What works for whom in compassion training programs offered to practicing healthcare providers: a realist review

Background Patients and families want their healthcare to be delivered by healthcare providers that are both competent and compassionate. While compassion training has begun to emerge in healthcare education, there may be factors that facilitate or inhibit the uptake and implementation of training into practice. This review identified the attributes that explain the successes and/or failures of compassion training programs offered to practicing healthcare providers. Methods Realist review methodology for knowledge synthesis was used to consider the contexts, mechanisms (resources and reasoning), and outcomes of compassion training for practicing healthcare providers to determine what works, for whom, and in what contexts. Results Two thousand nine hundred ninety-one articles underwent title and abstract screening, 53 articles underwent full text review, and data that contributed to the development of a program theory were extracted from 45 articles. Contexts included the clinical setting, healthcare provider characteristics, current state of the healthcare system, and personal factors relevant to individual healthcare providers. Mechanisms included workplace-based programs and participatory interventions that impacted teaching, learning, and the healthcare organization. Contexts were associated with certain mechanisms to effect change in learners’ attitudes, knowledge, skills and behaviors and the clinical process. Conclusions In conclusion this realist review determined that compassion training may engender compassionate healthcare practice if it becomes a key component of the infrastructure and vision of healthcare organizations, engages institutional participation, improves leadership at all levels, adopts a multimodal approach, and uses valid measures to assess outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-021-02863-w.

A "boost" version after the initial implementation period was used to refresh ideas and boost activities and principles.

An enhanced version included additional features with a focus
The program was introduced to the workplace during a 4month implementation period.
The program promoted relational ways of working between nurses: • Monthly ward leader actionlearning sets.
• Team learning activities, including local team climate analysis and values clarification.
• Peer observations of practice and feedback to team by K1 Reaction: Nurses valued the principles behind CLECC. Beyond the activities nurses were directly involved in, they struggled to visualize the purpose and potential of CLECC. The principles that underpin CLECC appeared to be well embedded into the teams, but the activities that support these principles had not continued on all the wards 12 months after the start of CLECC.
K2a Attitudes: Levels of empathy varied *. Nurses saw the CLECC as a way to build the team and improve care.
K4b Benefits to patients: The odds of a negative interaction were not significantly reduced because of the effect of the CLECC intervention † . Patient evaluations of emotional care were not significantly changed because of the effect of the CLECC intervention**.
• Team study days focused on team building and understanding patient experiences.
The CLECC property of plasticity enabled nurses to develop and adapt practices that suited local circumstances.
The CLECC empowered nurses and gave them the

Reference Context Mechanism Outcomes (intended or measured) Resource
Reasoning patient care demands were very high and staffing resource was low.
The extent to which the ward team perceived that they were supported in their endeavors by the matron was viewed as a strong mediator of whether or not CLECC was a success in influencing care.
There was no provision for inducting temporary or newly arrived nurses into CLECC, limiting their opportunity to make sense of CLECC.
The program was feasible to implement and may be of benefit in acute care settings when the local conditions are conducive. When conditions are not Appreciative inquiry (AI), which involves appreciating what was happening, reflecting this back to staff, and facilitating discussions and action to help them to develop their practice and make this more compassionate.
Senior staff valued the program.
Learning together in context.
Communities of practice (manager, charge nurse/ward manager, senior registered nurses and junior registered nurses) were supported to work together to take forward developments to enhance relationships and enhance compassionate care within their area.
Action learning sets made up of a band of specific peer groups with a facilitator.
K2a Attitudes: Nurses were more selfaware; nurses reported enhanced relationships with the team, patients and patients' families and being more sensitive to the perspective of others and more open and sharing of themselves. Nurses were motivated to learn about others' experiences and use this as a platform for continuous improvement. Nurses were committed to improving the care experience for patients, families and staff.
K3 Behaviors: Nurses reported using different conversations in the workplace with patients and to resolve difficulties in the workplace. Clinical nurse managers used the Caring Conversations framework to underpin their meetings with senior managers.
Work based activities to develop relational knowledge by understanding more about who people were, what mattered to them and how they felt about their experiences.
Staff culture questionnaire prompted feedback and discussion.
Being part of the program created networks for people to use peers as supporters and critical friends.
Tools and strategies that promoted continuous learning,

Reference
Context Mechanism Outcomes (intended or measured) Resource Reasoning reflecting and action rather than a set of defined management and leadership content. Dewar and Mackay, 2010. There is increasing focus in policy, practice and research about the importance of the caring dimension in healthcare as well as an ever increasing strive towards meeting targets, increasing patient throughput and working within financial constraints.
There is also emphasis on strengthening the climate for care, promoting models of practice that are centered around relationships, and the need to nurture and sustain core fundamental person centered caring skills AI, which involves appreciating what was happening, reflecting this back to staff, and facilitating discussions and action to help them to develop their practice and make this more compassionate.
Researchers spent time building relationships with nurses.
Feedback to nurses who enjoyed reading the excerpts from the data and stated that having them in print made them feel that their actions were legitimized.
Making statements about practices that worked well and generating positive care practices that could be shared debated and defended.
Matching statements to images and displaying these as a rolling program via a digital photoframe at the nurses' station. Opportunities for critical thinking in regard to palliative care.
No CME credits, but nurses were paid for the educational course, and a certificate of completion was issued. course in nursing orientation.
K2a Attitudes: Nurses felt they improved in providing palliative care to patients and in taking responsibility for their practice.
K2b Knowledge and skills: Nurses scored best on symptom management of patients with HIV/AIDS and scored lowest on basic information such as pathophysiology and drug therapy of patients with HIV/AIDS*.
Nurses may lack education and knowledge in the skills and competencies necessary for providing quality end-of-life care to patients and families during the transition at the end of life.
Evidence-based curriculum.
The CARES Tool Comfort, Airway, Restlessness and delirium, Emotional and spiritual support, and Selfcare. It is a pocketsize card reference that provides acronym-organized Program facilitators.
Content delivery.

K3 Behaviors
Participants were better able to communicate with patients, engage in active listening, and provide a supportive presence.

Reference Context Mechanism Outcomes (intended or measured) Resource
Reasoning prompts to address the most common symptom management needs of the dying. Betcher, 2010.
Nurses find discussions of emotional and spiritual issues with palliative care patients and families difficult and uncomfortable.
Lack of effective and compassionate communication is a barrier to planning care, developing mutually agreeable goals, and providing honest information while preserving hope.
Role-play and simulation.
Role-playing and simulation with actors from the University's School of Theatre and Film.
Creation of a realistic environment through role playing with actors.
Concentrating on the emotional issues instead of physical assessment.
Replaying conversations and discussing with facilitators.
Videotaping allowed nurses to identify what they were doing to help the patient and family. Reflection.
Emotional expression.
Self-awareness. Nurses working a 24hour shift pattern were unable to access supervision sessions.

K1 Reactions:
Nurses agreed or strongly agreed that the course achieved its objectives.
K2b: Knowledge and skills: Nurses had a better understanding of how to listen to patients and respect their autonomy whilst working with them to reach goals. Nurses had difficulty 'unlearning' habitual righting reflex responses as nurses made little attempt to understand the patient's point of view or develop a collaborative approach.

K4 Patient benefits:
Patient experienced was improved but not in a sustained manner**.

Context Mechanism Outcomes (intended or measured) Resource Reasoning
Locally, patient satisfaction surveys and serious incident reviews raised concerns about rehabilitation nurses' communication.
counterproductive for change).
As poor wellbeing is associated with reduced quality of patient care, staff sickness, higher turnover rates and provides a barrier to compassionate care, there is a need for addressing burnout and poor wellbeing in mental healthcare professionals.
Delivered by the originator of CMT.
Manager's enthusiastic support for the approach was highly influential in allowing staff the time to implement it Approach was layperson-friendly and provided common examples that were easy to relate to.
Multi-media, participatory elements and humor.
Adaptable program.

K1 Reactions:
The course was positively evaluated by staff, characterizing it as 'thought-provoking', 'useful', 'helpful', and 'beneficial'. The course was engaging and enjoyable. Some nurses lacked confidence in practicing CMT, or the practices felt unnatural and embarrassing. Reflection.

Discussion.
Scenario exploration increases theory practice links and relevance awareness.
Interactive learning.
Only relevant to small groups as resourcing is an issue when conducting the experience in a large cohort.
Not all educators are comfortable with these types of teaching methodologies.
share some of it with them.

Reflection.
Sharing and discussion of patient and family stories.
Educating and connecting with audiences.
Facilitators were key in K1 Reactions: The curriculum was reported to be highly informative. The experience of hearing patient stories was "real," "personal," "honest," or "relatable." Patient perspectives had educational value, but nurses called for delivery of a broader range of stories and perspectives to further enrich their learning. Participants functioned as models for each other in using program tools.
Program was accessible and useful, in the workplace.
Course credit and cash incentive.
Engaging with EPP practices.
Small group discussions. Feedback.
K1 Reactions:!Nurses questioned their abilities to sustain their practices on their own as the program was practice based. Nurses continued to apply several of the practices and principles 2 to 4-months following the intervention and were continuing to feel the positive impact of the practices on their well-being and their relationships within their work environments.
K2a Attitudes: Nurses reported enhanced personal capacities that were essential to workplace performance. Nurses felt a renewed sense of enjoyment in their work and more emotional balance at work. Nurses felt an increased ability to experience compassion and empathy. Nurses reported a new self-awareness that influenced their relationships. Reflective capacity is integral to core healthcare professional practice competencies.

Reflection is not necessarily intuitive for learners.
While both the arts and narrative can foster reflection and cultivate aesthetic ways of knowing within medical education, their combined use within a faculty development paradigm has not been reported in the literature.

Reflective practice.
Combined use of abstract paintings and narratives.
Use of art.
Viewing abstract paintings.
Writing and sharing narratives. Reflection.

K1 Reactions:
Viewing abstract paintings facilitated a valuable mood transformation and prepared participants emotionally for the reflective writing and the reflective exercise.
K2aAttitudes: Writing reflective narratives promoted compassion for self and compassion for others through recognition of shared humanity. Sharing the narrative promoted reflective self-assessment for personal and professional development. Burnout has serious negative consequences not only for clinicians themselves, but also for patient care and clinical outcomes.
Burnout can lead to increased medical errors and reduced quality of patient care.

Contemplative practice.
Presentation, discussion, MBSR training and practice at home.
GPs were self-selected.
MBSR training was offered as part of a regular continuing professional development program and accredited by the professional bodies.

K1 Reactions:
Most GPs stated that they learned and benefited from the training, but two GPs did not. GPs indicated the training was feasible and acceptable.

Reference Context Mechanism Outcomes (intended or measured) Resource Reasoning
GPs were allocated to the training period of their choice.
Taught by experienced trainers.
Weekly themes that were explicitly linked to the context of clinical care.
Supervising trainees at the start of the sessions also increased acceptance and facilitated learning.
Supportive environment (learning from one another).
Acceptance of thoughts and emotions to be able to put things into perspective. Burnout is linked to lower productivity, early retirement, and higher rates of turnover, which have profound financial impacts.
There is a need for evidencebased methods to reduce burnout and mitigate its negative impact among physicians. Training had secular and academic appeal, and a solid scientific foundation.

Medicine
Training was low cost, collegial, and time efficient.
Participants were encouraged to view clinical work as an opportunity to practice mindfulness.
Mindfulness instructors were professionally trained.

Shared group setting.
K2aAttitudes: Significant reductions in burnout, depression, anxiety, and stress but no significant change resilience or compassion *; effect was maintained over 9-months.

Context Mechanism Outcomes (intended or measured) Resource
Reasoning Dedicated Web site for the study that provided instruction.
Group effect. Palliative care Arnold et al., 2016. The personal and clinical experiences of physicians, which are grounded in their relationship with their patients, remain understudied and the least understood for delivering optimal palliative care.
Reflective practice.
Visual narratives using paintings.
Participants were at the conclusion of a oneyear palliative medicine fellowship.
Expression of thoughts and feelings through the arts and humanities.
K2a Attitudes: Physicians intended to integrate their clinical skills with their human skills. Riches et al., 2019. Simulation training is an increasingly widespread and effective teaching tool enabling learners to gain a subjective understanding of a range of skills.

Mental health
Technology that can simulate psychotic experiences and increase understanding may address issues with staff stigma towards people having psychotic experiences.

Simulation.
Simulation of auditory hallucinations.
Voice recordings by professional actors. Debriefing.
Participants were volunteers invited to attend an immersive art exhibition.
Group setting.
Professional actors performed voice "characterizations" developed in workshops with young people who hear voices.
Engaging clinical staff.

K1 Reactions:
The simulations were acceptable and enjoyable; participants were motivated to partake in experiential learning in relation to auditory hallucinations and other psychotic experiences.
K2a Attitudes: Participants reported increases in understanding what it feels like to hear voices, compassion towards people who hear voices, and comfort talking to people who hear voices; current happiness decreased*.

Context Mechanism Outcomes (intended or measured) Resource Reasoning
Tailoring voices to individuals.
Training conducted in an everyday setting but not a clinical setting.

Long duration.
Outcomes are intended and unintended consequences -K1 Reactions: Reactions and satisfaction with training (How much did they like it? How did participants react to it?); K2a Attitudes: Did attitudes change?; K2b Knowledge and skills: Did they learn anything? Did the authors use any established instruments to measure changes in knowledge; K3 Behaviors: Did the program or curriculum change their behaviors at all? Or future behaviors?; K4a Changes to clinical processes: Did the program or curriculum lead to any improvements to clinical processes?; K4b Benefits to patients: Did the program or curriculum lead to any improvements to patients? (clinical outcomes?; *outcomes on physician self-report measures; ** outcomes on patient report measures).
Contexts were defined as conditions in which compassion training was introduced and that triggered the training (

Reference Context Mechanism Outcomes (intended or measured) Resource
Reasoning MULTIDISCIPLINARY Chambliss et al., 1990. Healthcare providers must become aware of their own attitudes arising about members of a high-risk population.

High-risk populations
Evidence based curriculum.
Interactive staff training method including a presentation, videos and opportunity for asking questions.
Required attendance if adequate staffing of wards.
Sessions were scheduled to overlap shifts in order to accommodate staff needs and make participation more convenient.
Open discussion.
Interactive shared problem-solving strategy.
Training method seemed to circumvent an adversarial framework, where "management" is seen as presenting information as a means of coercing staff K2a Attitudes: Participants reported improved compassion and acceptance of obligation to treat and appropriate work-related risk reduction*. Participants expressed a greater appreciation for the special needs of AIDS patients and greater compassion for the problems facing the asymptomatic HIV patient, but only if they completed both training sessions. compliance in an authoritarian, unresponsive manner.
Training sessions were designed for consecutive participation; therefore, those who had failed to attend the first session and only came to the second session were not expected to derive full benefit from the second session. Palliative care Moore et al., 2017. There is a need for an integrated care approach for patients with dementia, where organizations and care professionals bring together all of the different elements of care that a person needs.
Providing good end of life (EOL) dementia care is complex, prognosis is unpredictable and managing symptoms is difficult when communication is compromised.
Leadership and team practices.
Weekly core meetings.
Education, training and support.

Discussions.
Interdisciplinary care leader (ICL) with a broad range of skills from the fields of nursing, social work or a profession allied to medicine.
ICL provided mentoring, role modeling, advice and training.
Time constraints to attend weekly meetings and training.

K1 Reactions:
Training was positively evaluated by staff; the intervention topic was perceived to be of high importance.
K2b Knowledge and skills: Clinical knowledge was improved; staff developed new skills and ideas to improve care. The need for staff development and a shift from taskdriven to compassionate care would require a longer duration and further training and support.

K4b Benefits to patients: The intervention did not cause harm to
The need for a complex intervention is reflected in the European Association for Palliative Care's 57 recommendations for optimal EOL dementia care. Implementation required a state of readiness for accepting the intervention with good external multidisciplinary support.
patients. The frequency of deaths, unplanned hospitalizations and out-of-hours calls was low.
There is a need to address the impact of stressors on the health and well-being of palliative care practitioners, as external factors including limited healthcare resources, increased clinical demands, and negative workplace cultures, can hinder the delivery of compassionate medicine.
"On the job" mindfulness and compassionoriented meditation training (meditations and one-to one sessions, meditate at home, CD with guided exercises and posters with reminders to practice mindfulness).
Participants were volunteers at a faithbased community hospital. Participants could apply meditation instructions within the context of their own spiritual background.
Participants already had a compassionate attitude in their work.
"On the job" program, learners were instructed to apply the techniques at work.

Experienced meditation teacher and
Tong-len expert.
Active participant involvement.

K1 Reactions:
Participants were satisfied or partly satisfied with the course. They recognized the usefulness of the course, planned to implement these techniques into their work in the future and would recommend the course to other palliative care professionals.
K2a Attitudes: Reduction in perceived stress, anxiety and burnout and an increase in level of general joy; significant improvement in resilience and awareness*. No participant reported the training would have enhanced their compassion in general, but they wanted to underpin their professional competence in this area.

K3 Behaviors:
Participants implemented self-care behaviors but few managed to optimize work routines. Interpersonal communication was enhanced.
Opportunity to integrate practices in real-life situations and person-to-person interactions. Self-awareness.
Training duration was short. The program was feasible and satisfactory for staff members in a busy unit. Rao and Kemper, 2017.
As hospitals and clinics are busy and intellectually demanding work environments, there is a need for meditation practices to improve cognitive function that could help clinicians process information more effectively and could improve patient outcomes.
Meditation practices: online modules, guided practice. Online. Cost-effective.

Self-reflection.
K2a Attitudes: Participants reported increased gratitude, well-being, selfcompassion, and confidence in providing compassionate care to others *. Suyi et al., 2017. There is a need to reduce stress and burnout and promote positive attitudes in healthcare professionals.

Discussion period
Monetary reimbursement facilitated recruitment.
Shortened program (6weeks duration) to accommodate high K2a Attitudes: Participants reported significant improvement in mindfulness, self-compassion, and compassion for others after a 6-week mindfulness program. Improvements in mindfulness and self-compassion scores were maintained 3-months later*. Stress to share stories.
Recordings of guided meditation for homework. caseloads and tight schedules.
Experienced MBSR certified main instructor and cofacilitators. was reduced after the program but this reduction was mot maintained for 3months*. No change in burnout or disengagement*. Ross et al., 2013. To improve the quality of care for older people deficits in specific knowledge, skills and attitudes of healthcare staff need to be addressed.

Elderly care
Role playing and simulation.
Human patient simulation in a high-fidelity simulation center and ward-based simulation exercises. Personal practice in Compassion Focused Therapy (CFT) has a number of benefits, both for the therapist personally and for acting as a therapist.

Role
Contemplative therapy.
CFT including personal practice.

Reflection.
Training was considered too short.
K1Reactions: The exercises were powerful; however, not having a CFT supervisor to be able to share the learning experience with, and to support participants in introducing it in clinical practice, was found by participants to have limited the potential benefits.
K2a Attitudes: Improved compassion for self and others, particularly clients.
There is the need to promote career-long competence with respect to medical advances (evidence-based medicine); and fine-tuning of professional values and principles (values-based medicine) through continuing medical education (CME).
Evidence-based curriculum.
Clinical ethics course.

Free.
Online.
Designed by a crossfunctional group (including medical doctors, teachers, anthropologists, sociologists, philosophers and bioethicists).

Motivational videos.
K2a Attitudes: Improved the highorder values of openness to change and self-transcendence*, justice, autonomy, love, charity compassion, and beneficence.
There is a requirement for professional training and personal development to equip clinicians with the skills or attitudes to offset patient disengagement that can occur during challenging patient presentations. Vignettes.
Online survey.

Imagery.
Social media and medical networks for recruitment.
K2a Attitudes: Compassion was induced*. There was less engagement with patients who were responsible for their illness and who presented with aversive symptoms*.
It is unknown whether and how staff who attend Compassionate Touch (CT) coach training use the program for residents in their own settings, whether and how they train other staff in their own settings, and what potential benefits and barriers they encounter while using the program for residents and training other staff.
CT: personcentered approach and touch protocol.
Leadership staff needed to lead by example.
Hands-on practice.
Video-recorded CT training material and handouts.
Scheduling issues.
Staff were paid to train.
Monthly training and an annual refresher.
Staff were uncomfortable with K1 Reactions: The CT program was easy to learn and use and participants felt confident, comfortable, satisfied, and pleasant about using the program. Staff were hesitant and uncomfortable using the CT program in the clinical setting and had difficulty in finding the time for it. K3 Behaviors: More than 95% of participants used CT with residents with dementia after training and 50% used CT fairly or very often. About 83% trained other staff in their settings after they attended the CT coach training.
K4b Benefits to patients: Using the CT program was beneficial for residents with dementia; reported the program.
Staff were resistant as 'it's not part of the job'. benefits included calming and redirecting residents, decreasing residents' behavioral issues, and improving residents' mood and increasing connection between residents and staff. Penson et al., 2010. Experienced practitioners regularly emphasize the significance of the patientcaregiver relationship when they refer to the art of healing.

Rounds.
Rounds focusing on caregivers' experiences, and encouraging staff to share insights, own their vulnerabilities, and support each other.

Reflection.
Clear leadership from physician leaders and facilitators to encourage comments and questions and involve the whole group.
"Safe" place with the security that allows people to be candid.
Multidisciplinary meeting, with a nonhierarchical atmosphere and a level playing field.

Respectful and nonjudgmental
K2a Attitudes: Positive impact on staff morale; rekindled a sense of vocation or mission; fostered self-awareness and self-reflection. Marketing was used to advertise the training. CME credit.
Supportive peer learning environment.
Opportunity to ask questions.
Sustainable, enrollment for 3 out of 4 topics well above the calculated minimal number for financial viability.
Training offered by experienced clinician-teachers.
Learners register in greatest numbers for topics they have K1 Reactions: Participants reported thatthe training met learning objectives, was well organized, that the training provided an opportunity to ask questions, and that they would recommend the training to other health professionals.
K2a: Attitudes: Participants reported that as a result of the training they planned to make changes in their personal self-care and their care of others*.

K3 Behaviors:
There was a significant decrease in the percentage of participants who had unplanned work absences.

requested.
Some resistance from some medical staff members to giving institutional ''approval'' to Reiki training. Kemper et al., 2017. There is a need to address the stress, burnout, and depression that is increasingly reported by health professionals.

Contemplative practices.
Mind-body therapies: online course.
Offered free of charge to health professionals and trainees at the university; others were charged a nominal fee.
Elective, no course credit.

Online.
No required minimum number of units.
No deadline for completing the course.

K3 Behaviors:
One year after the course, healthcare professionals reported changes in behavior associated with self care and caring for others*.

Moffatt-Bruce et al., 2019.
There is a need to identify and dedicate resources for maintaining and improving wellness and resilience among front line providers to assure quality of patient care.

Contemplative practices.
Multiprofessional, multimodal process and programs for introducing and sustaining Organization and funding support.

Committed leadership.
Partnership with the creator of the mindfulness program K1 Reactions: The program was well accepted and appreciated. Participants valued being taught breathing techniques.
K2a Attitudes: Participants reported significant improvements in confidence in providing calm, compassionate care self-compassion, at 8-weeks post-Outcomes are intended and unintended consequences -K1 Reactions: Reactions and satisfaction with training (How much did they like it? How did participants react to it?); K2a Attitudes: Did attitudes change?; K2b Knowledge and skills: Did they learn anything? Did the authors use any established instruments to measure changes in knowledge; K3 Behaviors: Did the program or curriculum change their behaviors at all? Or future behaviors?; K4a Changes to clinical processes: Did the program or curriculum lead to any improvements to clinical processes?; K4b Benefits to patients: Did the program or curriculum lead to any improvements to patients? (clinical outcomes; *outcomes on healthcare provider self-report measures; ** outcomes on patient report measures).
Contexts were defined as conditions in which compassion training was introduced and that triggered the training (background circumstances/ unmet need); mechanisms explained the impact of the component introduced by the context (the under lying resources) on the cognitive or emotional decisions and behaviors of the learners (reasoning) that caused compassion training to produce a change; and outcomes were defined as intended and/or unintended consequences of compassion training (Jolly and Jolly, 2014;Salter and Kothari, 2014;Dalkin et al., 2015).  Online modules; interactive lecture series; didactic; guided meditation practice.
Feasible and costeffective.
Interactive training with co-workers on the participants' unit, while clinical work was covered with float health care providers.
Booster sessions after the initial intervention offered at various times and supplemented with a meal.
Weekly reminders of mindfulness tips send by email. baseline, and in perceived stress, depersonalization, interpersonal selftranscendence, and work engagement at 6-months post-baseline*. Participants appreciated the difference in reacting versus responding to an event, and the value of examining what drives one's work meaning.

K4 Changes to clinical processes:
Cultural transformation around patient safety (significant reduction in the number of avoidable events).
K4b Benefits to patients: There were reduced safety events but no significant differences or decreases in participant self-reported patient satisfaction scores*.