Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study

Enhancing compassion in medical education - a comparative study of the efficacy of clinical clerkships versus simulation-based training methodologies

BACKGROUND

Compassionate behavior plays a crucial role in medicine by fostering patient-doctor relationships, enhancing adherence, and improving care quality. While partly innate, compassion can be significantly enhanced through structured educational interventions. Despite recent efforts to integrate compassion into medical curricula, methodological challenges persist, especially in understanding how different environments influence skill expression and development. This study aims to assess the effectiveness of traditional clinical clerkships versus simulation-based training in cultivating compassion skills among medical students.

METHODS

This retrospective longitudinal study evaluated the professional behavior and cognitive skills of 133 medical students at Humanitas University, Milan, Italy, over a three-year period from 2021 to 2024. The curriculum emphasizes problem-based learning and professional development through hospital clerkships and simulation-based training. Compassion was assessed quarterly using a standardized scorecard and continuously evaluated via a learning management system, simulation scenarios and objective structured clinical examinations (OSCEs).

RESULTS

In the initial assessment, compassion scores showed no significant difference between the two settings (clerkship: 3.25 ± 0.73, simulation: 3.30 ± 0.69, p = 0.45). Over subsequent evaluations taking place in the following two years, the differences remained non-significant (p = 0.39, p = 0.22) until a notable divergence was observed in later assessments, particularly in the final evaluation at the end of 5th year study (clerkship: 3.54 ± 0.78, simulation: 3.23 ± 1.18, p = 0.023). Clerkship students demonstrated a significant increase in compassion scores over time (+ 0.29, p = 0.023), benefiting from immersive patient interactions that deepened their compassionate behavior. In contrast, simulation scores peaked slightly but not significantly in Year 4 before returning to initial levels (-0.07, 95% CI [-0.24, 0.11]), highlighting the challenge of sustaining compassionate behaviors without ongoing real-world practice.

CONCLUSION

This study emphasizes the crucial role of deliberate curriculum design in medical education. While simulation-based training offers controlled environments, it incompletely replicates the emotional depth of real patient interactions crucial for sustaining compassion. Integrating compassion-focused training into medical curricula is essential for nurturing compassionate healthcare professionals, urging immediate action to enhance compassion in medical education.

TRIAL REGISTRATION

Not applicable. No health intervention has been proposed, and it's a purely retrospective analysis on an educational methodology.

Protecting mothers against posttraumatic stress symptoms related to childbirth: What's the role of formal and informal support?

BACKGROUND AND OBJECTIVES

The risk and protective factors of posttraumatic stress symptoms related to childbirth (CB-PTSD) have been recently investigated. Although the general support received by the mothers is considered to play a positive role, the precise function of each type of support is still misunderstood. This study aimed to ascertain whether forms of informal and formal support better predict CB-PTSD symptoms and whether adverse delivery experiences and prior psychological issues moderated this relationship.

METHODS

526 mothers of infants (< 24 months) completed an online survey containing the Modified Perinatal Post-Traumatic Stress Disorder Questionnaire, the Depression, Anxiety, and Stress Scale-21, and items that evaluated various sources of support.

RESULTS

Findings showed that satisfaction with support received from friends and during hospital stay contributed negatively to CB-PTSD symptoms, regardless of other forms of formal and informal support. Overall, the conditional effects revealed that less satisfaction with distinct forms of formal support was associated with more CB-PTSD symptoms among mothers with a high or moderate history of psychological problems. Adverse delivery experiences moderated the relationships between satisfaction with support during childbirth and hospital stay and CB-PTSD symptoms through a similar pattern.

CONCLUSIONS

The findings highlight the importance of specific forms of support and contextual factors in preventing CB-PTSD.

Need of the hour: A service failure recovery reorientation for U.S. hospitals

ISSUE

Many hospitals in the United States are facing significant postpandemic operational challenges largely as a result of increasing demand for health care services. Operational issues increase the risk of service failures. Improving the patient experience after service failures may lead to better outcomes for both patients and hospitals.

CRITICAL THEORETICAL ANALYSIS

Drawing support from service failure recovery and quality management paradigms, we suggest that hospitals could periodically obtain deidentified patient feedback data drawn from multiple sources-including social media-to build a comprehensive patient experience dashboard that can be used to improve health care quality.

INSIGHT/ADVANCE

We offer an overarching conceptual framework to support organizational learning and make hospitals more adaptive to patient feedback. Staff members and leaders could examine patient feedback data to identify service failures and take appropriate action to prevent their recurrence in hospitals. A patient experience dashboard can be developed to document and visualize remedial actions taken by hospitals against each past service failure and shared with all stakeholders.

PRACTICE IMPLICATIONS

Reorienting health care as a service where hospitals immediately listen to patients and promptly address their questions and concerns may help to strengthen the continuity of health care services offered by hospitals as well as improve their financial position, quality of care, and the overall patient experience.

Understanding adaptive tasks in cardiac rehabilitation among patients with acute myocardial infarction: a qualitative study

BACKGROUND

While Cardiac Rehabilitation (CR) programs have shown effectiveness in improving cardiac outcomes, there is limited understanding of how patients perceive and adapt to these interventions. Furthermore, alternative modes of delivering CR that have received positive evaluations from participants remain underexplored, yet they have the potential to enhance CR uptake.

OBJECTIVES

To explore the patient experience in CR programmes following Acute Myocardial Infarction (AMI) and describe their adaptive processing.

PATIENTS AND METHODS

This qualitative study was conducted at a nationally certified centre in China between July 2021 and September 2022, encompassing three stages: in-hospital, centre-based, and home-based CR programs. Purposive sampling was used to select eligible AMI patients for in-depth semi-structured interviews. The interview outline and analytical framework were aligned with the key concepts derived from the middle-range theory of adaptation to chronic illness and the normalization process theory. The findings were reported following the Consolidated Criteria for Reporting Qualitative Research checklist.

RESULTS

Forty AMI patients were recruited. Four main themes describing the process of AMI patients normalizing CR intervention were identified, including (1) experiencing CR service driving by role's responsibilities, (2) engaging in collaborative relationship based on interpersonal trust, (3) exploring a personalized rehabilitation plan by complex integration, and (4) expecting a promised outcome to shape decision-making.

CONCLUSION

Integrated care interventions for AMI patients could benefit from a collaborative co-designed approach to ensure that CR interventions are normalized and fit into patients' daily lives. Organizational-level CR services should align with the rehabilitation needs and expectations of patients.

Emergency department staff compassion is associated with lower fear of enacted stigma among patients with opioid use disorder

OBJECTIVES

Fear of enacted stigma (fear of discrimination or being treated unfairly) is associated with decreased health care-seeking behaviors among patients with opioid use disorder (OUD). We sought to describe the prevalence of fear of enacted stigma among patients presenting to the emergency department (ED) with OUD and to test whether experiencing greater compassion from ED staff is associated with lower fear of enacted stigma.

METHODS

We conducted a cross-sectional study in the ED of an academic medical center between February and August 2023. We included adult patients with OUD presenting to the ED and assessed patient experience of compassion from ED staff using a previously validated 5-item compassion measure (score range 5-20). The primary outcome measure was fear of enacted stigma in the ED, measured using the validated 9-item subscale of the Substance Abuse Self-Stigma Scale (score range 9-45).

RESULTS

Of the 116 subjects enrolled, 97% (95% confidence interval [CI] 91%-99%) reported some degree of stigma, with a median (interquartile range) score of 23 (16-31). In a multivariable model adjusting for potential confounders, patient experience of greater ED compassion was independently associated with lower fear of enacted stigma, β = -0.66 (95% CI -1.03 to -0.29), suggesting that every 1-point increase in the 5-item compassion measure score is associated with a 0.66-point decrease in the fear of enacted stigma score.

CONCLUSIONS

Among ED patients with OUD, fear of enacted stigma is common. Patient experience of compassion from ED staff is associated with lower fear of enacted stigma. Future research is warranted to test if interventions aimed at increasing compassion from ED staff reduce patient fear of enacted stigma among patients with OUD.

Genetics, Epigenetics, and the Environment: Are Precision Medicine, Provider Compassion, and Social Justice Effective Public Health Measures to Mitigate Disease Risk and Severity?

Environmental forces impacting public health include exposure to toxic substances, adverse childhood experiences (ACEs), diet, and exercise. Here, we examine the first two of these forces in some detail since they may be amenable to correction through cultural, medical, and practitioner intervention. At the same time, changing people's dietary and exercise routines are likely more resistant to these interventions and are referred to only incidentally in this review. That is, societal efforts could prevent exposure to toxicants and ACEs-not necessarily requiring cooperation by the affected individuals-whereas changing diet and exercise practices requires an individual's discipline. Toxic substances considered in this review include endocrine disruptors, arsenics, 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD), the organic solvent, Trichloroethylene (TCE), and the Benzo[a]pyrene (B[a]P) produced from incomplete combustion of tobacco and other organic materials. Exposure to each of these toxic substances may have serious adverse health effects, especially in genetically more susceptible individuals. For example, children of mothers exposed to the endocrine disruptor, Atrazine, have significantly lower birth length, weight, and head circumference. Moreover, male offspring exhibit genital abnormalities, and all of these effects may be transgenerational. However, analyses of interactions among genes, the environment, and epigenetic modifications have already revealed distinctive individual risks of adverse reactions to toxic exposure. So, interventions through precision medicine might improve the health of those exposed individuals. Adults previously exposed to more than one ACE (e.g., child abuse and inter-parental violence) are more likely to develop anxiety, cancer, and diabetes. Detecting ACE exposures in children in the general population is fraught with difficulty. Thus, the risks of ACEs to our health remain even more insidious than exposures to toxicants. Nevertheless, higher provider compassion is associated with significantly better clinical outcomes for patients with these afflictions. For all these reasons, the first major aim of this review is to recount several of the major forces contributing to or impairing public health. Our second major aim is to examine mitigating influences on these forces, including social justice and provider compassion in the setting of precision medicine. Idealistically, these mitigators might eventually lead to the development of more cooperative and compassionate cultures and societies.

Empathy and cultural competence remains stable for medical students: do the humanities have an effect?

There is a paucity of rigorous longitudinal data regarding the relationship between humanities and their effect on multiple psychometrics. Using an observational art course, we assessed pre- and post-course metrics and longitudinal impacts with 120 preclinical medical students taking the "Art of Observation" between 2016 and 2019. Jefferson Scale of Empathy (JSE) and Jeffreys Transcultural Self-Efficacy Tool (TSET) were assessed annually for four years. Budner Tolerance of Ambiguity (TOA) Scale was administered before and after the course. The JSE showed no drop in empathy as students progressed from first to fourth year (p = 0.374). The TSET showed statistically significant increases in cultural self-efficacy (p < 0.001) in the cognitive and practical components but no change in the affective component of the scale. After the art course, TOA significantly improved on two [solubility (p = 0.009) and complexity (p = 0.21)] of the three subscales, but not novelty (p = 0.62). Empathy and cultural self-efficacy remained consistently high throughout medical school and did not decrease during the clinical years in an institution prioritizing the humanities and community engagement. Comfort with cultural competency generally improved throughout training. After taking an art course that emphasizes cognitive flexibility and a multiple perspectival approach, students demonstrated greater tolerance for ambiguity.

Preconsultation compassion video to reduce anxiety among patients referred to a cancer centre: a randomised control trial

Objective

Anxiety is common among patients attending an initial oncology consultation. The objective of this trial was to test if an enhanced compassion video emailed to patients prior to their initial oncology consultation reduces anxiety compared with being sent an information-only introduction video.

Methods and analysis

We conducted a randomised control trial at a single university-based cancer centre between May 2021 and October 2023. We enrolled adult patients scheduled for an initial cancer consultation. Subjects underwent simple 1:1 randomisation to receive either a standard introduction video or an enhanced compassion video via email. Investigators and subjects were blinded to allocation. The primary outcome was degree of anxiety on arrival to the initial oncology consultation, measured using the Hospital Anxiety and Depression scale (HADS).

Results

Of 1005 subjects randomised to the standard video and 1038 to the enhanced compassion video, 183 and 179 subjects completed the HADS-anxiety in each group, respectively. Only 25% reported watching their assigned video. There was no difference in degree of anxiety between the standard or compassion video groups using intention to treat analysis (median (IQR) 7 (4-10) vs 7 (4-10), p value=0.473)) or per-protocol analysis (limited to subjects who reported watching the video) (median (IQR) 7 (4-10) (n=45) vs 7 (5-10) (n=46), p value=0.997).

Conclusion

Receiving an enhanced compassion video did not reduce anxiety compared with a standard introduction video. Given 25% of subjects reported watching their assigned video, future research should focus on identifying interventions at the point-of-care to reduce anxiety.

Trial registration number

NCT04503681.

Compassion Fatigue in Emergency Medicine: Current Perspectives

Compassion fatigue (CF), or loss of ability to empathize or feel compassion for others for whom one cares, is a growing concern for emergency physicians (EP). EPs, by the nature of their jobs, work under unpredictable conditions at odd hours with high levels of exposure to traumatic events. They are placed under substantial psychological, physical, and cognitive pressure, with little opportunity to recover or reflect. CF occurs when this workplace stress leads to feelings of being overwhelmed, helpless, unsupported, and unable to cope. Additionally, primary traumatic stress from threats of workplace violence and secondary traumatic stress (STS) from witnessing the suffering of others increase the likelihood of developing CF. Unchecked, this progression to CF causes reduction in quality of care to patients, reduction in patient satisfaction, increased levels of EP depression and anxiety, increased levels of EP substance use, and increased attrition from the specialty. To truly improve CF, individuals and organizations should be aware of the contributors to CF: namely, emotional exhaustion, depersonalization, primary and STS, and personal achievement. EPs should maximize their resilience to CF by using cognitive behavioral techniques and mindfulness, taking care of their physical health, seeking meaning and development within their work, developing hobbies outside of work, and creating boundaries between work and home. Organizations should actively address the known drivers of physician burnout: workload and job demands, efficiency and resources, meaning in work, culture and values, control and flexibility, work community, and work-life integration. Organizations should also provide adequate safety within facilities to reduce the threat of primary trauma and should supply adequate support and destigmatization for post-traumatic symptoms for EPs suffering from STS.

Compassionomics: The Science and Practice of Caring

PURPOSE

To summarize the scientific evidence that compassion can measurably improve patient outcomes, health care quality and safety, and the well-being of health care providers, and to consider specific strategies for cultivating compassion and better communicating it to patients.

DESIGN

Perspective.

METHODS

We selectively reviewed the literature on compassion in health care, including obstacles to its expression and the demonstrated effects of provider compassion on patient outcomes, health care quality and cost, and provider well-being. We also review evidence regarding the trainability of compassion, discuss proven methods for cultivating individual compassion, and recommend strategies for incorporating it into routine medical practice.

RESULTS

Compassion is the emotional response to another's pain or suffering, accompanied by a desire to alleviate it. Review of the literature shows that compassionate health care measurably improves physical and psychological patient outcomes, increases patient adherence, improves health care quality and safety, increases financial margins, and prevents physician burnout. Psychophysiological research shows that empathy and compassion can be actively cultivated through intentional practice. Validated models of compassion-based interactions can facilitate the consistent expression of compassion in daily medical practice.

CONCLUSIONS

Given its many proven benefits to patients, health care organizations, and providers, compassion should be cultivated by health care providers and systems and considered an essential component of optimal medical care.

Item development for a patient-reported measure of compassionate healthcare in action

BACKGROUND

Compassionate care is a fundamental component of healthcare today; yet, many measures of compassionate care are subjective in focus and lack clarity around what compassionate care looks like in practice. Measures mostly relate to physical healthcare settings, neglecting mental healthcare. They also lack significant involvement of people with lived experience (PLE) of healthcare delivery in their development. This study aimed to begin the process of developing a new patient-reported measure, one that captures the observable actions of compassionate care delivery or 'compassionate healthcare in action' by any healthcare professional working in any care setting. The study involves PLE of healthcare delivery, both patients and staff, throughout.

METHODS

A multistage mixed-methods scale development process was followed. First, items were derived inductively from reflexive thematic analysis of patient and clinician interviews about what compassionate care meant to them (n = 8), with additional items derived deductively from a literature review of existing measures. Next, a panel of patient, clinician and researcher experts in compassionate care was recruited (Round 1: n = 33, Round 2: n = 29), who refined these items in a two-round modified online Delphi process.

RESULTS

Consensus was reached on 21 items of compassionate care in action relating to six facets: understanding, communication, attention, action, emotional sensitivity and connection. These items will form the basis for further scale development.

CONCLUSIONS

This item development work has laid the foundation of a potential new tool to systematically measure what compassionate healthcare in action looks like to patients. Further research is underway to produce a valid and reliable version of this proposed new measure. We have outlined these initial stages in detail in the hope of encouraging greater transparency and replicability in measure development, as well as emphasising the value of involving PLE throughout the process.

PATIENT OR PUBLIC CONTRIBUTION

This study involved PLE of both physical and mental healthcare (as staff, patients and service users) throughout the development of the new measure, including initial project conceptualisation and participation in item generation and refinement stages.

Educational efficacy of medical humanities in empathy of medical students and healthcare professionals: a systematic review and meta-analysis

BACKGROUND

Medical humanities education is an important part of medical education. The purpose of this study was to determine the effectiveness of medical humanities in improving empathy among medical students and healthcare professionals.

METHODS

PubMed, Embase, EBSCO-ERIC, Web of Science were searched systematically for studies in the English language. The last retrieval date is May 1, 2023. Best Evidence Medical Education (BEME) Global Rating Scale and Kirkpatrick-based results were used to evaluate the quality of literature. In this study, a meta-analysis of continuous data was conducted.

RESULTS

The pooled results by single-arm test meta-analysis showed a benefit with medical humanities programs in empathy (SMD 1.33; 95% CI 0.69-1.96). For single-arm trials of medical humanities program interventions of less than 4 months, 4 months to 12 months, and more than one year, the standardized mean differences(SMD) between post-test and pre-test were 1.74 (P < 0.05), 1.26 (P < 0.05), and 0.13 (P = 0.46), respectively. The results showed a significant difference in the effect of medical humanities programs on male and female empathy (SMD - 1.10; 95% CI -2.08 - -0.13). The SMDs for the study of course, the course combined reflective writing, and the course combined reflective writing and practice as intervention modalities for medical humanities programs were 1.15 (P < 0.05), 1.64 (P < 0.05), and 1.50 (P < 0.05), respectively.

CONCLUSION

Medical humanities programs as a whole can improve the empathy of medical students and health professionals. However, different intervention durations and different intervention methods produce different intervention effects.

Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial

BACKGROUND

Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP.

METHODS

This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat.

DISCUSSION

The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.

Predictors of Medical Students' Compassion and Related Constructs: A Systematic Review

Phenomenon: Compassion, and related constructs such as empathy, are core values in healthcare, with known benefits for both patients and staff. Yet research on the factors that affect compassion and compassion-related constructs remains scattered. This review systematizes and synthesizes studies investigating the predictors of compassion and related constructs among medical students, allowing for a better understanding of the factors that both positively and negatively contribute to the development of compassionate future physicians. Approach: A systematic review of 12 databases for studies from database inception up until April 2020 was conducted. Non-peer-reviewed literature and studies in which >50% of the sample were non-medical students were excluded. Intervention studies were also out of the scope of this review. We assessed risk of bias and confidence in the findings using standardized tools. Data were categorized within the Transactional Model of Physician Compassion, a framework in which compassion is influenced by personal (student), environmental, patient/family, and clinical factors. Findings: Of 14,060 retrieved articles, 222 studies were included. Of these, 95% studied student factors, but only 25% studied environmental, 9% studied patient, and 6% studied clinical factors. Predictors of greater compassion included maturity; work and life experiences; personality traits of openness to experience and agreeableness; skills such as perspective taking, reflection, and mindfulness; and positive role modeling. Conversely, negative attitudes/emotions, burnout, stress, detachment, operating in cultures prioritizing knowledge and efficiency over humanistic care, negative role models, time constraints, and heavy workloads predicted lower compassion. Patient-related factors included "difficult" and "noncompliant" patients or those perceived as responsible for their illness. Overall, 60% of studies had a serious risk of bias, particularly confounding and participant selection biases. Insights: Medical student compassion is predicted by a wide range of factors relating to the student, their training environment, their patients, and the clinical situation. However, existing research has largely focused on student factors (e.g., sociodemographic and dispositional traits), many of which are not amenable to intervention. Skills such as perspective taking, reflection, and mindfulness are associated with higher compassion and may present opportunities for intervention. There is also strong evidence that environmental factors shape students' compassion. Researchers and educators should continue to explore the impact of patient and clinical factors on students' compassion. Studies remain at high risk of bias.

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care

Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

The impact of artificial intelligence on the person-centred, doctor-patient relationship: some problems and solutions

Artificial intelligence (AI) is often cited as a possible solution to current issues faced by healthcare systems. This includes the freeing up of time for doctors and facilitating person-centred doctor-patient relationships. However, given the novelty of artificial intelligence tools, there is very little concrete evidence on their impact on the doctor-patient relationship or on how to ensure that they are implemented in a way which is beneficial for person-centred care.Given the importance of empathy and compassion in the practice of person-centred care, we conducted a literature review to explore how AI impacts these two values. Besides empathy and compassion, shared decision-making, and trust relationships emerged as key values in the reviewed papers. We identified two concrete ways which can help ensure that the use of AI tools have a positive impact on person-centred doctor-patient relationships. These are (1) using AI tools in an assistive role and (2) adapting medical education. The study suggests that we need to take intentional steps in order to ensure that the deployment of AI tools in healthcare has a positive impact on person-centred doctor-patient relationships. We argue that the proposed solutions are contingent upon clarifying the values underlying future healthcare systems.

The Role of Compassionate Care in Medicine: Toward Improving Patients' Quality of Care and Satisfaction

INTRODUCTION

Despite its description as a cornerstone of a healthcare provider's professional identity, the impact of compassionate care on various aspects of medicine has been poorly defined. In this review, we aimed to elucidate the role of compassionate care in various aspects of medicine and healthcare delivery.

METHODS

Four databases were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol for a literature review regarding compassionate care and its intersection with medical education, patient-provider communication, patient care, and clinical outcomes, patient and provider characteristics, telemedicine and artificial intelligence, caregiver compassion fatigue, and cost of care.

RESULTS

Twenty-two articles met the inclusion criteria. Analysis revealed that clinical outcomes are correlated with the degree of patients' perception of empathy and compassion from their providers. Along with enhanced patient outcomes, compassionate care was shown to reduce the costs of care, compassion fatigue and burnout, and the number of malpractice claims. However, compassion can be perceived differently among patients of various cultural and ethnic backgrounds. Compassion training sessions can be implemented among residents in surgical and nonsurgical medical specialties to improve perceived compassion. Furthermore, the use of telehealth modalities may positively or negatively impact compassionate care, requiring further exploration.

CONCLUSIONS

Compassionate care plays a crucial role in improving patient care and clinical outcomes while reducing caregiver burnout and the risk of malpractice litigation. However, a lack of compassion training and caregiver compassion fatigue may detract from the delivery of effective compassionate care.

Drivers and drainers of compassion in intensive care medicine: An empirical study using video vignettes

BACKGROUND

The aim was to determine what factors drive and enhance compassionate care behaviors in the ICU setting and which factors drain and negate such caring attitudes and behaviors.

METHODS

Qualitative, focus group discussions using video vignettes. 20 participants agreed to be part of 3 separate focus groups facilitated by the authors.

RESULTS

Thematic analysis revealed emphasis on behavior and nonverbal cues, clinical decision making, communication and sensitivity, and building humane relations. The results show that physicians feel driven by the humanity and sensitivity felt in ICU work, however, there exists structural incompetence, as well as the stress and personal -systemic imbalances of ICU work, which leads to burnout and erosion of such motivations, draining compassion.

CONCLUSIONS

Regulatory and scheduling practices must be examined to foster the growth of compassionate behaviors and attitudes in healthcare, and these should be treated as essential patient centered metrics.

Stress and mental health of COVID-19 survivors and their families after hospital discharge: relationship with perceived healthcare staff empathy

Several studies attest to the long-term consequences of COVID-19 infection on survivors' mental illness, especially in terms of high prevalence of post-traumatic stress disorder (PTSD) 1-3 months after hospitalization. Aims of the present study were (1) to jointly evaluate PTSD and positive mental health among COVID-19 survivors and family members after hospital discharge, and (2) to investigate the relationship between perceived healthcare staff's relational empathy during hospitalization and survivors' post-traumatic stress levels. In this cross-sectional study, 60 survivors (M_age = 60.45; 63.3% men) and 40 family members (M_age = 52.33; 60% women) participated in an online survey 3-7 months after hospital discharge. In addition to providing socio-demographic data, they completed PTSD Checklist for DSM-5 and Mental Health Continuum Short Form. Survivors also completed the Consultation and Relational Empathy measure. Percentages of participants meeting a provisional PTSD and mental health diagnosis (flourishing, moderate, languishing) were calculated. A hierarchical regression analysis was performed on survivors' data, with perceived staff's empathy as predictor and post-traumatic stress symptoms (PTSS) as outcome. One-fifth of the participants received a provisional PTSD diagnosis, about half were diagnosed with flourishing or moderate mental health, and only 5% were languishing, with no significant between-group differences. Among survivors, a negative association was detected between perceived healthcare staff's empathy and PTSS, explaining 10.5% of the model variance over and above demographic and clinical variables. Findings highlighted the coexistence of PTSD and positive mental health among survivors and family members, suggesting the usefulness of assessing both negative and positive dimensions of mental health, in order to promote psycho-social adaptation once returning to everyday life. In addition, the role of compassionate care in clinical practice emerged as a potential means to mitigate severe traumatic reactions among survivors.

Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study

OBJECTIVES

In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.

DESIGN

An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.

SETTING

The ED of three academic medical centers.

PATIENTS

Mechanically ventilated adult patients that received neuromuscular blockers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).

CONCLUSIONS

AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.

Validation of a 5-Item Tool to Measure Patient Assessment of Clinician Compassion in Hospitals

BACKGROUND

We previously validated a 5-item compassion measure to assess patient experience of clinician compassion in the outpatient setting. However, currently, there is no validated and feasible method for health care systems to measure patient experience of clinician compassion in the inpatient setting across multiple hospitals.

OBJECTIVE

To test if the 5-item compassion measure can validly and distinctly measure patient assessment of physician and nurse compassion in the inpatient setting.

DESIGN

Cross-sectional study between July 1 and July 31, 2020, in a US health care network of 91 community hospitals across 16 states consisting of approximately 15,000 beds.

PATIENTS

Adult patients who had an inpatient hospital stay and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

MEASUREMENTS

We adapted the original 5-item compassion measure to be specific for physicians, as well as for nurses. We disseminated both measures with the HCAHPS survey and used confirmatory factor analysis for validity testing. We tested reliability using Cronbach's alpha, as well as convergent validity with patient assessment of physician and nursing communication and overall hospital rating questions from HCAHPS.

RESULTS

We analyzed 4756 patient responses. Confirmatory factor analysis found good fit for two distinct constructs (i.e., physician and nurse compassion). Both measures demonstrated good internal consistency (alpha > 0.90) and good convergent validity but reflected a construct (compassionate care) distinct from what is currently captured in HCAHPS.

CONCLUSION

We validated two 5-item tools that can distinctly measure patient experience of physician and nurse compassion for use in the inpatient hospital setting in conjunction with HCAHPS.

Posttraumatic stress disorder symptoms after respiratory and cardiovascular emergencies predict risk of hospital readmission: A prospective cohort study

BACKGROUND

Twenty-five percent of patients presenting to the emergency department (ED) for a respiratory or cardiovascular medical emergency develop clinically significant posttraumatic stress disorder (PTSD) symptoms. It is possible that development of PTSD symptoms in this cohort is associated with subsequent adverse physical health events. Our objective was to test whether clinically significant PTSD symptoms 30 days postdischarge are associated with increased risk for hospital readmission within 24 months after discharge among patients presenting to the ED for a respiratory or cardiovascular emergency.

METHODS

This was a prospective cohort study conducted between January 1, 2018, and December 31, 2020, at a U.S. academic medical center, including adult patients presenting with acute respiratory failure or cardiovascular instability requiring a potentially life-sustaining intervention in the ED. PTSD symptoms 30 days postdischarge were measured using the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5. The primary outcome was all-cause hospital readmission over the subsequent 24 months after hospital discharge from the index ED visit.

RESULTS

Of the 99 patients included, 73% (95% confidence interval [CI] = 63% to 81%) had a hospital readmission within 24 months. In a multivariable Cox proportional hazards model adjusting for potential confounders (e.g., age, severity of illness during index ED visit, preexisting comorbid conditions) presence of clinically significant PTSD symptoms at 30 days was independently associated with increased risk for all-cause hospital readmission at 24 months (hazards ratio = 2.19, 95% CI = 1.30 to 3.69). These results remained statistically significant across multiple sensitivity analyses.

CONCLUSIONS

Hospital readmission is common among survivors of acute respiratory failure and cardiovascular instability, and PTSD symptoms 30 days postdischarge are an independent predictor of hospital readmission. Survivors of medical emergencies may warrant follow-up evaluation for PTSD symptoms, and future research is warranted to better understand the relationship between psychological trauma and hospital readmission.

Predictors of Physician Compassion, Empathy, and Related Constructs: a Systematic Review

BACKGROUND

Compassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC).

METHODS

A systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach.

RESULTS

One hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians' perceptions of patients' motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC.

DISCUSSION

The growth of evidence in the recent years reflects ECRC's ongoing importance. However, evidence remains scattered, concentrates on physicians' factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors' effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.

The associations of subjective appraisal of birth pain and provider-patient communication with postpartum-onset PTSD

Childbirth-related PTSD is generally believed to result from multiple factors, including negative objective and subjective experiences and patient predisposing factors. There is conflicting evidence regarding whether severe childbirth pain affects development of PTSD. We hypothesize that a woman's retrospective subjective appraisal of birth pain is a greater predictor of postpartum-onset PTSD than medically documented measures of pain, and that a positive subjective experience communicating with medical providers during labor also reduces risk for postpartum-onset PTSD. A sample of 112 women, who screened positive for psychopathology within a year postpartum, were interviewed probing for their subjective labor experiences. Interviews were coded for subjective labor pain perception and quality of provider communication. Regression analyses tested associations between subjective labor pain perception and quality of provider communication with postpartum PTSD. Pain scores recorded during labor were not significantly associated to probable PTSD at any recorded time point up to 12 months postpartum. Positive perception of birth pain was associated with reduced risk of probable PTSD at 6 weeks postpartum (aOR = 0.34, p = 0.03). Positive provider communication was associated with reduced risk of probable PTSD at 6 months (aOR = 0.29, p = 0.02) and 12 months (aOR = 0.2, p = 0.03) postpartum. Pain recorded during childbirth is not necessarily a negative experience leading to trauma. For some women, even severe pain may be seen positively, and lacks traumatizing elements. Interventions to positively shift women's childbirth pain appraisal and educate medical workforce in patient-provider communication may reduce rates of postpartum PTSD. ClinicalTrials.gov Indentifier: NCT03004872.

Perceived Severity of Stressors in the Intensive Care Unit: A Systematic Review and Semi-Quantitative Analysis of the Literature on the Perspectives of Patients, Health Care Providers and Relatives

The aim of this study was to synthesize quantitative research that identified ranking lists of the most severe stressors of patients in the intensive care unit, as perceived by patients, relatives, and health care professionals (HCP). We conducted a systematic literature search in PubMed, MEDLINE, EMBASE, PsycInfo, CINAHL, and Cochrane Library from 1989 to 15 May 2020. Data were analyzed with descriptive and semi-quantitative methods to yield summarizing ranking lists of the most severe stressors. We synthesized the results of 42 prospective cross-sectional observational studies from different international regions. All investigations had assessed patient ratings. Thirteen studies also measured HCP ratings, and four studies included ratings of relatives. Data indicated that patients rate the severity of stressors lower than HCPs and relatives do. Out of all ranking lists, we extracted 137 stressor items that were most frequently ranked among the most severe stressors. After allocation to four domains, a group of clinical ICU experts sorted these stressors with good to excellent agreement according to their stress levels. Our results may contribute to improve HCPs' and relatives' understanding of patients' perceptions of stressors in the ICU. The synthesized stressor rankings can be used for the development of new assessment instruments of stressors.

What is empathy? Oncology patient perspectives on empathic clinician behaviors

BACKGROUND

Oncology patients and physicians value empathy because of its association with improved health outcomes. Common measures of empathy lack consistency and were developed without direct input from patients. Because of their intense engagement with health care systems, oncology patients may have unique perspectives on what behaviors signal empathy in a clinical setting.

METHODS

As part of a cross-sectional study of patient perspectives on clinician empathy at an academic cancer center in the northeastern United States, the authors solicited up to 10 free-text responses to an open-ended question about what clinician behaviors define empathy.

RESULTS

The authors categorized open-ended responses from 89 oncology patients into 5 categories representing 14 themes. These categories were relationship sensitivity, focus on the whole person, communication, clinician attributes, and institutional resources and care processes. Frequently represented themes, including listening, understanding, and attention to emotions and what matters most, aligned with existing measures of empathy; behaviors that were not well represented among existing measures included qualities of information sharing and other communication elements. Patients also associated clinician demeanor, accessibility, and competence with empathy.

CONCLUSIONS

Oncology patients' perspectives on empathy highlight clinician behaviors and attributes that may help to refine patient experience measures and may be adopted by clinicians and cancer centers to enhance patient care and outcomes. High-quality communication skills training can promote active listening and paying attention to the whole person. A system-level focus on delivering empathic care may improve patients' experiences and outcomes.

LAY SUMMARY

Oncology patients' responses to an open-ended question about empathic clinician behavior have revealed insights into a variety of behaviors that are perceived as demonstrative of empathy. These include behaviors that imply sensitivity to the clinician-patient relationship, such as listening and understanding and attention to the whole person. Participants valued caring communication and demeanor and clinician accessibility. Perspective taking was not common among answers. Many existing measures of clinical care quality do not include the behaviors cited by patients as empathic. These results can inform efforts to refine quality measures of empathy-associated behaviors in clinical practice. Cancer centers can use skills training to improve elements of communication.

Humanizing the ICU Patient: A Qualitative Exploration of Behaviors Experienced by Patients, Caregivers, and ICU Staff

Supplemental Digital Content is available in the text.

Objectives:

To understand how patients and family members experience dehumanizing or humanizing treatment when in the ICU.

Design:

Qualitative study included web-based focus groups and open-ended surveys posted to ICU patient/family social media boards. Focus groups were audio recorded and transcribed. Social media responses were collected and organized by stakeholder group. Data underwent qualitative analysis.

Setting:

Remote focus groups and online surveys.

Patients:

ICU patient survivors, family members, and ICU teams.

Interventions:

Not available.

Measurements and Main Results:

Semi-structured questions and open-ended survey responses. We enrolled 40 patients/family members and 31 ICU team members. Focus groups and surveys revealed three primary themes orienting humanizing/dehumanizing ICU experiences: 1) communication, 2) outcomes, and 3) causes of dehumanization. Dehumanization occurred during “communication” exchanges when ICU team members talked “over” patients, made distressing remarks when patients were present, or failed to inform patients about ICU-related care. “Outcomes” of dehumanization were associated with patient loss of trust in the medical team, loss of motivation to participate in ICU recovery, feeling of distress, guilt, depression, and anxiety. Humanizing behaviors were associated with improved recovery, well-being, and trust. “Perceived causes” of dehumanizing behaviors were linked to patient, ICU team, and healthcare system factors.

CONCLUSIONS:

Behaviors of ICU clinicians may cause patients and families to feel dehumanized when in the ICU. Negative behaviors are noticed by patients and families, possibly contributing to poor outcomes including mental health, recovery, and lack of trust in ICU teams. Supporting ICU clinicians may enable a more empathic environment and in turn more humanizing clinician-patient encounters.

Understanding the concept of compassion from the perspectives of nurses

BACKGROUND

The high level of satisfaction of users of a health service is largely due to the fact that they receive excellent care from healthcare professionals. Compassionate care is an essential component of excellent care. But what do nurses understand compassion to be?

RESEARCH OBJECTIVES

To analyse the concept of compassion from the perspective of nurses in the Andalusian Public Health System, Spain.

RESEARCH DESIGN

This is a qualitative study following the grounded theory model. Four focus groups and 25 in-depth interviews were conducted.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 68 nursing professionals working in the Andalusian Public Health System (Spain) participated. Theoretical sampling was used, with participants being recruited using the snowball technique.

ETHICAL CONSIDERATIONS

This research was approved by the Research Ethics Committee of the Centro-Almería Health District (CEICA 27/9/17).

FINDINGS

From the analysis of the data, four themes emerged that helped to understand the concept of compassion according to nurses: 'Negative perception of the term compassion', 'Compassion and empathy as synonyms', 'Beyond empathy', and 'Effects of having a compassionate attitude'.

DISCUSSION

Nurses perceive the concept of compassion differently to each other and even contradictorily. This concept is imbued with cultural elements, which adds confusion to understanding it, and is even perceived as something negative similar to pity.

CONCLUSION

Nurses confuse the concepts of empathy and compassion as if they were synonymous. Before considering training in compassion for healthcare professionals, it is essential to clarify the concept of compassion through educational interventions.

Coding of Sexual Assault by Emergency Physicians: A Nationally Representative Study

Introduction

Sexual assault is a public health problem that affects many Americans and has multiple long-lasting effects on victims. Medical evaluation after sexual assault frequently occurs in the emergency department, and documentation of the visit plays a significant role in decisions regarding prosecution and outcomes of legal cases against perpetrators. The American College of Emergency Physicians recommends coding such visits as sexual assault rather than adding modifiers such as “alleged.”

Methods

This study reviews factors associated with coding of visits as sexual assault compared to suspected sexual assault using the 2016 Nationwide Emergency Department Sample.

Results

Younger age, female gender, a larger number of procedure codes, urban hospital location, and lack of concurrent alcohol use are associated with coding for confirmed sexual assault.

Conclusion

Implications of this coding are discussed.

Socioeconomic, racial and ethnic differences in patient experience of clinician empathy: Results of a systematic review and meta-analysis

INTRODUCTION

Empathy is essential for high quality health care. Health care disparities may reflect a systemic lack of empathy for disadvantaged people; however, few data exist on disparities in patient experience of empathy during face-to-face health care encounters with individual clinicians. We systematically analyzed the literature to test if socioeconomic status (SES) and race/ethnicity disparities exist in patient-reported experience of clinician empathy.

METHODS

Using a published protocol, we searched Ovid MEDLINE, PubMed, CINAHL, EMBASE, CENTRAL and PsychINFO for studies using the Consultation and Relational Empathy (CARE) Measure, which to date is the most commonly used and well-validated methodology for measuring clinician empathy from the patient perspective. We included studies containing CARE Measure data stratified by SES and/or race/ethnicity. We contacted authors to request stratified data, when necessary. We performed quantitative meta-analyses using random effects models to test for empathy differences by SES and race/ethnicity.

RESULTS

Eighteen studies (n = 9,708 patients) were included. We found that, compared to patients whose SES was not low, low SES patients experienced lower empathy from clinicians (mean difference = -0.87 [95% confidence interval -1.72 to -0.02]). Compared to white patients, empathy scores were numerically lower for patients of multiple race/ethnicity groups (Black/African American, Asian, Native American, and all non-whites combined) but none of these differences reached statistical significance.

CONCLUSION

These data suggest an empathy gap may exist for patients with low SES. More research is needed to further test for SES and race/ethnicity disparities in clinician empathy and help promote health care equity.

TRIAL REGISTRATION

Registration (PROSPERO): CRD42019142809.

The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department

STUDY OBJECTIVE

Awareness with paralysis is a devastating complication for patients receiving mechanical ventilation and risks long-term psychological morbidity. Data from the emergency department (ED) demonstrate a high rate of longer-acting neuromuscular blocking agent use, delayed analgosedation, and a lack of sedation depth monitoring. These practices are discordant with recommendations for preventing awareness with paralysis. Despite this, awareness with paralysis has not been rigorously studied in the ED population. Our objective is to assess the prevalence of awareness with paralysis in ED patients receiving mechanical ventilation.

METHODS

This was a single-center, prospective, observational cohort study on 383 mechanically ventilated ED patients. After extubation, we assessed patients for awareness with paralysis by using the modified Brice questionnaire. Three expert reviewers independently adjudicated awareness with paralysis. We report the prevalence of awareness with paralysis (primary outcome); the secondary outcome was perceived threat, a mediator for development of posttraumatic stress disorder.

RESULTS

The prevalence of awareness with paralysis was 2.6% (10/383). Exposure to rocuronium at any point in the ED was significantly different between patients who experienced awareness with paralysis (70%) versus the rest of the cohort (31.4%) (unadjusted odds ratio 5.1; 95% confidence interval 1.30 to 20.1). Patients experiencing awareness with paralysis had higher mean values on the threat perception scale, denoting a higher degree of perceived threat, compared with patients who did not experience awareness with paralysis (13.4 [SD 7.7] versus 8.5 [SD 6.2]; mean difference 4.9; 95% confidence interval 0.94 to 8.8).

CONCLUSION

Awareness with paralysis occurs in a significant minority of ED patients who receive mechanical ventilation. Potential associations of awareness with paralysis with ED care and increased perceived threat warrant further evaluation.

How Do Health Professionals Maintain Compassion Over Time? Insights From a Study of Compassion in Health

Although compassion in healthcare differs in important ways from compassion in everyday life, it provides a key, applied microcosm in which the science of compassion can be applied. Compassion is among the most important virtues in medicine, expected from medical professionals and anticipated by patients. Yet, despite evidence of its centrality to effective clinical care, research has focused on compassion fatigue or barriers to compassion and neglected to study the fact that most healthcare professionals maintain compassion for their patients. In contributing to this understudied area, the present report provides an exploratory investigation into how healthcare professionals report trying to maintain compassion. In the study, 151 professionals were asked questions about how they maintained compassion for their patients. Text responses were coded, with a complex mixture of internal vs. external, self vs. patient, and immediate vs. general strategies being reported. Exploratory analyses revealed reliable individual differences in the tendency to report strategies of particular types but no consistent age-related differences between older and younger practitioners emerged. Overall, these data suggest that while a range of compassion-maintaining strategies were reported, strategies were typically concentrated in particular areas and most professionals seek to maintain care using internal strategies. A preliminary typology of compassion maintaining strategies is proposed, study limitations and future directions are discussed, and implications for the study of how compassion is maintained are considered.

Relationship between postpartum mood disorder and birth experience: a prospective observational study

BACKGROUND

This study aims to investigate the relationship between the birth experience and the risk of developing postpartum depression or post-traumatic stress disorder.

METHODS

In this prospective, longitudinal, observational study, women were assessed at different time points for depression and post-traumatic stress disorder. The risk of depression or post-traumatic stress disorder based on patient characteristics and specific birth events was assessed within three months postpartum.

RESULTS

We enrolled 600 women; 426 were eligible for postpartum assessment. At six weeks and three months postpartum, 15.9% and 12.7% screened positive for depression respectively. Positive post-traumatic stress disorder screenings at six weeks and three months postpartum were 6.2% and 5.1% respectively. Twenty-seven women (8.3%) with a negative screening at six weeks converted to a positive depression or post-traumatic stress disorder screening at three months. A pre-existing history of anxiety or depression was associated with an increased risk of developing depression (aOR 2.12, 95% CI 1.30 to 3.47) and post-traumatic stress (aOR 3.15, 95% CI 1.42 to 7.02) within three months postpartum. The risk of developing post-traumatic stress disorder within three months postpartum was also increased among patients experiencing their first delivery (aOR 2.55, 95% CI 1.10 to 5.88) or operative management of postpartum hemorrhage (aOR 4.44, 95% CI 1.16 to 17.02).

CONCLUSION

Depression and post-traumatic stress symptoms either persisted or had new onset at three months postpartum. Mental health screening and postpartum follow-up after six weeks should be considered in high-risk patients who have a history of psychopathology, nulliparity, or undergo operative management of postpartum hemorrhage.

Historic review of long-term outcomes research

PURPOSE OF REVIEW

This review summarizes the results from long-term intensive care outcome research over the past 50 years. Key findings from early studies are reflected in citations of contemporary research.

RECENT FINDINGS

The postintensive care syndrome (PICS) is a multifaceted entity of residual disability and complications burdening survivors of critical illness. Some interventions applied early in the history of outcomes research have now been confirmed as effective in counteracting specific PICS components.

SUMMARY

Interest in patient-centred outcomes has been present since the beginning of modern intensive care. Findings from early long-term studies remain valid even in the face of contemporary large registries that facilitate follow-up of larger cohorts. A further understanding of the mechanisms leading to experienced physical and psychological impairment of PICS will be essential to the design of future intervention trials.

Association Between Perceived Threat and the Development of Posttraumatic Stress Disorder Symptoms in Patients With Life-threatening Medical Emergencies

BACKGROUND

Our objectives were to test whether during a potentially life-threatening medical emergency, perceived threat (a patient's sense of life endangerment) in the emergency department (ED) is common and associated with the subsequent development of posttraumatic stress disorder (PTSD) symptoms.

METHODS

This study was an ED-based prospective cohort study in an academic hospital. We included adult patients requiring acute intervention in the ED for resuscitation of a potentially life-threatening medical emergency, defined as respiratory or cardiovascular instability. We measured patient-perceived threat in the ED using a validated patient self-assessment measure (score range = 0 to 21, with higher scores indicating greater perceived threat). We performed blinded assessment of PTSD symptoms 30 days after discharge using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5).

RESULTS

Ninety-nine of 113 (88%) patients completed follow-up, with 98% reporting some degree of perceived threat, median (interquartile range [IQR]) perceived threat score 12 (6 to 17), and 72% reported PTSD symptoms in relation to their ED visit (median [IQR] PCL-5 score = 7 [0 to 30]). Patients with respiratory instability had higher median (IQR) perceived threat scores (16 [9 to 18] vs. 9 [6 to 14)] and PCL-5 scores (10 [2 to 40] vs. 3 [0 to 17]) compared to patients without respiratory instability. In a multivariable linear regression model adjusting for potential confounders, greater perceived threat in the ED was independently associated with higher PCL-5 scores (β = 0.79, 95% confidence interval [CI] = 0.15 to 1.42). Among the individual perceived threat items, the feeling of helplessness during resuscitation had the strongest association with PCL-5 score (β = 5.24, 95% CI = 2.29 to 8.18).

CONCLUSIONS

Perceived threat during potentially life-threatening emergencies is common and independently associated with development of PTSD symptoms. Additional research to test whether reduction of perceived threat in the ED attenuates the development of PTSD symptoms following potentially life-threatening emergencies is warranted.

Circumnavigating the world of quality and patient safety: a compendium of highlights and perspectives

Background

In the UK, estimates suggest that approximately 10% of hospital admissions and 1–2% of primary care consultations result in some sort of adverse event. Globally, medication errors cost approximately US$42 billion annually, and 15% of total health spending in Organisation for Economic Cooperation and Development countries is used to deal with adverse events.

Method

Stemming from the Glasgow 2019 British Medical Journal and Institute for Healthcare Improvement International Forum on Quality and Safety in Healthcare (‘People Make Change’), a review of workforce characteristics, the psychology of change and design thinking in healthcare is presented. The concept of personalised care is also discussed.

Conclusion

In the last decade, the National Health Service in Scotland has undergone major reform around the integration of health and social care. In tandem with this, there have been a range of national initiatives to support patient safety and quality improvement. Moving forward, there is an increasing realisation of how service design, digital technologies and a national digitised infrastructure can improve services. Implications highlight the role of workforce development and in embedding design thinking in service organisation. This review article therefore presents an anthology of highlights and perspectives in improving healthcare quality and patient safety.

Stressing Out About the Heart: A Narrative Review of the Role of Psychological Stress in Acute Cardiovascular Events

OBJECTIVES

Survivors of acute cardiovascular disease (CVD) events, such as acute coronary syndrome (ACS) and stroke, may experience significant psychological distress during and following the acute event. Long-term adverse effects may follow, including the development of posttraumatic stress disorder (PTSD), increased overall all-cause mortality, and recurrent cardiac events. The goal of this concepts paper is to describe and summarize the rates of adverse psychological outcomes, such as PTSD, following cardiovascular emergencies, to review how these psychological factors are associated with increased risk of future events and long-term health and to provide a theoretical framework for future work.

METHODS

A panel of two board-certified emergency physicians, one with a doctorate in experimental psychology, along with one PhD clinical psychologist with expertise in psychoneuroendocrinology were co-authors involved in the paper. Each author used various search strategies (e.g., PubMed, Psycinfo, Cochrane, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors RESULTS: A meta-analysis of 24 studies (N > 2,300) found the prevalence of ACS-induced PTSD at nearly 12%, while a meta-analysis of nine studies (N = 1,138) found that 25% of survivors of transient ischemic attack and stroke report PTSD symptoms. The presence of PTSD doubles 3-year risk of CVD/mortality risk in ACS survivors. Cardiac patients treated during periods of ED overcrowding, hallway care, and perceived poor clinician-patient communication appear at greater risk for subsequent PTSD.

CONCLUSIONS

Psychological stress is often present in patients undergoing evaluation for acute CVD events. Understanding such associations provides a foundation to appreciate the potential contribution of psychological variables on acute and long-term cardiovascular recovery, while also stimulating future areas of research and discovery.

Validation of a 5-item tool to measure patient assessment of clinician compassion in the emergency department

Background

To test if the 5-item compassion measure (a tool previously validated in the outpatient setting to measure patient assessment of clinician compassion) is a valid and reliable tool to quantify a distinct construct (i.e. clinical compassion) among patients evaluated in the emergency department (ED).

Methods

Cross-sectional study conducted in three academic emergency departments in the U.S. between November 2018 and April 2019. We enrolled adult patients who were evaluated in the EDs of the participating institutions and administered the 5-item compassion measure after completion of care in the ED. Validity testing was performed using confirmatory factor analysis. Cronbach’s alpha was used to test reliability. Convergent validity with patient assessment of overall satisfaction questions was tested using Spearman correlation coefficients and we tested if the 5-item compassion measure assessed a construct distinct from overall patient satisfaction using confirmatory factor analysis.

Results

We analyzed 866 patient responses. Confirmatory factor analysis found all five items loaded well on a single construct and our model was found to have good fit. Reliability was excellent (Cronbach’s alpha = 0.93) among the entire cohort. These results remained consistent on sub-analyses stratified by individual institutions. The 5-item compassion measure had moderate correlation with overall patient satisfaction (r = 0.66) and patient recommendation of the ED to friends and family (r = 0.57), but reflected a patient experience domain (i.e. compassionate care) distinctly different from patient satisfaction.

Conclusions

The 5-item compassion measure is a valid and reliable tool to measure patient assessment of clinical compassion in the ED.

Protocol for a prospective, observational cohort study of awareness in mechanically ventilated patients admitted from the emergency department: the ED-AWARENESS study

INTRODUCTION

Awareness with paralysis is a complication with potentially devastating psychological consequences for mechanically ventilated patients. While rigorous investigation into awareness has occurred for operating room patients, little attention has been paid outside of this domain. Mechanically ventilated patients in the emergency department (ED) have been historically managed in a way that predisposes them to awareness events: high incidence of neuromuscular blockade use, underdosing of analgesia and sedation, delayed administration of analgesia and sedation after intubation, and a lack of monitoring of sedation targets and depth. These practice patterns are discordant to recommendations for reducing the incidence of awareness, suggesting there is significant rationale to examine awareness in the ED population.

METHODS AND ANALYSIS

This is a single centre, prospective cohort study examining the incidence of awareness in mechanically ventilated ED patients. A cohort of 383 mechanically ventilated ED patients will be included. The primary outcome is awareness with paralysis. Qualitative reports of all awareness events will be provided. Recognising the potential problem with conventional multivariable analysis arising from a small number of events (expected less than 10-phenomenon of separation), Firth penalised method, exact logistic regression model or penalised maximum likelihood estimation shrinkage (Ridge, LASSO) will be used to assess for predictors of awareness.

ETHICS AND DISSEMINATION

Approval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.

Curricula for empathy and compassion training in medical education: A systematic review

Background

Empathy and compassion are vital components of health care quality; however, physicians frequently miss opportunities for empathy and compassion in patient care. Despite evidence that empathy and compassion training can be effective, the specific behaviors that should be taught remain unclear. We synthesized the biomedical literature on empathy and compassion training in medical education to find the specific curricula components (skills and behaviors) demonstrated to be effective.

Methods

We searched CENTRAL, MEDLINE, EMBASE, and CINAHL using a previously published comprehensive search strategy. We screened reference lists of the articles meeting inclusion criteria to identify additional studies for potential inclusion. Study inclusion criteria were: (1) intervention arm in which subjects underwent an educational curriculum aimed at enhancing empathy and/or compassion; (2) clearly defined control arm in which subjects did not receive the curriculum; (3) curriculum was tested on physicians (or physicians-in-training); and (4) outcome measure assessing the effect of the curriculum on physician empathy and/or compassion. We performed a qualitative analysis to collate and tabulate effects of tested curricula according to recommended methodology from the Cochrane Handbook. We used the Cochrane Collaboration’s tool for assessing risk of bias.

Results

Fifty-two studies (total n = 5,316) met inclusion criteria. Most (75%) studies found that the tested curricula improved physician empathy and/or compassion on at least one outcome measure. We identified the following key behaviors to be effective: (1) sitting (versus standing) during the interview; (2) detecting patients’ non-verbal cues of emotion; (3) recognizing and responding to opportunities for compassion; (4) non-verbal communication of caring (e.g. eye contact); and (5) verbal statements of acknowledgement, validation, and support. These behaviors were found to improve patient perception of physician empathy and/or compassion.

Conclusion

Evidence suggests that training can enhance physician empathy and compassion. Training curricula should incorporate the specific behaviors identified in this report.