LEARNING OUTCOMES
After completing this module the paramedic will be able to:
Though there is no single agreed upon definition of empathy, a general consensus exists that it is an understanding of another person's reactions, thoughts, feelings and problems (Eisenberg, 2000; Myers, 2000; Burks and Kobus, 2012). Empathy involves not only understanding another person but also demonstrating that understanding to them while maintaining some level of emotional detachment (Burks and Kobus, 2012). Morse's components of empathy (Table 1) displays empathy as a multidimensional characteristic, encompassing all aspects of the human psyche (Morse et al, 1992). Empathy is not driven entirely by emotions as most would presume, which is what primarily differentiates empathy and sympathy. Empathy encompasses four components that lead to a successful human interaction.
| Component | Definition |
|---|---|
| Emotive | The ability to subjectively experience and share in another's psychological state or intrinsic feelings |
| Moral | An internal altruistic force that motivates the practice of empathy |
| Cognitive | The helper's intellectual ability to identify and understand another person's feelings and perspective from an objective stance |
| Behavioural | Communicative response to convey understanding of another's perspective |
Empathy between health professionals and patients helps to create and open an empathetic environment (Petrucci et al, 2016), which in turn facilitates honest, open communication, reduced stress, and lower complication rates (Reynolds et al, 2000; Hojat et al, 2004; Del Canale et al, 2012). Empathy is also associated with better clinical outcomes (Burks and Kobus, 2012), fewer medical errors (Brennan et al, 2004), less burnout and greater wellbeing of health professionals (Krasner et al, 2009).
The concept of empathy has been well studied in nursing, medicine and other health disciplines, but relatively little attention has been paid to it in paramedicine, with the exception of a number of studies in paramedic students. This gap in the literature is of concern for a number of reasons.
First, the nature of paramedic clinical practice is that it often requires the rapid establishment of a provider-patient relationship. Any assessment and subsequent treatments need to be based on honest, open communication between both parties.
Second, paramedics regularly interact with patients who are vulnerable and are often subject to negative stereotyping around issues such as poor health literacy, palliative care, family violence, poor living conditions and substance use (Williams et al, 2017). The paramedic's demeanour in these clinical situations can influence the care provided and patient outcomes.
Finally, low empathy is a potential contributing factor to high burnout among providers (and vice versa). In the context of current mental health concerns in paramedicine, this area warrants further exploration.
Aim
The aim of this article is to provide an overview of empathy in paramedicine, and to outline potential solutions to improve empathy levels among paramedics and paramedic students.
Search strategy
We conducted unstructured, non-systematic searches of the literature. Searches of electronic databases (Medline, CINAHL and Google Scholar) were conducted using combinations of keywords including paramedic, empathy, compassion, empathy levels.
The authors also referred to their own expertise and prior knowledge of the topic area when authoring this overview. An overview is a summary of the literature that attempts to survey the literature and describe its characteristics (Grant and Booth, 2009), and is not intended to be exhaustive in its identification of the literature.
This overview has been structured thematically under the following headings: empathy in paramedic practice; empathy and burnout; and strategies to improve empathy levels.
Empathy in paramedicine
A number of studies have explored empathy in paramedic students in Canada and Australia. These studies have generally indicated lower empathy scores towards substance users and mental health emergencies. Female students tend to demonstrate higher empathy scores than males (Williams et al, 2012; 2015a; Kus et al, 2018; Pagano et al, 2018). These findings generally align with those of studies into other healthcare professions students (Brown et al, 2010; Fjortoft et al, 2011; McKenna et al, 2012), while paramedic students tend to display overall lower empathy scores than other healthcare students (Williams et al, 2014; 2015a).
These trends may in part result from a student's struggle to deal with patients' and relatives' emotions, as well as their own in some situations. Themes that emerged in a study of emotion work in paramedic students included ‘not sure of what to say’, ‘stop myself crying’, and ‘getting on with the job’ (Williams, 2013). These themes highlight the significant emotional demands that are placed on paramedic students—demands that they may be inadequately prepared for through their education.
Despite the evidence that paramedic practice places high emotional demands on students, there is a distinct lack of literature that explores empathy among qualified, practising paramedics. The paucity of literature highlights many of the same concerns evident in research about students. For example, Grevin (1996) outlined that both paramedics and paramedic students had significantly low scores on empathy when assessed using the MMPI-2 PK Scale (Grevin, 1996).
Regehr et al (2002) explored empathy in paramedics and uncovered a significant use of ‘cognitive empathy’ or, in other words, emotional distancing. This perceived lack of emotional empathy may result in impaired communication with patients and caregivers (Nordby and Nøhr, 2008). While often used as a protective strategy, this can result in issues for paramedics in their personal lives.
Empathy and burnout
Like other health professionals, paramedics work long hours, and have diverse patient contacts and limited resources. Stressful shiftwork can also lead to poor work-life balance and, combined, these factors can contribute to provider burnout. Because of the lack of research regarding empathy and burnout among paramedics, literature from other healthcare professions has been explored to hypothesise their relationship in paramedicine.
A scoping review of these studies by Williams et al (2017) offers multiple explanations. Low levels of empathy have been found to be related to higher likelihood of burnout in some studies, while others suggest that healthcare providers use this desensitisation as a defence mechanism against the everyday realities of illness and death (Williams, 2017).
Others have explored the idea that being empathetic could be used as a protective mechanism against burnout (Williams, 2017). This highlights that empathy is about not only putting oneself in another's shoes to understand their emotions, but also recognising that they are separate from one's own emotions. This distinction may aid in the provision of more empathetic care, and help to preserve a sense of self.
Strategies to improve empathy
Results of studies into paramedic students consistently lead to recommendations for further empathy training and education (Williams et al, 2014; 2015a; Kus et al, 2018; Pagano et al, 2018) in light of low empathy scores demonstrated towards certain vulnerable populations.
Empathy is an interpersonal skill that can be learned and improved upon through methods that target interpersonal skill building, self-reflection and constructive criticism. Aside from empathy, critical thinking, awareness, self-concept and teamwork all incorporate affective traits, and this supports the broader importance of affective domain development (Batt, 2014).
Proven methods to improve empathy in students include simulation-based training (Williams et al, 2015b; Levett-Jones et al, 2019), neuroscience-grounded training (Riess et al, 2012), and reflection or feedback-based training (Cope et al, 1986; Levett-Jones et al, 2019).
Training should attempt to address the populations that professionals may encounter. For paramedics, this is a broad spectrum of society. Non-clinical interaction with vulnerable populations has generally improved health professionals' attitudes and given valuable insight into these patients' experiences (Varkey et al, 2006; Ross and Williams, 2015).
In addition to education and training, paramedics and paramedic students should be given access to institutional support, such as confidential and independent counselling, and personal tutors in the case of students. The appropriate selection of clinical practice mentors (who may also be termed preceptors), and their preparation is key to student wellbeing (Williams, 2012). A preceptor should be adequately prepared to guide a student through both the clinical and emotional aspects of paramedic practice. This includes training in empathy, giving feedback, and supporting reflection and debriefing (Williams, 2012).
Conclusion
Empathy in paramedic practice is complex, and vastly understudied. Some evidence suggests that paramedic students have variable empathy levels towards certain patient presentations, and that their empathy levels decline over time as they progress through their education.
There is a distinct lack of research into empathy in practising paramedics, and the trends evident in student-based studies may allude to factors that contribute to paramedic wellbeing upon graduation. In particular, the relationships between empathy and patient care, paramedic burnout, and wellbeing require further investigation.
In the meantime, there are proven strategies that are designed to increase empathy levels through training, such as simulation, reflection, and experiential placements. The implementation of any empathy training should be considered as a component of a broader affective domain teaching approach within initial and continuing paramedic education programmes.