Abstract
Background:
Despite the body of literature regarding the varying definition of compassion, there appears a lack of literature pertaining to the meaning of compassion from the perspective of health care professionals working in palliative care settings.
Objective:
The study aimed to explore how health care professionals working in palliative care settings view and/or understand the construct of compassion.
Methods:
A qualitative approach using semistructured interviews was used. Interviews were conducted with eighteen health care professionals working in pediatric, adult, and aged palliative care settings. Interviews transcripts were thematically analyzed.
Results:
Thematic analysis identified four main interrelated themes and supplementary subthemes. Health care professionals working in palliative care settings identified their perception of the (1) meaning of compassion, (2) importance of providing compassionate care, (3) barriers to providing compassionate care, and (4) facilitating compassionate care.
Conclusions:
This study presents a novel understanding of the components of compassion from the perspective of health care professionals working in palliative care. While there is need for future research, important areas of improvement include increased resourcing, reducing time pressures, and education within palliative care settings. This will enable the fostering of compassionate care to patients, as well as enhanced well-being both professionally and personally for health care providers delivering such care.
Background
Although health care professionals providing palliative care report a sense of satisfaction from their work, they can encounter challenging experiences, including patient suffering, confronting patient deaths, grief of patients' families, and dealing with complex symptoms associated with terminal illnesses.1,2 It is therefore not surprising that health care providers working with patients at the end of life may experience work-related burnout and compassion fatigue, possibly impacting on well-being and lowered standards of patient care.3,4
The construct of compassion has received increasing attention over the past two decades. 5 Research has explored the elements of compassion such as the capacity for empathic understanding, the ability to endure unpleasant emotions, nonjudgment, and motivation to care.5,6 In a recent review, Strauss et al. 7 proposed that compassion encompasses five main features: identifying suffering, understanding global human suffering, resonating with emotions, enduring uncomfortable feelings, and motivation to take action to ease suffering.
Evidence has demonstrated the benefits of compassion for emotion regulation6,8 as an important descriptive factor in understanding resilience and mental health, 9 and positive associations between social and relational well-being. 10 Numerous compassion-based interventions have been developed to encourage compassion regarding self and others. Kirby et al. 11 recently conducted a meta-analysis that examined the effects of compassion-based interventions. Although they found evidence that compassion-based interventions probably have benefits for recipients, they noted there remain a limited evidence base and a lack of consensus on defining and measuring the construct of compassion. 11
The term compassion fatigue is a stress-related response that can have a profound effect on well-being.3,12,13 Workload, leadership, interpersonal relationships and incidents, which may lead to moral distress, are deemed contributing factors to the experience of compassion fatigue. 14 Despite conflicting research, compassion fatigue is thought to be a major contributor to the loss of compassion within health care practice. 3 Increasing empirical evidence suggests that poor professional quality of life, including burnout and compassion fatigue, has a negative impact on the quality of patient care. 15 Moreover, compassion fatigue has been identified as a reason why health care providers disengage, display a reduced capacity to provide compassionate care, and depart from clinical practice.16,17
Despite compassion being one of the main referenced trademarks of quality patient care by patients, health care providers, and policy makers, literature is largely based on theoretical and anecdotal underpinnings. 18 A small body of emerging literature pertains to patients' perspectives of compassion, mainly relating to quality care. A qualitative study by Sinclair and colleagues 19 explored the experiences and understanding of compassion from the perspective of palliative care cancer patients, providing patient insight and an empirical model of compassion.
A more recent qualitative study explored how palliative care patients view, experience, and comprehend compassion from health care professionals, 20 which suggested that compassion was perceived as a connection between patient and health care provider, through which providers exhibit respect and care for patients in a positive way. Although this research examines the meaning of compassion to palliative care patients, there appears a gap in the literature pertaining to the understanding of compassion from the perspective of health care professionals.
The aim of the current study was to explore how health care professionals view and/or understand compassion. The information obtained from this qualitative study may inform future quantitative research and compassion-based interventions.
Methods
Research design
A qualitative research design using semistructured interviews was selected as it allowed for a rich description of participants' experiences to be generated. 21 This study applied a social constructionist approach, 22 through which the concept of compassionate caregiving is constructed by research and societal health care bodies, and aligns with health care professionals perceiving the socially constructed meaning/s of compassion.
Participants
Inclusion criteria included the following: older than 18 years and from a range of health professional backgrounds working in palliative care within Western Australia. Participants were recruited through purposive sampling and snowballing. 24 We used purposive sampling to ensure participants were interviewed from pediatric and adult palliative care settings; from community-based, inpatient, and consultative services; and from different disciplines. The initial purposive sample was chosen to provide rich contextual information to reflect the interdisciplinary approach to working in palliative care. We also distributed a research advertisement of the proposed study via e-mail. E-mails were distributed to health professionals working in palliative care settings, targeted toward health professionals who fit the inclusion criteria. The e-mail format allowed potential research participants to respond directly to the researcher and forward the research advertisement, creating a snowball effect. Snowball sampling is common in qualitative research and it allowed the initial contacted health care professionals to invite their own contacts in palliative care settings who may also be suitable participants. 24 The overall sample comprised six consultant physicians, five clinical nurses, four social workers, one Aboriginal and Torres Strait Islander health practitioner, one occupational therapist and one psychotherapist who worked across various pediatric, adult, and aged palliative care settings (Table 1). The higher proportion of females, and physicians and nurses, is reflective of the gendered nature and predominant disciplines of the industry.25,26
Participant Demographic Information and Professional Characteristics
Such a sample size provided a rich and in-depth analysis of consistencies across instances and individual experiences rather than focusing on generalizability. 21 This study aimed for data saturation and sample fairness rather than a planned number of participants. 27 Data were collected until no novel themes emerged. 28
Materials
A research advertisement e-mail was circulated to specialized palliative care (i.e., hospitals) and palliative care (i.e., aged care facilities) services within Western Australia for recruitment of participants. A semistructured interview schedule, which contained 10 questions and supplementary probes, was collated succeeding the review of relevant literature. Example questions include the following: “Can you tell me what compassion looks like to you” and “what are some of the barriers to compassionate care?” (Table 2). A demographic sheet was used to collect participant demographic information. A digital audio recording device was used to record interviews.
Interview Schedule
Procedure
Institutional ethical approval was obtained (HRE2018-0405). Participants engaged in either a face-to-face or telephone interview. The interviewer was a registered psychologist experienced in interviewing practices through research and clinical work. Participants were provided with a participant information sheet, were asked to sign a consent form, and completed a demographic sheet before the interview. Interviews ranged from 27 to 69 minutes (M = 46.78, SD = 13.96). Interviews were audio-recorded, transcribed verbatim, and data thematically analyzed.
Data analysis
Thematic analysis was conducted on interview transcripts by generating initial codes, organizing codes into themes, and assembling relevant data excerpts, refining and labeling generated themes and subthemes. 22 Themes were identified on an underlying level by systematically exploring the central concepts that were used to inform semantic content of interview data. 22
Quality procedures
An audit trail was used to assure improved quality and rigor of research, 29 including an ongoing reflexive journal and research meeting notes.29,30 Analytical documentation incorporated thematic mapping. 29 Researchers collaboratively provided input to reach a consensus regarding generated themes, thus improving credibility. 31
Results
Four main interrelated themes and supplementary subthemes emerged from the analysis. Supporting excerpts from interviews appear as inserts.
Meaning of compassion
Sense of connection
Participants discussed compassion to incorporate a sense of an intangible connection with their patient and/or families. Some participants described such connection as a “human connection” (palliative care consultant).
Most participants discussed the importance of developing a therapeutic relationship with patients and their families as a component of compassion, allowing opportunity for a reciprocal connection:
We always talk about building up that relationship with the family so when it comes to the end they know we are here for them, and they know us well, and we know the family well (clinical nurse).
Communication
Every participant described communication to be an important component of compassion, which translates into various forms of interaction, including reflective listening, using respectful gestures and verbally appropriate means:
I see it in doctors, sitting beside people, holding their hands, touching their shoulders, perhaps getting a tear in their own eye…Some of that is compassion at the time, the way they listen the way their body attends, the way they really try and understand something from the patient's perspective, the way they respond to emotion (palliative care consultant).
Being present
A majority of participants felt that the meaning of compassion encompasses a component of being present with their patient and/or family:
…I recognise that giving that person your, all your attention, allows them to trust you and relax and that obviously alleviates not just physical pain, but also their emotional pain as well (clinical nurse).
Some reflected that although there exist time restraints, the awareness to be mindful is important in communicating a sense of connection and, in turn, demonstrating the act of compassion.
Empathy as a facilitator for compassion
Participants described compassion to involve being empathic by attempting to understand their patients' experiences, in turn relating the acknowledgment of such experiences to connecting with others. Some participants described empathy as a tool for creating an emotional response to facilitate compassion through the desire to help those suffering:
I think you should have an empathic response to their [patients'] experience. That empathic response moves onto a feeling of, I guess, wanting to help in some way (palliative care consultant).
Importance of providing compassionate care
A holistic approach
Providing a holistic approach emerged as a component of delivering compassionate care within a palliative care framework, which focuses on understanding patients' emotional, psychological, physical, spiritual, and family context:
Really identifying from the patients' perspective about what's going on and what their priorities and values are which may be nothing to do with their medical problems, it may be that their daughter is sick or that their sister is graduating from university next week, really get an understanding of how, what makes that person tick…(palliative care consultant).
As such, working toward positive outcomes might include alleviating pain and suffering, providing support, and advocating for patients to provide a sense of autonomy.
Strong working alliance
Most participants discussed feeling the sense of a strong working alliance in the context of their multidisciplinary team within palliative care:
It's a very team-based approach towards caring for patients…And for the team as well it can be very bonding from a team perspective when we've got it right. And when things aren't going right, having a good team around you can even make the tough times easier (palliative care consultant).
A majority expressed that such team environment facilitated the deliverance of compassionate care to patients. Furthermore, most participants described their team members to be supportive, reflecting the act of receiving compassion.
Compassionate care as renewable and enriching
Some participants expressed that providing compassionate care can be renewable. They discussed that by providing compassion to others in turn provides a sense of personal and professional fulfillment and sustainability:
I think it has made me a better person. I think it has got me in touch with aspects of life, of the human condition…it has done nothing but embellish and enrich my life (psychotherapist).
Barriers to providing compassionate care
System challenges
Challenges within the health care system were identified by participants as negatively impacting on how health care professionals deliver a compassionate care approach to their patients. Of note, all participants regarded time pressures to be a significant barrier:
…it [time] does affect compassion, because everybody wants to give compassionate care. Everyone can see there's a need and I think most people can put themselves in the situation of the person in the bed, but they are constrained with what they have to do elsewhere…(clinical nurse).
Some participants expressed their concern for being unable to always provide adequate patient care within the context of under-resourcing:
How do we do our job properly if we don't have the resources? We talk about all of this advanced care planning and about what your wishes are but sometimes we can't actually achieve them (social worker).
Burnout and compassion fatigue
Participants interchangeably discussed the terms burnout and compassion fatigue in relation to the implications such concepts have on health care professionals. Some participants made reference to burnout and compassion fatigue compromising patient interaction and care:
Interaction with patients becomes matter-of-fact, process driven. The texture of the relationship changes completely. So, less warmth, less insight, less creativity in how you approach situations and the whole nature of it can change (palliative care consultant).
Some participants described their colleagues' inability to sustain themselves both professionally and personally:
In a sense they are totally disengaged…and it comes a time when you're not able to engage anymore and essentially you're just going through the motions and doing the minimum (social worker).
Facilitating compassionate care
Participants reflected on the importance of undertaking various personal and work-related self-care practices to alleviate or prevent burnout and to be able to work at a sustainable capacity. Collectively, participants described self-care practices as physical exercise, meditation, mindfulness, and spending time with family. Some participants regarded taking breaks, going on holidays, and working in a part-time capacity as important work-related self-care practices.
Most participants discussed the importance of informal and formal debriefing as an important reflection strategy, and to provide and receive support:
I often debrief with my work colleagues…I quite often pick up the phone and say “hi, I've had a really stressful day.” Or I let them know they can come into my office to talk (Aboriginal and Torres Strait Islander health practitioner).
A few participants discussed the benefits of engaging in formal clinical supervision.
A majority of participants identified having not participated in compassion-based training, while some reported this may be beneficial. Some participants identified engaging in mindfulness-based training and one explained undertaking a self-compassion training course, reporting this to be “really significant learning” (palliative care consultant).
Discussion
While previous studies have examined compassion in reference to its definition and understanding by patients, there is an absence of literature pertaining to the understanding of compassion from the perspective of health care providers in palliative care settings; this study was the first to explore this qualitatively. Findings reflect the construct of compassion to be multidimensional, how providing compassionate care to patients encompasses a holistic and multidisciplinary approach, as well as being rewarding work. Comments pertaining to the challenges involved in providing compassionate care to patients highlight the impact of system barriers on the deliverance of such care.
Consistent with existing literature,5,6 participant responses to what the meaning of compassion is encompassed a multidimensional view rather than consensus of a definitive definition. 11 Similar to other research,7,19,20,32 numerous participants discussed the importance of connecting with patients through verbal and nonverbal communication, to connect on an intangible level, and utilize this emotional response to aid in alleviating suffering. Notably, participants discussed compassion to involve being mindful and present, and although there exists a small body of literature pertaining to mindfulness-based interventions to accompany this, the underlying processes through which such interventions are based require additional research attention to understand the effect of “compassion” components within these interventions.11,33 Also consistent with previous research, participants perceived compassion to be a meaningful construct by way of being necessary in guiding adequate patient care.34,35
Time restraints and resourcing difficulties were barriers for health care professionals in being able to provide compassionate care at times, as well as contribute to possible symptoms of burnout and/or compassion fatigue. This supports previous work which found that compassionate behavior may be depleted by understaffing, resource demands, increasing administration requirements, and market tension for improved efficiency; and detached behaviors exhibited by individuals and governing bodies impacted by such environments may emphasize uncompassionate societal norms. 36 Similarly, compassion fatigue has been associated with health care providers' disengagement, reduced capacity to provide compassionate care, and parting from clinical practice.16,17 Given that participants expressed frustration with time and resourcing limitations, this provides suggestion for areas of required improvement. Participants offered a practical theme of facilitating compassionate care to self and others and alleviate work-related stress through engagement in self-care practices and work-related debriefing. This aligns with previous literature which identified that enhancing self-care practice and professional boundaries may assist with alleviating work-related stress, burnout, and compassion fatigue. 37
Limitations
While the qualitative approach elicited valuable data, the open-ended nature of interview questions limits the generalizability beyond this sample. 21 Although the sample comprised a variety of health care professionals, there were a larger number of participants from some professions than others, creating a potential bias within the sample. Finally, given time limitations, location, and availability of some participants, the duration and method of interview (face-to-face or telephone) varied; some participants may have been able to articulate their responses better with more time or with the addition of nonverbal cues from the interviewer, thus introducing other potential biases. Despite such limitations, the sample represented health care professions working across multiple hospital- and community-based settings within Western Australia, with varying years of experience in palliative care.
Implications
Self-care practices were identified as important for personal and professional well-being, as well as participation in compassion-based training. As such, future educational efforts should be offered to students undertaking health care studies and health care providers, and include specific content relating to professional self-care and focus compassion components.33,35 Given that participants discussed compassion to involve being mindful and present with patients, this provides tentative support for future quantitative research into mindfulness-based training and associated measures for clinical practice and patient care. 11 Furthermore, as a strong team working alliance is important in fostering compassionate care, greater implementation of formalized team activities, debriefing, and clinical supervision would likely provide benefit, compassionate care, self-compassion, and the ability to receive compassion38,39; further research would be required to assess the impact.
Conclusions
This study presents a novel understanding of the components of compassion from the perspective of health care professionals working in palliative care. Important areas of improvement include resourcing, reducing time pressures, and education within palliative care settings. This will enable the fostering of compassionate care to patients, as well as enhanced well-being both professionally and personally for health care providers delivering such care. 40
Footnotes
Acknowledgments
The authors acknowledge the participants for their time. Their dedication and compassion to their patients are inspiring. They also thank Dr Jason Mills, Charles Darwin University, for taking the time to discuss his compassion research.
Funding Information
The present research was conducted without any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author Disclosure Statement
No competing financial interests exist.