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Home Health Care

Management & Practice


Volume 21 Number 5

Compassionate Care
August 2009 319-324
© 2009 Sage Publications
10.1177/1084822309331468
http://hhcmp.sagepub.com
hosted at
A Concept Analysis http://online.sagepub.com

Lori Burnell, RN, MSN, NEA-BC


Scripps Mercy Hospital

Compassion may be nursing’s most precious asset, yet the concept of compassion (or compassionate care) remains notably
absent from nursing scholarship and the practicalities related to contemporary care delivery models. The provision of com-
passionate care is more than a professional mandate or an attribute of a model expressed in theoretical terms; it is the result
of an authentic bond between a nurse and a patient. A concept analysis using Walker and Avant’s methodology is employed
using compassionate care as the virtue that allows a nurse to enter into the pain, suffering, and adversities a patient experi-
ences as a way of establishing a meaningful connection.

Keywords:   compassion; compassionate care; patient connection; nursing care

A n unfortunate phenomenon of modern day life is


that human beings rarely, if ever, experience truly
compassionate care on a personal level. This trend may
anguish of another, even when that person is a stranger.
Presumably, those who possess the desire to provide
compassionate care are among those who heed the great
be in part a consequence of the media’s unbalanced call to join helping professions, including nursing. The
coverage of human suffering by its explicit, rehashing of importance of providing compassionate care is found in
events that focus on the anguish, vulnerability, and power­ nursing attributes and compassion is prominently cited
lessness of others (Höijer, 2004). Quite simply, misery as a principle of conduct guiding professional behaviors
boosts ratings. In this author’s experience, persistent and (Milton, 2003; Roach, 2007). Indeed, the first provision
repetitive exhibitions of the pain and suffering of others of the American Nurses Association’s (2001) Code of
compounded by one’s own personal tragedies result in Ethics calls for nurses to practice with compassion in a
an epidemic of emotional starvation in a society where way that respects every patient. According to the code,
abuse, neglect, willful violation of one’s conscience “the nurse, in all relationships, practices with compassion
(e.g., guilt), and chronic suffering are commonplace. and respect for the inherent dignity, worth and uniqueness
The dire need for compassionate care has reached an of every individual, unrestricted by considerations of
unprecedented level during this generation and is social or economic status, personal attributes, or the
unparalleled by any other time in history (Office of the nature of health problems” (p. 7).
Press Secretary, 2004). This condition looms large in our The purpose of this article is to provide a comprehensive
lives generally, but particularly in health care settings: analysis of the concept of compassionate care in the
acute hospitals, long-term care facilities, hospice, and context of the nurse–patient relationship and to introduce
home health care environments. Many of these patients it as an essential topic for future nursing research.
experience disaster, disease, and despair with their only Schantz (2007) supported this ideal by proclaiming
potential source of compassion being a nurse, someone compassionate care as “nursing’s most precious asset”
who barely knows them. In the midst of their fear and and expressed her grave concern that “nursing discourse
weakness, patients look to their nurse for that beam of featuring the profession’s altruistic ideals is not only
hope and compassion to guide them. scarce, but lukewarm at best” (p. 48). Literature describing
Compassionate care, according to Roach (2007), relationship-based care and compassion as a mere
requires immersion into the pain, brokenness, fear, and component of caring models has not clearly defined or
studied the influence of compassionate care and its effect
Author’s Note: Identification/names used in models are fictitious on patient care. This concept is more than a professional
and not intended to represent any specific individual/patient. mandate or attribute inherent in a care delivery model; it

319
320   Home Health Care Management & Practice

is characterized through actions that result when a nurse relieve it.” Compassion, according to this source, was
establishes a unique bond with a patient. Accordingly, “empathy, not sympathy—identification with and under­
this author will employ Walker and Avant’s (2005) standing of another’s situation, feelings, and motives”
methodology for concept analysis to explore compas­ (para. 1). A similar meaning of compassion is “the desire
sionate care as the virtue that facilitates a nurse’s full to help when a need is discovered” (God on the Net, n.d.,
appreciation of the pain, suffering, and myriad hardships para. 1).
the patient is experiencing through a means of establishing
this genuine connection (Schantz, 2007). Concept of Compassion Origin
The etymology of the word compassion, as well as
Identification of Concept Uses compassionate (i.e., showing compassion), stemmed from
the Aramaic word racham. Its translation dated back to
Concept Selection: Compassionate Care biblical times when the word meant “to love, pity, and be
Concept analysis is a process incorporating a thorough merciful” (Walker, 2007, para. 1). Von Dietze and Orb
examination of the basic elements that compose a (2000) affirmed, “The English version of compassion has
thought, idea, or notion. Walker and Avant’s (2005) been around since the 14th century, a word derived from
method for ideal concept selection is based on interest, the Latin-com (together with) and pati (to suffer), literally
work association, or something with a bothersome means to suffer with” (p. 168). Merriam-Webster’s (2007)
source. The desire for nurses to embrace the concept of definition of compassionate was the demonstration of “a
compassionate care in their practice as a means of sympathetic consciousness of others’ distress together
establishing an authentic and significant connection with with a desire to alleviate it” (para. 1).
each patient has been a heartfelt aspiration of this author, The Christian Bible urged believers to be compassionate
one formed during her 30-year nursing career. toward one another (1 Peter 3:8; New King James
Version). Despite theological differences, two other
prominent world religions shared similar views to those
Compassion/Compassionate Concept Uses of Christianity by declaring compassion as an overarching
The adjective compassionate merely means the ideal. One Muslim scholar (Engineer, n.d.) posited that
demonstration of compassion, which Wikipedia (2008a) when people were compassionate, they represented the
defined in its broadest sense as “an understanding of the true spirit of the Islamic faith demonstrated through
emotional state of another or oneself” (para. 1). Some of sensitivity to another’s needs. Representing Buddhism,
the more common uses of the terms compassion and the 14th Dalai Lama taught that being compassionate
compassionate were “a deep awareness of the sympathy “compels us to reach out to all living beings” and “true
for another’s suffering” and “the humane quality of compassion is universal in scope . . . to act altruistically,
understanding the suffering of others and wanting to do concerned only for the welfare of others, with no selfish
something about it” (WordNet, 2008, para. 1). Wikinfo or ulterior motives” (Gordon, 1998, p. 1).
(2004) described compassion as “a sense of shared suf­
fering, most often combined with a desire to alleviate or
reduce such suffering” (para. 1) and “to show special kind­ Compassionate Care
ness to those who suffer” (Wikipedia, 2008b, para. 1). Beyond the realm of nursing, other uses of the com-
Contrary to these familiar definitions of compassion passionate care concept include the following:
and compassionate is the fictional character Compassion,
also known as Laura Tobin, found in the Eighth Doctor • A benefit in the Canadian health insurance plan that
Adventures novels. Compassion, an illusory being, permits eligible workers the right to receive a tem-
originally came from a people known as Remote, a splinter porary leave of absence to provide care and support
group of the time traveling voodoo cult, Fraction Paradox for a gravely ill family member (Government of
(Wikipedia, 2008c). “Indeed, the name ‘Compassion’ was Yukon, 2008);
originally given to that iteration of Laura Tobin as an • Compassionate Care, Inc. (2005), a service that
ironic comment on her caustic personality” (para. 4). treats homebound and elderly clients as if they are
The Society of the Universal Living Christ (n.d.) cherished family members, respecting their inde-
identified compassion as “a primary law and prime pendence for as long as possible; and
virtue [demonstrated] when a person is moved by the • A Center for Compassionate Care, a project of the
suffering or distress of another and by the desire to Elizabeth Hospice Foundation, a hospice organization
Burnell / Compassionate Care   321  

operating in North San Diego County (Elizabeth Compassionate Care Defining Attributes
Hospice, 2008).
Walker and Avant (2005) defined the characteristics of
The search for a Center for Compassionate Care a concept as one that appeared repeatedly throughout
yielded numerous locations and sponsors of such named literature, helping to provide insight into the application
programs throughout the United States representing vari- of the concept. Prevalent characteristics of compassionate
ous hospices, comprehensive cancer treatment centers, care were (a) a dimension of caring, (b) sympathetic
and support programs. Additionally, the voice for compas- consciousness of another’s distress, (c) sensitivity to the
sionate care appears in facilitated panel discussions (i.e., pain and brokenness of another, (d) suffering alongside
Schwartz Center Rounds) throughout the country founded another, (e) a spiritual connection with another person,
by the Kenneth B. Schwartz shortly before he died of lung (f) attempting to comfort or alleviate the suffering, and
cancer (Kenneth B. Schwartz Center, 2008). (g) a demonstration of the fruit of the Holy Spirit, a
Schwartz Rounds include patient and caregivers biblical reference to the nine visible attributes of “love,
meeting in front of an audience to share personal joy, peace, longsuffering, gentleness, goodness, faith,
experiences and insights with the intended goal of meekness and temperance” (All About God Ministries,
improving communication and human connections. In Inc., 2008). These seven defining characteristics are
2005, Schwartz Center Rounds successfully branched pertinent to this concept analysis, as they embody the
out from the hospital setting into nursing homes (Kenneth heart of compas­sionate care.
B. Schwartz Center, 2007). The Schwartz Center also
offers a 5-month pastoral training program to clinicians Compassionate Care Case
from various disciplines in spiritual care (Kenneth B. Model Illustrations
Schwartz Center, 2004).
According to O’Brien (2003), “even if an individual A model case exemplifies the use of all the defining
has become alienated from a religious denomination or characteristics of the concept. Walker and Avant (2005)
church, a terminal illness may be the catalyst for return deemed this ideal a “pure case of the concept, a
to the practice of one’s faith” (p. 273). It makes paradigmatic example, or a pure exemplar” (p. 69). To
professional as well as human sense to prepare one’s promote further understanding of compassionate care,
mind and heart to help each patient compassionately, three ideal examples as well as two additional illustrations
address all of his or her pain, including spiritual pain. In will be presented. The model cases illustrate the defi­
the words of Taylor (2007), “when patients verbalize ning attributes of compassionate care and exemplify
spiritual distress, they invite nurses to receive their story it, whereas the borderline case includes some of the
and care for their spirit” (p. 15). defining attributes, and finally, the contrary example
Nursing literature and research of the concept of demonstrates an absence of the all-defining attributes of
spiritual and compassionate care could be both broad the concept of compas­sionate care. With the exception of
in scope and narrow in actual practice. Some sources the global model case, the names of the patients and
offered a global approach designed to reshape the caregivers in the remaining three examples were changed
nursing profession, whereas others provided a model along with potential identifying specifics to respect
advocating for a single, effective interaction between a confidentiality.
patient and a nurse. In both models, compassionate care
was the predominate theme. Crigger, Brannigan, and
Global Model Case
Baird (2006) believed “nurses as compassionate profes­
sionals are called to collaborate with people of all nations In an interview, Mother Teresa recalled her first
to seek a better future for all” (p. 23). patient experience when she cared for a single companion
Christian nursing scholars believed the delivery of in a borrowed apartment. After completing a course in
compassionate care was a nurse’s primary ministry, nursing, she went out, picked up a dying man at the edge
requiring a focus on “the whole person, in response to of a road, and brought him into her home where she
God’s grace toward a sinful world, which aims to foster single-handedly nursed him back to health. Her mission
optimum health and bring comfort in suffering and death field was the slums where she rescued elderly individuals
for anyone in need” (Shelly & Fish, 1988, p. 225). Others dying in gutters, abandoned babies discarded in garbage
viewed the impetus to providing compassionate care as a pails, and lepers rejected by both their families and
calling from God (O’Brien, 2001, 2003; Uustal, 2003). society (McGowan, 1997).
322   Home Health Care Management & Practice

First Model Nursing Case was caring for Mrs. Johnston, a patient in her early 70s
with left-sided hemiplegia. In an unexpected moment
Rosemary’s death rapidly approached as the cancer
after she provided the care as she was assigned, Mr.
metastasized throughout her body. After finishing a
Johnston told the nurse that his wife had an inoperative
hectic 13-hr shift, her nurse friend, Karen, rushed across
brain tumor. When the student saw tears well up in Mr.
the street to the Hospice Compassionate Care Center to
Johnston’s eyes, her heart began to ache. The student
visit her. Karen found Rosemary grimacing in bed
reported that she felt a tug on her heartstrings to comfort
because of a kink in her morphine line. Karen quickly
Mr. Johnston and to pray with him. Intimidated by the
and expertly reopened the intravenous line, repositioned
intensity of this situation, she instead walked away from
Rosemary, and picked up a book lying open at the
it. Three years passed and she still regrets not obeying
bedside. It was a Bible. Rosemary grabbed Karen’s hand
her inner-voice.
and held on for dear life. “Would you mind reading to
This is a borderline case of compassionate care, as
me?” Karen had a few minutes, so she began reading
three of the defining characteristics were missing:
where the pages were open.
connecting with the patient, attempting to comfort the
These two had first met in the Oncology Unit where
patient, and heeding to a call of the student’s heart.
Karen managed Rosemary’s chemotherapy after her first
surgery. Reflecting back on the past 3 months, tears
rolled down Karen’s cheeks as she contemplated the Contrary Case
future of Rosemary’s boys, who were the same age as Mr. Webster was a crotchety old man. Two weeks had
her own two sons. She made a mental note to contact gone by and a different nurse had been assigned to care
family bereavement follow-up services the next day to for him every shift. One night he was particularly
seek consultation on how best to approach Rosemary’s demanding, shouting obscenities and frequently
husband about the importance of accepting this support summoning help by using his call bell. Frustrated, during
to help each family member manage his or her grief and one of his many trips to Mr. Webster’s room, Jim moved
to participate in annual celebrations of Rosemary’s life. the call bell far from Mr. Webster’s reach and shut the
door on his way out. Upon returning to the central
Second Model Nursing Case nursing station, Jim boasted to his colleagues, “Good
news! I took care of everything and the geezer in 203
Tommy was confused and he gave off an unpleasant
won’t be bothering us for awhile!”
odor. It was another busy morning of being short staffed
in the skilled nursing facility, and even though Sarah was
in charge, she knew the staff could not handle assuming Identification of Antecedents and
care for another patient. Therefore, Sarah engaged in the Consequences
extensive routine of admitting the patient to his new
surroundings. Glancing up from her clipboard, she Antecedents
noticed Tommy’s head hung in what appeared like
shame. In response to her kind and gentle inquiry, Walker and Avant (2005) posited that “antecedents are
Tommy finally mumbled, “I think I made a mess in my those events or incidents that must occur prior to the
pants.” As was her nature, Sarah decided to postpone all occurrence of the concept” (p. 73). Schantz (2007)
the routine tasks to be done and instead patiently bathed succinctly described the primary antecedent of compas­
Tommy. While Sarah was tenderly washing his neglected sionate care in her concept analysis: “for compassion to be
body, Tommy recognized the hymn she was humming realized, suffering must be identified and acknowledged”
and started singing along with her. Before clocking out (p. 82). According to the Dalai Lama, compassion came
at the end of the shift, Sarah returned to Tommy’s room through morning meditation, dwelling on it throughout the
to say good-bye. It warmed her heart to see him sitting day, and reflecting on it in the evening (Barbauta, 2007).
upright in a chair and smiling as he thanked her for A Christian commentator identified the precursor to
“being his special angel.” compassion simply as “willingness to leave one’s comfort
zone” (Bloom, 2002, para. 13).
Borderline Case
Consequences
A novice nurse reflected back on an impressionable
experience that took place at one of the first patient Conversely, Walker and Avant (2005) defined a con­
residences she visited as a home health practitioner. She sequence resulting from a concept. Selected outcomes of
Burnell / Compassionate Care   323  

compassionate care were a decrease in suffering and an Conclusion


increase in strength that others (e.g., patients) drew on
for healing (Golberg, 1998). However, it is this author’s “As a human being, many a nurse will say that it was
belief that a primary result of compassionate care, in the compassion for others that inspired her to become a
context of this analysis, is its ability to bridge the human nurse” (Schantz, 2007, p. 54). To fully appreciate and
gap created through suffering. further expound on the ideals that drew nurses into the
profession, compassionate care must be defined through
Definition of Empirical Referents research encompassing lived patient experiences. Once
this is accomplished, praxis for compassionate care can
“Empirical referents are categories of an actual be embedded into the role of a professional nurse.
phenomenon that, when present, actually demonstrate
the occurrence of a concept itself” (Walker & Avant, References
2005, p. 73). Walker and Avant (2005) avowed that
empirical referents could interchange with the defining All About God Ministries, Inc. (2008). Fruit of the spirit: True
Christian living. Retrieved April 24, 2008, from http://www
attributes of a concept. For this analysis, the defining
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attributes and empirical referents of a caring presence, American Nurses Association. (2001). Code of ethics for nurses with
including the ability to recognize distress and be sensitive interpretive statements. Washington, DC: Author.
to another’s suffering, sharing the suffering experience, Barbauta, L. (2007). A guide to cultivating compassion in your life,
connecting spiritually, providing comfort measures, with 7 practices. Retrieved April 27, 2008, from http://zenhabits.
and demonstrating the qualities of the Holy Spirit are net/2007/06/a-guide-to-cultivating-compassion-in-your-life-with-
7-practices/
proposed as one in the same. These seven attributes, if Bloom, P. (2002). Judgment of the gentiles: Homily for Christ the
mentioned by patients interviewed after receiving treat­ King, Year A. Retrieved April 27, 2008, from http://www.geocities
ment in a setting that practiced compassionate care, would .com/Heartland/2964/ChristKing.html
confirm the experience. Without descriptive accounts Compassionate Care, Inc. (2005). About us: Our mission at
derived from the lens of patients, the concept of compas­ Compassionate Care. Retrieved April 23, 2008, from http://www
.compassionatecareofmn.com/about.htm
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Crigger, N. J., Brannigan, M., & Baird, M. (2006). Compassionate
nursing professional as good citizens of the world. Advances in
Nursing Science, 29(1), 15-26.
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324   Home Health Care Management & Practice

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Lori Burnell is vice president/chief nurse executive of Scripps
Society of the Universal Living Christ. (n.d.). Compassion. Glossary.
Retrieved April 21, 2008, from http://miriams-well.org/Glossary/
Mercy Hospital. In addition, Lori is working on her PhD in
index.html#C Nursing at the University of San Diego. Her research interests
Taylor, E. J. (2007, October 1). Spiritual pain: When patients verbalize focus on compassionate care, defining and recognizing nurs-
spiritual distress, they invite the nurse to receive their story and ing’s role towards connecting with patients on an individual
care for their spirit. Advance for Nursing, pp. 15-18. basis. While caring behavior has been researched extensively,
Uustal, D. B. (2003). The ethics of care: A Christian perspective. true compassion for patients has not been well articulated in
Journal of Christian Nursing, 20(4), 13-17. nursing praxis.