How does empathy training promote a healthy nursing workforce?
Authors: Jennifer Greenwood1, Alexandra Michel1, Lori Thuente1
1. Rosalind Franklin University Center for Interprofessional Evidence Based Practice: A JBI Centre of Excellence, Chicago, IL, USA
The World Health Organization estimates that in 2030, there will be a gap of about 5 million health workers globally, with nursing comprising the largest portion of that gap.1 Burnout is one reason why nurses are leaving the workforce. Researchers have determined that empathy is correlated to increased satisfaction with care, increased resilience, and decreased burnout.2-4 Hence, increasing and maintaining both self-empathy and empathy for others among nurses may decrease burnout and retain nurses in the workforce.
Nursing burnout significantly contributes to the nursing shortage. In 2020, prior to the COVID-19 pandemic, a study conducted by the American Nurses Association found that almost two-thirds of nurses reported feeling burned out, and that number is even higher among nurses under the age of 25.5 A post COVID-19 study conducted in Greece found that over 90% of nurses reported high levels of burnout and a diminished sense of job satisfaction,6 making burnout one of the primary causes of nurse turnover. Another study published in the Journal of the American Medical Association (JAMA) found that one-third of nurses left their current position for this reason.7 Then a vicious circle begins. As turnover increases, the remaining nurses must pick up more work, thus increasing their levels of burnout.
In addition to the impact on the nursing workforce, nurse burnout has a significant impact on patients, including increased medication errors, increased nosocomial infection rates, and falls. Given that nurses enter the profession to help people, causing accidental harm instead can undermine nurses’ sense of confidence, thus adding to their desire to leave.8
Enter empathy training
Communicating empathy is a core competency in nursing. The literature shows that demonstrating empathy improves the patient–provider relationship, improves patient outcomes, and enhances the resilience of providers. Empathy is a multi-faceted construct with multiple definitions. Hojat et al.8 distinguish clinical empathy from emotional empathy. Based on their definition, clinical empathy is a cognitive attribute that involves understanding of the patient’s perception, rather than having an emotional response to the patient’s experience.9 Researchers posit that clinical empathy can be taught9 and have demonstrated that simulation training can positively affect nursing students in developing deeper empathy.10 When measuring the impact of such simulations, studies tend to focus on a single form or episode of simulation involving a student “learning about” a patient’s condition, but not necessarily “experiencing” it.11-13There also appears to be only limited, data demonstrating a sustained improvement in empathy once nursing students enter the workforce, and how empathy affects other related issues such as resilience or burnout.14 Finally, research indicates that without formal empathy training, nursing students’ level of empathy actually decreases while in school.15, 16
Given the considerable need for nurses, the high cost of nurse turnover, as well as the cost of education, we want our students to become long-term career nurses. Here at the Rosalind Franklin University College of Nursing, we are proactively integrating empathy training into our nursing program in the hope of preventing or minimizing burnout. We focus on self-empathy as well as empathy for patients and colleagues. Using traditional adaptive equipment and innovative virtual reality with its corresponding software, we have integrated multi-modal empathy simulations throughout our curriculum.
The problem
Nursing burnout is at an all-time high. Lack of empathy among nurses has been linked to poor quality of nursing care, medical errors, and burnout.2-4 Teaching empathy has been shown to improve patient satisfaction and outcomes. This, in turn, improves nurse job satisfaction, thereby decreasing burnout.17-18 Hence, it is imperative that institutions teach empathy using immersive methods for lasting impact.
The search for answers
Given the impact of nurse burnout on both nurses and patients, it is imperative that we find solutions to prevent and counteract burnout. Our Empathy Lab simulations place the students “in the shoes” of their patients. Within each clinical course across eight-quarters of the curriculum, our students undergo an empathy simulation that aligns with the course content. Each simulation can last from 30 minutes to up to 8 hours.
For example, a student in a Gerontology course will participate in a virtual reality experience in which they “become” an elderly person named Beatriz who proceeds through early, middle, and late stage Alzheimer’s disease. Through the VR headset, students step into her world and feel her confusion and agitation, experience the visual and auditory changes associated with Alzheimer’s, suffer the family’s frustrated responses to her, and see how the professional caregiver manages her symptoms such as “sun-downing.”
A student in a Mental Health course will don traditional headphones and listen to auditory hallucinations similar to those that a person with schizophrenia might hear. During this time, the students are asked to read information, solve puzzles, and answer questions just as they normally would.
One more example is Disability Day. This is an 8-hour day during which students are assigned to be either a patient who is paralyzed from the waist down and confined to a wheelchair, or a patient who has had a stroke and wears restrictive medical equipment (arm sling with a wrist weight, knee brace with an ankle weight) on their dominant side to simulate hemiparesis. These physical impairments are designed to help students understand the challenges and difficulties that patients with these diagnoses encounter in their daily lives.
Following each simulation, we debrief the students to discuss their experiences. Then each student completes a written reflection answering three questions: How was this experience overall? What stood out to you the most? How will this experience change the care you provide to patients? The responses become part of a thematic analysis project being conducted. Although we have conducted pre- and post-test surveys, it is the written reflections that provide the most valuable data.
Potential global impact
Nurse burnout is a global problem and researchers across the world are studying different strategies to combat it. Many of the lessons utilized in the RFU Empathy Lab have come from collaborative conversations with educators across the globe, especially Australia, New Zealand, and the UK. As researchers continue to study the problem, publish the results, and implement evidence-based solutions— such as teaching empathy through simulation—we postulate that as empathy increases, burnout will decrease.
Challenges and lessons learned
As we continue to build the overall program curriculum, we are finding more ways to include empathy simulations into the courses. Resources such as class time, the availability of trainers, and funding continue to be obstacles that we are working to overcome. The reliability of the VR equipment remains a challenge and is something we are working on with the manufacturer.
Given the interprofessional mission of the university and the need for all healthcare providers to undergo empathy training, we are seeking to expand the Empathy Lab simulations to other programs within the university. Currently, we are evaluating the necessary resources to conduct an interprofessional Empathy Lab simulation with our physician assistant students, physical therapy students, and psychiatric mental health nurse practitioner residents.
Next steps
We are excited to grow the number of Empathy Lab simulations that we can offer and integrate them fully into the curriculum. We also anticipate working with clinical partners in the future to share this training with practicing nurses as well. Sharing our methods and resources with a global audience will accelerate the implementation of this type of training as a means of increasing empathy while creating reflective coping strategies to nurture the nursing workforce.
References
1. World Health Organization. (2024). Nursing and midwifery. https://www.who.int/news-room/fact-sheets/detail/nursing-and-midwifery
2. Yi, L., Cai, J., Shuai, T., Jiménez-Herrera, M. F., Gu, L., & Tian, X. (2024). Mediating effect of moral sensitivity and professional identity between moral courage and compassion fatigue among nursing interns: a cross-sectional study. BMC Nursing, 23(1), 551. https://doi.org/10.1186/s12912-024-02173-8
3. Duarte, J., & Pinto-Gouveia, J. (2017). Empathy and feelings of guilt experienced by nurses: A cross-sectional study of their role in burnout and compassion fatigue symptoms. Applied Nursing Research, 35, 42–47. https://doi.org/10.1016/j.apnr.2017.02.006
4. Sabanciogullari, S., Yilmaz, F. T., & Karabey, G. (2021). The effect of the clinical nurses' compassion levels on tendency to make medical error: A cross-sectional study. Contemporary Nurse, 57(1-2), 65–79. https://doi.org/10.1080/10376178.2021.1927772
5. American Nurses Association. (2024, April 25). What is nurse burnout? How to prevent it. https://www.nursingworld.org/content-hub/resources/workplace/what-is-nurse-burnout-how-to-prevent-it/#:~:text=How%20common%20is%20burnout%20in,nurses%20under%2025%20reporting%20burnout
Galanis, P., Moisoglou, I., Katsiroumpa, A., Vraka, I., Siskou, O., Konstantakopoulou, O., Meimeti, E., & Kaitelidou, D. (2023). Increased job burnout and reduced job satisfaction for nurses compared to other healthcare workers after the COVID-19 pandemic. Nursing Reports (Pavia, Italy), 13(3), 1090–1100. https://doi.org/10.3390/nursrep13030095
6. Shah, M. K., Gandrakota, N., Cimiotti, J. P., Ghose, N., Moore, M., & Ali, M. K. (2021). Prevalence of and factors associated with nurse burnout in the US. JAMA Network Open, 4(2), e2036469. https://doi.org/10.1001/jamanetworkopen.2020.36469
7. Pappa, D., Koutelekos, I., Evangelou, E., Dousis, E., Mangoulia, P., Gerogianni, G., Zartaloudi, A., Toulia, G., Kelesi, M., Margari, N., Ferentinou, E., Stavropoulou, A., & Dafogianni, C. (2023). Investigation of nurses' wellbeing towards errors in clinical practice: The role of resilience. Medicina (Kaunas, Lithuania), 59(10), 1850. https://doi.org/10.3390/medicina59101850
8. Hojat, M., Maio, V., Pohl, C. A., & Gonnella, J. S. (2023). Clinical empathy: definition, measurement, correlates, group differences, erosion, enhancement, and healthcare outcomes. Discovery Health Systems, 2, 8. https://doi.org/10.1007/s44250-023-00020-2
9. Hamaideh, S. H., Abuhammad, S., Khait, A. A., Al-Modallal, H., Hamdan-Mansour, A. M., Masa'deh, R., & Alrjoub, S. (2024). Levels and predictors of empathy, self-awareness, and perceived stress among nursing students: a cross sectional study. BMC Nursing, 23(1), 131. https://doi.org/10.1186/s12912-024-01774-7
10. Cho, M. K., & Kim, M. Y. (2024). Effectiveness of simulation-based interventions on empathy enhancement among nursing students: a systematic literature review and meta-analysis. BMC Nursing, 23(1), 319. https://doi.org/10.1186/s12912-024-01944-7
11. Efendi, D., Apriliyasari, R. W., Prihartami Massie, J. G. E., Wong, C. L., Natalia, R., Utomo, B., Sunarya, C. E., Apriyanti, E., & Chen, K. H. (2023). The effect of virtual reality on cognitive, affective, and psychomotor outcomes in nursing staffs: systematic review and meta-analysis. BMC Nursing, 22(1), 170. https://doi.org/10.1186/s12912-023-01312-x
12. Flood L. S. (2024). Use of virtual reality simulations to embody a patient: Exploring the impact on nursing students' confidence, feelings, and perceptions. Nurse Educator, 49(1), 36–40. https://doi.org/10.1097/NNE.0000000000001442
13. Delgado, N., Delgado, J., Betancort, M., Bonache, H., & Harris, L. T. (2023). What is the link between different components of empathy and burnout in healthcare professionals? A systematic review and meta-analysis. Psychology Research and Behavior Management, 16, 447–463. https://doi.org/10.2147/PRBM.S384247
14. Nunes, P., Williams, S., Sa, B., & Stevenson, K. (2011). A study of empathy decline in students from five health disciplines during their first year of training. International Journal of Medical Education, 2, 12–17. https://doi:10.5116/ijme.4d47.ddb0
15. Evli M. (2023). Compassion fatigue, empathy, and emotional contagion in nursing students. Journal of Education & Research in Nursing / Hemşirelikte Eğitim ve Araştırma Dergisi, 20(2), 105–110. https://doi:10.14744/jern.2021.833127
16. Waddimba, A. C., Bennett, M. M., Fresnedo, M., Ledbetter, T. G., & Warren, A. M. (2021). Resilience, well-being, and empathy among private practice physicians and advanced practice providers in Texas: A structural equation model study. Mayo Clinic Proceedings. Innovations, Quality & Outcomes, 5(5), 928–945. https://doi.org/10.1016/j.mayocpiqo.2021.08.009
17. Haley, B., Heo, S., Wright, P. B., Barone, C. P., Rettigantid, M. R., Anders, M. E. (2017). Effects of using an advancing care excellence for seniors simulation scenario on nursing student empathy: A randomized controlled trial. Clinical Simulation in Nursing, 13, 511-519. https://doi: 10.1016/J.ECNS.2017.06.003
18. Keshtkar, L., Madigan, C. D., Ward, A., Ahmed, S., Tanna, V., Rahman, I., Bostock, J., Nockels, K., Wang, W., Gillies, C. L., & Howick, J. (2024). The effect of practitioner empathy on patient satisfaction : A systematic review of randomized trials. Annals of Internal Medicine, 177(2), 196–209. https://doi.org/10.7326/M23-2168
To link to this article - DOI: https://doi.org/10.70253/BWTQ6847
Links to additional resources
Empathy Lab at Rosalind Franklin University, College of Nursing
https://www.rosalindfranklin.edu/helix/education-2024/empathy-lab/
Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.
