Compassion in Spanish-speaking health care: A systematic review.

Altought compassionate care is an important factor in health care, remains an unmet need in patients. The studies have been carried out in Anglo-Saxon countries with cultural environments and health systems that are very different from Spanish-speaking contexts. The aim of this study to understand the conceptual, evaluation and clinical application nuances of compassion and compassionate care in Spanish-speaking health care settings, through a systematic review. A search of the scientific literature was carried out following the PRISMA guidelines in ProQuest Central, PubMed and Web Of Science, resulting in 295 studies, of which 27 were selected, based on the following inclusion criteria: the article studied or analyzed the construct of compassion in healthcare setting and the participants were Spanish speakers or the authors spoke of the construct in Spanish. Two blinded evaluators performed the study selection process using the Covidence tool. The agreement between evaluators was in all cases satisfactory. Different definitions of the construct have been identified, that they generally share: the recognition of suffering and the attempt to alleviate it. There are few studies that focus solely on the analysis of compassion, since other concepts appear that are associated with it, such as empathy and self-compassion. Further research is needed to obtain a better and greater understanding of compassionate care adapted to the perceptions of patients and health professionals in different socio-cultural contexts. In this way, instruments that measure compassionate care can be better developed and adjusted, and interventions aimed at promoting compassion can be properly assessed.

Introduction

Compassion is defined as a deep awareness of the suffering of others along with the desire to alleviate it (Nunberg & Newman, 2011) and is considered a fundamental component of quality health care (Ques, 2019). The conceptualization of this construct is complex since many definitions have been provided, most of which are theoretical, without specificity or clinical applicability and with little conceptual validity (Sinclair et al., 2016a). In current studies, it has been defined as: “a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action.” (Sinclair et al., 2016a).

Furthermore, compassion is often confused with other terms such as empathy and sympathy, with which it is closely related. In fact, in many cases, they are used interchangeably as synonyms (Klimecki, Leiberg, Ricard & Singer, 2014; Preckel et al., 2018). However, compassion enhances the key facets of empathy while adding distinct features of being motivated by love, the altruistic role of the responder, action, and small, supererogatory acts of kindness (Sinclair, Beamer et al., 2016a).

Although compassion has a prominent place in the codes of ethics of professional organizations, and most health care facilities are willing to provide compassionate care, some studies have identified compassion as one of the most important unmet needs of patients (Riggs et al., 2014). This is especially relevant because lack of compassionate care increases adverse medical problems, symptom-control related discomfort, patient complaints, and negligence complaints to the health care system (Sinclair et al., 2017a). In the same vein, health care that includes compassion provides important benefits such as improved physician-patient relationships, increased patient satisfaction, and improved patient symptomatology and quality of life, in addition to aiding recovery (Seppala et al., 2014; Sinclair et al., 2016a).

This significant impact of compassionate care has led good practice policy makers, researchers, and educators in this field worldwide to view compassionate care as a patient’s right (Paterson, 2011), a fundamental professional competence (Callwood, Cooke, & Allan, 2014). Therefore there are theoretical works that attempt to conceptualize this construct (Chachula, 2020; Sinclair et al., 2016a, b, c, 2017a, b; Taylor et al., 2017); as well as qualitative studies that analyze the importance, experience and presence of compassion in the health field from different perspectives (Sinclair et al., 2016a, 2016b, 2016c, 2018), psychotherapeutic interventions based in compassion (Dodds et al., 2015) and reviews of instruments for evaluating compassionate care in clinical settings (Sinclair et al., 2017b).

The scientific evidence discussed above on this line of research, however, comes mostly from Anglo-Saxon countries with cultural backgrounds and health systems different from the Spanish-speaking context. There are differences between the different healthcare systems, for example, in the USA it is a private system while in the Spanish context it is a public system. One of the most characteristic features of the Spanish healthcare system is that it is a decentralized system, with a territorial organization for each Autonomous Community. The Spanish National Health System is somewhat in line with the original British Atlantic model, as opposed to the U.S. model (García-Altés et al., 2019). Firstly, in the Spanish system there is universalization of health services, always on an equal basis, regardless of social and personal circumstances. This means that public health coverage is extended to the entire population (an aspect that does not coincide with the American system). Solidarity is also a characteristic aspect of our healthcare system, i.e., citizens’ contributions are calculated according to their income. In addition, access to health care depends on the degree of need of each patient, something that in America depends on the socioeconomic level and health insurance (Sultana et al., 2020). Another aspect related to the latter is the equity of the system in terms of access to health benefits. Another of the most significant features of the system is its financing. In addition to providing healthcare, the Spanish system tries to provide what could be called “preventive healthcare”, through instruments such as disease prevention policies and health promotion policies, medical benefits, and pharmaceutical benefits (Sultana et al., 2020).

There are few studies that have addressed the term compassion in the Spanish-speaking healthcare context. Taking into account the differences in the health care systems, our research attempts to respond to this gap in the literature, to help health professionals to understand the application and evaluation of compassion among health professionals. Therefore, the objective of the present study is to understand the conceptual nuances, evaluation and clinical application of compassion and compassionate care in the Spanish-speaking healthcare setting, through a systematic review.

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard (Moher et al., 2015). The protocol for the systematic review was registered in PROSPERO (Booth et al., 2012) (CRD42020177268).

The ProQuest Central, PubMed and Web Of Science databases were consulted for relevant records published up to 12 March 2020. PICO approach was used to formulate the following research question (Sackett et al., 1996): What concept the Spanish-speaking population has of the construct of compassion in healthcare?

In the final search, two key words were combined using the following Boolean expression: (compass* AND Spanish) along with the most appropriate field labels in each database. Thus, in ProQuest we searched as follows: noft(compass*) AND noft(English)”, in Web Of Science: TS = (compass* AND English) and in Pubmed: (compass*[Text Word]) AND (English [Text Word]). No time limit was applied but the following additional parameters were marked in all databases: full text, language in Spanish or English, article, literature review or review in scientific journals in full text.

All retrieved articles were uploaded to Covidence Systematic Review Software (2018) an online data mining and screening tool. After elimination of duplicates, two people independently reviewed the titles and abstracts of all papers, excluding those articles that did not meet the inclusion criteria. The full text of the selected articles was then reviewed individually and blinded to judge their eligibility according to the inclusion and exclusion criteria. The reference lists of the selected studies were also inspected to assess the inclusion of quality references that had not appeared in the initial searches. Hand searching followed a snowball sampling to identify relevant articles in the reference lists of potentially useful documentation. Disagreements between the two were resolved by discussion.

Subsequently, Cohen’s Kappa (κ) was calculated (Orwin, 1994) with the objective of evaluating the index of interjudge agreement, considering that values between −1 and 0.40 are understood as unsatisfactory, values between 0.41 and 0.75 as satisfactory and ≥ of 0.76, very satisfactory (Hernández-Nieto, 2002).

Figure 1 shows the flow chart of the information used to answer the review question.

Fig. 1

Flowchart of selection proc

Studies meeting the following criteria were included in this systematic review: (a) the article studied or analyzed the construct of compassion (definition, conceptualization or application of the construct), (b) the participants were Spanish speakers or the authors spoke of the construct in Spanish, (c) the studies focused on the health field, (d) it was published in English or Spanish (e) and its full text was accessible through the University of Valencia databases. As criteria for exclusion were used: (a) the study could not refer only to concepts or terms related to compassion such as self-pity, compassion fatigue or compassion satisfaction, (b) studies that focused on the compassionate use of medicines or medical programs, and (c) papers published in congresses.

A data extraction form was developed and used to obtain relevant information from the included studies. This information is collected in Table 1 and includes: first author, and year of publication, country, sample, variables and instruments, study design, definition of compassion, results, and main conclusions.

Table 1

Summary of studies

First author and year	Country	Sample	Variables and instruments	Design	Definition of compassion	Main results and conclusions
Albright et al. (2016)	USA	Adolescents (n = 62; 51.6% men and 48.4% women) and their families (n = 30; 60% fathers and 40% mothers)	- Perceptions of school health lefts (ad hoc interviews).	Qualitative study.	The term compassion appears as a characteristic of the medical home.	-Adolescents and families reported high levels of satisfaction, accessibility, confidence, quality of care and coordination with other health professionals. -Needs differed between Hispanic and Anglo family members.
Alcorta-Garza et al. (2005)	Mexico	1022 medical students (48.3% females and 51.7% males) Age 21 ± 2.7	-Medical empathy (EEMJ-S; Hojat, 2016)	Transversal study of psychometric properties.	The concept of compassion appears as a component of empathy.	-The medical empathy scale obtained adequate psychometric properties. It consisted of three factors and an overall score.
Araya and Moncada (2016)	Chile	–	–	Narrative Review	-The Spanish Royal Academy defines compassion as a feeling of commiseration and pity towards those who suffer hardship or misfortune. -The etymology of compassion in Aramaic is racham, derived from a biblical term meaning love, pity or mercy. In Latin it is broken down into com- (along with) and -pathos (suffering). -Western culture: it is associated with resonating with shared suffering and is understood as accompanying suffering. -Buddhist culture: it adds the active desire to generate well-being to those who are suffering, i.e. it incorporates an active component to alleviate it.	-The Buddhist perspective of compassion provides a broader understanding of compassion. -Self-pity can be a new paradigm for health and research.
Asensio-Martínez et al. (2019)	Spain	845 people between 18 and 88 years old (49.16 ± 16.97) Males: 43.8%.	-Sociodemographics -Medical history - Quality of life (SF-36; Alonso et al., 1995). - Physical activity performance (IPAQ; Delgado-Fernández, Tercedor-Sánchez, & Soto-Hermoso, 2005). -Tobacco and alcohol consumption. -Anxiety and depression (EADG; Montón et al., 1993) -Resilience (CD-RISC; Soler et al., 2016) -Full coverage (FFMQ-SF; Cebolla et al., 2012). -Self-pity (SCS-SF; Garcia-Campayo et al., 2014).	Descriptive and analytical cross-sectional study.	It is a psychological construct that involves cognitive, affective and behavioral characteristics, in recognition of one’s own or others’ distress and as an attempt to alleviate it. It has been studied in terms of receiving compassion from others, and as compassion for oneself (self-pity). Compassion is considered a trainable skill.	-The perception of health is associated with age, educational level, resilience, full attention and self-pity. -Resilience is the most relevant factor in predicting quality of life. Greater mindfulness is associated with better quality of life, compassion, and self-pity.
Bellosta-Batalla (2019a)	Spain	–	–	Narrative Review	-Compassion is a feeling generated in situations of suffering (either our own or someone else’s) in which we welcome it with an open and kind attitude, and which includes the intention to alleviate it. -Compassion includes elements that are linked to each other: identification of suffering, understanding that it is a universal human experience, affective attunement with those who suffer, effective management of the emotions associated with this approach, and the actions that are carried out with the intention of alleviating it. -Compassion implies adopting an empathic attitude by including an identification of suffering, an affective attunement and an effective management of this emotional approach.	-Empathy is necessary in a healthy approach to suffering, to building a therapeutic bond, and is the basis of the compassionate attitude. It is therefore essential in the training of psychotherapists. -IBMCs can improve the empathy of psychologists, and are compatible with the different schools of psychotherapy.
Bellosta-Batalla et al. (2019b)	Spain	–	–	Narrative Review	-It is a healthy feeling that involves a kind attitude towards the suffering of others, and which includes the search for relief of their suffering. -It includes various cognitive and emotional aspects: identification of the sources of suffering, adopting a kind attitude in this approach, learning that experiencing it is a universal human experience, affective attunement with that state, effective management and separation of the negative emotions associated with it, and a series of healthy feelings including the intention to relieve, and which guide the actions focused on it. This vision contains several essential aspects of empathy and is an extension of it.	-Empathy is an essential skill in the psychological realm. -Empathy is associated with compassion and attention to the present.
Benito et al. (2016)	Spain	–	–	Narrative Review	-Compassion is not an emotion, but an action on behalf of the other to relieve their suffering. It begins with the internal commotion of the therapist who perceives the suffering of the other, feeling moved to act and transform the commotion into a caring for him or her to diminish the suffering of the other who is perceived as an equal. -In our cultural environment, it is a term that is discredited due to being misunderstood and it is important to differentiate it from pity. -Compassion is not true compassion if it is not active. -It is not only a feeling of pity or concern for the person who is suffering, nor just a sincere affection for the person or a clear recognition of their needs and pain - it is also a determination to do what one can to alleviate their suffering. -Compassion is not a psychological attitude, it is the fruit of mature awareness and the practice of silence. -Eckhart Tolle (2006) points out that there are two aspects to compassion: the awareness of sharing two conditions, the mortal and the immortal.	-Caring for people at the end of their lives and their families must involve spirituality. -The ability to heal depends on the therapist’s experience, coping and acceptance of one’s own suffering and death. -For this reason, the professional has to cultivate his or her spirituality and self-care.
Blanco et al. (2018)	Spain	506 medical students (72.9% female, 27.1% male)	-Empathy in Health Professionals (JSE-HP; Hojat et al., 2001) -Personality traits related to empathy (VipScan) -Objective Structured Clinical Examinations (OSCE) -Video-recorded clinical interview (VRCI) -General academic results. -Interpersonal Reactivity Index (IRI).	Transversal study of psychometric properties	Compassion is as a factor of empathy. The medical empathy scale consists of adopting perspective (cognitive empathy), compassionate care (emotional empathy) and placing oneself in the patient’s shoes, which is a residual dimension.	-Women and those with a preference for specialties focused on direct care of people gained more medical empathy. -The scale shows adequate psychometric properties (validity, internal consistency and reproducibility).
Díiaz-Narvaáez et al. (2017)	Colombia and Dominican Republic	1838 medical students	-Compassionate care of empathy (JSPE-S Alonso et al., 2013; Bilbao et al., 2013; Silva et al., 2014; Vera, 2014).	Transversal study.	- Mercadillo, Barrios and Díaz (2007) argue that compassion can be explained based on the theory of moral emotions. It is considered an emotion that we experience when we observe the destruction of a moral value or social standard and encourages us to restore that neglect. We therefore feel compassion when we look at a person who is suffering, especially if it is caused intentionally and it motivates us to try to alleviate the person’s suffering. -Compassion can be regulated by biological constitution and culture. One of the virtues that should characterize the action of a physician is compassion becoming a unifying psychological, cultural, sociological, ethnic and intellectual trait. Empathy and its component “compassionate care” comes from a complex process - a network with multiple external and internal factors that determine the degree of compassion. All of this would explain the differentiated form of the formation of compassion. In addition, compassion also interacts with the other components of empathy.	-Levels of medical empathy are generally higher in women and depend on the university of study.
Elices et al. (2017)	Spain	–	–	Narrative Review	-It is a fundamental aspect in Buddhism that involves being in touch with suffering and implies a commitment to alleviating it. -From an evolutionary perspective, it has been argued that compassion is rooted in our biology and has six attributes: sensitivity, sympathy, empathy, motivation, tolerance of distress and non-judgment. -Strauss et al. (2016) proposed an operational definition taking into account the different Buddhist and Western perspectives: a cognitive, affective and behavioral process that involves recognizing suffering, understanding its universality, feeling empathy (emotional resonance), tolerating uncomfortable feelings in response to suffering, and motivation to alleviate/act.	-Multiple instruments have been developed to assess compassion and self-pity, but there is a shortage of psychometric measures adapted or developed for the Spanish-speaking population.
Feliu-Soler et al. (2017)	Spain	32 people with borderline personality disorder (BPD) aged 18–45 (35.13 ± 8.25) in the intervention group and 32.50 ± 6.17 in the control group) 6.25% men and 93.75% women. All had received mindfulness training, but half also received a loving kindness and compassion meditation program (LKM/CM)	-Presence of BPD (DIB-R; Barrachina et al., 2004) -Clinical gravity (BSL-23; Soler et al., 2013). -Self-pity (SCS; Garcia-Campayo et al., 2014). -Cognitive style of self-evaluation (FSCRS; Gilbert et al., 2004). -Full attention skills (PHLMS; Tejedor et al., 2014).	Longitudinal, randomized study.	Loving kindness (LKM) and compassionate meditations (CM) are practices derived from Buddhism aimed at developing positive affective states of kindness and sincere sympathy for those affected by misfortune along with a sincere desire to alleviate this suffering.	-A 3-week LKM/CM training program administered after 10 weeks of mindfulness training is superior to practicing continuous mindfulness (CM) in promoting acceptance of the current experience in patients with BPD, as improvements in clinical severity, self-criticism, mindfulness, personal kindness, and acceptance with moderate and large effect sizes were achieved.
Flores et al. (2018)	Spain	–	–	Narrative review	Involves identifying and understanding another person’s suffering, with emotional resonance (active imagination of the person’s condition, concern for that person’s well-being, and a sense of shared distress) and a desire to relieve it.	-Compassionate communities is a movement to focus the comprehensive care model on the needs of people receiving palliative care. The All with You approach has enabled the development of compassionate communities and cities in care for people at the end of life.
Gonzalez-Hernández et al. (2018)	Spain	56 women between 39 and 70 (52.13 ± 6.96).	-Sociodemographics -Medical history -Health-related quality of life (FACT-B + 4; Belmonte et al., 2011). - Psychological well-being (BSI-18; Andreu et al., 2008). -Fear of cancer recurrence (FCRI; Simard and Savard, 2009) Self-pity (SCS-SF; Garcia-Campayo et al., 2014). -Compassion (CS; Pommier et al., 2020) -Full attention facets (FFMQ-SQ; Cebolla et al., 2012). - Satisfaction and adherence (CBCT Evaluation Survey).	Randomized clinical trial. 2 groups: CBCT (Cognitively Based Compassion Training) and TAU (usual treatment control group).	The desire to alleviate suffering and its causes in oneself and in those around us. When directed at oneself, it is called self-pity. Compassion can be trained using specific techniques such as compassion-based interventions designed to generate cognitive and emotional habits of compassion.	-The CBCT protocol is effective in reducing stress related to fear of recurrence, depressive symptomatology and distress. - It improved self-pity and attention to the present, but was not found to be effective in increasing compassion.
Horcajo et al. (2019)	Spain	10 women with ATD, M = 20.2 ± 8.06 age.	-Self-pity (SCS; Garcia-Campayo et al., 2014). -Full attention (FFMQ; Cebolla et al., 2012). -Attitudes toward food (EAT-26; Garner et al., 1982). -Depression and anxiety (DASS-21; Bados et al., 2005). -Body image (BIAQ; Jáuregui & Bolaños, 2011). -Self-esteem (RSE; Atienza et al., 2000).	Longitudinal study.	A feeling of deep sympathy and sadness for the victim of misfortune, accompanied by a strong desire to alleviate that suffering. One of the closest concepts is that of empathy, in which the observer shares the emotions of the observed subject. To achieve compassion, it must appear first in oneself (self-pity) and then towards others.	-Clinical improvement was obtained, since there was an increase in self-esteem, an improvement in eating attitudes, full attention and an increase in self-pity, as well as a decline in restrictive eating behaviors and test behaviors, improving the perception of body image and reducing psychological discomfort.
Julliard et al. (2008)	USA	28 women over the age of 18.	- Socio-demographic -Notions about medical confidentiality. -Experience with health personnel when they had to communicate information. All details were gathered by a semi-structured interview (Sankar & Jones, 2005).	Qualitative study	The construct appears in the doctor-patient relationship section and is considered as a quality of the doctor.	-The full disclosure of health issues between Latino patients and physicians occurs in the context of a warm, trusting and compassionate relationship in which the patient feels respected and truly heard. - Factors such as a cold doctor-patient relationship, language barriers, brevity of visits, discussing sensitive topics without an atmosphere of trust, and differences in gender, age and culture, which can make communication difficult.
Klos and Lemos (2018)	Argentina	385 high school and university students (54.5% female and 45.5% male) between the ages of 13–23 (17.32 ± 2.51)	- Socio-demographic -Compassion for others (COOL; Chang et al., 2014). -Empathic (emotional) concern and perspective (cognitive) taking (IRI; Davis, 1983)	Transversal study of psychometric properties	- Within the moral emotions, it is defined as an emotional response to a value judgment about a person’s suffering. -The sub-processes within compassion are noticing, feeling and relieving. It has been defined as a multidimensional process formed by four main components: an awareness of suffering (empathic cognition), sympathetic concern related to being emotionally moved by another’s suffering (affective component), the desire to alleviate that suffering (intention), and a response or willingness to help in the relief of that suffering (motivation-action). -The empathy-altruism theoretical model is also proposed for explaining compassion: the cognitive-affective component (empathy) and the altruistic act aimed at alleviating or lessening the other’s discomfort (altruism). This is covered on the COOL scale.	The translated and adapted version of the COOL scale presented satisfactory psychometric properties, making it feasible to use it to evaluate the compassion construct in adolescents and young adults in Argentina.
Melgar-Moran et al. (2018)	Peru	6 living kidney donor relatives	Interview to identify and study the resonances of care generated in the donation process (Minayo, 2003)	Qualitative study	Compassion is established as a resonance of care linked to other resonances such as love, and occurs when the donor family member moves away from their personal situation, worries about the suffering of their recipient family member (listens to them, shakes their hand, helps them, shares their spaces, leisure time and makes the decision to be a donor). It generates virtues such as kindness and solidarity in the donor family. It involves becoming close to the other person, and involved with their feelings and their history.	-Compassion and love for each other was one of the main reasons for the donation.
Molinier (2008)	France	–	–	Narrative Review	Compassion is the form of suffering generated by nursing work. Compassion must be understood in this case, beyond any religious connotation and in its literal etymology, as suffering with, in which sensitivity to the misfortune of the other must be demonstrated.	- The possibility of making the compassionate side of the technical work visible could eliminate barriers between technicians and caregivers.
Montero-Marin et al. (2016)	Spain	440 primary care professionals (214 physicians, 184 nurses, and 42 medical residents) Women (70.3%) aged 49.67 ± 10.86 years.	- Socio-demographic characteristics - Burnout subtypes (BCSQ-36; Montero-Marín & García-Campayo, 2010). - Burnout syndrome (MBI-GS; Bresó et al., 2007). - Self-pity (SCS; Garcia-Campayo et al., 2014). - Workplace engagement (UWES; Schaufeli et al., 2002). - Positive and negative affect (PANAS; Watson et al., 1988).	Transversal study of psychometric properties	In the western psychological tradition, compassion is a complex construction that involves cognitive, affective and behavioral characteristics to alleviate the suffering of others and oneself. In Eastern theories, compassion is a basic quality of human beings that is rooted in the recognition and desire to alleviate suffering and leads to pro-social behavior. Self-pity is one of the two facets of compassion, in addition to compassion for others.	-The BCSQ-36 scale of emotional exhaustion showed a good structure and adequate internal consistency in the Spanish primary care professionals. -The negative dimensions of self-pity play a relevant role in explaining burnout profiles.
Montero-Marín et al. (2018)	Spain	42 women with fibromyalgia. Aged between 18 and 65 years old (50.83 ± 8.70 in the ABCT group) and (52.21 ± 5.95) in the active control group.	-Sociodemographics -Health status (FIQ; Rivera & González, 2004). -Clinical severity (CGI-S; Díaz-Marsá et al., 2011). -Catastrophization of pain (PCS; García et al., 2008). -Anxiety and depression (HADS; Vallejo et al., 2012). -Health status in terms of quality of life (EQ-5D; Badia et al., 1999). -Psychological flexibility (AAQ-II; Ruiz et al., 2013).	Randomized controlled trial. 2 groups: ABCT (Spanish protocol; García-Campayo et al., 2016b) and relaxation (REL: active control group). Both combined with the usual treatment (TAU).	It is a psychological construct that involves recognizing and understanding the universality of suffering, feeling emotionally connected to the suffering of others, tolerating uncomfortable feelings as part of remaining open and accepting the suffering of others, and being motivated to act to alleviate suffering.	-The ABCT caused greater increases in the overall health status of women with fibromyalgia compared to the relaxation group. -Significant improvements were also seen in the ABCT group in clinical severity, depression, quality of life and psychological flexibility, but not in catastrophic pain. -ABCT may be helpful in improving the physical and mental health of women with fibromyalgia.
Montero-Marin et al. (2019)	Spain	90 patients with depressive, anxious or adaptive disorder (30 in each condition/group) between 18 and 75 years old	-General emotional distress (DASS-21; Daza et al., 2002). -Health-related quality of life (EQ-5D; Badia et al., 1999) -Full care facets (FFMQ; Cebolla et al., 2012). -Self-pity (SCS; Garcia-Campayo et al., 2014) -Use of social and health services (CSRI; Vázquez-Barquero et al., 1997).	Intervention protocol. Multi-left randomized controlled trial (RCT). 3 groups: ABCT intervention (attachment-based compassion therapy; adapted to Spanish; García-Campayo et al., 2016b) + TAU, MBSR (mindfulness-based stress reduction) + TAU and TAU alone).	Compassion forms a particular orientation of the mind, which is configured in a motivational system oriented to a certain sensitivity to suffering and a commitment to relieving suffering by recognizing the universality of pain and the capacity to face that pain with equanimity.	-Full attention meditation is increasingly being incorporated into mental health programs, but so far the construct of compassion has not been consistently integrated, so more evidence is needed. -
Napoles et al. (2009)	USA	1664 adult general practice patients: African American, non-Latino, English and Spanish speaking Latinos. 66% women, ages (50 ± 18).	-Sociodemographic data -Patient satisfaction (Hays et al., 1998; Care Survey, 1998) -Patient satisfaction with medical care and professional recommendation (ad-hoc) -Interpersonal care processes (IPC-Short Form; Stewart et al., 2007).	Transversal study	-It is included as an interpersonal style on the IPC scale, i.e. the scale includes three scales of communication, one scale of patient-lefted decision making, and three scales of interpersonal style (compassionate/respectful, racial/ethnic discrimination and disrespectful office staff). -It is explained or defined as follows: expressing concern for the patient’s feelings, respect for the patient as a person and an equal.	Interpersonal processes were important for everyone in terms of satisfaction, as all three dimensions of the scale were associated with all satisfaction measures.
Ortega-Barco and Muñoz de Rodríguez (2018)	Colombia	43 pregnant women. The mean age of the intervention group was 25.15 ± 7.91 years compared to 24.35 ± 5.77 years in the control group.	-Attention received (CPS; Vesga Gualdrón & Ruiz de Cárdenas, 2016)	Controlled clinical trial. 2 groups: control group with conventional care and group with care based on the processes of care proposed by Swanson (1993).	The scale was made up of two subscales: compassionate healer and competent healer. The items that made up the subscale of compassionate healer referred to whether the health professional understood him or her, showed interest, and listened attentively.	-The intervention improved women’s perception of professional nursing care during childbirth. -These results are consistent with other studies that indicate that women attach importance to the relational component of nursing care and influence the value of care.
Sacristán-Martin et al. (2019)	Spain	122 pregnant women and their partners in some cases.	-Sociodemographics - Depression (EPDS; García-Esteve et al., 2003). -Perceived stress (PSS; Remor, 2006). -Positive and negative emotions (PANAS; Sandín et al., 1999). -Full attention facets (FFMQ; Aguado et al.,2015; Cebolla et al., 2012). -Self-pity (SCS; Garcia-Campayo et al., 2014). -Satisfaction and self-efficacy about motherhood (EEP; Klein, 2008). -Use of health and social services (CSRI; Vázquez-Barquero et al., 1997).	Proposal for an intervention protocol. Multi-left randomized controlled trial with 2 groups: MBCP educational course + TAU or TAU.	Compassion is a particular orientation of the mind that recognizes the universality of suffering in the human experience and cultivates the capacity to face that suffering with kindness and empathy. It is characterized by the presence of sensitivity to suffering and a commitment to preventing and alleviating it with equanimity and patience.	-A childbirth education program that incorporates full-care and compassionate practices can be a complementary, preventive and beneficial form of healthcare for pregnant women and their partners for reducing symptoms of depression during pregnancy and postpartum.
Tejada-Pérez (2017)	Colombia	12 nurses (75% women and 25% men) who cared for or had cared for critically ill adult patients under sedation in an ICU, with an average age of 30 years.	-Participating observation. -Care experience (interview and focus group and records in field journal).	Qualitative study	The ability to perceive the suffering of others as one’s own, to interiorize the suffering of another and to live it as if it were one’s own experience. The nurse thereby provides comfort to the patient based on compassionate care, i.e. he or she understands the suffering of the person being cared for and assumes it as his or her own in order to satisfy their needs. It is an attitude involving understanding the patient and trying to “put oneself in the other’s place”.	-Comfort and compassion are an important issues for the participants in this study.
Ulloque et al. (2019)	Argentina	306 medical students from different courses (63.7% women and 36.3% men).	-Empathy (JSPE-S; Varela et al., 2012).	Transversal study	It does not define compassion, but instead one of the components/domains of the empathy construct that appears on the Jefferson scale. It is considered the emotional/affective component of empathy.	-Students have a compassionate base. -Women had higher levels of empathy and compassionate care than men. -Senior students showed more empathy.
Valentín et al. (2019)	Spain	422 nursing students (19.1% male) (22.86 ± 4 years).	- Socio-demographic -Empathy (JSE-HPS; Hojat, 2016) -Emotional Intelligence: (BEIS-10; Davies et al., 2010). -Resilience (CD-RISC-10; Dolores et al., 2013).	Longitudinal study of psychometric propieties	They do not define compassion, but it is a component of the scale. The first factor, ʼ‘taken from perspective’, is the predominant factor in the scale and refers to the cognitive aspects of empathy. The second factor is characterized by a combination of cognitive and affective aspects of empathy and is also considered an essential factor in professional relationships with patients. The third factor, ʽ Putting oneself in the shoes of the patient, is an inverse concept to emotional detachment.	-The Jefferson Medical Empathy Scale is a reliable, valid and appropriate instrument for assessing empathy among nursing students.

Results

Study Selection and Screening

The selection process of the study is shown in Fig. 1. The literature search produced a total of 292 articles. Once the duplicate records were eliminated, the total number of studies was 235. The initial selection excluded 119 papers based on the title and the abstract, and the remaining 116 were read in full text in a second selection process. The reliability of the previous agreement between the two independent raters of the full text screening was satisfactory (κ = 0.53). In the second screening, 91 papers were excluded, making 28 studies eligible for inclusion. In this second screening, the degree of inter-judge agreement was excellent (κ = 0.88).

Characteristics of the Study

The characteristics of the study are summarized in Table 1. Of the articles included in this review, 57% are empirical studies, 14% are validations of psychometric instruments and 29% are theoretical works. Fifty-four percent of the studies originated in Spain, followed by 14% in the United States, 7% in Colombia, 7% in Argentina, and the rest in Chile, Mexico, the Dominican Republic, Peru, and France. Most of the papers were published between 2015 and 2019 (n = 24).

Conceptualization of Compassion

As for the conceptualization of compassion, 61% of the selected studies provided a definition. It has been defined in various ways, for example as a construct, a feeling, a performance, an emotion or a capacity, but the majority (71%) mention the recognition of suffering and the attempt or desire to alleviate it.

There are studies that use various approaches to conceptualize compassion. Two studies explain compassion from different cultural traditions. In them, it is emphasized that from the western tradition it has been proposed that compassion is a complex construction that involves cognitive, affective and behavioral characteristics to alleviate the suffering of others and oneself. From this perspective, compassion is associated to resonate with and accompany shared suffering. While in Eastern theories, unlike this, compassion is understood as a basic quality of human beings rooted in the recognition of suffering and adds the active component of alleviating it, which results in pro-social behaviors in order to generate well-being to the person who suffers.

In this line, one of the studies mentions an operational definition considering the different Buddhist and Western perspectives. Strauss et al. (2016) defined compassion as a cognitive, affective and behavioral process that involves identifying suffering, understanding its universality, feeling emotionally connected or empathic with the experience of the other, tolerating uncomfortable feelings in response to suffering and being motivated to alleviate it/act. This definition is consistent with the description given by studies of the elements that make up compassion (Flores et al., 2018; Klos & Lemos, 2018; Sacristán-Martin et al., 2019; Valentín et al., 2019).

Likewise, other approaches appear to explain compassion such as the evolutionary perspective (which understands that compassion is rooted in our biology), the theory of moral emotions (which defines compassion as an emotion experienced when observing the destruction of a moral value or social standard and encourages us to restore that neglect) or the theoretical model of empathy-altruism (which contemplates the cognitive-affective component (empathy) and the altruistic act to lessen the discomfort of the other).

The rest of the articles included in our study did not contain an exact definition of compassion but conceptualized it from the description of the characteristics or concepts that were related to it.

Applying Compassion in Health Care

Since the present review includes heterogeneous works, it has been thought convenient to present the results distributing them according to the type of study:

Theoretical Studies

The selected theoretical studies that focus on the conceptualization of compassion in the health field in a Spanish-speaking context present very different objectives. Three papers have been identified that focus on compassion during much of the article. Two studies have also been found that focus on the application of compassionate care. The other study explains a project to develop compassionate communities to provide comprehensive care for the needs of individuals in palliative care.

In the remaining three papers, one briefly mentions compassion, as it focuses on describing the characteristics and scope in the therapeutic area of self-compassion. While the other studies are dedicated to analyzing the importance of empathy in the field of psychotherapy and the phenomena that can influence it in a negative way. But they also explain the relationship between mindfulness, empathy and compassion, offering an explanatory model of the association of these constructs and showing the advantages of applying mindfulness and compassion-based interventions (MCI) in the university training of clinical psychologists.

Empirical Studies

The 16 empirical studies included analyzed, as a whole, a total of 2144 medical students, 452 health professionals, 174 patients with pathologies (fibromyalgia, eating disorders, borderline personality disorder, depression, anxiety and adjustment disorders) and 2856 people representative of the general population.

As for the research design, 25% were qualitative studies, 31% were randomized clinical trials, 31% were cross-sectional studies and the rest of the works (12%) were pilot studies.

In relation to the evaluated variables, a great heterogeneity has been obtained as for the independent and dependent variables. The studies considered different outcome variables at the psychological level among which the following stand out: full attention (38%), self-pity (44%), compassionate care/compassion (38%) and empathy (6%). With regard to the compassion variable, in 80% of the works, it was evaluated with generally adapted to the population, with the exception of two of the studies. Finally, only one study (20%) evaluated compassion using cualitative methods through an interview designed to analyze the elements and criteria of a school health center, which include compassion.

In reference to the format of the interventions, six works have been found in which the following compassion-related intervention programs are applied: CBCT, ABCT (García-Campayo et al., 2016b), MBCP program with compassion training, CFT (García-Campayo et al., 2016a) and LKM/CM.

Instrument Validation Studies

As for the works included on instrument validations, three studies (75%) were based on the analysis of the psychometric properties of the Jefferson Scale of Physician Empathy, but in different versions. The results of them confirmed the internal consistency (Cronbach’s alpha around 0.74 and 0.82) and its construct validity based on a three-factor model: perspective taking, compassionate care and the ability to put oneself in the other’s shoes.

Finally, only one study (25%) aimed at translating and validating the instrument “The Compassion Of Others’ Lives scale” (Chang et al., 2014). This scale is based on the theoretical model of empathy-altruism, but only operationalizes the dimensions of empathy and relief behavior by excluding the assessment of altruistic motivations. It allows for an overall score of the degree of compassion towards others, as well as a score for each subscale (empathy and relief of suffering). The results presented satisfactory psychometric properties such as a high internal consistency (Cronbach’s alpha α = 0.93) and the validity of internal factor structure obtained differs from that proposed by the original authors in that this new study divides the scale into two sub-dimensions (empathy and relief of suffering), obtaining a better partial adjustment to the data than that provided by the one-dimensional model with a single factor (compassion).

Discussion

The aim of this study was to understand the conceptual nuances of compassion and compassionate care in the Spanish-speaking health care setting, through a systematic review. Most conceptual studies on compassion in Spanish-speaking healthcare contexts define compassion as the recognition of suffering and the attempt or desire to alleviate it. Some of the studies focus on its role in reinforcing empathy, love, altruism, kindness and action to alleviate suffering (Sinclair et al., 2016a, 2016b, 2016c). Other studies define it as a construct, a feeling, a performance, an emotion or a skill.

Through our review we have noted that there is no agreement on the term compassion since it is conceptualized from different perspectives such as the evolutionary approach, the theory of moral emotions, Buddhism and the differentiation between Eastern and Western culture. However, it has been identified that all definitions have two elements in common: the recognition of suffering and the active component that motivates it to alleviate it. It should be noted that four studies (Asensio-Martínez et al., 2019; Elices et al., 2017; Klos & Lemos, 2018; Montero-Marin et al., 2016) have a common definition, in which they categorize compassion as a complex construct or process involving cognitive, affective and behavioral characteristics in a situation of suffering. This is a multidimensional understanding of compassion that differs from other works that provide one-dimensional conceptualizations, limiting compassion to a feeling, a trait or a virtue.

Compassion is a complex concept that does not always seem to be well understood, as it is often associated with other terms such as empathy, sympathy, pity and other emotions that may arise in response to the suffering of others. In relation to these terms, a study has been identified (Araya & Moncada, 2016) that defines compassion as a feeling of commiseration and pity for those who suffer hardship. In this line, in the study by Benito et al. (2016), it is recognized that in our cultural environment it is a term that is misunderstood and discredited because it is associated with pity and it is necessary and important to differentiate these concepts. This reflection is consistent with another article, in which compassion is not understood as a passive emotion, which would be characteristic of pity, but as a more complex process that involves the desire for others to stop suffering and includes the active search for relief of suffering (Ques, 2019).

As regards the association with empathy, one study (Bellosta-Batalla et al., 2019a, 2019b) explains that empathy is a necessary condition in the healthy approach to suffering, becoming the basis on which, the compassionate attitude is sustained. This paper proposes an explanatory model in which the association between these constructs is established and influences the evolution from empathy to compassion. This evolution supposes a variation in the internal experience of the observer that generates healthy emotions in which the intention to alleviate suffering is included and favors the appearance of compassion. Specifically, the model explains that in the establishment of a healthy empathy and in the desire to alleviate the suffering of others, the different components of compassion are integrated: the increase in sensitivity to the suffering of others (cognitive and emotional empathy), the actions that are carried out with the intention of alleviating it and the effective management of the emotions associated with this approach, avoiding a response of sympathy and/or empathic distress, since a secure base is formed in which there is a separation from the emotions of others. In short, this model mentions that compassion is an extension of empathy since it integrates several essential aspects of it. This view is congruent with other studies that understand compassion as a construct beyond empathy (Sinclair et al., 2016a; Strauss et al., 2016).

The rest of the studies that do not provide a definition, mention some behaviors that characterize the compassionate care of health professionals, such as: getting involved in the feeling and history of patients, expressing concern and understanding for their feelings, actively listening, helping, being present and maintaining communication by showing interest. These aspects of compassionate care are consistent with previous research that explains how the presence of these elements positively influences the overall care experience and the patient’s perception of their physician (Sinclair et al., 2016a).

Despite the findings of this systematic review that contribute to knowledge about the conceptualization and application of compassion in the Spanish-speaking health care setting, our work has certain limitations. After an exhaustive search, few papers have been obtained that have studied only compassion in the Spanish-speaking health care setting, being a total of twenty-seven studies, with very different objectives. It has been noted that there is a greater focus on concepts related to compassion that seems to have led to a paradoxical neglect of the construct itself, as considerably more studies of self-pity, compassion fatigue, or compassion satisfaction have been identified during the article selection process. This fact has led to the inclusion in our analysis of studies that, although primarily focused on the analysis of self-pity or empathy, included a brief description of compassion. In addition, by means of the proposed search strategy, we have tried to collect all the evidence in Spanish language about compassion, but there is scientific information in other studies on this thematic line that has not been identified in this review since it is not framed within our inclusion criteria. In particular, the non-inclusion of grey literature may be an important limitation. Finally, another possible limitation is the use of general search terms, which may result in a less targeted search. However, this was done with the aim of reaching the maximum number of publications on the concept of compassion in the Spanish-speaking healthcare context. All these aspects will be taken into account in future studies.

Based on the results obtained that point out the gaps that still exist in the scientific evidence in this line of research mainly in the Spanish-speaking context, it is considered necessary to carry out in future research the conceptual analysis of compassion based on empirical studies that identify the perceptions and meaning that patients and health professionals attribute to compassionate care. In this way, a more explicit definition of the construct within health care would be obtained, distinguishing it from other contexts and codifying the central elements from the perspective of those who are at the epicenter of the exchange of compassionate care. This would provide an empirical basis for the operationalization of aspects of compassion in clinical practice and thereby contribute to the development of interventions that aim to improve compassionate care in the clinical setting and instruments to measure patients’ experiences of compassion. In this way, future lines of research could focus on the development of compassion assessment instruments adapted to the Spanish-speaking health care context, as well as the development of specific interventions to improve this skill and improve health care.

We believe that this review provides a good basis for even more systematic studies to be carried out in the future. In addition, our work can help to better understand the term compassion in the Spanish-speaking health care setting, which can help to design specific interventions adapted to this context. In this way, interventions can be tailored to the characteristics of health systems in the Spanish-speaking context, taking into account their specific potential and limitations. Therefore, we conclude that it is highly relevant and a priority to carry out more research on compassion in the Spanish-speaking healthcare context that will provide evidence regarding this construct and its application, taking into account the different socio-cultural and healthcare contexts, since it is an area of interest that has been little studied and is showing satisfactory results.