Do we really need to teach health professionals to be empathetic?

In May 2016 I went to an Empathy conference in Oxford, UK. For someone who is a self-confessed English history devotee the opportunity to meander around the 12th century university college buildings in the ‘City of Dreaming Spires’ was wonderful. However, as an educator and researcher with a passion for exploring the concept of empathy, the conference was thought provoking and inspiring.

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I’ve become increasingly interested in empathy over the last decade. For a long time I thought that people were either born with an empathetic disposition (as I assumed most health professionals were), or they weren’t (these are the narcissistic people we’ve all met at some stage in our lives). I didn’t conceptualise empathy as a skill that should and could be taught.

Then along came Naleya Everson, an exceptionally gifted and insightful person who taught me so much about the empathy deficit. Naleya was one of my undergraduate students, she soon became an honours student and is about to commence her PhD. She set me on a path where I became determined to fully understand this elusive construct and to discover ways to teach and assess students’ empathy skills.

So often you find that the students you are trying to inspire are the ones that end up inspiring you ~ Sean Junkins

Below I share a few of the key things I’ve learned about empathy over the last few years …

Contemporary definitions of empathy vary between and within disciplines, however, most researchers define empathy as a multi-dimensional construct with cognitive, affective and behavioural elements2. Review this animation by Brené Brown about the meaning of Empathy

Empathy … the ability to step into the shoes of another person, aiming to understand their feelings and perspectives, and to use that understanding to guide our actions.

Empathy is a required attribute for all health professionals and fundamental to quality patient care3. There is compelling research about the benefits of empathetic engagement with patients including: decreased levels of depression, anxiety, distress4; and increased levels of emotional wellbeing, motivation, satisfaction and adherence to treatment regimens5. Empathetic encounters with healthcare professionals have also been linked to a range of improved physiological outcomes such as improved tissue healing, immunity, cancer survival rates4; and a reduction in diabetic complications, blood pressure and pain6. For practitioners, empathy enhances diagnostic accuracy and is linked to job satisfaction, resilience and coping skills7. When healthcare professionals do not possess a requisite level of empathy skills they are at higher risk of burnout, distress, depression and attrition2,8.

Healthcare needs to have a culture of empathy and compassion. Such a priority cannot be assumed, it needs to be the subject of training1

The relationship between empathy and attitudes to stigmatised groups is of particular concern with evidence indicating that vulnerable groups frequently experience healthcare devoid of empathy7. For example, a lack of empathy has been demonstrated in interactions between healthcare professionals and people from culturally and linguistically diverse backgrounds8,9; Aboriginal and Torres Strait Islander People10; people with a physical or intellectual disability11; people experiencing a mental illness12; socio-economically disadvantaged groups9; people with lifestyle related illnesses (such as cirrhosis of the liver or obesity)10, and older people13. National and international healthcare reports tell stories of appalling suffering where healthcare providers failed to provide empathetic care to vulnerable patients; older people left in wet beds and excruciating pain for hours at a time, non-English-speaking people ignored or discriminated against, and people with a disability subjected to indifference and abuse, are just a few of the examples profiled in these reports1.

‘Healthcare is more than the sum of its parts. All healthcare professionals must be knowledgeable, clinically astute and able to provide empathetic care’1

In the general community there have been generational shifts in empathy levels, particularly over the last decade. A large retrospective study which aggregated the findings of 72 studies of American college students (n=13,737) identified that empathy levels have declined by more than 40% over the last 30 years, with the steepest decline occurring since 200014. Similar declines in empathy levels are evident in most Western countries15.

empathy decline

Although, one might expect graduates from healthcare degrees to have an empathetic disposition, a body of evidence has identified that empathy levels generally decline by up to 50% during the period of enrolment in an undergraduate nursing16 or medical degree4,17. This decline in empathy has been attributed to numerous factors including: curricula demands and time constraints leading to prioritisation of technical and procedural skills and knowledge over humanistic values such as empathy; limited attention to the formal teaching and assessment of empathy skills; and desensitisation, helplessness and compassion fatigue resulting from exposure to human suffering without appropriate educational preparation and support3,4.

Can empathy be taught?

Empathy is a key mediator of prejudice reduction and an emerging body of research indicates that educational interventions specifically targeting empathy are key to promoting understanding and changing the attitudes of healthcare professionals towards the care of vulnerable and stigmatised patient groups7. In recognition of the growing understanding of the importance of empathy for healthcare students, educators have made attempts to teach empathy using a range of methods such as communication skills training, mindfulness training and creative arts. Experiential simulations where learners are asked to ‘literally stand in the patient’s shoes’ have emerged as one of the most beneficial approaches for teaching empathy18.

You never really understand a person until you consider things from his point of view… until you climb inside of his skin and walk around in it ~ Harper Lee, To Kill a Mockingbird

Thus our journey began. We have focused on teaching and researching empathy towards people from vulnerable and stigmatised groups (for example people from culturally and linguistically diverse backgrounds, people with a disability, and older people) using experiential point-of-view simulations. The impact on students has been consistently positive with pre-post simulation results demonstrating statistically significant differences in empathy scores15. This is just the beginning though … in coming posts I will share more about our evolving story of teaching empathy to improve patient outcomes. In the meantime, if you are interested in learning more, I’ve provided three of my favorite introductory videos about empathy below and a few of my research team’s recent papers:

The power of empathy by Helen Riess

Empathy: The Human Connection to Patient Care

The power of outrospection by Roman Krznarich

Levett-Jones, T., Lapkin, S., Govind, N., Pich, J., Hoffman, K., Jeong, S., Norton, C., Noble, D.,Maclellan, L., Robinson-Reilly, M. & Everson, N. (2017). Measuring the impact of a point-of-view disability simulation on nursing students’ empathy using the comprehensive state empathy scale. Nurse Education Today. 57, 75-81 https://doi.org/10.1016/j.nedt.2017.09.007

Courtney-Pratt, H., Levett-Jones, T., Lapkin, S., Pitt, V., Gilligan, C., Rossiter, R. Everson, N. & Jones, D. (2015). Development and psychometric testing of the Satisfaction with Cultural Simulation Experience Scale. Nurse Education in Practice,15(6), 530-536. doi: 10.1016/j.nepr.2015.07.009

Everson, N. Levett-Jones, T., Lapkin, S., Pitt, V., Vander riet, P., Rossiter, R. Courtney-Pratt, H., Gilligan, C., & Jones, D. (2015). Measuring the impact of a 3D simulation experience on nursing students’ cultural empathy using a modified version of the Kiersma-Chen Empathy Scale. Journal of Clinical Nursing, 24, 2849-2858

Everson, N. Levett-Jones, T., Lapkin, S., Pitt, V., Vander riet, P., Rossiter, R. Courtney-Pratt, H., Jones, D. Gilligan, C., & (in press). Empathic concern: the impact of simulation and analysis of the psychometric scale. Journal of Nursing Education

Levett-Jones, T., Lapkin, S., Govind, N., Pich, J., Hoffman, K., Jeong, S., Norton, C., Noble, D.,Maclellan, L., Robinson-Reilly, M. & Jakimowicz, S. (in press). Exploring nursing students’ perspectives of a novel ‘point of view’ disability simulation. Clinical Simulation in Nursing

References

  1. Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London. midstaffspublicinquiry.com
  2. Scott H (2011) Empathy in healthcare settings. Goldsmiths, University of London, Goldsmiths Research Online.
  3. Reynolds, W. & Scott, B. (1999). Empathy a crucial component of the helping relationship. Journal of Psychiatric Mental Health Nursing, 6, 363-370
  4. Batt-Rawden, S., Chisolm, M., Anton, B. & Flickinger, T. (2013). Teaching empathy to medical students: An updated systematic review. Academic Medicine. 88(8), 1171-1177
  5. Rees-Lewis, J. (1994). Patient’s views on quality care in general practice: literature review. Social science in medicine. 39, 655-671
  6. Beckman, H. & Frankel, R. (1984). The effect of physician behaviour on the collection of data. Annals of Internal Medicine, 101, 692-696
  7. Batson, C., Chang, J., Orr, R. & Rowland, J. (2002). Empathy, attitudes, and action: Can feeling for a member of a stigmatized group motivate one to help the group? Personality and Social Psychology Bulletin, 28, 1656-1666.
  8. Everson, N. Levett-Jones, T., Lapkin, S., Pitt, V., Vander riet, P., Rossiter, R. Courtney-Pratt, H., Gilligan, C., & Jones, D. (2015). Measuring the impact of a 3D simulation experience on nursing students’ cultural empathy using a modified version of the Kiersma-Chen Empathy Scale. Journal of Clinical Nursing, 24, 2849-2858
  9. Saha, S., Beach, M. & Cooper, L. (2008) Patient Centeredness, Cultural Competence and Healthcare Quality. Journal of the National Medical Association, 100(11), 1275-1285.
  10. Pedersen, A., Bevan, J., Walker, I. & Griffiths, B. (2004). Attitudes toward indigenous Australians: the role of empathy and guilt. Journal of Community and Applied Social Psychology, 14, 233-249
  11. Iezzoni, L., Davis, R., Soukup, J. & O’Day, B. (2003). Quality dimensions that most concerned people with physical and sensory disabilities. Archives of Internal Medicine. 163(17), 2085-92.
  12. Muir-Cochrane, E.C. (2006). Medical co-morbidity risk factors and barriers to care for people with schizophrenia. Journal of Psychiatric and Mental Health Nursing, 13(4), 447-452.
  13. Higgins, I., Vanderreit, P., Slater, L., & Peek, C. (2007). The negative attitudes of nurses towards older patients in the acute hospital setting: A qualitative descriptive study. Contemporary Nurse Journal. 26(2), 225-237.
  14. Konrath, S., O’Brien, E. & Hsing, C. (2011) Changes in dispositional empathy in American college students over time: A meta- analysis. Personality and Social Psychology Review, 15(2), 180-198.
  15. Neumann, M., Edelhauser, F., Tauschel, D. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine. 86(8), 996-1009
  16. Ward, J., Cody, J., Schaal,M. & Hojat, M. (2012). The empathy enigma: An empirical study of declining empathy among undergraduate nursing students. Journal of Professional Nursing, 28(1), 34-40.
  17. Hong, M., Lee, W., Park, J.,Yoon, T., Moon, D., Lee, S. & Bahn, G. (2012). Changes of empathy in medical college and medical school students: 1-year follow up study. BMC Medical Education, 12(122).
  18. Bearman, M., Palermo, C., NutrDiet, L. & Williams, B. (2015). Learning empathy through simulation. Simulation in Healthcare. 10(5), 308-319

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