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The integration of medicine and compassionate care: an evaluation study

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The integration of medicine and compassionate care: an evaluation study

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Content Running head: MEDICINE AND COMPASSIONATE CARE 1

THE INTEGRATION OF MEDICINE AND COMPASSIONATE CARE:
AN EVALUATION STUDY

by

Lori K. Koutouratsas

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

May 10, 2019

Copyright 2019 Lori K. Koutouratsas

MEDICINE AND COMPASSIONATE CARE 2

Acknowledgements

I would like to acknowledge and thank several people, who without their support and
encouragement this project would not have been possible. First, I would like to thank my
dissertation advisor, Dr. Helena Seli, for her unfailing dedication and support, careful and quick
feedback, and enduring enthusiasm. Dr. Seli spent many hours dialoging with me about my
work and the theoretical concepts that framed my dissertation and their implementation, and
without her support this project would have been quite different. I am also grateful for her strong
and kind mentorship through this process. I also wanted to thank Dr. Patrick Crispen as the
professor who stands out as a pivotal influencer in my education. In my first semester, Dr.
Crispen brought to life how to be both creative and scholarly simultaneously. The seeds that
were planted in the first semester helped guide me through this journey. In addition, I am
grateful for Dr. Kim Hirabayashi and her involvement on my committee, as well as her online
presence in the lectures. I know that she was an integral part of creating this online program and
I appreciate all of her efforts. and in the online lectures.
This project was not a solitary endeavor. I am forever grateful for all of my colleagues
who walked this road with me, but a few are worth mentioning here. Dan Sosa, Armando
Zuniga, Jonathan Townsend, and Andre Stridiron provided encouragement when I needed it
most, celebrated the small moments of victory with me, and were generous in their feedback and
support throughout the program. Joe Cortez, Raju Hegde, Liz Kovach-Hayes, Megan Hutaff,
and Estella Chavarin were also an integral part of my cheering team.
I would like to acknowledge Tim Thorstenson for his seed-planting, which is what inspired
me to pursue this degree. As a former colleague turned invaluable mentor, his support and
encouragement in this program and in all things relating to life are appreciated and treasured. I
also want to thank all of my work colleagues, who cheered me on and supported me throughout
MEDICINE AND COMPASSIONATE CARE 3

this journey. They helped hold me up during the day when I was exhausted from doing school
work at nights.
My tribe of friends have sustained me through this journey and reminded me how to have
fun. Love and thanks to Leslie, Nancy, Keri, Stefanie, Kathie, and Kim. I would also like to
acknowledge my parents, Nikolaos and Dorothy, who instilled in me the importance of
education. I know they would be proud of me.
Most importantly, I would like to acknowledge the unwavering love and support of my
three children. Zach, Kia, and Kate have provided me with constant inspiration throughout this
endeavor. Their support and encouragement made this degree possible, and there would be no
dissertation without them. Their constant enthusiasm when I was overwhelmed and exhausted,
and their many hugs reminded me why I was on this road. This has been an incredible journey,
and there is no one I would have rather done it alongside than you three. I love you all.

MEDICINE AND COMPASSIONATE CARE 4

Table of Contents

List of Tables 6
List of Figures 7
Abstract 8
Chapter One: Introduction 9
Organizational Context and Mission 10
Organizational Goal 11
Related Literature 12
Importance of the Evaluation 13
Description of Stakeholder Groups 15
Stakeholder Groups’ Performance Goals 16
Stakeholder Group for the Study 16
Purpose of the Project and Questions 18
Methodological Framework 19
Definitions 20
Organization of the Study 22
Chapter Two: Review of the Literature 23
Factors that Impact Well-Being of Medical Residents 23
Burnout 23
Compassionate care 24
Spirituality and health 24
Physician communication 25
Religion and spirituality in medical education 26
Role of Stakeholder Group of Focus 27
Clark and Estes’ (2008) KMO Influences Framework 28
Medical Resident KMO Influences 29
Knowledge and Skills 29
Motivational Influences 32
Organizational Influences 35
Conceptual Framework: Medical Residents’ KMO Context 38
Conclusion 42
Chapter Three: Methods 43
Participating Stakeholders 43
Interview Sampling Criteria 45
Interview Sampling (Recruitment) Strategy and Rationale 45
Qualitative Data Collection 47
Interviews 47
Credibility and Trustworthiness 49
Ethics 50
Limitations and Delimitations 51
Chapter Four: Findings 53
Participating Stakeholders 54
Knowledge Findings 55
Deeper Compassionate Care Knowledge Needed 56
Physicians Need More Tools to Regulate Emotions 59
Motivational Influences 63
Medical Residents’ High Value for Compassionate Self-Care 64
MEDICINE AND COMPASSIONATE CARE 5

Medical Residents’ Confidence in Providing Self-Care 68
Organizational Influences 70
Cultural Settings and Models 71
Summary of General Themes 77
Knowledge Themes 77
Motivation Themes 79
Organizational Themes 79
Chapter Five: Recommendations 82
Introduction and Overview 82
Recommendations for Practice to Address KMO Influences 82
Knowledge Recommendations 82
Motivation Recommendations 87
Organization Recommendations 91
Integrated Implementation and Evaluation Plan 95
Implementation and Evaluation Framework 95
Organizational Purpose, Need, and Expectations 96
Level 4: Results and Leading Indicators 96
Level 3: Behavior 99
Level 2: Learning 104
Level 1: Reaction 107
Evaluation Tools 108
Data Analysis and Reporting 109
Summary 110
Strengths and Weaknesses of the Approach 112
Future Research 1134
Conclusion 114
References 117
Appendix A: Interview Protocol 124
Appendix B: University of Southern California Information Sheet for Research 127
Appendix C: Recruitment Letter 128
Appendix D: Immediately Following Debriefing Session Evaluation 129
Appendix E: Delayed Debriefing Sessions Evaluation 130

MEDICINE AND COMPASSIONATE CARE 6

List of Tables

Table 1: Stakeholder Groups’ Performance Goals 16
Table 2: Knowledge Influences and Knowledge Types 32
Table 3: Motivational Influences 35
Table 4: Organizational Influences 38
Table 5: Information about the Participants 55
Table 6: Summary of Knowledge Influences and Recommendations 84
Table 7: Summary of Motivation Influences and Recommendations 88
Table 8: Summary of Organizational Influences and Recommendations 92
Table 9: Outcomes, Metrics, and Methods for External and Internal Outcomes 98
Table 10: Critical Behaviors, Metrics, Methods, and Timing for Evaluation 101
Table 11: Required Drivers to Support Critical Behaviors 103
Table 12: Components of Learning for the Program 107
Table 13: Components to Measure Reactions to the Program 108
Table 14: Dashboard 110

MEDICINE AND COMPASSIONATE CARE 7

List of Figures

Figure 1: Relationship between self-care and compassionate care 21

Figure 2: Conceptual framework diagram 40

MEDICINE AND COMPASSIONATE CARE 8

Abstract

There are unprecedented challenges experienced in the health care field today. Studies report
that physicians do not adequately regulate their personal level of well-being. Providing
physicians with tools and resources to promote self-care with the support of the organization can
help physicians care for themselves and help promote greater well-being in physicians. To
successfully navigate these challenges, medical education leadership needs to collaborate with
organizational leaders to support committed, productive, and balanced physicians. Providing
physicians additional support, guidance and tools are necessary to teach physicians ways to
provide better care for themselves. Through a qualitative study interviewing Internal Medicine
medical residents, the findings identified that additional compassionate care training and self-
care training was needed. Although the medical residents felt fairly comfortable engaging in
difficult conversations with patients and families, they all agreed that additional compassionate
care education was needed to help them provide themselves with better self-care. Specific
medical education curriculum additions were identified, such as the implementation of
debriefings, reflection, and additional palliative care team involvement within the residency
program. In addition, the organization supported these findings. Further research to explore the
needs in medical students is recommended.

MEDICINE AND COMPASSIONATE CARE 9

Chapter One: Introduction
Introduction to the Problem of Practice
There are unprecedented challenges experienced in the health care field today. Studies
report that physicians do not accurately regulate their personal level of well-being and suggest
that providing them objective information on how their well-being compares with that of
physicians nationally helps promote behavior change (Shanafelt et al., 2014).

Providing
physicians with tools and resources to promote self-care and to orchestrate tangible ways the
organization can help physicians care for themselves can help promote greater well-being in
physicians. In addition, national studies suggest that more than half of United States physicians
are experiencing professional burnout, which has been shown to influence quality of care, patient
safety, physician turnover, and patient satisfaction (Shanafelt & Noseworthy, 2017). Although
burnout is a system issue, most institutions operate under the erroneous framework that burnout
and professional satisfaction are solely the responsibility of the individual physician. To
successfully navigate these challenges, health care executives need committed and productive
physicians working in collaboration with organization leaders. In order for health care
executives and physicians to effectively navigate these challenges, all participants need to feel
balanced, grounded, and at peace about their work. If physicians do not feel prepared to have
these collaborative conversations, then additional support, guidance and tools are required for
physicians to feel equipped to succeed (Shanafelt & Noseworthy, 2017). One of the issues is that
54.4% of physicians reported at least one symptom of burnout in a 2014 study, compared with
45.5% in a 2011 study, when assessed using the Maslach Burnout Inventory (Shanafelt et al.,
2015). Burnout is a syndrome characterize by exhaustion, cynicism, and negative self-
evaluation, leading to reduced effectiveness (Maslach & Johnson, 1981). Physician burnout has
been shown to influence quality of care, patient safety, physician turnover, and patient
MEDICINE AND COMPASSIONATE CARE 10

satisfaction (Kumar, 2016). In addressing burnout, Kraft (2011) contends that acknowledging
spirituality with the physician and incorporating notions of spirituality into patient conversations,
helps both patients and physicians. Although burnout is a system issue, most institutions operate
under the framework that burnout and professional satisfaction are solely the responsibility of the
individual physician (Shanafelt & Noseworthy, 2017). In order to address the patients’ well-
being, the physicians’ well-being must be attained first. Qualitative findings of Mitchel et al.
(2016) suggested that additions to the medical curriculum are needed in the areas of wellness,
religion and spirituality, and self-care practices, in order to reduce burnout in physicians. It is
important to address this problem because a person’s spirituality does not disappear when a
patient enters the hospital; a patient’s spirituality is part of the whole person and needs to be
considered when providing health care (Sheehan, 2003). In addition to the patient’s well-being,
the physician’s well-being is a factor in the care of the patient.
Organizational Context and Mission
Alphabet Health (a pseudonym) is one of the leading medical centers in the United States
and is located in one of the western states in the United States. It is a health system that is
comprised of two main hospitals and many clinics that surround the two hospitals. Hospital
Alpha and Hospital Beta provides patient care in nearly every medical specialty to over 500,000
people each year from the neighboring cities and around the world. The non-profit medical
centers have also served as teaching hospitals for over 60 years. Hospital Beta is located a few
miles away from Hospital Alpha, and together they have about 900 patient beds, employ over
200 full-time physicians, and more than 4,000 support staff.
The mission, vision, and values of Alphabet Health are to provide optimal patient care
that strives to heal each patient by alleviating suffering and improving health with kindness,
respect, integrity, and compassion. These goals are attained through continual research and
MEDICINE AND COMPASSIONATE CARE 11

education in all areas of medicine, supporting the teamwork of all members of the health system
towards excellence and discovery while turning great expectations into great accomplishments.
This humanistic approach to compassionate patient care creates an environment of change and
growth that benefits the patients and the greater community.
Organizational Goal
Alphabet Health’s business goal is that by July 2020, medical education leadership will
collaborate, design, and integrate compassionate care training into their medical educational
model. Shanafelt et al. (2014) report that individual physicians do not accurately regulate their
personal level of well-being and suggest that providing them objective information on how their
well-being compares with that of physicians nationally helps promote behavior change.
Providing individual physicians with tools for self-regulation, resources to promote self-care,
andorganizational changes that support the physicians, are three tangible ways that organizations
can help individuals care for themselves. In 2016, at least 50% of physicians in the United States
reported an increase in burnout and many institutions believe that burnout and professional
satisfaction are the responsibility of the individual physician, rather than the hospital system
(Shanafelt & Noseworthy, 2017). The same study also suggested that organizational leadership
should invest in efforts to reduce burnout and promote physician engagement in their own
emotional well-being. There is no standard set in medical education that helps medical residents
deal with the emotional impact of the illness and disease that a medical resident witnesses during
their clinical medical training. There is also no standard set on how to emotionally prepare for
telling patient’s their health is declining or how to handle patient deaths (Eng, Schulman,
Jhanwar, & Shah, 2015).
The intent of this study was designed as a response to Alphabet Health’s medical
education leadership recognizing the need to integrate compassionate care curriculum into
MEDICINE AND COMPASSIONATE CARE 12

medical residency training. Medical education leadership is comprised of the Internal Medicine
Residency Program Director and the Designated Institutional Official of the Graduate Medical
Education (GME) Office. The GME upholds the national Accreditation Council for Graduate
Medical Education (ACGME) requirements as the residency curriculum is designed. In order to
further enhance and support medical residents in their care for patients by providing the tools
needed to offer compassionate care to patients, the organizational performance goal is for
medical education leadership to collaborate, design, and integrate compassionate care training
into their medical educational model. The additional curriculum will provide compassionate
care training for the medical resident first, with the secondary gain being that patients will
ultimately receive more compassionate care. This study will look at the well-being of medical
residents and support may be through the participation in supportive and reflective groups, where
medical residents can further develop their compassion during their post-medical school clinical
training. The integration of these educational models can provide a structured yet practical way
to address emotional reactions following the death of a patient and other emotionally challenging
experiences. This will provide greater support to future and current physicians and increase
communication with team members, including non-physician staff.
Related Literature
The Accreditation Council for Graduate Medical Education’s (ACGME) mission is to
improve health care and population health by assessing and advancing the quality of medical
residents’ education through accreditation (ACGME, 2017). The ACGME revised their common
program requirements for medical residents in response to physicians not acquiring additional
education in medical residency training to navigate their own emotions as they participate in
difficult conversations with patients (Dyrbye & Shanafelt, 2016). Because patients seek to
receive care beyond the physical aspects of disease management, physicians can meet these
MEDICINE AND COMPASSIONATE CARE 13

needs by integrating spirituality into their care of patients. During medical education training,
medical residents primarily focus on the physical aspects of disease management in their
patients, with little training on how to address a patient’s spiritual needs. In addition, studies
demonstrate that job satisfaction by physicians was improved and burnout in physicians was
reduced when spirituality was integrated into patient care by enhancing patient-centered care,
and deepening connection with patients (Balboni et al., 2010, Bremault-Phillips et al., 2015,
Jagosh, Boudreau, Steinert, MacDonald, & Ingram, 2011, Kraft, 2011). Physicians recognized
the need for additional training to enhance and develop their skills of connecting with patients,
which included exploring compassion and spirituality in medicine (Balboni et al., 2015; Eng et
al., 2015; Mitchell et al., 2016; Ramakrishnan, 2015). As this research suggests, identifying an
added component to physician education that leads to the integration of compassionate care
training into the medical residents’ education would be beneficial. Foscarelli (2008) and Lown,
Rosen, and Marttila (2011) identified that physicians (and patients) agree that compassionate
care is mandatory in medicine because it improves the health outcomes and the patient’s care
experiences.
Importance of the Evaluation
It is important for Alphabet Health to introduce curriculum into medical education to
provide compassionate care training for physicians because there is an increase in physicians
experiencing burnout symptoms (Shanafelt et al., 2015). Although most institutions operate
under the framework that burnout and professional satisfaction is an individual problem, burnout
is a health system issue, as has been identified by the national medicine accrediting agency, the
Accreditation Council for Graduate Medical Education (ACGME, 2017). In order to prevent
burnout, medical education leadership, working with the ACGME, is now required to support
MEDICINE AND COMPASSIONATE CARE 14

compassionate care training that is characterized by vigor, dedication, and absorption in work
and is the positive antithesis of burnout (Shanafelt & Noseworthy, 2017).
Thomas J. Nasca, the CEO of the ACGME, stated that in the current health care
environment, medical residents are at increased risk for burnout and depression and in order to
combat these statistics, the ACGME is committed to supporting the psychological, emotional,
and physical well-being of medical residents (Nasca, 2017). Dr. Nasca argues that self-care is an
important component of professionalism; it is also a skill that must be learned and nurtured in the
context of other aspects of medical residency training in order to develop into competent,
resilient, and caring physicians. Medical residency programs, in partnership with their individual
medical centers, have a shared responsibility to address the well-being of medical residents as
well as evaluating the medical aspects of resident competence (Nasca, 2017). The practice of
medicine is not just about focusing on the technical aspects of care, but also on the patients’
spiritual dimension, which is central to their lives. Lown, Rosen, and Marttila (2011) surveyed
over 1,300 physicians and patients and determined that compassionate physicians were such an
important part of medical care that quality standards in medicine would ideally reflect this value.
This problem requires providing adequate support to physicians, so that they can provide
compassionate care to their patients. According to dictionary.com, compassion is defined as a
feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by
a strong desire to alleviate the suffering (www.dictionary.com), while compassionate care is
defined as serious attention offered while providing compassion (www.dictionary.com).
Compassionate care can be provided freely between people. Being genuinely compassionate is
showing, feeling, understanding, and listening to what is needed and providing it with the right
tone of voice, a simple touch, a loving glance and a listening attentiveness. In order for
MEDICINE AND COMPASSIONATE CARE 15

physicians to be able to provide compassionate care to others, they must first be able to provide
compassionate care to themselves.
Description of Stakeholder Groups
At Alphabet Health System, the stakeholders include physician leaders (attending
physicians and administrators), medical residents (students, post medical school education), a
spiritual care clinician, and members of the Patient Experience department. These stakeholders
were brought together to make up a multi-disciplinary team that collaborates to integrate
compassionate care training into both the medical school educational model as well as the
medical resident education model, in order to further enhance and cultivate the development of
compassionate physicians. The physician leaders strive to create a curriculum within the already
established medical school education program, as well as generate a supportive group that
teaches and supports the medical residents, with the help of attending physicians and the spiritual
care clinician. The attending physicians currently provide clinical medical training to resident at
the physicians the patient’s bedside. This study proposes that attending physicians will also
participate in regular supportive and reflective groups with the medical residents, where they can
together further develop their compassion for patients, as well as discover ways to care for their
own souls, in the midst of painful patient experiences. In addition, part of the evaluative team
will include members of the Patient Experience department; their role is to send out surveys to
the patients, which seek honest and anonymous evaluation of their hospital experience.

MEDICINE AND COMPASSIONATE CARE 16

Stakeholder Groups’ Performance Goals
Table 1

Organizational Mission, Organizational Goal, and Stakeholder Performance Goals

Organizational Mission
The mission of Alphabet Health is to provide optimal patient care that strives to heal
each patient by alleviating suffering and improving health with
kindness, respect, integrity, and compassion.
Organizational Performance Goal
By July 2020, medical education leadership will collaborate, design, and integrate
compassionate care training into their medical educational model.
Spiritual Care
Clinician
By Fall 2019,
Alphabet Health will
have integrated a new
compassionate care
curriculum into their
educational model.

Physician Leaders

By Fall 2019,
physician leaders will
have collaborated
with the Spiritual
Care Clinician to
create an effective
compassionate care
curriculum into the
medical residency
program.

Patient Experience
Department
By Spring 2020,
Patient Experience
Dept. will gather
feedback from
medical residents,
measuring the
effectiveness of the
pilot programs.

Medical Residents

By July 2020, 100%
of medical residents
will demonstrate
capacity to provide
compassionate care to
self.

Stakeholder Group for the Study
Although a complete analysis would involve all stakeholder groups, for practical
purposes, the focus of this study was on one stakeholder group. The Medical Residents are the
chosen stakeholder group because they have a significant role in the future of medicine and if
their wellness is not addressed while they are still in training, the burnout statistics may continue
to rise, potentially leaving fewer physicians to provide care for an increasing population. In
addition, informing medical education leadership that modifying the medical education
curriculum to support the well-being of their physician learners will encourage an environment
for all health care providers to find greater meaning and more joy in their work. Through this
MEDICINE AND COMPASSIONATE CARE 17

study, the needs of medical residents will be explored to determine how best to support and
implement compassionate care training into medical residency clinical training. Finally, a side-
effect of more compassionate physicians will be that the physicians are able to provide more
compassionate care to patients.
An important part of medical training is for medical residents to understand patients’
experiences of illness and to help guide them through complex medical, social, and ethical
situations. Some patients grapple with physical and psychosocial suffering, as well as with
questions regarding the end of life. Physicians engage in frequent conversations about goals of
care, in which they are tasked to present practical options that incorporate the patient’s clinical
condition and their values. Not infrequently, physicians send patients home on hospice or see
them die in the hospital. Witnessing suffering and death has a profound emotional impact on
physicians and can lead to compassion fatigue (Doolittle, Windish, & Seelig, 2013). Currently,
there is no consistent opportunity for physicians to reflect upon and learn from these difficult
encounters, or to have their emotional well-being addressed. The implementation of integrating
regular debriefing sessions will help address these concerns. The importance of the medical
residents to have the compassionate care curriculum integrated into their medical education will
help support the well-being of the medical residents, as well as help attain the organization’s
mission statement goals, which are to provide optimal patient care that strives to heal each
patient by alleviating suffering and improving health. The stakeholder goal is for medical
residents to demonstrate capacity to provide compassionate care to self, which will lead to
compassionate care of others. Without providing greater support for the medical residents,
attaining the organization’s mission statement goal of delivering optimal patient care cannot be
attained and the value and integrity of the organization will be compromised.

MEDICINE AND COMPASSIONATE CARE 18

Purpose of the Project and Questions
There is no standard set in medical education that helps medical residents process the
emotional impact of patient deaths or how to deliver difficult news to patients and families (Eng
et al., 2015). In order to further enhance and support physicians in their care for patients by
providing the tools needed to offer compassionate care to patients, the hospital discussed the
need to implement a program to help support medical resident physicians. This initiative is
designed to allow a safe space for current medical residents and the spiritual care clinician to
participate together in supportive and reflective groups, so that the medical residents can further
develop their compassion, post medical school.
The purpose of this project was to conduct a needs’ analysis in the areas of medical
residents’ knowledge and skill, motivation, and organizational resources necessary to reach the
organizational performance goal. While a complete needs’ analysis would focus on all
stakeholders, for practical purposes, the medical residents were the primary stakeholder group of
focus in this analysis. The analysis generated a list of possible needs related to the goal of
providing compassionate care education to the medical education for medical residents, which
can then be examined systematically to focus on actual or validated needs so that an intentional
and responsive compassionate care curriculum can be implemented into medical education.
The questions that will guide the needs’ analysis are the following:
1. What is the medical resident physicians’ knowledge and motivation related to
2. providing compassionate care to self? What is the interaction between organizational
culture and context and medical resident physicians’ knowledge and motivation?
3. What are the recommendations in the areas of knowledge, motivation, and
organizational resources for the organization?

MEDICINE AND COMPASSIONATE CARE 19

Methodological Framework
Based on the framework provided by Clark and Estes (2008), the research findings in this
study were categorized into knowledge and skills, motivation, and organizational resources and
solutions for medical resident physicians. The qualitative methodological approach using
interviews were used to identify the needs of medical residents, so that they can identify how to
provide compassionate care to themselves. The purpose of this study required the researcher to
explore if and how medical residents are prepared to provide compassionate care to themselves,
through interviews. In addition, one of the goals of the study was to make meaning from the data
collected, in the natural setting of the hospital. Due to the nature of the research, it was
anticipated that in spite of an already established interview protocol, each interview will be
unique and may provide additional and unexpected data. The approach to the research was
inductive, implying the theory and the results will generatively reveal themselves (Merriam &
Tisdell, 2016). Although the focus of this research was to determine if and explore how medical
residents can provide compassionate care to themselves, the researcher planned to remain
differentiated and neutral, by utilizing an outside mentor as a guide to maintain differentiation.
Face to face interviews were conducted, allowing the interview format and questions to change
as the conversation progressed. The critical research method was used in this qualitative
research examination. The goal of the research was to discern ways to advocate for medical
education curriculum that assists medical residents to be more emotionally attuned and
ultimately, more compassionate to themselves and more effective and more compassionate care
providers to their patients. The goal of critical research was to be able to identify ways to
implement change so that a desired outcome of greater compassion could be attained. The
sample size chosen was both deliberate and purposeful, and the data was interpreted and
analyzed as they were collected after the narrative interviews.
MEDICINE AND COMPASSIONATE CARE 20

Definitions
Compassion: A feeling of deep sympathy and sorrow for another who is stricken by
misfortune, accompanied by a strong desire to alleviate the suffering (“compassion,” n.d.).
Compassionate Care: The word compassion is defined as sympathetic consciousness of
others' distress, together with a desire to alleviate it. It is touching the heart of another by the
way you provide care to another (“compassion,” n.d.).
Consciousness: The state of being aware (“consciousness,” n.d.).
Coping Skills: Any characteristic or behavioral pattern that enhances a person’s
adaptation. Coping skills include a stable value or religious belief system, problem solving,
social skills, health-energy, and commitment to a social network (“coping skills,” n.d.).
Emotional Integration: Being emotionally mature enough to care for oneself while caring
for others is a sign of emotional integration (Brown, 2012).
Emotional well-being: Your ability to understand the value of your emotions and use
them to move your life forward in positive directions. Daily emotional well-being also involves
identifying, building upon, and operating from your strengths rather than focusing on fixing
problems or weaknesses. The better you are able to master your emotions, the greater your
capacity to enjoy life, cope with stress, and focus on important personal priorities (“emotional
well-being,” n.d.).
Engagement: The positive antithesis of burnout and is characterized by vigor, dedication,
and absorption in work (Maslach & Jackson, 1981).
Medical Education Leadership: Medical education leadership is comprised of the Internal
Medicine Residency Program Director and the Designated Institutional Official of the Graduate
Medical Education (GME) Office. The GME upholds the national Accreditation Council for
Graduate Medical Education (ACGME) requirements as the residency curriculum is designed.
MEDICINE AND COMPASSIONATE CARE 21

Medical Resident: Also known as a physician learner. A medical resident is a physician
who has completed their four-year medical school education and is now working on their clinical
education to comply with the requirements for full medical board certification.
Self-care: Any activity that we do deliberately in order to take care of our mental,
emotional, and physical health. Good self-care is key to improved mood and reduced anxiety
and is key to a good relationship with oneself and others (“self-care,” n.d.).
Spirituality: The essence of a person; includes a sense of connection to something else,
perhaps bigger than us. Spirituality typically involves a search for meaning in one’s life.
Spirituality does not equate religion, though it can if that is meaningful to a person. Spirituality
is seen as a universal human experience that touches all people (Brown, 2012).

Figure 1. Relationship between self-care and compassionate care.

MEDICINE AND COMPASSIONATE CARE 22

Organization of the Study
This study is organized in five chapters. This chapter provided the reader with the key
concepts and terminology commonly found in a discussion about how physicians provide
compassionate care to themselves and patients. The organization’s mission, goals and
stakeholders as well as the initial concepts of gap analysis adapted to needs analysis were
introduced. Chapter Two provides a review of current literature surrounding the scope of the
study. Topics about the emotional awareness of physicians and their emotional integration will
be addressed. Chapter Three details the assumed needs for this study as well as methodology
when it comes to choosing participants, data collection, and analysis. In Chapter Four, the data
and results are assessed and analyzed. Chapter Five provides solutions, based on data and
literature, for addressing the needs and closing the performance gap as well as recommendations
for an implementation and evaluation plan for the solutions.

MEDICINE AND COMPASSIONATE CARE 23

Chapter Two: Review of the Literature
This literature review will examine how changes in medical education can include
education and training that helps facilitate greater self-awareness through compassionate care
training, resulting in better coping skills for medical residents. The first section focuses on
physician awareness of both needing compassionate care training as well as emotional
integration. The second segment addresses motivation by examining physician expectations and
values, as well as their goals. The chapter ends with an analysis of physician awareness and
skills from the lens of learning and motivation literature utilizing the gap analysis dimensions of
knowledge, motivation, and organization, and the presentation of the conceptual framework.
Additional related literature has been embedded into the knowledge, motivation, and
organizational sections as well.
Factors that Impact Well-Being of Medical Residents
This section offers an overview of the well-being of medical residents. Medical
education reports that burnout is observed in clinical training, so ways to explore how to better
address and prevent burnout will be the focus of this study. Exploring ways to support medical
residents by providing additional education in communication and compassionate care training
will be examined. Finally, exploring the spiritual well-being of the medical resident, including
emotional integration will be addressed in this study.
Burnout. In a qualitative analysis conducted by Doolittle, Windish and Seelig (2013),
28% of medical residents reported burnout. In the study, the complex relationships between
burnout, behaviors, emotional coping, and spirituality were explored among medical residents.
The study concluded that helping foster a culture of respectful, courteous relationships during
medical residency training is important to help prevent the development of burnout. In addition,
MEDICINE AND COMPASSIONATE CARE 24

the study offered a range of emotional and spiritual coping strategies that may provide a
protective benefit to the medical residents.
Compassionate care. In May 2017, Thomas J. Nasca MD (Nasca, 2017), the Chief
Executive Officer of the ACGME, wrote a letter to the community to inform physicians that
together with the Association of American Medical Colleges and the National Academy of
Medicine, all three organizations were commiserating on how best to support the working and
learning environments for medical students, residents, fellows, faculty, and the entire health care
team. Dr. Nasca (Nasca, 2017) continued by stating that one of the most important functions of
all three organization’s work is to constantly enhance the educational programs. One suggested
area to enhance was in providing more support to medical residents with additional support in
the program and through stressful events. One of the essential tools to help support medical
residents is guiding them to provide compassionate care to themselves. In supporting medical
residents to provide themselves with compassionate care, they will then be able to extend
compassionate care to their patients. Caring for other is not attainable without caring for
yourself first. Once medical residents are able to provide themselves with self-care, then they
will be able to provide an outward expression of compassion to themselves and their patients.
Spirituality and health. Puchalski, Vitillo, Hull, and Reller (2014) reported on two
conferences that focused on compassionate care. In the November 2012 conference, they
discussed how to help create more compassionate systems of care in the hospital. In the January
2013 conference, they helped improve the spiritual dimension of whole person care, which
included the transformational role of compassion, love, and forgiveness in health care. The
conferences highlighted an awareness that spiritual care is a fundamental component of high-
quality compassionate care, as seen by providers and patients. Through this qualitative analysis,
MEDICINE AND COMPASSIONATE CARE 25

the conferences helped identify the growing movement in spirituality and health to generate
more compassionate care through the integration of spiritual care in medicine.
In order to reinvigorate medicine’s tradition of compassion and holistic care for the 21
st

century, Puchalski, Blatt, Kogan, and Butler (2014) describe a new field, “spirituality and
health,” and the role of this new field is to restore the balance between the scientific and
humanistic sides of health care. “Spirituality and health” are grounded in the core principles of
service, compassion, dignity, and the interconnectedness of all people, with a commitment to
making patients’ search for meaning and relationship an essential focus of medical education,
patient care, and the health care system. Puchalski et al. (2014) also described the history of the
field of spirituality and health and its ultimate incorporation into the curricula of over 75% of
United States medical schools.
Physician communication. In a qualitative study conducted by Jagosh, Boudreau,
Steinert, MacDonald, and Ingram (2011), research findings described the importance and various
functions of physician listening, as perceived by patients. Patients explained why listening was
important and these findings were organized into three themes. First, listening is an essential
component of clinical data gathering and diagnosis. Second, listening is a healing and
therapeutic agent. Finally, listening is a means of fostering and strengthening the doctor-patient
relationship. The findings are presented along with a conceptual model on the functions of
physician listening, as well as the benefits physicians can gain learning the verbal and non-verbal
cues of communication.
Balboni et al. (2010) conducted a qualitative study to determine whether spiritual care
from the medical team impacts medical care received and quality of life at the end of life. When
a patient’s spiritual needs were largely or completely supported by the medical team, patients
and families received more hospice care in comparison with those patients that did not feel their
MEDICINE AND COMPASSIONATE CARE 26

spiritual needs were addressed. Spiritual support from the medical team was associated with
higher quality of life scores near death. The Balboni et al. (2010) study showed that if
physicians can tend to a patient’s spiritual needs, signifying better communication skills, then
patients and families will report greater hospice utilization, less aggressive medical interventions,
and a better quality of life at the end of life. An additional result to these findings is a financial
savings of 1.3 billion dollars a year, which is a form of compassion to a patient and a benefit to
the medical center.
Religion and spirituality in medical education. In a qualitative study in New Zealand
medical schools, Lambie, Egan, Walker, and Macleod (2015) showed that physicians were not
familiar with “spirituality” and needed education on the fundamentals of a holistic approach to
patient care. This study revealed that education about spirituality is needed in medical school.
In another study by Mitchell et al. (2016), the perspectives of medical students and chaplaincy
students were explored regarding the development of curriculum to facilitate reflection on moral
and spiritual dimensions of caring for the critically ill and to educate students about self-care
practices that can promote and enhance professionalism. Although this study engaged medical
students and not medical residents, the qualitative study found that the curriculum format and
curriculum content were the two major qualitative themes that emerged. Designing and
implementing a curriculum on religion and spirituality (R/S) and wellness that focused on the
integration of R/S values and self-care practices within oneself and their care for patients, and
finally measuring the curriculum for its effectiveness was a desired outcome of the study.
Finally, Balboni et al. (2015) examined the influence of R/S on a physician’s medical practice.
The study reported that an increased awareness that R/S may have a possible influential role on
the way medical students cope with all of the challenging emotions of medicine. All of these
MEDICINE AND COMPASSIONATE CARE 27

studies demonstrate examples of the deficit in medical curriculum around the spiritual
development of the physician and their capacity to help spiritually guide their patients.
To summarize this literature review, these studies collectively highlight burnout,
spirituality and health, physician communication, and religion and spirituality in medical
education. All four subjects are interconnected and can be woven together. The stakeholder
group for this study are medical residents and the literature shows that burnout is an undesirable
outcome for physicians. In order to support physicians so that they avoid burnout, the literature
revealed integrating additional curriculum on communication, religion, spirituality, and self-care
to medical residents training can help restore balance between the science and humanistic sides
of healthcare. The literature also states that this additional curriculum may influence the way
medical residents cope with the challenging emotions of medicine, which could influence
whether or not a medical resident experiences burnout. Additional literature review will be
integrated into the knowledge, motivation, and organization section.
Role of Stakeholder Group of Focus
The stakeholder group for this study are the medical residents, who are physicians who
have completed their four-year medical school education and are now working on their clinical
education to comply with the requirements for full medical board certification. The group of
medical residents for this study are studying Internal Medicine, which is a three-year residency
program. The medical residents that were interviewed and surveyed were randomly chosen, and
therefore could be in any one of the three years of residency. Medical residents work six days a
week and average 10 hours of work per day. The number of hours worked in a day may vary
somewhat, depending on the specific rotation.

MEDICINE AND COMPASSIONATE CARE 28

Clark and Estes’ (2008) KMO Influences Framework
Clark and Estes (2008) provided a framework that offers a systematic and analytic
structure to helps clarify stakeholder and organizational performance goals. This framework
helped identify the relationship between the actual organizational performance and the
organization performance goal. Once the performance goals are identified, stakeholder
knowledge, motivation, and organizational influences to achieve the goal can be explored. Using
the framework provided in Clark and Estes’ (2008) work, Alphabet health can identify the needs
of the medical residents and determine to what degree they have the skills and knowledge to do
their job well (to provide exceptional care to patients) by first providing compassionate care to
themselves, all of which can lead to ultimately increasing their well-being and their productivity.
When education is provided to further enhance the knowledge and skills being used in patient
care, the medical residents benefit both personally and professionally.
Motivation is the guiding force that drives individuals towards attaining their goals
(Mayer, 2011). Clark and Estes (2008) encouraged looking at the motivation factors that
contribute positively or negatively to achievement, motivational needs, issues, and assets,
through three unique lenses that include active choice, persistence, and mental effort. The
desired outcome of increased performance results when motivation, work processes, knowledge,
and skills collectively unite together to achieve the desired goal.
Finally, Clark and Estes (2008) identified organizational influences on stakeholder
performance by examining work processes, resources and workplace culture. The gap analysis
elements that Clark and Estes (2008) developed will be further addressed in terms of physician
knowledge and motivation, as well as the organizational needs required to provide
compassionate care to self and others. The following sections will illustrate the assumed
influences on the medical resident performance goal in the context of knowledge, motivation,
MEDICINE AND COMPASSIONATE CARE 29

and organization influences. Additional literature review will be integrated into the knowledge,
motivation, and organization influences.
Medical Resident KMO Influences
Using a modified version of the Clark and Estes (2008) gap analysis framework, the
following sections examine the knowledge, motivation and organizational factors influencing
how and if medical residents are able to provide compassionate care to self to meet their
performance goal of integrating compassionate care curriculum into the medical education
model. The first section examines the assumed influences related to knowledge and skills that
impact medical resident performance. The second section discusses the assumed motivational
influences that impact medical resident performance. The final section addresses organizational
influences on medical resident goal achievement.
The knowledge, motivation and organizational influences will be explored to identify
how and if medical residents are able to provide compassionate care to themselves. In addition,
identifying the needs of medical residents so they can provide compassionate care to themselves
will be examined in this next section. Identifying ways to implement change so that an increase
in compassionate care can be attained will be addressed as well.
Knowledge and Skills
There is no standard set in medical education that helps medical residents deal with the
emotional impact of patient deaths or how to tell patients difficult news (Eng et al., 2015). In
order to further enhance and support physicians in their care for patients by providing the tools
needed to offer compassionate care for patients, the medical education leadership, in
collaboration with the medical residents, will design and integrate compassionate care
curriculum into the medical education model. The goal of medical residents being able to
provide compassionate care to themselves and others will be realized with this additional
MEDICINE AND COMPASSIONATE CARE 30

curriculum. In addition, medical residents may benefit from supportive and reflective groups
along with current fellow physicians and attending physicians, where they can together further
develop their compassion. In order to attain these goals, there are particular skills and
knowledge that are needed to guide the program development successfully.
Clark and Estes (2008) have provided a framework which can be used to guide Alphabet
Health medical education leadership in identifying the needs of medical residents, the
stakeholders. In addition, the framework can help identify if the medical residents have the skills
and knowledge to provide compassionate care to themselves, which can ultimately provide
exceptional care to patients. When education is provided to further enhance the knowledge and
skills being used in patient care, the physicians will benefit both personally and professionally.
Knowledge influences. According to Krathwohl (2002), there are four knowledge
dimensions: factual, conceptual, procedural, and metacognitive, and each knowledge dimension
builds to a higher level of integration than the previous knowledge dimension. First, factual
knowledge is basic knowledge, which is knowledge that is easily recalled and understood
without much effort. Second, conceptual knowledge involves the interrelationships between
different basic knowledge, allowing more complex understanding of information and the
relationship between them. Third, procedural knowledge involves a deeper understanding of
knowledge that informs how to do something, such as different skills, techniques, or methods.
Finally, metacognitive knowledge requires the most complex thinking and it is a knowledge of
cognition as well as an awareness of, or lack of, one’s own knowledge or cognition (Krathwohl,
2002; Rueda, 2011).
All four types of knowledge dimensions are important to understand what is needed to
enhance a physician’s communication with patients and families, as well as a greater self-
awareness. This study will examine two different knowledge dimensions, including procedural
MEDICINE AND COMPASSIONATE CARE 31

knowledge and metacognitive knowledge. The procedural knowledge that will be discussed is
important because research shows that physicians are aware that they have a deficit in a basic
skill, warranting additional education. The metacognitive knowledge that will be explored will
move physicians into a state of greater self-awareness which will benefit themselves, as well as
their patients and families.
Medical residents need the knowledge of how to be more compassionate care providers.
Caring for oneself and for another is a basic human skill, among healthy adults, which also
translates into a basic skill among physicians. However, there is evidence that medical residents
are aware that they do not adequately possess the procedural and metacognitive knowledge
needed to provide compassionate care to themselves. Eng et al. (2015) have identified that
currently there is no standard way to help support medical residents process the death of their
patients. Data collected from pre- and post- surveys in a qualitative study of debriefings for
oncology medical residents showed that the debriefings helped support medical residents
emotionally deal with the death of their patients better (Eng et al., 2015). In addition, Balboni et
al. (2015) examined the influence of religion and spirituality on a physician’s medical practice
and reported that an increased awareness that a medical resident’s religion and spirituality may
possibly have an influential role on the way medical students cope with the challenging emotions
of medicine. The research of Jagosh et al. (2011) highlights the need for and describes the
benefit of additional education for physicians to increase their awareness of verbal and non-
verbal communication cues.
Medical residents need to know how to self-reflect. Being emotionally mature enough
to care for oneself while caring for others is a sign of emotional integration. This type of
awareness is an example of metacognitive knowledge, where a physician has the ability to reflect
on their own knowledge, skills, and learning processes and then use that awareness to help
MEDICINE AND COMPASSIONATE CARE 32

others. The intent of this study is to examine the degree to which medical residents have the
metacognitive knowledge needed to guide them into a state of greater self-awareness regarding
their capacity to provide compassionate care to selfcare and others, which will benefit
themselves, as well as their patients and families.
Table 2 offers the organizational mission, organizational global goal, stakeholder goal,
and the two knowledge influences discussed in this literature review.
Table 2

Knowledge Influences and Knowledge Types

Knowledge Influence Knowledge Type
Medical residents need the knowledge of how
to be more compassionate caregivers to
themselves, through compassionate care
education.
Procedural
Medical residents need to know how to reflect
on their own personal level of compassionate
care.
Metacognitive

Motivational Influences
Motivation is the guiding force that drives people towards attaining their goals (Mayer,
2011). In addition, it is motivation that helps someone make a learning goal, stay on target to
attain excellence, and finally to stay committed until the goal is attained (Rueda, 2011). It is also
important to examine what motivational influences are contributing to performance problems, so
that new and different skills can be provided to offset these challenges, leading to increased
performance (Rueda, 2011). Clark and Estes (2008) encourage looking at the motivation factors
that contribute positively or negatively to achievement, motivational needs, issues, and assets,
through three unique lenses that include active choice, persistence, and mental effort. The
MEDICINE AND COMPASSIONATE CARE 33

desired outcome of increased performance results when motivation, work processes, knowledge,
and skills collectively unite together to achieve the desired goal.
This study will review literature to examine two different motivational influences: utility
value and self-efficacy. The utility value motivational influence assumes that physicians need to
see the value of how medicine and compassionate care intersect, in order to generate more
compassionate care to self and others in medicine. The self-efficacy motivational influence
assumes that physicians feel confident in their ability to provide compassionate care to self and
others by examining the influence of spirituality on medicine and how it helps physicians cope
better and communicate with greater skill.
Utility value in Expectancy Value Theory. The expectancy value model seeks to
answer two motivational questions: “Can I do the task?” and “Do I want to do the task?” Eccles
(2006) states that if an individual answers “yes” to these two questions, the motivational goals
towards positive outcomes can be attained and will lead to an enhanced personal or professional
life. Eccles (2006) describes four constructs where value can be experienced: 1) intrinsic value,
which relates to a positive experience while conducting a task; 2) attainment value, which aligns
with an individual’s self-identity; 3) utility value, which is determined by how well a task might
meet an immediate or long-range goal; and 4) cost value, which relates to the perceived cost of
the goal. If the perceived expectation of an individual’s contribution towards a desired goal is to
experience increased success, then they will be motivated to exert the time and energy it takes to
attain this success.
Medical resident’s utility value for compassionate care to self. The definition of utility
value from Eccles (2006) is “the value of the task for facilitating one’s long range goals or in
helping one obtain immediate or long-range external rewards” (p. 1). Using this definition in the
context of the stakeholder group of medical residents, the utility value for medical residents is for
MEDICINE AND COMPASSIONATE CARE 34

them to see the value of caring for themselves which will then provide them the ability to care
for others. This can be explored with the medical residents, where they can measure their ability
to recognize the importance of integrating compassionate care training in medical education
curriculum, so that medical residents can provide more compassionate care to themselves and
others.
Self-Efficacy Theory. The research of Eccles (2006) states that an individual’s self-
efficacy adds to the value an individual places on a goal, which then influences the level of
success attained in the desired goal. Pajares (2006) defines self-efficacy theory as the beliefs, or
“the self-perceptions that individuals hold about their capabilities” (p. 1) and states that
“according to social cognitive theory, self-efficacy beliefs provide the foundation for human
motivation, well-being, and personal accomplishment” (p. 1). Developing strong self-efficacy
beliefs can enhance an individual’s well-being and level of accomplishment by influencing the
choices individuals make and the courses of action they pursue. If an individual has the core
belief that they have the capability to accomplish a desired behavior, they will align their
behaviors with these choices so that they will ascertain their desired result (Pajares, 2006).
Medical residents’ self-efficacy for compassionate care to self. In the context of the
stakeholder group of medical residents, if they have a high self-efficacy or a strong sense of
personal competency, they will approach difficult tasks as challenges to be mastered rather than
as threats to be avoided. The medical residents demonstrate self-efficacy when they feel
confident in their ability to provide compassionate care to self. In addition, examining the
influence of spirituality in medicine can help physicians cope better and communicate with
greater skill. This awareness or mindfulness of the medical resident’s capacity to provide
compassionate care to themselves and others can be evaluated through regular verbal
MEDICINE AND COMPASSIONATE CARE 35

conversation that can measure the medical resident’s comfort level in providing compassionate
care and identify the need to implement compassionate care education in residency training.
Table 3 offers the organizational mission, organizational global goal, stakeholder goal,
and the two motivational influences discussed in this literature review.
Table 3
Motivational Influences
Motivational Construct Assumed Motivational Influence
Utility value Medical residents need to see the value of
caring for themselves.
Self-efficacy Medical residents need to feel confident in
their ability to provide compassionate care to
themselves.

Organizational Influences
Schneider, Brief, and Guzzo (1996) stated that in order to ensure the implementation of
change into the culture of the organization, getting to know the culture and “feel” (p. 7) of the
organization is a good place to start. The feel of the organization, which is created by the people,
creates both the climate and the culture of the organization. Gaining employee support at all
levels is imperative in creating change in the organization. The leader is also responsible for
identifying and communicating the current state of the organization and compare it to the vision
of the organization (Senge, 1990).
To ensure positive cultural models and cultural settings in the health care system, Rueda
(2011) suggested asking the following informative questions: How would you describe this
organization? What are the routines and normal gathering and meeting activities that occur here?
What are the spoken and unspoken rules, specifically about policy, procedures, regulations?
What is considered normal employee behavior? What structures are in place, if any, on how
MEDICINE AND COMPASSIONATE CARE 36

decisions are made? Rueda (2011) and Clark and Estes (2008) encouraged reflecting on the
answers to these questions to help discern how the institutional dynamics might be supporting or
hindering the goal. In the case of Alphabet Health, successfully implementing a new
compassionate care curriculum into the medical education by the medical education leadership is
the focus of this study.
Organizational resistance to compassionate care training. The implementation of a
new curriculum is likely to cause resistance. Agocs (1997) defined resistance as a process,
whereby some individuals struggle or refuse to consider the views, concerns, or information
presented by the individuals who are suggesting the implementation of a change in practices,
routines, goals, or norms within the organization. In addition, Schein (2017) contends that pain,
dissatisfaction, or possibly a learning anxiety can result from change, such as doing something
differently, learning something new, or unlearning something.
The mission of Alphabet Health is to provide optimal patient care that strives to heal each
patient by alleviating suffering and improving health with kindness, respect, integrity, and
compassion. In order to enhance the compassionate care skills of the physicians, a new
curriculum will be introduced to help guide medical education by 2020. Two specific factors
may be involved in identifying organizational problems: stretching the scope of medical
education to include compassionate care training and the identification and provision of
resources to design and integrate a compassionate care curriculum. First, in the context of
cultural models, anecdotal information reveals that some senior physicians within Alphabet
Health argue that compassionate care training for medical residents is not within the scope of the
physician. An underlying culture of resistance to add to an already well-established education
model creates challenges. It is important to recognize the need to integrate elements into medical
education training in order to enhance a physician’s compassion towards themselves and
MEDICINE AND COMPASSIONATE CARE 37

patients. One way to enhance how a physician provides compassion towards themselves is to
raise awareness and educate physicians on the more humanistic aspects of medicine, such as an
individual’s spirituality. Foscarelli (2008) argues that a patient’s spirituality is an important part
of them and therefore needs to be addressed between physician and patient. In a study in New
Zealand, Lambie, Egan, Walker, and Macleod (2015) explored how and if spirituality is
understood and taught in medical schools. The outcome of the study was to recognize that
addressing spirituality with patients has a positive impact on health outcomes and warrants
further discussion on how to further educate and support medical students. Finally, Balboni et
al. (2010) explored if spiritual care and a patient’s coping skills enhanced a patient’s quality of
life near the end of life. The results of the study determined that meeting the spiritual needs of
the patient (which requires the recognition that there are spiritual needs that need tending) led to
a better patient quality of life near the end of life. All this support for the implementation of a
compassionate care curriculum into the current medical education model at Alphabet Health
supports appropriate professional development to achieve the stakeholder goal.
Organizational identification of resources to provide compassionate care training.
The second factor that may be involved in recognizing organizational problems is the
identification and provision of resources to design and integrate a compassionate care
curriculum. This challenge is in the context of cultural settings. In spite of evidence that
burnout (which is alleviated by developing better coping strategies) affects many medical
residents (Doolittle, Windish, & Seelig, 2013), it has been difficult to gain administrative support
to provide the necessary resources for additional training and education that can ultimately
provide tools to reduce burnout. Deliberations at two conferences resulted in evidence that
spiritual care is a fundamental component of high-quality compassionate care and is most
effective when it is integrated into both the patients and all health care providers (Puchalski,
MEDICINE AND COMPASSIONATE CARE 38

Vitillo, Hull, & Reller, 2014). Furthermore, although additional research is needed, a qualitative
research study conducted by Mitchell et al. (2016) explored the development of a future medical
school curriculum that focused on the values of religion, spirituality, and wellness practices
within self, care of patients, and the medical team.
Table 4 offers the organizational mission, organizational global goal, stakeholder goal,
and the assumed organizational influences discussed in this literature review.
Table 4
Organizational Influences
Assumed Organizational Influence
Cultural Model:
The field of medicine has a culture of resistance about compassion care training being outside
of the scope of medical education.
Cultural Setting:
Organization needs to provide the support and resources to engage in self-care.

Conceptual Framework: The Interaction of Medical Residents’ KMO Context
Merriam and Tisdell (2016) state the theoretical framework stems from the contextual
orientation of the individual; in this dissertation, the lens used to view the world is by examining
the compassionate care provided by physicians. Maxwell (2013) describes the conceptual
framework as being the actual ideas and beliefs that the researcher holds about the studied
subject. Maxwell (2013) continues to describe a conceptual framework as essentially a concept
or a model of the subject to study and exploring what is going on with the subject and why things
are going on with the subject. Essentially, the conceptual framework is a tentative theory of the
phenomena that is being investigated, which can then inform the study design and help justify
the research.
MEDICINE AND COMPASSIONATE CARE 39

There is no standard set in medical education that helps medical residents deal with the
emotional impact of patient deaths or how to tell patients bad news (Eng et al., 2015). The
medical residents seek to develop the art of caregiving by nurturing humanism, ethics, creativity,
and self-critical reflection in the work of caring for the suffering patient through the new
compassionate care curriculum, which will be implemented by July 2020. Part of the mission of
Alphabet Health is to provide optimal patient care, and in order to do that, physicians need to be
equipped with the proper tools to alleviate the emotional burden physicians experience by
providing a supportive forum to share the daily experiences of caregiving. Optimal patient care
can be provided when compassionate care is first provided to each individual physician.
Qualitative findings of Mitchell et al. (2016) suggested that additions to the medical curriculum
are needed in the areas of wellness, religion and spirituality, and self-care practices. The
recommended knowledge, motivation, and organizational goals are to strengthen the care teams
by creating opportunities to understand and learn from the experiences of colleagues and
mentors.

MEDICINE AND COMPASSIONATE CARE 40

Figure 2. Conceptual framework depicting the interaction of stakeholders’ knowledge,
motivation, and organizational relationships, when implementing compassionate care curriculum
to medical residents.

MEDICINE AND COMPASSIONATE CARE 41

The review of the literature, along with organizational influences, provides data that
supports the stakeholder goal of designing a compassionate care curriculum by the medical
education leadership. The diagram in Figure 2 provides a visualization of how the knowledge
and motivational influences relate to the organizational influences, in the context of medical
residents being able to provide compassionate care to self and others. The knowledge,
motivation, and organization influences are intertwined, supporting and challenging each other.
Specifically, the Organization Influences (O) holds both the Knowledge Influences (K) and
Motivation Influences (M), so that together the KMO can attain the Stakeholder’s goal. The K
and M are part of the O, indicating that all cultural nuances be incorporated into the K and M. It
is only through the collaborative work of the KMO working together that the Stakeholder Goal
can be attained, which is identified in Figure 1 as the arrow pointing from the two intertwined
circles (which represent the KMO), towards the Stakeholder Goal.
In order to implement change in an organization, developing a relationship between
stakeholders is attained through constant communication between the stakeholders (Clark and
Estes, 2008). In addition, open and collaborative communication between disciplines supports
constructive feedback, which enhances knowledge and skills. Schneider et al. (1996) add that
organizational development perspective hinges on the relationships of people and their
organization. In order for medical residents to grow and develop their compassion skills while
expanding their medical training, they will need to feel supported, trusted, and part of a
collaborative environment where feedback and is welcomed and valued. Creating a culture for
medical residents that supports learning in compassionate education training, so that the
organizational performance goal can be attained through additional education, is the purpose of
this study. This project will focus on medical residents, who are seen as key care-providers at
Alphabet Health, an academic medical center. Identifying new knowledge and skills needed to
MEDICINE AND COMPASSIONATE CARE 42

achieve performance goals and coordinating the new skills to foster efficient and effective
educational models that are in line with the mission, vision, and values of the institution builds
trust and respect between colleagues (Clark and Estes, 2008).
Conclusion
Current medical education for resident physicians does not include a curriculum that
helps provide techniques on how to deliver difficult news patients or provide supportive
techniques to deal with the emotional impact of patient deaths (Eng et al., 2015). In order to
further enhance and support physicians in their care for patients by providing the tools needed to
offer compassionate care to patients, both the medical school curriculum and the physician
learners can integrate spirituality and compassion care training into their medical education
models. Integrating these models into the standard medical curriculum will provide a structured
yet practical way to address emotional reactions following emotionally challenging experiences.
This will provide greater support to physician learners by increasing communication with clinical
team members. Chapter 3 will present how data from the key stakeholder group, the medical
residents, will be gathered about their needs to engage in compassionate care of self and patients.

MEDICINE AND COMPASSIONATE CARE 43

Chapter Three: Methods
This chapter describes the qualitative approach used to conduct the study, including the
research design, sampling strategy, data collection, and instrumentation methods. The purpose
of this study was to explore how and if medical residents are able to provide compassionate care
to themselves. If needed, recommendations for compassionate care curriculum will be created as
a result of understanding the medical residents’ current capacity to engage in compassionate care
of themselves. The questions that guided the needs’ analysis that address knowledge and
skills, motivation, and organization resources and solutions for the medical residents were:
1. What is the medical resident physicians’ knowledge and motivation related to
providing compassionate care to self?
2. What is the interaction between organizational culture and context and stakeholder
knowledge and motivation?
3. What are the recommendations in the areas of knowledge, motivation, and
organizational resources for the organization?
Participating Stakeholders
For this study, a stakeholder group was comprised of eight medical residents. Medical
residents are physicians who have completed their four-year medical school education and are
now working on their clinical education to comply with the requirements for full medical board
certification. The eight medical residents chosen for this study are part of the three-year
residency program in Internal Medicine. The medical residents were randomly chosen from each
residency year. Four men and four women were interviewed for a duration of 45-60 minutes.
The class distribution of the eight medical residents interviewed: two were first-year medical
residents, three were second-year medical residents, and three were third-year medical residents.
MEDICINE AND COMPASSIONATE CARE 44

Medical residents were chosen as the stakeholder group because they are still in their
rigorous clinical training and their ability to provide compassionate care to themselves is
required to support longevity in the field of medicine. Medical residents also have a significant
role in the future of medicine and if their own wellness is not addressed while they are still in
their clinical training, the burnout statistics may continue to rise, potentially leaving fewer
physicians to provide care for an increasing population. In addition, seeking to provide an
environment for all health care providers to find meaning and purpose in work and life offers
medical education leadership the opportunity to modify medical education curriculum to support
the well-being of their medical residents. At the conclusion of this study and written
dissertation, medical education leadership will be informed of the outcomes, which identified the
need to implement compassionate care training into medical residency clinical training. The
addition and implementation of this new compassionate care curriculum will provide the medical
residents with tools to better manage their own emotions as they care for their patients. Finally,
a side-effect of more compassionate physicians is that the physicians will be able to provide
more compassionate care to patients. Physicians are often faced with witnessing suffering and
death and struggle with knowing how to care for themselves through the difficult patient
encounters (Dyrbye & Shanafelt, 2016). Providing medical residents with compassionate care
education will help them navigate their own emotions around these painful experiences.
Compassionate care education will also provide resources to more comfortably engage in
conversations about goals of care, where medical residents are tasked to present practical options
that incorporate the patient’s clinical condition and their values. Currently, there is no consistent
opportunity for physicians to reflect upon and learn from these difficult encounters, or to have
their emotional wellbeing addressed, which leads to compassion fatigue. Providing
compassionate care training into medical education curriculum and integrating regular debriefing
MEDICINE AND COMPASSIONATE CARE 45

sessions will provide a safe place to address these concerns. The importance of the medical
residents to achieve the goal of providing compassionate care to self and others will also meet
the organization’s mission statement goals. Attaining the organization’s mission statement goal
of providing optimal patient care will uphold the mission, vision, values, and integrity of the
organization.
Interview Sampling Criteria
The following criteria guided the sampling process.
Criterion 1. Participants are physician learners, specifically medical residents. They are
enrolled in the medical education residency program at Alphabet Health.
Criterion 2. The medical residents were in their first, second, or third year of Internal
Medicine residency at Alphabet Health. The Internal Medicine residency program is a three-year
clinical training educational requirement.
Criterion 3. The solid oncology rotation is one of the required rotations in the Internal
Medicine residency program and was chosen because historically it has been lauded the most
challenging rotation.
Interview Sampling (Recruitment) Strategy and Rationale
In a qualitative study, Fink (2013) advised that a purposeful sample be chosen from the
total sample. There are approximately 50 medical residents per class year for a three-year
residency in Internal Medicine at Alphabet Health. A purposeful sample was chosen from this
population of approximately 150 medical residents, with the expected number of medical
residents to be interviewed being no less than eight, and no more than 10. Eight medical
residents were interviewed for this qualitative study.
The answers recorded from the interviews were collected and evaluated in order to
determine how well medical residents care for themselves and equip themselves to provide
MEDICINE AND COMPASSIONATE CARE 46

optimal patient care. The major method for data collection for this study was the interview
method, which is appropriate for the qualitative research design. The qualitative methodological
approach was used to identify how to integrate compassionate care training into the clinical
training of medical residents. Controlled surveys or observations of medical residents with
patients was not conducted because they do not support the purpose of this study, which requires
the exploration of the emotional depths of medical residents. In addition, one of the goals of the
study was to make meaning from the data collected in the natural setting of the hospital
(Creswell, 2014), which supports the qualitative research design. Due to the nature of the
research, it was accurately anticipated that in spite of the structured interview questions,
additional data was collected during the interview process. The approach to the research was
inductive, implying the theory and the results would generatively reveal themselves (Merriam &
Tisdell, 2016). Although the focus of this research was to determine if and explore how medical
residents can be more emotionally evolved and more emotionally engaged with themselves and
their patients, the researcher remained differentiated and neutral. Face to face interviews were
conducted, allowing the interview format and questions to change as the conversation
progressed. The critical research method was used in this qualitative research examination.
The goal of the research was to discern ways to advocate for medical education
curriculum to assist physicians to be more emotionally attuned and ultimately more
compassionate and more effective care providers to themselves and their patients. The goal of
this critical research was to be able to identify ways to implement change so that a desired
outcome of greater compassion could be attained. The sample size chosen was both deliberate
and purposeful and the data was interpreted and analyzed as it was collected after the narrative
interviews.

MEDICINE AND COMPASSIONATE CARE 47

Qualitative Data Collection
The focus of this research study was on one stakeholder group, rather than a complete
analysis involving all stakeholder groups. The medical residents were the chosen stakeholder
group because physician burnout statistics have been steadily increasing, signifying the need to
inform medical education leadership that modifying the medical education curriculum to support
the well-being of their medical residents will encourage an environment for all health care
providers to find meaning in work and a sense of purpose in life (Perlo & Feeley, 2018).
Through this study, responses from medical residents revealed how well they care for themselves
and how well-equipped they are to provide optimal patient care. The awareness and value to add
compassionate care curriculum to medical resident’s education training was revealed, and the
data collected suggested ways to guide the curriculum changes. The addition and
implementation of this new curriculum will provide the medical residents with tools to better
manage their own emotions as they care for patients.
A qualitative approach was used in this research study, as it allows for the most
supportive data collection for my dissertation focus. Using the three research questions
identified above, I explored medical resident capacity and experiences to date through the lens of
knowledge, motivation and organizational influences, as presented by Merriam & Tisdell
(2016). The goals of my research were identified in order to ensure that my study was worth
doing, and to also justify my study.
Interviews
In this qualitative study, the recruited physician residents were a purposeful sample
chosen from the sum total of medical residents. There are approximately 50 medical residents
per class year for a three-year Internal Medicine residency. A purposeful sample was chosen
from this population of approximately 150 medical residents. In total, the expected number of
MEDICINE AND COMPASSIONATE CARE 48

medical residents that will be interviewed will be no less than eight and no more than 10 and
they will be interviewed individually. Eight interviews were completed, with each interview
lasting 45-60 minutes.
The interviews were semi-structured, which allowed for more organic conversation, as
well as some flexibility in the order and depth of questions (Merriam & Tisdell, 2016). The
interviews took place at or near the hospital, but away from the patient areas. The interview
locations included different patios near the cafeterias on the different Alphabet Health campuses,
two different private offices, and a patient examination room, after clinic hours were completed.
The reason for these location choices was for convenience for both the interviewer and
interviewees, as it reduced travel time from the workplace. The locations were also close enough
to the work environment, so the return to the patient areas after the interviews were quick and
convenient. The chosen areas also allowed for private conversation, to support confidential
interviews.
The timing of interviews was scheduled around the availability of medical residents. A
semi-structured protocol was used during the interview process because although it allowed for
the collection of specific required data, it also allowed issues to be explored, rather than
following a specifically worded series of questions. This format allowed the researcher to
respond to all of the new ideas and views being presented in the interview.
The criteria for the questions asked were formulated questions that provided responses to
help determine how well medical residents care for themselves and equip themselves to provide
optimal patient care. In addition, the goal of the data collection was to reveal the potential need
to add a curriculum component to medical resident’s education. The data suggested ways to
guide the curriculum changes to add compassionate care education.

MEDICINE AND COMPASSIONATE CARE 49

Credibility and Trustworthiness
Merriam and Tisdell (2016) stated that research conducted ethically and with rigor tends
to be treated as trustworthy. In addition, research that can be replicated by method and findings
are more trustworthy. Qualitative researchers often struggle with validity while performing the
type of research that often cannot be directly replicated. I used one data collection method
(interviews) in my research study. In order to ensure credibility, I conducted member checks,
where I solicited feedback on my preliminary findings from several of the people I interviewed.
In addition, I spent adequate time collecting and analyzing the data and purposefully looked for
variation in the understandings of my findings (Merriam & Tisdell, 2016).
My desire to explore this research topic invariably introduced the possibility of bias and
judgment in the data collection process. Merriam and Tisdell (2016) categorize this perspective
as reflexivity. They contend that researchers must understand both how the situation or problem
shapes them as a researcher, as well as how much they as researchers report the problem and
possibly shape the problem. In addition, Maxwell (2013) claims that researcher biases can never
be eliminated in qualitative research, but the implications of those biases can be understood and
mitigated in forming conclusions to the study. My work was to remain objective during the
interviews, data analysis, and final reporting phases of this study, by working closely with a
mentor, who facilitated my objectivity. In addition, I formed a group of two other peers and we
had regular meetings with each other to also help facilitate objectivity.
Merriam and Tisdell (2016) stated that one of the basic assumptions of qualitative
research is that qualitative data is constantly changing and is not a fixed and defined
phenomenon, as it is in quantitative data. Maxwell (2013) also supported that reality cannot be
captured and clearly defined but is something understood relative to its context and
circumstances. Merriam and Tisdell (2016) also stated that because humans are both the primary
MEDICINE AND COMPASSIONATE CARE 50

instrument of data collection and the ones doing the analysis, interpretation of reality is directly
accessed through observation and interviews, with no intermediary instrument to skew
interpretation. The question remained, though, how to define reality, when the data needed to be
interpreted by someone and bias may be interjected into the interpretation of the data, and
therefore the reality of the data.
Medical residents were interviewed, and it was important to verify the authenticity of the
interview information collected (Salkind, 2017). This research study sought to collect data
through a single form of assessment, which had the potential to obstruct the accuracy of the data
collection. For example, data was collected through in-person interviews, which automatically
allowed observations of the medical resident by the researcher to be experienced during the
interview. The observations made during the interviews offered a potential risk under the
study’s objective, but this awareness helped guide the data collection process so that the most
credible results were obtained. This study was voluntary, and there were several medical
residents who chose not to be interviewed, though eight medical residents did choose to
participate in the study.
Ethics
Qualitative research requires the design of a study that will address a problem revealed in
practice. Data was collected through conversations with human subjects and was analyzed, in
order to understand the relevance of the problem. Merriam and Tisdell (2016) argued that the
ethics and integrity of the investigator determine the credibility and trustworthiness of a research
study. During the interview process, it was important that the research ensured that participant’s
privacy was respected, that they suffered no harm, had an opportunity to give informed consent,
and were not deceived. The 12 items identified to engage qualitative research in the “Ethical
Issues Checklist” (p. 264-265) were followed, in order to ensure credibility, trustworthiness, and
MEDICINE AND COMPASSIONATE CARE 51

the protection of the participants. The 12 items of the “Ethical Issues Checklist” included: (a)
explanation of the purpose of the inquiry and the methods used; (b) reciprocity (what was in it
for the interviewee and issues of compensation); (c) promises; (d) risk assessment; (e)
confidentiality; (f) informed consent; (g) data access and ownership; (h) interviewer mental
health; (i) ethical advice from a counselor on ethical matters; (j) data collection boundaries; (k)
ethical and methodical choices; and (l) ethical versus legal (Patton, 2015, p. 496-497).
In order to protect the safety of the participants, the study was submitted to the University
of Southern California Institutional Review Board (IRB) and the IRB of Alphabet Health (a
pseudonym), where the rules and guidelines that were created to protect the rights and welfare of
the participants were adhered. The participants were informed that their participation in the
study was voluntary and that there was no reciprocity of any kind. In addition, the participants
were informed of any risks involved in their participation. All data collected through interviews
and all information gathered are confidential and saved on a password protected computer.
Finally, an Information Sheet was provided that did not require the participants’ signature. As
was recommended by Glesne (2011), the participants were informed that they may choose to
stop participating in the study at any time.
The catalyst for this research study was identified by medical residents seeking me out to
help them provide more compassionate care to themselves and ultimately, to their patients. No
incentives were provided in either direction, by either the medical residents to me for my
guidance, or from me to the medical residents for the purpose of this dissertation. Because no
incentives were provided, no coercion was experienced.
Limitations and Delimitations
This research study aligned with the qualitative research approach and involved the use
of interviews as the primary method of data collection. The study focused on a detailed
MEDICINE AND COMPASSIONATE CARE 52

examination of medical residents’ awareness of compassionate care and their ability to provide
compassionate care to self. Limitations to the study, the potential weaknesses out of my control,
will exist. The limitations of this study include the truthfulness of the participants in my
interviews and the significant time constraints of the medical residents. In addition, the very
nature of the problem of practice was to explore with the medical residents their own self-
awareness on how they engage themselves and others with compassion. I anticipated working
with medical residents who were conscious of their capacity to provide compassion. Through
the interview process, medical residents became more self-aware about their capacity to provide
compassionate care. The study was also limited to the knowledge, motivation and organizational
influences I selected for my conceptual framework.
Delimitation choices I made, such as the questions I asked in the interviews and the total
number of medical residents interviewed, limit the scope of this study. The experiences and
opinions shared in my interviews of the medical residents at Alphabet Health limit my results. I
chose medical residents as my stakeholder group because several medical residents approached
me to help them learn how to better care for themselves, recognizing that when they provided
greater care to themselves, they would be better able to compassionately care for others. The
methods chosen for this study were made with medical resident scheduling and availability in
mind, to accommodate their great time constraints in their educational environment.

MEDICINE AND COMPASSIONATE CARE 53

Chapter Four: Findings
The purpose of this study was to evaluate the medical resident physicians’ needs to
implement a compassionate care curriculum into the existing medical education program so that
the medical residents would have more tools to provide compassionate care to themselves and
through that, compassionate care of their patients. While a complete needs’ analysis would focus
on all stakeholders, for practical purposes, the medical residents were the primary stakeholder
group of focus in this analysis. This evaluation focused on the residents’ knowledge, motivation,
and organizational influences. The analysis generated a list of possible needs related to the goal
of providing compassionate care education to the medical education for medical residents, which
can then be examined systematically to focus on actual or validated needs so that an intentional
and responsive compassionate care curriculum can be implemented into medical education.
The questions that guided the needs’ analysis are the following:
1. What is the medical resident physicians’ knowledge and motivation related to
providing compassionate care to self?
2. What is the interaction between organizational culture and context and medical
resident physicians’ knowledge and motivation?
3. What are the recommendations in the areas of knowledge, motivation, and
organizational resources for the organization?
The medical resident interview protocol used was semi-structured and the interviews
were guided by a list of 12 questions organized by knowledge, motivation, and organization
themes. Flexibility was allowed in the interviews, so responses could be unique to the comments
made by the medical residents, where new ideas and new data could be uncovered through
spontaneous and relevant follow-up questions. The questions asked were constructed from ideas
inspired and formulated from the literature review.
MEDICINE AND COMPASSIONATE CARE 54

Participating Stakeholders
The Internal Medicine residency program has approximately 150 medical residents
enrolled over a three-year program. Thirteen emailed requests for interviews were made, with
eight interviews being conducted. Four residents did not respond to the request and one potential
medical resident expressed interest in being interviewed but was unable to find time in her
schedule. Of the eight interviews conducted, four medical residents identified as male and four
medical residents identified as female. Two medical residents were in their first year of
residency training, three medical residents were in their second year of residency training, and
three medical residents were in their third and final year of residency training. The first-year
medical residents (Participants 3 and 7) had been in the medical residency program for
approximately three months at the time of their interview. The second-year medical residents
(Participants 1, 2, and 6) had been in the medical residency program for approximately one year
and three months at the time of their interviews. The third-year medical residents (Participants 4,
5, and 8) had been in the medical residency program for approximately two years and three
months at the time of their interviews. Table 5 provides information about each participant.

MEDICINE AND COMPASSIONATE CARE 55

Table 5
Information about the Participants
Participant Sex Year
1 F 2
2 M 2
3 F 1
4 F 3
5 M 3
6 M 2
7 M 1
8 F 3

Knowledge Findings
Five interview questions were asked to explore knowledge influences as the foundation
of identifying the needs of the medical residents and determine if they have the skills and
knowledge to provide exceptional care to patients by first providing compassionate care to
themselves. The interview questions “Describe your overall comfort level in talking with
patients,” “Please share with me your coping skills when you are faced with emotionally difficult
patient encounters,” and “How do you heal after working with emotionally challenging
patients/families? Please share how you care for yourself and how often you care for yourself”
were asked to evaluate procedural knowledge influences. The interview questions, “Share how
you deal with your emotional reactions associated with patient care” and “To what degree do you
feel you have adequate coping skills for navigating emotionally difficult conversations with
patients and families?” were asked to evaluate the metacognitive knowledge influence. All eight
medical residents answered these questions.
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Medical residents have already completed a bachelor’s degree and four-years in medical
school and are board-certified physicians who are completing their required clinical education.
Due to the high level of education already completed, factual and conceptual knowledge were
not addressed in this study. Medical residents have already demonstrated their ability to
understand basic knowledge and the interrelations among the basic elements within a larger
structure that enable them to function together.
Deeper Compassionate Care Knowledge Needed
During all eight interviews with medical residents, their initial responses to the questions
focused on how they cared for their patients, rather than articulating the ways they cared for
themselves. All eight medical residents needed to be gently re-directed during the interview so
that they could reflect on the care they provided for themselves. With further exploration
through follow-up questions, all eight medical residents agreed that their medical education
focused on caring for others and did not include education on providing themselves with
compassionate care, though the education provided “well-being” opportunities, such as ice cream
socials or sitting outside for lunch.
Coping skills identified. Experiencing emotionally difficult patient encounters is part of
medical residency. The participants were asked to share their coping skills, when they are faced
with emotionally difficult patient encounters. Participant 1 shared,
As an intern, so many patients died. It never gets easier, but you kind of find ways to
deal with it. Even though the deaths are hard, it is even harder to see a patient suffering
from disease. After a difficult patient encounter, I rely on my fellow residents for support
and talk therapy.
A second-year medical resident, Participant 5, shared details about his painful experience with a
patient and her mother:
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I went in to see a young adult patient who was unable to talk because she was intubated
and sedated, so I addressed the mother, not the patient. The patient’s mother started
yelling at me saying that I was the worst doctor she had ever met. I left the room and that
night reflected on the mother’s anger towards me with my own mom and my girlfriend. I
realized that I had to check my own ego and recognize that this mother was going to have
to bury her very sick daughter soon. I had become her punching bag. The next day I
went in to apologize to the mother and she apologized for how harsh she treated me. It
was a tough situation, but I learned a lot from it, too.
Sometimes patients become emotionally challenging because they have come to appreciate the
care offered in the hospital and fear going home and caring for themselves or with family and
friends. Participant 2, a third-year medical resident offered:
I had to tell a patient and their family that they were going to be discharged. The family
got angry because they weren’t ready to take the patient home and yelled that I was
pushing then out of the hospital too quickly. Now that I’m a third-year, I have learned to
respond by saying that I hear what they’re saying and I’m on their side and I will do
everything I can to help you. That works about 60% of the time. I usually end up
venting with my roommate, who is also a resident.
All of the examples presented showed that although the medical residents are able to provide
compassionate care to themselves after challenging patient encounters, they admitted to wanting
more resources on how better to care for themselves and in increased awareness that “no one
necessarily has all the answers” (Participant 8).
Medical residents use coping skills in self-care practices. Identifying helpful coping
skills allowed medical residents to provide self-care to themselves. All eight medical residents
had more than one example of how their coping skills were formed during their rigorous medical
MEDICINE AND COMPASSIONATE CARE 58

training, which included spending time outside in nature, journaling, talking with colleagues,
friends, and family. For example, the modeling from her parents and an attending physician
during medical school helped Participant 3, a first-year medical resident, begin her clinical
training.
I had an attending who shared that she would always take a deep breath before going into
every room because it forced me to remember that each patient is different, and they need
your full attention and compassion.
Over the course of her three years in residency, Participant 8 shared that:
I’ve realized that it’s okay that I don’t know everything. I feel more prepared for
questions like, ‘What’s it gonna feel like to die?’ or ‘How much time do I have left?’ I
feel more prepared to give people more of a guiding answer.
As the medical residents shared patient stories during the interviews, they recognized the
importance of caring for themselves. All eight medical residents agreed that their ability to
provide compassionate care to themselves could be enhanced. Participant 3 shared, “I am
definitely a big believer in reflection and journaling. Patients have also taught me about
resilience.” She continues to share examples of how the reflective process and journaling have
helped her identify ways to care for herself after emotionally difficult days.
Medical resident self-grounding. Medical residents were asked about how they
recovered from emotionally challenging patient encounters, as a way to determine what guided
the medical residents to ground themselves or restore their souls. None of the eight medical
residents followed a formal religious practice as a type of grounding exercise. Four medical
residents had stepped away from their religious practice and have contemplated going back or
exploring new spiritual or religious practices. The other four medical residents looked to nature
and relationships with others as ways to ground themselves or heal their soul, when they were
MEDICINE AND COMPASSIONATE CARE 59

feeling battered after an emotionally difficult day. Participant 1, a second-year medical resident
shared that when she decided to go into medicine, “I thought it was going to be…I didn’t know
what I was signing up for…..I thought medicine was going be science, pure science, vocational
science It’s fine. It’s like a humanistic scientific experiment.” Participant 4, one of the two
medical residents that has stepped away from her religious practice shared:
It’s funny, I live right by a mosque, a Hindu temple, and a Catholic church. Sometimes I
feel a sense of regret when I walk by, because I see everyone on Sunday and they have a
sense of community and are part of something bigger than them and they have reserved
time for this…I’ve thought about joining one again, but I just haven’t. I consider myself
spiritual, but not religious.
Medical residents indicated that they continuously juggle the stress of emotionally challenging
patients with their own response to the patient’s emotions. Participant 7, an emotionally astute
first-year medical resident stated, “I try to just keep things in perspective. The hardest thing to
keep in perspective is life and death stuff. At the end of the day….generally I’m good at letting
things go.”
Physicians Need More Tools to Regulate Emotions
All eight participants agreed that they are able to care for themselves most of the time,
but certain challenging circumstances (or patient encounters) leave them feeling unable to
properly care for themselves with compassion. The interview results indicated that medical
residents have a basic metacognitive awareness about regulating their emotions. Medical
residents revealed during the interviews two practices that could help better regulate their
emotions.
Reflective practice is useful. The interview results also indicated that all eight medical
residents used reflection as a regular practice during and after their patient encounters. The
MEDICINE AND COMPASSIONATE CARE 60

depth and frequency of reflection exercised by the medical residents depended on the individual.
Participant 7, a first-year medical resident shared:
I feel like I’ve been through enough personally that when I have to deliver painful news, I
pull up a chair and really connect with the patient. And then I leave the room and wish I
had said it differently. I guess it’s just going to take years of practice.
Participant 2, a second-year medical resident, uses his roommate as a helpful companion in his
reflective process, stating it’s about “going home and venting to my roommate, so that it doesn’t
come out at work. No one can suppress that much negative emotion!” A third-year medical
resident, Participant 4, shared, “I remember being yelled at by a family member and going home
that night and reflecting on the encounter with my roommate. I can’t believe that it still hurts
me...” She ended the story with tears in her eyes, obviously moved by the memory. These
examples indicated that although the medical residents can navigate difficult conversations with
patients and families, they continued to wonder if something else could have been said to help
the patient and family. In addition, the medical residents shared they experience limitations in
their ability to respond to patients and families and to care for themselves after the conversation.
Participant 3, a first-year medical resident, shared that when she was faced with delivering
difficult news about a patient’s discharge, she chose to hold a hard line with the patient, “and I
was not an effective communicator with her. My attending had to follow-up with the patient and
used a different communication tactic to help her realize she needed to be discharged.”
Participant 3 struggled with this outcome and was able to recognize that her lack of experience
contributed to her limitations in communicating with the patient.
Medical residents grew their consciousness through reflection. The medical residents
were asked to reflect on how well they feel they navigated emotionally challenging patient
encounters, and what they learned about caring for themselves. All eight medical residents
MEDICINE AND COMPASSIONATE CARE 61

admitted to having a practice of reflection, especially when they had difficult patient encounters.
Participant 6, a second-year medical resident, however, was not able to identify any benefits
from his reflective practice. He apologized for not being able to reflect and answer the question,
stating that he was ready to be on vacation. (He was getting on a plane a few hours after he was
interviewed.) He cited feeling exhausted and mentally drained. Participant 6 was able to share
that for him, reflection typically took place alone, not with his fellow medical residents. He
shared, “I think it’s one of those things where when I leave [the hospital] I try not to think about
it.”
On the contrary, Participant 7, a first-year medical resident shared that when he is faced
with a challenging patient encounter, “I lean into that feeling. It’s just done me well.” All eight
medical residents demonstrated an overall level of confidence in caring for themselves and
others. The very nature of medicine requires physicians to be problem solvers with patients, so
a certain level of confidence that their training will provide answers much of the time is
expected. All eight medical residents viewed the challenges faced with difficult patient
encounters as opportunities to master a new skill, rather than as a threat to avoid.
Developing self-confidence through the reflective process was also a pathway for the
medical residents’ learning how to care for themselves compassionately. Participant 2 shared:
It’s definitely a learning process. At the beginning of the year, it was difficult to connect
with patients and it was especially hard to share bad news with patients. I would have a
lot of anxiety about the questions they would follow-up with, like “How is my life going
to change?” or “What does that mean?” I would end up deferring to my senior resident to
answer the questions.
He described how taking the time to sit with the struggle during reflection built his self-
confidence. He described the act of reflection as a form of self-care that he could engage in
MEDICINE AND COMPASSIONATE CARE 62

throughout the day. Medical residents described other ways they released stress at the end of the
day, such as exercising, taking a bath, and talking to roommates, all as ways to care for
themselves and be grateful. Participant 7, a first-year medical resident offered:
At the end of the day, I always try to shift to gratitude and just say, “I got to get to know
this woman.” I’m doing my dream job and patients just can let you take care of them.
And they trust me. Yeah, that level of trust is just, it’s amazing.
Additional skills and knowledge needed to help regulate emotions. A consistent
theme that emerged from the interviews was the observation from medical residents that they
needed additional education and possibly more time to develop skills and tools to help them be
more aware of emotions. Participant 8, a third-year medical resident, shared, “I think over the
past three years, I have only gotten more comfortable communicating painful news to
patients….and there’s always something more to learn.” Participant 2 offered, “I think we carry
a lot of our patients’ emotions with us and the easiest thing to do is to suppress them and try to
move on to the next patient….later we have to find an outlet.” When the residents were asked a
follow-up question about those outlets, they shared tactics that help during the day, such as
“taking a deep breath before walking through the door of a patients room, and then doing it again
as I leave” (Participant 5), and “while foaming my hand with sanitizer, I take a deep breath and
become mindful that I am entering a new patient’s room” (Participant 3), and “venting with my
roommate when I get home” (Participant 3).
A second-year medical resident, Participant 1, stated, “I have a better understanding of
how to navigate these conversations. Even if I share bad news with somebody, it’s not the end,
it’s actually the beginning.” This suggests the growth that has already happened, and an
awareness that there is room for more growth. Participant 3 shared, “I have more difficulty
getting back, snapping out of it, after a really sad or emotional interaction.” Three of the eight
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medical residents cried during the interview, as they reflected on painful patient experiences.
This observation and their awareness of their emotions revealed that they are not doing the
emotional work to heal themselves from the painful encounters. This information poses the
question, “Or is it that they don’t know how to heal themselves?” The metacognitive knowledge
questions that were explored helped move the medical residents into a state of greater awareness
about their emotional strengths and limitations, which will benefit themselves. Participant 4, a
third-year medical resident, shared:
I think my coping skills could definitely expand a little bit and that’s something I’m
continuing to develop. It takes a lot of investment and time to figure that out. Over time,
I think my coping skills have improved since medical school, and I’ve learned some good
self-care practices, like who I can talk to and spending time outdoors. I think they’ve
developed, but I do think there is room for them to grow further and I haven’t invested
the time into doing that yet.
The interviews revealed that medical residents were able to reflect and observe growth in their
ability to care for themselves during their clinical training. The data also revealed that medical
education leadership has an opportunity to provide curriculum to help better equip medical
residents with the emotional challenges of practicing medicine.
Motivational Influences
The interview process uncovered two general themes about the motivational influences
that guide medical residents towards attaining their goals. The first theme identified was the
high value placed on learning through observation. All eight medical residents articulated that
learning by example was beneficial in medicine, and seeing senior physicians demonstrate self-
care motivated the medical residents to adapt and learn new techniques of self-care. The second
theme realized by all eight medical residents was that although they believed they were good
MEDICINE AND COMPASSIONATE CARE 64

communicators, the interview process affirmed that the medical residents were inspired to
enhance their communication skills. In addition, the interviews revealed that although the
medical residents were able to recognize their emotions, they did not have adequate skills to
process and integrate the emotions.
Medical Residents’ High Value for Compassionate Self-Care
As discussed in Chapter 2, there are four components of expectancy value theory:
attainment, intrinsic, utility, and cost-benefit. These four components determine the overall
value a person places on a task (Eccles, 2006; Rueda, 2011). Utility value is determined by how
well a task might meet an immediate or long-range goal in order to attain an identified
performance expectation (Rueda, 2011). An individual may not place a high utility value on a
task, but will endure it anyway, so as to attain the benefits from completing the task (Clark &
Estes, 2008).
Using this definition in the context of the medical residents, the utility value for medical
residents is to see the value of caring for themselves so they can better care for others. All eight
medical residents agreed that providing compassionate care to patients and families was required
in medicine. The interviews revealed that all eight medical residents believed that they were
providing some level of compassionate care to others and had also cultivated some type of self-
care practices that led to compassionate care towards themselves. There were three themes that
emerged in the interviews. First, the interviews revealed how medical residents integrated
information impacted how they provided compassion. Second, the way medical residents
practiced self-care and how life circumstances provided education to the medical residents
impacted their ability to cope with emotionally challenging circumstances. Finally, the
identification of helpful coping skills allowed medical residents to provide self-care.
MEDICINE AND COMPASSIONATE CARE 65

Medical residents learn value for compassionate self-care from senior physicians.
All eight medical residents felt they have developed effective coping skills during their lifetime
and in their medical training so far and also stated that they could benefit from learning more
ways to cope with difficult emotional situations. The medical residents all shared that observing
senior physicians provide compassion to themselves identified a need to provide compassionate
self-care to themselves. Participant 1, a second-year medical resident shared when she learned
that it was acceptable to be emotional with patients:
I would like to say that I have pretty good coping skills. I had this really great cardiology
professor in medical school who cried with his patients and they loved him for it. He
taught me that it was okay to cry with patients.
Participant 1 shared that by having a senior attending physician demonstrate that tearful and
vulnerable connection with the patient, it helped her appreciate her ability to be emotional, even
in a professional encounter. Through the demonstrated emotional patient-physician encounter,
the medical resident shared that she saw the value in being able to connect with patients and
recognized that the best way to care for others was to first care for self. In addition, seven of the
eight medical residents had stories to share about how modeling from family and attending
physicians helped them develop their compassion and coping skills. Participant 8, a third-year
medical resident shared how a challenging patient event has changed the way she approaches
other patients:
During the incident (patient coded and survived, only to find out that she was DNR), I
didn’t feel like I had anyone to talk to about it. It was really hard to get over it. Usually I
am able to deal with things and talk to people about it, but sometimes things are really
tough and then it’s just hard to process in the moment.
MEDICINE AND COMPASSIONATE CARE 66

Participant 8 shared that when she reflected on that patient encounter and she had such a tough
time working through the emotions, she realized she needed more help in navigating the distress
she experienced and providing self-care to herself. In addition, Participant 3, a first-year medical
resident, shared an example of exemplary teaching by an attending physician. She shared that
during a conversation with a particularly challenging patient, the attending physician:
He crouched down on the ground next to her, and talked in a really soothing, nice voice.
And he didn’t show annoyance at everything she said, which I…it made my chest hurt
just being in the room with her. And the patient’s daughter was….well, they both had
significant personality disorders – it was awful.
Participant 3 was so grateful to see a more mature way to handle difficult patient conversations.
Comments from the eight medical residents that revealed value were limited, identifying an
opportunity for future research, which could probe more deeply into the utility value for
compassionate self-care.
Medical residents’ place high value on learning more about self-care. Medical
residents shared that their own practices of self-care evolved from life experiences and their
willingness to be vulnerable and tenacious. All eight medical residents stated that having a safe
place to share emotionally challenging patient encounters was helpful. Participant 8, a third-year
medical resident offered, “It’s good to realize you’re not alone in that and talk through it and
learn from it. I think that’s why it’s helpful. It helps to not internally brew it out.” Participant 8
continued:
Debriefings need to be about how you’re feeling about things. It’s helpful to me when
someone actually wants to hear what the residents have to say and to provide a safe place
to speak their peace. Ideally, a safe place where you can share equally and learn from
each other and not be told how to feel.
MEDICINE AND COMPASSIONATE CARE 67

The struggle and tenacity of Participant 5, a third-year medical resident, to reflect on and find the
courage to learn and grow from previous patient encounters was exemplified:
I think bringing bad news to patients…I think I'm much more comfortable now than I
was in the beginning of this year. If I already have a connection with the patient, it's very
easy. I hate being put in the situation where I have to give bad news early – I feel pushed
to try to rapidly build rapport and then it feels forced. It makes me uncomfortable,
because I feel like I'm cheating the patient by short-changing getting to know them so
that I can get to the goal of giving them bad news.
Participant 5 went on to explain how challenging it was to balance the need to honor the
development of a relationship with a patient and the demands of the senior physicians. That
night he recognized the value in having some self-care practices in place, by talking with his
mom and his girlfriend. He also recognized that he wished he had other self-care practices in
place to heal and recover from the encounter more quickly and more deeply, because he felt the
burden of this difficult emotional encounter for days.
Participant 1, a second-year medical resident, shared that she tries to take care of herself,
especially on hard rotations. She said the best ways she knows how to provide herself with self-
care is by sleeping.
Getting sleep for starters! I’m not a fan of working for 28 hours straight, which has
become a regular occurrence. I need time at the end of a day to decompress and I don’t
always get to do that. Some days are 12 hours long and when I get home, all I can do is
brush my teeth and go to bed, without dinner. I don’t call that taking care of myself.
Participant 1 continued to share that she would love to work less so she could enjoy playing and
watching more tennis, which is a form of self-care for her.

MEDICINE AND COMPASSIONATE CARE 68

Medical Residents’ Confidence in Providing Self-Care
As discussed in Chapter 2, self-efficacy theory is defined as the individual’s self-
perceptions and beliefs about their own capabilities to attain a desired goal (Pajares, 2006).
Strong self-efficacy beliefs enhance an individual’s well-being and level of accomplishment by
influencing the choices made and the courses of action pursued. The core belief that an
individual has the capability to accomplish a desired behavior aligns their behaviors to ascertain
their desired results (Pajares, 2006). Medical residents with high self-efficacy or a sense of
personal competency approach difficult tasks as challenges to be mastered rather than as threats
to be avoided. Medical residents demonstrate self-efficacy when they feel confident in their
ability to provide compassionate care to self.
Comfort with communication skills. The interview results from all eight participants
indicated that the medical resident’s comfort level in communicating with patients became easier
with practice. For example, Participant 2 shared, “I think as the year has gone on and now that
I’m a second year, I have seen a number of patients…and I know what kind of wording to use.”
Participant 6 differentiated the types of conversations by stating, "in general, I’m comfortable
talking with patients about quitting smoking or weight loss.” One of the third-year medical
residents, Participant 4, shared that as a first-year resident, “I would have been terrified…and run
away from challenging conversations, whereas now, I look forward to them.” These examples
provide evidence that the medical residents are aware of their growth during their medical
residency education program. Participant 8, another third-year medical resident shared that “I
don’t feel like I’m this perfect person, but I feel like I can be empathetic.” One consistent theme
that emerged from the eight participants is the awareness that although each medical resident was
able to reflect and see an improvement in their ability to communicate comfortably with patients,
MEDICINE AND COMPASSIONATE CARE 69

they also articulated that additional training would be beneficial to enhance their communication
skills.
Four participants attributed their comfort with their communication skills to their family
upbringing. Participant 5 shared, “I continue to be closest to my mom, and I think my job in the
family is more of a translator role, between my older sister and younger brother.” One of the
first-year residents, Participant 3, walked through the end-stages of her mother’s illness and
death during medical school. Grieving with her family before and after her mother’s death
helped her, “I would like to think that as a resident, I am using what I learned from being a
grieving family member, to help my patients and their families now.” Participant 7, a first-year
medical resident, shared that his older brother is one of his closest friends and is only a year
older. When he needs to process more emotional issues, his best friend from medical school is
who he reaches out to for support. “I feel like I have people that I talk to about different things,
which helps level the burden on them.” Another recurring theme that came up in the interviews
was that although participants felt their upbringing allowed them to learn good communication
skills, when it came time to share difficult or painful news with a patient and family, they
realized how challenging it was to find the right words to provide difficult news with
compassion. This realization led to their awareness that they needed additional training on how
to be more compassionate care providers.
Emotion-related findings. Exploring deep emotions with the medical residents was not
one of the intended goals of the interviews, but emotions did emerge. The intent of the interview
questions was to delve into the core of the medical residents’ and discover their ability and
competency at providing compassionate care to themselves. All eight medical residents
expressed gratitude in being able to go home and not stay as a patient in the hospital. Moving to
a place of gratitude also strengthened their self-perception of their ability to provide
MEDICINE AND COMPASSIONATE CARE 70

compassionate care to themselves, though the interviews did not adequately reveal an ability to
process and integrate the emotions. Participant 6, a second-year medical resident shared, “When
I have patients that are my age or younger and I see them battling these really tough illnesses, it
gives me appreciation for everything that I have….and at some point, I get to walk out of the
hospital.” He expressed that by appreciating his health, he wanted to support it by taking care of
himself through self-care practices. A second-year medical resident, Participant 1, stated that:
I go home and I give thanks for what I have…and then I try to do something nice for
myself that makes me feel grateful to be alive, to be healthy, to be free. It could be
something as small as getting a slice of pizza. I think that’s what keeps me sane – after a
slice a pizza, I feel good again! All eight of the medical residents shared stories, with
some of them being emotionally devastating, and yet they each demonstrated an
awareness of gratitude, while engaging the sorrow of the day.
A first-year medical resident, Participant 3, shared that:
I have more trouble getting back, snapping out of it, after a really sad or emotional
interaction. For example, I had gotten pretty attached to a patient and family and then she
died. I stayed with the family and grieved with them. And then I was supposed to get up
and go to another patient and I couldn’t.
Participant 3 stated that one of her colleagues encouraged me to “take a deep breath before going
into the next room” so that I could rejuvenate myself a little until I had time to reflect and
process the death later.
Organizational Influences
Five organizational influence themed questions were included in the interview protocol to
evaluate the cultural settings and cultural models at Alphabet Health. The questions included,
“Tell me about your community of support.”, “Is this community of support able to receive you
MEDICINE AND COMPASSIONATE CARE 71

when you’ve had a difficult day?”, “Please share the degree to which you feel emotionally and
professionally supported by your attending physicians and program directors.” and “What
changes, if any, might you suggest to the medical education leadership to help you feel better
equipped to communicate emotionally challenging patient encounters? What changes might you
suggest to the medical education leadership to help you take better care of yourself?” which both
explored cultural settings; “How helpful, if at all, do you believe debriefing sessions (weekly
opportunities to discuss the emotional aspects of medicine) would be for you? Why? Why not?”
which explored cultural models. All eight participants were eager to discuss the perceived
organizational barriers to preparing themselves to be more compassionate.
Cultural Settings and Models
Cultural settings are the social contexts of an organization where organizational policies
and practices influence the routines which organize everyday life (Rueda, 2011) and are the
visible aspects of the organization’s beliefs and opinions (Schein, 2017). In the case of Alphabet
Health, successfully implementing a new compassionate care curriculum into the current medical
education model by the medical education leadership was the focus on this study. Specifically,
this study aimed to identify two specific organizational problems: stretching the scope of medical
education to include compassionate care training and the identification and provision of
resources to design and integrate a compassionate care curriculum.
Cultural models are the invisible values, beliefs and automated attitudes in an
organization (Rueda, 2011). This study aimed to evaluate the cultural model or invisible beliefs
that some senior physicians within Alphabet Health argue that compassionate care training for
medical residents is not within the scope of the physician. In addition, this study aimed to
identify and provide resources in the medical education curriculum to assist medical residents in
providing self-care to themselves. I was curious to learn directly from the medical residents if
MEDICINE AND COMPASSIONATE CARE 72

they felt they were able to provide compassionate care to themselves and others, and specifically
how they were able to provide compassion to themselves and others.
Medical residents request additional compassionate care training. Although all eight
medical residents interviewed agreed that family of origin, experience with patients, and some
outstanding attending physicians helped them develop skills in providing compassionate care,
they also expressed a need and a desire to receive more training. All eight medical residents had
examples to share where the current medical education provided was responsive to their requests.
Participant 5 argued:
So, there are changes we want and changes we need…We're here for three years to learn
how to do a job well, and that means you are going to be working a lot. But I have also
seen a shift in attitudes…some residents think they are owed more, like some of their
wellness is owed to them…and the program has wellness opportunities, but each person
has to take them, not expect to be spoon fed your wellness.
In addition, seven out of the eight medical residents agreed with the sentiment offered by
Participant 4 (a third-year medical resident)that “If an issue or need is brought up to the program,
they do everything they can to make it happen or find ways to make it happen.”
One of the challenges noted in the current program is the size of the program. There are
approximately 50 students per class, totaling 150 students currently in the Internal Medicine
residency program at Alphabet Health. Participant 2 shared:
I think it's very easy to get lost amidst everybody else. It's hard to catch those red flags
that residents are struggling. So, I don't know how we would do better to remediate that.
I know a lot of the chiefs are taking more of a role to meet with residents regularly. I
think just frequent check-ins as a friend, not as a chief or program director, would be
helpful. Even if it's just an email, saying, “Hey, you had a really rough day with all those
MEDICINE AND COMPASSIONATE CARE 73

admissions. Are you holding up okay?” Just to know that someone's looking out for you
makes you feel less alone, especially in a such a large program, scattered over four
hospitals. I think just those check-ins, even if they're just once a month, would help.
The current education model for the medical residents includes utilizing “Chiefs” as additional
support in the program. There are currently eight chief residents. A chief resident is someone
who has already completed their three-year residency in Internal Medicine and is staying a fourth
year to help as a guide for the program leadership. Participant 8, a third-year resident, shared
that chief residents are supposed to be “both a friend and an enforcer. I think it would be helpful
if it was more formalized, where we had one chief that we went to, rather than any of them.”
Although the support offered is appreciated and helpful, all eight medical residents interviewed
felt that more support and more education could be provided.
Need to integrate compassionate care training in medical residency. The third-year
medical residents had more experiences to draw on to make observations and troubleshoot on
how to make the medical residency program better. The first-year medical residents, however,
had observations to offer from the perspective of fresh eyes to the program. Participant 3, a first-
year medical resident was having a particularly difficult time communicating with a patient and
her husband because of their dynamic. Her attending intervened when he saw that I was being
challenged by their dynamic. “He spoke calmly and didn’t allow the patient and her husband to
triangulate. I wasn’t sure what how to navigate that dynamic, but he took control of the
conversation beautifully.” The attending modeled for the first-year medical resident how to
provide compassionate care during difficult situations and she realized she needed to learn more
about how to better navigate these unique relationship dynamics. One of the third-year medical
residents, Participant 4, shared that:
MEDICINE AND COMPASSIONATE CARE 74

Back in medical school we had a doctoring class, which I don't think it really helped that
much because it was a little too basic. As a first-year medical resident, it was the tools
given to us from the lectures our attending gave us that helped build a framework. And
then overtime, it was the practice that we had. Whether it was being observed by an
attending physician or watching an attending do it was the most helpful.
Although participants indicated that some education on how to provide compassionate care was
offered in medical school, it was the hands-on experience of clinical training in medical
residency that helped develop the skills needed to be a compassionate care provider. Participant
4, a third-year medical resident, who will also be a chief resident next year shared:
A fellow third-year resident and I came up with a project to help teach interns how to
have goals of care conversations. We both felt that as first-year residents we felt
completely helpless for some reason and then as a third-year resident, somehow you gain
the comfort and the knowledge. I realized that having a framework in place on how to
have these difficult goals of care conversations really helped me. I would also add that it
would be great if we had a formed alliance where a palliative attending watched every
resident do goals of care conversation – treat it like a competency. I think that would be
a really helpful addition to our program.
Two third-year medical residents took it upon themselves to advocate for change in the current
medical education model for the medical residency, signifying that modifications are needed in
the current education program.
Organizational resistance to compassionate care training. All eight medical residents
interviewed spoke highly of the well-established medical education program at Alphabet Health.
In addition, all eight medical residents shared that they have had some attending physicians who
pushed back, when medical residents suggested change or feedback. This study aimed to
MEDICINE AND COMPASSIONATE CARE 75

recognize the need to integrate compassionate care training into medical education, in order to
enhance a physician’s compassion towards themselves. One way to highlight how a physician
provides compassion towards themselves is to raise awareness and provide education to medical
residents on the more humanistic aspects of medicine, such as an individual’s spirituality.
All eight medical residents interviewed agreed that adding compassionate care
curriculum to medical residency training would be beneficial to their medical education.
Participant 8 shared, “I feel like our residency in general tries to offer strategies to help prevent
burnout, so once in a while we talk about it.” All eight medical residents interviewed felt a layer
of support from the program directors, but also felt that more support could be provided.
Participant 6, a second-year medical resident shared:
I don’t think the reason people are burned out is because we’re not having enough ice
cream socials. I think it’s because of other systemic things like days off that we’re asked
to work and some of the duties that we’re asked to perform and the inflexibility with our
hours and our schedules, things like that.
The medical residents interviewed alluded to a culture of medicine that historically required
medical residents to work more than 80 hours a week. Although the expectation has changed
today, two of the medical residents interviewed expressed remnants of that old education model,
regarding expectations of time. Participant 4, a third-year medical resident stated, “The biggest
factor is time and the amount of time you’re spending at work. So, if you can’t really change
that, then you end up sacrificing other things, like your mental or physical well-being.” Another
second-year medical resident, Participant 6, shared:
I’ve personally never felt that the limitation for me in these cases is how to have the
conversation. And I probably could use help with these, but it’s just that I don’t often
MEDICINE AND COMPASSIONATE CARE 76

have time to. Even in the ICU and stuff, I don’t probably have as many of these goals of
care discussions as I probably should, just because it doesn’t feel like there’s time.
Two medical residents, both second-year residents, voiced concern that the tasks and time
expectations prohibited the ideal environment for learning skills, such as effective goals of care
conversations and providing compassionate care to patients.
One of the interview questions inquired if the medical residents felt supported from their
attending physicians. All eight medical residents agreed that for the most part, they felt
supported by their senior physicians. Many responses were similar to the statement from
Participant 3:
Attendings are variable, it really depends where you are. In the ICU, I did not feel
supported at all. Overall, there have been attendings so far that have been very
supportive, very intuitive, and great leaders. And there are ones that are just do the job
and get the work done.
Although all eight medical residents agreed that the current medical residency education program
provides some excellent guidance and training, they also agreed that there is room for
improvement. Participant 7 offered his gratitude at the role of the chief residents:
I had interacted with a chief right after coming off the ICU, and I was honest about my
experience, and I think this is the way that they can know that people are having a hard
time. I said that I had a really hard time in ICU, and so the chiefs have been great support
to me and have checked in with me. I also appreciate the way the second or third years
check in with the first years.
All eight medical residents had experiences to share about how other members of the residency
program offered support, even if they also had suggestions on how to improve the education
model. The stories told about the support received from fellow residents and chiefs painted a
MEDICINE AND COMPASSIONATE CARE 77

picture of a supportive family or team, working together to support and care for each other.
Having this community is another example of how the medical residents provide care to self.
In an effort to support medical residents process emotions, develop skills in providing
compassionate care to themselves, and explore ways to communicate more compassionately,
debriefing sessions to discuss the emotional aspects of patients were initiated. The debriefing
sessions are an ideal model in medical education, where confidentiality and support are offered
without judgment. Participant 8 shared:
I think talking about challenging situations after they happen is very helpful. I think a lot
of people have similar emotions or feelings after a big conversation or a difficult
experience. I think it’s a good practice to offer space to talk about it, realizing that you're
not alone and we can all learn from it together. I don’t think it’s helpful to try to figure it
out alone. It was helpful to me that someone actually wants to hear what the residents
have to say and provides a safe place to speak honestly, share equally, and learn from
each other and not be told how to feel.
One of the first-year medical residents, Participant 3, shared about the debriefings, "Don't get rid
of them. Please encourage people to go. Say that this is like part of your training. This should
be a mandatory part of the Medical ICU experience." Her medical residency training has always
included debriefings as part of her education and she couldn’t imagine doing the work without
the support.
Summary of General Themes

Knowledge themes. There were two main themes that emerged from the knowledge
influence evaluation in relation to the research questions. The first theme that all eight
participants agreed upon was that as they reflected on their knowledge and skills related to
compassionate self-care, a clear realization emerged that they would benefit from additional
MEDICINE AND COMPASSIONATE CARE 78

compassionate care training. The second theme that was revealed was that the medical residents
need more tools to regulate emotions.
The first theme of needing additional compassionate care training identified two sub-
themes. To begin, the medical residents felt that with each patient encounter, they grew to feel
more comfortable communicating with others. Although all eight medical residents generally
felt they were effective communicators, they all agreed that when they needed to deliver difficult
or painful news with a patient and family, they recognized how challenging it was to find the
right words to provide difficult news with compassion. This realization led to their awareness
that they needed additional training on how to be more compassionate care providers, starting
with their communication skills and their ability to respond to emotions. Secondly, the medical
residents identified coping skills that could aid in their self-care practices. These skills were
learned from life experiences and from observing senior physicians.
The second main theme that emerged was that medical residents need more tools to
regulate emotions. All eight medical residents admitted to having a practice of reflection,
especially when they had difficult patient encounters. The residents all agreed that they gained
self-confidence through their reflective practice, and were also aware that after challenging
patient encounters, properly caring for themselves with compassion was difficult. Three of the
eight medical residents cried during the interviews, signifying that more healing emotional work
on themselves was needed.
The question that was left unanswered and requires additional exploration is whether or
not the medical residents know how to heal themselves, or whether they do not have the time to
properly heal themselves. Based on the analysis of the research, the procedural and
metacognitive knowledge themes identified need to be addressed as they can increase the
MEDICINE AND COMPASSIONATE CARE 79

residents’ awareness of their emotional strengths and limitations. This greater awareness will
benefit the medical residents, as well as patients and their families.
Motivation themes. The eight medical residents interviewed all agreed that
compassionate care is an important concept in medicine. In addition, all eight medical residents
agreed that providing compassionate care to themselves was important. All eight medical
residents also agreed that they believe they are able to provide some level of compassionate care
to themselves. The eight medical residents attributed comfort with communication on life
experiences and practice through patient encounters. The medical residents realized the value of
the communication skills learned during their upbringing. In addition, during the interviews, the
specific quotes pointing to the value and self-efficacy for compassionate care of self were few,
due to the interviewer not specifically probing for them. Themes that emerged indicated that
although the medical residents could articulate that they were able to move to a place of gratitude
at the end of an emotionally challenging day, the interviews did not adequately reveal that the
medical residents had an ability to fully process and integrate the emotions, which could result in
greater awareness of how to better care for themselves.
The required education to become a physician is rigorous and requires great perseverance
in order to successfully complete the mandatory training. The endurance and motivation needed
to complete the education and training was demonstrated during the interviews with all eight
medical residents. Emotions were an unanticipated theme displayed during the interviews by
three medical residents and all eight medical residents admitted to having a practice of reflection.
The medical residents shared that one of the techniques of self-care that helps them get up each
morning is to start the day with statements of gratitude.
Organizational themes. The most prominent organizational theme stated by all eight
medical residents interviewed was that adding compassionate care curriculum to the medical
MEDICINE AND COMPASSIONATE CARE 80

residency program would be beneficial to their training. Although each medical resident
identified different ways they had identified and developed their individual coping strategies,
each medical resident also stated they would be interested in additional support in how to better
care for themselves, knowing that it would also benefit their patients. The interviews also
revealed that the organization is not only willing to receive requests for program changes but is
supportive in implementing them as well. Another presumed organizational theme was that there
would be resistance from the organization to implement changes, as requested by medical
residents. Although all eight of the medical residents shared an experience with an attending
physician that was not supportive of program change, the overwhelming response from medical
education leadership, as reported by the medical residents, was to support change and implement
additional programing and education, as requested by medical residents. The medical residents
shared that the medical education leadership was so supportive, for example, that they are
supporting two third-year medical residents in their venture to create a curriculum to assist first-
year medical residents as they embark on having goals of care conversations.
Another organizational theme that emerged from the medical resident interviews were
suggestions to medical education leadership on how to supplement the current medical education
program. All eight medical residents stated that reflection and verbal processing were helpful in
navigating their emotions through difficult patient encounters, with debriefing sessions being a
safe and helpful way to provide that support. In addition, four of the eight medical residents
specifically named involving palliative care members in their education. A first year-medical
resident suggested that palliative care be added to the first-year orientation, to help educate new
physicians. In addition, a third-year medical resident suggested that the debriefings were helpful
because of the involvement of the palliative care attendings and spiritual care provider. Another
third-year medical resident suggested that palliative care should not remain an elective but
MEDICINE AND COMPASSIONATE CARE 81

should instead be a required rotation in their program. And finally, two different palliative care
attendings were named by third-year residents as being helpful in providing education and
support.

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Chapter Five: Recommendations
Introduction and Overview
Chapter Four communicated the knowledge, motivation, and organizational findings in
relation to a needs’ analysis in the areas of medical residents’ knowledge and skill, motivation,
and organizational resources, all to attain the organizational performance goal. Chapter Five
presents the recommendations for organizational practice in the areas of knowledge, motivation,
and organizational resources related to the achievement of the organizational goal. After
analyzing the data collected during interviews with eight medical residents, the medical residents
all reported that adding compassionate care training to their current medical education program
would be beneficial to their own well-being. The medical residents also stated that they would
appreciate the addition of other forms of self-care education and opportunities as part of their
medical education. The central feature of the implementation plan is to add educational training
elements to the current medical education program, which include regular (weekly) debriefing
sessions. In addition, the recommendations include incorporating mandatory palliative care
education and support in the medical residency program.
Recommendations for Practice to Address KMO Influences
Knowledge Recommendations
The knowledge influences in Table 6 represent the knowledge influences used to measure
the effectiveness of the organization’s goal with qualitative interviews and the literature review.
The knowledge influences used to achieve the goal of medical residents being able to provide
compassionate care to themselves were examined based on the identified procedural and
metacognitive knowledge influences. Clark and Estes’ (2008) conceptual framework and gap
analysis was used for this study. The knowledge influences indicate what information is needed
to accomplish the organization’s goal through procedural and metacognitive knowledge
MEDICINE AND COMPASSIONATE CARE 83

(Krathwohl, 2002; Rueda, 2011). As indicated in Table 6, these influences can achieve the
advisors’ goal and recommendations for the knowledge influences are also provided.

MEDICINE AND COMPASSIONATE CARE 84

Table 6
Summary of Knowledge Influences and Recommendations
Knowledge Influences Principle and Citation Context-Specific
Recommendations
Medical residents need the
knowledge of how to be more
compassionate caregivers to
themselves. (Procedural
Knowledge)
Targeting training and
instruction between the
individual’s independent
performance level and their
level of assisted performance
promotes optimal learning
(Scott & Palincsar, 2006).

Social interaction,
cooperative learning, and
cognitive apprenticeships
(such as reciprocal teaching)
facilitate construction of new
knowledge (Scott &
Palincsar, 2006)
Provide medical residents
with educational forums
(mentors, lectures, reflective
groups) who model, coach
and provide other scaffolding
means of training designed to
help them make sense of and
master ways to be more
compassionate towards
themselves.

Medical residents need to
know how to reflect on their
own personal level of
compassionate engagement.
(Metacognitive Knowledge)
Knowledge of cognition in
general as well as awareness
and knowledge of one’s own
cognition (Krathwohl, 2002;
Rueda, 2011).

Social cognitive theory
suggests that self-regulatory
strategies, including goal
setting, enhance learning and
performance (APA, 2015:
Dembo & Eaton, 2000;
Denler, et al., 2009).
Medical residents will be
provided education and
training that will move
physicians into a state of
greater self-awareness which
will benefit themselves, as
well as their patients and
families. Design and
implement an emotionally
engaging education and
training, which includes
support groups/debriefings
that are facilitated by a
trained facilitator. A hired
facilitator will be trained in
working with small groups
around self-reflection that
leads to greater awareness of
self and others. This will
facilitate greater compassion
towards self and patients and
families.

Increasing knowledge about compassionate care training. The interview data
demonstrated that medical residents need the knowledge of how to provide compassionate care
MEDICINE AND COMPASSIONATE CARE 85

to themselves. In order to increase compassionate care to themselves, compassionate care
training is needed to develop the communication skills of the medical residents. In addition, the
data demonstrated that coping skills were identified and medical residents appreciated using
coping skills in their self-care practices, as well as self-grounding exercises.
Procedural knowledge is necessary in order to increase the knowledge needed to provide
more compassionate care to self. Krathwohl (2002) suggests that procedural knowledge
provides individuals with the ability to decide how to use their skills and how to determine the
appropriate time to implement. Clark and Estes (2008) state that by training individuals with the
“how to” knowledge and providing guided practice and feedback, individuals are better able to
achieve their goals. Therefore, it is recommended that the organization provide training to
medical residents on how to provide compassionate care to themselves. Clark and Estes (2008)
argue that in order for training to be effective, it must be detailed so that students will feel
empowered to know “how to” demonstrate their newly learned behaviors. Finally, feedback
provided to medical residents on how to be better engaged in their new skills of providing greater
compassion to themselves will be beneficial to meet the stated outcomes.
Mayer (2011) states that by practicing learned tasks, individuals will be more equipped to
succeed in the new learned behaviors. Schraw and McCrudden (2006) suggest that in order to
master a new skill, individuals must first acquire the knowledge, practice the skill, and then
appropriately apply the necessary skill. Targeting training and instruction between the
individual’s independent performance level and their level of assisted performance promotes
optimal learning (Scott & Palincsar, 2006). In addition, social interaction, cooperative learning,
and cognitive apprenticeships (such as reciprocal teaching) facilitate construction of new
knowledge. The literature supports the addition of curriculum to the already existing medical
education model that will provide medical residents with different learning environments and
MEDICINE AND COMPASSIONATE CARE 86

opportunities would support their learning, such as additional lectures, support groups, and
interactive learning conversations. Medical residency programs, in partnership with their
individual medical centers, have a shared responsibility to address the well-being of medical
residents as well as evaluating the medical aspects of resident competence (Nasca, 2017). The
recommendation for medical residents is to provide them with educational forums to help them
master ways to be more compassionate towards themselves. All eight medical residents
interviewed support the addition of compassionate care curriculum into the existing education
model.
Physicians reflect on their ability to self-regulate emotions. The interview data
demonstrated that medical residents need to know how to reflect on their own personal level of
compassionate care. In order to increase the medical residents’ awareness of emotions,
metacognitive knowledge requires the most complex thinking. Metacognitive knowledge is both
a knowledge of cognition as well as an awareness of, or lack of, one’s own knowledge or
cognition (Krathwohl, 2002; Rueda, 2011). As individuals increase their metacognitive
awareness, Mayer (2011) states that they become self-regulated learners that increase their
ability to determine what strategies work for them and appropriate timing to use these strategies.
It is important to provide opportunities for learners where they can learn how to engage in guided
self-monitoring and self-assessment (Baker, 2006). Therefore, it is recommended that medical
residents participate in reflection practices in a group setting with other medical residents and a
trained facilitator. All eight medical residents interviewed admitted to wanting additional
opportunities for reflection.
The data collected in the interviews revealed that medical residents agree that their
effectiveness in providing compassionate care to others needs to start with providing
compassionate care to themselves. Baker (2006) suggests that knowledge may be applied more
MEDICINE AND COMPASSIONATE CARE 87

easily from one situation to another when individuals are self-aware. In addition, Baker (2006)
argues that the ability to self-regulate occurs when individuals interact with each other. Mayer
(2011) contends that metacognition is when you are able to self-reflect on how you learn and
understand how to control your learning. Social cognitive theory suggests that self-regulatory
strategies, which include goal setting, can enhance learning and performance (APA, 2015;
Dembo & Eaton, 2000; Denler, et al., 2009). The medical residents agreed that providing
additional education and training to help them move to a state of greater self-awareness will
benefit themselves, as well as their patients and families. Designing and implementing education
and training that provides greater understanding of the medical resident’s personal level of
compassionate care to self will facilitate greater compassion towards self and patients and
families.
Motivation Recommendations
Motivation is the guiding force that drives people towards attaining their goals (Mayer,
2011). In addition, it is motivation that helps someone make a learning goal, stay on target to
attain excellence, and finally to stay committed until the goal is attained (Rueda, 2011). It is also
important to examine what motivational influences are contributing to performance problems, so
that new and different skills and knowledge can be provided to offset these challenges, leading to
increased performance (Rueda, 2011). Clark and Estes (2008) encourage looking at the
motivation factors that contribute positively or negatively to achievement, motivational needs,
issues, and assets, through three unique lenses that include active choice, persistence, and mental
effort. The desired outcome of increased performance results when motivation, work processes,
knowledge, and skills collectively unite together to achieve the desired goal.

MEDICINE AND COMPASSIONATE CARE 88

Table 7
Summary of Motivation Influences and Recommendations
Motivation Influence Principle and Citation Context-Specific
Recommendation
Utility value - Medical
residents need to see the
value of caring for
themselves.
Rationales that include a
discussion of the importance
and utility value of the work
or learning can help learners
develop positive values
(Eccles, 2006; Pintrich, 2003)

Learning and motivation are
enhanced if the learner values
the task (Eccles, 2006)

Model values, enthusiasm
and interest in the task
(Eccles, 2006)

Learning and motivation can
be positively influenced by
higher expectations for
success and perceptions of
confidence (Eccles, 2006)
Remind medical residents of
the purpose of what they are
learning and provide data that
shows the importance of
teaching medical residents
self-care.

Provide medical residents
with credible examples of
successful and effective self-
care practices.

Model enthusiasm and
interest in tasks, while
providing medical residents
with feedback on their self-
care practices.

Self-efficacy - Medical
residents need self-efficacy to
feel confident in their ability
to provide self-care.

High self-efficacy can
positively influence
motivation (Pajares, 2006)

Perceived confidence and
higher expectations for
success can positively
influence learning and
motivation (Eccles, 2006)

Feedback and modeling
increases self-efficacy
(Pajares, 2006)

Learning and motivation are
enhanced when learners have
positive expectancies for
success (Pajares, 2006)
Support medical residents to
select specific goals
that allow them to experience
self-care.

Provide medical residents
with scaffold support for
guided and independent self-
care practice.

Provide medical residents
with confidential and
constructive feedback and
guidance on self-care
practices.

MEDICINE AND COMPASSIONATE CARE 89

Increasing the medical residents’ value for compassionate self-care. The interview
data showed that the medical residents recognized the value of caring for themselves, so they can
better care for others. Although the value of caring for themselves emerged in the interviews,
self-care needs to be continuously reinforced so that the medical residents’ consistently engage
in self-care practices. Eccles (2006) states that learning and motivation are enhanced if the
learner values the task and is enthusiastic and interested in the task. This enthusiasm will
increase the utility value of medical residents caring for themselves. In addition, Eccles (2006)
states that learning and motivation can be positively influenced by higher expectations for
success and perceptions of confidence. Therefore, to improve the motivation of medical
residents, the recommendation is for medical education leadership to increase their expectancy
value by providing medical residents with credible examples of successful and effective self-care
practices and model enthusiasm and interest in tasks, as demonstrated by the attending
physicians, while providing medical residents with feedback on their self-care practices.
Eccles (2006) suggests that an individual’s expectancy values are influenced by the
perception of their utility and the cost involved with participating in the tasks. Furthermore,
rationales that include a discussion of the importance and utility value of the work or learning
can help learners develop positive values (Eccles, 2006; Pintrich, 2003). Clark and Estes (2008)
also state that an individual’s values and beliefs are an important motivational force behind their
accomplishment of task and goals. Bandura (2000) states that self-confidence in the work
environment is not as important as task-specific confidence and suggests that an individual’s
values and beliefs are an important motivational force behind their accomplishment of task and
goals. Therefore, increasing expectancy value in medical residents would improve their
motivation by increasing their understanding of the utility value of their personal contribution to
MEDICINE AND COMPASSIONATE CARE 90

the organization’s vision and values. All eight medical residents interviewed support this
recommendation.
Increasing the medical residents’ self-efficacy to provide self-care. The intended
outcome of the data collection was to show that medical residents need self-efficacy in order to
feel confident in their ability to provide self-care. The results of the data, however, did not show
that medical residents’ need self-efficacy in order to feel confident in their ability to provide self-
care. Instead, the interviews exposed emotions and an awareness that medical residents need to
provide compassionate care to themselves, though the interview data did not adequately reveal
an ability to process and integrate the emotions. Pajares (2006) suggest that that high self-
efficacy can positively influence motivation. He also suggests that learning and motivation are
enhanced when learners have positive expectancies for success (Pajares, 2006). Therefore, to
improve the motivation of medical residents, the recommendation is for medical education
leadership to maximize opportunities for medical residents to initiate practices of self-care that
will strengthen their self-efficacy and the integration of their emotions, so that they can provide
compassionate care to themselves.
Bandura (2000) states that an individual’s self-efficacy determines the tasks chosen, the
effort used, the expected results, and offers an explanation to why they choose to continue or
stop efforts to accomplish goals. Eccles (2006) suggests that an individual’s motivation and
interest are increased when they are provided opportunities to have choice and control over their
daily activities. Rueda (2011) also states that the factors that contribute to an individual’s self-
efficacy are prior knowledge, experience, and feedback. Bandura (2005) argues that individuals
are agents or contributors in their own life circumstances, not just products of their life.
Therefore, increasing self-efficacy in medical residents will increase their motivation to provide
self-care by inspiring personal interest and expectation for success through positive perceptions
MEDICINE AND COMPASSIONATE CARE 91

of self-confidence. The development of self-efficacy in medical residents will be encouraged by
providing designated time for self-care activities that lead to the integration of emotions.
Organization Recommendations
The organizational influences in Table 8 include a summary of the organizational
influences and recommendations. This study has identified two organizational influences
through semi-structured qualitative interviews and supported by the literature review, as being
influential to achieving the organization’s goals of providing compassionate care education to
support medical residents. Clark and Estes (2008) suggest that a lack of effective organizational
resources, policies and procedures, and cultural settings and models may prevent stakeholders
from achieving their performance goals. Rueda (2011) defines cultural settings as the visible
characteristics of the who, what, when, where, why, and how the daily workings function in an
organization, while the cultural models are often invisible and offer a shared mental
representation of the organization’s structures, values, practices, and policies that develop in the
work settings. The cultural settings and cultural models explored in this study represent the
organization’s ability to provide the necessary education and resources to medical residents so
that they can provide themselves with optimal compassionate care.

MEDICINE AND COMPASSIONATE CARE 92

Table 8
Summary of Organizational Influences and Recommendations
Organizational Influence Principle and Citation Context-Specific
Recommendation
Cultural Setting:
Organization needs to provide
support and necessary
resources to engage in self-
care.
Effective change efforts
ensure that everyone has the
resources needed to do their
job, and that if there are
resource shortages, then
resources are aligned with
organizational priorities
(Clark and Estes, 2008).
The organization needs to
provide support and resources
to increase self-care among
medical residents.
The organization leadership
can work with medical
residents to identify the
residents’ priorities of self-
care and provide diverse
opportunities to acquire self-
care practices, such as
educational didactics built
into the residency curriculum
and participation in Schwartz
Center Rounds.
Cultural Model:
The field of medicine has a
culture of resistance about
compassion training being
outside of the scope of
medical education.
Effective change ensures the
group knows why it needs to
change. It then addresses
organizational barriers and
then knowledge and skills
needs (Clark and Estes,
2008).
Medical residents (future
senior physicians and medical
education leadership)
recognize the need for a
change in culture and have
informed medical education
leadership of this need.
Medical education leadership
has the opportunity to provide
what the medical residents
need, changing the culture of
the organization. Once the
medical education leadership
agrees to provide what the
medical residents are asking
for, culture will change.

Provide medical residents with additional compassionate care training. The
interview data revealed that the organization needs to provide support and necessary resources to
engage in self-care, starting with the medical residents. This influence was chosen because of
the impact it has on the organization’s ability to care for all people, beginning with the medical
MEDICINE AND COMPASSIONATE CARE 93

residents, the stakeholders in this study. Cultural settings are represented in the manifestations
created from the collective and valued efforts of a group, such as the policies, processes, plans,
rewards and incentives that drive performance (Rueda, 2011; Gallimore & Goldenberg, 2001).
Clark and Estes (2008) state that effective change efforts ensure that everyone has the resources
needed to do their job, and if there are resource shortages, then resources are aligned with
organizational priorities. The data collected during the interviews with medical residents
revealed that the organization is mostly supportive of the requests made by the medical residents.
The organization leadership can work with medical residents to identify the residents’ priorities
of self-care and provide diverse opportunities to acquire self-care practices, such as educational
didactics built into the residency curriculum, support groups, and participation in Schwartz
Center Rounds. Therefore, inspiring diverse opportunities to provide self-care to medical
residents will ensure self-care among medical residents. It also suggests that by providing self-
care guidance to medical residents, it will in turn allow the medical residents to provide greater
compassionate care to patients, which will increase patient satisfaction scores.
Kyndt, Dochy, Michielsen, and Moeyaert (2009) declare that when employees have a
high organizational commitment, they identify strongly with the organization, value the sense of
membership within it, agree with its objectives and values systems, are likely to remain in it and,
are prepared to work hard on its behalf. In addition, Eckel and Grossman (2005) state that these
values also contribute to a person’s work identity, which is the image they have of themselves
including their values, beliefs, and goals and the perceived similarities with that of their work
environment. Clark and Estes (2008) argue that values are one way people express expectations
about what makes them effective. In addition, Clark and Estes (2008) state that an
organization’s goal should be to increase stakeholder commitment by connecting their values to
the benefits of achieving goals. Ensuring goals and objectives specific to the organization's
MEDICINE AND COMPASSIONATE CARE 94

desire to empower medical residents to exercise self-care, will also fulfill the organization’s
needs to provide exceptional patient care.
Create an organizational culture that is not resistant to compassionate care training.
The interview data intended to support the anecdotal evidence that organizational resistance
existed towards compassionate care training. The data, however, showed that there was little
resistance to adding compassionate care education in the medical residents’ clinical training
curriculum. This influence was chosen because of the significant impact it has on the ability of
the organization to recognize that there is a longstanding resistance to receive compassionate
care training in medical education. Anecdotal evidence shows that the field of medicine has a
culture of resistance about compassion training being outside of the scope of medical education.
Cultural models, which are nestled within a cultural setting, are represented by the more implicit
attitudes and beliefs reflected by a group (Gallimore & Goldenberg, 2001). One of the key
features of effective organizational change that Clark and Estes (2008) recommends is for
organizations to communicate constantly and candidly to those involved about plans and
progress. Through open and candid dialog, the organization creates an atmosphere of trust which
helps stakeholders adjust to unexpected events and occurrences (Clark & Estes, 2008). Clark
and Estes (2008) state that effective change ensures the group knows why it needs to change and
then addresses organizational barriers that identifies the knowledge and skills needs. This
suggest, then, that key leaders and administrators support an environment of trust, while
promoting organizational goals by creating opportunities for stakeholders to communicate ideas,
concerns, and thoughts about organizational initiatives and change efforts.
Govaerts, Kyndt, Dochy, and Baert (2011) state that organizational leadership appreciates
organizational practices that create productive and highly desired work environments that are
filled with strategies that establish employee trust with transparent policies, goals, and processes.
MEDICINE AND COMPASSIONATE CARE 95

A healthier organizational identity is formed by building and establishing trust in the work
environment (Northouse, 2016). In addition, Clark and Estes (2008) argue that when stakeholder
feedback is provided, organizational change efforts are determined as improvements occur. The
data collected during the medical resident interviews identified the need to add compassionate
care curriculum to the medical education program. The data also revealed that the presumed
culture of resistance is not as significant as was predicted. It is recommended that the medical
education leadership and the medical residents together design additions to the current medical
education curriculum, which will in turn change the culture.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
In order to evaluate training programs within work environments, the New World
Kirkpatrick Model was used as a framework to examine the effectiveness of the implemented
programs (Kirkpatrick & Kirkpatrick, 2016). The model outlines four levels, which measure the
value of learning: Level 4 (Results), Level 3 (Behaviors), Level 2 (Learning), and Level 1
(Reaction) (Kirkpatrick & Kirkpatrick, 2016). The levels are examined in reverse order,
beginning with Level 4, to support the Kirkpatrick theme that having a vision for the end result,
will help guide the process and the intent of training (Kirkpatrick & Kirkpatrick, 2016). Level 4
(Results) describes the degree to which targeted program outcomes occur and contribute to the
organization’s highest-level result. Level 3 (Behavior) describes the degree to which participants
apply what they learned during training when they are back on the job. Level 3 also requires
organizational drivers to monitor, reinforce, encourage, and reward learned behaviors
(Kirkpatrick & Kirkpatrick, 2016). Level 2 (Learning) describes the degree to which the
participant has acquired the intended knowledge, skills, attitude, confidence, and commitment
based on their participating in the training. Finally, Level 1 (Reaction) describes the degree to
MEDICINE AND COMPASSIONATE CARE 96

which participants find the training favorable, engaging, and relevant to their jobs (Kirkpatrick &
Kirkpatrick, 2016). The benefits of using the New World Kirkpatrick Model to create the
integrated implementation and evaluation plan for this study is that is provides a framework for
creating an effective training program that validates the value of the plan while ensuring
resources are focused on achieving desired performance and results and encourages change
throughout the entire learning process (Kirkpatrick & Kirkpatrick, 2016).
Organizational Purpose, Need, and Expectations
The mission of Alphabet Health is to deliver leading-edge patient care, research, and
education. In order to further enhance and support physicians in their care for patients by
providing the tools needed to offer compassionate care to patients, the hospital will enhance the
medical education curriculum, in order to integrate compassionate care training into their
medical educational model. The integration of compassionate care training will provide a
structured yet practical way to address emotional reactions following the death of a patient and
other emotionally challenging experiences. The intention of the training is to provide greater
support to future and current physicians and will increase communication with team members,
including non-physician staff. In order for Alphabet Health to deliver leading-edge patient care,
research, and education, the organization, along with medical education leadership, will
collaborate, design, and integrate compassionate care training into the medical education model.
By providing tools and training for medical residents to provide more compassion towards
themselves, they will be equipped to provide more compassionate care to others.
Level 4: Results and Leading Indicators
Kirkpatrick and Kirkpatrick (2016) suggest that leading indicators are used to identify
critical behaviors and measure if they are on track to create a positive impact on the desired
results. The proposed leading indicators for both external and internal outcomes, metrics, and
MEDICINE AND COMPASSIONATE CARE 97

methods are shown in Table 9. The internal outcomes indicate behaviors desired by medical
residents to achieve desired organizational goals. It is expected that through formal and informal
training, mentoring, and organizational support, the internal outcomes will be met. The listed
external outcomes are the desired results expected to be met with the accomplishment of internal
outcomes.

MEDICINE AND COMPASSIONATE CARE 98

Table 9

Outcomes, Metrics, and Methods for External and Internal Outcomes

Outcome Metric(s) Method(s)
External Outcomes
Increased patient
satisfaction scores, in
regards to compassion
provided by physicians.
(For hospital purposes.)
Collect data one month after
patients are discharged from the
hospital. Information gathered
for hospital evaluation.
Surveys administered by an
outside survey organization
(Press-Gainey) to all patients,
30 days after discharge from the
hospital.
Increased patient
satisfaction scores, in
regards to compassion
provided by physicians.
(For national survey
purposes.)
Collect data from national data
collection sources, after patients
are discharged from the hospital.
Information gathered for
national evaluation monthly.
Surveys administered by outside
survey organization for a
national magazine (US News &
World Report), ranking
hospitals in the US. One of the
metrics used in the survey is to
measure patient satisfaction in
regards to the compassion
offered by physicians.
Internal Outcomes
Medical residents will
experience reduced
burnout and increased
physician satisfaction.
100% of medical residents will
report decreased symptoms of
burnout, below the initial rate of
54%.
Inventory compared with
baseline every 6 months.

Medical education
leadership will integrate
compassionate care
curriculum into their
medical education model.

100% of medical residents will
report an increase in support,
and a decrease in burnout
symptoms.

Providing accessible resources
to foster community and
emotional well-being for
physician learners will be
necessary. For example, weekly
support groups or debriefing
sessions in the hospital units
where clinician moral distress is
high (for example, in the solid
oncology unit).
Medical education leadership
will integrate mandatory
curriculum in medical school
and medical residency training
that teaches and supports self-
care and well-being within the
individual, increasing their
compassion towards themselves.
MEDICINE AND COMPASSIONATE CARE 99

Medical residents will
provide more compassion
towards themselves.
100% of medical residents will
report they feel more equipped
to provide compassion towards
self.

The facilitator can help vision
and plan for an emotionally
engaging curriculum and can
facilitate support groups or
debriefings in specific hospital
rotations throughout residency.
Survey results will guide the
facilitator to make changes to
group curriculum, as needed.
Engage in weekly education,
support groups, or debriefings
with a trained facilitator. This
facilitator will be trained in
working with small groups
around self-reflection that leads
to greater awareness and
therefore greater compassion
towards self.
Collect data through surveys at
the end of debriefing sessions.
Medical residents will
provide greater
compassion to others.
100% of medical residents will
feel better equipped to provide
greater compassion to others.

The facilitator can help vision
and plan for an emotionally
engaging curriculum and can
facilitate support groups or
debriefings in specific hospital
rotations throughout residency.
Survey results will guide the
facilitator to make changes to
group curriculum, as needed.
Engage in weekly education,
support groups or debriefings
with a trained facilitator. This
facilitator will be trained in
working with small groups
around self-reflection that leads
to greater awareness and
therefore greater compassion
towards others.
Collect data through surveys at
the end of debriefing sessions.

Level 3: Behavior
Critical behaviors. The stakeholders of focus are medical residents. The first critical
behavior is that they will be present at weekly debriefings while on the solid oncology rotation.
MEDICINE AND COMPASSIONATE CARE 100

The second critical behavior is that the medical residents will engage in periodic compassionate
care curriculum provided through their daily educational seminars. The third critical behavior is
that medical residents will demonstrate compassionate care towards themselves. The final
critical behavior is that medical residents will feel better equipped to handle emotionally difficult
patient encounters. The specific metrics, methods, and timing for each outcome behavior
appears in Table 10.

MEDICINE AND COMPASSIONATE CARE 101

Table 10

Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
(1) Medical residents
will be present at
weekly debriefings
while on the solid
oncology rotation.
100% of medical
residents will
participate in
conversations during
weekly debriefings
while on the solid
oncology rotation.
Confidential surveys
will be electronically
collected from
participants after
debriefing sessions.
Feedback will be
integrated into future
debriefing sessions.
Weekly sessions.
Medical residents
participate in groups
during their two-
week solid oncology
rotation.
(2) Medical residents
will engage in
periodic
compassionate care
curriculum provided
through their daily
educational seminars.
100% of medical
residents will
participate in their
own learning daily
through reflection and
role-play.
Confidential surveys
will be electronically
collected from
participants after
educational sessions.
Feedback will be
integrated into future
educational seminars.
Daily educational
sessions offered to
residents. Monthly
or bi-weekly
compassionate care
educational sessions
provided to medical
residents.
(3) Medical residents
will demonstrate
compassionate care
towards themselves.
100% of medical
residents will provide
details of how they
have increased their
compassionate care
towards themselves.
Confidential surveys
will be electronically
collected from medical
residents, where they
can provide details of
their self-care practices.
Quarterly - four
times a year, or
every three months.
(4) Medical residents
will feel better
equipped to handle
emotionally difficult
patient encounters.
100% of medical
residents will
demonstrate capacity
to stay present and
provide compassion
towards patients and
families who are
emotionally
struggling.
Confidential surveys
will be electronically
collected from medical
residents, where they
can provide details of
the comfort level in
providing
compassionate care to
patients and families.
Quarterly - four
times a year, or
every three months.

Required drivers. Medical residents require support from their attending physicians,
mentors, peers, and the organization to help reinforce, encourage, and monitor the performance
of critical on the job behaviors. Organizational reinforcement drivers are used to remind and
assist individuals about learned behaviors and to provide follow-on training and guidance when
needed. Organizational encouragement drivers can occur in a formal or informal setting and are
MEDICINE AND COMPASSIONATE CARE 102

used to support, empower confidence, and stimulate desired behaviors. Organizational
rewarding drivers occur whenever a reward is merited and might include a verbal accolade
recognition from another clinician or might be experienced as an internal reward to self, after
overcoming a challenging situation. Finally, organizational monitoring drivers incorporate
systems of accountability through monitoring and feedback, which empowers that individuals to
report on training implementation efforts. Table 11 indicates the recommended drivers that
support the critical behaviors required for medical residents.

MEDICINE AND COMPASSIONATE CARE 103

Table 11
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical Behaviors
Supported
1, 2, 3 Etc.
Reinforcing
Provide medical residents with education
on how to provide compassionate care to
themselves.
Ongoing, monthly or more
often, as needed.
1, 2, 3, 4
Provide medical residents communal
opportunities to integrate education into
self-care practices.
Ongoing, weekly. 1, 2, 3, 4
Provide medical residents with individual
resources, as needed, to identify
appropriately healthy self-care practices.
As needed. 1, 2, 3, 4
Encouraging
Attending physicians and other clinicians
will model behaviors, coach and provide
formal and informal training that assist
medical residents in mastering all
information learned.
Ongoing. 1, 2, 3, 4
Attending physicians will provide
medical residents with opportunities to
experience success, and will provide
timely feedback, which will help them
recognize when positive results are of
their own actions.
Ongoing. 1, 2, 3, 4
Rewarding
Attending physicians, peers, other
clinicians, and patients will provide
affirming and positive feedback, as
warranted.
Ongoing. 1, 2, 3, 4
Medical residents will creatively
celebrate positive feedback.
Ongoing. 1, 2, 3, 4
Monitoring
Attending physicians and other clinicians
will provide feedback throughout all
rotations, as well as cumulative feedback
at the end of a rotation, and will provide
guidance on how to optimize training.
Ongoing and bi-weekly. 1, 2, 3, 4
Conduct culture and climate assessments
that provide an opportunity for medical
residents to confidentially share concerns
and propose improvements.
Annually. 1, 2, 3, 4

MEDICINE AND COMPASSIONATE CARE 104

Organizational support. The organization will provide the following support in order to
ensure that the required drivers are implemented in the organization. First, the organization will
provide medical residents with the various educational opportunities that are needed, such as
educational communication didactics on how to discuss goals of care, support groups, and
individual support. Second, medical residents will receive feedback and training throughout
each clinical rotation (both verbally and written) from attending physicians, with the support and
encouragement of the organization. If additional training or other educational resources are
required, the organization will provide these additions as well. Third, the organization will
create a culture that welcomes and models affirming and positive feedback among colleagues,
leaders, and administration. Fourth, the organization will model how to receive and integrate
feedback to optimize training programs. Finally, the organization will empower all physicians
involved (medical residents and attending physicians) in medical education to participate in an
annual survey, to measure the overall culture and climate of the organization, and to validate that
responses are aligned with the goals and objectives of the organization.
Level 2: Learning
Learning goals. Upon participation and completion of the recommended training,
medical residents will acquire the knowledge, skills, attitude, confidence, and commitment to be
able to:
1. Execute and implement knowledge of how to be more compassionate caregivers to
themselves (Procedural knowledge).
2. Reflect on their own personal level of compassionate engagement (Metacognitive
knowledge).
3. Apply and integrate reflective skills learned and shared with facilitator (Metacognitive
knowledge).
MEDICINE AND COMPASSIONATE CARE 105

4. Value the communication and feedback opportunities provided by the group process
between fellow medical residents and the facilitator (Value).
5. Demonstrate and implement skills in self-confidence that can provide compassionate care
to themselves (Confidence).
6. Value open communication with their colleagues (Attitude).
Program. The primary goal for implementing this learning program is to provide
medical residents with the useful and relevant knowledge, skills, and motivation required to
ensure they are equipped to successfully provide compassionate care to themselves. By
accomplishing this learning goal, the organization is expected to benefit by facilitating the
development of medical residents who provide compassionate care to themselves and
additionally, be able to provide compassionate care to their patients. In order to develop
knowledge and skills, medical residents will be provided with educational training opportunities
designed to provide scaffolding learning experiences focused on mastering knowledge and
information learned and developing self-managing motivation skills. This training will occur
during the three years of medical residency training and the practices and awareness gained from
the training will span the duration of their career. First, upon entrance into the residency
program, the organization will provide medical residents information that details and outlines the
mission, vision, and values of the organization and the residency program. Second, medical
residents will be provided a schedule of reflective opportunities, so that they will be able to begin
visioning and acquiring compassionate care skills to be used for their own benefit. Third,
medical residents will be presented with educational opportunities in the form of small groups to
participate in intimate workshops to discuss and share information specific to compassionate
care. Finally, medical residents will be provided additional individual resources, such as one-on-
one communication training with attending physicians and if needed, to further explore ways to
MEDICINE AND COMPASSIONATE CARE 106

provide compassionate care towards themselves or to work through and process any concerns
that are revealed during the reflective process.
Medical residents will also receive training and participate in opportunities specific to
increasing their motivation to positively influences their learning and professional growth
experience. The motivation-specific training will be designed to increase their self-efficacy and
utility values. First, medical residents will be reminded of the purpose of what they are learning
and will be provided data that shows the importance of learning self-care techniques. Medical
residents will also be provided credible examples of successful and effective self-care practices,
which will also be enthusiastically modeled for them, while confidential and constructive
feedback and guidance is offered. In addition, medical residents will be supported to select
specific goals that allow them to experience self-care, while also be provided scaffolding support
to guide their independent self-care practice. Finally, medical residents will be recognized when
self-care practices are attained, to increase their self-efficacy.
Components of learning. To apply what is learned to solve problems and meet
performance goals, medical residents must have the knowledge, skills, and motivation to achieve
their goals. Kirkpatrick and Kirkpatrick (2016) state that the results experienced from learning
programs are because of the intended recipients, in this dissertation, the medical residents. The
evaluation of learning addresses the degree to which medical residents acquire the necessary
knowledge, skills, attitude, confidence, and commitment, based on their participation and
involvement in the training. Table 12 lists the evaluation methods and timing for these learning
components.

MEDICINE AND COMPASSIONATE CARE 107

Table 12
Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Knowledge checks by facilitator and medical
residents during group debriefing sessions.
After the learning event.
Participation in organizational assessments, in
the form of surveys.
After the learning event.
Procedural Skills “I can do it right now.”
Feedback and engagement from facilitator
during group sessions.
During learning event.
Feedback and engagement from peers during
group sessions and with patient encounters.
During and after learning event.
Attitude “I believe this is worthwhile.”
Participation and feedback during group
sessions.
During and after learning event.
Participation and feedback through surveys. After learning event.
Confidence “I think I can do it on the job.”
Feedback from facilitator during group
sessions.
During learning event.
Feedback from peers during group sessions
and with patients.
During and after learning event.
Commitment “I will do it on the job.”
Feedback and engagement with facilitator and
peers.
During and after learning event.
Participation and feedback through surveys. After learning event.

Level 1: Reaction
It is important to determine how the medical residents respond to the learning event. In
order to assess the value of the learning event, Kirkpatrick and Kirkpatrick (2016) suggest
measuring the reactions to training by evaluating the participants engagement, relevance, and
satisfaction. Table 13 lists the reactions of the participants to the learning event.

MEDICINE AND COMPASSIONATE CARE 108

Table 13
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Checklist for facilitator, rating observations of
medical residents during training sessions.
During training event.
Evaluation of training session by medical
residents.
After training event.
Relevance
Pulse check of facilitator, during training
sessions.
During training event.
Evaluation of training session by medical
residents.
After training event.
Medical Resident Satisfaction
Pulse check with facilitator, via satisfaction
survey.
During training event.
Evaluation of training session by medical
residents.
After training event.

Evaluation Tools
Immediately following the program implementation. Following the group debriefing
sessions with medical residents and a trained facilitator, the medical residents will complete a
brief survey (see Appendix D for the survey questions). The survey is designed to provide
feedback to the facilitator, so that adjustments can be made immediately as needed between
debriefing sessions. The feedback will also measure and provide program feedback pertaining to
all dimensions of the medical resident’s Level 1 Reaction to the training, which includes their
engagement, the relevance, and medical resident satisfaction. Level 2 Learning will be used to
track information from the facilitator’s perspective, on how the debriefing sessions are going and
what changes may be beneficial for the medical residents. The facilitator is measuring the level
of engagement that the medical residents are providing during the debriefing sessions and will
provide feedback during the debriefing sessions, rather than in the form of a survey after the
debriefing sessions.
MEDICINE AND COMPASSIONATE CARE 109

The Level 1 Reaction survey, provided to medical residents immediately after the
debriefing session, uses a Likert-type items to respond to various questions related to their
personal reactions to the debriefing sessions. In addition, the Level 1 Reaction survey also
includes one open-ended question for the participant to provide any additional feedback for the
evaluators. The Level 2 Learning opportunity will take place as immediate feedback and
engagement by the facilitator during the debriefing sessions. The focus of the feedback will be
to help guide the medical residents during the debriefing sessions to demonstrate their capacity to
reflect and engage their ability to provide self-care.
Delayed for a period after the program implementation. A few months after the
training program, the medical residents will be requested to participate in a second survey
(Appendix E) that will use a blended evaluation approach to measure the effectiveness of all four
levels of the training program. The Level 1 assessment of this survey will measure the medical
resident’s understanding and thoughts of the debriefing sessions after having had time to observe
and apply training into their work environment. The Level 2 assessment portion of the survey
will assess the medical resident’s knowledge, skills, confidence, attitude, commitment and value
of the debriefing sessions, as it relates to their emotional awareness of how they respond to
patient care. The Level 3 survey questions will assess the medical resident’s observations of
behavior changes related to the debriefing sessions. Finally, Level 4 survey questions will assess
the medical resident’s understanding and observations pertaining to the impact and results that
the training has on their own emotional well-being.
Data Analysis and Reporting
The goal of this training program is to produce Level 4 Results, which would be realized
when medical residents feel that they are appropriately providing self-care to themselves. To
accomplish this, medical residents must have the knowledge, motivation, and organizational
MEDICINE AND COMPASSIONATE CARE 110

support required to facilitate compassionate care towards each medical resident. The New World
Kirkpatrick Model was used to evaluate this program and starts with intended goals and desired
Level 4 Results. The desired results are the key measures used in determining the effectiveness
and overall success of the training program. An annual dashboard report will be provided to the
medical education leadership reflecting measured Level 4 Results, as compared to the desired
goals. In addition, at the completion of two debriefing sessions, each medical resident will
respond to a simple survey to help the facilitator evaluate, measure, and make needed program
adjustments to the desired training results. Similar dashboards will be created to monitor Levels
1, 2, and 3.
Table 14
Dashboard

Dashboard Goal Fall 2019
Totals
Spring 2020
Totals
2019-2020
Annual Totals
Medical residents will
experience reduced burnout
and increased physician
satisfaction.
100% XX XX XX
Medical education leadership
will integrate compassionate
care curriculum into their
medical education model.
100% XX XX XX
Medical residents will
provide more compassion
towards themselves.
100% XX XX XX
Medical residents will
provide greater compassion
to others.
90% XX XX XX

Summary
This study uses the New World Kirkpatrick Model to inform the implementation and
evaluation plan (Kirkpatrick & Kirkpatrick, 2016). The four levels of training and evaluation are
MEDICINE AND COMPASSIONATE CARE 111

used to ensure that medical residents have the knowledge, motivation, and organizational support
to provide compassionate care to themselves. The New World Kirkpatrick Model begins with
the identification of the outcomes, metrics and methods to measure the results of the targeted
outcomes that are integrated with the organization’s goals. The program then evaluates if the
medical residents have established the critical behaviors critical behaviors to assess if they are
using what they have learned once they are back on the job. In addition, learning outcomes are
identified and the participants are evaluated on their learning and knowledge, attitude,
commitment, and confidence during the training. Finally, in order to determine the participant’s
satisfaction, engagement, and the relevance of the training, methods to assess how the
participants are reacting to training were developed. In order to implement change and
maximize the program results, it is important to evaluate and analyze data collection during
program implementation. To maximize the four levels of training evaluation, it is important to
ask the question “Are we meeting expectations? If not, Why?” (Kirkpatrick & Kirkpatrick,
2016).
If the level of reaction and learning does not meet expectations during training, then the
facilitator needs to identify the issue and make changes to the program. If the facilitator does not
learn and react as anticipated, then it is recommended that the facilitator do a pulse check with
the medical residents so that the issues raised can be addressed. If (when) the level of reaction
and learning meet the expectations of the facilitator, a pulse check will be beneficial to discern
what increased engagement (Kirkpatrick & Kirkpatrick, 2016).
In the event that the level of behavior and results after training do not meet the
expectations of the facilitator, then it is important to communicate with the medical residents and
discover what issues, required drivers, and critical behavior (for Level 3) are not being applied.
It is also important to note why the leading indicators and desired results for Level 4 are not
MEDICINE AND COMPASSIONATE CARE 112

successful (Kirkpatrick & Kirkpatrick, 2016). In order to solicit feedback, the facilitator can
send surveys to the medical residents to discern what behaviors would allow them to move
forward to achieve their performance goals. When expectations are being met, medical residents
can be questioned to identify what they are doing to increase their performance and share with
the organization.
Finally, a final report on the training outcomes can be provided to the medical residents
and medical education leadership. Kirkpatrick and Kirkpatrick (2016) argue that organizational
support is an important component of determining success in a training program. In order to
increase performance and results, Kirkpatrick and Kirkpatrick (2016) recommend providing
opportunities to allow change in the implementation process, if needed. Engaging managers in
important evaluation topics, allows them to address if the program offers relevance, credibility,
compelling, and efficiency (Kirkpatrick & Kirkpatrick, 2016).
Strengths and Weaknesses of the Approach
This evaluation study used the Clark and Estes (2008) performance improvement
framework to guide the organization into knowledge, motivation, and organization influences
that directed the data collection and analysis process, which led to the recommendations. In
addition, the interview protocol used in the data collection process organized the questions into
knowledge, motivation, and organization influences. The research-based Clark and Estes (2008)
framework has tested its performance improvement strategies, proving that it is successful and is
cost-effective. Although extensive research and evidence supports the Clark and Estes (2008)
framework, the performance improvement examples Clark and Estes (2008) provide in their
research come from for-profit business settings, which is different than the non-profit medical
center that I used in my research. Finally, the Clark and Estes (2008) framework is mostly a
deductive approach and an inductive approach may have enhanced the study.
MEDICINE AND COMPASSIONATE CARE 113

The most widely used training evaluation model is the New World Kirkpatrick and
Kirkpatrick (2016) model because it addresses the challenge of modifying people’s behavior to
achieve the most desired goals of an organization. Kirkpatrick and Kirkpatrick (2016) designed
the blueprint for training programs with four levels, each with indicators and actionable metrics
to help the organization maximize its results. Within the blueprint, the desired results and
behaviors are identified to best serve the stakeholders so that the goal may be accomplished. The
framework then recommends determining the attitudes, knowledge and skills required to create
the desired behaviors. Finally, a well-executed training program allows the stakeholders to walk
away with new skills and knowledge, while enjoying the educational process. One of the
benefits to the Kirkpatrick and Kirkpatrick (2016) approach is that it seeks feedback from the
learners, so that education can be modified to meet the needs of the participants. In addition, the
environment of the learners is taken into consideration, so as to maximize the desired learning
and results. The model allows for unique work environment and circumstances, such as an
academic medical center.
The capacity of the medical education leadership to develop and implement additional
curriculum to support compassionate care education for medical residents that adhere to the
Clark and Estes (2008) and Kirkpatrick and Kirkpatrick (2016) frameworks needs to be carefully
considered. Thankfully, the medical education leadership seeks feedback from medical residents
at every educational didactic and clinical rotation, so the conversation for requests and
improvements is ongoing and the leadership is receptive. The models provided a helpful
framework to evaluate and report the findings.
Future Research
This study focused on supporting medical residents to be more compassionate care
providers, and future research could expand to include medical students. The needs of medical
MEDICINE AND COMPASSIONATE CARE 114

students would need to be evaluated and the curriculum would need to be modified to collaborate
with the medical school education model. This study was limited to the knowledge, motivation
and organization influences selected for analysis, so that future research could study how best to
support medical students in providing compassionate care.
This study evaluated if and how medical residents were able to provide compassionate
care to themselves. This must be attained before compassionate care can be provided to patients.
Administration has surveys sent out to patients to review and provide feedback to the hospital
about their most recent hospitalization, so that changes can be made, if needed. Employees in
the hospital are asked to provide an “employee engagement” survey annually, to report their
feelings on how the administration and their departments are operating. The employee
engagement survey does not ask if the employee feels they treat themselves compassionately or
treat others compassionately. The irony of this is that the hospital expects each employee to
provide kindness and compassion to each patient and visitor and colleague.
Future research could also take place outside of healthcare. If the goal is to support and
educate individuals to be more compassionate, both to themselves and to others, then other
industries could also benefit from exploring the culture of the work environment. For example,
the employees of a company that focuses on technology could benefit from compassionate care
training, which would result in more compassionate employees and a more compassionate work
environment. Research could look at how productivity is affected when the well-being of
employees and the culture of the work environment are supported and compassion towards self
and others is the norm.
Conclusion
The purpose of this study was to conduct a needs’ analysis in the areas of medical
residents’ knowledge and skill, motivation, and organizational resources necessary to reach the
MEDICINE AND COMPASSIONATE CARE 115

performance goal for Alphabet Health. The interaction between organizational culture and
context and the medical residents’ knowledge and motivation related to the organization goal
was the specific focus of the evaluation. This study was pursued because medical residents
sought my support to help them with their emotional responses to patient encounters. In
addition, a study conducted by Eng et al. (2015) showed that there is no standard set in medical
education that helps medical residents process the emotional impact of patient deaths or offers
guidance on how to deliver difficult news to patients and families. Further analysis generated a
list of possible needs to attain the goal of providing compassionate care curriculum to the
medical residents, with the goal of designing an intentional and responsive compassionate care
curriculum that can be implemented into medical education.
Interviews were conducted with eight medical residents who are currently in their first,
second or third year of their three-year Internal Medicine residency, in order to evaluate the
degree of knowledge, motivation, and organization influences on their ability to provide
compassionate care. All eight medical residents reported that although they feel they are able to
provide compassionate care to self and others, they admit to needing additional training and
education on how to navigate the extremely difficult and painful patient encounters with
compassion.
The unexpected response received from medical residents in this study was the
affirmation that palliative care needs to be intentionally embedded in medical education
curriculum. Palliative care is an approach to patient care that improves the quality of life of
patients and their families, who are facing challenges with an illness, including physical,
psychosocial, and spiritual pain. Like the field of palliative medicine, medical residents were
able to recognize in their clinical training the value of looking at all aspects of the patient, not
just the body. The medical residents expressed a desire to add more training and education to
MEDICINE AND COMPASSIONATE CARE 116

their already full curriculum, in order to learn more about palliative care. Even though the
medical residents have had minimal exposure to palliative care, they recognize that additional
education in palliative medicine would help them emotionally and would ultimately provide
better care for their patients. The irony in the request made by the medical residents is their need
for a better quality of life parallels the purpose of palliative care. Even though the medical
residents have requested more work for themselves through additional training and education in
palliative medicine, they are able to see the benefit of learning how to be more compassionate to
themselves, which translates to providing more compassionate care to their patients. In the end,
everyone wins a better quality of life.

MEDICINE AND COMPASSIONATE CARE 117

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MEDICINE AND COMPASSIONATE CARE 124

APPENDIX A
Interview Protocol
I. Introduction (Appreciation, Purpose, Line of Inquiry, Plan, Confidentiality, Reciprocity,
Consent to Participate, Permission to Record):
Thank you for agreeing to participate in my study. I appreciate the time that you have set aside
to answer my questions. The interview should take about an hour.
Before we get started, I want to provide you with an overview of my study and answer any
questions you might have about participating in this interview. I am currently enrolled as a
doctoral student at USC and I am conducting a study to help understand the needs of medical
residents in caring for themselves so that they feel equipped and prepared to care for others more
compassionately. I am also interested in understanding the interaction between organizational
culture and context with medical resident knowledge and motivation.
I want to assure you that I am here today strictly as a researcher. In other words, the nature of
my questions is not evaluative. I will not be making any judgments on how you are performing
as a medical resident. In addition, your name will not be shared with anyone and the
perspectives you provide may only be shared with my dissertation chair and committee. I will
not share them with other medical residents, attending physicians, medical education leadership,
or administration.
The data I collect for this study will be used within my dissertation and although I may use some
of what you say as direct quotes, none of the data will be directly attributed to you. In addition, I
will use a pseudonym of this organization to protect your confidentiality and will try my best to
de-identify any of the data I gather from you. I am happy to provide you with a copy of the data
section of my dissertation if you are interested.
As stated in the Study Information Sheet I shared with you, I will keep the data in a password
protected computer and all data will be destroyed after three years.
Might you have any questions about the study before we get started? [Pause and answer any
questions posed by participant.]
If you don’t have any (more) questions, I would like to have your permission to begin the
interview. I have brought a recorder with me today so that I can accurately capture what you
share with me. The recording is solely for my purposes to best capture your perspectives and
will not be shared with anyone. May I also have your permission to record our conversation?

II. Setting the Stage (Developing Rapport and Priming the Mind, Demographic items of
interest (e.g. position, role, etc.))
I’d like to start by asking you some background questions about you.
• Could you tell me a little bit about your background in medicine?
o What year resident are you?
o What medical school did you attend?
MEDICINE AND COMPASSIONATE CARE 125

• How or when did you become interested in being a physician?
o Can you provide a specific example that best demonstrates your desire to be a
physician?

III. Heart of the Interview (Questions are directly tied to Research Questions):
I’d like to ask you some questions about your community or support system.
1. Tell me about your community – friends, family, or other individuals who support you.

2. Is this community able to receive you when you have had a difficult day?

Now I’d like to ask you some questions about your comfort level in talking with patients.
3. Describe your overall comfort level in talking with patients about what brought them into
the hospital and under your care.
a. What about when it is bad news?
4. Please share how you deal with your emotional reactions associated with patient care.

5. Please share details about any difficult patient care situations that you may have
experienced (death/goals of care conversations/suffering/difficult families).

I’d like to ask you how you feel about your coping skills.
6. Please share with me what your coping skills are when you are faced with emotionally
difficult patient encounters.
a. Can you provide a specific example, demonstrating your ability to cope with an
emotionally difficult patient encounter?
7. To what degree do you feel you have adequate coping skills for navigating emotionally
difficult /painful conversations with patients and families?

8. How do you heal after working with emotionally challenging patients/families? Please
share how you care for yourself and how often you care for yourself.

9. Please share what you have learned about yourself, after working with difficult patients.

Now, some questions about your training.
10. How helpful, if at all, do you believe debriefing sessions (weekly opportunities to discuss
the emotional aspects of medicine) would be for you?
a. Why?
b. Why not?

11. Please share the degree to which you feel emotionally and professionally supported by
your attending physicians and program directors.
MEDICINE AND COMPASSIONATE CARE 126

12. What changes, if any, might you suggest to the medical education to help you feel better
equipped to communicate emotionally challenging patient encounters?
a. What changes might you suggest to the medical education to help you take better
care of yourself?

IV. Closing Question (Anything else to add)
I am wondering if there is anything that you would add to our conversation today that I might not
have covered?
V. Closing (thank you and follow-up option):
Thank you very much for you sharing your thoughts with me today! I really appreciate your
time and willingness to share. Everything that you have shared will be very helpful for my
study. Again, thank you for participating in my study.

MEDICINE AND COMPASSIONATE CARE 127

APPENDIX B

University of Southern California
Information Sheet for Research

You are invited to participate in a research study conducted by Lori Koutouratsas through the
University of Southern California. Please read through this form and ask any questions you
might have before deciding whether or not you want to participate.

PURPOSE OF THE STUDY
I am conducting a study to help understand the needs of medical residents in caring for
themselves so that they feel equipped and prepared to care for others more compassionately. I
am also interested in understanding the interaction between organizational culture and context
with medical resident knowledge and motivation.

PARTICIPANT INVOLVEMENT
If you agree to take part in this study, you will be asked to participate in one interview, lasting
approximately one hour. Please feel free to answer or not answer any question asked.

POTENTIAL RISKS TO PARTICIPANTS
The nature of my questions are not evaluative. I will not be making any judgments on how you
are performing as a medical resident. In addition, your name will not be shared with anyone and
the perspectives you provide may only be shared with my dissertation chair and committee. I
will not share them with other medical residents, attending physicians, medical education
leadership, or administration.

PAYMENT/COMPENSATION FOR PARTICIPATION
You will receive no compensation for participation in this study.

CONFIDENTIALITY
Any identifiable information obtained in connection with this study will remain confidential. At
the completion of the study, direct identifiers will be destroyed, and the de-identified data may
be used for future research studies. If you do not want your data used in future studies, you
should not participate.
The members of the research team and the University of Southern California’s Human Subjects
Protection Program (HSPP) may access the data. The HSPP reviews and monitors research
studies to protect the rights and welfare of research subjects.

INVESTIGATOR CONTACT INFORMATION
If you have any questions or concerns about the research, please feel free to contact Lori
Koutouratsas at koutoura@usc.edu, and/or 310.999.8939.

IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research participant or the
research in general and are unable to contact the research team, or if you want to talk to someone
independent of the research team, please contact the University Park Institutional Review Board
(UPIRB), 3720 South Flower Street #301, Los Angeles, CA 90089-0702, (213) 821-5272 or
upirb@usc.edu.
MEDICINE AND COMPASSIONATE CARE 128

APPENDIX C

Recruitment Letter
Dear ________,
I hope you are doing well!
I am currently enrolled as a doctoral student at USC and I am conducting a study to help
understand the needs of medical residents in caring for themselves so that they feel equipped and
prepared to care for others more compassionately. I am also interested in understanding the
interaction between organizational culture and context with medical resident knowledge and
motivation.
The reason for my email is to ask you if you’d be willing to spend about an hour with me and
answer some questions about your feelings and thoughts around your level of preparedness about
caring for yourself (and others).
I want to assure you that I am here today strictly as a researcher. In other words, the nature of
my questions is not evaluative. I will not be making any judgments on how you are performing
as a medical resident. In addition, your name will not be shared with anyone and the
perspectives you provide may only be shared with my dissertation chair and committee. I will
not share them with other medical residents, attending physicians, medical education leadership,
or administration.
The data I collect for this study will be used within my dissertation and although I may use some
of what you say as direct quotes, none of the data will be directly attributed to you. In addition, I
will use a pseudonym of this organization to protect your confidentiality and will try my best to
de-identify any of the data I gather from you. I am happy to provide you with a copy of the data
section of my dissertation if you are interested. In addition, I will keep the data in a password
protected computer and all data will be destroyed after three years.
If you have any further questions, please let me know! If you are interested or would prefer to
not be involved, please let me know. I am happy to meet you wherever and whenever it is
convenient for you, hopefully in the next two weeks (schedules permitting!).
Thank you for your consideration,
Lori
Cell: 310.999.8939

Lori Koutouratsas, MDiv, BCC
Palliative Care Chaplain
Alphabet Health Medical Center
koutoura@usc.edu

MEDICINE AND COMPASSIONATE CARE 129

APPENDIX D

Immediately Following Debriefing Session Evaluation

Instructions: You recently participated in two debriefing sessions during your last solid oncology
rotation. This survey is an assessment to determine the value of your experiences applying what
you have learned.

For each of the questions below, circle the response that best characterized how you feel about
the statement as: SD (Strongly Disagree), D (Disagree), N (Neutral), A (Agree), or
SA (Strongly Agree)

1. The debriefing sessions were engaging for me. SD D N A SA
2. The debriefing sessions were applicable to me. SD D N A SA
3. I am confident that I will be able to apply the
information learned.
SD D N A SA
4. I am clear about where to find additional
resources related to the information discussed.
SD D N A SA
5. I would recommend the debriefing sessions to
others.
SD D N A SA
6. I was overall satisfied with the debriefing sessions. SD D N A SA

For the following question, please provide detailed feedback:
1. Please provide any additional comments regarding how these debriefing sessions can
be improved?

MEDICINE AND COMPASSIONATE CARE 130

APPENDIX E
Delayed Debriefing Sessions Evaluation
Instructions: You participated in two debriefing sessions during your last solid oncology
rotation a few months ago. This survey is an assessment to determine the value of your
experiences applying what you have learned.

For each of the questions below, circle the response
that best characterized how you feel about the statement as: SD (Strongly Disagree),
D (Disagree), N (Neutral), A (Agree), or SA (Strongly Agree)

1. I remembered most of what I learned during debriefing
sessions.
SD D N A SA
2. I applied what I learned during the debriefing sessions
and it helped me.
SD D N A SA
3. My job had the necessary resources described in the
training.
SD D N A SA
4. I was provided with adequate support from my
facilitator.
SD D N A SA
5. I find the job aids provided during the debriefing sessions
to be useful.
SD D N A SA

For the following question, please provide detailed feedback:
1. Please provide any additional comments regarding your experiences of applying new self-care
skills learned during the debriefing sessions.

Abstract (if available)

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Asset Metadata

Creator Koutouratsas, Lori Kia (author)

Core Title The integration of medicine and compassionate care: an evaluation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 02/14/2019

Defense Date 01/17/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag compassionate care,emotional integration,Medical education,medical residents,Medicine,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Seli, Helena (committee chair), Crispen, Patrick (committee member), Hirabayashi, Kim (committee member)

Creator Email gracefulrace@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-120123

Unique identifier UC11676912

Identifier etd-Koutourats-7071.pdf (filename),usctheses-c89-120123 (legacy record id)

Legacy Identifier etd-Koutourats-7071.pdf

Dmrecord 120123

Document Type Dissertation

Format application/pdf (imt)

Rights Koutouratsas, Lori Kia

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA