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Article

Compassion in care: A
qualitative study of older
people with a chronic disease
and nurses

Nursing Ethics
18(5) 672685
The Author(s) 2011
Reprints and permission:
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10.1177/0969733011403556
nej.sagepub.com

Margreet van der Cingel


Windesheim University of Applied Sciences, The Netherlands

Abstract
This article describes compassion as perceived within the relationship between nurses and older persons
with a chronic disease. The aim of the study is to understand the benefit of compassion for nursing practice
within the context of long-term care. The design of the study involves a qualitative analysis of in-depth interviews with nurses and patients in three different care-settings. Results show the nature of compassion in
seven dimensions: attentiveness, listening, confronting, involvement, helping, presence and understanding.
Analysis of the data also shows in what way opinions of participants relate to issues raised in a previous
literature study, for example the difference between pity and compassion. The conclusion states that compassion is a valuable process which motivates patients as well as nurses to cooperate in achieving relevant
outcomes of care. The discussion involves some methodological issues. For one thing, further confirmation
of the dimensions found is recommended.
Keywords
care, chronic diseases, compassion, humane approach, nursing, older persons

Introduction
This study focuses on the phenomenon of compassion in healthcare, specifically within the relationship
between nurses and older people with a chronic disease. These patients face loss of health and therefore loss
of possibilities in life. Their daily life is characterized by a continuous dependence on care. For them, good
care is of genuine value. Some care ethics literature and nursing theories state good quality of care analogous
to humane care.1,2 It is unclear, however, how the humane aspect of care should be made tangible in daily
nursing activities, professional job-descriptions or codes of ethics. Moreover, compassion as a concept has
received little attention in nursing theories.3 Previous to this study the researcher did a literature review on
compassion in the domain of professional care.4 The review indicates compassion to be a strong concept for
these humanizing aspects in nursing care. Time and again compassion is stated as a core concept for nursing
and is recently mentioned again as such.5 Could compassion perhaps be the concept that gives meaning to
what humane care is all about? Philosophies and theories should guide practice and inform the public as well

Corresponding author: Catharina Johanna Margaretha (Margreet) van der Cingel, Campus 2-6, PO Box 10090 8000 GB Zwolle,
The Netherlands
Email: cjm.vander.cingel@windesheim.nl

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as professionals about the underlying values that support practice.2 Therefore, the purpose of this study is to
gain knowledge about the benefit of compassion as a vehicle for humane care for patients in long-term care
settings. If the nursing profession wants to take the concept of humane care seriously, it being a metaphor for
their professional care for those patients, it is necessary to study the nature and significance of compassion.

Method
This study is to be placed in the tradition of qualitative research that aims for the elucidation of a phenomenon
in a specific time, place and context. Qualitative research nowadays uses many methods, but often these
blended methods adopt elements of Grounded Theory to function as their basic methodological principles.
This study uses a mixed method as well. To begin with, the emergent fit mode is used. This mode is one of the
two modes in Grounded Theory, and is often used to refine existing theory. In this study it is used in determining specific research questions. In addition, constant comparative analysis, analytical induction and theoretical sensitivity are relevant in this study.6,7 Constant comparative analysis was applied in several phases
of data collection and the analysis. Quotations of participants in answer to open questions on the nature of
compassion were compared and categorized in preliminary descriptions of the dimensions of compassion
until data saturation was achieved. Analytical induction is in place when literature research forms the basis
for hypotheses about the phenomenon. A theoretical framework on the nature and significance of compassion, based on the previously performed literature review, helped design the semi-structured part of the topic
lists for the interviews and also contributed to the analysis of the interviews. Quotations were paraphrased
and interpreted in light of this specific framework. Theoretical sensitivity has therefore supported theory
development on compassion. Thus, the hermeneutical approach in the review was complementary to the
interpretation of empirical quotations.8

Data collection
The research question in this study is: What is the nature and significance of compassion for older people
with a chronic disease in nursing practice? In order to find answers to this question nurses (n 30) and
patients (n 31) were interviewed (see Table 1).
Compassion as a phenomenon takes place within a relationship; therefore it is necessary to study both
perspectives. Data was collected from March 2008 till June 2009 in three settings in order to obtain enough
Table 1. Participants
Patients

Nurses

 Rheumatic diseases
 COPD
 Other chronic diseases
Setting:
 Rehabilitation centre for Chronic Diseases
 Home Care Organization
 Nurse consulting hours in outpatient clinic

17
8
6

16 specialized nurses (chronic diseases)


8 home care nurses
6 nurse specialists/nurse practitioners

Age (mean)
Males
Females
Totals

71
14
17
31

45
2
28
30

11
16
4

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Table 2. Topic lists questions*


Open questions:
What kind of associations comes to mind when you think of compassion?
What kind of situations do you think of when thinking of compassion?
How well do you know the patient/nurse?
What did you do to get to know the patient/nurse?
Do you know what is of importance to the patient? (nurse)
Does the nurse know what is of importance to you? (patient)
1. Compassion and suffering
What do you believe to be suffering?
What reactions on suffering did you observe (patient/nurse)
Is one type of suffering worse than the other? If so, which one?
2. Compassion and identification
What do you believe to be empathy?
In what way do you imagine what the patient is going through? (nurse)
Do you believe a nurse should imagine or identify with you in order to know what you are going through?
(patient)
3. The emotion compassion
Do you consider compassion a feeling or does it involve thinking in your opinion?
Does compassion connects with thoughts, what thoughts?
What kind of emotions are connected to compassion?
4. Motives for compassion
Do you consider compassion an altruistic emotion?
Could nurses have egoistic interests in having compassion?
Is pity the same as compassion, if not whats the difference?
5. The moral significance of compassion
Do you or the patient need(s) compassion?
What happens when there is no compassion?
How did you/the nurse show(ed) compassion?
*These questions are merely examples of questions that were posed in reference to the topic lists. Besides questions such as these,
participants were frequently asked to illustrate their answers by sharing their specific experiences.

diversity in long-term care situations. Patients, mainly with rheumatic diseases and chronic obstructive pulmonary diseases (COPD), and their nurses were sought in: a rehabilitation centre for chronic diseases, a home
care organization and outpatient clinics with nurse-consulting hours. Since the public debate in the Netherlands on healthcare in general and healthcare organizations in particular does not indicate that compassion is
a common characteristic in a professional setting,1 research locations had to be sites of best practices for compassion in order to actually find nurses and patients experiencing compassion. The research settings were
therefore chosen because of their good reputation. Patients were 65 years of age or older and were able to
express themselves properly in Dutch. Nurses had to have at least five years of experience in nursing in order
to find expert or at least proficient nurses who would have a holistic or full intuitive understanding of a
situation.9 Nurses in an earlier stage of their professional development were excluded because they could
either be too impressed by suffering and therefore have non-specific reactions or too absorbed in their development becoming a more experienced nurse.
Two semi-structured topic lists, one for patients and one for nurses, were developed to guide the interviews. One can only ask about the significance of a phenomenon when the nature of this phenomenon is discussed. Therefore open questions on the nature of compassion were included, in addition to questions related
to the theoretical framework (see Table 2). Four health scientists reviewed these topic lists previous to data
collection. Their criticism led to adaptations to improve comprehensibility, a uniform interpretation of

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questions and congruency with the theoretical framework. Besides the word compassion the interviewers
deliberately used two Dutch synonyms for compassion: medeleven and mededogen. This was done to
prevent the interviewers giving a too explicit explanation of the concept of compassion. Moreover, it seemed
important to raise the issue of semantics. The researcher and three nursing students (bachelor) carried out the
interviews. Nursing students were chosen to be interviewers for several reasons. For one thing the students
had easy access and were easily accepted as trainees on the job in the research settings. For another, they were
familiar with the issues they needed to address in the interviews and most importantly, because of the fact that
they were students they were able to ask questions without any diffidence or fear. Off course having students
perform interviews has disadvantages as well. Students are not experienced in necessary interview skills by
nature; therefore the researcher trained the students extensively in the use of interview techniques in several
two-day courses beforehand and throughout the data collection period. The students were also specifically
selected on criteria such as previous experience in research projects, verbal communication skills and motivation. Complimentary to the interviews, all four interviewers observed several conversations between
nurses and patients, for example care plan evaluation interviews, and moments when caretaking took place
such as assisting in daily activities. These observations, described in memos, were done in order to understand the context of a research setting and were used to support the analysis. Interviews were planned based
on voluntary admission or on the initiative of nurses themselves; patients were approached and asked to participate after being nominated by a nurse. The nomination was merely based on the inclusion criteria and
health status of the patient at the moment of the interview. After nomination patients were asked to sign a
letter of informed consent to participate. The letter also stipulated that patients could always withdraw their
consent without having to explain reasons to do so and that participation would never have any influence on
the care they received. Information from the interviews was always handled with confidentiality. For one
thing, the data transcription was performed by a research assistant outside the research settings. Interviewers
were nearly always received with openness and enthusiasm. The importance of compassion was often mentioned as the main reason for wanting to participate in the study.

Data analysis
The interviews were recorded and then transcribed into written documents. Subsequently, the interviews
were analysed with the software program Atlas-Ti by means of coding of quotations. Thus, the data was
structured and a list of concepts emerged. The researcher and students discussed and reached consensus
on several concepts after coding a set of interviews independently. The information from the memos of the
observations in practice was sometimes used to help coding the concepts. This was done by checking whether
a code definition would fit in the situation observed. The memos also provided some of the hypotheses that
helped to steer the analysis. Time and again the preliminary code list was augmented and adjusted by the
researcher based on the coding of new interviews until data saturation was reached. Eventually, a code list
with two levels of hierarchy was made.
In the last phase of the analysis core concepts were chosen and prioritized from a content perspective
based on rereading and paraphrasing quotations.
Thus, participants experiences in response to open questioning led to the seven dimensions that characterize the nature of compassion whereas the opinions of participants in response to the semi-structured part of
the questionnaire contributed to more clarity on both the nature as well as the significance of compassion.

Researchers role
The role of the researcher is an aspect of qualitative research methods which is subject to critique. Although
many results of the study emerge from literally quoted texts of participants, in the end results will always be

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interpretations by the researcher in particular. In formulating these interpretations, the researcher must
manoeuvre between tangible descriptions that stay close to original texts and a sufficient level of abstraction
in order to develop theoretical concepts. The danger in giving tangible descriptions is that it may reduce the
phenomenon by splitting it up. Such an unravelled description would do no justice to the experiences, thoughts
and expressions of participants. On the other hand, the researcher must work on theory development. This
work is at risk of replacing one abstraction by another. For example, when compassion is replaced by empathy,
which participants sometimes perceived as a synonym for compassion. Research as such would not produce
any useful knowledge and it would reduce the study to a game of semantics. Therefore, interpretations of the
researcher, the level of data saturation and the amount of quotations per group of participants must be open to
judgement. These figures on dimensions and issues of compassion can be found in Tables 3 and 4.

Results 1
The nature of compassion
Compassion is found to be a process of intuition and communication, in which one can recognize some sort
of a sequence. The outcome of this process is labelled as compassion. Compassion as a process has, according to the participants narratives, seven dimensions. They are described in paraphrases, illustrated with quotations, and elucidated by the researchers interpretation.

Attentiveness
First and foremost attentiveness is mentioned most often. Attentiveness, during a person to person encounter,
is described as a conscious approach of one person who shows interest in whatever issue is important for the
other person. According to participants attentiveness can be supported by gestures or touches, provided these
are appropriate.
To seek contact with others in a conscious way and show outgoing attentiveness to this person within such a contact. (Patient with rheumatic disease, rehabilitation centre for chronic diseases)

The first thing that comes to mind in thinking about compassion concerns approaching the other person as
a human being. Such a contact immediately compels a nurse to act, however small or non-verbal this act may
be. Acts such as making eye contact, or slowing your pace, or pulling up a chair to sit next to the bed, are an
invitation to the patient. This shows that there is a conscious wish for contact; the nurse gives her permission to continue. Behaviour in which one shows a level of attentiveness in order to consciously seek contact
is the key to the continuation of contact that leads to the patients narrative.
Table 3. The nature of compassion
Patients 31

Nurses 30

Dimensions

quotes

patients

quotes

nurses

Attention
Listening
Confronting
Involvement
Helping atitudes
Presence
Understanding

89
46
36
22
51
19
15

26
19
22
17
30
10
8

75
86
42
22
36
21
22

25
27
21
15
21
13
14

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Listening
The second dimension is to give room to the story of the patient. Nurses see active listening as an indispensable component of compassion. To them listening means stimulating the other person to tell the story. In
order to acknowledge that the patient can speak, the nurse keeps her silence and poses questions that will
encourage the patient to tell the complete story. Patients acknowledge that nurses indeed do listen, as the
following statement shows.
They listen to your story all the time. Actually, there is not a nurse that does not listen. (Patient with COPD, rehabilitation centre for chronic diseases)

After the first encounters between nurse and patient it is crucial to prolong the invitation to speak. Mainly,
the importance of listening is the willingness to really hear ones story. Here is a story that can and may be
told, that wants to be heard and has an audience. This is enough, for now, because in telling the story ones
heart is lifted and theres room to breathe.

Confronting
When the story is told, the room to breathe can be used for dialogue. In the context of compassion this dialogue is characterized by the verbalization of suffering and the accompanying emotions, according to participants. To confront the patient with the fact that these emotions are rightly felt because suffering because of
loss exists, is the third dimension of compassion.
No . . . , she said, you must not think so lightly about it, it is really not that easy. (Patient with COPD, rehabilitation centre for chronic diseases)

The dialogue, this talk, the verbalization of what is going on, is not just any conversation. For the nurse it
is about paraphrasing what she has heard, it is about acknowledging and valuing. It is crucial to value the
patients situation as being unpleasant, difficult, tedious or bad. For the dialogue to be a compassionate dialogue it is necessary, however paradoxical this may seem, to confront in order to help the patient to face his or
her loss. Patients mention that suffering is, among other things, caused by loss of possibilities in life. On the
one hand the confrontation is a check to find out the emotional significance of the loss for the patient. Nurses
describe in detail how they are able to recognize emotions such as grief, anger, fear and shame nonverbally,
besides inquiring about them. On the other hand these valuing statements acknowledge the emotions concerning the loss and suffering. The nurse legitimates the emotion, so to speak. Because it is bad to miss out
on things you used to love but cannot do anymore, it is difficult not to be able to go wherever you want to go
anymore or bear other losses.

Involvement
The fourth dimension of compassion is involvement. The acknowledgement of loss and suffering creates
involvement, so say participants. Involvement is about the idea that the nurse recognizes your emotion and
that she is concerned about you in the same way that you are yourself. Then, you are no longer the only one
who knows about your emotions. Because of these shared emotions a bond is established.
Hmm . . . I believe that there is some sort of alliance in it. It simply feels good . . . some sort of feeling like . . . God,
there is somebody else I can speak to . . . including the things that Im not keen on bringing out in the open. And
also . . . someone who wants to know everything. (Patient in homecare)

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Nurses show that their communication is not a one-way street when they are touched by the loss and suffering of the patient. For that matter, a lot of nurses mention the fact that they literally feel the same emotion
when they see a patient with a particular emotion. Because of that, patients also feel confident that the nurse
will handle their shared emotions with care. Confidentiality and trust were often mentioned in that perspective. Within the established bond there is a mutual understanding of trust and of this specific information to
be safe.

Helping
The fifth dimension is helping. According to a large majority of participants, compassion takes shape in
simply giving someone a hand. Thus, helping is to assist at the activities in daily life by responding or
anticipating to basic needs which the patient cannot perform him- or herself anymore. Instead of taking over
completely, helping can also mean suggesting alternative ways to handle things so patients can continue to
carry out activities themselves.
I was fiddling with a small cup of jam, while the person sitting next to me has capable hands and suddenly the
nurse was there, tapping my shoulder and he whispered . . . you see, that! (Patient with rheumatic disease, rehabilitation centre for chronic diseases)

Nurses associate compassion with a wish to do something for someone else. Patients value this behaviour
greatly because a helping hand is indispensable when you are not able to do things yourself. The best way to
help is to anticipate, to be salient to what is needed, because in this way laborious asking is prevented.
Helping often concerns apparently small favours but can also include, for example, mediating between a
patient and his or her doctor in case of communication problems. The heart of the matter is that it always
concerns acts that are of real importance to a patient.

Presence
Although presence is less often mentioned than helping, there still is a strong message in the way participants
value presence. To be there is the sixth dimension in which physical presence is the condition for emotional
presence and presence of mind. Saliency is inherent to being present. Actually, to be present is all about noticing what is going on with a patient.
The patient had bad news. Well then, I thought, I better stay with him. And just for that he thanked me three times
over. (Nurse at rehabilitation centre for chronic diseases)

This quotation shows that it is about noticing that someone needs you to be there. Nurses are, by profession,
privileged to be present in all kinds of intimate situations. It is almost self-evident to be present. And yet presence apparently is of such importance that participants mention presence specifically. It is not just a matter of
coincidentally being there. It is a conscious choice because the nurse notices the need for her presence.

Understanding
Finally, understanding is the seventh dimension of compassion. It is a dimension thats mostly mentioned by
nurses. They say it is important to let the patient know that you are at least trying to understand what is going
on for them. Patients acknowledge that this is indeed important.
and . . . the fact that this is really understood, as in acknowledging . . . like . . . yes, I do understand your anger . . .
or grief about it. (Patient in home care)

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Nurses say this is important from a human as well as a professional perspective because in this way you
show that you want to understand someones feelings correctly. You show that you have the intention to actually know about someones troubles and not to walk away from them. Moreover, when there is a mutual
understanding of the emotion you can also speak of evidence on which professional nursing is to be based.

Development of the theoretical framework


The literature review has been a guideline for the development of the theoretical framework and subsequently for the lists of topics for the semi-structured part of the interviews. The review explores views on
compassion and related concepts such as empathy by classical philosophers as well as contemporary scientists. These analyses lead to a phenomenological and tentative description of compassion. Compassion is, in
this view, a process with affective, cognitive, behavioural and moral dimensions, which is primarily triggered
by suffering of others.10,11 In order to feel compassion imagination and identification is necessary, at least to
some extend, although there is the danger of projection, which should be avoided.12 In her study on emotions
classicist and philosopher Nussbaum convincingly demonstrates that besides the feeling of compassion, one
also needs to believe that the suffering of the other person is a terrible thing.13 One needs to have a specific
thought for a specific emotion. Herewith, Nussbaum places compassion in a perspective of theories that suggests that emotions have rationality in them. The moral and subsequently related behavioural dimension of
compassion concerns acting from an altruistic perspective in which setting aside ones own interests and
withholding ones judgement are central.14 Finally, the fact that suffering is acknowledged by compassion
offers consolation; not to show compassion actually adds suffering to the suffering that already exists
because it denies suffering.15 In this view, compassion shows to be an answer to suffering. All these issues
raise specific questions on which philosophers and scientists sometimes reach consensus and sometimes disagree. In order to obtain opinions from participants, the interviewers asked questions about:








the context related to suffering in which compassion exists


emotions and responses to chronic illnesses and loss (what triggers compassion)
how to assess the suffering of others (identification and imagination)
thoughts and feelings on the suffering of others and views on experiencing compassion (how is the emotion explained)
motivation of participants to show compassionate behaviour (motives for compassion)
pitfalls related to unconditional compassionate behaviour (conditions for compassion)
the effects and significance of compassionate and uncompassionate behaviour on care (moral significance of compassion)

This theoretical framework of compassion thus consists of six leading issues concerning the nature as well as
the significance of compassion: compassion and suffering, compassion and identification, the emotion compassion, motives for compassion, conditions for compassion and the moral significance of compassion.

Results 2
Opinions on compassion
This article addresses opinions of participants on some issues from the theoretical framework. Some of these
discuss the nature of compassion while others try to grasp the significance of compassion for older patients with
a chronic disease. Other remaining issues of the framework will be addressed separately in the context of the
behaviour of the nurse and the relationship between the nurse and patient in another phase of the (PhD) study.

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Compassion and suffering


First of all, in most literature compassion is directly related to suffering. It is the trigger for compassion
according to Tudor, among others.11 Participants in this study, nurses as well as patients, subscribe to this
notion.
then, somewhere, at some moment . . . somehow, I feel an appeal is being made. (Nurse at rehabilitation centre for
chronic diseases)

Surprisingly enough it is not primarily pain or troubled breathing, the physical kind of suffering, that is
seen as the toughest part to deal with when participants address their suffering. The study shows that everyday troubles, as a consequence of loss of possibilities, are the main burden to people with a chronic disease.
Patients do not always explicitly call these troubles suffering, but as these limitations in performing daily
activities prolong they admit it becomes more and more difficult to endure them. To not being able to perform
simple activities, such as cycling to the store to fetch some groceries, brings about emotions such as grief or
anger. These various emotions express the kind of suffering that represents psychological distress, for example grief, helplessness, hopelessness or anxiety.16,17 The notion of a perspective in which the possibility to do
whatever you want in life is diminishing or will even be lost, probably sooner than later, brings about such
emotions.
Well yes, I can be very sad about it, sad . . . because I cannot do this or that . . . it is so disappointing . . . (Patient in
home-care)

As Tudor does, participants acknowledge the paradox that on the one hand suffering is not something to
measure and on the other hand there is a gradation in certain kinds of loss.11 Some quotations from nurses
address the subjectivity of suffering, for example the nurse who states: I think one suffers when one says he
suffers. Other quotations, however, describe the loss of loved-ones to death as being the ultimate form of loss
and therefore of a different order than any other kind of loss. Although suffering is the most important trigger
for compassion, it does not need to be restricted to that. Most participants also believe compassion to be
related to joyful occasions. Specifically participants from the rehabilitation centre of chronic diseases mention the importance of compassionate behaviour when joyful occasions happen. To cherish happy and joyful
moments in life is needed as a counterweight to troubles for patients. Next to that, it is a necessity that others
know or hear about these events. When nurses see my distress and suffering, they also need to know about the
events that keep me going and help me to survive, seems to be the argument. In this way, positive confirmation is used as a motivational instrument in the rehabilitation of patients with a chronic disease. Not surprisingly, because patients work hard and want their efforts to be worthwhile. Showing compassion at happy
occasions acknowledges these efforts to be worthwhile. Another advantage is that patients relive these positive emotions when they share these joyful events with nurses in narratives. Therefore the counterweight of
joyfulness can be used in repetition.
When a patients condition improves, or when someone, in all ones misery, enjoys a visit from ones grandchildren enormously and wants to talk about it . . . then I keep asking questions because then they relive it over and
over again . . . and I feel compassionate . . . (Nurse home-care organization)

Compassion and identification


Secondly, identification is an issue under discussion. Participants, mostly within the group of nurses,
described several forms of identification which all involved imagination. In many theories empathy is seen
as a preliminary condition for compassion, and in order to use your empathic ability, it is necessary to identify

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yourself with another person through imagination.12 The study shows that some of the participants indeed
imagine themselves to be in the same situation as their patients. How would I be, feel, behave if I were ill,
was in pain or had to adjust to another lifestyle. They identify by way of placing themselves in someone elses
shoes, they more or less try to become someone else. In addition, some participants use their personal experiences the way they believe actors probably do.
They (actors) take some event from their own life, something they can connect to . . . I believe it is the same with
empathy, you use parts of your own stuff too . . . actually . . . its not possible to do it otherwise. You cannot know
from theory how painful it is if you dont recognize a part of it. It doesnt have to be the exact same experience,
but you need to draw upon something. (Nurse home-care organization)

Others use their imagination to picture the other person as in a play or movie; they literally see their patient
as you do when you watch actors in a play, here imagination more than identification is doing the trick.
I actually see Mrs. A. walking around in her apartment; I see her walking in this specific kitchen . . . (Nurse in
rehabilitation centre for chronic diseases)

Of course nurses also use their professional experiences; they recall former experiences in their career as a
nurse and recognize the situation, feelings and behaviour of others in the past.
Recognition, you see . . . because of all the experiences I have nursing pulmonary distressed patients I recognize
all these patterns. (Nurse specialist at outpatient clinic)

The same mechanism of recollection applies when nurses recognize emotions based on verbal and non
verbal information that patients give them. It is easier to realize what is going on for a patient when you have
specific information. To get this specific information, nurses use different strategies in order to get to know
the meaning of loss for a specific patient. One nurse for example, deliberately told a patient that she was born
and raised on a farm, as he was, in order to connect and establish a bond.

The emotion compassion


In theories about emotions, questions concerning the relation between rationality and emotion are relevant.13
Are emotions entirely different from rational decisions? Are feeling and thinking as dichotomous as sometimes is assumed? In order to gain insights into the perception of the emotion compassion, participants in this
study were asked about feelings and thoughts they might have had experiencing compassion. Nurses and
patients mention both, although some participants believe compassion to be solely a feeling. Compassion
as a feeling has a spontaneity and therefore authenticity about it. This would disappear if compassion were
a rational thought, according to these participants. Without authenticity the feeling of compassion would
not be real and thats precisely what they feel: the nurse is really there for them so it cannot be a deliberate
process of thought. But most participants mainly describe the start of the emotion as a feeling.
I physically feel for this patient . . . I want to take care of him because hes in need . . . thats what I feel. (Nurse in
rehabilitation centre for chronic diseases)

Other participants describe their rising feelings in terms of I was touched or I was genuinely feeling
sorry for him. One nurse suitably called it agosh-feeling to address her feelings of shock when confronted
with someones sorrows and suffering. Yet, feeling and thinking seems to be happening almost simultaneously or at least in a very rapid succession. The feeling translates into a thought so quickly that some participants do not even notice the difference.

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the feeling rises very sudden. For example when someone tells you something and all of a sudden you think: this
must be really bad for him. (Nurse at rehabilitation centre for chronic diseases)

The transferral from spontaneous feelings to deliberate thoughts on the significance of suffering for
the other person does not seem to be as distinctive as one might think. One nurse describes this process
as a lot of little libraries in my brain that open up. She says she uses knowledge of earlier experiences
and combines them with signals she observes at the moment in order to be able to interpret the significance for her patient. A few nurses explicitly qualify this rapid and partly unconscious process as intuition. Besides compassion, nurses have other emotions regarding suffering of patients. This study
subscribes to results from other narratives in which nurses describe their frustration, anger or indignation
concerning their patients situation.16

Motives for compassion: the difference between compassion and pity


The third issue addresses similarities and differences between compassion and pity. Both concepts are used
to refer to an emotion that indicates a feeling of being sorry, of understanding someone elses predicament. In
several analyses the differences between both concepts become clear.14,18 Participants also see pity as a different concept from compassion. Pity, for them, has a negative connotation.
They can feel compassionate for me till death, but I dont want any pity. (Patient with COPD, rehabilitation centre for chronic diseases)

Pity is different from compassion but has, remarkably, two semantic explanations according to the participants in this study. Either, pity is associated with feeling sorry for someone in a pathetic and patronizing
way or the Dutch word for pity medelijden is associated with literally having the same feelings as the other
person. Feeling sorry victimizes a patient and evokes powerlessness. This powerlessness contaminates
the nurse as well. As a result she is not able to support a patient anymore. The Dutch word medelijden
or meelijden meaning literally feeling the same, has a much less negative connotation and is specifically
felt by nurses. It exceeds the concept of simply sympathizing with someone; it is much more a transferral of
the emotion.
it turned out that it hurt me, I felt it to the bone, I literally felt . . . almost at the same time . . . it is some kind of
reflex. (Nurse at home care organization)

Recent publications on neuroscience show that connections of mirror-neurons play a role in emotional
responses.18,19,20 Connections of mirror-neurons react when a person him/herself has an emotion as well
as when this person sees someone else having this emotion. These studies also show different connections
per emotion, in other words: specific and distinct emotions are recognized. Empathy in these theories is a
neutral given and a condition for compassion. Earlier, Morse and Mitcham already named this reflex compathy.21 More recently, the suffering of nurses was addressed by Ferrel and Coyle.16

The moral significance of compassion


The last issue of the theoretical framework to be discussed concerns the significance of compassion, the ultimate question in this study. In order to establish the significance for participants, they were questioned about
the effects of compassion. According to the Dutch philosopher Duijndam, the explicit verbalization of suffering offers the acknowledgement and consolation which characterizes compassion.15 But what are the
effects of compassion according to the participants in this study? Within the care settings researched,

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Table 4. Opinions on compassion


Patients 31
Issues theoretical framework
Suffering related to compassion
Suffering is trigger
Loss (of possibilities)
Other emotions related to suffering
Compassion related joyful situations
Compassion and identification
Several forms of imagination
Empathy related to information
The emotion compassion
Compassion as a feeling
Compassion as a thought
Other emotions nurse
Motives: Compassion and Pity
Pity is a negative emotion
Suffering with: compathy
Moral significance of compassion
Effect on outcomes of care
Opinions on asking attention
Inherent in concept of care
Direct positive effect in general

Nurses 30

quotes

patients

quotes

nurses

77
58
28
21

28
26
18
19

108
49
29
27

30
21
18
24

34
18

22
10

114
32

30
18

25
18

19
15

27
32
29

20
21
15

79
9

29
6

92
23

30
14

9
19
3
45

8
11
3
25

31
8
17
37

21
6
15
21

compassion shows itself to have several effects. First, compassion results in information which is useful in
reaching the outcomes of care. Compassion as such becomes an instrument of care.
If I can find intrinsic motivation . . . for example when someone wants to walk a bit longer and further than he can
and I happen to know that he really wants to fetch his granddaughter from school . . . then Ive got him, then he
understands why he is here, it becomes more and more tangible. (Nurse at rehabilitation centre for chronic
diseases)

Secondly, compassion softens the image of the difficult patient. Patients say that they do not want to be a
nuisance to nurses. But nurses in this study say they are able to understand difficult behaviour. They say
patients have good reasons to behave in such a way. It is the nurses professional task to find out what this
reason is. In this view, patients simply cannot be a nuisance to nurses. Behaviour that asks for attention is a
signal and is seen as such. These results correspond with theories that state that the denial of suffering adds
suffering.11,15,16
you can see that when patients experience compassion that the effect is that they do not ring the bell anymore . . .
simply because they get their share of genuine attention . . . ringing the bell all the time often is a cry of ignorance,
fear, processing of events . . . (Nurse at rehabilitation centre for chronic diseases)

Finally, compassion contributes directly to the quality of care according to those who promote compassion as the essence of nursing.22 Participants in this study agree. Compassion motivates to perform to the best
of ones ability, according to a patient. You do recuperate more quickly according to another participant.
Therefore compassion is inherent to the concept of care, and specifically to good nursing care. The nurse
in this quotation illustrates this argument when she passionately verbalizes the significance of compassion:

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I believe compassion as a theme to be of such importance in health care . . . , it is so very important that its really
all there is to it and with it the quality of care . . . We absolutely do not sell a pound of sugar. We sell a whole lot
more and I sincerely do hope that this will come to light. (Nurse at home care organization)

Discussion
This study acknowledges those who plead for compassion to be the ground on which nursing care should be
standing and offers a handhold to nurses who want to put compassion into practice. Although results of this
study should be understood only within the specific context of this study, they are still meaningful for nursing
practice in general. Obviously, external validity based on statistically significant results as in quantitative
research studies, is not under discussion; but theoretical validity does and has been achieved in this study.
Building a theory based on the seven dimensions found in this study is significant in itself, especially because
data saturation took place. Permanent losses and enduring suffering are relevant to many patients in more
than one setting of care; therefore results of this study are meaningful for nursing care in general. However,
the theoretical framework used in this study can attract criticism. Questions related to the issues from the
theoretical framework could have influenced participants while phrasing their views on compassion. On the
other hand, it can be argued that the seven dimensions are found independently of the theoretical framework.
Nevertheless, further confirmation of the dimensions found in this study in other settings in order to
strengthen this theory on compassion, is recommended. In continuation, further analysis of the research data
can also contribute to more clarity on the behaviour of the nurse that is necessary to enhance compassion in
nursing practice.

Conclusion
This study shows that compassion is seen as a valuable phenomenon in nursing practice areas where older
people with a chronic disease receive care. Compassion in this study has a structure in which at least seven
dimensions can be recognized. When a nurse and a patient meet each other, compassion is the instrument that
supports the professional process. The professional nursing process is, in this context, a relational process in
which nurses acknowledge loss and suffering and the emotions that go with it. Because of the fact that
patients share personal, meaningful information nurses are able to give care that is made to measure. Thus,
compassion can lead to good quality of care because individual, feasible and accurate outcomes of care are
understood. Eventually, compassion can motivate patients have courage and nurses to deliver good quality of
care.
Conflict of interest statement
The authors declare that there is no conflict of interest.
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