Compassion constitutes the foundation of the health care experience. Compassion is conceptualized in a manner similar to yet distinct from empathy and sympathy and is defined as both an emotional and behavioral response to suffering. 1,2 The concept of compassion is also considered a core ingredient in educational standards for several health professions, including nursing and medicine. 3,4 Despite research that compassionate care is associated with decreased risk of error, decreased burnout, and improved well-being, as well as lower health care costs, compassion appears to erode over the course of a health professional’s career. 5–8 Health professionals often practice with a restricted focus on biomedical inquiry, neglecting opportunities for compassion with patients and their caregivers. 9
There are several interventions designed to improve compassion through education. 10–12 Although many such interventions are focused on empathy rather than compassion, educational interventions include role modeling, reflection, experiential learning, and development of enhanced communication and interpersonal skills. 10 A recent review found education that enhances key behaviors, such as sitting during interviews, improves the detection of nonverbal emotional cues, boosts both verbal and nonverbal communication skills, and is effective at improving patient perceptions of compassion. 13 Compassion education varies along the continuum of medical education; however, most interventions include skill development along with some form of reflection and behavioral change. 13 Although the distinction between educational activities for health professionals that are designed to facilitate compassion rather than empathy alone is underexplored, existing literature suggests that compassion education may be similar to and yet distinct from empathy education. For example, an intervention that is designed to focus on compassion must include educational activities that provoke an emotional experience of shared suffering while motivating the learner to channel this emotion into actions that reduce this suffering. 14
Despite their promise, efforts to promote compassion through educational interventions for health professionals have not gained widespread acceptance. Researchers have highlighted several barriers to advancing compassion education. Existing educational interventions designed to enhance compassion are typically delivered exclusively through formal instruction such as in-class trainings that limit continuous and adaptive learning. 15 The material considerations necessary to deliver compassion education, such as space, time, and organizational infrastructure, may constrain the potential for delivering such curricula across distances and to wider audiences. 16 Consider the example of an educational activity intended to enhance patient-centered care within a hospital organization. The impact of such an intervention on compassion would likely be influenced by organizational factors such as leadership support, time to participate in trainings, and the ability for instructors and participants to gather together for in-person instruction. In response to a situation that limited the infrastructure to deliver compassion education, how would educators adapt? Circumstances such as rapidly evolving public health crises highlight the need for rapid adaptation of health professions curricula for delivery across considerable distances. Advances in technology-enhanced learning (TEL) may therefore have the potential to enhance teaching and learning about compassionate care.
TEL initially gained momentum in the 1990s. 17 More recent conceptualizations of TEL have expanded to include learning enhanced by mobile applications or through social media platforms. 18,19 Advantages include the provision of real-time information to health professionals who can access the latest knowledge instantly. 15,20 A rapidly expanding collection of digital tools such as blogs, wikis, and podcasts has the potential to enhance students’, clinicians’, and patients’ learning experiences while deepening levels of engagement and collaboration. 21
Digital and social media may have an advantage over traditional compassion education by providing more opportunities for collaboration and connection. 18,22 Through improved tailoring of individual content and versatile options and platforms for sharing information, in addition to immediate, real-time access, technology may provide a mechanism to enhance the scale and spread of compassion education, ultimately improving the provision of compassionate health care. 23 Although there are limited examples of how compassion education may be adapted through technology, promising examples include TEL adaptations of interventions that use storytelling to enhance compassion and empathy. 24,25
Despite the popularity of TEL in health care, there has also been considerable critique and controversy. There is a lack of consistent definitions of social media as well as a dearth of shared understanding of the mechanisms by which technology may enhance teaching and learning in general. 26,27 Furthermore, concerns about digital and social media relating to confidentiality, implications of public information sharing on trust and professionalism, and widespread availability of misinformation pose a challenge to educators seeking to leverage technology to enhance compassion education delivery. 28–30
Using technology to enhance the delivery of education also provokes tensions within discourses on compassion and humanistic care. One study found that when health professionals used technology to facilitate compassion in their role as educators, they perceived this experience as positive; however, when they used technology to help their patients, they feared technology would impede compassion. Technology was therefore perceived to both constrain and enable the delivery of compassionate care. 31 Similarly, theoretical considerations regarding the adaptation of existing health professions curricula delivered across distances have tended to focus on social and cognitive considerations without considering the complex interplay between teachers, learners, and the technological tools that mediate social interactions, teaching, and learning. 16,32 A further tension in the literature is between the concept of presence and distance. Any technological adaptations implemented to enhance distance learning must facilitate sustained cognitive and pedagogical presence for both teachers and learners to advance meaningful and educationally relevant learning outcomes. 33,34
Given the current barriers to the uptake of digital learning modalities in compassionate care curricula, an in-depth exploration of the relationship between compassion education and TEL may offer unique insights on how to address existing tensions and advance both areas of inquiry into the future. Despite the rapidly changing landscape of technology-enhanced options, the pace of academic inquiry on TEL and health professions education is slow. The potential for technology to enhance compassion through education will remain limited unless we can gain a deeper understanding into the interplay between technology and compassion-related education. Therefore, in this study, we explored how technology influences the delivery of compassion education for health professionals.
We used constructivist grounded theory to build theory toward a social process that is not well explained by an established theoretical construct. Constructivism works under the assumption that researchers and research participants construct their understanding and knowledge of the world through a constant comparative cycle. 35
We defined digital technology as a group of online and freely available technologies that allow for the creation and sharing of content, including websites, blogs, microblogs, content communities, social networking sites, and eLearning. Our definition was based on the scheme proposed by Kaplan and Haenlein 36 and used for similar research on digital and social media in health care. 22 We defined compassion as a construct that includes awareness of another’s suffering, an emotional experience as a response to such suffering, recognizing one’s emotional experience as a response to the suffering of another, and engaging in a behavior to alleviate another’s suffering. 37
Consistent with our research question, we sought a theoretical sample that represented individuals involved in the design and evaluation of compassion education for health professionals. We electronically shared recruitment notices via the Associated Medical Services (AMS) Phoenix Project network, indicating that we were seeking participants for a study exploring how digital technology influences compassion education. AMS started in 2012 with a focus on advancing the importance of compassionate, patient-centered care in medical practice in Ontario, Canada, and has provided funding for 48 grants and fellowships. 38 Thirteen individuals from across Ontario participated in semistructured interviews from March to October 2019. The study originated at the Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. Approval to conduct the study was obtained from the Western University Research Ethics Board.
Participants were a diverse group of individuals involved in health professions education including practicing health professionals, researchers, and educational specialists across a variety of disciplines. Although all participants were involved in designing interventions to enhance compassionate care, they varied in the degree that digital technology was a component of their intervention. Some did not incorporate any form of technology, whereas others developed interventions in which technology was an integral part of their work. Theoretical sampling in grounded theory involves iteratively revising the sample to work toward the generation and development of theory rather than creating a descriptive account. 35 By including compassion educators who had not yet incorporated TEL in compassion education, we hoped to address how technology may enhance compassion education both in the present and in the future, particularly among educators who may be reluctant or apprehensive to adapt their work through technology. Therefore, our participants provided a theoretically suitable sample for the topic we sought to explore. More information about participants’ roles in education and their experience with TEL is presented in Table 1.
Team members included the principal investigator (J.S.), a child and adolescent psychiatrist, faculty member, and PhD scientist in health professions education, and the co-investigator (J.P.), a medical student with previous experience conducting qualitative research. J.P. conducted interviews in person and via teleconference; each interview lasted approximately 30 to 90 minutes. Interviews began by reviewing the letter of information and consent, followed by semistructured questions to guide the conversation. During the initial sessions, participants were asked open-ended questions about the definition of compassion; their experiences designing educational interventions to enhance compassion; specific objectives and outcomes for their work; and the influence of digital technology on how compassion education for health professionals is designed, implemented, and evaluated. Interviews were audio-recorded, deidentified, and transcribed verbatim before analysis. Consistent with constructivist grounded theory, the discussion guide was iteratively revised as the study proceeded. The discussion guide is provided as Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B61.
Coding and inductive analysis were conducted by J.S. and J.P., who met regularly to revise the discussion guide and ensure that analysis was consistent with the effort to theoretically sample participants. J.P. coded the first 6 transcripts, using constant comparative analysis, and shifted toward focused consolidation of codes and analysis of relationships among themes. J.S. coded the next 7 transcripts line by line. The codes were developed by the researchers and entered into NVivo version 12 (QSR International, London, United Kingdom). At regular intervals, the team met to share and discuss the analysis as they worked toward the development of an explanatory theory and synthesized overall findings. Any discrepancies were addressed through consensus. We continued to collect data and revise our discussion guide until the team concluded there were enough data for a sufficient conceptual understanding of the process under study. 39
Participants provided a range of responses regarding technology and compassion education. Amid considerable fear, uncertainty, and concern about how technology may limit human interaction and constrain nonverbal communication, there was a sense that adapting the delivery of compassionate care curricula through technology was necessary and inevitable. Participants also described several unique ways in which technology may enhance the delivery of compassion education for health professionals. Improving facilitation and a balance between face-to-face instruction and TEL were potential factors that could advance compassion education into the future.
Technology is limiting
Most participants felt that technology limits the humanistic presence essential for compassion education. There was skepticism that technological advancements are not sufficiently nuanced to capture the human element of interpersonal relationships and could not effectively replace the human interactions necessary for effective teaching and learning regarding compassion in health care.
Participants described examples of how technology limits human interaction. They suggested that implementing TEL comes at a significant cost. For example, one participant stated that technology limits one’s ability to “look someone in the eye” (Participant 4), while another stated,
It’s hard when you’re having some sort of exchange online, it’s difficult, it’s not the same as visually seeing something…. I think the visual experience is quite important and you could not have the same kind of learning experience that you could have in person without physically being there using technology. (Participant 2)
There was a general sense that, although technology has potential, this potential is limited by the ability to be physically present with one another.
Another concern was how technology limits an instructor’s ability to access nonverbal information. Several participants felt that those involved in facilitating compassion-related educational activities while using technology require real-time feedback and indirect cues such as body language. Without such information, instructors could struggle to gauge learner engagement.
There was also apprehension that technology may allow individuals to be less authentic with one another. A potential limit of technology was that it might lead learners to put up a wall that inhibits vulnerability, honesty, and trust. One participant described the limits of technology by asserting,
You’re just doing what you need to do, you’re just going through the motions, but you’re not necessarily … it’s just not as genuine…. (Participant 2)
Conversely, there was a sense that more advanced technologies may improve opportunities for authentic connection.
The potential of technology to enhance compassion education was also thought to be constrained by numerous barriers. Although participants felt that some generations were socialized into technology, others were considered more apprehensive. Cost was also considered prohibitive for some individuals and organizations, and rural or remote regions where internet access was more limited were also cited as a concern. In addition, one participant highlighted how virtual spaces may favor certain individuals with certain types of learning or communication styles, thereby limiting the technology’s effectiveness.
Technological advances are inevitable and require our adaptation
Despite concerns about the limits of TEL in compassion education, most participants expressed a sense of inevitability. Several mentioned that the practice of health care is rapidly changing, and therefore there is a need to adapt education regarding compassionate care in relation to technological advancements in the field. One participant stated, “We’ll probably just have to suffer the consequences before we figure out the solution” (Participant 6), while another stated,
Online platforms and artificial or augmented intelligence will change our work … the nature of our work will change and I think that’s an important thing to look at as we move ahead with it…. It is happening … so it’s not if we move ahead with it, it’s as we move ahead with it. (Participant 8)
Another participant suggested that adapting compassion education with technology requires mechanisms that “enhance human interaction as opposed to distract from it” (Participant 6).
Technology is useful and has potential
All participants felt that some aspects of technology have utility and potential for compassion education. Participants identified unique areas where technology could enhance the delivery of compassionate care curricula, and most felt that technology could enhance accessibility and collaboration. A participant illustrated the unique potential of technology:
I think that’s a natural way of using technology to expand that community of learners beyond your immediate location. And I think that’s essential, because [compassion education] requires a nurturing environment and community, and one of the reasons why character sometimes degrades in medicine is through the lack of positive role models who value it and actually, examples of the opposite, bad role models that people are exposed to. (Participant 3)
Most participants also raised the issue of psychological safety as it relates to TEL. There was a strong sense that technology may enhance psychological safety for learners. An anonymized platform may encourage more candid and open conversations about controversial issues, and advances in technology were perceived as useful to create “safe spaces” for learners to engage with one another without fearing how others would perceive their emotional reactions to sensitive topics. A participant described this useful aspect of technology:
I think in a digital world we can have those conversations, and I think there’s a lot of benefit in relation to having those conversations, because I think it offers a safe space for people to really be quite candid and still feel like they can remain anonymous…. But I think also what’s important is ensuring that there’s facilitation that they’re, that we’re ensuring that there’s no harm done. (Participant 7)
Technology could therefore strengthen the delivery of compassion education by allowing learners to be more comfortable with being vulnerable. One way this could be achieved is through the anonymizing power of digital platforms. Through enhancing safety, technology was felt to have benefit for novice learners who are experimenting with new communication skills and can leverage technology to “try things out without hurting anybody or feeling foolish” (Participant 8).
Technology-enhanced compassion education should be balanced with face-to-face instruction
Most participants felt that a balance between face-to-face instruction and technology could be useful to educate health professionals about compassion. They were clear that face-to-face and physical interaction could not be replaced by technology, yet felt that technology could still afford a meaningful and impactful opportunity to learn how to be more compassionate. One participant stated that despite losing the effect of physical presence, technology might enhance physical presence in some circumstances by engaging individuals who would otherwise be unable to interact with one another, adding, “You might actually broaden the overall impact by increasing that access” (Participant 3). The participant further described striking this balance by explaining,
I’m doubtful that technology on its own, without physical support from the ground, can maintain a culture moving forward. But in conjunction with a physical support of a culture with physical interaction, technology, I do believe, could actually strengthen and build upon it in ways that without technology, you couldn’t. (Participant 3)
Others described the need for a “nice equal balance” of methods of learning (Participant 11) and noted that there were “wonderful opportunities” to use technology to mix online and face-to-face interaction (Participant 9). They also emphasized that balancing technology with face-to-face instruction requires the appropriate infrastructure and supports.
Adapting technology for compassion education requires appropriate facilitation
Several participants noted that effectively using technology to enhance compassion education requires attention to the role of facilitators. Any moderators or facilitators would require sufficient training to facilitate openness and psychological safety by being role models for others. One participant elaborated on the role of facilitators in their work by sharing,
The conversation is facilitated by a skilled professional who can anticipate dialogue and support a productive dialogue. And create safety in the virtual world. I’m sure teachers are doing this, so they know how to do that or a respectful learning environment, again, digitally. You’re right, you might have a bit more of people not being as thoughtful or careful with either their questions or their comments, so I think that there’s an important role for facilitators. (Participant 11)
Other participants emphasized that facilitators should be comfortable in a technological domain and possess skills to effectively use technology in a manner that engages learners who may be feeling disconnected with the material. One described the skill set for compassion-based digital education by stating,
It’s not the same as facilitation that might be required for in-person compassion-based education. I think the rules of engagement might need to be different; the contract you have with learners might need to be different. The way we read signals, you know it’s so hard in digital platforms … so I think it really does have to be more intentional and not assuming that because their facilitation skill is in one domain that [it’s] translatable to a digital environment. (Participant 10)
Another participant emphasized that to deliver compassion education, facilitators must “create educational climates that are compassionate; we have to show up as educators in a compassionate way” (Participant 13).
Our exploration of how technology influences the delivery of compassion education revealed a range of responses from participants. Technology was perceived as both limiting and having potential. Although there were concerns about technology limiting learner engagement and human connection, participants felt that technology has the potential to increase access to compassion education and could be useful to help open conversations for learners about sensitive topics. Participants suggested that technology could be leveraged to enhance the delivery of compassion education by augmenting, rather than replacing, face-to-face instruction. Effective and skillful facilitation was considered a vital ingredient in successfully adapting compassionate care curricula through technology.
Understanding technological ambivalence
Similar to other studies, we found that there is considerable tension, uncertainty, and apprehension about the use of technology to enhance compassion education for health professionals. Although it was not unexpected that there would be a tension between traditional approaches to education and disruptive innovations such as digital and social media, 40 our finding regarding technological ambivalence may provide insights for future efforts at compassion-based education. Our participants demonstrated distinct yet complementary perceptions of how technology relates to compassion education. This ambivalence compliments the findings of Stergiopoulos and colleagues, 34 who found friction between technical competence as a mechanism for standardization or universalization and individualized approaches to compassionate care. Similar to their analysis, our results suggest that humanism and technology could be simultaneously viewed as conflicting and complementary.
While our participants highlighted the anonymizing power of technology and its ability to promote deeper reflection, they also worried about the same power leading to decreased honesty and trust online. Technology can create a “disinhibition effect,” whereby the anonymity and asynchronicity offered by online environments may encourage individuals to leave negative or impersonal comments. 41 This disinhibition effect can affect the expression of empathy in TEL environments, which has considerable implications for compassion education.
By contrast, our findings suggest that TEL can serve as a balm to these concerns. Our participants suggested that technology might enhance psychological safety for learners, thereby creating spaces where students may feel more comfortable. 42 Because the threat of failure or embarrassment can be minimized in these supportive learning environments, students might be more willing to be open and vulnerable with peers and facilitators, which can encourage dialogue about delicate or awkward subject matter.
The role of psychological safety in the promotion of knowledge sharing in communities of learners has been well substantiated in the literature on organizational behavior. 42,43 In the context of medical education, the idea of fostering psychological safety for medical learners has been explored in simulation learning, especially as it pertains to the process of debriefing and the learner’s subsequent engagement in reflection about the simulation experience. 44 However, the consideration of psychological safety in simulation learning refers mainly to in-person, standardized patient role-play and not virtual scenarios. Other studies have examined the relationship between technology and psychological safety in TEL modalities such as blogs and discussion boards. Although not specific to digital compassion education, the findings of these studies support the claim that technology can provide forums in which learners can open up, address stereotypes, address challenges in clinical practice, and discuss breaches in professional conduct without fear of repercussions. 45–47
For TEL to effectively foster psychological safety, facilitators and learners must adopt attitudes that minimize judgment and overly critical interactions. 44,48 Developing strategies on how to foster a learning environment that preserves trust while permitting difficult conversations to occur is central to the adaptation of technology-enhanced compassionate care curricula. The potential for TEL to increase psychological safety, as well as the role of facilitators and learners in enhancing this sense of safety, merit further exploration in technology-enhanced compassionate care curricula.
Successfully adapting technology to deliver compassion education also requires attention to the role and competencies of facilitators. Existing literature highlights that interventions such as digital storytelling or videos to enhance compassion may lead to cognitive dissonance that requires skillful facilitation and navigation. 49 To harness the power of technology for transformative learning, teaching must also adapt to become more active and participatory.
One of our participants suggested that facilitators must be role models who embody an epistemology of compassionate practice by “showing up” as compassionate educators. This comment highlights the importance of presence for facilitators. The concept of teaching presence has a considerable influence on learning and the perception of community among learners. 50 Effective teaching presence entails the enactment of caring behaviors or competencies, including expertise, openness, timeliness, and empathic presence. 51
It is worth noting that presence can be carved out by more than just teachers. 52 Teachers are no longer the only ones acting as facilitators; due to the different nature of interactions made possible through technology, learners can have a greater responsibility in their learning and can act as facilitators themselves. 34,53 Peer-led facilitation has been found to promote an environment conducive to the sharing of personal stories that may serve an important role in compassion education. 54 This facilitation strength reiterates our earlier discussion of the advantage of technology in providing “psychological safety” for participants: careful facilitation, be it instructor or peer-led, can create these spaces. The findings from our study also complement previous suggestions to consider both social and material elements of TEL. 16 In addition to teachers and learners, technology can mediate and cocreate presence. We cannot create presence without sufficient technological software, hardware, and internet connection.
Fostering student engagement and human connection
Participants raised concerns about the inherent difficulty in understanding nonverbal communication when using TEL, leading to difficulties in assessing learner engagement and emotional cues. Assessing a learner’s level of engagement or “social presence” could involve monitoring expressions of personal experiences, beliefs, or emotions (affective); the initiation of discussions and provision of feedback to other students (interactive); and use of others’ names and inclusive pronouns as part of the cohesive dimension. 55,56 By assessing these activities, facilitators can develop a greater awareness of students’ participation and their levels of comfort, which would then allow them to intervene if required.
Striking a balance between technology and face-to-face instruction, as suggested by our participants, might mitigate the issues in assessing student engagement and building relationships between students and facilitators. Strategies may include scheduling occasional in-person sessions to complement interactions otherwise mediated through technology and using software that allows learners and facilitators to see one another (e.g., Skype, Zoom). Existing teaching strategies can also be redesigned according to principles from improv comedy to facilitate connection and enhance creative thinking. 57
Although technology cannot replicate the type of interaction possible in environments in which everyone is physically present, it can overcome geographic and temporal barriers to expand communities of learners. Our participants, especially those with experience working in smaller or rural communities, underscored this advantage. However, effort is still required to truly establish and maintain a community of learners. Facilitators must ensure that students are introduced to one another to enable learner–learner interactions and familiarity with peers. 58 Facilitators should be careful to create opportunities that encourage student-driven learning and promote learner autonomy.
Given the presence of technological ambivalence among educators, incremental changes to the adoption and adaptation of TEL in compassion education might prove more effective than radical shifts. We acknowledge that a slower pace of implementation might be challenging, given the rapidly evolving nature of technology and shifting generational dynamics as future learners and facilitators become increasingly comfortable with technology. Recent public health crises such as the COVID-19 pandemic highlight the need for balancing thoughtful and evidence-informed adaptations within a rapid time frame. Findings also suggest that adapting compassion education for online delivery may be enhanced through consultations with both staff and students, when possible, to ensure that pedagogy and teaching practices are driving the uptake of technology, not vice versa, and that both facilitators and learners are supportive of the technology’s use in curricula. Our ADAPT model (adapt, design, advance, potential, temper), described in Table 2, demonstrates how our key findings about TEL can be translated by educators and curriculum developers for the future.
Our study is not without limitations. All of the participants in this study were based in Ontario, Canada, which may have limited the insights we gained and the generalizability of these findings. Because all of the participants were either grant recipients or fellows with AMS, their perspectives were rooted in a specific sociopolitical context. There are also a wide variety of technological modalities used in TEL and, while we encouraged participants to remain cognizant of this breadth, participants generally spoke to the specific technologies with which they had experience. This specificity may have resulted in a heavier focus on the interactive forms of TEL, meaning that our findings may be more pertinent for certain types of technologies than others.
Despite concerns surrounding the constraints technology may impose on human interaction and nonverbal communication, adapting the delivery of compassionate care curricula through technology appears necessary and inevitable. Adapting compassion education for health professionals through technology has the potential to connect wider communities of learners and enhance psychological safety among students in digital learning environments. As TEL gains more traction in the field of compassion education, special attention should be paid to the role of facilitators and how they can best adapt technology to enhance their teaching practices. Understanding technological ambivalence and working toward fostering human connection should remain priorities in the implementation of TEL in compassion education.
The authors would like to acknowledge contributors and advisors, including Jill Sangha, Lisa Hawthornthwaite, Kerry Boyd, Lisa Liu, and Ayelet Kuper.
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