Background
Compassion is extolled as a cornerstone of quality healthcare by patients, families, clinicians, and policy makers [
1‐
5]. The necessity of compassion within healthcare is evident in the first principle of the American Medical Association [
1] Code of Ethics that states, “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights” [
1]. The importance of compassion was subsequently echoed in a campaign in New Zealand to include compassionate care as a patient right [
4] and most recently within the Francis Inquiry Report [
5]. The importance of compassion is attested to by patients and their families, who have consistently ranked features of compassion among their greatest healthcare needs [
6‐
9]. While compassion has broad application across healthcare domains, it has particular relevance to psychological and spiritual issues at the end-of-life, being recognized as a marker and medium of spiritual care and an ameliorator of suffering—a foundational goal of palliative care [
10‐
15].
Although compassionate care seems intuitive, and the vast majority of clinicians are dedicated to imbuing their practice with compassion, incidents of substandard care—such as those described in the Francis Report [
5]—have generated concern internationally about the state of compassion in health systems. This troubling trend prompted the Institute of Medicine [
16] to issue a report on improving medical education by enhancing the behavioral and social science curricula in medical school. Healthcare educators, however, remain challenged to develop and sustain these core competencies with students. Towards the end of their education, when more direct patient care occurs, students exhibit fewer caring behaviors and less empathy [
17‐
20], and once in practice, clinicians miss 70 % of clearly identifiable empathetic opportunities, even though they feel confident about their ability to provide such care [
21]. Clinicians and patients may also differ in their perceptions of compassionate care, further complicating matters [
22‐
24]. For example, in studies on the key components of quality care, clinicians consistently ranked technical skills higher than intrinsic qualities, which is opposite to responses from patients and families [
3,
9,
25,
26].
One of the inherent struggles identified by researchers who strive to improve compassionate care is distinguishing between the construct of compassion and variants of sympathy and empathy. A recent evolutionary analysis of compassion placed sympathy, pity, and empathy within a family of compassion-related states [
27]. Empathy has been defined as an ability to understand and accurately acknowledge the feelings of another, leading to an attuned response from the observer [
28,
29]. Sympathy, on the other hand, refers to an emotional reaction of pity toward the misfortune of another, especially those who are perceived as suffering unfairly [
30,
31]. Etymologically, compassion means “suffering with” [
32] and has been defined as “a deep awareness of the suffering of another coupled with the wish to relieve it” [
33]. Albeit overlapping with empathy and sympathy, compassion seems to differ in several ways: its psychological and spiritual motivators; its predication in suffering; its reciprocal and experiential nature; its orientation towards action; and the vulnerable role that clinicians play in engaging suffering. Compassion is further differentiated from self-compassion, which involves one’s own suffering and a desire to alleviate that suffering through loving-kindness [
34]. Compassion seems to reside between objective and affective understanding oriented to an other (empathy) and subjective responses oriented to the self, rooted in pity toward an other (sympathy). It requires emotion and action on the part of respondents, finds its basis in love, vulnerability, and reciprocity, and is actualized in the disadvantaging of oneself for the benefit of another [
27,
35].
Despite centuries-old dialogue from scholars in philosophy and religion, the language of compassion has functioned largely as a superlative embedded in a corpus of interchangeable and often conflated care terms within the healthcare literature [
27,
36,
37]. As a result, the evidence base for compassion in healthcare remains underexplored. Researchers have reviewed related evidence for compassion-based psychotherapy [
38,
39], self-compassion [
34,
40,
41], and empathy [
42‐
44]. However, a comprehensive review of compassion in clinical care, including interventions and perspectives of patients, families, and clinicians, has not been undertaken.
The objectives of the current study were (1) to conduct a 25-year scoping review of studies on compassion in healthcare across disciplines; (2) map out the field of study on compassion in healthcare and identify gaps in the existing evidence base; and (3) provide recommendations that will inform future research in the areas of theory, education, research, and clinical practice.
Methods
We conducted a scoping review [
45,
46], which is a rigorous systematic literature review methodology that is particularly appropriate when investigating abstract, emerging, or diverse topics, and for exploring or mapping the literature. The review question was: What is known about compassion in clinical care?
Search strategy
The review team comprised both content and methodological experts to ensure applicability and rigor throughout the review process. In consultation with a research librarian, the team developed the search strategy following a preliminary iterative and pilot search of research databases. Two research assistants conducted searches of electronic databases between September and October 2013, including MEDLINE (OVID), PubMed, CINAHL, EMBASE, PsycInfo, EBM Reviews, Scopus, and Academic Search Complete. Given the interconnected ways in which the term compassion is employed in the healthcare literature and its relationship to similar concepts such as empathy, we initially kept the search terms broad to ensure wide coverage of the topic. The terms compassion, empathy, and caring were combined with appropriate MeSH terms and wildcards of the following terms: delivery of healthcare, healthcare, palliative, palliative care, end-of-life, terminal, end-of-life care, terminal care, terminally ill patient, euthanasia, cancer, neoplasm, carcinoma, tumor, religion, spirituality. Grey literature searches were completed across relevant organizational websites (e.g., National Cancer Institute, Health Canada, World Health Organization Institutional Repository for Information Sharing, Schwartz Center for Compassionate Healthcare), Google Scholar, and feedback from a network of experts in the field. Reference lists of the included articles were screened. The search strategy was limited to English language articles published between 1988 and 2013, representing a 25-year review. We completed an update to include literature published in 2014.
Eligibility criteria
Studies were included in the final synthesis if they sampled patients and caregivers, clinicians, healthcare administrators, or healthcare students. Studies with non-clinical populations (e.g., community, healthy samples) were excluded. We were interested in studies that had a primary aim to explore compassion towards others in clinical care, or interventions and educational programs to improve compassionate care. Studies that primarily focused on other related concepts (e.g., empathy, compassion fatigue, self-compassion, caring, ethics, communication) or used interventions that aimed to foster self-compassion (e.g., mindfulness-based stress reduction, compassion-focused psychotherapy) were excluded. Broad categories of outcomes were explored in this review: perspectives, clinical outcomes, knowledge, skills, or attitudes. Primary and secondary studies using qualitative, quantitative, or mixed-method designs were included. Letters, commentaries, editorials, dissertations/theses, conference abstracts, and case studies were excluded.
Study selection
Prior to starting the screening process, the screening tool was tested, including a calibration exercise to ensure a minimum of 90 % inter-rater agreement at each level of screening. First, two research assistants independently screened 100 records with the screening tool in Excel, which detailed the inclusion criteria and recorded reviewers’ decisions. Level 1 (title and abstract) calibration achieved acceptable agreement (Cohen’s kappa = 0.92). Following the calibration exercise, two research assistants divided the records and applied the inclusion criteria to the study titles and abstracts. All potentially relevant records were independently screened by the two research assistants, with disagreements being independently screened and resolved by the principal investigator. Next, two reviewers independently applied the inclusion criterion to all full-texts. Any disagreements were resolved by consensus among the review team. The inter-rater reliability for Level 2 screening (full-texts) was acceptable (Cohen’s kappa = 0.96).
Data items and data collection process
Full-text articles were read and data were extracted by two reviewers. Detailed information for the included studies was charted in a standardized data extraction sheet in Excel, including basic study details including author, title, journal, publication year, country of origin, purpose, and how compassion was conceptualized, as well as methodological details of each study, including setting, design, sample, recruitment, interventions, data collection and analysis, and results. Quality assessments are typically not conducted in scoping reviews, as their purpose is not to synthesize or weight evidence on a topic [
45].
Data synthesis
Given the heterogeneity of studies, we used a narrative synthesis approach to collate, summarize, and map the literature, including a numerical count of study characteristics (quantitative) and thematic analysis (qualitative) [
45,
47]. Initially, publications were grouped by study purpose (perspectives of compassion, interventions) and content analysis was used to convert tabulated data about study characteristics into frequencies for each grouping. For the narrative synthesis [
47], quantitative data were converted to qualitative textual descriptions. We then translated findings into themes across studies using inductive coding. Through this iterative process, emerging themes and subthemes were converted to a tabular format. The review team met weekly to discuss the process and results of the data synthesis. Three research team members identified emerging categories and themes with five senior members of the research team, validating emerging categories and themes, auditing the decision making trail, and providing feedback on the study implementation and results.
Discussion
This scoping review synthesized the empirical literature on compassion in healthcare over the last 25 years, and charted perceptions of compassion, as well as the effects of interventions of compassion, across patients, families, students, and clinician populations. Despite considerable discussion on the topic over the last quarter century, this is still a nascent area of study within healthcare. Nearly three quarters of all articles were published in the last 5 years, signifying that patients, their families, and society increasingly view compassion as a fundamental patient right [
4,
5,
16]. Major themes across the literature included the nature of compassion, how compassion is developed or eroded within the clinical practice and education settings, the interpersonal qualities, skills, and actions that mark compassion, and outcomes of compassionate care. As recipients of compassionate care and an essential cohort in operationalizing compassionate care [
93,
94], patients were relatively underrepresented in the review. Few studies sampled patients exclusively, included patients’ definitions of compassion, or assessed outcomes related to patients’ health status or health-related quality of life.
Despite its centrality to quality care and its ubiquitous usage throughout the literature, an empirical understanding of the nature of compassion is not well developed. The current review provides some insight into the nature of compassion, suggesting that compassion occurs in relationships that are predicated by two conditions—the presence of suffering in a person and a desire by another person to relieve it [
48,
52,
54,
55]. It is important to note that compassion is not contingent on a pre-existing relationship, but rather engenders and is delivered through a relationship. At a granular level, compassion consists of specific skills and actions aimed at the amelioration of multifactorial suffering, namely, acknowledging, responding to, understanding, and actively addressing the suffering of another [
52,
53]. None of these skills or actions, in and of themselves, are inherently compassionate; rather, it is the composite of these skills and their augmentation with caregivers virtues, intuition, affect, and presence that constitutes compassion, thereby guarding against a formulaic approach [
48,
53]. The dynamic and temporal nature of compassion suggests that while there may be key time points within the therapeutic relationship where compassion can play a pivotal role, compassion can be titrated and tailored over time. It may be affected by the responder’s proximity to suffering; however, this requires further clinical research [
59‐
61].
At an epistemological level, there was debate related to the teachability of compassion and whether it can be nurtured or is simply an innate quality of students’ disposition. Training capacity seemed to be contingent on the inherent qualities of students at baseline, yet evidence suggests that these qualities can be developed and sustained over time [
49,
50,
53] or even diminished over the course of clinical training [
16,
17,
86]. Further insight was provided by a recent randomized controlled trial on empathy training, which suggests that these inherent qualities can be developed and sustained [
95]. Studies have identified predictors of empathy: those who are perceived as being self and goal relevant, deserving, and reflective of clinicians values, preferences, behavior, or physical characteristics being more likely to elicit an empathetic response than those who are not [
96‐
98]. Empathy, particularly affective empathy [
31], overlaps with the broader concept of compassion however, compassion is distinguished by its internal motivators, its unconditional nature, and its predication on action.
Clinical mentors, reflective practice, and experiential learning were identified as effective teaching methods, in that personal experiences, preclinical education, spirituality, personal development, and clinical experiences were highly formative in this regard [
53,
57,
66‐
68]. The innate nature of compassion suggests that training needs to be individualized and perhaps is best assessed prior to admission to clinical training programs. An individualized approach to compassion training and care also guards against an overly prescriptive approach. Beyond demonstrating the externalized features of compassion, effective compassion training engages the inherent qualities and virtues of students. Compassion seems to be optimally developed through experiential and reflective learning—both in the context of students’ clinical training and personal life experiences [
53,
57,
66‐
68]. Sanso et al. [
99] identified the importance and impact that palliative care clinicians’ inner life has on their professional practice and quality of life, suggesting that a ‘reflective practice’ is beneficial to the recipients of compassion and may serve a protective function for those who are frequently exposed to end-of-life distress. Reflective learning and self-awareness seem to be particularly important teaching methods, as compassion is highly individualized to students and their patients—personalized healthcare that is customized to both clinicians and patients.
Compassionate care was predominantly conveyed in the clinical setting through interpersonal factors, especially in the context of clinical communication. Clinicians’ willingness to engage and be affected by their patients and their experiences, suffering as fellow human beings, was an essential feature of compassionate communication, requiring vulnerability on the part of clinicians [
52,
53,
70]. Patients who feel that their clinician listens to them, knows them as a person, reflects a warm and open demeanor, and are actively present, positively influence their overall care experience and their perception of their clinician [
9,
25,
26,
100‐
102].
While compassion is largely conveyed through relational communication and clinicians’ presence [
12,
103], it is also conveyed through tangible means such as tactile contact, posture and body language, vocalization, and small acts of kindness. Practical aspects of compassion extends the scope of competent care, from the bedside [
37], to the office, and the board room. It can manifest in various and diverse ways, such as a physician advocating for drug coverage with a patient’s insurance company or a hospital administrator making operational decisions in order to enhance the quality of care, rather than being guided solely by efficiencies and economics. Practical compassion is also the quintessential outcome of both spiritual traditions and effective spiritual care [
104]. These intangible elements of clinician’s inner life seem to be made tangible through physical acts of caring and the integration of patients’ spirituality into the care plan [
100,
105].
This comprehensive review also identified barriers to compassion in healthcare, the most significant being the practice setting itself. While compassion aptitude is strongly influenced by the inherent qualities that healthcare students possess at baseline, the practice setting seems to have a similar and potentially more powerful effect on these inherent qualities and related healthcare training. Considering the pivotal role that the clinical setting has on students, clinicians, and patients’ experiences of compassionate care [
2,
5], research and healthcare reform at the organizational level are needed, including institutional ethnographies, social return on investment research, knowledge translation studies, and the development of performance measurements associated with compassion. An inherent tension, however, is marrying the intangible nature of compassion to concrete institutional initiatives mandating compassion as a patient right [
4] and a required practice competency [
5]. The absence of pediatric studies and the limited number of studies within palliative populations suggest those areas warrant further research, given that expressions and experiences of compassion seem to vary by patient population and practice setting.
Patient-reported outcomes research in healthcare aims to measure the impact of clinical interventions directly from patient reports, commonly focusing on feedback related to biomedical interventions. The delivery of high quality compassionate care is also a significant patient reported outcome, which positively affects a patient’s perception of care and quality of life [
9,
35,
53], while mitigating against patient complaints and malpractice suits [
5,
106,
107]. A multi-centered Canadian trial investigating patients’ and family caregivers’ perceptions of what matters most in end-of-life care identified receiving healthcare that is respectful and
compassionate as the fifth highest endorsed item (ranked very or extremely important) within a 28-item multidimensional needs survey [
8]. When considering the role of virtues in compassionate care and their relationship to the highest endorsed items of “having
trust and confidence in the attending doctor” (first) and that “information be communicated by the doctor in an
honest manner” (second), the case for compassion is further supported. Clinicians’ technical skills and specialized knowledge are vital aspects of comprehensive care; however imbuing these components with compassion seems to have a greater healing effect than skills alone for both patients and family members [
10]. A recent American study investigating bereaved family members’ priorities for improving end-of-life care identified compassionate care as the single greatest priority [
108]. Preliminary findings also suggest that compassion may have a positive effect on specific clinician outcomes, including increased job satisfaction and retention [
48,
52,
61,
68]. These data contrast and further inform the notion of compassion fatigue and related research [
109].
There are limitations to this review. First, relevant studies could have been missed, despite a robust search strategy that included contacting experts in the field of compassion. Second, only English publications were included and most of these (95.4 %) originated within a Western setting, limiting the generalizability of this review. The search findings, nonetheless, reflect the current state of compassion research within healthcare and stress the need for cross-cultural studies that account for possible cultural variations. Third, the issue of conceptual specificity was also a factor within this review as the research team’s conceptualization of compassion may have influenced the development of categories and themes and associated findings. Fourth, studies that were extraneous to compassionate care or focused on related but distinct topics (e.g., empathy) were excluded. In excluding articles that focused on compassion fatigue (n = 80) from our review, the salutary effects of compassion, such as increased job sustainment and satisfaction, emerged as most dominant, rather than the potential negative consequences affiliated with loss of compassion and burnout. This decision was made to assure focus and feasibility of the review. We remain uncertain whether there is something inherent to compassion that ultimately results in fatigue in clinicians, or whether instead compassion functions as a superlative for broader issues causing work-related fatigue or job-related stress. Finally, studies in this review were primarily exploratory in nature. Thus, while their clinical implications can be inferred, their clinical efficacy and feasibility require further research.
This review can guide educators, researchers, and clinicians. While conceptualizing, measuring, and developing compassion interventions is a persistent challenge, the importance that patients and clinicians attribute to this hallmark of care cannot be easily dismissed, especially in instances where compassion is absent [
5]. Training healthcare students to be compassionate is also a challenge as the inherent qualities that students possess at baseline seem to be a prerequisite. The issue does not seem to be whether healthcare education and clinical practice can influence these qualities, but whether these settings enhance or diminish students’ capacity for compassion over time. Enhancing compassion in clinical care requires experiential teaching methods that engage the learner professionally and personally, because compassion is rooted in the dispositions of students and the actualization of these qualities within clinical practice. Compassion in clinical practice is also experienced through tangible means, guarding against a “one-size-fits-all” approach to clinical care, which does not account for variability across patient populations, clinical settings, or the personalities of clinicians. Enhancing compassionate care through education and integration within clinical practice cannot sufficiently address the current theory-practice gap, as the clinical milieu and the organizational values of the healthcare system seem to be the greatest enablers or inhibitors in bridging this gap.
Competing interests
The author(s) declare that they have no competing interests.
Authors’ contributions
SS conceived the study, provided research support to conduct the study, developed the search strategy, provided substantive expertise, oversaw all stages of the review, analyzed the data, wrote the manuscript and gave final approval of the submitted manuscript. JN provided methodological expertise, developed the search strategy, extracted and screened articles, analyzed the data, contributed to the writing of the manuscript and gave final approval of the submitted manuscript. SJM conducted the initial literature search, extracted and screened articles, analyzed the data, contributed to the writing of the manuscript and gave final approval of the submitted manuscript. HMC, TH, NH, SM, SRB contributed to the conception and design of the study, provided expertise to the review and analysis process, critically revised the manuscript and approved the final version of the manuscript.