care and compassion in nursing essay

12 Ways to Show Compassion in Nursing (With Examples)

It is not uncommon to face difficult, often heartbreaking, situations as a nurse. Knowing what to say or how to respond is not always easy. Even the most experienced nurses can struggle at times. What happens when you don't know what to say to a patient or how to act when a loved one is given bad news? How can nurses show compassion in nursing practice while still maintaining composure and professionalism? Is that even possible? The good news is even though some days are easier than others, it is possible to learn ways to be more compassionate as a nurse. In this article, I will share why compassion in nursing is essential and offer 12 ways to show compassion in nursing practice.

What Does Compassion in Nursing Practice Exactly Mean?

Why is compassion important in nursing practice, 1. patients are more comfortable., 2. compassionate nursing practices improve patient outcomes., 3. compassion in nursing practice extends beyond patient care, affecting interprofessional relationships., 4. compassionate nursing helps strengthen nurse-patient relationships., 6 key skills a nurse must-have for delivering compassionate care, 1. resilience:, 2. excellent communication:, 3. emotional intelligence:, 4. confidence:, 5. cultural awareness:, 6. critical thinking:, how can nurses show compassion in nursing practice, 1. listen to what your patients and their loved ones say (and what they do not say)., for example:, 2. show genuine interest., 3. learn to express empathy when appropriate., 4. acknowledge your patient’s feelings., 5. be patient., 6. respect your patient’s need for privacy., 7. take the time to explain treatment plans and answer questions., 8. get to know your patients., 9. be present., 10. be aware of moments that require high levels of compassion., 11. even if you can’t empathize with your patient, you can sympathize., 12. take care of yourself., what causes compassion fatigue in nursing practice, 5 tips to prevent compassion fatigue in nursing practice, 1. set emotional boundaries., 2. practice self-awareness., 3. establish a healthy work-life balance., 4. implement active coping mechanisms., 5. develop a support system., useful resources to develop compassion in nursing practice, youtube videos, my final thoughts.

Compassionate Nursing Care and Its Perception Essay

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The idea of compassion is essential to nursing practice, and it is regarded as the cornerstone of the industry’s ethical standards. In their daily work, nurses everywhere deal with moral dilemmas involving compassion. As a result, the concept can be seen as an integral part of nursing. However, because of its complicated and abstract character, research is required to examine the meaning of compassionate nursing care and how it might be attained.

The study of compassionate care has benefited from the efforts of certain researchers. In particular, a recent study by Tehranineshat et al. (2018) sought to define compassionate nursing care based on patients’ and healthcare providers’ experiences. Its research questions were “What are the experiences of nurses, patients, and family caregivers about compassionate nursing care?” and “How do nurses, patients, and family caregivers describe compassionate nursing care?” (Tehranineshat et al., 2018, p. 1708). Answering these questions would help the authors better understand the nature of compassionate care and the attitudes of nursing professionals.

The subject of the study entailed a complex approach by the authors. A qualitative exploratory study was conducted using data collected from in-depth and semi-structured interviews, focus group interviews, and field notes from 34 participants selected from several educational hospitals in an Iranian urban area (Tehranineshat et al., 2018). Three themes were identified from the study of the data using the traditional content analysis method: “effective engagement”, “professionalism”, and “continuous comprehensive care” (Tehranineshat et al., 2018, p. 1712). Based on the analysis of the themes, the authors attempted to answer the initial research questions and discern the nature of compassionate care.

The study’s findings indicate that providing patients and family caregivers with compassionate nursing care requires efficient communication in order to fully comprehend their requirements. According to the categories found, sustaining professional ethics standards, clinical competency, professionalism, and continuity of treatment are also essential components of compassionate care (Tehranineshat et al., 2018). The findings that emerged from this study are consistent with recent nursing literature that emphasizes the value of holistic care.

In conclusion, nurses should make a conscious effort to provide their patients with holistic care that incorporates good communication, professionalism, and continuity of care. Nurses can offer improved compassionate care and enhance patient outcomes and satisfaction by being aware of the needs of patients and their families. For this reason, it is essential that nurses intentionally focus on providing compassionate care.

Tehranineshat, B., Rakhshan, M., Torabizadeh, C., & Fararouei, M. (2018). Nurses’, patients’, and family caregivers’ perceptions of compassionate nursing care . Nursing Ethics , 26 (6), 1707–1720. Web.

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• Katherine Curtis
• University of Surrey, School of Health Sciences , Surrey , UK
• Correspondence to : Dr Katherine Curtis, University of Surrey, School of Health Sciences, DK Building Guildford, Surrey GU2 7TE, UK; k.curtis{at}surrey.ac.uk

https://doi.org/10.1136/eb-2014-102025

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• ETHICS (see Medical Ethics)
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Commentary on : Bramley L , Matiti M . How does it really feel to be in my shoes? Patients’ experiences of compassion within nursing care and their perceptions of developing compassionate nurses . J Clin Nurs 2014 ; 23 : 2790 – 9 . OpenUrl CrossRef PubMed

Implications for practice and research

Patients’ experiences of compassion and lack of compassion contribute to current understanding of complexity within compassionate nursing practice.

Patients believe that nurses can develop compassionate practice through exposure to vignettes of their experiences.

Further research on patient experiences could help identify how to enable ‘fleeting acts’ that convey compassion.

Compassion is not a new concept within healthcare . 1 However, compassion has become the focus of much research and debate during the past 10 years, following reports of lack of compassion within UK healthcare practice. This recent intense focus has addressed many aspects of care practices and education, recognising that compassion is a complex concept. 2 This study adds a further dimension to understand the complexity of compassion, through a focus on patients’ perceptions.

Three main themes were found within the data: (1) patients saw compassion as based on acts that demonstrated human relationships ‘knowing me and giving me your time’; (2) patients believed the impact of compassion was a sense of empathising with their situation or ‘being in their shoes’; (3) compassion was the essence of nursing and required communication alongside inherent values-based care.

The study provides a further contribution to understand compassion within healthcare practice through the patient's experience and to promot and develop compassionate nursing.

During the past 10 years, reports of poor standards of care and outright cruelty have frequently been in the press and quite rightly have caused outrage within and outside healthcare professions. Compassion has been the focus of numerous recent research studies that have led to debates on how best to promote compassion within healthcare and health professional education. Some commentators reflect longingly back to several decades ago when healthcare systems supported a different and more limited scope of practice for nursing and where organisations supported higher levels of qualified staff to patient acuity. They suggest that nursing should go back to its ‘old ways’. They also suggest individual or society morality and the changes in nurse education are responsible for deficits in compassion today. However, identifying and correcting the ‘fault’ in the system is not as simple as some suggest. Time cannot be turned back and why would society want to when some of those ‘old ways’ included: parents kept away from their hospitalised children; people with mental health problems being shut way in institutions and restrained; far less sophisticated and less effective surgical and medical treatments for trauma and disease.

This study reaffirms compassion within 21st century healthcare as a complex concept. It has multiple predisposing and constraining factors within today's practice and education environments. 3 Compassionate practice does not simply rely on an individual demonstrating empathy and kindness but on the moral, emotional and organisational environment within which that individual learns their caring craft. 4 , 5 Attempts to identify and address deficits in compassion require recognition of this complexity in order to avoid over-simplified or single focused solutions. Dr Jocelyn Cornwell explained this clearly at the Kings Fund ‘One year on from Francis’ event, suggesting how UK healthcare systems, within which compassion is an expectation, are perfectly designed to produce the results they currently get. 6 It is therefore important to consider the findings from this study within a whole system approach to improving compassionate healthcare provision.

• Leninger MM

Competing interests None.

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Developing and maintaining compassionate care in nursing, amanda henderson nursing director, princess alexandra hospital, metro south health, queensland, australia, jenny jones ethicist, princess alexandra hospital, metro south health, queensland, australia.

Compassionate care is a fundamental aspect of nursing, and is an important value that is embedded in nurses’ professional standards and codes of practice. However, nurses may experience several challenges in their practice that can impede their ability to provide compassionate care. This article aims to support and guide nurses in developing their capacity to be compassionate. It explores concepts related to compassion, including compassion satisfaction, fatigue, literacy and self-compassion, and outlines strategies that nurses can implement to promote compassionate care. This article encourages nurses to identify their personal and professional values, to understand how these can influence their attitudes and behaviours. By raising awareness of these concepts, as well as the challenges and changing nature of compassion, it is hoped that nurses’ capacity to provide compassionate care will be enhanced.

Nursing Standard . 32, 4, 60-69. doi: 10.7748/ns.2017.e10895

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This article has been subject to external double-blind peer review and checked for plagiarism using automated software

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Received: 12 May 2017

Accepted: 26 July 2017

compassion - compassion fatigue - compassion satisfaction - compassionate care - person-centred care - self-compassion

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"nurse: just another word to describe a person strong enough to tolerate anything and soft enough to understand anyone.", empathy and compassionate care essay by: olivia gagne, december 4, 2019 ogagne.

One important thing I have learned in clinical is that I have the power to make a difference in patients lives, one patient at a time.  To do so, a nurse must remember to not only use empathy, but compassion as well.  One story that I always remember is the star fish story.  It’s about a five year old girl on a beach in Florida after a hurricane had destroyed their land.  There were thousands of star fish washed up on the shore.  The little girl was throwing starfish back into the ocean, one starfish at a time.  When her father saw her, he said “why are you even bothering?  You will never be able to save them all”.  As the little girl looked at her father, she picked one up and threw it back into the ocean.  She then said, “I saved that one”.  This is a story my high school guidance councilor told me.  It has always stuck with me and has made me realize one important lesson in nursing.  It’s not about how many lives you saved, its about making a difference one person at a time.

From the hallway of the hospital I heard my patient moaning.  When I walked in for the first time, they reached for my hand but spoke no words.  They squeezed my hand, very tight, and immediately calmed down.  As I introduced myself, they intimately looked at me and moaned “hi”.  At that moment I realized a few things.  They could hear and understand me, but they cannot talk due to the accident the patient was in.  Secondly, they needed human touch.  No student nurse had taken care of this patient prior to when I had arrived that day.  The nurses said the patient has been agitated and emotional since the morning.  But as I held the patients’ hand, they were relaxed and showed their half dropping smile.

Throughout my clinical I took care of this patient.  In the beginning, I immediately had empathy.  I put myself in the patients’ shoes and started to picture how scared I would be if I was waking up from a coma.  I pictured what it would feel like if I couldn’t talk or communicate the way I wanted to.  But during this time, I learned that communication isn’t always through speaking, but can also be from hand squeezing for yes, or shaking their head for no.  I could tell they were scared when they moaned after trying to speak to their PT instructor.  Later in the night, it was time to give the patient a bed bath.  After washing my patients’ body with a warm wet cloth, I asked the patient if they wanted lotion and a foot massage.  Immediately they squeezed my hand for yes.  When we massaged my patients’ feet, once again, their whole body relaxed.  At the end of the night, I realized that it’s important to focus on the small things for each individual patient.  Although some wouldn’t know how to comfort this patient, I slowly figured it out over my seven-hour clinical.  You need to have patience, and to focus on going above and beyond to make your patient feel cared for.  As a good nurse, you need to use compassionate care, and focus on the small actions throughout your shift.  During this shift I started to realize what compassionate care was.  It’s not about going into the patients; room, taking their vitals and leaving.  It’s about using empathy to feel what they feel and putting to action what you think would make them feel better; such as a foot massage with lotion and holding their hand when they reach out.

            As a future nurse, in order to use empathy and compassion in my future practice, it’s important to understand what they mean and how they intertwine with nursing.  Empathy is being able to feel what the patient is going through while putting yourself in their shoes.  How would you feel if this was you?  It’s important for nurses to use empathy.  By putting ourselves in the patients’ shoes, we are only then able to further understand what they are feeling, and what they are going through.  Jean Watson, a nurse herself, put together ten carative factors that help to support empathy in nursing.  She stated that it’s important to “create a healing environment for the physical and spiritual self, while respecting human dignity” (Watson, 2018).  While respecting the patient and creating an environment of healing, this encompasses empathy in nursing.  By trying to understand how they feel and what they are going through, the nurse then can move on to compassionate nursing.

Compassionate nursing is using kindness, empathy, and love to ultimately care for the patient.  It’s being able to focus on the patients’ needs and to help relieve their suffering.  Jean Watson’s carative factor one focuses on “the formation of a humanistic-altruistic system of values” (Gonzalo, 2019).  This refers to using love and kindness in your care of practice.  For example, this could be as simple as holding your patients’ hand while they are crying.  It’s holding back their hair while they throw up and giving them an ice pack when the medications haven’t relieved their pain.  Compassionate care is going above and beyond what one needs to do.  It’s not only providing physical healing, but as said in carative factor eight, it’s the “provision of support, and corrective mental, physical, societal, and spiritual” help for the patient (Gonzalo, 2019). 

A nurse who demonstrates compassionate care is able to “understand a deeper meaning of (the patients) healthcare situation”, as demonstrated throughout Jeans ten carative factors (Watson, 2018).  Both empathy and compassion are found throughout Jean Watsons Carative factors.  By using both, it truly changes the patients’ outcomes.  Carative factor four states the importance of the “development of a helping-trusting, human caring relation” (Gonzalo, 2019).  Therefore, by using empathy and compassion, the patient trusts the nurse more, and builds a stronger foundation of hope, care, and love between both the nurse and the patient.  This increases patient healing far past only physical healing, and truly benefits the clients outcomes.  Both compassionate care and empathy help to demonstrate the amazing power of a compassionate nurse in healing the patient not only physically, but mentally.

My role for the patient talked about above was wanting to help them feel loved and cared for.  By holding their hand when they reached out, and focusing on the small things the patient needs,  I was able to build a stronger patient nurse relationship.  I also met the patients’ spouse multiple times, and learned more about what they patient did before the accident.  In my future, I want to remember this patients impact on me, and my impact on the patient.  The patient made me realize that they aren’t only patients.  They are a mother, father, aunt, uncle, daughter, cousin, and friend.  They might be a couch, teacher, firefighter, singer, gymnast, or swimmer.  In my future, I want to improve in remembering that each patient has a different identity than what the nurse knows them as.  They are more than just a patient.  They are human.  They need touch just like we need touch, they need love and kindness, and ultimately they need understanding and care. 

In my future I will have more patients, more documentation, and more priorities.  But I need to remember this one special thing I have learned.  In my future, I want to remember why I joined nursing.  This includes something I learned from the starfish story.  It truly does not matter the amount of patients you helped compared to how many your co-worker helped.  It comes back to providing compassionate care for one patient at a time and being the best nurse you can be for that individual patient.  This includes helping people heal not only physically, but socially, emotionally, and mentally.  My goal is to improve on focusing on each patient for who they are and helping to provide the patient with what they need.  I will incorporate this into my everyday life as a future nurse by coming back to the core of nursing.  This includes being kind, loving, caring and compassionate.  By remembering a nurses’ core values, I will be able to focus on the little things every day to make a small difference one patient at a time.

Gonzalo, A. (2019, September 12). Jean Watson: Theory of Human Caring. Retrieved November 12,

2019, from https://nurseslabs.com/jean-watsons-philosophy-theory-transpersonal-caring/ .

Watson, J. (2018, October 7). Jean Watson Theorist Presentation. Retrieved November 12, 2019, from https://www.youtube.com/watch?time_continue=313&v=o1EN0VH9xCE&feature=emb_logo

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• Debate article
• Open access
• Published: 11 July 2016

Reflections about experiences of compassionate care from award winning undergraduate nurses – What, so what … now what?

• Stephen Smith 1 ,
• Asha James 3 ,
• Allison Brogan 2 ,
• Elizabeth Adamson 1 &
• Mandy Gentleman 1  

Journal of Compassionate Health Care volume  3 , Article number:  6 ( 2016 ) Cite this article

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From 2007 until 2012 Edinburgh Napier University’s School of Nursing Midwifery and Social Care in conjunction with NHS Lothian, collaborated on a programme of action research entitled, the Leadership in Compassionate Care Programme. One strand of this research focused on learning and teaching about compassionate care within the undergraduate curriculum. This debate article focuses on the care issues raised by two award winning nursing students who reflected on the development of their compassionate caring skills during their three year Bachelor of Nursing programme.

The reflective accounts debate the following issues related to compassionate care; Personal drivers supporting the provision of compassionate care, Challenging and influencing care practices, Providing relationship centred care and, Living with what can’t be achieved. Throughout the debate a model of compassionate care developed from the Leadership in Compassionate Care Programme is used to reflect on key practice issues and provide a framework for practice development.

The care issues presented in this paper identify a need to support students in healthcare to; Develop strategies in questioning care practices which do not meet expectations of compassionate care; undertake focussed reflective activities where each student can explore personal drivers, values and perspectives of compassion; actively connect learning in practice with theory in university, enable development in compassionate caring and strategies that support self-compassion; facilitate an understanding and development of emotional intelligence supporting development of resilience.

Implications for healthcare staff are to; Collectively seek, hear and respond to feedback about their service; activate caring conversations within the healthcare team; consider how the model of compassionate care presented in this paper, can be used to reflect on practice and provide a framework for development; consider how we maximise the experience of care during brief moments of contact with patients/families; activate leadership that promotes a culture of openness facilitating the development of compassionate care.

From 2007 until 2012 Edinburgh Napier University’s School of Nursing Midwifery and Social Care in conjunction with NHS Lothian, collaborated on a programme entitled, the Leadership in Compassionate Care Programme (LCCP) [ 1 ]. NHS Lothian provides a comprehensive range of primary, community-based and acute hospital services for the second largest residential population in Scotland - circa 800,000 people, it employs approximately 24,000 staff. The School of Nursing, Midwifery and Social Care at Edinburgh Napier University provides undergraduate and post graduate education to nurses, midwives and multidisciplinary staff involved in health and social care. There are approximately 1600 students in the school.

The LCCP utilised an action research approach with the aim of embedding compassionate care in NHS healthcare practice and within undergraduate nursing and midwifery education. The LCCP encompassed four key strands of work: developing compassionate clinical practice; supporting newly qualified practitioners; leadership development and undergraduate nurse education. This action research programme was funded by a private benefactor. A key outcome of this action research identified a model for compassionate care in practice which incorporates six components, see Fig.  1 . This model relates to activities undertaken between care providers, service users and their families/important others, for example caring conversations should take place between care providers as well as between staff and service users. Debating, challenging and celebrating care provision is an important activity to be undertaken amongst staff. The LCCP action research identified that this was a key activity if compassionate care is to flourish in a care setting. Throughout this article reference will be made to this model and how the reflections presented highlight its key components.

Model for compassionate care in practice [ 14 ]

This debate article focuses on the care issues raised by two nursing students (adult field) who reflected on development of compassionate caring skills during their three year Bachelor of Nursing programme. These reflections were written as part of their successful submission for the Simon Pullin award. The Simon Pullin award is given to students who have shown excellence in the development of person centred, compassionate caring skills during their programmes of study. The award is dedicated to the memory of Simon Pullin, who was a Senior Nurse on the Leadership in Compassionate Care Programme from its commencement in December 2007 until his death in July 2011. This award highlights the fundamental importance of compassionate care as part of contemporary Nursing and Midwifery practice. The award winners Alison Brogan and Asha James have contributed their reflections and analysis of compassionate care in the planning and writing of this paper and they have agreed to be identified within this writing. The key issues related to the provision of compassionate nursing care debated in this article are as follows:

Personal drivers supporting the provision of compassionate care

Challenging and influencing care practices, providing relationship centred care, living with what can’t be achieved.

This article incorporates the What, So what and Now what [ 2 ] reflective model as a way of reflecting on experiences of compassionate care.

Borton’s model asks individual’s to consider three questions: “What?”, “So what?” and “Now what?” The first question asks a person to consider what has happened, the second question is to allow the person to try and make sense of what has happened and evaluate events and the last question is to consider a way forward and think about what could happen in the future [ 3 ].

The LCCP identified that discussions about care ‘caring conversations’ and working with feedback are key activities enabling compassionate care to thrive. The use of a reflective model acts as a as a springboard supporting such discussions in practice (Table  1 ).

‘I was a child carer from a very young age for my mum, who suffered with alcohol dependency. Life was far from easy, but I always understood that my mum did not choose to live like this and what she had was an illness. However it appeared that many healthcare professionals did not share this understanding and their lack of compassion, respect and dignity often left my mum feeling judged, embarrassed and worthless. This caused a lot of distress for my mum and for the family. This was the beginning of my dream of becoming a nurse… if I was a nurse I would be kind to my patients and care for everyone the way I would have liked my mum to be cared for…. The negative attitudes we experienced as a family by healthcare professionals have enforced my passion for person centred, compassionate care.’ Asha

It is evident from this reflection that past negative experiences of healthcare had provided a strong personal driver to enter the nursing profession but moreover to develop a future focus on care that is compassionate and directed towards the person, their needs and their context. The negative elements of this account point to feelings of injustice, frustration and are a consequence of care experiences resulting in emotional distress for a vulnerable person and their family. It is indeed commendable on a personal level that despite these significant negative experiences this generated a desire for Asha to become a nurse and ultimately lead to successful completion of a nursing degree and recognition of excellence in the development of her compassionate caring skills.

This reflection triggers questions about how health and social care educators can support students to learn from their life experiences and consider their individual values and how this may support developments of caring and compassionate attributes in practice. In Asha’s reflective account, development in compassionate caring arose from her previous negative experiences of healthcare and this appears to have been integral to her approach to care and her values. It is necessary to support each student within their own context and personal experience. When considering Asha’s experience of caring for her mother, the complexity of this situation and the impact on Asha’s own health and wellbeing are key factors to consider.

‘ Like many children in my situation, I was exposed to domestic violence and parental mental health illness, as a result my functioning was adversely affected. School in general was a struggle and I left with practically no qualifications. I had no confidence and low self-esteem. When I was twenty four, my mum died, she had Cirrhosis of the liver. This was a devastating time for myself and my family. I went to counselling and gradually started to turn my life around. It’s taken many years and with the support of my husband, who has always believed in me, I started college to gain the qualifications I needed to get me into nursing. I could not ask for more. I am confident and happy in what I am doing today.’ Asha

It is clear from this candid reflection that considerable work and energy from Asha herself, her family and professionals have enabled a sense of wellbeing and healing to emerge. This in turn enables her to practice with emotional intelligence and to raise a challenge with colleagues when care standards are not achieved. It is critical to consider how colleagues, teams and organisations support this maintenance of functioning over time.

Questions are therefore raised as to how we support learners who have less clear articulation of past experiences of care, their personal values and where this leads in the development of caring skills. Indeed how does this issue play out for learners who have directly experienced abuse or life contexts where experiences of compassion would be deemed less than positive? There appears something fundamentally crucial about mirroring a compassionate, person centred learning experience for our students whilst we encourage them to explore their values and approach to care. This in turn raises questions about academic staff modelling attributes of care and compassion within their professional practice.

As we have discussed when students embark on their programme of study they bring with them their own life experience, values and beliefs, and some of these will be challenged as they experience healthcare practice. One way that students can be encouraged to reflect on the experiences of those who give and receive care is through listening to and reflecting on stories gathered within clinical practice and relating this to their own experiences of giving care ([ 4 – 6 , 1 ]). Nursing students often make reference to their own personal care encounters, episodes that have been deemed less than compassionate can present a strong driver for student nurses to achieve more positive experiences for others. Teasing out learning from stories provides a student centred approach to considering issues of care and compassion. What do I make of the care experience? What would I have done in this situation and why would I respond in this way? What possibilities of compassionate caring are evident in this story/context? Reviewing stories in a group learning context facilitates the student to further explore varied perceptions and approaches to care and compassion. This form of group learning requires careful facilitation enabling students to safely question practice and approaches to care, then consider possibilities for their future practice.

The intertwining of practice learning experiences with the students’ life experiences and values provides a potentially provocative opportunity for development. There are some thorny practical issues here that require deliberation if we are to maximise this practice learning. How do we support students and mentors to capture these learning stories from practice and how do we integrate these within theoretical learning about compassionate care within the university context? If personal stories and narratives are a key component of learning about compassionate care we need to activate the integration of this learning between theory and practice.

Caring is fundamental to nursing and therefore must be an integral part of nurse education. Concerns about poor care and lack of compassion are frequently reported in the media, those responsible for nurse education are acutely aware of this as they develop curricula and focus on preparing students for the profession. Whether compassionate care can actually be taught has been debated [ 7 ]. McLean [ 8 ] makes a case for a values based curriculum that encourages self-awareness through a values based enquiry model which encourages the student to challenge existing beliefs and values and develop the character they require to be providers of care and compassion. Nurse Educators can teach the theory of compassionate care but application in practice can be challenging as demonstrated in the reflective accounts in this paper. Curtis [ 9 ] found that student nurses wanted to provide compassionate care but felt unsure of their capacity to do this and sustain it in practice. Others suggest that students’ ideals of care, though already present as a strong motivator when they commence their studies, increased as they grew in knowledge and competence [ 10 ]. They also found that when students experience moral distress when these ideals are challenged through witnessing poor care, these ideals are upheld. These emotionally challenging situations can however become a vehicle for personal and professional growth when students find the courage to uphold their ideals and increase their ability to provide care that is more compassionate [ 10 ].

While nurses are focused on caring for others, it has been argued that practitioners require to be compassionate with themselves [ 11 ], and this is associated with the development of emotional intelligence [ 12 ]. The emotionally intelligent nurse is said to be one” that can work in harmony with thoughts and feelings” ([ 13 ], p. 94) therefore is able to respond to both when working directly with patients and their families. This form of emotional intelligence provides the potential of understanding and connecting with those being cared for whilst recognising and responding to personal strengths and vulnerabilities. Research evidence suggest a connection between emotional intelligence and cultural intelligence (Moon, [ 14 ]) and this is evident in the reflections of care shared by Asha and Allison. Cultural intelligence relates a person’s capacity to function successfully in culturally diverse situations (Ang, Dyne & Koh [ 15 ]). In the account of a clinical placement experience overseas, Asha expressed astonishment and concern at the discriminatory custom and practice she encountered. The cultural approach to care for indigenous people was in direct conflict with her ideals of compassionate person centred care and she felt unable to act in the way directed. Instead she engaged in building a trusting relationship with the family and was rewarded with expressions of gratitude. Not only did it take courage as a student to challenge the practice of a registered nurse but particular resolve and determination to do this in a different culture. By demonstrating how a person centred accepting approach could be not only successful but welcome by a patient and their family she challenged her colleague.

Whether compassionate care can actually be taught has been debated [ 7 ]. McLean [ 8 ] makes a case for a values based curriculum that encourages self-awareness through a values based enquiry model which encourages the student to challenge existing beliefs and values and develop the character they require to be providers of care and compassion.

In addition it has been argued that unless a healthcare practitioner is compassionate to themselves they cannot provide compassionate care for others [ 11 ], and this is associated with the development of emotional intelligence [ 12 ]. The emotionally intelligent nurse is said to be one” that can work in harmony with thoughts and feelings” ([ 13 ], p. 94) therefore is able to respond to both when working directly with patients and their families. This form of emotional intelligence provides the potential of understanding and connecting with those being cared for whilst recognising and responding to personal strengths and vulnerabilities. Research evidence suggest a connection between emotional intelligence and cultural intelligence (Moon, [ 14 ]) and this is evident in the reflections of care shared by these students.

Considering the model of compassionate care identified by the LCCP [ 1 ] it would seem appropriate that Caring conversations and Feedback would be critical components of the model to concentrate on. Observing and participating in caring conversations in practice will provide opportunities to hear debates and have discussions about how to care, and develop understanding of the real dilemmas of care. In addition receiving feedback about their own caring and compassionate skills from practice mentors will complement the potential for students to develop caring skills and reflexive practice. All of these activities will provide opportunities to both challenge and construct learning based on their own drivers and values.

Both of our students incorporated the issue of challenging and influencing compassionate care practices within their reflective accounts. They took different approaches to influence staff. It is recognised that for students and NHS staff raising concerns about practice with mentors and practice staff can be a daunting experience [ 16 ].

‘Encouragingly I recognised that as a third year student I was starting to feel confident in being able to influence colleagues. Whilst in the community setting I cared for a patient who could be rude and verbally aggressive. He was abrupt with me during my first solo visit and referred to me as student. He had COPD and leg wounds, he was very particular about everything and was quite obsessive. I realised that this man had little control over anything in his life and I suspected this is what drove his behaviour. By my third visit I had worked out exactly how he liked things done and instead of letting him get anxious and out of breath telling me what to do, I gently took control of the situation. I did things in the order he liked….. this didn’t take any more time – in fact it saved time. By the end of my fourth visit he asked my name. I was able to relay this during handover with my community colleagues and I explained that I thought his behaviour had been driven by fear and loss of control. With this understanding and consideration of what was driving his aggressive behaviour his relationships with the nursing team improved significantly. He seemed more content during nursing visits and so did some of the nursing staff.’ Allison

This reflective account highlights a particular approach to a challenging caring situation, namely approaching it with eyes wide open, thinking what is happening here and what could my contribution be? It is evident behaviours were observed with a view to understanding them and importantly considering how this guided practice. It is evident that emotional intelligence was key in considering and moderating practice behaviour in this context. ‘ Theoretical and editorial literature confirms emotional intelligence concepts are central to nursing practice. Emotional intelligence needs to be explicit within nursing education as emotional intelligence might impact the quality of student learning, ethical decision-making, critical thinking, evidence and knowledge use in practice’ [ 17 ]. The challenge to her community colleagues was to adapt their practice in the light of an enhanced understanding of the person’s situation. Talking about this openly with colleagues as part of a formal forum facilitated an enhanced change of communication style and active recognition of the reasons behind the patient’s irritable behaviour. In turn this gave an opportunity to consider action/practices which would enhance the care experience for both the patient and the nursing staff? Smith et al [ 18 ] highlighted the importance of reflective forums when considering an understanding of compassionate care in the workplace, findings from this action research identified three key themes; leadership, culture, professional and personal development. It is evident that these findings and key themes have congruence with Alison’s reflective account and the outcomes for the community team.

The influence and challenge here was based on Alison’s perceptions and experience of care provision. She used her own observations and positive practice experience to influence colleagues asking, can we learn from what I have done? This approach differs to asking the question what can we do about this? This way of influencing appeared natural and real, focusing on an approach which had been successful in practice ensured relevance for staff and additionally provided tangible possibilities for development.

Allison also identified,

‘The nurse manager in this setting was a role model to the team and often openly reflected on her experiences both positive and negative. This encouraged the nursing team to mirror this practice….. The team got together twice daily to discuss patient care. The nurse manager would often make a point of asking what went well and what would you improve. Change was not something to be feared rather it was embraced.’

With this insight Alison was able to utilise this team’s strengths to influence a development in care, further evidence of active emotional intelligence impacting upon practice.

Asha’s influence on care practices adopted a different approach.

‘I was fortunate to undertake a student placement in Western Australia, I was placed in a medical ward in one of Australia’s public hospitals where many of the patients lived in relative poverty. This was a fantastic learning opportunity for me…… There were a lot of aboriginal people attending the hospital and I witnessed some discrimination from Australian healthcare professionals which really surprised me. I was given three patients to care for, one was aboriginal. The nurse I was working with said to me that when caring for this particular patient I had to leave the room once I had done what I was supposed to do. I was not to make eye contact with the patient or the family and not to engage in conversation other than health related topics. I could not believe that I was hearing this from a healthcare professional, this goes against my own values and everything I have been taught. I challenged the nurse about her behaviour…… I was told that this is just how it is and aboriginal people take it as a threat if you make eye contact. I explained I cannot provide care like this and thought it was only fair to treat people as individuals. The next time we worked together she was surprised at how quickly I had built good trusting relationships with the patient and family. I spent time demonstrating empathy, kindness, dignity and respect I got to know everyone…… The family expressed how grateful they were to me for my care which made it all worthwhile!’ Asha

In this reflection the challenge to practice was forthright and highlighted concerns about the provision of compassionate, person centred care. It would appear that a growing awareness of discriminatory care in this clinical context triggered this response to the mentor. It is evident that Asha demonstrated commitment to the quality of care she wanted to provide, moreover she was able to articulate this clearly and challenge current practice with her mentor. This confidence is admirable given she was working in an unfamiliar setting where a culture of discrimination had been identified and working with unfamiliar staff. This brief scenario demonstrates a student nurse whose values, life experience, academic development and clinical practice enabled this way of challenging practice. Clinical confidence, commitment to quality of care and influence is demonstrated and indicates that this can be achieved by student nurses towards the conclusion of their studies.

Asha stated, ‘ when you are a student it is quite easy to feel unsure of yourself or your skills as a nurse, especially when faced with a new situation. Challenging my mentor was not something that came easy to me, however, being firm in my belief by speaking up I feel certain I have helped and cared. I continually set goals to push myself to have the confidence to speak up if I felt it was important to me. You are always going to meet people in life with negative attitudes, but it is important to me not to let them influence my thoughts and actions in any way. I found it difficult relating to the nurse who I reacted to as I felt that she stereotyped this patient and her family. I have no doubt that my own personal experience motivated my decision to question her practice. Having a bit of knowledge also gave me confidence to speak up. I had done a little research about communicating with Aboriginal people prior to visiting Australia, and I was aware that some (but not all) Aboriginal people are uncomfortable with direct eye contact. I felt that I was mature enough to make my own judgements on how to communicate effectively to overcome any barriers.’

Within recent public failures of NHS care, an inability to speak up and raise concerns about practice were highlighted as a factor in the general lowering of care standards, recommendations aimed at addressing this culture and behaviour were identified, ‘Ensure openness, transparency and candour throughout the system about matters of concern’ [ 19 ]. It is therefore critical that caring conversations are healthy and can positively influence the behaviour and care provided by practitioners and the culture of the caring environment. There is evidence of a need to talk about our healthcare organisations with positive values and a clear vision of how compassionate organisation should function [ 20 ].

It is evident that feedback from the patient, their family and the mentor indicated that the care experience provided by Asha was very positive. Unfortunately from this brief reflection we do not have evidence of influence on the mentors practice in this area of care other than her surprise at the positive level of therapeutic relationship developed. There is evidence however that the care provided to this patient and family was influenced and became consistent with Asha’s standards of compassion and person centeredness.

As discussed above Asha made earlier reference within her reflective account to personal experience early in her own life where she experienced discrimination as a consequence of family circumstances, and which enabled her to empathise with the indigenous family who may have felt isolated and misunderstood. Determination to provide compassionate care and challenge established practice took courage, confidence and commitment all of which are identified as fundamental values of care [ 21 ]. This emphasises the need to actively engage with each student throughout their period of study exploring their values, attitudes and caring behaviours.

Cultural sensitively is clearly an element of compassionate person centred care as demonstrated in this example and there is growing awareness that this should be taught within nursing education [ 22 ]. For some time nursing curricula has focused on fitness for practice and clinical competence and this is vital for patient safety but nursing is more than this. Nurses education is increasingly challenged to ensure that graduates are equipped with a spectrum of knowledge, skills and ability where compassionate, person centred care is consistent with safe and effective care. This requires acknowledgement that the students who enter our programmes of study come from a variety of life experiences and cultural backgrounds and as educators we too must meet the challenge to provide a learning experience that addresses and meets the needs of a diverse group of students. This raises the question of how this can be done and how can we ensure that nursing graduates are ready to meet the needs of the people in their care, can also care for themselves, and be able to grow with an ever changing healthcare system?

In relation to the LCCP model of compassionate care the examples provided above in relation to challenging and influencing care highlight the themes; Person centred risk taking and Involving valuing and transparency. Both reflections highlight practices that were focussed on adapting practice to individual need, for example following the instructions of the patient in order to develop trust and reduce anxiety whilst understanding their need for control. Similarly having an awareness of cultural practices but focusing and responding to the patient as an individual. Risks taken here related to deliberately doing things differently from colleagues and experiencing potential negativity as a consequence. Also taking a different approach may not be accepted by colleagues in the long run.

‘I will never forget one of the patients I cared for. After ten weeks she shared that she had outlived all her relatives ….. she said she didn’t know what she had done to deserve this and was so lonely she had no one to cuddle her, then she asked me for a hug. I will never forget the solitary tear drop running down her face when she gave me a hug. I wonder how long it had been since that woman had been hugged? This is one defining moment of my training which makes me strive to build appropriate compassionate therapeutic relationships at every opportunity.’ Allison

This example from practice highlights that personal connection is important in the delivery of compassionate care and that although the patient’s overall care was not being criticised, the emotional aspect of her being had somehow been forgotten. The question, what was important to that individual at that particular time had not been asked. This example also shows that relationships can take time to foster and develop. After 10 weeks of contact with Alison, this woman shared her feelings and vulnerability allowing Alison to respond to her needs in a simple but profound way. There is much debate in the nursing literature focused on terms such as relationship centred care, person centred care and compassionate care [ 23 ]. Following a pragmatic stance they each point to an approach to care that focuses on enhancing the experience of care itself, however relationship centred care provides a balance to this approach whereby the experience of the care giver and care receiver must equally be acknowledged to achieve an overall enriched environment of care [ 24 ].

This care experience emphasises the importance of touch, specifically the request for a hug when feeling isolated and lonely. Perhaps focusing on the appropriate use of touch within a caring relationship can support staff to maximise the caring experience when brief moments are all that are available to staff within busy clinical settings. Touch is not comforting or appropriate for everyone but the questions is, how can we maximise the appropriate use and effectiveness of touch when we have minimal time to care?

‘Many nurses hold the opinion that building relationships and honing communication skills are key to excellent patient care…. During my first year at university I observed that building therapeutic relationships and adapting communication style both saved time and improved patient care. I observed a colleague waking a patient abruptly in keeping with ward routine. The patient who had dementia did not take kindly to being rushed out of bed. She became tearful and ultimately aggressive. This resulted in two members of staff having to assist in calming the situation. In contrast, I witnessed another nurse gently rouse the patient in the morning. She held her hand and physically brought herself down to her level. This nurses’ tone and demeanour was gentle and patient centred, this initial interaction did take longer, however overall it saved time as the patient was happy to allow staff to assist her with her daily care. Inconsistency within the nursing team on this particular ward was very evident.’ Allison

How do we share and provide an opportunity to maximise good practice such as described in this account, and what is the role of a leader in promoting and sustaining compassionate care such as this? Role modelling has been celebrated in an earlier reflection by Allison. The intent and behaviours of leaders are important when establishing a culture of openness and transparency where feedback is viewed as “the norm”. This form of culture facilitates the possibility of sharing and maximising positive practice as well as giving consideration to practice situations which are challenging and fraught. In essence this is working directly with local feedback from patients and staff and holding a persistent focus on caring conversations.

‘What factors drive poor behaviours like this where there appears to be inconsistent approaches to patient care? Notably, the nurse manager on this ward was rarely available. The lack of direct leadership resulted in poor team work and communication within the team. How can we create environments where all patients are given this type of individualised care? Is this primarily driven by influential leadership? I believe a strong inspirational leadership style is a key factor in driving culture change? I believe cultures can be changed when staff are empowered to suggest improvement and champion change.’ Allison

This reflective account highlights the key theme of ‘Creating spaces that work’. What would it take to develop consistency of practice within the care team? Allison’s focus rests on leadership but moreover the need for the team to share, debate and consider how care can be enhanced, in essence work with ’Caring conversations’.

It is considered that most nurses will experience what is commonly termed Compassion fatigue. This concept has been debated widely within the nursing arena. Coetzee and Klopper [ 25 ] conclude that this this develops gradually and is a cumulative process. It is thought that this occurs when one is consistently subject to intense, acute interactions with patients and families. Compassion fatigue can be described as feeling negative emotions as a result of feeling unable to fulfil their moral role as nurses. Have more experienced healthcare providers become burnt out? In tandem with compassionate skills should we should also teach nurses to avoid becoming fatigued. This would allow compassion to be preserved rather than eroded. If this is the case how do we go about safeguarding ourselves and others from the effects of compassion fatigue? Indeed, what makes one person more adept at sustaining their compassion whilst working in highly charged emotionally draining environments? Can resilience be taught or nurtured? Gentry [ 26 ] highlighted that a healthcare providers ability to “self-care” seemed to have a positive influence on their ability to deal with the effects of compassion fatigue.

Self-care was identified primarily as anxiety management and included practices such as speaking to colleagues, exercise and meditation. During the three year nursing programme at Edinburgh Napier University students are given ample opportunity to reflect in peer groups there are also sessions teaching mindfulness. During one module nursing students were invited to organise aerobic exercise classes. Is the UK nursing workplace ready or able to uphold and commit to providing organisational strategies to combat the effects of compassion fatigue? There has been little research into techniques on how to reduce fatigue in healthcare professionals and the resulting effect this would have on standards of care, this is an area which would benefit from further research.

‘Within one clinical setting where I worked a colleague experienced the loss of her spouse. She was regularly involved with palliative patients and was given the option to move to a different role within the team. This role did not involve palliative care and is allowing an experienced and dedicated member of staff to better deal with her grief. It also means she is still effectively contributing to the workplace. What makes it possible for one clinical area to offer this type of support where as other areas do not? How can this become the norm as opposed to the exception?’ Allison

The example of good practice above highlights that relationship centred care is critical to staff relationships. This provides a practical but considered example of the theme Knowing you knowing me. Understanding a staff members context and vulnerability and responding to this may enhance the ability to care in practice and sends a message to staff that they are of value and matter.

As a student nurse, the relationship between myself the patient and their family is vital. Holistic care and having excellent verbal and non-verbal communication skills are essential in order to understand the needs of each patient and their loved ones whilst they are receiving healthcare…. I have learned how a person’s body language can say a completely different thing as to what they are telling you, thereby taking the time to listen and by doing the little things can not only make the patient feel cared for but actually cared about.’ Asha

The authors of this paper would acknowledge that courage can be required to pick up on non-verbal behaviours and then comment or respond to them [ 21 ]. These forms of interaction may take longer than originally anticipated but aim to get at the heart of what matters. In addition recognising the needs of the family/carers in the provision of care to promote a sense of caring for all involved is also important.

‘For the first time I felt inadequate in terms of providing compassionate care. It was my first exposure to an emergency medicine environment. During one shift I was very conscious of a daughter sitting with her mother. The mother was having an acute breathlessness problem and her daughter was crying. I was dealing with a patient who had a gastric bleed. On my way to get some clean linen for this patient, the only thing I could offer this distressed daughter was a tissue and a few words which seemed very inadequate…. I really felt I was letting someone down…. My thoughts were interrupted when my patient said you are so gentle thank you for being so gentle. I realised I was doing my best and providing care to the patient with the greatest need…. The lesson learned here is that in the demanding role of nursing I will have to prioritise and make decisions such as these.’ Allison

This reflection highlights the dilemma experienced by care providers when they identify distress and are unable to respond in a manner that meets their aspirations of care. A feeling of inadequacy related to compassionate care provision was acknowledged, this did not relate to an absence of compassion or a failure to respond, rather it points to a busy clinical context where priorities need to lie with those who have the most acute needs. A compassionate response was evident in the provision of a tissue and a few words and this is commendable practice amidst a busy clinical setting. It is interesting to note however that this intervention was deemed inadequate.

This reflection raises a number of key questions about the context and environment of care and the impact these factors have upon staff experience.

Was this area short staffed or experiencing an acutely busy period and feeling stretched at this time? What is the norm of practice here, do other members of the team feel similarly and where are these experiences and feelings discussed and debated as a team?

How would other members of the team manage this situation and how can staff retain their awareness and desire to be compassionate when the busyness of the area necessitates a focus on clinical priorities?

A further question relates to the resilience of staff, how do staff stay resilient and work with potential compromises to the compassionate care they aspire to deliver?

Brown [ 27 ] debates these issues concluding that, ‘in organisations there needs to be clear intention, leadership and determination for compassionate care to become central in all healthcare practice’. His conclusions focus on small group experiential reflection and learning by healthcare workers as the most effective way to consolidate compassionate care values in practice. Indeed within the LCCP [ 1 ] staff coming together to debate and discuss what compassionate care looks like in their service was a key activity in negotiating a definition for practice; moving the potentially nebulous concept of compassionate care into a more tangible approach for local practice. Principles of compassionate care were most usefully derived from hearing and understanding experiences of patients, relatives and staff and initiating responsive action [ 28 ].

Paley [ 29 ] argues that organisational and situational factors directly impact upon care delivery and that this results in care providers being too busy or focused on other organisationally directed issues to recognise or address compassionate care. It is argued that the blame for a compassion deficit therefore rests with the organisation. In a related issue Timmins and De Vries [ 30 ] also point to organisational factors that determine outcomes of poor care. These authors focus on cognitive dissonance as experienced by care providers; the aim is to provide good care however due to organisational pressures which dominate the context this form of care is not achievable. In order to rationalise this dissonance between care aspirations and the actual, less positive, care experience, standards of care are revised to a lower level thereby managing the dissonance experienced. In the reflection provided above neither of these two phenomenon were evident. Frustration was expressed due to the busyness of the practice area and a need to focus on clinical priorities but distress was identified and a compassionate response elicited.

It is interesting however that this student was dissatisfied with her compassionate response in this busy context, this response raises questions about how staff are supported and able to work through these situations when optimal care has not been possible. There is a wealth of evidence available testifying to the significant challenges facing healthcare professionals in contemporary practice (Iles, & Vaughan Smith [ 31 ] therefore it is important to consider how staff develop resilience and self-compassion as a counter to this situational and cultural context as well as responding to physical and organisational factors impacting upon compassionate caring.

The following practice example from Allison demonstrates tensions in achieving her desired standards of care and how she has been developing strategies to address these.

‘I have been a qualified nurse for a year now and often miss being a student. There was certainly more time to spend with patients. Instead of supporting an upset patient with post-operative nausea and vomiting it is my first priority to organise the administration of an anti-emetic. There is often no extra time to spend with the patient following this as I could have another patient returning from theatre. How do we make these shortened interactions count and make our patients feel cared for as an individual? Is it about tone and communication style? Is it about delegation and recognising that other members of the team can help. I have certainly asked student nurses or care assistants to comfort patients when I have been unable to fulfil this role due to time restraints.’ Allison

The challenge raised of maximising the positive impact for patients of brief interactions when a brief moment is all that is available, seems an important focus for learning. It is unreasonable for staff to experience a sense of guilt regarding care experiences such as those described above when staffing and situational variables dominate practice and are out with a nurses’ sphere of control or influence. What would help nurses and other care staff discuss their experiences, learning, and the positive strategies employed which would enable the possibility of working towards a shared understanding and improvement?

In regard to the LCCP model of care the key themes related to the reflections above could relate to Feedback and Creating spaces that work. It would have been fascinating to hear directly from the patients described in the reflections detailed above. What was their perception of the care and compassion they received? Did a tissue and a few words, or the provision of an anti-emetic meet their needs? Patients can be acutely aware of the busyness of clinical areas and consequently try to minimize the work load of staff as a response. Without seeking feedback directly from these people and their experience of care, we are left with assumptions and possibilities. There is the possibility that care staff can be unduly critical of their practice when deficits are perceived in the care provided, however such deficits may or may not be the experience of those we care for. Actively seeking, hearing and responding to feedback within the local context can provide a reality check and focus for both celebrating excellent care and genuinely understanding care deficits. Considering, Creating spaces that work, would focus reflections on issues connected to the physical environment, culture and ways of working. A group discussion may reassure the team that they are doing all they can, it may raise possibilities for change or connecting with the broader organisation for direct support and development.

Summary - Now what?

The student nurse reflections discussed within this paper prompt us to pause and be encouraged as we glimpse examples of excellent care and celebrate what can be achieved. They also remind us that provision of compassionate care is indeed possible, it does take place on a day to day basis and often hinges on the little things that make a massive difference to those receiving and providing care. However personal drivers, values and perspectives of quality care are critical aspects of providing compassionate care. These elements though are not little things to articulate and develop for individuals, teams and indeed organisations engaged in the provision of contemporary healthcare.

To support the development of compassionate care this article focused on key issues identified from the reflective accounts of two award winning student nurses. These included supporting students in healthcare to;

Develop strategies in questioning care practices which do not meet their expectation of compassionate care

Undertake regular focussed reflective activities where each student can explore personal drivers, values and perspectives of compassionate caring.

Actively connect learning in practice with theory and reflective activities within university, enabling consistent development in compassionate caring.

Facilitate an understanding of emotional intelligence, leading to strategies for self-compassion and the development of resilience

It is necessary to consider the implications of these reflections in terms of supporting healthcare staff to;

Collectively seek, hear and respond to feedback about their service

Activate caring conversations within the healthcare team, celebrate what works well and understand the reasons for this, considering what can be done differently and better and how can we learn and support one another.

Consider how the model of compassionate care, presented in this paper, can be used to reflect on practice and indeed provide a framework and focus for local practice development.

Consider how we maximise the experience of care during brief moments of contact with patients/families.

Activate leadership that strives for a culture of openness which facilitates the development of compassionate care.

Abbreviations

LCCP, Leadership in Compassionate Care Programme

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The information presented in this debate article does not originate from original research but from material presented by undergraduate nursing students as part of an award portfolio submission. As this paper does not represent research no ethical approval was sought.

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Students who win the Simon Pullin Award receive £250.00 prize money and an award letter from the university. The application process involves submitting a portfolio which contains the following: a reflective account written by the student identifying their experience of learning and development in compassionate caring during their undergraduate studies; accounts of feedback about compassionate care development from practice mentors, service users and university academic staff, usually the students’ personal development tutor. The portfolios are reviewed by a panel of academic staff and service users.

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Stephen Smith, Elizabeth Adamson & Mandy Gentleman

Distict Nursing Team, NHS Lothian, Edinburgh, Scotland

Allison Brogan

St John of God Hospital, Perth, Western Australia, Australia

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Smith, S., James, A., Brogan, A. et al. Reflections about experiences of compassionate care from award winning undergraduate nurses – What, so what … now what?. J of Compassionate Health Care 3 , 6 (2016). https://doi.org/10.1186/s40639-016-0023-x

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Essay: Compassionate care in nursing

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This essay, will be explore and discuss why ensuring compassionate care in nursing is important and how it relates to the NHS (National Health Service) values. Compassion can be described as, feeling sympathy for someone else’s misfortune (WordReference, 2015, cited in Perez-Bret et al., 2016). There is no correct definition for compassionate care as it is mainly demonstrated through the unique bond formed between the patient and nurse. It can be characterised by actions taken by the nurse to care and show an understanding for the patients’ needs and their suffering (Baughan & Smith, 2013). This essay will cover the different legislations which require nurses to provide compassionate, humanistic care to patients, theoretical frameworks and evidence-based practices which express the significance of compassionate care and therapeutic relationships. Additionally, how nurses implement techniques to form relationships with patients and relatives to provide patient-centred care.

Care and compassion being two of the 6 C’s express the importance of compassionate care and its importance to nursing. Being caring and compassionate is the minimum expectation of nurses, and it is endlessly stated by the NMC that care should be given effectively, without delays; this represents the significance of a caring nurse as they are the main aspects of nursing (NMC, 2015). Compassion is also stated in the NMC Code of Conduct (2015), it proclaims, compassionately is the way to respond to the needs to patients especially those who are in the last few days and hours of life. Compassion is fundamental, building trust between patients and nurses, also indicating patients are being treated as people rather than procedures. Bramley and Matiti (2014) held a study in compassion and what it means to patients; majority of patients stated, compassion is when nurses give them time and portray a caring attitude. This study also retrieved that patients find a striking link between care and compassion thus they would substitute care for compassion and vice versa. One of the patients in the study described compassion as “… a caring attitude to people as people and not things (Participant 5, ward D: L 4)” (Bramley and Matiti, 2014, p. 2794).  Bramley and Matiti (2014) found that patients express nurses demonstrating caring and compassionate attributes through giving them time, talking to them as people, nurses placing themselves in the situation of patients and caring about their feelings. This study helps nurses as knowledge of patients understanding of compassionate care can help them improve on attributes patients anticipate when being cared for.

The NHS constitution establishes the principles and values of NHS England. The purpose of this is to clarify the right entitlements for service users, the public and also staff. NHS values are also included, these have been inspired by patients, the public and staff, making sure nothing is missed. A few of the values are; respect and dignity, commitment to quality of care, compassion, improving lives and everyone counts (Department of Health & Social Care, 2015). These values are to ensure patients are the centre of attention and they are delivered humanistic, person-centred care. NHS values explain the significance of compassion as it is a key value that is naturally expected from nurses and other health care staff. The Royal College of Nursing (2018) developed eight principles with the help of the Department of Health and the NMC (Nursing and Midwifery Council), the public and health care staff were also a part of the progression process. The principles are there for nurses and student nurses to apply when caring for patients. One of the eight principles are, nurses and nursing staff treat everyone with care ensuring dignity and humanity is maintained throughout – nurses should understand the patients’ needs and requirements and are to show compassion and sensitivity, overall nurses should provide care in a way in which everyone is respected and treated equally (Royal College of Nursing, 2018).

Professionalism in nursing is the autonomous decision-making of a group of medical professionals who share similar values (NMC, 2017). Nurses providing good healthcare through excellent, professional practice and behaviour upholds the expected nursing standards. The NMC focuses nurses on professionalism to guarantee safe and effective, person-centred care (Glasper, 2017). Professionalism being a vital attribute to nurses is to prevent publicised scandals such as the ‘Mid-Staffordshire Inquiry’. Partnership is recognised in healthcare guidelines therefore is an attribute for nurses to either develop improve on (Baillie, 2016). Nurses working in partnership with their patients allows patients to make decisions about their own treatment, also this leads to improved communication skills between a nurse and service user (Baillie, 2016). A scenario of working in partnership with patients can be, a patient at a&e is suicidal and overdosed on paracetamol. The nurse is responsible for taking care and explaining the effects and treatments for overdose. While explaining to the patients the effects, the nurse is able to build a therapeutic relationship with the patient over time as partnership means the service user can ask questions. On the other hand, if the patient refuses treatment and disregards the recommendations of the nurse, it could lead to conflict.

Conflict can occur when a nurse tries to build a relationship/partnership with the service user. However, conflict can also arise between healthcare professionals due to poor leadership and change, plus issues with interpersonal relationships (McKibben, 2017). This type of conflict can affect the quality of care patients receive, therefore the NMC has highlighted, nurses must communicate and work cooperatively in partnership to resolve any conflict within healthcare teams (NMC, 2015). There are many different reasons of why conflict can arise between nurses and patients, reasons like disagreements in decision-making, conflicting medical and religious beliefs additionally, conflicting opinions. Through conflict, nursing standards can rise. Oglethorpe and Oglethorpe (2009) stated, nursing conflict can result in critical thinking leading to well thought-out/quality decision-making by nurses, resorting in enhanced care quality received by patients.

A therapeutic relationship is when nurses and patients communicate effectively, whether it is regarding treatment or general conversations asking how they are. Through communication, nurses can provide exceptional medical care. Good communication and interpersonal skills allow nurses to communicate with patient’s relatives as well as other health professionals. A therapeutic relationship is called ‘therapeutic’ because it helps nurses to meet the needs of patients through a shared agreement (McQueen, 2000). Therapeutic relationships are fundamental as they signify compassionate care since it shows there is good nurse-patient interaction, which aid nurses with smoother care plan administration as patients are more trusting of nurses.

Marsham (2012) explored learning disability nurses therapeutic role and found that it is a big focus when it comes to interventions raising standards in nursing. This is because patient-nurse relationships reflect a more humanistic approach to nursing which can also be referred to as compassionate care since nurses take time to build a rapport with patients to provide unique patient centred care. Therapeutic relationships are all the more important as they are seen as the “… heart of care” (Marsham, 2012, p. 237). To build a relationship with patients, it can be easy for nurses to start using jargon without realising, also it is very easy for them to dominate treatment as nurses are the professionals and the patients are not. Therefore, the NMC stated “work in partnership with patients to make sure you deliver care effectively” (NMC, 2015, p. 4). Nurses are to make sure their patients understand their treatment and care plans. To help explain procedures to patients and build a relationship, there are a few key attributes nurses should acquire. Being sensitive, showing empathy, being approachable, a good listener and also being receptive to the patient. Callery and Milnes (2012) undertook a study of communication between nurses, patients and their parents. The study showed that there is a ‘triadic’ relationship formed when communicating with 3 people. In their study, the child was known as the ‘dyad’ who observed the conversations between the nurse and parent. Overall evidence from this study showed, communication is imperative with everyone including children (Callery and Milnes, 2012). Callery and Milnes study links to clinical practice as communication helps provide effective nursing care, in addition to improvement in patient mental health.

To provide person-centred care, the main focus for a nurse should be, is the patient happy. Carl Rogers, a humanistic psychologist believed patient health improves better once they improve their psychological state of mind (McLeod, 2014). This theory links to clinical practice as nurses are not just helping patients medically but also mentally. Hence, nurses tend to focus on encouraging elderly patients to focus on something or someone instead of an unconscious motive. McLeod (2014) stated, Carl Rogers’ humanistic approach to therapy is to ensure patients are benefitting by feelings of greater self-worth. Nurses are able to use Rogers’ person-centred approach to build therapeutic relationships with service users by taking time to ask them ‘how are you’. The main emphasis on a therapeutic relationship with patients is to increase the care and compassion received by the service users. Bettering nurses on attributes alike care and compassion improves quality of care; as stated by Glasper (2017); professionalism enhances and guarantees safe and effective patient-centred care, therefore professionalism is the leading attribute which nurses should possess and is repeatedly stated in the NMC: Code of Conduct. Rogers (1975, cited in McLeod, 2014) stated, showing empathy to patients means the nurse is able to understand the patients’ feelings, in return this slowly allows the patient to open up to the nurse. The best way to form a therapeutic relationship with patients is to show sensitivity, receptiveness and empathy towards patients. Contrariwise, showing sympathy can be demeaning for patients (Rogers, 1975, cited in McLeod, 2014).

With nursing comes a great deal of legal issues. With healthcare involving many laws and legislations, it means there is a bigger spotlight on the performance of health professionals, more importantly, nurses. The NMC: Code of Conduct incorporates many different laws to ensure nurses perform safe clinical practice. Nurses have a duty of care, to protect patient’s rights to privacy and confidentiality (NMC, 2015). The ‘duty of care’ nurses have is to provide humanistic care as it is their human right, and to prevent any neglect and poor, unsafe practice. The Nursing and Midwifery Council has set Codes of Conducts for nurses to follow when practicing their profession; nursing without being registered on the NMC register is a crime (NMC, 2015). An example of failed duty of care is the Mid-Staffordshire Inquiry of which’s findings were, poor leadership within healthcare teams and inadequate staff policies leading to extremely low standards of care (Hughes, 2013). Dimond (2015) states the accountability and expectations of nurses to the public also how nurses can be liable whether or not they are aware of the laws which are imposed in the nursing profession. An example of this could be, if there is a road traffic accident, if there is a nurse present (not on shift), they are expected to help and in some circumstances can be morally responsible if they refuse to assist, even if there is no legal obligation to volunteer nursing services (Dimond, 2015). To prevent any scandals like the Mid-Staffordshire inquiry, nurses should have knowledge of the laws they are to follow and aim to care for patients compassionately, with patient needs having the most attention.

Compassionate care is having the patients best interest at heart. Ethics are a fundamental in nursing; respect for autonomy, beneficence, non-maleficence and justice are the four principles of biomedical ethics (UK Clinical Ethics Network, 2001). In the Mid-Staffordshire inquiry, findings showed patients autonomy was not respected and were faced with maleficence as the Francis Report (2013) highlighted, patients were ‘so dehydrated they resorted to drinking water from vases’ (Hughes, 2013). Autonomy can be demonstrated by treating patients as autonomous individuals. An example of this is, although dementia patients do not have capacity, it is still the nurses’ responsibility and duty of care to treat them as an autonomous individual by being caring and compassionate and having a ‘holistic’ view (Skår, 2010). Correspondingly, attempting to get to know the patient no matter their capacity demonstrates autonomy; nurses carry out autonomous practice when they show courage and competence while taking dominating situations they are responsible for (Skår, 2010). Compassion and care are basic attribute to when providing ‘humanistic’ care. Humanistic care is to be received by all patients, majorly palliative patients as providing humanistic care for patients is to promote consolation and protect patient dignity in their last stages of their life (Wu & Volker, 2012).

To conclude, care and compassion are the most important attributes nurses should possess to provide exceptional patient-centred care. Building therapeutic relationships/partnerships with patients and relatives can help provide adequate tailored care as patients can make decisions concerning their treatment, leaving both patient and nurse in mutual agreement (McQueen, 2000). Conflict can arise between patients if therapeutic relationships are not formed. Conflict develops between healthcare professionals also due to changes in leadership. Nurses should follow laws and legislations when caring for patients, demonstrating professionalism and also as the NMC incorporates professionalism numerous time in the NMC: Code of Conduct. Overall, compassionate care can be demonstrated through excellent implementation of laws and the Code of Conduct in clinical practice.

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Recognizing Care and Compassion in Nursing, Essay Example

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Words: 959

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Introduction

Professional nursing requires expert knowledge and understanding of a variety of health concerns that impact the live of patients and affect their wellbeing. To accommodate patients, nurses must also express emotion and compassion to support their needs and to raise awareness of the emotional context of health and healing. Patients often recognize when nurses do not show compassion for their situations and may experience setbacks in the process. Therefore, from a conceptual point of view, nurses must be able to perform their roles effectively and to support patient care quality through their actions towards patients. This process encompasses a moral component that requires nurses to provide a high standard of care and treatment to patients at all times (Beckett, 2013). However, in some respects, this is a learned concept that requires further investigation and evaluation in order to ensure that patient care is not compromised and that they respond favorably to direct care and compassion in the healthcare environment. Nurses who demonstrate compassion must be effective communicators and encourage a positive and meaningful environment to promote patient healing and recovery.

Nurses may not always demonstrate compassion in the work environment because it is somewhat ambiguous in nature, thereby creating a challenging environment in which patients are likely to experience the lack of emotion and connection to their needs (Beckett, 2013). Caring should be inherent with all nurses; however, this concept often requires learning and an understanding of patient care needs that will satisfy patient outcomes and stimulate healing (Beckett, 2013). Some nurses have not likely experienced a caring and nurturing home or family environment, thereby contributing to the disconnect to patients that is often observed, and as a result, requires some degree of nurturing and support to ensure that patients receive the best possible care and treatment in a timely manner (Beckett, 2013).

Nurses may disconnect from their responsibility to be compassionate with patients because they may not recognize that it is absent and that their own actions do not coincide with patient needs (Castledine, 2005). Therefore, it is necessary to develop a framework that will enable nurses to recognize how to exercise compassion and to be present for their patients at all times (Castledine, 2005). Furthermore, nurses also possess limitations of their own, and these must also be addressed in the context of their ability to be compassionate towards their patients (Castledine, 2005). First and foremost, patients who experience compassion from their nurses are likely to be receptive to this emotional context and will be successful in achieving the desired results in terms of their recovery (Castledine, 2005). Also, it is necessary to support an environment that embraces change and also supports progress for patients who experience compassion from their nurses with each interaction (Castledine, 2005).

From a conceptual point of view, nurses should recognize how patients from different age groups with different areas of need require compassion to promote recovery, and this is an important step towards the discovery of new challenges that will impact quality of care and also support the growth of practice settings to achieve the desired outcomes (Van der Cingel, 2011). Nurses must demonstrate a humane and moral approach to their practice that depends on offering a compassionate perspective and level of support to meet their needs (Van der Cingel, 2011).  The process of advancing healthcare practice through compassion is essential for nurses because it supports their own growth and maturity in the profession and provides patients with a caring and nurturing environment (Van der Cingel, 2011). Compassion is not a learned concept but it requires significant attention and focus by all nurses in order to achieve greater health and wellbeing for all patients (Van der Cingel, 2011).

Finally, nurses with limited levels of experience may find it difficult to exercise compassion and to determine how much compassion is required to support their patients (Horsburgh & Ross, 2013). In this capacity, nurses may not be up to the task of providing optimal compassion for their patients, and therefore, this process is likely to improve with experience (Horsburgh & Ross, 2013). At the same time, nurses with lower experience levels may find themselves conflicted regarding their roles and responsibilities, which requires an increased understanding of these roles to ensure that patient needs are met as required (Horsburgh & Ross, 2013). As a result, nurses must be exposed to compassionate care in the work environment so that they are able to effectively adapt to this process in their own experiences to improve patient recovery and satisfaction (Horsburgh & Ross, 2013).

Compassion is a key nursing concept that requires significant understanding and focus across all practice settings. Nurses must be able to provide a compassionate care and treatment environment that supports change and stimulates recovery and wellbeing. Although some nurses exercise compassion at higher levels than others, the concept is critical to the practice setting and requires much nurturing and ongoing support in order to facilitate the desired results. Compassion in nursing is essential to facilitate high quality patient care and treatment for all patients and requires an ongoing effort from nurses to be effective contributors to the practice setting in order to achieve effective results. Patients must be provided with an environment in which nurses show compassion towards their needs and encourage them to follow the steps that are necessary to encourage recovery.

Beckett, K. (2013). Professional wellbeing and caring: exploring a complex relationship. British Journal Of Nursing , 22 (19), 1118-1124.

Castledine, G. (2005). Castledine column. Recognizing care and compassion in nursing. British Journal Of Nursing , 14 (18), 1001.

Horsburgh, D., & Ross, J. (2013). Care and compassion: the experiences of newly qualified staff nurses. Journal of clinical nursing , 22 (7-8), 1124-1132.

Van der Cingel, C. J. M. (2011). Compassion in care: A qualitative study of older people with a chronic disease and nurses. Nursing ethics , 0969733011403556.

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What are Compassion in Practice and the 6Cs of nursing?

14 February, 2022 By Steve Ford

Here we summarise key nursing policy documents that were intended to set the tone for the profession in England during the 2010s.

Compassion in Practice: Nursing, Midwifery and Care Staff Our Vision and Strategy was a policy document published by NHS England in December 2012.

It was developed by Jane Cummings, then chief nursing officer for England, and Viv Bennett, director of nursing at the Department of Health and lead nurse at Public Health England.

The three-year strategy set out a shared purpose for nurses, midwives and care staff to deliver high quality, compassionate care, and to achieve excellent health and wellbeing outcomes.

It was built, said those behind the document, on the values, pledges and rights set out in the NHS Constitution that patients, the public and staff should and would expect.

The strategy, which was not directly backed with government funding, was underpinned by six fundamental values designed to support professionals and care staff to deliver excellent care.

The values were care, compassion, competence, communication, courage and commitment, and became commonly referred to as the “6Cs of nursing”.

Each of the six values, which were also backed by six areas of action, carried equal weight and focused on putting patients at the “heart of everything” that nurses do.

The aim was for the 6Cs to be universally adopted and embraced by everyone involved in commissioning and delivering care, and, therefore, to be an explicit part of planning guidance.

The definitions of the 6Cs, as set out in the Compassion in Practice document, were:

Care – Care is our core business and that of our organisations, and the care we deliver helps the individual person and improves the health of the whole community. Caring defines us and our work. People receiving care expect it to be right for them, consistently, throughout every stage of their life.

Compassion – Compassion is how care is given through relationships based on empathy, respect and dignity - it can also be described as intelligent kindness, and is central to how people perceive their care.

Competence – Competence means all those in caring roles must have the ability to understand an individual’s health and social needs and the expertise, clinical and technical knowledge to deliver effective care and treatments based on research and evidence.

Communication – Communication is central to successful caring relationships and to effective team working. Listening is as important as what we say and do and essential for "no decision about me without me". Communication is the key to a good workplace with benefits for those in our care and staff alike.

Courage – Courage enables us to do the right thing for the people we care for, to speak up when we have concerns and to have the personal strength and vision to innovate and to embrace new ways of working.

Commitment – A commitment to our patients and populations is a cornerstone of what we do. We need to build on our commitment to improve the care and experience of our patients, to take action to make this vision and strategy a reality for all and meet the health, care and support challenges ahead.

Action areas

As well as the focus on developing and communicating the 6Cs, the strategy set out six areas of action where it said nurses could concentrate their effort and create impact for patients.

The action areas, which are explained in detail in the strategy document, were:

• Helping people to stay independent, maximising well-being and improving health outcomes
• Working with people to provide a positive experience of care
• Delivering high quality care and measuring the impact of care
• Building and strengthening leadership
• Ensuring we have the right staff, with the right skills, in the right place
• Supporting positive staff experience

A set of implementation plans , focused on each of the action areas in the strategy, was subsequently published in April 2013.

A further document, called Compassion in Practice: Evidencing the Impact , was published three years later in May 2016.

It concluded there was evidence to illustrate a wide range of programmes had been delivered and contributions made to service delivery.

The review also said the experiences of staff and patients suggested that, overall, Compassion in Practice had made a difference to the “people we care for and our workforce”.

It added that the evaluation of impact, as a whole, had provided an opportunity to reflect on what should happen next and how to improve in the future.

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Compassion in Nursing Essay

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Home — Essay Samples — Nursing & Health — Universal Health Care — The Role of Compassion in Nursing and Healthcare

The Role of Compassion in Nursing and Healthcare

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Foundations of compassion in nursing, compassion as central to healthcare practice, conclusion: compassion as a cornerstone of nursing.

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Caring, compassion and competence in healthcare

Nompumelelo ntshingila.

1 Department of Nursing, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa

The theme for this section focused on caring, compassion and competence in healthcare. Caring as a phenomenon and as a science is about human beings (Karlsson & Pennbrant 2020 ). As stated by Watson ( 2022 ), caring as a science is grounded in nursing scholarship and is also relevant to other disciplines in the academia, such as feminist studies, peace studies, education, ethics and human service fields, for example, social work and healthcare professions generally.

Various authors have termed compassion as the fundamental concept in healthcare (Papadopoulos & Ali 2016 ; Pehlivan & Güner 2020 ). Following a systematic literature review conducted by Perez-Bret, Altisent and Rocafort ( 2016 ), compassion is defined as ‘the sensitivity shown to understand another person’s suffering, combined with a willingness to help and to promote the wellbeing of that person and to find a solution to their situation’. To be compassionate requires understanding the pain and experiences of others. The concept of compassion comprises respect and awareness of others. Bradshaw ( 2011 ) confirms that compassionate care as a concept dates back to the time of Florence Nightingale and is associated mainly with nursing as a profession. Compassionate care is instead expressed in actions rather than words. The actions needed are firm touch, gentle, courteous manner and kindness (Bradshaw 2011 ). Furthermore, compassionate care is said to entail a set of four attributes: wisdom, humanity, love and empathy (Su et al. 2020 ).

Core competence in healthcare is for the healthcare provider to practice skills that meet the needs of the patients using logical thinking (Fukada 2018 ). Healthcare professionals must be competent providers of compassionate care. Pehlivan and Güner ( 2020 ) highlight the benefits and challenges of providing compassionate care in various healthcare environments. The benefits are improving understanding of involving patients and families in care, determining patients’ and families’ needs, using appropriate approaches and improving patient outcomes. The challenges are work environment challenges and individual factors. Babaei and Taleghani ( 2019 ) further included sociocultural barriers such as gender and lack of mutual language as barriers to compassionate care.

For the 2022 Health SA Gesondheid special collection, several manuscripts were submitted under the theme of caring, compassionate care and competence. This theme had the most submissions. The manuscripts reviewed under this theme ranged from qualitative, quantitative and systematic reviews. The issues addressed pertained to the challenges of providing competent, compassionate care across the healthcare context. These were challenges related to patients, healthcare providers and students. The manuscripts addressed current issues of coronavirus disease 2019 (COVID-19), gender-based violence, post-exposure prophylaxis and mental health challenges in the healthcare context. The studies’ settings were urban and rural contexts in South Africa and Namibia.

It is evident from the submissions that compassionate care and competence is a theme that will generate conversations in the healthcare context and seems to be of significant interest. I am positive that the articles that are published on the theme of caring, compassion and competence will provide an opportunity for further evidence-based research.

How to cite this article: Ntshingila, N., 2022, ‘Caring, compassion and competence in healthcare’, Health SA Gesondheid 27(0), a2133. https://doi.org/10.4102/hsag.v27i0.2133

• Babaei, S. & Taleghani, F., 2019, ‘ Compassionate care challenges and barriers in clinical nurses: A qualitative study ’, Iranian Journal of Nursing and Midwifery Research 24 ( 3 ), 213–219. 10.4103/ijnmr.IJNMR_100_18 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bradshaw, A., 2011, ‘ Compassion: What history teaches us ’, Nursing Times 107 ( 19–20 ), 12–14. [ PubMed ] [ Google Scholar ]
• Fukada, M., 2018, ‘ Nursing competency: Definition, structure and development ’, Yonago Acta Medica 61 ( 1 ), 1–7. 10.33160/yam.2018.03.001 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Karlsson, M. & Pennbrant, S., 2020, ‘ Ideas of caring in nursing practice ’, Nursing Philosophy 21 , e12325. 10.1111/nup.12325 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Papadopoulos, I. & Ali, S., 2016, ‘ Measuring compassion in nurses and other healthcare professionals: An integrative review ’, Nurse Education Practice 16 ( 1 ), 133–139. 10.1016/j.nepr.2015.08.001 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Pehlivan, T. & Güner, P., 2020, ‘ Compassionate care: Can it be defined, provided, and measured? ’, Journal of Psychiatric Nursing 11 ( 1 ), 64–69. 10.14744/phd.2019.20082 [ CrossRef ] [ Google Scholar ]
• Perez-Bret, E., Altisent, R. & Rocafort, J., 2016, ‘ Definition of compassion in healthcare: A systematic literature review ’, International Journal of Palliative Nursing 22 ( 12 ), 599–606. 10.12968/ijpn.2016.22.12.599 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Su, J.J., Masika, G.M., Paguio, J.T. & Redding, S.R., 2020, ‘ Defining compassionate nursing care ’, Nursing Ethics 27 ( 2 ), 480–493. 10.1177/0969733019851546 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Watson, J., 2022, Watson’s caring science & human caring theory , viewed 15 August 2022, from https://www.watsoncaringscience.org/jean-bio/caring-science-theory/ . [ Google Scholar ]

• Open access
• Published: 28 June 2024

The role of Empathy in the relationship between emotional support and caring behavior towards patients among intern nursing students

• Mohamed Hussein Ramadan Atta   ORCID: orcid.org/0000-0002-5518-0892 1 , 2 ,
• Heba Abdel-Hamid Hammad 3 &
• Nadia Waheed Elzohairy 3  

BMC Nursing volume  23 , Article number:  443 ( 2024 ) Cite this article

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Metrics details

The empathic relationship between nursing students and patients allows them to understand and address caring behavior for patients. Appropriate emotional support equips them to overcome the complexities and difficulties inherent in patient care. This support cultivates resilience and self-awareness, enabling students to manage their emotions effectively and establish meaningful connections and caring with their patients.

To investigate the role of empathy in the association between emotional support and caring behavior toward patients among intern nursing students at Alexandria and Damanhur University.

The study subjects were 200 intern nursing students in their internship years of 2022–2023, randomly selected from an equal sample size from Alexandria and Damanhur University, Egypt.

A questionnaire of social information& academics from students, the Toronto Empathy Questionnaire, the Caring Dimension Inventory, and the Multidimensional Scale of Perceived Social Support are used to collect participants’ data.

Empathy was associated with caring behavior and emotional support among nursing students ( P  < 0.001), and higher levels of empathy indicated increased levels of caring behavior and emotional support. The caring behavior significantly increased when intern nursing students received more emotional support and among those who were not working in private hospitals ( p  < 0.001,& p  = 0.023 respectively). Empathy acts as a mediating role in the relationship between emotional support and caring behavior.

Implications

Implementing strategies to assist interns in navigating challenges and promoting a culture of support can facilitate the cultivation of caring behaviors. Shedding light on the interconnectedness of empathy, emotional support, and caring behavior can inform the design of interventions to strengthen empathy as a pathway to improving patient outcomes.

Empathy is a mediating factor in the relationship between emotional support and caring behavior. This suggests that interventions promoting empathy may serve as a pathway to enhancing caring behavior among nursing students and strategies for improving patient care outcomes by strengthening empathy skills among healthcare professionals.

Peer Review reports

Introduction

Internship experience offers nursing students a valuable opportunity to enhance their professional development by gaining practical experience in a field that aligns with their academic pursuits or desired careers. In nursing, intern students play a significant role in delivering high-quality patient care [ 1 , 2 ]. In Egypt, intern nursing students are vital to the healthcare system as they provide patient care under the supervision of experienced nurses and clinical instructors. Their responsibilities include indispensable assisting with patient assessment, administering medications, monitoring vital signs, and providing essential care such as bathing and feeding. Additionally, nursing interns are crucial in patient education, offering information on health promotion and disease prevention [ 3 , 4 ].

Furthermore, intern nursing students in Egypt are essential members of the healthcare workforce, especially in University hospitals. They also have an invaluable impact on patient outcomes. As new entrants in the care field, intern nursing students should possess empathy and demonstrate caring behavior towards their patients. These factors greatly influence patients’ well-being and health outcomes [ 5 , 6 ]. Moreover, intern nursing students will be able to gradually improve their caring behavior and empathy toward patients by receiving emotional support from others [ 1 , 7 ]. Intern nursing students who receive emotional support and exhibit empathy are more likely to engage in caring behaviors. This enhances care quality, patient satisfaction, and improved health outcomes [ 8 , 9 ]. Nursing students can receive emotional support within a social context, be it from family, friends, or significant others, and form a crucial web of connections that sustains and nurtures individual well-being. Each relationship contributes a unique blend of understanding, empathy, and encouragement, creating a tapestry of support that strengthens the fabric of one’s emotional resilience. Significant others as clinical educators, their role extends beyond imparting clinical knowledge; they become trusted allies who understand the unique challenges of nursing education and offer empathetic support, fostering a sense of belonging and confidence in the student’s ability to navigate the complexities of their chosen profession [ 10 , 11 ].

Empathy stands out as an essential trait and a valuable asset to be possessed by graduate nurses. It is identified as the ability to comprehend and share the feelings of others. According to the American Nurses Association (2021), empathy is entering into, being sensitive to, and understanding another person’s feelings, thoughts, and experiences without having those feelings, thoughts, and experiences of oneself [ 12 , 13 , 14 , 15 ]. An empathic nurse can help establish a strong rapport with her patient, understand his unique needs and circumstances, and provide compassionate care. Empathizing with the patients can provide more personalized care and support, leading to better patient health outcomes and improved patient satisfaction [ 1 , 8 , 13 ].

In addition, empathy can also help intern nursing students manage their own emotions and cope with the stress and challenges of their profession, which in turn helps them provide emotional support to their patients. Empathy is critical for nurses to enhance the quality of care and strengthen the nurse-patient relationship [ 16 , 17 ]. In this respect, Korkmaz Doğdu et al. (2022) conducted a correlational study on nursing students’ empathy levels and caring behavior perceptions. This research reveals the significant influence of a student’s development on their empathy and caring behaviors. As students progress in their educational levels, there is a corresponding increase in both empathy and caring behaviors. It has been established that maintaining empathetic understanding and possessing practical communication skills positively contribute to caring behaviors. This study distinctly emphasizes the crucial role of nurturing ontological caring competencies in the development of nursing students [ 18 ].

Emotional support is of utmost importance for the well-being of nurses, particularly intern students, who often face high levels of stress and emotional exhaustion due to the demands of their professional careers. According to Kort-Butler (2017), emotional support perception is a term rooted in the broader concept of social support, encompassing receiving care, consideration, empathy, affection, and trust (19). Emotional support is crucial to address these challenges and promote mental health and job satisfaction. Recognizing and offering emotional support to nurses is essential, as it can significantly enhance their job performance and overall well-being. Creating a therapeutic environment through emotional support facilitates self-healing and promotes well-being. Intern nursing students may receive support from their families, colleagues, and academic supervisors. Previous research demonstrated that emotional support from colleagues and supervisors is a crucial predictor of new nurses’ job satisfaction, intention to remain in their profession, and ability to deliver compassionate care to their patients [ 11 , 19 , 20 , 21 ].

A study by Zhou et al., 2022 found an association between perceived emotional support and psychological well-being among nursing students. This is clarified through the mediating factors of self-compassion and professional self-concept. A positive association between heightened self-compassion and a more favorable professional self-concept is noted. This suggests that perceived emotional support can foster self-compassion and a positive professional self-concept, enhancing psychological well-being. These findings emphasize the need for emotional support to improve nursing students’ assets and improve nursing care [ 22 ].

Caring behavior is a fundamental aspect of nursing care, including actions and attitudes that demonstrate compassion, empathy, and respect toward patients and their families. The International Council of Nurses (2012) defines caring as the “essence of nursing,” emphasizing establishing therapeutic relationships that acknowledge individual patient needs and promote well-being. Caring behaviors manifest in various forms, including providing emotional support, administering medications, and advocating for patients’ rights and preferences [ 9 , 23 , 24 ].

Furthermore, caring behavior plays a critical role in patient-centered care. It prioritizes involving patients and their families in the care process and delivering personalized care tailored to their needs and circumstances. When intern nursing students exhibit caring behaviors, they enhance the quality of care and foster a nurturing environment that supports patients’ recovery and well-being. In summary, caring behavior improves patient outcomes and is vital to nursing care. The nurse’s perception of emotional support and empathy can influence patient caring behavior [ 23 , 24 , 25 , 26 ].

Despite the existing knowledge on empathy, emotional support, and caring behavior, a paucity of research explicitly articulates the intricate interplay between these variables, especially in the context of intern nursing students. Few studies may have explored empathy as a mediator between emotional support and caring behavior. Yet, the unique challenges and dynamics faced by intern nursing students during their training were not addressed [ 16 , 19 , 26 , 27 , 28 ].

In the context of intern nursing students, it is hypothesized that the emotional support they receive may influence their empathy towards patients, affecting their caring behavior. When nursing students receive emotional support from their educators, mentors, or peers, they may develop a greater capacity for empathy toward patients. Through guidance, encouragement, and constructive feedback, clinical educators and staff help alleviate the stress and anxiety often associated with rigorous training. This enhanced empathy can translate into more caring and compassionate behaviors when interacting with patients. Understanding the role of empathy in this relationship is crucial for nursing education and practice. By recognizing the impact of emotional support on empathy and subsequent caring behavior, educators and mentors can emphasize the importance of creating a supportive learning environment that nurtures empathy development in nursing students. This, in turn, can contribute to cultivating a caring and empathetic healthcare workforce that prioritizes patient well-being and satisfaction [ 1 , 2 , 28 ]. Therefore, this study aims to identify the role of empathy in the relationship between the perception of emotional support and caring behavior toward patients among intern nursing students.

The study objectives are to

Investigate how empathy plays a role in shaping the relationship between emotional support and caring behavior among intern nursing students.

Investigate the direction of correlation between empathy, emotional support, and caring behavior among intern nursing students.

Assess whether empathy mediates the association between emotional support and caring behavior in intern nursing students.

Study questions

How Does Empathy Influence the Relationship Between Emotional Support and Caring Behavior among Intern Nursing Students?

Investigate the degree to which empathy enhances or mediates the connection between emotional support from nursing students and the subsequent demonstration of caring behavior towards patients.

What factors impact the caring behavior of intern nursing students?

Methodology and materials

Study design.

The present study employed a descriptive correlational design.

Setting &participants

The research was conducted at Alexandria and Damanhur University’s College of Nursing. A total of 450 and 400 nursing students were in their internship years of 2022–2023 at Alexandria and Damanhur University, respectively.

The G*Power Windows 3.1.9.7 software is employed for determining the sample size required for a study, explicitly using calculations based on F tests in the context of linear multiple regression with a fixed model and the R² deviation from zero. The analysis is a priori, aiming to compute the necessary sample size. In this case, the input parameters include an effect size of f² = 0.15, an alpha error probability (α) of 0.05, and a desired statistical power (1-β error probability) of 0.95. The analysis involves 10 predictors. The output from the program provides the noncentrality parameter (λ) as 25.8000000, the critical F value as 1.8899310, numerator degrees of freedom as 10, denominator degrees of freedom as 161, and the total sample size required for the study is calculated to be 195. The initial sample size was calculated as 206 intern nurses, but to account for potential attrition, the researchers opted to recruit a slightly larger sample, targeting 206 students.

The eligibility criteria for this study required participants to be novice intern nurses commencing their duties in September 2022, shaving completed three months of patient care as empathy depends on many factors, including the length of contact. Also, intern students should display consistent attendance and be willing to engage in research activities. Additionally, exclusion criteria were students with psychological illness, irregular attendance, and those over 30 years old to maintain a more homogeneous age group within the sample. This decision helps control for potential variations in life experiences and personal responsibilities while minimizing potential influences from diverse academic experiences or prior professional roles that may differ between younger and older nursing students.

The sample selection process utilized a blind approach, incorporating a systematic randomized technique to identify participants from the overall pool of intern nurses. The steps involved were as follows:

A comprehensive list containing all nursing interns’ names and relevant data was compiled and digitized into a computer-generated randomization list program (450, 400 for Alexandria, and Damnhour).

This randomization program selected 206 intern students from this list through a random sampling to ensure fairness and minimize bias.

Each randomly selected student was screened to identify those meeting the predetermined inclusion criteria and contacted to assess their willingness to participate.

Six nursing students declined to participate and didn’t match the inclusion criteria, leaving 200 intern students as the final sample size.

Participants were assigned to the Alexandria or Damanhur group (200), with an equal distribution of 100 students each for Alexandria and Damanhur University (Insert Figure: 1 ).

The data collection phase spanned two months, from the beginning of July 2023 to the end of August 2023, adhering to stringent guidelines to ensure the validity and reliability of the findings.

Sample graph

Measurements

This research utilized four distinct tools for data collection.

Tool I: The academic and social form survey comprised two sections. The first part gathered social information about the students, such as sex, age, place of residency, marital status, monthly expenses, and whether they had a job while studying. The other part gathered academic data, including the overall cumulative GPA and information about extracurricular activities.

Tool II: The Toronto Empathy Questionnaire (TEQ) by Spreng et al. (2009) for psychological assessment of an individual’s level of empathy. This scale captures cognitive empathy (the ability to understand others’ emotions) and affective empathy (the ability to share and experience others’ feelings). It consists of 16 items with 8 statements ( 2 , 4 , 7 , 10 , 11 , 12 , 14 , and 15 ) from the scale that are negatively stated and reversely scored. The responses to statements are rated on a five-point Likert scale that ranges from 0 (never) to 4 (always), with higher scores indicating greater levels of empathy [ 29 ]. Xu et al. (2020) found this tool valid and reliable among medical students [ 30 ]. Using the Pearson correlation coefficient in the current study, this tool proved to be trustworthy by test-retest (0.74).

Tool III: Caring Dimension Inventory (CDI) , developed by Watson & Lea (1997), consists of 25 items to measure different aspects of nursing caring behavior. Patient Responses were rated on a 5-point Likert scale, with higher scores indicating higher caring behavior [ 31 ]. The Caring Dimension Inventory is widely used among nursing students and has proven consistent with high reliability [ 32 , 33 ]. CDI was tested in the current study by test-retest and proved reliable (Pearson correlation coefficient = 0.8).

Tool IV: The Multidimensional Scale of Perceived Social Support (MSPSS) is a widely used self-report questionnaire designed to assess how individuals perceive support in various aspects of their lives [ 34 ]. The MSPSS consists of 12 items that cover three subscales (family support, friend support, and significant other support), with each item rated on a 7-point Likert-type scale, ranging from 1 (very strongly disagree) to 7 (very strongly agree). Higher scores indicate higher levels of perceived social support from that source. The MSPSS has demonstrated good reliability and validity among nursing students [ 35 ]. In the present study, MSPSS proved valid and reliable by test-retest with a Pearson correlation coefficient 0.72.

The research received approval from the Alexandria Research Ethics Committee ( IRB:13,620 ). The study obtained further official authorization from the Vice Dean of Students’ Affairs at the Faculty of Nursing in Alexandria and Damanhur, Egypt, granting permission to conduct the research. The contact information of the nursing interns, including their academic email addresses and phone numbers, was obtained from the Internship Affairs unit of Alexandria and Damanhur University and kept confidential.

The researchers developed a tool following a thorough review of the existing literature. A panel of five experts assessed the TEQ, CDI, and MSPSS instruments for face validity and confirmed their validity. Tools II, III, and IV were assessed by conducting a test-retest reliability analysis on a subset of 20 nursing intern students. The results demonstrated high reliability for these instruments.

Before nursing students’ involvement in the study, all participants provided informed consent, with full knowledge that their participation was voluntary and they had the right to withdraw without facing any consequences. A pilot study evaluated the clarity, comprehensibility, and feasibility of the research tools. The findings indicated that the instruments were clear, understandable, and practical for the primary research study. It is important to note that the test-retest reliability assessment involving the intern nursing students and the pilot study were not included in the primary research analysis.

Each recruited subject was interviewed individually to establish rapport and apply tool I, followed by II, III, and IV. Twenty to thirty minutes were needed to complete the data. The collected data were inputted into a computer and analyzed using the IBM SPSS software package version 23.0.

VII. Statistical analysis

The normality of variable distributions was assessed using the Kolmogorov-Smirnov test. Group comparisons were conducted using the Chi-square test for categorical variables. When comparing more than two categories, the one-way ANOVA test was utilized. The Student t-test was employed to compare two categories of quantitative variables that followed a normal distribution. The Pearson coefficient was used to examine the correlation between customarily distributed quantitative variables. Linear regression was assessed to detect factors that affect the Caring Dimension Inventory. Path analysis was evaluated using AMOS 23. 0 software to detect H’s direct and indirect effects. The Multidimensional Scale of Perceived Social Support on the Caring Dimension Inventory with the Toronto Empathy Questionnaire as a mediator.

Socio-demographic characteristics and relations with study variables

Table 1 presents participants’ social and academic data and differences in mean regarding empathy, caring behavior, and emotional support. It was observed that more than half of the participants were males. Regarding their age, approximately two-thirds of the participants fell within the age range of 23 to less than 25 years, with total Mean (SD) = 23.76 (3.6).

Table 1 also indicates a statistically significant relation between sex, age, residence, marital status, monthly expense, and private work and the mean of empathy ( p  < 0.001, p  = 0.004, p  < 0.001, p  = 0.035, p  = 0.025, and p  < 0.001, respectively). Regarding caring behavior, a statistically significant relationship was observed with sex, age, monthly expense, and private work ( p  < 0.001, p  = 0.049, p  = 0.013, and p  = 0.005, respectively). Finally, a statistically significant relationship was observed between sex, age, monthly expense, and private work about the mean of emotional support ( p  < 0.001, p  = 0.003, p  = 0.001, p  < 0.001, & p  < 0.001, respectively).

Table 2 shows participants’ academic characteristics and differences in mean regarding empathy, caring behavior, and emotional support. It was observed that intern nursing students affiliated with Alexandria University had a higher mean of empathy, caring behavior, and emotional support than those affiliated with Damanhur University. Participants’ affiliation revealed significant variations in caring behavior and emotional support ( p  < 0.001), while an insignificant relationship was noted between empathy and participants’ affiliation ( p  = 0.171). The results show that students who didn’t participate in social or academic activities had the highest mean of empathy, caring behavior, and emotional support, with a statistically significant difference ( p  = 0.001, p  = 0.021& p  < 0.001respectively. The table also illustrates that the studied students who obtained excellent or very good grades had the highest mean of empathy, caring behavior, and emotional support, with a statistically significant difference ( p  < 0.001).

Study measures and correlations

Table 3 reveals the association between empathy, caring behavior, and emotional support levels among the studied students. It can be noticed that a significant positive correlation was found between empathy, caring behavior, and emotional support ( P  < 0.001). This means that a high level of empathy indicates a higher level of caring behavior and emotional support.

Figure  2 ; Table  4 present the results of the standardized regression weights, standard error (SE), critical ratio (CR), and significance (p-value) for both the direct and indirect effects of emotional support on caring behavior mediated by empathy. These results were generated using SPSS-AMOS.

Regression analysis: predictors of caring behavior

Table  4 delineates the findings of a path analysis scrutinizing the direct and indirect effects of emotional support on caring behavior within the domain of intern nursing students, with empathy as a mediator. Significantly, a positive and statistically significant direct impact of emotional support on empathy is evident, underscoring the association between increased emotional support and heightened levels of empathy among intern nursing students. Moreover, a substantial direct effect of emotional support on caring behavior is highlighted, suggesting a strong link between augmented emotional support and intensified caring behavior towards patients during the internship.

However, while present, the indirect effect of empathy on caring behavior is quantitatively limited and lacks statistical significance at the conventional level. The modest impact of empathy in mediating the relationship between emotional support and caring behavior suggests that other factors may contribute more substantially to the observed caring behavior among intern nursing students.

The model demonstrates a commendable fit to the data, supported by Comparative Fit Index (CFI) and Incremental Fit Index (IFI) values close to 1.000 and a reasonable Root Mean Square Error of Approximation (RMSEA).

The path analysis of the standardized coefficients assessed emotional support’s direct and indirect effects on caring behavior, with empathy mediating

Table  5 presents factors predicting caring behavior among the studied subjects using multiple linear regression analysis. It can be noticed that caring behavior significantly increased with the increased intern nursing students’ emotional support and among those who were not working in private hospitals ( p  < 0.001,& p  = 0.023 respectively) with a regression coefficient of 0.644. Other sociodemographic characteristics and empathy were not significant predictors of caring behavior in the model.

As nursing students progress through their training, they encounter challenging and emotionally charged situations, such as witnessing patients’ suffering and dealing with family and patients’ grief and loss. During these moments, the value of receiving emotional support from peers, family, mentors, and faculty members becomes immense. This support creates safe and empathetic opportunities for nursing students to process their emotions, manage stress, and preserve their well-being. Consequently, it cultivates resilience, compassion, and empathy, which help them develop stronger connections with patients [ 36 ].

Intern nursing students receiving emotional support tend to exhibit caring behaviors, such as active listening, comforting touch, effective communication, and personalized care. They comprehend the significance of addressing not just the physical needs of patients but also their emotional and psychological well-being. Integrating emotional support into their practice prepares nursing students to deliver holistic care, fostering a therapeutic environment for healing and recovery [ 37 , 38 ]. Therefore, this study explored the association between empathy, emotional support, and caring behavior among intern nursing students.

The study findings revealed a significant positive correlation between empathy and caring behavior. This may be because empathy is one dimension of caring behavior, so intern nursing students with higher levels of empathy are more likely to exhibit more remarkable care development, leading to increased accountability, ethical problem-solving, and overall growth in providing care. These findings align with previous studies emphasizing the link between nursing students’ caring behaviors and empathy [ 39 , 40 , 41 ].

The study also found a significant association between emotional support and caring behavior. This result is supported by linear regression analysis in the present study, which showed that emotional support is one predictor of caring behavior toward the patient. This suggests that providing emotional support from families, peers, or others creates a nurturing and supportive environment that fosters a sense of concern, understanding, and appreciation among nursing students. Therefore, they can address patients’ emotional needs, utilizing active listening, offering reassurance, establishing meaningful connections, promoting trust, and delivering patient-centered care. This, in turn, enhances their caring behavior towards patients [ 42 ].

Moreover, the present study’s results revealed a statistically significant correlation between emotional support and empathy among intern nursing students. This suggests that individuals receiving higher emotional support tend to empathize more with their patients. Empathetic individuals are more attuned to others’ emotional states, better able to recognize when emotional support is needed, and more likely to respond in a caring and compassionate manner, alleviating distress and promoting well-being. Empathy creates a sense of connectedness, fostering trust and openness in relationships (27.42).

Furthermore, empathy is crucial in the relationship between emotional support and caring behavior toward patients among intern nursing students. Emotional support received by nursing students can profoundly impact their empathetic abilities. When students feel supported and understood by their educators, family members, and peers, they are more likely to develop a heightened empathy toward patients. Korkmaz Doğdu et al. (2022) concluded that increasing empathy among nursing students catalyzes demonstrating caring behaviors during patient interactions [ 18 ]. The mediating role of empathy is significant because it bridges the gap between the emotional support received by nursing students and their subsequent caring behavior towards patients. It has been proven that health professionals with high levels of empathy operate more efficiently to fulfill their role in eliciting therapeutic change [ 27 ]. .

Concerning the current nursing students’ social data and their relation to empathy, the present study found that younger nursing interns demonstrated significantly higher mean empathy than older nursing interns. This may be attributed to the influence of social environments, social prejudices, stereotypes, and racial bias, which can reduce empathic responses [ 43 , 44 ]. Regarding sex differences, female nursing students exhibited a higher mean of empathy compared to their male peers. This finding is consistent with previous studies attributing higher female empathy levels to their perceived emotional sensitivity and societal gender role norms [ 42 , 43 , 44 ]. Additionally, marital status impacted empathy, with married nursing students demonstrating the highest mean score. This may be related to the role of mothers in providing care, love, and support to their spouses and children. According to the author, the conflicting results could be due to the low percentage of married students (25.2%) in this study, which has resulted in biased results. This result aligns with a previous study that reported married nursing interns scored higher in the empathic concern subscale than unmarried nursing interns. This means that married nursing interns felt more sympathy and caring for others than unmarried nursing interns [ 1 ].

The study examined the academic characteristics of the studied students and their relation to empathy. It revealed a statistically significant positive association between empathy and the grade point average (GPA) of intern nursing students. This suggests that empathy is a skill that can be cultivated through educational processes, and higher-achieving students tend to exhibit higher levels of empathy [ 45 , 46 , 47 , 48 ]. However, some studies have reported no significant changes in empathy levels across different GPA points among nursing interns [ 49 , 50 , 51 ].

The study also examined the mean of empathy, emotional support, and caring behavior among intern nursing students related to University affiliation. Nursing students affiliated with Alexandria University had a higher mean compared to those affiliated with Damanhur University. These differences may be attributed to variations in the development of these competencies within each nursing program. The absence of a unified nursing curriculum between the two Universities highlights the need for a national unified nursing curriculum and standardized nursing education to ensure the consistent development of empathy and caring behavior among nursing interns (51,52).

In conclusion, emotional support is a crucial attribute for intern nursing students. This support helps them alleviate stress, boost their self-confidence, and contribute to their overall well-being. As a result, they are more likely to demonstrate caring behavior towards their patients and colleagues, resulting in improved patient outcomes and satisfaction.

The study underscores the considerable importance of emotional support received from others and empathy in promoting caring behavior among intern nursing students. Our findings emphasize the critical need for empathy training within nursing curricula. By investing in programs that enhance students’ ability to empathize with patients, educators can nurture a more compassionate approach to care. Additionally, our results highlight the importance of providing emotional support to nursing students, particularly during internships. Creating a supportive environment where students feel valued can foster empathy development and ultimately enhance patient care. Moreover, the study underscores the significance of tailoring support for interns, especially those working in non-private hospitals. Implementing strategies to assist interns in navigating challenges and promoting a culture of support can facilitate the cultivation of caring behaviors. Lastly, understanding the mediating role of empathy sheds light on the interconnectedness of empathy, emotional support, and caring behavior. This insight can inform the design of interventions to strengthen empathy as a pathway to improving patient outcomes. Our study underscores the vital role of empathy and emotional support in nursing education and practice, urging healthcare institutions to prioritize these aspects to cultivate a workforce of compassionate and empathetic nurses.

Limitations

The study focused on intern nursing students, which limits the generalization of the findings to other healthcare professionals or individuals in different stages of their nursing education. Further research with a more diverse sample is needed to validate the findings in various contexts. The research relies on self-reported data, which may be subject to social desirability bias or inaccuracies due to subjective interpretations. Future studies could incorporate additional objective measures or observational data to strengthen the validity of the findings.

Our study sheds light on the intricate dynamics between empathy, emotional support, and caring behavior among intern nursing students. The findings underscore the significant association between empathy, caring behavior, and emotional support, highlighting the pivotal role of empathy in fostering compassionate care. Significantly, higher levels of empathy were correlated with increased levels of caring behavior and emotional support, emphasizing the importance of nurturing empathy skills within nursing education and practice.

Furthermore, our results reveal the nuanced influence of emotional support on caring behavior, particularly among intern nursing students. The study demonstrates that providing emotional support is associated with enhanced caring behavior, especially in environments outside private hospitals. This underscores the need for tailored support systems to assist interns, particularly in non-private hospital settings, to foster a culture of empathy and compassion.

Moreover, our findings indicate that empathy is a mediating factor in the relationship between emotional support and caring behavior. This suggests that interventions promoting empathy may serve as a pathway to enhancing caring behavior among nursing students. Understanding the mediating role of empathy offers valuable insights into strategies for improving patient care outcomes by strengthening empathy skills among healthcare professionals.

Data availability

No, I don’t have any research data outside the submitted manuscript file.

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Acknowledgements

Our sincere thanks go to all the study participants.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

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Psychiatric and mental health Nursing, Psychiatric and mental- health nursing Department, Faculty of Nursing, Alexandria University, 9 Edmond Vermont Street, Smouha, Alexandria City, Egypt

Mohamed Hussein Ramadan Atta

Faculty of Nursing, Psychiatric Nursing Department, Admeon Freemon ST, Semoha, Alexandria City, Egypt

Psychiatric Nursing and Mental Health, Faculty of Nursing, Damnhour University, Damnhour City, Egypt

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Mohamed Hussein Ramadan Atta: Selection problem, Methodology, Ethical approval seeking, data collection, collecting data of participants, writing-original draft, and editing. Heba Abdel-Hamid Hammad: theoretical framework, blind data selection of the study, discussing the main results, and writing-review. Nadia Waheed Elzohairy: proposal revision, and data statistical analysis, collecting data of the study, table comments, writing-original draft, and editing. The authors read and approved the final manuscript.

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Correspondence to Mohamed Hussein Ramadan Atta .

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Atta, M., Hammad, HH. & Elzohairy, N. The role of Empathy in the relationship between emotional support and caring behavior towards patients among intern nursing students. BMC Nurs 23 , 443 (2024). https://doi.org/10.1186/s12912-024-02074-w

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• Caring Behavior
• Emotional support
• Intern nursing students
• Mediating role
• Nurse-patient relationship

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The Spanish Version of the Sussex-Oxford Compassion for Others Scale (SOCS–O) in Nursing Students: Psychometric Properties and Its Relation with Mindfulness

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• Published: 03 July 2024

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• Noemí Sansó   ORCID: orcid.org/0000-0002-5847-9654 1 , 2 ,
• Tamara Escrivá-Martínez   ORCID: orcid.org/0000-0001-6632-8402 3 , 4 ,
• Sarah Flowers   ORCID: orcid.org/0009-0003-2089-7716 1 ,
• Michael A. West   ORCID: orcid.org/0000-0003-2698-0847 5 , 6 &
• Laura Galiana   ORCID: orcid.org/0000-0002-5342-5251 7  

This study aimed to examine the psychometric properties of the Sussex-Oxford Compassion for Others Scale (SOCS–O) in a large sample of Spanish undergraduate nursing students.

After a forward–backward translation process, we conducted a cross-sectional study among nursing students in their first year of training at two Spanish universities. The mean age of the participants ( n  = 683) was 22.74 years old, and 83.46% were women. Together with compassion for others, mindfulness was also assessed.

Descriptive results revealed high scores across all dimensions of the SOCS–O. The data supported a 3-factor structure with correlated factors ( χ 2 (167) = 363.47, p  < 0.01; CFI = 0.96; TLI = 0.95; RMSEA = 0.05, 90% CI = 0.04, 0.05; SRMR = 0.04). Reliability estimates, measured by Cronbach’s alpha, were excellent, ranging from 0.87 to 0.93. Measurement invariance across gender was confirmed. Men exhibited significantly lower levels in all compassion dimensions: Recognizing suffering (mean difference =  − 0.40), Understanding the universality of suffering (mean difference =  − 0.33), and Behavioral compassion (mean difference =  − 0.57) (all p  < 0.01). The structural equation model showed a clear relationship between mindfulness and compassion ( χ 2 (581) = 1345.79, p  < 0.01; CFI = 0.92; TLI = 0.92; RMSEA = 0.04, 90% CI = 0.04, 0.04; SRMR = 0.06).

Conclusions

The findings showed that the Spanish version of the SOCS–O has robust psychometric properties. The SOCS–O is a reliable tool for measuring compassion with three subscales and helps advance understanding of compassion among student nurses. The positive relationship between mindfulness and compassion suggests that incorporating mindfulness training into nursing curricula could enhance the delivery of compassionate care.

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Compassion has long been esteemed as an essential virtue in the major contemplative traditions (Dahlsgaard et al., 2005 ). Compassion is a fundamental human quality that generates altruism and generosity, as it motivates people to help alleviate suffering so resulting in a greater connection with others (Lama, 2002 ). It has been suggested that this sense of connection that compassion generates is a protective factor of mental health, due to its positive relationship with well-being and its negative relationship with depressive symptoms and stress (Gilbert et al., 2017 ). Consequently, compassion has become an area of special interest in many different fields, such as psychology, nursing, medicine, and education in recent years (Seppälä et al., 2017 ).

Compassion has been defined in many ways. Generally, it is understood as the awareness of another’s suffering and the desire to alleviate it (Chochinov, 2007 ; Goetz et al., 2010 ; Klimecki & Singer, 2013 ; Sprecher & Fehr, 2005 ). A review of the literature showed five principal dimensions of compassion: the recognition of another’s suffering, the understanding of another’s suffering, the feeling of empathy and concern for the person suffering, the tolerance of the distress caused by seeing the person suffer, and the motivation to reduce the suffering of the other (Gu et al., 2020 ; Jazaieri et al., 2013 ; Strauss et al., 2016 ).

Researchers’ efforts to understand compassion in clinical contexts have yielded significant insights, such as higher job satisfaction, mental health protection, and patient well-being (Galiana & Sansó, 2019 ; Klimecki & Singer, 2013 ; Matos et al., 2022 ; Seppälä et al., 2017 ); however, challenges remain from an educational perspective, where there is a lack of knowledge about how students practice compassion. Being compassionate to others is considered essential in all settings, yet is especially true in the healthcare context, and even more so within nursing (Bickford et al., 2019 ; Sinclair et al., 2018 ). The nursing profession is defined by its close contact with people’s suffering, stemming from health problems and negative emotional experiences. Understanding the suffering of others and the attempt to alleviate it is essential within this profession, where it is necessary to cater to patient needs and to enhance patient care. Ultimately, it can be argued that compassion is needed to improve the overall quality of healthcare delivery (Kelley et al., 2014 ). This is reflected in the six Cs of caring, where compassion is identified as one of its key pillars—compassion, competence, confidence, conscience, commitment, and comportment (Roach, 2002 )—thus emphasizing its importance in nurse education.

Although compassion is essential for nurses and, therefore, should be addressed during their training, research studying compassion among nursing students, along with its determinants and consequences, is scarce. For example, some studies have focused on the role of optimism, hope, or resilience (Jarden et al., 2021 ), but have been descriptive in nature, without delving into their role as sources of compassionate healing. Although the literature on nursing students has expanded in recent years, it continues to be extremely poor in terms of addressing compassionate care. Increasing our understanding of compassion as a resource is key, especially in light of recent studies that indicate higher levels of burnout and work-induced stress in the nursing profession, a factor which has been shown to increase compassion fatigue and erode the capacity for compassion (Galiana & Sansó, 2019 ; Jinpa, 2015 ; Trzeciak & Mazzarelli, 2020 ). The little available evidence also suggested that nursing students’ caring behavior decreased as they progressed through their studies (Curtis, 2014 ).

With consideration of the highly stressful challenges faced by the nursing profession today and the documented erosion of the capacity to deliver care with compassion as a result of it, fostering compassion is essential. Especially among students, who are to be the future of the profession. It is of note then that there remains limited evidence of compassion in the vision, mission, and value statements of many nursing institutions. In a review carried out by Younas and Maddigan ( 2019 ), no evidence of the importance of compassion in nursing schools’ guiding statements was found. A closer look at our context, which included nursing education curricula from the University of Valencia and the University of the Balearic Islands, leads us to believe that this is also the case for the Spanish curricula. The lack of attention regarding compassion and compassionate resources by nursing schools is concerning, as compassionate care is needed in every nurse-patient interaction, as seen by repeated calls to action to foster compassion in students. Nursing education is formative in the socialization of nurses’ attitudes and values, particularly that of compassion. Nursing education is therefore an opportunity to improve the current situation, where compassion is not regarded as the powerful resource it could be.

One of the ways to improve compassion among nursing students is to introduce mindfulness-based interventions as part of their educational program. Mindfulness has been repeatedly shown to increase feelings of compassion among those who practice it, so could benefit students who are about to enter potentially stressful situations, not only with their own compassionate self-care but also for their patients (Conversano et al., 2020 ; Dariotis et al., 2023 ). Mindfulness has been defined as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994 , p. 4). Mindfulness can also occur during interpersonal interactions and has been termed “interpersonal mindfulness” (Pratscher et al., 2019 ). Being present with others, here and now, is a prerequisite for recognizing pain and distress and therefore being capable of compassion.

A recent systematic review noted that compassionate interventions increase levels of mindfulness and reduce interpersonal conflict (Conversano et al., 2020 ). In turn, compassion is also strengthened through mindfulness exercises (Huppert, 2018 ). Both mindfulness and compassion have many benefits, including reducing negative emotions (Don et al., 2022 ; Han & Kim, 2023 ), increasing positive emotions (Tran et al., 2022 ), and helping to build a more enriching family environment (Dariotis et al., 2023 ), as well as reducing caregiver burden (Juberg et al., 2023 ).

Several mindfulness-based interventions have been proven to improve well-being among nurses and nursing students. For example, the review carried out by van der Riet et al. ( 2018 ) showed that mindfulness meditation had a positive impact on stress, anxiety, depression, burnout, sense of well-being, and empathy. However, there has been less empirical research on the relationship between mindfulness and compassion among nurses and nursing students. Erkin and Aykar ( 2021 ) found an increase in nursing students’ self-compassion after a yoga course. More recently, Baminiwatta et al. ( 2023 ) found a positive correlation between trait mindfulness and compassion in nurses, with the latter partially mediating the effects of trait mindfulness on helping and avoidance. Other studies, however, have failed to find an effect of meditative-based interventions on nursing students’ compassion levels (Joseph & Raque, 2023 ). Despite this last study, which had several limitations (brief intervention, post-intervention measures only), it has been widely demonstrated that compassion has numerous benefits (Matos et al., 2022 ). This is why in recent years there has been an increasing interest in the development of scales that can provide a reliable and valid measurement of this construct.

There are various scales that measure the construct of compassion for others: the Compassionate Love Scale (CLS; Sprecher & Fehr, 2005 ), a 21-item self-reporting scale that measures compassionate love for others, both strangers and close contacts, across three areas (kindness and affection, acceptance and understanding, and help and sacrifice); the Relational Compassion Scale (RCS; Hacker, 2008 ), a 16-item scale that measures compassion for self and others; the Santa Clara Brief Compassion Scale (SCBCS; Hwang et al., 2008 ), a 5-item self-reporting scale that measures compassionate love felt toward strangers; the Compassion Scale (CS; Pommier et al., 2020 ), a 16-item scale made up of four subscales that measures: compassion for others, common humanity, mindfulness, least indifference, and most kindness; the Compassion Scale (CS-M; Martins et al., 2013 ), a 10-item self-reporting scale that measures five domains of compassion: generosity, hospitality, sensitivity, tolerance, and objectivity; and finally, the Compassionate Engagement and Action Scale (CEAS; Gilbert et al., 2017 ), a 10-item self-reporting scale that assesses engagement, compassion for others and compassion for self.

Scales assessing compassion for others within the healthcare context, as reported by healthcare providers, have also been recently developed and published. The Compassion Competence Scale (CCS; Lee & Seomun, 2016 ) consists of 18 items measuring three dimensions of compassion for nursing professionals (communication, insight, and sensitivity). The Bolton Compassion Strengths Indicators (BCSIs; Durkin et al., 2020 ) consists of 48 items that measure the strength of compassion in nursing students, including self-care, empathy, commitment, and competence.

Yet despite the development of compassion measures, there remains a lack of consensus on the definition of compassion and its distinguishing characteristics, which impedes the development of reliable measures. Strauss et al. ( 2016 ), in a review of definitions, demonstrated that compassion for others consisted of five elements: (1) recognizing suffering, (2) understanding suffering, (3) caring and empathizing with the suffering person, (4) tolerating the distress generated by another’s suffering, and (5) being motivated to alleviate the other’s suffering. The scales described above fail to capture these five dimensions, or fully measure compassion (Gu et al., 2020 ; Strauss et al., 2016 ). Furthermore, none of them assessed compassion in a methodologically rigorous manner, and few employed robust psychometric measures (Strauss et al., 2016 ).

To address these shortcomings, Gu et al. ( 2020 ) developed the Sussex-Oxford Compassion for Others Scale (SOCS–O), a 20-item self-administered scale that measures compassion, including the five dimensions discussed above. Items score in a 5-point Likert-type scale ranging from 1 ( not at all true ) to 5 ( always true ). Unlike previous self-report scales, this measure demonstrates robust psychometric properties including reliability, interpretability, convergent and discriminant validity, and internal consistency (Gu et al., 2020 ), factors which allow for its use in practice and research. In further studies, this five-factor with correlated factors structure has been replicated (i.e., de Krijger et al., 2022 ; Sarling et al., 2024 ). A specific example of this was Sarling et al. ( 2024 ) who also tested a unidimensional structure and a three-factor with correlated factors structure, in which items of Caring and empathizing with the suffering person; Tolerating the distress generated by another’s suffering; and Being motivated to alleviate the other’s suffering were explained by a Universal latent variable, which both resulted in a poorer fit.

Regarding reliability estimates, the ones reported by Sarling et al. ( 2024 ) ranged from 0.70 for Tolerating the distress generated by another’s suffering to 0.87 for Recognizing suffering. Similar values were found by de Krijger et al. ( 2022 ), with values ranging from 0.68 for Recognizing suffering to 0.88 for Being motivated to alleviate the other’s suffering.

Evidence of measurement invariance for gender has been gathered, with varying results. Whereas Kim and Seo ( 2021 ) found partial evidence of measurement invariance, Sarling et al. ( 2024 ) found evidence of metric invariance, but pointed out some concerns with scalar invariance. De Krijger et al. ( 2022 ), in turn, found evidence of scalar invariance across gender in a sample of crisis line volunteers and in a sample of soldiers. However, they did not test gender invariance for nursing students.

The SOCS–O has been validated in different countries and languages, namely Swedish (Sarling et al., 2024 ), Dutch (de Krijger et al., 2022 ), Korean (Kim & Seo, 2021 ), Persian (Nikgoo et al., 2022 ), Slovak (Halamová & Kanovský, 2021 ), and Italian (Lucarini et al., 2022 ). However, few studies have examined the psychometric properties of the SOCS–O scale in the Spanish language, the fourth most widely used language in the world (after English, Mandarin and Hindi), spoken by more than 500 million people worldwide.

It is important that future nurses have the competency for compassion in order to provide high-quality, compassionate patient care. The first step towards this is to have a robust and valid instrument that assesses compassion in nursing students. Therefore, the main objective of the present study is to examine, for the first time, the psychometric properties of the SOCS–O in a large sample of Spanish undergraduate nursing students. Our specific aims were (1) to provide evidence of nursing students’ levels of compassion; (2) to study the internal factor structure of the Spanish version of the SOCS–O; (3) to provide evidence of the reliability of the scale; (4) to test its measurement invariance across gender; and (5) to evaluate criterion validity of the SOCS–O by means of structural equation modelling in which students’ levels of mindfulness are related to their levels of compassion, while simultaneously controlling for gender and age.

Participants

Raosoft® software was used to calculate the minimum sample size needed in order to adequately represent the nursing students’ population from the two participating universities. The population of the first year of nursing students was calculated to be n  = 892, with a confidence interval of 95% (alpha = 5%) with an error limit of 5%, and p  =  q  = 0.50; the number of elements of the sample to obtain was n  = 269.

For this specific study on the psychometric properties of the SOCS–O, we also calculated the sample size required for a confirmatory factor analysis. The calculation was based on the original structure, given the number of observed (20) and latent variables in the model (5), the anticipated effect size (0.50), and the desired probability and statistical power levels (0.05 and 0.90, respectively). For this purpose, we used Daniel Soper’s Free Statistics Calculator version 4.0. The recommended minimum sample size was n  = 100.

The final sample was composed of 683 nursing students. 83.5% ( n  = 570) were women. The mean age was 22.74 years old ( SD  = 7.65). 54.8% ( n  = 374) were University of Valencia students, and 45.2% ( n  = 309) were students of the University of the Balearic Islands. The majority of the students were not working at the time of the survey (70.4%, n  = 481). 13.5% ( n  = 92) were working as healthcare professionals. For more details, see Table  1 .

The study had a cross-sectional design. The first-year nursing students at the University of Valencia and the University of the Balearic Islands (Spain) were encouraged to participate. They were identified via the universities’ list of registered students. In order to be included, participants had to be nursing students in the first year of their degree. The students completed the questionnaire online in approximately 20 min. Data were gathered in May 2022 and May 2023.

The present study included, together with sample description characteristics, two main measurement instruments: the Spanish version of the Sussex-Oxford Compassion for Others Scale (SOCS–O; Gu et al., 2020 ) and the Freiburg Mindfulness Inventory (FMI; Walach et al., 2006 ) (Spanish version; Pérez-Verduzco & Laca-Arocena, 2017 ).

For the translation of the SOCS–O, we used the backward and forward translation process. First, the scale was translated into Spanish by a professional native speaker; it was then translated back into English by another native professional speaker. The final version was revised by three experts in psychometrics and mindfulness. In the final version, no differences were found. The resulting Spanish version of the scale can be consulted in Table  2 . Reliability estimates in this sample for the original structure of the scale were as follows: α  = 0.87 and ω  = 0.87 for Recognizing suffering; α  = 0.88 and ω  = 0.88 for Understanding the universality of suffering; α  = 0.82 and ω  = 0.82 for Feeling for the person suffering; α  = 0.74 and ω  = 0.88 for Tolerating uncomfortable feelings; and α  = 0.88 and ω  = 0.79 for Acting to alleviate suffering.

The FMI is a 14-item scale, assessing a general factor of mindfulness. Responses were made on a Likert-type scale, and ranged from 1 ( almost never ) to 4 ( almost always ). Reliability estimates in this sample were α  = 0.84 and ω  = 0.88.

Data Analyses

Firstly, descriptive statistics for the items and the total scores of the Spanish version of the SOCS–O were calculated. These included mean, standard deviation, and minimum and maximum scores.

Secondly, for the study of the internal structure, we used a sequence of models, including three confirmatory factor analyses that were hypothesized, estimated, and tested. A first five-factor with correlated factors model was hypothesized, in which five factors—Recognizing suffering, Understanding the universality of suffering, Feeling for the person suffering, Tolerating uncomfortable feelings, and Acting to alleviate suffering—explained the 20 items of the scale. The structure followed both the original work (Gu et al., 2020 ) as well as later translations (de Krijger et al., 2022 ; Sarling et al., 2024 ). Based on the high intercorrelations observed among certain subscales, two simpler structures were tested. The first one hypothesized a general factor of compassion for others that explained the 20 items of the scale. The last one hypothesized three-correlated factors of compassion for others: Recognizing suffering, Understanding the universality of suffering, and Universal or Behavioral compassion. The first two factors were based on the original structure of the scale, Recognizing suffering and Understanding the universality of suffering, whereas the third factor explained Items 3, 4, 5, 8, 9, 10, 13, 14, 15, 18, 19, and 20, corresponding to the original factors Feeling for the person suffering, Tolerating uncomfortable feelings, and Acting to alleviate suffering. This latest factor was renamed Behavioral compassion , following the classification used by Halamova and Kanovsky ( 2021 ).

To assess the model’s overall fit, several criteria were used: the chi-square statistic, the Comparative Fit Index (CFI), the Standardized Root Mean Square Residual (SRMR), and the Root Mean Square Error of Approximation (RMSEA). CFI and TLI values above 0.90 (better over 0.95) and SRMR and RMSEA values below 0.08 (better under 0.06) were indicative of a good fit (Hu & Bentler, 1999 ; Perry et al., 2015 ). Particular relationships within the model were also examined, including factor loadings and correlations between factors. In addition, following the recommendations of Kline ( 2023 ), modification indices were checked to ensure the absence of cross-loadings and unmodeled relationships, as well as a visual inspection of the residuals.

Model comparison was done using delta indices. Specifically, differences between models’ CFI were calculated. CFI differences of 0.05 or less (Little, 1997 ) or 0.01 or less (Cheung & Rensvold, 2002 ) can be interpreted as negligible. Each model was compared to the simpler one: the three-factor with correlated factors model was compared to the one-factor model in terms of ∆CFI, and the five-factor with correlated factors model was compared to the three-factor with correlated factors model.

Thirdly, the best fitting structure for the SOCS–O was tested for measurement invariance by using multi-group models that compared invariance between gender (women, n  = 570, and men, n  = 108). As a previous step, and once the best-fitting model had been retained, the structure was tested separately in samples of women and men. Because the model fitted both sets of data adequately, the invariance routine was developed. Invariance was assessed using a sequential strategy testing the invariance at different levels. First, a configural or unconstrained model was evaluated. This model imposed no equality constraints on parameters and provided a baseline model for comparing the more restrictive models (Byrne, 2012 ). If this model holds, the metric or weak model is tested. This model is nested into the configural model and examines the extent to which the magnitude of item factor loadings is the same across groups (Brown, 2006 ). Finally, if metric invariance holds, the scalar or strong model is evaluated. This model tests for the evidence that thresholds (intercepts) for the items are invariant across groups (Brown, 2006 ). If scalar invariance is held, then latent means can be compared across groups.

To compare the nested models in the invariance routine, we used χ 2 differences (∆ χ 2 ). However, as this statistical comparison presented the well-known problem of being too sensitive to trivial differences (Cheung & Rensvold, 2002 ), we also calculated delta indices. CFI differences (ΔCFI) and changes in RMSEA and SRMS were considered. Regarding the interpretation of ∆CFI, differences lower than 0.01 or 0.05 are usually used as cut-off criteria for equivalence across groups (Cheung & Rensvold, 2002 ; Little, 1997 ). For adequate metric invariance, ∆RMSEA and ∆SRMR should be ≥ 0.01 and ≥ 0.025, respectively (Chen, 2007 ). While evaluating scalar invariance changes ≥ 0.01 in RMSEA and ≥ 0.005 in SRMR are considered indicators of invariance (Chen, 2007 ).

Finally, criterion-related validity evidence was studied by predicting the SOCS–O scores through students’ levels of mindfulness, while controlling for gender and age. For this purpose, a structural equation model was hypothesized, estimated, and tested, in which gender, age, and a latent factor of mindfulness, as measured with the Freiburg Mindfulness Inventory, predicted the three-correlated factors measured by the SOCS–O. Correlations between mindfulness and gender and age and between the dimensions of compassion for others were also estimated.

Normality was tested for the variables under study. Non-normal distributions were found for all the items. Therefore, all the models were estimated using maximum likelihood with robust standard errors. This is the recommended option for non-normal outcome variables, such as the one under study (Kline, 2023 ).

For the statistical analyses, SPSS version 28 (IBM Corp, 2021 ) and Mplus version 8.4 (Muthén & Muthén, 2017 ) were used.

Spanish Version of the Sussex-Oxford Compassion for Others Scale

The SOCS–O was translated into Spanish. The final version was reviewed by three experts in psychometrics and mindfulness, who agreed on the adequacy of the item content in the Spanish version of the SOCS–O. The resulting Spanish version of the scale can be consulted in Table  2 .

Descriptive Statistics

Descriptive statistics were calculated for the dimensions and the items of the SOCS–O. Regarding the dimensions of compassion for others, the lowest mean was found for Recognizing suffering ( M  = 15.75, SD  = 2.72), whereas the highest was for Understanding the universality of suffering ( M  = 17.80, SD  = 17.80). Item means ranged from 3.57 (Item 19, “When someone else is upset, I can be there for them without feeling overwhelmed by their distress”) to 4.50 (Item 2, “I understand that everyone experiences suffering at some point in their lives”). More details can be consulted in Table  2 .

Construct Validity and Reliability

For the study of the psychometric properties of the SOCS–O, three confirmatory factor analyses were specified, estimated, and assessed, using the structures detailed in the “ Method ” section. These models were as follows: a one-factor model, a three-factor with correlated factors model, and a five-factor with correlated factors model. In Table  3 , model fit indices for the three CFAs are shown.

When the models’ fit was studied, one-factor model was discarded, as model fit was not acceptable. The three-factor with correlated factors model and five-factor with correlated factors model showed excellent fit, with no CFI differences. Taking this evidence into account, together with the fact that very high correlations were observed in the five-factor with correlated factors model between the dimensions of Feeling for the person suffering, Tolerating uncomfortable feelings, and Acting to alleviate suffering, the three-factor with correlated factors model was retained as the best structure to represent the Spanish version of the SOCS–O internal structure.

When the particular relationships within the retained model were examined, evidence of adequate factor loadings were found. Indeed, factor loadings ranged from 0.75 (Item 1 and Item 11) to 0.84 (Item 6) for Recognizing suffering; from 0.76 (Item 2) to 0.83 (Item 12) for Understanding the universality of suffering; and from 0.34 (Item 19) to 0.81 (Items 13, 5, 10, and 15) for Behavioral compassion. All of these results were statistically significant ( p  < 0.01). Correlations among latent variables were positive, high and statistically significant, as expected (Fig.  1 ). No cross-loadings or unmodeled relationships emerged in the modification indices. The pattern of the residuals was also inspected, with no evidence of misspecification in the model.

Analytical fit of three-factor with correlated factors model for the Spanish version of the SOCS–O. Notes: All factor loadings and correlations among factors were statistically significant ( p  < 0.01). For the sake of clarity, standard errors are not shown

To study the reliability of the SOCS–O scale, Cronbach’s alpha and McDonald’s omega were calculated, with values of 0.87 for Recognizing suffering; 0.88 for Understanding the universality of suffering; and 0.93 for Behavioral Compassion; thus, estimations indicated adequate reliability for all the dimensions.

Measurement Invariance Across Gender

Multi-group analyses were conducted to examine the measurement invariance between women and men for the three-factor with correlated factors model. Table 3 shows the results of these multi-group analyses. The configural model demonstrated adequate fit, and so was used as the basis for testing more constrained models. Accordingly, the metric model was tested, in which factor loadings were constrained to be equal across gender. This model did not present statistically significant differences from the configural model (∆ χ 2  = 26.53, ∆df = 20, p  = 0.15) and showed no deterioration of model fit (∆CFI = 0.00; ∆RMSEA = 0.00). Next, intercepts were constrained to be equal across gender. Again, no statistically significant chi-square differences were found when compared to the metric model (∆ χ 2  = 20.05, ∆df = 17, p  = 0.27), nor was any worsening of the model’s fit observed (∆CFI =  − 0.01; ∆RMSEA = 0.00). Thus, it can be seen that the Spanish version of the SOCS–O demonstrated measurement invariance across gender.

When latent means were compared, men repeatedly exhibited lower levels in all the compassion dimensions: Recognizing suffering (mean difference =  − 0.40, standard error = 0.12, p  < 0.01), Understanding the universality of suffering (mean difference =  − 0.33, standard error = 0.11, p  < 0.01), and Behavioral compassion (mean difference =  − 0.57, standard error = 0.12, p  < 0.01).

Criterion-Related Validity

Evidence for criterion-related validity was studied with structural equation modelling, in which gender, age, and a latent factor of mindfulness predicted the three dimensions of the Spanish version of the SOCS–O. The model showed an adequate overall fit: χ 2 (581) = 1345.79 ( p  < 0.01), CFI = 0.92, TLI = 0.92, RMSEA = 0.04 (90% CI = 0.04, 0.04), and SRMR = 0.06. The measurement part of the model pointed to adequate factor loadings for the factors of mindfulness and compassion for others. Mindfulness showed positive and statistically significant correlations with gender, which meant higher scores for men, who were coded as 1 (whereas women were coded as 0), and age, with higher levels of mindfulness for older students. The predictive part of the model showed statistically significant effects of gender on the three dimensions of compassion for others, as already pointed out in the latent means comparison; a negative effect of age in all the dimensions of compassion for others, except for the Understanding the universality of suffering; and a positive effect of mindfulness on the three dimensions of compassion for others. Details are displayed in Fig.  2 .

Structural equation modeling predicting compassion for others dimensions with gender, age, and mindfulness. Notes: * p  < 0.05; ** p  < 0.01. All factor loadings were statistically significant ( p  < 0.01). For the sake of clarity, they are not shown

The aim of this study was to explore the SOCS–O scale using a large sample of Spanish undergraduate nursing students. We examined the psychometric properties of this scale with a particular focus on the five elements of compassion, initially identified by Strauss et al. ( 2016 ) and further developed by Gu et al. ( 2020 ).

Our specific aims were to measure nursing students’ levels of compassion; to study the internal factor structure through confirmatory factor analysis (CFA); to provide evidence of the reliability of the scale in the Spanish language; to investigate its measurement invariance across gender; and, finally, to evaluate criterion validity through the relationship between SOCS–O and gender, age, and mindfulness.

Descriptive statistics indicated high mean results (ranging from 3.57 to 4.50), in line with the findings by Lucarini et al. ( 2022 ), who found values ranging from 3.58 to 4.21. The dimension of compassion with the highest mean results was that of understanding the universality of suffering. Perhaps this is not so surprising, as nurses are exposed to others suffering on a daily basis as part of their work, so are accustomed to the presence and ubiquity of suffering (Kelley et al., 2014 ). The areas with the lowest means were Recognizing suffering and the management of one’s own emotions in the face of another’s distress. Similar conclusions have been drawn in other language validations. In Lucarini et al. ( 2022 ), for example, two themes were drawn from the data on compassion: “universality” (of feelings/suffering) and “acting” on these feelings. In Halamova and Kanovsky ( 2021 ), a distinction was drawn between rational compassion (i.e., to recognize and understand suffering) versus emotional or behavioral compassion (which concerned feelings, tolerance, and the desire to act). Similarly, Kim and Seo ( 2021 ) noted these trends in their Korean validation, where most variation was within the category of Tolerating uncomfortable feelings, and most agreement (least variations) was found in identifying and being concerned over the suffering of others. The fact that similar patterns were identified across various validations suggests the underlying psychometric robustness of the SOCS–O.

In order to support the underlying robustness ascertained with descriptive statistics, construct validity was examined using competitive confirmatory factor analyses. Evidence pointed to an excellent fit for the three and five-factor with correlated factors solutions. In order to maintain simplicity and taking into account the high correlations observed among the dimensions of Feeling for the person suffering, Tolerating uncomfortable feelings, and Acting to alleviate suffering, the three-factor model with correlated factors was retained as the best representation of the data. Therefore, the structure of compassion, as measured with the SOCS–O, was better represented in Spanish nursing students by the following three dimensions: Recognizing suffering, Understanding the universality of suffering, and Behavioral compassion. These results are in line with the ones presented by Halamova and Kanovsky ( 2021 ) for the SOCS–S in Slovakia. The authors defended a rational versus behavioral approach to compassion, the latter composed of items from the original dimensions of Feeling for the person suffering, Tolerating uncomfortable feelings, and Acting to alleviate suffering, as in the present work. Previous literature has already pointed to these different components of compassion (Galiana & Sansó, 2019 ), distinguishing between a more cognitive component, which involves awareness of others’ suffering (Jinpa, 2015 ) and refers to recognizing and understanding others’ suffering (Galiana & Sansó, 2019 ); and a behavioral component, which includes the actions we perform to address suffering, and are always preceded or accompanied by feelings towards and tolerance of the person suffering (Galiana & Sansó, 2019 ).

All factor loadings were greater than 0.50, except for 19 in the dimension of Behavioral compassion (“When someone else is upset, I can be there for them without feeling overwhelmed by their distress”). This may be due to the fact that this item not only measures compassion, but also emotional management skills, specifically, the management of managing one’s own distress. This was also observed in the original research results (Gu et al., 2020 ), with Item 19 being the only one with a factor loading < 0.50, so showing important similarities between the scale functioning in both studies.

Regarding the third aim of our study, internal consistency was established using the statistical measures of Cronbach’s alpha and omega. Results showed all reliability estimates to be excellent, indicating that participant responses across all questions were consistent. This then allows for validation of the research, as results within this study are not only internally consistent, but also comparable with those of the original research by Gu et al. ( 2020 ), as well as other validated models of this scale (Kim & Seo, 2021 ; Lucarini et al., 2022 ; Nikgoo et al., 2022 ).

The fourth aim was to study the measurement invariance of the scale across gender. Measurement invariance is a key element when making group comparisons when the groups can be understood as different populations (different genders, countries, races, cultures, professions, etc.), as it concerns whether scores have the same meaning under different conditions (Kline, 2023 ). For this purpose, a hierarchical set of increasingly restricted models was employed. The scale showed evidence of scalar invariance, which is an important prerequisite for group comparison (Putnick & Bornstein, 2016 ). This equivalence of compassion across gender, as assessed by the SOCS–O, has been previously demonstrated in other languages, such as Swedish (Sarling et al., 2024 ). However, the only study focused on nursing students had a very small sample of males so gender comparisons were not possible (de Krijger et al., 2022 ).

When latent means were compared, results consistently showed statistically significant differences in the levels of compassion for men and women, with women displaying higher values of Recognizing suffering, Understanding the universality of suffering, and Behavioral compassion. Although there were similar findings in the study by Gu et al. ( 2020 ), where females scored significantly higher on the compassion scale compared to male counterparts, other SOCS–O validations do not always show this. Kim and Seo ( 2021 ) found that there were no differences between Korean gender scores in relation to compassion for others. The Italian validation by Lucarini et al. ( 2022 ) did not use gender as a criterion for validity but did observe higher compassion scores among female participants. It is important to note however that this was a large random sample and not focused on nursing students or healthcare workers.

If we look to the wider literature however, women have traditionally shown higher levels of compassion. This can be seen anecdotally in popular culture (Yarnell et al., 2019 ), where women are frequently depicted as caring, emotional, and nurturing in contrast to men who stereotypically are described as feeling awkward talking about their emotions; as well as in more robust scientific studies, where women are often shown to better identify emotions (Connolly et al., 2019 ) and recognize suffering (López et al., 2018 ). It is interesting however to examine gender and compassion within the context of nursing, traditionally a caring field that now attracts both men and women. It could be argued that these results imply that men are less compassionate than women in nursing care. However, it is important to note culture and the socialization of genders, especially in the face of caring behaviors (Gilbert, 2014 ; Yarnell et al., 2019 ). Both genders may feel compassion but the way in which it is manifested may differ. For instance, in a study carried out by Mercadillo et al. ( 2011 ) when male and female participants were placed in an MRI scanner and exposed to compassion-evoking images, both genders demonstrated neural responses, but in different parts of the brain. The research suggested that certain moral elements are gender-relative, evolving from neural mechanisms of socially learned patterns. So, it is not that men and women experience more or less compassion, but that they may express it differently. Seppälä ( 2013 ) suggested that compassion has traditionally been portrayed as a soft feminized skill (perhaps reflected in the questions and results of compassion scales) and argued that men often show “aggressive compassion,” something our society does not frame as compassion but instead as protection, such as firefighters or police. We could potentially apply this perspective to the field of nursing, where compassion can be demonstrated (but perhaps is not always recognized) in different ways.

Finally, criterion-related validity was established by relating mindfulness to compassion, while controlling for the effects of gender and age. As found in the measurement invariance results, and previously discussed, gender predicted all the dimensions of compassion, with higher scores for women. In contrast, age was negatively related with the compassion dimensions of the SOCS–O, except for the Understanding of universal suffering. That is, younger nursing students showed greater levels of compassion. These results were unexpected, as compassion is considered to be a universal human quality, regardless of the age of the perceiver of suffering (Lama, 2002 ; Seppälä et al., 2017 ). In fact, in the few studies that examined age differences on compassion, results pointed to younger participants being less compassionate, especially with regard to self-compassion (Jarden et al., 2021 ; Murn & Steele, 2020 ; Tran et al., 2022 ). The only dimension that was not affected by age was the dimension of Understanding the universality of suffering, but it must be interpreted in its context: it may be the higher scores found on this dimension are due to low variability that has not allowed us to find an effect of age. Future research could explore the relationship between compassion and age and how it can affect the caring professions.

As for the effect of mindfulness on the dimensions of compassion, this was repeatedly positive and statistically significant. This supports previous research that has repeatedly found that mindfulness, defined as the way of paying attention to the present moment without judgment (Bishop et al., 2004 ), could help nurses and nursing students understand and address patients’ suffering. Incorporating mindfulness into the nurses’ curriculum could improve students’ skills for compassionate care, which may also enhance the student experience (Walker & Mann, 2016 ).

The validation of the SOCS–O compassion scale in Spanish has shown not only a robust internal factor structure and criterion validity, but also serves as a reliable tool to measure compassion within the Spanish-speaking world. As discussed above, it is important to be able to measure compassion, as it is a previously unquantifiable element of nursing care that impacts positively on both the professional and the patient. Now this essential element of nursing can be accurately measured, akin to symptom management scales. All these more tangible factors of nursing have associated tools to measure their efficacy which allows for protocols and improvements in patients’ care delivery to be put in place. Now it will be possible to do this with compassion as well, something which has not always been possible due to conflicting terminology and lack of robust internal measures. With the aid of the validated SOCS–O, not only can compassion be more accurately measured in different languages, but there is also potential to further advance the delivery of patient-centered, compassionate care. It will now be possible to monitor how students (and in the long-run experienced nurses) acquire compassionate competencies throughout their training, so allowing for tailored educational activities regarding compassionate competencies to be designed and applied for future educational programs.

Limitations and Future Research

As regards the study's shortcomings, one potential limitation was that the validation of this scale was carried out at two universities. In order to gain a greater representation of potentially different manifestations of compassion, future studies could incorporate universities from more regions across the country. Additionally, although the samples of women and men were unbalanced, the total size of the men’s sample did not allow us to adjust group size. However, it is worthy to note that simulation studies testing factorial invariance with unbalanced samples have pointed out that the chi-square values are not much affected by measurement non-invariance (Yoon & Lai, 2018 ). Therefore, as we have found evidence of scalar invariance in terms of not statistically significant differences in the chi-square, it can be argued that it is indeed a gender-invariant scale. In any case, this limitation will be taken into account in subsequent studies, providing evidence in balanced samples.

Considering current results, it will now be possible to explore how nursing students manage compassion in a more robust and reliable way, using the SOCS–O. One area that would benefit from deeper research is the five dimensions of compassion in different cultural contexts. Another future direction, also noted by Gu et al. ( 2020 ), would be the development of a longitudinal study, to address any potential common method variance, often associated with self-reporting data (Podsakoff et al., 2003 ) as well as to further explore response bias and the tendency for participants to reply in accordance with social desirability expectations (Lucarini et al., 2022 ).

Finally, by validating the SOCS–O in Spanish, further cross-cultural exploration of compassion, as suggested by Gu et al. ( 2020 ) and Halamová and Kanovský ( 2021 ), will be possible in the Spanish-speaking world. The original sample consisted mainly of White (85.7%) females (87.9%) from southern England. Halamová and Kanovský ( 2021 ) also observed cultural differences in understanding the translated instrument within Slovakia, so highlighting the potential for further cross-cultural research with the validated Spanish tool.

The findings of this study demonstrate the robust psychometric properties of the Spanish version of the Sussex-Oxford Compassion for Others Scale. The descriptive results show that nursing students have high scores on all the dimensions of the SOCS–O. Validity and reliability results are excellent, and confirm the Spanish version of the measure is a valid and reliable tool to evaluate compassion for others in Spanish-speaking contexts. The SOCS–O offers a useful instrument to examine gender differences in compassion. The study showed women have consistently higher self-reported levels of compassion than men. Additionally, the positive relationship between mindfulness and compassion, as measured with the SOCS–O, was found on all the dimensions of the measure, suggesting the value of incorporating mindfulness in nurses’ curricula in order to support the delivery of compassionate care.

In conclusion, this study validates the SOCS–O scale in Spanish, and offers a reliable tool with which to measure compassion using a three-dimension subscale as well as exploring how student nurses manage compassion in the face of their placements. The main contribution of this study to the field of nursing is that it will facilitate the use of a robust, psychometric measurement of compassion among student nurses that could enable interventions to support and sustain compassion during nurse education.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Open Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature. This publication is part of the R&D project “Longitudinal research of Nursing Students’ Inner resources for Compassionate Care: Consequences for burnout, compassion fatigue and satisfaction, well-being and quality care (NurSInCC)” PID2022-139199OB-I00, funded in the 2022 call for Knowledge Generation Projects by MCIN/AEI/10.13039/501100011033/FEDER, EU.

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Sansó, N., Escrivá-Martínez, T., Flowers, S. et al. The Spanish Version of the Sussex-Oxford Compassion for Others Scale (SOCS–O) in Nursing Students: Psychometric Properties and Its Relation with Mindfulness. Mindfulness (2024). https://doi.org/10.1007/s12671-024-02400-y

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