The importance of compassion and respectful care for the health workforce: a mixed-methods study (2024)

Study design, area, and period

A mixed-methods study was carried out through quantitative and qualitative data collection from April to May 2019 in North Shewa Zone, Oromia Region. Quantitative data were gathered through a questionnaire administered to the HWF. Qualitative data were collected from key informants (HWF having a position in a health care facility) through focus group discussion to determine their understanding and/or insight regarding CRC services in health care facilities.

Study participants

The quantitative study participants were randomly determined using Epi Info version 7, with a 95% confidence interval (CI) and a 5% margin of error. We assumed a prevalence of 56% based on a study done in the Tigray Region (Berhe et al. 2017). After adjusting for a non-response rate of 5%, the final sample size was 398. Participants were randomly recruited from four hospitals and six health centers. The total sample size was allocated proportionally to each facility based on their number of HWF. The allocated number was in turn proportionally assigned to each department. A systematic sampling technique was used to select the HWF working in each selected department. All selected HWF who had been working for more than 6months in the NSHFs were included. Those HWF who were on annual leave were excluded from the study.

For the qualitative study, focus group participants were recruited from four hospitals and two health centers. Seventy-two participants were selected from each department depending on their position and clinical experience, using a purposive sampling technique. We invited them to participate in scheduled focus groups through the invitation letter for volunteer key informants. A total of six FGDs were conducted, each containing 12 members; the number of participants was large, as the HWF was interested in participating in the FGDs.

Data collection tools and procedure

Quantitative data were collected using a standardized and pretested questionnaire. Data were collected by six diploma nurses and supervised by three BSc nurses. The questionnaire contains a sociodemographic query (age, sex, marital status, educational status, profession, years of experience, and monthly salary), CRC and health care ethics-related training, types of health care facilities (hospital or health center), awareness of policy and guidelines for CRC, knowledge about CRC, and attitude toward CRC.

The outcome of compassionate care was measured using a five-point Likert scale from 1 to 5 (1 = almost never, 2 = seldom, 3 = sometimes, 4 = often, 5 = almost always). It contains six subscales (kindness, indifference, common humanity, separation, mindfulness, and disengagement) with a total of 24 question items. Indifference, separation, and disengagement were reversed to calculate a total compassion score. A total compassion score was calculated, each subscale’s mean was taken, and a total mean was computed and considered a cutoff point. A score greater than the mean was considered good compassionate care practice, and less than the mean score was considered poor compassionate care practice (Pommier 2010).

The respectful care outcome was measured using a five-point Likert scale (1 = almost never, 2 = seldom, 3 = sometimes, 4 = often, 5 = almost always), containing 21 items. The mean was computed, and the mean score was considered as a cutoff point. A score greater than the mean was considered respectful care practice, and less than the mean was considered poor respectful care practice (Reis et al. 2012).

The reliability of the compassionate and respectful care scale was pretested and found to be acceptable, with Cronbach’s α = 0.878 and 0.856, respectively, and the total sum of the CRC scales was Cronbach’s α = 0.907 (Cronbach’s α of CRC = 0.907).

Knowledge was measured using eight questions, each with a “yes or no” response; each correct answer “yes” scored 1 point, and “no” scored 0. Again, attitude was measured by a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree) using eight questions and dichotomized into disagree (0) and agree (1). A score of 6 and above (>75%) from eight questions was taken as a cutoff point for both knowledge and attitude. Greater than 75% were considered knowledgeable and a positive attitude and less than 75% were poor knowledge and negative attitude toward CRC.

In a qualitative study, FGDs were conducted at Fitche General Hospital, Kuyu General Hospital, Muka Turi Primary Hospital, Gundomaskel Primary Hospital, Wara Jarso Health Center, and Debratsige Health Center. Data were collected through guiding questions in both Amharic and Afan Oromo languages. A semi-structured interview guide was developed to elicit an advanced understanding of the value or benefit and knowledge of CRC, and behaviors associated with CRC. During FGDs, one moderator and reporter were present for each FGD and audio-recording during the discussion for an average of 2h.

Data processing and analysis

Quantitative data were coded, edited, cleaned, and entered into EpiData version 3.2 and then exported to SPSS version 23. Descriptive data analysis was carried out and presented in frequency, percentage, tables, and graphs. Analysis was performed with an odds ratio with 95% confidence interval, and a two-tailed P value was calculated to identify the presence and strength of association. Variables with a p value ≤0.2 in the binary analysis were included in a multivariable logistic regression analysis to control the confounding variables. A value of p <0.05 was considered indicative of statistical significance.

The qualitative data were transcribed and translated from both Amharic and Afan Oromo to English. The verbatim transcripts were separately verified against the audio recorded by the interviewer and a member of the analysis team. The analysis team further guaranteed the consistency of each focus group and interview session. The teams also analyzed the interviewer’s adherence to each transcript’s probing questions and provided feedback and correction. They read through each transcript again to reduce differences between individual codes and mark out parts of the transcript that were non-specific to CRC through a consensus process. Rigor was further ensured by the study team, who was not involved in analyzing the interviews or focus groups, and independently audited the coding process. Finally, the narrative was organized and integrated according to emerging themes and concepts set out in the research objectives, and the result was triangulated with quantitative findings at the interpretation level.

Ethical consideration

Ethical clearance was obtained from the Salale University Ethical Review Committee (Ref. No. SLUERC/32/2019, on March 18, 2019). Written permission was obtained from the North Shewa Zone Health Bureau (NSZHB), and written informed consent was obtained from each respondent. The respondents were informed that their inclusion in the study was voluntary and that they are free to withdraw from the study if they were not willing to participate. To ensure respondents’ confidentiality, their names were excluded from the questionnaire, and the respondents’ anonymity was maintained.

Quantitative findings

In this study, a total of 392 individuals participated, with a response rate of 98.5%. More than half of the participants were from the hospitals. The study respondents’ mean age was 28.42 (± standard deviation = 5.17), and two-thirds were aged 20–29years. Most of the study participants were male (52.3%), single (52.6%), and had a bachelor’s degree (52.8%). Nurses (194; 49.5%) constituted the majority of the HWF, and 208 (53.1%) of the respondents had less than 5years of experience. More than half (207; 52.8%) of the study participants earned a monthly salary of less than 5000 Ethiopian birr (Table ​(Table11).

The majority of records officers (79.1%) facilitated patient registration in a timely manner, and 72.4% of participants treated patients and families respectfully. Eighty percent of the facilities ensured a safe and clean care environment for the patients, and 32.1% of the facilities detained patients against their will. Most of the HWF had good knowledge of CRC (62.8%), greeted the client respectfully (89.3%), and had a negative attitude toward CRC (52.6%). Nearly three-fifths of leaders empowered patients and employees positively (Table ​(Table22).

The practice of compassionate and respectful care

The full scale of compassion contains six subscales, including kindness, indifference, common humanity, separation, mindfulness, and disengagement. The majority (224; 57.1%) of the respondents reported poor kindness while 168 (42.9%) reported good kindness for their patients. Half (198; 50.5%) of the study participants had high indifference, and 194 (49.5%) had low indifference. More than half (51%) of the study participants had poor common humanity and mindfulness, and 49% did not. About 214 (54.6%) and 204 (52%) of the respondents had poor separation and disengagement, respectively (Fig. ​(Fig.11).

The overall compassionate care among the HWF was reported as 38.8% of good compassionate care practices, and 240 (61.2%) of the HWF reported poor compassionate care practice. On the other hand, 181(46.2%) of the study participants reported good respectful care practices, and 53.8% of the respondents reported poor respectful care practices (Fig.2).

Factors associated with compassionate and respectful care

In multivariable logistic regression analysis, the age category of 30-39 and married participants were adjusted for compassionate care practice (Table ​(Table3).3). Similarly, female participants, HWF who had a bachelor’s degree and good knowledge of respectful care were adjusted in multivariable logistic regression analysis for respectful care practice (Table ​(Table44).

In multivariable logistic regression analysis, female participants were twice as likely to practice compassion as male participants [AOR = 1.95; 95% CI = (1.40, 3.64)]. Health officers had significantly higher odds of providing good compassionate care practice than nurses [AOR = 3.61, 95% CI = (1.56, 8.34)]. The study participants who had a monthly salary equal to or greater than 5000 Ethiopian birr were twice as likely to practice compassionate care as those who whose monthly salary was less than 5000 Ethiopian birr [AOR = 1.56; 95% CI = (1.13, 3.29)]. The study participants who had a positive attitude toward compassionate care were 1.23 times as likely to practice compassion as the study participants with a negative attitude toward compassion [AOR = 1.23; 95% CI = (1.24, 3.72)] (Table ​(Table33).

The study participants in the 30–39 age category were twice as respectful as those aged 20–29 [AOR = 1.80; 95% CI = (1.24, 3.84)]. The study participants who had a positive attitude toward respectful care were 1.59 times as likely to practice respectful care as those who had a negative attitude toward respectful care practice [AOR = 1.59; 95% CI = (1.02, 2.50)]. The study participants who had ensured safe and clean care for their patients were three times as likely to practice respectful care as the study participants who did not [AOR = 3.39, 95% CI = (2.31, 8.35) (Table ​(Table44).

Qualitative findings

A qualitative approach was applied to explore compassionate and respectful care not addressed by the quantitative study. We developed an understanding of the topic through concurrent data collection from 72 participants in six FGDs. The collected data were analyzed, and four categories of themes emerged: definition/knowledge of CRC, CRC barriers, the benefit of CRC, and leadership will.

1. Definition and knowledge of CRC

The participants provided the knowledge and definition of CRC as fundamental for health care workers. It is a part of psychotherapy that has no negative effect and increases patient satisfaction and care provision. Most of the participants described the meaning of CRC as:

CRC is the psychological and medical supporting of the patients. Improving from pain or suffering regardless of their economic status, culture, religion, and ethnicity. (FGD5 participant 6)

Knowing the patient's rights and responsibilities is mandatory to provide the correct care for clients. The CRC has three criteria: first, our clients come to our health care system to heal me; second, if you can't heal me, respect me, and third, if you can't respect me, don’t harm me. (FGD3 participant 1)

The majority of FGDs claimed that CRC is a deep sense to alleviate clients suffering, empathy, sharing their pain, developing the inner feelings to build relationships. It is more kindness for human beings rather than clinician to patient relationship. It also includes honesty, attention, never stereotypes; demonstrate humanity and kindness to promote high-quality care for all clients' needs. (FGD5 participant 1)

Compassion and respectful care is sharing one’s pain or suffering and responding with respectful behavior to the client's suffering. (FGD2 participant 3)

If CRC is initiated in the health care facilities, with the attitudes of empathy, caring, kindness, and respect, it creates meaningful partnerships between HCPs and patients or families. It is a motivating feeling of HCPs that makes the patient feel relief from suffering. (FGD6 participant 4)

• 2.

  Barriers to CRC

The barriers to CRC have inhibited the ability to provide daily routine activities. Health care professionals faced countless challenges that hinder their ability to provide CRC. It includes lack of integration and continuity care, technologies that help and hinder communication and relationship-building, growing operational and administrative supplies, insufficient communication skills training, alarming burnout rates, and increased cost and limited market resources. The focus group discussion reflected that the unorganized health care administration, skill gap, autocracy, and professional dissatisfaction are the main obstacles for the CRC practice.

There is a Hippocrates quote, "Wherever the art of medicine is loved, there is also a love of humanity." Mostly, the person who wants to be a health care professional is a person that loves human beings. However, due to the high workload, language barrier, attendant attitude, medical supply, cultural views, and lack of incentive, HCPs may be restricted in the provision of CRC practice. (FGD4 participant 8)

Unorganized administration, shortage of training, lack of joy in his/her profession, and HCPs' dissatisfaction are the main obstacles for CRC practice. (FGD6 participant 9)

There are communication difficulties and patient load, and HWF do not explain more health information. Similarly, lack of good relationships, resource shortage, ignorance, the autocracy of a few HCPs, deficiency of knowledge, and skill gap are among the barriers preventing CRC implementation. (FGD1 participant 12)

• 3.

  Benefit of CRC:

The HWF believed that CRC is one of the most important professional values. However, it is determined by HWF values, in which protection, honor, honesty, respect, and trust are key values in CRC. The FGDs argued that the provision of CRC, maintaining the code of ethics, better counseling, and a respectful approach is useful for patients and HCPs. Some HWF had an active form of articulating CRC, while other individuals used more restricted behaviors such as maintaining serenity, reluctance to clients, inquiry, and being present only.

Suppose we use CRC correctly in our daily activities. In that case, it minimizes medication adherence or compliance issues, improves health care professionals' burnout, increases loyalty and respect for the clients, and relieves pain and distress. In addition to health ethics, CRC orientation is essential. It is not only learned but needs updated training and psychological advice to adhered health care service. (FGD6 participant 1)

In low-resource settings, the community comes to health care facilities after they are deteriorating; they need psychological, social, compassion, counseling, and treatment with respectful care. (FGD2 participant 5)

If the HWF advanced CRC, both patients and HCPs would be satisfied. The quality and utilization of health care facilities are increased. (FGD participant 10)

• 4.

  Leadership will:

Leadership is essential for enabling the workplace environment and continuing CRC in health care facilities. Participants noted that compassionate leadership starts to see and feel what others see and feel around health care facilities. (FGD6 participant 7)

An understanding and respectful leader puts himself with the other person's idea, view, and honor, with a respectful approach. Most of the leaders only slightly demonstrated actual CRC; they put political commitments first, and some could not show real compassion. (FGD1 participant 12)

The FGDs described multifaceted health care facilities in low-resource settings as having several challenges arising from client feelings, expressions of emotion, scarcity of resources, health care physical problems, and shortage of trained and compassionate leaders. The participants also described their experience in health care settings.

The biggest problem in a health care setting is the presence of uncompassionate and disrespectful leaders. Leaders may not take the positive reward, not share the ability to solve the problems rather than criticizing and following a higher level of punishment. (FGD2 participant 1)

Health care systems need well-organized leaders, good governance, administrators, and HWF who practice CRC to improve patient suffering. There is a weakness of follow-up in health care service management to minimize shortages of compassionate leadership, starting from the health care bureau. (FGD5 participant 11)

I was a leader 2 years ago; there is a complicated clinical situation, individual behaviors, patient, and family concerns. The leader should maintain all factors and be responsible for positively responding and managing their moods that develop good communication and relationships. (FGD3 participant 2)

Limitations of the study

Although our study utilized quantitative and qualitative analysis and a saturated number of qualitative participants, with the quantitative study’s pertinent findings to strengthen it, it does not show a causal relationship due to its cross-sectional. The study has been conducted at health care facilities located in North Shewa Zone of Oromiya Region. Therefore, our findings cannot be generalizable to the other regions of Ethiopia HWF.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the institutional and/or national research committee’s ethical standards and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Salale University Ethical Review Committee (Ref. No. SLUERC/32/2019, on March 18/2019).

Informed consent

Written informed consent was obtained from each respondent. The respondents were informed that their inclusion in the study was voluntary, and that they were free to withdraw from the study if they were not willing to participate. To ensure respondents’ confidentiality, their names were excluded from the questionnaire, and the anonymity of the respondents was maintained.

Ethics approval and consent to participate

Ethical clearance was obtained from the Salale University Ethical Review Committee (Ref. No. SLUERC/32/2019, on March 18/2019). Written permission was obtained from the North Shewa Zone Health Bureau (NSZHB), and written informed consent was obtained from each respondent. The respondents were informed that their inclusion in the study was voluntary, and that they were free to withdraw from the study if they were not willing to participate. To ensure respondent confidentiality, their names were excluded from the questionnaire, and their anonymity was maintained.

Consent for publication

Not applicable.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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