In healthcare, the importance of providing patient-informed care is increasingly recognized. This explains the increasing use of Patient Reported Outcomes (PROs) as key means for including the patient’s perspective in the assessment of quality care. Among the different PROs, Patient Reported Experience Measures (PREMs) are those patient-reported measures that directly assess the patient’s experience of some aspect of care (1, 2).

Concurrently, compassion has been recently identified as an essential indicator of quality care, requiring researchers to develop an understanding of how patients perceive and experience compassion in healthcare (3–5). Thus, a patient-informed, empirical definition of compassion was recently developed: “a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action” (6). In this sense, compassion is not restricted exclusively to physical aspects related to pain and symptom management but considers all of the patient’s holistic needs. In recognition of the centrality of compassion to patients’ experience of quality care, compassion has increasingly been taken into consideration in international clinical practice standards and policies, which recognize compassion as a fundamental dimension of quality care that needs to be integrated into the practice and education of healthcare providers and embedded within the larger healthcare system (5, 7–9).

Notably, the absence of compassion in health care has been linked to poor symptom control, patient complaints, high chronic stress, and medical complications (3, 4, 9–12). At the same time, the presence of compassion in healthcare has been linked to greater emotional well-being in patients, improved quality of life, and greater satisfaction with care (4, 5, 9, 13–16). Furthermore, several studies on quality care in healthcare indicate that patients identify compassion as one of their most important unmet needs (3, 5, 9, 13, 14).

The significant impact of compassion on various indicators of healthcare quality has led researchers, educators, and policymakers worldwide to consider compassion as: (1) a patient right (17), (2) a core professional competency (18–20), and (3) a standard of care that healthcare organizations, educators, and care providers need to implement, measure, evaluate, and report on (5, 7, 16, 21–23). Despite the recognition of the importance of compassion in research, education, policy, and practice, there is a gap between what is known in theory and integration into practice (3–5, 16, 24–26).

Several explanatory factors play a role in this paradoxical situation between the direction healthcare practice should be heading and the day-to-day reality of practice. Indeed, the difficulty of defining compassion and distinguishing it from other related terms such as empathy or sympathy; the different connotations that the term has in different languages or cultures; the difficulty of operationalizing the concept due to its subjective nature are among the possible reasons for such a discrepancy (27, 28). Closely related to all of them, the absence of valid and reliable patient-reported measurement tools (PREMs) to assess patient care and the impact of training and intervention programs aimed at fostering compassion in the healthcare setting arises as a key obstacle.

The relevance of the use of PROs has been widely recognized in the scientific literature and by health authorities, including those from Spanish-speaking countries or countries with a significant Spanish-speaking population (29). Thus, it is pivotal to know which patient-reported instruments have been used to assess compassion and their psychometric properties in order to ensure that this standard of care and this reputed patient right is assessed in a psychometrically rigorous manner.

Therefore, the aims of this systematic review are: (1) to explore which compassion measures have been used in Spanish settings; (2) to determine which tools are capable of assessing compassion in healthcare from the patient’s perspective; (3) to evaluate the quality of these patient-reported compassion measures in Spanish contexts; and (4) to assess which of these instruments would be best suited to be used in Spanish-speaking patient populations.

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard (30).

The first aim of this study was to determine which tools have been used in Spanish settings to measure compassion. While there has been a rapid influx of research on compassion within Spanish contexts (Figure 2), these are not without limitations. Namely, while the number of publications assessing compassion in Spanish-speaking contexts has increased in recent decades, the number of Spanish studies on this subject is still relatively small compared to data from other countries. While 6.3% of the world population’s primary language is Spanish, making it the world’s second most spoken language by native speakers after Mandarin (117), a recent scoping review on compassion in healthcare revealed that of the 50 studies included in the review, only 4 (8%) of the studies where carried out in Spanish speaking countries, with almost 46 (92%) of the studies being conducted in English speaking countries (4).

Regarding the studies on measuring compassion in Spanish populations reviewed herein, only 3% of studies assessed compassion from the recipient’s perspective, with no studies assessing compassion from the patients’ perspectives specifically (Table 2). In fact, 48% of studies focused exclusively on self-compassion, and 37% focused on compassion for others, all of which were based on responder/provider self-report. This is particularly problematic considering that: (1) the relationship and association between compassion and self-compassion has not been adequately demonstrated (27); (2) Responder/Provider self-reports are biased and do not equate with recipients’ actual experiences of compassion (6, 23) and; (3) compassion is an inherently relational construct (4, 6, 28) which etymologically means “to suffer with another” (118). Despite the necessity of assessing compassion from the recipients’ perspective, only 9% of reviewed studies assessed compassion from others, none of which were translated and validated in Spanish nor included patient populations (see Table 2; Figure 2).

As evident in Table 2, the most suitable instrument for measuring self-compassion in Spanish is the Self-Compassion Scale (65), validated by García-Campayo et al. (34). While there were various instruments measuring compassion toward others in Spanish populations, the Jefferson Scale of Physicians Empathy (JPSE) (74) has been validated in Spanish (66, 67) and is currently the most suitable tool available. However, there are some significant limitations that need to be noted: (1) it is a provider self-report and not a patient-reported measure, and importantly, (2) it was designed and validated to measure empathy which, while sharing attributes of compassion, does not require a pro-social response or action aimed at the alleviation of suffering (27, 28). Researchers have nonetheless argued that two of the 20 items within the scale are relevant to compassion—“taking perspective” and the “ability to put oneself in the patient’s shoes.” Of the two studies that measured compassion with instruments that simultaneously assessed compassion toward others and toward oneself, one used a projective technique and a qualitative approach (112). The other (111) focuses on positive/negative feelings toward self/others and not on the construct of compassion specifically. Neither of these two assessment tools has been validated in Spanish.

In addition, two studies measured compassion from multiple perspectives, namely--from/to others, between others, and to oneself. One focused on assessing the connotative meaning of concepts, and the second measured compassion using the Relational Compassion Scale (RCS) (115). The RCS was designed to measure compassion as received from others; the study that used it assessed compassion from multiple perspectives but did not focus on any one subgroup specifically. Despite these limitations, when considering the assessment tools that could be potentially used to assess compassion in health care settings and from a patient perspective, this tool could be considered after additional validity and reliability testing.

An unexpected and surprising finding was that only six studies measured compassion from the recipients’ point of view, three of which used a measurement tool that had been validated in a Spanish setting, with no study using a patient-reported experience measure (assessment was done with subscales or some items from a broader scale assessing other variables as well). This inhibited our ability to address two of the four research questions related to this study, namely, the research aims: (3) evaluate the quality of these patient-reported measures in Spanish contexts, and (4) determine which of these instruments would be best suited to be used in healthcare settings. The absence of a patient-reported, valid, and reliable, Spanish compassion measure remains a persistent and significant gap in studying, measuring, intervening, and ultimately improving compassion among Spanish-speaking patient populations.

It should also be noted that all the studies that measured compassion received from others used a subset of items from a larger scale. In other words, these studies aimed to evaluate a broader construct that included a facet of compassion that was reputedly linked to compassion received by others. For example, two of the six studies used the Professional Care Rating Scale (115), and one study used the Dental Home Concept Scale (102), which, while being validated in Spanish populations were not designed or validated tools intended for measuring compassion to others specifically.

In addition, the three studies that used a validated tool to assess compassion from others among a Spanish-speaking population were all conducted in the United States and none among patient populations. It is, therefore, likely that the participants were, at least to some extent, familiarized enough with the English language to have an understanding of the meaning of the construct of “compassion” in English, which may or may not be different from conceptualization of compassion in countries were Spanish is the primary language and culture group. This possibility is relevant and needs to be considered because the word “compassion” in Spanish settings may have different connotations than the word “compassion” in English settings (119, 120). In Spanish-speaking cultures, the word “compassion” is often associated with religion and is very closely related to the concepts of mercy or pity (119). In fact, due to this understanding, some studies have operationalized the term for compassion in Spanish as “advantageous inequality” (81), which is not the case in the English-speaking context, where compassion is differentiated from, and preferred over, similar related concepts of empathy and sympathy (27, 28).

As we have already pointed out, the poor results found in this review limited the scope of the third objective of this study. Of the six studies that assessed compassion received from others, only one indicated the instrument’s psychometric properties, the Professional Caregiving Rating Scale based on Swanson’s Theory (103). According to that study, the scale had a Cronbach’s Alpha of 0.89 within the study sample. Even though this is an acceptable reliability score, further studies are needed to consider whether this scale is a valid tool to assess compassion in a healthcare setting from a patient’s perspective. Likewise, in terms of the last aim of this study, the lack of patient-reported compassion measures did not allow us to appraise the most suitable tool to be utilized among Spanish-speaking patient populations. The few studies that aimed to assess compassion received from others were significantly limited as they did so using items from broader assessment tools that were not designed to measure compassion, of which only half of them were validated in Spanish. Considering that compassion is a key element in the care provided in the healthcare context, a patient’s right, an increasingly recognized indicator of quality care, and a critical factor in promoting the patient’s well-being, it is remarkable that there are no valid and reliable instruments to measure compassion in Spanish-speaking patient populations.

Although the authors attempted to carry out a systematic review in accordance with strict methodological guidelines, this review is not free of limitations. As noted, when it comes to measuring compassion in Spanish, researchers have been using instruments that more correctly measure related constructs or sub-components of compassion. This may, in part, be of a larger issue, namely differences between conceptualizations of compassion in Spanish-speaking contexts compared to English-speaking contexts where most measures originally were developed. As a result, one of the limitations of this review is that studies may have been excluded that measured facets of compassion that did not use the term compassion. This underscores the importance of establishing face and construct validity among Spanish populations to determine what constitutes compassion within this context. While this review was restricted to studies that expressly referred to the concept of compassion to ensure methodological rigor, it did include studies that reported measuring compassion, even if it was as a subscale or facet of the broader construct. For example, questionnaires that more correctly measured empathy were included, provided that both the authors of the questionnaire and the researchers who utilized it reported that it measured an aspect of compassion. This was the case with the Jefferson Scale of Physicians Empathy (JSPE), which is the most widely used instrument in Spanish populations aiming to measure compassion toward others.

Despite the growing number of publications in which compassion appears as a variable in Spanish-speaking contexts and the increased interest in the topic among Spanish researchers, there have been no systematic reviews to synthesize and evaluate the evidence associated with this burgeoning field of scholarship. Assessing the experience of compassion in Spanish patient populations could provide a foundation for exploring the importance of compassion in sectors beyond healthcare, such as organizational compassion and within society in general (121).

While there are valid and reliable measures, validated in Spanish, that measure aspects of compassion, there are no valid and reliable instruments, developed and validated in Spanish, that measure compassion in a comprehensive, methodologically rigorous manner from patients’ perspective. In light of the centrality of compassion to healthcare, quality care ratings, and patient, family, and healthcare staff well-being, there is an increasing urgency to address this gap in order to conduct research and improve care in this area.

In order to ensure and promote compassion in the health care context, it is essential to have a valid and reliable tool to measure this construct in a patient-informed way, and this is currently not possible in the Spanish-speaking context because of the lack of such an instrument in Spanish.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

AS-R: Writing – review & editing, Writing – original draft, Investigation, Formal analysis, Conceptualization. CP: Writing – review & editing. BG-J: Writing – review & editing. YA-V: Supervision, Writing – review & editing, Writing – original draft, Investigation, Funding acquisition, Formal analysis. MP-M: Writing – review & editing. SS: Conceptualization, Writing – review & editing, Supervision, Investigation.