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RESEARCH ARTICLE
Open Access
Healthcare providers perspectives on
compassion training: a grounded theory
study
Shane Sinclair
1,2,3*
, Thomas F. Hack
4,5,6
, Susan McClement
5
, Shelley Raffin-Bouchal
1
,
Harvey Max Chochinov
4,7
and Neil A. Hagen
2,8
Abstract
Background:
There is little concrete guidance on how to train current and future healthcare providers (HCPs) in
the core competency of compassion. This study was undertaken using Straussian grounded theory to address the
question:
“
What are healthcare providers
’
perspectives on training current and future HCPs in compassion?
”
Methods:
Fifty-seven HCPs working in palliative care participated in this study, beginning with focus groups with
frontline HCPs (
n
= 35), followed by one-on-one interviews with HCPs who were considered by their peers to be
skilled in providing compassion (
n
= 15, three of whom also participated in the initial focus groups), and end of
study focus groups with study participants (
n
= 5) and knowledge users (
n
= 10).
Results:
Study participants largely agreed that compassionate behaviours can be taught, and these behaviours are
distinct from the emotional response of compassion. They noted that while learners can develop greater
compassion through training, their ability to do so varies depending on the innate qualities they possess prior to
training. Participants identified three facets of an effective compassion training program: self-awareness, experiential
learning and effective and affective communication skills. Participants also noted that healthcare faculties, facilities
and organizations play an important role in creating compassionate practice settings and sustaining HCPs in their
delivery of compassion.
Conclusions:
Providing compassion has become a core expectation of healthcare and a hallmark of quality
palliative care. This study provides guidance on the importance, core components and teaching methods of
compassion training from the perspectives of those who aim to provide it
—
Healthcare Providers
—
serving as a
foundation for future evidence based educational interventions.
Keywords:
Compassion, Grounded theory, Healthcare training, Compassion training, Compassionate care, Model
© The Author(s). 2020
Open Access
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) applies to the
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* Correspondence:
sinclair@ucalgary.ca
1
Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary,
Alberta T2N 1N4, Canada
2
Division of Palliative Medicine, Department of Oncology, Cumming School
of Medicine, University of Calgary, 2500 University Drive NW, Calgary, Alberta
T2N 1N4, Canada
Full list of author information is available at the end of the article
Sinclair
et al. BMC Medical Education
(2020) 20:249 https://doi.org/10.1186/s12909-020-02164-8
Background
The ability to provide compassion has become an ex-
pected
core
competency
for
healthcare
providers
(HCPs), mandating the need to understand, develop and
evaluate training opportunities for the provision of com-
passion [
1
–
4
]. While the topic and feasibility of how to
train HCPs to provide compassion is contentious, pa-
tients feel it is not only possible, but necessary [
5
]. Des-
pite this endorsement, there are challenges to developing
compassion training programs
—
including a lack of con-
ceptual clarity, a lack of clinical research measuring the
impact on patient care, and limited training on skills and
behaviours associated with compassion. Recent research
has shown that compassion is a dynamic, individualized
and complex construct that stems from innate virtues of
the healthcare provider. It is conveyed through relational
communication, an in-depth understanding of the per-
son and a range of clinical behaviours that are not con-
ducive to a strict didactic approach or rote learning [
6
,
7
].
Compassion has been simply defined as a response to
the suffering of others that motivates the desire to allevi-
ate it [
8
]; however, the provision of compassion is com-
plex, involving a broad range of qualities, skills and
behaviours which together focus on the alleviation of
suffering [
1
]. These include: acting with warmth and un-
derstanding [
1
,
6
,
7
], providing personalized care [
1
,
6
,
7
,
9
], acting toward a patient the way you would want them
to act toward you [
1
], providing encouragement [
1
,
6
,
7
,
9
], communicating effectively [
9
], and acknowledging a
patient
’
s emotional issues [
1
,
6
,
7
,
10
]. Importantly, com-
passion requires HCPs to engage suffering on both a
personal and professional level, using interpersonal skills
to care for patients and intrapersonal skills to care for
themselves as caregivers [
6
,
7
]. While patients and HCPs
agree that compassion involves a multitude of skills and
behaviours, they need to be coalesced with virtues such
as love, genuineness, acceptance and kindness to be con-
sidered compassionate, suggesting that the cultivation of
virtues is a key, albeit challenging, component of com-
passion training [
5
,
6
,
9
]. The complexity and multiple
domains of compassion are embedded within the follow-
ing definition of compassion, which will be used herein--
a
virtuous and intentional response to know a person, to
discern
their
needs,
and
ameliorate
their
suffering,
through relational understanding and action
[
7
]. The
core components of compassion within this definition
generated the healthcare provider compassion model
(Fig.
1
).
The benefits of compassion include: improved health-
care provider-patient relationships; higher patient satis-
faction; reduced patient anxiety; higher pain tolerance;
and an improved stress response [
3
,
10
,
11
]. Notably, pa-
tients
and
family
members
who
perceive
a
lack
of
compassion in their healthcare experience may have
more adverse medical events, poorer symptom manage-
ment, and are more likely to lodge complaints and sue
for malpractice [
12
–
17
]. Publications characterizing the
impact of compassion on HCPs have largely focused on
the potential negative outcomes under the rubric of
compassion fatigue, a concept that has recently been
questioned by researchers and HCPs alike, while noting
the beneficial aspects of compassion [
3
,
18
–
21
]. High
profile healthcare failures have been attributed to defi-
ciencies of compassion within the healthcare system,
and have resulted in calls to enhance competency train-
ing in compassionate healthcare delivery [
13
,
22
–
25
].
The findings and recommendations of these reports have
highlighted the necessity for compassion training of fu-
ture HCPs, with over half (58%) of current HCPs in the
United Kingdom identifying that students need add-
itional training in order to provide compassion in prac-
tice [
1
]. There is emerging evidence that attitudes and
qualities associated with compassion can be nurtured,
and that compassionate behaviors can be taught through
formal instruction [
5
,
26
,
27
]. However, there is no con-
sensus in the literature as to the best approaches for
training HCPs in compassion and there is a dearth of
evidence-based compassion training programs to equip
healthcare students and providers in the process.
The objective of this study was to address the research
question
“
What are healthcare providers
’
perspectives on
training current and future HCPs in compassion?
”
in
order to generate evidence to inform the development of
learner-informed,
clinically
relevant,
evidence-based
training interventions to equip current and future HCPs
in providing compassion.
Methods
Study population
This study was conducted using Straussian grounded
theory to directly understand healthcare providers
’
per-
spectives on compassion [
7
,
28
–
31
], including their per-
spectives on compassion training, which is the focus of
the current article. Grounded theory studies focus on
theory development, with data collection and analysis
occurring concurrently,
allowing
for subsequent data
collection to be informed by the emerging theory. Partic-
ipants in this study were part of a larger study that in-
vestigated healthcare providers
’
broader perspectives and
experiences
of
providing
compassion.
Generating
a
healthcare provider model of compassion (Fig.
1
) [
7
]. In
grounded theory studies, facets of the larger theory are
often analyzed and reported independently, which led
the research team to prospectively develop specific guid-
ing questions related to the topic of compassion training
at the design stage, with the results being reported ex-
clusively herein [
6
,
32
].
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 2 of 13
The participants in this study were palliative care pro-
viders (
n
= 57) working in a variety of settings (palliative
care unit, hospice, homecare, hospital based palliative
consult service) in urban and rural Alberta, Canada. In-
dividuals were eligible to participate if they: 1) were
≥
18
years of age; 2) were able to read and speak English; 3)
had worked in palliative care for at least 6 months; and
4) were able to provide written informed consent. In the
first stage, frontline palliative care providers (
n
= 35) par-
ticipated in one of seven focus groups in order to elicit
the perspectives of individuals who are keenly aware of
the pragmatic skills, clinical challenges and requisite
knowledge base that is necessary when providing com-
passion within the demands of a healthcare system. For
Stage 2, interview participants (
n
= 15, three of whom
were also focus group participants) were nominated by
focus group participants in response to the following
question on the study demographic form
“
Who among
your interdisciplinary palliative care peers do you feel
possesses great skill in providing compassion?
”
Stage 3
focus
groups
with
study
participants
(
n
= 5)
and
knowledge users (
n
= 10) consisting of clinical educators,
faculty, administrators and clinical leaders were con-
ducted to verify the categories and themes generated in
stages 1 and 2 in order to achieve data saturation. Stage
3
participants
were
also
asked
additional
knowledge
translation questions in order to glean insight on the im-
plementation of compassion training into university cur-
ricula and continuing healthcare education. While we
anticipated needing a large sample to comprehensively
address the study objectives, sample sizes are not prede-
fined in qualitative research but rather determined when
data saturation is reached, which in this study occurred
after conducting focus groups and interviews with 57
participants.
Data collection and analysis
Data were collected over a 12-month period using inter-
view guides based on our review of the literature and
based on previous experience conducting qualitative re-
search on the topic of compassion in healthcare (Table
1
)
[
2
,
6
,
7
]. After receiving approval from the University of
Fig. 1
Healthcare Provider Compassion Model
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 3 of 13
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Table 1
Guiding Questions Utilized in Focus Group and Semi-Structured Interviews that Pertain to Compassion Training
Stage 1 Focus Group Guiding Questions
1 Based on your professional and personal experience, what does compassion mean to you?
2 Can you give me an example of when you felt you provided or witnessed care that was compassionate? [What do you feel were the key aspects
of these interactions?]
3 What do you feel are the major influencers of compassion in your practice?
4 What do you feel inhibits your ability to provide compassion?
5 Do you think patients and/or family members influence the provision of compassion? [How or how not?], [If yes, what characteristics of patients
and/or families, do you feel facilitate or inhibit compassion?]
6 What advice would you give other healthcare providers on providing compassion?
7 Do you think we can train people to be compassionate? [If so, how]?
8 Based on your experience what role, if any, do you feel compassion has in alleviating end of life distress? [What happens when compassion is
lacking?]
9 What impact does providing compassion have on your personally and professionally?
10 Is there anything related to compassion that we have not talked about today that you think is important or were hoping to talk about?
Stage 2 Interview Guiding Questions
1 You have been identified by your peers as possessing great skill in providing compassion. What do you feel might be some of the reasons for this
recognition? [Why do you think others identify you as a compassionate healthcare provider]?
2 In your own terms, how would you define compassion? [What does compassion mean to you?]
3 How did you become a compassionate caregiver? [What beliefs, situations, individuals and/or life experiences in your life and practice do you feel
have informed your understanding and provision of compassion? Have you always been that way? [Were you always like that? How did you learn it?
Can it be learned?]
4 If you reflect back on your current position, can you walk me through the best example of when you provided compassion? Please guide me
through the process of this encounter in a sequential fashion, highlighting the key components of this interaction from the initial approach to the
consequences of this interaction?]
5 Based on your professional and personal experiences, what shapes your compassion?
6 If you were responsible for training students in compassion, how would you go about it? [What would you teach them?]
7 Is there anything that gets in the way of your ability to provide compassion?
8 How do patients and/or families influence your ability to provide compassion? [What characteristics of patients and/or families, do you feel facilitate
or inhibit compassion?]
9 A number of participants have identified the healthcare system as being a significant factor in delivering compassion? From your perspective, how
does/can the healthcare system facilitate or inhibit compassion?
10 In light of the things you
’
ve just identified as facilitators and barriers, what suggestions would you have for enhancing compassion at a systems
level? [Where and what would you focus your efforts on in order to enhance compassion at a systems level]?
11 From what you
’
ve told me so far, it sounds like compassion is important. So what happens [to patients, families or HCPs] when compassion is
lacking?
12 What impact does providing compassion have on you personally and professionally?
13 Our focus group participants, previous studies and review of the literature have reported how critical and fundamental compassion is to providing
quality patient care, but we also know that compassion varies. So given all that we know about the importance of compassion, why aren
’
t healthcare
providers more compassionate?
14 Before we end, given all we
’
ve talked about, I just want to revisit one of the first questions I asked, which is how do you personally define
compassion? [In light of our discussion, what does compassion mean to you?]
15 Is there anything related to compassion that we have not talked about today that you think is important or were hoping to talk about?
Stage 3 Focus Group Questions
1 Does the healthcare provider model of compassion make sense to you? [Does it resonate with you]? [Why or Why not]?
2 Do you feel there is anything missing from the model?
3 How do you feel this model might be relevant to you and your work?
4 How do you suggest the model might be integrated into healthcare practice and education?
5 Is there anything related to the model that we have not talked about today that you think is important or were hoping to talk about
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 4 of 13
Calgary Conjoint Health Research Ethics Board (#REB
15
–
1999), study participants were recruited via study
posters and in-services, through convenience, snowball
and theoretical sampling. Stage 2 interview participants
were contacted in rank order based on the number of
nominations they received from Stage 1 participants.
Stage 2 participants were informed about their nomin-
ation and the study via a work email asking them if they
would be willing to participate
in a semi-structured
interview.
All
participants
volunteered
(non-remunerated)
for
this study and provided written informed consent. Inter-
views and focus groups were conducted by a seasoned
qualitative interviewer in a private room in the partici-
pant
’
s place of work at a time that was mutually con-
venient.
Interviews
and
focus
groups
were
audio
recorded with the interviewer recording non-verbal con-
tent, such as group dynamics and emotions, in written
field notes. Audio files were transcribed verbatim by a
professional transcriptionist, with each transcript being
cross-verified by the qualitative interviewer after com-
paring the transcript with the original audio recording.
Focus group and individual interviews ranged from 1
to 1.5 h in duration. Demographic information was col-
lected for each participant (Table
2
). Data on the topic
of compassion training were elicited through targeted
questions pertaining to compassion training (Table
1
,
Stage 1 question #6, 7; Stage 2 question #3, 6; Stage 3
question
#4)
and
other
interview
guiding
questions
within the primary study focused on HCPs perspectives
and experiences of compassion, which indirectly elicited
responses about compassion training (e.g. identifying a
lack of education as a barrier to compassion). In devel-
oping the interview guide, we intentionally used the
term
‘
training
’
rather than
‘
education
’
as patient study
participants in our previous qualitative research consist-
ently interpreted the term
‘
education
”
as didactic learn-
ing or formal lectures, and based on this understanding
felt that educating healthcare providers about compas-
sion was not feasible [
5
]. While the interview guide pro-
vided a framework for the interviews and focus groups,
the qualitative interviewer was permitted to interject
additional probes based on the participants
’
responses.
Data analysis occurred through the open, axial and se-
lective
coding
stages
of
Straussian
grounded
theory
which are reported in detail elsewhere [
7
,
30
]. The ana-
lysis team (SS, TH, SM, SRB) have extensive qualitative
research experience and expertise, with three members
of the team teaching qualitative research courses at their
respective universities. In the open coding stage, each
member of the team independently read the transcripts,
line-by-line, to identify and organize emergent patterns
using substantive codes and participants
’
actual words.
The research team then met and coded each transcript
Table 2
Participants
’
characteristics
Mean Age (Years)
48.6
Men
14 (8)
Women
86 (49)
Mean number of years in palliative care (range)
11.8
Employment Status*
Full-time
57.8 (33)
Part-time
33.3 (19)
Casual
7.0 (4)
Profession
Registered Nurse
45.6 (26)
Physicians
22.8 (13)
Healthcare Aide
7.0 (4)
Spiritual Care Specialist
5.2 (3)
Unit Clerk
3.5 (2)
Occupational Therapist
3.5 (2)
Licensed Practical Nurse
3.5 (2)
Housekeeper
1.7 (1)
Social Worker
1.7 (1)
Psychologist
1.7 (1)
Respiratory Therapist
1.7 (1)
Physiotherapist
1.7 (1)
Care Setting**
Home Care
29.8 (17)
Hospice
26.3 (15)
Hospital Dedicated Palliative Care Unit
21.0 (12)
Hospital Palliative Care Consult Service
14.0 (8)
Palliative Care Administrator
7.0 (4)
Outpatient Oncology Palliative Care Consult Service
5.2 (3)
Rural Palliative Care Consult Service
5.2 (3)
Other
1.7 (1)
Religious Affiliation*
Christian
52.6 (30)
Buddhist
7.0 (4)
Jewish
3.5 (2)
Muslim
1.7 (1)
Hindu
1.7 (1)
None
31.5 (18)
Religious and Spiritual Status*
Spiritual and Religious
33.3 (19)
Spiritual but not Religious
56.1 (32)
None
8.7 (5)
*The total for these categories is less than 100% due to nonresponse by
participants
**The total for these categories is more than 100% due to some participants
working in multiple care settings
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 5 of 13
collectively, comparing and contrasting their individual
codes until consensus was reached. In the axial coding
stage, consensus codes were compared, collapsed and
clustered into initial themes and categories creating a
coding schema, serving as a repository for the coding of
subsequent interviews with additional codes being added
as necessary. Finally, selective coding was performed to
develop theoretical constructs from the data that identi-
fied relationships between categories, validated estab-
lished relationships and refined categories as required.
Results
Based on the focus group and interviewee responses,
three categories and associated themes were identified
that pertained to compassion training within healthcare
(
Table
3
)
. Verbatim quotes from the focus group and
interview responses were selected to illustrate each of
the categories and themes based on their overall repre-
sentativeness or to reflect differences of opinions be-
tween participants in the response categories.
Category: the feasibility and necessity of compassion
training
While HCPs recognized that compassion training was a
challenge, they felt that it was feasible and could be
achieved through a variety of teaching techniques, ex-
periential learning opportunities and a learner-centred
approach. Three themes were generated from these data:
Teachable Moments: Teach the Behaviours and Culti-
vate the Qualities; The Learner: The Role of Innate
Qualities and Experience; and Compassion Competency:
An Educational Priority and Practice Requirement.
Theme: teachable moments: teach the Behaviours and
cultivate the qualities
Participants unequivocally felt that compassionate be-
haviours (e.g., communication skills, clinical behaviours)
could be taught. There was less consensus related to the
feasibility of training the emotional and attitudinal domains
of compassion. Most participants, however, asserted that
the innate facets of compassion could be nurtured through
self-awareness, contemplative practices or by practicing
compassionate behaviours towards others.
I think some of those personal characteristics are in-
nate and are traits that you
’
re born with
…
But I
think there also is an element of education
…
the
more people practice and learn strategies and learn
phrases and learn techniques I think it can be im-
proved upon...(Interview Participant 7).
I do think compassion
’
s more than that and so I
think you can train the behavioral aspects of it but
the emotional and attitude components I
’
m not sure
are so easy (Focus Group Participant 18).
Theme: the learner: the role of innate qualities and
experience
A second theme that participants identified in compassion
training focused on developing aptitude for the emotional
and innate components of compassion. Integral to this ap-
titude was learners
’
pre-existing emotional capacity and
past experience with compassion or its antecedent--suffer-
ing. Developing an awareness of the suffering of another,
being willing to engage the suffering of another, and rec-
ognizing suffering as a key facet of the shared humanity
between themselves and their patients, were considered
essential basic building blocks of compassion in HCPs.
You have to have some experience with compassion
or with that deep sense of trust and understanding
somewhere in your life in order to be able to provide
that to someone else (Focus Group Participant 4).
I don
’
t know if a person who hasn
’
t experienced a
reason to find compassion or to have compassion be
given to them would come by it as innately as other
people who have experienced those things (Focus
Group Participant 5).
I mean a lot of stuff that you do in terms of being able
to care and look after people is not something I ever
learned in a textbook (Focus Group Participant 2).
Table 3
Overarching Categories and Themes Identified that Pertain to Training Palliative Care Providers to Provide Compassionate
Care
Category
Themes
The feasibility and necessity of compassion
training
Teachable Moments: Teach the behaviours and cultivate the qualities
The Learner: the role of innate qualities and experience
Compassion competency: An educational priority and practice requirement
Training techniques and practices for developing
compassion competency
Self awareness
Experiential learning
Effective and affective communication skills
Sustaining Practices: Self Care and Communities of
Compassion
Self-care
Communities of Compassion: The need and responsibility of practice settings and healthcare
organizations in sustaining compassion training
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 6 of 13
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Theme: compassion competency: an educational priority
and practice requirement
Despite inherent challenges, the majority of participants
felt that compassion training needed to be formally em-
bedded within healthcare curricula and be considered a
practice competency. Ironically, all participants indicated
that the topic was limited in their own healthcare train-
ing. While substantive content on the topic of compas-
sion was largely absent, participants felt that in addition
to dedicated training on the topic, there were ample op-
portunities to integrate compassion alongside existing
curricula and clinical education opportunities.
So you know, speaking professionally, honestly, you
know there are things that teach compassion, but
really, there
’
s not enough. There just isn
’
t enough. As
a nurse I don
’
t think in school I learnt enough of
that (Interview Participant 2).
I think that there is certain things you can teach to
help enable compassion to kind of grow and one of
those things that I found was actually in nursing
school they really harped on it but it makes sense
the determinants of health and how all of that
comes together to, all these different factors, some of
which a person has no control over, such as early
childhood education before they
’
re 2 years old, where
they
’
re born, things like that all come together to
bring that person to the situation they
’
re in. And
when you understand some of those factors and that
they are out of people
’
s control I think you can de-
velop a greater compassion just by knowing some of
those things (Focus Group Participant 17).
Category: training techniques and practices for
developing compassion competency
Participants
identified
several
learning
techniques
or
training methods they had personally found effective,
suggesting these might be helpful in developing compas-
sion
aptitude
in
others.
Within
this
category,
three
themes emerged from the data: Self-Awareness; Experi-
ential Learning; and Effective and Affective Communica-
tion Skills.
Theme: self-awareness
Participants emphasized the importance of developing
self-awareness in compassion training and the cultivating
virtues or noble qualities that serve as antecedents and
markers of compassion within a clinical encounter. In
relation to compassion, participants emphasized the ne-
cessity of having learners reflect on their own under-
standing and experiences of compassion and suffering in
addition to developing an awareness of their virtues,
including, but not limited to, authenticity, vulnerability,
honesty, kindness, and love.
What you bring as a person to that encounter is vi-
tally important and you better know what that is be-
cause it will affect how you interact with your patients
if you
’
re not aware of it (Interview Participant 5).
I
’
d also want to do some real inquiry around what
their [trainees] conceptualization is of compassion
and then talk about what it is and what it isn
’
t
…
I
’
d
be curious for them to develop their own awareness of
what compassion would look like and how they would
tend to it for themselves (Interview Participant 15).
Theme: experiential learning
While participants acknowledged that training future
and current HCPs in compassion was likely not easy,
most recognized that experiential learning opportunities,
rather than didactic learning, were the most effective
techniques.
This
largely
seemed
to
be
informed
by
reflecting on how the participants personally cultivated
compassion in their own healthcare training and prac-
tice. In particular, participants identified mentors who
expressed
compassion
to
their
patients
as
powerful
teaching moments, along with personal experiences of
being the recipient of compassion.
Can it be learned? Yes. But I think that no matter
how many times you sit in a classroom or how many
times someone talks to you about it, or even how
many times you witnessed something, until that has
an emotional impact on you, you aren
’
t fully going
to grasp what it means to be compassionate (Focus
Group Participant 5).
I think having, watching people who are experienced
and just observing their approach to it as well
‘
cause I
think people when they first go in they are not sure
what to do, right and so probably that internal dis-
comfort makes them more self-conscious and not sure
how to approach things, right. And so I think that
having someone more experienced to observe and to
talk things through afterwards, kind of debriefing, is
very helpful (Focus Group Participant 18).
In addition to preceptors and clinical mentors, patient
narratives and role playing that involved learners assum-
ing the role of the patient were important sources of ex-
periential
learning.
Developing
a
reflective
practice,
whereby learners personally reflected on each patient
visit or debriefed with a preceptor or clinical mentor on
the compassion touch points of a visit, were also identi-
fied as experiential learning techniques.
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 7 of 13
Either role play or video, but I think video at least
as a start to hear from the patient
’
s perspective
…
So
I think hearing it from the patient
’
s voice I think is
critical in teaching to hear you know, how do pa-
tients perceive you (Interview Participant 7).
That would be a great thing to do in the course if
they actually have to go in and be a patient (Inter-
view Participant 8).
I think it
’
s a reflective thing too. It
’
s kind of under-
standing the ways that your actions impacted others
and then circling back to so knowing that now, what
could I have done differently or what could we have
done
differently,
right?
So
those
feedback
loops
(Interview Participant 14).
Theme: effective and affective communication skills
The third theme within this category was training re-
lated to effective and affective communication skills. Par-
ticipants
emphasized
the
importance
of
traditional
communication skills such as building rapport, active lis-
tening and presenting clinical information in an under-
standable
manner.
Beyond
this,
compassionate
communication
required
the
development
of
more
affective skills, such as engaging patients in a sensitive
manner, and addressing emotional and existential dis-
tress. Communicating support, acceptance and under-
standing the patient as a person were also central skills
identified by participants, as well as routinely eliciting
patient feedback about whether they felt they were being
treated with compassion.
And you have to ask the person who
’
s on the other
end of the intended compassion right, whether they
feel that compassion (Focus Group Participant 18).
You have to put yourself in other people
’
s shoes to know
how, what it feels like to be there. That is the way you
learn compassion (Focus Group Participant 20).
You
’
ve got to listen and you
’
ve got to know when to
talk. You
’
ve got to know that silence is okay some-
times, because they
’
re not right with you then
…
I
think listening is the most important thing (Interview
Participant 13).
Category: sustaining practices: self-care and communities
of compassion
While the classroom and clinical setting provided the
foundation for training compassion, participants empha-
sized the necessity of developing personal and profes-
sional
practices
to
sustain
and
enhance
compassion
across
the
curricula
and
over
the
course
of
their
healthcare career. Participants believed that each health-
care provider was responsible for nurturing compassion,
however participants felt that the practice setting and
larger system were instrumental to sustaining and en-
hancing an individual
’
s ability to provide compassion. In
fact, many participants felt that without a practice cul-
ture that was conducive to compassion, focusing exclu-
sively
on
enhancing
individual
learners
’
capacity
for
compassion would be short-lived and even futile. There
were two themes that emerged from the data within this
category: Self-Care; and The Need and Responsibility of
Practice Settings and Healthcare Organizations in Sus-
taining and Further Developing Compassion Training.
Theme: self-care
Most participants noted that learners should be taught
what constitutes compassion, and concurrently, how to
sustain themselves through self-care. Many provided an-
ecdotal examples about the impact that occupational
stress, burnout and personal stressors had on their care-
giving, including their ability to provide compassion, em-
phasizing
the
need
for
training
on
self-care
and
educating
healthcare
providers
about
additional
re-
sources to support them.
If you don
’
t care for yourself you can
’
t give them
compassion
‘
cause you
’
re out, you
’
re empty
’
(Focus
Group Participant 29).
Maybe there
’
s something and changes that you need
to make within that so that you can continue to
have compassion. Finding an outlet, whether, some-
times for people it
’
s exercise, for other people it
’
s go-
ing to the movies. I believe everyone should be in
therapy to [laughter] have someone safe like that
that you can process and talk to. All of that I think
is important (Focus Group Participant 20).
Theme: communities of compassion: the need and
responsibility of practice settings and healthcare
organizations in sustaining and further developing
compassion training
Participants were clear that there was a significant, and
often
unrecognized,
role
that
the
healthcare
system
played in compassion. The assumption that learners can
be trained to provide compassion in a clinical setting
was felt to be predicated on a practice environment that
values, imparts and embeds compassion in clinical train-
ing and as an organizational priority. Participants felt
that this responsibility extended from the point of hire
to ongoing learning opportunities, as without such a
supportive environment, the individual efforts of health-
care providers and compassion training programs were
thought
to
be
ineffective.
Participants
felt
that,
in
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 8 of 13
addition to training, if compassion was to be considered
a core competency, then practice settings and healthcare
organizations
needed
to
make
compassion
an
organizational expectation and build in tangible prac-
tices and design spaces to support this.
You know from a system perspective you know I
think if you
’
ve got a work environment, a team, you
know your colleagues, your manager and up the
chain of command all the way through the system
…
I also think that there
’
s relational factors you know
with that other individual (Interview Participant 8).
Just having that cultural expectation in the culture
of the workplace would go a long way. Because then
there would be some understanding amongst all the
providers about how to support one another and
providing that kind of care (Interview Participant 9).
My instinct is to leave a situation, I can
’
t be helpful,
I don
’
t know what to do, but when you have those
opportunities to debrief and they say, no, you did
this right, or this is what works for me. Sometimes I
try seeing it this way. I think you can absolutely, like
[name] was saying and [name] was saying, help sort
of teach those skills and help cultivate (Focus Group
Participant 11).
Discussion
In this study participants agreed that compassionate be-
haviours could be taught but were less certain about how
to develop training to cultivate the underlying virtues and
affective and relational components of compassion. In
part, this was due to a recognition that compassion train-
ing was dependent on the innate qualities, life experience
and interpersonal skills that individuals possess prior to
training. In relation to the HCP compassion model (Fig.
1
),
this suggests that the themes of virtues, presence and in-
tent within the Virtuous Intent domain, which function as
motivators of compassion and distinguish it from routine
care,
are
best cultivated
through
contemplative
prac-
tices
—
whether in terms of a personal practice or by
reflecting intentionally on HCPs clinical practice. As such,
participants in this study felt that while baseline compas-
sion aptitude varies, learners can enhance the innate qual-
ities
and
the
affective
and
relational
components
of
compassion
through
three
areas
of
training:
self-
awareness, experiential learning and effective and affective
communication skills.
Action aimed at alleviating the suffering of an individual
is a central and distinguishing aspect of compassion in
comparison to sympathy or empathy [
33
]. In recognizing
the inherent challenges in training aimed at cultivating the
requisite qualities and affective and relational domains of
compassion, study participants suggested that one way
learners can cultivate the internal virtues associated with
compassion is by providing them with opportunities to
engage in compassionate action within their clinical train-
ing and practice. Accordingly, while changing learner atti-
tudes can lead to behavioural change, recent research
within the field of social psychology suggests that the op-
portunity to integrate them into practice is not only im-
perative to sustaining attitudinal change but may change
the innate qualities of learners in the process [
34
–
36
]. Ex-
posing learners to clinical case scenarios or experiences
requiring compassionate action illustrated within the cat-
egories and themes within the relational space domain of
the HCP compassion model, may in turn function as a
positive feedback loop that develops the innate qualities
within the virtuous intent domain
—
cultivating virtues
through action. In support of this, functional neural plasti-
city studies show that compassion training using tech-
niques based on Eastern contemplative traditions activates
neuro regions in the brain associated with the positive
affective states of reward, love, affiliation and concern for
another [
37
]. Finally, these findings on HCPs perspectives
of compassion training and the multidimensional nature
of compassion as illustrated in the compassion model
(Fig.
1
) suggest that compassion training needs to focus
on equipping learners with the behaviours, skills, know-
ledge and qualities spanning the entirety of the HCP
Compassion Model and not simply a single dimension,
which while developing the virtues associated with com-
passion through meditation, for example, is void of behav-
ioural or clinical communication training.
Although participants provided many specific sug-
gestions for compassion training based on their own
education and practice experience, they were unified
in their view that compassion training is currently
lacking and needed in healthcare education
—
affirming
the findings of previous studies [
1
,
6
]. Some research
has attempted to identify the specific skills or experi-
ence that would fill this training gap [
38
]. One report
revealed that the actions that underlie the provision of
compassion should be grounded in an understanding
of a patient
’
s values, beliefs and needs [
38
]. This sug-
gests that teaching compassion using simple state-
ments such as
“
do what is right
”
limits a learner
’
s
understanding of what is required of a compassionate
care provider, and that compassion mandates caring
for patients as they would wish to be cared for, not as
a provider would wish to be cared for [
38
]. A previous
study
investigating
patients
’
recommendations
sug-
gested that compassion training should focus on de-
veloping a connection with the patient and seeing the
patient as a person; patient-centered communication,
reflective practice and role modeling were identified as
important for compassion training [
5
].
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 9 of 13
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Compassion training programs have emerged consid-
erably in recent years [
39
]. One review identified eight
compassion-based training programs, six of which have
been investigated in randomized clinical trials. These in-
clude Compassion-Focused Therapy [
40
], Mindful Self-
Compassion [
41
], Compassion Cultivation Training [
26
],
Cognitively Based Compassion Training [
42
], Cultivating
Emotional Balance [
43
], and Compassion and Loving-
Kindness Meditations [
44
]. All these training programs
include meditation interventions that intend to engender
compassion to others and self. A key limitation of these
training programs is that none of the approaches have
been evaluated in healthcare providers and their pa-
tients, despite this being an essential primary outcome
of any compassion training program to be used within
the healthcare setting. Furthermore, they are all based
on differing definitions of compassion and target a var-
iety of competencies [
39
]. A second review of interven-
tions
for
compassionate
nursing
care
identified
25
interventions based on staff training, staff support or
introducing a new care model to practice [
45
]. However,
none of the interventions were fully described or rigor-
ously
investigated.
Several
interventions
evaluated
patient-based outcomes, including patient anxiety and
satisfaction, but only showed a moderate effect [
46
,
47
].
These findings demonstrate that compassion training is
currently inadequate and emphasize that the quality, ef-
fectiveness and comprehensiveness of compassion train-
ing
programs
could
benefit
from
an
empirical
foundation that identifies the core domains of compas-
sion that training programs need to address and a vali-
dated
measure
to
evaluate
how
these
educational
opportunities impact learner and patient outcomes.
Most participants in the current study identified for-
mal structured learning modules that are experiential,
and
incorporate
the
patient
perspective
as
potential
learning mediums. Digital narratives of compassionate
clinical interactions have previously been used to effect-
ively elicit reflective thinking and discussion with nurs-
ing students [
27
], suggesting this as a feasible approach
to compassion training. The importance of a mentoring
relationship in training learners to become compassion-
ate HCPs was also emphasized. In addition to role-
modeling compassion in practice, participants indicated
that mentors are essential for debriefing and serving as
an emotional buffer that allows healthcare students to
engage in compassion while they explore how best to
sustain themselves in the process. Studies in healthcare
fields have found that mentoring improved medical stu-
dent satisfaction with their training programs, increased
mentee knowledge and skills, enhanced mentee personal
and
professional
development
and
improved
organizational outcomes [
5
,
48
,
49
]. Currently however,
clinical
mentors
are
an
overlooked
educator
of
compassion, who need to be supported and trained in
compassion as they impart their
‘
applied
’
knowledge of
compassion to learners.
Study
participants
felt
that
sustaining
compassion
training required HCPs to practice self-care. Accord-
ingly, personal and professional self-care is increasingly
accepted as critical in sustaining the satisfaction and lon-
gevity of HCPs [
50
–
53
]. Personal self-care recognizes
that an individual
’
s inner-life, family, work, community
and spirituality contribute to their personal and profes-
sional life [
50
,
54
] and involves strategies that include
tending to close relationships such as those with family;
following a healthy lifestyle (regular sleep, exercise, vaca-
tions); prioritizing time for recreational activities and
hobbies; contemplative practices; and engaging in spirit-
ual development [
50
,
55
–
57
]. Professional self-care strat-
egies
may
be
individual
or
team-based.
Individual
professional self-care strategies involve regular evalu-
ation of work life; establishing a network of peers and
mentors; improving communication and management
skills; setting limits; and reflective writing [
50
,
58
]. Team
self-care strategies recognize that team structure and the
team processes contribute to a team
’
s well-being and in-
clude empowering team members to empathize with
others; developing formal structures, policies and proce-
dures to guide team meetings; and sharing personal and
professional opinions on meaning [
50
,
59
,
60
]. Self-
awareness is a vital aspect of self-care. In HCPs, self-
awareness has been defined as the ability to combine
self-knowledge with an understanding of the needs of
the patient [
50
]. Self-awareness among HCPs has been
reported to result in higher job engagement, better self-
care and improved quality of patient care and patient
satisfaction [
50
].
Self-care in HCPs is especially important because com-
passion specifically requires a willingness on the part of
HCPs to be professionally and personally vulnerable by
‘
suffering with
’
their patients. A previous report found
that nursing students had concerns about their own
emotional vulnerability when learning to provide com-
passion [
61
], while a separate study reported that med-
ical residents felt they needed to limit their compassion
in order to meet the demands of their clinical training
[
62
]. Likewise, nursing students managed their fears in
part by choosing when to engage in and when to move
away from providing compassion, based on the perceived
impact on their own emotional health [
61
]. While self-
care is an important facilitator of compassion, placing
the onus of responsibility for enhancing compassion
on individual HCP efforts, especially since most suggested
self-care activities occur outside of their professional lives,
was felt to be short-sighed by study participants and failed
to account for the responsibilities of the culture of care
wherein HCPs practiced.
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 10 of 13
As a result, study participants felt that support from
healthcare faculties and healthcare organizations was es-
sential for sustaining compassion training. However, the
dissonance caused by training systems that recognize
and value the provision of compassion and
“
real-world
”
systems where compassion is often usurped by econom-
ics, efficiencies and practice targets [
1
,
63
–
65
], has been
identified by medical and nursing students as a signifi-
cant theory-practice gap in care [
64
,
66
]. The current
study suggests that healthcare education institutions and
the organizations that healthcare students and providers
work in need to partner in order to address this gap, al-
leviating the dissonance within HCPs and ensuring that
learnings in the classroom are congruent with practice.
While the current study and published literature have
focused on training HCPs, this novel finding emphasiz-
ing the instrumental role that healthcare organizations
and practice settings play in sustaining healthcare pro-
viders
’
training, suggests that compassion training tar-
geted
toward
healthcare
administrators,
clinical
managers, preceptors and policy makers may be as im-
portant as clinical training. The characteristics of a sup-
portive environment include leaders who act as positive
role models, positive interdisciplinary relationships, au-
tonomy in the workplace, compassion toward colleagues
and an intentional focus on staff well-being [
24
,
67
,
68
].
The current study is limited in sampling only palliative
care providers. However, almost all clinicians who par-
ticipated in this study have extensive clinical experience
beyond provision of palliative care. Future research is
needed to replicate the results of this study in other
fields of healthcare. Further, there may have been sample
and selection bias. Our use of convenience, snowball
and theoretical sampling meant study participants senti-
ments about the importance and content of compassion
training was reflective
of individuals who were
self-
motivated to participate and had an interest in the topic.
Because interviewees were nominated by their peers as
exemplary compassionate care providers, they may have
only
nominated
individuals
whose
perspectives
were
congruent with their own and there may be some elem-
ent of selection bias on the part of interviewees in the
responses
provided.
Finally,
we
conducted
the
focus
groups and interviews within a Western, well-resourced,
publicly
funded,
team-based
healthcare
system
and
therefore
findings
may
not
be
generalizable
to
the
provision of compassion in other cultures where educa-
tional opportunities and healthcare practices vary.
Conclusions
Providing compassion has become a core expectation of
healthcare and increasingly is being considered a core
competency of healthcare education. Providing evidence
based,
clinically
informed
training
to
help
learners
practice with compassion is crucial to their success, to
organizational outcomes, and most importantly, to pro-
viding quality patient care. Based on the results of this
study, we suggest that a combination of formal experien-
tial learning modules and clinical mentorship that fo-
cuses on teaching learners techniques to engage with
persons, self-awareness, and practices for sustaining the
ability to provide compassion are necessary for training
compassionate care providers. In order to achieve this,
further research is needed to determine learner needs,
along with systematic reviews and environmental scans
of existing training to determine needs, content, teaching
methods and the barriers and facilitators of existing
training programs. Healthcare organizations are instru-
mental to provision of compassionate health care deliv-
ery, as the success and longevity of training clinical
teams or individual HCPs in compassion will be contin-
gent on the degree that organizations cultivate sustain,
and consider a culture of compassion as a core business
of healthcare.
Acknowledgments
We acknowledge and thank each of the participants who gave their time,
enthusiasm and wisdom to this study. We also want to thank trainees and
members of the Compassion Research Lab (
www.drshanesinclair.com
) for
their insights and administrative support of this study.
Authors
’
contributions
All authors SS, TH, SM, SRB, HC, NH: 1) made substantial contributions to the
conception and design of the study, acquisition of data, and analysis and
interpretation of data; 2) were involved in drafting the manuscript or revising
it critically for important intellectual content; 3) gave final approval of the
version to be published and have participated sufficiently in the work to take
public responsibility for appropriate portions of the content; 4) agreed to be
accountable for all aspects of the work in ensuring that questions related to
the accuracy or integrity of any part of the work are appropriately
investigated and resolved; and 5) have read and approved the manuscript.
Funding
MSI Foundation (Grant #880). This study was funded by the MSI Foundation
(Grant #880). The funders had no role in the study design, data collection,
data analysis, interpretation, or the preparation of the manuscript.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Ethics approval and consent to participate
This study was approved by the University of Calgary Conjoint Health
Research Ethics Board (#REB 15
–
1999). All participants provided their written,
signed consent prior to participating in this study.
Consent for publication
N/A; As all individual patient data is anonymized, we are not seeking
individual patient consent for publication.
Competing interests
We have read and understood BMC policy on declaration of competing
interests and the authors declare that they have no competing interests.
Author details
1
Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary,
Alberta T2N 1N4, Canada.
2
Division of Palliative Medicine, Department of
Oncology, Cumming School of Medicine, University of Calgary, 2500
University Drive NW, Calgary, Alberta T2N 1N4, Canada.
3
Compassion
Sinclair
et al. BMC Medical Education
(2020) 20:249 Page 11 of 13
Research Lab, University of Calgary
http://www.drshanesinclair.com
.
4
Research Institute in Oncology and Hematology, CancerCare Manitoba,
Winnipeg, Manitoba, Canada.
5
College of Nursing, Rady Faculty of Health
Sciences, University of Manitoba, 89 Curry Place, Winnipeg, Manitoba R3T
2N2, Canada.
6
Psychosocial Oncology & Cancer Nursing Research, I.H. Asper
Clinical Research Institute, 369 Taché Ave, Winnipeg R2H 2A6, Manitoba,
Canada.
7
Department of Psychiatry, University of Manitoba, 771 Bannatyne
Avenue, Winnipeg, Manitoba R3E 3N4, Canada.
8
Departments of Clinical
Neurosciences and Medicine, Cumming School of Medicine, University of
Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada.
Received: 25 October 2019 Accepted: 21 July 2020
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