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Empathy New Zealand

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Tracy Levett-Jones

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Transcript of Empathy New Zealand

EMPATHY ... What we thought we knew and why it matters
Tracy Levett-Jones
Professor of Nursing Education
University of Technology, Sydney

OUTLINE:

The meaning of empathy
The relationship between empathy and patient outcomes
Teaching empathy ... should we ... could we?

THE 'BIG' QUESTIONS
What is empathy?
How does empathy impact patient outcomes?
Can we assume that ‘most’ nurses are empathetic?
Can (or should) empathy be taught in nursing programmes?
Can we be too empathetic?
EMPATHY vs SYMPATHY
While empathy and sympathy are both reactions to the plight of another person, sympathy is a feeling of pity for their misfortune. Sympathy does not involve perspective taking and does not have a behavioural orientation [1].
Empathy is walking a mile in someone else's shoes.
Sympathy is being sorry their feet hurt.
THE THREE ELEMENTS OF EMPATHY
Affective
- understanding and experiencing emotions congruent with the person and oriented to their wellbeing
Cognitive
- perceiving the experience of another person from their perspective
Behavioural
- communicating that understanding, checking its accuracy and acting on that understanding a helpful/therapeutic way
Empathy is a multi-dimensional construct with cognitive, effective and behavioural elements [1]
AFFECTIVE EMPATHY

Requires empathetic imagination

Understanding and experiencing emotions congruent with the person and oriented to their wellbeing

Taps into an experience that is familiar to or that resonates with us (often in relation to the ‘type’ of people we are familiar with).

Most people are hard wired for affective empathy

Even babies and young children experience affective empathy (contagion).
COGNITIVE EMPATHY
Perceiving the experience of another person from their perspective

Requires empathetic intelligence and the ability to see the word through another person’s eyes, to understand their perspective and views

Requires a non-judgmental stance

A NON-JUDGMENTAL STANCE ?
If we could look into each other eyes and understand the unique challenges each of us face, we would treat each other much more gently, with more empathy, patience, tolerance and care.
EMPATHIC INTELLIGENCE: WHAT DO YOU THINK THIS PERSON
IS THINKING OR FEELING?
WHAT DO YOU THINK THIS PERSON
IS THINKING OR FEELING?
BEHAVIOURAL EMPATHY
Behavioural empathy is the highest form of empathy

Requires empathetic concern and is synonymous with compassion

Refers to the willingness to communicate one’s concern for another person and to take action to address their concerns.

This type of empathy requires effort, intelligence and deliberate practice!

DECLINING EMPATHY LEVELS
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 2000 [2].
INCREASED
USE
OF
SOCIAL
MEDIA
DECLINING EMPATHY LEVELS
IN NURSING STUDENTS
A body of evidence has identified that empathy levels generally decline by up to 50% during the period of enrolment in an undergraduate nursing (or medical degree) [3, 4]
WHY HAVE HEALTHCARE STUDENTS' EMPATHY LEVELS DECLINED?
Curricula demands which prioritise technical and procedural skills and knowledge over humanistic values such as empathy

Limited attention to the formal teaching and assessment of empathy skills in many programs

Desensitisation, helplessness and compassion fatigue resulting from exposure to human suffering without appropriate educational preparation and support [3, 4]
WHY DOES EMPATHY MATTER?
Empathy is considered to be a basic component of all therapeutic relationships and a key factor in patients’ definitions of quality care [5]

There is compelling research about the benefits of empathetic engagement with patients, including:

Decreased levels of depression, anxiety and distress [6]
Increased levels of emotional wellbeing, motivation, satisfaction and adherence to treatment regimens [7].
Improved physiological outcomes such as improved tissue healing, immunity, cancer survival rates [5], and a reduction in diabetic complications, blood pressure and pain [6].
WHY DOES EMPATHY MATTER TO HEALTH PROFESSIONALS?
For health professionals, empathy enhances clinical reasoning ability and is linked to job satisfaction, resilience and coping skills [9]

When nurses do not possess a requisite level of empathy skills they are at higher risk of burnout, distress, depression and attrition [10]
WHO NEEDS EMPATHY THE MOST?
Evidence indicates that vulnerable groups frequently experience healthcare devoid of empathy [11]. A lack of empathy has been demonstrated in interactions between healtcare professionals and:

People from culturally and linguistically diverse (CALD) backgrounds [12, 13]
Aboriginal and Torres Strait Islander People [14, 15]
People with a physical or intellectual disability [16]
People experiencing a mental illness [17, 18]
older people [19, 20].
People with lifestyle related illnesses (such as cirrhosis of the liver or obesity) [11]
SHOULD EMPATHY BE TAUGHT?
Educational interventions specifically targeting empathy are key to promoting understanding and changing the attitudes of healthcare students towards the care of vulnerable and stigmatised patient groups [21]


CAN EMPATHY BE TAUGHT?
SIMULATION
Four recent randomised controlled trials indicate that experiential simulations where learners are asked to ‘literally stand in the patient’s shoes’ are the most beneficial approach for teaching empathy [8]

These types of vicarious and authentic simulation experiences allow students to understand the lives of people whose backgrounds and lived realities are different from their own.

CULTURAL EMPATHY SIMULATION
THE PROBLEM
Culturally and linguistically diverse (CALD) patients are twice as likely to experience serious adverse events in hospital as English speaking people[2], for example:
Medication errors [2]
Misdiagnosis and incorrect treatment
Poorer pain assessment and treatment
Experiences of powerlessness, vulnerability, loneliness and fear when undergoing health care[3]

Contemporary educational approaches tend to improve knowledge about the care of CALD patients but do not change discriminatory attitudes or enhance culturally competent behaviours[4,5].
STUDY AIM
To explore the impact of an immersive 3D cultural simulation on nursing students’ cultural empathy.


3D CULTURAL SIMULATION
A 10 minute 3D video of an unfolding scene in a hospital ward of a developing county.

The hospital environment, language, and clinical practices exhibit an amalgamation of cultural behaviours, symbols and metaphors unfamiliar to people from Anglo-Celtic Australian backgrounds.

The video was developed in consultation with staff and clients from the local Migrants and Refugees centre.
STRUCTURE OF THE 3D CULTURAL SIMULATION
Introductory briefing

Students lie on a bed and view the video through 3D glasses while imagining that they are a patient in the ward.

This is a sensory experience with students exposed to a range of unfamiliar sights, sounds and smells.

The simulation is immediately followed by a debrief and guided reflection.
WHAT THE PARTICIPANT SEES
WHAT THE PARTICIPANT SEES
WHAT THE PARTICIPANT SEES
BRIEFING FOR SIMULATION
Imagine that you have been travelling in a foreign country. Over the last few days you have felt increasingly unwell with tiredness, headaches, neck stiffness, fever, dizziness, nausea, visual changes and auditory changes.
 
You phoned a friend who is a doctor in Australia and she advised you to seek immediate medical care as your symptoms are consistent with those of meningitis or even encephalitis.
 
You presented at the local community hospital and were admitted. You were given a medication that eased your headache somewhat but your visual and auditory changes are still present.
 
During the simulation:
 
Lie quietly on a bed and wear a pair of 3D glasses and head phones
Imagine the scene that unfolds is real. As the patient you will observe the ward and your care but do not need to participate.
Accept that any distortion of sounds or sights are symptoms of your illness.
Focus on your feelings – do not analyse the scene, just experience it.
PARTICIPANTS
Sample: n = 460 from a population of 530 2nd year Bachelor of Nursing students (response rate 87%)

Age: Mean: 27.35 ± 8.62; Range: 18 to 60

Gender: Female (88%) and Male (12%)

Country of birth: 84% born in Australia; 5.8% Asia; 3.6% Africa; 6.6% other countries

Languages: 87% spoke only English
Changes in cultural empathy were measured using a Comprehensive State Empathy Scale (CSES).


RESULTS: CULTURAL EMPATHY
COMPREHENSIVE STATE EMPATHY SCALE (CSES)
Paired-samples t-test indicated that participants reported higher scores on the CSES post simulation compared to pre simulation

(M= 5.76, SE ± 0.32) vs (M= 5.91, SE ± 0.35)

The difference was significant: t (459) = -3.193, p < 0.002
EMPATHETIC CONCERN SCALE (ECS)
Paired-samples t-test indicated that participants reported higher scores on the ECS post simulation compared to pre simulation:

(M= 5.57, SE ± 0.49) vs (M= 6.10, SE ± 0.45)

The difference was significant: t (455) = -12.419, p < 0.001
THEORY OF PLANNED BEHAVIOUR: CULTURAL COMPETENCE SCALE
Behavioural intentions in relation to cultural competence and the predictor variable of attitudes, perceived behavioural control and social norms were measured using a quasi-experimental design and the Theory of Planned Behaviour: Cultural Competence Questionnaire (TPB:CCQ)[9].

Participants were randomly allocated to the control group (those who had not experienced the simulation) or experimental group (those who had experienced the simulation)
CORRELATION BETWEEN EMPATHY AND INTENTION TO BEHAVE IN A WAY THAT PROMOTES CULTURAL COMPETENCE
Correlation analyses were conducted to explore the relationship between empathetic concern scores and TPB-CCQ intention scores.

Empathetic concern had weak positive linear relationship with intention, r = .232, p < 0.01.

This indicates that as empathetic concern increases, the intention to behave in a way that promotes cultural competence also increases.
QUALITATIVE RESULTS: PARTICIPANT SATISFACTION
I thought I had an understanding of what it meant to be culturally aware and empathetic until the roles were reversed and I was the patient. I now have an understanding of how it really feels to be an 'outsider'.

It was amazing how quickly my opinions have changed after just a 10min video. You don't really understand until you are placed in the situation yourself. Amazing!

Invaluable experience! I took a lot away from this and faced some realisations about my own culture and (I'm ashamed to say) cultural ignorance. I consider myself an empathetic person but this experience will stay with me.
DIRECTOR'S CUT OF 3D VIDEO
DISABILITY SIMULATION -
THE PROBLEM
In Australia almost 20% of people have a disability and 3% (634,600) have severe disabilities and require help with mobility, communication and/or self-care (ABS, 2015).

People with disabilities frequently report that health professionals have limited understanding of their experiences, needs and healthcare preferences.

A lack of empathy has an adverse effect on people with disabilities, leading to negative consequences such as low self-esteem, apprehension when seeking healthcare and reduced participation in care and treatment.
To explore the impact of an immersive disability simulation on nursing students’ empathy scores.
DISABILITY SIMULATION
Second year nursing students were allocated the role of either a person with an acquired brain injury or a rehabilitation nurse.

The simulated patients wore a hemiparesis suit that replicates the experience of aphasia, dysphagia, hemianopia and hemiparesis.

The simulation was immediately followed by a group debrief and guided reflection.
STUDY AIM
‘PATIENT’ BRIEFING
You have recently been transferred to a rehabilitation unit after being in ICU and a neurology ward for many weeks. You have an acquired brain injury as a result of being involved in a car accident on your way to university three months ago. Your long term prognosis is uncertain.
A rehabilitation nurse will come and help you prepare to go for a walk
He/she will support you while you put on a jacket, pants and shoes
The nurse will take you for a walk and then leave you sitting on your own in a place with a lot of pedestrian traffic for approximately 5 minutes
While sitting on your own you are to look as if you are in need of assistance by attempting (unsuccessfully) to stand
Take note of whether and when anyone comes to your assistance
The nurse will return and walk with you back to the simulation unit
Pour yourself a cup of thickened fluids and drink it
‘NURSE’ BRIEFING
You are working in a rehabilitation unit and caring for a person with an acquired brain injury. Their long term prognosis is uncertain but your goal is to help them become as independent, self-caring and confident as possible.
You are to support the patient as they put on a jacket, pants and shoes
Following the map provided take the patient for a walk
Sit the patient on their own in a place with a lot of pedestrian traffic
Walk away to a place where you can see the patient but are not obvious to passers by
Leave the patient alone for 5 minutes
Return to the patient and walk with them back to the simulation unit
PARTICIPANTS
Sample: n = 391 from a population of 488 2nd year Bachelor of Nursing students (response rate 80%)

Age: Mean: 28.28 ± 9.41; Range: 19 to 67

Gender: Female (93%) and Male (7%)

Country of birth: 87% born in Australia; 2.8% UK; 2.6% Asia; 2.1% Africa; 5.5% other countries/continents

Languages: 87% spoke only English

Experience with disability: Yes (63%) and No (37%)
RESULTS
Changes in empathy scores were measured using a pre-test post-test Comprehensive State Empathy Scale (CSES)
COMPREHENSIVE STATE EMPATHY SCALE SCORES
Paired-samples t-test indicated that participants who adopted the ‘nurse’ role reported higher scores on the CES post simulation compared to pre simulation:


(M= 3.37, SD = 0.65) vs (M= 3.65, SD = 0.76).
The difference was significant: t (187) = -5.76, p < 0.05



COMPREHENSIVE STATE EMPATHY SCALE SCORES
Independent t-test indicated that participants who adopted the ‘nurse’ role reported higher scores on the CSES post simulation compared to those who adopted the ‘patient’ role:


Nurse: (M= 3.65, SD = 0.76);
Patient: (M= 3.44, SD = 0.83).

The difference was significant: t (388) = 2.51, p < 0.05


COMPREHENSIVE STATE EMPATHY SCALE SCORES
QUALITATIVE RESULTS: PARTICIPANT SATISFACTION
It was hard … for instance, while walking I tired easily because coordinating my movements took a lot of effort and I was worried about falling because my balance was affected. I do wonder if this is how patients feel.

I wanted the nurse to support me, not just do everything for me…but I felt that I could not speak up due to my impairment…so just let them tell me what to do…

When I put the stroke suit on, I was suddenly standing in someone else’s shoes. It was hard to move and people looked away from me. They saw me but they didn’t want to see me.


Tools such as film, art, and literature involving personal stories and oral testimonies can enhance perspective taking and empathy development [23, 24]

These types of learning activities help students gain in-depth understandings of the unique insights and perspectives of people they may not normally encounter or engage with in a meaningful way (e.g. people who are dying, disabled, from a CALD background or grieving)
CREATIVE ARTS AND THE HUMANITIES
CONTEMPORARY MEDIA
DIGITAL STORIES
Digital stories are the modern expression of the ancient art of storytelling
They combine narrative pedagogy through the use of videos, audio, voice, text, still images and music.
Digital stories are multidimensional, enabling exploration of reality from different perspectives.
Unfolding digital stories promote a strong emotional resonance and feelings of empathy.
MINDFULNESS & LOVING KINDNESS MEDITATION
CONCLUSION
Could a greater miracle take place than for us to look through each other’s eyes for an instant?
Henry Thoreau
REFERENCES
1. Scott H (2011)
Empathy in healthcare settings.
Goldsmiths, University of London, Goldsmiths Research Online.
2. 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.
3. 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.
4. 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
5. Rees-Lewis, J. (1994). Patient’s views on quality care in general practice: literature review.
Social science in medicine. 39,
655-671
6. Reynolds, W. & Scott, B. (1999). Empathy a crucial component of the helping relationship.
Journal of Psychiatric Mental Health Nursing, 6
, 363-370
7. Kim S, Kaplowitz S & Johnston MV (2004). The effects of physician empathy on patient satisfaction and compliance.
Evaluation & the health professions, 27,
237-251.
8. Bearman, M., Palermo, C., NutrDiet, L. & Williams, B. (2015). Learning empathy through simulation.
Simulation in Healthcare. 10(
5), 308-319
9. Beckman, H. & Frankel, R. (1984). The effect of physician behaviour on the collection of data.
Annals of Internal Medicine, 101
, 692-696
10. 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
11. 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.
12. Everson, N. Levett-Jones, T., Lapkin, S., Pitt, V., Vander riet, P., Rossiter, R. Courtney-Pratt, H., Gilligan, C., & Jones, D. (online 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.
13. Saha, S., Beach, M. & Cooper, L. (2008) Patient Centeredness, Cultural Competence and Healthcare Quality. Journal of the National Medical Association, 100(11), 1275-1285.
14. Kowal, E. & Paradies, Y. (2010). Enduring dilemmas of Indigenous health.
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(10), 599-600.
15. 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
16. Iezzoni, L., Davis, R., Soukup, J. & O’Day, B. (2003). Quality dimensions that most concerned people with physical and sensory disabilities.
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(17), 2085-92.
17. Muir-Cochrane, E.C. (2006). Medical co-morbidity risk factors and barriers to care for people with schizophrenia.
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18. Bunn, W. & Terpstra, J. (2009). Cultivating empathy for mentally ill using simulated auditory hallucinations.
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19. Henry, B., Ozier, A. & Johnson, A. (2011). Empathetic responses and attitudes about older adults: How experience with the aging game measures up.
Educational Gerontology. 37
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20. 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.
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21. Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London. www.midstaffspublicinquiry.com
22. Department of Health (2002.).Learning from Bristol: the Department of Health's response to the report of the public enquiry into children's heart surgery at the Bristol Royal infirmary 1984-1995. London, UK: HMSO.

Paired-samples t-test indicated that participants who adopted the ‘patient’ role reported higher scores on the CSES post simulation compared to pre simulation:


(M= 3.26, SD = 0.73) vs (M= 3.45, SD = 0.83).
The difference was significant: t (201) = -2.69, p < 0.05



In addition to safety, healthcare needs to have a culture of empathy. Such a priority cannot be assumed, it needs to be the subject of training [21]
Identifying Essential Clinical Skills for Nursing Graduates


A study to identify the technical and non-technical skills required by graduate nurses as they commence employment

Ethics approval:
UTS HREC ETH17-1713. The results used to inform future BN curricula.

Project team:
Tracy Levett-Jones, Tamara Power, Natalie Govind and Kelly Eyre .

Recruiting:
RNs who have employed, worked with, supported or educated graduate nurses in the last two years.
Please complete this 5-10 minutes online survey:

https://www.surveymonkey.com/r/BXJNMDR
Full transcript