|Year : 2017 | Volume
| Issue : 2 | Page : 91-96
Contextual facilitators and maintaining of compassion-based care: An ethnographic study
Sima Babaei1, Fariba Taleghani2, Mahmoud Keyvanara3
1 Student Department of Adult Health Nursing, Nursing and Midwifery Care research center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Adult Health Nursing, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Health Services Management, Social Determinate of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||9-May-2017|
Department of Adult Health Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: Compassion is an important part of nursing. It fosters better relationships between nurses and their patients. Moreover, it gives patients more confidence in the care they receive. Determining facilitators of compassion are essential to holistic care. The purpose of this study was to explore these facilitators. Materials and Methods: This ethnographic study was conducted in 2014–2015 with 20 nurses, 12 patients, and 4 family members in the medical and surgical wards. Data collection was done through observations and in-depth semi-structured interviews with purposive sampling. The study was carried out in 15 months. Data analysis was performed using constant comparison based on Strauss and Corbin. Results: Data analysis defined three main themes and eight subthemes as the fundamentals of compassion-based care. Nurses' personal factors with subcategories of personality, attitudes, and values and holistic view; and socio-cultural factors with subcategories of kindness role model, religious, and cultural values are needed to elicit compassionate behaviors. Initiator factors, with subcategories of patient suffering, patient communication demands, and patient emotional and psychological necessity are also needed to start compassionate behaviors. Conclusions: The findings of this study showed that nurses' communication with patients is nurse's duty in order to understand and respect the needs of patients. Attention should be paid to issues relating to compassion in nursing and practice educational programs. Indeed, creating a care environment with compassion, regardless of any shortcomings in the work condition, would help in the development of effective nursing.
Keywords: Communication, compassion, ethnography, Iran, nursing care
|How to cite this article:|
Babaei S, Taleghani F, Keyvanara M. Contextual facilitators and maintaining of compassion-based care: An ethnographic study. Iranian J Nursing Midwifery Res 2017;22:91-6
|How to cite this URL:|
Babaei S, Taleghani F, Keyvanara M. Contextual facilitators and maintaining of compassion-based care: An ethnographic study. Iranian J Nursing Midwifery Res [serial online] 2017 [cited 2018 Jan 22];22:91-6. Available from: http://www.ijnmrjournal.net/text.asp?2017/22/2/91/205967
| Introduction|| |
Care, as an important part of nursing, has been considered by many nurses and researchers. Compassion as the core of care  is the most valuable source in nursing. Compassionate care is considered to be an essential principle of patient-centered care.,, Healthcare consumers request compassion in the form of compassionate care from nurses.,, In the literature, compassion is defined as propitiation combined with action. Compassion has also been described as caring toward another's suffering and being present emotionally.
According to the Agency for Healthcare Research and Quality, 10.8% of the patients believe that health care providers sometimes or never listen to them, they do not explain things clearly, they do not respect what they say, and they do not spend enough time with them.
Basic aspects of care such as the nature of nurse education, low staffing levels, inappropriate skill mix, increased bed and patient turnover, or heavy workloads need more attention.
It is important for nurses to consider how compassion is demonstrated because it is at the heart of good nursing care. It is useful to improve relationships between nurses and patients to give them more confidence in the care.,,
Despite the importance of compassionate care in improving patients' satisfaction and effective communication with them, studies in this field have been limited, for example, in certain wards such as cancer homes. These studies emphasize nurses' perception of the concept, importance of compassionate care, and the lack of it. A few studies have been conducted on effective and facilitating factors in compassion-based care, and more factors related to nurses and patient have been proposed as deterrents.
Esmaeili et al. showed that a number of factors such as the lack of cooperation between the health care team, nurses' lack of motivation, lack of a holistic perspective, shortage in nursing staff, and lack of support of nursing organizations could be barriers to holistic care.
Bolster and Manias showed that imposing care duties on nurses in task-oriented organizational climate would decrease compassion toward the patient. Organization's attention to nurses' needs and requesting them to take on roles more than their usual routines and duties would lead to nurses' attention to all the needs of patients. They also showed that, in the interaction between nurses and patients during routine care activities, nurses were mostly focused on routine activities than unique measures for the patient.
Manongi et al. revealed that patients mostly believe that language, age, and sex differences with the nurse, heavy load of nurses' work, and nurses' bad temper are barriers to patient–nurse relation. While nurses believe that their heavy workload, hard nature of their work, physical and mental tiredness, and lack of appreciation system are barriers.
Therefore, these barriers and facilitators could be affected by the dominant culture and religion of the society. In Islamic societies, such as the Middle Eastern countries, religion has an important role in care principles.
Personality characteristics, attitudes, and values of nurses as well as holistic perspective, love-based behavior, the use of good cultural and religious values of society, emotional and communication needs of the patient can have a facilitating role in compassionate care.
An in-depth study on these facilitators could improve understanding of the factors that are effective in compassion. Interventions and sharing policy in the health services is more realistic to promote the facility to work. This study explores the facilitators and maintaining the factors of compassionate care.
| Materials and Methods|| |
This study is a classic ethnographic approach. Ethnography is valuable because it is an approach with contextual focus. Through ethnography, nurses can find cultural sensitivity and can determine cultural effects on studied individuals and groups.
The adaptive nature of classic ethnography resulted in the most flexibility in data collection during the study. Correct perception of compassionate care in nurses could be studied by an in-depth investigation of emotions and experiences of those who are directly or indirectly related to this matter.
The study environment was adult general wards (6 internal and 4 surgery) of hospitals. Participants were 20 nurses (16 women and 4 men) of different ranks and 12 patients. Purposive sampling was used by the researcher to collect samples from different wards and shifts (morning, afternoon, evening) and from different age groups with different experiences.
Data collection was done by observations and in-depth semi-structured interviews. Data collection was done from June 2014 to October 2015 in Iran. Observations were made directly by the first author of the study.
The observation was conducted directly by the first author of the study. After explaining the purpose of the study to the participants and obtaining their consent to be included in the research, the observation was started.
The researcher was a nurse but was not a staff in the selected wards; therefore, she was considered as an outsider in this context. The researcher was only an observer in the first 18 days of the study. Hence, she was only involved in observation without entering into situations and interacting with participants. However, the researcher played the role of an observer as a participant in subsequent observations and contributed in some nursing care activities. She also observed nurses' caring behaviors such as tone, look, communication with patients, standing beside the patient's bed, listening and empathy toward the patient, etc. Field notes were recorded immediately after each activity or during observations. Each observation lasted 4–40 min. The participants were observed during 10 months for 290 h. To complete the observation data, interviews were conducted with 20 nurses, 8 patients, and 4 family members from 6 internal and 4 surgical wards of the teaching hospitals. Semi-structured interviews lasted between 20 and 60 min. The interviews were conducted in the head nurse's office. Sample interview questions included when you want to show your compassion to your patients, how do you treat them? Which factors would affect compassionate care? What are the facilitators of compassionate care?
The researcher tried to encourage participants to share their experiences and express their perception. Data analysis was done by the Strauss and Corbin approach, which is based on constant comparison.
The Grounded theory identifies the relationship between concepts and categories. The Grounded theory adds to the authenticity of an ethnographic research by comparing and sorting the data.
Data analysis was started with notes and the texts were read line by line. Then, sentences and phrases which includes messages in relation to the study purpose were identified. Furthermore, codes were allocated to sentences and concepts. Codes were labeled using the participants' words and perceived concepts of the text. Similar codes were first grouped together in one category, and primary categorization of codes led to the formation of primary categories. The categories that were conceptually similar were located around a common and core axel. Consequently, they were classified according to the label by constant comparison. Data collection continued until no new data were accessed.
Credibility, confirmability, dependability, and transferability were used for rigor. The technique of time integration was used to ensure validity. Hence, sampling was done at three times of day; morning, afternoon, and evening. Data credibility was performed through member check. Moreover, some of the codes and categories were compared with the participants' remarks. Nurses were immersed in the nursing culture, which is a prerequisite for ethnographic research.
In addition, data saturation was used to increase the reliability of the study. For confirmation of the information, the research process was recorded and reported accurately. In addition to the main researcher, two other academic members also studied and approved the results. Dependability was achieved through collecting, external checking, and reviewing data.
This study was approved by the ethics committee of Isfahan University of Medical Sciences. Ethical considerations such as informed consent form, maintaining anonymity and confidentiality, and freedom of participants for leaving the study at any time were followed. Before the interview, the purpose of the study was explained. Written consent was obtained from nurses.
This study was approved by ethics committee of Isfahan University of Medical Sciences. Ethical considerations like informed consent form, keeping anonymity, confidentiality and freedom of participants for leaving the study at any time were observed. Before the interview, the purpose study was explained. Written consent was obtained from nurses.
| Results|| |
Three themes and eight subthemes were obtained including personal facilitators (nurse's personality characteristics, their attitudes and values, and having a holistic view; Socio-cultural facilitators (having a role model for compassionate behavior and having common language between the nurse and patient); and initiator facilitators (patient's suffering, patient's communication needs, and patient's emotional and psychological needs). Extracted findings are shown in [Table 1].
|Table 1: Themes and subthemes explaining the facilitators of compassionate-based care from the point of view of participants|
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The study participants aged from 21 to 78 years. Participants were 20 nurses (16 females and 4 males), 8 patient and 4 family members.
Personal facilitators refer to factors relating to nurses' personality and help to improve compassionate care. These factors are personality characteristics, attitudes and values, and holistic view.
Most participants stated that nurses who have a kind, emotional, and altruistic character and interested in helping others resulting in intimacy, empathy, and effective communication and better understanding the patient's problem.
If a nurse is inherently kind, she/he can transfer this to patients… I think nursing along with kindness is more effective than pure care. I mean care without any kindness (A female nurse).
Nurses' attitudes and value
In this study, nurses' attitude was mentioned as a very significant component in compassionate care. Participants believe that nurses must understand compassionate care. They must engage physically and mentally in patient care. Most nurses mentioned the following factors as factors leading to holistic and continued compassionate care such as internal and external motivation, belief in compassionate care, and seeking help from God.
… I myself care consciously and with inner belief… I know that patients need to receive a pleasant feeling (A female nurse).
Some nurses' stated external motivation such as income and salary provide incentives for compassionate care.
Oh sometimes I spend all work time for compassionate care. I care him/her. I provide all the care needed. But I don't receive enough salary. It makes me disappointed for good care (A male nurse).
Remembrance of God and his help is one of the input energy for nurses to do good works for charity.
… Even a little kindness affects patients… Remembrance of God produces energy for caring (A female patient).
Having a holistic view
Participants mentioned that sufficient attention to providing holistic care can be an important facilitator in compassionate care. Holistic approach implies attention to patients and their families as well as solving the patients' problems (in and out of hospital).
During patient care we should not only focus on a specific problem, we should assess holistically the patient's needs and problems. It increases patient's satisfaction (A female nurse).
Nurses believed that, for achieving and maintaining holistic care, they must apply their scientific knowledge. They believed that routine activities without using clinical knowledge are barriers for compassionate care.
. Some nurses do not update their knowledge about nursing procedures… So they cannot provide compassionate care (A female nurse).
Participants' statements showed that maintaining a holistic approach is necessary for compassionate care. Individual aspects play an important role in compassionate behavior. Improving nurses' attitudes toward holistic care (via supporting and encouraging nurses who provide compassionate care) can promote their compassionate behavior.
Sociocultural factors include having a role model for compassionate behavior and having a common language between nurses and patients.
Having a role model for compassionate behavior
Participants noted the existence of successful colleagues in compassionate care; religious leaders' behaviors play an important role in compassionate care.
. I worked in different wards. I learned love in the workplace. I have colleagues who taught me compassion. (A female nurse).
Participants referred to religious leaders' behavior as an important factor to show and maintain compassionate care.
In history we see how Zainab cared her brother Imam Hussein, and her family. She is a symbol of love and caring (A female nurse).
Having common language between nurses and patients
A common language between nurses and patients is a facilitator in compassionate care. Participants believed that a common language between the nurse and patient facilitate continued compassionate care.
Sometimes we have patients with Afghan, Luri, Turkish and other languages, or from another culture. I feel I pay less attention to them, I mean we provide less compassion for them… but if she/he is Persian, it will be easier to empathize him… (A male nurse).
Religious and cultural aspects play an important role in compassionate behavior. However, nurses must follow the policies of healthcare system as well as cultural-related policies to achieve compassionate care.
This category includes factors that start the compassionate care process. This category contains three subcategories, namely, patient suffering, patient's communication needs, and patient's emotional and psychological needs.
In general, suffering is the starting point for compassion. Participants believed compassion in nursing care starts when you see human suffering and pain.
…A patient was crying, while dressing his leg, nurse stopped, stood, and begun to sing a song from Saadi Shirazi (observation).
Patient's communication needs
Compassion is a patient-centered communication during nursing interventions. Hence, if the patient has no problem, the nurse does not speak with him or look at him and she/he just follows routine actions.
…If I have pain or have questions about illness or medication, the nurse explains to me. sometimes stays and takes my hand … (A male patient)
Patient's emotional and psychological needs
A form of compassionate care is empathy with others. Participants said patients need companionate care and empathy.
A patient became so sad and anxious after hearing of her diagnosis… so nurse stopped her task, took her hand, and sat beside her… (observation)
Compassion starts by understanding others' suffering and continues with empathy.
| Discussion|| |
This study explained the factors that facilitated and maintained compassionate nursing care. The results indicated that several factors can play a facilitating role in compassionate care. Some factors have been mentioned in other studies.
Nurses' personality characteristics can lead to intimacy, empathy, and communication between nurses and patients and provide a holistic view of the patient's problem. McEvoy and Duffy noted that nurses' personality characteristics and attitude affect their actions, and it is necessary to provide holistic care. Penney et al. showed that personality traits, values, and beliefs are the most important factors affecting motivation and intrinsic motivation in the workplace. Caris-Verhallen et al. showed the nurses' positive attitude toward patients was valuable variable in social dialogue with patients.
Another finding is that nurses' attitude and values affect compassionate care. Kaya et al. reported that the presence of religious and moral beliefs of nurses makes them more responsible, intelligent, and ethical along with more tolerance threshold than other personnel. Jasemi et al. showed that social and friendly character and religious beliefs are facilitators in holistic care.
Manongi et al. showed nurses' problems such as low income and long-term work as well as shortage of nurses led to a lack of power and poor nurses' attitude toward patients. Holistic view and philosophy facilitate compassionate care, and attention to all patients and their families, meeting patients' needs. Researchers in a previously reported study showed that the lack of a holistic view was a barrier in patient-centered communication and emotional support.
The present study revealed that having a role model for compassionate behavior is an important element of compassionate care. The religious and cultural view in nursing care in Iran is based on models such as Hazrat Zainab.
Esmaeili et al. stated that a lack of positive organizational model is a barrier in holistic care.
In addition, in this study, a common language between nurse and patient plays a facilitating role for compassion. The results of a study conducted by Magnusdottir showed that nurses who have a common language with their patients were more comfortable in communicating with patients and nurses than those who have no common language. Rassouli et al. showed that a lack of common language between nurses and patients is a barrier in communication with patients.
In this study, communicational, emotional, and psychological needs of the patients that motivate them to express their problems and interact with nursed were facilitating factors for starting compassionate care.
Sheldon et al. stated that patients interacted with nurses due to their health problems and transferred their distress to nurses.
Suikkala et al. reported that patients' conversations about their status and physical condition maintained the relationship between nursing students and patients.
In fact, on one hand, nurses' attitude toward the patient as a person who needs care, and on the other hand, nurses' belief about the importance of compassionate care as the most important nursing action produces a timely response to patients' needs and maintain minimum interaction.
| Conclusions|| |
The findings of this study showed that determining the facilitators of compassionate care could be the first step in solving communication problems. Communication with patients and understanding and respecting their needs is a nursing responsibility. It is important to consider nurses' personal characteristics and attitudes. In addition, it is necessary to use role models to develop compassionate care in practice. Therefore, communication with the patient, patient's emotional needs, pain, and suffering should be considered by nurses. Further attention to teach the concept of compassion and holistic as well as patient-centered care to increase the number of nurses and to create more positive attitude toward nursing profession in society are the most important factors that should be considered. These factors can be effective in providing compassionate care regardless of any shortcomings in the work condition.
This article was derived from a PhD thesis of sima babei with project number 393458 Isfahan University of Medical Sciences, Isfahan, Iran. We appreciate Clinical Research Development Center of Alzahra, shahid chamran and all the participants in this study who had collaborated in the production of information, also of the University of Medical Sciences Isfahan for financial support and underlying the field of study, sincerely thank them.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Schantz ML. Compassion: A concept analysis. Nurs Forum 2007;42:48-55.
Dewar B. Caring about caring: An appreciative inquiry about compassionate relationship centred care. Thesis for PhD degree. Edinburgh Napier University; 2011.
Flynn M, Mercer D. Is compassion possible in a market-led NHS. Nurs Times 2012;7:12-4.
Hooper C, Craig J, Janvrin DR, Wetsel MA, Reimels E. Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. J Emerg Nurs 2010;5:420-7.
Oveis C, Horberg EJ, Keltner D. Compassion, pride, and social intuitions of self-other similarity. J Pers Soc Psychol 2010;98:618-30.
Suliman WA, Welmann E, Omer T, Thomas L. Applying Watson's nursing theory to assess patient perceptions of being cared for in a multicultural environment. J Nurs Res 2009;17:293-7.
Hudacek SS. Dimensions of caring: A qualitative analysis of nurses' stories. J Nurs Educ 2008;47:124-9.
Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172:405-11.
Babaei S, Taleghani F, Kayvanara M. Compassionate behaviors of clinical nurses in Iran: An ethnographic study. Int Nurs Rev 2016 [Epub ahead of print].
Crigger NJ, Brannigan M, Baird M. Compassionate nursing professionals as good citizens of the world. ANS Adv Nurs Sci 2006;29:15-26.
Finfgeld-Connett D. Qualitative convergence of three nursing concepts: Art of nursing, presence and caring. J Adv Nurs 2008;63:527-34.
Straughair C. Exploring compassion: Implications for contemporary nursing. Part 1. Br J Nurs 2012;21:160-4.
Esmaeili M, Ali Cheraghi M, Salsali M. Barriers to Patient-Centered Care: A Thematic Analysis Study. Int J Nurs Knowl 2014;25:2-8.
Bolster D, Manias E. Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: Qualitative observation and interview study. Int J Nurs Stud 2010;47:154-65.
Manongi RN, Nasuwa FR, Mwangi R, Reyburn H, Poulsen A, Chandler CI. Conflicting priorities: Evaluation of an intervention to improve nurse-parent relationships on a Tanzanian paediatric ward. Hum Resour Health 2009;7:50.
Zakaria Kiaei M, Salehi A, Moosazadeh Nasrabadi A, Whitehead D, Azmal M, Kalhor R, et al
. Spirituality and spiritual care in Iran: Nurses' perceptions and barriers. Int Nurs Rev 2015;62:584-92.
Hammersley M, Atkinson P. Ethnography: Principles in practice, 3rd
ed. London: Routledge; 2007.
Holloway I, Wheeler S. Qualitative Research in Nursing and Health Care, 3rd
ed. John Wiley & Sons Publication, Oxford, UK; 2010.
Charmaz K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. Sage Publication, London, UK; 2006.
Streubert HJ. Carpenter DR. Qualitative Research in Nursing, 5th
ed. Philadelphia: Wolters Kluwer; 2011.
Guba EG, Lincoln YS. Naturalistic Inquiry. Sage Publication, Newbury Park, CA; 1985.
McEvoy L, Duffy A. Holistic practice–A concept analysis. Nurse Educ Practice 2008;8:412-9.
Penney LM, David E, Witt LA. A review of personality and performance: Identifying boundaries, contingencies, and future research directions. Hum Resour Manage Rev 2011;21:297-310.
Caris-Verhallen WM, De Gruijter IM, Kerkstra A, Bensing JM. Factors related to nurse communication with elderly people. J Adv Nurs 1999;30:1106-17.
Kaya N, Aştı T, Turan N, Karabay B, Emir E. The feelings of guilt and shame experienced by Nursing and Midwifery students. Nurse Educ Today 2012;32:630-5.
Jasemi M, Valizadeh L, Zamanzadeh V, Taleghani F. The effect of motivational factors in providing holistic care: A qualitative study. Iran J Med Ethics History Med 2014;6:77-87.
Magnusdottir H. Overcoming strangeness and communication barriers: A phenomenological study of becoming a foreign nurse. Int Nurs Rev 2005;52:263-69.
Rassouli M, Zamanzadeh V, Abbaszadeh A, Nikanafar AR, Alavi-Majd H, Mirza Ahmadi F, et al
. Patient-Centered Communication Barriers: Experiences of patients with cancer, their family members and nurses. J Urmia Nurs Mid Faculty 2014;11:753-64.
Sheldon LK, Barrett R, Ellington L. Difficult communication in nursing. J Nurs Scholarsh 2006;38:141-7.
Suikkala A, Leino-Kilpi H, Katajisto J. Nursing student-patient relationships: A descriptive study of students' and patients' views. Int J Nurs Educ Scholarsh 2008;5:1-2.