https://orcid.org/0000-0003-4542-9911
Abstract
Phenomenon
Training programs have been used to improve compassion in healthcare, but the factors necessary to make such programs successful and sustainable have not been identified. This thematic analysis aimed to bridge the gap between theory and practice by drawing on the experiences of international leaders and educators of compassion training programs to develop a clear understanding of what is relevant and effective and how compassion training is implemented and sustained.
Approach
International leaders and educators of compassion training programs (N = 15) were identified through convenience sampling based on academic and gray literature searches. Semi-structured face-to-face interviews with these participants were conducted between June 2020 and November 2020 in order to identify facilitators, barriers, and environmental conditions influencing the implementation and maintenance of compassion training programs. The interviews were recorded, transcribed verbatim, and analyzed using thematic analysis.
Findings
Six categories affecting the operationalization of compassion training programs were identified 1) origins, foundational principles and purpose, 2) curricular content, 3) methods of teaching and learning, 4) trainer qualities, 5) challenges and facilitators, and 6) evaluation and impact.
Insights
Compassion training should be rooted in the construct of interest and incorporate patients’ needs and their experience of compassion, with patient-reported compassion scores integrated before and after training. Compassion training should be delivered by highly qualified educators who have an understanding of the challenges associated with integrating compassion into clinical practice, a dedicated contemplative practice, and a compassionate presence in the classroom. Prior to implementing compassion training, leadership support should be secured to create an ethos of compassion throughout the organization.
Introduction
Compassion in healthcare has been defined as “a virtuous and intentional response to know a person, to discern their needs and ameliorate their suffering through relational understanding and action.”Citation1(p. 5) Accumulating evidence suggests that compassion can make a major contribution to each of the ‘Quadruple Aims’ for improving healthcare: an enhanced patient experience; better patient outcomes; improved healthcare provider wellbeing; and lowered healthcare costs.Citation2–9 Compassion has a strong positive effect on the patient experience,Citation7 resulting in improved clinical communication,Citation10–13 emotional resonance,Citation10,Citation14–16 and patient-centered care.Citation17–19 Compassion impacts patient outcomes, by decreasing patient symptom burdenCitation20–24 and increasing patient health-related quality-of-life.Citation21–23,Citation25–27 Compassion seems to protect healthcare provider wellbeing, by mitigating moral distress, burnout, and occupational stress while increasing engagement at work and job satisfaction.Citation1,Citation22,Citation28–33 Compassion has been associated with lower healthcare costs through improvements in patient-centred care, which have been associated with fewer unnecessary specialist referrals, hospitalizations and laboratory and diagnostic tests,Citation18 higher quality care ratings, reduced medical errors and malpractice lawsuits, and decreased employee turnover and absenteeism.Citation8,Citation33–42
Patients recognize the importance of compassion in healthcare; however, many report care experiences where compassion is lacking.Citation7,Citation11,Citation21–23,Citation39,Citation43–46 System-level failures, where patients were neglected, received sub-optimal care, and/or were treated with ‘callous indifference,’Citation36 have prompted governments, healthcare organizations, and healthcare provider licensing bodies to focus their efforts on improving compassion in healthcare.Citation36,Citation47–52 Training programs have been implemented to cultivate compassion in healthcare providers; however, a recent systematic review reported that these programs were challenged by issues of poor construct validity, including inadequate content coverage, particularly in relation to the interpersonal domains of compassion, a lack of skill-based training, and a lack of patient-reported outcomes in evaluating clinical effectiveness.Citation53
There remains a critical need to enhance the quality of evidence in this emerging field of education. This includes understanding the barriers and facilitators to implementing and sustaining an evidence-informed, competency-based, clinically relevant, feasible, and accredited compassion training program. A recent realist review of the literature identified attributes that explain the successes of compassion training programs offered to healthcare providers. Findings showed that compassion training programs that become a key component of the infrastructure and culture of healthcare organizations, use multi-modal teaching and learning methods, and rely on valid measures to assess outcomes, are most likely to engender compassion in learners.Citation54 Realist reviews take a retroductive approach, which uses researchers’ inductive and deductive reasoning, based on their knowledge, to identify factors that cause patterns and changes in those patterns.Citation55 The current study extended this research using qualitative thematic analysis of interviews with international leaders and educators of compassion training programs. The interview process provided direct insight into the thoughts, beliefs, and experiences of the participants.
The aim of this study was to determine the tangible and intangible factors that affect the operationalization of compassion training programs in the healthcare setting. The research used a pragmatic paradigmCitation56 to bridge the gap between theory and practice by drawing on the experiences of study participants to develop a clear understanding of what is relevant and works, and how compassion training is implemented and sustained in healthcare.
Methods
Study population
Following approval from the Conjoint Health Research Ethics Board (REB20-0907), participants were recruited through convenience sampling from international program leaders and institutions that are centers of excellence for compassion training. These participants were identified from a systematic review,Citation53 realist review,Citation54 and search of the gray literature of compassion training programs. In the gray literature, the topic was searched in two separate search engines that use different algorithms (Google & DuckDuckGo), and 12 databases and catalogues of gray literature (Gray Literature Report, Open Gray, Trip Medical Database, OAIster, CMA Infobase, Health Canada, Health Quality Ontario, Canadian Institute for Health Information, National Institute for Health and Care Excellence, Agency for Healthcare Results, Government of Canada, and FedSys) to identify relevant authorities and organizations. Finally, research team members were asked to nominate authorities and organizations.
Between June 2020 and November 2020, participants were contacted by a graduate trainee (DH) via email and a follow up phone call if necessary, to participate in a qualitative interview on the scope and implementation of their compassion training programs. Participants were eligible for recruitment if they were: English speaking; 18 years of age or older; had designed or were leading or facilitating a compassion training program; and had the decision-making capacity to provide their oral consent to participate. Recruitment ceased when the list of prospective participants was exhausted.
Data collection
After oral consent was obtained, participants were asked about the descriptive details of and their personal reflections on their respective programs. The interviews were intended to elicit challenges, facilitators, conditions, and operational factors affecting the successful implementation and sustainment of compassion training programs from the perspective of international program leaders and educators. Interviews were approximately 60 minutes and were conducted by a trained graduate trainee (DH) via an online video platform.Citation57 A semi-structured interview guide (Supplemental Appendix) was developed based on the research team’s literature reviewsCitation53 and previous qualitative studies focused on the feasibility of compassion training from the perspective of healthcare providersCitation58 and patients.Citation21–23 Interviews were audio-recorded, transcribed, and were independently verified (DH) against the original audio file. To protect participant anonymity, transcripts were stripped of identifying individual information, but program names were retained. Participants who requested to review their transcripts were given the opportunity to do so. All data, including audio recordings and transcriptions, were kept on secure cloud-based servers to which three research team members (SS, PJ, DH) had access.
Data analysis
Thematic analysisCitation59 was used for data analysis as a qualitative method that aims to identify, analyze, and report patterns (themes) of a phenomenon of interest in an iterative and descriptive fashion. Codes, or units of meaning, in the form of participants’ actual words were identified by six members of the research team (SS, TH, ALR, JK, PJ, DH) who analyzed each transcript independently in a line-by-line fashion, with codes being recorded in the margin of each transcript. After independently coding 3-4 transcripts, the research team met and went through each transcript again in a line-by-line fashion, sharing their individual codes, in order to reach consensus on each code, producing a master transcript containing consensus codes. This process was then repeated for all subsequent transcripts. Following an inductive process, consensus codes from all master transcripts were captured in a master coding schema.
Researchers practiced reflexivity through a collaborative approach to individual and consensus coding. This dialogue between team members during the coding process uncovered a variety of clinical practice experience, different bodies of knowledge, assumptions, and attitudes among researchers. The move from individual coding to consensus was a process of becoming aware of individual perspectives and how these divergent and convergent ways of knowing, when combined, provided a fuller, more developed understanding of compassion training in healthcare.
Constant comparison techniques were applied, and saturation was achieved when no new codes were discovered in subsequent transcripts. After data saturation was reached, five members (SS, ALR, JK, PJ, DH) of the research team used the master coding schema to identify recurring patterns in the data and develop a draft thematic framework. Next, four members of the research team (SS, ALR, PJ, DH) refined and organized initial themes into categories to finalize the thematic framework. To ensure integrity, interview data, the coding schema, the developed categories and themes, and the thematic framework were reviewed by a member (TH) of the research team who was involved in coding but was not involved in the framework development.
The four criteria for rigor in qualitative studies were met in this study.Citation60 Fit (the degree to which the thematic framework is representative of transcript data) occurred by independently coding each interview transcript; workability (the extent to which the thematic framework explains the phenomenon of interest and predicts and interprets patterns) was achieved through the constant comparative technique; relevance (the extent to which the thematic framework reflects the actual concerns and the phenomenon of interest) was achieved by member checking when clarification was needed; and modifiability (the extent to which themes and categories are able to readily accommodate new data) was assured by having a separate member of the research team verify the thematic framework against the coding schema and interview transcripts.
Results
Interviews were conducted with international leaders and educators from 15 of the 18 prospective compassion training programs identified (details in the Acknowledgements section). Information describing the compassion training programs is provided in the Supplemental Appendix, and the thematic framework is provided in .
Table 1. Thematic framework.
Data analysis produced six overarching categories: 1) origins, foundational principles and purpose; 2) curricular content; 3) methods of teaching and learning; 4) trainer qualities; 5) challenges and facilitators of compassion training programs; and 6) evaluation and impact of compassion training. Each category contained several themes and subthemes, which are described below along with supporting verbatim quotes.
Category: Origins, foundational principles and purpose
Theme: Origins & foundational principles: leader-, learner-, and government-Identified need
Several compassion training programs were adapted from preexisting training programs on related topics (e.g., self-care, mindfulness, shame, self-criticism) that leaders had previously developed, were teaching, or had attended. One leader was a scientist and a meditation teacher who was asked to secularize and refine an existing program rooted in Buddhist teachings. Another leader worked with a mindfulness teacher to develop a program that would enable healthcare providers to integrate meditation into clinical practice. Some leaders developed programs that focused on “creating the condition for compassion to flourish in acute health and human services” (Participant 4). One leader augmented an appreciative inquiry approach to promote a program of compassionate relationship-centered practice, partnering with healthcare organizations to contextualize training and cultivate organizational support.
A smaller number of compassion training programs originated from learner-identified gaps in medical education and professional practice. These programs developed after a healthcare provider or a student “thought, this is what my people need… dealing with the stress and burnout” (Participant 7), and they encouraged a program leader to adapt generalized self-help or meditation courses and workshops to improve compassion in the healthcare setting.
A number of compassion training programs designed to evaluate or improve compassion in healthcare were created based on government initiatives or funding opportunities that “basically promote(d) and support(ed) and spread compassion initiatives and research and projects” (Participant 5).
“It’s like a jigsaw puzzle… I didn’t actually sit down and say, okay, let’s design, but it was a gradually evolving process." (Participant 11)
Theme: Purpose: Developing compassionate leaders, a compassionate self, and compassion for others
The primary objective of most compassion training programs was not to impart or codify knowledge to learners about how to deliver compassionate care; rather, it was to “create that local culture in which expansive learning can take place and in which people are supported to deliver compassionate care” (Participant 6). These programs used a variety of approaches to generate the conditions for compassion to flourish, including quality improvement training “to build leaders who can provide compassionate care” (Participant 2); equipping leaders to better support their staff to provide compassionate care; developing manager and healthcare team practices intended to create a learning environment to improve compassionate care; “help(ing) people (learners) uncover their inherent capacity to care and grow it" (Participant 15); creating opportunities for interdisciplinary teams to become aware of and debrief about clinical challenges to compassion; and empowering learners to develop expertise in facilitating a compassionate response within the professional organizations, institutions, and communities in which they lived and worked.
Nurturing healthcare providers’ innate capacity for compassion for the primary benefit of self, was reflected by a number of programs that aimed to improve compassion by nurturing the personal qualities, intrapersonal skills, and self-care practices of learners. The majority of these programs used mindfulness and relaxation training to help learners develop mindfulness, a calm presence, loving–kindness, and healthcare provider wellbeing.
Finally, a small number of compassion training programs aimed to provide healthcare providers’ with the knowledge, behaviors, and skills specifically intended to improve compassion for others, which usually involved “shar(ing) their stories for learning and insight about compassionate patient-family-centered care and quality improvement” (Participant 5), and “amplify(ing) the human side and the compassionate side that already exists” (Participant 12).
Category: Curricular content
Theme: Mindfulness/meditation theory and techniques: Integrating mindfulness into compassion training
The majority of compassion training programs contained a strong mindfulness/meditation component. These programs used meditation techniques to help learners relax, focus, develop self-awareness, diminish self-criticism, acknowledge their emotions, and “bring some of that meditative state of mind with them into their office” (Participant 2). In relation to compassion in clinical care, mindfulness/meditation training was felt to provide a means for more effectively noticing and attending to patient’s physical, psychosocial, and spiritual suffering:
“Cultivating these skills of attention are fundamental because if you can think of attention as the gateway to compassion, you have to notice that they’re suffering in order to be moved by it, want to do something about it, whether the suffering is in somebody else or the suffering is in you." (Participant 15)
Theme: Intrapersonal theories and knowledge to help foster compassion: Cultivating self kindness to cultivate compassion
The majority of compassion training curricula included a strong intrapersonal component focused on teaching learners how to direct kindness, love, and peace to oneself in order to cultivate wellbeing and internal feelings attributed to compassion. Topics included examining self-criticism, nurturing a compassionate self, understanding the link between compassion and burnout, and self-regulation training. These programs adopted relaxation techniques, autogenic theory and training, guided imagery, and self-compassion and self-care practices. One program used psycho-education and a series of experiential activities to promote engagement with personal suffering and kindness for oneself:
We teach learners to reflect on experiences in a way that allows you to open yourself and turn towards whatever feelings might arise—whatever thoughts and feelings might arise—rather than trying to analyze and solve.” (Participant 2)
Theme: Interpersonal theories and knowledge to help foster compassion: Interpersonal skills to establish a compassionate connection
A few compassion training programs included an interpersonal component that focused on teaching learners the importance and provision of compassion to others. Topics were designed to create “a learning culture which supports the relational capacity of the whole team and therefore its individual members to provide compassionate care” (Participant 6); understand the connection between clinician wellbeing and caring for others (including those who are perceived as difficult); recognize shared humanity; appreciate and emotionally connect to others; and “understand how people struggle and so forth, to have that empathic concern, but also to see what we can do” (Participant 9). Very few compassion training programs integrated topics relevant to the patient experience of compassion or assessed what patients wanted from healthcare providers in terms of compassion. One program, however, used patient and family storytelling to promote dignity and compassion within a broader patient experience program. One program used a topic and case-based approach in which ‘caregivers’ shared their professional experiences of compassion or the impact of illness on a patient and family to promote group discussion. Another program supported the development of learner-patient relationships, helping learners to understand individual patients as people, connect with patients, and involve patients in care and treatment decisions, which was also applied to enhance learners’ relational capacity with other members of the healthcare team.
Category: Methods of teaching and learning
Theme: Meditation practice: Contemplating compassion
Meditation practice was an important method of teaching and learning in eight compassion training programs. A variety of programs used formal meditation practices (sitting meditation, walking meditation) that learners were encouraged to integrate into the work environment; loving-kindness and Tonglen meditations as “a very stable anchor that they [learners] could use at work to keep an open mind and kind and aware form of attention for the patients and at the same time that gave them this feeling that they are being protected, that there is something they can connect with to bear this suffering” (Participant 10); audio-recorded meditations for learners to practice meditation at home; and informal meditation techniques applicable to clinical practice, such as waiting and discerning mindful pauses between patients and in clinical conversations. Other programs used personal meditative practices to cultivate learners’ ability to access nurturing moments (connecting to places, people, and activities that provided safety) in difficult situations, develop breathing techniques to regulate the sympathetic nervous system, or increase self-awareness. Two programs include interpersonal meditation where participants were invited into dyad or larger group conversations to facilitate pausing and relaxing, letting thoughts flow freely, and listening deeply together. While programs were unified in meditation as a teaching method, there were differences of opinion on which types of meditation were best to use.
Theme: Experiential learning: Self-reflection and creative techniques to enhance compassion
Experiential learning was a predominant method of teaching and learning in the compassion training programs studied. Experiential learning enabled “people [learners] to come up with the solutions themselves rather than being… ‘spoon fed,’ like, ‘you need to do this’” (Participant 3), and “experience it for yourself to understand it” (Participant 4). Experiential teaching and learning methods included learner-reflection to develop insights into the topic of compassion; a drawing exercise that involved sketching what kindness looked like to individual learners; exploring the topic of emotional hygiene and learning from personal mistakes; repeating a mantra focused on compassionate commitment; postural practices to stimulate physiological systems linked to caring motivation; and visualization practices. Other experiential teaching and learning methods involved the use of a baseline self-assessment of mindfulness, stress, emotional valence, positive and negative emotions, and empathy intended to promote self-awareness; role-play to promote self-learning; role-modeling; poetry and story-telling; and experiential self-compassion exercises in clinical practice.
Theme: Patient narratives and case-based learning: Patients as teachers of compassion
Patient narratives and case-based learning were important methods of teaching and learning in two compassion training programs. These programs used patient-based case studies, a panel of patient storytellers followed by a group discussion, or a topic and a case-based approach in which ‘caregivers’ were supported in perspective-taking through group discussion. One program used clinical narratives, where stories about a meaningful or distressing personal or professional moment were shared with others who listened in a deep and mindful manner:
“There are these amazing experiences, not just of felt experiences of compassion as you listen to the stories of others and you think about the impact of illness on a patient and family listening to what it’s been like to take care of that patient or family.”(Participant 8)
Theme: Group learning: Learning and listening from others
Group learning was identified as a preferred method of teaching and learning in six compassion training programs. These programs emphasized the value of participants learning from one another; receiving peer support and encouragement related to the challenges associated with providing compassion; and developing active listening skills as peers shared their experiences of practicing medicine and compassion. Other programs incorporated a mindful teamwork exercise to help learners become focused and attuned to each other, and practices during which learners gave their attention and listened mindfully, engaged group members with compassion, and reinforced compassion as a way of life:
“What we really found was just that the social interaction and conversation, I call it the secret sauce of our program.” (Participant 14)
Theme: Clinical skill development and evidence-based learning: Embedding learning in the practice setting
Clinical skill development and evidence-based learning was a principal method of teaching and learning in many of the compassion training programs. One program translated classroom training into clinical practice through teaching communication skills and “actually go(ing) into practice and help(ing) them (learners) to do this work on the job rather than setting aside a room and having a particular workshop” (Participant 12). Some programs used a reflective practice approach, such that program learnings were implemented into practice and changes discussed. Other programs used conversation starters and information sharing to encourage individuals or a team to commit to a change, or a capstone project supported by mentoring and coaching.
Theme: Compassion toolkits: Supplemental learning resources to sustain learning
A number of compassion training programs emphasized the importance of providing learners with additional educational resources to sustain learning and support the integration of training into clinical practice. Toolkit resources included online training and webinars that supported and built on program material, meditation resources, supplemental reading lists, “a whole film… made to begin courageous conversations about the suffering that we meet in health and human services and how we meet it with compassion” (Participant 4), video modules, access to conferences, and a chat group created for learners to share their experiences of compassion and maintain the momentum after program completion. “All the things they are doing become WhatsApp statements that go out every week… that keeps the learning dialogue going” (Participant 12). While these extracurricular methods were intended to compliment in-class teaching methods, some leaders or educators observed that they could have an adverse effect by overwhelming learners with additional work and practices.
Category: Trainer qualities: Guide on the side and embodied teaching
Theme: Teaching skills: Guide on the side
While seemingly obvious, leaders and educators felt it was essential that trainers/instructors possessed good teaching skills and were comfortable speaking, both in small and large groups. Beyond their knowledge or personal experience of the topic, ideal trainers were friendly, interactive, and able to educate without lecturing. “The teacher is not a sage on the stage, but rather a guide on the side” (Participant 9). Additionally, trainers had a “facilitating role rather than like “we’re here to lecture you”” (Participant 3), which they continued to develop. This role included being nurturing and understanding; sensitively engaging different types of learners, including those who appeared to be disengaged; effective time-management skills; asking open-ended questions and fostering learner-directed discussion; and maintaining a psychologically safe teaching environment where learners felt they could be vulnerable.
"…So there’s the value set, sort of the attitudinal set, the ‘how you orient yourself in relation to other people.’ There are sort of the self-reflection capacity, self-awareness capacity. There’s the skill set involved and really managing a good discussion. And then there’s that whole capacity to really be reflective in the moment and aware of what’s happening in the group, the sort of metacognition, meta-awareness skill and that’s really important for a good facilitator.” (Participant 8)
Theme: Embody compassion: Exemplifying compassion in the character of the trainer
The most endorsed trainer quality was embodying compassion in their demeanor, attitudes, and behaviors within the classroom, having “some of these values already in their body" (Participant 12). Specifically, leaders and educators felt that desired trainer qualities included authenticity, a nonjudgmental and open-minded attitude, pursuit of life-long learning, and embodying compassion in their actions and words: "The biggest thing is embodiment… even more important than what you say is kind of how you say it, and how you hold yourself.”(Participant 7) Trainers had to connect with the subject matter in a personal and experiential way, believing in the topic, and the value and benefits of the program. Leaders and educators felt it was essential that trainers were aware of their own moral and empathic distress, and were able to connect emotionally with individual learners and understand their suffering and challenges.
Theme: Contemplative and self-care practice: Knowing and caring for oneself
In addition to exemplifying qualities and behaviors associated with compassion in the classroom, leaders and educators felt it was imperative for trainers to be engaged in contemplative practice (e.g. meditation, reflective practice, spiritual practice), “so that they are speaking out of their own direct experience” (Participant 2). These contemplative practices were focused on developing aspects of compassion, such as attentiveness to personal suffering, extending loving–kindness to others, or connecting to an ultimate source of compassion (God, the Universe, a Higher Power).
“In our teaching, we are really meeting people who had lived moral distress, had lived traumas… and I mean if I am soaking in that and I don’t have a solid practice and an outlet, then you can downward spiral. I’m not sure the world sees this.” (Participant 4)
Theme: Empirical knowledge and clinical experience: Knowing the organizational culture and practice setting
In light of the learner audience, leaders and educators felt it was particularly important that trainers had a working knowledge of “being case-based, which is how clinicians learn, and evidence-based” (Participant 1). Trainers also needed to be “senior enough to have the authority and the credibility with people that they’re going to be listened to” (Participant 6), including having the necessary qualifications to teach the program. In some cases, a co-facilitator model was employed, whereby external trainers were coupled with a trainer from the learning setting as a way of contextualizing and legitimizing the training for specific learner groups and disciplines.
"…So there should be some previous experience in translating or trying to create the space for people to talk, discuss and experience compassion… an openness, a capacity to get used to the to the rhythm at the hospital because this is a very special environment…and also I would even say a wise person.” (Participant 10)
Category: Challenges and facilitators of compassion training programs
Theme: Learning challenges: Background, values, expectations, personal issues, and misperceptions of compassion aptitude
Learners’ misconceptions about the purpose and content of the course included misperceptions and fears related to compassion, whereby they perceived a personal cost of compassion. Other misconceptions included conceptualizing compassion strictly as a virtue as opposed to an action, dismissing compassion as “light fluffy and sort of the cherry on top” (Participant 8), and not appreciating the connection between compassion, quality patient care, and healthcare provider wellbeing. Some learners “felt that they were selected because they weren’t compassionate enough” (Participant 3), seeing the programs as remedial instead of educational, punitive instead of affirmative, mandated instead of voluntary; and some participants were cynical of the underlying purpose of the training, particularly in programs with external facilitators. Other learners perceived that practices such as meditation were largely a passive practice of emptying the mind or were in conflict with their own religious beliefs.
“Now, one of the ways in which you deal with fears is to help people recognize what compassion is. It’s not about having to love everybody. It’s not about kindness. We never go anywhere near kindness… we always focus on the courage and the wisdom [of compassion]…" (Participant 11)
A much more subtle, but pervasive challenge reported among many learners was a preconceived or inflated sense of compassion competence. Leaders and educators noted this as a reason why healthcare providers abstained from voluntary training programs, and it engendered an ‘expert mind’ in mandatory training sessions. Learners saw “themselves as compassionate already, and just coming from the outside saying “okay, we are going to teach you compassion,” there was a lot of resistance” (Participant 10). This had an impact on learners and others.
A final challenge identified by leaders and educators was learners who displayed a general lack of motivation to learn or had personal issues that hindered both their ability to learn and their fellow learners. These learners seemed particularly averse to components of the training program that were action-oriented, required sharing personal feelings, focused on personal development, and involved engaging personal suffering and the need for self-care. Leaders and educators identified learners with a history of personal trauma as having particular challenges with compassion training programs, as training often evoked memories of personal suffering or personal incidents where learners had experienced a lack of compassion:
“So people who have had traumatic backgrounds, people who should have had people who cared for them and didn’t or they were neglected or abused, what happens for these individuals is that when they start to do compassion training, you start to open up these systems… So, you’ve got to be a little bit careful with that… it can relate to the fact that as you stimulate the system, any toxic memories in that system will start to emerge." (Participant 11)
Theme: Facilitators: Successful compassion training programs are supportive, situated, individualized, and accessible to learners
Many leaders and educators were emphatic that the longevity and overall success of a compassion training program were dependent on engaging organizational leaders through pre-orientation training and securing an organizational commitment to change. Participants identified that senior leadership, at both organizational and team levels, “actually has to sign off of on it [compassion training] and say they’re going to support whatever costs it incurs” (Participant 8), establish “congruence between the values of the institution and what the course is trying to teach” (Participant 10), prioritize compassion across the organization, and ensure that staff understood and valued the training.
In terms of learner-related facilitators, most leaders and educators felt that making program offerings voluntary rather than institutionally mandated or required, had a significant impact on the overall program success and learners’ desire to learn. Likewise, a learner-centered, non-authoritative and collaborative teaching environment, where learners felt safe among their fellow learners and free from ridicule, and training activities that included extracurricular activities such as healthcare provider self-care and self-awareness practices, were identified as contributing to program success: “There is a team effect that you don’t want to miss…" (Participant 10)
Compassion training was also perceived to be more successful when individual learner needs were assessed prior to training, allowing programs to be tailored to learner needs and expectations: “And kind of pick and choose which skill or tool that we want to offer them depending on the group.” (Participant 14) At program outset, it was important for learners to understand the value and meaning of compassion to the organization, and to demonstrate accountability by setting and sharing learning goals.
On a practical level, leaders and educators felt that compassion training programs needed to be accessible to learners, with a mix of online and in-person training. Likewise, training programs needed to be cognizant of learners’ clinical demands, providing offerings that were close in proximity to the learner’s workplace, “extremely responsive… to their (learners’) time pressure, their needs for brief practices" (Participant 14), and offered in a condensed format during regular paid working hours, with learner’s clinical duties being covered by their employer so that they did not have to catch up on missed work post-training.
Category: Evaluation and impact of compassion training: How is training assessed and who determines impact?
Theme: Measuring success & missing measures: Learner reported outcomes and the need to integrate patient reported outcomes
All leaders and educators recognized the need to link compassion training programs with patient and family health outcomes. However, not a single compassion training program evaluated the impact of compassion training from the perspective of the patients. The outcomes of one program that was contextualized to each host healthcare organization noted that some host organizations benchmarked the training to patient complaint and satisfaction scores, but this was based on individual organization’s impetus and not reported systematically across organizations, producing mixed results. One program used a panel of patient storytellers followed by a group discussion, where both learners and patients were able to provide open-ended feedback about the impact of compassion on their care and caregiving. Some programs had considered including an observation-based approach, in which clinical colleagues evaluated learners in the course of providing patient care. Some organizations stressed the importance of developing and integrating compassion performance indicators as part of routine care or working with healthcare accreditation bodies to embed compassion as an accreditation standard.
“Basically, what we have measured is impact on those who participate, there is no way to really link up with patient or family health outcomes… too many confounders.” (Participant 8)
Predominant evaluation methods were program-specific learner satisfaction surveys. A small number of programs used validated learner assessments, which included self-report questionnaires assessing learner wellbeing, mental health, mindfulness, self-criticism, self-assurance, personal distress, stress, anxiety, burnout, emotion regulation competencies, self-compassion, compassion satisfaction, and perceived compassion for others.
Theme: Reported outcomes
The reported outcomes of compassion training programs varied widely, evident in a diverse set of sub-themes including: perceived patient impact, improved healthcare provider reported wellbeing, perceived impact on clinical practice, and the organizational impact. The vast majority of programs considered outcomes focused on learners, such as improved personal and professional wellbeing, with impact at a clinical or organizational level being reported to a lesser degree and primarily in the form of open-ended learner feedback. Only one program measured a patient reported outcome, citing evidence for the positive impact the training program had on institutional patient experience scores:
“We did have evidence of our patient experience scores improving, it’s a corporate metric… and that was my goal… to try to improve how we made patients feel.” (Participant 5)
“We did pilots and ways of doing qualitative interviews with people [patients] in a private way to enable them to have an input… but we really didn’t get on very well. It was really difficult to do.” (Participant 6)
Reported learner outcomes included reduced stress, isolation, loneliness and depression, and improved healthcare provider personal and professional wellbeing, self-awareness, self-compassion, self-care, relaxation, sleep quality, focus/attentiveness, mental strength, and spatial awareness:
“When you learn mind-body skills, it helps you strengthen different mental capacities. It can help you strengthen focused attention. It can help you develop awareness, situational awareness. It can help you develop objectivity and a sort of objective distance from what’s going on.” (Participant 1)
The majority of programs provided anecdotal reports on improved clinical practice, citing learners’ feedback related to feeling “positively about suffering" (Participant 10), being more able to access their internal resources, and sensing a greater capacity for compassion. Other learner feedback indicated that the training programs allowed them to reestablish a compassionate practice, better align their practice with the principles of patient and family-centred care, develop patient partnerships, implement shared decision making, and promote workplace wellbeing. Learners also reported a positive effect of the program on interpersonal outcomes, including improved interpersonal relationships, enhanced respect, teamwork, and communication among coworkers and becoming less individualistic:
“So it’s kind of like I would say people feel energized and they often will say that they’re better listeners and others notice that they’re better listeners, that they’re able to make choices that represent their deeper values as opposed to more reactive choices.” (Participant 3)
Two programs reported impacts relevant to the organization, with one program noting the program fostered a collective vision for creating a compassionate care environment and another program reporting that some learners “came in with an idea and they came out and that idea had been implemented and shifted and changed along the way, but that process happened, and lives were touched as a result of that (Participant 13).”
Discussion
Using thematic analysis of individual interviews with leaders and educators of international compassion training programs, we have identified the practical and intangible factors that affect the operationalization of compassion training programs. Six core categories were identified from the study data, including the origins and purpose of the programs, their curricular content, the methods of teaching and learning, trainer qualities, program challenges and facilitators, and program evaluation and impact. Findings from the analysis are summarized as a table of recommendations ().
Table 2. Recommendations for the development of a compassion training program.
The genesis of compassion training programs came from three sources–program leaders, learners, and governments. Most compassion training programs were adapted from preexisting training programs on similar topics including mindfulness, meditation, psychological science exploring shame and self-criticism, quality improvement, leadership training, self-compassion, and compassionate relationship-centered practice. As such, the purpose of most compassion training programs was not to teach healthcare providers how to deliver compassion, but to create both the internal and external conditions for compassion to flourish by providing training on these related topics. While adopting content and teaching methods from established training programs in related fields is an important initial step, we recommend that compassion training origins, content, methods, and outcomes be rooted in the actual construct of interest.Citation53
The curricular content of compassion training programs in this study concentrated on three main topic areas: mindfulness/meditation, and interpersonal theory and skill-building. We acknowledge that cultivating the qualities, attributes, self-awareness, and relational skills associated with compassion is important, but suggest that future programs supplement these approaches with clinical skills and patient-reported compassion measures in order to ensure training is indeed changing clinical practice and achieving its ultimate outcome: improved patient experiences of compassion. Further, the content of compassion training programs should be evidence-informed and clinically relevant, equipping healthcare providers with the attitudes, knowledge, and skills that are reported to span each of the domains of compassion.Citation1,Citation4,Citation21–23,Citation58 Importantly, we recognize the critical need to incorporate patients’ needs and their experience of compassion within the curriculum, including the findings from patient-orientated research studies, and involving actual patients in the training.Citation7,Citation15,Citation21,Citation23,Citation39,Citation43,Citation58 Very few programs identified in this study assessed patient needs or the patient experience. The ultimate goal of any compassion training program should be to improve the patient experience while sustaining the healthcare provider.
While participants identified program content and teaching methods that were felt to be essential to the success of compassion training programs over time, a third equally influential, intangible factor was identified as being particularly important: the embodiment of compassion by trainers. We recommend that training be delivered by highly qualified educators with clinical experience and coupled with a dedicated contemplative practice, a compassionate presence in the classroom, and first-hand experiences of the challenges associated with integrating compassion into clinical practice.
This study identified a number of practical challenges associated with implementing compassion training programs that have not previously been reported. These included misperceptions of the purpose and content of the training, learners’ preconceived compassion competence, and learners who were unmotivated or had personal issues. Learners’ personal issues and clear communication regarding the purpose of training are common challenges to training implementation in general, while preconceived compassion competency seems to be a specific challenge to the training programs in this study. Studies evaluating compassion training programs have showed no post-intervention shift in compassion for many learners,Citation53,Citation61–64 suggesting learners may indeed have high baseline levels of innate compassion, creating a ceiling effect in evaluating compassion training interventions. Other studies investigating ratings of quality care and clinical communicationCitation65–67 have consistently revealed a discord between patient and healthcare provider assessments of these interactions, with the latter overestimating their ability compared to patient perceptions. In addition to adopting an appreciative inquiry approach to learning that acknowledges and builds upon the existing strength of learners,Citation68 this phenomenon might be further addressed by integrating patient-reported compassion scores before and after training.Citation53,Citation69 A few programs did consider including patient-reported outcomes in their training evaluations, however the lack of valid and reliable measures of compassion at the time were cited as barriers. Instead, the majority of training programs relied heavily on learner/healthcare provider self-reports of personal wellbeing as outcomes. It may be logical to suggest increased healthcare provider wellbeing (less stress, more attentive, more self-compassion, more mindfulness) leads to increased compassion to others; however, the outcomes measured were predominately focused on improving the wellbeing of the individual, not others—a phenomenon that is prevalent in other facets of the compassion literature.Citation53,Citation70–74
The most frequently cited factors affecting the success and sustainability of the compassion training programs in this study were the leadership and ongoing support of the healthcare organizations in which learners work. This finding was consistent with previous reviewsCitation53 and research that suggested that without organizational buy-in, resources, support, and the adoption of compassion as a priority across the organization, training initiatives were short-lived and possibly futile.Citation53,Citation58,Citation75,Citation76 To circumvent this, we recommend securing leadership support prior to implementing a compassion training program; offering pre-training to senior leaders to demonstrate the benefit of compassion training and to help them create an ethos of compassion throughout their organization; and tailoring the training program to meet both individual learner needs and the needs of the organization. As reported in the literature, programs that are based on an organizational model that acknowledges the importance of effective leadership in the delivery of safe, high-quality, compassionate healthcare are more likely to be sustained over time and create a ‘ripple effect’ of compassion across all levels of the organization.Citation19,Citation77–86
This study has several strengths. Previous work in this field has focused primarily on the literature, including a recent systematic review evaluating the evidence of compassion training programs,Citation53 and a realist review that identified what works, for whom, and in what contexts in relation to compassion training.Citation54 The systematic review of 103 compassion education interventions revealed that all were limited because they focused on a single domain of compassion, inadequately defined compassion, and lacked external assessments by patients.Citation53 The realist review used a retroductive approach to identify the contexts and mechanisms commonly associated with the outcomes of compassion training for practicing healthcare providers.Citation54 The current study expands on this work by identifying institutions that are centers of excellence for compassion training and international program leaders to gain insight on practical and operational issues affecting compassion training programs. The study adds to the body of knowledge by generating an evidenced-based thematic framework for compassion training () that is relevant across multiple types of care settings.
Limitations
Study limitations are associated with sample selection and lack of observational data. Leaders and educators of compassion training programs who participated in this study were recruited through convenience sampling, based on a systematic review,Citation53 realist review,Citation54 and a search of the gray literature. The intent was to develop a representative sample of international compassion training programs, although the sampling technique may have omitted other compassion training programs and the views of their leaders and educators. The participants were all administrators of compassion training programs rather than learners, which may have led to bias in the responses to some of the matters discussed. The institutions represented in this study were from North America and Europe and culturally homogeneous (English-speaking, Western, developed countries): therefore, our findings may not be generalizable to other contexts. The leaders and educators of the included compassion training programs reported information about origins and purpose, curricular content, methods of teaching and learning, trainer qualities, facilitators and challenges, and evaluation and impacts of compassion training programs; however, these were not verified by observational data.
Conclusion
In conclusion, this analysis provides healthcare providers, educators, and researchers with a guide for implementing and sustaining compassion training in healthcare. It characterizes the individual components that underpin the delivery of successful compassion training programs, and describes how they interrelate. Future compassion training programs might consider aligning their programs with these findings, and then adapting them to ensure contextual relevance across various healthcare disciplines and settings.
Acknowledgements
The authors would like to acknowledge the time and expertise of the program leaders and educators who participated in this study, including the following individuals who agreed to be acknowledged by name: Dr. Belinda Dewar, Dr. James R. Doty, Dr. Ronald Epstein, Dr. Paul Gilbert, Monica L. Hanson, Lisa Hawthornthwaite, Dr. Beth Lown, Laura Martin, Dr. Kristin Neff, Dr. Lobsang Tenzin Negi, Dr. Claudia Orellana-Rios, Dr. Erika Rosenberg, Dr. Mohamad Saab, and Micheline St-Hilaire.
Additional information
Funding
References
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