Compassionate communication: a scoping review

Introduction

Origins of compassion lie in the Buddhist philosophy (Rubin, 1996) and have been considered an integral part of social communication (Salazar, 2013; Tracy and Huffman, 2017). Regardless of whether the motive behind the demonstration of compassion is altruistic or egoistic (Wuthnow, 2012), it is generally characterised by connecting with others, either through affective empathic concern or cognitive perspective-taking, followed by behaving or communicating in a caring way (Kanov et al., 2004; Miller, 2007). Despite an abundance of empirical studies across diverse contexts pointing out the positive impact of compassion on the physical, social, and psychological health of both the giver and receiver (Kanov et al., 2004; Neff and McGehee, 2010; Patel et al., 2019), communicative aspects of compassion remain a nascent area of research. The feeling of compassion stands out from related concepts like sympathy and empathy as it involves an additional active motivation to do something that alleviates another person's distress (Salazar, 2013; Mascaro et al., 2020). Though an antecedent, this motivation might not always translate into comforting communication or helpful actions (Salazar, 2013). Some of the reasons for this can be attributed to the factors pertaining to the communicator's control, such as compassion fatigue (Miller, 2007; Bayne et al., 2013), lack of confidence in communication skills (Nosek et al., 2014; Kahriman et al., 2016), etc., as well as factors lying outside the communicator's control like recipient's resistance (Bayne et al., 2013; Taylor and Hodgson, 2020), cultural norms (Kataoka et al., 2019; Strekalova et al., 2019), unavailability of private space for confidential interaction (Archer and Meyer, 2021) and so on. The unique salience of compassionate communication over compassionate actions gets noted in situations where even no actions taken would account for a partial reduction in the recipient's suffering. For example, nothing much can be done in action to help another completely resolve the grief that comes with the death of their loved one. However, communicating with them in a way that conveys one's acknowledgement of their feeling, and expressing support and reassurance about their situation are some of the ways through which compassion can be used to empower those undergoing suffering (Cameron et al., 2015).

Though an integral component of human relationships, compassionate communication is quite under-explored (Kanov et al., 2004). The most popular definition of compassionate communication describes it as a benevolent way of communication that involves recognising another person who needs compassion, relating to their need, followed by reacting verbally and/or non-verbally to address the need (Way and Tracy, 2012). Though compassionate communication has its initial roots in the positive psychological concept of compassion, it has been adopted and employed extensively by researchers in many disciplines, including palliative care, sociology, and organisational behaviour. With a lack of appropriate verbal skills being the predominant cause of unhealthy conflicts (Infante and Wigley, 1986; Suarez et al., 2014), developing one's skills for compassionate communication can ward off and diffuse destructive communication (i.e., blaming, shouting, etc.) found as a common part of personal and professional relationships (Whitaker et al., 2007; Paakkanen et al., 2020). Thus, compassionate communication extends beyond the notion of ‘reducing the suffering of another person' to ‘reducing violence prevalent in the society'. Developing compassionate communication skills can serve as an indirect strategy that mitigates the high prevalence of non-physical violence, which may lead to physical violence if prolonged (Suarez et al., 2014).

With numerous studies describing the normalisation and under-reporting of passive aggression, the necessity to bring awareness about the merits of compassionate communication stays undisputed. Considering the negative impacts of violent communication on the mental health of an individual (Glenn and Nock, 2014; Stamatis, 2017; Einarsen et al., 2020), compassionate communication can be identified as a skill that aids in the effective resolution of one's intra-personal and inter-personal problems and enhances the meta-cognitive functions that help with the effective management of distress (Nafise and Ghazal, 2018; Wacker and Dziobek, 2018; Zandkarimi et al., 2019). Compassionate communication also plays a role in determining prosocial behaviour (Salazar, 2013; Suarez et al., 2014). In summary, based on the limited empirical evidence on compassionate communication across various study settings (i.e., health care, education, workplace etc.), compassionate communication can undoubtedly be identified as an approach that enhances the quality of social relationships through its positive impact on the smooth exchange of information, conflict resolution, emotional insight, intimacy, self-awareness, and perceived responsibility (Museux et al., 2016; Nosek and Durán, 2017; Archer and Meyer, 2021).

Research findings highlighting compassion deficits among professionals in service sectors that require compassionate communication as an integral part of their roles (e.g., psycho-oncologists, teachers, etc.) raise important questions about the efficacy of conventional communication training provided to them (Bayne et al., 2013; Deb et al., 2017; Burstein et al., 2022). These findings serve as a critical starting point for a broader dialogue aimed at better equipping professionals in service sectors with the communication skills and support needed to meet the evolving demands of their roles and enhance the quality of care and service they provide. This underscores the need for a more comprehensive and shared understanding of the communicative aspects of compassion, both among researchers and policy-makers across nations.

A preliminary review (conducted by the present review's authors) to examine the empirical foundation of compassionate communication could identify the recent surge in interest regarding the manifestation of compassion in communication. Compassionate communication is a sub-component often intertwined with other care-related constructs, such as compassionate care, prosocial behaviour, and altruism. It is commonly discussed using interchangeable terms, particularly within clinical contexts, such as therapeutic and empathic communication. Consequently, literature that explicitly addresses 'compassionate communication' is frequently overlooked by researchers, who may find it challenging to distinguish this construct from the compassion-related terms. The present review aims to clarify researchers' difficulties in distinguishing the concept of 'compassionate communication' from other compassion-related terms.

Studies on compassionate communication have primarily utilised qualitative approaches or applied best practise recommendations from experts in specific settings rather than universally standardised methods for conceptualising compassionate communication. The very few quantitative research conducted so far on compassionate communication have been in the contexts of healthcare (doctor-patient interaction) and intimate relationships (close friendships or romantic relationships) (Cameron et al., 2015; Vazhappilly and Reyes, 2017). To measure and apply compassionate communication in other contexts (for example, professional relationships in the workplace), it is imperative to have an in-depth overview of the recent definitions and theoretical approaches to compassionate communication.

Sinclair et al.'s (2016) scoping review on compassion based on healthcare literature identifies compassionate communication as one of the sub-themes coming under interpersonal factors associated with compassion within a clinical setting. In addition, it had ‘compassionate actions' as a theme that is separate and different from compassionate communication, yet again suggesting the present review topic as having a unique identity of its own compared to the other compassion terms (Sinclair et al., 2016). Primary studies exploring patient perspectives of doctors' clinical communication illustrate the importance of having warm, compassionate relationships with patients for better treatment outcomes (Pollak et al., 2010; McArthur and Fitzgerald, 2013; Pehrson et al., 2016). However, Sinclair's review primarily focuses on the role of compassion in the effective communication of medical information, with less emphasis on its impact on interpersonal dynamics or relationships (Sinclair et al., 2016). The present review does not consider studies focusing on compassionate communication coming solely from a place of liability (i.e., without the primary motivation to alleviate another's suffering or have a compassionate relationship). Extending beyond the context of healthcare and intimate relationships, the present review becomes the first attempt to understand how compassionate communication unfolds across multiple contexts based on literature from various research disciplines (i.e., psychology, sociology, management, education, etc.). This, in turn, would help to gain more insights into the verbal and non-verbal indicators of compassionate communication within social interactions across multiple cultures.

Other reviews of the compassion literature reported that it is inherently difficult to teach compassion-related qualities and indicated the recent transition towards promoting interventions focusing on communication skills associated with compassionate care (Mascaro et al., 2020; Burstein et al., 2022). However, these reviews point out the limited understanding of the conceptualisation of compassionate communication that is limiting research initiatives to enhance compassionate communication. Salazar's (2013) tool development study on compassionate communication within intimate relationships explicitly states compassionate communication as an emerging concept of research that requires more scientific contributions and methodological rigour. Due to the methodological issues in the research to date, there is no comprehensive understanding of compassionate communication. Moreover, the definitions provided by the individual studies seem very heterogeneous, affecting the scientific understanding of compassionate communication. Research advancements have resulted in developing tools and interventions for compassionate communication, most of which lack strong theoretical support. Consequently, it could be inferred that no globally accepted conception of compassionate communication exists.

Given the absence of a strong empirical and theoretical understanding of compassionate communication, it would be difficult to prove the potential positive implications of compassionate communication for different domains of society. Considering the absence of a comprehensive and consolidated overview of compassionate communication, the present review seeks to map the existing literature on compassionate communication to provide a systematic and organised scientific understanding of the concept. This will direct future efforts to reduce violence, prevent compassion fatigue, improve personal and professional relationships, nullify the drawbacks of existing communication skills training, etc.

The more systematic methodology used by the present review differentiates it from the traditional narrative type of review (Arksey and O'Malley, 2005). Considering the methodological issues, lack of quantitative findings, and heterogeneous research on compassionate communication, a systematic review confined to a specific objective is not possible on this topic at this stage. Nonetheless, a scoping review on compassionate communication will be appropriate to make sense of the inconsistencies in the concept and serve as a source of guidance for future research on theory, education, and interventions. Thus, the present scoping review findings will identify the existing research gaps and serve as a precursor for more quality studies with well-operationalised definitions of compassion. The review's findings can be interpreted in the light of both contemporary and traditional communication theory and have practical implications for different domains of society (i.e., family, workplace relationships, business, healthcare, etc.).

To sum up, the major objective of the present scoping review is to identify and integrate the definitions and theoretical approaches to compassionate communication based on the existing literature

Method

The present review followed the PRISMA-ScR guidelines (Tricco et al., 2018) for scoping reviews (with no prior protocol registration).

Eligibility criteria

Only published studies having full-text availability were considered for inclusion. Studies in the English language only were considered. Owing to the minimal and heterogeneous nature of the evidence on compassionate communication, the authors of the present review designed the eligibility criteria to explore broader outcomes. Thus, no limitations were kept regarding the publication date, kind of population (irrespective of the setting, participant age, and sex), or methodology (for example, tools used, sampling method, sample size, study context, etc.). Primary studies on human participants that used qualitative, quantitative, or mixed-method designs were incorporated. Studies published before 2005 (as ninety per cent of the studies in this area had taken place afterwards), Review papers, Case studies, and PhD dissertations were included only if the content provided some novel contribution to compassionate communication that was not mentioned in the remaining empirical papers. More interest was shown in studies that specifically explained the concept of compassionate communication towards others or experiences from others (even without a clearly described theory or model) or interventions and educational programs that aimed to improve compassionate communication.

Through the initial titles and abstract screening, it could be understood that a large number of studies focused on empathic communication towards people suffering from physical ailments, trauma, etc., and a few other studies implied the importance of compassion in professional communication with the motivation of gaining compliance from customers and not with the primary motivation to alleviate their suffering or build a relationship with them. Thus, the eligibility criteria had to be updated to exclude studies that focused on compassion manifested in clinical communication or informative communication where the relational attributes of the concept were not emphasised. Studies that primarily focused on other related concepts (for example, communication etiquettes, compassion fatigue or other compassionate acts of caring, social support, etc.) were not considered.

Studies that used interventions to foster compassionate care (e.g., loving-kindness meditation, etc.) that did not focus much on the communication aspect of compassion were excluded. Studies focusing on the neurophysiological aspects of the concept were also excluded. Articles that did not contain proper citations and/or that seemed to be written based on that particular study authors' opinions were excluded. Books, Letters, conference abstracts, editorials, commentaries, and other grey literature were excluded.

Information sources

Conducting a preliminary iterative and pilot search of research databases aided the search strategy preparation. The first set of searches was conducted on September 25th, 2022, on major electronic databases, including PubMed, APA PsycNet, Scopus, Science Direct, and Web of Science (as these publish most psychology-related publications). Given the overlapping ways compassionate communication is employed across literature and its close relationship to variables like compassion and empathy, the initial search terms were kept a bit broad to ensure wide coverage of the topic. The authors of the present review decided on the search terms collaboratively after having a detailed discussion with the concerned subject-matter expert. The search terms were as follows:

“Compassionate communication” OR “non-violent communication” OR “empathic communication” OR “compassionate conversation” OR “compassionate expression” OR “compassionate touch” OR “compassionate messaging” OR “authentic communication” OR “collaborative communication”

The synonyms mentioned above were combined with appropriate usage of the Boolean operators: “AND”, “OR” and “NOT”, to get more subject-specific articles.

To identify other additional relevant articles, the literature search was complemented by a Google Scholar database search and an additional manual search of reference lists from books, a publication list of authors of the key articles of compassionate communication, and a reference list of the retrieved articles. Searches were completed across relevant organisational websites and repositories (for example, Non-violent Communication (NVC)-PuddleDancer Press, The Centre for Non-violent Communication, Schwartz Centre for Compassionate Healthcare).

The final database search was conducted on 30 June 2023.

Search strategy

The corresponding author of the present review drafted the search strategy, which was later revised through group discussions with others in the review team. Limiters like language and article type were kept in whichever database it could possibly be applied. The following is an example of a search strategy used in one of the databases (SCOPUS):

( ( ( ( ( ( ( ( ALL (“compassionate communication”) ) OR ALL (“non-violent communication”) ) OR ALL (“empathic communication”) ) OR ALL (“collaborative communication”) ) OR ALL (“authentic communication”) ) OR ALL (“compassionate expression”) ) OR ALL (“compassionate conversation”) ) OR ALL (“compassionate touch”) ) OR ALL (“compassionate messaging”) AND ( LIMIT-TO ( LANGUAGE , “English”) ) AND ( LIMIT-TO ( DOCTYPE , “ar”) OR LIMIT-TO ( DOCTYPE , “cp”) OR LIMIT-TO ( DOCTYPE , “re”) OR LIMIT TO ( DOCTYPE, “sh”) ).

Study selection

The search results were exported to the Zotero software. Duplicates were removed, and independent reviewers screened the remaining records for eligibility in Excel. The screening took place in two stages- (1) Title and abstract screening; (2) Full-text screening. In the first stage, the records were equally divided between two of the present review authors who read the title and abstract of each article (placed in an Excel sheet), keeping the eligibility criteria in mind, and typed down their decision in the Excel sheet. The review supervisor validated the decision, and disagreements were resolved by obtaining consensus among the review team. In the second stage, the full texts of all the retrieved records were read independently by two of the present review authors, who further assessed the eligibility for inclusion. Discrepancies in decisions between the two authors about eligibility at this stage were resolved by referring to and discussing with the review supervisor. An acceptable inter-judge agreement index (κ) of 0.94 and 0.91 was found at stages 1 and 2, respectively. Reasons for exclusion were recorded at all stages of screening.

Data charting process and Data items

Full-text of each eligible record was read and analysed by two of the authors of the present review who collaboratively charted data in a standardised data extraction sheet in Excel, which entailed: (1) basic study details including author(s), publication year, country of origin, article type and objectives; (2) rationale for inclusion; (3) how compassionate communication was termed (for example, compassionate communication, compassionate conversation, non-violent communication, etc.), conceptualised and its underlying theoretical approach (if mentioned). In addition, for empirical records, (4) the methodological details of each study (whatever is available), including the context of the study (for example, within the organisation, informal interactions, etc.), study design (experimental, longitudinal or cross-sectional), sample characteristics (sample size, demographic details, etc.), sampling method, tools used, key findings and study limitations were noted. Identification of the key study findings comprised an extraction of the characteristics, predictors, barriers, and outcomes of compassionate communication, irrespective of the assessment method used by the study. Noting down the detail of each included study helped in better contextualisation of the results (for example, unlike in longitudinal studies, if a cross-sectional study had implied certain variables to be consequences of compassionate communication, the respective construct was better identified to be a correlate rather than a consequence)

The review supervisor validated the extracted data. Disagreements were resolved through group discussion among the review team. Quality assessments were not done since it is typically not conducted in scoping reviews, as their purpose is not to synthesise or weigh evidence on a topic.

Synthesis of results

Considering the heterogeneous nature of the literature, a narrative synthesis approach was taken by the authors of the present review to amalgamate the evidence, which included a thematic analysis (qualitative) and content analysis (quantitative).

Besides the broader findings, the records were grouped initially based on the study objectives (i.e., perspectives on compassionate communication and interventions fostering compassionate communication). Content analysis of study characteristics was done to get frequencies for each grouping. For thematic analysis, quantitative data from studies were translated into textual descriptions. Using inductive coding, themes and subthemes were then derived by the corresponding author and presented in a tabular format to the review team for validation. The review team discussed and confirmed inferences from the finalised records through recurrent meetings. The rigour in the methodology used by each study was also kept in mind during the analysis of the results of each study.

On reaching content saturation during the full-text review of empirical papers, certain articles had to be removed based on lack of rigour in methodology and the year of publication (preference given to the most recent articles as the older articles were found to have narrative content that did not make any novel contribution to compassionate communication i.e., content that was already covered by the other included articles of the review). For more than one theoretical paper written by the same author about a particular model/perspective on compassionate communication, one representative paper with rich content concerning the working definition of compassionate communication in the present review was considered for inclusion.

Results

Study flow

A primary search through the major databases generated 5,764 records (PubMed- 614; APA PsycNet-23; Web of Science- 434; Scopus- 4693), which, when added to the 49 records identified through manual search of other sources (i.e., citations, organisational websites, research repositories, etc.), totalled up to an initial set of 5,813 records. On removing 720 duplicates, the title and abstracts of the remaining records were read to screen out records meeting inclusion criteria. Thus, from the 5,093 records that underwent title and abstract screening, 810 were identified as relevant and sought for full-text retrieval. Subsequently, 753 records were excluded in the next stage. Unavailability of full-text, language of content being non-English, type and content of the record not meeting the eligibility criteria, etc., were noted as major reasons for exclusion. Consequently, 57 records consisting of 1 review article and 56 empirical articles were retained for the final analysis of the present review. Supplementary Figure 1 indicates the PRISMA-ScR flow diagram portraying the selection of sources of evidence.

Study characteristics

Supplementary Table 1 entails the frequency and corresponding percentage values of the study characteristics obtained through quantitative content analysis. Three-fourths of the articles on compassionate communication were published after 2013 (many being published within recent years).

In attempting to extract information about the location of the empirical studies, it could be seen that about half of the studies originated in Asia (Iran, Korea, Philippines, Indonesia, Qatar, Japan, China, and India) and Europe (United Kingdom, Germany, Spain, Portugal, and Norway), around one-third in the United States and the remaining in Australia, South Africa, Turkey, and Canada. The studies predominantly used observational (n = 8), mixed-method (n = 15, comprised of experimental and non-experimental studies), or qualitative research designs (n = 15). Eighteen articles were experimental studies (either qualitative or quantitative).

From the 52 articles from which information about the study settings could be extracted, more than half (n = 29) of the studies had taken place in healthcare settings (hospitals, medical colleges, rehabilitation clinics, palliative care units, therapeutic settings, etc.). Target populations in such studies included hospice employees (doctors, nurses, therapists, group C staff, hospital maintenance workers, medical radiation technologists, etc.), nursing/medical students, and patients. Most of the remaining studies were conducted in education institutes (schools and non-medical colleges) and social work settings (non-profit charity organisations, human service agencies, online support groups, etc.). All the studies conducted in an educational setting (n = 8) had the student population as participants. The sample population of the studies conducted in a social work setting (n = 7) consisted of caregivers in human service organisations, social work practitioners, homeless/at-risk adolescents, young adults, and other vulnerable groups.

Apart from the populations mentioned above, there were studies imploring the communication of compassion among employees from other professions like engineers, practising attorneys, etc., while fewer focused on compassionate communication between romantic couples. Four studies collected data from multiple settings.

Sample size reported across the empirical studies ranged from 2 to 2067 participants (control groups and sample for different phases included), the total being 10,312 participants. Among the studies that mentioned gender details of the sample (n = 48), two studies had only males as participants, five studies had only female participants, and the remaining 41 studies samples consisted of both males and females. Participant age varied from 3 to 75 years.

Supplementary Table 2 illustrates the characteristics of the 57 finalised articles.

Conceptualisation

The current section provides a synthesis of the diverse ways in which the concept of compassionate communication has been defined and interpreted within existing literature and highlights the common themes and variations in the characteristics of compassionate communication. The content of the present section has been organised to represent the evolution of thought on compassionate communication over time.

Across the 54 articles that explained the concept of compassionate communication, five different terms were used as labels for the definitions of compassionate communication (‘non-violent communication', ‘empathic communication', ‘compassionate communication', ‘empathic expression', ‘response empathy′). Though the most frequent term of usage was ‘empathic communication', which is a construct that is conceptually different from compassionate communication, the definition given in the respective articles matched or was identified to be part of the broader working definition of compassionate communication used in the present review. Supplementary Table 3 presents the detailed citations for the major aspects explained in the conceptualisation of compassionate communication.

Over one-third of the finalised articles had a less explicit definition of compassionate communication. Most of the studies conceptualised compassionate communication based on pre-existing theories/definitions, while 14 studies gave novel definitions or contributed more to the conceptual framework of the construct. The heterogeneous definitions obtained could be synthesised as having two different aspects. These aspects relate to (1) cognitive-affective aspects, and (2) behavioural aspects of compassionate communication. Thirty-one articles defined compassionate communication in terms of its behavioural attributes only (i.e., without mentioning the underlying cognitive-affective aspects), while the remaining described compassionate communication as a combination of both.

Cognitive-affective aspects refer to all those cognitive and affective processes involved in effectively communicating compassion. This could be differentiated into:

a) Recognising the need for compassion in the recipient that involves perspective-taking, i.e., to make sense of the verbal and/or non-verbal cues indicating another's need or feeling,

b) Relating to the recipient to enable sharing of emotions, values, and decisions and involves a consubstantial manner of either or both of the following:

1. Feeling with (i.e., kind compassion comprising of sympathy and kindness) or feeling for (i.e., affective empathy comprising of emotional resonance without having emotional stimulation to oneself) another's experience

2. Cognitively connecting with another's experience (experiential and relational understanding)

Behavioural aspects concern the features of recognising, relating, and reacting compassionately to the recipient's compassion-needy situation through verbal (can be direct or indirect- for example, online message or mail) and non-verbal means. Unlike the ‘recognition' and ‘relating' components of compassionate communication that have been described in the articles as consisting of cognitive-affective aspects as well as behavioural aspects, the ‘reacting' component pertains to all those verbal/non-verbal behaviours that are perceived or could be perceived as compassionate by the communicator, recipient or any other individual (Way and Tracy, 2012, p. 307). A few of the articles had definitions that explained beyond the notion of compassionate reacting as ‘verbal/non-verbal communication of compassion' to ‘helpful actions to take care of the recipient's need' (Miller, 2007; Way and Tracy, 2012; Cameron et al., 2015; Huffman, 2017; Sinclair et al., 2018; Bottino and Manji, 2020; Powers and Myers, 2020).

Verbal means to communicate recognition encompasses conversational attempts to understand another's perspective/feeling and/or reflection/acknowledgement of their situation/feelings, while verbal strategies to relate with another's perspective/feeling encompasses vulnerable self-disclosure, verbal affirmation, and/or emotional responses mirroring or expressing concern/support for the recipient's feeling. Verbal responses indicating the reacting component of compassionate communication encompasses information content sufficient enough to facilitate connection (for example, encouraging expression of feelings/perspectives) or alleviate another's suffering (for example, helping them deal with their feelings), personalisation, affirmation/acceptance, reassurance, supplementary humour, expressing caring/kindness, proposing to take actions that honour recipient's needs/perspectives and/or appreciation.

It is important to observe the overlap between certain verbal indicators in the definitions of the 'relating' and 'reacting' components of compassionate communication. This overlap serves as a crucial point of consideration as it highlights the nuanced and multifaceted nature of compassionate communication. For instance, verbal reassurance and affirmation are noteworthy examples of this overlap. They are mentioned as communicative indicators of relating with compassion in some definitions, and concurrently, they also appear as communicative indicators of reacting with compassion in a few other definitions. This contradicts the arguments made about ‘relating' and ‘reacting' as two separate components of compassionate communication and underscores the need for a more nuanced understanding of how specific verbal cues may encompass both relational and responsive aspects of compassionate communication. The study by Way and Tracy (2012) that used in-depth qualitative research through fieldwork and long-term participant interaction (ethnographic interviews) to conceptualise compassionate communication explains this confusion by finding that the three processes of recognising, relating, and responding with compassion cannot be considered mutually exclusive (Way and Tracy, 2012). The finalised studies also added possibilities for the behavioural indicators of compassion to occur before or without feelings of compassion (i.e., ‘reacting' compassionately can come before ‘relating' with compassion) (Way and Tracy, 2012; Bayne et al., 2013). These studies question any possible notion of temporal sequence in the three processes of compassionate communication.

Fifteen articles specifically explained the non-verbal (i.e., through body language including body postures, facial gestures, etc.) and paralinguistic expressions (for example, voice tone, speed, pauses, etc.) of compassion. Interestingly, only those non-verbal/paralinguistic expressions that convey embodied aboutness (i.e., become bodily present, sustain immediacy, and make one's body for the sake of the other) and are congruent to the recipient's emotional state (i.e., reflects understanding and mirrors the recipient's situation), were perceived as compassionate. This overlooks all other non-verbal and para-linguistic expressions from being classified under compassionate communication. Thus, even a positive non-verbal smile and remembrance of names that convey pro-active engagement could be used to communicate compassion (Huffman, 2017; Tracy and Huffman, 2017; Falconer et al., 2019; Grondin et al., 2019; Kelly et al., 2020; Taylor and Hodgson, 2020).

Eleven studies described listening as an imperative communication skill that helps to recognise the need for compassion in a recipient. Non-verbal acknowledgement (i.e., silence, pause, or sigh) and non-verbal immediacy (specifically, eye contact, mirroring the recipient's expression, and turning towards the recipient) were identified by some of the articles as the non-verbal ways to communicate the recognition of another's compassion-need.

Empathic touch, eye contact, face-enhancement strategies, etc., were mentioned by some of the articles as non-verbal ways to relate to another's compassion need, whereas silence, long pauses, softening of tone, the rhythm of speech, emphasis/animation could be identified as the para-linguistic expressions to communicate relating.

Physical care, presence/non-abandonment, acts of service, environmental structuring, giving the gift of quiet time and personal space, and immediacy behaviours like touch, eye contact, spending time, active listening, and body orientation/gestures were the behavioural attributes extracted from the articles about non-verbal means of reacting compassionately.

Considering all those mentioned above, it could be inferred that the non-verbal and para-linguistic expressions of compassion can be broadly classified under ‘non-verbal immediacy behaviours' which serve as an inevitable non-verbal part coming under the behavioural aspect of compassionate communication. Besides communication of recognition, relation, and reaction to another's compassion need, ‘non-verbal immediacy behaviours' convey availability, increase sensory stimulation and reduce the psychological distance (Huffman, 2017, p. 157). However, it was noteworthy to see Huffman (2017) study mentioning ‘organisational immediacy' as one of the communication practices that indicate recognition and relation to another's compassion need (Huffman, 2017, p. 158).

Based on the conceptualisations given in 9 articles, a non-judgmental response (i.e., withholding negative judgment or abstaining from communicating personal evaluations of another's shortcomings) to another's compassion need could be identified as a salient characteristic of compassionate communication (Cox and Dannahy, 2005; Salazar, 2013; Arnesen-Trunzo, 2015; Vazhappilly and Reyes, 2017; Nafise and Ghazal, 2018; Falconer et al., 2019; Grondin et al., 2019; Zandkarimi et al., 2019; Hadsall Jakowich, 2020). Similarly, deference (Tracy and Huffman, 2017; Hadsall Jakowich, 2020; Mann et al., 2020), authentic self-expression (Museux et al., 2016; Araújo et al., 2019; Hadsall Jakowich, 2020; Mann et al., 2020; Yang and Kim, 2020), positive language intensity (Tracy and Huffman, 2017), mindfulness (Way and Tracy, 2012), shared values/needs among dialogue partners (Vazhappilly and Reyes, 2017; Zandkarimi et al., 2019) were reported by few articles as basic elements of compassionate communication. Overall, inconsistencies could be seen regarding the role of non-judgmental attitude, empathy, compassion, listening, nonverbal immediacy, deference, authentic self-expression, positive language intensity, organisational immediacy, compassionate acts and shared values/needs among dialogue partners, that have been described as components/characteristics of compassionate communication in definitions given in some articles and as separate (i.e., correlates/predictors) in conceptual frameworks provided by a few other articles.

Six studies talk about compassionate communication as an antonym of violent communication (involves blaming, verbal aggression, etc.) or directive communication (involves educating, advising, correcting, etc.) that helps dismantle conflicts and other challenging social situations (Marlow et al., 2012; Nosek et al., 2014; Arnesen-Trunzo, 2015; Nosek and Durán, 2017; Vazhappilly and Reyes, 2017; Hadsall Jakowich, 2020).

There are many communication techniques like the Conscious Discipline (CD) approach developed by Bailey (2015), the Love and Logic technique developed by Cline and Fay (2006), and ‘first-then' statements by Perry (2005) etc. that have been discussed as different techniques for effective interpersonal communication (Perry, 2005; Cline and Fay, 2006; Bailey, 2015). But on closer scrutiny, all those mentioned above are found to have the same underlying principles that are analogous to that of compassionate communication. Like there are many meditation techniques, all these communication techniques can be synthesised to come under the umbrella term ‘compassionate communication' (Hadsall Jakowich, 2020).

Six articles viewed compassionate communication as a virtuous trait that is more or less stable irrespective of the situation in which an individual is in, while 35 articles viewed the construct as a state, i.e., a momentary communication of compassion evoked by the particular situation the individual is in. Thirteen articles viewed compassionate communication as a communicative ability/skill without specifying whether it is state-dependent or trait-dependent, or both.

Most articles described compassionate communication as stemming from a desire to alleviate another's suffering/distress, while some articles elucidated compassionate communication as a response to address another's needs or emotions (irrespective of whether the recipient's emotions are negative or positive). Few articles emphasised relationship building/maintenance as a motive behind an individual's compassionate communication to another, which can unfold even when the recipient does not have a need or distress. Finally, based on the conceptualisations given in 15 studies, it could be inferred that either of the motives mentioned above can initiate compassionate communication.

Except for two articles that did not mention the direction of compassionate communication (Jo et al., 2019; Ibrahimoglu et al., 2021), all the remaining articles discussed the direction of compassionate communication. Specifically, 42 articles defined compassionate communication as a one-way expression of compassion from an individual to a target recipient. Among the 11 articles that defined compassionate communication as a mutual expression of compassion among dialogue partners, 3 studies explained the concept from the recipient's perspective. In other words, they described it as the target initiating communication (verbally or non-verbally) in a way that evokes compassion from other individuals. In addition, the study by Yang and Kim (2020) mentions that it's not always necessary for compassionate communication to occur between two individuals, but it may include communication of compassion to self as well (Marlow et al., 2012), based on self-introspection of one's own need/emotional state (Araújo et al., 2019).

In conclusion, it can be understood that the concept of compassionate communication has been defined in the existing literature by referring to its cognitive-affective and behavioural characteristics. In addition to the verbal expressions of compassion, this review has identified various passive and active ways of communicating non-verbal compassion. Ambiguities discovered regarding the concept's nature, motive, direction, and relationship with related variables shed light on areas that require further research to achieve a consensus on the operationalisation of compassionate communication.

Theoretical approaches

Drawing from 35 studies across diverse sources and disciplines, each referencing one or more theories to substantiate their claims, the present review has extracted numerous theories that offer insights into compassionate communication. This section explains the theories in an order that emphasises their interrelatedness, providing an organised description of how each theory builds upon or complements the others.

On examining Clark's (1997) model of interactive sympathy as consisting of role-taking, feeling, and display of the feelings, Kanov et al. (2004) theorised compassionate communication to comprise three inter-dependent processes, namely: noticing another's emotional state, feeling the other's pain through empathic concern and responding in a way that alleviates another's suffering. But Miller (2007, p. 232) reworked Kanov's second process of compassionate communication by replacing “feeling” with “connecting” (involves cognition as well) and claimed the newly proposed term of connecting meant both internal feeling and corresponding behavioural display that is relational and experiential. Consequently, Miller's theory can be considered to directly or indirectly serve as a broader framework to fit most of the definitions of compassionate communication provided across the finalised articles in the present review.

Some of the article definitions of compassionate communication could be traced back to Baxter's (1990) dialectical approach towards relationships. Baxter (1990) puts forth the three dialectical forces that are integral to the experience of interpersonal relationships, namely, connection/autonomy, closedness/openness, and novelty/predictability. The theory emphasises the need for a dialectic understanding of communication, emphasising a balance of these dialectic forces when communicating compassion. Miller (2007) later adds to the tension between rationality and emotion while conceptualising compassionate communication in the workplace context. Comparable to this lies Habermas (1987) theory of communicative action, which portrays communication as symbolic of supreme human potential that helps to surpass competing tensions. In the context of compassionate communication, Habermas's theory underscores the importance of open and constructive dialogue to balance the dialectic forces of connection and autonomy. It suggests that effective communication, marked by autonomy and connection, can resolve the competing tensions and lead to more harmonious interpersonal relationships. This aligns with the broader theme of dialectical balance in compassionate communication, where the interconnected forces of connection and autonomy are essential for its successful practise.

Babrow's (2001) problematic integration theory highlights the importance of communication in shaping and reflecting an individual's perceptions of different experiences and a consequent reaction to the experience. Babrow's theory implies that compassionate communication, both in personal/impersonal relationships and across private/public contexts, is a valuable resource for individuals dealing with problematic integration. When individuals experience incongruencies between their beliefs about the likelihood of events and the value they place on those events, it can lead to conflicts or discomfort across cognitive, affective, motivational, and communicative dimensions, as outlined by Babrow (2001). In this context, compassionate communication provides a means of addressing and resolving these conflicts by fostering understanding, empathy, and effective communication strategies. This, in turn, aids individuals in managing the challenges associated with problematic integration in various aspects of their lives.

A grounded theory-based study by Bayne et al. (2013) provided a comprehensive model of compassion explaining the facilitators and barriers to the appropriate expression of compassion. The model helps to understand compassionate communication as a multi-level sequential process that starts with the communicator's qualities (e.g., personality traits, motivation) and continues through overcoming plausible internal barriers (e.g., ego, burnout) and external barriers (e.g., acute/high-pressure scenarios) to compassion opportunities, leading to different levels of compassionate interaction indicating consideration and positive outcomes for the recipient. The model details the behavioural manifestation of empathy on two levels, i.e., initial compassion and genuine compassion. Initial compassion refers to a primary level of empathy characterised by micro-skills such as active listening, usage of open-ended questions, attention to the recipient's comfort, etc., where the communicator focuses on alleviating the presenting problem of the recipient without having a deeper connection towards the other. Genuine compassion extends initial compassion to a level where a compassionate connection is rooted in a desire to understand and be there for another. Genuine compassion goes beyond just trying to solve the recipient's immediate problem by being more concerned about the whole individual (Bayne et al., 2013).

Salazar (2013) developed the first quantitatively tested theoretical model of compassionate communication based entirely on its behavioural indicators. According to this model (mentioned in 4 of the finalised studies), compassionate communication is a complete behavioural manifestation of compassion and consists of three components, i.e., compassionate messaging, compassionate conversation, and compassionate touch (Salazar, 2013; Jo et al., 2019; Ibrahimoglu et al., 2021; Suwinyattichaiporn et al., 2021).

The empathic-communication model of burnout by Miller et al. (1988) asserts that a lack of empathic communication skills has the potential to cause burnout. Later, Snyder (2012) extrapolates the original model to include the predicting role of individual differences (i.e., self-monitoring traits and emotional intelligence) in the emotional-communicative response to another's distress and the consequent burnout level. The new model elucidates how an individual can prevent burnout and communicate effectively with another compassion-needy recipient by having appropriate control over one's expressive behaviour and by regulating one's mood to have optimistic perspectives (i.e., lower levels of contagion of negative affect, higher levels of empathic concern and communicative responsiveness) (Snyder, 2012).

The empathy-altruism hypothesis gives a theoretical underpinning to the behavioural manifestation of compassion by stipulating that being sensitive to the emotional experiences of needy people instigates empathic concern in an individual, which in turn serves as a primary motivator of prosocial behaviours (Batson et al., 1991; Falconer et al., 2019).

Compassionate communication can be examined under the “expressive” category of the speech act theory by Searle (1976, p. 12), as it involves the communicator expressing one's feelings about self or the world (Searle, 1976). This is further supported by the systemic functional approach to discourse analysis that talks about expressive choices (interpersonal/attitudinal) that include the dialogue partners evoking and responding to emotions and positive appraisals of each other (Pounds et al., 2018).

According to the theory of mind mentioned in 2 articles (Grondin et al., 2019; Strekalova et al., 2019), compassionate communication can be understood as the aptitude to keep aside one's perspective and, through abstract inference, reflect on another individual's thoughts, wishes and behavioural traits (Leslie, 1987; Astington et al., 1988; Bzdok et al., 2012). The cognitive-affective aspects of compassionate communication can be better understood in light of Dökmen's (1988) theory on empathic communication, which claims the concept to have both emotional and cognitive components. The theory mentioned in 4 of the finalised studies (Ançel, 2006; Ozcan et al., 2010; Özcan et al., 2011; Kahriman et al., 2016), proposed empathic communication to have three stages, namely: ‘they', ‘you', and ‘I' stage. An individual employing the ‘they' stage relies on social judgments rather than the presented problem while evaluating and shows low levels of empathy. An individual in the ‘I' stage of empathic communication uses criticism and advice based on one's understanding of another's problem and shares one's feelings and previous experiences on the presented problem. An individual is considered to show high levels of empathy in communication when they understand and reflect on the problem from the other's perspective and deep feelings and continue to render support (Dökmen, 1988). Thus, the theory helps to conclude that an individual engaging in compassionate communication is using Dokmen's ‘you' stage of empathic communication. Similarly, Ritter (2009) also explains a framework identifying four levels of empathic communication in which the fourth (highest) level more closely represents the construct of compassionate communication (Ritter, 2009).

On drawing upon Watzlawick et al.'s (2011) work, there are two distinguishable goals of communication, i.e., (1) to pass on information and (2) to impart meaning and express a relationship between the dialogue partners (affective goal). This explains how compassionate communication predicts conflict resolution as integrating compassion into one's communication will help one learn to meta-communicate, i.e., one can rightly identify the information part and affective part and would know how to alter between the two (Cox and Dannahy, 2005).

Fourteen articles discussed the theory of Non-violent communication (NVC) proposed by Rosenberg (2005), which is based on the underlying assumption that all individuals have universal needs which, when met, lead to the experience of positive feelings and otherwise to negative feelings. The theory suggests a new language of life, which is a four-stage process to effective conflict resolution and positive relationship building as it prevents one from responding violently to challenging social scenarios (Marlow et al., 2012). According to NVC theory, compassionate communication goes through a first stage, where a non-judgmental objective observation about a particular situation is followed by acknowledging the accompanying emotional response to the observed situation as the second stage. The third stage involves identifying met and unmet needs related to the observation, which is greatly influenced by an individual's self-awareness and knowledge about distinct feelings and underlying universal needs (Wacker and Dziobek, 2018). The fourth stage involves addressing a non-demanding request towards the dialogue partner for behaviours satisfying one's unmet needs. As a listener with NVC skills, an individual can foster compassion with the dialogue partner by non-judgmentally receiving the observations, feelings, needs, and requests communicated overtly or covertly by the dialogue partner (Wacker and Dziobek, 2018). On interlinking NVC theory with Watzlawick's theory (Watzlawick et al., 2011), it can be concluded that compassionate communication has the potential to promote change as it has a balance of both the information part (entailed in the observation and request stage) and the affective part of communication (feelings and needs stage) (Cox and Dannahy, 2005).

The study by Arnesen-Trunzo (2015) examines Rosenberg's compassionate communication (2005) in connection with Kolb's experiential learning theory (Arnesen-Trunzo, 2015). Kolb (1984) conceptualises learning to be an active, self-directed process that can be applied at any time across various personal and social situations, which in turn leads to the development of knowledge (Kolb, 1984). Considering the impact of compassionate communication on one's knowledge, abilities, and attitudes, it could be deduced that effective usage of language and skills for compassion across different situations can nurture one's abilities for concrete experience, reflective observation, abstract conceptualisation, and active experimentation, thereby promoting learning and knowledge development. Thus, Arnesen-Trunzo (2015) claims that the four steps of compassionate communication (observation, feelings, needs, and requests respectively) consist of the following: involving oneself in different experiences without bias, which is the first step that uses concrete experience abilities; reflecting on the observations made from the experience from different angles that are employed in the second and third step (i.e., reflective observation abilities used when one reflects on and share own feelings and needs); constructing ideas based on the reflections (i.e., the abstract conceptualisation abilities used to listen and reflect upon the feelings and needs shared by one's dialogue partner) and acting upon the newly constructed ideas in the fourth step (i.e., active experimentation abilities used to make negotiable requests with each other).

The concept of compassionate communication proposed by Rosenberg (2005), can be better understood based on insights from Patfoort's (1995) major-minor theory on violent interactions (i.e., found to be more common) and non-violent interactions among humans. The theory describes violence as stemming from an incongruent relationship between a ‘major' (i.e., the one who is presumed to have a more powerful position featured by more usage of positive or destructive arguments) and a ‘minor' (i.e., the one who is presumed to have a less value position and who may give in, for example, one whose viewpoint does not align with the norms) having viewpoints that are incompatible with each other. Comparable to the NVC theory, Patfoort (1995) defines a non-violent interaction as involving dialogue partners with the same positions of power and having viewpoints stemming from their respective needs. The theory calls for the importance of communication as a tool to attain or maintain power in an unbalanced human interaction. In addition, the theory unravels the different reverberations of the major-minor system, some of which are mistrust, frustration, the feeling of control over another, etc., thereby emphasising the importance of power and imbalance in human interactions. It was reported that individuals try to attain a ‘major' position by placing the other in a minor position (i.e., the less favoured position). In certain situations, when the opposing dialogue partner is too powerful or when there are many opposing dialogue partners, the individual leaves the conflicting situation and finds another potential minor, failing, which would cause the individual to internalise violence and mistreat oneself (Alshughry, 2018).

In trying to understand compassionate communication through the lens of the empathic opportunity-response model conceptualised by Suchman et al. (1997), it could be inferred that communication of compassion involves recognising and responding to the compassion opportunities presented by another (Suchman et al., 1997; Bylund and Makoul, 2005; Pehrson et al., 2016). The model talks about two types of compassion opportunities, i.e., empathic opportunity (an individual's explicit in-person disclosure about one's emotions) and praise opportunity (an individual's explicit in-person disclosure about something that deserves praise from another). Further, a prospective empathic opportunity is an implicit expression made by an individual from which an underlying emotion or some aspect of the individual's life events can be deduced by another (Suchman et al., 1997; Levinson et al., 2000). A communicator is considered to miss a compassionate opportunity if they fail to give an empathic response (i.e., expressing recognition towards an empathic opportunity) or praise (i.e., expressing recognition and positive evaluation towards a praise opportunity) and is considered to terminate a compassionate opportunity if they change the topic of dialogue (Suchman et al., 1997). Concerning Suchman et al.'s (1997) empathic opportunity-response model, Levinson et al. (2000) elaborated on different kinds of appropriate (for example, praise, rendering acknowledgement, reassurance and support) and inappropriate responses (for example, insufficient acknowledgement, insensitive usage of humour, discounting the other's distress, terminating or changing the topic of discussion) that could be given to an empathic opportunity.

A topical review by Goubert et al. (2005) presents a model summarising the different contextual factors (for example, nature of the relationship, intimacy, etc.) that influence an individual's affective and behavioural responses to alleviating the painful suffering of another (Goubert et al., 2005; Grondin et al., 2019). Another interesting claim pointed out by the model was about the two types of affective responses one can have on observing another's suffering: (1) distress that is oriented towards self, and (2) sympathy that is oriented towards the other. Goubert et al. (2005) claim that personal distress and sympathy have different behavioural consequences: (1) egoistic efforts to deal with personal distress, like withdrawal, undermining the observed pain, etc.; (2) altruistic efforts to help the other, like rendering comfort, reassurance, etc.) (Goubert et al., 2005; Batson, 2014). Though these affective responses may occur together, they are different in quality. The model highlights the role of recipient characteristics (termed bottom-up influences) and communicator characteristics (termed top-down influences) in the accurate sense-making of the observable painful experience. It could be noted that the bottom-up influences like the recipients' verbal and non-verbal expressions of distress that may be voluntary or involuntary, attempts to hide pain owing to their fear of misunderstanding or stigmatisation, etc., serve as powerful cues of their suffering (Morley et al., 2000; Hadjistavropoulos and Craig, 2002; Williams, 2002; Herbette and Rimé, 2004; Botvinick et al., 2005). In addition, the communicator's previous personal experiences of similar suffering, the ability to differentiate between the sense of knowing another's suffering and one's affective response to the suffering without getting overwhelmed, the ability to rightly identify the empathic opportunities without missing, the natural tendency to share emotional experiences with close ones leading to more knowledge about the situation at hand, the extent of pain catastrophisation (i.e., beliefs about the severity and controllability of other's painful state), etc. serve as the important top-down influences (Hadjistavropoulos and Craig, 2002; Rimé et al., 2004; Cano et al., 2005; Jackson et al., 2005).

Burleson et al.'s (1994) theoretical work on the features, functions, and outcomes of comforting messages enlightens professionals and laypeople about alleviating another's emotional distress through one's sophisticated communication (Burleson et al., 1994; Taylor and Mamier, 2013). Burleson et al.'s (1994) work proposes that individuals' distressed reactions are majorly based on their evaluations and interpretations of life events. Therefore, the most appropriate response to help the suffering individuals should include verbal strategies that facilitate their self-introspection and meaningful re-appraisal of a distressful situation. The key features of such comforting messages, supported by empirical evidence, include (1) Active attention on the distressed individual; (2) Having a non-judgmental attitude; (3) Responses focused on the recipient's feelings and not thoughts; (4) Validation and acceptance of the recipient's personal experience; (5) Giving feedback about the recipient's feelings from a cognitively oriented stance (Burleson et al., 1994).

Based on the empathic interaction cycle conceptualised by Barrett-Lennard (1981), it can be inferred that compassionate communication cannot be limited to a response to another's painful state, but other emotional states as well, bring about similar cues that demand the expression of compassion (Barrett-Lennard, 1981; Grondin et al., 2019). Barrett-Lennard (1981) delineates three major phases involved in direct empathic interaction between two individuals, where one is called the expressing/exploring partner (Ex), and the other becomes the empathising partner (Em). The model points down the prerequisites initiating an empathic interaction, suggesting that Em should have an actively attending empathic mindset towards Ex, who, in turn, should be able to explore and express his or her personal experience (concurrently trusting or expecting Em to be receptive). Phase 1 involves empathic resonation of Em towards Ex in which Em experiences and clearly understands the explicitly or implicitly expressed experience of Ex; In Phase 2, Em attempts to communicate their understanding of Ex's emotional experience, which is followed by Phase 3 in which Ex actively evaluates Em's communicative efforts to render understanding. Consequently, Ex continues or resumes to give explicit or implicit feedback to confirm or correct Em's communicated understanding of Ex's personal experience (i.e., expressed already in Phase 2). This feedback may also include informing Ex's perception of their relationship with Em regarding their understanding of each other. Upon feedback, if the basic prerequisites for an empathic interaction are still maintained between the dialogue partners, the cycle continues and reaches Phase 1 again with added new content about the personal experience of Ex. At this point, it is important to note that the dialogue partners may exchange the positions of Ex and Em after one or more cycles (Barrett-Lennard, 1981). However, the presumption of empathic interaction as a healing and growth-enhancing experience in healthy relationships remains unquestioned. As empathic interaction is inevitable in the broader construct of compassionate communication, Barrett-Lennard (1981) model's relevance remains undisputed.

In summary, the different theories identified by the present review symbolise the evolving nature of compassionate communication in today's interconnected world. Synthesising various perspectives offers a comprehensive overview of the intricate connection between existing theories, unveiling the common threads and differences. This deepens our understanding of the multifaceted nature of compassionate communication across different contexts and underscores its enduring relevance in promoting positive relationships and collective wellbeing.

Discussion

The current section is intended to discuss the major insights of the present scoping review, outline the major merits and drawbacks within the existing literature and stamp the implications of the review for further primary research. Based on a synthesis of the existing literature on compassionate communication across various contexts, the present review gives an in-depth scientific understanding of compassionate communication by presenting a comprehensive overview of the different definitions of compassionate communication. In addition, the review identifies and integrates the theoretical frameworks that explicitly or implicitly explain the concept of compassionate communication. By and large, the definitions and theoretical approaches reported across the 57 finalised articles showed high heterogeneity. Thus, the present review tries to bring about more consistent operationalisations of compassionate communication.

Irrespective of the definitions of compassionate communication varying across the studies, most of the study conceptualisations could be placed under Way and Tracy's (2012, p.307) broad explanation of compassionate communication as a process of 1) recognising, 2) relating and 3) reacting. Still, there were disparities in how each study described the three processes mentioned above. Firstly, few studies use the term ‘noticing' instead of ‘recognising', explaining it as awareness of the need for compassion and observing the details about another's situation to render a more appropriate response of compassion. However, the thematic synthesis of the definitions across the studies helps to understand that ‘recognising' is more than just ‘noticing' as it goes beyond comprehending the communicated behaviours of the recipient by understanding even the uncommunicated aspects of the recipient's situation (Way and Tracy, 2012).

Secondly, based on the operational definitions of compassionate communication across different study contexts, it could be understood that ‘relating' to another involves (a) ‘feeling with/feeling for' a distressed recipient and (b) relational/experiential connecting with the recipient. Relating may also imply reciprocity and communicative interaction. It is also possible to feel for another without connecting with them (Way and Tracy, 2012). Also, it could be inferred that though ‘relating' in a given situation may involve feeling and connection, neither is given more importance. Moreover, almost all the studies portray compassionate communication as a virtuous quality that can only have positive outcomes. However, the present review brings in research evidence notifying the probable negative impact of compassionate communication. Compassionate communication leads to compassion fatigue, burnout, and the detrimental consequences associated with it if the ‘relating' process of compassionate communication involves ‘feeling with' (characteristic of sympathy and empathic concern) instead of ‘feeling for' (characteristic of affective empathy that does not involve emotional stimulation to oneself) another's distress over a long period (Snyder, 2012; Powers and Myers, 2020). This is validated by studies suggesting distress tolerance to be a mediating variable in the relationship between compassion and prosocial behaviours (Eisenberg et al., 1989; Gilbert, 2009; Kaltwasser et al., 2017; Falconer et al., 2019). This is an important insight that can be considered to design interventions in a way that nullifies any possible negative outcomes of ‘relating' with compassion. Though it looks like the researchers have different understandings about the ‘relating' aspect of compassionate communication, this unravels the scope for researchers to explore the determinants of the ‘relating' aspects of compassionate communication in different study contexts based on which the conceptualisation of ‘relating' may differ.

Thirdly, on seeing many definitions repeatedly talking about the temporal sequence in the three processes of compassionate communication, the present review calls for further empirical studies to verify the applicability of Way and Tracy (2012) claim about the possibility of ‘responding' to come before ‘relating' (Way and Tracy, 2012). Some studies define compassionate communication as devoid of educating or advising (Marlow et al., 2012; Nosek et al., 2014; Arnesen-Trunzo, 2015; Nosek and Durán, 2017; Vazhappilly and Reyes, 2017; Hadsall Jakowich, 2020). However, many other studies talk about compassionate communication only in terms of how it can reduce the distress of another (Bayne et al., 2013; Cameron et al., 2015; Huffman, 2017; Schreckenbach et al., 2018), according to which a piece of advice or knowledge shared can be considered as a way to address others' needs/emotions and can be perceived as helpful by the recipients and thus contribute to the alleviation of the suffering at hand (Özcan et al., 2011; Suarez et al., 2014; Alshughry, 2018; Mann et al., 2020).

Though the majority of the studies highlight compassionate communication as an approach to alleviate the suffering of another, the present review helps us understand that it is possible to study compassionate communication beyond the suffering context. The present review describes compassionate communication as involving (1) cognitive aspects, (2) affective aspects, (3) behavioural/state aspects, (4) relational aspects/mutuality, (5) self-compassion, and (6) individual-specific virtuous traits or values. These findings carry profound implications for professionals in service industries, such as psycho-oncologists, teachers, and other sectors where compassionate communication is integral to their roles. For instance, let's consider a teacher who, apart from providing comfort to a distressed student, also utilises compassionate communication to encourage and inspire learning. In a healthcare context, compassionate communication extends beyond consoling a patient to encompass the empathetic delivery of good news and establishing trust in doctor-patient relationships. Similarly, in profit-driven workplaces, strategic communication of compassion may be employed to foster positive workplace cultures, motivate employees, and enhance overall productivity. Training individuals in compassionate self-communication can assist in altering their self-critical attitude, enhancing their self-esteem, and aiding in the management of imposter syndrome, among other benefits. On an initial look, all the varying perspectives across the studies tend to indicate different conceptualisations of compassionate communication. However, present review findings suggest that the definitions can be viewed as only reflecting different emphases given by the studies to the concept of compassionate communication. Thus, it can be understood that the varying definitions and theories examined in the present review do not contradict each other; instead, they represent different facets of the same concept, 'compassionate communication.' This realisation highlights the versatility and adaptability of this communication approach in diverse professional settings and underscores the need for tailored training and support for professionals in the service industry. In doing so, we can bridge the gap between compassionate communication theory and its practical implementation, ensuring its effectiveness in improving both personal wellbeing and the quality of service provided.

It can be noted that compassionate communication has been defined by some studies as a state and some as a trait. Figuring out what it means to call a construct a ‘trait' or when to call a construct a ‘state' is a usual topic of scientific argument. The present review findings encourage one to conclude compassionate communication as a trait, state, or both, depending on the study context. Most studies consider compassionate communication as a complete behavioural manifestation of compassion towards one another and therefore define the concept in terms of its behavioural aspects while mentioning factors like compassion, empathy, etc., as separate constructs that facilitate compassionate communication (Snyder, 2012; Cameron et al., 2015; Huffman, 2017; Jo et al., 2019; Ibrahimoglu et al., 2021; Suwinyattichaiporn et al., 2021). This is validated by literature evidence supporting compassionate communication to manifest itself as a communicative skill used to alleviate another's distress, even in the absence of a compassionate feeling for the other (Platt and Keller, 1994; Way and Tracy, 2012; Bayne et al., 2013; Pehrson et al., 2016). But with the remaining studies defining cognitive aspects of compassion, empathy, etc., as part of compassionate communication (Miller, 2007; Tracy and Huffman, 2017; Sinclair et al., 2018; Powers and Myers, 2020; Taylor and Hodgson, 2020), there arises a need for a more explicit integrative understanding of the present study concept.

Literature evidence describing the role of non-verbal and para-linguistic expressions usually perceived as compassionate is quite vague. While many studies mention all kinds of listening to self and others as important to effective compassionate communication, some studies classify compassionate listening as active (not passive) and empathic (not apathetic) (Taylor and Hodgson, 2020). However, more clarity is needed on whether active listening is a part of compassionate communication or a micro-skill that facilitates compassionate communication (Marlow et al., 2012; Nosek et al., 2014). In addition, the studies give inconsistent views about listening as a non-verbal aspect or a paralinguistic way of communicating compassion. Likewise, empathic voice as well is classified under para-linguistic expressions of compassion in some studies (Cameron et al., 2015; Grondin et al., 2019) and as a non-verbal expression of compassion in others (Taylor and Hodgson, 2020; Suwinyattichaiporn et al., 2021). Most studies consider body language a non-verbal expression of compassion, whereas Araújo et al. (2019) mention it as a facilitator of compassionate communication (Araújo et al., 2019). The study by Falconer et al. (2019) gives a clear understanding of the expression and perception of compassion through face, which is one of the non-verbal ways of compassionate communication (Falconer et al., 2019). Contrary to the popular presumption of one single compassionate facial expression (McEwan et al., 2014), Falconer et al. (2019) explain that compassionate facial expressions vary across the different situations in which compassion is being communicated, i.e., the facial expression while trying to alleviate another's suffering maybe be different from the facial expression while trying to resolve a conflict compassionately (Falconer et al., 2019). It would not be wrong to assume that different motives for showing compassion can have different communicative functions. Similarly, future primary studies can find the different body postures/gestures that effectively convey compassion in each context.

With inconsistency existing across studies about the three processes of compassionate communication (i.e., recognising, relating, and reacting) as mutually exclusive or not, a more precise and consolidated identification of the verbal and non-verbal indicators of ‘recognising', ‘relating' and ‘responding' with compassion is of paramount importance. For example, there is a need for more clarity on the specific behavioural indicators of ‘non-verbal acknowledgement' and ‘non-verbal immediacy' as ways to communicate the recognition of another's compassion need and how to use these for different situations. Deference, positive language intensity, positive endearment, and positive framings have been mentioned as specific ways of ‘relating' with compassion by some studies (Huffman, 2017; Hadsall Jakowich, 2020) but as antecedents to compassionate communication in others (Tracy and Huffman, 2017). Physical presence and organisational immediacy are mentioned as other ways to non-verbally ‘react' with compassion by some studies (Cameron et al., 2015; Huffman, 2017) but as a separate factor facilitating compassionate communication by other studies (Tracy and Huffman, 2017). Similarly, some definitions imply helpful actions to be included under non-verbal ways of ‘reacting' to another's compassion need (Snyder, 2012; Way and Tracy, 2012; Bottino and Manji, 2020). But this misleads many researchers to consider compassionate communication synonymous with its related, yet broader and conceptually different term called ‘compassionate care'. Such claims confuse the communicative function of ‘compassionate communication' and hinder the development of valid theories. Some definitions vaguely represent the reacting process in compassionate communication as ‘responding effectively' without the specific verbal/non-verbal indicators of the same (Ançel, 2006; Snyder, 2012; Kahriman et al., 2016; Bottino and Manji, 2020).

Notably, many definitions mentioned the antecedents and outcomes of compassionate communication besides specifying its behavioural/state elements. Though these antecedents or outcomes might not directly indicate the state of compassionate communication, consideration of all such variables helps develop the prerequisites for compassionate communication for different study contexts. For instance, authentic self-expression by the recipient can be considered a criterion for the effective communication of compassion towards the recipient, but few of the finalised studies mention this as part of the definition of compassionate communication (Strekalova et al., 2019; Mann et al., 2020; Yang and Kim, 2020). Comparably, a non-judgmental attitude towards the recipient has been mentioned as a central characteristic of compassionate communication in some studies (Cox and Dannahy, 2005; Pounds et al., 2018; Zandkarimi et al., 2019), as an antecedent of compassionate communication in some studies (Nerdrum and Høglend, 2003; Marlow et al., 2012; Taylor and Mamier, 2013; Wacker and Dziobek, 2018) and as both in some others (Falconer et al., 2019; Hadsall Jakowich, 2020). The present review presents sufficient evidence to suggest a non-judgmental attitude as a criterion while assessing the trait level of compassionate communication, while an individual's state of compassionate communication may or may not have a non-judgmental underpinning. For example, the study by Araújo et al. (2019) on organisational compassion insinuates that one can communicate compassionately to another with ulterior motives of personal gain without having a genuine desire to benefit the other who might be in distress (Araújo et al., 2019). This can be further explained based on Habermas's discourse theory (1996), which implies that organisations communicate to their employees in a way that strikes a harmonious balance between ethical discourse and economic bargaining (Habermas, 2015).

Talking about the theoretical underpinnings behind the empirical research done so far on compassionate communication, many of the finalised studies did not have a specific theoretical framework to support their findings' reliability and validity. The existing theories related to compassionate communication vary in their focused content. While only a few theories directly/indirectly describe the components of compassionate communication, most indirectly explain the factors influencing the unfolding of compassionate communication. In addition to examining existing theories on variables closely associated with compassionate communication (i.e., empathic-altruism, interactive sympathy etc.), this review also raises questions about the validity of theories that directly address compassionate communication (i.e., NVC theory, Salazar's compassionate communication theory etc.). The present review highlights the pressing need for the development of a comprehensive theory specifically focused on compassionate communication instead of relying on theories or concepts related to compassionate communication (i.e., theories of compassionate care, prosocial behaviours etc. in general).

The present review questions the validity of Rosenberg's (2005) theory of non-violent communication, which is one major theory of compassionate communication. Though the NVC theory assumes that all humans are compassionate by nature, the theory propagates compassionate communication as an antipode to ‘violent communication' that includes criticising, blaming, etc. Studies drawing inferences from the NVC theory claimed an individual's compassionate communication to be inversely related to verbal aggression (Salazar, 2013; Nosek et al., 2014; Arnesen-Trunzo, 2015). However, these contradict studies stating that an individual might not necessarily communicate compassion even if they feel compassion for others (Platt and Keller, 1994; Bayne et al., 2013; Pehrson et al., 2016). Though it is possible to reduce violent communication by teaching them compassionate communication skills (Nosek et al., 2014; Suarez et al., 2014), the present review questions the probability of labelling an individual to have violent communication if they show no compassionate communication. One possible reason can be explained using literature evidence stating that individuals low in distress tolerance get distressed to know about others' suffering, because of which they fail to show compassion while attempting to detach themselves from the emotion-stimulating situation (Eisenberg et al., 1989, 1996; Falconer et al., 2019). Owing to the inconsistencies in the operational definition of compassionate communication among the studies that relied on NVC theory, it was noted that there is no clarity on whether Rosenberg (2005) considered non-violent communication as a trait, state, or communication skill. In addition, NVC theory assumes all humans have the same needs, thus discounting the role of a different culture in shaping the needs and values among individuals. Nevertheless, the validity of this assumption needs to be empirically proven across different study contexts. Yang and Kim (2020) discuss NVC as a conversation model with components that primarily contribute to the development and maintenance of mature relationships. They identify honest expression as an integral part of NVC due to its essential role in fostering long-term relationships. So, when attempting to understand how individuals manifest compassion in their immediate, day-to-day interactions based on NVC theory, it is crucial to assess the authenticity of overt expressions of compassion. This raises questions about the applicability of NVC theory in research focusing only on the state aspects of compassionate communication, i.e., studies that do not consider the cognitive-affective aspects underlying expressions of compassion. For instance, the appropriateness of using NVC theory to define compassionate communication in a study that overlooks egoistic or ulterior motives behind the expression of compassion and primarily focuses on the impact of compassionate communication may be questionable.

Considering theories that discuss opportunities for expressing compassion, it is notable that these theories lack specific details regarding non-verbal cues that signal these opportunities. For example, the theory by Levinson et al. (2000) discusses various ways to respond to empathic opportunities but does not provide clear guidance on effective responses for different types of empathic opportunities. In this theory, there is no distinction between acknowledging someone's feelings and simply confirming them, as both are categorised as positive responses to empathic opportunities. Furthermore, these theories do not offer criteria for identifying individuals with varying compassionate communication skills. Additionally, there is no differentiation between empathic and compassion opportunities within these theories, leaving room for future research to explore effective responses to situations demanding compassion. Although some studies mention facial expressions and tone of voice as common non-verbal cues for expressing compassion, specific empirical details regarding the precise facial expressions and tones of voice that distinctly signify a need for compassion are not addressed in the available literature (Suchman et al., 1997; Levinson et al., 2000; Pehrson et al., 2016; Grondin et al., 2019).

A plethora of research evidence points out the influence of culture on affective communication (Gudykunst and Ting-Toomey, 1988; Shrank et al., 2005). Thus, there exists a high demand to know how to communicate compassion in a culturally sensitive way, i.e., how to frame the content and structure of compassionate communication aligning with the values and preferences of the specific study culture. This probes into the need to develop a more integrative theory on compassionate communication that can be generalised across multiple cultures. Primary research can be done to check the validity and reliability of the pre-existing theories of compassionate communication across different cultures. Moreover, most of the theories identified by the present review had their roots in healthcare or intimate relationships and may not apply to another context. For example, the state of compassionate communication for a particular individual in a workplace setting (having strict hierarchies and work norms) will differ from how they are in their intimate relationships (Hofstede, 1984; Hofstede and Hofstede, 2001). Similarly, much research evidence proves the beneficial impact of NVC skills in conflict resolution. But, before applying NVC theory in the context of suffering, one needs to cross-examine how a recipient in chronic distress would be able to identify one's unmet need, figure out what behaviour of the other person would fulfil the need, and make the non-demanding request accordingly. Practically speaking, it is not always possible for distressed individuals who feel helpless to communicate what others can do to meet their unmet needs. In such situations, a communicator can only look for compassion opportunities and communicate in a way they think is appropriate to make the recipient feel better (Bylund and Makoul, 2005; Taylor and Mamier, 2013; Yang and Kim, 2020). Thus, the present review encourages researchers to bring forth more context-specific theories of compassionate communication.

Upon examining the developmental aspects of compassionate communication, it was observed that a few studies mentioned compassionate communication as a teachable skill that can be acquired (Nerdrum and Lundquist, 2008; McArthur and Fitzgerald, 2013; Cameron et al., 2015; Bottino and Manji, 2020), while a few others emphasised the inherent nature of the concept, suggesting that it may not be significantly altered through training (Sinclair et al., 2018; Araújo et al., 2019). However, some studies that considered compassionate communication as innate mentioned that it can be enhanced further through training (Vazhappilly and Reyes, 2017; Hindiarto et al., 2020; Mann et al., 2020). Some studies mentioned many prerequisites like baseline compassion, social expressivity, sincerity, etc., in an individual's personality as antecedents for the communicative skill of compassion to be developed (Nerdrum and Rønnestad, 2004; Ruiz-Moral et al., 2017; Lynch et al., 2019; D'souza et al., 2020), while some presumed all humans to be compassionate beings having the ability to learn the communicative skills of compassion (Nosek et al., 2014; Vazhappilly and Reyes, 2016; Mann et al., 2020). Incompatible evidence can be found in literature admitting that though developing the cognitive-affective quality of compassion is fundamentally difficult, the communicative skills of compassion are a teachable quality (Batt-Rawden et al., 2013; Fragkos and Crampton, 2020). Morse (2006) give a hierarchical model of nurse-patient communication according to which the initial stage of compassionate responses is involuntary and impulsive, while the second stage of compassionate responses is learned and, hence, more controllable (Ançel, 2006; Morse, 2006). Despite the ambiguity about how compassionate communication can be taught, all the study findings designate that compassionate communication can be nurtured over time. However, the present review suggests that an individual's compassionate communication as a sustainably trainable skill or not depends on the context-specific conceptualisation of the construct (for example, whether the state or the trait aspects of the construct are being tapped into; the facilitators and barriers to communication of compassion in the given context, etc.).

When the present review tried to identify the reasons for individual differences in compassionate communication to better understand the concept, the role of sociodemographic factors, was looked into. Though males and females have similar abilities for compassion, literature to date declares females to have more skills of compassionate communication owing to their higher motivation to showcase themselves as highly compassionate and thus confirms the gender stereotype of compassion (Graham and Ickes, 1997; Falconer et al., 2019; Meinecke and Kauffeld, 2019; Strekalova et al., 2019). The study by Strekalova et al. (2019) hints at the need for gender-sensitive intervention/training programs to develop compassionate communication skills (Strekalova et al., 2019). However, none of the finalised studies of the present review proves this claim empirically through its findings. This calls for future primary studies to check for variations, if any, in levels of compassionate communication based on gender. In addition, it could be understood that with increasing age, education, and years of professional experience, an individual's empathic accuracy will also develop, facilitating compassionate communication (Pfeil and Zaphiris, 2007; Ritter, 2009; Ozcan et al., 2010; Sinclair et al., 2018; Falconer et al., 2019; Suwinyattichaiporn et al., 2021). Bayne et al., 2013 pointed out that with more years of professional experience, one's expertise also develops, leaving them more time and energy to show compassionate communication, while new joiners will be more focused on building their expertise and might not be aware of the need for compassionate communication in the workplace (Bayne et al., 2013). Despite evidence claiming more experience in communicative skills of compassion to develop further, contradictory findings show that verbal responses decrease with age and years of professional experience (Reid-Ponte, 1992; Ançel, 2006). Such contradicting findings were attributed to the tendency of individuals with high educational levels and experience to show less compassion as they shoulder more roles in planning and focus more on technical skills at work (Watt-Watson et al., 2000; Ançel, 2006). All the inconsistencies mentioned above instigate one to consider an individual's compassionate communication a function of other factors.

Olsen (2001) theory on empathic maturity supports this notion by suggesting one's level of compassionate communication be determined by one's level of empathic maturity (Olsen, 2001; Taylor and Mamier, 2013). According to the theory, an individual who fits the criteria for the third level (i.e., highest level) of empathy maturity will be able to show higher levels of compassionate communication compared to an individual who is on level one or two (irrespective of being older or years of professional experience) (Taylor and Mamier, 2013; Sinclair et al., 2016). This brings in a research question of how one's empathic maturity can be developed to increase his or her levels of compassionate communication. Moreover, studies propound many other factors influencing compassionate communication, some of which include one's here-and-now focus, the propensity to show encouragement to continue the recipient's sharing of emotions, skills for reflection, self-knowledge (i.e., knowledge about one's feelings, personality, motivation, sources of distress, body perception, physical potential) (Ançel, 2006), prior experience of giving and receiving compassionate communication (for example, negative experience of one's attempts getting humiliated, rejected or not being valued) (Alshughry, 2018; Grondin et al., 2019), violent/compassionate behaviour of family, social environment and relationships (Ançel, 2006; Yang and Kim, 2020), etc. Nevertheless, future research initiatives can clarify the context-specific facilitators and barriers to compassionate communication.

All things considered, the definitions and theories of compassionate communication helped to understand how compassionate communication is conceptually different from plausibly related constructs like compassionate care, social expressivity, etc. It is possible to classify all the similar constructs as an antecedent or an outcome of compassionate communication. Thus, the finalised studies in the present review give a very preliminary indication of the antecedents, components, and outcomes of compassionate communication, which can be empirically tested and confirmed in future research endeavours. This, in turn, would help to generate a methodologically sound theoretical framework of compassionate communication.

Limitations and De-limitations

Experience of compassion and demonstration of compassion have always been studied separately from the recipient's perspective and the communicator's perspective, respectively. To be specific, the non-verbal cues that convey a need for compassion are different from the non-verbal aspects of compassionate communication. The present review consisted of a few articles that studied compassionate communication from the communicator perspective only and a few articles that studied the concept from the recipient perspective only, and a few that studied the concept by collecting data from both dialogue partners. In addition, the finalised studies of the present review spanned 18 countries with very different cultures. The overriding influence of culture, study context, and sample characteristics, in the demonstration, experience, and development of compassionate communication skills is indisputable. These heterogeneities could have influenced the findings of the present review.

Often, the self-reported measurement of compassionate communication is less reliable as the participants have a social desirability bias to present themselves as having high levels of compassionate communication. Very few studies verified whether the communicator's self-perception of their compassionate communication was congruent with the perceived compassionate communication reported by the recipients. As methodologically weak studies affect the interpretability of the findings, future studies need to use more valid and reliable ways to measure compassionate communication that is context-specific. Tools of compassionate communication that go beyond the outcomes reported by the participants are essential for future research advancements on this topic. Most of the studies have small sample sizes and used a non-probability sampling strategy. Also, most samples did not have an appropriate representation of different gender. The present review highlights the need for future research designs to collect data from a large sample and choose a sampling strategy that helps to get a more accurate representation of the population.

Despite the extensive efforts of the authors to gather comprehensive evidence on the review topic, the specific eligibility criteria of the review may have led to the exclusion of some potentially eligible articles. Future reviews related to the current topic can include studies from all languages and try to see if the outcomes of compassionate communication vary accordingly. Many articles from research areas like psycho-oncology, communication, management, and others were found to be ineligible as they focused more on clinical communication or informative communication, where the compassionate attributes of the communication were not emphasised much. Considering this, the present review might have missed some important theoretical frameworks that could be related to compassionate communication.

Just as compassion is different from empathy, compassionate communication is a more active form of empathic communication and extends beyond the communication of understanding towards another's suffering to the communication of support and willingness to take helpful actions that address the recipient's suffering (Kurtz et al., 1998; Engelen and Röttger-Rössler, 2012; Pehrson et al., 2016). Many of the finalised studies of the present review use empathic communication as synonymous with compassionate communication. Particularly, some of the studies mentioned empathic communication as ‘communication of empathy towards a sufferer' and further elaborated it in a way that matches the operational definition of compassionate communication. Besides this, studies directly using the term ‘compassionate communication' was less. Therefore, the present review included studies on ‘empathic communication' to extract theories that might become useful in understanding the concept of compassionate communication.

Thematic analysis performed in the present review is only a preliminary contribution to the conceptual framework of compassionate communication. All the authors of the present review are researchers in the field of psychology. A better scientific understanding of compassionate communication requires content validation, evaluation of experts from multi-disciplinary fields, and primary qualitative research findings.

Conclusion

The present review consolidates and combines the essence of the pre-existing definitions, empirical findings, and theoretical approaches to conceptualise and explain compassionate communication. In totality, more focus has been given to compassionate communication as an interpersonal process involving compassion as the central antecedent and relationship satisfaction as the central outcome. The review findings, taken together, compel one to judge compassionate communication as a salient contributor to positive relationships. It can be concluded that each existing theory describes only specific aspects of compassionate communication, most of which are context-specific. The necessity for an integrative definition of compassionate communication and a theoretical framework that links the components of compassionate communication with its antecedents and outcomes is highlighted.

Data availability statement

The data analysed in this study is subject to the following licences/restrictions: The datasets analysed during the current review are available from the corresponding author at reasonable request. Requests to access these datasets should be directed to jacobjulia97@gmail.com.

Author contributions

GJJ: Conceptualization, Data curation, Formal analysis, Methodology, Writing—original draft, Writing—review & editing. JR: Methodology, Project administration, Supervision, Validation, Writing—review & editing. JGA: Data curation, Formal analysis, Methodology, Writing—review & editing. ER: Data curation, Formal analysis, Methodology.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

This manuscript was prepared in relation to GJJ's doctoral research work, which the Indian Council of Social Science Research sponsored. However, the responsibility for the facts stated, opinions expressed, and conclusions drawn is entirely that of GJJ.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fcomm.2023.1294586/full#supplementary-material

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