Empathy levels among Canadian paramedic students: a cross sectional survey.

Empathy levels among Canadian paramedic students: a cross sectional survey. Authors Lucy Kus BSc(Hons.)1,2, Cassidy Gosling BSc(Hons.)1, Taylor Wilson1,3, Alan M. Batt MSc PhD(c)1,4,5 1. Fanshawe College, London, Ontario, Canada. 2. Huron County EMS, Ontario, Canada. 3. Middlesex-London EMS, Ontario, Canada. 4. Paramedic Science Discipline, CQUniversity, Queensland, Australia 5. Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia. Author for correspondence: Alan M. Batt, Paramedic Programs, Fanshawe College, 1001 Fanshawe College Blvd, London, ON N5Y5R6, Canada. Email: [email protected] Competing Interests None declared. This work was not supported or funded by any drug company. Each author of this paper has completed the ICMJE conflict of interest statement. Author Declarations The authors declare that this work has not been published elsewhere. Data from this study were presented at the Fanshawe College Paramedic Programs Research Day, Ontario, Canada, April 8th 2017. The authors declare that they are responsible and accountable for the accuracy and integrity of all aspects of this work. Funding & Support No funding or support has been received for this manuscript or study from any manufacturer, pharmaceutical company, grant-awarding or commercial body. Acknowledgments The authors would like to thank Ms. Chelsea Gould for her contributions to the conduct of the study, and all paramedic students who participated in the study. Author Contributions LK, CG and TW conducted the literature review, designed and conducted the study, performed data analysis, and authored the manuscript. AB aided with data analysis, literature review, and study design. All authors contributed to the final writing and editing of the manuscript. All authors have approved the final version for publication. Empathy levels among Canadian paramedic students: a cross sectional survey. Abstract Background Empathy is an important factor in communication between healthcare provider and patient. Previous studies have shown that empathy benefits patient care in multiple ways. Empathy allows a space of decreased vulnerability and as a result, builds trust in healthcare relationships, fosters open communication that leads to improved patient care, improves patient satisfaction and buffers healthcare provider burnout. This study aimed to determine the empathy levels demonstrated by paramedic students to patients with various medical conditions, and to compare these findings to previous studies. Methods This study employed a cross sectional design of a convenience sample of first and second year paramedic students in a community college program in Ontario, Canada. The Medical Condition Regard Scale (MCRS) was used to measure empathy levels in these students across five medical conditions: physical disability, intellectual disability, suicide attempt, mental health emergency, and substance abuse. Results A total of 43 students participated in the study; 27 males and 15 females (1 unknown). Males demonstrated a mean empathy score of 232.44 while females demonstrated a mean of 266.4. Across the five medical conditions, substance abuse had the lowest mean empathy score (42.88), followed by mental health emergency (49.58), suicide attempt (49.47), intellectual disability (50.42) and physical disability (53.0). Conclusion Results from this study suggest that paramedic students demonstrated the lowest levels of empathy towards patients suffering from substance abuse issues, and the highest levels of empathy towards patients with a physical disability. Male paramedic students are less empathetic than their female peers, and second year paramedic students are less empathetic than their first year counterparts. These results provide an insight into paramedic student attitudes in Canada, and provide a foundation for further studies. Introduction Empathy helps healthcare providers to create a positive interpersonal relationship that creates a non-defensive environment, and allows the patient to be more forthcoming (Mercer and Reynold., 2002; Neumann et al., 2009; Petrucci et al., 2016; Hemmerdinger et al., 2007). Empathy is an important characteristic in the relationship between a healthcare practitioner and his or her patients. When empathy is present, it can enhance both the patient and the provider's overall experience. There are different understandings of the word empathy and what being empathic is; the general consensus of the definition state that empathy is the understanding of another person’s reactions, thoughts, feelings and problems (Myers, 2000; Eisenberg, 2000; Burks & Kobus., 2012, Petrucci et al., 2016). Empathy involves not only understanding another person, but demonstrating that understanding back to the patient while maintaining emotional detachment (Burks & Kobus., 2012). The ability to communicate this understanding and a paramedic’s intention to help is important to create an empathetic and open environment (Petrucci et al., 2016). There is an important need to differentiate empathy from sympathy in the healthcare field, as failing to do so could lead to misdirection in patient support. Sympathy is an expression of concern or sorrow about stressful events in a person’s life; this expression usually comes from judgement and may not be in the interest of the patient (Meier & Davis., 2008; Clark, 2010). Sympathy may also prove ineffective when a paramedic assumes that his or her own experience matches or equates to that of the patient (Egan, 2010). Not only is expressing sympathy a disadvantage to the patient and their care, it is also a disadvantage to the paramedic. If healthcare providers assume the emotional burden of every patient they encounter, it may not take long before they begin to suffer compassion fatigue, and burnout (Hamilton et al., 2016; Williams et al., 2017). Therefore, it is imperative to know the difference between empathy and sympathy, and how to demonstrate the appropriate trait during patient interactions. Clinical outcomes have been shown to improve when patients perceive their health provider to be empathetic (Burks & Kobus, 2012). This open climate encourages patients to be more vocal about their symptoms and problems, which allows health providers to obtain more accurate information, and facilitates better overall clinical care (Burks & Kobus., 2012). There are many favourable outcomes for patients when empathy is displayed such as reduced psychological stress, improved self-concept, reduced rates of anxiety and depression and lower complication rates (Del Canale et al., 2012; Hojat et al., 2011; Reynolds, 2000). The ability to set one’s emotions aside when practising empathy can be particularly beneficial to the provider by preserving professional well-being and positively influencing clinical encounters (Burks & Kobus., 2012). Previous studies in healthcare students in Australia (Williams et al. 2012; McKenna et al., 2012; Williams et al., 2014; Williams et al., 2016) have demonstrated that empathy scores are low among paramedic students, scores decrease as one progresses through paramedic education, and empathy scores vary significantly for certain medical conditions. The aim of this study was to assess empathy scores of first and second year paramedic students at Fanshawe College in Ontario, Canada. The authors hypothesized that in concordance with existing evidence, empathy scores would vary across medical conditions, and that certain medical conditions would elicit relatively low empathy scores. Methods and materials This study was a cross-sectional study using a web-based questionnaire and convenience sampling of first and second year paramedic students at Fanshawe College in Ontario, Canada. Ethics approval was granted by the Research Ethics Board at Fanshawe College (approval S1600-1). The MCRS and demographic questions were input into Google Forms, and a link to anonymously complete the form was provided to participants. An invitation to participate was distributed via a closed social media group consisting only of paramedic students. Participants were provided with an explanatory statement and informed that participation was voluntary and anonymous. This study utilised the Medical Condition Regard Scale (MCRS), a 6-point Likert scale consisting of eleven statements for each medical condition. The MCRS is a validated tool used to measure empathy, regard, and bias for a number of medical conditions (Christison et al., 2002). The MCRS has a Cronbach-α co-efficient of 0.87 when assessed for internal consistency and a test-retest reliability co-efficient of 0.84 (Christison et al., 2002). The statements in the MCRS investigate common stigmas, likes, dislikes, and the desire to treat patients with certain medical conditions. This scale has previously been used to measure empathy levels in medical and nursing students, and in paramedic students (Williams et al., 2012; McKenna et al., 2012; Williams et al., 2016). Other scales exist to measure empathy, such as the Jefferson Scale of Empathy; we elected to utilise the MCRS due to its simplicity and ease of use, proven validity and consistency, and to allow for comparisons to previous studies in other healthcare professions students that utilised the MCRS. The MCRS requires respondents to rate their agreement to each statement from 1 (strongly disagree) to a 6 (strongly agree). Five questions are phrased negatively and thus the scores for these questions are reversed for analysis (strong agreement with these questions would indicate lower empathy). Overall empathy scores can vary from the lowest score (55) to the highest score (330). For each individual medical condition, scores can vary from the lowest score (11) to the highest score (66). Higher scores indicate a higher regard of empathy for the medical condition in question. This study utilised the MCRS to assess empathy levels for five medical conditions: physical disability, intellectual disability, suicide attempt, mental health and substance abuse. These medical conditions were selected based on previous studies of empathy levels in healthcare professions. In addition to the MCRS, brief demographic questions were posed regarding age, gender, year of study in the paramedic program, and open-ended questions investigating students’ perceptions on empathy education in the program. The Statistical Package for Social Sciences (SPSS; Version 20.0, New York, USA) was used for data storage, tabulation and the generation of descriptive statistics. Means, t-tests and oneway analysis of variance tests were used to assess differences between age groups, gender, and year of study. Results were considered statistically significant if the p-value was less than 0.05. Results A total of 43 paramedic students participated out of a possible 90 (47.8% response rate). Respondents comprised 18 (38.3%) first year students, and 25 (61.7%) second year students, with 15 females (35.7%) and 27 males (64.3%) respectively. One respondent did not respond to the gender question. Male paramedic students displayed a mean empathy score of 232.44 (standard deviation (SD) ±29.17), while their female counterparts had a statistically significant higher mean score of 266.4 (SD±29.99) (p=0.001) There was notable variance between respondents’ attitudes towards patients with the five different medical conditions as measured by the MCRS. Physical disability and intellectual disability were held in similar regard according to the MCRS. Suicide attempt and mental health emergencies were held in lower regard, with substance abuse held in significantly lower regard by respondents. Means for each medical condition are presented in Table 1. Table 1. Mean Medical Condition Regard Scale scores for each medical condition Medical condition Mean SD Intellectual Disability 50.42 8.73 Physical Disability 53.00 7.22 Suicide Attempt 49.47 7.75 Substance Abuse 42.88 10.62 Mental Health Emergency 49.58 10.02 The respondents were divided into four age groups for analysis. The mean empathy scores between age groups were not statistically significant [F(3, 38) = 2.329, p=0.09], suggesting that age does not play a significant role in influencing empathy scores in this population. One respondent did not respond to the age question. There were several statistically significant differences for year of study and gender for mean scores across the five medical conditions. First year paramedic students had a mean empathy score of 257.11 (SD±32.46), while second year students had a mean score of 236.88 (SD±32.10) (p=0.049). First year paramedic students also demonstrated a higher mean empathy score towards mental health emergencies (mean 53.72 v 46.6; p=0.02). Female paramedic students displayed higher mean empathy scores than their male counterparts for all conditions: intellectual disability (mean 55.0 v 47.66; p=0.008), physical disability (56.66 v 50.81; p=0.011), substance abuse (44.93 v 41.22; p=0.278), suicide attempt (54.53 v 46.44; p=0.001), and mental health emergencies (55.26 v 46.29; p=0.005). (Figure 1). A total of 37 respondents (86%) indicated that more empathy training was required in the program. Suggestions to improve empathy training included increasing high-fidelity simulation, inviting guest speakers, and undertaking more mental health service placements. A selection of quotes from respondents, of interest to the research question, were selected, and are outlined in Text-box 1. “…include holistic/biopsychosocial views of health…” “…LTC [long-term care] placements only made people feel less empathy for the elderly patients…” “…you can't teach empathy…” Text-box 1. Selected free-texts responses from respondents Discussion Our study demonstrated that empathy scores vary across medical conditions, and are significantly lower when dealing with substance abuse presentations. The results of our study also demonstrate that females display higher empathy scores than their male counterparts and this is consistent with previous literature (Williams et al., 2012; Hojat et al., 2004; Williams et al., 2015). Our results did not demonstrate any significant differences in empathy scores among age groups, although this is likely attributable to our small sample size. The low levels of empathy demonstrated for substance abuse could be attributed to the view that substance abuse is a disorder that the patient is responsible for. The stigma around substance abuse creates a belief that the user has the ability to stop using drugs or alcohol whenever they choose to do so. There is a need for further exploration and explanation as to why this disorder is treated with less empathy. Looi (2008) attributes the differences in male and female empathy scores to differences in brain architecture and neural circuitry. Looi suggests that men are predisposed to being unemotional in order to facilitate more rational decision making. Regarding differences in empathy with age, Beadle et al. (2013) posits that older adults portray more motivation to help others than younger people, and this marked difference was seen at the age of 24. While our study demonstrated no differences among age groups, previous studies have demonstrated differences, with higher empathy scores demonstrated by middle aged participants (Williams et al., 2012; Williams et al., 2014)