Compassionate Care: Perceptions of English-, Spanish-, and Armenian- Speaking Hospitalized Patients using the Compassionate Care Assessment Tool

Abstract

Background: Compassion remains a value intrinsic to the professional practice of nursing. Much has been published about the provision of this type of care from the nurses perspective, however, there is a paucity of studies querying hospitalized patients about their expectations and experiences with compassionate care. Objective/Aims. The aim of this study was to explore further and compare the importance of 28 elements thought to comprise compassionate nursing care. The CCAT survey was administered in one hospital setting in the primary languages of the patient (i.e., English, Spanish, Armenian). Methodology: This cross-sectional, prospective, quantitative study included an adequately-powered sample of 254 acute-care inpatients responding to the importance and provision of compassionate care. Results: Statistical differences were detected among three primary languages of the survey participants. English speakers rated the delivery of compassionate care higher than how important it was for them to receive that type of care. English speakers emphasized the importance of compassion through a subscale of Caring Attributes, while Armenian-speaking patients valued items within Meaningful Connections and Spanish-speaking patients emphasized the attributes in the Patient Experience subscale. Conclusion: Many elements comprise the construct of compassionate nursing care from the patients vantage point; however, further exploration focusing on preferences guided by individual, cultural, and educational considerations is needed. Responding to the compassionate needs of every patient remains a professional obligation for nurses that is especially relevant in todays era of diversity, equity, and inclusion.

Headnote

Research site: Valley Presbyterian Hospital, 15107 Vanowen St., Van Nuys, CA 91405

Correspondence: Lori L. Burnell, Valley Presbyterian Hospital, 15107 Vanowen St., Van Nuys, CA 91405. (office) 818-902-5734 (email) [email protected]

Abstract

Background: Compassion remains a value intrinsic to the professional practice of nursing. Much has been published about the provision of this type of care from the nurses perspective, however, there is a paucity of studies querying hospitalized patients about their expectations and experiences with compassionate care.

Objective/Aims. The aim of this study was to explore further and compare the importance of 28 elements thought to comprise compassionate nursing care. The CCAT survey was administered in one hospital setting in the primary languages of the patient (i.e., English, Spanish, Armenian).

Methodology: This cross-sectional, prospective, quantitative study included an adequately-powered sample of 254 acute-care inpatients responding to the importance and provision of compassionate care.

Results: Statistical differences were detected among three primary languages of the survey participants. English speakers rated the delivery of compassionate care higher than how important it was for them to receive that type of care. English speakers emphasized the importance of compassion through a subscale of Caring Attributes, while Armenian-speaking patients valued items within Meaningful Connections and Spanish-speaking patients emphasized the attributes in the Patient Experience subscale.

Conclusion: Many elements comprise the construct of compassionate nursing care from the patients vantage point; however, further exploration focusing on preferences guided by individual, cultural, and educational considerations is needed. Responding to the compassionate needs of every patient remains a professional obligation for nurses that is especially relevant in todays era of diversity, equity, and inclusion.

Key words: compassionate care, language and healthcare, patient perception, healthcare survey, nurse-patient relations, compassion

Introduction

From the patients vantage point, compassion has been acclaimed as the hallmark of exemplary nursing with a myriad of opportunities to delve deeper into this complex human longing. To help bridge the gap and determine the relevance of compassionate care to hospitalized patients, Burnell and Agan (2013) developed the Compassionate Care Assessment Tool (CCAT©) at a time when an instrument for measuring compassionate care from the patients perspective was absent from nursing praxis or healthcare research. Since its introduction, the CCAT© has been translated into at least five other languages and cited in over 70 peer-reviewed publications. Acknowledging the universality of this instrument, interest in the research community to develop a comprehensive description of its elements, and the prospect of expanding research into more diverse healthcare settings, the authors of the CCAT© proposed a study to a hospitals nursing professional practice council. This proposal was predicated on bedside nurses' participation in a study germane to the mission of their organization.

In a large, stand-alone, safety-net community hospital in Southern California, nurses and the authors tested the CCAT© in a diverse community to explore the importance and provision of compassionate care. In this setting, various languages were spoken by patients in their homes, including English (29.2%), Spanish (55.0%) and Armenian (7.9%). Supporting this research project was the organization's mission to improve the quality of health in its service area as well its core value of compassion.

Background: The healthcare landscape has changed significantly during the worldwide pandemic; however, professional mandates continue to require nurses everywhere to respond to their patients with compassion according to national and international codes of ethics (e.g., American Nurses Association [ANA], 2015; International Council of Nurses [ICN], 2012). Furthermore, compassionate care has been unanimously accepted as the ethos of nursing defined by the values and experiences of both the patient and the nurse (Dalvandi et al., 2019, Perez-Bret et al., 2016, Singh et al., 2020). Since the publication of the Burnell and Agan (2013) instrument, the authors received inquiries to administer the English version of the CCAT© from researchers in Canada, England, Australia, and the United States. Requests to authorize translations into Finnish, Turkish, Korean, Greek, Persian, and Irish were received and analytic summaries of CCAT© results have been published in English (N = 250; Burnell & Agan, 2013), Greek (N = 123, Grimani, 2017), and Persian (N = 300; Vaisi-Raygani et al., 2021).These examples highlight the interest in surveying patients and nurses in a variety of geographical locations; yet, studies addressing the perception of compassion in a single, multicultural setting remain absent from nursing and healthcare journals.

Research Aims: The purpose of this study was twofold: (1) to compare multiple language versions (i.e., English, Spanish, Armenian) of the CCAT© and (2) explore how these three distinct cultures rated the importance and experience of compassionate care from their nurses.

Methodology: Steps to complete this crosssectional, prospective, quantitative study included (a) administering the CCAT© to an adequate sample of hospitalized patients in their primary language; (b) uncovering differences in the importance and delivery ratings of compassionate care components, subscale scores, and the total score based on language and other demographic variables; and (c) evaluating the importance of individual items and subscales scores thought to embody the construct of compassionate care as well as a comparison of importance to nurse's performance. To ensure an adequate sample size, a power analysis was performed using G·Power (Version 3.1.9.7, Faul, 2020). For ANOVAs examining differences in subscale scores by language with a medium effect size (ES = 0.25), alpha level (a = .05), and power (ß = 0.8) in 3 groups, the total sample size would need to be at least 159 participants. Chi-square analysis with 3 languages and 4 levels of rating (ES = 0.3, a = .05, ß = 0.8, df = 6) indicated a minimum sample size of 152 subjects. Therefore, each language group needed a sample of at least 50 participants with the eventual goal of attaining 100 participants per language.

Inclusion and Exclusion Criteria: Patients selected to participate in this study were 18 years of age or older; English-, Spanish-, or Armenian speaking; hospitalized for a minimum of 24 hours; and expected to be discharged within 24-hours. Excluded from the study were patients in critical care, positive for Covid-19, maternity patients, prisoners, employees who were patients, those with a primary psychiatric diagnosis, as well as anyone assessed by nursing personnel to be confused or experiencing uncontrolled pain.

Protection of Human Subjects: This study was submitted to the Western Institutional Review Board per research protocol wherein it was determined to be an exempt study.

Registered nurses (RNs) certified in English, Spanish, and/or Armenian who successfully completed the Collaborative Institutional Training Initiative (CITI Program), required for the protection of human subjects, served as research assistants for this study. Prior to administering surveys to patients, research assistants described the purpose, benefits, risks, implications, and obtained patients' consent.

Research assistants also reinforced the voluntary nature of the study and that neither refusal nor agreement to participate would affect the care rendered. Furthermore, patients were forewarned of the remote possibility of becoming upset by the survey content, being inconvenienced, or experiencing a breach of confidentiality.

Survey Administration: Research assistants identified potential participants by querying clinical supervisors on the designated patient-care units according to the study protocol. Members of the research team approached potential subjects and explained the purpose of the study. A total of 254 inpatients were surveyed by a member of the research team, including the primary investigator/nurse manager/educator (n = 63) and 6 clinical supervisors/bedside RNs (n = 191). A standardized method was employed when offering to patients the option of having the survey read to them (n = 9) or responding to the survey independently (n = 245). Upon completion, the signed informed consents and surveys were placed in an envelope, sealed, and returned to a research analyst. After verifying properly-executed informed consents and to protect confidentiality, consents were then separated from the surveys before information was entered into an Excel spreadsheet with individual identifiers omitted. Results were subsequently uploaded into SPSS (Version 27). Patient surveys and consents were then placed in separate files in locked file cabinets and data were stored on encrypted, password-protected computers.

Results

Hospitalized patients participated in the CCAT© survey from February 2020 through February 2021. Research assistants did not include patients with a diagnosis of Covid-19 due to their restricted ability to communicate (e.g., shortness of breath), to reduce exposure to staff, and to preserve personal protective equipment.

Demographic Analysis: Demographic information was analyzed by characteristic and language (Table 1). For gender, the proportion of males-to-females by language was reasonably distributed, except for a higher number of Armenian males than expected (x2 = 14.125, p = .001). Noteworthy for generational data, there were fewer than expected Spanish participants and more than expected Armenian participants from the Silent Generation, and the number of Armenian Generation Y participants was less than expected (x2 = 24.024, p = .001). Marital status was evenly distributed by language except the number of single Armenian participants was less than expected (x2 = 16.094, p = .013). The reason for hospitalization in English participants was predominately surgical; medical for Armenian participants (x2 = 42.298, p < .001). Lastly, the level of education was not proportional by language. Over one-half of Spanish-language participants had some high school education; however, they did not complete high school. Almost all the "Prefer not to say" (16 out of 17) were Spanish participants and were not included in the analysis of education relative to compassionate care. Armenian participants had an increased proportion of high school, associate degree, or trade school education and English participants had an increased frequency of bachelor's degrees or higher (x2 = 122.859, p < .001). Importance of Compassionate Care by Language

Patients rated the importance of compassionate care on 28 items using a scale from 1 (not important at all) to 4 (extremely important). Scores were calculated from 20 of the 28 components, representing four subscales, and all 28 items were used to calculate a total score. When compared by language (Table 2), Armenian patients' subscale scores revealed a higher rating of importance for the Meaningful Connection subscale (F[2, 244] = 9.648, p < .001) and the Patient Expectations subscale (F[2, 241] = 5.478, p < .01) as well as the Total Score (F[2, 244] = 11.188, p < .001). English survey responders rated the subscale, Caring Attributes, significantly lower than Spanish survey responders, and Armenian participants rated the importance of Caring Attribute items significantly higher than the other two languages (F[2, 250] = 17.923, p < .001).

With 28 components believed to comprise the core of compassionate care according to the CCAT©, the next step in this data analysis was to examine each participant's item-rating by their primary language. The top five, highest-rated items in each group revealed a diverse selection by importance. Of note, the item, pain control, was in the top five items of importance for English and Spanish participants and the sixth highest-rated item for the Armenian participants. Attempting to capture congruence amongst the top elements by language, the researchers contemplated topical names to convey the similarities of the highest-rated individual items within each language group: capable and impartial (English), reliable and considerate (Spanish), and sensitive and tranquil (Armenian; Table 3). Comparing these top five elements to the CCAT© subscale headings, the highest-rated components in the English-language surveys were categorized as Capable Practitioner; Spanish-language surveys indicated that Patient Expectations were the most important subscale; and Armenian-language survey participants accentuated components of Caring Attributes.

Importance vs. Performance

A comparison score was calculated subtracting the importance rating from the performance level for all subscale/total scores. These differences were then examined using ANOVA and grouped by language. When comparing these differences, on average, English surveys indicated a positive differential in every subscale score, meaning that RNs performed higher than the patient's rating of importance on these elements of compassionate care. Conversely, in 3 of 4 subscale scores, the average Spanish and Armenian patients rated RN performance somewhat or significantly lower than their importance rating. The one exception was the subscale score of Capable Practitioner where, on average, RNs performed higher than the patients' importance rating, regardless of language. Significant differences by language are noted in Table 4.

Bifurcating surveys by language, the ratings of importance-to-performance were compared in each language using paired-sample t-tests. All English subscales indicated significantly higher RN performance scores when compared to importance (p < .001). For Spanish surveys, while ratings were somewhat lower for RN performance, only the Meaningful Connection subscale score (performance) was significantly lower than importance (t = 4.737, p < .001). In the Armenian surveys, all but Meaningful Connection subscale scores were significantly lower in RN performance. The performance ratings for the remaining Spanishand Armenian-language subscale scores were not significantly different than the patients' rated level of importance and that differential could be explained by chance. Figure 1 displays a side-byside comparison of importance and RN performance for each subscale category by language.

Discussion

The purpose of this research study was to explore compassionate care from the patients' perspective using versions of the CCAT® in three languages: English, Spanish, and Armenian. In a 28-item survey thought to represent elements of compassionate care, patients were asked to rate how important each component was to them as well as to rate the performance of their nurses. In a sample of 254 patients, responses were analyzed by patient demographics and language spoken in the home. Results suggested unique patterns of importance and performance that could be attributed to cultural differences among patients and the nurses providing their care.

Limitations of the Study

A primary limitation of this study was timing as it commenced during the worldwide Covid-19 pandemic. During this unprecedented period, nonCovid healthcare admissions decreased due to the community's fear of viral spread, perceptions that others had a greater need for hospital care, the rapid shift to telemedicine as an alternative to traditional healthcare, and patients/providers delaying necessary treatments (e.g., surgery, medical procedures). All these factors could have influenced the profile of patients accessing acute-care hospitals for their non-Covid-19 healthcare needs during this time.

Another potential limitation was the low number of Armenian-speaking patients consenting to the study. Further research would be warranted to explore any dynamics impeding their participation.

Education Level of Patients

Less than 10% of English and Armenian participants reported an education level below that of a high school graduate. Meanwhile, over 50% of Spanish-language participants relayed having Some high school as their highest level of education. Additionally, most of the Prefer not to say responses (16 of 17 responses) came from the Spanish surveys. Most Armenian surveys implied at least a high school education and a preponderance of English-language surveys divulged a college education. The disparity of education must be considered when RNs (i.e., college graduates) are trying to establish meaningful connections with patients while attempting to deliver compassionate care. Patients' educational backgrounds may be a factor in explaining the contrary ratios in the importance-to-performance ratings for the Spanishand Armenian-language participants.

Implications for Nursing Practice

The expectation that healthcare ought to be delivered with compassion abounds in nursing praxis and offers endless opportunities for additional research on the topic. According to patient experience experts (Dempsey, 2018; Malott & Ayala, n.d.), communication and compassion are symbiotic and both of these suppositions need to be enculturated into the routine practices of hospital RNs who serve as the primary coordinators and advocates for their patients. These nurses are ideally positioned to make the most meaningful patient connections culturally, verbally, and through other characteristics that emulate compassion.

Correspondingly, this study revealed the nursing care provided to the English-speaking patients surpassed their compassionate needs (i.e., the performance level exceeded the importance ratings), whereas survey outcomes from patients speaking other languages were less impressive. Additional exploration into these findings is recommended to understand what constitutes compassionate nursing care from the lens of the Spanish- and Armenian-speaking patients and optimally address their needs.

Succeeding a careful review of the survey results, members of the research team recommended inpatients be queried about what compassionate care means to them during the nursing admissionassessment process. The team proposes that RNs translate and incorporate patients' characteristics of compassionate care into individualized, holistic, nursing care plans. Moreover, the research team believes that additional exploration and education is needed regarding patients' diverse expectations associated with their cultural perceptions of compassionate care. This could be accomplished by engaging language-specific focus groups, investigating experts' understanding of Armenianand Spanish-speaker's cultural values, and incorporating newfound knowledge into the overall hospital experience. Hearing and responding to the compassionate needs of every culture remains a professional obligation for nurses that is especially relevant in today's era of diversity, equity, and inclusion.

Acknowledgments: The authors would like to express their utmost gratitude to the exceptional RNs and the analyst who made this research possible including Aaron Acquisto, Monica Azpeitia, Coca Corcuera, Lila DiBella, Mindy Galvin, Analissa Gellekanao, Daneh Goharderakhshan, Megan Ann Guardiano, Liana Marzvanyan, and Vinicia Recalde.

References

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