Compassion as a Key Value
Compassion is a central value underpinning health and social care. As we explored in Chapter 4 (‘Medical Professionalism and Compassion’), compassion is listed in many codes of ethics and guides to professional standards which are produced by regulatory and professional bodies. Patients, professionals, and public bodies also commonly indicate a need for greater compassion when there is a perceived deficit in healthcare, with some suggesting that compassion be made mandatory and others questioning this (Baguley et al., Reference Baguley, Pavlova and Consedine2022; Paterson, Reference Paterson2011). Emphasis on compassion also increases following investigations or reports which highlight shortcomings in services, deficits in compassionate care, and a need for more patient-centred services and quality assurance.
Despite this attention, the term compassion is often not explicitly defined or delineated, as we explored in Chapters 1 (‘What Is Compassion?’) and 3 (‘What Compassion Is Not’). As a result, the literature about values in healthcare contains many terms which are sometimes used interchangeably. These terms include ‘compassion’, ‘sympathy’, ‘empathy’, ‘kindness’, and ‘communication skills’. On the opposite side, terms such as ‘burnout’ and ‘compassion fatigue’ are used to refer to negative and unhelpful states in which healthcare providers sometimes find themselves for various reasons. The associated emotions include a sense of anger and injustice when staff are unable to provide what they see as compassionate care, often owing to systemic failures in healthcare systems in which they work.
Against this backdrop, Chapter 2 outlined the ‘Background to Compassionate Healthcare’ and noted that while compassion lies at the heart of healthcare, there are many reasons for the erosion of compassion in day-to-day clinical practice. These include increased demand on services, limited resources, large caseloads, insufficient time to spend with patients and families, and a consequent transactional rather than relational approach to each person. Other factors include a systemic focus on efficiency and throughput, and growing reliance on technology and electronic health records which can further depersonalise patient interactions and reduce compassion, despite their many benefits.
Chapter 2 explored these and other factors which tend to diminish compassion, and went on to reflect on overarching values in medical education, especially ‘equanimity’. The role of health systems in limiting compassion and empathy was balanced by evidence supporting the importance and possibilities of compassionate care, especially during times of emergency such as the Covid-19 pandemic in the early 2020s. Compassion might lie at the heart of healthcare, but changing circumstances shape the degree to which such compassion is evident in day-to-day service provision.
The current chapter continues this exploration of compassion in healthcare by noting the occasional confusion surrounding the term ‘compassion’, and the distress that an absence of compassion can cause for patients, families, and staff. This chapter asks: What, precisely, does compassionate healthcare mean to patients and healthcare providers? What are the key elements of compassionate care, and how can these be identified and achieved? Can they be taught by qualified professionals and learned by trainees?
This chapter starts by seeking to describe or define compassionate healthcare, looking to research that delineates the elements of compassionate care and, insofar as possible, identifies attitudes and actions that comprise compassion in practice. The chapter then moves on to look at specific models of compassion as a way to think about practising with compassion and teaching compassionate care to trainees. The chapter concludes with considerations of cultural and ethnic factors relating to compassion, as well as the importance of awareness and engagement in generating and deepening compassionate practice.
What Is Compassionate Healthcare?
Despite its expanding presence in codes of professional practice and ethical guidance for healthcare professionals (see Chapter 4: ‘Medical Professionalism and Compassion’), there is limited research into the precise components of compassion in clinical settings. This is, perhaps, not surprising: it is not easy to research compassion. In addition, compassion is such an accepted value that it would be unethical (as well as impossible) to conduct a randomised controlled trial that compared compassionate healthcare with services that were explicitly lacking in compassion.
As a result of these methodological considerations, the evidence base on compassion in healthcare is not enormous, although it is nonetheless interesting, helpful, and practical. Overall, evidence to date suggests that patients experience compassionate care when their providers are emotionally present, communicate effectively, enter into their experience, and display understanding and kindness. It is worth examining some of the research in this area more closely in order to present a detailed picture of the elements of compassionate care as they are experienced by patients.
One study of people who experienced care asked participants what compassion looked like to them (Baguley et al., Reference Baguley, Pavlova and Consedine2022). This research group used ‘topic modelling analysis’ to ‘identify empirical commonalities in the text responses of 767 patients describing physician behaviours that led to their feeling cared for’:
Descriptively, seven meaningful groupings of physician actions experienced as compassion emerged: listening and paying attention (71% of responses), following‐up and running tests (11%), continuity and holistic care (8%), respecting preferences (4%), genuine understanding (2%), body language and empathy (2%) and counselling and advocacy (1%) … These findings supplement prior work by identifying concrete actions that are experienced as caring by patients. These early data may provide clinicians with useful information to enhance their ability to customize care, strengthen patient-physician relationships and, ultimately, practice medicine in a way that is experienced as compassionate by patients.
The authors add that, ‘perhaps most importantly, our analyses suggest that compassion is more than just a feeling for patients and that there is a range of concrete techniques that physicians may engage in, which are normatively experienced as compassionate by patients’ (p. 1700, emphasis original).
This is a useful study which provides a close, practical examination of the constituent elements of compassion in healthcare. The findings can help shift thinking forward from simply endorsing compassion as an overall value and towards identifying how to achieve compassionate care on a day-to-day basis. We might not feel deep compassion in every moment at work, owing to stresses in the workplace or complexities in our own lives, but, even at those times, we can use simple techniques to build compassion, provided we know which actions and approaches are seen as compassionate by patients.
‘Listening and paying attention’ is key among the techniques identified by Baguley and colleagues as exemplifying compassionate care. Listening in a meaningful way is a relatively simple activity that does not require special training, but it was the most meaningful of all the behaviours associated with compassion in this study. Listening need not be time-consuming either, but is, rather, time well spent. Careful, attentive listening can save time in the end. The data in the study by Baguley and colleagues accorded overwhelming importance to listening, which was present in some 71% of responses. The next most frequently mentioned factors were considerably less common: following‐up and running tests (11%), continuity and holistic care (8%), and respecting preferences (4%). Listening is clearly the dominant feature of compassionate care.
Models of Compassion
Consistent with the work of Baguley and colleagues (Reference Baguley, Pavlova and Consedine2022), Sinclair and colleagues have developed a clinically informed, empirical model of compassion from a patient perspective (Sinclair et al., Reference Sinclair, McClement and Raffin-Bouchal2016). This work defines compassion as a virtuous response that strives to address the suffering and needs of the person by using relational understanding and action. This model also notes the importance of communication, including listening to the patient, which was such a key feature in the study by Baguley and colleagues (Reference Baguley, Pavlova and Consedine2022). While most healthcare professionals already know that listening and paying attention have many benefits, these research findings underline their advantages in terms of compassionate care as it is experienced by patients.
From a practical perspective, exploration of these patient and provider-informed models of compassion can advance understanding of what patients perceive as compassionate healthcare and how this can be achieved. In conceptual terms, too, these models have a great deal to offer when we think about compassion as an overarching value that should inform all domains of healthcare (i.e., service delivery, planning, teaching, reviewing care, etc.), in addition to helping operationalise compassion in day-to-day clinical settings.
Sinclair and colleagues’ model of compassion in healthcare includes the patient, the healthcare provider, and the relational space between them (Sinclair et al., Reference Sinclair, Hack and Raffin-Bouchal2018). Patient-related factors include suffering, while provider-related qualities include virtues, presence, and intention. Factors in the relational space between the two include getting to know the person, creating a healing alliance, and relieving suffering. All three elements are vital: the patient, the provider, and the changing, often quite intense relational space between the two in which a therapeutic relationship is formed, and a great deal of healing can occur.
This is a clear, useful model which provides a helpful framework for reflecting on the elements of compassion and ways to enhance it. Many of the virtues which are identified can be practised and improved provided there is awareness of their importance and an intention to co-create a compassionate space for therapy, healing, and recovery. Similarly, many of the actions which promote compassion are simpler and less time-consuming than providers often think: listening, reflecting, and connecting with the patient.
The other key virtue of this approach is that it can be incorporated into education and training for healthcare providers and students in order to enhance compassion in care. We explore educational strategies in some detail later in this book. Many of these techniques focus not only on the patient and the healthcare provider, but also on the relational space between the two, which was so usefully highlighted by Sinclair and colleagues (Reference Sinclair, Hack and Raffin-Bouchal2018).
Baguley and colleagues, in their study of ‘compassion in healthcare’, conclude that further research is needed to provide additional insights into the components of compassionate care:
Compassion is desired by patients, professionally mandated and central to effective clinical care, with potential benefits throughout the healthcare system. Yet, despite its importance, the physician behaviours that communicate compassion to patients have remained unclear, with prior work concentrated on the experience of care. The present study employed a mixture of quantitative and qualitative techniques to contribute to knowledge in this area, revealing key themes constituting the experience of care from the patient’s perspective … Further work focusing on real, concrete skills or behaviours will inform the development of targeted interventions and training to enhance the experience of compassionate care.
Compassion Across Cultures
Given the centrality of compassion to codes of ethics and guidelines for professional practice, in light of research highlighting listening as a key component of compassionate care, and given the significance of not only the patient and the healthcare provider, but also the relational space between the two, is there evidence that compassionate healthcare is experienced similarly around the world? Are there important social or cultural differences in understandings of compassion in different countries and cultural settings? Or, to what extent do such understandings map onto an identifiable common humanity?
In 2018, Singh and colleagues published a grounded theory study of the perspectives of healthcare providers on perceived barriers and facilitators of compassion (Singh et al., Reference Singh, Raffin-Bouchal and McClement2018a). This work identified several themes related to challenges to compassion including personal challenges, relational challenges, and systemic challenges, as well as maladaptive responses. This work also identified facilitators of compassion, embracing personal facilitators, relational facilitators, and systemic facilitators, as well as adaptive responses of intentional action.
Also in 2018, Singh and colleagues published ‘a systematic review of the perspectives of compassion among ethnically diverse patients and healthcare providers’ (Singh et al., Reference Singh, King-Shier and Sinclair2018b). This work aimed ‘to identify and describe the perspectives, experiences, importance, and impact of compassionate care among ethnically diverse population groups’ (p. 1). To this end, the authors conducted ‘a systematic search of peer-reviewed research focused on compassionate care in ethnically diverse populations published between 1946 and 2017’.
For this review, the authors retrieved ‘a total of 2296 abstracts … out of which 23 articles met the inclusion criteria’:
Synthesis of the literature identified the perspectives, facilitators and barriers of compassion in healthcare within ethnic groups. Compassion was described as being comprised of healthcare provider (HCP) virtues (honesty, kindness, helpful, non-judgment) and actions (smile, touch, care, support, flexibility) aimed at relieving the suffering of patients. The importance and impact of providing compassion to ethnically diverse patients was also identified which included overcoming cultural differences, alleviating distress at end-of-life, promoting patient dignity and improving patient care.
These findings echo the importance of the patient, the healthcare provider, and the relational space between the two, as highlighted by Sinclair and colleagues (Reference Sinclair, Hack and Raffin-Bouchal2018). Singh and colleagues also draw useful attention to qualities of the healthcare provider, such as kindness and helpfulness, as well as specific behaviours, such as smiling (Singh et al., Reference Singh, King-Shier and Sinclair2018b). These are simple ways to demonstrate the compassion that healthcare workers feel routinely but occasionally do not convey to those for whom we care, owing to difficult or challenging circumstances.
The issue of ‘touch’ is an important and delicate one, because while some people find appropriate touch helpful, people with a history of trauma might find touch difficult or even upsetting. Ethnicity and culture can also be important in relation to touch:
Patients of different ethnicities could unintentionally perceive certain actions of HCPs as non-compassionate. For example, even though supportive touch is generally considered an act of compassion across various cultures, it can be perceived as non-compassionate in certain cultures if the HCP and the patient are of a different gender [Babaei et al., Reference Babaei, Taleghani and Kayvanara2016]. Therefore, expanding the understanding of how different ethnic groups understand and experience compassion is important in informing HCPs working within ethnically diverse groups.
These issues matter not only during routine care provision, but also at times of particular stress or occasions when cultural or religious factors have added importance, such as at the end of life. Again, there are both individual and cultural determinants of the appropriateness of touch at these times, so it is vital that healthcare workers do not inadvertently undermine their own compassionate intentions at these significant moments. These risks can be minimised, and true compassion can be optimised, through sustained awareness of cultural diversity, fundamental respect for the dignity of the person, and attending carefully to verbal and nonverbal cues in these highly fraught clinical situations.
As Singh and colleagues point out, further research into perceived compassion across different cultural groups would also help:
This review also identified the need for more contextual studies directly exploring the topic of compassion from the perspectives of individuals within diverse ethnic groups, rather than superimposing a pre-defined, enculturated and researcher-based definition of compassion.
Awareness
So far in this chapter, we have examined research that seeks to define compassionate healthcare and tries to delineate its constituent elements. Evidence to date suggests that patients experience compassionate care when their healthcare providers are emotionally present, communicate effectively, enter into their experience, and display understanding and kindness. It is also clear that listening is the most dominant feature of compassionate care, along with following‐up and running tests, continuity, holistic care, and respecting preferences (Baguley et al., Reference Baguley, Pavlova and Consedine2022). Other relevant factors among healthcare providers include honesty and kindness, as well as specific behaviours, such as smiling (Singh et al., Reference Singh, King-Shier and Sinclair2018b). These are simple ways to demonstrate the compassion that healthcare workers routinely feel but sometimes do not convey clearly to our patients owing to challenging working circumstances.
We have also recognised the roles of cultural and ethnic factors relating to compassion, noting various facilitators of compassion, including personal facilitators, relational facilitators, and systemic facilitators, as well as adaptive responses of intentional action (Singh et al., Reference Singh, Raffin-Bouchal and McClement2018a). This chapter concludes with a consideration of the importance of awareness and engagement in generating and deepening compassionate practice in healthcare. These matters are linked with the idea of ‘emotional intelligence’ and its use in clinical care, as well as the links between emotional intelligence, mindful clinical practice, and compassion in healthcare.
In 2021, Jiménez-Picón and colleagues published a ‘systematic review’ of ‘the relationship between mindfulness and emotional intelligence as a protective factor for healthcare professionals’ in the International Journal of Environmental Research and Public Health (Jiménez-Picón et al., Reference Jiménez-Picón, Romero-Martín, Ponce-Blandón, Ramirez-Baena, Palomo-Lara and Gómez-Salgado2021). This research group defined ‘emotional intelligence’ as ‘a type of social intelligence that includes the capacity for controlling one’s emotions as well as those of others, identifying them and using this information to guide thoughts and actions, promoting a creative thought process, redirecting attention towards priority problems, increasing motivation and allowing for flexible planning’ (Jiménez-Picón et al., Reference Jiménez-Picón, Romero-Martín, Ponce-Blandón, Ramirez-Baena, Palomo-Lara and Gómez-Salgado2021; p. 1).
In other words, emotional intelligence involves recognising emotions in oneself and others, reflecting on that information, and incorporating this awareness into decision-making and subsequent actions. Healthcare can be a highly fraught setting, in which many emotions are engaged, sometimes in quick succession. As a result, it is not surprising that emotional intelligence can play a vital role for both healthcare providers and patients in navigating these complex landscapes.
There is growing evidence of the benefits of emotional intelligence in a number of domains, including quality of care, empathy, and compassion. As Jiménez-Picón and colleagues point out:
In the context of healthcare, [emotional intelligence] is taking on an increasingly relevant role. [Emotional intelligence] has been shown to positively influence healthcare professionals’ bio-psycho-social welfare, increasing their individual resilience, their perception of social support, empathy, job performance and satisfaction, and reducing stress … Moreover, there is ample evidence showing the benefits of health professionals’ [emotional intelligence] while undertaking daily tasks and on the physical and emotional care patients receive. [Emotional intelligence] has been identified as a predictor of professional success. Similarly, patients also perceive that professionals with [emotional intelligence] provide higher quality care, recognizing empathy, active listening and compassion as aptitudes related to [emotional intelligence].
The link between emotional intelligence and compassion that Jiménez-Picón and colleagues identify is important. Both of these qualities require careful engagement with the patient and their family, and both offer unique opportunities to strengthen, deepen, and generally improve the therapeutic relationship, as well as clinical outcomes.
From the patient’s perspective, this kind of engagement is most apparent through attentiveness and mindful listening, along with timely responses to queries and questions. Non-verbal cues such as sitting rather than standing indicate a willingness to be present with the patient and a readiness to relate directly to their experiences of illness and care. Looking at screens or clinical notes, rather than at the patient themselves, is often perceived as disengagement or a desire to avoid difficult conversations. For healthcare professionals, this might not be apparent, because looking at a computer screen might actually reflect deep engagement with test results or other clinical information that is needed for patient care. Nonetheless, diverting attention in this way can be misinterpreted by patients as distraction rather than engagement, so it is helpful to be mindful of how this appears.
Good communication with other members of the healthcare team about the treatment plan can also signal attentiveness and engagement, although it is important to note that this team effort is not always apparent to the patient, who might not identify the subtle, powerful communication patterns across clinical teams. When referrals go missing or are not followed up, or when promised communications do not happen, patients and families can perceive a lack of attentiveness. Clear, honest dialogue can help greatly in these situations, communicating clinical information and processes accurately and sensitively, without jargon or impersonal terminology, and clarifying when necessary.
Careful use of silence and space for the patient to participate can also help, along with a tolerance of their often-conflicted emotions about healthcare information. There can be deep compassion in simply being there for patients when they need us, especially at times of uncertainty or complexity. This quality of ‘being there’ is a powerful clinical skill which requires a willingness to answer questions and wait while patients process information, without necessarily intervening to change their emotional state. It involves finding not only time to spend with the patient, but also a quality of presence that reflects solidarity and acceptance of the patient’s response to their situation.
Sometimes, people need to experience negative emotions for a period of time in order to work through difficult scenarios. For the healthcare practitioner, responding to this might mean simply being aware of the emotions that are present, in oneself and the patient, without trying to alter them, and simply being available for the patient and their family. Jiménez-Picón and colleagues write about the importance of ‘mindfulness’ in these situations:
Mindfulness meditation is an effective way of training [emotional intelligence]. Mindfulness is a form of meditation based on the ability to bring one’s attention to what they are currently experiencing in the present moment, accepting it without judgement and identifying the sensations, emotions and thoughts. This meditation is used as a therapeutic psychological treatment with positive results, reducing levels of anxiety, depression and stress, and alleviating physical symptoms such as pain as well as vulnerability due to psychiatric illnesses … mindfulness could be a link between professionals’ clinical practice and their emotional management, helping them to maintain their own psychological health, while also resulting in direct benefits for patients and the healthcare system.
Overall, compassionate healthcare is rooted both in listening and in doing, and it invariably involves being present for our patients and their families, especially in uncomfortable situations. Emotional intelligence helps by facilitating engagement and deepening mindful awareness of the complicated, challenging scenarios that commonly develop in healthcare settings, and often require a great depth of compassion to navigate effectively.
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