What's the role of kindness in the healthcare context? A scoping review

Abstract

Introduction

The role of kindness in healthcare is receiving increased attention. Indeed, international research shows that a culture of kindness has a positive impact on healthcare organizations, healthcare staff members, and patients. Benefits include better patient outcomes, as well as a humanized work environment, which helps to prevent stress and burnout among healthcare workers. Studies across different settings suggest that healthcare managers need to foster not only technical and organizational skills, but also social skills such as empathy and kindness.

The purpose of this scoping review is to provide an overview of the current research landscape regarding initiatives based on acts of kindness in healthcare organizations. We will also explore whether this is a topic of interest to academics, which countries have conducted the most research on the subject, the practical implications for healthcare management, and potential directions for future research.

Methods

This scoping review was conducted using the Arksey and O’Malley framework. A search was performed in the electronic databases ScienceDirect, Pubmed and Web of Science, to identify studies published in English between 1994 and 2023 describing or evaluating kindness-based interventions in the healthcare context.

Based on the predefined eligibility criteria, screening and studies selection were performed. Data were extracted and analyzed descriptively to summarize the evidence.

Results

19 studies were analyzed and included in the review. The article assessment revealed four categories: 1) organizational culture; 2) burnout reduction and staff well-being; 3) staff education / training; and 4) communication and patient experience.

Kindness in healthcare is a relatively new topic, but of great scientific interest. The countries most interested in the topic are English speaking (with a particular interest in category 2) and Western European, and the methodology most commonly used to investigate this topic is qualitative.

Conclusions

The need for additional research on kindness in healthcare arises from a complex and dynamic healthcare environment, where the concept of kindness holds the potential to revolutionize the quality of care and the well-being of healthcare providers.

The interest of the various countries in the 4 thematic categories proposed by the study and the performance results of healthcare organizations promoting kindness compared to others without this focus also bear further consideration.

Introduction

Definition of kindness and differences with empathy and compassion in healthcare

"Kindness" lacks a universally accepted definition in the scientific literature. The construct is considered easier to identify than to define [1], as its manifestations in actions or behaviors are often intuitive and observable, while its abstract nature makes precise articulation more challenging.

Campling [2] states that the word “kindness” has its roots in the Old English word “cynd”– meaning nature, family, lineage – i.e., kin. Kindness implies the recognition of being of the same nature as others, being of a kind, in kinship. It implies that people are motivated by that recognition to cooperate with one another, to treat others as members of the family, and to be generous and thoughtful.

Canter et al. [3] describe kindness as a “gesture motivated by genuine warm feeling for others”. This highlights one of the essential elements of kindness: it involves an action (whether mental or physical) that carries a “warm” component, aimed at promoting “well-being or flourishing” [4]. From an external perspective, kindness can be seen as an action that provides some benefit to the recipient of that action [5].

The distinctiveness of positive psychology lies in redirecting the emphasis from illness to one’s strengths, moving beyond merely treating pathology to uncovering and nurturing the positive attributes of people and groups, fostering their growth to enhance well-being, health, and happiness [6]. From this viewpoint, Seligman and Peterson regard kindness as a potential, grouping it with love and social intelligence among the virtues that categorize the strengths of the human being [7, 8].

Kindness is viewed as a virtue connected to other prosocial behaviors, such as compassion, which involves concern for the well-being of others [1]. Specifically, kindness, is seen as a human quality, often described as the virtue of being friendly, generous, and considerate, and it finds a profound resonance within the healthcare context [9].

Despite technological advancements and medical breakthroughs, the foundation of healthcare remains the relationship between providers and patients. This foundation transcends mere medical treatment and includes holistic care. Providers who exhibit kindness create a supportive environment where patients feel valued, respected, and heard. This enhances patient experience, leads to better outcomes, and fosters trust and a compassionate approach to healing [10, 11].

Acts of kindness can trigger a “ripple effect”, creating a chain reaction where individuals feel compelled to offer the same kindness they receive [12]. Psychologists call this “prosocial contagion” [13]. Experiencing or witnessing prosocial behavior can have an uplifting effect [14]. Those who experience this are likely to continue such behaviors, contributing to a cycle of kindness [15].

In healthcare, kindness, empathy and compassion are often used interchangeably, but they represent distinct aspects of patient care [16].

• Kindness involves demonstrating generosity, consideration, and warmth, including gestures like offering comforting words or assistance, and extending beyond clinical competence to embrace the holistic well-being of patients [5, 17, 18].

• Empathy is the ability to understand and share another person’s feelings. In healthcare, it involves putting oneself in the patient’s shoes, actively listening and responding with understanding, thereby fostering trust and patient-centered care [19–21].

• Compassion combines empathy and kindness, motivating actions to alleviate suffering. Compassionate healthcare providers offer support, pain relief, and guidance through difficult decisions, showing a deeper commitment to patient wellness [1, 22, 23].

While each concept has unique attributes, they are interconnected and enhance the patient experience, improve outcomes, and establish a culture of respect and benevolence in healthcare.

Importance of kindness in humanized care and gaps in the literature

The rationale for conducting a scoping review on the topic of “kindness in healthcare” is grounded in the recognition of the critical importance of kindness as a fundamental component of high-quality and patient-centered healthcare. Kindness, which includes compassion, empathy, and respect, is not merely a superficial nicety in healthcare but a pivotal component that can significantly influence patient outcomes, staff well-being and the overall quality of healthcare delivery [24].

Kindness is central to the humanization of healthcare, addressing the relational and compassionate dimensions of care. It transcends technical and clinical competencies, creating environments where patients feel valued, respected, and heard. The concept aligns with the principles of humanized care, bridging advancements in medicine with the need for empathy and personalized attention [25].

There is a notable gap in the literature regarding the role and influence of kindness within healthcare organizations. Research has primarily focused on aspects such as humanized care, compassion interventions, and workplace dynamics, but a comprehensive understanding of kindness as a distinct and integral factor in healthcare remains underdeveloped. The following paragraphs highlight key findings from existing reviews on related topics, underscoring the need for further investigation into kindness in the healthcare area.

Bush et al. [25] conducted a systematic review to identify the key elements of humanization of care by analyzing stakeholders’ (patients, caregivers, and healthcare providers) perspectives. These themes are particularly relevant to the study of kindness as they emphasize the relational and organizational dimensions that underpin compassionate and patient-centered care, which are integral to understanding how kindness operates within healthcare settings. The authors identified three descriptive themes (relational, organizational, and structural) and 30 key elements (e.g., relationship bonding, healthcare providers’ personal characteristics, and a holistic approach to medicine). Several obstacles to the implementation of humanization of care emerged from the study. For instance, fragmentation of work processes, lack of time, intense workload, and excessive bureaucratic processes pose significant obstacles to achieving humanized care, according to healthcare providers. The generalization of findings is limited, since most of the reviewed studies were conducted in Brazil (where a National Policy of Humanization of Care and Management was implemented in 2003), though they remain indicative.

More recently, Malenfant et al. [26] conducted a scoping review updating a previous study [22] and explored what is currently known about compassion in healthcare. The review provided information about the impact of clinical and educational compassion “interventions” on medical students, the benefits of integrating compassion in healthcare, and the challenges that may prevent fully achieving this goal.

Hashim et al. [27] also conducted a scoping review on kindness in the workplace in order to counter bullying on the job. They identified elements of kindness and unkindness, and considered how the built environment may affect work happiness. This paper also considered the work environment in general, though the review was not specific to healthcare.

Based on current understanding, there is little evidence-based literature exploring the influence of kindness within healthcare organizations. Our review aims to contribute to the topic by focusing on kindness in the overall health care environment, not just the provider-patient relationship.

The primary objective of this study is to map the existing literature on kindness in healthcare in order to provide an overview of the current state of knowledge on this topic. This includes identifying its defining features, relevance, and impact on staff and patient outcomes, as well as organizational dynamics. This scoping review integrates bibliometric analysis to offer a comprehensive understanding of the construct, addressing gaps in the literature related to organizational dynamics, leadership roles, and team interactions. By exploring these areas, the review underscores kindness's value in advancing healthcare practices and fostering improved patient and staff outcomes.

Methods

This section outlines the systematic approach used to conduct the scoping review on kindness in healthcare organizations, ensuring a comprehensive examination of the literature and a clear presentation of the results.

Our scoping review was conducted using the Arksey and O’Malley framework for analyzing comprehensive texts, to explore the number, scope, and nature of available studies on the impact of kindness in healthcare settings. The findings are presented following the PRISMA Extended Program for Scoping Review (PRISMA-ScR) guidelines. This method involves six steps: 1) defining the research question, 2) identifying relevant studies, 3) setting criteria for study selection, 4) extracting and categorizing key findings, 5) summarizing and reporting the results, and 6) consulting stakeholders (optional) [28].

The goal of a scoping review is to conduct a thorough exploration of texts in a specific area without evaluating the quality of the studies. As a result, qualitative assessments are generally not performed, and studies are not critically analyzed [29].

Each of these steps is detailed below.

Search strategy

A systematic search strategy was developed, in collaboration with a university librarian, to ensure a comprehensive and methodological approach to identifying relevant literature. As a first stage, we searched the databases ScienceDirect, PubMed and Web of science for the date range 1994–2023. Search terms included “kindness”, “compassion”, "empathy” and related terms, combined with “healthcare”, “hospitals” and “healthcare organizations”, and we used Boolean operators (AND, OR) to refine search results.

The decision to use Web of Science as a primary database is supported by its comprehensive coverage of academic journals, conferences, and scholarly literature across various fields of study [30]. Its extensive indexation of reputable peer-reviewed sources ensured that it would contain a vast repository of articles on the topic “kindness in healthcare”. Moreover, Web of Science’s multidisciplinary scope aligns with the interdisciplinary nature of this topic, thus making it a suitable database to retrieve literature from a wide range of disciplines. Of note, Web of Science is considered the most widely used software in the Social Sciences [31].

Moreover, Web of Science incorporates a robust citation indexing system, allowing for the identification of items related to “kindness in healthcare”, thereby facilitating the scoping review’s identification of foundational literature [32].

Elegibility criteria

Inclusion criteria were defined to ensure that relevant literature was collected, while irrelevant sources were excluded.

We adopted an inclusive approach regarding primary and secondary research, including all conceptual papers and articles exploring kindness, empathy, or compassion published in peer-reviewed journals through December 2023.

The definition of the inclusion and exclusion criteria (Table 1) was an iterative process shaped by a series of preliminary searches and discussions to reduce the number of irrelevant articles.

Table 1.

Inclusion and exclusion criteria

Inclusion criteria

▷ Peer-reviewed articles

▷ Based in a healthcare/hospital setting

▷ Focused not only on the provider-patient relationship

▷ Discussed/assessed kindness

▷ Kindness included as part of the study design

Exclusion criteria

▷ Editorials and opinion pieces

▷ Grey literature

▷ Non-English language publications

▷ Published after December 2023

The first criterion, “peer reviewed articles”, excluded commentaries, editorials, calls for papers, and book reviews that did not provide empirical findings, as well as publications from grey literature. The choice to include only peer-reviewed articles was made to ensure the highest level of rigor, credibility, and reliability in the evidence base. Peer-reviewed articles undergo systematic evaluation by experts, which minimizes the risk of errors, biases, or unsupported claims. While recognizing the potential value of gray literature and other sources, their inclusion could have introduced inconsistencies due to varying levels of scrutiny and methodological rigor. This decision also allowed for a more focused analysis, maintaining a manageable scope for the review and prioritizing well-vetted findings. The goal was to provide a scientifically robust overview of the topic, ensuring that the results are relevant and applicable within academic and professional contexts.

The second inclusion criterion required that articles were related to the context of healthcare services (i.e., hospitals, clinics and healthcare facilities). The third criterion sought to ensure that the included articles involved healthcare service providers (rather than only patients and their family members, carers, or the provider-patient relationship). For the purpose of this analysis, we considered service providers to be anyone whose professional role and responsibilities broadly represent the delivery of health and social care services. These could include health and social care professionals, administrative and support staff, and any personnel who can infuence, directly or indirectly, the process or quality of care given to a service user.

Additionally, given our focus on the word “kindness”, its etymology in English, and the various alternative terms used to refer to it (e.g., empathy and compassion), we only considered material written in the English language.

The search string which resulted in the most relevant findings for our review aims was:

• ((TS = (Kindness)) AND TS = (Kindness or humanization or humanisation or civility or empathy or compassion)) AND TS = (healthcare or "health care" or hospital*)

Search and selection process

The search involved a two-stage screening process. In the first stage, two reviewers independently conducted the screening of title and abstract to identify potentially relevant sources. In the second stage, full-text reviews were conducted to assess elegibility based on the inclusion and exclusion criteria. Any discrepancies between the two reviewers were resolved through discussion and consultation with a third reviewer if needed.

Data extraction and synthesis

A standardized data extraction form was developed to collect relevant information from each included publication. Data extraction categories included author(s), publication year, study design, population, key findings, and relevant themes. The data were synthesized using a thematic analysis approach to identify and categorize key themes, concepts, and trends in the literature.

Literature analysis was conducted using Bibliometrix and its web app, Biblioshiny, which are open-source and freely available for use. The Bibliometrix package, written in R, provides a set of tools for quantitative research in bibliometrics and scientometrics. Bibliometrix automates the bibliometric analysis workflow, while Biblioshiny combines the functionality of Bibliometrix with the ease of web apps using the Shiny package environment [33]. The software has been cited as the best application in its category [34].

Quality appraisal

Since this is a scoping review, a formal quality appraisal of the included sources was not conducted. The goal is to comprehensively map the literature rather than to assess the quality of individual studies.

Reporting

Findings will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), guidelines to enhance transparency and rigor in reporting the review results [28].

Ethical considerations

Ethical approval was not required for this scoping review as it involved the analysis of existing literature.

Results

The search, spanning nearly 30 years of publication history across the three selected databases, yielded 299 records. Initially, the search string retrieved 357 documents, but following the application of exclusion criteria, some records were removed: 5 documents outside the period of interest, 22 items categorized as grey literature (including letters, biographical items, book reviews, poetry, and editorial materials), 23 non-English documents, and 8 records with an inadequate Web of Science Index. Only documents classified as Articles, Early Access, or Review Articles were included. As expected, the vast majority of the articles were identified through the Web of Science database, because of that platform’s ability to host multiple research databases and to link an article through both references and citations.

Starting from 299 articles, after removing duplicate records and screening titles and abstracts, the majority of these studies (184 articles) were excluded because they did not meet the inclusion criteria. We focused on the remaining 105 articles. Following title and abstract screening, 57 papers underwent a full text review, after which 38 were excluded. As a result of this process, 19 articles met the inclusion criteria and were included in this review (Fig. 1).

Fig. 1.

Flow diagram of systematic literature search

We found articles written by the same author(s), discussing elements proposed in preceding papers. In these cases, we included only the most recent article, which generally confirmed or further developed the ideas previously proposed. The reference lists of the selected articles were also searched to identify any additional relevant articles (snowballing). However, we did not include any of the papers from the references search, because none of these met the criteria.

The following figures, taken from Bibliometrix version 4.1.3, cover the identification phase of the articles. They illustrate the main information (Fig. 2), the geographic context (Fig. 3), the main journals that have published articles on kindness (Fig. 4) and the number of papers published on the topic by year (Fig. 5).

Fig. 2.

Main information (by Bibliometrix)

Fig. 3.

Corresponding Author’s Countries (by Bibliometrix)

Fig. 4.

Most relevant sources (by Bibliometrix)

Fig. 5.

Annual Scientific Production (by Bibliometrix)

During the period from 1994 to 2023, 299 articles were published in 234 journals by 1′208 authors. The annual growth rate of article production is approximately 10%. Fifteen percent of the papers were written by a single author, while the remaining 85% have an average of 4 authors per article. The keywords chosen by the authors were 937 and the references cited in the articles were 11′962, with 17.28 citations per article. The articles are all fairly recent, published within the last 6 years (Fig. 2).

English speaking countries (the United States, the United Kingdom, Australia, Canada and New Zealand) had the highest number of corresponding authors, followed by Western Europe (Spain, Germany and Italy), then the Middle East (China, Korea and Turkey), which record no collaboration with other countries on this research topic (Fig. 3).

Most of the articles were published by the following journals (Fig. 4): Frontiers in Psychology (8 articles), PLOS ONE (7 articles), Journal of Clinical Nursing (6 articles), BMC Health Research and Mindfulness (5 articles).

In addition to the increased growth of scientific literature on the topic of kindness in health care over the past 10 years, the graph emphasizes the shift from an average of 5 publications (between 1994 and 2012) to a peak of 50 publications in 2022 (Fig. 5).

Figure 6 illustrates the geographical context of the 19 articles included in the research and shows names of authors, year of publication, and location of the study.

Fig. 6.

Articles included in scoping review: the geographic context

For convenience, we grouped the reviewed articles into four categories: 1) organizational culture; 2) burnout reduction and staff well-being; 3) staff education/training; and 4) communication and patient experience of care.

The categories with the highest concentration of articles are: burnout (7 articles), communication/patient experience (6 articles), organizational culture/leadership (4 articles), while education/training shows the lowest concentration (2 articles).

1. Organizational culture and leadership.

In the healthcare sector, an organizational culture that emphasizes both kindness and kind leadership is crucial for fostering a supportive and effective care environment. This category includes the studies analyzing how kindness-related actions and strategies taken by health organizations (with regard to leadership, organizational culture, organizational climate, etc.) may influence the capacity of health workers to provide care and improve the patient experience of care.

According to Jemal et al. [35], a culture of kindness can lead to increased trust and collaboration among healthcare teams, which is essential for providing high-quality patient care. Catlow et al. [36] highlight the point that leadership modelling kindness and compassion can reduce stress and burnout among healthcare workers, leading to improved job satisfaction and higher retention rates. Wei et al. [37] further assert that kind leadership encourages open communication, which is vital for addressing challenges and ensuring patient safety. Moreover, Denier and Gastmans [38] emphasize that a compassionate organizational culture aligns with ethical healthcare practices, enhancing the overall patient experience by ensuring that care is delivered with empathy and respect. Together, these studies underline the significant impact that kindness-centered leadership and culture can have in the healthcare sector, benefiting both caregivers and patients alike.

Kind initiatives in healthcare are not isolated efforts.

Some articles explore the relationship between initiatives promoting kindness and organizational culture and leadership in healthcare. They highlight how these elements interact to create a supportive, and effective healthcare environment [39].

Kindness initiatives encourage a culture of empathy where healthcare professionals are motivated to understand the feelings and experiences of their patients and colleagues. This culture of empathy becomes a core aspect of the organization’s values, influencing how staff interacts with patients and each other. When healthcare organizations promote these values, it encourages staff to speak openly about challenges and concerns, creating an environment where problem-solving and collaboration are prioritized [37].

• 2)Burnout reduction and staff well-being.

Compassion fatigue and burnout for health care workers can affect anyone working with individuals who are experiencing physical and/or emotional stress.

In this group we included articles providing evidence of kindness in the workplace as a strategy to reduce the risks of developing burnout and compassion fatigue among healthcare professionals.

The meta-analysis conducted by Wilkinson, Whittington, Perry, and Eames [40], which carried out a rigorous and systematic exploration of the literature, investigating the relationship between burnout and empathy in the medical and healthcare field, showed interesting results, validating the negative correlation between burnout and empathy in healthcare professions. Higher levels of empathy reduce the level of burnout. The research results in general demonstrate the high levels of burnout affecting healthcare workers and suggest the need for preventative strategies—for example, increasing the levels of empathy for at-risk individuals when it is not possible to make changes in the work. The findings of this review shed light on the importance of kindness for reducing burnout and promoting staff well-being in the healthcare sector. Ward et al. [41] emphasize that a culture of kindness within healthcare settings can lead to significant reductions in burnout by fostering a supportive environment where staff feel valued and understood. Similarly, Soderberg and Romney [42] argue that when healthcare organizations prioritize kindness, it helps create a sense of community and belonging, which is essential for staff morale. Lapaine [43] notes that kind interactions among colleagues can enhance emotional resilience, allowing healthcare workers to cope better with the high stress demands of their roles. Furthermore, Gilligan et al. [44] found that healthcare workers who experience kindness and compassion from their peers and supervisors report higher job satisfaction and lower levels of emotional exhaustion. Wilkinson et al. [40] and Davidson et al. [45] both suggest that leadership practices grounded in kindness not only improve staff well-being but also lead to better patient outcomes, as caregivers are more engaged and present in their work. Seppala et al. [46] highlight the physiological benefits of kindness, including reduced stress and improved health, further underscoring its importance in maintaining a healthy, effective workforce. Collectively, these studies demonstrate that embedding kindness into healthcare practices is significant for reducing burnout and enhancing the well-being of healthcare professionals.

• 3)Staff education / training.

Staff education and training that incorporate kindness as a core element are essential to improve both patient care and employee well-being. Weingartner et al. [47] emphasize that training programs focused on kindness can enhance healthcare professionals’ ability to communicate empathetically, which is crucial for building trust and rapport with patients. Such training also prepares staff to handle challenging situations with compassion, thereby reducing conflict and improving patient satisfaction. Arthur et al. [48] further highlight that integrating kindness into healthcare education fosters a positive organizational culture where staff feel supported and valued. This supportive environment not only enhances teamwork and collaboration but also contributes to the mental and emotional resilience of healthcare workers. By prioritizing kindness in education and training, healthcare organizations can ensure their staff are equipped to provide compassionate care, ultimately leading to better patient outcomes and a healthier, more engaged workforce.

• 4)Communication and patient experience.

Kindness between staff members and the patient will promote better emotional connection and greater understanding, which will build trust, improve health outcomes, and lower patient anxiety. Uncaring actions by just one staff member can ruin a patient’s experience. Small gestures such as a smile, a warm tone of voice, and empathetic listening are facets of patient-centered care and can make the difference in patients’ perception [5]. A patient-centric approach to healthcare, involving kindness, empathy, and compassion, is considered paramount to providing the highest quality of healthcare.

Effective communication, grounded in kindness, is fundamental to enhancing patient experience in healthcare settings. Hake and Post [5] highlight that when healthcare professionals communicate with kindness and empathy, it significantly improves patient satisfaction and trust, as patients feel more understood and valued. McKinnon [49] confirms this and further notes that kind communication helps alleviate patient anxiety, making them more comfortable and engaged during medical interactions. Chen et al. [39] found that when healthcare providers use a kind and empathetic approach, it can lead to better patient adherence to treatment plans, as patients are more likely to follow advice from caregivers who show genuine concern for their well-being. Herbland et al. [50] emphasize that kind communication is crucial to managing difficult situations, such as delivering bad news, ensuring that patients feel emotionally supported throughout their healthcare journey. Rider et al. [51] suggest that training healthcare staff in kind and compassionate communication can improve overall patient outcomes by fostering a more caring and collaborative environment. Fujita et al. [52] point out that kind interactions not only enhance patient experience but also reduce the likelihood of conflicts and complaints. Collectively, these studies demonstrate that kindness in communication is a vital component of patient care, leading to better health outcomes and more positive healthcare experiences.

Table 2 shows the results of the search across the resulting categories.

Table 2.

Summary of the reviewed studies

Study	Journal	Title	Objective	Setting	Participants	Research design / Method	Outcomes / Findings
Category 1) Organizational culture and leadership
Jemal et al. (2021) [35]	Journal of Public Health	The importance of compassion and respectful care for the health workforce: a mixed-methods study	To assess the practice of compassionate and respectful care and its associated factors among the health workforce (HWF)	Four hospitals and six health centers (in North Shewa Zone, Ethiopia)	398	A mixed study was conducted through quantitative and qualitative data collection from April to May 2019 in health care facilities. For quantitative analysis, participants were selected using a systematic random sampling technique. Participants for qualitative analysis were selected using a purposive sampling technique. Bivariable and multivariable logistic regression analyses were performed to determine the associated factors. Thematic analysis was carried out for qualitative data	A total of 392 HWF respondend to a self-administered survey, and 72 participants were involved in focus group discussions. Four categories of themes emerged: definition/knowledge, barriers, benefit, and leadership will. The prevalence of compassionate and respectful care practices was 38.8% and 46.2%, respectively. The age category of 30–39, positive attitude, and ensuring a safe and clean environment were significantly associated with respectful care practice. Findings suggest that compassionate and respectful care (CRC) among HWF requires an actual demonstration of humanity and kindness to promote person-centered practice for their clients. Therefore, CRC continuity should be enphasized by including it in the health care curriculum, improving the health care ethics skill gap, designing appropriate policy to reduce workload, and promoting patient rights
Catlow et al. (2020) [36]	International Journal of Orthopaedic and Trauma Nursing	Empathy in Action in Healthcare (EACH): A mixed methods study of nurses' and therapists' empathy	To investigate nurses' and therapists' empathy levels and to explore their views regarding its impact on clinical decision making at a national specialist orthopaedic centre	A national specialist orthopaedic centre (England)	126	A mixed-method analysis was conducted. Data were collected from 126 respondents using an online validated empathy scale (Jefferson scale) supplemented by interviews with a convenience sample of 20 respondents. Questionnaire data were analysed using descriptive and inferential statistics. Qualitative interview data were subjected to a standard process of inductive thematic analysis prior to seeking relationships between the two datasets	There was a statistically significant difference in empathy levels between nurses and therapist, with nurses scoring lower than therapists. Interview findings identified four key themes; displaying empathy, therapeutic use of self, influences and impacts, an learning. Differences between empathy scores and participants' subjective accounts of empathy were apparent. Empathy is an important construct built upon personal and professional experiences. Previous research reports empathy as a positive tool, however, data from this study suggest that its inappropriate use might also have a negative impact on service delivery and health outcomes
Wei et al. (2020) [37]	Journal of Interprofessional Care	A culture of caring: the essence of healthcare interprofessional collaboration	To investigate healthcare professionals' perspectives on ways to promote interprofessional collaborative practice (IPCP)	A university-affiliated hospital on the east coast of the United States	36	A qualitative descriptive study	The findings indicated that the underlying facilitator of IPCP was a culture of caring -human connections among interprofessional team members. The culture of caring could be fostered through five processes: building caring relationships, developing an ownership mentally, providing constructive feedback, applying the strengths-based practice, and acting as the first and last lines of defense. Creating a caring culture is a dynamic process requiring all team members' efforts
Denier and Gastmans (2013) [38]	Social Science & Medicine	Realizing good care within a context of cross-cultural diversity: An ethical guideline for healthcare organizations in Flanders, Belgium	To develop an ethical guideline for cross-cultural healthcare on the organizational level for improving quality and eliminate ethnic disparities in healthcare	Flanders, Belgium	Non specified	Quantitative analysis. A Delphi consensus was conducted	A guideline providing an ethical framework within which various cross-cultural issues in particular healthcare organizations can be dealt with. As such, the guideline challenges healthcare professionals and management to actively focus at the theme by offering the ethical tools to develop their own ethics policy concerning cross-cultural care. The guideline shapes the organizational preconditions for culturally competent care to take place in the clinical context
Category 2) Burnout reduction and staff well-being
Ward et al. (2022) [41]	BMJ Open	The kindness COVID-19 toolkit: a mixed-method evaluation of a programme designed by doctors in training for doctors in training	To evaluate and explore the impact of the COVID-19-specific well-being programme, as a whole, on the cohort of obstetrics and gynaecology (O&G) doctors in training (DiT)	Melbourne, Australia between September 2000 and April 2021	55	The authors conducted a mixed-methods analysis A quantitative evaluation was conducted on the WHO Well-being Index (WHO-5) and Copenhagen Burnout Innovatory (CBI) measures that were administered prior to and at multiple time points following the programme For the qualitative analysis, the authors used the Most Significant Change (MSC) technique	The study suggests an overall 31.9% improvement in well-being scores. The MSC evaluation captured a shift in workplace culture as a result of the programme, with improvement across the domains of connection, caring, communication, confidence and cooperation
Soderberg and Romney (2022) [42]	Business Horizons	Building trust: How leaders can engender feelings of trust among followers	To explore what leaders can do to generate trust among the individuals within their organizations to help facilitate better relationships and positive outcomes for both individuals and organizations	An elderly care center located in the Midwestern United States	27	A qualitative study in which semi-structured interviews with employees at an assisted-living care facility highlights two ways that leaders can build trust within their organizations: (1) by demonstrating humility in their communication and (2) by exhibiting compassion in their behavior	By making humility and compassion part of how they lead, leaders and managers can more successfully generate feelings of trust among the individuals within their organizations and help their organizations to maintain and strengthen their competitive advantage
Lapaine (2021) [43]	Healthcare Management Forum	Embracing the Quadruple Aim: One hospital's experience	To investigate the relationship between burnout and empathy in healthcare staff	A hospital (Bluewater Health) in Ontario, Canada	Non specified	A case study was conducted (qualitative analysis). The hospital used the Quadruple Aim since 2016 (to improve patient health outcomes, improve patient experience, reduce costs, and improve the experience of clinicians) to foster employee engagement	By pursuing the Quadruple Aim and working to improve employee engagement, Bluewater Health has succeeded in improving patient outcomes and experience and reducing costs. Bluewater Health's experience has demostrated that focusing on employee experience and engagement will help achieve everything in the Quadruple Aim
Gilligan et al. (2019) [44]	Patient Education and Counseling	Views of institutional leaders on maintaining humanism in today's practice	To explore leadership perspectives on how to maintain high quality efficient care that is also person-centered and humanistic	Seven U.S. medical school	32	The authors interviewed and collected narrative transcripts from a convenience sample of 32 institutional healthcare leaders at seven U.S. medical schools. The institutional leaders were asked to identified factors that either promoted or inhibited humanistic practice. A subset of authors used the constant comparative method to perform qualitative analysis of the interview transcripts. They reached thematic saturation by consensus on the major themes and illustrative examples after six conference calls	Institutional healthcare leaders supported vision statements, policies, organized educational and faculty development programs, role modeling including their own, and recognition of informal acts of kindness to promote and maintain humanistic patient-care. These measures were described individually rather than as components of a coordinated plan. Few healthcare leaders mentioned plans for organizational or systems changes to promote humanistic clinician-patient relationships
Wilkinson et al. (2017) [40]	Burnout Research	Examining the relationship between burnout and empathy in healthcare professionals: A systematic review	To conduct a systematic exploration of the literature investigating the relationship between burnout and empathy in healthcare staff	Multisite (Japan, Spain, Poland, France, Korea, Italia and U.S.A	Non specified	A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance	Ten studies were reviewed. Eight of them provided empirical support for a negative relationship between empathy and burnout. One study provided support for a positive relationship between burnout and empathy. One study reported contradictory evidence with positive and negative correlations between different subscales of the empathy and burnout measures
Davidson et al. (2017) [45]	Explore	Code Lavender: Cultivating intentional acts of kindness in response to stressful work situations	To test the feasibility of providing Code Lavender	A university teaching hospital in San Diego, California	500	A mixed method analysis was conducted. Pilot program testing and evaluation. Staff and physicians on four hospital units were informed of the Code Lavender kit availability, which includes words of comfort, chocolate, lavender essential oil, and employee health referral information. Feasibility data and ProQoL scores were collected at baseline and three months	At baseline, 48% of the participants reported a stressful event at work in the last three months. Post-intervention, 51% reported experiencing a stressful workplace event, with 32% receiving a Code Lavender kit from their co-workers as a result. Of those who received the Code Lavender intervention, 100% found it helpful, and 84% would recommend it to others. No significant changes were demonstrated before and after the intervention in ProQoL scores or job satisfaction, however the emotion of feeling cared-for improved
Seppala et al. (2014) [46]	Journal of Compassionate Health Care	Loving-kindness meditation: a tool to improve healthcare provider compassion, resilience, and patient care	To address two questions: 1. can even a short compassion-inducing exercise (e.g., LKM) that is sufficiently time-effective (10 min) to fit into even the busiest of schedules produce reliable and meaningful changes in affective responding to others, even strangers? 1. How does LKM compare to other forms of affective interventions in its effectiveness?	Stanford University	134	A quantitative method was conducted The effectiveness of a short, 10-min session of loving-kindness meditation (LKM) to increase compassion and positive affect was assessed comparing LKM to a non-compassion positive affect induction (PAI) and a neutral visualization (NEU) condition. Self- and other-focused affect, self reported measures of social connection, and semi-implicit measures of self-focus were measured pre-and post-meditation using repeated measures ANOVAs and via paired sample t-tests for follow-up comparisons	Findings show that LKM improves well-being and feelings of connection over and above other positive-affect inductions, at both explicit and implicit levels, while decreasing self-focus in under 10 min and in novice meditators Findings suggest that LKM may be a viable, practical, and time-effective solution for preventing burnout and promoting resilience in healthcare providers and improving quality of care in patients
Category 3) Staff education / training
Weingartner et al. (2019) [47]	BMC Medical Education	Compassion cultivation training promotes medical student wellness and enhanced clinical care	To strengthen student compassion, kindness, and wellness through compassion training and mindfulness meditation training modeled by a faculty instructor. The research objectives were understand students' application and perceptions of this training	The University of Louisville School of Medicine (USA)	45	Over three years, 45 students participated in the elective at the University of Louisville School of Medicine. The course administered a pre/post Kentucky Inventory of Mindfulness Skills that measured observing, describing, acting with awareness, and accepting without judgement Qualitative analyses of self-reported experiences were also used to assess students' perceptions of compassion training and their application of skills learned through the elective	The mindfulness inventory showed significant improvements in observing and accepting without judgment skills for some elective cohorts. Qualitative data indicated that students across all cohorts found the elective rewarding, and they used mindfulness, meditation, and compassion skills broadly outside the course. Students described how the training helped them address major stressors associated with personal, academic, and clinical responsibilities. Students also reported that the new skills strengthened interpersonal interactions, including with patients. These outcomes illuminate students' attitudes toward compassion training and suggest that among receptive students, a brief, student-focused intervention can be enthusiastically received and positive influence student's compassion toward oneself and others
Arthur et al. (2017) [48]	Health Soc Care Deliv Res	Can Healthcare Assistant Training improve the relational care of older people? (CHAT) A development and feasibility study of a complex intervention	To assess the feasibility of a cluster randomised controlled trial to compare the performance of an HCA training package in relational care against current training in improving the care of older patients in acute NHS settings	Wards within three acute NHS Hospital Trusts in England	Non specified	A quantitative analysis was conducted A pilot cluster randomised controlled trial conducted to compare a healthcare assistant (HCAs) training package in relational care with HCA training as usual Semi-structured interviews of a purposive sample of healthcare assistants receiving the intervention, and all trainers delivering the intervention, will be undertaken to gain insights into the experiences of both the intervention and the trial, and its perceived impact on practice	The study suggests the viability of a definitive cluster randomised controlled trial of a new training intervention to improve the relational care provided by healthcare assistants working with older people in hospital
Category 4) Communication and patient experience
Hake and Post (2023) [5]	PLoS One	Kindness: Definitions and a pilot study for the development of a kindness scale in healthcare	One, to set forth a rigorously defined explanation of kindness. Two, to use that definition to compile a list of potential scale items about kindness and design a pilot cross-sectional clinical study to correlate them to a patient's subjective perception of physician kindness. Three, to use this pilot study to evaluate the correlation between a perception of kindness and the patient's subjective perception of care and trust in their physician	Stony Brook Hospital	45	A mixed method was conducted A literature search was performed to rigorously define kindness. A kindness scale based on this definition was then compiled and administered to 45 patients across three outpatient clinical settings to evaluate the association between several actions and the patient's perception of kindness	Kind actions are small, take little effort, and are short in duration to their intended effect. The results indicate several actions such as greeting the patient with a smile, asking questions about the patient's daily life, listening carefully, and appearing interested in the patient have a moderate strength correlation to a perception of kindness. The physician being perceived as kind also has a weak-moderate strength correlation to the patient subjectively reporting improvement after their visit
McKinnon (2022) [49]	Asia Pacific Viewpoint	Positioning kindness and care at the centre of health services: A case study of an informal health and development programme oriented to surviving well collectively	To explore how a project with a different approach to health centres relationality, colectivity and an ethic of kindness; and to discusses the advantages of being relationship based, small and informal	Remote rural health centres in Luang Prabang Province, in northern Laos	Non specified	A qualitative analysis (case study) was conducted). Two training programme were run in January–February 2019 and 2020. Then, an ethnographic approach was taken to the evaluation of the training programme, using participant observation during the two-to three week training periods in 2019 and 2020, with informal and open-ended interviews conducted with key stakeholders involved in delivery of health care in Luang Prabang Province. Observations took place during formal training sessions held at two district hospitals in 2019 and 2020, and one Provintial Health Clinic in 2019	The training programme was able to orient to building skills for sufficient care, with a ethic of kindness, in circumstances which are unlikely to be ideal The analysis provides a way to foreground how practices that create and maintain human lives and livelihoods, are always already, entangled with relationships of care
Chen et al. (2021) [39]	International Journal Environmental Research and Public Health	Effects of Loving-Kindness meditation on doctors’ mindfulness, empathy, and communication skills	To explore and examine the effects of loving-kindness meditation (LKM) on doctors' mindfulness, empathy, and communication skills	A hospital in China	106	A quantitative analysis was conducted Participants were randomly divided into an LKM training group (n = 53) and waiting control group (n = 3). The LKM training group received 8 weeks of LKM training intervention, whereas the control group received no intervention. Three major variables (mindfulness, empathy, and communication skills) were measured before (pre-test) and after (post-test) the LKM training intervention	The empathy and communication skills of the LKM group were significantly improved compared with those of the control group, but the level of mindfulness did not significantly change.The results suggested that LKM may contribute to improving physicians' empathy and communication skills
Herbland et al. (2017) [50]	Intensive and Critical Care Nursing	Thank you letters from patients in an intensive care unit: From the expression of gratitude to an applied ethic of care	To analyse the thank you letters from patients who required intensive care treatment and to identify messages that could be intended for the intensive care unit team	The medical-surgical intensive care unit of a French general hospital	Non specified	A qualitative study according to a thematic analysis. The body of research consisted of 17 letters from patients hospitalised in intensive care unit (it is made up 16 resuscitation beds and four continuous monitoring beds)	Two main themes emerged: (i) expression of gratitude through a description of the caregivers' behaviour (humanity and professionalism) and recognition for surviving (ii) the narrative of the intensive care unit experience Thank you letters give a rich insight into how the patients perceived their stay in intensive care unit. Letters from patients give direct feedback on the quality of care provided, contribute to give meaning work and raise the question of what the core values of care should be for all concerned in the healthcare providers-patients relationship
Rider et al. (2014) [51]	Patient Education and Counseling	The International Charter for Human Values in Healthcare: An interprofessional global collaboration to enhance values and communication in healthcare	To describe the development of the International Charter for Human Values in Healthcare which delineates core values, articulate the role of skilled communication in enacting these values, and provide examples showing translation of the Charter's values into action	The First International Symposium and Roundtable on Healthcare Communication (at Hong Kong Polytechnic University)	30	A mixed-method analysis was conducted. The authors describe development of the Charter using combined qualitative research methods and the international, interprofessional collaboration of institutions and individuals worldwide	Five fundamental categories of human values for every healthcare interaction were identified (compassion, respect for persons, commitment to integrity and ethical practice, commitment to excellence, and justice in healthcare), and subvalues within each category were also delineated. The Charter was disseminated internationally and incorporated into education/training
Fujita et al. (2012) [52]	Midwifery	Humanised care and a change in practice in a hospital in Benin	To describe the process of introduction and implementation of humanised care (humanised childbirth); to determine how the practice of humanised care affects midwifes, obstetricians and other service providers in the hospital, and to determine the factors influencing the change in practice	A hospital in Benin (Africa)	16	A qualitative study with grounded theory approach. A semi-structured, in-depth individual interview was conducted for data collection with open coding and a constant comparative analysis until the saturation of concepts	Humanised care appears to affect the professional value of midwives, their levels of job satisfaction, and their personal motivation for work towards improving their performance. A positive influence on obstetricians and other staff was observed. These individuals were inspired to make changes in hospital culture to improve care, to avoid unnecessary interventions, and to improve communication. Important factors in achieving favourable results were the leadership and commitment of the hospital management team and the recognition and support they extended towards the hospital staff, especially the midwifes

Discussion

The role of kindness in healthcare is increasingly recognized as a vital component of patient care and overall healthcare delivery. However, the scope and impact of kindness in this context are not well understood, with existing research scattered across various studies and disciplines. Conducting a scoping review on the role of kindness in healthcare will provide a comprehensive overview of current knowledge, identify gaps in the literature, and establish a clearer understanding of how kindness can improve patient outcomes, enhance caregiver-patient relationships, and contribute to a more empathetic and compassionate healthcare environment. The goal of this review is to map existing evidence and identify areas that need further exploration.

Practical implications

In a world marked by competitiveness and the pursuit of productivity, fostering kindness in organizations is essential.

One of the most effective ways to foster kindness in organizations is through training in empathy and emotional intelligence – the ability to recognize and understand emotions in oneself and others, and the ability to use this awareness to manage one’s own behavior and relationships – [53]. Through workshops, seminars, and coaching sessions, employees can develop a deeper understanding of their own emotions and learn how to relate to the emotions of their colleagues. Empathy and emotional intelligence training not only improve individual relationships but also contribute to a more compassionate workplace culture.

Recognition programs are also powerful tools for fostering kindness and appreciation in the workplace. These initiatives can take various forms such as employee of the month awards, peer to peer recognition, or simple thank-you cards. Recognizing and appreciating employee’s efforts and contributions not only boosts morale but also encourages a culture of gratitude and kindness.

Encouraging and celebrating random acts of kindness within the workplace can have a significant impact. This might include surprise treats, kind notes, or simple acts of helpfulness. Creating a “pay it forward” culture fosters an environment where kindness becomes contagious.

Kindness can also be expressed through flexible work policies, which allow employeees to balance their work and personal lives. Initiatives such as flexible work hours, telecommuting, and paid time off for personal matters demonstrate an organization’s understanding and support for employee well-being.

Conflict is inevitable, but how conflicts are addressed can greatly impact workplace culture. Formal conflict resolution and mediation programs can help resolve issues with kindness and empathy, thereby promoting a more harmonious work environment.

Leadership training programs that emphasize kindness, empathy, and servant leadership principles can have a profound effect on an organization’s culture. When leaders model kindness, it sets the tone for the entire organization, promoting respectful and considerate interactions [54].

In summary, fostering a culture of kindness in healthcare requires a collective effort from all stakeholders. From the literature reviewed, we found these key strategies to promote kindness within the healthcare system:

1. Education and training: incorporate kindness and empathy training into the curriculum for healthcare professionals [55]. Encourage them to practice active listening, effective communication, and emotional intelligence [47, 48].

2. Leading by example: healthcare leaders and managers should lead by example. When kindness is evident in leadership, it permeates the entire organization [42, 44, 56].

3. Patient-centered care: emphasize patient-centered care, where the patient’s well-being, preferences, and values are at the forefront of decision-making. Encourage healthcare providers to involve patients in their own care [43, 57].

4. Feedback and evaluation: implement systems for patients to provide feedback on their healthcare experiences. Constructive feedback should be used to continuously improve the quality of care and ensure that kindness remains a priority [5, 50].

5. Support for healthcare workers: recognize the emotional toll that healthcare work can take on healthcare professionals and offer support services and programs to help them cope with stress and burnout [40, 45, 46, 58].

There are two additional key strategies, not mentioned in the 19 review articles, but relevant according to the authors for their practical implications. Their absence in the scoping reviews highlights the need for future studies to investigate and explicitly connect these areas to kindness policies. The two strategies are:

• 6)Psychological safety and a “no blame culture” workplace of learning from mistakes and critical incidents. Creating psychological safety at work provides an opportunity for learning and helps build a culture of growth and innovation. In addition, research literature suggests that learning from mistakes, and a culture aimed at preventing mistakes (a just culture) rather than criminalizing them (a blame culture), promote patient safety, facilitate new insights and lead to professional development [59].
• 7)Environmental responsibility and waste reduction: waste reduction and kindness are intertwined in fostering a more sustainable and compassionate world. By minimizing waste in our daily lives, whether through recycling, composting, or mindful consumption, we not only lighten our environmental footprint but also demonstrate kindness towards future generations and the planet. Choosing reusable alternatives or supporting initiatives that promote waste reduction exemplify acts of kindness that benefit both the environment and communities [24, 60].

Knowing all these key strategies for promoting kindness and their outcomes can support healthcare institutions and managers in making informed decisions about interventions to implement in this area.

Implications for research

According to the results of our review, we observed that there is currently a huge fragmentation in editorial placement. The high number of authors compared to the number of published articles also suggests that each author has probably written an impromptu article on kindness in health care or that the latter is not the main research topic for these authors. At the same time, the average age of articles shows that this is a relatively young topic, yet one of great scientific interest (significant number of authors interested in the topic, a high number of unique keywords and bibliographic references, a high average number of citations, and a sustained annual growth rate of publications), for which international collaboration has not yet taken off (only 18.06% are Multiple Country Publications).

In light of the above findings and considerations, one could imagine a Special Issue on the topic in a scholarly journal, in which contributions from different perspectives could be collected.

In relation to the 19 articles included in the study, we also checked whether there were differences in content and method depending on the setting of the study.

At the level of content covered, it appears that English speaking countries are mainly interested in the topic “Burnout reduction and staff well-being” (category 2), while in China the main interest is in “Communication and patient care experience” (category 4). Finally, in Europe there is no specific topic of interest: articles written during the reporting period covered the following three categories: Organizational culture and leadership (category 1), staff education/training (category 3), and category 4. Regarding methodology, in English speaking countries most studies primarily used qualitative methods. For the other countries, given the small numbers, we cannot say whether there is a favored method.

The predominance of authors from Commonwealth and Latin countries, as opposed to those from Northern Europe, could be a topic for future research. This investigation could explore potential relationships with the cultural, linguistic, and healthcare approaches characteristic of a specific country (or group of countries).

For example, it could be investigated whether countries with more industrialized healthcare systems demonstrate greater interest in the topic due to a perceived need for increased humanization of care. Alternatively, it could be explored whether the countries more interested in kindness are those with a more developed culture of relationship marketing, inspired by the Nordic School of Services, as conceptualized by Gummesson and Gronroos [61]. In such contexts, healthcare personnel assume the dual role of caregiver and promoter of relationship quality, aiming to enhance the perceived quality of care by patients and families, improve the hospital’s reputation, and ultimately achieve higher service volumes and better financial results. This is particularly relevant in countries where market-based incentives are present in healthcare, where patients pay for health insurance, and where supply exceeds demand and there are no waiting lists.

Furthermore, as the body of literature on kindness in healthcare expands, future research may also yield insights into the reasons behind differences in study methodologies and the specific topics preferred by different countries.

Finally, indicators could be defined in the 4 categories considered and compare the performance of health care organizations that promote kindness versus those that do not.

Limitations

The search was limited to peer reviewed articles, which may have resulted in the exclusion of potentially valuable documents. To mitigate this risk, we decided to review the abstracts of 22 documents classified as grey literature. In our study, we included reflections from the only document we deemed relevant (specifically, Campling [2]).

Another limitation is the lack of a formal quality assessment of the included studies. To address this limitation, during the identification phase, we decided to include only documents classified as Articles, Early Access, or Review Articles and indexed in SCI-EXPANDED, ESCI, or SSCI. This ensured greater homogeneity in selection criteria, higher source quality, and greater scientific relevance of the results. These indices are widely recognized as standards of quality and scientific impact.

Conclusion

Kindness is an essential element that can lead to better patient outcomes, improved healthcare experiences, and the establishment of trust and rapport between patients and healthcare providers, increased employee satisfaction, better teamwork, lower turnover rates, and enhanced productivity.

This study analyzes key characteristics of scholarship on kindness in healthcare, identifying it as an emerging and growing topic.

The need for additional research arises therefore from a complex and dynamic healthcare environment, where kindness holds the potential to transform the healthcare landscape and revolutionize not only the quality of care but also the well-being of healthcare providers.

While the existing body of literature provides valuable insights into the importance of kindness in healthcare settings, it is evident that further research is not only warranted, but imperative to improve healthcare practice, patient experience and the overall effectiveness of healthcare organisations.

The literature review also highlights potential reasons why certain countries appear to show greater interest in kindness within healthcare and reveals variations in the specific areas of focus, such as organizational culture (1), burnout reduction and staff well-being (2), communication and patient experience (3), staff education and training (4), and analytical methodologies. These differences bear further investigation.

Finally, this study recommends that journals focused on healthcare consider dedicating a special issue to this subject.

Authors’ contributions

A.G. conceptualized the study and together with L.G.G.O. conducted the investigation and the study design, wrote the main manuscript text and prepared Figs. 1, 2, 3, 4, 5 and 6 and Tables 1 and 2. L.G. collaborated in the revision of the original draft and D.L. conducted a further final review of the draft. All authors read and approved the final manuscript.

Funding

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Are not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.