Assessment
Can compassionate healthcare be measured? The Schwartz Center Compassionate Care Scale™

https://doi.org/10.1016/j.pec.2015.03.019Get rights and content

Highlights

  • We describe the psychometrics of an instrument that measures providers’ compassion.

  • Patient ratings of compassionate healthcare are valid and reliable.

  • Compassion ratings correlate significantly with patient satisfaction.

  • Ratings correlate specifically with patients’ perceptions of emotional support.

  • Patient ratings of compassionate care can inform assessment and quality improvement.

Abstract

Objective

Assess psychometric characteristics of an instrument to measure patient ratings of treating physicians’ compassionate care in a recent hospitalization.

Methods

We used Cronbach's alpha to examine scale reliability, exploratory and confirmatory factor analysis to examine scale structure of two sets of items on compassionate care. We used Mokken analysis to determine if items in each set belonged to a unidimensional scale.

Results

Results indicated that both sets of items had strong reliability when used to rate individual physicians (Cronbach's α = .97 and .95). A one factor model was a good fit to both sets of items. Mokken analysis supported unidimensional scales. Both sets of items correlated with an overall measure of patient satisfaction with physicians and even more strongly with an item measuring emotional support.

Conclusions

A patient-rated scale reliably measured hospital physicians’ compassion and correlated significantly with an item measuring overall patient satisfaction and a specific measure of satisfaction with emotional support. Measurement of compassionate healthcare should be included in research, educational assessment, and quality improvement programs.

Practice implications

Clinicians should participate in efforts to enhance their ability to demonstrate compassionate care including eliciting and sharing information and acting collaboratively to ameliorate patients’ socioemotional concerns and needs.

Introduction

Compassionate care is a process that involves recognition, understanding, emotional resonance and empathic concern for another's concerns, distress, pain or suffering, coupled with their acknowledgement, motivation and relational action to ameliorate these conditions [1]. Such care should not be reserved for end of life, but rather, offered whenever the need arises for patients and their families. Compassion is central to ethical codes across the health professions and sustains healthcare professionals who identify compassion and caring as their most deeply felt personal and professional commitment [2], [3], [4], [5]. Patients’ and families’ perceptions of providers’ empathy and compassion have also been correlated with important outcomes including increased immune responsiveness [6], long term psychological adjustment after cancer diagnosis [7], better control and reduced hospitalizations for diabetic complications [8], [9] and decreased intensive care utilization at end of life [10]. A recent systematic review and meta-analysis of randomized controlled trials of interventions to improve the patient–clinician relationship showed small but significant effects on health outcomes for patients with asthma, obesity, and lower respiratory infections [11].

Ongoing efforts to improve care quality include required measurement and reporting of patients’ care experiences. Examples include the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program in the U.S. [12], [13] and the NHS Adult In-Patient Survey in England [14]. Uncompassionate care may result in low ratings of these publicly reported measures. This will have negative economic consequences. In the U.S., the hospital value-based purchasing program links a portion of hospitals’ payment from the Centers for Medicare and Medicaid Services to these results [15]. Feedback from these surveys can be used to improve care. However, translating feedback into actionable strategies has been challenging and variable across settings [16]. Further, important aspects of compassionate care, e.g. emotional support and contextual knowledge of the patient, are not robustly represented in many patient experience surveys, which hampers performance improvement efforts (Table 1).

Researchers have developed various instruments to measure patients’ perceptions of physician communication in ambulatory settings, notably Makoul et al. Their “Communication Assessment Tool” includes 14 items that load onto a single communication factor, including one which includes “demonstration of care and concern” [17]. Others have created instruments to explicitly measure empathy among healthcare professionals. Some measure self-reported qualities, particularly the cognitive aspects of empathy [18]. Others focus on ambulatory patient's perceptions of their physicians’ emotional support and caring behaviors [19]. Few instruments, however, measure hospitalized patients’ perceptions of providers’ compassion, including contextual understanding the patient as person, impact of illness, ability to discuss sensitive issues and to express caring and concern. Instruments that do so assess nursing but not physician behaviors [20], [21] with the exception of an instrument developed and tested within a single hospital [22].

To better understand how U.S. physicians and patients view compassionate inpatient care by physicians, the Schwartz Center for Compassionate Healthcare, a nonprofit organization in Boston, Massachusetts, commissioned five focus groups and a national telephone survey in 2010. Results of this previously reported survey indicated that such measurement was both feasible and valuable [23]. Here we report our psychometric analysis of patients’ responses to these survey questions in order to create an instrument that can be used for performance improvement, education and research, the Schwartz Center Compassionate Care Scale™ (SCCCS).

Section snippets

Instrument development

The Schwartz Center developed 16 criteria to assess the compassionate care provided by physicians and other caregivers in 1998, as part of its work to recognize and highlight caregivers who demonstrate compassion for patients and families. The initial criteria were developed by a 20-member committee composed of individuals with diverse viewpoints and experience, including cancer survivors, individuals suffering from chronic pain and/or debilitating illnesses, family members of patients, and

Analysis of ratings regarding the importance of specific compassionate behaviors

Results for all items are presented in Table 2. The first set of columns refers to data about the importance of compassionate care. It is clear that the majority of the items are considered to be very important with all of the items having a median of 10, and 11 of them having means of over 9. Item 13 which concerned cultural and religious beliefs had the lowest mean and also the largest variance, indicating the most disagreement between participants. Cronbach's alpha for the first eight items

Discussion and conclusions

Preliminary analysis shows that our scale demonstrates excellent reliability and measures patients’ perceptions of a unidimensional factor related to compassionate care by hospital physicians. We omitted items that received an unacceptable number of missing responses. Missing responses may have been due to items that were confusing or thought not applicable by some participants. For example, the item “Give you hope when/if the news is bad” involves a qualification, in that there must be bad

Practice implications

In light of randomized interventions and observational studies demonstrating correlations between clinicians’ empathy, compassion and clinical outcomes and satisfaction [6], [7], [8], [9], [10], [11], and in some countries, the economic implications of improving patients’ perceptions of care [15], clinicians should be encouraged to improve their demonstration of compassionate care. Various experiential skills training strategies as well as audit and feedback may be helpful [31], [32], [33].

Competing interests

Beth Lown, MD is an employee of the Schwartz Center for Compassionate Healthcare, an autonomous, nonprofit organization operating under the 501(c)(3) tax-exempt status of the Massachusetts General Hospital, Boston, Massachusetts, USA. Drs. Steven Muncer and Raymond Chadwick report no competing interests.

Funding source

The authors received no funding for the statistical analysis or creation of this manuscript. Funding for the national survey on which the SCCCS is based was provided by the Schwartz Center for Compassionate Healthcare.

Contributorship

Beth Lown contributed to the acquisition of the data. Steven Muncer contributed to the data analysis. All authors contributed to the interpretation of data, drafting and revising the manuscript, provided final approval of the manuscript and agree to be accountable for all aspects of the work.

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