Historically, the value compassion spans thousands of years, particularly in a religious context. Despite the historical usage and interpretations of the term 'compassion', there is still discussion on how to define it, particularly as it may encompass a number of values such as sympathy, empathy, and respect. Speaking at a recent event in the UK, Jocelyn Cornwell, Director of the Point of Care Programme at the Kings Fund1, suggested that compassion in its totality differs from other values in that it goes beyond simply 'feeling' something for another person, and implies some kind of action and effort as a result of the desire to 'do' something for another. Along similar lines, perhaps a most widely used definition of compassion is that it reflects 'a deep awareness of the suffering of another, coupled with the wish to relieve it'2.
In recent years attention has been drawn to the fact that compassion towards the patient seems to have decreased, with events at certain hospitals in the UK, Greece and elsewhere showing alarming gaps in the humanity of the care offered. Although there is limited evidence regarding the effects of compassionate care, it is thought that patients who are treated with understanding and compassion may recover faster and manage chronic disorders more effectively. Patient anxiety might also be reduced as a result of compassionate care3.
A recent UK Department of Health Report (2009)4, states that in providing compassionate care:
...we respond with humanity and kindness to each person's pain, distress, anxiety or need. We search for the things we can do, however small, to give comfort and relieve suffering. We find time for those we serve and work alongside. We do not wait to be asked, because we care...
Until the current time, much work in the field of compassion has focussed on hospital settings, or more urbanised primary care settings. However, the importance of compassionate care is clearly relevant to all healthcare sectors, and we currently invite discussion on the importance of compassionate care in rural and remote areas. Recent efforts by Robin Youngson, anaesthetist and co-founder of the New Zealand Centre for Compassion in Healthcare5, have focussed on promoting compassionate care to wider international communities. Youngson's work with the Indigenous people of Aotearoa has uncovered fundamental spiritual traditions, crucial to understanding the health needs and beliefs of this population, particularly in relation to the closeness of the family, and the belief that suffering is 'the illusion of separateness'. With a passion for offering personal service to patients, Youngson's experience suggests that5:
...when practitioners develop the skills to bring open-hearted compassion to their patients, then the effectiveness of care greatly increases and our patients and families feel safe and cared for...
It is perhaps important, therefore, when delivering health care to hard to reach populations such as those in rural and remote areas, to seek to identify the extent to which the care provided reflects compassion and understanding towards the values, traditions, and identities of these groups.
Individuals residing in remote and rural areas are likely to hold traditional health beliefs and values typical to their social surroundings or family setting. An understanding of these values beyond and in association with conventional medicine and treatment, might increase the trust and confidence that the patient places in the physician. In addition, issues related to poverty, education, and ageing populations tend to be associated with individuals in remote areas, which may also require the application of various components of compassion, such as empathy.
Compassionate care is not only concerned with the broader care of the patient, however, but also with care and understanding towards colleagues, and other members of the healthcare team. To provide compassion requires support and receipt of compassion oneself, at a 'team-work' level, and at an 'organisational' level, in addition to clinical and communication skills. Stress, depression and burnout can be common in doctors and nurses, making them more self-critical and less compassionate towards themselves, rendering it harder to show compassion towards their patients. Rural healthcare practitioners frequently work in isolation far from other professional teams and families. O'Neil suggests that 'aspects of isolation as well as the requirements of empathetic engagements with clients leave practitioners vulnerable to various constructs of secondary trauma'6 . Thus, if we seek to address compassion at a rural healthcare level, then it is crucial to address the needs of physicians as well as patients in an effort to secure a productive and holistic healthcare service.
The personal needs of physicians serving in rural areas, and the likelihood of their demonstrating compassion towards patients may depend on various factors. A physician commuting from a urban area to deliver health care to individuals in rural areas may receive more support, but may experience less of a cultural understanding of his/her patients, compared with physicians residing and working in rural areas. Several years ago the image of the 'family doctor' in the UK was that he/she would be very much a part of the local community, and would have an in-depth knowledge of his/her patients and their families, both in terms of medical history and general lifestyle, and in everyday encounters and problems. It is possible that rural physicians residing in rural areas still hold traditional values and have a wider understanding of their patients, assisting them to deliver compassionate health care. Based on the second author's personal observations, there is an element of religiosity/spirituality which needs to be understood when treating people in rural areas in Greece. Doctors are often perceived as being 'representative of God', and as such, patients will often pray to God to mandate effective healing properties to them. There is an expectation that in addition to paying attention to the patients' health problems, rural physicians will also respect their cultural and personal values. Patients' relief from pain, discomfort and anxiety is frequently reported following reassuring and encouraging words, and warm eye-to-eye contact with the rural physician. Unfortunately, however, the high urbanisation rhythm of rural Crete has resulted in many physicians leaving rural areas in preference for work in cities. This has, of course, affected the doctor-patient relationship, decreased the rate of home visits, and limited the number of available healthcare services, making it more difficult for compassionate care to be received and sustained.
It is perhaps not surprising in the light of a changing world, economic crises, and other catastrophes, coupled with time pressure, organisational structures, and resource issues, that attention to basic human needs, and preservation of human dignity can be overlooked, even among physicians who are an integrated part of their local rural community. But for the same reasons, compassion towards the patient and towards other members of the health care team might be more crucial now, than ever before. This appears to be particularly relevant to countries in similar situations to Greece, where the financial crisis is expected to have an enormous effect on health and social care.
The subject of compassionate care appears to be somewhat neglected in Rural and Remote Health, with a narrative search of the Journal's archive revealing only two publications with some relevance. Although advocating for and research into compassionate care in rural healthcare settings is limited at the current time, efforts elsewhere suggest that it is not beyond the realms of possibility to raise the issue and work towards putting compassion back into health care. The Point of Care Programme, operated by the King's Fund in London, works to improve patient experience, with a close emphasis on compassionate care1. Their work involves workshops aimed at identifying the meaning of compassion, the factors that prevent it, and the approaches that enable staff to deliver compassionate care. Likewise, the Schwartz Centre in the USA7, which emphasises caring for the whole patient - body and mind - conducts programs to educate, train and provide support in the art of compassionate care. Their initiatives include 'the patient voice for compassionate care' which incorporates the experiences and perspectives of patients and their families.
A widely reported reason for a decrease in compassion relates to the training that doctors and nurses receive, which may emphasise scientific values while placing little focus on the emotional wellbeing of the patient. Thus, compassion might be 'taught out' of them during their training. Speaking at a recent NHS consideration, held at the King's Fund in London, clinicians drew attention to the fact that HCPs have fears, anxieties and personal vulnerabilities of their own, which often cannot be expressed. A process of 'brutalisation' that occurs in training and early practice was referred to, together with a call for researchers to work with doctors at the level of undergraduate and postgraduate training to create a 'safe place' where doctors can discuss their own vulnerability and think and reflect on their practice.
With the above in mind, and because the training of doctors and nurses may emphasise scientific knowledge rather than development of character and compassion, introducing training in compassionate care seems a highly practical way forward. However, it is essential that training in compassion does not stop at graduation, and that compassionate care is sustainable in the longer term, both towards the patient, and towards members of the healthcare team. In certain countries, even issues such as 'communication' seem to be missing from the medical school curriculum. In Greece for example, the University of Crete is the only medical school to include an optional course on doctor-patient relationships and communication skills, offered to 1st year medical students8, while a further optional course on compassionate care has also recently been approved, for delivery in the second semester of 2011.
Fundamental questions therefore include: 'Can 'Compassion' be taught?', 'To what extent can medical and nursing students be exposed to the skills necessary for compassionate care?', 'Can compassion be taught in the context of physicians working or planning to work in rural and remote areas?', and 'How can compassion be sustained in the longer term?'.
Chochinov reported that compassion can be arrived at through various channels, and may be cultivated by exposure to the humanities, social sciences and arts2. Such a multidisciplinary approach can help to offer an insight into the human condition and the pathos that accompanies illness. In a much earlier but well cited essay, Pence discussed the issue of whether compassion can be taught, or whether we must agree with Socrates' conclusion in Meno that the presence of a virtue such as compassion in any particular medical student is 'a gift of the gods'9. Pence concludes that compassion can be taught if medical education systems reward this virtue alongside other medical virtues, thus ensuring its sustainability.
Traditional teaching methods are perhaps not the most appropriate way forward in terms of teaching a virtue such as compassion. However, innovative and interactive teaching techniques such as workshops, discussion groups, role modelling, and the use of films, theatre, art and literature could be of great value. Such techniques might address: the human and psychosocial aspects of medicine; team work (communication, trust, shared objectives); and organisational factors (workload, time, lack of support). In addition, exposing students to real-life situations and home visits may enhance a deeper understanding of what the patient and his/her family is experiencing. Thus, taking a multidisciplinary approach and exposing students to issues which may affect patients living in rural and remote areas could help to promote compassionate care in the context of healthcare professionals working, or planning to work, in such areas. Longer-term support and the sharing of experiences at a local and international level may help to ensure that the fundamental elements of compassion are not lost during training but maintained throughout a healthcare professional's career.
Initiatives are underway that could help to assist in promoting compassionate care in rural areas. Development of 'rural week' for medical students has been established as a part of the 1st and 2nd year curriculum at the University of Adelaide Medical School, indicating that educational programs could be implemented outside the traditional classroom10. Education and health services have also been successfully developed in the USA with the aim of improving the care of rural Hispanic communities11.
At the current time, Robin Youngson and his team at the Compassion in Healthcare Trust in New Zealand5 are striving to create an International Charter in Compassionate Healthcare at all levels, involving world-wide collaborations. They aim to develop a comprehensive consensus paper for publication in a peer-reviewed journal, which will take a whole-system view, including examining the relevance of compassion to many aspects of healthcare delivery.
Overcoming barriers to compassionate care is clearly an issue of importance, and emphasising its value in rural settings has clear implications for quality of care and patient outcomes. Advocating for the introduction of training in compassionate care for those working in a rural healthcare setting, and sharing 'stories' with colleagues at an international level, may be a way forward. At the current time, discussions are in process between academics and researchers from the University of Greenwich, UK and the University of Crete which may open new doors to introducing this subject and sharing experiences.
The international journal Rural and Remote Health opens this discussion with regard to compassionate health care, and invites rural practitioners, researchers and teachers to submit their views, reports and experiences.
S Shea1,2, C Lionis2,3
1School of Health and Social Care
University of Greenwich, London, UK
2Clinic of Social and Family Medicine, Faculty of Medicine
University of Crete, Heraklion, Greece
3European Regional Editor, Rural and Remote Health
1. The Kings Fund. The Point of Care - compassion. (Online) 2010. Available: http://www.kingsfund.org.uk/current_projects/the_point_of_care/compassion/ (Accessed 13 December 2010).
2. Chochinov HM. Dignity and essence of medicine: the A, B, C, and D of dignity conserving care. BMJ 2007; 335: 184.
3. Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety? Journal of Clinical Oncology 1999; 17(1): 371.
4. Department of Health UK. The NHS constitution: The NHS belongs to us all. (Online) 2009. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093442.pdf (Accessed 13 December 2010).
6. O'Neill LK. Mental health support in northern communities: reviewing issues on isolated practice and secondary trauma. Rural and Remote Health 10: 1369. (Online) 2010. Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1369 (Accessed 13 December 2010).
9. Pence GE. Can compassion be taught? Journal of Medical Ethics 1983: 9: 189-191.
10. Newbury JW, Shannon S, Ryan V, Whitrow M. Development of 'rural week' for medical students: impact and quality report. Rural and Remote Health 5: 432. (Online) 2005. Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=432 (Accessed 13 December 2010).
11. Sherrill W, Crew L, Mayo RB, Mayo WF, Rogers BL, Haynes DF. Educational and health services innovation to improve care for rural Hispanic communities in the USA. Rural and Remote Health 5: 402. (Online) 2005. Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=402 (Accessed 13 December 2010).