Patients and families have choices related to their healthcare. An empathetic environment in any setting can help create loyal customers and directly impact patient and family satisfaction.1 A systematic review of the association between empathy and patient outcomes in cancer care found that clinicians’ empathy was related to higher patient satisfaction and lower distress.2 Another systematic review of empathy revealed a growing interest in the relevance of empathy to patient care.3 Since the late 1970s, studies have been published on educational programs designed to enhance nursing empathetic skills.4-10 One recent study, conducted in an intensive care unit (ICU), found that focusing on education related to communication skills improved the nurses’ ability to respond with empathy.11 Enhancing the nurse’s ability to communicate with empathy to patients and families is of particular importance because families can be overwhelmed, stressed, and anxious when dealing with their loved one being critically ill, compounded by the complexities of a highly technical ICU environment.
Patient and Family Advisors
Patient and family advisors (PFAs) are family members or other individuals close to someone who has received care in a hospital. Patient and family advisory councils offer insight and input to help hospitals improve care delivery.12 Patient and family advisors provide a singular perspective on how well systems, processes, and policies work along with opportunities to participate in improving quality, safety, communication, and patient-family centered care. According to the Agency for Healthcare Research and Quality,12 working with PFAs can promote benefits in 6 areas: 1) health outcomes for patients; 2) employee satisfaction; 3) financial performance: 4) patient loyalty; 5) reduction of errors and adverse events; and 6) reduction in the risk of malpractice. Pediatric facilities or academic medical centers in the United States tend to use PFAs more frequently than do other types of facilities.13 Despite the evidence supporting PFA involvement, there is little in the literature to describe how hospitals should incorporate them in educating staff and awareness raising.
While building a new surgical ICU (SICU) and medical ICU (MICU), we had the unique opportunity to collaborate with community stakeholders, that is, patients and families. Patient and family advisors who have previous exposure to an ICU environment were in a position to help design education for nurses in this unique area based on how they envision empathetic patient- and family-centered care. The purpose of this study was to determine if a higher level of ICU nursing empathy can be achieved as a result of nurses’ participation in PFA-designed educational offering.
The results of a qualitative study revealed that families wanted empathy from the ICU team; it was one of the most important issues expressed.14 An examination of the literature revealed that patients perceive that empathy is frequently not conveyed by nursing staff15-18 and empathy is on the decline in both nursing students and medical students.19,20 Creating a culture of empathy in hospitals can be challenging for young nurses who have never experienced illness themselves, as well as for more seasoned nurses who perhaps have developed compassion fatigue over time.1 The ability to offer empathy varies as some individuals are more empathetic by nature than others, with women tending to be more empathetic.21 Training programs for nursing on empathy tend to focus on the communication aspects,4,6,11 highlighting listening and responding. Education for the ICU nurses, in this study, focused on scenarios incorporating cognitive understanding, emotional, and communication responses (verbal and nonverbal) to families.
This study used a descriptive preintervention/postintervention design. The intervention consisted of a 4-hour class using simulation-based role playing, a video (both designed in collaboration with PFAs), and an evidence-based PowerPoint presentation on empathy developed by the principal investigator (PI). Scenarios focused on nursing empathetic communication on 4 dynamics: family support for admission to the SICU late at night with multiple family members, family support during a procedure, family support during an emergency, and family conflict. Scenarios included an empathetic supportive as well as nonempathetic/nonsupportive clinical response followed by a debriefing session. The nonempathetic scenarios, scripted for both the nurse and PFAs, generally ended with either the nurse not allowing family members to be present, interrupting, or instructing them to leave the room, referring to rules and visitation policies, calling security, or otherwise not honoring family requests. Immediately after the nonempathetic scenario, the scenario included an empathetic supportive scripted response scenario. The supportive empathetic scenarios were inclusive of the patient and family and included some boundary setting. Empathetic supportive responses included acknowledging patients and families and their emotions, listening, maintaining eye contact, clarifying, and offering options and information in a supportive and nonjudgmental fashion.
The PFAs interacted with the nurses and were present during the entire class, acted in the scenarios, and participated in the debriefings. At the beginning of class, PFAs included in their introduction why they had chosen to become PFAs, some sharing brief personal stories of their own illness or that of a loved one they had lost. A minimum of 2 PFAs participated in each session and role played in the scenarios. Different nurses volunteered in each of the 4 scenarios with PFAs simulating the role of the family member or patient. Those nurses who did not volunteer to be an active participant in a specific scenario were observers.
Simulations were followed by a 25-minute video featuring a PFA who spoke of her experiences while her husband was hospitalized, sharing both good and poor nurse interactions. A debriefing after the video allowed PFAs to speak about their own hospital experiences, and some nurses chose to share if they or a loved one had been in a hospital what those experiences were like for them.
Sample and Setting
Eligible study participants were recruited from the 83 registered nurses (RNs) working in the SICU and the 63 RNs working in the MICU at an academic medical center in the Southeast. Thirty nurses participated in the study. The sample size was based on an a priori power analysis with an α of .05, power of 0.80, and medium effect size.
Instruments and Reliability
The revised Toronto Empathy Questionnaire (TEQ) (Figure 1) was used to quantify levels of nurse empathy preintervention and postintervention. The TEQ is a valid and reliable measure of empathy.22 It was minimally revised from its original form by replacing the term “people” with “patients.” In previous studies, the TEQ correlated positively with the Empathy Quotient (r = 0.80, P < .001), with an internal consistency of α = .87 and high test-retest reliability (r = 0.81, P < .001).22 It consists of 16 statements; participants rate their level of agreement for each statement on a Likert-type scale from “never” to “always.” Study participants also completed a PI-developed brief demographic form.
Study approval was obtained from the hospital institutional review board (IRB) as well as the University of Alabama at Birmingham IRB before beginning the study. No participant identifiers were included on any data collection forms.
Descriptive statistics were used to measure nurses’ self-ratings on levels of empathy. Correlations (Pearson r for continuous normally distributed measures and Spearman ρ for ordinal scaled items) and independent t tests were performed to test for association between study participants’ characteristics and responses to the TEQ questionnaire. Total scores were computed for the TEQ from the 16 items, which had responses ranging from 0 (never) to 4 (always), yielding total scores ranging from 0 to 60. The 30 participants completed the TEQ at baseline (pre) and after completing the education (post). Paired t tests were performed to test for significant changes in the TEQ scores and for the 16 individual item responses from pre-education to posteducation. Internal consistency (reliability) was computed via Cronbach’s α for the 30 participant responses on the 16 TEQ items at baseline. All statistical analyses were completed using SPSS v. 23 (Armonk, New York). Data are stored on a password-protected computer.
Most of the nurses were 30 years or younger (53.4%; n = 16), were female (90.0%; n = 27), had a bachelor of science in nursing degree (80.0%; n = 24), had been in nursing for 7 years or less (66.6%; n = 20), had been in the ICU for 3 years or less (60.0%; n = 18), and were in the SICU (60.0%; n = 18). Participant responses on the 16 TEQ items yielded acceptable reliability (internal consistency), with an α = 0.71 (P < .05). Overall, total TEQ empathy scores increased significantly (P = .04) after nurses completed the PFA-designed educational program. Pre-education TEQ scores averaged 49.8 ± 4.32, with post-education TEQ scores averaging 51.6 ± 5.86, increasing by an average of 1.81 ± 3.22 (P = .004). Six individual TEQ items significantly improved after the educational intervention: (1) “Other patient’s misfortunes do not disturb me a great deal” (P = .003); (2) “I have tender concerned feelings for people less fortunate than me” (P = .017); (3) “I find I am in tune with other patient’s moods” (P = .043); (4) “I I do not feel sympathy for patients who cause their own illnesses” (P = .036); (5) “I get a strong urge to help when I see a patient who is upset” (P = .017); and (6) “When I see patients being taken advantage of, I feel kind of protective toward him/her” (P = .009). For a complete list of TEQ item scores, refer to Table 1.
The changes in TEQ scores from preintervention to postintervention were assessed for potential statistical associations with age, gender, education, years in nursing, years in ICU, and unit. No statistically significant associations were noted between age, gender, education, years in nursing, and unit with the TEQ scores both preintervention and postintervention. However, years in the ICU was moderately correlated with TEQ scores at preintervention (Spearman ρ = −0.363, P = .049) and at postintervention (ρ = −0.350, P = .058). For the changes in TEQ scores from preintervention to postintervention, age was significantly associated with improvements in TEQ scores. Younger nurses (<30 years) improved, on average, 3.03 ± 3.6 points pre-education to posteducation compared with older nurses (>30 years), who improved, on average, only 0.43 ± 2.06 points pre-education to posteducation (t 24.4 = 2.46, P = .021) (Figures 2 and 3).
The study results show that ICU nurses’ level of empathy can be improved by an education intervention where PFAs participate in the development and implementation. Because age was significantly associated with improvements in TEQ scores, with younger nurses (≤30 years) improving the most in postintervention scores compared with older nurses (>30 years), there is opportunity for healthcare educators to partner with PFAs in teaching and using scenarios to increase empathy levels among younger nurses. This is particularly significant given that a previous study showed empathy on the decline among nursing students.22 Using PFAs to assist in education with nursing students to enhance their levels of empathy should be considered.
Older nurses (>30 years) also improved in TEQ scores, although not as much as the younger nurses. These findings may be attributed to older nurses experiencing burnout or compassion fatigue. Compassion fatigue is defined as “as a combination of physical, emotional, and spiritual depletion associated with caring for patients in significant emotional pain and physical distress.”23 (p1) It is noted that compassion fatigue may develop when nurses encounter ongoing stress from dealing with the overwhelming needs of patients and families. In addition to the physiologic manifestations (eg, headache, fatigue, chest pain), compassion fatigue can also manifest with a decreased ability to be empathetic toward patients or families.23
The impact of the PFAs should not be underestimated in designing an intervention to increase empathy. In this study, the PFAs provided a singular perspective regarding how well systems or processes worked along with opportunities to improve in quality, safety, communication, and patient- and family-centered care. Their engagement and willingness to share with transparency regarding what empathy from a nurse means were instrumental in allowing ICU nurses to hear directly from PFAs. Infrequently, ICU nurses receive feedback from the patients or families they care for, so the role of the PFAs was invaluable in sharing of their experiences. Nurses all report lacking confidence communicating with families.24 Including scenarios of how nurses can convey empathy as well as how nurses do not convey empathy from the PFA perspective allowed study participants to observe differences. For example, supportive cognition displayed in the presence during procedure scenario included the nurse portraying understanding of the patient’s need to want his partner present to provide comfort and assurance. Nonsupportive cognition included a lack of understanding patient’s needs by the nurse, portraying the nurse as imposing his/her own needs or insecurity over the PFA’s.
The main limitation of this study was the use of a convenience sample at 1 academic medical center. This limits the generalizability of the findings to other ICUs and other patient groups. Another limitation of this study is the demographics of the PFAs. Most of the PFAs in this study were older and retired. A younger cohort of PFAs may provide a different perspective on their experiences and input.
Ensuring that bedside nurses consistently empathize with the patients and families for whom they care helps creates positive patient experiences. This study demonstrated that a higher level of ICU nurse empathy was achieved as a result of having PFAs collaborate in the design and implementation of an educational program. This study further addressed an identified gap in utilization of PFAs to educate ICU nurses in improving caring attitudes in nursing healthcare delivery. Education programs to improve empathetic care among nurses have been shown to have a positive impact and is further supported by this study. Further research is needed regarding the use of PFAs in education and scenario development for nurses, perhaps collaborating with younger PFAs. Other potential areas for research include exploring the relationship between nurses’ personality traits on levels of empathy as well as the relationship between nurses’ levels of empathy and compassion fatigue, staff retention, or both.
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