Query: compassion-centric care

title: Tuberculosis control needs a complete and patient centric solution.
abstract: Whether it is mobile phone service or vacation travel, good businesses know that success depends on providing a complete and customer centric solution. Should patients with tuberculosis not be offered a complete solution that is patient centred? After all, millions are affected and a large market at the base ofthe pyramid remains unserved. A complete and patient centric solution will not only include care that meets the International Standards for Tuberculosis Care, but also be delivered with dignity and compassion, grounded in the reality of patients' lives as they navigate the long pathway from symptoms to cure. Such solution based innovation requires a systems thinking approach that must place patients at the centre of design strategies, recognise their clinical and psychosocial needs, and be cost effective. Are tuberculosis patients in high burden countries currently getting such a patient centric solution? Let us consider India, which accounts for quarter of all tuberculosis cases in the world. Whether patients in India seek care in the public or the private sector, they struggle to get a complete solution. Although the Revised National Tuberculosis Control Programme (RNTCP) has done well to reach scale and provide free diagnosis and treatment for patients with drugsensitive disease in the public sector, the programme falls short in making sure that all patients get screened for drug resistance and in ensuring adequate therapy for all patients with multidrug resistant (MDR TB) and extensively drug resistant tuberculosis. Of the estimated 64 000 cases of MDR TB in 2012, only 17 373 cases were diagnosed under the RNTCP. The diagnostic infrastructure in the public sector relies mainly on sputum smear microscopy that cannot detect drug resistance. It is only when patients fail to get better on standard treatment, or have recurrence of tuberculosis, that they get screened for MDR TB, resulting in morbidity, continued transmission, and movement of patients from the public to the private sector. Recognising these problems, the RNTCP is actively scaling up capacity to diagnose and treat MDRTB. If adequately funded and successful, these initiatives should improve patient experience in the public sector. But the stark reality of tuberculosis in India is that 50% of all cases are managed in the private sector, where the quality of tuberculosis care is suboptimal with inaccurate diagnosis, non standard drug prescriptions, and limited effort to ensure treatment adherence. Also, private practitioners often do not screen for drug resistance and empirical antibiotic abuse is rampant. All this means that drug resistance can emerge or worsen, with poor outcomes. Lastly, out of pocket expenditure in the private sector can be catastrophic. Are there examples of initiatives that address the above systemic problems? Operation ASHA is a nongovernmental organisation that extends the RNTCP model, and uses public sector diagnostics and drugs to orchestrate a solution by establishing community based treatment centres and ensuring adherence using local community providers and partners. It also leverages biometrics to increase efficiency and effectiveness. It relies on donors and the public sector for funding. This social enterprise model, however, does not offer a solution to patients who seek care in the private sector. World Health Partners is a donor supported social marketing and social franchising model that delivers affordable reproductive and primary care (including tuberculosis) in underserved rural areas, by leveraging local entrepreneurs and informal providers and by connecting them to the formal For Operation

title: Faith Based Hiv Care and Prevention in Chinese Immigrant Communities: Rhetoric or Reality?
abstract: Ethnic churches attended by first generation Chinese immigrants are uniquely positioned to address emerging HIV prevention and care needs within the Chinese community at large. Efforts to develop faith based HIV programs necessitate identifying how HIV intersects with the sinicization of Christianity within Chinese churches. This article will review the process of contextualizing HIV within theological and cultural frameworks that are meaningful for ethnic Chinese church leaders and members. The authors specifically propose two points of integration between public health and ecclesial functions: (1) HIV stigma mitigation initiatives as informed by Christo centric teachings of compassion and justice, and (2) HIV prevention and care reframed as social responsibility and informed by the Christian tradition of evangelism. Systems and practices that hinder and promote the involvement of Chinese churches in HIV prevention, care, and stigma reduction will be discussed.

title: Understanding physician burnout syndrome: Antithesis of physician well being
abstract: A PersonAl nArrAtive reflection After 10 years of experience abroad in academia, honing two postdoctoral fellowships and research experience, I relocated to India almost a decade ago. Reminiscing upon my epicenter of working experience in India, being in my sixth decade of life, and after being in this profession for about four decades, I have found myself racing along, seeing neurological patients 50 hours a week, and keeping a student centric schedule of teaching, my own writing and research, and balancing a positive work life culture. Looking back at my doctorhood experience during the last decade or so, I do now reminisce upon all the unexpected stresses and conflicts I had to face. I know myself to be an erudite bedside physician, an educator, a mentor, personified as an "exemplary" physician, a recipient of Doctor's Day award, an effective clinician neurologist emboldened with virtues of compassion, altruism, empathy, professionalism, and relation centered care. I would state that I was doing an excellent work of selfless service, teaching in classrooms and the clinical bedside, and passionately pursued all avenues for career and professional development. Over the last few years, my insight increasingly mirrored upon me that I have insidiously been transforming to "new avatar" where my good humor was getting progressively tarnished. Astonishingly and ironically, I experienced a progressive loss of idealism and energy and a "compassion fatigue." In fact, I seemed to be "burning out" but never did realize this as a defined phenomenon or medical diagnosis. All I knew was that I was experiencing a work related "maladaptive phenomenon" characterized by the erosion of my soul full professionalism, cynicism, and a sense of depersonalization (DP) In short, I was not happy, lost my emotional resilience and the experience felt akin to "an erosion of my human soul and work life balance," and a struggle analogous to the Greek mythological character Sisyphus. I attempted to introspect what happened to the passion and enthusiasm I had as a compassionate empathetic physician who had unflinching commitment to quality care and patient satisfaction.

title: Commit to Sit in Radiology.
abstract: At Houston Methodist Hospital, Commit to Sit is a program that encourages radiology professionals to communicate with patients in a way that demonstrates compassion, respect, empathy, and competence in order to foster a trusting relationship. Using active and empathic listening, dialogue is received and understood in the way it was intended, creating a patient centric environment resulting in high quality, safe patient care with improved outcomes. The implicit understanding derived from results and outcomes confirms the fact that patients prefer the radiology staff to sit while communicating with them. This understanding allows the voice of the patient to be heard and should be a consistent practice among all staff.

title: Wanted: Morally Courageous Leaders
abstract: FACHEThe GREATEST risk of silence is that eventually we become morally blind and deaf to difficult issues that arise in healthcare (Bird 1996) The specter of such a risk calls for highly ethical and moral leadership, especially in a system in desperate need of transformation. The choice to take the easy path, instead of the moral one, is unacceptable, whether for clinicians or healthcare executives. As the authors of the feature articles in this issue describe, achieving financial success and high quality care delivery for any organization without a morally centric philosophy is at best a short term and unsustainable approach.THE POWER OF A MORAL COMPASSThe concept of the moral compass in healthcare is based on four guiding points: (1) integrity, (2) responsibility, (3) compassion, and (4) forgiveness. Having the ability to visualize this compass creates a sense of direction toward an inspired vision. Healthcare organizations guided by leaders with a strong moral compass operate within a framework of humility and intellectual curiosity that is grounded in doing the right thing.Morals do not shift or change with time; rather, they are constant. The major difference between morals and ethics is that morals are personal characteristics of individuals and ethics involves a structure that is more applicable to systems and may be dependent on a number of external variables. Recognizing the difference between these two concepts can help executives understand how moral characteristics of individuals play out in the social context of ethical codes and systems.Some readers may easily miss the warning that Ruth W. Brinkley, FACHE, expresses in her article, so it is worth repeating here: Leaders must be ever mindful that their personal moral compass also serves as the moral compass of the companies they lead. This notion is cautionary in that leaders in healthcare, in general, have little formal training in broad ethical principles or in ethics frameworks that can be applied across business, clinical care, quality, safety, and service domains. More often, these leaders receive training only in compliance and business ethics; issues related to bioethics, for example, are absent from their training.Ethics Training and the Moral CompassWe see this trend in the nursing profession. A study by Grady and colleagues (2008) found that just 57 percent of nurses reported having any level of ethics education in their professional programs. Considering that nurse leaders represent the largest portion of all leaders in healthcare, a clear gap exists between the ideal state, in which moral and ethical leaders are able to draw on a knowledge base of ethics training in their practice, and the current state of practice.Jameton's (1984) seminal work frames the concept of moral distress as arising when one knows the morally right thing to do but cannot act on that knowledge because of organizational constraints. According to Jameton, moral issues are defined not by the scientific how to but by the question of ought to. For example, deciding how to provide care is different than deciding for whom the care should be provided.Jameton (1984) further notes that nurses act as the moral center of healthcare and provide the image and inspiration of ethical care and compassion. Corley (2002) found that nurses act as moral agents in the healthcare system, and as a result, patients, nurses, and the organizations in which they work all benefit. These moral acts lay the foundation for increasing nurse retention, promoting patient comfort, relieving patient suffering, and enhancing the reputation of the organization (Edmonson 2010).Can healthcare leaders who act in a morally courageous manner in difficult situations similarly affect these stakeholders? I hope and believe so.IS YOUR ORGANIZATION A HIGHLY RELIABLE MORAL ORGANIZATION?Many hospitals and health systems seek to become high reliability organizations (HROs) in which what should happen does happen, and what should not happen does not.

title: Empathy, compassion and trust balancing artificial intelligence in health care
abstract: Empathy, compassion and trust are fundamental values of a patient centred, relational model of health care. In recent years, the quest for greater efficiency in health care, including economic efficiency, has often resulted in the side lining of these values, making it difficult for health care professionals to incorporate them in practice. Artificial intelligence is increasingly being used in health care. This technology promises greater efficiency and more free time for health care professionals to focus on the human side of care, including fostering trust relationships and engaging with patients with empathy and compassion. This article considers the vision of efficient, empathetic and trustworthy health care put forward by the proponents of artificial intelligence. The paper suggests that artificial intelligence has the potential to fundamentally alter the way in which empathy, compassion and trust are currently regarded and practised in health care. Moving forward, it is important to re evaluate whether and how these values could be incorporated and practised within a health care system where artificial intelligence is increasingly used. Most importantly, there is a need to re examine what kind of health care society ought to promote is needed.  Empathy, compassion and trust are fundamental values of a patient centred, relational model of health care. In recent years, the pursuit of greater efficiency in health care, including economic efficiency, has often resulted in these values being side lined, making it difficult or even impossible for health care professionals to incorporate them in practice. Artificial intelligence is increasingly being used in health care and promises greater efficiency and effectiveness and a level of personalization not possible before. Artificial intelligence could help improve diagnosis and treatment accuracy, streamline workflow processes and speed up the operation of clinics and hospital departments. The hope is that by improving efficiency, time will be freed for health care professionals to focus more fully on the human side of care, which involves fostering trust relationships and engaging with patients with empathy and Publication: Bulletin of the World Health Organization; Type: Policy practice Article ID: BLT.19.237198 Page 2 of 11 compassion. However, the transformative force of artificial intelligence has the potential to disrupt the relationship between health care professionals and patients as it is currently understood, and challenge both the role and nature of empathy, compassion and trust in health care. In a time of increasing use of artificial intelligence in health care, it is important to re evaluate whether and how these values could be incorporated and exercised, but most importantly to re examine what kind of health care society ought to promote. Empathy, compassion and trust Over the past decades, the rise of patient centred care has shifted the culture of clinical medicine away from paternalism, in which the therapeutic relationship, the relationship between the health care professional and the patient, is led by medical expertise, towards a more active engagement of patients in shared medical decision making. This model of engagement requires the health care professional to understand the patient's perspective and guide the patient in making the right decision; a decision which reflects the patient's needs, desires and ideals, and also promotes health related values. The central point of the patientcentred model of doctor patient relationship is that medical competency should not be reduced to technical expertise, but must include relational moral competency, particularly empathy, compassion and trust. Empathy, compassion and trust are broadly recognized as fundamental values of good health care practice. Empathy allows health care professionals to understand and share the patient's feelings and perspective. Compassion is the desire to help that is instigated by the empathetic engagement with the patient. Patients seek out and prefer to engage with health professionals who are competent, but also have the right interpersonal and emotional skills. The belief and confidence in the professional's competency, understanding and desire to help is what underpins patient trust. Research has demonstrated the benefits of trust and empathetic care, including improved patient satisfaction, increased treatment adherence and improved health outcomes. Despite their importance, empathy and compassion in health care are often side lined. In recent years, for example, socioeconomic factors, including an ageing population and austerity policies in Europe that followed the 2008 economic collapse, have led to the marginalization of these values. As health care systems struggle with resourcing, the space for empathy and compassion has shrunk while the need for efficiency has grown. In the United Kingdom of Great Britain and Northern Ireland, high profile cases and reports, such Publication: Bulletin of the World Health Organization; Type: Policy practice Article ID: BLT.19.237198 Page 3 of 11 as the Francis report which followed the Mid Staffordshire scandal, the report by the Health Service Ombudsman entitled Dying without dignity and the Leadership Alliance for the Care of Dying People report, all pointed at lack of empathy as a major problem in clinical care. What these cases also showed was a conflicting relationship between the need for empathy and the pursuit of greater economic efficiency and of meeting operational targets. In 2017, Sir Robert Francis, who chaired the inquiry into the Mid Staffordshire scandal, mentioned in an interview that "at the time at Mid Staffordshire there was huge pressure on organizations to balance their books, to make productivity improvements, and matters of that nature. It all became about figures in the books, rather than outcomes for the patient. And I do believe there's a danger of that happening again." Research in 2017 in accident and emergency departments in England on the effect of austerity policies on the everyday experiences of health care professionals found that the pressure to meet targets negatively affected the doctors' and nurses' ability and opportunity to practise empathetic and holistic care, which led to moral distress and burnout among these professionals. Against this backdrop, artificial intelligence has been heralded as a way to save struggling national health care systems and transform the future of health care by providing greater efficiency, effectiveness and high levels of personalized care. Artificial intelligence in health care Artificial intelligence is broadly defined as "computing technologies that resemble processes associated with human intelligence, such as reasoning, learning and adaptation, sensory understanding, and interaction." The hope is that these technologies will transform healthcare delivery "from streamlining workflow processes to improving the accuracy of diagnosis and personalizing treatment, as well as helping staff work more efficiently and effectively." Artificial intelligence could help health care systems achieve greater efficiency, including economic efficiency, in two ways: (i) by improving time to and accuracy of diagnosis and treatment for patients, and where possible assisting with early prevention; and (ii) by using health care staff more efficiently. A report published in 2018 in the United Kingdom suggested that the national health system could save up to 10% of its running costs by outsourcing repetitive and administrative tasks to artificial intelligence technologies. The same report also envisaged bedside robots performing social care tasks such helping patients to eat, wash and dress, thus reducing the workload on care staff by 30% But it is not only nursing and administrative tasks that Publication: Bulletin of the World Health Organization; Type: Policy practice Article ID: BLT.19.237198 Page 4 of 11 artificial intelligence can help with. With regard to effectiveness, artificial intelligence systems could be used to deliver better clinical services both by assisting with the diagnosis and management of patients, and by providing the diagnosis and prescribing treatments. Research conducted so far has shown that machines can perform as well as, or even better than, humans in detecting skin cancer, heart arrhythmia and Alzheimer disease. Furthermore, human machine partnerships can provide far better results than either humans or machines alone. In these examples, the principal benefits of artificial intelligence stem from its ability to improve efficiency and effectiveness by guiding diagnoses, delivering more accurate results and thus eliminating human error. With regard to greater efficiency through prevention, artificial intelligence technologies that track and analyse the movement of individuals could be used to detect people at risk of stroke and eliminate that risk through early intervention. Health care is already using technology to improve its efficiency and effectiveness. From scalpels and syringes to stethoscopes and X ray machines, the list of technologies used in medicine to facilitate and improve patient care is long. However, artificial intelligence differs from previous medical technological advances. Whereas previous technologies were used to increase the senses and physical capacities of health care professionals consider, for example, how the stethoscope enhanced the hearing of doctors and X rays their vision the main role of artificial intelligence is to increase their reasoning and decision making capacities. In this way, artificial intelligence is entering the health care arena as another morally relevant actor that assists, guides or makes independent decisions regarding the treatment and management of patients. Proponents of artificial intelligence technology in health care maintain that outsourcing tasks and decisions to r

title: A cross sectional pilot study of compassion fatigue, burnout, and compassion satisfaction in pediatric palliative care providers in the United States
abstract: Compassion fatigue (CF) is secondary traumatic distress experienced by providers from contact with patients' suffering. Burnout (BO) is job related distress resulting from uncontrollable workplace factors that manifest in career dissatisfaction. Compassion satisfaction (CS) is emotional fulfillment derived from caring for others. The literature on BO in healthcare providers is extensive, whereas CF and CS have not been comprehensively studied. Because of ongoing exposure to patient and family distress, pediatric palliative care (PPC) providers may be at particular risk for CF. We conducted a cross sectional pilot study of CF, BO, and CS among PPC providers across the United States.  The Compassion Fatigue and Satisfaction Self Test for Helpers and a questionnaire of professional and personal characteristics were distributed electronically and anonymously to PPC physicians and nurses. Logistic and linear regression models for CF, BO, and CS as a function of potential risk factors were constructed.  The survey response rate was 39% primarily consisting of female, Caucasian providers. The prevalence of CF, BO, and CS was 18% 12% and 25% respectively. Distress about a "clinical situation," physical exhaustion, and personal loss were identified as significant determinants of CF. Distress about "coworkers," emotional depletion, social isolation, and "recent involvement in a clinical situation in which life prolonging activities were not introduced" were significant determinants of BO. Physical exhaustion, personal history of trauma, "recent involvement in a clinical situation in which life prolonging activities were not introduced," and not discussing distressing issues were significant predictors of lower CS scores.  CF and BO directly influence the well being and professional performance of PPC providers. To provide effective compassionate care to patients, PPC providers must be attentive to predictors of these phenomena. Further work is needed to explore additional causes of CF, BO, and CS in PPC providers as well as potential interventions.

title: A Cross Sectional Analysis of Compassion Fatigue, Burnout, and Compassion Satisfaction in Pediatric Critical Care Physicians in the United States*
abstract: To determine the prevalence of compassion fatigue, burnout, and compassion satisfaction and identify potential personal and professional predictors of these phenomena in pediatric critical care providers.   Pediatric critical care practices in the United States. Subjects: Pediatric critical care fellows and attending physicians.  None. Measurement and Main Results: A modified Compassion Fatigue and Satisfaction Self Test for Helpers and a questionnaire of personal and professional characteristics were distributed electronically to pediatric critical care physicians nationally. Prevalence of these phenomena was calculated. Hierarchical linear regression models for compassion fatigue, burnout, and compassion satisfaction as a function of potential risk factors were constructed. The survey response rate was 35.7% The prevalence of compassion fatigue, burnout, and compassion satisfaction was 25.7% 23.2% 16.8% respectively. Burnout score, emotional depletion, and distress about a patient and/or the physical work environment were each significant determinants of higher Compassion Fatigue scores. Preparing for didactics, Compassion Fatigue score, distress about administrative issues and/or coworkers, and "self care is not a priority" were each significant determinants of higher burnout scores, whereas female sex, Compassion Satisfaction score, and distress about the physical work environment were each significant determinants of lower burnout scores. Prayer/meditation, talking with colleagues, senior faculty level, and student and/or chaplain involvement when delivering bad news were each significant predictors of higher Compassion Satisfaction scores, whereas female sex, burnout score, emotional depletion, and distress about coworkers were each significant predictors of lower Compassion Satisfaction scores.  In our population, chronic exposure to distress in patients and families puts pediatric critical care physicians at risk for compassion fatigue and low compassion satisfaction. Awareness of compassion fatigue, burnout, and compassion satisfaction and their predictors may benefit providers both personally and professionally by allowing them to proactively manage their distress.

title: Self care behaviours and their relationship with Satisfaction and Compassion Fatigue levels among social workers
abstract: Compassion fatigue is a syndrome resulting from an empathic listening to the client's distress. Social workers, by the relational nature of their task, can be at risk and may suffer from adverse health effects. This quantitative research (N 270) aimed to assess the efficiency of social workers' self care practices. The conclusion is that personal and professional self care practices reduce compassion fatigue levels as well as increase satisfaction levels. Promoting self care practices will bring benefits for the professional and, therefore, in the client and the institution.

title: Competence and Compassion: Key Elements of Professional Care at the End of Life From Caregiver's Perspective
abstract: In the act of caring for and helping people in the end of life process, the professional who provides care and assistance must know how to maintain a relationship of closeness, empathy, and compassion for the pain and suffering of the person who is going to die. The objective was to understand, elaborate on, and characterize the key elements of end of life care of patients from a caregiver's perspective through a qualitative phenomenological multicenter study. Participants were caregivers who had lost a family member at least 2 months but less than 2 years in the past. The techniques used were 5 discussion groups and 41 in depth interviews, which included a total of 81 participants. To analyze the information, a protocol developed by Giorgi was followed. Two dimensions or units of meaning, with subdimensions, emerged: (1) Technical competence, with the subdimensions "Control of symptoms" and "Continuity of care," and (2) Compassion, with the subdimensions "Effective/affective communication," "Attitudes of kindness and closeness toward the patient and the family," and "Generosity and personalized flexibility of care." Assistance at the end of life requires the proper preparation of professionals who care for these patients, in addition to a compassionate attitude on the part of professionals and the people accompanying the dying person, that fosters a more humanized and dignified treatment in the dying process.