Exploring patient views of empathic optimistic communication for osteoarthritis in primary care: a qualitative interview study using vignettes

Talking in primary care (TIP): protocol for a cluster-randomised controlled trial in UK primary care to assess clinical and cost-effectiveness of communication skills e-learning for practitioners on patients' musculoskeletal pain and enablement

INTRODUCTION

Effective communication can help optimise healthcare interactions and patient outcomes. However, few interventions have been tested clinically, subjected to cost-effectiveness analysis or are sufficiently brief and well-described for implementation in primary care. This paper presents the protocol for determining the effectiveness and cost-effectiveness of a rigorously developed brief eLearning tool, EMPathicO, among patients with and without musculoskeletal pain.

METHODS AND ANALYSIS

A cluster randomised controlled trial in general practitioner (GP) surgeries in England and Wales serving patients from diverse geographic, socioeconomic and ethnic backgrounds. GP surgeries are randomised (1:1) to receive EMPathicO e-learning immediately, or at trial end. Eligible practitioners (eg, GPs, physiotherapists and nurse practitioners) are involved in managing primary care patients with musculoskeletal pain. Patient recruitment is managed by practice staff and researchers. Target recruitment is 840 adults with and 840 without musculoskeletal pain consulting face-to-face, by telephone or video. Patients complete web-based questionnaires at preconsultation baseline, 1 week and 1, 3 and 6 months later. There are two patient-reported primary outcomes: pain intensity and patient enablement. Cost-effectiveness is considered from the National Health Service and societal perspectives. Secondary and process measures include practitioner patterns of use of EMPathicO, practitioner-reported self-efficacy and intentions, patient-reported symptom severity, quality of life, satisfaction, perceptions of practitioner empathy and optimism, treatment expectancies, anxiety, depression and continuity of care. Purposive subsamples of patients, practitioners and practice staff take part in up to two qualitative, semistructured interviews.

ETHICS APPROVAL AND DISSEMINATION

Approved by the South Central Hampshire B Research Ethics Committee on 1 July 2022 and the Health Research Authority and Health and Care Research Wales on 6 July 2022 (REC reference 22/SC/0145; IRAS project ID 312208). Results will be disseminated via peer-reviewed academic publications, conference presentations and patient and practitioner outlets. If successful, EMPathicO could quickly be made available at a low cost to primary care practices across the country.

TRIAL REGISTRATION NUMBER

ISRCTN18010240.

Pain Empathy and Its Association with the Clinical Pain in Knee Osteoarthritis Patients

Objective

Knee osteoarthritis (KOA) is a painful chronic disorder. Evidence has shown that a history of chronic pain plays an important role in shaping empathy. Empathy, a valuable indicator of social functioning that refers to an individual's ability to share the experiences of others, however, has been overlooked in KOA patients. This study aimed to investigate empathy and its association with clinical pain in KOA patients.

Methods

KOA patients (n=47) and healthy controls (HCs, n=44) completed two empathy-for-pain tasks: a pain judgment task in which participants judged whether a person in an image felt pain or not, and a pain rating task in which they estimated pain intensity for themselves and others. The Interpersonal Reactivity Index was used to measure participants' trait empathy, and clinical severity and psychological factors were assessed using relevant instruments.

Results

Compared to HCs, KOA patients showed higher accuracy when judging pain and non-pain images and reported overall higher pain intensity when rating for themselves and others. KOA patients also showed greater personal distress than HCs in terms of their self-reported empathy. Moreover, pain catastrophizing particularly mediated the relationship between pain severity and pain ratings for others, and depression, anxiety, and pain catastrophizing all mediated the association between pain severity and empathy-induced personal distress.

Conclusion

These findings suggest that patients with KOA have increased empathy, demonstrated by elevated sensitivity to pain-related scenes and intense emotional responses.

Experiences of empathy training in healthcare: A systematic review of qualitative studies

OBJECTIVE

To synthesise qualitative studies reporting student, practitioner, or patient experiences of empathy-training in healthcare.

METHODS

We included qualitative studies exploring (i) student or practitioner experiences of empathy training, or (ii) patient experiences of being treated by someone who has undergone empathy training. We used the Critical Appraisal Skills Programme (CASP) tool to assess study quality. Thematic synthesis was used to integrate findings from studies and to generate new insights.

RESULTS

Our search yielded 2768 citations, of which 23 (1487 participants) met inclusion criteria. Two clusters of themes were identified from included studies. Firstly, themes related to practitioner/trainee professionalism and wellbeing, where the main finding was that participants experienced benefit from therapeutic empathy training. Secondly, themes related to the understanding and treatment of patients, where the main finding was practitioners' deeper recognition of the positive impact of empathic care.

CONCLUSIONS

This review found that taking part in empathy-focused training can benefit practitioner/student personal growth and professional development, and benefits patient care. This review is limited by the difficulty in defining empathy and heterogeneity amongst included studies.

PRACTICE IMPLICATIONS

These results support a rationale for empathy training and the development of a framework to ensure training is having the desired effect.

Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study

Background

The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship.

Methods

Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation.

Results

Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05).

Conclusions

In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07345-9.

The role of spiritual intelligence in predicting the empathy levels of nurses with COVID-19 patients

AIM

Given the prolongation of the newly emerging COVID-19 pandemic and the significance of caring for the patients by nursing staff, investigating and planning for the different psychological dimensions of this group is of paramount importance. Hence, this study investigated the role of spiritual intelligence in predicting nurses' empathizing with COVID-19 patients.

METHODS

This descriptive-correlation study was conducted in 2021 on nurses caring for COVID-19 patients in three public hospitals. The researchers used two standard questionnaires, including the Jefferson Scale of Empathy (JSE) and Spiritual Intelligence (SI), for data collection. The collected data were analyzed in SPSS16 using descriptive statistics and the following: The Mann-Whitney U test, Kruskal-Wallis test, Regression, chi-square test, and Pearson and Spearman correlations.

RESULTS

The statistical population consisted of 338 nurses with an average age of 34 and ten years of work experience. There was a significant positive relationship between the empathy scores and spiritual intelligence scores of the nurses caring for COVID-19 patients (P < 0.05). It was also concluded from the regression analysis that, spiritual intelligence affect empathy. Mean score of empathy was higher in hospitals where more nursing staff had MSc degrees. There was a significant difference between the empathy scores of the three hospitals (P < 0.05).

CONCLUSION

The results indicated that there is a positive relationship between empathy and spiritual intelligence. Therefor improving spiritual intelligence is the appropriate strategy to ameliorate empathy during the COVID19 pandemic. At the same time, study indicated attention to the issue of nurses' mental health. Hence, it was suggested to incorporate these issues in the training programs and national/international decisions.

Harnessing Placebo Effects in Primary Care: Using the Person-Based Approach to Develop an Online Intervention to Enhance Practitioners' Communication of Clinical Empathy and Realistic Optimism During Consultations

Background: Empathic communication and positive messages are important components of "placebo" effects and can improve patient outcomes, including pain. Communicating empathy and optimism to patients within consultations may also enhance the effects of verum, i.e., non-placebo, treatments. This is particularly relevant for osteoarthritis, which is common, costly and difficult to manage. Digital interventions can be effective tools for changing practitioner behavior. This paper describes the systematic planning, development and optimization of an online intervention-"Empathico"-to help primary healthcare practitioners enhance their communication of clinical empathy and realistic optimism during consultations. Methods: The Person-Based Approach to intervention development was used. This entailed integrating insights from placebo and behavior change theory and evidence, and conducting primary and secondary qualitative research. Systematic literature reviews identified barriers, facilitators, and promising methods for enhancing clinical empathy and realistic optimism. Qualitative studies explored practitioners' and patients' perspectives, initially on the communication of clinical empathy and realistic optimism and subsequently on different iterations of the Empathico intervention. Insights from the literature reviews, qualitative studies and public contributor input were integrated into a logic model, behavioral analysis and principles that guided intervention development and optimization. Results: The Empathico intervention comprises 7 sections: Introduction, Empathy, Optimism, Application of Empathico for Osteoarthritis, Reflection on my Consultations, Setting Goals and Further Resources. Iterative refinement of Empathico, using feedback from patients and practitioners, resulted in highly positive feedback and helped to (1) contextualize evidence-based recommendations from placebo studies within the complexities of primary healthcare consultations and (2) ensure the intervention addressed practitioners' and patients' concerns and priorities. Conclusions: We have developed an evidence-based, theoretically-grounded intervention that should enable practitioners to better harness placebo effects of communication in consultations. The extensive use of qualitative research throughout the development and optimization process ensured that Empathico is highly acceptable and meaningful to practitioners. This means that practitioners are more likely to engage with Empathico and make changes to enhance their communication of clinical empathy and realistic optimism in clinical practice. Empathico is now ready to be evaluated in a large-scale randomized trial to explore its impact on patient outcomes.