REVIEW

 

Care and Compassion in Healthcare Provision

 

 

LM Sykes^I; J Bester^II

^IBSc, BDS, MDent, IRENSA, Dip Forensic Path, Dip ESMEA, FCD (Pros) Head of Department of Prosthodontics, University of Pretoria. https://orcid.org/0000-0002-2002-6238
^IIPhD, Department of Physiology, School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa. https://orcid.org/0000-0002-8931-9194

Correspondence

 

 

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ABSTRACT

The quality of patient care forms the basis of all doctor-patient relationships. However, it requires more than mere provision of what is necessary to maintain or restore their health, and should encompass an emotional connection, and a desire to help them.
Care covers a wide range of activities and is often seen as the technical and procedural aspects of medicine, while compassion revolves around the relational aspects of patient care. It requires clinicians to be able to express empathy and understanding, share their patients' feelings, be available, communicate, try to provide support and encouragement, and treat them with respect and dignity. This paper discusses care and compassion and explores issues such as whether a person can be taught to care and/ or show compassion; if too much compassion could cloud a practitioner's judgement; if it's possible to deliver good care without being compassionate; and whether a person who has never experienced compassion can develop this ability.
Care and compassion are essential components of effective medical practice, and need to be integrated into healthcare. Clinicians should adopt a patient-centred approach that prioritises the patient's values, needs and preferences during their decision-making process. At the same time, they must cultivate emotional intelligence, and identify when they need mental, emotional or physical support.

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INTRODUCTION

In health provision, the quality of patient care forms the basis of all doctor-patient relationships, and can impact the outcomes and effectiveness of the treatment, as well as the patient's overall wellbeing. However, providing good quality care alone may not be enough in terms of treating patients holistically.¹ Jane Cummings, the NHS England Chief Nursing Officer, was one of the first to identify this gap. She tried to formulate a way of describing and "conveying the values which she felt should be part of the culture and practice within healthcare organisations". In 2017, she proposed the "6 Cs model where the Cs refers to the need for Care, Compassion, Courage, Commitment, Communication and

Competence.^2,3 This paper will use her model as a basis for the discussion around the need for both care and compassion in all healthcare settings where patients are treated.

Care and compassion

The Oxford English dictionary defines care as "the provision of what is necessary for the health, welfare, maintenance and protection of someone or something". The definition of compassion is similar but includes "having a strong feeling of sympathy and sadness for the suffering or bad luck of others and a wish to help them".⁴ Thus, compassion entails recognising their suffering, and attempting to share their emotional state in order to gain an understanding of how they feel, and then taking action to help. It is a tangible expression of love for those who are suffering or in need.² Both care and compassion may share many characteristics, but there are also a number of fundamental differences. From an ethical viewpoint many believe that compassion should be considered as the first ethical principle required in order to deliver quality of care.^5,6

To explore the characteristics of caring and compassion desired by those who practice medicine, dentistry or allied healthcare services we need to first look at the way in which students are trained. This includes assessing their behaviour when interacting with their teachers, peers and patients, the supervisors' roles in guiding them during all patient interactions, and how all of these may impact on their final conduct and manner of performance in practice.

Caring for someone refers to the act of showing kindness and concern for them. Care in medicine relates to the actions and services that need to be provided to maintain or improve a patient's health. This covers a wide range of activities such as careful clinical examination, formulation of the correct diagnosis, provision of the appropriate treatment including those steps needed to prevent illness (such as vaccines and lifestyle advice), management of chronic conditions, provision of palliative care and/or symptomatic relief, and patient education to inform them about their condition and empower them to manage themselves better. Care is often seen as the technical and procedural aspects of medicine, involving knowledge, skills, and requisite competencies acquired through education and experience (ChatGPT, June 16 2024). Compassion on the other hand goes beyond this and includes the more emotional aspects. The word CARE itself may be expanded upon and used as an acronym for the additional qualities that are needed to turn care into compassion.

C - The first C entails Connecting with another person during times of suffering and distress, and understanding their suffering and vulnerability. Thereafter there needs to be honest and open Communication with them using understandable language and delivering the appropriate amount and detail of information they will need, at an appropriate time and level. Clinicians also need to be Committed to their duty to serve and strive to do everything within their power, training, expertise, ability and job description when providing treatment. This includes taking pride in themselves and their work and delivering quality healthcare. Competence requires that all healthcare providers ensure they are skilled enough to carry out the requisite treatment, to constantly update themselves by attending refresher courses, reading relevant peer reviewed literature, consulting with colleagues, manufacturers or product specialists, and enrolling in regular hands-on training courses when new technology emerges. It also entails them to know if and when to refer their patients to more skilled or competent colleagues. C also relates to the need for Compassion and the ability to provide Comfort to patients and their families in times of illness. The "sick role" often places patients in a vulnerable position and they value this emotional support as much as the actual therapy or intervention. Finally, C also talks to having the Courage to be open and honest when informing patients about their condition. To this end they must tell them the truth about their condition, its aetiology and possible treatment options.

A - Refers to paying Attention to the patient when they present with their initial complaint and desires, and how closely these relate to their actual needs. Healthcare professionals are often overwhelmed with the number of patients they are expected to care for, yet they are still expected to give individual attention to each one. They must then present their patients with viable Alternatives, explaining the relevant risks and benefits, pros and cons, and time and financial costs associated with each. They need to also ensure they equip and allow the patient to make an Autonomous decision as to the chosen treatment and how this may impact their future wellbeing and livelihood. To this end the treating therapist may provide Advice and offer and opinion, but the final decision is still in the hands of the patient, and they need to respect that choice.

R - refers to showing Respect to patients, by taking the time to listen, and engage with them as individual people and not just as medical cases or conditions. Their behaviour in this regard can often be traced back to how they dealt with patients as a student. Those who viewed patients as a "means to a quota" very often take this mindset forwards into practice where the patient is seen as an entry in an appointment book, a number in the bank balance or a condition to be managed. They forget that patients are people with emotions and feelings on top of their medical ailments.⁷

Medical humility may also form an important part of respect for patients. Coulehan defined it as "unflinching self-awareness; empathetic openness to others; and a keen appreciation of, and gratitude for, the privilege of caring for sick persons".⁸ In a study conducted by Ruberton et al (2016), it was found that clinicians who displayed general humility towards their patients were perceived as more effective communicators compared to those who exhibited less humility. This aligns with the concept of humility as a state focused on others rather than oneself. Instead of asserting their authority and potentially alienating patients, humble clinicians demonstrated sensitivity and empathy in their communication.⁹

E - relates to the duty to Empower and Equip patients to take more ownership of their own health and wellbeing. For this to happen, they need to first Educate patients about their condition, how it developed, how it can be treated, how to maintain their health after treatment, and how to prevent or limit further progression of the ailment. It is closely linked to autonomy, and ensuring that patients have the ability to make sound and appropriate decisions for themselves. Healthcare professionals also need to show Empathy and provide Emotional support.

Thus, based on the above, we can see that although care and compassion are different, they are also deeply interconnected, and each enhances the other. Caring involves action, while compassion includes the emotional and relational aspects of patient care, of having a connection with them, trying to understand their needs, and then driving actions aimed at meeting those needs. It requires clinicians to be able to express empathy and understanding through sharing the feelings of their patients, being physically and emotionally present and available, being able to communicate on various levels and engage in meaningful conversations, acknowledging patients' concerns, providing support, comfort and encouragement, attempting to alleviate their fears and anxiety, treating them with respect and dignity, and seeing them as individuals with unique and specific needs, desires and values (ChatGPT, June 16 2024).

Providing technically proficient medical services without empathy can make a patient feel like they are not seen or valued as individuals, leading to dissatisfaction and a lack of trust in the healthcare provider. At the same time, expressing empathy and concern without delivering the correct or appropriate medical treatment is clinically, ethically and legally unacceptable. Being able to balance the two is crucial for holistic patient care. Patients who feel understood and respected reportedly have more positive experiences, are generally more satisfied, tend to be more complaint and adhere better to treatment and advice, and ultimately experience improved overall health outcomes. At the same time, healthcare professionals who practice compassion often have greater job satisfaction and enhanced mental and emotional wellbeing (ChatGPT, June 16 2024).

Further ethical issues to ponder

There are a number of other ethical issues related to care and compassion that can be considered. Most of these do not have definite answers, but are posed as questions that aim to stimulate healthcare providers to introspect and think about the way in which they see themselves, and how this impacts the way they manage and treat their patients.

1. Can a person be taught to care and/or show compassion, especially if these qualities are not innate in their personalities?

This issue has been debated widely in the field of child development in the nature versus nurture debate. Some believe that a person's genetic predisposition (nature) guides their behaviour, while others argue that their emotions and actions are moulded by their life circumstances, physical world and the way they are raised (nurture). The arguments generally revolved around "stability" versus "plasticity".¹⁰ However, most recent behavioural epigenetic research has indicated that life experiences can affect gene expression.¹¹ In other words, "nature is vulnerable to nurture, and there is evidence for bidirectional and interactive effects between parenting and children's characteristics".¹² Children need appropriate experiences during the different phases of their development to "support and promote their interest in exploration, experimentation and self-direction".¹³ It is believed that exposing a child to nurturing ways that are adapted to their nature will lead to desirable consequences and growth of the individual, and society at large.¹⁴

Current teaching also revolves around promoting "self-directed learning". A crucial element relates to the guidance and feedback students receive from their tutors. This interface between teacher and learner can enhance, or be detrimental to learning, depending on the mode of delivery.¹⁵ The efficacy will depend on the teacher's ability to appropriately convey the message, as well as the student's ability and willingness to self-reflect, and to adapt when necessary.¹⁶ Immermann believes that students will regulate their learning through self-efficacy, belief and motivation. The aim should be to help learners develop skills such as self-control, metacognitive monitoring, perseverance in trying to successfully complete a task, the ability to reflect on their performance, take responsibility for their own failures, and then adapt accordingly.¹⁷ It goes hand in hand with emotional intelligence which is believed to be necessary in order to attain practical skills, and is based on Ave key components: self-awareness, self-regulation, motivation, empathy and appropriate interaction with others.¹⁸ The emotional intelligence obtained during undergraduate training may then allow the clinician to be cognisant of interpersonal relationships and have more empathy for their patients.¹⁸ Unfortunately, many medical and dental curricula are overloaded and do not allow time for this reflective process and subsequent engagement. In addition, they are often still discipline-based and quota-centred. This results in uncoordinated care with students addressing biological needs rather focusing on a holistic approach that encompasses the broader biopsychosocial aspects of their and their patients' lives. The risk is that this mindset could be carried into their future practice where the chasing of quota is replaced with an obsessive pursuit for money. In both cases, the patient is a means to an end that benefits them first and foremost.

What makes it challenging to develop and incorporate compassion in healthcare training is that there is a lack of understanding of how compassion is conceptualised by clinicians and patients.⁶ In addition, compassion has been linked to the ability to experience emotions evoked by specific thoughts, or from witnessing certain events and/or conditions in others, and in believing that their suffering is a terrible thing. The degree of compassion experienced is, in turn, influenced by a person's preconceived ideas about suffering, their religious or cultural beliefs, their personal experiences and their value systems.⁶

2. In medicine, does compassion matter as long as the patient gets the correct treatment when needed?

Compassionate care involves acting with kindness and sensitivity to the suffering of patients, who are often already feeling vulnerable due to the possibility that they could lose their independence, self-respect and control over their own bodies.¹⁹ Krolak believes that "empathetic people are more popular, gain more trust and have a better ability to motivate others".¹⁸ Thus, for a clinician, having these qualities would be beneficial in the doctor-patient relationship where communication and compliance play a key role in treatment outcomes. Goleman believes that the term empathy encompasses three elements, all of which are desired in the doctor-patient situation. These include: having the knowledge of what another person is feeling; as feeling what the other is feeling; and as reacting with sympathy to their pain.¹⁸ (Goleman cited by Krolak.) If we add a fourth element of trying to assist, then empathy would equate to the definition of compassion. It is also believed that "the higher the empathetic skills, the better the patient relationship will be in terms of verbal and non-verbal communication, safeguarding against stereotyping and bettering the patient's levels of satisfaction after their consultations" (13). This could indirectly have a positive effect on the clinician in terms of decreasing their workloads as it was found that the more satisfied the patient, the fewer times they returned for follow-up visits and the less number of complaints they have at these visits.

3. Can too much compassion prevent a person from delivering the appropriate care, and can it cloud a practitioner's judgement?

Some clinicians aim to please every patient's needs and desires, no matter how unrealistic the expectations. This is humanly impossible, and runs the risk of affecting them personally. Sykes and Postma (2022) debated the issues around being self-ish, self-less or well-balanced (which they termed being "other-ish"), and how this may relate to the practice of medicine and dentistry. They postulated that healthcare providers who take the patient's illness or dissatisfaction as a "personal failure may become stressed or depressed. They termed those who try too hard to meet all their patients' demands, even at the expense of their own health or pocket, as "selfless givers". Examples of this type of behaviour include practitioners who try to give every patient the best treatment, even for those who cannot afford to pay for it. In these cases they undercharge for their services, sponsor materials or cover laboratory costs, resulting in them being out of pocket. Others concede to patients' desires for treatment times, and may start work very early, finish late and even consult over weekends or on public holidays to accommodate their patients' schedules. In so doing they sacrifice personal relaxation and family time. In extreme cases healthcare providers may be pressurised to carry out more complex procedures than they are trained or certified to handle. This often happens in situations where a patient cannot afford to see a specialist, but still wants to have the procedure done. This places immense stress on an ethically conscious practitioner, who may also have to endure the fear of failure or be responsible for any repercussions of actual failure. While being selfless is admirable, therapists who are relentlessly selfless givers, to the point of neglecting their own interests, can end up doing a greater disservice to themselves and their patients. They run the risk of burning out and/or developing resentment towards their careers. This, in turn, deprives them of energy, and leaves them in a state where they are of no use to the very people they set out to please.²⁰ This condition has been described as "compassion fatigue", and has been widely discussed in literature. It refers to a healthcare provider's reduced capacity to care as a result of repeated interactions requiring high levels of empathic engagement with distressed patients. Fatigue in healthcare providers can lead to reduced service quality, low levels of efficiency, high attrition rates and, eventually, workforce dropout. These all have a major impact on patient care and outcome. To mitigate the risk of developing compassion fatigue in healthcare providers it is important to educate them on identifying the condition and provide them with the tools to manage and deal with their own mental, physical and emotional health issues appropriately. As stated by Prof Flavia Senkubuge (personal correspondence): "There is no honour in NOT taking care of yourself".²⁰

4. Can one deliver good care without being compassionate, and what does a patient value more - the outcomes of the therapy or the manner in which it was delivered?

Patients have a right and expect to receive high quality, competent care. This entails they be given a comprehensive clinical examination, get an accurate diagnosis, be offered treatment alternatives and understand the risks and benefits of each, make autonomous educated decisions, and then be provided with the best management possible given their circumstances. The clinician also needs to ensure that, as far as possible, all treatment provided is appropriate, and given safely and efficiently. High quality of care helps prevent complications and promotes better and faster recovery (ChatGPT, June 16 2024). At the same time, patients need to feel valued as individuals. Compassionate care recognises the need for emotional and psychological support which can help reduce anxiety, stress and feelings of isolation. Open and empathetic communication channels allow healthcare providers to have a better understanding of patients' needs, leading to more accurate information sharing. It also helps build trust between the patient and their healthcare providers, greater understanding and often to improved adherence to recommended treatment. Compassionate care has been shown to be associated with higher levels of patient satisfaction, less post treatment consultations, fewer incidences of litigation and overall better outcomes. Generally, patients do not value one over the other but rather seek a balance between both. Effective care without compassion can feel impersonal and cold, while compassion without competent care will leave the patent with unmet needs and is legally unacceptable.

5. Can a person who has never been cared for or experienced compassion be aware of what this entails and can they then learn how to exhibit care and compassion if shown?

Psychologists believe that compassion can be learnt and cultivated through various practices and approaches. However, the first requisite is that the clinician needs to be aware that they lack this characteristic and must want to develop this attribute. Literature is replete with advice and programmes aimed at bettering oneself. Interventions include practicing mindfulness and meditation to help a person increase self-awareness as well as awareness of others' suffering; practicing focusing on thoughts of goodwill and kindness towards oneself and others; empathy training to better understand and share the feelings of others; developing active listening skills to be able to see situations from another person's perspective; reading and attending workshops that highlight how to identify different perspectives and experiences; volunteering in services to help others; cultivating and building strong supportive personal relationships that emphasise kindness, understanding, mutual respect and compassion; regular reflection on one's own thoughts, feelings and actions; journalling, or taking part in group discussions and mentorship programmes with trusted counsellors or friends; practicing self-compassion which then makes it easier to show the same to others; and learning from compassionate role models (be it historical figures, current leaders, international celebrities or personal acquaintances). By incorporating these practices into daily life, individuals can gradually develop a more compassionate mindset and behaviour.

 

CONCLUSIONS

Both care and compassion are essential components of effective medical practice. Care ensures that patients receive the necessary and appropriate medical interventions. Compassionate care is broader and more holistic as it recognises the patient as a whole person and not just a medical condition, and aims to ensure that the interventions are delivered in a way that respects and values their individuality. It addresses their mental and emotional states along with their physical health. To integrate both effectively, healthcare providers should aim to develop communication skills that encompass active listening, and providing empathetic responses that will include giving clear explanations, offering viable alternatives and guiding patients toward making the best decisions about their own health status. They should also adopt a patient-centred approach that prioritises the patient's values, needs and preferences during their decision-making process. At the same time, they need to look after themselves by cultivating emotional intelligence and be able to identify and manage their own feelings and responses, and also be able to identify when they need mental, emotional or physical support.

 

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Correspondence:
Leanne M Sykes
Email: Leanne.sykes@up.ac.za