Compassion

Compassion can be defined as the sensitivity shown in order to understand another person's suffering, combined with a willingness to help and to promote the wellbeing of that person, in order to find a solution to their situation.

What is compassion in healthcare?

In our fast-paced, high-tech health care system we must be reminded that health care is about people and relationships.

Lanyard K. Dial, Adventures in Caring Foundation.

 

Compassion combines an empathic response to another’s suffering with actions to relieve that suffering. It’s an important aspect of what patients need when they see their healthcare practitioner, but the demands of healthcare work can make it difficult for practitioners to sustain compassion consistently.

“Compassionate healthcare is safer, more effective, satisfies patients, saves time, reduces demand, gives meaning to work and costs less.”

Dr Robin Youngson

Key points

A lack of compassion in healthcare provision can lead to patients feeling devalued and lacking in emotional support. For example, its absence is frequently cited in complaints by health consumers to the Health and Disability Commission. Researchers have shown that compassionate caring is associated with greater patient satisfaction, better doctor-patient relationships, and improved psychological states among patients.

Research has also found positive relationships between one form of compassion, for example, positive clinical-patient communication, and treatment compliance, various health outcomes, better emotional well-being, lower stress and burnout symptoms, lower blood pressure, and a better quality of life for both doctors and patients.

Patients report that receiving compassionate care from their clinician aids recovery, including an increased sense of responsibility and control over their health, an important finding in terms of the promotion of patient self-management.

Combining clinicians’ technical skills and specialised knowledge with compassion seems to have a greater healing effect than skills alone for both patients and family members.

The field of interpersonal neurobiology researches this phenomenon and has demonstrated that any meaningful relationship can reactivate neuroplastic processes and alter the structure and biochemistry of the brain, for example, positively through compassion and negatively through cruelty.

However, other research shows that empathy declines dramatically as medical students progress through medical school, and this change coincides with students’ and medical residents’ reports of high rates of burnout and psychological distress.

What are the benefits of cultivating compassion in your practice?

The Adventures in Caring Foundation list the following benefits of cultivating compassion:

  • increased patient satisfaction scores
  • increased staff morale and retention
  • reduced risk of litigation
  • improved patient safety, conservation of hospital resources
  • staff time saved on damage control after clumsy communication
  • better medical outcomes.

(Source: Top ten scientific reasons why compassion is great medicine Hearts in Healthcare)

Doctors, as well as patients, feel better when they are compassionate. For example, neuroscientists have identified neural networks that generate shared representations of directly experienced and observed feelings, sensations, and actions. When shared representations evoke empathic concern or compassion for another's painful situation, humans experience altruistic motivation to help. The resulting behaviours are associated with activation of areas in the brain associated with affiliation and reward.

Preliminary findings also suggest that compassion may have a positive effect on specific clinician outcomes, including increased job satisfaction and retention.

What helps convey compassion to patients?

A scoping review of the healthcare literature on compassion over the past 25 years found that:

  • Compassionate care was predominantly conveyed in the clinical setting through interpersonal factors, especially in the context of clinical communication.
  • Clinicians’ willingness to engage and be affected by their patients and their experiences, suffering as fellow human beings, was an essential feature of compassionate communication, requiring vulnerability on the part of clinicians.
  • Patients who felt that their clinician listens to them, knows them as a person, reflects a warm and open demeanour, and are actively present, positively influence their overall care experience and their perception of their clinician.
  • While compassion is largely conveyed through relational communication and clinicians’ presence, it is also conveyed through tangible means such as tactile contact, posture and body language, vocalization, and small acts of kindness.

In practice, that can mean things like:

  • Treating patients with dignity, respect, empathy in your communication and actions.
  • Conveying genuine care and interest through your words and actions.
  • Taking as much time as is possible to listen, while using reflective listening skills.
  • Being really present to your patient, rather than half distracted by other tasks.
  • Maintaining eye contact.
  • Not standing over someone, but sitting at their bedside.
  • Not having a desk/table in between you and the patient.
  • Ensuring your responses and interventions are appropriate to their cultural and spiritual beliefs rather than one-size-fits-all ones.
  • Knowing that the smallest things can make the biggest difference, such as an appropriate touch when they are upset, a well-timed query, cup of tea, help with standing up, opening a door, and so on.
  • Being willing to show vulnerability, when appropriate, so allowing a heartfelt response such as tears welling up when you give bad news or the patient’s life situation is tough.
  • Remembering that compassion is about connecting with your feeling of empathy for the other person and demonstrating that through your words and actions.
  • Acting in the knowledge that a compassionate response contributes to healing through the changed physiological experience not only in yourself but in the patient as well.


Compassionate care

What gets in the way of compassion?

Often a lack of compassion to a patient is explained as the healthcare practitioner experiencing compassion fatigue. But Auckland psychiatrist Tony Fernando and his University of Auckland colleague Nathan Consedine critique the term compassion fatigue and make a case for a more differentiated understanding of what gets in the way of a compassionate response to a particular patient. They say that the focus on compassion fatigue means that valid and reliable measures of physician compassion and the factors that inhibit and promote it have not yet been fully researched.

Fernando and Consedine assert that compassion fatigue implies that being compassionate is tiring and will deplete over time, and cite research suggesting that compassionate approaches are pleasurable, increase social connections, decrease the focus on oneself, and may buffer against stress.

Fernando and Consedine suggest that compassion is not only a function of physician characteristics but also reflects the physician in a transactional relationship with the patient, the clinical picture and the institutional setting. Transactional approaches explain behaviour by emphasising the dynamic interplay of a person and their environment. They have developed the Transactional Model of Physician Compassion to demonstrate this.

This model shows that multiple variables affect a physician’s ability to respond compassionately in the moment, these being in:

  • The physician (such as personality, clinical experience, communication skills).
  • The patient and their family (such as being grateful and appreciative or rude, hostile and noncompliant).
  • Clinical factors (such as diagnoses stemming from the patient’s unhealthy behaviour, complex comorbidities, lack of improvement, clinical context e.g. ED).
  • Environmental and institutional factors (such as lack of privacy, interruptions, competing demands such as teaching junior staff or administrative requirements).

Other researchers have also recognised the lack of an empirically based model of compassion, and that patient views have been under-researched. In a study that defined and codified the core elements of compassion from the perspective of patients at the end of life, researchers provided an empirical foundation for the development of a compassion inventory to measure patients' experiences of compassion. 

From this, the researchers developed a model that contextualises practitioner compassion in the relationship with the patient, and identifies virtues as underpinning compassion, hereby differentiating it from empathy or sympathy.

View Fernando and Cosedine's 2014 article in the Journal of Pain & Symptom Management to view the related images and tables.

What can clinicians do to increase their compassion?

Implications from Fernando and Consedine’s research include that there are multiple possible points of intervention in the four areas of physician, patient and family, clinical factors and environmental and institutional factors.

In terms of physicians, these interventions could include:

  • Education into the nature of compassion as well as the benefits on the doctor, the patient, and their families can derive from compassionate clinical care i.e. that compassion is not a trade-off or optional extra, but central to their ability to relate to their patients and effectively conduct their clinical duties.
  • Providing physicians with basic knowledge of the promoters and inhibitors of compassion to inform better self-management (eg, for which patients or in which situations their own compassion drops).
  • Training doctors how to manage their expectations of patient behaviour and outcomes, eg, learning to tolerate clinical ambiguity and uncertainty without becoming uncompassionate.

In one study, methods suggested by physicians to being compassionate without becoming overwhelmed were to:

  • realise that you cannot fix everything
  • entrust your colleagues
  • step back from your initial emotional reactions
  • have some sort of “spiritual” practice
  • keep in mind the meaning and privilege of being a healer
  • have a balanced life & claim the time for it
  • be empathic, but the patient’s suffering is not your suffering (let it go).

Auckland psychiatrist Tony Fernando recommends a short practice at the end of each day to reflect on how many people you’ve helped each day. “It can sustain you,” he says. "It's a very stressful vocation. It will deplete us. But we're sitting on a goldmine in terms of our own self-care. If you reflect daily on the number of people you've helped or attempted to help, then you'll feel good, and realise it's worth the effort."

Research suggests that inherent qualities of compassion can be further developed through education and training, but that education must be aligned with changes in clinical practice to sustain compassionate care.

Compassion training enhances a practitioners’ ability to:

  • be aware of others’ suffering
  • develop concern for others
  • wish to relieve that suffering and
  • be ready to relieve that suffering.

Approaches to compassion training

A scoping review of healthcare literature on compassion over the past 25 years found that clinical mentors, reflective practice, and experiential learning have been identified as effective teaching methods. The study also found that beyond demonstrating the externalised features of compassion, effective compassion training engages the inherent qualities and virtues of students, and that reflective learning and self-awareness seem to be particularly important teaching methods, as compassion is highly individualised to students and their patients – personalized healthcare that is customized to both clinicians and patients.

A review of compassion training programmes and the evidence for them found that the most researched was compassion-focused therapy.

Compassion-focused therapy is a system of psychotherapy developed by Paul Gilbert that integrates techniques from cognitive behavioural therapy with concepts from evolutionary psychology, social psychology, developmental psychology, Buddhist psychology, and neuroscience to teach the skills and attributes of compassion.

Lown used a social neuroscience approach to develop a compassion process model and framework with examples of educational goals, interventions and resources for curriculum development.

Mindfulness-based compassion training has also been shown to increase compassion, including in a landmark study of primary care physicians. Evidence is mounting that mindful medical practice enables clinicians to offer whole person care.

“Mindfulness may be an important pathway to a more humanistic, effective, and satisfying practice of medicine. The highly reciprocal influence of patients and clinicians on one another is in itself a powerful and positive medical tool—perhaps in some situations more powerful than other interventions that can be offered to patients. In an era in which many physicians suffer from professional burnout, mindful practice may be the way in which physicians not only heal themselves, but heal their patients as well.”

MC Beach et al

In New Zealand, Dr Robin Youngson and his wife Meredeth Youngson have founded Hearts in Healthcare, a group lobbying internationally for health systems to place more emphasis on compassion and whole patient care.

Resources

Transformative learning & resources Hearts in Healthcare
Dr Robin Youngson – Time to Care Hearts in Healthcare 

References

  1. Perez-Bret E, Altisent R, Rocafort J. Definition of compassion in healthcare: a systematic literature review. Int J Palliat Nurs. 2016 Dec;22(12):599-606. http://dx.doi.org/10.12968/ijpn.2016.22.12.599
  2. Bramley L, Matiti M. How does it really feel to be in my shoes? Patients' experiences of compassion within nursing care and their perceptions of developing compassionate nurses. J Clin Nurs. 2014 Oct; 23(19-20): 2790–2799. http://dx.doi.org/10.1111/jocn.12537
  3. Dudding A. When doctors have compassion fatigue. Stuff. 2013 Oct 13. stuff.co.nz/national/health/9271509/When-doctors-have-compassion-fatigue
  4. Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol 1999;17:371e379
  5. Street, R.L., Jr.; Makoul, G.; Arora, N.K.; Epstein, R.M. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ. Couns. 2009, 74, 295–301.
  6. van der Cingel M. Compassion in care: A qualitative study of older people with a chronic disease and nurses. Nurs Ethics. 2011;18(5):672–85. doi:10.1177/0969733011403556
  7. Lloyd M, Carson A. Making compassion count: equal recognition and authentic involvement in mental health care. Int J Consumer Stud. 2011;35(6):616–21
  8. Chochinov HM. Dignity and the essence of medicine: The A, B, C, and D of dignity conserving care. Br Med J. 2007;335(7612):184–7. doi:10.1136/bmj.39244.650926
  9. Cozolino L. The neuroscience of human relationships: attachment and the developing social brain (Norton series on interpersonal biology). New York: Norton; 2014.
  10. Shanafelt, T.D.; West, C.; Zhao, X.; Novotny, P.; Kolars, J.; Habermann, T.; Sloan, J. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J. Gen. Intern. Med. 2005, 20, 559–564.
  11. Chang, E.; Eddins-Folensbee, F.; Coverdale, J. Survey of the prevalence of burnout, stress, depression, and the use of supports by medical students at one school. Acad. Psychiatry 2012, 36, 177–182.
  12. Adventures in Caring Foundation. adventuresincaring.org/the-trilogy/for-health-care-professionals/the-medicine-of-compassion/
  13. Lown BA. A social neuroscience-informed model for teaching and practising compassion in healthcare 2016 March; 50(3):332–342. 10.1111/medu.12926. http://onlinelibrary.wiley.com/doi/10.1111/medu.12926/abstract
  14. van der Cingel M. Compassion in care: a qualitative study of older people with a chronic disease and nurses. Nurs Ethics. 2011;18(5):672–85. doi:10.1177/0969733011403556., 52 Way D, Tracy SJ.
  15. Sinclair S, Norris JM, McConnell SJ, Chochinov HM, Hack TF, Hagen NA, McClement S, Raffin Bouchal S. Compassion: a scoping review of the healthcare literature. BMC Palliative Care. 2016, January;15:6 doi 10.1186/s12904-016-0080-0 https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-016-0080-0
  16. Fernando AT, Consedine NS. Beyond compassion fatigue: the transactional model of physician compassion. J Pain Symptom Manage. 2014 August; 48(2): 289–298. doi:10.1016/j.jpainsymman.2013.09.014. jpsmjournal.com/article/S0885-3924(13)00617-9/fulltext
  17. Seppala, E. The compassionate mind. Association for Psychological Science. 2013. psychologicalscience.org/observer/the-compassionate-mind#.WQlLTfmGOUk
  18. Sinclair S, McClement S, Raffin-Bouchal S, Hack TF, Hagen NA, McConnell S, Chochinov HM. Compassion in health care: an empirical model. J Pain Symptom Manage. February 2016;51(2):193–203. 10.1016/j.jpainsymman.2015.10.009. jpsmjournal.com/article/S0885-3924(15)00573-4/fulltext
  19. Post SG. Compassionate care enhancement: benefits and outcomes. The International Journal of Person Centered Medicine. 2011;1(4):808–813. stonybrook.edu/bioethics/CCE.pdf
  20. Jazaieri, H., Jinpa, G., McGonigal, K. et al. Enhancing compassion: a randomized controlled trial of a compassion cultivation training program. J Happiness Stud. 2012; 14: 1113–1126
  21. Kirby JN. Compassion interventions: the programmes, the evidence, and implications for research and practice. Psychol Psychother Theory Res Prac. 2016. 1111/papt.12104 http://onlinelibrary.wiley.com/doi/10.1111/papt.12104/full
  22. Gilbert P. An introduction to compassion focused therapy in cognitive behavior therapy. Int J of Cog Ther. 2010;97–112. doi:10.1521/ijct.2010.3.2.97. http://guilfordjournals.com/doi/abs/10.1521/ijct.2010.3.2.97
  23. Krasner, M.S., Epstein, R.M., Beckman, H. et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009; 302: 1284–1293.
  24. Amutio-Kareaga A, García-Campayo J, Delgado LC, Hermosilla D, Martínez-Taboada C. Improving communication between physicians and their patients through mindfulness and compassion-based strategies: a narrative review. J. Clin. Med. 2017, 6(3), 33; doi:10.3390/jcm6030033
  25. Beach, M.C.; Roter, D.; Korthuis, P.T.; Epstein, R.M.; Sharp, V.; Ratanawongsa, N.; Saha, S. A multicenter study of physician mindfulness and health care quality. Ann. Fam. Med. 2013, 11, 421–428.

Further relevant research includes the following: