Original Article

Components of Compassionate Care in Nurses Working in the Cardiac Wards: A Descriptive Qualitative Study

Introduction

Compassion, the core of care,¹ is the most valuable asset in nursing² and a key element in nursing care.³ Illness and hospitalization are usually stressful and have threatening experiences for patients and their family members.⁴ Nurses are an important member of the health team who spend the most time with patients and their families, and by applying care skills, including compassionate care and emotional work, play a major role in reducing stress and negative experiences resulting from hospitalization.⁵

Nurses become aware of their patients’ care needs through compassion-based care. The nurse’s kind and emotional work leads to many caring behaviours that are considered to be the foundation of caring with love and quality. In fact, kind and emotional relationships between the nurse and the patient can lead to improving the health of the patient.⁶Although caring with affection can be accomplished by actions such as a smile, a reassuring look, and a caress, it is a complicated process. For nurses and caring organizations, this means that opinions, values, and beliefs of patients should be identified and respected in care based on compassion. Moreover, patients should be encouraged to intervene in their care and related decisions.⁷

Compassionate care is a process in which nurses interactively communicate with patients, try to explore patients’ concerns by putting themselves in their positions and understanding their situations, and do their utmost to eliminate these concerns.⁸This process is influenced by cultural, religious, social factors as well as the nurse’s attitude. Therefore, scientific knowledge requires a careful analysis of the conditions affecting nursing care.⁹A review of various studies shows different dimensions of the importance of compassion-based care. Some studies, consider the typical characteristics of compassion- based care as follows: conscious sympathy with others’ problems, sensitivity to the suffering of others, staying with others in their discomfort and pain, an effort to relieve suffering. In fact, they know these features as an aspect of care.¹⁰ Sinclair et al consider compassion as a moral virtue with originality, love, openness, honesty, integrity, kindness, and tolerance. They also observe communication space, patient awareness and involvement in care, virtue-oriented response, communicating with the patient by understanding and reporting the outcome of the patient’s treatment, along with reducing pain and suffering, and promoting recovery and care as important parts of compassion.¹¹

Compassion care is usually context-based and there is not a single theory for explaining the process of compassion-based care.¹²Providing compassion-based nursing care is especially important in cardiac wards where patients are exposed to sensitive conditions. Nurses who work in these wards face high tension and stress as they should take care of patients with various problems. In the cardiac wards, nurses must constantly balance the science and art of nursing, so it is important to identify compassion-based nursing care in these wards.¹³ Therefore, this study was performed to describe the components of compassion care in nurses who work in cardiac wards.

Materials and Methods

In this study, the descriptive qualitative method was applied. In this type of study, the researcher provides a comprehensive summary of a phenomenon or related events in a common language but does not go into the deep phase of interpretation. These studies are less interpretive than other qualitative methods such as phenomenological or grounded theory research.¹⁴

The participants included 36 clinical nurses, 20 patients and 8 family members in 5 medical and 1 surgical cardiac wards of the selected hospital affiliation to Isfahan University of Medical Sciences in 2020-2021. The participants were selected using purposive sampling. In order to achieve different experiences, participants have the maximum diversity in terms of age, gender, background, and work place.

The data collection was done using in-depth semi-structured interview (36 nurses, 20 patients and 8 family caregivers), focus group (36 nurses, 4 patients and 3 family caregivers) and field notes. The data collection lasted 6 months (October to March). The interviews were conducted in the medical and surgical cardiac wards. All interviews were conducted in a quiet room at the hospital and varied in length between 20 to 60 minutes. All interviews began with general questions: “Please tell me about some of your caring behaviors that show compassionate during a work shift; what factors affect compassionate care?” Probing questions were asked as necessary to motivate participants to express their experiences, memories, and their perceptions. Field notes were written immediately after interview.¹⁵ Eight focus group sessions were held separately for nurses, patients, and family caregivers in hospital. Participant selection continued until saturation, i.e. the stage where no new concept was obtained by data analysis. Saturation refers to the repetition of discovered information and confirmation of previously collected data and when ongoing analysis reveals no new information appearing and no new categories emerging, sampling may cease.¹⁵

Data analysis was carried out using the qualitative content analysis approach proposed by Graneheim and Lundman.¹⁶ Recorded interviews and focus group sessions were transcribed word by word and then, transcripts were perused and meaning units were identified. By definition, meaning units are excerpts from the data which “relate to the same central meaning”. Identified meaning units were condensed, abstracted, and coded. Similar codes were grouped into subcategories, while subcategories were inductively grouped into main categories according to their similarities. The field notes were written verbatim and analyzed simultaneously with the transcribed interviews using the qualitative content analysis.

Rigor of the qualitative data was ensured through credibility, confirmability, dependability, and transferability.¹⁷ Confirmability was enhanced by bracketing and keeping a clear audit trail of all research activities. To strengthen the credibility, peer debriefing or reviewing of the data, codes, sub-sub categories, and subcategories was done. Furthermore, extracted codes and results were taken back and shared with the participants (6 faculty member who expert in qualitative research) to validate the congruency of the codes with their experiences. Dependability was also improved by engaging more than one researcher in data analysis. Recruiting participants with varied demographic characteristics helped the transferability of the results.

Results

Different participants were recruited 36 nurses (28 female nurses and 8 male nurses) participated in the research. Seven participants had master’s degrees in nursing and 29 nurses had undergraduate degrees. The mean age of participants was 42.2 years and their average working experience was 18.18 years. In addition, 20 patients (11 female and 9 male) participated in this study. Five female family caregivers and three male family caregivers (spouse and offspring) also participated. The results of this study are presented in one main category, four sub categories including “using verbal and non-verbal language to express feelings”, “doing empathy activities”, “Organizing patient-centered care”, and “adhering to the cultural context”, and twelve sub- sub categories. The main category, sub-categories and sub-sub categories are explained in Table 1.

According to the results, the patient-centered emotional discourse is a main category, which is the main issue in shaping the compassion care in nurses. Nurses have recognized the strong role of language in compassion care. The nurses’ activities are based on the care. Sometimes they express their feelings during patients care with non-verbal language, verbal language and sometimes poetry and literature.

Clients have a point of sharing whether they are patients, or family caregivers, or are in critical or stable situation. All clients emotionally require psychological support. Therefore, nurses should interact with these people. This interaction can be done with the supporting them through standing with clients, response to their emotional states, or in a variety of demonstrative and active ways.

Nurses have treated patients and family members compassionately depending on their caring, supporting, artistic, and cultural roles in the community. They seek to organize the care through providing patient-centered care, creating a secure interpersonal communication atmosphere and creating a supportive-collaborative care atmosphere.

Several reasons indicated the extent to which compassionate nursing care will be emerging. Nurses try to adhere to cultural context and to respect and value the patients’ and their families’ religious beliefs.

Using verbal and non-verbal language to express feeling

A good interpersonal relationship in which tone and behavior plays an important role was considered as a prerequisite for optimal nursing care. The importance of using non-verbal behaviors to express kindness to the patient was highlighted. Nurses have persuaded clients for conversations and communication using the non-verbal emotional behavior, showing kindness through smile, sometimes touching and squeezing the patient’s hands, and looking at, and active listening. For example, one Nurse said: “Communication or even listening to the patient, asking what happened to them, it could all be compassion...” (P4).

Another nurse said: “... The kind nurse listens to the patient, tries to consider the patient’ comfort, touches his/her hand, embrace, especially for those who are bad, have more problems, and these are signs of compassion...” (P8).

Culture and language are inextricably interconnected, and understanding one without another is not possible. Because language is not just a means of expressing opinions, it is also a format of thought and plan and is a guide for mental activity. Some participants argued that compassionate response during compassioning process is closely related to family and social behaviors and interpersonal relationships. Moreover, one of the compassionate-based caring behaviors for nurses is to say positive caring terms. One participant said: “.... The tone of the voice and the sentences that you tell to the patients and their relatives will make them feel important. This will treat them sooner, and I think the nurses who practice this behavior are really kind...” (N9).

One symbol of the compassionate behaviors is to us literary terms, poetry, and humor during patient care. Most of the nurses in this study believed that only a short communication such as a small joke, humor or a short sentence in accordance with the patient’s culture will make sense of intimacy and will result in a better acceptance of treatment and consequently reduce patient’ stress. One participant said: “I myself... pulling the patients’ leg in the morning, in a way that I take their thought away from illness, depending on the position, I say a joke for one, or tell story for another one, or I’m singing poetry...” (N15). Nurses have a special place in the health care system and have a great deal of talking with patients, listening to their concerns and feelings and their needs. Undoubtedly, compassionate care is noted during the nurse’s communication with the patient.

Doing empathy activities

One part of the compassioning care is empathic skills, and it includes actions and behavior that appear in response to the others’ suffering. Its purpose is to get the feelings of others, to unite with others, and to express the nurse’s understanding of the patient’s sensation. It is an intrinsic characteristic of humans.

One of the compassionate-based caring behaviors in nurses is patient support based on presence alongside the patient and family. Compassion can be found with a simple support at bedside. The manifestation of this behavior in most nurses reflects their cultural beliefs. In this regard, a nurse said: “.... Unlike other people working in a hospital who have technical skills, the emotional and empathic presence is something just we can offer...” (N27). The condition that emerges during illness is a major concern for patient. This situation result in the sense of loneliness. In this case, the patient needs emotional and affectionate support more than the therapeutic aids. The nurse must express these supports with his/her moves, speeches, encounters, and relationships, and assure the patient that she/he is worried about his/her health. Nurses must have a sense of affability, and they should relieve the patient. In our observations, we saw that: At the time of the death of the patient, his relative sat down on the floor. The nurse accompanied him, help him to sit on the chair in the room, and in his slang, he said, “The death happens for all, your father’s disease was hard, he suffered. I’m hoping that he would have a good life in the next world....” Drops of tears fall from the corner of the nurse’s eyes... and he empathy with his family (Field note).

One of the nurses’ compassionate behaviors that were seen in the study was the ability to enter the personal world of others.

By creating a healthy and unreasonable atmosphere, the nurse can provide conditions for expressing the patients’ feelings and thoughts. The experience of another participant was as follows: “It is important to understand the person who lies here on the bed, to understand how difficult it is for him/her to be in this situation. Do not assume this situation is normal. We need to know that just sitting on bed for someone who may not even need anyone before, is difficult” (N15). One of the most important ways to protect a patient is to do not leave him/her alone. If the patient were left alone and lonely, he/she suffers and experience more pain. However, accompanying and empathy with the patient can relieve him/her worries and give him/her encouragement and tranquility.

Organizing patient-centered care

This study showed a classes named establishing favorable conditions for patient-centered care. Participants’ experiences indicated the urgent need for nurses’ availability for attending at patient bedside and timely nursing intervention and ongoing attention. In this regard, a participant said: “... Every time I called a nurse, she/he came up beside me, did everything for me, I said, I feel pain in my hand, he/she quickly touched my hand and bring me drug...” (P18).

Creating a secure interpersonal communication atmosphere is one part of the compassioning care. It means respecting the personality of the patients and their family caregivers and respecting them with politeness and courtesy. Some nurses believed that respecting and paying attention to patients and families is a compassionate behavior. For example: “... Of course, because you care, you respect to the patient, and you transfer this message that you worth...” (N18).

Some participants believed that attention and respect for patients’ privacy is in fact a way of creating a secure c interpersonal communication atmosphere. If nurses compliance with this rule they would have better relationship, and this is a compassionate behavior. One participant also said: “... It’s true that in this section we have the same sex, but I prefer that my nurse change my clothes in the way that nobody see my body... Well, here the nurses use a sheet to hide my body during change dressing” (F4).

Creating a supportive-collaborative care atmosphere was the other important point in organizing patient-centered care. Its related themes represent what nurses were doing for compassioning. Encouraging each other to do benevolent work is a sign of the nurse’s kindness. So they help voluntary patients and each other when they feel that their coworker or patients need help. For example, a nurse said: “The head nurse helped me and actually showed that the patient is important and I’m also important, and I should not be alone or if he/she could not help me, asked the rest to help me for suction or change positioning or etc.” (N30). The patient-centered care along with intimate and cooperative atmosphere and attention to all aspects of human needs during care is considered as a vital part of compassion care and is the base of the nursing profession.

Adhering to the cultural context

Culture has an outstanding role in all areas of nursing and moral care. Cultural differences affect how we deal with illness and medical care. Some people from specific social groups prefer to have a formal relationship with the medical staff and doctors, but others prefer a friendly relationship, thus creating a better relationship. Because of different beliefs about illness and treatment, medical behaviors are different in different cultures.

Participants in this study encountered patients and families with religious beliefs. Data analysis showed that nurses’ efforts are to respect and value the different religious beliefs and values. In this case, one of the participants said: “We had a patient… It was so bad, his daughter stood beside him and started reading the Bible, when I finished my nursing care I also stood by them.…” (N18). Despite the common aspects of nursing care, attention must be paid to the subcultures, beliefs and religious values, and even the patient’s and patient’s desires, which undoubtedly vary from country to country. A nurse said: “Every time talk about compassionate care, it is said that care is individual and unique to any patient. I mean it depends on values, beliefs and culture. It is related to the religious issues. We must take into account the level of education, the social level and all of these...” (N19).

Some nurses who participated in the study believed that patient gender is one of the cultural barriers to providing compassionate caring for patients and is one of the factors that lead to diminished compassion. A nurse said: “You know one of the most compassionate works is that you can transfer your feeling through the touch. Or now, in our culture, it’s hard for men to do this, move kindness, transfer that I understand you. It is hard. So nurses and patients should have the same sex, so that they can show their affection” (N7). It is emphasized that nurses should avoid prejudicing about specific cultures by paying attention to interpersonal communication and respect for the patients’ value system. They must familiarize themselves with the cultural characteristics of patients and families, and consider it during care. They need to be informed about cultural tendencies, interactive patterns and patients’ attitudes toward health and disease.

Discussion

The findings of this study described the components of compassion care in clinical nurses in the medical and surgical cardiac wards. Based on the finding, the components of compassion care include four categories: “using verbal and non-verbal language to express feelings”, “doing empathy activities”, “organizing patient centered care”, and “adhering to the cultural context” that formed the patient-centered emotional discourse as main category.

In the model of mind-education for compassion, Gilbert, the first feature for compassion is the decision to be compassionate. Sensitivity to the others’ emotions and needs, and being responsive to the suffering of others, are other characteristics of compassion in this theory. This means that you have to touch the emotions and move toward empathy with the suffering of others.¹⁸

In the present study, “using verbal and non-verbal language to expressing feelings” played an important role in the process of compassion. In this regard, the findings showed that nurses entered the care with emotional, non-verbal emotional behaviors such as showing interest and affection to patients with open-face, touch, and smile. The study of van der Cingel in the Netherland showed that nurses use non-verbal behaviors such as touch and eye contact as compassionate behaviors in caring for chronic patients.¹⁹ A study showed that in Edinburgh, nurses used behaviors such as greetings to provide compassionate care.¹²One of the compassion-based care behaviors in nurses was the use of verbal skills to convey feelings. In this study, nurses used verbal communication to communicate more. The study showed that nurses used language to reflect feelings and shared understanding with others; they also used positive caring statements to express their feeling towards patients.¹²

The present study showed that attending in a patient’s bedside and supporting his/her during pain and discomfort are a part of compassion in nurses. In a study, approaching and empathy with patient during pain and suffering and compassion-based emotional challenges in nurses leads them to better patient care.²⁰ In another study, nurses said that feeling close to the patient would lead to nurses’ satisfaction and eventually lead to compassion.²¹ In a study in Vancouver on managing emotions in the medical care system, hearing-based presence is actually a kind of emotional support for building an emotional bridge and creating a safe atmosphere by resident clerics.²²

The present study showed that nurses should be able to enter the patient’s personal world for compassioning. The participants considered numerous behaviors (such as the continuous presence and monitoring, availability of nurses, prompt response to care demands, timely delivery of medication and food, nurses’ attention and constant supervision during hospitalization, being with patients and timely recall of the doctor) as a sign of compassionate care. The patients felt calm in nurses’ presence. The result of study showed that nurses were required to perform all tasks and meet the patient’s needs for providing compassionate care. Nurses were also responsible for providing quality care, treatment and patient recovery.²³

The findings of this study showed that nurses led to the organization of patient centered care through creating a supportive-collaborative care atmosphere, encouraging each other to do charitable work, and creating a supportive atmosphere. The results of other studies confirm these findings. In Drayton and Weston’s study the belief in teamwork reinforces the motivation for the collaboration of healthcare team, and contributes to team members’ contribution to improving quality and promoting care.²⁴

The findings of this study showed that nurses provide compassionate care through impartial attention to cultural-based religious and spiritual beliefs. One aspect of spiritual care in other study was to show kindness and forgiveness to others. Also, the other aspect of spiritual care was the provision of spiritual care, with the support and being with patient.²⁵ Also, in this study, nurses have tried to provide compassionate care through creating equal opportunities for caring all patients, creating a space to meet the expectations of all patients, trying to understand the patients’ health beliefs for therapeutic communication.

The finding revealed that, nurses provide formal and no intimate care for opposite sex patient and preferred to care for patient with the same sex. It was based on the cultural context of the community in dealing with the opposite sex. Participants have identified gender as a determinant of compassionate behavior and a major barrier to compassionate care. In study on emotion management in clerics in the Toronto health system, it was found that the clergymen is specifically concerned with the importance of keeping hands, as a powerful tool for communicating with clients. Therefore, emotional behaviors in dealing with both sexes are same culturally (even by clerics).²²This finding also indicates the importance of compliance with the cultural norms in the research community. Compassionate care is crucial for patients and nurses in the development of the nursing profession.²⁶ In the context of Iran, most of the nurses are Muslim. The Muslim tradition encourage all people as well as nurses to help others and be compassionate as a human being. Theretofore, it is expected Muslim nurses to provide a compassionate care in their working context.²⁷Cultural and religious differences in Islamic and other cultures can justify these differences. For example some compassionate behaviors, such as touching the opposite sex are inappropriate and forbidden according to Islam, and Muslim nurses behave in this instructed manner.

This research is limited to compassionate behaviors in Iranian nurses, and only used from medical and surgical cardiac wards nurses.

Conclusion

The patient-centered emotional discourse is a main category, which is the main issue in shaping the compassion care in nurses. They used the verbal and non-verbal language to express their emotions in the compassion care and contribute to the emergence of compassionate behaviours in social and cultural contexts through showing empathy. They presented their patient centered care in a secure communicative environment. These findings can have specific applications for the improvement of nursing care behaviours in nursing clinical, educational, and research areas. Teaching compassion and patient-centered care in clinical fields is among the most important issues that need further attentions. The results of this study can be used as a guide for the development of quantitative and qualitative research in other areas. Managers can have a significant role in achieving care with affection by preparing appropriate work environment, paying attention to lack of nursing staff, ensuring the principles defined in compassion care, and supporting nursing staff. This research is limited to compassionate behaviours in nurses who working in medical surgical cardiac wards, thus it is suggested to conduct research separately in the other wards including intensive care unit and cardiac care unite.

Acknowledgments

The researchers would like to express their gratitude to the vice chancellor for research of Isfahan University of Medical Sciences for the financial support of this study (project number: 299100) and to all participants in this study.

Authors’ Contributions

SB, SF: Conducting the study, data gathering, writing original draft of article; SB, SF, FT: Interpreting and analyzing data; All authors review and final approval of article, conception and design.

Funding

This research was financially supported by Isfahan University of Medical Sciences (project number: 299100).

Data Accessibility

The datasets are available from the corresponding author on reasonable request.

Ethical Issues

Medical Ethics Committee of the Isfahan University of Medical Sciences approved this research (IR.MUI.RESEARCH.REC.1399.565). Informed consent was obtained from all nurses, patients, and family caregivers who involved in the research process. Participants were informed about purpose of study, confidentiality of information and recording interviews. We used numeric codes in place of personal names to secure the confidentiality. The participants were free to withdraw from the study anytime.

Conflict of Interests

Authors declare no conflicts of interest.

Research Highlights

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