How important is compassionate healthcare to you? A comparison of the perceptions of people in the United States and Ireland

Abstract

Compassionate care requires understanding of another’s pain or suffering, with commitment to doing something to relieve this. It is endorsed by nursing and other healthcare professionals in their codes of ethics as one of their main responsibilities. Yet too often it comes to public attention as a deficiency in healthcare organisations. Any effort to achieve meaningful quality improvement must start with a method of measuring patient experience. The Schwartz Center Compassionate Care Scale™ (SCCCS) is a unidimensional 12-item questionnaire with high internal reliability, developed from a study of physicians and recently hospitalised patients in the US. The present study extends usage of the SCCCS to a sample of the people in Ireland. The SCCCS again shows high internal reliability, with all items loading on a single factor. The findings indicate that recently hospitalised patients and non-hospitalised individuals were in agreement about the importance of the elements of compassionate care. Patients’ ratings of their doctors’ compassionate behaviours were significantly correlated with ratings of their healthcare team. However, patients reported that demonstration of compassion – whether by their doctor or the whole healthcare team – fell short of what they considered important. The SCCCS is a reliable and valid measure of perceptions of compassionate care across different countries, with potential to contribute to quality improvement in healthcare.

Keywords

caregivers communication compassionate care descriptive quantitative evaluation research organisation and service delivery patient experience survey

Introduction

All human beings want to be treated with respect and compassion, especially when ill and vulnerable. Healthcare professionals recognise and endorse compassion as one of their primary responsibilities, as evidenced by its inclusion in professional codes of ethics (American Medical Association, 2001; American Nurses Association, 2015). Yet the lack of compassion has been cited as a critical problem in healthcare organisations and systems (Francis, 2013; Health Information and Quality Authority, 2015). The ability to address organisational and systemic deficiencies requires measurement of issues that are important to patients and professionals alike, reporting of patients’ experiences and translation of measurement into meaningful quality improvement. Examples of measurement of patient-reported experiences of care include the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) in the United States (Hospital Consumer Assessment of Healthcare Providers and Systems, 2005), the National Health System Adult In-Patient Survey in England (Care Quality Commission, 2014) and the Irish Society for Quality and Safety in Healthcare (ISQSH) survey (Irish Society for Quality and Safety in Healthcare, 2011).

Important aspects of compassionate care, however, are not routinely measured. This stems in part from lack of consensus among professionals, researchers and the public about definitions of compassion, empathy and related constructs (Papastavrou et al., 2011). Some researchers suggest that empathy involves perspective-taking and experiencing emotions congruent with another (Bernhardt and Singer, 2012). Others view empathy as primarily a cognitive process – the ability to understand the concerns and perspectives of another and the ability to communicate that understanding (Hojat, 2007). Empathy may not necessarily evoke helping behaviours. When another’s emotions or context suggest pain, distress or suffering, the perceiver may experience empathic personal distress – feelings of being overwhelmed and the desire to detach from or avoid the other (Decety and Lamm, 2009). Alternatively, the perceiver may experience empathic concern, which is also called compassion, motivation to help and pro-social behaviour (Batson, 2011). One’s responses to others’ concerns and distress depend on myriad variables that include state and trait empathy, self-awareness and ability to regulate one’s emotions, whether one has down-regulated responsiveness due to repetitive exposure to others’ pain and suffering or whether one is suffering from burnout or compassion fatigue (Figley, 2002; Lown, 2016; Maslach et al., 2001).

Based on extant research in cognitive and social psychology and social neuroscience, we define compassionate care as a process that involves understanding and empathic concern for another’s concerns, distress, pain or suffering, coupled with relational action to ameliorate these conditions (Lown, 2016). Compassionate care emerges from relationships based on empathy, emotional support and efforts to understand and relieve the patient’s concerns and distress; effective communication within interactions, over time and across settings; respect for and encouragement of participation in decisions and care; and contextualised knowledge of the patient as an individual within a complex network of relationships and circumstances at home and in the community (Lown et al., 2011).

Inability to provide compassionate care, emerging from the elements described above, may affect patients’ satisfaction, their health outcomes and costs of care. For example, patients rate their care experiences more highly following treatment in hospitals that support and recognise employees’ compassion, and are more likely to recommend them (McClelland and Vogus, 2014). A meta-analysis of outpatient physician and nurse training interventions designed to increase focus on the patient as a person within a unique social context, and to share control of consultations and decisions, showed improved patient perceptions of professionals’ communication skills, empathy and attentiveness to their concerns (Dwamena et al., 2012). Health outcomes, including control of chronic conditions such as hypercholesterolemia and diabetes, and hospitalisation for their severe complications, are better among patients whose clinicians self-report higher levels of empathy and compassion than among patients whose clinicians report lower levels (Del Canale et al., 2012; Hojat et al., 2011). Costs of care are also higher when clinicians do not adapt care based on contextualised knowledge of the patient and his or her concerns, preferences and psychosocial constraints (Epstein et al., 2005; Schwartz et al., 2012; Teno et al., 2000).

The myriad causes of compassionate care deficiencies require systemic approaches and solutions. We suggest that compassion capacity among professionals and staff may be seen as a barometer of the health and values of a healthcare organisation and system. Compassionate care cannot be sustained without organisational and systemic support and sufficient time and resources to demonstrate it. Patients’ perceptions provide insight into how robustly these values that are foundational to the caring professions are inculcated and supported. The Schwartz Center for Compassionate Healthcare (SC) developed an instrument to measure these perceptions: the Schwartz Center Compassionate Care Scale™ (SCCCS).

The SC conducted a study of the importance and successful demonstration of 16 elements of compassionate care among a nationally representative sample of 800 recently hospitalised patients and 510 physicians in the US (Lown et al., 2011). In this study, physicians and patients generally agreed on the importance of these elements. However, while 78% of physicians agreed that most healthcare professionals provide compassionate care, only 54% of patients agreed that they do. A psychometric analysis of the data from this survey resulted in the creation of the unidimensional 12-item SCCCS, which has high internal reliability, item-total correlation and factor loading onto the central concept of compassion (Lown et al., 2015). Responses to the SCCCS correlated significantly with patient satisfaction.

Here the authors describe additional assessment of the validity and reliability of the SCCCS scale. We aimed to assess similarities and differences between US and Irish perceptions of the importance of the behaviours queried, and whether, as in the US, the SCCCS indicated gaps between perceived importance and observed demonstration of these behaviours.

Methodology

The ISQSH adapted the SC’s original survey to query public perceptions in Ireland about the importance of 16 elements of compassionate care and, if recently hospitalised, respondents’ perceptions of the successful demonstration of these behaviours (see Appendix online). The purpose of the current analysis is to further examine the face validity of the originally identified 16 compassionate care items and their reliability by comparing the perceptions of people in Ireland with those in the US. We also report recently hospitalised Irish patients’ ratings of their doctors’ and healthcare teams’ compassionate care and variables that influenced these perceptions.

ISQSH placed a request to the general public to participate in a survey and a link to the survey on its website. The ISQSH also contacted other patient and advocacy organisations and asked them to promote the survey on their respective social media sites. The introduction to the survey indicated that clicking ‘next’ signified participants’ voluntary participation in the survey, and that by completing the survey, participants had agreed to take part. They were told that participation was voluntary and that they were free to withdraw at any time. Participants were also told that individual information would not be passed on to anyone outside the survey team, that the results would be being tabulated on an anonymous basis and that responses were entirely confidential. The survey asked participants to rate the original 16 behaviours in terms of the importance of the healthcare team’s ability to demonstrate each behaviour (version 1) and, if hospitalised within the previous 12 months, the successful demonstration of each behaviour by the healthcare team (version 2) and by the doctor in charge of their care (version 3).

Principal axis factoring was used to examine the factor structure of the SCCCS. Student t-tests and analysis of variance were used to compare scores between groups and across surveys. Pearson correlation was used to examine the relationship between scores. All results were also checked using non-parametric alternatives and only significant results of both were reported.

Results

A total of 501 respondents completed the survey. Demographic information is available for hospitalised patients of whom 19 were male and 127 female; 39 did not report gender. The median age was 47.

Basic psychometric analysis

Table 1 shows the behaviours rated by respondents on all three versions of the survey.

Table 1.

Surveyed compassionate behaviours of healthcare providers and teams.

1	Express sensitivity, caring and compassion for your situation.
2	Strive to understand your emotional needs.
3	Consider the effect of your illness on you, your family and the people most important to you.
4	Listen attentively to you.
5	Convey information to you in a way that is understandable.
6*	Give you hope even if/when the news is bad.
7	Gain your trust.
8	Always involve you in decisions about your treatment.
9	Comfortably discuss sensitive, emotional or psychological issues.
10	Treat you as a person not a disease.
11*	Apologise if he or she made a mistake.
12	Show respect for you, your family and those important to you.
13*	Show understanding for your cultural and religious beliefs.
14	Communicate results in a timely and sensitive manner.
15	Spend enough time with you.
16*	Only involve you in decisions about your treatment when you want to be involved.

People in Ireland were asked to rate the importance they attributed to 16 interpersonal behaviours in the provision of compassionate healthcare. If recently hospitalised, they were asked to rate the successful demonstration of these behaviours on a scale of 1–10 with 1 being the lowest possible rating and 10 the highest possible rating. Items marked with an asterisk (*) were omitted in the 12-item SCCCS.

Reliability

The Cronbach’s alpha for analysis of survey version 1 (importance of the 16 behaviours) was high at .925 with all 16 items, but better when just the 12 items of the SCCCS were included at .949. As in the US data, items 6, 11, 13 and 16 had the lowest item-total correlations, hence the improved alpha for the 12-item version. For analysis of survey version 2 (successful demonstration by the patient’s team) the pattern of results overall was similar in that the alphas were high for the 16 items at .967, and .970 for the 12-item scale. For analysis of survey version 3 (successful demonstration by the doctor in charge) the alphas were .983 for both scales. As there seems good evidence that the 12-item scale is at least as good as the 16-item scale, the rest of the analysis reported here will concentrate on the 12-item scale.

Factor analysis

For version 1, the items load onto one factor which accounts for 63.47% of variance, with a minimum factor loading of .7 onto that factor. For version 2, the items load onto one factor which accounts for 73.16% of the variance, with a minimum factor loading of .62. For version 3, the items load onto one factor which accounts for 82.92 % of the variance, with a minimum factor loading of .86. Overall the results suggest that all versions of the scale are measuring one factor.

Ceiling and floor effects for total scale scores

For version 1, 31% of participants gave top endorsement to all items; for version 2, one person gave the lowest endorsement for all items and 13% gave the highest; for version 3, the same people repeated their endorsement pattern.

Score comparisons among different versions of the compassionate care survey

A repeated measures analysis of variance with total scores on the 12-item scale across versions revealed significant differences between versions 1, 2 and 3 (F(2, 164) = 38.45, p < .001). In total, 83 participants completed all three versions of the scale. Mean total score was 109.89 (SD 15.11) for version 1, 86.90 (SD 27.56) for version 2, and 85.19 (SD 32.95) for version 3. Version 1 is significantly different from both of the other versions on post hoc tests. Versions 2 and 3, however, in which participants rated successful demonstration of compassionate care by their healthcare team and then their doctor, respectively, were not significantly different (t(85) = .69, p = .45).

A total of 127 participants completed ratings of versions 1 and 2. In a direct comparison of ratings on version 1 (importance) and 2 (successful demonstration by healthcare team), there was a significant difference between total scores (t(126) = 9.98, p < .0005). The mean total score for version 1 was 110.06 and for version 2 it was 84.20. There were also significant differences for each individual item in versions 1 and 2. The largest mean difference (2.65; t(155) = 12.18, p < .0005) was on item 4, ‘Listen attentively to you’.

There were no significant differences between any of the items between version 2 (team) and version 3 (doctor). The survey also asked recently hospitalised patients to rate overall levels of compassion provided by nurses, and in another question, overall levels of compassion provided by doctors/consultants. There were significant positive correlations between the ratings of the compassion of both nurses (r = .53, p < .001) and doctors (r = .58, p < .001) and the score on the SCCCS.

Three potential responses were offered to a global question that asked ‘Overall do you think the care you received was compassionate?’. There was a correlation of .6 between this and the total SCCCS scores. Answers to this question were highly correlated with total scores on the SCCCS (r(113) = .60, p < .001).

We also compared importance rating scores of recently hospitalised and non-hospitalised people. The total rating score by recently hospitalised patients on version 1 (M = 110.24, SD = 14.95) was not significantly different from the non-hospitalised people (M = 110.33, SD = 15.45; t(384) = −.06, p = .96).

Irish and US ratings of compassionate behaviours

We could not compare Irish and US overall scale results as participants in the US survey were initially presented with two different sets of 8 items each rather than a single set of 16 items as in the Irish survey. We therefore compared differences on individual survey items. Table 2 demonstrates the similarities between Irish and US ratings of the importance of each compassionate behaviour. Ratings were significantly different only on the items ‘spend enough time with you’ and ‘gain your trust’. However, given the multiple individual tests in this analysis one might expect this to occur by chance.

Table 2.

A comparison of American and Irish ratings of importance of compassionate care behaviours on the 12-item SCCCS.

Compassionate behaviour item	Irish mean (SD)	American mean (SD)	t-test
Express sensitivity, caring and compassion for your situation.	9.01 (1.75)	9.11 (1.57)	t(576) = 0.68
Strive to understand your emotional needs.	8.45 (2.10)	8.75 (1.91)	t(564) = 1.68
Consider the effect of your illness on you, your family and the people most important to you.	8.77 (1.92)	9.06 (1.73)	t(564) = 1.79
Listen attentively to you.	9.35 (1.71)	9.51 (1.24)	t(567) = 1.32
Convey information to you in a way that is understandable.	9.32 (1.71)	9.56 (1.26)	t(571) = 1.88
Gain your trust.	9.12 (1.58)	9.50 (1.15)	t(569) = 3.25
Always involve you in decisions about your treatment.	9.41 (1.31)	9.42 (1.39)	t(567) = 0.08
Comfortably discuss sensitive, emotional or psychological issues.	9.11 (1.53)	8.99 (1.75)	t(576) = −0.08
Treat you as a person not a disease.	9.51 (1.32)	9.49 (1.28)	t(579) = −0.17
Show respect for you, your family and those important to you.	9.45 (1.38)	9.52 (1.23)	t(580) = 0.61
Communicate results in a timely and sensitive manner.	9.28 (1.39)	9.43 (1.30)	t(581) = 1.26
Spend enough time with you.	8.55 (2.13)	8.89 (1.74)	t(579) = 2.03

People in Ireland were asked to rate the importance they attributed to various interpersonal behaviours in the provision of compassionate healthcare. Survey responses provided ratings on a scale of 1–10 with 1 being the lowest possible rating and 10 the highest possible rating. A t value above 1.96 is significant at 0.05 (shown in bold).

Variables influencing patients’ perceptions of compassionate healthcare

Table 3 shows recently hospitalised patients’ ratings of their healthcare team’s compassionate behaviours. Continuity of care and frequency of contact were associated with higher SCCCS ratings. Those who met the doctor in charge of their care (M = 88.43, SD = 27.15) had significantly higher SCCCS ratings than those who did not (M = 68.48, SD = 31.29; t(124) = 2.99, p = .003). This was reinforced by the finding of a significant positive correlation between the question asking ‘How often did your doctor come to speak to you?’ and SCCCS rating (r = .34, p = .001). Those who were checked regularly by a member of their healthcare team (94.93, 22.84) also endorsed significantly higher SCCCS ratings than those who were not (56.16, 26.41; t(108) = 7.72, p < .001). Further, those who had their pain managed (96.37, 21.77) endorsed significantly higher SCCCS ratings than those who did not (63.65, 29.37; t(100) = 6.25, p < .01).

Table 3.

Irish patients’ ratings of successful demonstration of compassionate behaviours by their healthcare team when recently hospitalised.

Compassionate behaviour item	Irish mean (SD)
Express sensitivity, caring and compassion for your situation.	7.06 (2.73)
Strive to understand your emotional needs.	6.31 (2.86)
Consider the effect of your illness on you, your family and the people most important to you.	6.17 (3.02)
Listen attentively to you.	6.72 (2.76)
Convey information to you in a way that is understandable.	7.32 (2.84)
Gain your trust.	6.70 (2.95)
Always involve you in decisions about your treatment.	7.21 (2.93)
Comfortably discuss sensitive, emotional or psychological issues.	6.47 (3.01)
Treat you as a person not a disease.	7.09 (2.85)
Show respect for you, your family and those important to you.	6.88 (2.94)
Communicate results in a timely and sensitive manner.	7.03 (2.73)
Spend enough time with you.	6.13 (3.07)

Recently hospitalised patients in Ireland were asked to rate the successful demonstration of various interpersonal behaviours in the provision of compassionate healthcare by their healthcare providers and teams. Survey responses provided ratings on a scale of 1–10 with 1 being the lowest possible rating and 10 the highest possible rating. As there was no significant difference between provider and team ratings, but a greater number of respondents rated teams than providers, the team ratings are shown here.

Patients’ desire for connection and contact was further demonstrated by their responses to a question related to their relationship with the care team. Those who answered ‘nothing’ to the question ‘What is the single most important thing that the healthcare team could have done to improve their relationship with you?’ (105.8, 13.52) scored significantly higher on SCCCS than those who endorsed some possible improvement (77.74, 29.21; t(124) = 5.08, p < .001). Those who wanted their concerns to be more closely listened to had the lowest SCCCS ratings (70.21, 32.65), followed by those who wanted more consideration about how the illness affected them and their family’s lives (75.52, 28.04). These concerns received the most endorsements (28 and 21, respectively).

The value of an apology was shown among those who believed a mistake was made in their care (n = 45). Those who received an apology endorsed significantly higher SCCCS ratings (91.44, 21.23) than those who did not (66.67, 33.91; t(43) = 2.08, p = .04). Only 20% of those who believe a mistake was made received an apology.

There was no significant difference in ratings on the SCCCS among those who had been treated in a public hospital (84.53 vs 29.89) and a private hospital (85.0 vs 25.14; t(114) = −.07, p = .95).

Discussion

This study adds to our understanding of the validity, reliability and potential utility of the SCCCS. It also provides a glimpse into public perceptions of the provision of compassionate healthcare in Ireland. It is clear that for the most part there is little difference between Irish and US respondents’ views on the importance of the elements of compassionate care. The Irish survey found that, whether recently hospitalised or not, the importance of the compassionate care behaviours was similarly endorsed. This suggests that these elements may be generally important to the public regardless of health status.

As healthcare is increasingly provided by teams, the Irish survey added queries about team compassion. The finding that there was no significant difference in ratings between recently hospitalised patients’ perceptions of compassionate behaviours of their doctors and their healthcare team suggests that the SCCCS could be used to assess team as well as individuals’ behaviours and to explore how the team influences perceptions of compassionate care. This was further substantiated by the finding that there were significant correlations between overall ratings of compassionate care by nurses and overall ratings of compassionate care by doctors with overall SCCCS score. We can only speculate on the implications of these findings, but they suggest that each and all members of the team influence such perceptions; that is, that the perception of compassionate care is ‘averaged’ over the sum of its parts by patients.

As in the US survey, Irish respondents indicated that the demonstration of compassionate behaviours, whether by providers or healthcare teams, falls short of what they consider important and therefore desirable. A question about overall perceptions of whether care received was compassionate was highly correlated with total SCCCS scores, suggesting that a single-item question may potentially be used for global assessment. Because of the differences in the way the Irish and US surveys were implemented, here we do not report a comparison of Irish and US patients’ overall perceptions of successful demonstration of compassionate behaviours. However, we did find significant differences between US and Irish ratings on individual behaviour items, suggesting that the SCCCS may be able to discriminate the relative success of compassionate care performance in different countries.

Conclusion

This study adds to the evidence that the SCCCS is a valid and reliable measure of patients’ perceptions of compassion and correlates with questions designed to measure fundamental aspects of compassionate healthcare and patient satisfaction with care received. We again note a gap between patients’ perceptions of the importance of the compassionate behaviours included in the scale and their successful demonstration in a recent hospitalisation. The finding that there are no significant differences in SCCCS scores when used to assess individual or team performance also adds to our understanding of patients’ perceptions of compassionate care, and further, this suggests that all healthcare professionals bear both individual and collective responsibility for its provision.

We hope to stimulate further use and investigation of the SCCCS by other researchers. We hope others will use the SCCCS as an instrument to assess patients’ perceptions of the results of quality improvement efforts and resource management designed to improve compassion in healthcare. Perhaps the use of such instruments will also foster reflection about the importance placed by society as a whole on the importance of compassion alongside the push for efficiency and efforts to reduce healthcare costs. Our ultimate goal is to ensure that the demonstration of the fundamental values of the caring professions is enabled by healthcare organisations and systems, and that barriers to the demonstration of compassionate care are addressed.

Key points for policy, practice and/or research

The Schwartz Center Compassionate Care Scale™ (SCCCS) is a reliable and valid measure of patients’ perceptions of compassionate healthcare of physicians and healthcare teams.

There is agreement between patients and members of the public in different countries about the importance attached to the elements of compassionate care.

Recently hospitalised patients in different countries indicated that demonstration of compassion in practice falls short of what they consider important and desirable.

The SCCCS has the potential to support quality improvement in healthcare across different countries.

Footnotes

Authors' note

The survey incorporates the 16-item Schwartz Center Compassionate Care ScaleTM. This original scale is reproduced with permission from the Schwartz Center for Compassionate Healthcare and can be obtained from Beth Lown at the Schwartz Center for Compassionate Healthcare. Additional survey elements were devised by Hilary Dunne who has given permission for their presentation here.

Declaration of conflicting interests

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

Supplemental material

Supplementary material for this paper can be found at .

Beth A Lown is an Associate Professor of Medicine, Harvard Medical School and Medical Director of the Schwartz Center for Compassionate Healthcare, both in Boston, Massachusetts, and a general internist at Mount Auburn Hospital, Cambridge, Massachusetts.

Hilary Dunne is the Chairperson of the Irish Society for Quality and Safety in Healthcare (ISQSH). She has continuously worked to promote quality and safety in Irish healthcare and to provide a channel for effective feedback and improvement initiatives.

Steven J Muncer is an Academic Director of the Clinical Psychology Programme at Teesside University. He has a Bachelor of Science degree in Experimental Psychology and a Master's from Oxford University, and a PhD from the Institute of Psychiatry, University of London.

Raymond Chadwick is a Postgraduate Tutor in Clinical Psychology at Teesside University, and a Consultant Clinical Psychologist at South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK.

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