Empathy in healthcare professions: risky strength?
The health crisis we are witnessing today, due to the covid-19 emergency, has greatly affected the workload of health workers, their physical fatigue and their psychological well-being by exponentially increasing the risks of developing burnout syndromes.
Morelli Elisabetta and Poli Eleonora – OPEN SCHOOL Cognitive Psychotherapy and Research, Mestre
Advertising message The professions in the health sector are characterized, more than others, by constant interpersonal involvement and contact with human suffering. Doctors and nurses, with a multidisciplinary team work, face daily life-threatening patients (Yoguero et al., 2017). Emotional participation is inevitable and, if it can bring satisfaction and a sense of personal effectiveness, it is for some sources of strong stress and risk of burnout.
It is shown how a key element for the success of the patient’s treatment is the empathy manifested by the attending figure (Walocha, Tomasewski, Wilczek-ruzyczka & Walocha, 2013). It increases patient compliance and confidence in therapy, improves disease prognosis and patient satisfaction and reduces the number of lawsuits against the doctor (Decety, Smith, Norman & Halpern, 2014; Fulop, Devecsery , Hausz, Kovacs & Csabai, 2011). Patients also tend to recommend the doctor if he is recognized as empathic (Zenasni, Boujut, Woerner & Sultan, 2012).
In short, it is now clear that empathy in the health professions represents an important element which, associated with better clinical skills and efficacy in treatment, produces a positive effect on the quality of life of patients as well as of the attending physician who evaluates the relationship with patients as source of greater personal satisfaction.
However empathy, while being a strong point, can sometimes become risky especially in the healthcare environment where one has to deal with the most emotionally distressing situations: illness, death and suffering in all forms. This painful reality can put a strain on healthcare professionals leading to compassion fatigue, exhaustion, professional stress and all of this can result in a low sense of accomplishment and severe emotional exhaustion.
What exactly is empathy? There are several definitions of empathy in the literature. Singer (2006), for example, defines empathy in this way: we empathize with others when there is an affective state which is isomorphic to the affective state of another person, who was aroused by observing or imagining an emotional state of another person and when we know that the affective state of the other person is the source of our affective state. In other words, empathy is the ability to see the world as others see it, to be non-judgmental, to understand the feelings of others while keeping them distinct from their own. It is a multidimensional construct characterized by two main components: emotional empathy and cognitive empathy. Emotional empathy, also called emotional contagion, it is an automatic response that leads us to experience the same emotion felt by the person in front of us. Cognitive empathy, more sophisticated, consists in the ability to understand other people’s internal states and take their point of view. It is an intentional process that involves executive resources and self-regulation skills of the emotions experienced. Both forms are necessary because one person could well understand what the other thinks and feels, without however “feeling” the emotions of the other and having compassion for them, or a person can be infected and overwhelmed by the emotions of others, without understanding what happens and distinguish one’s mental contents from those of the other. it consists in the ability to understand other people’s internal states and take their point of view. It is an intentional process that involves executive resources and self-regulation skills of the emotions experienced. Both forms are necessary because one person could understand well what the other thinks and feels, without however “feeling” the emotions of the other and having compassion for them, or a person can be infected and overwhelmed by the emotions of others, without understanding what happens and distinguish one’s mental contents from those of the other. it consists in the ability to understand other people’s internal states and take their point of view. It is an intentional process that involves executive resources and self-regulation skills of the emotions experienced. Both forms are necessary because one person could understand well what the other thinks and feels, without however “feeling” the emotions of the other and having compassion for them, or a person can be infected and overwhelmed by the emotions of others, without understanding what happens and distinguish one’s mental contents from those of the other.
So empathy is synonymous with quality of care and better therapeutic outcome. But what are the long-term consequences of this empathic structure? Is strong emotional involvement with the patient beneficial to the doctor himself or can it instead cause stress, emotional exhaustion, and potentially lead to burnout? The health crisis we are witnessing today, due to the covid-19 emergency, has had a huge impact on the health workers’ workload, their physical fatigue and their psychological well-being. The rapid spread of the epidemic, the scarcity of resources and equipped treatment places, the management of stressful shifts,
Burnout, defined as “helping relationship pathology” (Galam, 2007), is a state of physical, emotional and mental exhaustion due to long-term involvement in work situations that are highly emotional in demand. This chronic occupational stress has both personal and interpersonal implications. It decreases the interest in one’s work and in the patient’s well-being, leads to less communication and a loss of an active attitude towards the outside world. According to Maslach’s model, burnout is defined by three interrelated dimensions: emotional exhaustion, depersonalization and poor personal satisfaction. Emotional exhaustion is manifested by loss of enthusiasm at work and feeling helpless, trapped and defeated. The person may experience symptoms such as headache, aggression and irritability, isolation, anxiety and depression, sleep disturbances, up to the possibility of implementing risky behaviors. Depersonalization occurs when the healthcare professional becomes cynical and begins to treat the patient with indifference, objectifies him and develops a negative attitude towards his colleagues and the profession. The sense of low self-efficacy is characterized by the withdrawal of the individual from his responsibilities, a detachment from work and the tendency to adopt a negative conception of himself as a consequence of situations without personal rewards and rewards (Ferri, Guerra, Marcheselli, Cunico & Di Lorenzo, 2015; Romani & Ashkar, 2014). If the consequences of burnout are significant for the individual, so are the consequences for the workplace. In the professional, the ability to be of help to the other is lost, thus reducing the quality of care and increasing patient dissatisfaction. In addition, work delays, absenteeism and layoffs entail high costs for the company.
Burnout and empathy are closely linked but in the literature there are contradictory results regarding the nature of this relationship. This reflects the variety of hypotheses that seek to explain the causal relationship between the onset of burnout and empathy (Thirioux, Birault & Jaafari, 2016; Vévodová, Vévoda, Vetešníková, Kisvetrová & Chrastina, 2016). Can empathy cause burnout or, on the contrary, could it represent a protective factor? According to the theory of compassion (Figley, 2002), burnout would be linked to an excess of empathy, which would make it more vulnerable to the stressful factors inherent in the profession; on the contrary, according to the theory of emotional dissonance (Bonino, 2006), burnout would be associated with poor empathic abilities found especially in people with alexithymic traits (Gleichgerrcht & Decety,
Which theory to give credit to? Clarity can be done by considering the two main components of empathy: emotional and cognitive. Emotional empathy acts as a reflex and makes us involuntarily experience what the other person feels, his suffering and this can lead to hyperarousal and high distress. The malaise of patients and their constant need for attention and listening will lead to being emotionally exhausted and to experience an extreme state of tension, worry and inability to detach from patients’ problems. In this case, the negative emotional state experienced will cause an action to be taken in order to reduce the malaise felt and not that of the other person with the consequent inability to provide compassionate care and to make effective diagnoses. This high personal distress,
Advertising message Cognitive empathy allows you to represent the mental states of the self and the other as distinct entities and to regulate your emotions in different situations. A person with good levels of cognitive empathy will be able to identify which emotions belong to those who, during empathic involvement, will be able to operate the right interpersonal involvement with the patient while protecting their emotional boundaries (Hunt et al., 2017). Here then the doctor, as well as the patient, will benefit and satisfaction from the interaction and the relationship of care with a consequent reduction of the potential risks of developing burnout. The ability to regulate one’s emotions is crucial. Without this ability, an excess of emotional empathy could be detrimental to the well-being of the health figure and lead to an inability to actually help the patient. Emotional empathy can only be useful when it is adaptively mediated by cognitive empathy and self-regulation otherwise, it can become a danger. The literature has shown that vulnerability to distress in the care professions is specifically linked to deficits in the regulation of one’s negative emotions (Decety et al., 2014). Doctors who have difficulty describing, identifying and regulating their emotions seem to be more prone to emotional exhaustion, detachment and low sense of accomplishment. In reverse,
Hence, emotional sharing with poor self-regulation and reduced ability to take the perspective of the other can lead to personal discomfort, which diminishes empathic concern and pro-social behavior. On the contrary, functional empathy is given by a good balance between the emotional and cognitive dimensions. Being overly empathetic with the pain of others without having the ability to regulate one’s emotions ends up generating the empathy syndrome, also known as compassion fatigue. Charles Figley (2002) defines it as a state of profound fatigue and unceasing concern for helping people who have gone through difficult or traumatic situations.
The ideal approach for healthcare professionals should therefore be that of clinical empathy (Zenasni et al., 2012), which prevents one from being too compassionate and sympathetic, but without thereby ignoring patients’ emotional reactions and feelings. It involves understanding the patient’s internal experiences and perspectives as a separate individual, combined with an ability to communicate that understanding to the patient. Clinical empathy must include the ability to distinguish the self from the other in such a way as not to experience his own emotions and sufferings. This protects in the long term from exhaustion, from depersonalization and helps prevent burnout (Ekman & Halpern, 2015; Juszkiewicz & Debska, 2015).
In light of the benefits that an empathic approach can bring to the psychophysical well-being of health professionals and patients, and to the high social and economic costs that burnout can entail, it is useful to evaluate what strategies can be used to enhance the empathic skills of healthcare figures avoiding burnout. Evidence-based approaches and the technological push in the diagnosis and treatment of patients, certainly fundamental and precious, can make us lose the human perspective on the patient and lead to the false idea that empathy is foreign to all this and that it has no relevance in the treatment and care process.
At an organizational level, in the workplace, it is important to encourage positive personal interactions and create a sense of belonging to the group, provide positive feedback to the health worker, take care of his well-being and enhance his empathic attitude (Haramati, Cotton, Padmore, Wald & Weissinger, 2017; Yoguero et al., 2017). As for the intervention on the individual, it has been seen that empathy is a skill that can be learned and developed through education and practice. Empathic training has proved effective both on university students and on doctors and nurses already in the profession. They focus on skills such as giving attention to others, knowing how to listen to oneself and others, knowing how to self-monitor and self-regulate one’s emotional reactions, learn active listening,
Mindfulness practices have demonstrated a significant effect on reducing burnout among healthcare professionals (Surguladze et al., 2018). Mindfulness could be considered more generally as an attitude to deal with emotional situations that every day, especially in this period, healthcare personnel live with a focus on current experience. From this perspective, awareness could have a positive effect on the regulation of emotions in everyday emotional situations thus reducing anxiety and stress and contributing to the maintenance of empathy.
Empathy in the healthcare professions is a demanding exercise that requires cognitive flexibility and high levels of self-regulation. These cognitive resources can become limited due to the demanding and very stressful work that exposes doctors and nurses to greater vulnerability for burnout.
It is important to be able to recognize the negative emotions aroused by daily experience and to know that there is the possibility of talking about them and of burnout in the workplace, without incurring the risk of being stigmatized. Favoring training programs on empathy therefore becomes a fundamental objective to promote professional well-being, especially in a historical moment like the one we are going through.