Compassionate Care In Nursing: Strategies And Interventions

Overview of Compassionate Care in Nursing

Discuss about the Interventions For Compassionate Nursing Care Using A Sysetematic Review.

Nursing profession demands a practitioner to have a compassionate attitude towards their clients (Francis, 2010). The department of health identified it as a high priority tow strengthen deliverance of social care services that portrayed more compassionate care. Reviews into qualitative research reports that it is a desire of a majority of the elderly people to receive warm and humane connections established by nurses and other medical practitioners in a hospital setting. They further stated that it would be of more comfort if the so said personnel developed a personal touch with them especially in the wards. A four-month practical development program was therefore formulated to under the heading “Creating Learning Environments for Compassionate Care,” abbreviated as, CLECC. The program’s key aim is the promotion of compassionate care to patients and patient oriented service by nurses. The study also targeted ward leaders and their corresponding responsibilities and authority over nurses in attempt to come up with the interventions applicable to improve compassionate care to patients (Craig et al., 2013).

Targeted by the program also is the senior nurse, who plays a vital role in facilitating initiatives aimed at promoting compassionate health care (Dewar, Nolan, 2013). Twice a week, the chief nurse organized discussion with patients and other subordinate nurses so as to get a clear understanding of the level of compassionate care that the patients were receiving. The program involved daily rounds around all wards giving proper attention to all patients while at the same time collecting views from the same patients about the kind of care that they were receiving from the other nurses. Cases of complaints from patients who had received uncompassionate care from any nurse were taken with deep seriousness and reported with immediate effect to the senior nurse. Who was again very vigilant on such cases and apprehended any nurse reported with such behavior. The whole process was meant for educational purposes and thus nurses with such behavior received adequate guidance for transformational purposes.

Various methods and materials were used throughout the whole program whereby, results from various methods were compared and merged to obtain final results. The various factors that influence compassion were the key drivers of the methods to be used in the study. Availability of time is a key compelling factor towards provision of sufficient compassionate care by nurses to patients (Dewar, Cook, 2014). It was observed that the more substantial amount of time was availed to nurses while doing their routine rounds in the wards, the more time they had to spend with patients. It was during such interactive moments that the patients got the chance to open up and share their feelings with the nurse about their health conditions particularly pointing out areas of improvement or deterioration. Patients pointed this as the most efficient move towards improving compassionate care as they previously lacked anyone willing to dedicate enough time to their situations. (Strada, 2018)

The Creating Learning Environments for Compassionate Care Program

As more highly experienced nurses took turn in the ward, patients admitted that their experience was directly attributable to the amount of compassionate care rendered to them. This was a direct implication that the amount of clinical experience of the nurse is not the key determinant of the amount of care that the nurse in question is capable of offering, the amount of time that nurses undertook for acclimatizing is (Glembocki, Dunn, 2010). Nurses however admitted that they were more often overwhelmed by the environment of work. Patients commended majority of the elderly nurses who they deemed more experienced, for the amount of compassionate care that they offered to them. They additionally pointed out that such nurses had dealt with a wide range of similar cases and thus knew how to handle them. Such nurses are in addition considered to have already developed a personal touch with patients due to their previous dealings.

Primary research for evaluation of compassionate care interventions was taken using a systematic search that curtailed three databases which were; Medline, Cochrane library (included is economic evaluation database, controlled trials central register, systematic reviews with regards to Cochrane database, database of abstracts of reviews of effectiveness and the assessment database of health technology cumulative index to nursing and allied health literature (CINAHL) (Guyatt et al 2008). Terms used to relate to compassionate care however pose numerous problems as there is no single agreed definition of the same. On the contrary a wide range of terms are used inconsistently & interchangeably throughout the literature of healthcare.

While conducting the preliminary searches, the approach adopted to map the field was inclusive and broad. Numerous terms in relation to compassionate care were pinpointed and utilized while at the same time identifying a large number of studies that were related to one or more of the key areas that have been mentioned above. It was through this mapping that chief key words relevant to the area of study were identified (McCance, Slater & McCormack, 2009). The key terms include; empathy, dignity, person-centered care, professional-patient relationship, caring, relation-centered care and finally emotional intelligence (Dwan et al., 2013). It was also the key words identifiable during the preliminary outsourcing that were used for final searches. A combination of terms associable to compassion were merged with terms relating to occupational groups and methods. (Chan and Altman, 2005)

The framework that was used to guide in the selection was Effective Workplace Culture Framework (Manley et al., 2011). Included were results from primary search that were aimed at outcome comparison of the interventions that was designed to facilitate enhancement of nursing care that was compassionate throughout any kind of setting and to clients in any particular group. Designs that were eligible for selection were interrupted time series which could be either controlled or uncontrolled before and after studies quasi random studies, or randomized controlled trials which could again include cluster randomized trials. Exclusive student focused studies were excluded out of such interventions as they were not directed towards behavioral change of the nursing staff. (Nicholson, et al., 2010a)

Strategies and Interventions for Improving Compassionate Care

Adopting a study that was inclusive in approach to areas that necessarily addressed ‘compassion’ was necessitated by deficit of conceptual clarity regarding comparison within the literature (Cameron et al., 2013). The selection criteria developed was based on the four health care compassion chief elements which are; nurses’ awareness of suffering and vulnerability, actions of response aiming to relieve suffering while at the same time ensuring dignity, relational capacity of nurses and empathy. Studies were included only if they met one or both of the following criteria.

1. Preliminary outcomes assessing or evaluating quality of observed interaction or any other compassion measure which could include responsive action and situational awareness, and/or self-reports of nurses for compassion and /or their capacity and capability of delivering compassionate care.
2. Improving compassion in nursing care or a construct that is closely related i.e. relational care, emotional care, and dignity as this was the primary and explicit goal of the interventions. It could be achieved through addressing of nurses’ awareness of situation, responsive action, moral attributes and relational capacity.

It was during the screening process that nurses met through frequent meetings to make comparisons of independent selections formulate resolutions to disagreements and to top it all, make decisions.

Attempt to represent the variation in quality of study as evidenced by results emanating from the phase of initial mapping, and to again and inflict proper reflection on the strength of evidence effectively, simple grading was undertaken in attempt to categorize strengths of points of the retrieved underlying study designs. Weak, medium or strong ratings were assigned to every study in regards of where the study design was based on the hierarchy of evidence for effectiveness in tandem with an assessment of its design and execution (Greenhalgh, 2014; Guyatt et al., 2008). Where there was explicit demonstration of equivalence between group comparisons of treatment and control, such studies were ranked as top quality. Randomized controlled trials (RCTs) and clusters randomized controlled trials were the study designs involved and met the pre-mentioned conditions. (Chenoweth et al., 2014).

Medium rating was assigned where group equivalence was demonstrated through comparisons between control and intervention groups but otherwise weakened by other issues of methodology. Such issues included, limited sample size and groups allocation that were non-random. Pre and post controlled studies using non-random allocation to groups and cluster random controlled trials of small clusters were the designs used (Chenoweth et al., 2014). Low quality ratings were assigned to other studies that were affected by significant methodological shortcomings that weakened the possibility of demonstrating effectiveness. The pre-mentioned quality assessments were conducted individually and merged with other ratings from other nurses until there was attainment of consistent ratings. Each study was however analyzed using the criteria of describing behavior change interventions that are group based as devised by Borek et al. (2015).

In order to pinpoint mechanisms, contexts and types of interventions necessary for change, conducting a qualitative analysis was necessary through-out various interventions that had been reported. The so said analysis was conducted through small groups and further on enriched by discussing the process and emerging findings amongst all nurses. (Hall et al., 2009)

Factors That Influence Compassionate Care in Nursing

From each study, data was extracted and included outcomes and measurements, details summarizing interventions sample and settings, study design and results. Results that had been tabulated were used in generation of summary descriptions across all the key characteristics. Studies that were heterogeneous in terms of methods, outcomes and interventions signified that a more descriptive approach was merited as there was no warranting in meta-analysis (Brown et al., 2013). It was through team discussions that the major types of outcomes and interventions were agreed upon. Results on individual interventions and effectiveness were plotted against chief types of outcomes and were used as the based on analysis of evaluating strategies through types of interventions and evidence strength cutting across types of intervention and the nursing field as a whole (Bridges et al., 2011). Recorded and tabulated were both group directional differences wherever reported and the statistical significance of the reported differences.

Presented are the review findings aimed at addressing each of the objectives of the review. To begin with, a description of the study characteristics is done to portray an overview of the studies that are used in evaluating interventions for compassionate care (McCormack B, et al., 2010). Secondly is a presentation on evaluation of reporting interventions quality as highlighted in the included studies with inclusion of foundations of their theoretical (Greenhalgh, 2014).  Following will be a presentation on the evidence effectiveness of the interventions of the studies and an analysis of quality of the evidence.

The ultimate set of data was resolved to after twenty-four studies and comprised of 25 interventions. The types of interventions that were identified were three. Nurse support interventions focused on appraisal of the nursing support staff and their wellbeing (Hartrick, 1997) which could be actualized through providing clinical supervision. Intervention based on care model focused on introducing new care models to a service and could include person-centered care. The third type of intervention was based on staff training and its main focus was on developing new and knowledge skills amongst nursing including offering a training course in communication and skills on empathy. (Nicholson, et al., 2010b)

 Summary of findings, study design features and study characteristics reflected a wide range of study setting that included care/nursing homes, hospital and the wider community. (Higgins, Green, 2011). Apart from one, all the other studies on staff training were conducted in a hospital setting. Out of eight interventions on care model, six of them were conducted in care homes settings. studies based on nurse support interventions were conducted on outpatient oncology service, hospice at home, hospital settings and district nursing services. Study participants were nurse managers, relatives, patients and nurses themselves.

Primary Research for Evaluation of Compassionate Care Interventions

Identified were three types of interventions which are; nurse support, staff training and care model. There was considerable variation in the extent to which interventions drew on an explicit theoretical foundation (Boscart, 2009). Components of staff training included; verbal interactions training, communicating about spiritual care and spirituality, communication and empathy. Staff training interventions that were based on explicit theoretic were; Tibetan Buddhist tradition, reminiscence theory and adult, relationship-based care model/caring theories and Solution-Focused Brief Therapy. All the other studies could not establish any explicit theoretical foundation and were therefore solely based on prior research. Below is comprehensive table indicating all the interventions and their ratings.

Table 1: Interventions focused on training

STUDY	RATING	SETTING/SAMPLES	INTERVENTIONS
Before and after uncontrolled study	Low	Nurses Adult department Patients Hospital setting	Training programs Empathic skills Communication Educational verbal interactions intervention on between staff and patients. Workshop based communication skills training
Cluster randomized controlled study	Medium	Nurses Patients Hospital setting	A course in physical assessment Empathy training program

Table 2: interventions focusing on care models

STUDY	RATING	SETTING/SAMPLES	INTERVENTION
Uncontrolled before and after study	Medium	Staff Families Care homes	Training programme based on the senses framework Implementation of a plan that conserved dignity Education and supportive care both at individual and group levels
Cluster randomized controlled study	High	Nursing homes Staff members Residents	Implementation of person-centered care Implementation of person centered environment Advanced care planning Pain and symptom management.
Before and after study with separate intervention and control groups	Medium	Nursing staff Residents Nursing homes	Implementation of relationship-enhancing programme of care.

Table 3: Interventions focusing on nurse support

STUDY	RATING	SETTING/SAMPLES	INTERVENTION
Uncontrolled before and after study	Medium	Nurses	Multifaceted compassion fatigue resiliency intervention programme Interactive seminar Multimedia Mindfulness meditation/instruction in workplace at the beginning of each shift. Mindfulness based cognitive therapy training
Before and after study with separate interventions and control groups.	High	Nurses	Mindfulness training Programme. Education and Practice. Training programme on medical care and treatment for breast cancer. Crisis intervention, and organization of nursing care

The quality of care outcomes was examined by six care model interventions and four training interventions. Eight of them presented a significant s6tatistical improvement in one or more outcomes. There were reports of significant change in one quality of care dimension following implementation of person-centered care as brought forth by Cluster Randomized Controlled Study (Nicholson, et al., 2010c). Uncontrolled before and after study resulted to other improvements in outcomes of quality of care. Majority of intervention displayed positive outcomes with improvements being noted in patients, nurses and the quality of care. The overall quality of evidence was desirable and desirable and this was therefore an indicator that several higher quality studies would result positive results

Most of the studies involved more than one hundred participants. The study that involved cognitive therapy basing on evaluation of mindfulness had the least samples of nine nurses. Studies that involved using intervention types that were similar displayed a tendency of using similar outcome types. For studies involving nurse support interventions, nurse-based outcomes were primarily measured. Significant differences were less likely to be shown by patient outcomes with only 20% of them all showing significant differences statistically. Of all the training interventions studies, three of them reported patients based outcomes whereby, a significant positive effect was portrayed by two of them.

Quality of care was examined by six care model intervention and four training interventions. Significant improvements in quality of interactions were associated with the Combined Person centered care model intervention. However, conclusions to this finding are tampered with by deficiency of the intervention description named above which is from a high quality study. Cluster Randomized Control Test which was rated as high quality showed significant deviation in one quality care dimension after emotion oriented care was implemented in nursing home settings. In medium quality however, evaluating the relationship-enhancing programme which was conducted in nursing homes showed reasonable improvements in continuity of care, relational care and relational behavior of the care provider. Hospital nurses who were evaluated after undergoing empathy training (rated at medium quality) found no difference however in interpersonal support. Several more outcomes related to improvements in quality of care were reported from a range of low quality studies.

It was the primary aim of this systematic review to provide an overview evidencing the effectiveness of nursing interventions for compassionate care. A wide range of intervention studies is reflected on the findings where a variety of approaches have been used to address compassion. The interventions are worth emulating to as a means of addressing any kind of perceived compassionate care defiance in nursing. Majority of interventions however were in deficit of explicit theoretical foundation. Interventions however were directly associable to positive outcomes displayed by nurses, quality of care results and patients. However, no intervention was tested more than once due to limiting factors the most limiting one being time. Majority of the most common intervention types focused on training nursing staff. Most of the interventions were in deficit of explicit mechanisms of change

Conclusion

Whereas there is a wide variety of published articles, all serving a main aim of offering potential and possible solutions to deficits in compassionate care, this is a literature body minimal use to nurses already in practice. Challenges arise more so in the context where there are requirements of more compassionate health care as professed from the frontline of the national government. Issues that are of urgent requirement includes; interventions that have a more preferable design, and evaluations that implement stronger designs of research. Interventions that have therefore proven more effective in improving compassionate care should therefore be implemented and backed up even by government administrators and all role players in the health sector.

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