Background

There are many definitions of compassion in nursing; however, there is not a consensus for one definition. This may indicate that compassion is a value and an emotion which is contextually and culturally specific. In seeking to understand how nurses in the United States (U.S.) view compassion, the literature revealed that most articles about compassion in nursing were from the United Kingdom, Australia, or Scandinavian countries. Literature published in U.S. based journals typically referenced caring, rather than compassion. The findings of this research study build on previous results to offer new insights into what caring and compassion means to nurses in the United States.

... the concept of compassion in the United States... is often used interchangeably with the term caring. According to Schantz (2007), the concept of compassion in the United States is not as clearly defined in nursing scholarship and is often used interchangeably with the term caring. Schantz also noted that nursing research in the United States uses the terms compassion, sympathy, empathy, and caring interchangeably. Similarly, in a phenomenological study to identify clinical actions, interventions, and interpersonal relationships that exhibited compassion and caring by healthcare clinicians, Graber and Mitcham (2011) noted that the words compassion and caring were used interchangeably.

... early U.S. nurse leaders considered compassion an inherent quality of a nurse and the essence of nursing. Sadler (2004), in assessing baccalaureate student essays, noted that the word caring replaced compassion. This is not to say that nurses no longer have compassion, rather, that nurses are utilizing different language to discuss how they show compassion and how they define compassion. However, she pointed out that early U.S. nurse leaders considered compassion an inherent quality of a nurse and the essence of nursing.

Burnell and Agan (2013) developed a tool to measure compassionate care delivered by nurses, arguing that if compassionate care is routine, then it should be identifiable to patients and therefore measurable. In Burnell and Agan’s tool the ‘caring attributes’ of a compassionate nurse were described as thoughtfulness, kindness, understanding the patient’s needs, and being empathetic.

Wallis (2005) described compassion as the “page upon which caring nursing is written” (p. 267). She discussed the context of critical care. In this setting, competence in technology and the practice of evidence based nursing are at the forefront of the nurses’ professional responsibilities, but it is paramount that nurses do not neglect compassionate caring. Watson (2009) noted that with the shift to heavier patient loads and other non-caring trends in healthcare, nurses must also be capable of establishing caring relationships with patients, an action that suggests compassion.

In sum, U.S. studies that examined this topic used the terms caring, compassion, and compassionate caring interchangeably in the literature. Gaps exist in our understanding about how U.S. nurses elaborate on the meaning of these terms and how they are actualized in practice. The purpose of this project was to explore how U.S. nurses identify, define, and display compassion in practice.

Methods and Analysis

Research Design and Sample
The research study was a cross-sectional, descriptive, exploratory online survey design which was part of a large international study about views and opinions of nurses about compassion, and how it is defined and demonstrated in practice. The methods and results of the larger study are reported in detail elsewhere (Papadopoulos et al, 2015; 2016).

Nurses from 15 countries participated in the larger international research study. The study received ethical approval through Middlesex University, England. We recruited participants in each country via an email letter of invitation which explained the purpose of the study, notice of ethical approval from Middlesex University, and the confidential and anonymous nature of their participation.

Data Collection Tool
The survey tool was developed and piloted by Irena Papadopolos with nurses from South Korea. Surveys for this study were provided in the country’s native language; American English was used for the U.S. survey. We utilized convenience sampling methods and delivered the survey using Survey Monkey (online survey software). Participants were given a link to the survey which they could forward to other registered nurses, thus we also employed a snowball sampling technique. Participants eligible for the study were registered nurses or nurse educators.

The survey (see Table) included seven multiple choice questions (Q 2-4 and 6-9), two open-ended questions (Q5, Q10), and one mixed response question (Q1). Open ended questions prompted nurses to describe how compassion was demonstrated, and to elaborate on the meaning and use of compassion in practice. All data were sent to the principal investigator at Middlesex University for processing, collation, and reporting. Data for each country were sent to each investigator for further analysis. This article focuses solely on findings based upon responses of the U.S. based nurses to the open-ended questions.

Table. Survey Questions

Data Analysis
The open-ended questions were analysed utilizing content analysis. Schreier (2012) defines qualitative content analysis as a research technique that "describes the meaning of your material" (pg. 3). Content analysis utilizes specific constructs and procedures to analyse the text (Krippendorf, 2004; Schreier, 2012).

Inductive coding for qualitative content analysis was utilized through a specialized process consisting of open coding, coding sheets, grouping, categorizing, and abstraction (Elo & Kyngäs, 2008). Consistent with inductive coding, transcripts were read several times to assure all aspects of the content were captured. Codes were grouped by similarities, relationships to each other, as well as similar means of describing a phenomenon (Elo & Kyngäs, 2008; Vaismoradi, Turunen, & Bondas, 2013). At this point, the transcripts were reread with the codes and emerging categories in mind to obtain a sense of the whole picture and assure that the essence of the intention had been captured (Vaismoradi et al., 2013).

In the next step, categories were written on coding sheets and further reduced through the process of abstraction, as described by Elo & Kyngäs (2008). Abstraction involves naming categories by using words that are consistent with the notions described in the transcripts, as well as words consistent with the overall topic under study. As categories and themes generated no new data, it was clear when we reached data saturation (Creswell, 2014). Content analysis produced five themes related to compassion, discussed in detail below.

Credibility and dependability were assured by piloting the questionnaire with 78 South Korean Nurses prior to the larger 15 country study. Clear instructions about many research processes were provided by the principal investigator to the country co-ordinators, which assured consistency in the research processes across all countries. The large data set has undergone extensive analysis and interpretation in terms of both universal transferability and local fit. However, in terms of local (U.S.) transferability results should be viewed as a baseline upon which additional qualitative studies can be built.

Results and Discussion

This section will present results and discussion considering data from the open ended questions (Q1, Q5, and Q10). These responses supported the five emerging themes noted in the study analysis.

Fifty respondents from the United States took part in the survey. Of those who responded to Question 1, the majority (50%) defined compassion by selecting survey choice number three: “deep awareness of the suffering of others and a wish to alleviate it.” Four respondents selected Other and provided the following additional ways to define compassion;

“…a desire to help, service to others”

“Caring deeply”

“We may not be able to alleviate suffering so understanding with an ability to listen to the truths of others is critical…”

Question 5 asked: How is compassion demonstrated in practice? Question 10 asked respondents: Please offer any comments, advice, views or stories which can shed light on the meaning and use of compassion by U.S. nurses. Analysis of these data indicated that both the words compassion and caring were used in responses, along with characteristics that respondents believed illustrated and defined them. In “Transcultural Caring Dynamics in Nursing and Health Care,” author Marilyn Ray (2016) discussed the essence of caring using the words, love, empathy, authenticity, compassion, co-presence, availability, attendance, communication (pg. 4). The attributes found in this study that we believe demonstrated compassion emerged as five themes that we will discuss individually: 1) listening, 2) developing a relationship, 3) alleviating suffering, 4) touching, and 5) going beyond the role of the nurse.

Listening
The most frequently occurring attribute or characteristic noted by the U.S. nurses that demonstrated compassionate care was listening to the patient. The most frequently occurring attribute or characteristic noted by the U.S. nurses that demonstrated compassionate care was listening to the patient. Listening may be a simple act, but the literature confirms that it is perceived by nurses and patients as a sign of a compassionate and caring nurse (Dawes, 2000). Nurses in a study by Godkin and Godkin (2004) reported that attentiveness and listening were actions that were incorporated in creating a caring presence with the patient. This caring presence developed into being with the patient, which is part of developing a provider-patient relationship. Comments from the U.S. nurses that exemplified the attribute of listening included:

“Nurses often listen to patients or family members during times of need.”

“Sitting with a patient who is grieving and listening to his/her story.”

“Make a connection with the patient, be humble and take time to listen.”

Developing a Relationship
The second most important characteristic in compassionate caring for U.S. based nurses was developing a relationship with the patient. Godkin and Godkin (2004) stated that “The nurse-patient interaction, which validates and affirms nursing practice, is ‘lean’ at the outset and increases to ‘rich’ as the nurse’s caring behaviours become more pronounced before the patient” (p. 260). This statement is reaffirmed by responses from the U.S. nurses in this study, who talked about the development of the relationship over time, the depth of the relationship and the building of trust and rapport that came with a compassionate and caring relationship.

... relationships could be as brief as one shift, or endure over many years. Lewis (2015) relates the concept of developing a nurse-patient relationship to moving beyond ourselves; choosing to listen to a person’s perspectives; and taking care to being in relationship with another. In a study with clinicians selected by their hospital colleagues as compassionate caregivers, Graber and Mitcham (2004) noted developing a relationship with patients as the number one expression of caring and compassion demonstrated by these employees. These relationships could be as brief as one shift, or endure over many years. It was not the length of the relationship that was important, but the effort to get to know the patient (Graber & Mitcham, 2004). An illustration of compassion/caring by a U.S. nurse in this study included:

“I work in a homeless shelter where a lot of compassion is required for patient situations. Getting to know the clients and their situations greatly facilitates working with them. I have one 61 year old African-American client who initially accused me of discrimination when I was not able to get him on the schedule. After 3 times he finally got on the schedule, but walked away in the middle of the history. On the 5th attempt I was able to see him and learn about his health concerns. He had one very swollen leg from PVD for which I was able to provide him some emollient cream to relieve the discomfort of the dry and tight skin on the leg. After that patient contact, the patient-provider relationship was sealed and a bond of trust was developed between the patient and me.”

Alleviating Suffering
Nurses need the knowledge and competency to ease pain both through use of medications and by non-pharmacological means. The third attribute of compassionate caring was alleviating suffering. Too often we focus on the diagnosis and forget about the need to alleviate the pain and suffering of the patient; caring is what helps us to remember this (Benner, 2000). As nurses we need to appreciate what suffering is, and understand how it is perceived by the patient, to provide the necessary compassion and caring to alleviate it (Ohlen, 2002). Nurses need the knowledge and competency to ease pain both through use of medications and by non-pharmacological means. They need to be able to comfort the patient who is suffering emotionally, as well as physically. The caring and compassionate nurse responds with openness to the specific situation of patients who are suffering and adapts his or her actions to the situation. This demonstrates a sensitivity to their suffering (Watson, 2008) and a responsibility to alleviate it (Ohlen, 2002). U.S. nurses in this study described alleviating suffering as follows:

“Where I work, patients are treated with dignity and respect despite their criminal records. We offer them ways to help alleviate their suffering.”

“Pain is one experience in which a patient may suffer. In my practice (acute care), I observe nurses who are actively engaged in managing pain to levels acceptable to the patient. Another area is the support of family; I observe nurses who seek out and provide care to families who are dealing with a challenging patient situation. Last, nurses seek to alleviate emotional and psychological suffering; this presents challenges in the acute care setting, yet, nurses have demonstrated compassion.”

Touching
... touching was another caring/compassionate characteristic that manifested as a theme in several ways. In this study, touching was another caring/compassionate characteristic that manifested as a theme in several ways. Participants referred to touch as holding a patient’s hand, giving a back rub, placing a hand on the patient, healing touch, or human touch.

Nurses routinely touch patients when providing physical care. Compassionate touch differs because its purpose is to alleviate suffering and not merely perform a caring task (e.g., lifting a patient out of bed, taking someone’s blood pressure). Corbin (2008) stated that the point when touch provides healing and comfort is when it becomes compassionate and caring. Nurses are privileged to be intimately involved with patients through the act of touch.

Patients of all ages may be starved of human contact and the touch of a nurse fills that void, which is compassionate and caring (Hudacek, 2008). In this study, nurses’ comments frequently mentioned touch and demonstrated how this is an important part of compassionate care:

“…through holding a hand or rubbing a back.”

“A patient receives news she has cancer and the nurse places a hand on the patient shoulder or hand.”

“To use appropriate touch and eye contact and to spend enough time with the patient so that the patient’s caring needs are met.”

“By giving care with dignity. By using touch to heal.”

Going Beyond the Role of the Nurse
Finally, nurses often go beyond their role as a nurse, doing more for the patient, family and community, both locally and globally, than is asked of them in their job description. Giving of oneself may include small things, such as picking up coffee for a grieving family member; giving extra time; and doing something extra just to make life a little better for a patient and/or their family (Hudacek, 2008).

Whether the going above and beyond our usual nursing role is with patients, or in the global community, it demonstrates caring and compassion. Going beyond is also described as giving unselfishly of oneself; helping in any way possible; and doing something without hesitation (Morse, Broder & Lazenby, 2011). It might also be fulfilling a personal mission by traveling abroad to provide care in a low income country where medical and nursing care is lacking (Kelly, 2010). When Kelly (2010) decided to go to Honduras, she talked to other nurses about joining her because she knew that nurses have a passion to volunteer. Whether the going above and beyond our usual nursing role is with patients, or in the global community, it demonstrates caring and compassion. These quotes illustrate how nurses in this study described going above and beyond their role as a nurse:

“Going the extra mile and doing the little things for {patients} that are not ordered by the MD, but noticed by the patient and family.”

“Nurses take time to volunteer in free clinics, schools, health fairs, churches to provide their knowledge, care, and compassion to the people in the communities.”

“Compassion requires action. I see nurses volunteering to help in disasters, using their vacation time, praying with patients, and caring for people…especially the less fortunate. Nurses get involved with policy and take risks because of how much they care for people.”

Conclusion

These examples and quotations exhibited five characteristics, or themes, that elucidated the attributes of caring and compassion, listening, developing a relationship, alleviating suffering, touching, and going beyond the role of the nurse. These themes further support evidence from current literature regarding compassion, caring, and compassionate caring by nurses in the United States.

Nurses in this study shared their definitions of compassion and caring as caring deeply, service to others, and a desire to help others. Findings of this study illustrate how nurses in the United States view compassion and caring in their practice. Nurses in this study shared their definitions of compassion and caring as caring deeply, service to others, and a desire to help others. They shared examples of their own actions of caring and compassion and how they saw other nurses demonstrate caring. Compassionate caring, or caring deeply for another, is characteristic of the nursing profession and is both beingwith someone and actions carried out with intent (Papadopoulos et al., 2015).

In conclusion, the findings of this study provide additional understanding about how nurses in the United States perceive the concept and provision of compassionate care. Caring is about paying attention to the patient and engaging with him or her in intentional actions that may provide support during challenging times (Watters, 2009). Watters’ description aligns with participant responses in our study about listening; developing a relationship; and alleviating suffering, all of which are intentional acts of caring to provide support. These intentional caring actions are the art, the essence, of nursing.

Authors

Magdeline Aagard, EdD, MBA, RN, BAN, PHN
Email: magdeline.aagard@waldenu.edu

Dr. Aagard is currently Core Faculty with Walden University. Dr. Aagard previously worked as an Associate Professor at Augsburg College’s School of Nursing. Dr. Aagard has conducted qualitative research of the cultural understanding of nursing leadership in Tanzania and India. She is currently working with a project in Tanzania with the Maasai training Community Health Workers to improve health in 21 Maasai villages.

Irena Papadopoulos, PhD, MA (Ed), BA, DipNEd, DipN, DNCert, RGN, RM, FHEA
Email: r.papadopoulos@mdx.ac.uk

Dr. Papadopoulos is currently the professor of Transcultural Health and Nursing at Middlesex University, London. She is the Head of the Research Centre for Transcultural Studies in Health, which she established in 1995. Her main research interests are culture/ethnicity/diversity/compassion and health, as well as inequalities in health and cultural competency.

Jessica Biles, BN; MHSc (Ed)
Email: jbiles@csu.edu.au

Jessica Biles is a Lecturer at Charles Sturt University and her primary teaching focus is Indigenous Australian cultural competence and foundational nursing skills. Jessica has a great passion for Indigenous Australian health and hopes to see major changes in the health and education of Indigenous Australian people.

Ray, M. (2016). Transcultural caring dynamics in nursing and health care. Philadelphia, PA: F.A. Davis.