Compassion is key in nursing, but are interventions designed to foster it effective? A systematic review found that the evidence is too weak to allow us to draw firm conclusions
The need to strengthen compassionate nursing has been highlighted as a high priority for the NHS. A range of strategies have been recommended, including changes in education. However, although there are many proposed interventions to support the delivery of compassionate care in practice, there is uncertainty as to how truly effective they are. As evidence-based strategies should be given priority, this article reports findings of a systematic review of interventions to promote compassionate care by nurses.
Citation: Ball J et al (2017) Are interventions to support delivery of more compassionate nursing care effective? Nursing Times [online]; 113: 11, 57-58.
Authors: Jane Ball is principal research fellow; Peter Griffiths is chair of health services research; Jacky Bridges is professor of older people’s care; Jo Hope is research fellow; Ewa Crunden is BSc healthcare management, policy and research student all at NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton.
- Scroll down to read the article or download a print-friendly PDF here
Compassion is a key element of nursing care (Watson, 2008; Eriksson, 1992). In recent years, nurses’ delivery of compassionate care has been under close scrutiny, in the context of a series of healthcare scandals, with much attention focusing on nurses in general hospitals. The 2010 Francis report highlighted substantial and significant differences in the quality of delivered care and the compassion shown towards patients. These were identified as a main issue in the failings that were under investigation (Francis, 2010).
Although there is a general consensus that compassionate nursing care needs improvement (Dewar et al, 2014; Dewar and Nolan, 2013; Youngson, 2011; Maben et al, 2010), there is little evidence available on the effectiveness of interventions aiming to support its delivery, and therefore no clear guidance on how to achieve this aim.
National strategies such as the chief nursing officer’s ‘6 Cs’ (NHS England, 2016) have prompted a range of initiatives, but the evidence behind many of the activities and programmes designed to promote compassion is unclear.
In this article, we summarise a systematic review of evidence for interventions that aim to support or improve the delivery of compassionate nursing care (Blomberg et al, 2016).
A review of evidence
Due to the lack of clear definition of compassionate care, the review used an inclusive approach and did not rule out studies that did not explicitly address ‘compassion’. It included studies aiming to make nursing care more compassionate, but also looked at studies that assessed or evaluated nurses’ self-reports of compassion, and/or the ability to deliver compassionate care, and/or the observed quality of interactions (including patient reports of experienced compassion).
The review was based on studies selected from a comprehensive search of the literature using CINAHL, Medline and the Cochrane Library databases up to June 2015. It included primary research studies comparing outcomes of interventions to promote compassionate nursing care with a control condition. Studies were graded according to the relative strength of methods and quality of description of the interventions (Blomberg et al, 2016).
A range of interventions
Blomberg et al identified 24 primary studies reporting on 25 interventions, which included staff training, changes to the care model and staff support system. The studies had been carried out in a range of settings: hospital, care or nursing homes, and other community settings. Eleven studies had been conducted in the US and the others in various countries, mostly in Europe but also Australia, Canada, China and Turkey.
Study participants included nurses, nurse managers, patients and relatives. The effectiveness of interventions was measured using a range of tools, although self-reporting by nurses was the most common method. The outcome measures varied widely but can be classified into three types:
- Nurse-based outcomes;
- Quality of care;
- Patient-based outcomes.
Intervention types included staff training (n=10), care model (n=9) and staff support (n=6). Staff training interventions comprised focused training on verbal interactions, communication, communicating about spirituality and spiritual care, as well as training on empathy. By contrast, care model interventions took a broader approach to changing the functioning of a team in practice. Finally, staff support interventions focused on individual or group programmes to address problems (such as compassion fatigue) or bolster individual psychological resources.
Overall, it was difficult to obtain a clear picture of the interventions from the description provided in the review. This means that evidence is less useful because the interventions become difficult or impossible to replicate. The description of participants and facilitators was unclear, as was the description of the mechanisms for change.
Nurse support intervention studies primarily measured nurse-based outcomes. In contrast, care-model intervention studies primarily used outcomes related to quality of care and patient-based outcomes, and less commonly nurse-based outcomes. Training intervention studies used the widest range of outcome types, although the majority used nurse-based outcomes.
Most studies reported improvement in their primary outcomes; however, the study design was often weak so methodological quality was judged to be low. Most studies were uncontrolled in their approach, relying on simple ‘before and after’ comparisons.
Of the 67 outcome types assessed across all studies, 32 (48%) showed significant positive effects for the intervention, with a further 18 (27%) showing positive but non-significant results. There were no significant negative differences and only three non-significant negative results.
The few higher-quality studies (five out of 24) were less likely to report positive changes. Patient outcomes were less likely to show significant differences, with only five out of 17 (29%), studies reporting those outcomes showing statistically significant differences. None of the interventions had been tested more than once.
Based on the quality of the evidence, we could not recommend implementing any of the reviewed interventions. The weakness of the evidence does not create a compelling reason to consider any particular approach that was researched.
Although any of the interventions may be worthy of further investigation, it would be difficult to replicate them because of the lack of reported information and general lack of theoretical underpinnings. None should be routinely implemented or considered ‘evidence-based’ without further research.
Box 1 summarises the conclusions we drew from looking at this review of the evidence.
Box 1. Conclusions
- There is a large variety of interventions aimed at supporting compassionate nursing care described in the nursing literature
- The interventions reviewed focused on staff training, staff support or the introduction of a new care model
- While most studies showed mainly positive effects on outcomes, their methodology was weak
- As a result, there is no clear guidance about which interventions effectively support compassionate nursing care
- The benefit of programmes to support compassionate care should not be assumed
- To be able to strengthen the delivery of compassionate nursing care, there is a need for clear, well described and evaluated interventions with stronger research design
- This article is based on Crunden E et al (2017) Are interventions to support the delivery of more compassionate nursing care effective? Evidence Brief; NIHR CLAHRC Wessex; Issue 6, July 2017. Reproduced under the terms of the CC by 4.0 licence. Minor edits have been made to the article.
- Nurses’ delivery of compassionate care has been under close scrutiny in recent years
- A systematic review of interventions for compassionate nursing care failed to show compelling evidence of their effectiveness
- It should not be assumed that interventions aimed at making care more compassionate are beneficial
- We need clear, well-described and evaluated interventions with stronger research design
Blomberg K et al (2016) Interventions for compassionate nursing care: a systematic review. International Journal of Nursing Studies; 62: 137-155.
Dewar B et al (2014) Clarifying misconceptions about compassionate care. Journal of Advanced Nursing; 70: 8, 1738-1747.
Dewar B, Nolan M (2013) Caring about caring: Developing a model to implement compassionate relationship centred care in an older people care setting. International Journal of Nursing Studies; 50: 9, 1247-1258.
Eriksson K (1992) The alleviation of suffering - the idea of caring. Scandinavian Journal of Caring Sciences; 6: 2, 119-123.
Francis R (2010) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009. London: The Stationery Office.
Maben J et al (2010) In praise of compassion. Journal of Research in Nursing; 15: 1, 9-13.
NHS England (2016) Leading Change Adding Value: a framework for nursing, midwifery and care staff. London: NHSE.
Watson J (2008) Nursing: the philosophy and science of caring. In: Smith MC et al (eds). Caring in Nursing Classics: An Essential Resource. New York: Springer.
Youngson R (2011) Compassion in healthcare: the missing dimension of healthcare reform. In: Renzenbrink I (ed). Caregiver Stress and Staff Support in Illness, Dying and Bereavement. Oxford: Oxford University Press