The Development of Empathy in Healthcare PDF

YU et al. BMC Medical Education (2022) 22:245 https://doi.org/10.1186/s12909-022-03312-y RESEARCH Open Access The development of empathy in the healt...

YU et al. BMC Medical Education (2022) 22:245 https://doi.org/10.1186/s12909-022-03312-y RESEARCH Open Access The development of empathy in the healthcare setting: a qualitative approach Chou Chuen YU1, Laurence TAN1,2, Mai Khanh LE1, Bernard TANG1*, Sok Ying LIAW3, Tanya TIERNEY4, Yun Ying HO5, Beng Eng Evelyn LIM6, Daphne LIM6, Reuben NG7, Siew Chin CHIA8 and James Alvin LOW1,2 Abstract 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 ena- bled 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 catego- rized. 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, profes- sional 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. Keywords: Empathy, Empathy development, Empathy assessment, Empathy definition, Medical education Introduction improves diagnostic accuracy, patient satisfaction and Mercer and Reynolds defined empathy in the medical compliance, and lowers psychological distress and medi- context as the understanding of patients’ emotions, con- cal complications [2–5]. Lack of empathy is correlated cerns and situations, communicating that understanding with physical, emotional, and work-related issues such as to the patient and acting on that understanding. Empathy depression, burnout, sleep disturbance, and poor concen- tration, all of which could negatively impact patient care. *Correspondence: [email protected] Despite extensive efforts to promote empathy through 1 Geriatric Education and Research Institute Ltd, Singapore, Singapore education, a decline in empathy has been observed Full list of author information is available at the end of the article © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. YU et al. BMC Medical Education (2022) 22:245 Page 2 of 13 among medical students, especially when they have the development of empathy in healthcare workers [7, spent more time interacting with patients [7–12]. This 8, 27–31]. Hence, the aim of this study is to qualitatively decline persists throughout residency and into their understand the underlying construct of empathy both as practice. Residents have been found to be less empathic a trait and state in healthcare professionals and students, and humanistic, and more cynical over time, while phy- and determine what are the factors that may influence sicians from different specialties are at risk of compas- the development of empathy in the heatlhcare context. sion fatigue [7, 12–14]. While a decline in empathy was commonly reported in American medical schools, recent Method studies observed conflicting empathy trends in medical Research design schools and empathy trends in other parts of the world The research design was informed by the constructivist were inconclusive [15, 16]. Consequently, this highlights approach to grounded theory [32, 33] in which the aim a need to understand how clinical empathy develops was for researchers and participants to co-construct the among healthcare students and professionals. theory on the development of empathy. A qualitative Nezlek et al believed that empathy should be con- approach was adopted for this study as it was considered sidered both as a trait (a personal disposition that deter- the most appropriate way to uncover and understand mines one’s ability to recognize, experience, and react to the meaning of empathy from the ‘emic’ perspective others’ emotions) and a state (the extent to which one (i.e. the contexts, lives and meanings of those involved). empathizes with others in a specific event at a specific This approach was also important considering that lit- time). The same view was shared by Hojat who con- tle is known about the theory of change whereby vari- sidered empathy as neither a highly stable trait nor an ous factors influence the development of empathy of easily fluctuating state, which was a result of a complex those experiencing empathy in the clinical setting. In interplay of factors such as evolution, genetic disposi- view of practical constraints faced by the study team, tions, individual development, education and personal approaches in grounded theory were adapted for the pur- experiences. Hence, targeting these factors is thought to pose of data collection and data analysis. Ethics approval enable modification and development of empathy. for this study was granted by the National Health Group Many factors can affect an individual’s empathy level, Domain Specific Review Board (DSRB), reference num- such as gender, personality, career choices, common ber 2018/00020. experience with patients, education background, and work environment. Females have been shown to have Data collection personality traits that lower stress levels [11, 19]. Medical Data was collected from care providers consisting of students who prefer specialties with a more human touch physicians, nurses, multidisciplinary teams, as well as [10, 11] have higher levels of empathy. Sharing common medical and nursing students. While grounded theory experiences with patients allowed healthcare profession- would employ theoretical sampling to focus on and sup- als to empathize more with patients. Medical edu- port a constant comparative analysis of data, this study cation which focused more on science than humanities, adapted the sampling approach whereby clinicians on and trainee distress are thought to lower empathy lev- the study team made a strategic a priori decision based els [7, 20–22]. Work experience and work environment on their expertise to sample from various groups who could either positively or negatively influence empathy would provide the most information-rich source of data. levels while stress and burnout have been shown to Healthcare professionals from various hospitals, medi- lower empathy levels [5, 24]. cal students from a medical school and nursing students Unfortunately, little is known about how these factors from a nursing school were invited via email to partici- influence empathy at the trait and state levels. In social pate in the study. Participants were informed of the study science, childhood experiences have been shown to have details and written informed consent was obtained. Data a long-lasting impact on individual trait empathy [5, 25]. was collected from 60 participants via 12 homogene- On the other hand, cognitive load impedes empathy ous focus group discussions (FGDs). Each FGD lasted experience and reduces empathic responses , which approximately two hours. All FGDs were conducted in is highly applicable to healthcare professionals as they English and hence translation was not required. The constantly face massive workloads and responsibilities, demographic information is presented in Table 1. thus affecting how they experience and exhibit empa- The FGDs were conducted in pairs by a female research thy. While empathy research in healthcare has focused officer (MK) with either a male medical doctor (LT), or mainly on the experience of healthcare students and male research fellow (CC) in rotation. All have practice research on empathy interventions has focused solely experience in qualitative research and interviewing. MK on the success of these interventions, few have evaluated and CC also had educational qualifications in psychology. YU et al. BMC Medical Education (2022) 22:245 Page 3 of 13 Table 1 Demographic information of participants Profile of Participants All Doctor Nurse Multidisciplinary Medical student Nursing student team Characteristics N = 60 N=5 N = 11 N=5 N = 21 N = 18 Sex Female 40 (66.7) 5 (100) 10 (90.9) 3 (60) 7 (33.3) 15 (83.3) Male 20 (33.3) - 1 (9.1) 2 (40) 14 (66.7) 3 (16.7) Race Chinese 39 (65) 4 (80) 5 (45.5) 4 (80) 18 (85.7) 8 (44.4) Malay 9 (15) - 1 (9.1) 1 (20) 1 (4.8) 6 (33.3) Indian 5 (8.3) - 1 (9.1) - 2 (9.5) 2 (11.1) Other 7 (11.7) 1 (20) 4 (36.4) - - 2 (11.1) Education Secondary 2 (3.3) - 1 (9.1) - - 1 (5.6) Post-secondary (non-tertiary) 32 (53.3) - 2 (18.2) - 19 (90.5) 11 (61.1) Polytechnic diploma 5 (8.3) - - - 2 (9.5) 3 (16.7) Bachelors 14 (23.3) 3 (60) 7 (63.6) 3 (60) - 1 (5.6) Masters 4 (6.7) 2 (40) - 2 (40) - - Professional Qualification 2 (3.3) - - - - 2 (11.1) Postgraduate Diploma Certificate 1 (1.7) - 1 (9.1) - - Age (years) M = 27.9 M = 32.6 M = 36 M = 33.4 M = 22.5 M = 26.4 SD = 8.9 SD = 3.9 SD = 13.3 SD = 7.9 SD = 0.7 SD = 7.4 Years of Practice M = 6.4 M = 12 M=9 SD = 5.8 SD = 13.8 SD = 8.8 Being a clinician, LT was able to reflexively use his knowl- What are your personal experiences of empathy in edge of clinical practice to facilitate discussions in the the care of patients? clinical context whereas MK and CC approached the What are some of the things doctors or nurses do interviews from an outsider “naïve” position, thereby when they show empathy? reducing the possibility of biasing the responses. For each Do you think empathy levels in someone can be FGD, one researcher would keep notes of the conversa- changed? Or is it inborn, meaning it cannot be tion to aid the interpretation of transcripts. Prior to the taught? start of the FGD, each participant was provided with an Some questions were focused on more, or were information sheet containing details about the study and included during subsequent interviews, as investi- the research team introduced their roles in the study. gators felt that they were important issues that had Only researchers were present at all data collection set- surfaced during earlier interviews. This required the tings except at the nursing school where the site inves- investigators to be sensitive and open to the views tigators (part of the study team) were present to provide being shared. Examples of such questions included: logistical support. These procedures in place adhered Limited time to see patients is a factor that can influ- to common best practices to ensure trustworthiness in ence empathy levels? What are your views on this? qualitative research. Participants had no contact Some people are able to maintain their level of empa- with the research team prior to study commencement. thy despite personal or work related problems. Why The initial guided questions were broad and developed do you think this is the case? based on existing literature on empathy. Stressors at work can impact empathy levels. What is These questions focused on beliefs, thoughts, emo- your view on this? tional feelings, behaviors and experiences and served as a guide to encourage participants to share their personal Negative case discussions were also encouraged as stories about their experiences of empathy especially in it allowed for emerging theories to be developed and the clinical context and emerging themes were explored modified while cases that did not fit led to generating. Examples of such questions included: of new knowledge. Examples of such discussions YU et al. BMC Medical Education (2022) 22:245 Page 4 of 13 included asking participants to discuss the negative con- high, medium, and low. High stability factors form the sequences of having no empathy and possible negative foundation of an individual’s trait empathy (e.g. child- effects that could result from having empathy. To ensure hood experience, parental values and religious values). that the groups sampled were adequate, the investigators Their impact on one’s empathy, for instance, how one reviewed their field notes and logic diagram following responses and reacts to others’ emotions, is long-lasting each FGD to aid the assessment of saturation. and less amenable to change. Low stability factors are those that are highly situation specific (e.g. unexpected Data analysis stressors faced at work) whereby the impact is to cause Investigators met after each FGD to compare their momentary fluctuations in empathy levels. Medium memos, identify key themes generated by participants, stability factors are those that tend to be persistent and compare findings with previous FGDs, and revise ques- enduring in one’s environment (e.g. one’s job scope) and tions based on new themes that emerged. Upon com- arguably have the potential to influence empathy lev- pletion of every two FGDs, the audio recordings were els over the long run. These factors often represent the transcribed ad verbatim by one of two investigators and environmental and personal constraints that exist for an counterchecked against the recordings by LT. The inves- extended period of time, and can influence one’s ability tigators subsequently met regularly over a period of to empathize over the long run. The interaction between 12 months to compare codes and to form themes. Dif- these factors and how they define empathy are presented ferences in opinion were mediated till a consensus was in Fig. 1. All factors which influenced empathy, along reached. This “immediate analysis” approach is an impor- with their representative quotes are listed in Table 2. tant part inspired by grounded theory as it allowed the investigators to identify similarities and differences 1. High stability factors moulds trait empathy in the data. Additionally, it also informs the manner through which questions were developed and raised in High stability factors were often the first thoughts each subsequent round of data collection. that came to the participants’ mind when asked where Coding occurred in three stages. First, open cod- they derived their sense of empathy from. Participants ing was conducted from the onset to generate as many believed that individual baseline empathy determined ideas as possible regarding how empathy was described their tendency to empathize with others and was shaped by participants, and whether the components of empathy by inborn characteristics and early life experiences. The could be categorized into the four domains postulated influence of high stability factors on empathy was persis- by the investigators. Axial coding then determined how tent and fairly stable. Some participants felt that factors the various codes related to each other throughout the which occurred at the later stages of life, such as empa- dataset (e.g. factors related to childhood, environment, thy training in schools, may not be able to fundamentally workplace, stress affecting empathy). Finally, selective change an individual’s trait empathy level and response: coding involved the investigators selecting central core “[…] everybody is born with a certain personality categories of ‘between and within person changes’ and type. And whatever nurture you get beyond that ‘development over time’ and relating the codes to these is still working on the baseline that you’re already categories. To support this whole process, diagrams of inborn [born] with, and nurture might not be able how the factors influenced participants’ empathy were to overcome what nature has already given you”. constructed to identify the relationship between fac- 20-FGD4. tors and categories after each FGD. A coherent theory of ‘empathy development’ was drafted by the ­6th FGD. This As different individuals have different upbringing and theory was further refined throughout the study until early life experiences, high stability factors also seemed ­ 2th FGD. data saturation and this was achieved by the 1 to explain the differences in empathy levels among individuals. Results “I think it depends on the person’s upbringing and Participants on the whole considered empathy as both a the environment they grew up in ‘cause [because] trait and state. Although there were innate qualities that throughout my life I’ve seen a lot of people who are determined empathic tendencies and responses, these able to put themselves in other people’s shoes and could also be learned and developed over time. Envi- some who just aren’t.” 59-FGD12. ronmental and personal factors later in life are impor- tant determinants and these factors can be categorized according to difference in resistance to change which we 2. Medium stability factors can have enduring effects termed ‘stability factors’ of which there are three levels: empathy levels YU et al. BMC Medical Education (2022) 22:245 Page 5 of 13 Fig. 1 Empathy development model in healthcare setting Medium stability factors can have an important influ- experiences you’ve been through which allows you ence on empathy levels, despite less permanent impact to put yourself in the shoes of these patients which than that of high stability factors. These include current you’ll be seeing, and also having that experience belief and value systems, education and training, group of [for example] like say breaking bad news to this influences, work experiences and culture, supervisory patient multiple times, I would learn how to do it influences, and the professional identity that one adopts. better, and improve myself like maybe the fifth [time] In the clinical context, values in medical practice guides and by- compared to the like one hundredth time how one understands or appreciates another person’s I’ve done it, so I think if I had to choose one I think behavior and situation, which in turn influences their empathy is something that yes, as- there’s a basal empathy level and response. Additionally, factors such as level of like inborn like empathy, but it can definitely emotion regulation, coping capabilities, perspective-tak- be developed and honed, so that you are able to like ing, self-reflective ability, as well as verbal and non-verbal connect with your patients better.” 25-FGD5. communication skills, allowed healthcare professionals Most participants felt that it was easier to empathize to feel, understand, and communicate better in response with patients when they had more experience. Partici- to patients’ emotions and reactions. pants also shared various examples of how work respon- Participants also shared that religious teachings or sibilities, standards and guidelines, culture, supervisors, other forms of educational training could benefit in help- surveillance, and reward structure affected empathy ing one empathize with others. Tools and frameworks levels, as shown in Table 2. Despite the stress and vari- from educational training helped in relating and com- ous challenges that came with the role of providing care, municating affectively, for instance, what to say and do in participants highlighted that their professional identi- certain scenarios faced by the patients. Interestingly, with ties spurred them to maintain empathy even in difficult more life experiences, healthcare professionals found it times, and they did this by contemplating what it meant easier to relate to the lived experiences of patients. Work to be a healthcare professional as well as prioritizing experiences could also improve emotional maturity, work and responsibilities of patient care. knowledge acquisition, coping strategies and communi- Although participants felt that the impact of high cation skills: stability factors was harder to alter, empathy levels “… empathy also comes from your experience, as could still change over time through interactions with all of them have mentioned earlier, like the kind of medium stability factors. In some situations, they could YU et al. BMC Medical Education (2022) 22:245 Page 6 of 13 Table 2 Factors influencing empathy in healthcare settings Impact level Factors Components Quotes High stability Born characteristics Personalities “[…] everybody is born with a certain personality type. And whatever nurture you get beyond that is still working on the baseline that you’re already inborn with, and nurture might not be able to overcome what nature has already given you”. 20-FGD4 Early life experience Childhood experience “I have a cousin who’s… he’s a child but he’s like quite- quite sick, always in and out of hospital, and he has a lot of medical problems, so I’ve seen how it affects like their family and then I always hear how like his mum, who’s my aunt, talk about a lot of things, you know, a lot of things they’re worried about, and things like that. So I guess sometimes when I speak to patients then I will be reminded of how sometimes all they want is to be reassured, or to know some things they’re really just worried about and they don’t know”. 22-FGD4 Parental guidance “So, little things, little experiences I still can remember, like people on the street asking for money and my mum will just put some in, and she said things like, ‘although this might not be much for us but to them it’s still a lot of money,’ and yeah just helping those in need, just doing little things through little experiences.” 16-FGD3 Medium stability Non-work-related life experience “I think actually another point really broadened my perspective was actually when we went for National Service. I think it really gave me a great deal of people from really diverse backgrounds that because previously the 12 formal years of education, it’s quite a small bubble, because we always hang around with people from very, very similar backgrounds. […] It helps you understand more like where people are coming from, or why people will approach certain problems in certain ways.” 12-FGD2 Personal value and belief system Sense of right and wrong “I have certain personal biasness towards certain group of people. I know that’s my inherent bias- ness and it’s and professionally I shouldn’t have that kind of biasness, but I know I do. So these are the ones that I try a lot harder to work with. So one specific example is those with eating disorders, those anorexic. So to me, they do have an underlining issue. It may be psychiatric, it could be whatever. But it’s very difficult for me to empathize with them. Like, what makes you starve yourself?” 53-FGD11 Professional identities “If your top priority as a nurse, if let’s say, your own principle, your value as a nurse is number one to care for the patient, I think it will always be at the back of your mind. Even though you’re busy, you just find like ten seconds to just pop your head and tell the patient ‘are you okay, do you need my help?’ ‘No’ that’s all. Just merely ten seconds will do.” 48-FGD10 Religion “I mean some religions they teach about showing love and showing kindness to the people you meet, so definitely for some their religion would also teach them these values which would help them develop empathy.” 09-FGD2 YU et al. BMC Medical Education (2022) 22:245 Page 7 of 13 Table 2 (continued) Impact level Factors Components Quotes Culture & social norms “Sometimes because of the culture that which you are from, maybe you’re not aware that some of your behaviour hurt others. But- you don’t have that, how to say, that- didn’t (wasn’t) aware that some of your behaviour hurt others. But if someone tell you that your behaviour is not properly (proper) that’s why (you) will hurt others, you better behaviour in the other way, if someone alert you, then you just realise then you will consciously (try) to change your behaviour.” 01-FGD1 Personal skills Communication skills “[…] even though you get the translator, some- times it might not be words to words translating you see, so you couldn’t really get the meaning out of it, then you just guess a bit and all that.” 29-FGD6 Emotion regulation & coping abilities “Some people, like what I used to be along in my career, when it got too painful, I avoided. That was my strategy to deal with the feelings related to empathy that I couldn’t handle, at the earlier point of my life as a social worker.” 54-FGD11 Work related experience Work culture “I think if you create an empathetic environ- ment, I think generally anyone who works in that environment can actually pick up on it and they themselves be able to develop that soft skill as well, I feel, in a way. If your colleagues or people you’re working with do not display such attitude, then even if you yourself display such attitude, it may last you for a while. But perhaps after a long time, that might just die off as well.” 37-FGD7 Work experience “[…] after serving people through my career and things like that, the empathy kind of evolved into walking with you but not carrying you while I walk with you. The boundary making is a part of the thing now, I realized. Last time it used to be ‘woah I’m totally one with you’, like watching Korean drama, cry my eyes out and things like that. But now there’s a little bit of boundary, I know that I’m a watcher of the whole situation, I’m not in it and losing myself.” 54-FGD11 Work guidelines & standard “I would think also because structurally we have a lot of paper works that are legal documents. So we are very on task to fill up the documents more than talking to patient. Which is what happens the moment you graduate. Which is why staff who work long enough start to just become task oriented.” 60-FGD12 Work set up “[…] or even in terms of like the layout of the clinic room, for example, if like the doctor’s computer is facing the wall then end up like sometimes they may not even look at the patient, which makes the patient feel very neglected or like the doctor doesn’t care…” 13-FGD3 YU et al. BMC Medical Education (2022) 22:245 Page 8 of 13 Table 2 (continued) Impact level Factors Components Quotes Monitoring & reward system “The kind of recognition that people get, I think, it’s very easy for organizations to recognize peo- ple who are very successful in terms of academic, very objective markers of success like academic or how many research papers you produce, how many patients you treat, what medal you won, but we don’t very often, we are doing it more now, but we don’t very often reward people for empathy obviously because it’s harder to see someone displaying empathy, because it’s a very one-to-one thing but I think recognizing it also tilts the focus towards that and makes people realize that it’s actually a more important aspect of the care that you give.” 17-FGD3 Supervisor influence “[…] different senior doctors have different preferences when it comes to presentations, so, in the same way, if they don’t consider showing empathy a very important…, or they think it’s just a waste of time, then definitely juniors who are still learning how to become doctors, they would adjust and they would learn accordingly.” 21-FGD4 Role model “[…] it’s also perhaps significant people along the way that affects us, that bolds us, that changes our way of thinking, our reaction or coach or mental guide. So I think that is also significant in shaping me as a healthcare professional.” 53-FGD11 Training & education “What’s being taught nowadays in school is not so much how to care, but how to show- or how to pretend that you’re caring. At the start you know we’re just pretending, you know, but after going through our clinical years you sort of understand what it means to care and how- what kind of impact it can have and I think that in itself is sort of teaching you like empathy in a sense that why you need to care. And the how to show you’re caring, it sort of makes sense once you see why you need to care.” 07-FGD2 YU et al. BMC Medical Education (2022) 22:245 Page 9 of 13 Table 2 (continued) Impact level Factors Components Quotes Low stability factors Physiological states “[…] sometimes really you just didn’t have enough sleep, you didn’t each much, you just get really tired, you just don’t want to care.” 60-FGD12 Mental states Mood “If I’m actually in a terrible mood in the morning and usually the first patient of the day usually gets it. (Laughter) I mean we’ll try not to, cause we remind ourselves ‘you shouldn’t vent’, but sometimes I mean you’re all human right.” 31-FGD6 Burnout “Anyone who’s worn out definitely will try to pro- tect themselves more. Like look at survival situa- tions. Nobody’s going to care about other people, they only care about themselves.” 59-FGD12 Situational stressors & priorities “Usually in the most emergency situations also, empathy takes the backseat. I would say that the priority is to stabilise the patient. But of course at the same time you try to maintain dignity and all, you try to not let patient suffer”. 33-FGD6 Interpersonal interactions Patient-healthcare professional relationship “I mean some of the family members are just rude and harsh and they expect us in a way like robots, emotionless. So it’s like whatever they can do, like they are hurt by the doctors diagnosis, results, wrong results, like results everything, so they will push the blame on the nurse. And, it kind of triggered us to the point where we will suddenly just burst and treat harshly to the patient, to the family members. And that will effect over (affect) empathy.” 47-FGD9 override the influence of high stability factors, as men- 3. State empathy fluctuates due to low stability fac- tioned by one participant: tors “Parents teach us [to] always be nice to people, do While trait empathy is relatively stable, one could still things nicely. But when we step out to the world, experience transient fluctuations in the experience and we see like the world is not actually friendly. We expression of empathy due to the presence of low sta- try to be nice to people but they just shut us out. bility factors. These factors often acted as short-term So it’s a different kind of empathy, and what trig- barriers or facilitators that determined how health- gers this empathy in us is experiences. How we see care professionals felt or expressed empathy in a given things, how we mature ourselves and for example situation: if we have a situation at hand, how we handle it, how we show our feelings, is different from what “… how much innate empathy you have and then our parents would teach us. And depends, either your experiences, and then how that leads to how we ourselves would want to follow what our par- much empathy you feel, but how much you express ents have taught, or we want to change and adapt depends also a lot on the circumstances of the prac- to it.” 47-FGD9. tice, and how much time you have.” 28-FGD5. Similar to high stability factors, there are inter-individ- Low stability factors in individuals ranged from physio- ual differences in medium stability factors. At the same logical states, such as being tired or hungry, to psycholog- time, these factors of influence do change over time (e.g. ical conditions, such as stress and anxiety. Occasionally, transitioning from medical school to the clinical setting situational imperatives and demands such as in the case resulted in changes in work responsibilities and expecta- of a medical emergency, made it challenging to feel or tions). Hence, medium stability factors could account for express empathy. Negative interactions and poor rapport both interpersonal (between individuals) and intraper- between healthcare professionals and patients or fam- sonal (within an individual at different time points) dif- ily members (e.g. rude demands from family members) ferences in empathy level. that affected mood could also hamper empathic response YU et al. BMC Medical Education (2022) 22:245 Page 10 of 13 whereas positive interactions have been reported to have have an influence on empathy. As culture often dic- the opposite effect. tates communication norms, this determines the ability With prolonged negative interactions, participants to build trust between patients and healthcare profes- shared that healthcare professionals in certain conditions sionals as well as the perception of empathy in healthcare might become ‘desensitized’ or even experience burn- settings. out, leading to avoidance behavior as a coping strategy, Factors attributable to the erosion or development with negative consequences on empathy levels. However, of empathy during medical school training and clinical high and medium stability factor can have protective practice which were reported in previous studies were effects and buffer against some of the negative interac- also found in our study. The inability to relate to patients tions. As one participant shared in response to negative due to lack of life experience or contact with patients, experiences faced by healthcare professionals, possess- negative encounters with patients, heavy workload, ing strong trait empathy and a supportive work environ- desensitization, burnout, stress, hostile work environ- ment might protect individuals from the effects of stress ment, training, and work culture could lower empathy or burnout, and help individuals maintain their empathy level. On the other hand, emphasizing the value of empa- level: thy during training or in the work culture, interactions with a role model and supervisor, and conducting com- “It’s tough. I mean if you got it you got it. May munication training could improve empathy [46–57]. [Maybe] you got a very strong empathy, I think you Our findings on the effects of low stability factors gen- can keep that. […] Maybe situation supports them; erally mirrored previous studies where mental state, situ- maybe the environment supports them to be there.” ational stressors, and interpersonal interactions were 38-FGD7. found to influence empathy [7, 24, 48, 49]. Similar to an exploratory study by Pohontsch et al. , we found that Discussion negative mood, work stress, lack of time, and negative Understanding empathy in the clinical setting allows interactions with patients, inhibited empathy although trainers and mentors to focus on factors which will posi- our study included not only students but also healthcare tively influence empathy development in clinicians. Our professionals. Other than one study in the healthcare study showed concurring opinions among students and setting that the authors are aware of, extant evidence is healthcare professionals with regard to empathy devel- limited regarding the effects of physiological state (e.g. opment in clinicians. The key findings suggest that the mood, hunger, fatigue) on empathy and findings from factors affecting empathy development can be catego- this study add to the literature by suggesting they can rized into high, medium, and low stability factors, which have detrimental effects. Thomas et al. showed that explains the inter-individual and intra-individual varia- well-being correlated positively with empathy whilst tions in the experiences and expressions of empathy. poor sleep impacted the capacity of mental health nurses In line with past research, high stability factors such as to provide empathic and compassionate care. Such inborn personal characteristics have been shown to influ- effects on empathy were also reported in our sample. ence empathy [11, 37, 38]. This is also the case for other Supporting the well-being of trainees and clinicians, factors identified such as childhood influence from fam- as well as investing in a healthy work-place culture that ily members and parenting style [39, 40]. As highlighted includes measures to protect healthcare professionals by the participants, social interactions during childhood from verbal abuse, could therefore be important. including school experiences could also determine an Overall, findings from this sample suggest that empa- individual’s emotional and prosocial tendency develop- thy tended to be more trait-like and stable in nature but is ment [5, 25]. also susceptible to regular fluctuation depending on the Medium stability factors were also found to be impor- circumstances healthcare professionals find themselves tant in the development of empathy. As with prior in. The stability of their effect has been studied mostly research, the findings suggest that empathy development in the field of social and developmental psychology. The could be influenced by whether one’s values prioritizes work of Knafo and colleagues demonstrated the the welfare of others. The relationship between reli- influence of genetic and environmental factors on empa- gion and empathy was another area of interest among thy development at an early age. Empathy was found to researchers. In line with what other studies have found, be a stable disposition determined by genetics but could while religion seemed to have an influence on prosocial change due to both genetic and environmental factors. behaviors, the relationship between religion and empa- The environmental variables shared by children could thy was affected by how individuals interpreted religious explain empathy stability while non-shared environmen- teachings [42, 43]. Similarly, culture was also found to tal variables determined the change in empathy. Taylor YU et al. BMC Medical Education (2022) 22:245 Page 11 of 13 et al. showed that the long-lasting impact of person- addition, this study was conducted in a multi-cultural alities, parental guidance, and experiences on empathy at setting with participants from different ethnic groups, an early age were able to predict future prosocial behav- religious beliefs and work setting (acute hospital, com- iors. In addition, Greenberg et al. showed that people munity hospital, home care and schools). With findings who experienced traumatic events when they were young echoing those found by scholars in the field of empathy, tended to have higher levels of empathy at adulthood. this suggests that the theory of empathy development is applicable in the international community as it provides Implications for practice a framework to understand potential targets for empathy Our tentative theory of empathy development provides a interventions. framework to understand potential targets for empathy One limitation was that as mentioned in the method interventions. While targeting high stability factors may section, theoretical sampling was not used. This would be not be possible in an attempt to change trait empathy, expected for any study that adhered strictly to grounded developing the manner healthcare professionals/students theory. The sampling procedure therefore was guided by understand, relate and respond emphatically to patients strategic a priori decision based on the expertise of the in medical or nursing schools as well as other clinical set- clinicians in the study teams that was in part guided by tings can be achieved and sustained by targeting both situational constraints and access especially with regards medium and low stability factors. Attempts to improve to the doctors and nurses. As there were more partici- empathy in medical schools, nursing schools, and clini- pants coming from ‘high-touch’ clinical setting such as cal practice over the years have largely been focused on palliative care and geriatrics, future studies may need to social skills and perspective-taking [30, 31, 62, 63]. A consider whether views about empathy from other set- recent longitudinal study of Japanese medical students tings such as the emergency department may differ. As showed that communication skills education could identified in this study, participants felt that empathy improve empathy, but the effect was short-lived. The levels may be affected in highly demanding clinical situa- challenge with focusing on social skills alone was that it tions such as an emergency. often felt forced into a teaching curriculum as individuals Another limitation of this study is that the use of FGDs were not always able to feel authentic empathy in simu- may have induced socially desirable responses from par- lated settings. Shapiro et al. was more success- ticipants. For the healthcare professionals, there is a pos- ful in creating a sustainable positive effect by targeting sibility that what was shared may not be truly reflective different factors such as communication skills, coping of their personal views since the sessions were conducted techniques, well-being enhancing strategies, and expo- in the presence of fellow colleagues from the same insti- sure to patients; these are some of the factors outlined in tution. Likewise, the study team also felt that the role our proposed model which adopted a more experiential of religion was not fully explored in the FGDs as there approach in a real-life setting. were instances participants did not feel comfortable or Our theory of empathy development is holistic and appropriate sharing their personal views on religion in highlights that healthcare professionals should be the presence of other fellow medical professionals and equipped with the necessary skills, experience, and guid- associates. ance to react empathically in the clinical setting, and that their work environment has to be conducive to minimize the effect of low stability factors. For example, forming Conclusion healthcare students’ and professionals’ professional iden- To a large extent, empathy is an inborn trait and funda- tity at an early stage and regularly reinforcing the identity, mental to being human. However, it is dynamic, con- creating a supportive work culture, training and educa- stantly evolving, and develops under the influence of tion, supervisory guidance and peer influence, and even various personal and situational factors. Our proposed developing a monitoring system that rewards empathic theory of empathy development consolidates the factors behaviors could help eliminate the effect of low stability influencing empathy and describes their involvement in factors on empathy. influencing empathy over time both intra-personally and inter-personally. With a clearer understanding of how Strengths and limitations empathy develops in the healthcare setting, quality of The strength of this study involves understanding views clinical care in the future may be improved as healthcare from a sample of doctors, nurses, multidisciplinary team providers could implement measures during training or members, medical students and nursing students and at the workplace, to encourage empathy and compassion findings is therefore not narrowly confined to only one in healthcare. group, which is quite typical for qualitative research. In YU et al. BMC Medical Education (2022) 22:245 Page 12 of 13 Abbreviation 4. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-phy- FGD: Focus group discussion. sician relationship. JAMA. 2005;293(9):1100–6. https://​doi.​org/​10.​1001/​ jama.​293.9.​1100. Acknowledgements 5. Neumann M, Bensing J, Mercer S, Ernstmann N, Ommen O, Pfaff H. The authors would like to thank Khoo Teck Puat Hospital, Tan Tock Seng Hos- Analyzing the “nature” and “specific effectiveness” of clinical empathy: a pital, Yong Loo Lin School of Medicine (National University of Singapore), Lee theoretical overview and contribution towards a theory-based research Kong Chian School of Medicine (Nanyang Technological University), and Nan- agenda. Patient Educ Couns. 2009;74(3):339–46. https://​doi.​org/​10.​1016/j.​ yang Polytechnic for their assistance in recruitment. Additionally, the authors pec.​2008.​11.​013. wish to thank Ms. Isabelle Lim, Geriatric Education and Research Institute, for 6. Sorenson C, Bolick B, Wright K, Hamilton R. Understanding compassion contributions to research administration support. fatigue in healthcare providers: a review of current literature. J Nurs Scholarsh. 2016;48(5):456–65. https://​doi.​org/​10.​1111/​jnu.​12229. Authors’ contributions 7. Neumann M, Edelhäuser F, Tauschel D, et al. 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Naturally occurring variability in 2 Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singa- state empathy. Empathy in Mental Illness. 2007;187–200. https://​doi.​org/​ pore. 3 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, 10.​1017/​cbo97​80511​543753.​012 National University of Singapore, Singapore, Singapore. 4 Lee Kong Chian 18. Hojat M. Empathy in Patient Care: Antecedents, Development, Measure- School of Medicine, Nanyang Technological University, Singapore, Singapore. ment, and Outcomes. New York, NY: Springer; 2007. 5 Ministry of Health Holdings, Singapore, Singapore. 6 School of Health & Social 19. McManus IC, Keeling A, Paice E. 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