Edinburgh Beginning a conversation on teaching about empathy in practice

This ‘On the Horizon’ paper presents insights from a small interdisciplinary project exploring student perspectives on the role of empathy in professional training and practice. Using a qualitative methodology, this study provides some initial thoughts around four areas identified by the researchers. All the students, from veterinary, nursing and dementia health studies, defined empathy using classic definitions similar to those published in academic literature, but some with more in practice experience showed how this had modified over time. The vet students did recognise empathy to clients as important but admitted that the animals were their first priority, which at times caused tension with how they related to the client. Even the students with limited work experience recognised that often the expression of empathy had to be balanced against time and other demands, leading to stress and in some cases a feeling of a loss in their caring ability. Role models were mentioned by the students as key influencers in their expression of empathy – one nursing student stated that they had been encouraged to “harden up ” rather than outwardly express empathy. When asked about how the role of empathy in practice was taught, most of the students stated this was explicit in their programmes and they would welcome more formal discussion and time provided to this topic. The researchers are now aiming to carry out a larger study to explore this further across a number of health care professions with the aim to provide guidance to aid educators involved in teaching students in these areas.


Introduction
For the health professions as in many others, empathy for the patient or client plays an important role in the care and support offered by practitioners yet previous research suggests this may at times be seen as lacking (Neumann et al., 2011). Some studies have shown empathy levels to decline over time during medical/veterinary/nursing/healthcare training, however they do often report these changes without exploring why that may be the case (Pedersen, 2009). Burnout has been associated with empathy decline along with reduced optimism (Hojat, Vergare, Isenberg, Cohen, & Spandorfer, 2015). There is however evidence that empathy is a skill that can be taught and improved upon (Coulehan et al., 2001). Given that empathy is a skill/attribute that is valued in the health professions, as in many others (Ficarra, 2013), the researchers wished to explore if this is something that could and should be addressed in professional training.
The initial idea for this project came from a chance encounter with three of the researchers at a Higher Education Academy conference and their then discussion around empathy -how is it understood and developed in their different disciplines? This resulted in the formation of the research team made up mainly of colleagues involved in teaching undergraduate veterinary students and one (JA) teaching nursing students and postgraduate professionals on the online MSc in Dementia Care. The team perceived that these different cohorts would have quite different experiences and views on what empathy meant in practice and these differences would be a way in to starting to explore empathy in health care and how educators could support student development of empathy. Using a qualitative methodological approach the project aimed to explore the students' own understanding of empathy and what it looks like within their own professional practice. This paper presents highlights from this preliminary work which is now forming the basis of a larger study across a wider range of disciplines.

Student background
Students were recruited from the two schools in which the researchers are based: Veterinary Medicine and Health in Social Science. In April 2016 students were introduced to the proposed study at the start or end of a lecture, or through normal contact channels for online students and asked to contact the team if they wished to be involved. Sampling was opportunistic and convenience, with a cohort of five student participants, all female, expressing an interest in being involved. All of the students were from differing cultural backgrounds ranging from America, Australia, Southeast Asia and the UK. In contrast to the two participants from the full time This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Clinical Veterinary programme, the postgraduate participants were mature students who had achieved previous degrees or diplomas in their subject area and were undertaking further study to complement their current practice. The Nursing student was a full-time on-campus MSc student and the two Dementia Care students were undertaking the part time MSc Dementia programme online.

Interviews
To address the aim of the study, interview questions were developed into a brief schedule by all of the researchers and used as a guide for discussion rather than as a prescriptive list to follow. All of the 40 minute, one-to-one interviews with each of the five participants were undertaken either face-to-face or via Skype and conducted by KH, a non-teaching member of staff. The semi-structured interview format included three main questions which were: "How do students conceptualise empathy in their lives and practice?"; "What are the challenges to and factors that help facilitate empathy in practice?" and "Where and how do students learn about empathy in practice?". Participants were also encouraged to express if they felt that the teaching of empathy was currently part of their programme curricula. The interviews were transcribed and to ensure robust analysis were thematically analysed by three of the researchers and through content analysis and discussion with all members of the project team. During the analysis of data and project team discussion, it became apparent that although there was much to explore within five students' experiences and reflections, that this was only the tip of the iceberg in thinking about approaches to teaching about empathy in practice. We therefore decided that the initial findings from this small study would be the basis for a much larger scale study across a number of different disciplines to explore more thoroughly the role and/or need for empathy in practice and how educators could facilitate this.

Ethical Approval
The project was reviewed and approved by the R(D)SVS Human Ethics Committee (HERC) and School of Health in Social Science (HiSS) prior to commencement.

Insights from the student interviews
What is empathy?
The students described some aspects of empathy which mapped to how it is defined in the literature; such as being able to place yourself in another's shoes and use your understanding of their perspective to guide your actions (Mercer & Reynolds, 2002). When asked what empathy looked like, students used examples from their own experiences in describing empathy and what it meant for them. This included being there for another person without judgement, helping them to feel validated in how they feel and using appropriate language tone and body language to be supportive.
I think empathy for me means putting myself and other people first, thinking about life, what that situation would be like for them, how they perceive either good or not so good things that are happening around them, how they perceive that, how that would be for them. Dementia M.Sc. student 1 The students also defined empathy in relation to their professional practice, with one describing the contrast she had witnessed to what she thought patients deserved.
For me, empathy is a kind of perception of patients. I was intensive care unit nurse but sometimes, especially in intensive caring field is some kind of dehumanised perception of patients by nurses... So for me, empathy means I think that it's a kind of patient dignity. Nursing M.Sc. student

The challenges of empathy in practice
All the students felt that empathy was important in their professional practice and most of them talked about it being their primary motivation for their work. There was a feeling from some that if you couldn't feel empathy, you shouldn't be in the job however there was also recognition that empathy was something that develops over time. For example, one of the veterinary students had not really considered the human aspect of the veterinary profession when she started out but through her own life experiences and experiences of practice had learned the importance of empathy in client communication. Both veterinary students felt however that there was a tension between doing what was the best for the animal, which as a vet is their priority, and managing the expectations and feelings of the human owner. This aspect of tension also came out from the healthcare students as having to balance the patient's needs and expectations against those of the family or caregiver.
…the kind of thing that will make you go like 'oh why didn't you bring it in earlier?' kind of situation, and instead of like being more sensitive to the owner, the vet was kind of annoyed that he left it so late… I could tell that caused a bit of tension between the owner and the clinician, in the sense that you are just going to come here, get it done and leave, there is not going to be a relationship formed between them. Vet Student 2 This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Those working in the health sciences talked about the overall workplace culture being a huge influence on whether practitioners felt able to spend time with and reach out to patients or not and one of the vet students also mentioned how a particularly caring vet was pressured to hurry up because her consults were taking too long. Two students who had worked primarily in nursing particularly felt that often there was a lack of empathy in nursing due to the technical focus on being efficient and getting things done.
I came across a new graduate trying to restrain an older person with dementia by bandaging her hands and then tying them to cot sides and I stopped her and again was very shocked by that. But yeah, I suppose really what was shocking about it was her complete lack of empathy for that person and the sense that that was acceptable. And it was acceptable within that culture and that team so I think some of the barriers there were workload, lack of support and supervision a culture which was about blame and therefore created a lot of fear so there weren't systems in place that were supportive… Dementia M.S.c. student 2 The sustainability of empathy in such a busy environment was also discussed and the risk of burnout due to caring too much was highlighted which might lead to practitioners' adopting self-protective measures and switching off their emotions to the experiences of others or simply being too tired to care.

And then there have been times when I have, even with my own children not being empathetic or my own partner, and my clients, I haven't been empathetic, and a lot of that happens I think because we get tired, particularly in the human services, the same stories over and over and over, and it gets a bit tiring. Yes, so I guess for clients it must be really hard too, because it
is not their fault I have heard the same story 50 times! Dementia M.Sc. student 1

The impact of role models on perceptions of empathy in practice
It was clear from the student interviews that role models can have a major impact on how students and practitioners perceive empathy in practice. These role models had the potential to be either extremely positive or negative influences on how students and new practitioners incorporate empathy into their practice. For example, the nursing student spoke about when she had started in practice and she had been told to harden up by senior nurses, then found herself doing the same to novices when she was in this role.

I remember the first CPR I experienced after I start work, I was about to cry but I couldn't because all the senior nurses told me that you should be very calm and not to be emotional because this is work. This is work. If you feel like some kind of… feel like… their family or you feel very close to patients this distracts your work so you should be very… I think that is the dehumanised kind of perception… I think that student nurses and novice nurses right after they graduate, they are full of empathy I think, in my experience… I think the development of empathy level is needed in the senior nurses more maybe. I am influenced by some novice nurses when they feel real empathy to patients, it's like fresh flow. Nursing M.Sc. student
One of the vet students on the other hand talked about observing empathy expressed by vets in practice and learning from that and trying to emulate it. There were also influences from the workplace that played a role in modeling whether being empathic as a practitioner was seen as desirable and encouraged as mentioned above.
I think most vets are quite good at it, I have still seen many vets that have come out of practice for a long time, shed a tear or two when clients and patients that they are close to are put down, and I think that means quite a lot to the owner, or even being able to say things like 'oh I understand your situation', something like that, it does… it does help the owner, I can see them give a bit more information, a little bit more, now that they have said okay we are on the same page, yes. Vet student 2

Students' experiences of learning about empathy and how this can be facilitated
The students all felt that empathy to patients and clients was considered important within their professions and that this was recognised to varying extents within their particular programmes. The two vet students had differing views on whether empathy for clients was something that was particularly covered within the veterinary programme and if it was something that could be included more. Vet Student 1 did not really recognise empathy within the curriculum or think that her peers would be interested if it were while Vet Student 2 felt that empathy was something that was included and something students were marked on and that it would be useful to have more on it including getting feedback on it.
…you do a little bit, yeah, like when they have you do the awkward conversations during… is it fourth year? Because… during fourth year, they give you like 'Oh, yeah I had to kill your horse before you got here', sort of odd situations. And I think those do, to an extent. We don't explicitly talk about empathy, we just sit there and grade each other on, 'Oh, that would be perceived badly', but nobody says that it's about empathy itself, if that makes sense? Vet student 1 We have had a few practicals, like communication skills wise and even our OSCEs where we are asked to think about empathy in terms of how we talk to the clients, and we are even graded for it… It would be good to get feedback, I guess, from clinicians during our final year, because… that is not the kind of feedback that we get. Vet Student 2 The healthcare students also felt discussions around empathy were included in their programmes to a greater or lesser extent.
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There is not that specific word empathy but I am studying person-centred care, the last semester, I think it's quite related to the dignity of patients. Nursing M.Sc. student

I am trying to think, I have done quite a few since then! It may be brought up informally in informal discussions like through our collaborate sessions, but I don't know if it is really set down and looked at in a more formal way, what is empathy, yes.
Dementia M.Sc. student 1 I think it's come across quite explicitly in some modules. Interestingly, now you've asked me that question, I would have to say not at all in one particular module which interestingly was the module from the nursing department. Dementia M.S.c. student 2 All students felt that there was room for more discussion within their formal teaching around understanding the role empathy can play in patient and client care, as well as the challenges of sustaining empathy in practice. Discussion on this centred around whether or not talking about 'empathy' in and of itself would be helpful or accepted by students but instead focusing more on how to protect oneself from burnout through self-care and how to balance the various challenges of the workplace may be more helpful. The students also saw an opportunity for learning and support when in practice when they were having to deal with the issues directly, such as through peer support groups.

Discussion
This study has shown that for these five students at least, empathy is important to them personally and their professional practice. However, maintaining an emphathetic approach can be challenging given the pressures of life and work.
For educators, the students also noted that while teaching about empathy is clearly important, this does not necessarily have to be something that is taught directly but rather it is probably better covered indirectly within other classes. Indeed from our discussions, the team felt that teaching empathy at a general level and as an entity in its own right was probably problematic. Instead it may be better to use an indirect approach such as through activities that help students understand the importance of building practitionerclient/patient relationships, such as setting boundaries and knowing limits. Jeffrey & Downie, (2016) speak of teaching empathy through consideration of perspective taking, empathic concern, behaviours and ethics that tunes with our suggestion.
Another area highlighted was the need to help students to understand the difference between empathic or compassionate concern and sympathy and personal distress in order to maintain a healthy balance and prevent burnout.
The influence of role models was also highlighted. If those who teach students and trainees do not role model empathy for and to them as well as the clients and patients they work with then they may learn to emulate those role models even if they are taught to employ empathy in practice.
The future study will explore some of these complex issues across a wider selection of disciplines.

Conclusion and next steps
This small-scale study identified a number of key areas requiring further research around the topic of empathy in practice both in student training and in the workplace. Students want more discussion within their training of empathy and what this means in the workplace and how to remain empathetic in a demanding work environment. In addition, this project showed the benefits of interdisciplinary projects allowing both the pooling of resources and the outsider take on findings.
The initial findings from this exploration have led to discussions with colleagues in a range of disciplines such as medicine, counselling, social work and business and the researchers are now working on obtaining funding to carry out a more in depth study to explore this area further. In addition to further research into the areas identified, this new study will consider how best to approach discussions around empathy within different disciplines and whether a cross-disciplinary approach to sharing experiences could be successful or whether the requirements within each area are too specialised to meet the needs of the students.