The development of empathy in the healthcare setting: a qualitative approach.

BACKGROUND: Healthcare professionals' empathetic behaviors have been known to lead to higher satisfaction levels and produce better health outcomes for patients. However, empathy could decrease over time especially during training and clinical practice. This study explored factors that contributed to the development of empathy in the healthcare setting. Findings could be used to improve the effectiveness and sustainability of empathy training. METHOD: A qualitative approach, informed by aspects of grounded theory, was utilized to identify factors that enabled the development of empathy from the perspectives of doctors, nurses, allied healthcare workers and students. Twelve sessions of focus group discussions were conducted with 60 participants from two hospitals, a medical school, and a nursing school. Data was analyzed independently by three investigators who later corroborated to refine the codes, subthemes, and themes. Factors which influence the development of empathy were identified and categorized. This formed the basis of the creation of a tentative theory of empathy development for the healthcare setting. RESULTS: The authors identified various personal (e.g. inherent characteristics, physiological and mental states, professional identity) and external (e.g. work environment, life experience, situational stressors) factors that affected the development of empathy. These could be further categorized into three groups based on the stability of their impact on the individuals' empathy state, contributed by high, medium, or low stability factors. Findings suggest empathy is more trait-like and stable in nature but is also susceptible to fluctuation depending on the circumstances faced by healthcare professionals. Interventions targeting medium and low stability factors could potentially promote the development of empathy in the clinical setting. CONCLUSIONS: Understanding factors that impact the development of empathy allows us to develop measures that could be implemented during training or at the workplace leading to improve the quality of care and higher clinical work satisfaction.

Key challenges in simulated patient programs: an international comparative case study.

BACKGROUND: The literature on simulated or standardized patient (SP) methodology is expanding. However, at the level of the program, there are several gaps in the literature. We seek to fill this gap through documenting experiences from four programs in Australia, Canada, Switzerland and the United Kingdom. We focused on challenges in SP methodology, faculty, organisational structure and quality assurance. METHODS: We used a multiple case study method with cross-case synthesis. Over eighteen months during a series of informal and formal interactions (focused meetings and conference presentations) we documented key characteristics of programs and drew on secondary document sources. RESULTS: Although programs shared challenges in SP methodology they also experienced differences. Key challenges common to programs included systematic quality assurance and the opportunity for research. There were differences in the terminology used to describe SPs, in their recruitment and training. Other differences reflected local conditions and demands in organisational structure, funding relationships with the host institution and national trends, especially in assessments. CONCLUSION: This international case study reveals similarities and differences in SP methodology. Programs were highly contextualised and have emerged in response to local, institutional, profession/discipline and national conditions. Broader trends in healthcare education have also influenced development. Each of the programs experienced challenges in the same themes but the nature of the challenges often varied widely.

Defining clinical empathy: a grounded theory approach from the perspective of healthcare workers and patients in a multicultural setting.

OBJECTIVE: To define clinical empathy from the perspective of healthcare workers and patients from a multicultural setting. DESIGN: Grounded theory approach using focus group discussions. SETTING: A health cluster in Singapore consisting of an acute hospital, a community hospital, ambulatory care teams, a medical school and a nursing school. PARTICIPANTS: 69 participants including doctors, nurses, medical students, nursing students, patients and allied health workers. MAIN OUTCOME MEASURES: A robust definition of clinical empathy. RESULTS: The construct of clinical empathy is consistent across doctors, nurses, students, allied health and students. Medical empathy consists of an inner sense of empathy (imaginative, affective and cognitive), empathy behaviour (genuine concern and empathic communication) and a sense of connection (trust and rapport). This construct of clinical empathy is similar to definitions by neuroscientists but challenges a common definition of clinical empathy as a cognitive process with emotional detachment. CONCLUSIONS: This paper has defined clinical empathy as 'a sense of connection between the healthcare worker and the patient as a result of perspective taking arising from imaginative, affective and cognitive processes, which are expressed through behaviours and good communication skills that convey genuine concern'. A clear and multidimensional definition of clinical empathy will improve future education and research efforts in the application and impact of clinical empathy.

The Imperial Stress Assessment Tool (ISAT): a feasible, reliable and valid approach to measuring stress in the operating room.

BACKGROUND: Stress can impair surgical performance and may compromise patient safety. This prospective, cross-sectional study describes the feasibility, reliability, and validity of the Imperial Stress Assessment Tool (ISAT) as an approach to measuring stress during surgery. METHODS: A total of 54 procedures were observed with 11 surgeons (4 attendings, 4 senior residents and 3 junior residents) in a large university teaching hospital in London, UK. Data collection involved physiological measures of operating surgeons [heart rate (HR) and salivary cortisol] and self-report questionnaires (State Trait Anxiety Inventory, or STAI). RESULTS: In all, 23 of 54 procedures were stressful, as identified by self-reporting. For stressful procedures compared to nonstressful ones, STAI was higher (mean +/- SD) 9.81 +/- 2.20 vs. 12.87 +/- 4.27, t (30.64) = 3.15 as was the HR (mean +/- SD) 79.94 +/- 8.55 vs. 93.17 +/- 14.94, t(32.57) = 3.81) (p < 0.05). Significant positive correlations were obtained between the measures indicating concurrent validity: Pearson's r = 0.47 (HR vs. STAI), 0.34 (cortisol vs. STAI), and 0.57 (HR vs. cortisol) (p < 0.05). Perfect correlation of subjective and objective measures was found for 70% of the procedures. HR and cortisol had specificities of 78% and 91% and sensitivities of 91% and 70% respectively for detecting stress during surgery. CONCLUSION: ISAT is a nonintrusive, feasible approach that combines subjective and objective methods for measuring stress in the operating room. The ISAT may increase understanding of the effects of stress on clinical performance and outcomes, leading to improved patient care.

Real patient involvement in role development: evaluating patient focused resources for clinical procedural skills.

BACKGROUND: Simulated patients (SPs) are widely used in medical education. The literature offers little evidence for scenario or SP role development. Published materials describe guidelines for structuring roles but there is little information on process. Anecdotal evidence suggests that SP roles are usually created by health care professionals and teachers. Although this approach has advantages it places the role at risk of omitting or misrepresenting real patients' experiences. AIM: We wanted to explore a systematic approach to role development that was based on individual patient's experiences. METHODS: Real patients were interviewed about their experiences of procedures they had undergone. This information formed the basis of our procedural skills SP roles. RESULTS: Eight new roles were created. Evaluation by SPs (n = 22) showed more positive comments about realism on roles based on real patients' experiences compared with those crafted by our multidisciplinary team although there were no statistically significant differences in numerical ratings. CONCLUSIONS: The approach to writing roles described here is not suited to all simulations. However, it offers guidance to those involved in writing scenarios and has led us to critically reflect on the ways in which we provide educational materials that are patient focused.

Role-play for medical students learning about communication: guidelines for maximising benefits.

BACKGROUND: Role-play is widely used as an educational method for learning about communication in medical education. Although educational theory provides a sound rationale for using this form of simulation, there is little published evidence for its effectiveness. Students' prior experiences of role-play may influence the way in which they engage in this method. This paper explores students' experiences with the aim of producing guidelines for maximising the benefits of role-play within this learning context. METHODS: First-year undergraduate medical students participated in a role-play session as part of their communication programme. Before and after the session, students completed questionnaires. In the pre-session questionnaire, students were asked about their experiences of role-play and asked to identify helpful and unhelpful elements. Immediately after the session, students answered similar questions in relation to the role-play activity they had just completed. Descriptive statistics were used to analyse quantitative data and qualitative data was thematically analysed. RESULTS: 284 students completed evaluation forms. Although 63 (22.2%) had prior unhelpful experiences, most students (n = 274; 96.5%) found this experience helpful. Summary findings were that students reported the key aspects of helpful role-play were opportunities for observation, rehearsal and discussion, realistic roles and alignment of roles with other aspects of the curriculum. Unhelpful aspects were those that evoked strong negative emotional responses and factors that contributed to a lack of realism. CONCLUSION: Role-play was valued by students in the acquisition of communication skills even though some had prior unhelpful experiences. Guidelines for effective role-play include adequate preparation, alignment of roles and tasks with level of practice, structured feedback guidelines and acknowledgment of the importance of social interactions for learning.

Annexin 1, glucocorticoids, and the neuroendocrine-immune interface.

Annexin 1 (ANXA1) was originally identified as a mediator of the anti-inflammatory actions of glucocorticoids (GCs) in the host defense system. Subsequent work confirmed and extended these findings and also showed that the protein fulfills a wider brief and serves as a signaling intermediate in a number of systems. ANXA1 thus contributes to the regulation of processes as diverse as cell migration, cell growth and differentiation, apoptosis, vesicle fusion, lipid metabolism, and cytokine expression. Here we consider the role of ANXA1 in the neuroendocrine system, particularly the hypothalamo-pituitary-adrenocortical (HPA) axis. Evidence is presented that ANXA1 plays a critical role in effecting the negative feedback effects of GCs on the release of corticotrophin (ACTH) and its hypothalamic-releasing hormones and that it is particularly pertinent to the early-onset actions of the steroids that are mediated via a nongenomic mechanism. The paracrine/juxtacrine mode of ANXA1 action is discussed in detail, with particular reference to the significance of the secondary processing of ANXA1, the processes that control the intracellular and transmembrane trafficking of the protein of the molecule and the mechanism of ANXA1 action on its target cells. In addition, the role of ANXA1 in the perinatal programming of the HPA axis is discussed.

Macrophage migration inhibitory factor is released from pituitary folliculo-stellate-like cells by endotoxin and dexamethasone and attenuates the steroid-induced inhibition of interleukin 6 release.

Macrophage migration inhibitory factor (MIF) is a proinflammatory cytokine produced by peripheral immune cells and also by endocrine cells in the anterior pituitary gland. MIF exerts its proinflammatory actions in the host-defense system by blocking the inhibitory effects of glucocorticoids on the release of other proinflammatory cytokines (e.g. IL-1, IL-6, TNFalpha). Reports that pituitary folliculo-stellate (FS) cells share many characteristics with immune cells led us to propose that these cells may serve as an additional source of MIF in the pituitary and that pituitary-derived MIF may act in an autocrine or paracrine manner to modulate endotoxin-induced cytokine release from FS cells. In the present study we addressed this hypothesis by using 1) immunohistochemistry to localize MIF in primary pituitary tissue and 2) well-characterized FS (TtT/GF), corticotroph (AtT20), and macrophage/monocyte (RAW 264.7) cell lines to explore the effects of CRH, endotoxin, and dexamethasone on MIF release and to examine the effects of MIF on IL-6 release. Our immunohistochemical study showed that MIF is expressed in abundance in S100-positive FS cells and also in other pituitary cell types. All three cell lines expressed MIF protein and responded to endotoxin (10-1000 ng/ml, 24 h) and dexamethasone (100 pM to 10 nM, 24 h) with concentration-dependent increases in MIF release. CRH (10-100 nM) also stimulated MIF release from AtT20 cells but, unlike endotoxin and dexamethasone, it had no effect on MIF release from TtT/GF or RAW cells. Recombinant MIF did not affect the basal release of IL-6 from TtT/GF cells; however, it effectively reversed the inhibitory effects of dexamethasone (1 nM) on the endotoxin-induced release of IL-6 from these cells. The results suggest that the FS cells are both a source of and a target for MIF and raise the possibility that MIF serves as a paracrine/autocrine factor in the pituitary gland that contributes to the protective neuroendocrine response to endotoxin.

Design and validation of the surgical ward round assessment tool: a quantitative observational study.

BACKGROUND: Ward round skills are essential for the best management of surgical inpatients, but assessment of their quality has received inadequate attention. This study aims to design and validate the surgical ward round assessment tool (SWAT). METHODS: We used modified Healthcare Failure Mode and Effects Analysis to develop the SWAT by identifying ward round steps. We assessed the validity of the SWAT using simulated and real surgical ward rounds. RESULTS: The Healthcare Failure Mode and Effects Analysis identified 30 ward round steps that were developed into the SWAT. Nineteen surgeons completed simulated surgical ward rounds. Eight fully trained surgeons scored significantly higher than 11 trainee surgeons when assessed with the SWAT (P = .001). On average, the participants thought the realism of the simulation was good. Forty-four surgeons completed real surgical ward rounds. Fifteen experts scored significantly higher than 29 trainee surgeons when assessed with SWAT (P = .001). Inter-rater reliability was .85 to .89, respectively. CONCLUSIONS: The SWAT can be used to assess the quality of task-based and nontechnical surgical ward round skills.

Evaluation of a clinical communication programme for perioperative and surgical care practitioners.

INTRODUCTION: Communication is integral to clinical work. This paper describes a communication programme (CP) designed for two new professional roles. Training in communication is often focused on interactions with patients. Equally important is supporting clinicians to communicate with each other. The authors devised a CP for perioperative specialist and surgical care practitioners. METHODS: The CP spanned the broader training programme. The evaluation combined trainees' self-ratings, value of educational methods, summative assessments, written reflections and focus groups. RESULTS: The CP was offered over three consecutive years (29 trainees) and showed a progressive increase in trainees' satisfaction. Educational methods were valued. Trainees appreciated the close alignment of CP content and work. Some trainees initially placed little value on learning communication, since they were already experienced clinicians. The CP was perceived to be competing with topics of greater importance. As trainees progressed, all recognised the benefits and valued the opportunity for protected time to focus on commonly used skills. Trainees reported increased awareness and ability in patient-centred and other professional communications. Most trainees were successful in summative assessments. Faculty observations noted benefits accruing from increased alignment of content with clinical practice. DISCUSSION: Trainees responded positively to an experiential CP underpinned by education and communication theory. The opportunity for distributed learning enabled trainees to consolidate learning. The balance of teaching patient- and colleague-focused communication was successful. The framework of this CP is applicable to trainees in medical and other health professional roles.

Factors compromising safety in surgery: stressful events in the operating room.

BACKGROUND: Stressful events occur in the operating room (OR) with potentially severe consequences for patient safety. We recorded the incidence of these events in the OR, assessed the levels of stress that they caused, and investigated their detectability. METHODS: Stressful incidents in the OR were recorded and rated in real time by an observer in 55 general and orthopedic procedures. Operating surgeons also rated incident stressfulness and their stress (validated State Trait Anxiety Inventory). RESULTS: The total count of stressors/case ranged from 1 to 23.5 (mean, 5.87). Technical, patient, and equipment problems occurred frequently and were most stressful. Frequent but least severe stressors were distractions/interruptions, whereas least frequent/most severe stressors were teamwork problems. These events were associated with an increase in surgeons' self-reported stress. The observer was able to capture surgeons' stress accurately. CONCLUSIONS: Systematically occurring stressors in the OR affect surgeons and can be assessed accurately. Further research should investigate the impact of stress on surgical performance.

Managing intraoperative stress: what do surgeons want from a crisis training program?

BACKGROUND: Current surgical training provides little opportunity for surgeons to recognize and manage intraoperative stress before it affects performance and compromises patient safety. We explored the perceived need for structured stress training and propose an intervention design that may be acceptable and appropriate. METHODS: Fifteen semistructured interviews identified stressors in the operating room, characterized coping strategies, and explored surgeons' views about a training intervention. Interviews were analyzed using standard qualitative methods. RESULTS: Stressors and coping strategies confirmed those identified in previous work. Key components of an intervention should include recognizing stress in oneself and in others; experiencing the impact of stress on performance; providing effective coping strategies; offering feedback; and providing opportunities to practice what has been taught in a safe, simulation-based environment. CONCLUSIONS: There is a need for structured training in management of intraoperative stress. Surgeons would welcome a simulation-based intervention to enhance performance and patient safety.

Annexin 1: a paracrine/juxtacrine mediator of glucorticoid action in the neuroendocrine system.

Glucocorticoids (GCs) play an essential role in the maintenance of homeostasis. In normal circumstances their secretion is tightly regulated by a complex servo mechanism through which the steroids suppress the synthesis and release of ACTH and its hypothalamic releasing factors (CRH and AVP) and thereby reduce the positive drive to the adrenal cortex. The feedback actions of GCs on hormone release develop rapidly (within minutes), well before any changes in hormone synthesis are apparent. By using immunoneutralization, gene targeting and pharmacological strategies in in vivo and in vitro models, we have identified annexin 1, a Ca(2+)- and phospholipid-binding protein, as a key mediator of the early inhibitory actions of GCs on peptide release. This brief review outlines this work and describes molecular and cellular studies which have provided insight into the mechanism of annexin 1-dependent GC signalling in the neuroendocrine system.