reflective essay on compassionate care

Johns (2017) suggested that reflective practice is integral to nursing curricula and advocated reflecting through writing rather than speaking. He defined reflective practice as a ‘mirror to see images or impressions of self in the context of a particular situation in a realistic way’ ( Johns, 2017:2 ). An example of a written reflection submitted by a second-year student nurse (Donna Doran) as part of her practice assessment is the main focus of this paper. It exemplifies a powerful way of contributing to personal learning and practice knowledge and highlights the value of reflective practice.

Student reflection

I have chosen to reflect upon this specific incident because it highlights challenging elements of both the art and science of nursing ( Jasmine, 2009 ), which will be discussed, including the humanisation of care. I will critically analyse my own nursing practice and decision-making skills, while drawing on areas of relevance, such as health education, evidence-based practice and compassionate care. The purpose of this activity was to achieve reflective learning and development of my self and professional role through exploring an experience by bringing it into focus and looking at it from various angles. Jasper et al (2013) suggested that this results in action, which positively informs professional practice by improving knowledge, skills and attitudes. In order to uphold my duty of confidentiality to the patient ( Nursing and Midwifery Council (NMC), 2015 ), a pseudonym has been used throughout this text.

Rolfe et al's (2011) reflective framework begins with discussing ‘what?’, which aims to explore the event that has taken place, and, therefore, this reflection begins with an explanation of what happened during one of my shifts working with a community team. A client named Susan regularly attended the local leg club, as she had leg ulcers, which were fully healed at the time of our interaction. Susan would regularly attend without compression stockings, which she had been advised to wear daily; she said this was because she could not put them on, as she experienced a lack of mobility and regularly used a wheelchair. As it was documented that Susan had been saying this for a number of weeks, I decided to spend some time exploring her situation further. First, I asked if Susan had anybody who could help her to put her stockings on, and she explained that her husband tried to apply the stockings each morning while she lay on her bed. Susan explained and described the method her husband used and said that this was a very painful procedure, which appeared to be placing pressure on her skin. She went on to say that this caused tension between herself and her husband on a daily basis, and because of this, they had stopped trying to use the stockings. I asked Susan if her husband had ever been shown how to apply the compression stocking, pointing out that they can be difficult to put on and that a demonstration might be helpful to them both. I asked if Susan would be happy to bring her husband to the leg club the next week so I could explain and demonstrate a better way of applying the hosiery. Susan seemed very pleased with this, and the following week, I was able to follow this up and show her husband an alternative method to apply his wife's stockings, which was safer and more comfortable. I also re-measured Susan's legs to ensure her stockings were not too tight; there did not appear to be a problem with sizing.

In order to discuss the ‘so what?’ section of Rolfe et al's (2011) framework, I will begin by exploring the role of the nurse in delivering compassionate care and the maintenance of dignity. Palos (2014) discussed how attributes such as compassion and good communication skills are seen as the art of nursing, in contrast to the science, which is usually empirically proven and evidence based. Palos (2014) suggested that, within contemporary healthcare, it can be difficult for nurses to find the time to practise developing the art of nursing, and this is why I believe it is important for student nurses to reflect on how they communicate with and care for patients. When discussing the practical application of dignity and compassion, NHS England (2014) highlighted that these are not merely ‘buzzwords’; they are values that should be embedded into daily practice to achieve excellence in care for patients and their relatives and carers.

Throughout the scenario described, my attempt to deliver care compassionately and with dignity was underpinned by a humanising values framework ( Galvin and Todres, 2013 ), which I had learned about at university. Galvin and Todres (2013) advocated that nurses should, as part of their everyday practice, place the patient and their relatives at the heart of care and try to make them feel respected and valued as human beings. I could see that both Susan and her husband needed to be more informed and thus empowered to cope with their situation. It was clear to me that the tension with her husband was more of a concern to Susan than the lack of hosiery, and she did not want to trouble him further by asking for help. By adopting a humanised approach, I felt as though I was truly helping Susan and her husband, and the intervention we planned together focused on them as a couple and not just her legs and the risk of the leg ulcers recurring. This approach was endorsed by Nicholson et al (2010) , who explained that focusing on the social dimension throughout decision-making confers to the service user a sense of importance as a person, rather than the nurse simply completing a task. My actions were further supported by Perez-Bret et al (2016) , who in their systematic literature review, recognised that compassion is a complex concept and defined it as:

‘The sensitivity shown in order to understand another person's suffering, combined with a willingness to help and promote the wellbeing of that person, in order to find a solution to their situation.’

Building on this quote, it seemed important to me to be led by compassion throughout the decision-making process so as to resolve Susan and her husband's situation. Throughout the consultation, I discussed ideas with Susan and asked for her consent to educate her husband at a subsequent leg club. By requesting consent, a practitioner offers dignity and respect for the patient's choice, making the experience patient-centred as well as adhering to national policies, such as Essence of care ( Department of Health and Social Care (DHSC), 2010b ). Upon further reflection, I believe that, while delivering care to Susan with compassion and dignity, I had to overlook the immediate issue (i.e. the lack of stockings), which had previously been investigated, and search a little deeper, to identify what was troubling Susan and assist with this. I continued to read around the subject of compassion and focused my interest on the series of Compassion in Practice reports ( DHSC, 2012 ; NHS England, 2014 ; 2016 ), which highlighted the need for nurses to ensure best practice and advocated that compassion become embedded in care. This reflection has equipped me with a stronger sense of self-awareness and enabled me to focus on how I deliver compassionate care, which I now understand in a new light and can, therefore, take forward in my future nursing practice.

So far, my reflection has focused on the ‘art’ of nursing, but ensuring the appropriate application of Susan's compression hosiery leans more towards knowledge and skill based on theory, or the ‘science’ of nursing. Thus, I decided to involve Susan's husband in a demonstration of hosiery application, which I believed would be the most effective form of education. Through the process of reflection and reading around the subject, I now know that a leading factor in lack of concordance with compression hosiery is application difficulties and discomfort ( Johnson, 2002 ; Tandler, 2016 ). Tandler (2016) mentioned poor education techniques as a cause for this, suggesting that written or verbal instructions may not be enough to educate patients on how to apply their stockings. As a result of this reflection, I now realise this is particularly true in the case of older people in community settings. I was conscious that the method I had been using to apply the stockings was not necessarily evidence-based practice; I had, in fact, been copying others. Therefore, I decided to investigate further and identified a different technique, which according to Johnson (2002) as well as more recent manufacturer guidelines, appeared easier and, most importantly, was evidence based.

Supporting practice with a strong evidence base can challenge student nurses ( Ryan, 2016 ); yet, its importance should not be underestimated if students are to learn how to deliver best practice while studying at university and on practice placements ( Hill et al, 2009 ; Emanuel et al, 2011 ). Through this reflection, I understand the risks of following custom and practice and relying on role models rather than developing my own knowledge by reading pertinent literature. At the time, I was not aware of national guidelines informing nurses on the management of patients wearing compression stockings, such as those produced by the National Institute for Health and Care Excellence (NICE) (2012) . This guidance supports a person-centred approach by advising that the health practitioner involve the patient in the choice of colour of their stockings, for example, and, more importantly in relation to Susan and her husband, provides education of how to apply them. By reading the NICE (2012) guidance as part of this reflection, I have advanced my own knowledge around compression hosiery, and this has reinforced my understanding of the importance of evidence-based practice. I learned that strengthening Susan's understanding of why she needed to wear compression stockings, discussing various application aids and listening to her all reflected person-centred care. This highlights the value of students learning through reflection and extending their knowledge of evidence-based practice, which ultimately enhances humanised care.

The final part of Rolfe et al's (2011) reflective framework is ‘now what?’, focusing on how new learning can be carried forward in future practice. The greatest impact of this reflection has undoubtedly been to highlight the importance of adopting a humanised and compassionate approach and how I can use this in my role as a nurse to help people resolve issues and improve their quality of life. Before my community placement, I felt that delivering compassionate care was something I was good at, but I was not consciously aware how I was doing this or thinking about the impact I was having on my patients. Exploring the evidence that underpins compassion has taught me that nurses need to demonstrate their understanding of a patient's situation through listening, observing and respectful questioning. I have learned that it is important to see the patient (and their family members) as people first, rather than focusing on their problems. It has become important to me to work with them to find a way to resolve their issues so that their quality of life can be enhanced. Exploring the humanising values framework ( Galvin and Todres, 2013 ) has made me think about what it means to be human as I care for my patients and, as suggested by Scammell and Tait (2014) , it has given me a support system to deliver the best care that I possibly can.

On further reflection to seek and know more about the ‘science of nursing’, I wonder if more could have been done to support this couple. Susan had complex health needs. She is an older woman who is supported by her husband to live in their own home in the community. This is not an unfamiliar picture, and the aim should be to enable this couple to remain in their own homes ( DHSC, 2010a ) and prevent hospitalisation. In 2016, the electronic frailty index (eFI) was introduced in primary care ( Clegg et al, 2016 ). Its aim is to identify patients who are frail, where they are on the frailty continuum and who would benefit from targeted interventions to improve their outcomes. Frailty is a clinical syndrome, which is a combination of the natural effects of ageing and the impact of multiple long-term conditions leading to a loss of function and reserves ( Clegg et al, 2013 ). Frailty takes 5–10 years to develop, and there is often a slow trajectory of functional deterioration ( Rogers et al, 2017 ). However, frail older people often present in crisis, and clinicians may manage the crisis but not recognise and address the underlying frailty ( Inouye et al, 2007 ). If recognised early, there are effective interventions that can prevent exacerbation and improve independence and quality of life ( Rodriguez-Manas and Rodriguez-Manas, 2014 ; Clegg et al, 2016 ; Elliott et al, 2017 ). The intervention with the most compelling evidence is comprehensive geriatric assessment (CGA) ( Beswick et al, 2008 ; British Geriatric Society, 2014 ). In considering Susan's needs, we did not assess where she was on the frailty continuum or consider if she would benefit from a CGA. Perhaps, as the use of the eFI becomes more embedded in primary care, the needs of patients like Susan will be considered from a more holistic perspective, and targeted interventions will be put in place before a crisis occurs.

Emanuel et al (2011) suggested that reflection is a strategy students can use to gain a deeper understanding of the practical implementation of evidence-based practice. Although I understood the meaning of evidence-based practice before my encounter with Susan and her husband, the process of reflecting has undoubtedly illuminated what compassionate care really means and encouraged me to find out more about trends in healthcare, such as frailty. My personal learning through reflection has been powerful and has the potential to influence my future nursing practice.

In the future, I hope to identify my own personal barriers to adopting evidence-based practice as a means to safe and skillful nursing. Majid et al (2011) suggested that a copious amount of new theory is produced at any given time, and therefore, hoping to keep abreast of everything is unrealistic. Instead, I intend to identify what is most relevant to my area of nursing and the knowledge and skills I need to sustain and develop my practice. By linking theory to practice and focusing on patient safety and humanised care, I can see how theory will enhance both my nursing practice and decision-making skills. I aim to continue to use reflection to develop my skills in balancing the art with the science of nursing, as I believe this will be an effective way to overcome the challenges encountered by many nurses.

Value of reflecting on practice

This students reflection highlights the value of completing an academic assignment that facilitates students' reflective skills in relation to their developing knowledge for practice. It is evident that the process of reflecting on a scenario from practice prompts student nurses to consider alternative ways of thinking and can result in impactful learning. Using a reflective model, such as the one designed by Rolfe et al (2011) , provides a framework of ordered sequences that empowers students to think critically about their practice and the role they play within it. The final stage of the framework stimulates questions around the student's future practice and how they can take their new learning forward. Perhaps, most importantly, this scenario demonstrates how reflection can prompt changes to a student's approach to their practice, which positively impacts on the quality of care that patients and their loved ones receive.

Had the student nurse chosen not to reflect on this incident and the role she played in delivering compassionate care, she would have missed a valuable learning opportunity. The questions she asked of herself in following Rolfe et al's (2011) framework prompted her to explore both the art and science of nursing and the need to consider wider issues such as frailty.

Working in a community setting offers opportunities for student nurses to care for people who may be old and frail and attend to what might appear on the surface to be minor issues but, in reality, make all the difference to a person's quality of life. This paper shows how reflection can be a powerful way of helping students explore their practice and the surrounding underpinning evidence, with the result that learning and care quality are enhanced.

• Reflection can be a powerful way of helping student nurses explore their practice and develop their caring skills while working in community settings
• Nurses working in secondary care are ideally placed to recognise frailty and identify the need to request and contribute to Comprehensive Geriatric Assessments
• The humanised values framework provides a powerful focus for student nurses to explore the art of nursing
• The value of listening to the patient's voice when planning care should not be underestimated

CPD REFLECTIVE QUESTIONS

• How can practice supervisors and practice assessors encourage student nurses to reflect on their practice on a daily basis?
• How can practice supervisors and practice assessors facilitate the development of caring skills in student nurses they work with?
• Reflect on the way you deliver care and adopt a person-centered approach

Olivia's Site

"nurse: just another word to describe a person strong enough to tolerate anything and soft enough to understand anyone.", empathy and compassionate care essay by: olivia gagne, december 4, 2019 ogagne.

One important thing I have learned in clinical is that I have the power to make a difference in patients lives, one patient at a time.  To do so, a nurse must remember to not only use empathy, but compassion as well.  One story that I always remember is the star fish story.  It’s about a five year old girl on a beach in Florida after a hurricane had destroyed their land.  There were thousands of star fish washed up on the shore.  The little girl was throwing starfish back into the ocean, one starfish at a time.  When her father saw her, he said “why are you even bothering?  You will never be able to save them all”.  As the little girl looked at her father, she picked one up and threw it back into the ocean.  She then said, “I saved that one”.  This is a story my high school guidance councilor told me.  It has always stuck with me and has made me realize one important lesson in nursing.  It’s not about how many lives you saved, its about making a difference one person at a time.

From the hallway of the hospital I heard my patient moaning.  When I walked in for the first time, they reached for my hand but spoke no words.  They squeezed my hand, very tight, and immediately calmed down.  As I introduced myself, they intimately looked at me and moaned “hi”.  At that moment I realized a few things.  They could hear and understand me, but they cannot talk due to the accident the patient was in.  Secondly, they needed human touch.  No student nurse had taken care of this patient prior to when I had arrived that day.  The nurses said the patient has been agitated and emotional since the morning.  But as I held the patients’ hand, they were relaxed and showed their half dropping smile.

Throughout my clinical I took care of this patient.  In the beginning, I immediately had empathy.  I put myself in the patients’ shoes and started to picture how scared I would be if I was waking up from a coma.  I pictured what it would feel like if I couldn’t talk or communicate the way I wanted to.  But during this time, I learned that communication isn’t always through speaking, but can also be from hand squeezing for yes, or shaking their head for no.  I could tell they were scared when they moaned after trying to speak to their PT instructor.  Later in the night, it was time to give the patient a bed bath.  After washing my patients’ body with a warm wet cloth, I asked the patient if they wanted lotion and a foot massage.  Immediately they squeezed my hand for yes.  When we massaged my patients’ feet, once again, their whole body relaxed.  At the end of the night, I realized that it’s important to focus on the small things for each individual patient.  Although some wouldn’t know how to comfort this patient, I slowly figured it out over my seven-hour clinical.  You need to have patience, and to focus on going above and beyond to make your patient feel cared for.  As a good nurse, you need to use compassionate care, and focus on the small actions throughout your shift.  During this shift I started to realize what compassionate care was.  It’s not about going into the patients; room, taking their vitals and leaving.  It’s about using empathy to feel what they feel and putting to action what you think would make them feel better; such as a foot massage with lotion and holding their hand when they reach out.

            As a future nurse, in order to use empathy and compassion in my future practice, it’s important to understand what they mean and how they intertwine with nursing.  Empathy is being able to feel what the patient is going through while putting yourself in their shoes.  How would you feel if this was you?  It’s important for nurses to use empathy.  By putting ourselves in the patients’ shoes, we are only then able to further understand what they are feeling, and what they are going through.  Jean Watson, a nurse herself, put together ten carative factors that help to support empathy in nursing.  She stated that it’s important to “create a healing environment for the physical and spiritual self, while respecting human dignity” (Watson, 2018).  While respecting the patient and creating an environment of healing, this encompasses empathy in nursing.  By trying to understand how they feel and what they are going through, the nurse then can move on to compassionate nursing.

Compassionate nursing is using kindness, empathy, and love to ultimately care for the patient.  It’s being able to focus on the patients’ needs and to help relieve their suffering.  Jean Watson’s carative factor one focuses on “the formation of a humanistic-altruistic system of values” (Gonzalo, 2019).  This refers to using love and kindness in your care of practice.  For example, this could be as simple as holding your patients’ hand while they are crying.  It’s holding back their hair while they throw up and giving them an ice pack when the medications haven’t relieved their pain.  Compassionate care is going above and beyond what one needs to do.  It’s not only providing physical healing, but as said in carative factor eight, it’s the “provision of support, and corrective mental, physical, societal, and spiritual” help for the patient (Gonzalo, 2019). 

A nurse who demonstrates compassionate care is able to “understand a deeper meaning of (the patients) healthcare situation”, as demonstrated throughout Jeans ten carative factors (Watson, 2018).  Both empathy and compassion are found throughout Jean Watsons Carative factors.  By using both, it truly changes the patients’ outcomes.  Carative factor four states the importance of the “development of a helping-trusting, human caring relation” (Gonzalo, 2019).  Therefore, by using empathy and compassion, the patient trusts the nurse more, and builds a stronger foundation of hope, care, and love between both the nurse and the patient.  This increases patient healing far past only physical healing, and truly benefits the clients outcomes.  Both compassionate care and empathy help to demonstrate the amazing power of a compassionate nurse in healing the patient not only physically, but mentally.

My role for the patient talked about above was wanting to help them feel loved and cared for.  By holding their hand when they reached out, and focusing on the small things the patient needs,  I was able to build a stronger patient nurse relationship.  I also met the patients’ spouse multiple times, and learned more about what they patient did before the accident.  In my future, I want to remember this patients impact on me, and my impact on the patient.  The patient made me realize that they aren’t only patients.  They are a mother, father, aunt, uncle, daughter, cousin, and friend.  They might be a couch, teacher, firefighter, singer, gymnast, or swimmer.  In my future, I want to improve in remembering that each patient has a different identity than what the nurse knows them as.  They are more than just a patient.  They are human.  They need touch just like we need touch, they need love and kindness, and ultimately they need understanding and care. 

In my future I will have more patients, more documentation, and more priorities.  But I need to remember this one special thing I have learned.  In my future, I want to remember why I joined nursing.  This includes something I learned from the starfish story.  It truly does not matter the amount of patients you helped compared to how many your co-worker helped.  It comes back to providing compassionate care for one patient at a time and being the best nurse you can be for that individual patient.  This includes helping people heal not only physically, but socially, emotionally, and mentally.  My goal is to improve on focusing on each patient for who they are and helping to provide the patient with what they need.  I will incorporate this into my everyday life as a future nurse by coming back to the core of nursing.  This includes being kind, loving, caring and compassionate.  By remembering a nurses’ core values, I will be able to focus on the little things every day to make a small difference one patient at a time.

Gonzalo, A. (2019, September 12). Jean Watson: Theory of Human Caring. Retrieved November 12,

2019, from https://nurseslabs.com/jean-watsons-philosophy-theory-transpersonal-caring/ .

Watson, J. (2018, October 7). Jean Watson Theorist Presentation. Retrieved November 12, 2019, from https://www.youtube.com/watch?time_continue=313&v=o1EN0VH9xCE&feature=emb_logo

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• Open access
• Published: 18 May 2022

Compassion in healthcare: an updated scoping review of the literature

• Sydney Malenfant 1 , 2 ,
• Priya Jaggi 1 , 3 ,
• K. Alix Hayden 4 &
• Shane Sinclair 1 , 3 , 5  

BMC Palliative Care volume  21 , Article number:  80 ( 2022 ) Cite this article

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A previous review on compassion in healthcare (1988-2014) identified several empirical studies and their limitations. Given the large influx and the disparate nature of the topic within the healthcare literature over the past 5 years, the objective of this study was to provide an update to our original scoping review to provide a current and comprehensive map of the literature to guide future research and to identify gaps and limitations that remain unaddressed.

Eight electronic databases along with the grey literature were searched to identify empirical studies published between 2015 and 2020. Of focus were studies that aimed to explore compassion within the clinical setting, or interventions or educational programs for improving compassion, sampling clinicians and/or patient populations. Following title and abstract review, two reviewers independently screened full-text articles, and performed data extraction. Utilizing a narrative synthesis approach, data were mapped onto the categories, themes, and subthemes that were identified in the original review. Newly identified categories were discussed among the team until consensus was achieved.

Of the 14,166 number of records identified, 5263 remained after removal of duplicates, and 50 articles were included in the final review. Studies were predominantly conducted in the UK and were qualitative in design. In contrast to the original review, a larger number of studies sampled solely patients ( n  = 12), and the remainder focused on clinicians ( n  = 27) or a mix of clinicians and other (e.g. patients and/or family members) ( n  = 11). Forty-six studies explored perspectives on the nature of compassion or compassionate behaviours, traversing six themes: nature of compassion, development of compassion, interpersonal factors related to compassion, action and practical compassion, barriers and enablers of compassion, and outcomes of compassion. Four studies reported on the category of educational or clinical interventions, a notable decrease compared to the 10 studies identified in the original review.

Conclusions

Since the original scoping review on compassion in healthcare, while a greater number of studies incorporated patient perspectives, clinical or educational interventions appeared to be limited. More efficacious and evidence-based interventions or training programs tailored towards improving compassion for patients in healthcare is required.

Peer Review reports

Compassion in healthcare has continued to receive growing interest over the past decade [ 1 ] from researchers, educators, clinicians, policy makers, patients, and families alike, with patients strongly emphasizing its importance to their overall quality of care [ 2 , 3 , 4 , 5 ]. Compassion has been associated with a positive impact on the patient experience and a variety of patient-reported outcomes – specifically, reduced patient symptom burden [ 6 , 7 , 8 ], improved quality of life [ 6 , 9 , 10 , 11 ], and even an enhancement in quality-of-care ratings [ 5 , 6 , 12 , 13 , 14 , 15 , 16 ]. While compassion is recognized as a standard of care and a core component of patients’ healthcare experience, it is also been found to be lacking in terms of its provision [ 3 , 5 , 6 , 12 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ] and in much need for improvement [ 24 , 25 , 26 , 27 , 28 ]. A lack of compassion has been associated to increased patient/family complaints, healthcare costs, and adverse medical events [ 19 , 24 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. Both the Canadian and American Medical Associations list compassion as one of their core virtues exemplified by the ethical physician [ 37 , 38 ], with the Canadian Medical Association (CMA) stating that “a compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances of each patient, attempts to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient” (p.2) [ 37 ]. Furthermore, researchers agree that while compassion is vital across healthcare settings, it is a central goal and tenant of quality palliative care where multifactorial suffering is prevalent, requiring future research, including how it can be sustained in palliative care providers [ 39 , 40 , 41 , 42 ]. However, it was only recently that compassion was delineated from a related construct, empathy (i.e. the ability to resonate with another’s positive or negative feelings) [ 43 , 44 ], highlighting action as one of its additional, yet paramount components [ 6 , 44 , 45 ]. The necessity of action within conceptualizations of compassion was independently affirmed by both palliative care patients' and palliative care providers' definitions of compassion, with patients defining compassion as “ a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action ” [ 6 ], and healthcare providers (HCPs) defining compassion as: “a virtuous and intentional response to know a person, discern their needs and ameliorate their suffering through relational understanding and action” [ 45 ]. With the emergence of empirical models and definitions of compassion [ 6 , 45 ], and a valid and reliable patient-reported compassion measure for research and clinical use [ 15 ], studies have now shifted towards determining whether compassion can be trained or cultivated in practicing clinicians, while nurturing and sustaining the innate qualities related to compassion that these individuals already possess [ 8 , 46 , 47 , 48 , 49 ]. Recent studies suggest that while compassion is largely inherent, it can be influenced by life experiences and can fluctuate over time [ 50 , 51 ]. Educational leaders within healthcare settings have also emphasized the need to incorporate compassion training into their curriculum [ 52 ]. A systematic review found that implementing various curriculum strategies could result in practicing clinicians enhancing their overall levels of compassion and empathy, as perceived by the physician participants themselves, patients, standardized patients, or third-party observers, using a variety of measurement tools [ 52 ]. While recent reviews have identified the current landscape of compassion training programs [ 53 , 54 ], (i.e. those with the goal of cultivating compassion in others), studies identified in these reviews still present significant limitations such as: an absence of training to develop HCP skills within the interpersonal domains of compassion; lack of multi-modal training programs for practicing HCPs; reliance on self-reported assessments of learning outcomes as opposed to patient-reported outcomes; and a lack of Randomized Controlled Trials (RCTs) and longitudinal studies determining the retention and integration of skills into clinical practice [ 54 ]. As such, developing compassion training that is empirically based, clinically relevant and addresses these limitations is required and necessary in evidence-based, patient-centred healthcare delivery [ 54 ].

Despite remarkable efforts towards enhancing compassion in healthcare and a burgeoning knowledge base on the topic, the academic literature on compassion in healthcare remains deficient, specifically in regard to how compassion is perceived by patients themselves – the ultimate beneficiaries [ 1 , 55 ]. This lack of patient perspectives was a key limitation identified in a previous scoping review by Sinclair et al. (2016), a study which undertook a synthesis of the existing literature within a 25-year period (1988-2014) in order to determine what is known about compassion in healthcare. This original scoping review demonstrated an array of study types, settings, participant types (i.e. clinicians and patients), operational definitions and cultivation techniques, while also affirming the interpersonal nature of compassion, its predication on action, and associated barriers and facilitators in both education and practice [ 1 ]. Interestingly, patients themselves were widely underrepresented throughout the identified studies, with only 30% of them including patients, largely in a limited fashion, and the remainder focusing on clinicians, and/or students, and/or caregivers. Studies also failed to include patient-derived definitions of compassion, and studies that exclusively sampled patients and/or outcomes related to patients’ health and quality of life were also lacking [ 1 ]. Further, of the compassion interventions that were identified in this original review, only two were randomized controlled trials evaluating clinical interventions, and eight were educational interventions, of which only two of the interventions used validated tools to measure compassion – one of which used a tool measuring empathy [ 1 ]. The absence of a comprehensive knowledge base and an ambiguous understanding of how compassion is conceptualized by patients and HCPs in various healthcare contexts, makes operationalizing and improving its delivery to patients an extremely daunting and challenging task.

Despite considerable advancement in the field of compassion in healthcare over the past 30 years, including the identification of associated research gaps and recommendations to guide research [ 1 ], there has been a rapid influx of disparate studies over the past 5 years (Fig.  1 ) that require a further mapping of the literature to determine if previously identified limitations have been addressed and if any new domains of compassion research have emerged. Therefore, in keeping with the iterative nature of scoping reviews [ 56 , 57 ], the objective of this scoping review was to provide an update to our original review [ 1 ] to include contributions to the healthcare literature over the past 5 years. The review question was: What is currently known about compassion in healthcare? In addition to an overview of how the field of compassion in healthcare has evolved, readers of this review will gain evidence-based knowledge in four specific areas: 1) the nature of compassion and how it is conceptualized in the healthcare literature; 2) the feasibility and reputed impact of clinical and educational compassion interventions; 3) challenges and enablers to integrating compassion in contemporary healthcare; and 4) whether compassion can be meaningfully and rigorously measured.

Number of documents from 2000 to 2021 (Scopus search: Compassion in healthcare)

Search strategy

Through consultation with a research librarian (KAH), a search for existing knowledge synthesis reviews on compassion in healthcare was performed using MEDLINE, Google Scholar, and Prospero. Apart from the original scoping review [ 1 ] and a more recent review targeting compassion in the pediatric population [ 58 ], no other completed knowledge synthesis reviews were identified on this topic.

The current scoping review is an update of the original scoping review published in 2016 [ 1 ]. A study protocol was written a priori to guide this current review, which is reported in accordance with the PRISMA-ScR reporting guidelines [ 59 ]. The included studies from the original review ( n  = 44) were first analyzed for keywords and subject headings by KAH. The search in the original review was intentionally broad and included terms such as “delivery of healthcare, healthcare, palliative, palliative care, end-of-life, terminal, end-of-life care, terminal care, terminally ill patient, euthanasia, cancer, neoplasm, carcinoma, tumor, religion, spirituality” (p.2) [ 1 ]. These terms, however, did not show up consistently in the 44 included studies of the original review and as such, were not included into the refined updated search strategy. This initial analysis determined that two concepts were constant across the 44 studies: compassion and HCPs, becoming the focus of the refined search for the current review. For each concept, both keywords and subject headings were utilized, where keywords were the same for all databases, and subject headings were defined by each database’s controlled vocabulary. The draft search strategies were tested to ensure all the original included studies were captured. Once the search strategy was finalized, it was limited to English and date limits of January 1, 2015 – November 2020. The original review included studies published up to December 31, 2014. The final searches were run between November 16 and November 27, 2020, and results uploaded into Covidence, with each upload automatically deduplicated.

Congruent with our original review, the following databases were searched: MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily 1946 to November 16, 2020 (OVID), Embase 1974 to 2020 November 25 (OVID), EBM Reviews - Cochrane Central Register of Controlled Trials October 2020 (OVID), APA PsycInfo 1806 to November Week 32,020 (OVID), CINAHL Plus with Full Text (Ebsco), Academic Search Complete (Ebsco), and Scopus (Elsevier). Additional file  1 provides the search strategies for each database.

Eligibility criteria

Studies that sampled inpatients or outpatients, and/or qualified clinicians (e.g. physicians, nurses, healthcare aides) were included in the final analysis. Studies were excluded if they sampled healthy non-clinical populations exclusively, as our focus was on clinicians or patients—individuals within society who have had significant experiences of suffering. While the original study [ 1 ] and search strategy herein did not exclude students, in keeping with the iterative nature of scoping reviews [ 56 ], the search criteria was refined at the title and abstract screening phase to exclude studies that sampled students exclusively (i.e. nursing students, residents, medical students, etc.), for the sake of feasibility and in recognition that barriers and facilitators to compassion in healthcare primarily occur in ongoing clinical practice [ 60 , 61 ]. We were interested in studies that had a primary aim to explore compassion towards others within the clinical setting or those that focused on interventions or educational programs aimed at improving compassion in clinical care. As such, studies that focused on other related concepts such as compassion fatigue, compassion satisfaction, empathy, or intervention studies aimed at fostering self-compassion (i.e. mindfulness-based stress reduction or compassion-focused therapies) were excluded. Congruent with the original scoping review [ 1 ], we retained a broad interest on categories of studies exploring compassion in healthcare such as perspectives, clinical outcomes, knowledge, skills, or attitudes on the topic [ 1 ]. Only primary and secondary studies using qualitative, quantitative, or mixed method designs were included. As such, systematic reviews, books, chapters, letters, commentaries, editorials, dissertations/theses, conference abstracts, and case studies were excluded [ 1 ].

Study selection

At the title and abstract screening (level 1), a calibration exercise of a random sample of articles ( n  = 50) was conducted by two independent reviewers (SM and SS), to test the screening tool to ensure a standardized application of the selection criteria. At level 1, a minimum threshold of 80% agreement (number of agreements/number of agreements + disagreements) [ 62 , 63 ] was utilized to guide screening of the remaining titles and abstracts. Congruence in the calibration exercise of the 50 articles was 90%, after which one reviewer (SM) proceeded with screening the remaining titles and abstracts [ 64 ]. Following the title and abstract screening, two independent reviewers (SM and PJ) conducted a full-text review (level 2) of a random sample of included studies ( n  = 10) to determine whether they would either be included or excluded for data extraction. Congruence in Level 2 screening was initially 70%, with all disagreements being resolved through clarification of the selection criteria and discussion between reviewers until consensus was reached, refining the inclusion/exclusion criteria in an iterative manner, prior to conducting an independent review of the remaining articles that would then proceed to the data extraction phase [ 65 ].

Data items and extraction process

Two reviewers (SM and PJ) independently reviewed each study meeting the criteria for a full-text review to identify eligible studies for data extraction. As an additional measure of rigour and quality assurance, the data extraction form was initially tested between the reviewers for 10 articles, with modification incorporated thereafter [ 65 ]. The review team (SM and PJ) met bi-weekly to review the extracted data from each study, resolve any identified discrepancies, and ensure completion and accuracy of the extracted data. A standardized data extraction sheet in excel was used to extract the following variables: study title, author, year published, journal, country of origin, study background and purpose, study setting, design, sample, participant information, data collection methods, analysis methods, results, conclusions, and limitations (both author and reviewer-identified). The manner in which the topic of compassion was conceptualized was also documented for each study.

Data synthesis

A narrative synthesis of the data was performed given the heterogeneity of studies, in accordance with the original review [ 1 ]. Each study was initially grouped by study participants (i.e. HCPs/students or HCPs/patients or patients/students or HCPs/patients/students) and study type (compassion interventions or perspectives of compassion and compassionate behavior). Frequencies for each of these groupings were tabulated. For the narrative synthesis [ 66 ], any quantitative data were initially translated to qualitative descriptions. The previously identified categories, themes, and subthemes (Table  1 ) [ 1 ] that emerged from the data in the original scoping review were utilized as a template, allowing us to map the current results onto these pre-existing categories, themes, and subthemes. Any new potential categories, themes, and/or subthemes that emerged were documented and discussed through a consensus process (SM, PJ, SS). Data were analyzed by three members of the research team (SM, PJ and SS), by reviewing the extracted data, resolving any inconsistencies or answering any queries that arose. A decision-making trail was compiled for the placement of the data into their respective categories, themes, and subthemes.

Search flow and study characteristics

Our search strategy resulted in a total of 14,166 records identified from the eight databases (Fig.  2 ). Removal of duplicates resulted in 5263 records remaining. After title and abstract screening, 133 potentially relevant reports underwent a full text review, after which 84 studies were excluded. A total of 49 articles underwent data extraction and synthesis of results (Table  2 ) (Fig. 2 ). One article [ 67 ] contained two separate eligible studies and has been reported herein as two separate studies [ 67 , 68 ]. Thus, for sake of clarity, this narrative synthesis consists of 50 studies. Overall, we found that the studies fell within two overarching categories: perspectives or behaviours of compassion, and compassion interventions (Table 1 ) [ 1 ]. Studies that fell within each of these categories were organized as per their themes and subthemes, according to those that were identified in the original scoping review (Table  3 ). No new themes or subthemes were identified from the updated search.

PRISMA 2020 flow diagram for updated systematic reviews which included searches of databases and registers only

Studies were predominantly qualitative in nature, with some quantitative and mixed-methods study designs. Two studies were randomized controlled trials (quantitative design). Most of the studies were conducted in the United Kingdom (Table 2 ), followed by Canada and the United States. Two studies collected data from 15 different countries (Table 2 ), with two other secondary studies utilizing this larger dataset to report exclusively on the results from Greece and Cyprus, and the USA exclusively. Twelve studies sampled patients, and the remainder focused on HCP participants or a mix of HCP, students, patients, and/or family caregivers (Tables  2 and 3 ).

Category: perspectives on compassion and compassionate behaviours in healthcare

Forty-six studies explored perspectives on the nature of compassion or compassionate behaviours (Table 3 ). Similar to the previous scoping review [ 1 ], perspectives on compassion were presented from either patients or HCPs, or a combination of participants (i.e. HCPs and/or patients along with students, family caregivers or even the public) (Table 3 ). The majority of these studies presenting perspectives on compassion were qualitative in design ( n  = 35), followed by mixed methods ( n  = 5) and cross-sectional survey studies ( n =  5). Two were quantitative randomized clinical trials. Twenty-three studies on perspectives of compassion sampled HCP participants exclusively (Table 3 ).

Theme: the nature of compassion in healthcare

Twenty-seven studies reported participants’ perspectives on the nature of compassion, which included the conceptualization of compassion and/or its temporal aspects (Table 3 ).

Subtheme: conceptualizing compassion in healthcare

Compassion was conceptualized through patient perspectives ( n  = 12 studies), in which participants were asked about what compassion meant to them in reflecting on their personal experiences with their HCPs [ 6 , 45 , 98 , 101 , 102 , 103 , 106 , 107 , 109 , 110 , 111 , 112 ]. Several features that patients recognized as signifying compassion included: kindness, authenticity, attentiveness, forming a relational connection, displaying presence and warmth, acceptance, understanding, listening, helping, communicating effectively, being involved, and being gentle and caring [ 6 , 44 , 98 , 101 , 102 , 103 , 106 , 107 , 109 , 110 , 111 , 112 ]. Sinclair et al. (2016; 2018) conceptualized and validated an empirical model of compassion from both the patient and HCP perspective, further defining compassion as “a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action” [ 6 , 45 ]. Menage et al. (2020) also conceptualized compassion in midwifery care through a model, highlighting its key components as “being with me”, “relationship with me”, and “empowering me” [ 109 ]. International, online survey studies conducted with a total of 1323 nurses, nurse educators, and nurse managers representing 15 different countries (Table 3 ) used a pre-imposed dictionary definition of compassion “a deep awareness of the suffering of others and a wish to alleviate it” [ 77 , 82 , 87 , 88 ]. Interestingly, while this survey defined compassion a priori [ 77 , 82 , 87 , 88 ], some participants provided their own definitions, with some participants from Spain identifying this definition as problematic, noting that the term compassion itself was problematic in being associated with religious beliefs, and as such, diminishing the evidence-based approach of nursing care within the Spanish context [ 77 ]. One study aimed to investigate compassion in a specific cultural context focusing particularly on South Asian patients [ 111 ]. While South Asians perceived compassion in a similar vein to other patient groups (i.e. compassion being composed of HCP embedded qualities, relational connection, and an action-orientated nature) [ 6 , 110 ] and as a universal concept that extends across humanity regardless of cultural differences, they also highlighted the importance of compassionate HCPs possessing cultural sensitivity, and accepting cultural beliefs and practices in a non-judgemental manner [ 111 ]. In another study, patient participants felt that compassion was demonstrated through HCPs’ ability to demonstrate intuition, provide evidence-based care, and be proficient in managing time in their clinical practice [ 99 ]. Similarly, Dalvandi et al. (2019) reported that patients perceived compassion to be associated with a capable HCP [ 107 ]. In fact, the authors reported that HCPs’ caring attributes or ability to meaningfully connect with his/her patients was seen as less desirable compared to their overall clinical competence [ 107 ].

Eighteen studies highlighted HCP conceptualizations of compassion and compassionate behaviours [ 45 , 77 , 79 , 81 , 82 , 83 , 84 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 95 , 98 , 101 , 102 ]. Similar to patients, HCPs recognized compassion as involving an inner desire to want to relieve one’s suffering [ 45 , 79 , 87 ] and as a response based on sensitivity to patients’ preferences [ 90 ]. Sinclair et al. (2018) generated a HCP model of compassion, in which HCPs defined compassion as a “virtuous and intentional response to know a person, to discern their needs and ameliorate their suffering through relational understanding and action” (p. 5) [ 45 ]. Additionally, in a study by Tierney et al. (2017), HCPs defined compassion in the workplace as “professional compassion,” which encompassed traits such as being a good communicator, being cognizant of patients’ needs, and through providing small acts of kindness [ 84 ]. This study also described the concept of professional compassion as involving some degree of “tough love” or through providing “scare tactics” (i.e. emphasizing to patients their medical conditions that may result in their mortality), which was driven from practitioners’ desire to help prevent future medical complications in patients – an approach to care that was further emphasized in relation to compassion sometimes requiring a more conscious effort as opposed to it occurring spontaneously [ 84 ]. In studies involving physicians from palliative care and medical oncology contexts [ 81 , 89 ], while compassion was thought to consist of both intangible and tangible skills (i.e. being present, holding a patient’s hand, and supportive touch) to address patients’ emotional needs [ 81 ], having standardized end-of-life conversations with patients and their family caregivers was integral to ensuring that their needs were adequately addressed and to educating them about their disease trajectory [ 81 , 89 ].

Subtheme: temporal aspects of compassion in healthcare

Patient and HCP participants alike perceived time as one of the components related to the nature of compassion, describing compassion as being fluid and dynamic in nature, something that can be developed over time, while also being influenced by the availability of time (i.e. taking time to listen to patients) [ 6 , 81 , 83 , 87 , 94 , 95 , 110 ]. Although compassion has been reported as developing over time, it has also been recognized as something that can be attained by HCPs in instances where there is a limited amount of time, through thoughtfully connecting with patients in the moment, acknowledging the difficulties that they’re facing, using humor, physical gestures conveying comfort, and relating to patients’ social concerns [ 81 , 94 ]. Compassion was recognized as adaptable to the situation and clinical setting [ 83 , 90 ] and something that patients may better appreciate and become more aware of overtime during their care journey [ 90 ]. Interestingly, nurse participants in the rehabilitation setting thought that providing compassion should not be obligatory given its situational nature and should instead be delivered with discretion or tempered [ 90 ]. As such, the provision of compassion depended on the individual nurse’s own personal values balanced with their duty of care [ 90 ]. Compassion was also perceived as requiring HCPs to “slow down” [ 83 , 89 ], particularly in the palliative care context where creating a space for dying was characterized by ‘slowness’ [ 89 ].

Theme: the development of compassion in healthcare

Thirty studies explored the development of compassion, which included both its innate nature and external factors that could equip clinicians with the necessary skills to further enact compassion in their clinical care.

Subtheme: antecedents of compassion

Patients and HCPs both recognized the intrinsic qualities or virtues of individual HCPs to be integral to providing compassion, some of which included virtues of love, kindness, genuineness, consideration, understanding, and wisdom [ 6 , 44 , 45 , 50 , 68 , 73 , 77 , 79 , 80 , 82 , 84 , 85 , 88 , 90 , 94 , 95 , 98 , 101 , 102 , 106 , 109 , 110 , 111 , 112 ] (Table 3 ). While various participants in a study by Kneafsey et al. (2015) described compassion as an innate emotion and a part of one’s personality at birth [ 94 , 95 ], other studies recognized that past experiences also shape one’s ability to be compassionate [ 76 , 80 , 85 ]. For example, nurses described their own psychological empowerment to contribute to their ability to provide more compassion, as driven by their length of experience working within the field of healthcare [ 85 ]. Patients and clinicians also perceived compassion to be motivated by their own personal experiences of suffering, having had to provide care to ill family members, or to be developed through family upbringing, role modelling, self-reflection and life experiences [ 6 , 76 , 80 , 110 ]. Religion, spirituality or culture, and an appreciation for a recognition of the shared humanity between oneself, patients, family, and colleagues were also perceived as external factors that could facilitate or motivate one to provide compassion [ 80 , 90 , 110 , 111 ]. Furthermore, various HCP participants in a study by Taylor et al. (2020) indicated that their own cultural values must denote they are person-centred, caring, and open, and hold intent to be compassionate [ 98 ]. Additionally, a HCP’s attitude was found to be a forerunner of compassion, influencing their behaviour and practices towards their patients [ 98 , 102 ]. In a few studies, HCP participants felt that compassion should be a prerequisite to pursuing a career in healthcare [ 79 , 80 , 84 , 94 ]. In one study, HCP participants felt that a personal interest in compassion must be vested in, dismissing the notion of any external motivations or conditions compelling one to being compassionate (i.e. from the healthcare organization itself) [ 80 ]. In other studies, participants described compassion as a predisposition or a driver through which they chose to pursue a career in healthcare and a core value that draws many physicians and nurses into healthcare professions [ 84 , 94 ].

Subtheme: cultivating compassion

Several studies reported that compassion can be taught and that HCPs can be equipped with tangible knowledge and skills for improving compassion in their professional practice [ 50 , 82 , 88 , 94 , 95 , 101 , 106 ]. Both HCP and patient participants emphasized clinical role-modeling, by compassionate HCPs, as being a salient means for improving compassion [ 50 , 72 , 80 , 83 , 100 , 106 ]. While role models in the form of teachers or peers were seen as imperative for motivating physicians and nurses (especially newly graduated clinicians) to be compassionate [ 80 , 94 ], it was also suggested that uncompassionate behaviours (i.e. answering to patients indifferently, ambivalence, and disregard) were equally transferrable to HCP colleagues [ 100 ]. A supportive environment that is conducive to learning was another factor that patients thought to be advantageous in compassion training [ 50 ]. Patients receiving palliative care believed that HCPs might increase their capacity for compassion by adopting a more reflective practice – through contemplating their own beliefs and reflecting on what their patients may be experiencing [ 50 ] – an experiential approach that was further supported by patient and HCP participants in a study by Smith-MacDonald et al. (2019) [ 101 ].

Reynolds et al. (2019) explored the effectiveness of “compassion-inducing” images to combat clinical scenarios that were thought to challenge medical students’ and health professionals’ (physicians, nurses, other) ability to be compassionate in dealing with patients presenting with “disgusting symptoms” and/or those who were thought to be responsible for their own health problems [ 93 ]. The authors reported that while patients presenting with “disgusting symptoms” (i.e. more challenging, more likely to wear a mask) influenced medical students more than the qualified HCPs, the use of compassion-inducing images mitigated group differences [ 93 ]. Similarly, Ling et al. (2020) tested the impact of “common humanity scenarios” on one’s ability to provide compassion and found that study participants (nursing, medicine, social work, occupational therapists, pastoral care practitioners, etc.), reported enhanced levels of compassion after being exposed to scenarios reflecting common humanity, further identifying common humanity as a prerequisite for providing compassion [ 75 ].

Theme: interpersonal factors associated with compassion in the clinical setting

Both relational and clinical communication were the predominant interpersonal dimensions associated with compassion, identified in studies involving both HCP and patient participants.

Subtheme: relational factors

The ability of HCPs to interact with patients, to deeply connect and share in their experience through an outward expression of their innate virtues, along with creating a relational space to do so, was seen as paramount to the provision of compassion in healthcare. This space was commonly described by patients as extending beyond a clinical relationship to one in which HCPs would actively engage in the patients’ suffering through awareness and engaged caregiving [ 6 , 44 , 45 , 73 , 91 , 101 , 110 , 111 ]. This entailed not only being physically present with the patient and addressing their medical needs, but seeking to understand their unique needs (e.g. emotional) and appreciate the patient as a person [ 6 , 44 , 45 , 73 , 79 , 89 , 99 , 101 , 110 , 111 ]. An inability to understand the emotional state of the patient or leaving patients feeling worried or vulnerable was felt to be associated with uncompassionate HCPs [ 91 , 94 , 99 , 102 ]. Skills such as being able to express affection, kindness, tenderness, being able to actively listen [ 77 , 78 , 88 , 89 , 94 ], showing understanding, and being supportive were perceived to be more effective expressions of compassion than routine, task-oriented care [ 99 ]. The ability to relationally understand patients was further highlighted as a distinct feature from sympathy, in which a shallow and superficial emotional response from HCPs can leave patients feeling demoralized, depressed, and feeling pity for themselves [ 44 ]. Getting to know the patient and going through a process of knowing through recurrent interactions and building rapport was important to both patients and HCPs alike [ 84 , 87 , 98 , 112 ]. Study participants indicated that encounters which lack connection renders HCPs as ingenuine and as having a lack of compassionate intent [ 98 ]. HCPs highlighted relational challenges such as receptivity, proximity, fragmentation, and lack of shared understanding between and within the healthcare team(s) and patients as potential hinderance to compassion [ 72 ]. On the contrary, being able to build rapport and connect with or relate to patients and their family was perceived as essential [ 76 ]. As such, relational aspects of compassion were found to be multidirectional, expressed between two or more people including patients, families, and HCPs [ 83 ]. Inside the workplace, supportive inter- and intra-disciplinary relationships helped to enhance the unity of the care team and thus aid in the development of more concise care plans which led to more consistency in patient care [ 76 , 102 ]. A few studies noted some subtle differences in the expressed relational needs of females versus males, which may impact compassion. For example, female participants emphasized their emotional needs requiring more attention in comparison to men [ 107 ] and thus, reflecting the need for female nurse HCPs to be able to better relate to them and subsequently personalize their care more effectively [ 108 , 109 ].

Subtheme: clinical communication

Both patient and HCP participants identified clinical communication to be a prominent component of compassion in healthcare. An integral domain of the Patient Compassion Model [ 6 , 110 ] was relational communication, referring to the verbal and non-verbal displays of compassion within the clinical context that seeks to establish a deeper understanding of a person as an individual – an aspect of compassion that was also identified in other studies [ 6 , 45 , 101 , 110 ]. Facets of relational communication included HCPs demeanor, affect (emotional resonance), engagement and behaviour [ 6 , 45 , 101 , 110 ]. It was also stated in one study that through relational communication, actively listening, involved listening to the subtext of what is not said (i.e., being attuned to the non-verbal cues, using silence, and paying attention to tone of voice), can help uncover patients’ concealed suffering [ 45 ]. Taylor et al. (2020) further differentiate that indicative communication is different from traditional communication, such that body language must be accompanied with tone of voice to demonstrate a compassionate intent [ 98 ].

Other studies have also highlighted notable components of verbal and non-verbal communication in which HCPs can convey compassion to their patients, such as tone of voice, personalization, attentiveness, actively listening, body language (i.e. smiling, eye contact) and even touch [ 79 , 87 , 88 , 89 , 91 , 94 , 95 , 99 , 109 ]. While communicating relevant information in a timely manner was seen as paramount to providing compassion for patients undergoing withdrawal of life-sustaining treatment [ 86 ], it was also found that HCPs’ display of emotion could help further humanize the interaction with patients, as long as it was exhibited in ways that were not too burdensome to the patient’s family [ 86 ]. Patients’ perception of compassion may also depend largely on the content that is being delivered [ 72 , 104 , 105 ]. For example, using the Physician Compassion Questionnaire to rate clinicians on five dimensions of warm-cold; pleasant-unpleasant; compassionate-distant; sensitive-insensitive; and caring-uncaring [ 104 ], advanced cancer patients in a randomized clinical trial considered physicians who provided a more optimistic prognosis to be significantly more compassionate compared to physicians who delivered less optimistic prognostic information [ 104 , 105 ]. Similarly in another study, HCP participants felt that despite a HCP’s intention, more emotionally challenging conversations involving goals of care or prognostication may be perceived by patients as being less compassionate [ 72 ]. Various studies suggest that communicating information through plain and simple language for patients to understand, delivered in a sensitive manner, was crucial in demonstrating compassion [ 6 , 95 , 103 , 110 ]. Also, women participants who received midwifery care during their pregnancy perceived midwives as more compassionate when they “communicate as an equal” – i.e. without any implied professional superiority [ 109 ].

In two cross sectional survey studies, in addition to other modes of non-verbal communication such as listening and connecting with patients, nurse participants particularly highlighted “touching” (i.e. holding a patient’s hand, giving a back rub, placing a hand on the patient, healing touch, or human touch) to be paramount to relieving one’s suffering and offering a sense of healing and comfort [ 87 , 88 ]. Along with having HCPs identify with patients by trying to understand their situation, patients and HCPs in various studies emphasized supportive touch to be an important aspect of HCPs connecting with the patients [ 45 , 50 , 83 , 101 , 103 ].

Theme: action and practical compassion in healthcare

Patients and HCPs stipulated action-based components of compassion as quintessential, particularly those directed at proactively alleviating patient suffering and addressing their needs through tangible means [ 6 , 44 , 45 , 50 , 73 , 81 , 95 , 101 , 110 , 111 ], whilst considering sensitivity to the patients’ condition [ 6 , 45 , 103 ]. Participants referred to the importance of “small acts of kindness” across a few studies [ 6 , 44 , 45 , 72 , 83 , 84 , 103 , 110 ], such as providing comfort [ 86 , 87 , 103 ] and performing actions that were supererogatory in nature or going above and beyond without expectation of receiving anything in return, as key features of actions associated with compassion [ 6 , 77 , 81 , 87 , 110 ]. For nurses in palliative care, action was evident in being proactive in planning the palliative pathway with the patients and families before the patient had reached their terminal phase [ 89 ]. In some cases, the technical and physical aspects of compassion compared to other humanistic approaches were more desirable to patients, particularly those in hospital surgery wards, where the alleviation of pain is more critical to their overall health quality [ 107 ], or when looking for compassion in the task-based features of having to undergo diagnostic tests, such as radiography [ 112 ]. In contrast, clinicians in a study conducted by Roze des Ordons et al. (2020) felt that an overly biomedical approach could contribute to the over medicalization of an illness which in turn can lead to more patient suffering and even missed opportunities for integrating patients’ goals and values into their care plans, which is paramount in improving quality of life [ 72 ]. Similarly, nurses in one study felt that to be compassionate, there is a strong need for competency in relieving pain through both pharmacological and non-pharmacological means [ 87 ], including but not limited to, providing emotional comfort. Finally, in addition to utilizing a proactive action-based approach to care, patients receiving midwifery care felt that a midwife’s ability to teach and coach mothers by providing them with necessary information about their condition was considered an act of practical compassion [ 109 ].

Theme: challenges and enablers of compassion in healthcare

More than half of the studies ( n  = 30; 60%) identified various educational and/or practice-setting challenges and enablers to compassion (Table 3 ), with 11 studies specifically identifying the exploration of barriers and facilitators to compassion in hospital, critical care, palliative care, intensive care, mental health, acute care, long-term care, and medical-surgical contexts as a primary study aim [ 67 , 68 , 72 , 73 , 74 , 76 , 84 , 92 , 100 , 101 , 102 ].

Subtheme: educational challenges and enablers

Four studies identified educational challenges and barriers to providing compassion [ 50 , 74 , 83 , 107 ]. HCP participants identified feeling particularly challenged in providing compassion within clinical practice, when there was a perceived incongruence between their theoretical knowledge of compassion and their ability to apply it [ 72 , 74 ]—a phenomena conceptualized as compassion distress [ 44 ]. Similarly, while clinicians acknowledged that they could learn compassion vicariously through their colleague role models (i.e. enablers to compassion), not having those role models routinely available impeded HCPs’ ability to grow in their capacity for compassion [ 72 ]. Patients, on the contrary, felt that a supportive teaching environment was necessary to allow HCPs to safely reflect on their innate qualities, such as their virtuous, past life experiences, and vocational motivators to further nourish their abilities to provide compassion [ 50 ]. Patients in this study also felt that experiential methods of learning compassion would likely be more beneficial to HCPs over traditional didactic approaches [ 50 ]. Interestingly, in contrast to HCP education in providing compassion, a survey conducted with 300 hospitalized patients that aimed to determine the importance and extent of providing compassion in nursing care revealed that patients level of education influenced how compassion was experienced – i.e. patients with an academic-level of education were more aware of system issues, had better communication skills and a higher expectation to participate in the treatment process, and as such perceived HCPs as being less compassionate than those who had lower than a diploma level of education [ 107 ].

Subtheme: practice setting challenges and enablers

Numerous studies ( n  = 29) identified specific challenges and enablers impacting the provision of compassion within the healthcare setting, with challenges being identified disproportionally in comparison to enablers. The most commonly identified challenges were time constraints [ 72 , 73 , 74 , 77 , 79 , 81 , 84 , 88 , 91 , 92 , 95 , 96 , 101 , 106 , 112 ], organizational culture (i.e. excessive workload and inadequate staffing) [ 72 , 73 , 77 , 79 , 84 , 88 , 90 , 92 , 94 , 96 , 100 , 106 , 109 , 112 ], lack of resources [ 79 , 100 ], and the clinical environment/culture itself [ 72 , 74 , 79 , 89 , 90 , 92 , 94 , 95 , 98 , 100 , 101 , 106 , 112 ]. Some studies commented on how advancing technology in the clinical setting can serve as a barrier to HCPs’ ability to provide compassion [ 72 , 106 ]. For example, HCPs in critical and palliative care settings perceived technology as distracting them from attending to their patients’ emotional needs, requiring them instead to focus more on physical aspects of care [ 72 ]. HCP and patient participants in other studies felt that the need for HCPs to juggle daily administrative or organizational requirements contributed to a myopic focus of care that centred on tasks or checking off “ticky boxes” rather than on providing high-quality, compassion [ 77 , 109 ]. One study identified organizational threats (i.e. daily organizational demands and workplace stresses) as inhibitors to compassion [ 67 ], where increased perceived organizational threats led to a decreased ability for HCPs to provide compassion to patients [ 67 ]. Sims et al. (2020) further examined “intentional rounding”, a structured process that involves nurses performing periodic checks of their patients’ fundamental care needs using a standardised protocol and documentation, and its contribution to the delivery of compassionate nursing care. Ironically, this care strategy was actually perceived by participants to be more of a barrier to providing compassion, as nurses were left to prioritize their documentation over direct patient care [ 96 ].

Another practice setting barrier to providing compassion was the lack of managerial engagement or support [ 74 , 101 ], which can contribute to fragmented teams, lack of unity [ 76 , 101 ], resulting in less compassion to patients in settings were collaboration between nurses was lacking [ 89 ]. Additionally, nurses in hospital settings felt muted in their ability to provide compassion when their managers failed to support them in its delivery [ 74 ]. HCPs also felt that after the death of a patient, their grief and mourning affected their ability to provide compassion to their patients, highlighting the need for managerial support and compassion towards themselves from their colleagues or managers as they worked through their own mourning [ 98 ]. In the acute care context, care was thought to be susceptible to fragmentation given the various division of HCP roles, multiple team members, shiftwork, and sequential transitions, all leading to varying intensity and duration of patient interactions [ 72 ]. On the other hand, support networks amongst HCPs were also seen as enablers to compassion within various practice settings [ 68 , 76 , 78 , 79 , 91 , 98 ]. For example, the need for HCPs to engage in a team dynamic to support the delivery of compassion to patients was highlighted by Murray et al. (2020), specifically with respect to maintaining good communication, encouraging and listening to one another, being present, and open-minded [ 78 ]. Findings from Brennan et al. (2019) concur with this notion of the importance of HCPs fostering strong connections with their colleagues to enhance the delivery of compassion within their organizational settings [ 79 ].

In general, literature on clinical challenges and enablers from the patient perspective appeared to be lacking. Ironically, the majority of studies focused on HCPs perspectives on patient factors (personality, behaviours, communication issues, etc.) effecting HCPs ability to provide compassion in clinical care, with little discussion of HCP factors (personality, behaviours, communication issues, etc.). Studies that did include patients’ perspectives, identified language barriers as a significant challenge to experiencing compassion from their HCPs [ 72 , 100 , 102 , 111 ], reportedly undermining HCPs’ motivation or aptitude for providing compassion in the process [ 100 , 111 ]. However, a study by Singh et al. (2020), acknowledged that language barriers could be overcome by having interpreters readily available and by being cognizant of patients, particularly female patients, preferences related to the sex and gender of their HCPs [ 111 ]. Interestingly, in a qualitative study of nurses, family members and patients, sex was also a predictor of compassion, with women being perceived as being more innately compassionate than men [ 100 ].

Theme: outcomes of compassionate care

Three studies identified the impact of compassion on patient health outcomes exclusively from the patient perspective [ 6 , 44 , 111 ], and one from the perspectives of both family physicians and inpatient/outpatient residents [ 94 ]. Patients felt that compassion alleviated their suffering, enhanced overall well-being, and positively augmented the quality of care they received from their HCPs by allaying distress and enhancing their relationship with their HCPs [ 6 , 44 , 111 ]. On the contrary, those patients who recoined healthcare interactions lacking in compassion reported negative outcomes such as frustration, being overwhelmed, and a lack of dignity and hope [ 6 ]. In a separate study, patients felt that compassionate physicians achieve a better understanding of their patients’ issues and concerns, facilitating more open communication, which in turn helps to strengthen the level of trust in the patient-physician relationship [ 94 ]. Compassion was also felt to have assisted physicians in constructing more supportive and caring treatment plans for their patients, which ultimately facilitated patient compliance [ 94 ]. Lastly, a compassionate approach was perceived to help enable physicians to better cope with more challenging patient scenarios, such as those patients presenting with more psychosocial or emotional distress [ 94 ].

Category: compassion interventions

Four studies focused on compassion interventions for HCPs (i.e. clinicians, policy makers, and managers) and patients (Table  4 ). These interventions studies traversed the themes of clinical and educational interventions (Table 3 ).

Theme: clinical interventions

Gould et al. (2017) conducted a quantitative (baseline and 4 months post) intervention with clinicians (ward managers, healthcare assistants, staff nurses and charge nurses) and patients [ 97 ]. This study sought to evaluate the “Creating Learning Environments for Compassionate Care (CLECC)” program that aimed to enhance clinicians’ capacity for providing compassion by embedding ward-based manager and team practices including dialogue, reflective learning, and mutual support [ 97 ]. As indicated by patient-reported evaluations of emotional care using the Patient Evaluation of Emotional Care during Hospitalisation (PEECH) tool, higher scores post-intervention indicated better patient-reported experiences. However, staff self-reported empathy, using the Jefferson Empathy Scale, did not show any significant difference in scores between baseline and follow-up. Overall, the CLECC program was favorable towards reducing negative staff-patient interactions and was anecdotally felt to offer potential benefit in reducing patients’ experiences of lack of emotional connection with the healthcare team [ 97 ].

Theme: educational interventions

Three studies were thematized as educational interventions, each of which were components of the Leaders for Compassionate Care Programme (LCCP) [ 69 , 70 , 71 ], which aims to empower leaders while supporting their teams in delivering high-quality and compassionate patient-centred care [ 69 , 70 ]. These studies varied in design – one being a quantitative cross-sectional survey [ 69 ], and two being qualitative and mixed-methods longitudinal designs [ 70 , 71 ]. Two studies explored the impact of the LCCP on participants’ personal development, learning experience, service and care delivery, and overall satisfaction with the program; one of these studies identified factors that can embed compassionate care in healthcare environments [ 69 , 70 ]. In one study, there were reported improvements in participants’ perceived ability to show respect and empathy in their interactions with patients [ 69 ]. The study authors also reported that the program was felt to increase motivation and confidence in leading the delivery of compassionate care [ 69 ]. A conceptual model was offered by MacArthur et al. (2017), centering on ‘compassionate care’ where the needs of patients, relatives and staff are viewed as being distinct, and on the other hand, inter-related, in which sustainability requires a focus on relationship-centred care mediated through relational practice and relational inquiry, and a need for investment in infrastructure and leadership at both the strategic and local levels [ 70 ].

The LCCP also influenced ways of working and specific practice development techniques – particularly, staff receiving regular feedback from patients on how their delivery of compassion influenced their communication with their patients [ 70 ]. Smith et al. (2017) evaluated how the LCCP impacted participants’ ability to listen, learn, and respond to patient feedback – a practice that reportedly improved compassion [ 71 ], with staff finding value in the experiences of sharing and learning from feedback.

State of the science: the ongoing monotony, persistent gaps, and incremental progress of compassion research in healthcare

This scoping review provides an updated synthesis of the current literature on the topic of compassion in healthcare over the past 5 years (2015-2020), in keeping with the methodology of the original scoping review that was conducted by members of the Compassion Research Lab [ 1 ]. Since the publication of the original scoping review, studies presenting exclusively on patient conceptualizations of compassion have increased (nine studies in total compared to only two that were identified previously), addressing a previously identified limitation—the underrepresentation of the recipients of compassion – patients themselves. This updated review also revealed that HCP and patient perspectives on compassion and compassionate behaviours traversed the themes and subthemes that were previously identified (Table 1 ), including but not limited to temporal aspects of compassion (i.e. situational in nature, with an ebb and a flow), interpersonal features (i.e. relational care and clinical communication), action, and practicality. While HCPs and patients also identified numerous barriers and enablers to compassion, adaptive behaviours to overcome challenges to compassion were reported in numerous studies coinciding with a general aversion by participants – the notion of absolute barriers to dynamic nature and robustness of compassion. This suggests that in relation to compassion, barriers need to be reconceptualized as challenges—challenges that can be overcome.

The nature and conflation of compassion: the need for conceptual specificity

In regards to the nature of compassion, while a lack of conceptual specificity persists, additional research focused on the construct of compassion in healthcare over the last 5 years, including the establishment of empirical models of compassion, has produced a growing consensus that compassion is inherently relational, consisting of acknowledging, engaging and proactively attending to another person’s suffering that stems from the innate qualities and good intentions of a fellow human being [ 6 , 45 , 79 , 82 , 87 , 88 , 101 ]. The centrality and willingness to proactively address multifactorial suffering, is not only the central aim of palliative care [ 40 , 41 , 42 ], but is a defining feature of a compassionate relationship in comparison to other forms of relationships, including empathetic and caring relationships [ 44 ]. HCP participants in multiple studies were clear that compassion was other-orientated, was predicated in suffering, and required action aimed at alleviating it [ 6 , 82 , 87 ]. While conceptual clarity and consensus has grown since our original study, additional research over this period also identified some slight cultural variances in relation to compassion, specifically in how it is both expressed and experienced. For example, while there were similarities in how Greek and Cyprus participants perceived compassion, differences also persisted in their definitions, with more than half of the Cyprus participants defining compassion as “empathy and kindness”, whereas Greek participants were more likely to define it as “a deep awareness of the suffering of others and a wish to alleviate it” [ 88 ]. However, caution should be exercised in attributing these results strictly to ‘cultural difference’, as is evident in further interpretation of these study results that one plausible reason for these differences is the fact that the Greek participants were practicing registered nurses, whereas those from Cyprus were nursing students who had less clinical experience and exposure to patient suffering. Further, although patients have clearly delineated compassion from empathy and sympathy [ 44 ], a couple of included studies utilized definitions of compassion that embedded the term or aspects of empathy [ 77 , 103 ]. Despite established differences between these terms, one study argued that compassion and empathy are in fact interdependent [ 98 ], while participants in another study, concluded that empathy was subsumed within compassion, with compassion enhancing components of empathy while adding action [ 95 ]. Despite this lack of conceptual clarity, the attributes or skills comprising compassion were recognized across most of the studies, including the dynamic, responsive, and proactive nature of compassionate action, in comparison to a more static, reactionary, and passive nature of empathy, sympathy, and routine care [ 44 , 50 , 86 , 92 , 99 , 107 ].

Clinical and educational compassion interventions: can compassion be taught?

The notion of whether one can be trained to become compassionate remains the topic of ongoing debate within the literature, although this debate has dissipated since the previous review. Antecedents, in the form of inherent virtues or personal qualities, and previous personal experiences of suffering and receiving compassion have been previously identified as facilitators of compassion [ 1 , 6 , 45 , 101 , 110 , 111 ]. Studies within this current review have extended what previously was a largely dichotomous (nature vs. nurture) approach to this issue to a more intersectional understanding, comprised of various factors [ 80 , 94 ]. This complex relationship between intrapersonal factors embedded within individual HCPs and interpersonal factors embedded in the relational and clinical space, was advanced by Uygur in their Compassion Trichotomy [ 94 ], which highlights the importance and interdependence of motivation (personal reflection and values), capacity (awareness and regulation of energy, emotion, and cognition), and connection (sustained patient–physician relationship) which influences physicians’ level of compassion [ 94 ]. Other studies also highlighted intrinsic altruistic motivators (e.g. personal attitudes, virtues) as catalysts, but not preconditions to providing or enhancing compassion [ 45 , 76 , 80 , 98 , 106 ]. While there is ongoing debate on whether virtues themselves can be cultivated, we have reported elsewhere that virtues can be cultivated, however the outcomes of this training will vary based on the innate virtues that trainees possess at baseline [ 50 ].

Clinical and educational compassion interventions: how do we teach compassion?

An equally compelling question related to compassion training, arising from studies in this updated review, is how and what are the best methods for cultivating compassion amongst practicing clinicians. While studies suggested that compassion could be cultivated [ 82 , 88 , 95 ] and broad educational approaches such as personal development practices were proposed [ 95 ], the intricacies of how and what would be required in a training program remained largely unexplored. While participants in other studies, provided suggestions for teaching methods associated with compassion training [ 50 , 94 , 101 , 106 ], including the use of compassion-inducing imagery, sharing heartfelt stories or narratives [ 75 , 93 ], being exposed to compassionate role models and leadership [ 50 , 106 ], and through using an experiential approach to learning involving mentorship and self-reflection [ 50 , 79 , 101 ], these recommendations lacked augmentation with educational studies investigating these issues specifically. While one study aimed to investigate the impact of common humanity scenarios on cultivating compassion [ 75 ], results from this study were largely predicated on the relational features of compassion and failed to include its action component [ 75 ]. Although this study and others focus exclusively on enhancing elements of affective compassion in HCPs [ 75 , 93 ], viewing common humanity scenarios and interventions focused on perspective-taking of HCPs towards patients, fails to address the multiple domains that comprise compassion and the potential benefit of interventions aimed at enhancing patient perspective-taking towards HCPs [ 6 , 45 , 61 ]. Regardless of these shortcomings, the need to develop, enhance, and sustain a culture of compassion in complex healthcare systems is well-recognized [ 24 , 25 , 26 , 27 , 28 , 113 , 114 ]. A recent realist review [ 54 ] and environmental scan [ 52 ] on compassion education literature revealed the intricacies of compassion education programs, describing what works for whom and in what context, which could ultimately inform the development of a comprehensive, evidence-based, clinically-informed compassion training program for HCPs. An imperative, and neglected, factor to cultivating and sustaining compassion in healthcare identified in this recent realist review, was the role of healthcare system and organizational leaders in creating the conditions, educational resources, and policies to ensure that compassion is not only embedded across the healthcare system, but is considered a shared responsibility, and not simply the onus of HCPs [ 54 ]. A recent systematic review of predictors of physician compassion revealed similar findings, namely that research on the barriers and facilitators to compassion in healthcare remains disproportionately practitioner-centric, requiring greater research on the both the patient perspective and the influence of broader organizational and system factors [ 61 ].

Clinical and educational compassion interventions: can we measure compassion?

Surprisingly in this updated review, only four of the studies pertained to evaluating compassion educational or clinical interventions – a notable decrease from the 10 interventions identified in the previous review [ 1 ]. While one intervention study’s primary aim was to evaluate the Creating Learning Environments for Compassionate Care (CLECC), an educational programme focused on developing managerial and team practices at a group level to enhance team capacity to provide compassionate care for patients (Table 4 ), researchers utilized the Jefferson Scale of Empathy (JSE) to obtain a nurse-reported measure of empathy at baseline and follow-up [ 97 ], rather than using a valid and reliable measure of compassion—the construct of interest. It is interesting to note that the rational for using the JSE in this intervention study was attributed to the fact that the authors were unable to identify a sufficiently psychometrically robust, valid, and reliable measure for compassion, affirming the findings of a previous systematic review of existing compassion measures [ 55 ]. The lack of a sufficiently robust compassion measure in this and other intervention studies has been a significant impediment in the advancement of the field and the validity of these compassion interventions, further conflating the concepts of compassion and empathy in the process. The inherent limitations of previous compassion measures were recently addressed in the development of the Sinclair Compassion Questionnaire (SCQ) [ 15 , 55 ] – a psychometrically rigorous and robust patient-reported compassion measure. The other three intervention studies identified were educational interventions conducted in the UK, aimed towards HCPs, which analyzed the Leaders for Compassionate Care Program (LCCP) within the hospital settings, none of which included patient outcomes [ 69 , 70 , 71 ]. Additionally, while the results of these studies focused heavily on participants’ overall satisfaction with the LCCP programme itself, whether it actually improved compassion to patients and families was precariously not assessed.

Challenges and enablers to compassion

With respect to the literature on challenges and enablers of compassion within practice settings, time constraints, workloads, and staff shortages, remained a prevalent issue in this updated review, as was the case in our original review [ 72 , 73 , 74 , 77 , 79 , 81 , 84 , 92 , 94 , 95 , 100 , 101 , 106 , 112 ]. Despite this persistent challenge, both HCP and patient participants felt that forging a compassionate connection between patients and HCPs could be established in the moment, through ones’ demeanor, the tenor of care, intention, and presence within even the shortest of interactions [ 6 , 45 , 73 ].

Limitations

There are a few limitations to this updated review . First , despite applying a robust methodology to identify eligible studies, it is possible that relevant studies could have been inadvertently missed. Secondly, since only English publications were included, we recognize that numerous non-English studies on compassion were excluded, thus limiting generalizability to other non-English speaking settings. Thirdly, in utilizing the previously identified thematic framework generated from the original review in synthesizing the studies within this current review, there is a possibility that this hindered the emergence of additional themes. This decision was purposeful on the part of the review authors in order to remain methodologically congruent with our original review, a decision that we nonetheless were cognisant of in allowing new categories to emerge from the results through a consensus process, thereby avoiding the force fitting of current studies into a predetermined framework. Fourth, while the evidence that self-compassion improves compassion is lacking [ 115 ], in excluding intervention studies that focused on improving self-compassion as a means to create more compassionate HCPs, there is a remote possibility that pertinent results were missed. Lastly, despite their inclusion in the original study, studies focusing solely on medical students, trainees, or residents were excluded (except when combined with HCP participants), for the sake of feasibility and because our primary focus was practicing HCPs– who are frequently exposed to patient suffering in a healthcare system were compassion is challenged.

Implications

An empirically-based, clinically-relevant, patient orientated definition of compassion, that reflects the dynamic nature and multiple domains of the construct of interest is imperative to the fidelity and advancement of educational and clinical interventions designed to improve it. In our original review, there was a notable paucity of studies that conceptualized compassion from not only the perspectives of those who receive it, but also those who strive to provide it—where compassion and suffering reside [ 1 ]. Since our original review, targeted efforts to establish the conceptual foundation of compassion were undertaken in various studies identified herein, including but not limited to the development of models of compassion from the perspectives of both patients and clinicians alike. These models of compassion further provide an empirical blueprint depicting the nature, components, flow, facilitators, and inhibitors of compassion for use in research, education, and practice. While these recent studies addressed a conceptual gap identified in the original review, a growing theory-practice gap has emerged in its place over the last 5 years between researchers and HCPs’ knowledge of compassion and their ability to adequately assess it in research and address in clinical practice. While the recent development of a psychometrically rigorous and robust patient-reported compassion measure has partially addressed this issue, there is now a critical need to further address this theory-practice gap through the development of evidence-based educational training programs that equip practicing HCP with the attitudes, knowledge, skills, and behaviours that comprehensively traverse each of the domains of compassion. Similarly, there is a pressing need for RCTs, including future 3-arm RCTs that compare the compassion intervention group to not only standard care, but other related educational interventions such as empathy training. Furthermore, since cultural and gender differences pertaining to how compassion is both expressed and experienced were alluded to within the studies reviewed herein, these individuals and differences must evolve from the realm of platitudes and good intentions to the realm of research priorities and action. While compassion was affirmed as a universal concept in this review, compassion also seeks to understand the uniqueness of the person and their individual needs—whether those individuals are patients or practicing HCPs. Future studies on the topic of compassion need to investigate and honour these differences, whether in the form of validating existing definitions, measures, and interventions of compassion within various cultures, genders, or individuals who experience systemic inequities in care and in society more broadly. Lastly, while assessing the transferability of recently developed valid and reliable patient compassion measures is needed, the existence and further development of valid and reliable research tools offers the ability to begin to meaningfully assess these differences, and provides the means to assess and deliver personalized compassion.

Since the publication of original scoping review 6 years ago, research on the topic of compassion in healthcare while seeing considerable advances, remains largely theoretical in nature, with limited educational and clinical intervention studies. Despite these limitations, compassion has received increasing attention from researchers, policy makers, educators, HCPs, and particularly patients who consistently identify compassion as a central feature of their overall experience of healthcare. With a firm conceptual foundation of compassion now established with the perspectives of patients embedded therein, greater attention needs to focus on addressing the growing theory-practice gap between what is empirically known and implemented into training and practice. Additional research is needed on developing compassion training programs that honour and are tailored to individuals—including but not limited to their gender identity and cultural background.

Availability of data and materials

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Healthcare Providers

Randomized Controlled Trials

Creating Learning Environments for Compassionate Care

Leaders for Compassionate Care Program

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SM conceptualized the study, developed the search strategy, screened the articles, performed data extraction and analysis, and provided interpretation of the data, and contributed to the writing of the manuscript. PJ coordinated the entire study, conceptualized the study, developed the search strategy, screened the articles, performed data extraction and analysis, and provided interpretation of the data, and contributed to the writing of the manuscript. KAH provided methodological expertise, developed the search strategy, and contributed to the writing of the manuscript. SS oversaw the entire study, conceptualized the study, developed the search strategy, screened titles and abstracts, provided guidance on data extraction, performed data analysis and provided interpretation of the data, and contributed to the writing of the manuscript. All authors have read and approved the manuscript.

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Malenfant, S., Jaggi, P., Hayden, K.A. et al. Compassion in healthcare: an updated scoping review of the literature. BMC Palliat Care 21 , 80 (2022). https://doi.org/10.1186/s12904-022-00942-3

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Compassion: A Powerful Tool for Improving Patient Outcomes

The release of Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference , authored by physician-scientists Stephen Trzeciak and Anthony Mazzarelli, has ignited a conversation on the relationship between physician compassion and patient outcomes.

Stanford Medicine’s Emma Seppala discussed the topic with Trzeciak and Mazzarelli in a recent Q&A in the Washington Post . In the interview, the authors share findings on the link between bedside manner and healing. Among the many positive outcomes achieved by demonstrations of physician kindness, they name medication adherence, better achievement of adequate sedation before surgery and a decrease in need for opiate medication post-surgery.

And the proof is in the numbers. PubMed research cited by the Compassionomics authors reinforces their philosophy. When a healthcare provider shows compassion, studies show the following benefits:

·      The likelihood that a diabetic patient has optimal blood-sugar control is 80 percent higher and odds are 41 percent lower the patient will experience serious complications related to the disease.

·      Patients are less likely to utilize excessive health care services and, on average, have lower medical bills by about 50 percent.

·      Patients recover more quickly from the symptom that brought them to the doctor and have fewer visits, tests and referrals. Furthermore, “the proportion of these patients who are referred to specialists is 59 percent lower and diagnostic testing is 84 percent lower.”

Research involving MRI scans further confirms that when a patient experiences “compassion — the action component of trying to alleviate another’s suffering,” a “reward” pathway in the brain is activated. The connection is quite apparent, but as Trzeciak and Mazzarelli emphasize, it’s underestimated throughout the medical community.

So how can physicians actively demonstrate compassion? Mazzarelli names four behaviors that can be practiced at the patient bedside: sitting (versus standing) while speaking; face to face communication with eye contact; taking an active interest in emotional and psychological well-being, and not interrupting. We agree that these exercises, in combination with physical exam skills, are practices vital to improving patient outcomes.

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Sympathy, empathy, and compassion: A grounded theory study of palliative care patients’ understandings, experiences, and preferences

Shane sinclair.

1 Faculty of Nursing, University of Calgary, Calgary, AB, Canada

2 Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Kate Beamer

Thomas f hack.

3 Manitoba Palliative Care Research Unit, CancerCare Manitoba, Winnipeg, MB, Canada

4 College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada

Susan McClement

Shelley raffin bouchal, harvey m chochinov.

5 Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada

Neil A. Hagen

6 Departments of Clinical Neurosciences and Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Background:

Compassion is considered an essential element in quality patient care. One of the conceptual challenges in healthcare literature is that compassion is often confused with sympathy and empathy. Studies comparing and contrasting patients’ perspectives of sympathy, empathy, and compassion are largely absent.

The aim of this study was to investigate advanced cancer patients’ understandings, experiences, and preferences of “sympathy,” “empathy,” and “compassion” in order to develop conceptual clarity for future research and to inform clinical practice.

Data were collected via semi-structured interviews and then independently analyzed by the research team using the three stages and principles of Straussian grounded theory.

Setting/participants:

Data were collected from 53 advanced cancer inpatients in a large urban hospital.

Constructs of sympathy, empathy, and compassion contain distinct themes and sub-themes. Sympathy was described as an unwanted, pity-based response to a distressing situation, characterized by a lack of understanding and self-preservation of the observer. Empathy was experienced as an affective response that acknowledges and attempts to understand individual’s suffering through emotional resonance. Compassion enhanced the key facets of empathy while adding distinct features of being motivated by love, the altruistic role of the responder, action, and small, supererogatory acts of kindness. Patients reported that unlike sympathy, empathy and compassion were beneficial, with compassion being the most preferred and impactful.

Conclusion:

Although sympathy, empathy, and compassion are used interchangeably and frequently conflated in healthcare literature, patients distinguish and experience them uniquely. Understanding patients’ perspectives is important and can guide practice, policy reform, and future research.

What is already known about the topic?

• Compassionate care is increasingly considered by patients, family members, and policymakers as a core dimension of quality care, particularly in palliative care.
• Sympathy, empathy, and compassion are often used interchangeably within the healthcare literature despite some key notable differences.

What this paper adds?

• While there have been studies investigating the constructs of sympathy, empathy, and compassion independently, to date no known studies have analyzed the three constructs using direct patient accounts.
• The study identifies the key elements of each construct from the perspective of patients, including unique definitions.
• While sympathy was considered largely unhelpful, empathy and compassion were received positively by patients, with most patients preferring compassion’s orientation toward action- and virtue-based motivators.

Implications for practice, theory, or policy

• Understanding patients’ perspectives on the similarities, differences, and preferences between sympathy, empathy, and compassion can guide patient-oriented research and optimize evidence-based, patient-centered care.
• This study provides conceptual clarity for healthcare policy and system reform related to enhancing compassionate healthcare systems from the perspective of the individuals these systems serve.

Healthcare today is paying a great deal of attention to patient-reported outcomes and person-centered care delivery. 1 , 2 Clinicians, policymakers, patients, and their families are calling for healthcare providers to move beyond the delivery of services and to more explicitly consider the preferences, needs, and values of the persons receiving these services. 3 – 6 Within this discussion, the constructs “empathy,” “sympathy,” and “compassion” are important principles within these models of care. But what exactly do these three constructs mean within the context of healthcare delivery? How should healthcare providers and researchers define, differentiate, and integrate them into practice? And, more importantly, how do patients understand and experience these constructs within the delivery of their healthcare? The aim of this study was to investigate advanced cancer patients’ perspectives, understandings, experiences, and preferences of “sympathy,” “empathy,” and “compassion” in order to develop conceptual clarity for future research and to inform clinical practice. Understanding the similarities and differences between these constructs can provide conceptual clarity in a field of research that often utilizes these terms interchangeably, thereby guiding healthcare policy and practice efforts to provide evidence-based, patient-centered care.

Sympathy, empathy, and compassion are closely related terms. They are often used interchangeably within healthcare policy, delivery, and research in describing some of the human qualities that patients desire in their healthcare providers. 7 – 10 But what specifically do these terms mean, how are they related to one another, and what are patients’ perceptions and preferences toward each of them? A scoping review of the literature 11 revealed that, while considerable scholarly activity has been conducted to distinguish between these constructs, 12 – 16 there is a lack of empirical research informing this topic. While addressing this gap is important throughout all of healthcare, it is perhaps most important within palliative care, where relief of suffering and providing compassion in patients with advanced illness are explicit goals of care. 17 , 18

Sympathy has been defined in the healthcare literature as an emotional reaction of pity toward the misfortune of another, especially those who are perceived as suffering unfairly. 16 , 19 In contrast, empathy has been defined as an ability to understand and accurately acknowledge the feelings of another, leading to an attuned response from the observer. 16 , 20 , 21 In general, researchers identify two types of empathy: cognitive empathy (detached acknowledgment and understanding of a distressing situation based on a sense of duty) and affective empathy, which while containing each of the elements of cognitive empathy, extends to an acknowledgment and understanding of a person’s situation by “feeling with” the person. 16 , 22 Neurological studies have reported that witnessing a person in suffering activates neural pain pathways in the brain of the empathizer. 22 Studies investigating empathy from the perspective of healthcare providers have identified a troubling trend—the erosion of empathy over the course of healthcare education and clinical practice. 23 – 25

Etymologically, “compassion” means to “suffer with” 26 and has been defined as “a deep awareness of the suffering of another coupled with the wish to relieve it.” 27 Our previously published grounded theory study of patient perspectives of compassion, defined compassion as “a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action.” 28 Compassion seems to differ from sympathy and empathy in its proactive approach, the selfless role of the responder, and its virtuous motivators aimed at ameliorating suffering. Gilbert and Choden 29 discuss the relationship between these three constructs from a Buddhist perspective, conceptualizing sympathy as an emotional reaction, without conscious thought and reflection. Empathy is understood as a more complex interpersonal construct that involves awareness and intuition, while compassion is defined as “a way to develop the kindness, support, and encouragement to promote the courage we need—to take the actions we need—in order to promote the flourishing and well-being of ourselves and others” (p. 98). According to Way and Tracy, 30 compassion is marked by the following three elements: recognizing suffering, relating to people in their suffering, and reacting to suffering. While there have been studies conducted on the nature of compassion from the perspective of healthcare providers, we could locate only two studies that included a patient cohort. 31 , 32

What is certain in the healthcare literature and policy is that patients’ desire increased compassion within healthcare. 33 – 38 Furthermore, research has indicated that compassion and empathetic care are ways of improving patient-reported outcomes and patient satisfaction. 16 While there have been individual studies on sympathy, empathy, and compassion in a clinical setting, to date no studies have analyzed the three constructs using direct patient reports. To address that gap in the literature, we conducted a secondary analysis of data subset from a larger grounded theory study on the construct of compassion, 28 which focused on palliative cancer patients’ understandings, experiences, and preferences of the constructs of sympathy, empathy, and compassion.

Study population

Prior to developing the larger study protocol, the research team conducted a review of the literature which revealed a significant research gap related to the relationship between sympathy, empathy, and compassion. As a result of this review, the research team decided, at a protocol development meeting, to add additional questions to the interview guide in order to collect data and conduct a secondary analysis on this related field of inquiry ( Box 1 ). The research protocol was approved by the University of Calgary Conjoint Health Research Ethics Board (E-24268). All participants provided signed informed consent to participate in the qualitative interviews, after receiving information on the study and after all participant questions were answered. Participants were eligible for the study if they were at least 18 years of age, able to read and speak English, had a terminal cancer diagnosis and a life expectancy of less than 6 months, did not demonstrate evidence of cognitive impairment, and were able to provide written informed consent. Patients were excluded from the study if they were cognitively impaired or too ill to participate in the study as determined by their palliative care team. Patients meeting the inclusion criteria were first informed of the study by a member of the palliative care team and if interested, were then contacted by a member of the research team.

Guiding interview questions.

Source: Sinclair et al. 28

Participant recruitment occurred from May through December, 2013. Members of the palliative care team initially approached patients on an individual basis to gauge interest; a total of 151 patients were referred to the study nurse. Of those expressing initial interest, 25 were too ill to participate and were ineligible to participate. Among the 126 participants, 48 were not interested in participating, 5 were discharged, and 18 died prior to the scheduled interview. Two participants were not included in the results, as one was transferred to hospice before the interview could be completed, and the other was excluded due to audio recorder difficulties. A final sample of 53 patients was needed to obtain data saturation.

Data collection

Data were collected through semi-structured, individual interviews ( Box 1 ) and a demographic questionnaire ( Table 1 ). In order to mitigate interview bias and the Hawthorne effect, all interviews were conducted by an experienced research nurse and held in a private space within the hospital. The research nurse was employed by the Clinical Trials Research Unit of the host hospital and was neither a member of patients’ clinical care team nor participated in the data analysis. Interviews, averaging 1 h in length, were audio recorded and transcribed verbatim.

Demographic information (numbers expressed as percentages, unless otherwise stated).

Data analysis

Interview data related to patients’ understandings of the constructs and relationship between sympathy, empathy, and compassion were analyzed in accordance with the three stages and principles of Straussian grounded theory (open, axial, and selective coding), using the constant comparative method, 39 , 40 alongside data within a larger study aimed at conceptualizing, codifying, and constructing a patient-informed empirical model of compassion ( Figure 1 ), described in detail elsewhere. 28 Our original rationale for conducting a secondary analysis on the relationship between these three constructs was further validated in the analysis process, as our large qualitative sample ( n  = 53) generated considerable substantive data warranting a separate report which was beyond the scope of the compassion model. 28 The three stages of Straussian grounded theory analysis generated codes, themes, and categories related to the constructs of interest which were further analyzed by members of the research team (S.S., T.H., S.M., S.R., and K.B.). The purpose of this secondary analysis was to gain conceptual clarity, codify the key elements of each construct, determine their relationship to one another, and identify the gaps leading which are outlined ( Table 3 ) and illustrated ( Figure 2 ). The reported results of this study were in accordance with and met each of the consolidated criteria for reporting qualitative studies (consolidated criteria for reporting qualitative research (COREQ)).

The compassion model.

Reprinted from Sinclair et al. 28

Sympathy, empathy, and compassion.

The relationship between sympathy, empathy, and compassion.

After the data had been coded and analyzed, the three constructs of sympathy, empathy and compassion generated several themes ( Table 2 ). While patients distinguished and preferred compassion to empathy, they also identified overlapping features. In contrast, patients identified sympathy as a largely distinct and unhelpful construct based on pity and a lack of understanding ( Table 3 ).

Major categories and themes.

Most participants described sympathy as an unwanted and misguided pity-based response that was easily given and seemed to focus more on alleviating the observer’s distress toward patient suffering, rather than the distress of the patient. After comparing and contrasting individual patient responses, the following definition of sympathy emerged: a pity-based response to a distressing situation that is characterized by a lack of relational understanding and the self-preservation of the observer .

An unwanted pity-based response

Participants repeatedly described sympathy as a pity-based response that was unwelcomed and in some incidences despised by patients. Patients acknowledged that expressions of sympathy could be well-intended on the part of acquaintances and healthcare providers. Ultimately, however, they were experienced as being misguided and, ironically, had a largely detrimental effect on patient well-being. Specifically, patients felt that sympathy left them feeling demoralized, depressed, and feeling sorry for themselves:

I do not want sympathy in any way, shape or form … I don’t have any room to rent out to that space and I’ve said it many, many times to those who come and visit me and those who want to come and visit me. Don’t come and look like this is going to be the last time you’re going to see me because it’s not. To feel sorry for me … that is wasted energy. (Patient 5) I prefer, you know, compassion is okay, but sympathy, I’m not really fond of because it might put me into a feeling sorry for myself mode. … too much sympathy, you don’t want that because that doesn’t boost you so I think compassion is, and empathy and compassion are the important things, but I find it’s got me down if anybody is too sympathetic, you know, it makes you cry, (Patient 4)

A shallow and superficial emotion based on self-preservation

In comparing sympathy, empathy, and compassion, participants agreed that sympathy was the easiest of the three responses for observers to give away. Participants felt this was due largely to sympathy being a shallow and superficial emotion that was typically exhibited by individuals who wished to remain distant from the patient’s situation. While sympathy often involved thoughtful words or gestures, it was described by patients as disingenuous, depersonalized, and emotionally distant and detached from the person in suffering. Many participants expressed that the detached nature of sympathy was a visceral reaction that was primarily concerned about the self-preservation of the observer, rather than an attempt to understand the person in need or a desire to alleviate suffering:

Sympathy is very easy, it’s an emotion, probably one of the easiest emotions to fake. I hate sympathy! (Patient 40) If you’re thinking of looking for sympathy, you’ll find it between shit and syphilis in the dictionary. (Patient 34) I hate sympathy, it feels shallow, it feels like, “Oh I’m so sorry you’re going through this,” and it doesn’t feel genuine to me. (Patient 7)

An unhelpful and misguided reaction to suffering

Patients’ dislike of sympathy was not merely due to its pity-based motivators and associated superficial responses but its lack of utility in relieving patient suffering. Although participants felt that sympathy was rooted in emotional distancing, it was not necessarily a passive state as it could equally invoke a demonstrative reaction on the part of the responder, leaving patients feeling overwhelmed by sympathetic phone calls, a flood of get-well cards, and other emotionally laden, energetic expressions of concern by others. Unlike empathy, and especially compassion, sympathy was short-lived and dissipated shortly after its initial expression. Participants experienced sympathy as not understanding their own individualized needs, but rather as a reaction intended to serve the needs of the observer. Therefore, it ultimately was not meaningful and was ineffective in meeting patient needs:

Sympathy is, it’s like flattery, it sounds pretty but it goes nowhere and it does nothing. (Patient 51) Sympathy, I think is you’re feeling sorry for that person. I don’t want somebody to feel sorry for me, I want you to help me. (Patient 48) When I was first diagnosed. I got all kinds of sympathy cards, you know well wishes from people, and you know people phoning that you haven’t heard from for years and things like that. That’s sympathy … because you know they phone you know, wish you well and I haven’t heard from them since. (Patient 13)

Patients had a much more positive response to empathy than to sympathy. They described empathy as a more emotionally engaged process, whereby individuals attempted to attune to the emotions of the patient through acknowledgment of suffering. Patients experienced this as a warm, gentle attempt to understand their emotional state. Whereas patients described sympathy as a self-motivated, emotional reaction to someone else’s suffering based on a lack of understanding of the person’s needs, empathy was an affective response that acknowledges and attempts to understand an individual’s suffering through emotional resonance .

Engaging suffering

An essential and distinguishing feature of empathy was the proximity of the responder in relation to the suffering of the patient. Unlike sympathy, which involved individuals emotionally distancing themselves from suffering by avoidance or by an overly demonstrative and misguided reaction, empathy required the individual to approach the patient’s suffering, in a vulnerable manner:

Empathy enters into another’s suffering … it’s just the ability to be there. (Patient 8)

Connecting to and understanding the person

Patients identified empathetic individuals as not only engaging suffering but also personally connecting to patients, in ways that sympathetic individuals were incapable or unwilling to do. What was deficient in sympathy but intrinsic to empathy was the notion of understanding. According to patients, a personal connection allowed the empathizer to develop a deeper understanding of the person and their individualized suffering, thereby allowing the empathizer to address patient issues in a more effective and personalized manner:

That’s because empathy is, for me, empathy is that personal connection … whereas sympathy doesn’t have to be personalized, it can be, it can just be, you know it’s just all those comments, my thoughts are with you, blah, blah, blah, all that kind of stuff, but empathy is where you’re actually connecting with the person. (Patient 46) … I think empathy is the ability to be able to communicate on a visual, physical whatever level with the other individual and sort of make a connection with them … but there’s also sort of a deeper understanding of the situation and this sort of thing. (Patient 49)

Emotional resonance: putting yourself in the patient’s shoes

The metaphor of individuals “putting themselves in the patient’s shoes” was frequently used by patients in describing empathy. This metaphor speaks to healthcare providers’ ability to emotionally relate to what their patient is feeling—to engage suffering by way of understanding and being able to relate on an affective level:

… empathy is, yeah, like stepping inside somebody else’s shoes and, you know, trying to see what it’s like without actually being there … being able to slip and slide in somebody else’s shoes and trying to understand from their standpoint what it means to be going through this. (Patient 5) Empathy is where you put yourself in the person’s shoes, and you try to imagine yourself walking in those shoes, and how you personally would react. (Patient 19) When you empathize with people you, you’ve crawled right into their moccasins. (Patient 44)

Compassion was identified as the preferred care medium by patients, enhancing the key aspects of engaging suffering, understanding the person and emotional resonance contained within empathy, while adding defining qualities of being motivated by love, the altruistic role of the responder, action, and small but supererogatory acts of kindness. The definition of compassion that emerged from the data was a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action .

Motivated by love

Patients recognized compassion as an affective response to suffering, motivated within the virtues of the individual responders. While patients identified virtues such as kindness, genuineness, and honesty as the sources of a compassionate response, love was the most frequently cited virtue distinguishing compassion from sympathy and empathy. Patients described compassionate love as non-conditional, independent of patient behavior, relatedness, and deservedness, and not being contingent on the responder’s own emotional state during the clinical encounter:

Compassion I think means to me, giving me love, giving me love, unconditional. (Patient 45) I think you can tell those that are there for the paycheque, or those that are there because they love what they do and they love the patients. (Patient 26) I think it’s all about love, not getting, you know, like not getting hung up on what the big picture is, it’s about the now and ensuring that that person has been given that chance to be in the now. (Patient 6)

The altruistic role of the responder

A related theme that emerged prominently from the interview data was the ability of compassionate responders to put aside their needs to meet the needs of the patient. Whereas sympathy involved a focus on the needs of the observer and empathy involved responders being attuned to the needs of the patient, compassion involved responders using themselves as an instrument in the relief of suffering. Patients felt that the selfless role of compassionate individuals had an enduring impact as their care extended beyond the clinical interaction and their professional role to a long-term commitment to the patient:

… I think I’ve come across a lot of people who have been very, very compassionate in understanding where I’m coming from, in accepting who and what my decisions are without, sort of, throwing their own feelings and empathy into this situation, they’re thinking about me. (Patient 5) It’s being tender, it’s being aware of someone’s needs before yourself. (Patient 11)

Action oriented

Compassion, in contrast to both sympathy and empathy, was described by participants as action oriented, aimed at ameliorating suffering. While both compassion and empathy acknowledge and attempt to understand the needs of a person in suffering, empathy was solely a responsive state, while compassion added a proactive element that aimed to augment shared suffering with action—feeling for and doing for. In contrast to empathy where emotional resonance is an end point, emotional resonance in relation to compassion was a catalyst to a deeper emotional and physical response that aimed to improve the situation:

Compassion is actions … sympathy are thoughts and well wishes. (Patient 14) I think empathy is more of a feeling thing where you’re aware of somebody’s suffering, and compassion is when you act on that knowledge. (Patient 23) Sympathy are words and you know, “jeez I hope you feel better” and “it’s terrible you got this” and compassion is running over and getting a barf bag. (Patient 13)

Small supererogatory acts of kindness

Whereas sympathy was often expressed demonstratively, whether through grandiose gestures of care or over-expressions of emotion, compassion was often conveyed by subtle acts of kindness that often fell outside of routine care. Patients described these supererogatory acts in metaphorical language of “going above and beyond” or “going the extra mile.” It was in small acts of kindness, particularly acts that were not duty based, non-remunerated, and not part of the job description, where patients felt that the true intentions and nature of their healthcare provider was made plainly evident. The impact that patients ascribed to these small supererogatory acts was immense—it relieved their suffering, enhanced their sense of well-being, and positively influenced their perceptions of the quality of care they received from their healthcare providers:

Well because they put themselves out, they’re doing it uh that extra little bit that you don’t normally get. (Patient 36) Just going that extra mile. It’s just a feeling. It’s hard to explain … that extra smile, that extra you know, “hi how are you?” Hand on your shoulder, you know, we’re here for you. (Patient 50) Putting your arm around the shoulder and just letting them know that, “I’m here,” be it big or little, it doesn’t matter … (Patient 5)

Patients living with an incurable illness are uniquely positioned to provide insights into the constructs of compassion, empathy, and sympathy ( Table 3 ). They often have extensive experience with the healthcare system and in their most vulnerable moments, are in the hands of, and at the mercy of, a healthcare system and its ability to respond to their suffering.

In this study, patients distinguished between the constructs of “sympathy,” “empathy,” and “compassion” ( Table 3 and Figure 2 ). While patients acknowledged considerable overlap between empathy and compassion, they were unequivocal in identifying sympathy as a distinct and unhelpful reaction to patients’ suffering. Sympathy was described as a superficial acknowledgment of suffering, invoking a pity-based response that failed to sufficiently acknowledge the person who was suffering. Hence, sympathy appears to be a coping strategy that individuals invoke when exposed to situational suffering that they feel unable or inadequate to address.

In contrast, empathy and compassion were welcomed and valued by patients. Patients felt that empathy and compassion share attributes of acknowledging, understanding, and resonating emotionally with a person who is suffering. Compassion also added distinct features: action, supererogatory acts, virtuous motivators, and unconditional love, with compassionate responders functioning in an instrumental fashion in the amelioration of suffering ( Table 3 and Figure 2 ). These results are consistent with studies focused on healthcare providers’ conceptualizations of compassion as an intensification of both cognitive and affective empathy coupled with the addition of action 30 , 41 aimed at the alleviation of suffering. 16 , 30 , 41

Neuroplasticity research is beginning to offer important insights on the human experiences of empathy and compassion. One study found differences in brain activation in participants who engaged in contemplative exercises focused on enhancing empathy (resonating with another person’s suffering) compared to participants who meditated on compassionate thoughts (extending caring feelings to others). 42 Whereas conjuring empathic thoughts produced a negative effect in participants activating regions of the brain associated with aversion, compassionate feelings produced a positive effect, activating regions of the brain associated with reward, love, and affiliation. Taken together, these findings suggest that compassion may not only be better for patients but also for their healthcare providers, requiring a reconceptualization of the notion of compassion fatigue as empathetic distress. 42 , 43

Motivators and antecedents

From the perspective of patients, compassion, sympathy, and empathy had distinct motivators ( Table 3 ). Patients perceived sympathy as being motivated by pity, ego, and obligation, leading to an avoidant or over-reactive response. Empathy was motivated by the affective state of the healthcare provider toward the patient and a sense of duty. Compassion differed from empathy, finding its motivation in the inherent virtues of individuals, particularly unconditional love, generating a virtuous response and culminating in action aimed at the amelioration of suffering. 28 The virtue-based motivators of compassion mean that relative to empathy, compassion is less dependent on a sense of duty, less dependent on the emotional state of the observer, and, as has been confirmed by other studies, is less influenced by the perceived relatedness and deservedness of the patient. 28 , 44 – 46 In contrast, although patients felt that compassion engendered relationship, they did not feel it was contingent on relationship, but rather the unconditional acceptance of the patient, even when the patient was at their worse. 28 , 30 , 47

Implications and limitations

Results of this study shed light on different responses healthcare providers may manifest in response to suffering ( Table 3 and Figure 2 ). While participants believed that sympathy positioned individuals as “outsiders” in the clinical encounter, compassion and empathy placed the responders in a more vulnerable position alongside (empathy) and within suffering (compassion). Patient accounts of this important difference often used metaphorical language related to responders putting themselves in the patient’s shoes—to situate themselves in close proximity to suffering. In addition to this notion of orienting to the patients’ perspective, a number of patients expanded this metaphor in reference to compassion, which they felt also involved “walking a mile in a person’s shoes,” implying a long-standing commitment to the patient over time, regardless of the actual or anticipated duration of the clinical relationship. A final difference related to the role of compassionate carers was the altruistic and instrumental functions they played in ameliorating suffering. These findings align with other studies that reported that compassionate individuals used self-effacement to meet the needs of another person, 48 , 49 often through small, yet impactful supererogatory acts. 8 , 31 , 50 These results highlight the importance of research that examines healthcare providers’ perspectives and experiences, including how their responses to suffering might impact their personal and professional lives.

Our study comparing and contrasting patients’ experiences of sympathy, empathy, and compassion addresses an important gap in the literature. One of the most compelling findings of this study is how patients distinguish and prefer compassion. Although patients appreciated empathy, they also noted a number of limitations, namely, that it is not linked to action, is conditional, and does not involve supererogatory acts. These results are consistent with neuroplasticity research that reported that empathy activates neural networks that are isomorphic (mirroring) to the emotional state of the sufferer. 22 As a result, the authors postulate that empathy has a potential dark side, whereby it can be used to find a weakness to make a person suffer or can cause empathetic distress and burnout on the part of the caregiver. 42 , 51 While participants in our study did not identify an adverse effect of empathy, they did note some provocative differences related to the role of emotional resonance in each of these constructs. In contrast to empathy where emotional resonance seemed to function as an end point, in relation to compassion, emotional resonance was coupled with an intention to transform suffering, requiring the responder to move from “feeling with” (empathy) to “feeling for” the patient—a distinguishing feature of compassion identified by others. Finally, in terms of study limitations, as this was a qualitative study, generalizability is limited, and as 72% of our sample had at least some university education, this may have resulted in an overly intellectualized understanding of these three constructs. 52

This study reports on palliative cancer patients’ experiences of sympathy, empathy, and compassion, including differences and their preferences between them. While these three constructs tend to be used interchangeably within the healthcare literature, there are marked differences according to the individuals who are the main recipients of these care constructs—patients. In contrast to sympathy, patients reported both empathy and compassion as having a positive effect on their care experiences, allowing them to feel heard, understood, and validated. In addition to these patient outcomes, compassion was distinguished by its orientation toward action, its foundation in unconditional love, its expression through small supererogatory acts, and the altruistic role that compassionate carers played in this process. Deconstructing these terms can inform future research comparing these three constructs on patient quality of life, family member grief, and healthcare provider job satisfaction. Additionally, it provides a conceptual framework for the development of targeted educational interventions that acknowledge individual variance in expressions (trainees) and receptivity (patients) of compassion. 53 Ultimately, this research can inform evidence-based clinical practice to enhance this vital, but previously ill-defined dimension of healthcare.

Acknowledgments

The authors would like to acknowledge Barb Gawley, research nurse, for her dedication and commitment to this study. They would also like to acknowledge and thank the research participants who were compelled to join this research study, despite time being precious.

Declaration of a conflict of interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Canadian Institutes of Health Research Open Operating Grant (grant number 125931).

• DOI: 10.12968/bjcn.2020.25.1.16
• Corpus ID: 209474146

Compassionate care in the community: reflections of a student nurse.

• D. Doran , Jill Phillips , Michele Board
• Published in British Journal of Community… 2 January 2020
• Medicine, Education

21 References

What do nurses do student reflections., care, compassion, and communication in professional nursing: art, science, or both., art, science, or both keeping the care in nursing., an exploration of the perceptions of caring held by students entering nursing programmes in the united kingdom: a longitudinal qualitative study phase 1., undergraduate nursing students' attitudes and use of research and evidence-based practice - an integrative literature review., professional development, reflection and decision-making in nursing and health care, adopting evidence-based practice in clinical decision making: nurses' perceptions, knowledge, and barriers., caring and well-being: a lifeworld approach, definition of compassion in healthcare: a systematic literature review., evidence-based practice in health education and promotion: a review and introduction to resources, related papers.

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Reflective Account of Developing 6 C's for Health Care Assistant

Info: 2955 words (12 pages) Reflective Nursing Essay Published: 3rd Nov 2020

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• “6 c’s implemented by the NHS in 2012”-
• Department of health and social care (2012) Top nurses announce new strategy to build culture of compassionate care across the NHS. Available at:  
• (https://www.gov.uk/government/news/top-nurses-announce-new-strategy-to-build-culture-of-compassionate-care-across-the-nhs )(accessed:09/12/2019)
• “When we feel compassion, we find it easier to listen deeply, understand more fully and demonstrate empathy”-
• According to (Embracing empathy in health care, London, radcliffe publishing, Bikker et al, 2014. p.25)
• “Caring defines us and our work. People receiving care expect it to be right for them consistently throughout every stage of their life”-
• Definition of care according to website- National health service- (2012) The 6 c’s. Available at:
• (https://www.england.nhs.uk/6cs/wp-content/uploads/sites/25/2015/03/introducing-the-6cs.pdf) Accessed on the 09/12/19
• “Being aware of yourself, your abilities, your strengths and your weakness’s enables you to develop all of them into practice”
• According to (Sapin. 2013. Essential skills for youth work practice, 2nd edn, London, sage publications ltd)
• according to (Koprowska. 2014. communication and interpersonal skills in social work, 4th edn, London, sage publications ltd)- “knowing your role, within the setting you are in and the people you work with will help you manage your own personal feelings when they maybe involved in a situation”
• By then using a reflective account tool such as (Johns, 1994. model for structured reflection [10th edition]).
• “non-verbal behaviour is as important as, or even more important than, your words” (Egan. 2014. The skilled helper, 10th edn, Belmont, Cengage learning)
• is “SOLER, this stands for facing the sender squarely, with an open posture, leaning towards the other, making good eye contact and remaining relatively relaxed or natural in these behaviours” (Egan. 2014. The skilled helper, 10th edition, Belmont, Cengage learning, inc.)
• I make use of certain facial expressions such as smiling and nodding according to (parris. 2012. An introduction to social work practice, maiden head, McGraw-Hill Education) these are known as nonverbal prompts.
• “Spoken messages are like a braid of which only one strand is the word themselves” (koprowska. 2014. Communication and interpersonal skills in social work, 4th edition, London, Sage publications Ltd).

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Compassionate care in the community: reflections of a student nurse

Affiliations.

• 1 Second-Year Student Nurse.
• 2 Senior Academic.
• 3 Principal Lecturer, all at Bournemouth University.
• PMID: 31874085
• DOI: 10.12968/bjcn.2020.25.1.16

Reflecting on practice and analysing situations when compassionate care has been delivered can be a valuable way of helping student nurses develop their understanding of humanising care. This exemplar showcases a scenario when a second-year student nurse studying for a BSc (Honours) in adult nursing explored an experience while working in the community. She critically reflected on an incident highlighting a simple yet powerful example of how she helped an older couple manage an aspect of their care. This exercise helped the student to explore and understand what compassionate care means and highlighted how the value of reflection can be used to gain new insights to enhance the care of older people in her future practice in the community.

Keywords: Compassionate care; Humanised value framework; Older persons; Reflection; Student nurses.

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Home — Essay Samples — Nursing & Health — Medicare — Compassionate Care for Homeless Individuals

Compassionate Care for Homeless Individuals

• Categories: Medicare

About this sample

Words: 1117 |

Published: Mar 14, 2019

Words: 1117 | Pages: 2 | 6 min read

Works Cited

• Katz, S. (2017). Homelessness and Health: What Can Nurses Do?. MEDSURG Nursing, 26(1), 63-66.
• Landefeld, J.C. (2013). Health Conditions, Health Status, and Health Care Utilization Among Homeless Adults. Journal of Health Care for the Poor and Underserved, 24(1), 38-56.
• Landefeld, J.C. (2017). Chronic Pain in Homeless Persons: Characteristics, Causes, and Consequences. Current Pain and Headache Reports, 21(5), 23. https://link.springer.com/article/10.1007/s11916-017-0624-6
• O’Grady, E.T. (2018). Caring for People Experiencing Homelessness: An Interprofessional Perspective. Nurse Educator, 43(1), 21-24.
• Withers, J. (2011). Street Medicine: A Revolution in Health Care Delivery. The Permanente Journal, 15(3), 77-81.
• National Alliance to End Homelessness. (2022). Who Experiences Homelessness? https://endhomelessness.org/homelessness-in-america/who-experiences-homelessness/
• United States Department of Housing and Urban Development. (2021). The 2021 Annual Homeless Assessment Report (AHAR) to Congress. https://www.huduser.gov/portal/sites/default/files/pdf/2021-AHAR-Part-1.pdf
• United States Interagency Council on Homelessness. (2020). Ending Homelessness: Strategies for Connecting People Experiencing Homelessness to Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI).
• United States Interagency Council on Homelessness. (2022). Federal Resources for Homelessness.
• Wenzel, S.L., Longshore, D., Turner, S., Williams, M.L., & Kloos, B. (2001). Homeless Veterans' Utilization of Medical, Psychiatric, and Substance Abuse Services. Medical Care, 39(3), 328-343.

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