Empathy as Therapeutic Infrastructure in Wound Care: A Conceptual Synthesis

ABSTRACT

To develop a conceptual understanding of empathy in chronic wound care through synthesis of patient, healthcare professional, and informal carer perspectives. An integrative qualitative synthesis was conducted using empirical and review literature representing multiple stakeholder perspectives in chronic wound care. A reflexive thematic synthesis approach was applied to identify patterns across datasets and develop higher‐order conceptual constructs through iterative comparison and abstraction. Rigour was supported through triangulation and reflexive team discussions. Empathy emerged as a multidimensional construct operating across relational, clinical, and organisational levels. Five interconnected themes were identified: relational connection, engagement and adherence, distributed care networks, structural constraints, and emotional labour. These themes informed the concept of empathy as therapeutic infrastructure, conceptualising empathy as a set of interconnected processes underpinning care delivery and care experiences across settings. Empathy in wound care extends beyond interpersonal interaction to function as a foundational component of care systems. Conceptualising empathy as therapeutic infrastructure highlights the importance of embedding empathy within clinical practise, professional education, and organisational structures. This framework provides a foundation for future research and the development of interventions to strengthen person‐centred wound care.

Key Messages

• Empathy in wound care operates across relational, clinical, and organisational dimensions rather than as an isolated interpersonal skill.

• Empathetic care supports trust, treatment engagement, adherence, and continuity of care for people living with chronic wounds.

• Conceptualising empathy as therapeutic infrastructure highlights the need to embed empathy within healthcare systems, education, and wound care practice.

1. Introduction

Chronic wounds (CWs), including venous leg ulcers, diabetes‐related foot ulcers, and pressure injuries, represent a significant and growing global health burden [1]. Their complex pathophysiology, prolonged healing trajectories, and association with multiple chronic comorbidities require sustained management [2]. Beyond their physiological impact, CWs profoundly affect quality of life, contributing to persistent pain, reduced mobility, social isolation, and psychological distress [3]. These challenges highlight the need for holistic, person‐centred approaches that extend beyond biomedical management. Living with a CW often means living with a visible and highly embodied condition that affects not only physical functioning but also dignity, self‐image, and social relationships. Patients frequently experience persistent pain, exudate, malodor, mobility limitations, and prolonged healing trajectories that contribute to psychological distress and reduced quality of life [2]. CWs may also be associated with stigma, social isolation, loneliness, and concerns related to appearance and body image, particularly when symptoms such as wound drainage, odour, or bulky dressings are visible to others [4]. Many individuals require assistance with intimate aspects of care, including dressing changes, personal hygiene, mobility, and activities of daily living, creating repeated experiences of vulnerability and dependence throughout the healing process. These challenges highlight why empathy is particularly important in chronic wound care, where acknowledging the individual's lived experience, preserving dignity, and fostering trusting therapeutic relationships are essential components of person‐centred care. CW management frequently involves prolonged therapeutic relationships, repeated clinical encounters, and substantial self‐management demands, making relational aspects of care particularly important.

Empathy is widely recognised as a central component of person‐centred care and a key determinant of healthcare quality [5, 6]. It is conceptualised as a multidimensional construct encompassing cognitive, affective, and behavioural components [7]. Within healthcare contexts, empathy involves not only recognising a patient's experience but also communicating understanding and subsequently responding in a therapeutically meaningful way [6]. Empathy is increasingly recognised as a key mechanism underpinning person‐centred care. A substantial body of evidence demonstrates that empathy is associated with improved patient outcomes across different clinical settings [8, 9, 10]. Systematic reviews indicate that higher levels of empathy are associated with improved treatment adherence, enhanced patient satisfaction, reduced anxiety and pain, and better clinical outcomes [6, 11]. For example, empathic communication has been shown to produce measurable improvements in psychological and physical outcomes, even when delivered briefly [11].

Emerging evidence further suggests that empathy is not only beneficial but also modifiable. Interventions aimed at enhancing empathy among healthcare professionals have demonstrated moderate and sustained effects, indicating that empathetic skills can be cultivated through structured training and experiential learning [12, 13, 14]. However, empathy is also vulnerable to erosion over time due to factors such as workload, burnout, and organisational pressures, highlighting its dependence on both individual and broader system conditions [15, 16]. Despite this growing evidence base, research on empathy in healthcare remains fragmented. Existing studies have largely focused on isolated aspects of empathy, including its measurement, outcomes, or educational interventions, often within specific professional groups or settings [6, 17, 18]. Consequently, there is limited integrative understanding of how empathy operates across the full continuum of care, particularly within the context of CW care.

In wound care specifically, empathy has been identified as a critical yet underexplored component of effective practice. Empathetic care has been associated with improved patient engagement, adherence to treatment, and healing outcomes through both psychological and physiological mechanisms [19]. Qualitative research further highlights that empathy supports trust, communication, and collaboration between patients and healthcare professionals, facilitating more effective and individualised care [20, 21]. Patients describe empathy as essential to feeling understood and supported, influencing their motivation to engage in care [20]. Importantly, empathy in wound care extends beyond the clinician–patient interaction. Informal carers also play a central role in supporting individuals with CWs, often providing both emotional and practical care [19]. These carers experience empathy as a critical resource for sustaining caregiving while reporting emotional burden and limited recognition within healthcare systems [22]. This suggests that empathy operates within a broader relational and systemic context, rather than as an individual attribute alone. These findings align with broader healthcare literature, which identifies organisational context, workload, and system‐level factors as key determinants of empathy and its effects [6, 12].

Empathy in wound care is a complex, multi‐level phenomenon encompassing relational, clinical, and systemic dimensions. However, there is currently no comprehensive conceptual framework that integrates these dimensions or explains how empathy functions across stakeholders and care contexts. Therefore, this study aims to develop a conceptual understanding of empathy in wound care by synthesizing perspectives across patients, healthcare professionals, and informal carers involved in CW care.

2. Methods

2.1. Study Design

This study employed an integrative qualitative synthesis to develop a conceptual understanding of empathy in wound care. Integrative approaches are appropriate for generating theoretical insights by combining evidence from different methodological traditions, including qualitative studies and reviews [23, 24]. Given the multidimensional nature of empathy, this approach enabled the synthesis of complementary perspectives across the wound care continuum. No new primary data was collected for this study.

2.2. Data Sources and Context

The synthesis drew on previously published qualitative studies examining empathy in CW care, encompassing perspectives of patients [20], healthcare professionals [21], and informal carers [22]. The studies were selected to reflect the complexity of wound care delivery across healthcare and community settings and to capture multiple stakeholder perspectives. The included material explored key dimensions of empathy, including interpersonal interactions and caregiving relationships. Together, these perspectives provided a comprehensive basis for examining how empathy is experienced, enacted, and sustained across CW care contexts.

2.3. Analytical Approach

A reflexive thematic synthesis was undertaken, informed by thematic analysis [25] and qualitative evidence synthesis [26]. This approach supports the systematic identification and interpretation of patterns across datasets while enabling the development of higher‐order conceptual constructs. The analysis was iterative and comprised three interconnected stages. In the first stage, familiarisation and data immersion were achieved through repeated engagement with the findings of each source, enabling a detailed understanding of how empathy was described and experienced across stakeholder groups. In the second stage, themes identified within individual datasets were compared across sources using a constant comparative approach. Themes relating to relational dynamics, clinical processes, and organisational influences were progressively refined. In the final stage, conceptual abstraction was undertaken by grouping related themes into higher‐order constructs. Through iterative discussion and refinement, these constructs were synthesized into an overarching conceptual understanding, resulting in the identification of empathy as therapeutic infrastructure.

2.4. Reflexivity

Reflexivity was maintained throughout the analysis in recognition of the interpretive nature of qualitative synthesis. The research team engaged in ongoing reflection on their assumptions, disciplinary perspectives, and prior knowledge of empathy and wound care. These reflections informed the analysis and supported critical examination of emerging interpretations. Regular discussions were undertaken to challenge assumptions, refine conceptualizations, and ensure findings remained grounded in the data while allowing for theoretical development [25]. As the included studies were conducted by the research team, reflexive engagement was considered essential to critically examine interpretive assumptions and minimise potential bias throughout the synthesis process.

2.5. Rigour and Trustworthiness

Rigour was supported through strategies aligned with established criteria for qualitative research. Credibility was enhanced through the integration of multiple stakeholder perspectives, enabling triangulation across patients, healthcare professionals, and carers [27]. Dependability was supported through a systematic and transparent analytical process, including documentation of theme development and interpretive decisions. Confirmability was strengthened through collaborative analysis and reflexive engagement to ensure interpretations were critically examined. These strategies align with the principles of trustworthiness outlined by Lincoln and Guba [28].

2.6. Conceptual Orientation

The synthesis was informed by principles of person‐centred care, which emphasize relational, psychological, and social dimensions of health alongside biomedical considerations [5, 29, 30]. This orientation supported the interpretation of empathy as a dynamic, context‐dependent process embedded within interactions, care relationships, and healthcare systems. Rather than viewing empathy solely as an individual attribute, the analysis examined how empathy is shaped by interpersonal and structural factors and contributes to holistic wound care.

3. Results

3.1. Overview of Findings

The reflexive thematic synthesis generated three interrelated themes describing how empathy was experienced, enacted, and sustained within wound care across patients, healthcare professionals, and informal carers. Across the datasets, empathy emerged as a relational and contextual process shaping communication, participation in care, and experiences of providing and receiving wound management. The themes reflected interpersonal and organisational dimensions of empathy and informed the overarching concept of empathy as therapeutic infrastructure.

3.2. Empathy as Relational Connection

Across participant groups, empathy was consistently described as foundational to establishing trust, connection, and emotional safety within wound care interactions. Empathy was experienced as being heard, understood, and recognised as a person within the care relationship. Patients associated empathy with interactions in which healthcare professionals moved beyond task‐focused care and engaged with them as individuals. One patient reflected on how relational interaction shifted attention away from the wound itself: “We sat and laughed. We talked about the tomatoes I used to grow in my backyard. And in that moment, I wasn't thinking about my wounds. That, that's empathy” [20].

Healthcare professionals similarly framed empathy as an intentional process of understanding patient experiences and perspectives. Empathy was described as involving responsiveness to the emotional, social, and practical impacts of living with CWs. One healthcare professional explained: “Empathy is about understanding the patient's needs, not what I would want in their place” [21].

Carers also described empathy as feeling recognised and supported within demanding caregiving roles. Across caregiving accounts, empathy was associated with reassurance, emotional validation, and collaborative interaction with clinicians. One carer characterised empathy as: “a person putting themselves in your position and trying to understand how it's affecting you” [22]. Patients described rushed or impersonal interactions as emotionally distressing and associated these encounters with feelings of neglect, embarrassment, and withdrawal from care. Carers linked limited communication and acknowledgement with increased uncertainty and emotional burden. Across the synthesis, empathy functioned as a relational process that fostered trust, communication, and emotional connection within wound care interactions.

3.3. Empathy as an Enabler for Participation in, and Continuity of Care

Empathy was closely linked to participation in care and the continuity of wound management across clinical and home settings. Across the datasets, empathetic interactions were described as increasing engagement, supporting adherence to management strategies, and strengthening collaboration between patients, healthcare professionals, and carers. Patients described being more willing to participate in treatment when they trusted healthcare professionals and experienced care as empathetic. Relational continuity and emotional reassurance were particularly important during painful or prolonged treatment. One participant explained: “If I trust my nurses, I'm more likely to follow their advice and stick to the treatment plan they recommend” [20].

Healthcare professionals similarly described empathy as enabling care to be adapted to individual patient circumstances and capacities. Across accounts, empathy was associated with tailoring treatment recommendations, supporting shared decision‐making, and helping patients manage emotional and physical barriers to healing. One physician noted: “Empathy is crucial for understanding the patient's life and tailoring recommendations to what is manageable for them. Without empathy, adherence becomes much harder to achieve” [21].

Empathy also extended beyond formal clinical encounters and was sustained across wider care networks. Informal carers described providing continuous emotional and practical support beyond wound care routines including advocacy and coordination of care services. One carer reflected: “Dressings are only part of it … put your stocking on, keep your legs up” [22]. Caregiving narratives highlighted the relational continuity required to sustain CW care outside healthcare environments. Carers often described acting as intermediaries between patients and healthcare systems, maintaining treatment routines. At the same time, carers frequently experienced exclusion from communication and decision‐making processes. One participant described this experience as: “We were barely acknowledged … we had to remind them that we're there and we're worried about him” [22]. Across the synthesis, empathy was experienced as a critical enabler of participation in care through improved trust, collaboration, reassurance, and continuity of support across clinical and community settings.

3.4. Sustaining Empathy Within Constrained Systems

The delivery and receipt of empathetic care were consistently described as being influenced by organisational and structural conditions within healthcare systems. Across stakeholder groups, barriers including time pressures, fragmentation of clinical care, workload demands, and limited continuity of care influenced empathetic engagement within wound care interactions. Healthcare professionals described tension between task‐oriented clinical systems and the relational demands of empathetic care. Time constraints and competing responsibilities were frequently described as limiting opportunities for meaningful communication and emotional engagement. One nurse explained: “In acute settings, it's task oriented. There's little time to invest in empathy, even though it's critical” [21].

Patients and carers similarly described fragmented communication and inconsistent care experiences as limiting trust and relational continuity. Limited information and fragmented support contributed to feelings of uncertainty and isolation. One carer reflected: “Communication options were shut off … it was either ED or try and Google it and work it out” [22]. Empathy was also described as a skill that required sustained emotional effort. Healthcare professionals referred to emotional fatigue associated with repeated exposure to patient suffering, treatment resistance, and prolonged care demands. One podiatrist stated: “It's emotionally draining, and you have to find ways to keep yourself motivated” [21]. Similarly, carers described feelings of stress, responsibility, and emotional burden associated with long‐term caregiving. One carer explained: “Sometimes you just feel like … it's all on me. It can get a bit overwhelming at times” [22].

3.5. Emergent Concept: Empathy as Therapeutic Infrastructure

Across the three themes, empathy extended beyond isolated interpersonal interactions and operated across relational, clinical, and organizational dimensions of wound care. Empathy shaped communication, participation in care, caregiving practices, and treatment experiences, while also being influenced by structural conditions including time constraints, continuity of care, workload, and emotional demands. Empathy was also sustained across wider care networks through the involvement of informal carers, whose emotional and practical labour extended empathetic care beyond formal clinical settings. At the same time, participants described empathy as constrained by organizational pressures and requiring substantial emotional effort to sustain overtime. These interconnected experiences positioned empathy as embedded within the broader structures and processes of wound care rather than as solely an individual attribute. Across these findings, empathy is conceptualised as therapeutic infrastructure within wound care. In this context, empathy comprises interconnected relational, clinical, and organizational processes shaping how care is delivered and experienced across settings (see Figure 1).

FIGURE 1.

Empathy as therapeutic infrastructure.

4. Discussion

This study developed a conceptual understanding of empathy in wound care by integrating perspectives across patients, healthcare professionals, and informal carers. The findings demonstrate that empathy operates across relational, clinical, and organizational dimensions of care. Conceptualising empathy as therapeutic infrastructure extends existing understandings by positioning empathy as a foundational component of healthcare systems that supports how care is delivered and experienced, rather than as a discrete interpersonal skill [31].

Extensive literature has demonstrated that empathy is associated with improved patient outcomes, including increased satisfaction, reduced distress, and enhanced adherence [6, 10, 11, 32, 33]. Empathic communication has also been linked to measurable improvements in psychological and physical outcomes across clinical conditions [11]. The present findings build on this evidence by demonstrating how these effects are embedded within ongoing relational and care processes in wound care. Empathy is commonly described as a multidimensional construct comprising cognitive, affective, and behavioural components [7]. The findings reflect this multidimensionality while highlighting that empathy is enacted within interactions and shaped by context. This aligns with theoretical perspectives that conceptualise empathy as a dynamic and relational process rather than a fixed individual attribute [6, 34, 35]. At the relational level, empathy supports trust, communication, and engagement, consistent with research demonstrating its role in strengthening therapeutic relationships and shared decision‐making [36]. In CW care, where treatment is prolonged and burdensome, these relational processes appear to be particularly important. Empathy also influenced clinical engagement and adherence, in line with previous research demonstrating that empathy facilitates information exchange and improves adherence to management plans [37, 38]. The present findings extend this understanding by demonstrating how empathy shapes sustained participation in care over time.

An important contribution of the current study is the identification of empathy as a distributed practise across care networks. Informal carers were shown to sustain empathetic care beyond clinical settings, highlighting the role of multiple actors in shaping care experiences. This supports relational care models that emphasize the interconnected nature of healthcare delivery [39]. Structural conditions, including time constraints, workload, and continuity of care, influenced the expression of empathy. These findings are consistent with evidence that organizational context plays a key role in enabling or constraining empathetic practise in healthcare [6, 19]. Empathy should therefore be embedded within healthcare systems rather than solely dependent on individual clinicians. The role of emotional labour further highlights the complexities of empathetic care. Sustaining empathetic engagement has been described as demanding, particularly in chronic care contexts [14, 40]. While empathy contributes to improved patient outcomes, it may also increase the risk of emotional fatigue for both carers and health professionals when adequate support is lacking [41].

Conceptualising empathy as therapeutic infrastructure integrates relational, clinical, and organizational dimensions of care into a unified framework. While existing research has largely focused on individual‐level interventions such as empathy training [12, 13], this perspective emphasizes the broader conditions that enable empathy to be enacted and sustained within healthcare systems. This conceptualization shifts empathy from being viewed solely as an individual clinician attribute towards understanding it as a broader healthcare system capacity that shapes care experiences, participation, and continuity across wound care settings.

4.1. Strengths and Limitations

This study has several strengths. The integrative qualitative synthesis combined perspectives from patients, healthcare professionals, and informal carers, providing a comprehensive understanding of empathy across wound care contexts. This multi‐perspective approach strengthens the credibility of the findings and addresses a gap in research that has often focused on single stakeholder groups. Reflexive thematic synthesis supported the development of a novel conceptual framework integrating relational, clinical, and organizational dimensions of empathy. Several limitations should also be acknowledged. The synthesis was based on a limited number of data sources, which may restrict the diversity of perspectives included. Although the studies provided rich and complementary data, further research across different healthcare settings may refine the conceptualization. As with all qualitative synthesis, the findings remain interpretive and influenced by the perspectives of the research team. As the included studies were conducted by the research team, there is potential for interpretive alignment across datasets. However, reflexive engagement, triangulation across stakeholder groups, and collaborative analysis were used to strengthen analytical credibility. Finally, the proposed concept has not yet been empirically tested. Further research is needed to examine its applicability across clinical settings and explore how empathy as therapeutic infrastructure can be operationalised in practice.

5. Conclusion

This study provides a conceptual understanding of empathy in wound care, demonstrating that it operates across relational, clinical, and organizational levels. Conceptualising empathy as therapeutic infrastructure highlights its role as a foundational component supporting care delivery and patient experience. This perspective emphasizes the importance of integrating interpersonal and system‐level approaches to empathy within wound care. Future research should examine the applicability of this framework across clinical settings and explore how empathy can be embedded within practise and healthcare systems to improve outcomes for patients and carers.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.