Evaluating the Outcomes of a Registered Nurse Empathy Education Program in an Academic Medical Center

Sunday, 30 July 2017: 1:15 PM

Dawn M. Gubanc-Anderson, DNP
BSN Program, Chamberlain College of Nursing, Cleveland Campus, Cleveland, OH, USA

Oncology patients face many challenges in our current health care system. Some of the most notable include an increasing number of medical errors, escalating cost, and a lack of healthcare-provider compassion (Schwartz & Bohay, 2012). Such challenges have the potential to create a patient care experience that is both dehumanizing and dissatisfying (Rogers, Karlsen & Addington‐Hall, 2000). When patients do not experience empathy in the healthcare setting, they miss opportunities to build a therapeutic relationship with their provider, may encounter additional pain and anxiety, and are more likely to be non-compliant with medication regimes (Kelley, Kraft-Todd, Schapia, Kossowsky, & Reiss, 2014). Patients and their families may feel alienated, unheard, or disenchanted when not treated with dignity and respect, hallmarks of empathic communication (Wald & Reis, 2010). Dwamena, et al., (2013) states that a lack of empathy can even increase the risk that patients will initiate litigation against providers. Additionally, it has been established that healthcare providers who give patients the impression they do not believe or understand them can worsen patients' symptoms by creating anger and distress (Greville-Harris & Dieppe, 2015).

In addition to having a negative effect on patients, a lack of empathy can also have a financial impact on a healthcare organization. The Centers for Medicare & Medicaid (CMS) in the United States created a Hospital Value-Based Purchasing (VBP) Program which rewards acute-care hospitals with incentive payments for the quality of care they provide to people with Medicare (Giordano et al., 2009).The VBP program uses, in part, data from the Hospital Consumer Assessment of Healthcare Providers (HCAHPS) survey, which includes many questions focused on nurse communication (Giordano et al., 2009). When nurses lack empathy, it places patient satisfaction and patient outcomes at risk (Paley, 2014) and can decrease a hospital's incentive payments from CMS.

To address the potential lack of healthcare provider empathy in the oncology population, a cost-effective, readily accessible web-based training program was created. This web-based empathy training module for the oncology registered nurse was created using the Communicate with C.A.R.E. Model®. The Communicate with Care Model® program was designed by applying the following principles from the educational literature: (1) lecture-style methods alone are ineffective; (2) adult learning principles must be used; (3) teaching needs to include skills practice; (4) teaching must attend to learner attitudes and emotions; (5) the learning environment must integrate knowledge, skills, and attitudes; and (6) reinforcement is critical for the learning process.

 Despite the fact that relationship-based care is a cornerstone of good nursing practice, and empathic communication is part of such care (Koloroutis, 2004), nurses rarely receive empathy training (Herbek & Yammarino, 1990). Even though health care providers differ in their innate capacities, as with any other skill in healthcare, clinical empathy can be taught and acquired (Buckman et al., 2011). When nurses receive empathy education, many positive outcomes impact both the patient and the provider. For example, possessing an empathy skill set allows a registered nurse to feel empowered and prepared for his/her shift (LaSala & Bjarnason, 2010). It may even improve employee engagement as the nurse may feel more confident in his/her abilities (Tulsky, et al., 2011). Engaging in an empathic way can also lead to greater nursing satisfaction related to the quality of their work (Tulsky, et al., 2011). Empathy has also been shown to decrease caregiver fatigue in those who practice it (Tulsky, et al., 2011). And patient outcomes seem to improve after provider empathy training as well. An Italian study analyzed the clinical outcomes of more than 20,000 patients with diabetes. These patients were assigned to three different groups of physicians who were pre-evaluated for their levels of empathy. Physicians with the highest empathy scores achieved the best clinical outcomes for their patients; their patients had statistically significant lower levels of diabetic complications than the groups in which physicians had scored lower in empathy. Dwamena, et al., (2013) concludes that effective provider-patient communication improves patients' symptoms, emotional health, physiologic responses, and pain levels, creating a very strong argument that teaching empathy skills can have many favorable outcomes (Kelley, Kraft-Todd, Schapia, Kossowsky, & Reiss, 2014).

Although little research on empathy training in nursing has been done, there are types of training that have been shown to be effective (Lane & Rollnick, 2007). Human simulation has been used as a successful learning strategy for empathy instruction for health care providers and can provide the opportunity for provider’s self-awareness and values assessment (Cook et al., 2011; Gonzalez et al., 2010; Mullen & Kothe, 2010). Simulation has been widely used as an educational tool in both "live" and "recorded" educational offerings (Vaniaere, Timmerman, Stevens, & Gastmans, 2012). The evidence suggests that human simulation methodology is effective for both new knowledge acquisition and knowledge retention (Gair, 2012). Tulsky et al., (2011) have demonstrated that web-based physician empathy education significantly increases the patient's trust in the provider's care and builds self-confidence in the provider using the skills. Web-based training offers a cost-effective solution and can be accessible to a large number of participants. The use of a web-based educational tutorial including patient simulations may prove to be a valid and reliable solution to educate nurses on empathy skills (Cook et al., 2011).


 In this pre-post quality improvement project, 24 oncology nurses were instructed on the cognitive and affective skills required for empathic communication. The primary goal was to increase registered nurses' comfort level with using empathic communication skills.

Empathy confidence levels of the participating nurses were assessed before the nurses watched the training video, and measured again immediately after completing the web-based training program. The results of this quality improvement project support previous findings that empathy skills can be taught to healthcare providers. It also reinforces the research that human simulation is an effective teaching strategy in healthcare. This quality improvement project demonstrated an overall improvement in Jefferson Empathy Scale (JES) scores, t (24) =.78, p = .000. Additionally, individual item comparisons revealed a statistically significant increase in the JES questions related to “perspective taking” p = .000, and the “compassionate care” subscale p = .000. While the third subscale “walking in patients shoes” did show an increase in the pre and post score, it was not statistically significant;  p = .108.

These findings demonstrate that web-based learning using human simulation can provide a teaching methodology that satisfies practicing oncology nurses. Additionally, this empathy training program can increase a Registered Nurse's comfort and confidence in using empathic skills. These findings warrant additioanl research in this area in a larger sample, varying settings and nursing specialities, as well as in student nurse education.