR, cooperation was significantly more common.

Measuring Compassion in Healthcare: A Comprehensive and Critical Review

BACKGROUND

There is international concern about the lack of compassion in healthcare systems. A valid and reliable tool for measuring compassion in healthcare systems and educational institutions is required. This comprehensive and critical narrative synthesis identified and compared existing measures of compassionate care in clinical settings.

METHODS

PubMed, MEDLINE, CINAHL and PsycINFO databases and grey literature were searched to identify studies that report information on instruments that measure compassion or compassionate care in clinicians, nurses, healthcare students and patients. Textual qualitative descriptions of included studies were prepared. Instruments were evaluated using the Evaluating Measures of Patient-Reported Outcomes (EMPRO) tool.

RESULTS

Nine studies containing information on the Compassion Competence Scale, a self-report instrument that measures compassion competence among Korean nurses; the Compassion Scale, the Compassionate Care Assessment Tool©, and the Schwartz Center Compassionate Care Scale™, patient-reported instruments that measure the importance of healthcare provider compassion; the Compassion Practices Scale, an instrument that measures organisational support for compassionate care; and instruments that measure compassion in educational institutions (instructional quality and a Geriatric Attitudes Scale), were included. Each instrument is associated with significant limitations. Most only measure certain aspects of compassion and lack evidence of adaptability to diverse practice settings. The EMPRO of self-report instruments revealed a lack of psychometric information on measurement reliability, validity, responsiveness and interpretability, respondent, administrative and scoring burden, and use in subpopulations.

CONCLUSION

The findings of this narrative synthesis identified an unmet need for a psychometrically validated instrument that comprehensively measures the construct of compassion in healthcare settings.

On caring and sharing-Addressing psychological, biographical, and spiritual aspects in integrative cancer care: A qualitative interview study on physicians' perspectives

BACKGROUND

Patients confronted with a cancer diagnosis experience a variety of existential needs encompassing emotional, psychological, and spiritual areas of being. A patient-centered care approach addressing such existential issues is recognized as an essential aspect of health care. The aim of this study is to explore what role psychological, biographical, and spiritual factors play for experienced doctors working in integrative cancer care.

METHOD

The qualitative study was based on in-depth interviews with 35 purposively sampled doctors, all practicing integrative oncology in the field of anthroposophic medicine in hospitals and/or office-based practices in Germany and other countries. Data were analyzed using structured content analysis.

RESULTS

Psychological, biographical, and spiritual factors are important issues in integrative cancer care. Prevailing themes identified in this study were enabling patients to participate in life, promoting autonomy and coping, stabilizing patients emotionally and cognitively, overcoming the disease, and-primarily if addressed by patients-integrating spiritual issues. Doctors offered conversation, counseling, and time, but also referred to art, music, literature, and nature, so that patients' ongoing emotional, psychological, and spiritual needs could be explored and addressed. Doctors' attitudes with regard to existential issues were seen as important, as was maintaining an attitude of openness towards existential issues.

CONCLUSION

Doctors in integrative cancer care utilize different methods to explore the needs of patients and employ a variety of treatment methods that address not just patients' medical issues but their existential concerns as well.

Barriers to Medical Compassion as a Function of Experience and Specialization: Psychiatry, Pediatrics, Internal Medicine, Surgery, and General Practice

CONTEXT

Compassion is an expectation of patients, regulatory bodies, and physicians themselves. Most research has, however, studied compassion fatigue rather than compassion itself and has concentrated on the role of the physician. The Transactional Model of Physician Compassion suggests that physician, patient, external environment, and clinical factors are all relevant. Because these factors vary both across different specialities and among physicians with differing degrees of experience, barriers to compassion are also likely to vary.

OBJECTIVES

We describe barriers to physician compassion as a function of specialization (psychiatry, general practice, surgery, internal medicine, and pediatrics) and physician experience.

METHODS

We used a cross-sectional study using demographic data, specialization, practice parameters, and the Barriers to Physician Compassion Questionnaire. Nonrandom convenience sampling was used to recruit 580 doctors, of whom 444 belonged to the targeted speciality groups. The sample was characterized before conducting a factorial Multivariate Analysis of Covariance and further post hoc analyses.

RESULTS

A 5 (speciality grouping) × 2 (more vs. less physician experience) Multivariate Analysis of Covariance showed that the barriers varied as a function of both speciality and experience. In general, psychiatrists reported lower barriers, whereas general practitioners and internal medicine specialists generally reported greater barriers. Barriers were generally greater among less experienced doctors.

CONCLUSION

Documenting and investigating barriers to compassion in different speciality groups have the potential to broaden current foci beyond the physician and inform interventions aimed at enhancing medical compassion. In addition, certain aspects of the training or practice of psychiatry that enhance compassion may mitigate barriers to compassion in other specialities.

Eloquent silences: A musical and lexical analysis of conversation between oncologists and their patients

OBJECTIVE

Silences in doctor-patient communication can be "connectional" and communicative, in contrast to silences that indicate awkwardness or distraction. Musical and lexical analyses can identify and characterize connectional silences in consultations between oncologists and patients.

METHODS

Two medical students and a professor of voice screened all 1211 silences over 2s in length from 124 oncology office visits. We developed a "strength of connection" taxonomy and examined ten connectional silences for lexical and musical features including pitch, volume, and speaker turn-taking rhythm.

RESULTS

We identified connectional silences with good reliability. Typical dialog rhythms surrounding connectional silences are characterized by relatively equal turn lengths and frequent short vocalizations. We found no pattern of volume and pitch variability around these silences. Connectional silences occurred in a wide variety of lexical contexts.

CONCLUSION

Particular patterns of dialog rhythm mark connectional silences. Exploring structures of connectional silence extends our understanding of the audio-linguistic conditions that mark patient-clinician connection.

PRACTICE IMPLICATIONS

Communicating with an awareness of pitch, rhythm, and silence - in addition to lexical content - can facilitate shared understanding and emotional connection.

Interventions for compassionate nursing care: A systematic review

BACKGROUND

Compassion has been identified as an essential element of nursing and is increasingly under public scrutiny in the context of demands for high quality health care. While primary research on effectiveness of interventions to support compassionate nursing care has been reported, no rigorous critical overview exists.

OBJECTIVES

To systematically identify, describe and analyse research studies that evaluate interventions for compassionate nursing care; assess the descriptions of the interventions for compassionate care, including design and delivery of the intervention and theoretical framework; and to evaluate evidence for the effectiveness of interventions.

REVIEW METHODS

Published international literature written in English up to June 2015 was identified from CINAHL, Medline and Cochrane Library databases. Primary research studies comparing outcomes of interventions to promote compassionate nursing care with a control condition were included. Studies were graded according to relative strength of methods and quality of description of intervention. Narrative description and analysis was undertaken supported by tabulation of key study data including study design, outcomes, intervention type and results.

RESULTS

25 interventions reported in 24 studies were included in the review. Intervention types included staff training (n=10), care model (n=9) and staff support (n=6). Intervention description was generally weak, especially in relation to describing participants and facilitators, and the proposed mechanisms for change were often unclear. Most interventions were associated with improvements in patient-based, nurse-based and/or quality of care outcomes. However, overall methodological quality was low with most studies (n=16) conducted as uncontrolled before and after studies. The few higher quality studies were less likely to report positive results. No interventions were tested more than once.

CONCLUSIONS

None of the studies reviewed reported intervention description in sufficient detail or presented sufficiently strong evidence of effectiveness to merit routine implementation of any of these interventions into practice. The positive outcomes reported suggest that further investigation of some interventions may be merited, but high caution must be exercised. Preference should be shown for further investigating interventions reported as effective in studies with a stronger design such as randomised controlled trials.

Compassion training in healthcare: what are patients' perspectives on training healthcare providers?

BACKGROUND

The purpose of this qualitative study was to investigate advanced cancer patients' perspectives on the importance, feasibility, teaching methods, and issues associated with training healthcare providers in compassionate care.

METHODS

This study utilized grounded theory, a qualitative research method, to develop an empirical understanding of compassion education rooted in direct patient reports. Audio-recorded semi-structured interviews were conducted to obtain an in-depth understanding of compassion training from the perspectives of hospitalized advanced cancer patients (n = 53). Data were analyzed in accordance with grounded theory to determine the key elements of the underlying theory.

RESULTS

Three overarching categories and associated themes emerged from the data: compassion aptitude, cultivating compassion, and training methods. Participants spoke of compassion as an innate quality embedded in the character of learners prior to their healthcare training, which could be nurtured through experiential learning and reflective practices. Patients felt that the innate qualities that learners possessed at baseline were further fashioned by personal and practice experiences, and vocational motivators. Participants also provided recommendations for compassion training, including developing an interpersonal relationship with patients, seeing the patient as a person, and developing a human connection. Teaching methods that patients suggested in compassion training included patient-centered communication, self-reflection exercises, and compassionate role modeling.

CONCLUSIONS

This study provides insight on compassion training for both current and future healthcare providers, from the perspectives of the end recipients of healthcare provider training - patients. Developing a theoretical base for patient centred, evidence-informed, compassion training is a crucial initial step toward the further development of this core healthcare competency.

Compassion in Health Care: An Empirical Model

CONTEXT

Compassion is frequently referenced as a hallmark of quality care by patients, health care providers, health care administrators, and policy makers. Despite its putative centrality, including its institution in recent health care reform, an empirical understanding based on the perspectives of patients, the recipients of compassion, is lacking-making compassion one of the most referenced yet poorly understood elements of quality care.

OBJECTIVES

The objective of this study was to investigate palliative cancer patients' understanding and experiences of compassion to provide a critical perspective on the nature and importance of compassion.

METHODS

This grounded theory study used semi-structured interviews to investigate how patients understand and experience compassion in clinical care. Using convenience and theoretical sampling, 53 advanced cancer inpatients were recruited over a seven-month period from a specialized palliative care unit and hospital-wide palliative care service within a Canadian urban setting. Data were analyzed by four members of the research team through the three stages of Straussian grounded theory.

RESULTS

Qualitative analysis yielded seven categories, each containing distinct themes and subthemes. Together, they constitute components of the compassion model-the first empirically based clinical model of compassion. The model defines compassion as a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action.

CONCLUSION

The components of the compassion model provide insight into how patients understand and experience compassion, providing the necessary empirical foundation to develop future research, measures, training, and clinical care based on this vital feature of quality care.

Compassion: a scoping review of the healthcare literature

BACKGROUND

Recent concerns about suboptimal patient care and a lack of compassion have prompted policymakers to question the preparedness of clinicians for the challenging environment in which they practice. Compassionate care is expected by patients and is a professional obligation of clinicians; however, little is known about the state of research on clinical compassion. The purpose of this scoping review was to map the literature on compassion in clinical healthcare.

METHODS

Searches of eight electronic databases and the grey literature were conducted to identify empirical studies published over the last 25 years. Eligible studies explored perceptions or interventions of compassionate care in clinical populations, healthcare professionals, and healthcare students. Following the title and abstract review, two reviewers independently screened full-texts articles, and extracted study data. A narrative approach to synthesizing and mapping the literature was used.

RESULTS AND DISCUSSION

Of 36,637 records, 648 studies were retrieved and 44 studies were included in the review. Less than one third of studies included patients. Six themes emerged from studies that explored perceptions of compassionate care: nature of compassion, development of compassion, interpersonal factors related to compassion, action and practical compassion, barriers and enablers of compassion, and outcomes of compassion. Intervention studies included two compassionate care trials with patients and eight educational programs that aimed to improve compassionate care in clinicians and students.

CONCLUSIONS

This review identifies the limited empirical understanding of compassion in healthcare, highlighting the lack of patient and family voices in compassion research. A deeper understanding of the key behaviors and attitudes that lead to improved patient-reported outcomes through compassionate care is necessary.

How does a physician's accurate understanding of a cancer patient's unmet needs contribute to patient perception of physician empathy?

OBJECTIVE

Unmet supportive care needs of patients decrease patient perception of physician empathy (PE). We explored whether the accurate physician understanding of a given patient's unmet needs (AU), could buffer the adverse effect of these unmet needs on PE.

METHODS

In a cross-sectional design, 28 physicians and 201 metastatic cancer patients independently assessed the unmet supportive care needs of patients. AU was calculated as the sum of items for which physicians correctly rated the level of patient needs. PE and covariates were assessed using self-reported questionnaires. Multilevel analyses were carried out.

RESULTS

AU did not directly affect PE but acted as a moderator. When patients were highly expressive and when physicians perceived poor rapport with the patient, a high AU moderated the adverse effect of patient unmet needs on PE.

CONCLUSION

Physician AU has the power to protect the doctor-patient relationship in spite of high patient unmet needs, but only in certain conditions.

PRACTICE IMPLICATIONS

Physicians should be encouraged toward AU but warned that high rapport and patient low emotional expression may impede an accurate reading of patients. In this latter case, they should request a formal assessment of their patients' needs.