Abstract
Despite the current focus on patient centeredness, healthcare professionals face numerous challenges that impede their ability to provide compassionate care that ameliorates concerns, distress, or suffering. These include fragmentation and discontinuity of care, technologies that both help and hinder communication and relationship-building, burgeoning operational and administrative requirements, inadequate communication skills training, alarming rates of burnout, and increased cost and market pressures. A compassionate healthcare system begins with compassionate people, but the organizations in which they train and work must reliably enable them to express and act on their compassion rather than impede it. We present a set of guiding commitments and recommendations to foster a more compassionate healthcare system. We urge healthcare organizations to adopt these commitments and take action to embed compassionate care in all aspects of training, research, patient care and organizational life.
Keywords
Brody, Institute for the Medical Humanities at the University of Texas Medical Branch; Judy Bugarin, Cambridge Health Alliance; Sandra Clancy, Massachusetts General Hospital for Children; Paul Cleary, Yale School of Public Health; Stacy Collins, National Association of Social Workers; Jim Conway, Pascal Metrics and the Institute for Healthcare Improvement; Liz Crocker, Institute for Patient- and Family-Centered Care; Erica Dente, Beth Israel Deaconess Medical Center; Deborah Dokken; Andrew Dreyfus, Blue Cross Blue Shield of Massachusetts; Ronald Epstein, University of Rochester Medical Center, Center for Communication and Disparities Research; Len Fishman, Hebrew SeniorLife; Rich Frankel, Indiana School of Medicine; Tawara Goode, National Center for Cultural Competence, Georgetown University Medical Center; Charles Hatem, Mount Auburn Hospital; Virginia Hood, American College of Physicians; Jeanette Ives Erickson, Massachusetts General Hospital; Becky Kapp, Intermountain Healthcare; Michael Kappel, National Coalition for Cancer Survivors; William Kassler, Centers for Medicare and Medicaid Services; Tara Montgomery, Consumer Reports; Peggy Plews-Ogan, Center for Appreciative Practice, University of Virginia; Judy Salerno, Institute of Medicine; Matthew Sorrentino, Bucksbaum Institute for Clinical Excellence, University of Chicago; Cheryl Tupper, Arthur Vining Davis Foundations; Steven Weinberger, American College of Physicians; David Weissman, Center to Advance Palliative Care; and Anthony Yamamoto, Society for Social Work Leadership in Healthcare.
We also acknowledge Tony Suchman of McArdle Ramerman & Company and Julie Rosen, Executive Director, and Petra Langer, Senior Director of Communications, both at the Schwartz Center for Compassionate Healthcare, for their participation and support of this effort.
Background
While patients and physicians alike believe that compassionate care is important to health outcomes and can even make a life or death difference, many share the view that our current healthcare system is not a compassionate one. 9 Despite the current focus on patient centeredness and important efforts to make care safer, more effective and less costly, caregivers face numerous challenges that impede their ability to provide care that honors and strengthens the relationships caregivers have with patients, families and their communities, and with each other. Such care is both compassionate and “relationship-centered.” 10 In November 2012, we convened healthcare professionals, educators, researchers, administrators, health policy and measurement experts, and patients and family members to discuss how to address the mounting challenges and create a more compassionate healthcare system. Here we present the guiding commitments that came out of these discussions, along with recommendations to prompt further discussion and action. The aim of the commitments is to ensure that all patients and families receive compassionate care. We ask all healthcare organizations to adopt these commitments and take action to embed compassionate care in all aspects of training, research, patient care and organizational life.
Commitment to compassionate healthcare leadership
We believe that healthcare leaders who embrace and model compassion foster a culture of compassion within their organizations and institutions. They articulate the value and benefits of compassionate care, motivate others by their example, marshal resources that make compassionate care possible, provide training and a supportive infrastructure, and help others understand their role in relation to this common aim. They use tools to assess organizational climate and effectiveness in delivering compassionate care and are committed to its continuous improvement. 11
As an example, England's chief nursing officer has established “Compassion in Practice” as a primary vision for its healthcare system and has developed a comprehensive national strategy to create a culture of compassionate care within the National Health Service (NHS). Leaders at all levels within and across the NHS must engage in an open dialogue about the importance of compassion, educate others about how they foster organizational cultures of compassion and create incentives that advance compassionate care. 12
Leaders themselves may suffer as a result of having to make difficult decisions among competing priorities and may also need support and opportunities to discuss the emotional impact of this responsibility.
Commitment to teach compassion
Healthcare leaders, educators and clinicians who teach, model and reinforce the core values and skills of compassionate care foster them in students and trainees. Medical schools and residency programs are required to teach and assess communication and interpersonal skills for accreditation, and students' communication skills are evaluated in national licensure exams.13,14,15 While medical schools offer courses on the patient-physician relationship, communication skills and social issues, several studies have shown that caring attitudes and compassion are inconsistently taught, reinforced and assessed, 16 and that self-reported empathy declines in medical and nursing students during their clinical training.17,18,19
Students and trainees may suffer secondary traumatic stress while caring for patients, 20 and like clinicians, they, too, may suffer from distress and burnout. Moreover, during clinical training in hospitals, they may experience mistreatment by superiors and see examples of uncaring behavior, creating an implicit “hidden curriculum” that degrades empathy and inculcates norms of uncompassionate behavior. 21 Nearly half of 12,195 medical students surveyed nationwide by the Association of American Medical Schools in 2012 said they were subjected to mistreatment, most frequently public humiliation, little of which they felt comfortable reporting. 22 One academic medical center that began surveying students about mistreatment during clinical training and mandated faculty workshops on the topic reduced incidents of mistreatment by half. 23 Faculty development programs that support and enhance faculty members' ability to teach and model caring attitudes and compassion are critically important, but infrequently provided.16,24
Clinicians and educators in health professional schools and training programs have responded to these challenges with a variety of educational initiatives; most are offered as optional opportunities.25,26,27,28,29,30,31 Some health professional schools, however, have integrated caring and compassion as a longitudinal theme taught throughout undergraduate education, and teach residents how to model and nurture it in students.32,33 Some medical schools also offer longitudinal experiences in which students participate in the care of patients over time and develop relationships with the clinicians who care for these patients. These students perceive more positive role modeling than students in traditional clinical learning experiences. 34
Stakeholders have articulated competencies for interprofessional collaborative practice and the need to align interprofessional learning with clinical practice redesign as a strategy to build positive relationships and create compassionate healthcare environments.35,36 These initiatives may promote the values, skills and habits that underlie compassionate care.
Commitment to value and reward compassion
Valuing, supporting and rewarding the cognitive, emotional and collaborative work and time required for caregivers to provide compassionate care encourage such care to thrive. This may occur by creating compassionate organizational cultures, staffing, scheduling and policies that permit time for meaningful interactions, financial incentives, recognition awards and other mechanisms. In addition to local recognition, the DAISY Award and the Schwartz Center's Compassionate Caregiver Award provide national recognition of compassionate caregivers.37,38
Organizations may fear that financial incentives that pay for performance may degrade the moral and professional imperative to provide compassionate, relationship-centered care, and may actually undermine caregivers' intrinsic motivation to do so. Others suggest that incentives may weaken collaboration, or conversely, strengthen teams, organizations and systems that are able to work collaboratively toward a shared purpose. 39 Evidence is limited about the effectiveness of financial incentives on clinician, team and organizational behavior, and is inadequate regarding their impact on patient outcomes. 40
Nonetheless, hospitals are rewarded for performance in the U.S. and elsewhere. For example, hospitals may receive incentive-based payments based on patients' perceptions of their healthcare experiences. This is measured by standardized surveys such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and others. 41 Hospitals' scores are publicly reported on the Center for Medicare and Medicaid Services' Hospital Compare website. 42 Since July 2007, hospitals that are subject to Medicare's Inpatient Prospective Payment System have been required to collect and submit HCAHPS data to receive their full annual payment update. In addition, the Patient Protection and Affordable Care Act of 2010 specifically included HCAHPS performance in the calculation of value-based incentive payments to hospitals. 43 Despite the importance of the emotional and relational aspects of care, these surveys likely do not fully capture these characteristics. Understanding that these surveys will be used to incentivize healthcare providers and systems, they must include psychometrically sound measures of caring and compassion.
Financial and nonfinancial incentives may be effective if they emerge from a sense of shared moral and professional purpose, and if there is transparency and stakeholder collaboration in their development, monitoring, application, evaluation and continuous revision. 44
Commitment to support caregivers
Healthcare organizations that exhibit compassion for caregivers commensurate with the compassion shown to patients and families preserve caregivers' resilience and sense of purpose. Caregivers witness suffering, trauma and conflict on a daily basis. Their ability to sustain their own compassion and provide compassionate care to patients and families rests on both systemic and individual factors. Systemic factors, such as excessive workloads, decreased autonomy, lack of rewards, loss of a sense of community with colleagues, perceived unfairness and loss of respect, and conflict between organizational and individual values contribute to burnout and erode engagement with one's work and sense of purpose.45,46 Individual factors that sustain compassion include the capacity to effectively recognize, process and manage the challenges of patient care. 47
Burnout, characterized by emotional exhaustion, depersonalization (unfeeling and impersonal responses toward those in one's care) and low sense of personal accomplishment,48,49 degrades compassion. It is common among physicians (25 to 60 percent among physicians, up to 75 percent in residents) 50 and nurses (34 to 37 percent). 51 Physicians who are burned out more often report they have made medical errors and have diminished attentiveness, empathy and compassionate behaviors toward patients than those who are not.52, 53 The depersonalization dimension of burnout has been associated with lower patient satisfaction and longer post-discharge recovery time. 54 Conversely, physician wellness and work satisfaction are associated with empathic perspective-taking, 55 patient adherence and patient satisfaction. 56
The Affordable Care Act of 2010 includes incentives for organizations to offer workplace wellness programs, and a recent survey by the American Hospital Association showed that 86 percent of hospitals offer programs that focus primarily on physical health. Only about half offer classes in stress management, and these are not linked to incentives. 57 Healthcare organizations can mediate factors that degrade the psychological and emotional wellness of caregivers and provide infrastructure, interventions and incentives to promote it.58, 59 Studies of programs that train clinicians in self-care, self-compassion and mindful communication have shown that participants acquire the needed skills required to avoid burnout.60, 61, 62 Other programs that provide regularly scheduled opportunities for group reflection about the challenges of patient care help renew compassion, restore a sense of individual and collective purpose, foster community and enable clinicians to feel less isolated and alone. 63
Commitment to partner with patients and families
Patients' needs and perspectives should be the organizing principle around which compassionate care is provided. 64 Patients and families should play an active role in shaping and evaluating their own care. When patients have the knowledge, skills and confidence to manage their own health care, they have higher-quality interactions and relationships with their physicians and better health outcomes.65, 66 As suggested in a recent Institute of Medicine (IOM) report, 67 embracing the value and skills of collaboration and partnership with patients and families will require a significant shift in the culture of medicine and changes in infrastructure, education and incentives to support their participation.
In addition, healthcare organizations must be responsive to the emotional, social, cultural and linguistic needs of the patients and families they serve. Patients and families should be involved in designing and evaluating care delivery and the policies of healthcare organizations. Members of some Patient and Family Advisory Councils currently advise hospital committees in areas ranging from generating ideas for new initiatives to participating in co-training and hiring of new staff. 68 Policymakers and system leaders might also require primary care practices to demonstrate patient and family engagement in quality improvement efforts to qualify as patient-centered medical homes, as suggested by the Agency for Healthcare Quality and Research, to ensure more compassionate, patient-and family-centered care. 69
Commitment to build compassion into healthcare delivery
Healthcare organizations must remove the barriers that prevent clinicians from interacting directly with patients and that impair continuity of relationships within and across settings. Personal interactions are not secondary processes that must be trimmed to maximize efficiency — they are care, and in and of themselves can be therapeutic. 64
Care must also be taken to ensure that new health information technologies support, rather than detract, from compassionate care. For example, information systems that capture patients' and families' emotional and social needs, and care goals and preferences would enhance compassion. However, the need to enter data into electronic health records diverts time that clinicians might better spend interacting with patients, families and each other. As a result, hospitalists, trainees and hospital nurses now spend more time interacting with computers than they do with patients.70, 71, 72 Administrative and regulatory demands, interruptions and multitasking distract clinicians, add to their sense of workload and frustration, and affect clinical care.73, 74, 75, 76, 77 As a result, clinicians, feeling pressed for time, or unprepared to manage the emotional aspects of patient care, often overlook clues that might uncover the source of their patients' distress.78, 79
The Institute of Medicine included “care based on continuous healing relationships” as its first rule among 10 simple rules for a 21st century health system. 80 “Continuity of relationships” implies that the patient has an ongoing relationship with a trusted clinician or care team that assumes responsibility for the patient's overall health and care, and manages shared care and transitions in care.81, 82 In our changing health care system, it has been difficult to ensure and measure the continuity of these relationships within hospitals, across different care settings and during care transitions. 83 Hospitalized patients experience many handoffs of care regardless of whether a community physician or hospitalist attends to them, and verbal and written communication among clinicians at patient discharge is infrequent and suboptimal.84, 45 As a result, patients and families must assume an increasingly active role in coordinating and managing their care across settings and at home; many lack the knowledge, skills, confidence or resources to do so. 86 Patients and their families must feel supported rather than cast adrift during handoffs and transitions in care. As care becomes increasingly team-based, caregivers must be supported in their efforts to provide compassion to patients that is sustained and shared.
Recommendations to Create a More Compassionate Healthcare System
An integrated research agenda is needed to better understand the nature, development and impact of compassion, as well as the factors that influence its demonstration at all levels. In addition, we must better understand the factors and interventions that influence caregivers' resilience and ability to sustain compassion.
While research is emerging correlating empathy and compassion with healthcare quality and patient outcomes, it is not yet robust. Researchers have correlated measures of physicians' empathy with patients' health outcomes such as diabetes control and frequency of hospitalization for significant diabetic complications.87, 88 Patients' assessments of physicians' empathy and compassion have been correlated with long-term outcomes in cancer patients, 89 physiologic biomarkers of immune response to viral infections, and even the duration and severity of the common cold. 90 Measures of physicians' responsiveness to patients' concerns have also been correlated with decreased expenditures on diagnostic testing. 91
Research on the impact of empathy and compassion on patients' and families' experiences of care, quality of life, health outcomes and cost is directly related to the triple aim of improving health at lower cost while improving patients' healthcare experiences and should be included among foundation and governmental funding priorities.
Conclusion
Important efforts are under way to make healthcare safer, more effective and less costly. Yet, many patients and physicians are concerned that these changes may be making our healthcare system a less compassionate one. The barriers that impede connection, caring and compassion must be addressed so that caregivers can offer, and patients and families receive, compassionate, patient- and family-centered care. Compassionate care must be a fundamental element of our healthcare system — available to all patients and families every day and in every interaction.
Footnotes
Acknowledgement
The author would like to acknowledge the many working group participants in the Schwartz Center's National Consensus Project meeting who contributed to the formulation of the seven commitments. Their names are listed in the journal's web version of this manuscript. We also thank the editors of the International Journal of Health Policy and Management who published a brief version of the commitments in our Commentary, 30 April 2014.