Nurse’s perceptions of organisational barriers to delivering compassionate care: A qualitative study

Abstract

Background:

Compassionate care is an international priority of healthcare professionals. There is little understanding about how workplace issues impact provision of compassionate care in nursing practice. Therefore, it is important to address the workplace issues and organizational factors which may hinder compassionate care delivery within nursing practice.

Objective:

The aim of this study was to explore workplace and organizational barriers to compassionate care from the nurses’ perspective.

Research design:

The study used a qualitative exploratory design, and data were analyzed by conventional content analysis.

Participants and research context:

A total of 15 nurses working in different fields of nursing were recruited from four hospitals at northwest of Iran. Participants were selected by purposive sampling. Semistructured interviews were conducted for data collection.

Ethical consideration:

Ethical approval of this study was gained from the Ethical Review Board of Tabriz University of Medical Sciences.

Findings:

The main theme which emerged from data analysis was “unsupportive organizational culture.” This theme had two main categories including “excessive workload alongside inadequate staffing” and “the lack of value on compassionate care.”

Discussion:

Organizational barriers to development of compassionate in clinical practice were identified in this study. A closer examination of these barriers is required to move compassionate practice from an individual responsibility to a collective responsibility that is owned and shared by organizations.

Conclusion:

For compassionate care to flourish, policy makers, managers, and healthcare providers must foster an organizational atmosphere conducive to compassionate care.

Keywords

Compassion compassionate care nursing care

Introduction

Compassionate care is an international priority of healthcare professionals.^1,2 Similarly, there is consensus that compassionate care is the most important part of the healthcare system, especially in nursing practice.^3,4 In fact, it could be argued that compassion is synonymous with nursing care.² Compassion is a complex concept which has been defined as “a deep awareness of the suffering of another together with a wish to alleviate it.”⁵ Dewar⁶ proposed that vulnerability also prompts someone to act compassionately. She defined compassionate as

… the way in which we relate to human beings. It involves noticing another person’s vulnerability, experiencing an emotional reaction to this and acting in some way with them, in a way that is meaningful for people. It is defined by the people who give and receive it, and therefore interpersonal processes that capture what it means to people are an important element of its promotion.

When caregivers share in the other’s suffering and vulnerability, they strengthen and comfort the person by expression of compassion.⁷ Therefore, compassion is related not only to the practical expressions and actions for relief for the patient who is suffering⁸ but also to day-to-day acts when someone recognizes a person is vulnerable.⁹

Compassion, as a complex concept, has many attributes.¹⁰ Cole-King and Gilbert¹¹ developed a specific model of compassion in their work. The model represents six main attributes of compassion including motivation to be supportive toward others, the capacity for being sensitive to other’s suffering (sensitivity), emotional response to another’s distress (sympathy), the abilities to bear difficult emotions (distress tolerance), to be in the shoes of others and imagining his or her needs (empathy), and accepting a person’s distress without judging his or her pain (none-judgment). In another study, Proctor¹² described the active listening to patient’s needs, preserving patient’s dignity, and anticipating their anxieties as other attributes of compassionate care.

Because of the nature of nursing work, nurses see some kind of suffering in their clinical practice. Therefore, compassion is highly relevant for the nursing profession,¹³ and it has been reported as the essence of nursing care.¹⁴ Furthermore, it is considered a central concept to some nursing theories.¹⁵

Despite increasing work pressures, nurses are pressured to deliver compassionate care in clinical settings for meeting patients and general public expectations.¹⁶ Compassionate care is an underpinning philosophy of nursing profession¹⁷ and a moral dimension of nursing care.^13,18 Compassionate care in nursing is an active and engaged practice rather than a simple expression of pity, which is passive and reactionary.¹⁹ Having compassion, as a stronger feeling, urges nurses to understand patients’ suffering or vulnerability which results in doing something for reducing or alleviating of their suffering or vulnerability.²⁰

There is increasing evidence of the important role that compassionate care can play in improving health outcomes.²¹ Anandarajah and Roseman²² believe that combining the clinical competence with compassion is actually the ideal feature of clinical practice within healthcare systems. Other literature suggests that therapists who express compassion have been found to be more effective therapists.²³ Brown et al.²⁴ have argued that compassion-focused therapies are therapeutically influential and effective. Moreover, findings of prior studies showed that compassionate care leads to the building of trust between nurses and patients, hence results in accurate understanding and diagnosis of patients’ condition.²⁵ It also has other patient benefits such as better adherence to nursing recommendations and reduced anxiety of patients^21,26 which could help to provide quality care for people in need.⁷

Despite the obvious central role of compassionate care in nursing,² some studies have reported the compassionate care deficit within the nursing discipline.^3,10,24 Nurses are constantly confronted with pain, illness, and even death within the complexities of modern healthcare practice, and a large number of nurses are trying to cope with these distresses through detaching themselves from the suffering of patients and from work.¹⁹ This may lead to compassion fatigue for nurses which can affect their health and diminishes their ability to provide quality of care.²⁷

It is clear that nurses and other healthcare providers take care of patients within the context of organizations, not in isolation. Therefore, the organization plays a key role in providing a supportive or unsupportive environment for compassionate care.¹⁰ In this regard, Mills et al.² argued that if the workplace is not compassionate, how we can expect nurses to provide compassionate care.

In a study on pre-qualifying healthcare students and health professionals, Christiansen et al.²⁸ examined the enablers and barriers to compassionate care. They found a range of individual, team, and organizational factors which impact compassionate care delivery. Good role models, collaborative team, and supportive leadership were reported as the main enabler factors, while target-driven culture, time constrains, and difficulty of building compassionate-centered care with patients who are aggressive were mentioned as barriers to compassionate care. In other studies, the lack of self-compassion has been reported as barriers to cultivation of compassionate care toward others.^2,7,27 Dewar and Nolan²⁹ proposed that enriched environments, strong leadership, and appropriate support are necessary for developing compassionate relationship–centered care in an older people care setting. Another study by Horsburgh and Ross³⁰ showed that receiving support from senior staff nurses helped newly graduated nurse to deliver compassionate care. Using an appreciative action approach, Dewar and Mackay³¹ identified the processes which helped people to provide compassionate care. They found that the processes of knowing what mattered to people, understanding how they feel and using this knowledge to work together to shape the way things were done helped development of compassionate care.

While literature has placed increased value on compassionate care,^32
–34 there is little understanding about how workplace issues and organizational barriers would impact provision of compassionate care in nursing practice. To remove the obstacles of compassionate care, it is necessary to address the workplace issues and organizational factors which may hinder the compassionate care delivery within nursing practice.

Aim

Since the barriers to compassionate care have not been studied from the unique perspective of clinical nurses and due to contextual differences, the aim of this study was to explore the organizational barriers to compassionate care from the unique perspective of nurses working in clinical settings of Iran.

Method

Design

Since compassion is a subjective experience,^17,35 a qualitative exploratory design was selected for this study. Qualitative approach also fitted well with the focus of being able to understand in detail perceptions of nurses.

Settings, sample, and participants

A total of 15 nurses working in different fields of nursing were recruited from four university-affiliated hospitals in Tabriz. Tabriz is the biggest city in northwest of Iran in East Azerbaijan province. Participants were selected through a purposeful sampling method. This sampling is generally used in qualitative research and helps the selection of participants who are information-rich cases.³⁶ Inclusion criteria for nurses were (a) having at least baccalaureate degrees in nursing, (b) working as a nurse with at least 1 year of clinical experience, and (c) willing to participate in study. Data were collected between April 2015 and October 2015.

Ethical considerations

Ethical approval of this study was gained from the Ethical Review Board of Tabriz University of Medical Sciences. All participants received full information about the objectives of the study and were assured of confidentiality and anonymity. Also, we obtained a written consent from all participants for recording of the interview.

Data collection

Semistructured in-depth interviews were conducted for data collection. In a qualitative study, the researcher starts the interview with open-ended questions and then he or she uses probing questions focusing on the participant’s comments.³⁷ Questions were focused on nurses’ thoughts regarding organizational barriers to providing compassionate care. Each interview lasted between 20 and 80 min. We used the main following question for eliciting responses from nurses on compassionate care: “Please describe the organizational barriers of compassionate care in your nursing practice?” Further questions were asked according to the participant’s response. All interviews were recorded digitally, transcribed verbatim, and transferred into MAXQDA software for data management. Interviews were continued until two last interviews gained no new information, and we reached data saturation.

Data analysis

This study used conventional content analysis. Qualitative content analysis is mainly used for subjective interpretation of collected data using the organized classification process of coding, where data analysis results in codes and code categories.³⁷ Content analysis is mainly well matched to analyzing the multidimensional and subjective phenomena in the nursing field.³⁸ Therefore, in this study, a qualitative content analysis was used for deep understanding of factors that hinder the implementation of compassionate care in nursing practice.

The conventional content analysis, as described by Hsieh and Shannon³⁷ and Graneheim and Lundman,³⁹ was used for interpretation of interview transcripts. At first, the transcripts were read several times by two main researchers to obtain the general understanding of the experiences of the participants. The meaningful units of the text were then extracted and labeled with a code. Finally, codes were grouped under subcategories and categories according to the similarity of codes. The discussion between other researchers was continued until an agreement was reached in terms of categories and category.

For establishing trustworthiness and credibility of the study, we used peer checking in the phase of data analysis;³⁹ two other experienced researchers read the transcripts and analyzed data. A consensus was found on the emerging themes. Moreover, member checking with three participants was done to determine the accuracy of data and to ensure the validity of results.^40,41

Findings

A total of 15 nurses (9 female and 6 male nurses) with an average age of 33 years participated in this study. Working experience in nursing field ranged from 3 to 26 years. A total of 11 participants had bachelor’s degree and 4 had master’s degree.

The main theme which emerged from data analysis was “unsupportive organizational culture.” Table 1 summarizes the theme, categories, and subcategories that contributed to organizational barriers to compassionate care.

Table 1.

Theme, categories, and subcategories.

Theme	Category	Subcategory
Unsupportive organizational culture	Excessive workload alongside inadequate staffing	– Time pressure – Paper works – Overcrowded wards – Conspicuous staff shortages – Poor salaries
Unsupportive organizational culture	The lack of value on compassionate care	– Lack of appreciation or acknowledgement – Lack of professional education

Unsupportive organizational culture

The result showed that nurses value compassion, but there are many factors that can gradually destroy these values. Most of them were related to systems or organization in which nurses work there. These factors were abstracted to two main categories including “excessive workload alongside inadequate staffing” and “the lack of value on compassionate care.”

Excessive workload alongside inadequate staffing

Participants discussed that they were eager to deliver compassionate care but having a heavy workload dampened their motivation. They described many workload-related issues that hampered their ability to deliver compassionate care to their patients.

Time pressure

Time pressure was considered as the main barrier for nurses to show compassionate-focused activities. They felt that they are working under more time pressures in clinical settings. When time is an issue, they try to complete their task quickly, rather than spending more time to establish a compassionate-based relationship. Participants discussed this issue as follows:

I must do a lot of work in my shift. For example I assess patients’ needs, control vital signs, … In this situation I ignore psychological aspects and compassionate care, I only focus on physical care. I think for finishing my ordinary tasks. (Nurse 3)

As the number of patient is more, I can’t communicate with them all … I have not more time to listen to them … (Nurse 4)

I provide care to many patients in each shift, I take care of 15 patients. You only think about the amount of time I allocate to control their vital sign … I must do other tasks too. I am under pressure to finish my tasks. (Nurse 2)

Paper works

One task that staff perceived as wasting nurse’s time is the filling out of papers in daily practice. Participants felt that they spent more time filling out forms and papers rather than spending time with patients and delivering compassionate care. The following quotes illustrate this:

We complete a lot of paper work in our daily practices, it wastes our time. I think it is a main barrier … Most of my time is wasted by filling out written work; so I could not spent my time on clinical work and compassionate care. (Nurse 3)

When I want to transfuse blood to my patient I fill out a lot of forms … In fact, most of this works is not necessary. (Nurse 4)

My organization wants me to fill some papers. Unfortunately, the system gives more importance to paper work, rather than giving importance on providing high quality care. Therefore, I have to complete them. (Nurse 10)

Overcrowded ward

When wards become overcrowded, each nurse must deliver care to more patients. Therefore, they could not efficiently communicate with their patients. Therefore, in the overcrowded environment, person-centered compassionate care is often difficult to sustain:

Our ward is overcrowded. We are three nurses with 33 patients; therefore we could not meet the needs of all patients. (Nurse 6)

Others said,

When I take care of fifteen patients, how I can communicate with each patient … Without communication, how I can deliver compassionate care. (Nurse 3)

When the ward is overcrowded and we have a large number of patients, my compassionate acts are less. In this situation, I don’t try to explore the needs of all patients. (Nurse 8)

Conspicuous staff shortages

Nurses felt that staff shortages were the main barrier to showing compassion to their patients. This issue was reported by most of the participants. This barrier is exemplified by the following quotes:

The number of nurses who work in each ward is very important … It is clear that when I take care of 20 patients in a ward, I could not think on all dimensions of patient care such as their feelings or compassion … (Nurse 1)

There is nursing shortages in all hospitals… The ministry of health don’t employ nurses, all hospital suffer from this problem … (Nurse 7)

Our workload is high, but the number of nurse is low. This is the major barrier to compassionate care. (Nurse 9)

Poor salaries

Some nurses reported that they receive inadequate salaries as compared with other healthcare professionals. They argued that this suppresses their commitment on compassionate care:

I like to do clinical practice, but my salary is very low when compared to our responsibilities in clinical practice. The salary is not satisfying. This is a barrier to my effort on compassion. (Nurse 3)

The lack of value on compassionate care

Participants argued that their organization and educational systems place little value on compassionate care, which would hamper implementation of compassionate practice. They felt that it had low value for the organization and education. This category included two main subcategories: lack of appreciation or acknowledgement and lack of professional education.

Lack of appreciation or acknowledgement

Participants reported that lack of appreciation from managers or colleagues leads to challenges in providing compassionate care. Nurses argued that when managers do not support their efforts for compassionate care delivery, it suppresses their motivations for providing such kind of care:

In our hospital, there is no appreciation strategy. Managers don’t support the effort of nurses who treat people compassionately … Of course we don’t need such appreciation, but we expect managers to understand our efforts. (Nurse 4)

The system does not distinguish between nurses who listen to patients’ suffering and those who are not compassionate. (Nurse 13)

Another nurse, with 10 years of experience, made a similar comment:

We don’t receive any appreciation for doing compassionate practice. (Nurse 12)

Lack of professional education

Most of the nurses lacked the professional education and formal training on compassionate care in nursing schools and within clinical practice:

Unfortunately we did not have any specific courses on compassionate care in our nursing education. The nursing faculty has not provided enough information about how we can deliver compassionate care. (Nurse 10)

Our issues regarding compassionate care is rooted in nursing education … We learned about many things in our nursing programs. But, when I was a student, there was not any content or credits related to compassionate care, so I lack the information about compassionate care. (Nurse 4)

Discussion

Nurses, as front-line practitioners, are in direct contact with patients; therefore, addressing the barriers to compassionate care from their view is important. The results of our study showed that compassionate care in nursing practice is deterred by some factors. Participants identified key organizational and workplace factors that hindered them in their efforts to deliver compassionate care. In this regard, work-related issues such as time pressure, paper work, overcrowded wards, staff shortages, and poor salaries were identified as the main barriers for providing compassionate care in nursing practice.

Freeney and Tiernan⁴² argue that work overload drains nurses’ energy and inhibits work engagement among them. Heavy workload not only increases the occurrence of poor communication between nurses and patients but also leads to nurses job dissatisfaction.⁴³ In a study on Australian nurses, McKenna et al.⁴⁴ found time pressure as the main barrier for nurses to do advanced care for their patients. This supports our finding that nurses are working in time pressure due to heavy workload.

Nurses argued that paper work is a time-consuming act. In a study in Ireland, nurses reported paper work as the filling out of futile forms which hinder them to spending more time with their patients.⁴² However, documentation tasks take priority over nursing care.⁴⁵ To this end, computer nursing documentation within healthcare organizations could help alleviate this problem. Therefore, this can free up nurses time to concentrate on providing compassionate care.⁴⁶

In an ethnographic study conducted on emergency nurses in Australia, Fry et al.⁴⁷ found that organizational pressures restrained nurses’ ability to convey compassionate care. Firth-Cozens and Cornwell⁴⁸ also found that organizational pressures were the main barrier to compassionate care. In our study, staff shortages were identified as another important factor that affected compassionate care delivery. Nursing shortage is a serious challenge worldwide,⁴⁹ as well as in Iran.^50,51 It has been found that this shortage decreases the quality of care provided by nurses.⁵²

Other identified factor which impeded the implementation of compassionate care was the poor salaries which nurses receive. Studies conducted in Iran has shown that nurses receive poor salaries compared to other healthcare professional.^51,53 Freeney and Tiernan⁴² noted that when nurses receive poor salaries compared to other members of the healthcare team, they think that their effort goes unrecognized, thereby results in degrading the nursing profession.

Other factors which impact compassionate care are the value that is placed on compassion by the organization and in education. In our study, lack of appreciation or acknowledgement was identified as another barrier for developing compassionate care. This result is consistent with other studies which found that a negative workplace culture alongside inadequate support prohibits healthcare providers in providing high-quality care.^32,42,44 Maslach et al.⁵⁴ argued in their model that when employees receive inappropriate or lack of reward they are more susceptible to job burnout. Therefore, staff who work in challenging situations without support from the wider system are not able to deliver compassionate acts and finally become burnt out.^55
–57 Similarly, in a systematic review, Khamisa et al.⁵⁸ concluded that lack of professional recognition and insufficient reward has a negative impact on nurses’ quality of work. In another study with oncology nurses, Perry et al.⁵⁹ found that continued lack of support from peers and administrators was related to the onset of compassionate fatigue, which consequently resulted in poor quality of nursing care.

However, healthcare systems could promote compassionate care by supporting positive nurses’ experience.¹⁰ Frampton et al.²⁶ argued that providing a gratitude environment in which healthcare providers feel valued will fuel them for providing compassionate care activities. They also found that gratitude and appreciation of nurses’ work by on-the-spot recognition and handwritten thanks note boost delivery of compassionate care.

Crawford et al.¹⁰ argue that compassionate care occurs within the context of organizations, not in isolation. Therefore, it is impossible to provide compassionate care unless the leaders of healthcare system prioritize and support the development of compassionate care by creating compassionate spaces and demonstrating a strong commitment to the activities that support this kind of care.

In short, research have found that organizational stress and lack of support reduces compassionate care within healthcare systems.^42,48 Conversely, healthcare institutions that try to create compassionate spaces and processes allow compassionate care to thrive,¹⁰ and nurses can deliver the compassionate care within these supportive environments.²

Limitations and suggestions for future research

There are some limitations in our study. Like other qualitative studies, the finding could not be generalized to other populations outside of those who participated in this study. However, intensive study of participants provided a contextualized and rich understanding of barriers to compassionate care. In this study, we only examined the nurses’ experiences on compassionate care, and we did not evaluate other healthcare professionals’ experiences. So, it would also be valuable to evaluate the barriers to compassionate care from the viewpoints of other healthcare providers, clinical teachers, and students. Also, we did not explore the patients view on compassionate care; thus, additional research with participation of patients and their family will result in a better understanding of barriers to compassionate care.

Conclusion

Although nursing literature highlights the importance of compassion, there are some organizational and work-related factors which may impact the development of compassionate care in clinical practice. For compassionate care to flourish, policy makers, managers, and healthcare providers must foster an organizational atmosphere conducive to compassionate care.

In this study, the main barriers was related to workload-related issues, and most of the nurses’ time in Iran is wasted for completing paper works; thus, decreasing paper works by using computer nursing documentation could help to solve the problems. Since the lack of value on compassionate care was perceived as another barrier to compassionate care, healthcare managers and nurse leaders should emphasize on appreciation of nurses’ work alleviate. Moreover, establishment of collaborative team work between healthcare providers could foster development of compassionate-based care delivery. Furthermore, incorporating specific education about compassionate care in nursing programs could develop better understanding of nursing students and faculties on attributes of compassionate care. Similarly, implementation of continuing education programs in nursing which relates to ethical dimension of care such as compassionate care could develop nurse’s skills and knowledge for providing this kind of care.

Footnotes

Acknowledgements

This project is related to the PhD thesis in nursing of M.G. We would like to thank all nurses who participated in our research.

Conflict of interest

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 financially supported by the research vice-chancellor of Tabriz University of Medical Sciences.

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