The empathic process and its mediators. A heuristic model

A Multifaceted Educational Intervention in the Doctor-Patient Relationship for Medical Students to Incorporate Patient Agendas in Simulated Encounters

From the beginning of their clinical training, medical students demonstrate difficulties when incorporating patient perspectives. This study aimed to assess if students, after an instructional programme, increased their sensitivity towards patients' needs and carried out bidirectional conversations. An observational study involving 109 medical students prior to their clerkships was designed. They attended a five-step training programme designed to encourage the use of communication skills (CSs) to obtain patients' perspectives. The course developed experiential and reflective educational strategies. The students improved their use of CSs throughout three sessions, and the overall score for these patient consultations went up in the opinions of both the external observer (EO) (5; 6.6; 7.5) and the simulated patients SPs (5.3; 6.6; 7.8). Most of the students (83.9%) considered that the CSs addressed were useful for clinical practice, particularly the interviews and the feedback received by the SP and the lecturer. The programme seems to help the students use CSs that facilitate a more bidirectional conversation in a simulated learning environment. It is feasible to integrate these skills into a broader training programme. More research is needed to assess whether the results are applicable to students in real settings and whether they influence additional outcomes.

Teaching Shared Decision Making to Undergraduate Medical Students

Despite the wide endorsement of shared decision making (SDM), its integration into clinical practice has been slow. In this paper, we suggest that this integration may be promoted by teaching SDM not only to residents and practicing physicians, but also to undergraduate medical students. The proposed teaching approach assumes that SDM requires effective doctor-patient communication; that such communication requires empathy; and that the doctor's empathy requires an ability to identify the patient's concerns. Therefore, we suggest shifting the focus of teaching SDM from how to convey health-related information to patients, to how to gain an insight into their concerns. In addition, we suggest subdividing SDM training into smaller, sequentially taught units, in order to help learners to elucidate the patient's preferred role in decisions about her/his care, match the patient's preferred involvement in these decisions, present choices, discuss uncertainty, and encourage patients to obtain a second opinion.

Teaching medical students to express empathy by exploring patient emotions and experiences in standardized medical encounters

OBJECTIVES

To increase medical students' ability to detect contextual and emotional cues and to respond empathetically to patients.

METHODS

a training course in communication skills and patient-centered care with different teaching activities (didactic, reflective and interactive: workshops and encounters with simulated patients) was delivered to third-year medical students just before their clerkships. The program was evaluated by an external observer (OE) and simulated patients (SP) in 2 or 3 videotaped encounters.

RESULTS

Students improved significantly from baseline to 3rd interview in all communicative skills and domains explored both in OE (32.4%) and SP (38.3%) measurement. At the end of the course students detected significantly more clues and made more empathetic expressions.

CONCLUSIONS

The course seems to improve the ability of students to explore the illness experience, showing more empathy in a more genuine way. This was carried out in consultations lasting 10min.

PRACTICAL IMPLICATIONS

The program is effective and feasible to be applied as a regular formative activity. Further research is needed to assess whether this training program is applicable to students in more advanced educational levels and if it has any additional outcomes.

Exploring Registered Psychiatric Nurses' Responses towards Service Users with a Diagnosis of Borderline Personality Disorder

This study explored registered psychiatric nurses' (RPNs') interactions and level of empathy towards service users with a diagnosis of borderline personality disorder (BPD). A qualitative approach was used, and 17 RPNs were interviewed using a semistructured interview schedule incorporating the “staff-patient interaction response scale” (SPIRS). Four themes emerged following data analysis: “challenging and difficult,” “manipulative, destructive and threatening behaviour,” “preying on the vulnerable resulting in splitting staff and other service users,” and “boundaries and structure.” Additionally, low levels of empathy were evident in the majority of participants' responses to the SPIRS. The findings provide further insight on nurses' empathy responses and views on caring for service users with BPD and further evidence for the need for training and education for nurses in the care of service users diagnosed with BPD.

The Postoperative Pain Assessment Skills pilot trial

BACKGROUND⁄

OBJECTIVES

Pain-related misbeliefs among health care professionals (HCPs) are common and contribute to ineffective postoperative pain assessment. While standardized patients (SPs) have been effectively used to improve HCPs' assessment skills, not all centres have SP programs. The present equivalence randomized controlled pilot trial examined the efficacy of an alternative simulation method - deteriorating patient-based simulation (DPS) - versus SPs for improving HCPs' pain knowledge and assessment skills.

METHODS

Seventy-two HCPs were randomly assigned to a 3 h SP or DPS simulation intervention. Measures were recorded at baseline, immediate postintervention and two months postintervention. The primary outcome was HCPs' pain assessment performance as measured by the postoperative Pain Assessment Skills Tool (PAST). Secondary outcomes included HCPs knowledge of pain-related misbeliefs, and perceived satisfaction and quality of the simulation. These outcomes were measured by the Pain Beliefs Scale (PBS), the Satisfaction with Simulated Learning Scale (SSLS) and the Simulation Design Scale (SDS), respectively. Student's t tests were used to test for overall group differences in postintervention PAST, SSLS and SDS scores. One-way analysis of covariance tested for overall group differences in PBS scores.

RESULTS

DPS and SP groups did not differ on post-test PAST, SSLS or SDS scores. Knowledge of pain-related misbeliefs was also similar between groups.

CONCLUSIONS

These pilot data suggest that DPS is an effective simulation alternative for HCPs' education on postoperative pain assessment, with improvements in performance and knowledge comparable with SP-based simulation. An equivalence trial to examine the effectiveness of deteriorating patient-based simulation versus standardized patients is warranted.

Theory of protective empowering for balancing patient safety and choices

Registered nurses in psychiatric-mental health nursing continuously balance the ethical principles of duty to do good (beneficence) and no harm (non-maleficence) with the duty to respect patient choices (autonomy). However, the problem of nurses’ level of control versus patients’ choices remains a challenge. The aim of this article is to discuss how nurses accomplish their simultaneous responsibility for balancing patient safety (beneficence and non-maleficence) with patient choices (autonomy) through the theory of protective empowering. This is done by reflecting on interview excerpts about caring from 17 registered nurses taking part in a grounded theory study conducted in three acute urban psychiatric hospital settings in Canada. The interplay between the protective and empowering dimensions of the theory of protective empowering was found to correspond with international, national, and local nursing codes of ethics and standards. The overall core process of protective empowering, and its associated reflective questions, is offered as a new lens for balancing patient safety with choices.

Empirical research on empathy in medicine-A critical review

OBJECTIVE

There is a growing amount of empirical research on empathy in medicine. This critical review assesses methodological limitations in this body of research that have not received adequate attention.

METHODS

Scientific publications presenting empirical research on medical students' or physicians' empathy were systematically searched for.

RESULTS

206 publications were identified and critically reviewed. Multiple empirical approaches have been used. However, there are some remarkable tendencies given the complexity of the study object: empathy is often not defined. Qualitative approaches are rarely used and the predominant quantitative instruments have a relatively narrow or peripheral scope. For example, the concrete experiences, feelings, and interpretations of the physician and the patient, and empathy in clinical practice, are often neglected. Furthermore, possible influences of medical training and working conditions on empathy have not been adequately explored.

CONCLUSION

The empirical studies of empathy in medicine tend to separate empathy from main parts of clinical perception, judgment, and communication. Thus, important aspects and influences of empathy have been relatively neglected.

PRACTICE IMPLICATIONS

Future studies should include transparent concepts, more than one method and perspective, qualitative approaches, the physician's and the patient's concrete experiences and interpretations, and the context in which empathy is developed and practiced.

Evaluation of a communication skills program for first-year medical students at the University of Toronto

BACKGROUND

Effective doctor-patient communication has been linked to numerous benefits for both patient and physician. The purpose of this study was to evaluate the effectiveness of the University of Toronto's Therapeutic Communication Program (TCom) at improving first-year medical students' communication skills.

METHODS

Data were collected during the 1996/97, 1997/98, 1998/99 and 1999/00 academic years. The study used a repeated measures design with a waiting list control group: students were randomly assigned to groups starting the educational intervention in either September (N = 38) or February (N = 41), with the latter being used as a control for the former. Communication skills were assessed at the pre- and post-intervention times and at the end of the academic year from the perspectives of student, standardized patient and external rater.

RESULTS

Only the external rater, using an instrument designed to assess the students' empathy based on their written responses, showed a time x group interaction effect (p = 0.039), thereby partially supporting the hypothesis that TCom improved the students' communication skills. Students rated themselves less positively after participation in the program (p = 0.038), suggesting that self-evaluation was an ineffective measure of actual performance or that the program helped them learn to more accurately assess their abilities.

CONCLUSION

The lack of strong findings may be partly due to the study's small sample sizes. Further research at other medical or professional schools could assess the effectiveness of similar courses on students' communication skills and on other capacities that were not measured in this study, such as their understanding of and comfort with patients, their management of the doctor-patient relationship, and their ability to give and receive feedback.

Advanced practice psychiatric mental health nursing, finding our core: the therapeutic relationship in 21st century

TOPIC

Increasingly, students from various professional backgrounds are enrolling in Psychiatric Mental Health (PMH) Nursing graduate programs, especially at the post-master's level. Faculty must educate these students to provide increasingly complex care while socializing them as PMH advanced practitioners.

PURPOSE

To present how one online program is addressing these issues by reasserting the centrality of the relationship and by assuring it has at least equal footing with the application of a burgeoning knowledge base of neurobiology of mental illness.

SOURCES

Published literature from nursing and psychology.

CONCLUSIONS

The PMH graduate faculty believes that they have developed strategies to meet this challenge and to help build a PMH workforce that will maintain the centrality of the relationship in PMH practice.

What is empathy, and how can it be promoted during clinical clerkships?

The ability of medical students to empathize often declines as they progress through the curriculum. This suggests that there is a need to promote empathy toward patients during the clinical clerkships. In this article, the authors attempt to identify the patient interviewing style that facilitates empathy and some practice habits that interfere with it. The authors maintain that (1) empathy is a multistep process whereby the doctor's awareness of the patient's concerns produces a sequence of emotional engagement, compassion, and an urge to help the patient; and (2) the first step in this process--the detection of the patient's concerns--is a teachable skill. The authors suggest that this step is facilitated by (1) conducting a "patient-centered" interview, thereby creating an atmosphere that encourages patients to share their concerns, (2) enquiring further into these concerns, and (3) recording them in the section traditionally reserved for the patient's "chief complaint." Some practice habits may discourage patients from sharing their concerns, such as (1) writing up the history during patient interviewing, (2) focusing too early on the chief complaint, and (3) performing a complete system review. The authors conclude that sustaining empathy and promoting medical professionalism among medical students may necessitate a change in the prevailing interviewing style in all clinical teaching settings, and a relocation of a larger proportion of clinical clerkships from the hospital setting to primary care clinics and chronic care, home care, and hospice facilities, where students can establish a continuing relationship with patients.

A self-psychology approach to narcissistic personality disorder: a nursing reflection

TOPIC

The use of Heinz Kohut's self-psychology perspective in understanding and providing care for patients with narcissistic personality disorder (NPD).

PURPOSE

To describe how nurses can apply the self-psychology perspective as a way to understand the development of self for individuals with NPD and to enhance the therapeutic relationship between the nurse and patient with NPD.

SOURCES

Theoretical literature; the author's clinical experience.

CONCLUSIONS

Self-psychology provides nurses with a theoretical perspective that can enhance the interpersonal relationship between the nurse and patient with NPD.

Detecting nurse-perceived patient treatment difficulty of psychiatric patients in hospital: an evaluation of a patient assessment sheet

Many changes have occurred in hospital psychiatric care, including decreased length of hospital stay and increased patient acuity. These changes highlight the need for nurses to adequately assess and formally document patient treatment difficulties. The purposes of this study were to determine the ability of the Patient Assessment Sheet (PAS) to predict patient 'problems' that psychiatric nurses perceived as associated with patient treatment difficulty, and to identify the patient problems missing from the PAS. These purposes were accomplished by comparing the PAS to the Hospital Treatment Rating Scale (HTRS). A correlational design and multiple linear regression technique were used. Eight psychiatric registered nurses assessed a total of 110 patients, admitted consecutively to one inpatient psychiatric unit. The HTRS and the PAS were used independently for each patient. Four PAS items (active affect, passive affect, aggression toward self, and patient confusion) significantly predicted 38% of the variance from the HTRS; and three HTRS items (isolation and withdrawal from relationships, noninvolvement in treatment, and wide variability in mood) significantly predicted 22% of the residual variance from the HTRS. The identified PAS and HTRS items help to make visible patient problems associated with nurse-perceived patient treatment difficulty. This identification is potentially important for both clinical and political purposes.

Nurses' confirming/disconfirming responses to patients diagnosed with borderline personality disorder

This study examines whether in group situations, patients with borderline personality disorder (BPD) received less empathic verbal responses from nurses than non-BPD patients. Nurses' feelings toward specific diagnoses were also examined. Twenty patient groups were observed involving 17 nurse leaders and 164 patients. Responses by the nurse leaders were rated using Heineken's Confirmation/Disconfirmation Rating Instrument. The staff response portion of Colson's Hospital Treatment Rating Scale was used to determine nurses's feelings toward specific diagnoses. The study provides some initial evidence that in actual practice situations nurses respond to BPD patients in a less empathic manner than to patients with other diagnoses.