Act of Consoling Helps Those Who Console: A Multicenter Observational Survey Study in Hospice Services

Abstract

Background:

The contemporary scientific literature documents a lack of attention toward the act of consoling put into practice by health care professionals (HCPs) in hospice services.

Objective:

To describe the act of consoling and its meaning for hospice-employed HCPs.

Design:

A multicenter observational survey study was performed through a paper-based questionnaire.

Subjects:

The study was sent to the directors of 10 hospices in Northern Italy and distributed to 232 HCPs.

Results:

A total of 218 HCPs responded (94%). The results showed that most HCPs consider the practice of consoling to be essential to their profession, but they also underscored the extreme complexity of the process.

Conclusion:

The act of consoling is not simply a professional duty defined in contractual clauses. Rather, it is a set of specific communicative practices and skills required of HCPs.

Introduction

Beyond responding to clinical inquiries by patients and patients' families, health care professionals (HCPs) are often requested to respond to spiritual and existential queries as an integral part of whole-person care. Guaranteeing a patient's physical health and well-being is a widespread value among physicians and nurses.^1–8

The responses to these needs are opportunities for HCPs to reflect on their own work, vulnerability, and on the effects of their actions not only on patients or patients' families, but also on their own selves.^9–12

Religious beliefs may be held as vital to those who console, but the act of consoling is not a form of religious or spiritual practice in its own right.^9,11,12

The ill or dying patient may or may not feel the need to be consoled in a manner that involves religious or spiritual aspects. The study was based on the concept that actions of consolation should be considered simply as acts of love and sensitive care, and should not be influenced by the religious or spiritual beliefs of the consoler.

Aim

The aim of this study was to describe the act of consoling and its meaningfulness for HCPs with reference to the effectiveness of their own work and to the professional culture acquired, with a focus on the communicative practices and skills required for consolation.^9,11 The idea of consoling was based on the concept that only a person who is close to those who suffer is fully able to perform this difficult task.

Methods

Studies suggest that consolation can be conceptualized as a communicative act resulting from a combination of verbal and nonverbal cues.^9,11 Based on these considerations, we defined consolation as “the set of gestures, attitudes and words used by HCPs ‘to be close to’ those who suffer, to assist them in their suffering.”

We performed a multicenter observational survey study of HCPs across 10 hospice services in Northern Italy. The 10 hospices were selected based on the length of their activity (i.e., minimum 10 years). We considered this to be a sufficiently long period to allow the consolidation of a well-established organizational culture, including a shared set of communicative patterns among HCPs.¹³

The final version of the questionnaire consisted primarily in the presentation of our definition of “consolation” and included 32 single- and multiple-choice questions with open-ended options for some answers (Supplementary Appendix Table SAT1).

The questionnaire was divided into five parts based on question type (Tables 1 –5).

Table 1.

Sociodemographic and Professional Characteristics of Respondents

	Total	n (%)
Age (years)	215
<30		24 (11)
31–40		34 (16)
41–50		80 (37)
51–60		59 (28)
>60		18 (8)
Female gender	218	174 (80)
Profession	214
Physician		27 (12)
Nurse		94 (44)
HCA		49 (23)
Chaplain		8 (4)
Other		36 (17)
Having children	217
Yes		133 (61)
Religion	211
Practicing		107 (51)
Not practicing		72 (34)
Not religious		32 (15)
Years of work in a hospice	213
<3		43 (20)
3–10		91 (43)
11–20		58 (27)
>20		21 (10)

HCA, health care assistant.

Table 2.

Agreement with and Understanding of the Definition of Consolation among Respondents

	Total	n (%)
Degree of agreement	217
Strongly agree		130 (60)
Mostly agree		84 (39)
Slightly agree		3 (1)
Understandability	217
Strongly agree		125 (58)
Mostly agree		90 (41)

Table 3.

Composition, Function, Importance, and Effects of the Act of Consoling for the Patient, Patient's Family, and Health Care Professionals

	Total	n (%)
(12) The act of consoling is composed of the following:	216
Mainly by gestures of closeness		16 (7)
By a presence made of both gestures and words		199 (92)
Mainly by words		1 (1)
(13) What is the fundamental nature of consoling?	213
It is above all a human virtue		47 (22)
It is above all a religious quality		2 (1)
It is above all a professional responsibility		14 (7)
It is above all a possible moment of profound sharing with the patient and patient's family		150 (70)
(16) What impact does having consoled have on the operator?	202
Mainly satisfaction for one's professional competence		55 (27)
Mainly a feeling of being useful to others		121 (60)
Mainly a feeling of gratitude deriving from the good action performed		22 (11)
Mainly a form of burnout prevention		2 (1)
Mainly as a way to fulfill the contractual mandate		2 (1)
(17) When is the act of consolation most effective?	211
In end-of-life conversations		2 (1)
In the transition phase between active care and palliative care		12 (6)
In all phases of the terminal illness pathway		163 (77)
When the person is no longer able to manage suffering		34 (16)
(21) Which is the most suitable place to console the patient?	207
The patient's room		156 (75)
The common living space		0 (0)
The doctor's or nurse's office		0 (0)
A dedicated room		12 (6)
The atrium/lobby		0 (0)
Other		39 (19)
(22) Which is the most suitable place to console family members?	209
The patient's room		9 (4)
The common living space		22 (11)
The doctor's or nurse's office		21 (10)
A dedicated room		113 (54)
The atrium/lobby		0 (0)
Other		44 (21)
(30) Do you believe you are able to console the patient(s) and his/her family because you have been consoled in certain moments of your own life, including in the workplace?	210
Yes, being consoled in the workplace can be useful for improving the quality of one's own performance		111 (53)
No, consolation is above all a personal aspect external to the professional environment		10 (5)
No, those who console do not need to have been consoled in the workplace		81 (38)
Other		8 (4)

Table 4.

Practical Aspects of Consolation, Including Modality, Places, and Reasons, for Unsuccessful Consolation Processes from the Perspective of Health Care Professionals

	n (%)
(18) In case of refusal of dialogue, how do you think the patient can be best consoled taking into account the definition of consolation we have given?
With simple daily routines	47 (22)
With simple gestures of care	40 (19)
Respecting silence while remaining present	165 (79)
Simply being available to a relationship	104 (50)
Other	3 (1)
(19) In case of refusal of dialogue, how do you think family members can be best consoled taking into account the definition of consolation we have given?
With simple daily routines	31 (15)
With simple gestures of closeness	47 (22)
Respecting silence while remaining present	128 (60)
Simply being available to a relationship	150 (70)
Other	2 (1)
(20) If the patient does not want to talk about his condition, how do you think relatives can best console him/her, taking into account the definition of consolation we have given?
With simple daily routines	64 (31)
With simple gestures of care	36 (17)
Respecting silence while remaining present	133 (64)
Simply being available to a relationship	100 (48)
Other	3 (2)
(23) In your opinion, when consolation is effective with what adjectives can be defined?
Free	66 (30)
Sincere	158 (73)
Engaging	97 (45)
Satisfying	40 (18)
Other	29 (13)
(25) If you answered “often” or “sometimes” what do you think the reasons are?
Lack of time	103 (59)
Personal difficulties in the practice of consolation	48 (26)
High number of requests for consolation	33 (18)
Poor training in this area	30 (16)
Other	44 (24)
(27) If you answered “often” or “sometimes” what do you think the reasons are?
Lack of time	92 (54)
Personal difficulties in the practice of consolation	42 (25)
High number of requests for consolation	25 (15)
Poor training in this area	25 (15)
Other	41 (24)
(28) Taking into account the given definition of consolation, do you consider that your ability to console the patient and/or family members is also linked to your personal experience of received consolation in particular moments of your life, including those outside the workplace?
Yes, life experiences can be useful in daily work	140 (66)
Yes, often the act of consoling is efficient because having received consolation means one is able to offer it	50 (24)
Yes, the act of consoling is often efficient because, having received no consolation means we are able to understand its lack and, therefore, we are more likely to offer it	0 (0)
No, consolation is more of a professional skill	8 (4)
No, it is not certain that whoever consoles must necessarily have been consoled in his/her turn	72 (34)
Other	9 (4)
(31) Based on your experience, which acts of consolation are most effective?
A smile	155 (71)
A word	112 (52)
A hug	106 (49)
Touching hands	96 (44)
Simply remaining silent	104 (48)
Putting the patient in the condition to be able to talk about the situation he/she is experiencing	159 (73)
Reading a poem/a prayer together	38 (18)
Other	23 (11)
(32) In your experience, when you were consoled, what consoling acts did you find most helpful?
A smile	105 (49)
A word	106 (49)
A hug	136 (63)
Touching hands	36 (17)
Simply remaining silent	56 (26)
Being put in the condition to express the situation I was experiencing	145 (67)
Reading a poem/a prayer together	20 (9)
Other	15 (7)

The table reports answers to multiple-choice questions.

Question 25 is referred to the following question: Have you ever realized that you have not consoled the patient enough, taking into account the definition of consolation we have given?

Question 27 is referred to the following question: Have you ever realized that you have not consoled family members enough considering the definition of consolation we have given?

Table 5.

Experience-Related Consolation Skills and Potential Relationship to the Quality of the Work from the Perspective of Health Care Professionals

	Total	n (%)
(14) In your professional experience, how important is console the patient for the health care professional?	216
Very important		179 (83)
Moderately important		35 (16)
Of little importance		2 (1)
(15) In your professional experience, how important is consoling the family members for the health care professional?	216
Very important		163 (75)
Moderately important		51 (24)
Of little importance		2 (1)
(24) Have you ever realized that you have not consoled the patient enough, taking into account the definition of consolation we have given?	215
Often		23 (11)
Sometimes		159 (74)
Almost never		30 (14)
Never		3 (1)
(26) Have you ever realized that you have not consoled family members enough considering the definition of consolation we have given?	216
Often		13 (6)
Sometimes		151 (70)
Almost never		50 (23)
Never		2 (1)
(29) In your experience, does feeling satisfied in the consolation act increase the quality of your own work?	215
Very much		95 (44)
Moderately		99 (46)
Not significantly		5 (2)
Not at all		2 (1)
I do not have a precise opinion on this		14 (7)

From January 1 to June 30, 2018 a paper-based survey was administered to 232 HCPs who were requested to complete the questionnaire anonymously.

The study was approved by the Brescia Ethics Committee on September 12, 2017 (NP 2846).

Results

At the end of the study period, 218 (94%) questionnaires were returned. Four of these were incomplete but were, however, retained for the descriptive analysis (the total number of answers for each item are indicated in Tables 1–5).

Respondents' demographics are reported in Table 1. The majority of HCPs were women (80%). Most were aged 41–60 years (65%) and had at least one child (61%). HCPs were doctors (13%), nurses (44%), caregivers (i.e., orderlies) (23%), priests/pastoral/spiritual workers (4%), and other HCPs (17%). The vast majority of respondents (80%) reported extensive experience in palliative care.

Concerning the religious sphere, half of the respondents claimed to be practicing (51%, especially doctors and other HCPs), but the remaining subjects either did not actively practice any form of religious worship (34%) or were nonbelievers (15%). The majority of HCPs strongly (60%) or mostly (39%) agreed with the definition of “consolation,” and only few (1%) considered it hardly understandable (Table 2).

The great majority of HCPs (92%) believed that the act of consoling is best carried out by a combination of gestures and words. The hospital room was considered the ideal place for consoling patients (75%), whereas a dedicated room/area was deemed to be the best place for consoling the patients' families (54%). More than half of HCPs (53%) felt that having received consolation in the workplace had helped to improve the quality of their work (Table 3).

In the event of a patient refusing dialogue, most respondents (79%) recognized that a respectful silence was the best form of consolation along with additional multiple nonverbal communicative acts (respondents who filled in open-ended answers most frequently indicated a smile, a caress, a hug, openness to dialogue, willingness to listen, and other gestures expressing care). As for the patient's family, the option chosen by most HCPs (70%) was to remain available for dialogue. According to respondents the three features that best describe effective consolation are sincerity (73%), emotional engagement (45%), and spontaneity (30%) (Table 4).

The analysis revealed that most HCPs (65.7%) felt that the capacity to console is primarily acquired through personal life experiences lived outside the workplace. The act of consoling was considered to be very important both toward the patient (83%) and patient's family (75%). The majority declared that “sometimes” they had not been able to console patients (74%) or the patients' families (70%). Finally, almost all HCPs (90%) found fulfilment in actions of consolation and this had an impact on the quality of their work (Table 5).

Discussion

This study provided evidence that the act of consoling implies a set of attitudes and behaviors serving the function of supporting those who suffer. At the same time, it revealed that the actions of consoling equally impact on the comforter. The ability to console is not only a rich experience bringing personal gratification to the HCP, but it is also a set of specific competences required of HCPs.^10,13

Consistent with prior studies, HCPs underlined that the act of consoling is not a one-time event.^2,13–15 Rather, it is a process unfolding throughout a long-term relational dimension.

Research has remarked on the importance of the atmosphere in the hospice room.⁹ In line with this, the HCPs in our study reported that the hospice room should be regarded as the most suitable setting for consolation to be most effective.

Adding information to previous research, the HCPs in our study reported that the least suitable place to console the patient and his/her family was the doctor's office or infirmary.^16,17

Regarding the relationship between HCPs' ability to console and their personal experiences of receiving consolation, the questionnaire differentiated between workplace and private life experiences. Most respondents believed that their experience of receiving consolation in the workplace, especially in hospices and palliative care settings, helped them to improve the quality of their day-to-day practice. Receiving consolation in personal situations also proved to contribute to their ability to console others. Therefore, private life experiences play a critical role in making HCPs effective consolers. Being ready to offer consolation entails being open to dialogue, to oneself, and one's own life experiences along with the ability to discern.

Consolation speaks of an asymmetrical relationship where the consoler is able to hear the patient's request, recognize its specific characteristics, and take on the responsibility of responding to it.²

The practice of consolation is essential in good care and allows HCPs to carry out their duties in an empathic manner.^18,19

Limitations of the study

This study has some limitations. First, regardless of the degree of religious engagement of HCPs, only a minority of subjects in our study were nonbelievers. Prior research has shown that religion has a major impact on the attitudes of HCPs in end-of-life care.^20,21 It is possible that the considerable proportion of believers in our sample may have influenced the results. Furthermore, we focused on HCPs and did not investigate the experience of consolation from the perspective of patients and patients' families. Future research to explore the view of consolation of patients and patients' families is warranted.

In addition, because consolation is a communicative act concerning human existence, future studies should assess the most appropriate educational format for the training of HCPs.

The association of cultural and sociodemographic factors, individual and/or workplace experiences with consolation in end-of-life care across different geographical areas equally requires further investigation.¹⁸

Authors' Contributions

F.N., E.M., A.G., G.Z., A.A.G., G. Miccinesi, and M.P. made a substantial contribution to the concept or design of the study and acquisition, analysis, and interpretation of data; G. Mangeri has participated sufficiently in the study to take public responsibility for appropriate portions of the content; C.P. revised the article critically for important intellectual content.

Footnotes

Acknowledgments

We thank the directors and the staff of the 10 hospice services for their co-operation in this study.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Disclosure Statement

The authors declare that there is no conflict of interest.

Supplementary Material

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