1 Teaching compassionate-based behaviors across communication partners to students of behavior analysis: a preliminary investigation of comparative effectiveness of bst components in a brief experimental analysis

The field of Applied Behavior Analysis (ABA) has evolved significantly since its inception in the mid-1960s. Rooted in the early behaviorism of Watson [37] and the experimental analysis of behavior of Skinner [33], ABA was at its core an attempt to apply the experimental behavioral learning principles in a meaningful and socially significant way [4]. Researchers and practitioners today continue to utilize ABA as an applied science which allows for assessment and interventions that promote opportunities for meaningful behavioral change, however issues surrounding the ethics related to its use are now also being considered.

2 Compassionate care in ABA

Recently, increasing attention has focused on ethical standards and requirements of practice in the field of ABA. Research has suggested that although Board Certified Behavior Analysts (BCBAs) tend to be highly technically skilled and effective in making recommendations to promote socially significant behavior change, they may have skill deficits related to compassionate-care-based skills, interpersonal skills, and ‘soft skills’ [27, 36]. These skills are essential and foundational elements that can enhance the quality of comprehensive behavioral analytic treatment and services [36].

Recent research indicates that parents of autistic children receiving ABA treatment also noted practitioner skill deficits in the area of compassionate care [36]. Additionally, direct feedback from individuals with disabilities, specifically autistic individuals, has provided opportunities for shared first-hand perspectives of ABA treatment [17, 18, 20,21,22]. Specifically, some individuals from the autistic community expressed concerns related to the delivery of ABA services in a compassionate and caring manner [17, 18, 20,21,22]. These individuals note that some practitioners may lack emphasis or fail to prioritize compassionate-care-based skills. In turn, ABA practitioners and researchers are considering various avenues of practice that may require targeted differentiation to better meet the needs of individuals and families.

Further compounding this situation, ABA practitioners themselves have noted a lack of training and a subsequent need for support in compassionate-care-based skill development [15]. BCBAs are required to abide by the Behavioral Analyst Certification Board’s Code of Ethics which guides various ethical standards that BCBAs are required to practice within an abide by [1]. The BACB Code of Ethic’s provides a framework of boundaries specific to multiple areas of ethical standards to guide practicing BCBAs. Although the BACB’s Code of Ethics requires that BCBAs “treat clients with compassion, dignity, and respect” (p. 4), there is a dearth of evidence related to effective ways to teach compassionate-care-based skills to future and current BCBAs in the ABA literature. Additionally, the BACB [2, 3] has indicated an upcoming change in requirements of proficiency in their sixth edition task list update which states practitioners must “identify and apply interpersonal and other skills (e.g., accepting feedback, listening actively, seeking input, collaborating) to establish and maintain professional relationships. This change further highlights a need for compassionate-care-based skills to be operationalized and explicitly taught from a behavioral-analytic lens.

2.1 Conceptual frameworks of compassion

Recently, researchers in the field of ABA have prioritized the need to identify what compassion means conceptually. As a result, the Journal of Behavior Analysis in Practice issued a call for a special issue that explored research in compassionate care within a behavioral analytic lens and the need for the conceptualization and operational development of compassionate-care-based skills in the field of ABA [30]. Early attempts at definitions of compassion through a behavioral analytic lens have been theoretical [19]. Killeen [14] defined compassionate behaviorism as a philosophy that includes actionable elements such as humility, behavioral flexibility, self-control, perspective-taking, and empathy. Callahan et al. [6] defined ‘behavioral artistry’ as a set of behaviors, including care, attentiveness, and creativity. Taylor et al. [36] defined compassion through the elements of sympathy, empathy, and compassion and noted that compassion results from "bringing empathy to action" (p. 655).

These broad definitions provided opportunities for subsequent researchers to create individualized, specific, and operational compassionate care skills and begin to identify their subsequent associated behaviors. To make compassionate-care-based skills less conceptual and more accessible, Reinecke and colleagues created a framework designed specifically to embed compassionate-care-based skill concepts into ABA university programs. They offer the following user-friendly, jargon-free definition which states “compassion means taking the time to listen to others, try to understand them, and do what we can to help them."(p. 2) [26].

3 Behavioral skills training for teaching compassionate-care-based skills

Behavioral Skills Training (BST) is an evidence-supported method for teaching individuals how to implement elements of behavior modification and associated techniques [24]. BST is widely recognized as an effective training approach and has been successfully utilized for teaching various behavior-analytic skills to individuals [31]. BST involves performance and competency-based training components [24], where the trainer and trainees demonstrate the skills of concern and continue training until the trainees can perform the target skills competently. BST typically includes six steps: providing instructions with a rationale and operational definition, providing a clear written description, demonstrating or modeling the skill, practicing or role-playing the skill, providing performance feedback during rehearsal, and repeating the practice and feedback until the skill is mastered. Additional components may include providing specific examples and non-examples, data collection, and on-the-job training [24, 25].

BST has been found to be more effective in training staff to perform target skills than other approaches such as didactic training only [34]. By incorporating BST into curricula or professional development programs, supervisors and training professionals can provide trainees with a structured framework for improving their skills. Using this training method, participants are guided through a step-by-step process that includes modeling, role-playing, feedback, and reinforcement. Some researchers have noted barriers and areas for future research required for teaching compassionate care skills using BST [11, 28]. Among these barriers includes the significant time requirements to implement BST which could affect training feasibility and implementation especially with larger groups.

4 Operationalized compassionate-care-based skills & teaching strategies

Before a behavior can be studied and evaluated for change, it must be operationally defined. Compassion is no exception. Researchers have now started to operationalize elements of compassion in practice and analyze effective ways to teach compassionate-care-based skills. Two teams of researchers have identified some concepts of compassionate-based-care skills and aimed to teach those skills explicitly using behavior skills training (BST). Rohrer and Weiss [28] operationalized compassionate-based basic interviewing skills, skills to indicate interest in the family, and skills to indicate joining with the family using BST. They used a multiple baseline across skill set design to teach these compassionate care skills to ABA students. Results of the study indicated that compassionate care skills could be taught using BST. Further, results also indicated that all participants increased their skills in operationalized compassionate care subsections. Further, Rohrer et al. [27] provided a framework focused on how each specific skill was operationalized within the more extensive compassionate care skill set.

Subsequently, Gatzunis et al. [12] used a multiple baseline across skill sets design to teach compassionate-based skills to ABA graduate students. Researchers implemented BST to teach functional assessment-based interview skills, cultural responsiveness, and ethical and compassionate care skills. Specifically, Gatzunis et al. [12] expanded the literature and research to explore the application of cultural responsiveness in compassionate care-based skills given the field’s call to action related to needs for practitioners in this area but an overall lack of empirical support to explore how to teach these skills [23]. Results indicated that all participants improved their skills, with the most significant improvement occurring in functional assessment interviewing. Results also indicated that skills were maintained approximately one month after training.

5 Compassionate-care-based skill of receiving feedback

Gathering feedback is a foundational element of the science of behavior. Feedback can include verbal feedback, written feedback, and/or reinforcement for various behaviors when feedback is shared between the BCBA and communication partners involved in treatment. Receiving feedback effectively from others is a foundational and critical skill of a compassionate care-based behavioral repertoire. For example, being able to effectively listen to others and subsequently indicating how that feedback will be incorporated into future practice can increase cultural responsiveness, social validity, effectiveness in supervisory relationships, and collaboration between multiple communication partners. In 2022, the BACB released revisions to test content, effective in 2025, requiring BCBAs “identify and apply interpersonal and other skills (e.g., accepting feedback, listening actively, seeking input, collaborating) to establish and maintain professional relationships. Minimal research exists that explores effective ways to teach interpersonal and compassionate care skills [12, 27, 28]. Table 1 operationalizes various behavioral skills that contribute to receiving feedback from clients, caregivers, and colleagues in a compassionate manner and was used in this study and was developed and refined based on the previous compassionate care research teachings of Rohrer [28] and Gatzunis [12]. The curriculum includes user friendly definitions of receiving feedback, examples of verbal statements to receive feedback from others embedded with compassion, and rationale for those approaches. Given the foundational nature of receiving feedback as a compassionate-care-based skill and the generalizability of receiving feedback across communication partners and settings, this skill was the selected area of focus for this research. Although foundational in its approach, it is also important to note that compassionate care-based skills can differ and be mediated by societal influences and cultural factors. Therefore, the development of compassionate care-based skills identified in this study was heavily influenced by scientific healthcare systems that primarily utilize the deficit model of disability when providing services to disabled individuals [38] and thus should be interpreted with caution, especially when considering applying compassionate care skills outside of this current scope [13]. Although foundational in its approach, it is also important to note that compassionate care-based skills can potentially differ and be mediated by societal influences and cultural factors. Therefore, the development of compassionate care-based skills identified in this study were developed based on consideration of an operational definition of compassion within the scope of the culture where it was developed at a US Midwestern private university. For example, in this study, participants were encouraged to reframe and restate what the communicative partner said in the role plays. In some cultures, asking a caregiver or elder to restate information recently shared may be considered inconsiderate or rude.

Table 1 Lists, Operational Definitions, and Rationale of Compassionate-care-based Skills of Receiving Feedback Across Communication Partners
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6 Purpose

This research explores the effectiveness of teaching the compassionate-care-based skill of receiving feedback using modified versions of BST to understand if all components of BST are required in order to teach a compassionate care skill or if selected components of BST can be used without sacrificing the efficacy of skill development to improve the rate of skill acquisition. Further, this research was specifically designed to consider how educators to begin to teach compassionate care-based skills in a university classroom environment. The intervention was systematically manipulated using an additive component analysis. The research also explores if the modified BST allows skills to generalize to multiple communication partners (clients, caregivers, colleagues). The researchers initially considered using Brief Experimental Analysis (BEA) however; given the nature of delivery of the interventions as well as the potential lack of irreversibility related to compassion care-based behaviors the researchers determined that an experimental case study was more practically and conceptually appropriate [10].

Specifically, an experimental case study design was used to answer the following research questions:

  1. 1.

    Can behavior skills training (BST) be used to teach the compassionate-care-based skill of receiving feedback?

  2. 2.

    Are all the components of BST required in order to develop compassionate-care-based skill of receiving feedback?

  3. 3.

    Can BST generalize to different communication partners (i.e., client, caregiver, colleague) and/or novel scenarios?

7 Method

7.1 Participants

The researchers were approved to conduct the study through Duquesne University’s Internal Review Board (IRB). The experimental protocol used in this study was approved by the Duquesne University’s IRB and covers all experimental methods as outlined in the study. All interventions and data collection procedures were performed in accordance with the guidelines and regulations as outlined by the IRB as well as the Ethics Code for the Behavior Analyst Certification Board (BACB). Once informed consent was provided, participants included 8 of 12 students enrolled in a Master of Special Education program in a private Mid-Atlantic university. One student chose not to participate in the study and three students did not complete all required training elements for their results to be included. The participants were enrolled in the first ABA course in a series of coursework toward obtaining a Master’s in Special Education or a Master’s in Applied Behavior Analysis. The training was part of the required coursework required however; students had the right to refuse to have their results included in the study. Participants were not eligible to participate in the study if they had previously taken an ABA ethics course in an attempt to control for participants having experience in the area of learning compassionate-care-based skills. All participants who participated in the study were female. Seven participants previously earned a bachelor’s degree and one student had previously earned a master’s degree (e.g., in education, psychology, mental health, or occupational therapy). Participants, on average, had two months of previous experience delivering ABA services, two months of teaching in the general education classroom, and zero months as a teaching paraprofessional, indicating that most participants were novel to the field of ABA and roles in formal education outside of student teaching experiences.

7.2 Setting and materials

After IRB approval was obtained and consent from the participants was received, all training was conducted through online video recordings and live online meetings for role plays. The technology-related materials included using Zoom to record training sessions (i.e., directions, discussion, and rationale). Zoom sessions were also used to provide examples of role-plays for compassionate care-based skills. These modeling sessions were pre-recorded by the researchers. Participants were required to have access to a computer with internet connectivity, the ability to access Zoom, and a camera and microphone to record their role plays with both video and audio. Participants were all provided with written documentation, including definitions, examples, non-examples, and rationale of the skill taught to access throughout instruction (see Table 1). Participants had continued access to references as well as written and recordings of trainings throughout the teaching and assessment process. Participants could access the training and role-play models as often as they chose. Performance feedback, when applied, was also provided via recorded video Zoom sessions by the course instructor which was the first research author. Participants were given an opportunity to ask follow-up questions via written response or through video conference however, they were not required to ask questions. The participants recorded their demonstration of the skills by role playing via Zoom with a self-selected partner from the class for all sessions except the BST + R&PF NOV. During the BST + R&PF NOV session the participants role played with one of the researchers. The participants received performance feedback for each of their role plays. Each of the sessions were one week apart.

7.3 Independent variable

The independent variable was the implementation of multiple single session modified versions of behavioral skills training (BST) to assess the relative effectiveness of BST and the additive component effects of BST when teaching a compassionate-care-based skill to students of ABA. Due to the multiple components required when utilizing BST in its complete form and the relative time constraints and costs associated with using BST, this research specifically sought to understand a breakdown of teaching compassionate care-based skills by analyzing student skill acquisition throughout the BST process. The treatment conditions included BST without performance feedback or rehearsal opportunities (BST NO R or PF), BST including individualized performance feedback and rehearsal opportunities (BST + R & PF), and finally, demonstration of generalized skills across novel communication partners and novel scenarios after BST with performance feedback and rehearsal opportunities (BST + R & PF NOV).

7.4 Dependent variable

Dependent variables of this study included participant's mastery of specifically identified discrete operationalized compassionate-care-based skills in the area of receiving feedback (see Table 2). A total of 12 compassionate care skills related to receiving feedback were taught across three communication partners. Two skills were dedicated to a client as a communication partner, six skills were dedicated to a caregiver as a communication partner, and four skills were dedicated to a colleague as a communication partner. For example, the student could demonstrate a total of four skills in the session where the participant role-played a colleague specific scenario. If a student demonstrated 2 out of 4 skills, they would score 50% in the receiving feedback category. Communication partner percentages were calculated individually and averaged together for an overall score. For example, in the baseline session, if a student demonstrated 0/2 skills (client), 1/6 skills (caregiver), and 1/4 skills (colleague), the aggregate score would be 2/12 or 13.88%.

Table 2 Receiving Feedback Monitoring Checklist
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7.5 Experimental design and data analysis

BST using a single-subject design across skills has been used to teach compassionate-care-based skills [12, 28]. However, previous researchers indicated that although BST interventions to teach compassionate-care-based skills were successful, the amount of time to teach the skills using BST was significant and posed a potential barrier to training the skills especially within the classroom format. In an effort to reduce some of these barriers the researcher used an experimental case study design to evaluate the additive component effectiveness of implementing modified versions of BST when teaching the compassionate-care-based skill of receiving feedback in an introduction to applied behavior analysis masters level course. This design allowed for a systematic experimental procedure where additive components of BST interventions (i.e., BST No R or PF and BST + R & PF) were rapidly evaluated after single teaching sessions. The researchers considered the use of a Brief Experimental Analysis (BEA) due to the intention of adapting a pre-selected set of design elements to quickly comparing two or more treatment alternatives and the previous use of this design in classroom settings [8, 9, 32] however; given the irreversibility of compassionate care-based behaviors the researcher rejected this pathway and decided to use an experimental case study approach for analysis. The experimental case study approach allowed for the researchers to observe the variables of the component additive analysis of BST [39] and use that observation to determine how each component of the BST training correlated to the an increase or decrease in the researchers operationalized definition of compassionate care-based skills of receiving feedback.

The study was comprised of a baseline phase and three subsequent brief intervention phases which also included one generalization phase. The baseline session required participants to role play with a self-selected mock communication partner with no compassionate-care-based training. Most role-play partners included other students enrolled in the course however; some participants used role play partners outside of the course. Teaching session one recorded the participant's percentages of receiving feedback compassionate care-based skills responses after completing partial BST training, which included didactic training, review of operational definitions, and video modeling. Participant were also given opportunities to ask questions about the skills (BST NO R or PF). Teaching session two recorded the participant's percentages of percentages of receiving feedback compassionate care-based skills responses after participants reviewed the didactic training and video modeling for a second time. Students were also provided with opportunities to ask questions about the skills and also asked to complete one rehearsal with a self-selected peer. After one rehearsal individualized performance feedback from the course instructor was provided to the student (BST + R & PF). This session represented all components of BST complete training but also included generalization components. For example, this session included all of the training elements in session two however, it required the participant to complete the role-plays with novel scenarios and novel communication partners that were not self-selected (BST + R & PF NOV). It was decided to add this next level of intervention specific to assessing generalized skills instead of replicating another version of BST given the participants high scores during component interventions of BST training (BST NO R or PF) and (BST + R & PF). In session three, the participants were not provided with the scenarios before the generalization assessment probe, nor were they notified of who their new communication partners were to prevent the possibility of pre-rehearsal.

Visual analysis was used to evaluate participants graphs for changes in performance level across participants, phases, and communication partners as well as to evaluate the overall aggregate of skills acquired across communication partners and training sessions for the group.

7.6 Procedure

7.6.1 General procedures

Participants were enrolled in a graduate-level introductory ABA course offered asynchronously online. The training was part of their course; however, participants were given the option to have their results be part of the research or to opt out. Participants did not receive extra credit for participating, and the researchers were not aware if students were participants in the study until the completion of the training and data collection to ensure equity across training sessions and to ensure that students did not feel an obligation to participate. Each session was recorded via Zoom to enable analysis post-session.

BST was directly implemented by the first, second, and third authors. Participants were trained in a virtual online format which included recorded didactic training, video recordings outlining the compassionate care-based skills, written materials with operational definitions of the skills, examples of the skills, a summary of training procedures, and video models of researchers engaging in the compassionate care skills during role-plays. The first intervention did not include opportunities for the participants to rehearse the skills or receive individual feedback practicing the skills in role-plays. The second intervention included all the elements of the first intervention but also included opportunities for one rehearsal within a role-play and individualized performance feedback. The third intervention included all the components of the second intervention but Also required students to generalize the skills to new communication partners and scenarios they were not given before the role plays.

7.6.2 Baseline sessions

The participants were provided a basic script informing them that they would be given three written communication scenarios similar to what they might see in a practice setting. Participants were told they would receive a scenario related to a client, caregiver, and colleague. They were also told that the research was related to demonstrating compassion in their ability to provide treatment to clients, caregivers, and colleagues. The participants were asked to role-play as if they were a BCBA, with a self-selected communication partner, and attempt to demonstrate skills that would indicate to the person that they were effective at receiving feedback from the various communication partners. Data was collected using a yes/no analysis rubric where the observer determined if the participant engaged in the skill or did not engage in the skill during the role play (Table 2). If the participant engaged in the skill at least once, the observer marked "yes." If the participant did not engage in the skill at least once during the role-play, the participant marked "no."

7.6.3 Training session probes

The participants received two subsequent training sessions after the baseline session. After each session, the participants were asked to engage in a role-play. For the first role play, the participants used the same script as the baseline sessions. They also were allowed to self-select a role-play partner. Data was collected through the same yes/no analysis where the observer determined if the participant engaged in the skill or did not engage in the skills at least once during the role play. These reflected the additive component of the treatments. The first treatment session included a portion of BST that did not include rehearsal opportunities or individual performance feedback. This was referred to as BST NO R or PF. This session was created specifically to see if students could develop compassionate-care-based skills with a portion of the BST treatment that was not individualized to their unique skill-set. This training was less time intensive as students could access the training individually and did not require a rehearsal of skills or individualized feedback from the instructor. The second treatment session included an additional additive component of the BST treatment. It included the full BST with opportunities for one rehearsal with a self-selected peer and individual performance feedback. This session took more time than the previous intervention session as students were required to rehearse once with a self-selected partner before the role play and also the instructor needed to view, access and provide individual feedback for all students.

7.6.4 Generalization session probes

Following baseline and one treatment session, participants were asked to engage in a final role-play session. Given the results and increase of skills demonstrated by the participants in sessions one and two participants were given a novel script and a novel communication partner to demonstrate the compassionate care-based skills of receiving feedback. Before the session, participants did not know the written scenarios they would be required to role play in advance, and their communication partners were selected to prevent pre-rehearsal and simulate a more authentic conservational situation across partners.

7.7 Interobserver agreement and treatment fidelity

Interobserver agreement (IOA) was conducted for 33% of the sessions across each treatment level. IOA was obtained by having an independent observer watch the recorded sessions and determine if the participant engaged in the compassionate-care-based skills. The observer was provided with a list of the skills trained, which included definitions, examples, and rationale for each skill (Table 1). Monitoring checklists were also provided to the observers to note if the skill occurred or did not occur (Table 2). IOA was calculated by dividing the number of agreements by the number of agreements plus disagreements and multiplying by 100. Across baseline and all treatment phases, IAO averaged 96% (range from 93 to 100%). Agreements were defined as both observers scoring an occurrence (or non-occurrence) of the participant's response for each session. An independent observer also reviewed procedural fidelity, which was assessed by watching the recorded training sessions and noting if the researcher engaged in talking about the skill and modeling each skill on the checklist both during training and modeling. Procedural fidelity averaged 99% (range 97%-100%) across sessions.

8 Results

The researchers aimed to assess a viable and effective way to teach compassionate care skills for students of ABA in a classroom setting. The results are reviewed and analyzed using individual results of each participant as required in single-case design (see Table 3 and Fig. 1) as well as aggregate scores to better understand the overall classroom group performance (see Table 4 and Fig. 1). Individual scores were calculated by finding the average of each participant score based on the receiving feedback checklist across communication partners. For example, a student’s individual score in Table 3 was calculated by finding the percent correct of receiving feedback skills demonstrated across three communication partners and then averaged to get an overall score. Aggregate scores aimed to identify the mean percentage of combined student scores for each separate communication partner. For example, all eight students individual scores in BSL with clients as a communication partner were averaged to obtain an aggregate BSL client receiving feedback aggregate score. Visual analysis of Table 4 and review of Fig. 1 reveal that participants' skills increased from baseline across each of the treatment sessions and across communication partners. After introducing various BST training sessions, each participant’s percentage of compassionate care-based skills in the area of receiving feedback based on the skills measured immediately increased. With the expectation of participant two, participants demonstrated a slight additional increase in average skills after the BST + R & PF interventions session. In the final session, when the participants were asked to generalize the skills to novel scenarios and communication partners, each participant’s percentage of demonstration of compassionate care-based skills decreased slightly; however, it remained higher than all baseline phase percentages. Some participant's skills remained high even in generalization sessions.

Table 3 Individual Participant Performance Across Interventions Settings
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Fig. 1
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Individual Participants Percentage of Correct Compassionate-Care-Based Skill for Receiving Feedback Across Treatment Sessions and Communication Partners

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Table 4 Aggregate Participant Performance of Receiving Feedback Compassionate Care Skills by Communication Partner and Across Interventions Settings
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8.1 Social validity

Given the complexity of compassionate care-based skills and the nuances of this area in ABA, the researchers wanted to provide participants an opportunity to share their unique experiences while learning the compassionate care-based skill of receiving feedback. An inductive thematic analysis was used to extract data and analyze responses provided by participants [5]. Students were asked open-ended questions to better understand their lived experience, ushering a deeper understanding of the importance of learning the skill for each individual. In order to assess social validity, students were also asked if the compassionate care training would be important to their future work as BCBAs and special educators and why they felt it was important or why they felt like it was not important. Three researchers reviewed student responses multiple times independently and coded the responses. The researchers then compared their results to identify major themes. Results indicated all eight students stated the training was important to their future work. Themes across the provided answers indicated that the training allowed them to understand implementing behavior change from a compassionate-based lens. Participants also indicated that they had not previously thought of compassion in terms of behaviors they could demonstrate but from more subjective and abstract terms such as sympathy and empathy.

Additionally, this study explored teaching compassionate care to a group of self-identified female participants. Although currently inconclusive, some research provides evidence to support that self-identified females may excel in demonstrating compassion. Thus, this should be a factor when considering the results of this study, as each participant self-identified as female [16]. Further, understanding empathy in health care and helping professions has gained recent attention and researchers are beginning to explore this phenomenon. For example, researchers have explored if female physicians have greater baseline empathy skills than their male counterparts [35]. Results from this study indicated that empathy was measured as higher for females more often within self-reports but was not a significant predictor of patient outcomes. Given the participants were all females interested working in helping positions these results should be considered for implications and generalization.

9 Discussion

This study examined the effects of modified systematic applications of various additive components of BST training to teach receiving feedback compassionate care-based skills to graduate students of applied behavior analysis. Results indicated that many students did not possess a high percentage of the compassionate-care-based skill of receiving feedback before the training. During each additive component all participants made immediate and significant gains in the percentage of compassionate care-based skills demonstrated following the introduction of both BST treatment sessions across multiple communication partners (Fig. 1). Additionally, when looked at as an aggregate of scores across the classroom (Fig. 2), students collectively made gains during each training session. During the final session, where students were asked to generalize the skills that they learned to a novel scenario and novel communication partner, the overall percentage of skills demonstrated decreased slightly during the generalization session role play, all participant's scores were higher than during baseline sessions despite brief single session intervention sessions, given the experimental design. Previous research in teaching compassionate care-based skills [12, 28] used a single-subject design across skill sets. Researchers noted challenges related to the amount of time and the cost implications of using complete BST methods as a package to teaching compassionate care-based skills, although effective. These designs also pose significant challenges for instructors attempting to teach these skills in classroom or group-based settings. The results from this study indicate that compassionate care-based skills can be taught to students of ABA which support previous research demonstrating that BST is effective in teaching compassionate care-based skills [12, 28]. However, this study also explored ways to teach these skills using parts of BST and considered how to deliver this instruction within larger group sessions.

Fig. 2
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Aggregate Participants Percentage of Correct Compassionate-Care-Based Skill for Receiving Feedback Across Treatment Sessions and Communication Partners

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9.1 Implications for practice

The present findings may be of particular interest to researchers and practitioners as they add to the existing literature in the following ways. Previous research focused on teaching compassionate care-based skills using BST specific to caregivers as communication partners. This study included caregivers as communication partners but also extended the training to include clients and colleagues as communication partners. This extension is particularly important because elements of compassion and ethical practice must also include clients directly in addition to collaborative efforts with colleagues (i.e., teachers, counselors, speech and language pathologists) as part of treatment teams. Additionally, training included aspects of teaching the participant how to effectively and compassionately receive feedback from both vocal and non-vocal clients to highlight that communication outside of vocal words is a crucial means of communication during treatment sessions.

Previous research also indicated that “core” compassionate care skills may provide the basis for other compassionate care-based behaviors to evolve. Rosales-Ruiz et al. [29] defines behavioral cusps as behaviors that, when demonstrated, open the learner up to a whole new set of environmental contingencies, including reinforcement and punishment. This study specifically focused on a compassionate care-based behavior that would be foundational to other compassionate-care-based skills. For example, learning how to listen to others and receive feedback based on their unique and individualized needs can be generalized to several different communication partners, various treatments, and various settings (see Table 3).

The significant amount of time to deliver BST to teach compassionate care-based skills is also noted in the current literature as a particular challenge [12, 28] This study addressed portions of these challenges by analyzing the component effects of BST delivered asynchronously, both with and without individual performance feedback and rehearsal opportunities. The study also delivered the various components of BST in relatively short sessions (30 to 45 min) with supporting materials (i.e., operational definitions, examples, non-examples, and role-plays) for reference as needed for the learner to review. The first intervention allowed the participants to access the material and training when they could fully engage in learning. It also allowed them to self-select a communication partner and did not require individual monitoring of the sessions, thus reducing the overall time for basic training. It is important to note that with one training and subsequent review of the materials by the participant, a significant increase in skills was demonstrated across all eight learners. The second BST intervention included individual performance feedback, which increased the time for the trainer to assess and provide feedback to each student. However, communication partners were self-selected, and role plays were recorded, which allowed for assessment to occur during times that were most convenient for the instructors. Feedback was video recorded and provided to the learner, which allowed participants to listen to their feedback more than once if they chose to. All but one participant scored slightly higher percentages with individual feedback; however, it is important to note that individual feedback was given once, and the percentage of skills demonstrated before individual feedback was relatively high before the individual feedback was provided. These findings support that compassionate care-based skills can be taught with and without individual performance feedback, with a significant cautionary note that individual feedback likely would increase the acquisition of skills and will be an important consideration for generalization and authenticity of communication interactions.

It is important to note that although skill acquisition was high during both components of the BST treatment sessions, the study was specifically designed to assess if all components of BST were required to demonstrate skill acquisition and which treatment showed the most significant effects.

Social validity narratives based on open-ended reflections from participants indicated that performing the skills was more difficult than the learners initially thought they would be; however, the training overall allowed them the opportunity to think critically about the skill, why it would be essential to build relationships, and how they could demonstrate the skill using specific behaviors. All participants indicated they felt the skills were essential to their future roles working with clients, caregivers, and colleagues.

Lastly, considerations for relevance, appropriateness, and individualization are required when contemplating how best to teach ABA students compassionate care-based skills [11]. For example, research outside the field of ABA has noted that variations related to diverse cultures, traditions, and practices can impact the effectiveness of interventions, and cultural relevance should be considered [7].

10 Limitations

There is a dearth of research analyzing how to effectively teach compassionate care-based skills to students of ABA and current practitioners. This is the third study to date, to the researcher’s knowledge, known to teach compassionate care-based skills through a behavioral analytic lens. Although the findings generated positive results, they have limitations.

First, all training and assessment sessions were held virtually. Participants accessed the training and models through recorded sessions and engaged in role-play within a virtual synchronous session was completed through am online synchronous recorded video call. Feedback that was provided was given via a video recording. Conducting compassionate care-based training online instead of in person may create challenges specific to teaching certain compassionate care-based skills, specifically skills that may be less mediated by verbal behavior. For example, it was challenging to consider how a practitioner could respond to a client with limited vocal communication when they were not in the same physical space as the child.

Second, these trainings focused on one specific operationalized example of a compassionate care-based skill. Although the overarching skill of receiving feedback included various discrete behaviors and could be identified as a potential foundational compassionate care-based skill, in practice, BCBAs are required to demonstrate multiple compassionate care-based skills simultaneously; thus, the potential ability to learn and use multiple compassionate-care based skills at the rate these participants demonstrated may decrease significantly. Future research should focus on continuation of teaching multiple skills and building scenarios that may require them to assess and use multiple compassionate care-based skills in one role-play session.

Third, this training was only provided to students of ABA. It did not focus on teaching skills to BCBAs that are currently in practice. This training may not generalize to a set of individuals with more experience in the field. Additional research is needed to identify specific compassionate care-based skill deficits in BCBAs in practice to determine if their needs are consistent with student needs and if they also respond favorably to compassionate care-based skill training in these formats.

Fourth, the communication partners used were role plays and did not include people in their actual roles (i.e., clients, caregivers, colleagues). Completing these role-plays with actual clients, caregivers, and colleagues could make the role-plays more authentic. It may add to the ability to design curriculums around the authenticity of training and the generalizability of skill set development. This could potentially be assessed in practicum placements or field supervisions sites.

Fifth, the case study research methodology has limitations. The independent variables were observed and not specifically manipulated and thus functional control was not achieved in this study. The overarching goal of the study was to observe the component effects of compassionate care-based skills within a classroom setting with multiple students at the same time. The design provided a single data point collection for each level of the component treatment. The study measured a specific set of skills that allowed the participant to focus solely on receiving feedback skill subsets within role-plays. Future research should expand on exploring how various parts of BST for teaching compassionate care-based skills over multiple sessions could influence skill acquisition. Additionally, further research should explore additional opportunities for demonstrate of functional control across multiple communication partners. This could be achieved by creating multiple studies addressing each partner. Further, an additional limitation present was that additional sessions were not completed after the generalization phase to see the if the interventions were long lasting over time. This data was not collected as the course had ended after the generalization sessions.

Sixth the operationalized curriculum designed to teach the compassionate care-based skills of receiving feedback did not specifically include non-examples. The video models did not include non-examples. Future research should consider explicitly incorporating the use of non-examples in curriculum and models to support creation of boundaries around the conceptualization of compassion and a lack of compassion.

Lastly, when considering culturally responsive practices in ABA this study did expand looking at the importance of receiving feedback from the varied perspectives of clients, caregivers, and colleagues but did not directly consider training related to specific variations that may be present related to diverse cultural populations.

10.1 Future research and practitioner directions

Given the limited research in teaching compassionate care-based skills and the importance of opportunities to continue to understand the role compassionate care-based skills have in the field of ABA, further exploration is needed to understand how to effectively teach compassionate care skills to students of ABA and current BCBAs.

First, based on the initial work of Rohrer et al. [27] and Rohrer and Weiss [28], a framework for teaching compassionate care skills was developed. This framework has been used and modified to teach additional compassionate care-based skills through the work of Gatzunis et al. [12] and the skills in this study. Future research should continue to refine and use this base framework to build additional ways to teach compassionate care-based skills. Researchers should also continue to assess results for learners who are asked to practice multiple compassionate care-based skills simultaneously to see if additional strategies are required in order to acquire and maintain those skills.

Second, previous research demonstrated that although a robust and complete version of BST generated the best results, modified versions of BST with shorter overall training sessions yielded positive and quite significant results. Future research should explore how compassionate care-based skills can be trained effectively and efficiently, including ways that the skills can be trained using small and large groups. This could be particularly helpful for university programs attempting to implement compassionate care-based skills training or agencies working towards teaching these skills. Further, researchers should explore the feasibility of teaching skills collaboratively and providing feedback in small and large group formats. In such settings, participants could learn from each other by receiving feedback in groups and receiving personalized feedback during some sessions. This pedagogical style could create opportunities for compassionate-care-based training to become more efficient when teaching university courses or in larger groups. Researchers should also consider exploring the potential of self-management for learners to monitor their own compassionate care-skills behavior after the skill is taught conceptually. This model of learning could be particularly useful for skills in maintenance or generalization phases.

At this time future research should consider exploring opportunities to incorporate training in small increments, allowing the learner to learn new compassionate care-based skills continuously and subsequently reflect on and practice the skills during the learning progressions. For example, in a university setting, compassionate-care-based skills could be built into the curriculum for all classes in ABA based on the particular content of the course, with a deep dive of learning being centered in the course dedicated to ethical practice. In practice, clinics and agencies could build training around teaching these skills during onboarding training, such as orientation sessions. Practitioners could also be asked to reflect on these skills during structured supervision and continued education training.

Additionally, future research should consider the importance of cultural competence related to its intersection with ABA and compassionate care-based practices. This could include expanding on the work currently being completed in the field related to this topic [11, 12]. For example, future research could identify how various cultures view and define compassion and highlight how different intersections of identities may require variations to more secular views on compassionate-based care.

Lastly, future researchers should consider the development of compassionate care-based skill frameworks for each course required for students in ABA programs as opposed to attempting to address compassionate care within one or two courses. Compassionate care-based skills require multiple exemplar opportunities to be applied and generalized in a multitude of settings and scenarios. Introducing compassionate care-based training early and throughout the learning continuum can support a foundational approach to implementing ABA services with compassion.

10.2 Summary and conclusion

This research was the first study to implement teaching the compassionate care-based skill of receiving feedback using components of BST to understand the relative effectiveness of teaching the skill with and without rehearsal and performance feedback through a case study analysis. The study adds to ABA compassionate care-skills literature in two important ways. First, it demonstrates that the compassionate care-based skill of receiving feedback can be effectively taught to students of ABA, with and without individual rehearsal and performance feedback. Although individualized rehearsal and performance feedback increased overall skills, skills increased rapidly in both sessions, indicating that teaching and modeling are a strong foundation for teaching such skills, which can be enhanced through rehearsal and individualized feedback. Second, it demonstrates that compassionate care-based skills can be taught across multiple communication partners, including clients, caregivers, and colleagues.