Program Leaders' and Educators' Perspectives on the Factors Impacting the Implementation and Sustainment of Compassion Training Programs: A Qualitative Study.

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.

Compassion in healthcare: an updated scoping review of the literature.

BACKGROUND: A previous review on compassion in healthcare (1988-2014) identified several empirical studies and their limitations. Given the large influx and the disparate nature of the topic within the healthcare literature over the past 5 years, the objective of this study was to provide an update to our original scoping review to provide a current and comprehensive map of the literature to guide future research and to identify gaps and limitations that remain unaddressed. METHODS: Eight electronic databases along with the grey literature were searched to identify empirical studies published between 2015 and 2020. Of focus were studies that aimed to explore compassion within the clinical setting, or interventions or educational programs for improving compassion, sampling clinicians and/or patient populations. Following title and abstract review, two reviewers independently screened full-text articles, and performed data extraction. Utilizing a narrative synthesis approach, data were mapped onto the categories, themes, and subthemes that were identified in the original review. Newly identified categories were discussed among the team until consensus was achieved. RESULTS: Of the 14,166 number of records identified, 5263 remained after removal of duplicates, and 50 articles were included in the final review. Studies were predominantly conducted in the UK and were qualitative in design. In contrast to the original review, a larger number of studies sampled solely patients (n = 12), and the remainder focused on clinicians (n = 27) or a mix of clinicians and other (e.g. patients and/or family members) (n = 11). Forty-six studies explored perspectives on the nature of compassion or compassionate behaviours, traversing six themes: nature of compassion, development of compassion, interpersonal factors related to compassion, action and practical compassion, barriers and enablers of compassion, and outcomes of compassion. Four studies reported on the category of educational or clinical interventions, a notable decrease compared to the 10 studies identified in the original review. CONCLUSIONS: Since the original scoping review on compassion in healthcare, while a greater number of studies incorporated patient perspectives, clinical or educational interventions appeared to be limited. More efficacious and evidence-based interventions or training programs tailored towards improving compassion for patients in healthcare is required.

Implementing compassion in pediatric healthcare: A qualitative study of Canadian patients', parents', and healthcare providers' perspectives.

BACKGROUND: Compassion has received significant scholarly attention over the past decade. Research has been largely theoretical, with interventions focused on self-care practices of healthcare providers (HCPs), rather than implementation at a systems level. This study aimed to identify how compassion can be operationalized within pediatric healthcare. DESIGN AND METHODS: Data was analyzed from a secondary dataset of a larger Straussian grounded theory study of perspectives and experiences of compassion in pediatric healthcare. Patients (n = 33); parents (n = 16); and HCPs (n = 17) were asked specifically how compassion could be implemented within the clinical culture and healthcare system. RESULTS: 66 participants generated an operational model of compassion indicating how compassion could be implemented across the organization and larger healthcare system. The data revealed four themes and associated subthemes: teach and train; recognize and reward; measure and report; and embed compassion across the healthcare system. CONCLUSIONS: Improving compassion in pediatric healthcare needs to extend beyond the efforts of individual HCPs. Compassion is the responsibility of the entire healthcare system and needs to traverse the patient and family experience. In addition to embedding compassion in policy, procedures, practice, and education, compassion should be considered a performance indicator that is measured and reported. PRACTICE IMPLICATIONS: This study provides a preliminary framework for organizational leaders to operationalize compassion across the services, structures, polices, procedures and practices of pediatric healthcare. This includes ongoing compassion training across the organization; assessing compassion, recognizing compassion as a performance indicator, and ensuring that the infrastructure and ancillary services of the organization reflect compassion.

What works for whom in compassion training programs offered to practicing healthcare providers: a realist review.

BACKGROUND: Patients and families want their healthcare to be delivered by healthcare providers that are both competent and compassionate. While compassion training has begun to emerge in healthcare education, there may be factors that facilitate or inhibit the uptake and implementation of training into practice. This review identified the attributes that explain the successes and/or failures of compassion training programs offered to practicing healthcare providers. METHODS: Realist review methodology for knowledge synthesis was used to consider the contexts, mechanisms (resources and reasoning), and outcomes of compassion training for practicing healthcare providers to determine what works, for whom, and in what contexts. RESULTS: Two thousand nine hundred ninety-one articles underwent title and abstract screening, 53 articles underwent full text review, and data that contributed to the development of a program theory were extracted from 45 articles. Contexts included the clinical setting, healthcare provider characteristics, current state of the healthcare system, and personal factors relevant to individual healthcare providers. Mechanisms included workplace-based programs and participatory interventions that impacted teaching, learning, and the healthcare organization. Contexts were associated with certain mechanisms to effect change in learners' attitudes, knowledge, skills and behaviors and the clinical process. CONCLUSIONS: In conclusion this realist review determined that compassion training may engender compassionate healthcare practice if it becomes a key component of the infrastructure and vision of healthcare organizations, engages institutional participation, improves leadership at all levels, adopts a multimodal approach, and uses valid measures to assess outcomes.

A Randomized Crossover Trial of Conventional versus Modified "Koch" Chest Compressions in a Height-Restricted Aeromedical Helicopter.

Aim: Low overhead height can negatively affect chest compression performance. An adapted compression technique has been proposed by paramedic H. Koch (pron. "Cook"). This study compares conventional to Koch technique in a height-restricted aeromedical helicopter. Methods: Eighteen clinicians were randomized to 2 minutes of conventional or Koch compressions, then crossed-over. Koch technique uses a forearm/elbow instead of overlapping hands. Compression quality was assessed with a Skill Reporting Laerdal Resusci-Anne manikin. Quality variables were: the number and rate of compressions, compression depth, release, land marking, and overall aggregate quality score. Participant feedback was collected using the Borg Scale of Perceived Exertion, and compression difficulty using a zero-to-ten scale. Furthermore, we solicited open-ended descriptive responses. Results: The average overall quality score was 63% for conventional compressions versus 79% for Koch compressions (p = 0.04). On average, the Koch compression method increased compression depth by 5 mm (95% CI 4.3 to 5.7) and the proportion of compressions at the correct depth by 17% (95% CI 7.55 to 26.45), although these were not statistically significant. Correct release and land marking showed no statistically significant difference between techniques. Koch compressions resulted in statistically significant reductions in physical exertion and difficulty (p < 0.001). Qualitative feedback described modified compressions as easier and more sustainable. Conclusions: In a height-restricted aeromedical helicopter, the average overall quality score improved using Koch compressions, although the mean rate, mean depth, correct release and land marking were found to be similar between techniques. Qualitative feedback described Koch compressions as easier and more sustainable. In settings where the compressor is affected by reduced overhead working height, Koch compressions may be an advisable alternative.

Assessing the credibility and transferability of the patient compassion model in non-cancer palliative populations.

BACKGROUND: A lack of evidence and psychometrically sound measures of compassion necessitated the development of the first known, empirically derived, theoretical Patient Compassion Model (PCM) generated from qualitative interviews with advanced cancer inpatients. We aimed to assess the credibility and transferability of the PCM across diverse palliative populations and settings. METHODS: Semi-structured, audio-recorded qualitative interviews were conducted with 20 patients with life-limiting diagnoses, recruited from 4 settings (acute care, homecare, residential care, and hospice). Participants were first asked to share their understandings and experiences of compassion. They were then presented with an overview of the PCM and asked to determine whether: 1) the model resonated with their understanding and experiences of compassion; 2) the model required any modification(s); 3) they had further insights on the model's domains and/or themes. Members of the research team analyzed the qualitative data using constant comparative analysis. RESULTS: Both patients' personal perspectives of compassion prior to viewing the model and their specific feedback after being provided an overview of the model confirmed the credibility and transferability of the PCM. While new codes were incorporated into the original coding schema, no new domains or themes emerged from this study sample. These additional codes provided a more comprehensive understanding of the nuances within the domains and themes of the PCM that will aid in the generation of items for an ongoing study to develop a patient reported measure of compassion. CONCLUSIONS: A diverse palliative patient population confirmed the credibility and transferability of the PCM within palliative care, extending the rigour and applicability of the PCM that was originally developed within an advanced cancer population. The views of a diverse palliative patient population on compassion helped to validate previous codes and supplement the existing coding schema, informing the development of a guiding framework for the generation of a patient-reported measure of compassion.

Initial Validation of a Patient-Reported Compassion Measure in a Mandarin-Speaking Long-Term Care Patient Population.

Background and Purpose: Compassion is increasingly considered essential to quality nursing care and is a concept that is strongly embedded across cultures, including Chinese culture. The Patient Compassion Model (PCM) depicts the unique yet overlapping domains of compassion. The Sinclair Compassion Questionnaire (SCQ) was directly developed and validated from this empirical model. In this study, we sought to establish initial validation of a translated SCQ among Mandarin-speaking patients by assessing the transferability of the PCM and the clinical sensibility of the SCQ. Methods: Forward and back-translation of the PCM and SCQ were performed in accordance with World Health Organization guidelines. Qualitative interviews were used to assess the transferability of the PCM with conceptualizations of compassion within a Chinese context. Cognitive interviews were conducted to assess the clarity, readability, wording, questions, and response scales of the Mandarin translation of the SCQ. Qualitative data were analyzed using constant comparative analysis, and cognitive interviews were analyzed using framework analysis. Results: The original categories of the PCM were verified in this Mandarin-speaking patient population. Specifically, participants' understandings of compassion is described as consisting of healthcare provider virtues, emphasizing the importance of a virtuous response that sought to understand the individual and their unique needs, to relationally communicate from a place of shared humanity and to ameliorate suffering. Participants were able to answer, comprehend, and endorse all 15 Mandarin SCQ items, resulting in no modifications to the Mandarin SCQ. Conclusions: This study provides initial validation of the Mandarin SCQ and PCM. Future studies should consider further establishing the validity and reliability of the Mandarin SCQ among a larger Chinese patient population.

Development and validation of a patient-reported measure of compassion in healthcare: the Sinclair Compassion Questionnaire (SCQ).

OBJECTIVES: Compassion is a key indicator of quality care that is reportedly eroding from patients' care experience. While the need to assess compassion is recognised, valid and reliable measures are lacking. This study developed and validated a clinically informed, psychometrically rigorous, patient-reported compassion measure. DESIGN: Data were collected from participants living with life-limiting illnesses over two study phases across four care settings (acute care, hospice, long term care (LTC) and homecare). In phase 1, data were analysed through exploratory factor analysis (EFA), with the final items analysed via confirmatory factor analysis (CFA) in phase 2. The Schwartz Center Compassionate Care Scale (SCCCS), the revised Edmonton Symptom Assessment Scale (ESAS-r) and Picker Patient Experience Questionnaire (PPEQ) were also administered in phase 2 to assess convergent and divergent validity. SETTING AND PARTICIPANTS: 633 participants were recruited over two study phases. In the EFA phase, a 54-item version of the measure was administered to 303 participants, with 330 participants being administered the final 15-item measure in the CFA phase. RESULTS: Both EFA and CFA confirmed compassion as a single factor construct with factor loadings for the 15-item measure ranging from 0.76 to 0.86, with excellent test-retest reliability (intraclass correlation coefficient range: 0.74-0.89) and excellent internal reliability (Cronbach's alpha of 0.96). The measure was positively correlated with the SCCCS (r=0.75, p<0.001) and PPEQ (r=0.60, p<0.001). Participants reporting higher experiences of compassion had significantly greater well-being and lower depression on the ESAS-r. Patients in acute care and hospice reported significantly greater experiences of compassion than LTC residents. CONCLUSIONS: There is strong initial psychometric evidence for the Sinclair Compassion Questionnaire (SCQ) as a valid and reliable patient-reported compassion measure. The SCQ provides healthcare providers, settings and administrators the means to routinely measure patients experiences of compassion, while providing researchers a robust measure to conduct high-quality research.

What Is the State of Compassion Education? A Systematic Review of Compassion Training in Health Care.

PURPOSE: To investigate the current state and quality of compassion education interventions offered to health care providers during training or practice, determine how the components of each education intervention map onto the domains of an empirically based clinical model of compassion, and identify the most common approaches to compassion education. METHOD: The MEDLINE, Embase, CINAHL Plus with Full Text, Sociological Abstracts, Web of Science, ERIC, and Education Research Complete databases were searched from inception to March 2020 in this systematic review. Studies that evaluated a compassion education intervention for health care providers or those in training to enhance compassion toward patients and/or families were included. A narrative synthesis of the included studies was performed. The components of each intervention were mapped onto the domains of compassion described in the Patient Compassion Model. RESULTS: One hundred eight peer-reviewed publications describing 103 interventions were included. Modalities ranged from establishing curricula and interventions in clinical settings to programs that used humanities-based reflective practices, clinical simulation, role modeling, and contemplative practices, with many education interventions adopting a multimodal approach. Most interventions mapped to the virtuous response domain of the Patient Compassion Model; very few mapped to the other domains of this model. CONCLUSIONS: Most interventions were limited as they focused on a single domain of compassion; did not adequately define compassion; were assessed exclusively by self-report; were devoid of a comparator/control group; and did not evaluate retention, sustainability, and translation to clinical practice over time. The authors suggest that compassion education interventions be grounded in an empirically based definition of compassion; use a competency-based approach; employ multimodal teaching methods that address the requisite attitudes, skills, behaviors, and knowledge within the multiple domains of compassion; evaluate learning over time; and incorporate patient, preceptor, and peer evaluations.

A Practical Guide for Item Generation in Measure Development: Insights From the Development of a Patient-Reported Experience Measure of Compassion.

BACKGROUND AND PURPOSE: Although various measure development guidelines exist, practical guidance on how to systematically generate items is nascent. This article provides practical guidance on item generation in measure development and the use of a Table of Specifications (TOS) in this process. METHODS: In addition to a review of the literature, the item generation process within an ongoing study to develop a valid and reliable patient-reported measure of compassion is provided. RESULTS: Consensus on an initial pool of 109 items and their response scale was achieved with the aid of a TOS. CONCLUSIONS: Dynamic, experiential, and relational care constructs such as compassion lie at the heart of nursing. Practical guidance on item generation is needed to allow nurses to identify, measure, and improve compassion in research and practice.

Initial Validation of a Patient-Reported Measure of Compassion: Determining the Content Validity and Clinical Sensibility among Patients Living with a Life-Limiting and Incurable Illness.

BACKGROUND: Although compassionate care is considered a cornerstone of quality palliative care, there is a paucity of valid and reliable measures to study, assess, and evaluate how patients experience compassion/compassionate care in their care. OBJECTIVE: The aim was to develop a patient-reported compassion measure for use in research and clinical practice with established content-related validity evidence for the items, question stems, and response scale. METHODS: Content validation for an initial 109 items was conducted through a two-round modified Delphi technique, followed by cognitive interviews with patients. A panel of international Subject Matter Experts (SMEs) and a Patient Advisory Group (PAG) assessed the items for their relevancy to their associated domain of compassion, yielding an Item-level Content Validity Index (I-CVI), which was used to determine content modifications. The SMEs and the PAG also provided narrative feedback on the clarity, flow, and wording of the instructions, questions, and response scale, with items being modified accordingly. Cognitive interviews were conducted with 16 patients to further assess the clarity, comprehensibility, and readability of each item within the revised item pool. RESULTS: The first round of the Delphi review produced an overall CVI of 72% among SMEs and 80% among the PAG for the 109 items. Delphi panelists then reviewed a revised measure containing 84 items, generating an overall CVI of 84% for SMEs and 86% for the PAG. Sixty-eight items underwent further testing via cognitive interviews with patients, resulting in an additional 14 items being removed. CONCLUSIONS: Having established this initial validity evidence, further testing to assess internal consistency, test-retest reliability, factor structure, and relationships to other variables is required to produce the first valid, reliable, and clinically informed patient-reported measure of compassion.

Medical students' perspectives of their clinical comfort and curriculum for acute pain management.

OBJECTIVES: Acute pain is a common presenting complaint in health care. Yet, undertreatment of pain remains a prevailing issue that often results in poor short- and long-term patient outcomes. To address this problem, initiatives to improve teaching on pain management need to begin in medical school. In this study, we aimed to describe medical students' perspectives of their curriculum, comfort levels, and most effective pain teaching modalities. MATERIALS AND METHODS: A cross-sectional, online survey was distributed to medical students at the University of Alberta (Edmonton, Canada) from late May to early July 2015. Data were collected from pre-clerkship (year 1 and 2) and clerkship (year 3 and 4) medical students for demographic characteristics, knowledge, comfort, and attitudes regarding acute pain management. RESULTS: A total of 124/670 (19.6%) surveys were returned. Students recalled a median of 2 (interquartile range [IQR]=4), 5 (IQR=3.75), 4 (IQR=8), and 3 (IQR=3.75) hours of formal pain education from first to forth year, respectively. Clerkship students were more comfortable than pre-clerks with treating adult pain (52.1% of pre-clerks "uncomfortable" versus 22.9% of clerks, p<0.001), and overall, the majority of students were uncomfortable with managing pediatric pain (87.6% [64/73] pre-clerks and 75.0% [36/48] clerks were "uncomfortable"). For delivery of pain-related education, the majority of pre-clerks reported lectures as most effective (51.7%), whereas clerks chose bedside instruction (43.7%) and small group sessions (23.9%). Notably, 54.2%, 39.6%, and 56.2% of clerks reported incorrect doses of acetaminophen, ibuprofen, and morphine, respectively, for adults. For children, 54.2%, 54.2%, and 78.7% of clerks reported incorrect doses for these same medications. CONCLUSION: Medical students recall few hours of training in pain management and report discomfort in treating and assessing both adult and (more so) pediatric pain. Strategies are needed to improve education for future physicians regarding pain management.

Sleep and Exercise in Emergency Medicine Residents: An Observational Pilot Study Exploring the Utility of Wearable Activity Monitors for Monitoring Wellness.

Introduction Burnout is well-documented in residents and emergency physicians. Wellness initiatives are becoming increasingly prevalent, but there is a lack of data supporting their efficacy. In some populations, a relationship between sleep, exercise, and wellness has been documented; however, this relationship has not been established in emergency medicine (EM) residents or physicians. We aim to determine whether a wearable activity monitor is a feasible method of evaluating exercise and sleep quality and quantity in emergency medicine residents and if these assessments are associated with greater perceived wellness. Methods Twenty EM residents from two training sites wore a wearable activity monitor (Fitbit ChargeTM, Fitbit, Inc., San Francisco, CA, USA) during a four-week EM rotation. The Fitbit recorded data on sleep quantity (minutes sleeping) and quality (sleep disruptions), as well as exercise quantity and quality (daily step count, daily active minutes performing activity of 3 - 6, and > 6 metabolic equivalents). Participants completed an end-of-rotation Perceived Wellness Survey (PWS), which provided information on six domains of personal wellness (psychological, emotional, social, physical, spiritual, and intellectual). PWS levels were compared between groups of subjects with higher or lower levels of activity and sleep (i.e., above and below the median subject-averaged values) using the Mann-Whitney U test. Other subject characteristics were similarly assessed for their association with PWS. When a possible confounding effect was seen, the data was stratified and reviewed using a scatterplot. Results Of the 28 eligible residents, 23 agreed to participate. Of these, 20 and 16 wore the device for at least 50% of the respective days and nights during the observation period. Two devices were lost. One PWS was not completed. There was no statistically significant correlation between resident perceived wellness survey scores, sleep interruptions, average daily sleep minutes, daily step count, or average daily active minutes for the sample overall. However, first-year residents and residents from years two to five reported different median PWS scores of 13.9 and 17.1, respectively. Further exploration by the training group suggested that step counts may correlate with wellness in participants in their first year of residency, while the quantity of sleep may have an association with wellness in participants in years two through five of their residency. Conclusion Using wearable activity monitor devices to capture sleep and exercise data among residents does not seem to be an effective approach. Our data does not support our hypothesis that overall resident wellness was associated with exercise and sleep quality and quantity as measured by such a device. These results are counterintuitive and may be complicated by several measurement-related limitations and the possibility that benefits depend on the stage of training.