Validation of a 5-item tool to measure patient assessment of clinician compassion in the emergency department

Compassion has been defined as the emotional response to another’s pain or suffering involving an authentic desire to help [1‐3]. Although closely related to empathy, defined as the ability to understand another’s emotions, compassion is the responsive action that flows from that understanding and thus can be perceived by patients [1‐5]. Clinician compassion is considered a vital aspect of high quality healthcare by patients and clinicians [6]. Not only is clinician compassion desired by patients, but it is also associated with improvement in clinical outcomes [7]. For example, compassionate care has been demonstrated to reduce patient fear and anxiety during medical care [8], and conversely, a lack of compassionate care in the emergency department (ED) is a cause of acute patient distress [9]. Further, a recent study found patient perception of greater clinical compassion in the ED during resuscitation of a potentially life threatening medical emergency to be associated with less post-traumatic stress disorder symptoms at 30 days after discharge [4]. Compassion is also vital for clinicians as current evidence suggests that increased clinician compassion is associated with more resilience, an improved state of well-being, and decreased rates of burnout [10‐12]. This relationship between compassion and burnout may be especially important for emergency medicine clinicians who have the highest rates of burnout among medical specialties and a burnout prevalence that continues to rise [13]. Therefore the ED may be a unique context where increased compassion could provide maximal benefit for both patients and clinicians.

Given that compassionate care is associated with important patient- and clinician-oriented outcomes, having the ability to measure patient assessment of compassion (as opposed to clinician self-assessment of compassion or third party observation of compassion) in the ED would be an important advancement for assessing healthcare quality. However, a recent systematic review identified a need for a psychometrically validated instrument that comprehensively measures the construct of compassion in healthcare settings [5]. Realizing this need, we previously developed and validated a 5-item compassion measure for administration with the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey, a patient satisfaction survey for adult outpatient clinic visits used by the United States (U.S.) Centers for Medicare and Medicaid Services for all healthcare organizations that receive payments from Medicare [14]. Although we found the 5-item compassion measure to be a reliable tool to measure patient perception of clinician compassion in the outpatient setting, this tool has not yet been validated for use in the ED setting. Given the inherit differences in patient experiences during outpatient clinic visits compared to ED visits, the tool must be psychometrically validated among ED patients before it can be reliably used in the ED setting. The objective of this study was to validate the 5-item compassion measure for use in the ED. We hypothesized that the 5-item compassion measure is a valid and reliable tool to quantify a distinct construct (i.e. compassion) among patients evaluated in the ED.

Response rates are displayed in Fig. 1. Patient self-reported characteristics are displayed in Table 2. Patient age ranged from 18 to 93 years. Fifty-five percent of participants were female, and 40% had some degree of college education. The cohort was diverse with respect to race and ethnicity. Fifty-two percent of patients were discharged home from the ED.

Confirmatory factor analysis found all five items loaded well on a single construct (Table 3). We found our model had good fit based on our a priori definition: CFI = 1, TLI = 0.99, and SRMR = 0.02. Given the large sample size, as expected the chi-square test for model fit was significant, p = 0.042. The model was found to have good fit across all three institutions: Cooper University Hospital (CFI = 0.99, TLI = 0.99, SRMR = 0.02, chi-square test p = 0.157), Washington University in St. Louis (CFI = 1, TLI = 1, SRMR = 0.01, chi-square test p = 0.721), and Hennepin County Medical Center (CFI = 0.99, TLI = 0.99, SRMR = 0.03, chi-square test p = 0.234).

Reliability was excellent (Cronbach’s alpha = 0.93) among the entire cohort, as well as across the three institutions: Cooper University Hospital (alpha = 0.93), Washington University in St. Louis (alpha = 0.95), and Hennepin County Medical Center (alpha = 0.89). The 5-item compassion measure ranged the full scale (5 to 20), and 49% of respondents gave perfect scores (i.e. score of 20). Additional file 1: Figures S1-S5 display the frequency for response scores for each individual item for the 5-item compassion measure. The 5-item compassion measure had a moderate correlation with overall patient satisfaction [r = 0.66 (95% CI 0.62–0.69)] and recommendation of the ED to friends and family [r = 0.57 (95% CI 0.52–0.61)]. Given the likelihood ratio test comparing the two nested models was statistically significant, we reject the null hypothesis that the covariance between the two latent structures is 1 (i.e. the two factor model has better fit). We found the two-construct model to have good fit, CFI = 0.99, TLI = 0.99, SRMR = 0.02, chi-square test p = 0.030. These results suggest that the items in the 5-item compassion measure quantify a discrete construct and do not simply reflect overall patient satisfaction with the ED visit.

This study provides validation of the 5-item compassion measure to assess patient perception of clinician compassion in the ED. To accomplish this aim, we enrolled a moderately large number of racially diverse emergency department patients both admitted to the hospital and discharged home in geographically distinct areas of the United States, while maintaining excellent response rates. We found the 5-item compassion measure to be valid and reliable across three academic institutions, as demonstrated by good model fit and the consistently high alpha across institutions. The 5-item compassion measure was found to have only a moderate correlation with patient satisfaction. This suggests the 5-item compassion measure is not another (redundant) patient satisfaction measure. In addition, confirmatory factor analysis found the 5-item compassion measure assesses a separate construct from patient satisfaction. These results have implications for both patients and clinicians.

There is currently evidence supporting an association between compassionate care and better clinical outcomes for patients [4, 7, 24‐30]. Alternatively, a lack of compassion is associated with lower quality of care and increased risk of harm to patients through medical errors [31]. However, despite the substantial evidence demonstrating the importance of compassionate care, there is currently a lack of (or inconsistency in) compassionate care across health care systems globally [7], with physicians frequently overlooking opportunities to be compassionate, instead taking a narrow biomedical focus during bedside patient encounters [32]. Thus, having a means to assess patient perception of compassionate care in the ED is of the utmost importance.

Historically, it has been thought that investing oneself in patients may be emotionally demanding and could have a negative effect on clinician well-being (i.e. “empathic distress”) [3]. However, recent data suggest that clinician compassion can promote long-term resilience and well-being for clinicians and therefore may represent a method of counteracting or preventing burnout [10‐12].

Emergency medicine is a very high stress discipline. Emergency medicine clinicians frequently have secondary exposure to trauma, which is now a valid Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criterion stressor for posttraumatic stress disorder [33]. Further, the prevalence of burnout among emergency medicine clinicians continues to rise, and emergency medicine clinicians have the highest rate of burnout across all medical specialties [13]. Identifying means to reduce stress and burnout, and improve job satisfaction is therefore paramount to emergency medicine clinicians.

Being compassionate is not simply an inherent trait, which clinicians either do or do not possess; rather, recent evidence supports that compassionate behaviors can be learned through training and practice [2, 34]. Thus, by being able to measure patient assessment of compassion in the ED it will be possible to identify physicians who could potentially benefit from interventions to promote compassionate care. In addition, further research is needed to develop and test if interventions aimed at promoting compassion among clinicians improves patient outcomes and/or decreases clinician burnout. Having the ability to measure patient assessment of compassion will be vital for such research studies.

We acknowledge that this study has important limitations to consider. First, this study was performed in three academic EDs, thus it is possible that a study performed among a different population would find different results. However, our consistent good model fit and reliability across all three sites provides evidence of generalizability. Second, due to staffing constraints we performed a convenience sample, as opposed to enrolling consecutive patients. Thus, we are unable to report the total number of patients who presented to the ED who met all inclusion and no exclusion criteria. However, we believe our sample is well representative of the ED population as a whole at our study sites given the inclusion of patients discharged to home as well as those admitted to the hospital, and the large, demographically diverse sample size across the three institutions. Furthermore, as the goal of this study was to validate the 5-item compassion measurement tool in the ED (i.e. not to measure or quantify compassion at this time), it is unlikely that having consecutive patients would have significantly altered our results. In addition, we administered the compassion measure while patients were still in the ED in order to avoid lower response rates typically associated with after-care mail surveys and the potential for non-response bias. Third, completion of the study questionnaire (i.e. study participation) was voluntary. Figure 1 displays the number of patients from each site who chose not to complete the questionnaire. It is unknown why subjects chose not to complete the questionnaire in the ED, specifically why a greater number of patients from Hennepin County Medical Center chose not to complete the questionnaire. However, the overall completion rate was 96%, and our psychometric results were similar between the three centers. Fourth, it is possible that patient assessment of clinician compassion is influenced not only by clinician behaviors, but also by clinician characteristics (e.g. clinician sex, age) and non-clinician variables (e.g. illness severity, ED length of stay). Further, it has previously been demonstrated that the ED environment, such as hallway care [35], perceptions of neighboring patients’ risk [36], and ED crowding [37], may impact psychological perceptions of care. Thus, further research is needed to determine what clinician behaviors (e.g. eye contact, statements of support), clinician characteristic, and non-clinical variables, if any, impact patient assessment of compassion. Specifically, the 5-item compassion measure could be used to identify potentially modifiable variables to improve patient perception of clinician compassion. Fifth, we only tested the psychometrics of the English version of the 5-item compassion measure and future research is needed to test the validity of the 5-item compassion measure in different languages. Sixth, this current study tested the psychometrics of the 5-item compassion measure at one point in time and future research is required to test if the 5-item compassion measure can be used to trend patient perception of compassion over time.

In summary, the 5-item compassion measure appears to be a reliable tool to measure patient perception of clinician compassion in the ED. Future studies among differing cohorts are warranted to further test generalizability of this measurement tool. This provides a framework in which to measure clinical compassion as part of future trials testing interventions aimed at improving patient- and clinician-oriented outcomes.