Compassion in Care

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DOI: 10.1177/0969733011403556 2011 18: 672 originally published online 3 June 2011Nurs Ethics

Margreet van der CingelCompassion in care: A qualitative study of older people with a chronic disease and nurses

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Compassion in care: Aqualitative study of olderpeople with a chronic diseaseand nurses

Margreet van der CingelWindesheim University of Applied Sciences, The Netherlands

AbstractThis article describes compassion as perceived within the relationship between nurses and older personswith a chronic disease. The aim of the study is to understand the benefit of compassion for nursing practicewithin the context of long-term care. The design of the study involves a qualitative analysis of in-depth inter-views with nurses and patients in three different care-settings. Results show the nature of compassion inseven dimensions: attentiveness, listening, confronting, involvement, helping, presence and understanding.Analysis of the data also shows in what way opinions of participants relate to issues raised in a previousliterature study, for example the difference between pity and compassion. The conclusion states that com-passion is a valuable process which motivates patients as well as nurses to cooperate in achieving relevantoutcomes of care. The discussion involves some methodological issues. For one thing, further confirmationof the dimensions found is recommended.

Keywordscare, chronic diseases, compassion, humane approach, nursing, older persons

Introduction

This study focuses on the phenomenon of compassion in healthcare, specifically within the relationship

between nurses and older people with a chronic disease. These patients face loss of health and therefore loss

of possibilities in life. Their daily life is characterized by a continuous dependence on care. For them, good

care is of genuine value. Some care ethics literature and nursing theories state good quality of care analogous

to humane care.1,2 It is unclear, however, how the humane aspect of care should be made tangible in daily

nursing activities, professional job-descriptions or codes of ethics. Moreover, compassion as a concept has

received little attention in nursing theories.3 Previous to this study the researcher did a literature review on

compassion in the domain of professional care.4 The review indicates compassion to be a strong concept for

these humanizing aspects in nursing care. Time and again compassion is stated as a core concept for nursing

and is recently mentioned again as such.5 Could compassion perhaps be the concept that gives meaning to

what humane care is all about? Philosophies and theories should guide practice and inform the public as well

Corresponding author: Catharina Johanna Margaretha (Margreet) van der Cingel, Campus 2-6, PO Box 10090 8000 GB Zwolle,

The Netherlands

Email: [email protected]

Nursing Ethics18(5) 672685

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as professionals about the underlying values that support practice.2 Therefore, the purpose of this study is to

gain knowledge about the benefit of compassion as a vehicle for humane care for patients in long-term care

settings. If the nursing profession wants to take the concept of humane care seriously, it being a metaphor for

their professional care for those patients, it is necessary to study the nature and significance of compassion.

Method

This study is to be placed in the tradition of qualitative research that aims for the elucidation of a phenomenon

in a specific time, place and context. Qualitative research nowadays uses many methods, but often these

blended methods adopt elements of Grounded Theory to function as their basic methodological principles.

This study uses a mixedmethod as well. To begin with, the emergent fit mode is used. This mode is one of the

two modes in Grounded Theory, and is often used to refine existing theory. In this study it is used in deter-

mining specific research questions. In addition, constant comparative analysis, analytical induction and the-

oretical sensitivity are relevant in this study.6,7 Constant comparative analysis was applied in several phases

of data collection and the analysis. Quotations of participants in answer to open questions on the nature of

compassion were compared and categorized in preliminary descriptions of the dimensions of compassion

until data saturation was achieved. Analytical induction is in place when literature research forms the basis

for hypotheses about the phenomenon. A theoretical framework on the nature and significance of compas-

sion, based on the previously performed literature review, helped design the semi-structured part of the topic

lists for the interviews and also contributed to the analysis of the interviews. Quotations were paraphrased

and interpreted in light of this specific framework. Theoretical sensitivity has therefore supported theory

development on compassion. Thus, the hermeneutical approach in the review was complementary to the

interpretation of empirical quotations.8

Data collection

The research question in this study is: What is the nature and significance of compassion for older people

with a chronic disease in nursing practice? In order to find answers to this question nurses (n 30) andpatients (n 31) were interviewed (see Table 1).

Compassion as a phenomenon takes place within a relationship; therefore it is necessary to study both

perspectives. Data was collected from March 2008 till June 2009 in three settings in order to obtain enough

Table 1. Participants

Patients Nurses

Rheumatic diseases COPD Other chronic diseases

11164

Setting: Rehabilitation centre for Chronic Diseases 17 16 specialized nurses (chronic diseases) Home Care Organization 8 8 home care nurses Nurse consulting hours in outpatient clinic 6 6 nurse specialists/nurse practitionersAge (mean) 71 45Males 14 2Females 17 28Totals 31 30

Cingel 673


diversity in long-term care situations. Patients, mainly with rheumatic diseases and chronic obstructive pul-

monary diseases (COPD), and their nurses were sought in: a rehabilitation centre for chronic diseases, a home

care organization and outpatient clinics with nurse-consulting hours. Since the public debate in the Nether-

lands on healthcare in general and healthcare organizations in particular does not indicate that compassion is

a common characteristic in a professional setting,1 research locations had to be sites of best practices for com-

passion in order to actually find nurses and patients experiencing compassion. The research settings were

therefore chosen because of their good reputation. Patients were 65 years of age or older and were able to

express themselves properly in Dutch. Nurses had to have at least five years of experience in nursing in order

to find expert or at least proficient nurses who would have a holistic or full intuitive understanding of a

situation.9 Nurses in an earlier stage of their professional development were excluded because they could

either be too impressed by suffering and therefore have non-specific reactions or too absorbed in their devel-

opment becoming a more experienced nurse.

Two semi-structured topic lists, one for patients and one for nurses, were developed to guide the inter-

views. One can only ask about the significance of a phenomenon when the nature of this phenomenon is dis-

cussed. Therefore open questions on the nature of compassion were included, in addition to questions related

to the theoretical framework (see Table 2). Four health scientists reviewed these topic lists previous to data

collection. Their criticism led to adaptations to improve comprehensibility, a uniform interpretation of

Table 2. Topic lists questions*

Open questions:What kind of associations comes to mind when you think of compassion?What kind of situations do you think of when thinking of compassion?How well do you know the patient/nurse?What did you do to get to know the patient/nurse?Do you know what is of importance to the patient? (nurse)Does the nurse know what is of importance to you? (patient)1. Compassion and suffering

What do you believe to be suffering?What reactions on suffering did you observe (patient/nurse)Is one type of suffering worse than the other? If so, which one?

2. Compassion and identificationWhat do you believe to be empathy?In what way do you imagine what the patient is going through? (nurse)Do you believe a nurse should imagine or identify with you in order to know what you are going through?(patient)

3. The emotion compassionDo you consider compassion a feeling or does it involve thinking in your opinion?Does compassion connects with thoughts, what thoughts?What kind of emotions are connected to compassion?

4. Motives for compassionDo you consider compassion an altruistic emotion?Could nurses have egoistic interests in having compassion?Is pity the same as compassion, if not whats the difference?

5. The moral significance of compassionDo you or the patient need(s) compassion?What happens when there is no compassion?How did you/the nurse show(ed) compassion?

*These questions are merely examples of questions that were posed in reference to the topic lists. Besides questions such as these,participants were frequently asked to illustrate their answers by sharing their specific experiences.

674 Nursing Ethics 18(5)


questions and congruency with the theoretical framework. Besides the word compassion the interviewers

deliberately used two Dutch synonyms for compassion: medeleven and mededogen. This was done to

prevent the interviewers giving a too explicit explanation of the concept of compassion. Moreover, it seemed

important to raise the issue of semantics. The researcher and three nursing students (bachelor) carried out the

interviews. Nursing students were chosen to be interviewers for several reasons. For one thing the students

had easy access andwere easily accepted as trainees on the job in the research settings. For another, theywere

familiar with the issues they needed to address in the interviews andmost importantly, because of the fact that

they were students they were able to ask questions without any diffidence or fear. Off course having students

perform interviews has disadvantages as well. Students are not experienced in necessary interview skills by

nature; therefore the researcher trained the students extensively in the use of interview techniques in several

two-day courses beforehand and throughout the data collection period. The students were also specifically

selected on criteria such as previous experience in research projects, verbal communication skills and moti-

vation. Complimentary to the interviews, all four interviewers observed several conversations between

nurses and patients, for example care plan evaluation interviews, and moments when caretaking took place

such as assisting in daily activities. These observations, described in memos, were done in order to under-

stand the context of a research setting and were used to support the analysis. Interviews were planned based

on voluntary admission or on the initiative of nurses themselves; patients were approached and asked to par-

ticipate after being nominated by a nurse. The nomination was merely based on the inclusion criteria and

health status of the patient at the moment of the interview. After nomination patients were asked to sign a

letter of informed consent to participate. The letter also stipulated that patients could always withdraw their

consent without having to explain reasons to do so and that participation would never have any influence on

the care they received. Information from the interviews was always handled with confidentiality. For one

thing, the data transcription was performed by a research assistant outside the research settings. Interviewers

were nearly always received with openness and enthusiasm. The importance of compassion was often men-

tioned as the main reason for wanting to participate in the study.

Data analysis

The interviews were recorded and then transcribed into written documents. Subsequently, the interviews

were analysed with the software program Atlas-Ti by means of coding of quotations. Thus, the data was

structured and a list of concepts emerged. The researcher and students discussed and reached consensus

on several concepts after coding a set of interviews independently. The information from the memos of the

observations in practice was sometimes used to help coding the concepts. This was done by checkingwhether

a code definition would fit in the situation observed. The memos also provided some of the hypotheses that

helped to steer the analysis. Time and again the preliminary code list was augmented and adjusted by the

researcher based on the coding of new interviews until data saturation was reached. Eventually, a code list

with two levels of hierarchy was made.

In the last phase of the analysis core concepts were chosen and prioritized from a content perspective

based on rereading and paraphrasing quotations.

Thus, participants experiences in response to open questioning led to the seven dimensions that charac-

terize the nature of compassion whereas the opinions of participants in response to the semi-structured part of

the questionnaire contributed to more clarity on both the nature as well as the significance of compassion.

Researchers role

The role of the researcher is an aspect of qualitative research methods which is subject to critique. Although

many results of the study emerge from literally quoted texts of participants, in the end results will always be

Cingel 675


interpretations by the researcher in particular. In formulating these interpretations, the researcher must

manoeuvre between tangible descriptions that stay close to original texts and a sufficient level of abstraction

in order to develop theoretical concepts. The danger in giving tangible descriptions is that it may reduce the

phenomenonby splitting it up. Such an unravelled descriptionwoulddo no justice to the experiences, thoughts

and expressions of participants. On the other hand, the researcher must work on theory development. This

work is at risk of replacingone abstraction by another. For example,when compassion is replacedby empathy,

which participants sometimes perceived as a synonym for compassion. Research as such would not produce

any useful knowledge and it would reduce the study to a game of semantics. Therefore, interpretations of the

researcher, the level of data saturation and the amount of quotations per group of participants must be open to

judgement. These figures on dimensions and issues of compassion can be found in Tables 3 and 4.

Results 1

The nature of compassion

Compassion is found to be a process of intuition and communication, in which one can recognize some sort

of a sequence. The outcome of this process is labelled as compassion. Compassion as a process has, accord-

ing to the participants narratives, seven dimensions. They are described in paraphrases, illustrated with quo-

tations, and elucidated by the researchers interpretation.

Attentiveness

First and foremost attentiveness is mentioned most often. Attentiveness, during a person to person encounter,

is described as a conscious approach of one person who shows interest in whatever issue is important for the

other person. According to participants attentiveness can be supported by gestures or touches, provided these

are appropriate.

To seek contact with others in a conscious way and show outgoing attentiveness to this person within such a con-

tact. (Patient with rheumatic disease, rehabilitation centre for chronic diseases)

The first thing that comes to mind in thinking about compassion concerns approaching the other person as

a human being. Such a contact immediately compels a nurse to act, however small or non-verbal this act may

be. Acts such as making eye contact, or slowing your pace, or pulling up a chair to sit next to the bed, are an

invitation to the patient. This shows that there is a conscious wish for contact; the nurse gives her permis-

sion to continue. Behaviour in which one shows a level of attentiveness in order to consciously seek contact

is the key to the continuation of contact that leads to the patients narrative.

Table 3. The nature of compassion

Dimensions

Patients 31 Nurses 30

quotes patients quotes nurses

Attention 89 26 75 25Listening 46 19 86 27Confronting 36 22 42 21Involvement 22 17 22 15Helping atitudes 51 30 36 21Presence 19 10 21 13Understanding 15 8 22 14



Listening

The second dimension is to give room to the story of the patient. Nurses see active listening as an indispen-

sable component of compassion. To them listening means stimulating the other person to tell the story. In

order to acknowledge that the patient can speak, the nurse keeps her silence and poses questions that will

encourage the patient to tell the complete story. Patients acknowledge that nurses indeed do listen, as the

following statement shows.

They listen to your story all the time. Actually, there is not a nurse that does not listen. (Patient with COPD, reha-

bilitation centre for chronic diseases)

After the first encounters between nurse and patient it is crucial to prolong the invitation to speak. Mainly,

the importance of listening is the willingness to really hear ones story. Here is a story that can and may be

told, that wants to be heard and has an audience. This is enough, for now, because in telling the story ones

heart is lifted and theres room to breathe.

Confronting

When the story is told, the room to breathe can be used for dialogue. In the context of compassion this dia-

logue is characterized by the verbalization of suffering and the accompanying emotions, according to parti-

cipants. To confront the patient with the fact that these emotions are rightly felt because suffering because of

loss exists, is the third dimension of compassion.

No . . . , she said, you must not think so lightly about it, it is really not that easy. (Patient with COPD, rehabilita-

tion centre for chronic diseases)

The dialogue, this talk, the verbalization of what is going on, is not just any conversation. For the nurse it

is about paraphrasing what she has heard, it is about acknowledging and valuing. It is crucial to value the

patients situation as being unpleasant, difficult, tedious or bad. For the dialogue to be a compassionate dia-

logue it is necessary, however paradoxical this may seem, to confront in order to help the patient to face his or

her loss. Patients mention that suffering is, among other things, caused by loss of possibilities in life. On the

one hand the confrontation is a check to find out the emotional significance of the loss for the patient. Nurses

describe in detail how they are able to recognize emotions such as grief, anger, fear and shame nonverbally,

besides inquiring about them. On the other hand these valuing statements acknowledge the emotions con-

cerning the loss and suffering. The nurse legitimates the emotion, so to speak. Because it is bad to miss out

on things you used to love but cannot do anymore, it is difficult not to be able to go wherever you want to go

anymore or bear other losses.

Involvement

The fourth dimension of compassion is involvement. The acknowledgement of loss and suffering creates

involvement, so say participants. Involvement is about the idea that the nurse recognizes your emotion and

that she is concerned about you in the same way that you are yourself. Then, you are no longer the only one

who knows about your emotions. Because of these shared emotions a bond is established.

Hmm . . . I believe that there is some sort of alliance in it. It simply feels good . . . some sort of feeling like . . . God,

there is somebody else I can speak to . . . including the things that Im not keen on bringing out in the open. And

also . . . someone who wants to know everything. (Patient in homecare)

Cingel 677


Nurses show that their communication is not a one-way street when they are touched by the loss and suf-

fering of the patient. For that matter, a lot of nurses mention the fact that they literally feel the same emotion

when they see a patient with a particular emotion. Because of that, patients also feel confident that the nurse

will handle their shared emotions with care. Confidentiality and trust were often mentioned in that perspec-

tive. Within the established bond there is a mutual understanding of trust and of this specific information to

be safe.

Helping

The fifth dimension is helping. According to a large majority of participants, compassion takes shape in

simply giving someone a hand. Thus, helping is to assist at the activities in daily life by responding or

anticipating to basic needs which the patient cannot perform him- or herself anymore. Instead of taking over

completely, helping can also mean suggesting alternative ways to handle things so patients can continue to

carry out activities themselves.

I was fiddling with a small cup of jam, while the person sitting next to me has capable hands and suddenly the

nurse was there, tapping my shoulder and he whispered . . . you see, that! (Patient with rheumatic disease, reha-

bilitation centre for chronic diseases)

Nurses associate compassion with a wish to do something for someone else. Patients value this behaviour

greatly because a helping hand is indispensable when you are not able to do things yourself. The best way to

help is to anticipate, to be salient to what is needed, because in this way laborious asking is prevented.

Helping often concerns apparently small favours but can also include, for example, mediating between a

patient and his or her doctor in case of communication problems. The heart of the matter is that it always

concerns acts that are of real importance to a patient.

Presence

Although presence is less oftenmentioned than helping, there still is a strongmessage in the way participants

value presence. To be there is the sixth dimension in which physical presence is the condition for emotional

presence and presence of mind. Saliency is inherent to being present. Actually, to be present is all about noti-

cing what is going on with a patient.

The patient had bad news. Well then, I thought, I better stay with him. And just for that he thanked me three times

over. (Nurse at rehabilitation centre for chronic diseases)

This quotation shows that it is about noticing that someoneneeds you to be there. Nurses are, by profession,

privileged to be present in all kinds of intimate situations. It is almost self-evident to be present. And yet pres-

ence apparently is of such importance that participants mention presence specifically. It is not just a matter of

coincidentally being there. It is a conscious choice because the nurse notices the need for her presence.

Understanding

Finally, understanding is the seventh dimension of compassion. It is a dimension thats mostly mentioned by

nurses. They say it is important to let the patient know that you are at least trying to understand what is going

on for them. Patients acknowledge that this is indeed important.

and . . . the fact that this is really understood, as in acknowledging . . . like . . . yes, I do understand your anger . . .

or grief about it. (Patient in home care)



Nurses say this is important from a human as well as a professional perspective because in this way you

show that youwant to understand someones feelings correctly. You show that you have the intention to actu-

ally know about someones troubles and not to walk away from them. Moreover, when there is a mutual

understanding of the emotion you can also speak of evidence on which professional nursing is to be based.

Development of the theoretical framework

The literature review has been a guideline for the development of the theoretical framework and subse-

quently for the lists of topics for the semi-structured part of the interviews. The review explores views on

compassion and related concepts such as empathy by classical philosophers as well as contemporary scien-

tists. These analyses lead to a phenomenological and tentative description of compassion. Compassion is, in

this view, a process with affective, cognitive, behavioural andmoral dimensions, which is primarily triggered

by suffering of others.10,11 In order to feel compassion imagination and identification is necessary, at least to

some extend, although there is the danger of projection, which should be avoided.12 In her study on emotions

classicist and philosopher Nussbaum convincingly demonstrates that besides the feeling of compassion, one

also needs to believe that the suffering of the other person is a terrible thing.13 One needs to have a specific

thought for a specific emotion. Herewith, Nussbaum places compassion in a perspective of theories that sug-

gests that emotions have rationality in them. The moral and subsequently related behavioural dimension of

compassion concerns acting from an altruistic perspective in which setting aside ones own interests and

withholding ones judgement are central.14 Finally, the fact that suffering is acknowledged by compassion

offers consolation; not to show compassion actually adds suffering to the suffering that already exists

because it denies suffering.15 In this view, compassion shows to be an answer to suffering. All these issues

raise specific questions on which philosophers and scientists sometimes reach consensus and sometimes dis-

agree. In order to obtain opinions from participants, the interviewers asked questions about:

the context related to suffering in which compassion exists emotions and responses to chronic illnesses and loss (what triggers compassion) how to assess the suffering of others (identification and imagination) thoughts and feelings on the suffering of others and views on experiencing compassion (how is the emo-

tion explained)

motivation of participants to show compassionate behaviour (motives for compassion) pitfalls related to unconditional compassionate behaviour (conditions for compassion) the effects and significance of compassionate and uncompassionate behaviour on care (moral signifi-

cance of compassion)

This theoretical framework of compassion thus consists of six leading issues concerning the nature as well as

the significance of compassion: compassion and suffering, compassion and identification, the emotion com-

passion, motives for compassion, conditions for compassion and the moral significance of compassion.

Results 2

Opinions on compassion

This article addresses opinions of participants on some issues from the theoretical framework. Some of these

discuss the nature of compassionwhile others try to grasp the significance of compassion for older patientswith

a chronic disease. Other remaining issues of the framework will be addressed separately in the context of the

behaviour of the nurse and the relationship between the nurse and patient in another phase of the (PhD) study.

Cingel 679


Compassion and suffering

First of all, in most literature compassion is directly related to suffering. It is the trigger for compassion

according to Tudor, among others.11 Participants in this study, nurses as well as patients, subscribe to this

notion.

then, somewhere, at somemoment . . . somehow, I feel an appeal is being made. (Nurse at rehabilitation centre for

chronic diseases)

Surprisingly enough it is not primarily pain or troubled breathing, the physical kind of suffering, that is

seen as the toughest part to deal with when participants address their suffering. The study shows that every-

day troubles, as a consequence of loss of possibilities, are the main burden to people with a chronic disease.

Patients do not always explicitly call these troubles suffering, but as these limitations in performing daily

activities prolong they admit it becomesmore andmore difficult to endure them. To not being able to perform

simple activities, such as cycling to the store to fetch some groceries, brings about emotions such as grief or

anger. These various emotions express the kind of suffering that represents psychological distress, for exam-

ple grief, helplessness, hopelessness or anxiety.16,17 The notion of a perspective in which the possibility to do

whatever you want in life is diminishing or will even be lost, probably sooner than later, brings about such

emotions.

Well yes, I can be very sad about it, sad . . . because I cannot do this or that . . . it is so disappointing . . . (Patient in

home-care)

As Tudor does, participants acknowledge the paradox that on the one hand suffering is not something to

measure and on the other hand there is a gradation in certain kinds of loss.11 Some quotations from nurses

address the subjectivity of suffering, for example the nurse who states: I think one suffers when one says he

suffers. Other quotations, however, describe the loss of loved-ones to death as being the ultimate form of loss

and therefore of a different order than any other kind of loss. Although suffering is the most important trigger

for compassion, it does not need to be restricted to that. Most participants also believe compassion to be

related to joyful occasions. Specifically participants from the rehabilitation centre of chronic diseases men-

tion the importance of compassionate behaviour when joyful occasions happen. To cherish happy and joyful

moments in life is needed as a counterweight to troubles for patients. Next to that, it is a necessity that others

know or hear about these events.When nurses see my distress and suffering, they also need to know about the

events that keep me going and help me to survive, seems to be the argument. In this way, positive confirma-

tion is used as a motivational instrument in the rehabilitation of patients with a chronic disease. Not surpris-

ingly, because patients work hard and want their efforts to be worthwhile. Showing compassion at happy

occasions acknowledges these efforts to be worthwhile. Another advantage is that patients relive these pos-

itive emotions when they share these joyful events with nurses in narratives. Therefore the counterweight of

joyfulness can be used in repetition.

When a patients condition improves, or when someone, in all ones misery, enjoys a visit from ones grandchil-

dren enormously and wants to talk about it . . . then I keep asking questions because then they relive it over and

over again . . . and I feel compassionate . . . (Nurse home-care organization)

Compassion and identification

Secondly, identification is an issue under discussion. Participants, mostly within the group of nurses,

described several forms of identification which all involved imagination. In many theories empathy is seen

as a preliminary condition for compassion, and in order to use your empathic ability, it is necessary to identify



yourself with another person through imagination.12 The study shows that some of the participants indeed

imagine themselves to be in the same situation as their patients. How would I be, feel, behave if I were ill,

was in pain or had to adjust to another lifestyle. They identify byway of placing themselves in someone elses

shoes, they more or less try to become someone else. In addition, some participants use their personal experi-

ences the way they believe actors probably do.

They (actors) take some event from their own life, something they can connect to . . . I believe it is the same with

empathy, you use parts of your own stuff too . . . actually . . . its not possible to do it otherwise. You cannot know

from theory how painful it is if you dont recognize a part of it. It doesnt have to be the exact same experience,

but you need to draw upon something. (Nurse home-care organization)

Others use their imagination to picture the other person as in a play ormovie; they literally see their patient

as you do when you watch actors in a play, here imagination more than identification is doing the trick.

I actually see Mrs. A. walking around in her apartment; I see her walking in this specific kitchen . . . (Nurse in

rehabilitation centre for chronic diseases)

Of course nurses also use their professional experiences; they recall former experiences in their career as a

nurse and recognize the situation, feelings and behaviour of others in the past.

Recognition, you see . . . because of all the experiences I have nursing pulmonary distressed patients I recognize

all these patterns. (Nurse specialist at outpatient clinic)

The same mechanism of recollection applies when nurses recognize emotions based on verbal and non

verbal information that patients give them. It is easier to realize what is going on for a patient when you have

specific information. To get this specific information, nurses use different strategies in order to get to know

the meaning of loss for a specific patient. One nurse for example, deliberately told a patient that she was born

and raised on a farm, as he was, in order to connect and establish a bond.

The emotion compassion

In theories about emotions, questions concerning the relation between rationality and emotion are relevant.13

Are emotions entirely different from rational decisions? Are feeling and thinking as dichotomous as some-

times is assumed? In order to gain insights into the perception of the emotion compassion, participants in this

study were asked about feelings and thoughts they might have had experiencing compassion. Nurses and

patients mention both, although some participants believe compassion to be solely a feeling. Compassion

as a feeling has a spontaneity and therefore authenticity about it. This would disappear if compassion were

a rational thought, according to these participants. Without authenticity the feeling of compassion would

not be real and thats precisely what they feel: the nurse is really there for them so it cannot be a deliberate

process of thought. But most participants mainly describe the start of the emotion as a feeling.

I physically feel for this patient . . . I want to take care of him because hes in need . . . thats what I feel. (Nurse in

rehabilitation centre for chronic diseases)

Other participants describe their rising feelings in terms of I was touched or I was genuinely feeling

sorry for him. One nurse suitably called it agosh-feeling to address her feelings of shock when confronted

with someones sorrows and suffering. Yet, feeling and thinking seems to be happening almost simultane-

ously or at least in a very rapid succession. The feeling translates into a thought so quickly that some parti-

cipants do not even notice the difference.

Cingel 681


the feeling rises very sudden. For example when someone tells you something and all of a sudden you think: this

must be really bad for him. (Nurse at rehabilitation centre for chronic diseases)

The transferral from spontaneous feelings to deliberate thoughts on the significance of suffering for

the other person does not seem to be as distinctive as one might think. One nurse describes this process

as a lot of little libraries in my brain that open up. She says she uses knowledge of earlier experiences

and combines them with signals she observes at the moment in order to be able to interpret the signifi-

cance for her patient. A few nurses explicitly qualify this rapid and partly unconscious process as intui-

tion. Besides compassion, nurses have other emotions regarding suffering of patients. This study

subscribes to results from other narratives in which nurses describe their frustration, anger or indignation

concerning their patients situation.16

Motives for compassion: the difference between compassion and pity

The third issue addresses similarities and differences between compassion and pity. Both concepts are used

to refer to an emotion that indicates a feeling of being sorry, of understanding someone elses predicament. In

several analyses the differences between both concepts become clear.14,18 Participants also see pity as a dif-

ferent concept from compassion. Pity, for them, has a negative connotation.

They can feel compassionate for me till death, but I dont want any pity. (Patient with COPD, rehabilitation cen-

tre for chronic diseases)

Pity is different from compassion but has, remarkably, two semantic explanations according to the parti-

cipants in this study. Either, pity is associated with feeling sorry for someone in a pathetic and patronizing

way or the Dutch word for pity medelijden is associated with literally having the same feelings as the other

person. Feeling sorry victimizes a patient and evokes powerlessness. This powerlessness contaminates

the nurse as well. As a result she is not able to support a patient anymore. The Dutch word medelijden

or meelijden meaning literally feeling the same, has a much less negative connotation and is specifically

felt by nurses. It exceeds the concept of simply sympathizing with someone; it is much more a transferral of

the emotion.

it turned out that it hurt me, I felt it to the bone, I literally felt . . . almost at the same time . . . it is some kind of

reflex. (Nurse at home care organization)

Recent publications on neuroscience show that connections of mirror-neurons play a role in emotional

responses.18,19,20 Connections of mirror-neurons react when a person him/herself has an emotion as well

as when this person sees someone else having this emotion. These studies also show different connections

per emotion, in other words: specific and distinct emotions are recognized. Empathy in these theories is a

neutral given and a condition for compassion. Earlier, Morse and Mitcham already named this reflex com-

pathy.21 More recently, the suffering of nurses was addressed by Ferrel and Coyle.16

The moral significance of compassion

The last issue of the theoretical framework to be discussed concerns the significance of compassion, the ulti-

mate question in this study. In order to establish the significance for participants, they were questioned about

the effects of compassion. According to the Dutch philosopher Duijndam, the explicit verbalization of suf-

fering offers the acknowledgement and consolation which characterizes compassion.15 But what are the

effects of compassion according to the participants in this study? Within the care settings researched,



compassion shows itself to have several effects. First, compassion results in information which is useful in

reaching the outcomes of care. Compassion as such becomes an instrument of care.

If I can find intrinsic motivation . . . for example when someone wants to walk a bit longer and further than he can

and I happen to know that he really wants to fetch his granddaughter from school . . . then Ive got him, then he

understands why he is here, it becomes more and more tangible. (Nurse at rehabilitation centre for chronic

diseases)

Secondly, compassion softens the image of the difficult patient. Patients say that they do not want to be a

nuisance to nurses. But nurses in this study say they are able to understand difficult behaviour. They say

patients have good reasons to behave in such a way. It is the nurses professional task to find out what this

reason is. In this view, patients simply cannot be a nuisance to nurses. Behaviour that asks for attention is a

signal and is seen as such. These results correspond with theories that state that the denial of suffering adds

suffering.11,15,16

you can see that when patients experience compassion that the effect is that they do not ring the bell anymore . . .

simply because they get their share of genuine attention . . . ringing the bell all the time often is a cry of ignorance,

fear, processing of events . . . (Nurse at rehabilitation centre for chronic diseases)

Finally, compassion contributes directly to the quality of care according to those who promote compas-

sion as the essence of nursing.22 Participants in this study agree. Compassion motivates to perform to the best

of ones ability, according to a patient. You do recuperate more quickly according to another participant.

Therefore compassion is inherent to the concept of care, and specifically to good nursing care. The nurse

in this quotation illustrates this argument when she passionately verbalizes the significance of compassion:

Table 4. Opinions on compassion

Issues theoretical framework

Patients 31 Nurses 30

quotes patients quotes nurses

Suffering related to compassionSuffering is trigger 77 28 108 30Loss (of possibilities) 58 26 49 21Other emotions related to suffering 28 18 29 18Compassion related joyful situations 21 19 27 24Compassion and identificationSeveral forms of imagination 34 22 114 30Empathy related to information 18 10 32 18The emotion compassionCompassion as a feeling 25 19 27 20Compassion as a thought 18 15 32 21Other emotions nurse 29 15Motives: Compassion and PityPity is a negative emotion 79 29 92 30Suffering with: compathy 9 6 23 14Moral significance of compassionEffect on outcomes of care 9 8 31 21Opinions on asking attention 19 11 8 6Inherent in concept of care 3 3 17 15Direct positive effect in general 45 25 37 21

Cingel 683


I believe compassion as a theme to be of such importance in health care . . . , it is so very important that its really

all there is to it and with it the quality of care . . . We absolutely do not sell a pound of sugar. We sell a whole lot

more and I sincerely do hope that this will come to light. (Nurse at home care organization)

Discussion

This study acknowledges those who plead for compassion to be the ground on which nursing care should be

standing and offers a handhold to nurses who want to put compassion into practice. Although results of this

study should be understood only within the specific context of this study, they are still meaningful for nursing

practice in general. Obviously, external validity based on statistically significant results as in quantitative

research studies, is not under discussion; but theoretical validity does and has been achieved in this study.

Building a theory based on the seven dimensions found in this study is significant in itself, especially because

data saturation took place. Permanent losses and enduring suffering are relevant to many patients in more

than one setting of care; therefore results of this study are meaningful for nursing care in general. However,

the theoretical framework used in this study can attract criticism. Questions related to the issues from the

theoretical framework could have influenced participants while phrasing their views on compassion. On the

other hand, it can be argued that the seven dimensions are found independently of the theoretical framework.

Nevertheless, further confirmation of the dimensions found in this study in other settings in order to

strengthen this theory on compassion, is recommended. In continuation, further analysis of the research data

can also contribute to more clarity on the behaviour of the nurse that is necessary to enhance compassion in

nursing practice.

Conclusion

This study shows that compassion is seen as a valuable phenomenon in nursing practice areas where older

people with a chronic disease receive care. Compassion in this study has a structure in which at least seven

dimensions can be recognized.When a nurse and a patient meet each other, compassion is the instrument that

supports the professional process. The professional nursing process is, in this context, a relational process in

which nurses acknowledge loss and suffering and the emotions that go with it. Because of the fact that

patients share personal, meaningful information nurses are able to give care that is made to measure. Thus,

compassion can lead to good quality of care because individual, feasible and accurate outcomes of care are

understood. Eventually, compassion can motivate patients have courage and nurses to deliver good quality of

care.

Conflict of interest statement

The authors declare that there is no conflict of interest.

References

1. Van Heijst A.Menslievende zorg. Een ethische kijk op professionaliteit. (Humane Care, an ethical perspective on

professionalism.) Kampen: Uitgeverij Klement, 2005 (in Dutch).

2. Fawcett J.Analysis and evaluation of contemporary nursing knowledge: nursing models and theories. Philadelphia,

PA: FA Davis Company, 2000.

3. Schantz ML. Compassion: a concept analysis. Nursing Forum 2007; 42(2): 4855.

4. Cingel van der CJM. Compassion and professional care: exploring the domain. Nursing Philosophy 2009; 10:

12436.

5. Chambers C and Ryder E. Compassion and caring in nursing. Abingdon: Radcliffe Publishing Ltd, 2009.



6. Boeije H. Analyseren in kwalitatief onderzoek. (Analysis in Qualitative Research.) Amsterdam: Boom Onderwijs,

2005 (in Dutch).

7. Chenitz WC and Swanson JM. From practice to grounded theory. Menlo Park, CA: Addison-Wesley, 1986.

8. Annells M. Triangulation of qualitative approaches: hermeneutical phenomenology and grounded theory. Journal

of Advanced Nursing 2006; 56(1): 5561.

9. Benner PE. From novice to expert. Excellence and power in clinical nursing practice. New Jersey: Prentice Hall

Inc., 2001.

10. Carr B. Pity and compassion as social virtues. Philosophy 1999; 74: 41129.

11. Tudor SK. Compassion and remorse: acknowledging the suffering other. Leuven: Peeters, 2001.

12. Roeser S and Willemsen M. Compassie en verbeelding. Over Nietzsche, Nussbaum en de onwenselijkheid van

egoysme. (Compassion and imagination. About Nietzsche, Nussbaum and the undesirable consequences of ego-

ism.) Algemeen Nederlands Tijdschrift voor Wijsbegeerte 2001; 96: 5365 (in Dutch). 2001.

13. Nussbaum M. Upheavals of thought. Cambridge: Cambridge University Press, 2001.

14. Richmond S. Being in others. Empathy from a psychoanalytical perspective. European Journal of Philosophy

2004; 2(2): 24464.

15. Duyndam J. Denken, passie en compassie, tijdreizen naar gemeenschap (Thinking, passion and compassion. time-

traveling to a sense of community.). Kampen: Kok Agora, 1997 (in Dutch).

16. Ferrel BR and Coyle N. The nature of suffering and the goals of nursing. Oxford: Oxford University Press, 2008.

17. Carpenito-Moyet LJ. Handbook of nursing diagnosis. Philadelphia, PA: Lippincott Williams and Wilkins, 2006.

18. Cartwright DE. Schopenhauers compassion and Nietschzes pity. Schopenhauer-Jahrbuch 1988; 69: 55767.

19. Keijsers C and Jabbi M. Inferior frontal gyrus activity triggers anterior insula response to emotional facial expres-

sions. Emotion 2008; 6: 77580.

20. Knafo A, Van Hulle C, Zahn-Waxler C, Robinson JL and Rhee SH. The developmental origins of a disposition

toward empathy: genetic and environmental contributions. Emotion 2008; 6: 73752.

21. Morse JM and Mitcham C. Compathy: the contagion of physical distress. Journal of Advanced Nursing 1997; 26:

64957.

22. Maben J, Cornwell J and Sweeney K. In praise of compassion. Journal of Research in Nursing 2009; 15(1): 913.

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