Leadership Lived Experiences in Implementing Compassionate,Respectful,and Caring Practices: A Hermeneutic Phenomenological Study

Abstract

Compassionate, respectful, and caring (CRC) programs have been introduced in Ethiopian health facilities in the last 5 years to transform health care quality and provide patient-centered, compassionate, and respectful care. Therefore, this study aimed to examine the lived experiences of leaders to understand the meaning of successful CRC implementation and identify factors that influence implementation success in the health sector. A hermeneutic phenomenological qualitative study was employed through in-depth interviews with 26 participants from January 2022 to January 2023. Participants were selected purposively based on their position and role in CRC implementation experience from 6 regions of Ethiopia: Amhara, Oromia, South Nation Nationality People Region (SNNPR), Sidama, Benishangul Gumuz, and Southwest Ethiopian People Region (SWEPR). The ATLAS.ti version 7.02 software was used for data analysis, and interpretative phenomenological analysis was carried out. We found 5 main themes and 14 sub-themes from an in-depth interview. The 5 main themes that emerged include health care leaders’ commitment to CRC, lived enablers of CRC, embodying CRC through actions of volunteerism, leaders’ call to transform CRC advocacy, and sustaining CRC integration into systems and structures. These themes stress the transformative impact of CRC in health care settings, emphasizing leadership, collaboration, volunteerism, advocacy, and sustainability as key pillars for CRC implementation success, which enhances health care quality. The findings highlight that the implementation of CRC programs across all health care facilities is successful, leading to improvements in health care quality, organizational effectiveness, person-centered care, and the promotion of fundamental human rights.

Introduction

Compassionate care is a response to others’ suffering that prioritizes patients’ emotional, psychological, and social needs through empathy, kindness, and patient-centered care.^1,2 In contrast, respectful care emphasizes dignity, autonomy, inclusivity, consent, professionalism, and support to create a positive and accessible health care environment.^3,4

The Compassionate, Respectful, and Caring (CRC) approach integrates both compassionate and respectful care, focusing on trust, empathy, dignity, and kindness, ensuring effective communication, patient-centered care and the protection of patient rights across all levels of the health system.^{5 -8} Through promoting professionalism, treatment adherence, service quality, and client needs, CRC also helps reduce ethical malpractice and health care costs.^{9 -11}

As part of the Ethiopian Health Sector Transformation Plan I (HSTP I), the CRC program was introduced to enhance equity, coverage, utilization, quality, and overall health system capacity in selected model health facilities.^{12 -15} The CRC implementation is centered on compassionate leadership, health professional ethics, person-centered care, community engagement, and education.^{15 -19} Furthermore, CRC has been incorporated into health institutions’ curricula,^{18,20 -22} alongside ongoing efforts to raise client awareness^23,24 and establish monitoring and evaluation systems for broader adaptation. ¹⁸

The Health Sector Transformation Plan II (HSTP II) places strong emphasis on cultivating a Motivated, Competent, and Compassionate (MCC) health workforce (HWF) to strengthen the health care system. ²⁵ This strategic shift integrates competence-based practices to sustain CRC initiatives, leading to improvements in health care quality, systemwide performance, job satisfaction, and workforce retention.^{12,18,26 -28} The MCC program aims to strengthen CRC practices by promoting motivation, compassion, and retention mechanisms among HWF to improve service quality, increase public service dedication, and create a more robust system of caring.^12,18,23

Several studies have examined CRC’s implementation, evaluation, and effectiveness, as well as the barriers that hinder its progress.^{9,18,22 -24,29} Other studies explore quality improvement strategies, stakeholder engagement, and feedback from patients, health care providers, and the community.^17,19,29,30 However, there is a significant gap in the literature, as no qualitative studies have explored the lived experiences of leaders in relation to CRC program’s success.

To address this gap, the present study employs a hermeneutic phenomenological methodology, ³¹ to investigate the lived experiences of health care leaders, providing a deeper understanding of CRC’s implementation and the factors that contribute to CRC’s success. The findings will offer valuable insights that inform MCC strategies, strengthen CRC programs, and guide the expansion of CRC within sub-Saharan countries’ health care settings.

With extensive research experience in Ethiopia’s health sector, our team brings a unique perspective shaped by direct engagement with CRC implementation. Our collaboration with the Ministry of Health Ethiopia, academic institutions and diverse stakeholders has provided firsthand insight into health care settings. These experiences have fueled our commitment to exploring the lived experiences of leaders involved in CRC implementations. Through careful planning and rigorous methodology, this study aims to generate valuable knowledge that informs policy, strengthens leadership strategies, and enhances the scalability of CRC initiatives within the health sector and beyond.

Methods

Study Setting

This hermeneutic phenomenological qualitative study was conducted from January 2022 to January 2023 to explore the lived experiences of CRC implementation success among HCPs in Ethion, between 30° and 150° north latitude and 330° and 480° east longitude. Ethiopia is the second most populated African nation, with a population of over 110 million. Sudan and South Sudan border Ethiopia on the west, Eritrea and Djibouti on the northeast, Somalia on the east and southeast, and Kenya on the south. The sex ratio for males and females is almost equal, and women of reproductive age (15-49) comprise about 23% of the population. Nearly 80% of the population lives in rural areas, mainly depending on subsistence agriculture. Ethiopia is composed of 11 regional states and 2 city administrations. The regional states and city administrations are subdivided into administrative woredas (districts). A woreda/district is the basic decentralized administrative unit and is further divided into kebeles, the smallest administrative unit in the governance. ³²

In June 2022, Ethiopia had more than 273 601 health workforces employed in public health facilities. ³² Around 66.5% are health care professionals (HCPs), and the highest 3 professionals are Nurses (32.5%), Health Extension Workers (23%), and Midwifery (10.08%). There are 17 162 functional health posts, 3678 health centers and 340 types of hospitals across all regions of the country that provide health services to the community. ³² There are 22 tertiary hospitals, 73 general hospitals, and 245 primary hospitals in the year 2022. ³²

The CRC initiative was started during the Health System Transformation Plan I (HSTP I) period (2015-2020) and was implemented in all regions and city administrations. Currently, the CRC initiative, modified as MCC, is being implemented to reduce morbidity and mortality and improve client satisfaction and health care quality during HSTP II (2020-2024).

Study Design

This study used a hermeneutic phenomenological approach based on Martin Heidegger’s philosophy, which interprets the meanings of lived experiences within their context, incorporating the researcher’s perspectives.^33,34 Unlike Edmund Husserl’s descriptive phenomenology, ³⁵ Heidegger’s approach integrates hermeneutics to understand and interpret experiences. ³⁴ Hermeneutic phenomenology goes beyond descriptive accounts by interpreting the meaning of lived experiences and analyzing participant narratives, perceptions, and emotions.^{36 -38} Moreover, it considers contextual factors like culture, gender, and well-being for deeper understanding and tailored care.^{38 -40}

The hermeneutic phenomenological methodology is ideal for investigating leaders’ lived experiences during CRC implementation, allowing for deep exploration of their perspectives, emotions, and perceptions.^37,41,42 This methodology helps understand the true meaning of everyday experiences, aligning with a holistic view of health care delivery and focusing on individual interactions during the CRC process.^33,40,43

Study Participants

A purposive sampling technique was used to select the study participants, whereas the regions were selected randomly. Six regions (Amhara, Oromia, South Nation Nationality People Region (SNNPR), Sidama, Benishangul Gumuz, and Southwest Ethiopian People Region (SWEPR)) were selected from 11 regional states and 2 city administrations. Leaders aged 18 years and above, who had been working for more than 6 months and involved in the implementation of CRC in Ethiopia for the last 5 years, were included in the study. Leaders who had transferred from other health care facilities that served less than 6 months were excluded from the study.

Information power was used to estimate the number of participants. ⁴⁴ Information power is about estimating how a given sample will provide adequate information based on shared methodological principles. ⁴⁴ Marshall et al proposed 15 to 30 participant interviews in a single study. ⁴⁵ From 6 regions, 26 participants were selected purposely for in-depth interviews: 4 participants from each SNNPR, Sidama, Benshangul-Gumuz, and SWEPR, and 5 participants from each Amhara and Oromia regions. The included health facilities were comprehensive, general, and primary hospitals. Participants included 19 males and 7 females, with ages ranging from 31 to 40 years. The participants comprised 7 Chief Executive Officers (CEOs), 5 Chief Executive Directors (CEDs), six CRC Focal Persons, 5 Quality Directors, and three CRC Ambassadors. The participants included 21 health professionals and 5 non-health professionals (human resource management). The participants were selected based on their engagement experience of CRC implementation for an in-depth understanding of the lived experiences of the success of CRC implementation.

Data Collection

The data collection methods were informed according to the hermeneutic phenomenological approach.^41,46 Various data collection methods, such as focus groups, in-depth interviews, participant observations, and document reviews, are employed by researchers who conduct qualitative research studies. ⁴⁷ We employed in-depth interviews, which are widely regarded as the gold standard for data collection about lived experiences in phenomenological research.^41,46 The in-depth interview guides were prepared in English and translated into Amharic language, then translated back into English to observe the consistency of the interview guide. The in-depth interviews were conducted by 9 research teams in Amharic to allow participants to express themselves fully, using a language understood across all regions. The interview guides were pre-tested in a comparable health facility, with key informants from a health workforce with prior expertise in implementing CRC. In-depth interviews addressed the implementation of CRC in health care facilities, pre-service education, enablers, and possible strategies to bring success (see supplemental Material, File 1). An audio recorder was recorded during interviews, which lasted an average of 1.5 h, with a minimum of 55 min and a maximum of 130 min. Field notes were collected from each facility, focusing on best practices for successful CRC implementation.

Participants’ privacy and confidentiality were ensured by conducting interviews in private offices or research rooms chosen by participants, creating a comfortable and secure environment for sharing their experiences. We have considered the following measures to maintain the confidentiality of the participants: (1) a non-identifiable code was assigned to each participant, and the lists of participant names were kept separate from the data; (2) interviews were conducted in private and research rooms depend on participant choice; (3) all raw data (audio recordings and transcripts) were stored in a locked cabinet, and on a password-protected research center computer; (4) the information provided by participants were used only for the study purpose; (5) during data collection, analysis, and result writing, data were kept in a locked cabinet, locked briefcase and password-protected research center computer.

Interviews were concluded upon data saturation and meaningful information gathered, ensuring the data’s content and richness adequately addressed the research question, guided by the principle of information power data saturation. ⁴⁴

Data Analysis

The interpretative phenomenological analysis method was employed to analyze participants’ transcripts. ⁴⁸ Interpretive analysis is an organized method of analyzing data that involves preparing, editing, organizing, recognizing themes, segmenting data into meaningful units, revising, and eliminating redundancies.^48,49 The process incorporates participant discourse, cross-examination, verification, and contextualization of the findings within the broader domain, acknowledging participants’ lived experiences and addressing the research question through rigorous analysis.^48,49 The data were translated from Amharic to English and compiled from audio recordings and field notes. Feedback from study participants was obtained on the transcript, themes and sub-themes. The analysis began by carefully listening to, reading, and reviewing the transcripts to identify significant phrases or sentences from each transcript. ⁴⁹ Data were entered and coded using ATLAS.ti version 7.02 software. A codebook was developed, and all the data were coded, patterns identified and weaving them into sub-themes. This iterative process involves choosing relevant codes and quotations from each transcript. Sub-themes are aggregated to create themes integrated into an exhaustive description. Data transcription, coding, and thematizing peer auditing were conducted frequently to minimize errors. ⁵⁰ The verbatim transcripts were independently checked against the audio recordings of the interviewers and further guaranteed the consistency of each interview session by the analysis team. The teams also analyzed the interview adherence to the protocol, and the probing questions’ each transcript was rechecked to reduce differences between individual codes and mark out the transcript that was non-specific to CRC throughout the process. The study team further ensured rigors during data collection and analysis. Finally, the narrative was categorized into themes and sub-themes.

Trustworthiness

Lincoln and Guba explain that the trustworthiness of qualitative research depends on the credibility, dependability, confirmability, and transferability of the research findings, and researchers maintain these criteria. ⁵¹ Credibility is maintained through prolonged engagement with participant interviews, transcription, analysis, and detailed fieldwork steps. We ensure dependability through continuous observation, audit trail, transparency, peer debriefing, diverse perspectives, member checking, consistency checks, contextual richness, external peer review, and constructive feedback to prevent bias. The research team identified the limitations, validated results, maintained an audit trail, maintained a reflexive journal, and discussed and maintained multiple layers of analysis to maintain confirmability.

The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist, ensuring rigor and transparency in qualitative reporting ⁵² (see Supplemental Material, File 2).

Findings

The analysis uncovered 5 main themes, such as health care leaders’ commitment to CRC, lived enablers of CRC, embodying CRC through actions of volunteerism, leaders’ call to transform CRC advocacy, and sustaining CRC integration into systems and structures, along with 14 sub-themes that reflect participants’ lived experiences with CRC implementation. These themes highlight how participants’ roles as care providers and leaders, shaped by their relational and situational contexts, influence their understanding and practice of CRC.

Theme I: Health Care Leaders’ Commitment to CRC

Health care leaders’ commitment to patient well-being, ethical decision-making, and collaboration is crucial to the success of CRC implementation.^53,54 Their engagement is shaped by individual motivation, leadership, and a culture of continuous learning.^21,55 This theme is explored through 3 sub-themes: personal value and inner motivation, leadership as a relational and ethical commitment, and fostering a culture of learning and reflection.

Sub-theme I: Personal value and inner motivation

The narratives reflect how individual motivation in health care leaders stems from a sense of belonging and purpose within their professional environment. Their (leaders) roles are closely linked to personal and collective meaning-making in the context of CRC strategies. For instance, the Chief Executive Director and Chief Executive Officer exemplify leadership as a relational process that motivates through recognition and engagement with departments and frontline workers.

. . .We are influencing others to engage in CRC implementation, motivating and recognizing the staff with day-to-day progress follow-up. (Chief Executive Director, Participant, p. 5)

The CRC success was brought through coaching, spot maintaining, and solving problems with the department and senior manager; based on the job description, the individual commitment performance was presented with green and yellow. (Chief Executive Officer, p. 6)

The CRC Focal Person similarly highlighted the interplay between motivation and localized support:

The CRC’s success is mainly due to motivated employees, locally available technical support, and leadership dedication. (CRC Focal Person Participant, p. 4)

The focal person described how leaders view their actions as purposeful and transformative, guided by an intrinsic desire to promote compassion and excellence through the implementation of the CRC.

Sub-theme II: Leadership as a relational and ethical commitment

Leadership is a purposeful and dynamic process centered on mobilizing resources, engaging stakeholders, and empowering staff. This indicates that leadership is not just an authority position but a relational and ethical commitment. A quality officer described leadership as a participatory and rewarding process:

Hospital leaders and management teams volunteer to facilitate the budget and provide training and orientation for their staff about CRC implementation initiatives.

The CRC focal person also provides related perspectives: “The hospital leaders and managements are committed, and health professionals were devoted to their profession, time, and efforts” (CRC Focal Person, p. 5).

In these narratives, leadership is deeply attuned to creating a culture of care and recognition. Also, the Chief Executive Director emphasized the collective dimension of leadership, where CRC success is understood as a co-constructed reality born from shared commitment and collective efforts.

As hospital managers, we have managed, led, and coordinated CRC’s success. Similarly, we have identified stakeholders, influential personnel, community leaders, political leaders, and large-scale managers to mobilize and allocate resources for CRC success. (Chief Executive Director, p. 1)

Sub-theme III: Fostering a culture of learning and reflection

Key informants emphasized ongoing evaluations, including client and stakeholder feedback, community, and staff recognition and training. These activities were essential for sustaining and enhancing CRC practices, fostering openness and continuous improvement. The Chief Executive Officers shared their approach to fostering a learning culture:

I attempted to deliver training for the entire health workforce. After assessing the quality standards of health care provision, take appropriate action accordingly. Then we attempted to recognize the staff that performed best based on the assessment criteria. (Chief Executive Officer, p. 7)

We have assigned a focal person to monitor and evaluate the CRC implementation regularly. Based on the evaluation, CRC ambassadors are nominated at each department and recognized with the presence of the larger group. (Chief Executive Officer, p. 3)

These narratives highlight the role of acknowledgment and structural feedback in cultivating a sense of purpose and alignment with the CRC approach. The CRC Focal Person further described how recognizing staff contributions inspires collective progress:

We have learned from staff and clients’ feedback for CRC success, and start to acknowledge and recognize our staff, and nominate thanks day on Friday. (CRC Focal Person, p. 2)

Leaders’ commitment is shaped by their professional context, ethical convictions, and relational experiences, which drive CRC implementation. It emphasizes the interconnectedness between individual actions, organizational dynamics, and the broader goal of CRC.

Theme II: Lived Enablers of CRC

The data analyzed indicate that the success of CRC implementation is rooted in various enablers, such as embodying CRC through transformative initiatives, feedback as a lived dialogue of CRC, changing CRC challenges into growth, and recognition as an affirmation of shared kindness. Leaders express CRC through actions such as training, clear guidelines, cultural competence, feedback, and patient and family involvement, which enhance care quality, patient satisfaction, and outcomes.

Sub-theme 1: Embodying CRC through transformative initiatives

CRC activities, deeply embedded in participants’ lived experiences, represent a transformative shift toward person-centered health care. The CRC initiatives represent compassion, ethical care, and professionalism, enhancing patient satisfaction, HWF morel, and good outcomes. For example, the Chief Executive Officer reflected:

We have had a lot of success, including increased patient satisfaction, minimizing patients dropping out of treatment, helping internally displaced people and adopting abandoned children, and treating patients regardless of their financial situation. (Chief Executive Officer, p. 4)

CRC initiatives address systemic issues like financial barriers and social inequities, focusing on patient satisfaction and inclusive care and demonstrating compassion beyond clinical care. Similarly, the Quality Directors provide a comprehensive view of CRC initiatives: elaborate CRC initiatives from multiple perspectives, including problem-solving, client satisfaction, staff morale, ethical practices, training, budget allocation, performance recognition, and creating a conducive working environment.

We believe that CRC initiation is an account and problem-solving platform, making CRC a culture, contributing to initiating the CRC account, and developing a system to treat clients who could not afford it. Furthermore, it improved client satisfaction, reduced staff burden, improved team spirit, increased professionalism, and improved clinical ethical practices. These are enabled by providing training for the entire staff, allocating budget for capacity building, staff, and leadership commitment, incorporating CRC in the individual BSC plan, recognizing best performers in the facility, and attempting to make the working environment conducive. (Quality Director, p. 2)

Sub-theme II: Feedback as a lived dialogue of CRC

Feedback during CRC implementation is crucial for shaping its meaning and fostering continued learning. The feedback enhances practice by analyzing human interactions and feedback from participants’ input. For example, a Chief Executive Director highlighted the transformative impact of CRC initiatives and emphasized the importance of listening to and acting on feedback to improve care practices.

The successful implementation of the CRC shows that the patient is very pleased with the service received from the health care professional. Patient satisfaction increased from 60% to 85%, and staff satisfaction increased from 45% to 80%, as our surveyed evidence indicates. (Chief Executive Director, p. 4)

Relatedly, the CRC Focal Person emphasized the motivational role of client feedback:

. . . The satisfied clients provide recognition for health care providers through certificates and preparing thanksgiving programs. Consequently, health care workers demonstrated professionalism and expressed satisfaction with the feedback they received from the clients. (CRC Focal Person, p. 1)

The Quality Director further elaborated on the importance of feedback:

Surprising that we obtained many—many feedback from staff, stakeholders, and board engagement during training provision and awareness creation on CRC/MCC, which have enabled the success of CRC implementation in our setting. (Quality Director, p. 3)

Positive feedback from staff, stakeholders, and governance structures strengthens CRC initiatives and reinforces leaders’ professionalism and respectful care. It also reflects a collaborative and inclusive approach that fosters successful CRC implementation.

Sub-theme III: Changing CRC challenges into growth

Participants’ experiences in CRC implementation highlight the importance of overcoming challenges through collaboration, dialogue, and shared responsibility. Leaders demonstrate flexibility and proactive engagement in the CRC process. For instance, a CRC Ambassador emphasized the importance of a collective problem-solving approach in CRC implementation:

Different challenges faced while implementing CRC but solved by conducting a proper discussion with different level managers. It is good to share responsibility among all health workforces instead of leaving it to the CRC focal. Consider the challenges as good opportunities and solve them by prioritizing challenges to provide solutions. This is “Challenging the challenges.” (CRC Ambassador, p. 1)

Likewise, the Chief Executive Director described their approach to addressing financial and staffing challenges:

Throughout the implementation of the CRC, we encountered many challenges, such as an imbalance between our budget and the number of consumers supported and insufficient staff. We have resolved the problems by engaging in frequent discussions with the staff to augment the contribution amount. Additionally, we have occasionally utilized credit from the hospital’s internal revenue and established a clear method for budget allocation. (Chief Executive Director, p. 1)

This reflection emphasizes the use of adaptive strategies to overcome systemic limitations, emphasizing collaborative dialogue and resource management. It highlights the transformative potential of challenges, articulating leaders’ authentic care as opportunities for growth.

Sub-theme IV: Recognition as affirmation of shared kindness

The recognition of staff during CRC implementation motivates HCPs, validates efforts and reinforces commitment to compassionate care. Leaders emphasize their role in fostering collaboration, determination, and dedication to CRC initiatives as acknowledging contributions resonates with purpose and relational engagement.

A Quality Director highlights the significance of prioritizing staff well-being and aligning individual performance with CRC goals, fostering supportive environments that value individual interconnectedness with the system.

. . .Staff commitment to CRC implementation, employee recognition for top performers, training for newly assigned staff, making duty rooms staff-friendly, and incorporating CRC into performance measuring are significant enablers for our best CRC successes. (Quality Director, p. 2)

Additionally, the CRC focal person emphasized the role of recognition alongside leadership and community engagement:

CRC has brought many things; for instance, all working days named “Self-Introduction Day,” “Thanksgiving Day,” “Compassion Day,” “Calling the Patient by Name Day,” and “Recognition Day” were nominated. During the holiday, the staff volunteer to provide thankful recognition for senior staff and support for low-income staff, sharing resources with the community and celebrating the holiday with patients. (Chief Executive Director, p. 3)

CRC initiatives have influenced health care culture by promoting compassion, gratitude, and recognition. These practices enhance caregivers’ motivation, foster a sense of belonging, and deepen professional commitment.

Theme III: Embodying CRC Through Actions of Volunteerism

CRC’s success is attributed to the integration of volunteerism, where HCPs engage with their community and stakeholders, enhancing caregivers and recipients, and demonstrating active CRC implementation. The themes were subdivided into 3 sub-themes: co-creating CRC with stakeholder and community engagement, staff voluntarism as a commitment to humanity, and holiday celebrations as rituals of solidarity and healing.

Sub-theme I: Co-creating CRC with stakeholder and community engagement

Stakeholder and community engagement in CRC implementation fosters collaboration and resource allocation and improves service delivery. It provides essential support, financial contributions, professional services, equipment maintenance, and blood donations. A CRC focal person explained:

. . .We have done much work with our community and stakeholders in our hospital settings. For example, free payment for professional support, financial support from stakeholders, free maintenance of medical equipment, blood donation, and professional advising, and works day and night without any payment. (CRC Focal Person, p. 4)

The impact of stakeholder contributions shows how external support can enable health care facilities to deliver more equitable and effective services. Similarly, a Chief Executive Officer reflected on the collaborative planning and evaluation process:

Engaging the community and stakeholder in the planning and evaluation of hospital activities is additional input for CRC successes in our facility. (Chief Executive Officers, p. 5)

Stakeholder engagement in health care delivery fosters a shared responsibility and partnership, resulting in a more inclusive approach that aligns with CRC’s values. This demonstrates how diverse actors can achieve meaningful transformation.

Sub-theme II: Staff volunteerism as a commitment to humanity

The CRC initiative facilitated staff volunteerism, allowing HCPs to extend their roles beyond formal duties to address community needs, transforming health care practices by providing essential services to vulnerable populations. A CRC focal person shared:

Our best practice is working on voluntarism, mainly establishing Enat Debremarkos charity center and hiring teachers and staff for children who have no family, children left in the hospital after delivery, children left on the street, and we gave them free medical care, food, milk and shelter. (CRC Focal Person, p. 6)

Staff volunteerism, ranging from providing necessities to creating institutions like charity centers, can address systemic gaps in care delivery and create lasting social value. A Chief Executive Officer reflected on resource mobilization through collective effort:

We developed smooth platform systems [CRC project initiative volunteer] for resource contribution and collection mechanism, and clothing bank established from monthly salary, which was good and played a key role for volunteerism. (Chief Executive Officer, p. 1)

Sub-theme III: Holiday celebrations as rituals of solidarity and healing

The celebration of holidays with patients facilitates shared humanity, commitment and solidarity, aiming to alleviate distress and create joy, transcending health care settings. A CRC focal person emphasized the importance of leadership and collective participation:

My main contribution to the CRC implementation is to lead, demonstrate by example, acknowledge staff ceremony, and support the employees get together, and celebrating holidays with the client. (CRC Focal Person, p. 2)

Leaders foster compassion, engaging meaningful interactions between staff and patients. Celebrating holidays with patients breaks routine care, transforming health care into a shared space of joy and connection. Similarly, a CRC Ambassador reflected on the collective effort behind these celebrations:

. . .Health professionals collect money by their willingness to celebrate holidays with patients. Besides this, the community recognizes our staff by inviting media professionals, and the clients feel as their house. (CRC Ambassador, p. 3)

This narrative indicates the collective celebrations of the holidays involving HCPs, patients, and the community, highlighting the value of CRC in the public eye and promoting emotional and social well-being.

Theme IV: Leaders Call to Transform CRC Advocacy

Advocacy is the most important factor in adhering to the CRC implementation and the health system’s strengthening strategy. ⁶ In-depth interviews revealed the importance of ongoing advocacy efforts, including appointing CRC ambassadors and conducting awareness campaigns. The theme is subdivided into 2 sub-themes: becoming a CRC ambassador in action and CRC campaign as collective awareness and transformation.

Sub-theme I: Becoming a CRC ambassador in action

The role of CRC ambassadors is to foster collaborative efforts and promote CRC implementations through meaningful involvement. ¹³ Participants highlighted the importance of choosing role model professionals as CRC ambassadors in health institutions, as they embody ethical standards, professionalism, and humanity. A Chief Executive Officer emphasizing the importance of ethical leadership in ambassador selection:

Our success is to select each department coordinator based on CRC focus criteria they have for humanity and encouragement of CRC implementation. We have obtained the best performer exemplary in ethics and professionalism that working with our ambassador. (Chief Executive Officers, p. 7)

A CRC ambassador reflected on their responsibilities:

Oh, I was selected as an ambassador to influence others and create followers for CRC implementation success. My main responsibilities included demonstrating by example, proposing new ideas to improve CRC implementation, orienting updates and efforts, and ensuring appropriate application of CRC directives and rules. (CRC Ambassador, p. 2)

This narrative shows the ambassador’s role as a leader and guides CRC implementation in line with its core principles. They demonstrate authenticity and facilitate collective efforts toward a shared vision, embody ethical leadership and the transformative potential of advocacy in the health care context.

Sub-Theme II: CRC Campaign as Collective Awareness and Transformation

The CRC campaign promotes awareness and implementation of CRC transformative in healthcare practices, and fosters shared values, community involvement, and compassionate care. Key informants emphasized awareness creation as the cornerstone for the success of CRC implementation. The CRC focal person shared:

The CRC implementation program creates a role model, establishes a functional committee, designs specific tasks, develops a work plan, prepares performance report, stakeholders mobilized on CRC, monitors and evaluates the overall client satisfaction process. (CRC Focal Person, p. 1)

The statement outlines the establishment of structured committees to establish practices that prioritize collective well-being through systematic planning, evaluation, and stakeholder collaboration. Similarly, the Chief Executive Officer highlighted the importance of the CRC campaign in initiating volunteerism and transforming health care providers toward patients. She described:

The CRC implementation was vital in initiating volunteerism activities; health care providers considered patients as their families while providing care. (Chief Executive Officers, p. 1)

Theme V: Sustaining CRC Integration Into Systems and Structures

The CRC program’s long-term viability requires successful implementation across all health facilities and sectors. Sustainability involves dignified health care, extending reach through regional bureaus, involving sectors, and collaborating with nonprofit organizations, positively affecting the health workforce, community, clients, and organizational empathy. The theme is subdivided into strategic direction as an ongoing commitment and a shared vision of CRC across sectors.

Sub-theme I: Strategic direction as an ongoing commitment

The concept of “strategic direction” in CRC implementation involves active engagement, structural organization, and commitment to sustainability. This ensures compassionate, human-centered care through dynamic stakeholder engagement at various health care system levels.

A Chief Executive Officer explained the structure that depends on evidence base as follows:

We established a clear structure at all levels of the health care system, organizing large-scale innovative evidence-based experience sharing, benchmark platforms curriculum design, and developing transparent and inclusive motivation packages for all staff is essential for the continuity of CRC implementation. (Chief Executive Officer, p. 2)

The statement advocates for a proactive approach to integrating CRC sustainability into health care by integrating it into organizational culture and evidence-based experiences. CRC sustainability relies on active system engagement, professional relationships, and continuous dialogue to ensure motivation, competence, and commitment to the CRC approach. These ideas were supported by the Quality Director narration:

I hope engaging professional associations and higher management to lower-level workers are essential for implementing CRC/MCC. The health system is dynamic, considering benefits packages and motivating health professionals to make competent health workforces. (Quality Director, p. 1)

Sub-theme II: A shared vision of CRC across sectors

The implementation of the CRC is crucial for various sectors, including health, nongovernmental organizations, business institutions, and private sectors. CRC is recommended for expansion, country development, worker performance improvement, and professional motivation. A Chief Executive Officer explained that:

Engage all sectors in the CRC implementation, like regional bureaus, NGOs, and the Ministry of Health. Allocating budget for CRC service implementation at all levels might best expand the CRC implementation in the country. (Chief Executive Officers, p. 5)

The statement emphasizes the need for cross-sectoral collaboration involving regional bureaus, NGOs, and government entities to sustain and expand CRC initiatives through shared responsibility, resource allocation, and transformative practices. Similarly, the Quality Director explained:

I believe that all sectors should consider the initiative as a priority agenda since CRC is a key point for all professions and sectors. (Quality Director, p. 1)

The CRC approach is a foundational principle in various fields like education and governance, promotes respect, empathy, and improves interprofessional relationships across all disciplines and institutions.

Discussion

The success of CRC implementation in Ethiopia has relied on the commitment and readiness of diverse implementers, including leaders, health care personnel, stakeholders, the community, higher education institutions, and nongovernmental organizations.^16,18,23 The correlation between the commitment of top leaders and managers in the health care systems and their support of innovation significantly influences intermediate managers’ and frontline workers’ dedication to implementing planned innovative initiatives for achieving success.^20,53 Implementation success occurs after accepting an invention when personnel acquire the necessary skills and consistently utilize the innovation.^55,56 Implementing health care initiatives with success has been demonstrated to be tough, and achieving planned targets with realistic employee engagement is rare.^20,57

The data from the informants indicated personal value and inner motivation, leadership commitment, and a culture of learning and reflection that we found in the analysis for the successful implementation. Evidence suggests that personal motivation influences the implementation of health sector reforms, which positively improves the success of initiatives by addressing multiple challenges to achieve the goal. ⁵⁸ Leaders and managers may impact the implemented strategy’s success in achieving the CRC program’s target. ¹⁸ In fact, leaders and managers strive to achieve common goals in the health care system that are distributed to health care providers and collectively benefit from the success obtained in the health care setting. ²³ The lessons were learned from the output and feedback from the beneficiaries and implementers that support health care providers’ attitude change, improved work performance, and successfully implemented programs.

In this finding, some enablers enhance the success of CRC implementation in health facilities. One of the enablers for successful implementation is embodying CRC through transformative initiatives, such as Health Sector Transformation Plan I and II (HSTP I and II), which have driven implementation for the last 5 years and will continue for the next 5 years in HSTP II. ¹² The WHO also encourages global strategy on human resources for the health workforce to improve health service coverage and realize the right to the highest attainable standard of health service on their availability, accessibility, acceptability, quality, and adequate coverage in 2030. ⁵⁹ As health services have grown, there has been an emphasis on improving person-centered care. This means delivering compassionate, respectful and humanized care to clients while also meeting the community’s needs at the health sector and community level. ²³ The other enabler we found is participant feedback, which is suggested by Nigusie et al and is helpful for early managing the shortage of service and improving client service and satisfaction and shines the CRC implementation to success. ¹⁷ In addition, the well-performed implementer recognition and learning from previous challenges are the other enablers for the success of CRC implementation. Many studies conducted in Ethiopia had similar findings.^16,23

On the other hand, the implementation of CRC has led to significant voluntary engagement in the health care industry. The establishment of volunteerism has enhanced the implementation of CRC by fostering community participation, engaging stakeholders, providing complimentary health care services, ensuring maintenance and donation of medical equipment, involving staff in health service campaigns, and maintaining a secure environment for clients, all of which have contributed to the success of CRC. ⁶⁰ Most people worldwide have the right to freely offer their time, talent, and energy to their communities through individual and collective action without expectation of financial reward.^60,61 The stakeholder and community engagement in CRC implementation provided staff volunteerism, and the staff started celebrating the holiday with the client at health facilities. The finding is comparable to what was previously discovered in Ethiopia. ²³

Advancing the health care system through an innovative approach and technological technique and advertising the method of disease prevention and health promotion for customers and end users can benefit health seeking, disease prevention and increased cure rate.^25,59 From the in-depth interview point of view, establishing CRC ambassadors and raising awareness through campaigns may increase community understanding of the benefits of using health care services and disease prevention. Awareness creation through campaigns, TV, Radio and social media may enable information dissemination to enhance client rights, health care providers’ compassion and quality improvement. ⁶² The CRC ambassadors have been working on advocacy and awareness creation on CRC and are mentoring other health care providers to improve collaboration among professions.

The study highlights the need to ensure the long-term sustainability of the CRC program in health care and other industries. The report provides guidance on strategy orientation, employee compensation plans, and professional affiliations. Esteemed directors propose extending CRC implementation to enhance workers’ performance and increase motivation, which is similar to the findings of the USA study. ²⁰ The health care industry needs client and professional satisfaction toward problem-solving and in-depth disease investigation. Quality health care is a cornerstone for any health care system to meet human needs, fundamental human rights, and universal health care.^63,64 CRC initiatives are some of the most important for human beings to address client human rights, maintain professional ethics, improve quality health care, achieve universal health coverage, and enhance health sector and other organization collaboration on strategies and policy direction for further health care improvement. ⁵⁴ Sustaining CRC implementation across all medical facilities and other sectors is essential for its long-term success.

Strengths and Limitations of the Study

This study used a hermeneutic phenomenological qualitative methodology to investigate the lived experiences of leaders’ in-depth interviews, which suggests the success of CRC implementation. The interviews were also done nationally, representing all Ethiopian areas. The limitation of the study is that the participants were not evenly distributed; they were based on the position role, which did not include health care workers with a range of knowledge and expertise who were employed in health care institutions.

Conclusion

We found 5 main themes and 14 sub-themes from the in-depth interview. The 5 main themes that emerged include health care leaders’ commitment to CRC, lived enablers of CRC, embodying CRC through actions of volunteerism, leaders’ call to transform CRC advocacy, and sustaining CRC integration into systems and structures. The findings highlight the transformative impact of CRC in health care settings, emphasizing leadership, collaboration, volunteerism, advocacy, and sustainability as key pillars for CRC implementation success. These pillars lead to improvements in health care quality, organizational effectiveness, person-centered care, and the promotion of fundamental human rights. The success of CRC implementation suggests that health care and other organizations can benefit from its integration into strategic planning, expanding CRC across all health care facilities.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251329198 – Supplemental material for Leadership Lived Experiences in Implementing Compassionate, Respectful, and Caring Practices: A Hermeneutic Phenomenological Study

Supplemental material, sj-docx-1-inq-10.1177_00469580251329198 for Leadership Lived Experiences in Implementing Compassionate, Respectful, and Caring Practices: A Hermeneutic Phenomenological Study by Kemal Jemal, Abiyu Geta, Fantanesh Desalegn, Lidia Gebru, Tezera Tadele, Ewnetu Genet, Mesfin Kifle, Abebe Bimerew and Assegid Samuel in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-docx-2-inq-10.1177_00469580251329198 – Supplemental material for Leadership Lived Experiences in Implementing Compassionate, Respectful, and Caring Practices: A Hermeneutic Phenomenological Study

Supplemental material, sj-docx-2-inq-10.1177_00469580251329198 for Leadership Lived Experiences in Implementing Compassionate, Respectful, and Caring Practices: A Hermeneutic Phenomenological Study by Kemal Jemal, Abiyu Geta, Fantanesh Desalegn, Lidia Gebru, Tezera Tadele, Ewnetu Genet, Mesfin Kifle, Abebe Bimerew and Assegid Samuel in INQUIRY: The Journal of Health Care Organization, Provision, and Financing