Feasibility of a compulsory online compassion training module in final year medical student curriculum

Abstract

Background

Psychological distress among medical students and junior doctors is a significant concern, with burnout and mental health issues being common. Compassion training has shown promise in improving psychological well-being among healthcare workers, including medical students, and has been shown to mitigate empathic distress and burnout. However, few studies have explored the feasibility and student perceptions of integrating compulsory compassion training in medical curricula. This study aimed to assess the feasibility of a compulsory online compassion training module as part of the final-year medical student curriculum.

Methods

A survey-based evaluation of 306 respondents, made up of final-year medical students participating in the Compassion Training for Healthcare Workers (CTHW) course, was conducted. The CTHW course was provided as an online asynchronous self-paced module in four modules over four weeks, each covering approximately two hours of content. Quantitative data obtained via Likert scale surveys and qualitative data obtained via open-ended responses were collected from a student survey. Descriptive and inductive content analyses were conducted to examine the responses.

Results

The majority of students responded positively to the module, appreciating the content, variety of teaching media, discussion forums, and practical strategies learned. The students emphasized the importance of compassion in healthcare and reported a positive shift in attitudes toward compassion. Although some students suggested a preference for face-to-face components, the online asynchronous format was well received for its flexibility and self-paced learning.

Conclusion

This study demonstrates the feasibility and positive reception of incorporating a compulsory online compassion training module into the final-year medical student curriculum.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08220-5.

Background/Introduction

Compared with the general community, medical students and junior doctors face high rates of psychological distress [1, 2]. Compassion training is a promising intervention found to improve wellbeing and quality of care amongst healthcare workers [3, 4]. Compassion is a key predictor of quality healthcare [5] and is associated with improved patient satisfaction and health outcomes [6–8]. Importantly, healthcare workers are calling for compassion training to be included in medical education [9].

The Australian Medical Association recommends that medical schools “ensure medical students are educated to enable them to effectively maintain their health and well-being.” [10] Dyrbye, Thomas [11] found up to 47% of the medical students surveyed reported burnout. These rates are found to be even higher at 68–75% among junior doctors, with up to 73% reporting psychiatric morbidity during their internship [12, 13]. Such findings suggest a significant deficiency in the training of medical students to optimize their capacity to manage the future psychological demands of the job. Burnout negatively impacts job performance, increases medical errors, and worsens patient care and satisfaction [14–17]. This represents a clear motivation to develop and implement interventions to promote well-being and improve psychological health within medical education.

Compassion training has been found to not only increase levels of compassion but also decrease anxiety; increase calmness, happiness, and emotional regulation; and enhance mindfulness [4, 18–21]. It has been shown to mitigate empathic distress, a significant factor contributing to the poor state of psychological wellbeing among healthcare workers [22]. Empathic distress can be described as “a strong aversive and self-oriented response to the suffering of others, accompanied by the desire to withdraw from a situation.” [18] Brain imaging studies have shown that compassion can downregulate areas associated with negative emotions and withdrawal in empathic distress and upregulate areas associated with positive emotions and increased prosocial behavior [18, 23, 24].

Systematic reviews suggest that compassion can be enhanced in doctors and medical students through training in medical education [25, 26]. However, little research has explored the feasibility and student perceptions of integrating compassion training into medical curricula. A study on a small cohort of self-selected students showed promising results [27]. Students enjoyed the training and reported using the learned skills broadly outside the course, helping them “address major stress…[and] strengthen interpersonal relationships, including with patients” [27]. The students in the study expressed uncertainty as to whether compassion training should be included as a compulsory component of the course, as it might lead to resentment from nonreceptive students [27].

The Monash medical course is comprised of a five-year undergraduate program and a four-year postgraduate program. The two programs combine for the final three years of the course. The curriculum is best described as an integrated spiral curriculum, with the first year (postgraduate) or two (undergraduate) delivered on university campus with an emphasis on foundational biomedical sciences. The latter three years, predominantly based in health services, focus on immersive clinical learning. In this study, compassion training was included as a compulsory component in the final year of this curriculum. It was delivered as an online asynchronous course, a teaching medium proven to be successful in the past [28, 29]. This study is designed to discover how a large cohort of medical students respond to the addition of a compulsory online compassion training module as part of the final-year medical student curriculum.

Methods

Description of the intervention

The compassion training course was adapted from the Compassion Training for Healthcare Workers (CTHW) developed by the Faculty of Medicine, Nursing and Health Sciences (FMNHS) in collaboration with the Monash Centre for Consciousness and Contemplative Studies (MC3S) at Monash University. The course was provided to medical students as an online, asynchronous, self-paced course over four weeks. It was divided into four modules, each covering approximately two hours of content. Each module included recorded discussions, reading materials, reflective and contemplative activities, moderated discussion forums with weekly feedback videos and a quiz. The course culminated in a live webinar so that students could interact more directly with presenters and facilitators, share insights and experiences, and ask questions. The CTHW learning objectives are set out in Table 1.

Table 1.

Compassion training for healthcare workers’ learning objectives

1. Increase understanding of compassion, how to support it and the science that underpins it.

2. Teach how to transform empathy into compassion to avoid accidentally going into empathic distress.

3. Provide strategies for managing when compassion is challenging.

4. Recognize and enhance the five moments of compassion.

5. Strengthen the perception of common humanity to help cultivate compassion for anyone.

6. Develop routines to sustain compassion in day-to-day work for increased wellbeing, improved patient care and greater job satisfaction.

Study design

The study employed a survey-based evaluation. A feedback survey was built into the course designed to gain feedback about the educational intervention. It was a compulsory component of the unit, and students could give consent for their responses to be used for research purposes. The survey consisted of questions (Appendix 1) using Likert scales and free-text open-ended responses.

Data collection

Data was collected from students who completed the compassion training course by the 12th of June 2023. Seven students completed the course evaluation after this date and were not included in this dataset.

The survey included ten questions with Likert scale responses (Appendix 1) assessing the students’ general evaluation of the course (Appendix 1, A), each individual module (Appendix 1, B) and the amount of content (Appendix 1, C).

Open-ended responses were also collected to answer the following questions:

(1) What did you enjoy most about the course? (2) Are there any other topics you would like to see included? (3) What improvements would you suggest for this course? (4) Who would you recommend this course to?

Data analysis

Descriptive analysis of the quantitative data was performed with SPSS Version 29. The frequency results of all the Likert scale responses were produced. Items from the Likert scale responses were summed to create a total score for each participant. Outliers among the total scores were identified, and Spearman correlations were performed to look at relationships between individuals’ total score and their evaluation of the amount of content.

The qualitative data from open-ended free-text responses were downloaded to NVivo 14 to aid in data management and coding. Inductive content analysis was used to develop themes from the students’ survey responses. Author PD, a final year medical student at Monash University was supervised by CB and CH, senior research staff at Monash university with experience in qualitative research. PD read responses and developed a preliminary coding framework from free-text responses, iteratively refining the codes on the basis of comparisons between different participants [30]. This initial coding framework was discussed in depth with CB and CH and refined, and the data re-coded. These codes were then organized into themes. The frequency of reference to the codes was assessed via a quantitative content analysis methodology to determine the most common sentiments and perceptions of the students completing the feedback survey [30].

Results

Participants

Survey data from 306 respondents of the 482 students who completed the course were available for analysis. The response rate was 63%. The students were all in their final year of medicine from the Australian (73%) and Malaysian (27%) campuses of Monash University.

The curriculum is the same in Malaysia and Australia. The Malaysian cohort is undergraduate, whereas the Australian campus has 80% undergraduate and 20% postgraduate. Both the Australian and Malaysian cohort has international students, 24% and 14% respectively. The local and international students come from a broad range of cultural backgrounds. Proportionally, the response rate was similar between Australian (63%) and Malaysian (65%) campuses.

Quantitative results

Most students responded positively to the course. The question evaluating the teaching staff and presenters had the highest rating, with a mode score of 5 (Strongly Agree) (Table 2). The median response was 4 (agree) for each of the other general evaluation questions and 4 (very useful) for each question evaluating the individual modules. The live Q & A webinar scored lower and had a median rating of 3 (moderately useful).

Table 2.

Measures of central tendency likert scale responses

General Evaluation	N		Median	Mode
	Valid	Missing
The course has improved my understanding of compassion, avoiding empathic distress, managing when compassion is challenging and sustaining compassion in my daily work.	306	0	4.00	4
The online resources and activities have improved my skills and knowledge to maintain best practice.	306	0	4.00	4
The teaching staff and presenters were enthusiastic, knowledgeable, and provided me with useful advice.	306	0	4.00	5
The online program was well organized and well-administered.	306	0	4.00	4
Individual Module Evaluation
Week 1: Introducing compassion	306	0	4.00	4
Week 2: Barriers to compassion	306	0	4.00	4
Week 3: Common humanity	306	0	4.00	4
Week 4: Sustaining compassion	306	0	4.00	4
Week 4: Live event (online workshop)	306	0	3.00	3

The responses to the general evaluation questions were originally collected on a five-point Likert scale. These were simplified to a 3-point scale (Table 3) to aid interpretation of the findings. There was a strong positive response from the students.

Table 3.

Results of the general evaluation of the course

Questions	Response	Frequency	Percent
1) The course has improved my understanding of compassion, avoiding empathic distress, managing when compassion is challenging and sustaining compassion in my daily work.	Disagree	15	4.9
	Neutral	24	7.8
	Agree	267	87.3
2) The online resources and activities have improved my skills and knowledge to maintain best practice.	Disagree	19	6.2
	Neutral	50	16.3
	Agree	237	77.5
3) The teaching staff and presenters were enthusiastic, knowledgeable, and provided me with useful advice.	Disagree	3	1.0
	Neutral	33	10.8
	Agree	270	88.2
4) The online program was well organized and well-administered.	Disagree	30	9.8
	Neutral	57	18.6
	Agree	219	71.6

Most students (229, 74.8%) felt that the amount of content provided was “just right” (Table 4). There was a weak inverse correlation (Rho=−0.291, p < 0.001) between a student’s rating of the amount of content and total score, suggesting that students who felt there was too much content evaluated the overall course more negatively. However, the majority (74.8%) felt that the amount of information was “just right”.

Table 4.

Frequency results amount of content

Amount of Content	Response	Frequency	Valid Percent
The amount of information and content provided was:	Not enough	7	2.3
	Just right	229	74.8
	Too much	70	22.9
	Total	306	100.0

Qualitative results

Four themes were identified from the open-ended free-text responses that captured the students’ experiences with the module. These are described below with exemplar quotes.

Compassion literacy

This theme described the students’ growing literacy around compassion. When asked what they learned, they reported specifically learning about compassion (133 references) and empathy and the difference between these (85 references).

“This course greatly increased my understanding of compassion” (Candidate 191).

They described developing an understanding of concepts such as empathic distress (23 references), compassion fatigue and burnout, and scientific evidence around compassion. They reported learning about the benefits of compassion in healthcare for both patients and providers, particularly that compassion is protective of empathic distress in healthcare workers. As well as an understanding of the common barriers to compassion and concepts such as common humanity and mindfulness.

“The difference between compassion and empathy and the concept of empathic distress” (Candidate 261).

Many students explicitly reported enjoying learning about compassion (35 references), the distinction between empathy and compassion, the barriers to compassion and that the teaching was grounded in evidence.

“Most valuable was the distinction between compassion and empathy” (Candidate 234).

Shift in attitude

A second theme that emerged from the students’ responses was a change in their attitudes around compassion. The students stated that the course taught them the importance of compassion (128 references) in health care and in their personal lives.

“I learned that compassion is important, and as much as it is easy to miss out on compassion to patients, we have the responsibility to provide compassion to our patients, as that could significantly improve patient care.” (Candidate 41).

Students were motivated and reminded to be more compassionate. They enjoyed being encouraged to reflect on their own experience of compassion.

“It has reignited some of my passion of becoming a future doctor which I have, regrettably slightly lost my way throughout these 5 years of medical school. It reminded me of my true and original goal of being able to help people in a caring and personal way” (Candidate 291).

Practice

The third theme captured the students’ descriptions of practical strategies and techniques. Students learned how to (i) practice and sustain compassion (57 references); (ii) recognize and avoid empathic distress (36 references) and other barriers to compassion (23 references); (iii) deal with emotional situations in the workplace; communicate, listen, and understand people better; and (iv) practice mindfulness, strategies in self-care and how to improve their own wellbeing.

“Practical strategies to avoid empathic distress and reduce risk of burnout. Skills to identify warning signs and strategies in self-care” (Candidate 154).

“I have found myself suffering from empathic distress without being able to realize what this is so it’s truly helped to be able to identify this and understand how I can shift” (Candidate 330).

Learning practical strategies was one of the most liked aspects of the course (23 references). The students felt that this was useful for their practice and timely at this point in the medical course before they entered professional clinical practice the next year. Students suggest including more practical strategies (27 references) as an area for improvement.

“More concrete strategies for reducing burnout/compassion fatigue in the longer term” (Candidate 30).

Delivery and materials

This theme captures students’ sentiments regarding the course material and the delivery of the course. The students valued the external resources (39 references) and the variety of teaching media (15 references) used.

“I liked the different learning styles with watching, reading and thought-provoking exercises we could do” (Candidate 124).

They particularly (76 references) enjoyed the videos of presenters discussing the topics, external internet videos and feedback videos. They reported enjoying real-life examples, anecdotes, real-life scenarios, and stories (15 references). The students suggested more real-life examples (21 references) to improve the training.

“Personally, watching the talks by various experts who provide real-life scenarios of application of compassion was the most enjoyable and helpful.” (Candidate 59).

Subtheme: forums

The discussion forums were commonly alluded to (69 references), with different opinions emerging about their value to learning. The students who enjoyed the forums (53 references) stated that they appreciated that it gave them an opportunity to exchange opinions, share their own perspectives and hear others’ stories. The interactive element that the forums added to the training was important to these students.

“I love seeing my colleague’s response every week, especially when we are physically apart - truly makes me feel connected!” (Candidate 319).

Others, fewer in number (16 references), disliked the forums, found them difficult to engage with and suggested that there should be fewer forums (15 references).

“I found that I struggled to engage with the online forums” (Candidate 237).

Subtheme: face-to-face vs. online asynchronously

The students (36 references) felt that in person, face-to-face workshop style teaching would improve the course. They wanted more interactive content and felt that this would make the course more engaging. The students felt that the material would be better suited to an in-person workshop.

“I’d love to have a face-to-face day where we discuss compassion.” (Candidate 125).

“A workshop would be better, as these skills are better taught in person than online” (Candidate 251).

On the other hand, many students appreciated the flexibility of the online asynchronous format (23 references).

“It was very helpful that the course was flexible and that I could complete it in my own time” (Candidate 239).

Outliers

Box plots were used to identify students whose ratings of the course could be considered outliers. Their responses to the free text questions were then examined as a subset to understand their experience with the training. Their responses suggested that they struggled to engage with the training due to the amount of content, the organization of the content and the lack of close interaction with teaching staff.

“The content was…too much, disorganized, overly complicated, and unnecessary.” (Candidate: 441).

“I feel like I did not interact with any staff or have my responses acknowledged.” (Candidate: 418).

Discussion

In this study, students completing an online compassion training course responded predominantly positively to compulsory online compassion training as part of the final-year medical student curriculum. The students’ feedback indicated that the course achieved the learning objectives; most students felt that the course was organized and administered well and that the amount of content provided was “just right”. This online compassion training module appears to be a feasible method for incorporating compassion training into the medical student curriculum.

Students in elective compassion training courses elsewhere expressed worry that compulsory compassion training may lead to resentment from students [27]. This was not supported by our study. The number of negative responses was low (12.7%, 22.5%, 11.8%, 28.4%) and only a small minority of participants (1.3%) expressed consistent negative feedback. These students, though low in number, still warrant attention as they may represent a cohort at greater risk of psychological distress once qualified. Their feedback is valuable to enhance future iterations of the course.

The qualitative feedback provides an understanding of what the learners valued. Students enjoyed learning concepts related to compassion, hearing real-life scenarios, learning practical strategies and reflective activities. The students enjoyed the variety of teaching media, supporting suggestions from Sinclair, Kondejewski [31] to include “multimodal teaching methods” in the compassion curriculum. The students appreciated sharing their own experiences and hearing from other students, in line with previous studies [27], indicating that discussion is important in compassion training for medical students.

The online asynchronous course format received positive feedback. Students enjoyed that it gave them flexibility to self-direct their learning, enabling them to learn when they were available and motivated. The ability to work at one’s own pace has been identified as a factor supporting participation and acceptability in online courses [29]. This is a possible contributor to the student’s positive evaluation of an additional compulsory component within the medical curriculum.

The online asynchronous model is a low-cost, low maintenance and scalable intervention. Once developed, it required a Learning Management System (LMS) with IT support and approximately two teaching staff for weekly tasks requiring approximately two to three hours a week. The live Q & A utilized two to four staff for a single one-hour webinar. A significant strength of this model is that it is easily transferable to other universities or health-professional programs with a LMS and easily scalable to accommodate varying class sizes.

Areas for improvement for compassion training at this university and aspects to incorporate in future compassion training curricula were identified. Specifically, a face-to-face component and more practical strategies should be incorporated. This is supported by Sinclair, Hack [9], who suggests experiential learning as an effective method for learning compassion. Another suggested learning method was the use of reflective activities, a well-liked component of this compassion training [9].

Strengths and limitations

The notable strengths of this feasibility study of a compulsory compassion training module include the large sample size of 306 students combined with a high survey response rate of 63%. This enabled a broader and more representative sampling of final-year medical student opinion, compared to studies that rely on a smaller sample of students who are prepared to volunteer for a focus group or interview. In addition, the fact that all the students in the medical cohort were required to complete the training removed the self-selection bias of only sampling students who opt-in to training, which has been present in many previous studies on the topic.

The study has several important limitations: (1) Demographic data for participants were not collected, so demographic factors associated with receptivity to the training were not assessed. (2) This evaluation is focused on feasibility and limited to the lower levels of Kirkpatrick’s model of evaluation [32]. Although our methodology is suitable for drawing conclusions about feasibility, it was not designed to measure some important aspects of the effectiveness of compassion training, such as knowledge retention, transfer of knowledge to practice or effects on recipient well-being or burnout. (3) Although our data collection method enabled a high response rate, the free text survey response format did not allow for further probing of students’ responses. (4) The study represents only one medical school.

The incorporation of formal compassion training into medical school curricula is still very new. There is great scope and need for scholarly enquiry regarding justification, pedagogy and efficacy given the significant potential for positive impacts on clinician well-being and patient care.

Conclusion

This study demonstrates the feasibility and positive reception of incorporating a compulsory online compassion training course into a final-year medical student curriculum. These results support the growing interest in compassion training for healthcare professionals. This study provides justification for future research to assess the long-term impact and efficacy of compassion training in medical education. Ultimately, fostering compassion among medical students can improve their well-being and enhance patient care, making it a valuable addition to medical curricula.

Abbreviations

CB

Chris Barton

CH

Craig Hassed

CTHW

Compassion Training for Healthcare Workers

FMNHS

Faculty of Medicine, Nursing and Health Sciences

MC3S

Monash Centre for Consciousness and Contemplative Studies

NVivo

NVivo 14 Program (NVivo)

PD

Paul Didaskalu

SPSS

International Business Machines Corporation Statistical Package for the Social Sciences Statistic Program

Authors’ contributions

Dr. Paul Didaskalu made substantial contributions to the study conception, design, analysis and interpretation of the data, drafted the original manuscript and substantively revised the work. Associate Professor Chris Barton made substantial contributions to the conception, analysis and interpretation of the data and substantively revised the work. Dr. Debbie Ling made substantial contributions to the acquisition of the data and substantively revised the work. Associate Professor Julia Harrison made substantial contributions to the acquisition of the data and substantively revised the work. Professor Michelle Leech made substantial contributions to the acquisition of the data and substantively revised the work. Professor Craig Hassed made substantial contributions to the conception, analysis and interpretation of the data and substantively revised the work. All the authors have: approved the submitted version (and any substantially modified version that involves the author's contribution to the study). AND agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even those in which the author was not personally involved, were appropriately investigated and resolved and that the resolution was documented in the literature.

Funding

No funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethics approval was given by the Monash University Human Research Ethics Committee. Approval number: 39097. The study adheres to and complies with the Declaration of Helsinki. All participants provided informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that D.L. and C.H. are contributors to and beneficiaries of the Compassion Training for Healthcare Workers short course provided by Monash University. This article supports this short course.