Compassion-based care for COVID-19 patients: a qualitative analysis of nurses' perceptions.

Compassion is a basic approach to medical practice and is the core component of health care. The purpose of the present study was to explore nurses' perceptions of compassion-based care (CBC) for COVID-19 patients. In this qualitative study, the participants were selected using purposeful sampling. Individual and semi-structured interviews were conducted with 25 nurses, and conventional content analysis was used to categorize the data. In the care of COVID-19 patients, CBC consisted of three categories including pro-social behaviors, paying attention to the beliefs and values of patients, and concern for family members. The first category had three subcategories including empathy, altruism, and helping in critical situations. The second category included the subcategories of the spiritual approach to care and respect for cultural aspects. The third category, concern for family members, had one subcategory: the need to consider the patient's family. Our findings may help to develop a comprehensive model in COVID-19 care according to which, in addition to routine patient care, nurses will consider concepts such as empathy, altruism, helping in critical situations, spirituality, cultural values, and the family's needs at the end of the patient's life.

Introduction

The year 2020 may be considered as the "year of the corona" due to the coronavirus disease 2019 (COVID-19) pandemic (1). The healthcare personnel responded to the COVID-19 pandemic with a herculean effort at the beginning of the pandemic and were willing to provide quality care (2). Accordingly, they needed the necessary skills to make flexible and rapid decisions, and effective leadership to prevent moral distress. In fact, due to their capability in addressing physical, psychological, and spiritual needs, they were able to help other healthcare personnel develop human relationships with the patients in addition to supporting them in dealing with stress and fear (3). It can be said that COVID-19 has created new experiential knowledge for healthcare personnel (4). Among healthcare workers, nurses have been the key factor in the development and implementation of policies related to patient care standards during the pandemic (5). COVID-19 patients need nursing care to avoid further complications (6), and nurses are the first healthcare workers who care for COVID-19 patients, who are suffering from a potentially deadly disease (7). Nurses are actively involved in the initial evaluation, triage, and care of these patients (8). During the COVID-19 pandemic, nurses experienced both negative and positive emotions at the same time. The negative emotions included fatigue, distress, and helplessness, and the positive emotions consisted of psychological adjustment, growth under pressure, and professional responsibility. In the early phase of this pandemic, negative emotions were dominant, while the positive emotions appeared slowly. For instance, by providing care to COVID-19 patients, nurses have been able to achieve psychological growth and improve their professional performance (9). On the other hand, they have experienced ethical challenges in providing care for these patients (10) in addition to occupational and moral distress. As a matter of fact, nurses may even lose their lives while caring for COVID-19 patients (11).

However, COVID-19 showed us that a healthy person and a healthy world are one. Certainly, the concept that led us to this belief is compassion. Compassion gives us an understanding of how we built the world and how we can make it better. This concept is based on the equality of all people in terms of social, ethnic, racial, and gender issues (12). In addition, compassion is a basic approach to medical practice and the core component of health care (13). Accordingly, interest in the concept of compassion-based care (CBC) has increased among healthcare workers, especially nurses (14), so that CBC is recognized as one of the main elements of quality care (15). In fact, CBC is a pivotal value in clinical practice (16). This type of care not only reduces nurses' burnout but also improves patients' satisfaction and quality of life (17).

Studies worldwide have investigated the role of compassion in patient care. Nurses in the UK believe that in clinical settings, the impact of compassion in responding to patients' emotional needs is complex, and that compassion is a driving force for care (18). An analysis of nurses' experiences in Italy showed that CBC is intertwined with positive elements such as loving and supporting the patient (19). In another study that examined the views of nurses internationally, it was found that despite cultural differences among nurses, all of them considered compassion as an important element of nursing care (20). On the other hand, research results in Iran have shown that compassion for patients may be influenced by the current culture of the society (21). However, the results of a systematic review showed that while the emphasis is on improving the quality of patient care, there are shortcomings in the international health system that may be due to a lack of compassion in patient care (15).

The results of a study on the care of COVID-19 patients in Spain showed that healthcare workers experience high levels of compassion fatigue as a result of caring for these patients (22). A study in Italy also found that healthcare workers feel low levels of compassion during the COVID-19 pandemic (23). Since the literature review showed that CBC is a concept that is based on community culture, there is a need for a qualitative study on the perception of nurses working in COVID-19 wards in Iran, because it is possible that nurses’ interpretation of CBC has been influenced by the cultural context, they live in. In this regard, research shows that compassion and culture are interrelated. For example, Papadopoulos et al. (2016) found that compassion is dependent on one’s cultural context (20). Thus, the aim of the present study was to explore nurses' perceptions of CBC for COVID-19 patients.

Methods

To identify the nurses' perceptions of CBC for COVID-19 patients, we used a qualitative methodology. We performed content analysis, which consists of analyzing written, spokenو or visual communications through inferences from the raw data to summarize and categorize them. In this study, we used conventional content analysis, that is, the categories and their titles flow from the text of the data (24, 25).

The study setting consisted of the general wards and intensive care units of 2 public hospitals in Iran that are designated for the treatment and care of COVID-19 patients. These hospitals were affiliated with Tehran University of Medical Sciences (Imam Khomeini Hospital) and Kashan University of Medical Sciences (Shahid Beheshti Hospital). We received the names and phone numbers of eligible participants from the head nurses of COVID-19 units but included only those who had at least one month’s experience in COVID-19 wards and had worked full time the morning, evening, and night shifts. The exclusion criterion was being disinterested in participation. The nurses were recruited by maximum variation purposive sampling to include a wide range of participants in terms of age, gender, education level, work setting, nursing work experience, and work experience in COVID-19 care. Recruitment continued until data saturation.

The nurses participated in individual and semi-structured in-depth interviews. Due to restrictions in COVID-19 units, for instance, full isolation, forbidden entry and exit, risk of viral spread, and participants’ work overload, the interviews were done by WhatsApp voice (6 nurses) and video (19 nurses) call, based on the preference of the nurses. Prior to the interviews, the researcher and the nurses reached an agreement about the time of the interviews, which were scheduled for when the nurses were not on their work shift. The duration of the interviews ranged from 35 to 50 minutes. Each nurse was interviewed once, and 25 interviews were done in total. The researcher chose the interview questions based on the researcher’s expertise, the study aim, and research design. The participants answered these questions: 1) How would you describe CBC for patients? 2) How would you describe CBC for COVID-19 patients? and 3) What is your experience of CBC? The interview continued with follow-up questions such as “What do you mean by…?”, “Could you provide more details?”, or “Can you specify an example?”. Data were collected between October and December 2020.

Data analysis and data collection were conducted simultaneously. The interviews were recorded, transcribed, and then typed on the computer. All the interviews were transcribed verbatim so as to highlight the keywords in the text that contained meaning units, and to extract the codes. After extracting the codes from the important sentences and paragraphs, they were categorized based on their similarities and differences, and eventually, similar subcategories were combined into categories based on their associations (25).

To determine the rigor of the study, we used the criteria for credibility, dependability, confirmability, and transferability (25). In order to assess data credibility, perspectives of the research team were used in the process of the interviews and data analysis. Transcriptions of the interviews and the results were shared with some nurses. In order to verify data dependability, we used the opinions of an external person who was not part of the research team, but was acquainted with the subject matter and content analysis; there was agreement on our results. To verify confirmability, all activities were documented and a report was prepared on the process of the study. To verify transferability, the results were shared with two nurses who were not part of the study but had similar conditions, and the results were confirmed.

This article was part of the research project number IR.IUMS.REC.1400.247 approved by Iran University of Medical Sciences. The participants gave their consent after being informed about the study’s aim. Also, they were reassured that their information would remain confidential and that they retained the right to withdraw from the study at any time.

Results

A total of 25 nurses participated in this study. They were aged between 28 and 49, were mostly females (17 nurses), and had a bachelor’s degree (19 nurses). In terms of work setting, 15 were employed in general wards, and their nursing work experience varied from 5 to 20 years. Moreover, they had 1 to 6 months’ work experience in COVID-19 care (Table 1).

Table 1

Characteristics of the nurses

Characteristics		Number
Education Level	Master's degree	6
	Bachelor's degree	19
Hospital	Imam Khomeini	16
	Shahid Beheshti	9
Work Setting	General ward	15
	Intensive care unit	10

In the data analysis phase, 885 codes were identified. The nurses' narratives indicated that CBC in the care of COVID-19 patients consisted of three categories including pro-social behaviors, paying attention to the beliefs and values of patients, and concern for family members. The category of pro-social behaviors had three subcategories of empathy, altruism, and helping in critical situations. The category of paying attention to the beliefs and values of patients included the subcategories of spiritual approach to care, and respect for cultural aspects. The category of concern for family members had one subcategory of the need to consider the patient’s family (Table 2).

Table 2

Results of the data analysis

Categories	Subcategories
Pro-social behaviors	Empathy
	Altruism
	Helping in critical situations
Paying attention to the beliefs and values of patients	Spiritual approach to care
	Respect for cultural aspects
Concern for family members	The need to consider the patient’s family

Nurses believed that in the care of COVID-19 patients, CBC includes a set of pro-social behaviors. These behaviors consist of empathy, altruism, and helping in critical situations.

Empathy

According to the nurses, compassion-based inpatient care for COVID-19 patients means being by their bedside, accepting them, and being kind to them. "In addition to the routine care of the patients and meeting their physical needs, listening to the patients and making sure that they are satisfied are among their needs. When the nurses see patients in this way, it means that they have accepted them. Patient acceptance is very important because it enables the nurse to provide compassionate care for the patient." [Participant No. 4]

According to the participants, mutual understanding and seeing the patient as a family member or relative is important in CBC for COVID-19 patients. This leads to understanding the patient promptly and relieving his/her suffering. "Empathy is the cornerstone of patient care. When there is mutual understanding in caring for these patients, we can take care of them better, because we can understand them in an instant ... This feature in caring for a COVID-19 patient relieves his/her suffering." [Participant No. 6]

"I'm saying that there’s no difference if I or my sister, my parents, or one of my relatives is hospitalized here for COVID-19." [Participant No. 18]

Altruism

According to the nurses, CBC is not possible for a COVID-19 patient without altruism. Behaviors such as going the extra mile and doing things that the patient has not asked the nurse to do are examples of altruism. "The nurses here do a number of things at the request of patients, but some of them are not requested by the patient, and the nurses really do them beyond their duties. These are actions the nurses do not expect to be rewarded for, and they do them according to their moral values and altruism. Well, CBC makes no sense without altruism." [Participant No. 22]

"Last week I was on shift. One patient’s urine bag was full, and I could not wait for the support worker anymore. Emptying the urine bag is not in our job description. Nobody told me to do it, but I emptied it myself." [Participant No. 2]

Helping in critical situations

According to the nurses, CBC means helping patients and standing by their side in critical situations. Although COVID-19 is a life-threatening disease, nurses emphasized the importance of commitment and accountability in patient care during times of crisis. "Nurses have an unconditional commitment toward people. Even when they know that their health and well-being may be endangered due to COVID-19, they still serve the community and the sick, which means compassion in times of crisis." [Participant No. 25]

"When COVID-19 became widespread, we faced a critical situation. Our responsibility to the health system really doubled, and we became more sensitive about our work and the patients’ lives. Our shifts became heavier, but we stayed beside the patients despite the risk of getting sick." [Participant No. 12]

"Not seeing their families for a long time has been a problem for nurses and that’s how they have helped patients during the COVID-19 crisis." [Participant No. 17]

"Nurses sometimes stay in the hospital dormitory for up to 20 days for patients’ sake and may not be able to see their families, spouses, and children. Well, they do that because the situation is critical and is not the same as before." [Participant No. 8]

The nurses believed that for COVID-19 patients, CBC is possible with a spiritual approach to care and respect for cultural aspects.

Spiritual approach to care

According to the nurses, a spiritual approach can help COVID-19 patients to pray and perform their religious duties. In addition, a spiritual approach can show the patient the path of life. "Patients who like to pray should be helped and respected. They should be able to pray any way they want because they believe that it is not possible to bear the burden of disease without God's help. If nurses can provide this type of care, patients will be spiritually happy, and CBC is delivered in such a way that the spirituality of the patient is considered." [Participant No. 21]

"Most COVID-19 patients know they are on the verge of death and are afraid. Well, here CBC shows patients the path of life in a spiritual structure. It shows them that even if COVID-19 is the end of life, that’s fate, and death is a part of life." [Participant No. 9]

Respect for cultural aspects

Among the elements of CBC for COVID-19 patients mentioned by the nurses were the right to a same-sex nurse and respect for privacy, both of which have cultural roots. "Our patients want to be cared for by same-sex nurses. I think this is rooted in our culture, and the patient’s culture must be respected. But we cannot always cater to that, because of the situation and shortage of staff. For instance, I was fixing a chest lead for a female patient, and she complained to me that a male nurse had done it for her the previous shift." [Participant No. 14]

"Patient privacy is very important to me. If the curtain is not drawn for patients who are not able to change their clothes themselves, they will complain, because being exposed is not acceptable in our culture." [Participant No. 23]

The nurses believed that another factor in CBC for COVID-19 patients was a concern for the patient’s family.

The need to consider the patient’s family

According to the nurses, CBC in COVID-19 is a type of care that considers not only the patient but also the family. The need to consider the patient’s family is more conspicuous when the patient is close to the end of his/her life. As a rule, families view ​​saying goodbye to patients at the end of life as a value, and nurses strive to respect this value. In addition, nurses believe that it is important to grieve with the patient’s family after his/her death.

"When the patient is at the end-of-life stage, it is a value for the family to be able to say goodbye to the patient, but due to the pandemic, it is not possible for them to see the patient before death. I talk to patients’ families over the phone and tell them that I understand that they want to say goodbye to the patient. I do this to calm them down." [Participant No. 5]

"When a patient passes away, the family cannot mourn because of the social distancing that must be observed at the mourning rituals. Since getting together and holding memorial services for the deceased is currently not possible due to the pandemic, we should respect the family’s values.... So, expressing our condolences and telling them that we share their grief may be comforting for them." [Participant No. 11]

Discussion

In the present study, nurses' perceptions of CBC for COVID-19 patients were explored. According to the nurses, this type of care is intertwined with pro-social behaviors and consideration for the beliefs and values of patients and their families. The nurses said that pro-social behaviors in CBC for these patients include empathy, altruism, and helping in critical situations. During the COVID-19 pandemic, it is vital for individuals to exhibit pro-social behaviors to support one another (26). It can be said that pro-social behaviors help people understand a situation and make decisions that benefit patient care (27). It is obvious that the rapid spread of COVID-19 has affected all classes of society. COVID-19 has taught people to be together, have compassion toward each other, and cooperate with others (28). In fact, COVID-19 is a social crisis that has also provided an opportunity for social empathy (4). Thus, during the pandemic, health systems sought to create an empathy epidemic with the goal of establishing a humanistic relationship with patients (29). In this regard, it should be acknowledged that for COVID-19 patients, humanistic care based on mutual understanding between the nurse and the patient is a necessity (30). In other words, providing optimal care for these patients depends on the caregivers’ empathy, which occurs through effective communication with the patient (31). If we can listen to people wholeheartedly, we can help to restore their health considerably (12). Nurses also reported that relieving patients’ suffering and understanding them by putting ourselves in their shoes are factors that lead to empathy toward patients. In this regard, it should be noted that compassion is known as an empathic concern and a desire to alleviate the suffering of oneself and others (12). In addition, by imagining that we could contract the disease at any time, we realize the need to protect ourselves and others from the disease (13).

According to the nurses, CBC for COVID-19 patients is based on altruism. It should be noted that compassion is a state that has an altruistic nature (12). The results of a systematic review showed that CBC has ethical aspects and is based on a humanistic relationship with patients (15). The nurses in our study mentioned unconditional commitment and accountability to the health system, accepting the risk of sickness and death, and not seeing their families for a long time. Similarly, caregivers in Africa stated that they experienced family isolation when providing care for COVID-19 patients (32). It seems that helping these patients and the health system during the COVID-19 crisis has been institutionalized for the nurses participating in this study, so they have served patients by observing ethical principles such as commitment, accountability, and dedication. Therefore, it can be said that CBC for COVID-19 patients is rooted in clinical nursing ethics and includes pro-social behaviors.

Nurses believed that issues such as a spiritual approach to care, respect for cultural aspects, and the need to consider the patient’s family are important in CBC. Since the patients are afraid of death, this approach helps them realize that death is part of life. In this regard, researchers found that CBC also has a spiritual dimension (15). In addition, for COVID-19 patients, spiritual care is a vital component of health management that helps them cope with illness and suffering (30). On the other hand, spiritual care entails showing compassion during periods of heightened crisis such as stress, distress, and anxiety (33), and therefore, providing spiritual care is of great significance for these patients (34). The findings of a study in Spain also showed that nurses provided spiritual care for COVID-19 patients (35). In fact, there is evidence that spiritual care may even provide a deeper type of immunity for these patients (36). The nurses in our study said that maintaining the patients’ privacy while providing care and assigning same-sex nurses are important to patients for cultural reasons, but this has been difficult during the pandemic due to a shortage of nurses. Therefore, in order to ensure CBC, it is necessary for the health system to take action and recruit more nursing staff.

The nurses in our study emphasized the families’ desire to say goodbye to patients before their death. In Spain, in order to alleviate the suffering of families at the time of COVID-19 patients’ death and to facilitate the acceptance process, healthcare workers use daily video conferencing to communicate with each other and also allow communication between patients and their families. This allows families to see their patients and expands the connection between employees, patients, and their families (37). Unfortunately, due to the COVID-19 crisis, funeral services have been banned. The researchers found that when COVID-19 patients pass away, it is important for their families to be informed about the burial process and mourning rituals, and since memorial services are not permitted due to the pandemic, they may develop prolonged grief disorder (38). Given that it is not currently possible for the families of dying patients to say goodbye or observe the customary mourning rituals, they will need the help of psychologists to cope with these problems in addition to the routine measures taken by the nurses.

As a final point, it should be mentioned that the sample recruitment approach and the nature of the study limited our ability to generalize the presented findings. One main limitation of the present study was that the researchers were not allowed to enter the clinical setting due to the critical conditions in COVID-19 wards. In order to overcome this limitation, the interviews were conducted using the WhatsApp mobile messaging platform. In addition, since the nurses preferred voice calls for data collection, we could have missed some benefits of video calls. To compensate for these limitations, all calls were recorded, and the number of video calls substantially exceeded that of voice calls.

Conclusion

Our study investigated nurses’ general perception of CBC for COVID-19 patients through a qualitative approach. Since this was the first qualitative study on Iranian nurses’ views about CBC for COVID-19 patients, the results can reveal the various aspects of their perceptions regarding this type of care in Iran. Based on our findings, CBC for COVID-19 patients could comprise elements such as pro-social behaviors related to the beliefs and values of patients and their families. The results also indicated CBC for these patients to have moral, cultural, and spiritual roots. The findings of this study can be the basis for a comprehensive model in COVID-19 care according to which, in addition to routine patient care, nurses need to consider concepts such as empathy, altruism, helping in critical situations, spirituality, cultural values, and family needs at the end of patients’ life. Finally, nursing managers must consider the necessity for compassionate nursing care in the current COVID-19 pandemic in clinical settings.