Creating Learning Environments for Compassionate Care (CLECC): a feasibility study

BACKGROUND: Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable. OBJECTIVES: To assess the feasibility of implementing Creating Learning Environments for Compassionate Care programme (CLECC) in acute hospital settings and evaluating its impact on patient care. DESIGN: Pilot cluster randomised controlled trial (CRT) and associated process and economic evaluations. SETTING: Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n=4) or control (n=2) PARTICIPANTS: 639 patients, 211 staff, 188 visitors. INTERVENTION: CLECC, a workplace educational intervention focused on developing sustainable leadership and work-team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. Control: no planned staff team-based educational activity. MAIN OUTCOME MEASURES: Quality of Interaction Schedule (QuIS) for staff-patient interactions; patient-reported evaluations of emotional care in hospital (PEECH); nurse-reported empathy (Jefferson Scale of Empathy). DATA SOURCES: structured observations of staff-patient interactions; patient, visitor and staff questionnaires and qualitative interviews; qualitative observations of CLECC activities. RESULTS: CRT: Pilot proceeded as planned and randomisation was acceptable to teams. There was evidence of contamination between wards in the same hospital. QuIS performed well achieving a 93% recruitment rate with 25% of patient sample cognitively impaired. At follow-up there were more positive (78% versus 74%) and less negative (8% versus 11%) QuIS ratings for intervention wards versus control wards. 63% of intervention ward patients scored lowest (i.e. more negative) scores on PEECH connection subscale, compared with 79% of control group patients. These differences, while supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: The CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. We found strong evidence of good staff participation in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: We also identified the costs associated with using CLECC and recommend that an impact inventory be used in any future study. LIMITATIONS: Findings are not generalizable outside of hospital nursing teams and this feasibility work is not powered to detect differences due to CLECC. CONCLUSIONS: Use of experimental methods is feasible. The use of structured observation of staff-patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research but further validation is required. Further development of the CLECC intervention should focus on ensuring it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers.