Research in Gerontological Nursing

Theory 

Model of Empathic Pain Assessment and Treatment in Persons With Dementia

Lauren T. Starr, PhD, MBE, BA, RN; Kristin Corey Magan, PhD, RN, AGPCNP-BC

Abstract

The current article presents an evidence-based model for understanding clinical empathy's relationship with the assessment and treatment of pain in persons with advanced dementia. A literature review informed creation of an interdisciplinary conceptual framework of clinician empathy in pain assessment and treatment among persons with advanced dementia. Driven by observation of behaviors indicating pain in persons with dementia unable to self-report, the model represents the cognitive, affective, ethical, and behavioral components of clinical empathy involved in assessing and treating pain, relevant patient outcomes, and contextual factors influencing empathy and outcomes; and provides a framework for testing clinical empathy interventions to improve adverse outcomes in persons with advanced dementia. Understanding the relationship between clinician empathy and the assessment and treatment of pain in persons with advanced dementia may improve care quality and help reduce pain behaviors in this patient population. This model may be used to inform pain research in persons with dementia and develop clinical interventions and clinician education programs. [Research in Gerontological Nursing, 13(5), 264–276.]

Abstract

The current article presents an evidence-based model for understanding clinical empathy's relationship with the assessment and treatment of pain in persons with advanced dementia. A literature review informed creation of an interdisciplinary conceptual framework of clinician empathy in pain assessment and treatment among persons with advanced dementia. Driven by observation of behaviors indicating pain in persons with dementia unable to self-report, the model represents the cognitive, affective, ethical, and behavioral components of clinical empathy involved in assessing and treating pain, relevant patient outcomes, and contextual factors influencing empathy and outcomes; and provides a framework for testing clinical empathy interventions to improve adverse outcomes in persons with advanced dementia. Understanding the relationship between clinician empathy and the assessment and treatment of pain in persons with advanced dementia may improve care quality and help reduce pain behaviors in this patient population. This model may be used to inform pain research in persons with dementia and develop clinical interventions and clinician education programs. [Research in Gerontological Nursing, 13(5), 264–276.]

More than 130 million people worldwide are expected to have Alzheimer's disease or a related dementia by the year 2050 (Alzheimer's Disease International, 2015), with one half likely to regularly experience pain as current evidence suggests (Achterberg et al., 2013; Corbett et al., 2012; van Kooten et al., 2015). Prevalence of persistent pain (58%) is even higher for persons with dementia living in long-term care facilities (van Kooten et al., 2017), a population expected to grow in coming years (Shih et al., 2014). Although a recent study found most nursing home residents with moderate to severe dementia had mild usual pain and a majority received at least one pain treatment the previous week (e.g., acetaminophen), approximately one half of residents experienced moderate to severe pain during the previous week (Ersek et al., 2019).

Language difficulties, which increase as cognition and function progressively decline in dementia, commonly affect persons with dementia (Banovic et al., 2018; Tang-Wai & Graham, 2008) and limit a person's ability to self-report pain (Corbett, Husebo, et al., 2014; Flo et al., 2014; Ford et al., 2015). In the early stage of dementia, persons may forget words and common names; but as illness progresses, difficulty with comprehension, sentence construction, pronunciation, and conversational cohesion increase until language and speech are fully compromised in the most severe stage of dementia (Alzheimer's Association, n.d.; Klimova & Kuca, 2016; Klimova et al., 2015). To identify pain in the absence of self-report in persons with advanced dementia, clinicians must routinely rely on observable pain behaviors as indicators of pain in the context of recommended pain assessment techniques (Herr et al., 2019; Lautenbacher et al., 2018). Clinicians must also rely on observable pain behaviors when assessing pain in persons with stroke-related dementias, mixed dementias, and delirium superimposed on dementia when self-report is unavailable (Flanagan & Fick, 2010). Unfortunately, many clinicians are unsure how to interpret pain behaviors (Lautenbacher et al., 2018). These limitations contribute to underrecognition and undertreatment of pain in persons with dementia (Ford et al., 2015; Hadjistavropoulos et al., 2014; Herr et al., 2011) and may explain why approximately one half of persons with dementia who experience moderate to severe pain receive no pain medication at all (Thakur et al., 2017).

Evidence suggests higher levels of clinician empathy are associated with more sensitive identification and interpretation of pain behaviors and treatment of pain in the general population (Gleichgerrcht & Decety, 2014; Goubert et al., 2005; Green et al., 2009). Clinical empathy, the modifiable ability to perceive the meanings, feelings, and lived experiences of others and communicate that understanding through words and actions (Gagan, 1983; Halpern, 2003; Irving & Dickson, 2004; Larson & Yao, 2005; Santamaría-García et al., 2017), motivates clinicians to apply time, energy, and effort to identify and alleviate the source of distress harming their patients (Decety & Yoder, 2016; Lockwood et al., 2017).

In the literature, it is sometimes difficult to distinguish between empathy and compassion, which is defined as a rational response to help alleviate suffering that proceeds from empathy (Perez-Bret et al., 2016). Specifically, compassion originates from empathic concern for others (Soto-Rubio & Sinclair, 2018). The current model focuses on empathy and not compassion because empathy is the source of compassion (Perez-Bret et al., 2016) and because neurological studies about brain activity related to pain observation, evaluation, and treatment predominantly focus on empathy and not compassion (Bzdok et al., 2012; Lamm et al., 2011).

Although clinician empathy studies involving persons with dementia and pain are limited, early evidence suggests clinician empathy, specifically the cognitive aspects involved in perspective-taking, are positively associated with pain assessment ratings in persons with dementia (Lee, 2019). According to expert opinion, given the variability in behaviors that persons with advanced dementia demonstrate to indicate pain and other forms of distress (Kolanowski, 1999) and how persistent clinicians must be to routinely make sense of nonverbal information and sensory cues, the level of empathic motivation to reduce discomfort and distress is relevant to how a clinician understands and treats pain in persons with advanced dementia (Digby, 2016; Herr et al., 2011). In fact, in its 2018 dementia care practice recommendations, the Alzheimer's Association promoted clinician empathy as a core component of person-centered dementia care and pointed to empathy's role in correctly identifying and treating problems that are generating adverse outcomes including pain behaviors in persons with dementia (Fazio et al., 2018). Specifically, the recommendations called clinicians to engage in empathic perspective-taking and empathic communication— communication that reflects this perspective-taking and consideration of emotional experience—that recognizes behavior as a form of communication and validates feelings and experiences from each patient's own reality (Fazio et al., 2018). More evidence is needed to understand how clinician empathy is associated with accurate assessment and treatment of pain behaviors in persons with advanced dementia.

Therefore, the purpose of the current article is to review evidence on the relationship between clinician empathy and pain assessment and treatment; present a conceptual model of clinician empathy's role in the observation, diagnosis, and alleviation of pain-related outcomes in persons with dementia who cannot self-report pain; identify research gaps that can be tested using the model; and discuss how the development of clinician empathy interventions may relate to adverse outcomes associated with pain. Although this model can be applied to the observation, diagnosis, and alleviation of other types of adverse outcomes indicated by atypical behaviors in persons with advanced dementia, the model focuses on pain and pain correlates because evidence is most robust concerning the relationship between observer empathy and pain assessment. When assessing pain in persons with dementia who are unable to self-report, clinicians can apply the model with a clearer understanding of empathy's role in their assessment and treatment of pain. In addition, clinicians can use the model to inform development of interventions to improve pain assessment in persons with advanced dementia and interventions for clinical empathy.

Method

To inform development of the current model, the authors conducted a literature review by identifying references through PubMed, Ovid/Medline, and CINAHL from January 1, 2000 to November 1, 2019, and reviewed references cited by relevant articles. Search terms included dementia, pain, pain assessment, pain treatment, empathy, clinical empathy, and compassion. All study types and populations were included; dementia studies were emphasized. Articles were selected based on topical relevance and effect, and findings were synthesized into common variables that were then used in the model. By prioritizing evidence published in the past 10 years, the authors aimed to minimize inherent bias (McDonagh et al., 2008).

Based on evidence that empathy is involved in pain appraisal and treatment in general populations and among persons with dementia (Jackson et al., 2005; Lamm et al., 2011; Latimer et al., 2011; Lee, 2019; Lee & Park, 2016; Yan et al., 2017) and that pain appraisal and treatment are associated with the management of adverse outcomes associated with pain in persons with dementia (Elliott & Horgas, 2009; Husebo, Ballard, Sandvik, et al., 2011; Sandvik et al., 2014), the model was developed using clinical guidelines for assessing pain in persons who cannot self-report (Herr et al., 2011) and noncommunicative persons with advanced dementia (Hadjistavropoulos et al., 2014; Snow et al., 2004); a model of empathy from the field of psychology (Preston & de Waal, 2002); and models of empathy applied to pain and medicine, developed in psychology using neuroscience research (Decety & Fotopoulou, 2015; Goubert et al., 2005) (Table A, available in the online version of this article). Evidence used to develop the model was independently rated for quality by the authors (L.T.S., K.C.M.) using the Oxford Centre for Evidence-based Medicine (2009) Levels of Evidence grading guide (Table A). The model was created with three assumptions derived from available evidence: (1) The pain experience can be measured in persons with dementia who cannot self-report pain; (2) empathy influences an observer's sensitivity to observing pain in others; and (3) empathy augments cognition by providing additional data for clinical judgment. Variables identified in the literature were used to create the model and are described in detail below. Evidence for the relationship between each variable of the model is described and supported in Table A.

Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with DementiaAccording to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.

Table A:

Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with Dementia

According to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.

Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.

Results

Figure 1 presents the major elements of the model and the relationships among them. When a clinician observes a person with dementia demonstrating pain, a multidimensional empathic response involving cognitive, affective, ethical, and behavioral components results. This empathic response influences the clinician's assessment of pain, contributing to diagnostic success, and generates empathic actions (e.g., treatment to reduce suffering) that influence pain outcomes and correlates of pain in persons with dementia (e.g., agitation, mood). This process occurs in the context of myriad factors (e.g., cultural, situational, environmental, social). Components of the model are described below.

Model of empathic pain assessment in persons with dementia. A person with advanced dementia experiences multidimensional pain and expresses that pain through behavioral indicators, which are observed and assessed by a clinician. Empathy—which comprises an ethical response, cognitive response, affective response, and behavioral response—influences the clinician's observation, assessment and diagnostic success, and resulting actions. Clinicians' behaviors (e.g., treatment) influence pain and empirically correlated pain-related outcomes in persons with dementia. This process occurs in the context of cultural, situational, environmental, and social factors.

Figure 1.

Model of empathic pain assessment in persons with dementia. A person with advanced dementia experiences multidimensional pain and expresses that pain through behavioral indicators, which are observed and assessed by a clinician. Empathy—which comprises an ethical response, cognitive response, affective response, and behavioral response—influences the clinician's observation, assessment and diagnostic success, and resulting actions. Clinicians' behaviors (e.g., treatment) influence pain and empirically correlated pain-related outcomes in persons with dementia. This process occurs in the context of cultural, situational, environmental, and social factors.

The Patient Pain Experience

The model begins with the patient's multidimensional pain experience, illustrated by the circle on the left, which includes sensory (e.g., physical sensations), behavioral (e.g., resistance to movement), emotional (e.g., distress, anxiety), and cognitive components (e.g., thoughts about pain or altered coping) (Snow et al., 2004). A person with advanced dementia may be unable to integrate his or her experiences to make sense of pain or accurately describe painful sensations, which makes it necessary for clinicians to find meaning in the pain behaviors these patients demonstrate (Snow et al., 2004). This behavioral communication includes nonverbal expressions, such as vocalizations, grimacing, and guarding (Herr et al., 2011). Studies show persons with dementia express pain in ways similar to cognitively healthy controls (Beach et al., 2016; Kunz et al., 2007) and that observation of facial responses to acute pain provides valid indication of pain similarly in persons with and without dementia (Lautenbacher et al., 2018). In fact, one recent study showed facial descriptors of pain in dementia and non-dementia populations were better at identifying pain than global pain estimates (Lautenbacher et al., 2018). Empathy may influence how a clinician interprets these pain-induced behaviors and facial expressions of pain.

Clinician's Assessment of Pain

The clinician's experience observing and assessing pain in a person with dementia is illustrated within the hatched lines in Figure 1. Experts agree that when assessing pain in persons who are unable to communicate, clinicians should follow an established hierarchy of pain assessment techniques (Herr et al., 2011), which starts with obtaining patient reports of pain (if possible); then assessing pain history and causes, behaviors indicating pain, proxy reports, and data from objective indicators (e.g., scans); and ends by considering a patient's response to analgesic therapy (Herr et al., 2011).

Observation of Pain Behaviors. The observation of pain-related behaviors is considered a critical element of assessing pain in nonverbal persons (Bjoro & Herr, 2008; Corbett, Achterberg, et al., 2014; Ford et al., 2015; Hadjistavropoulos et al., 2007; Herr et al., 2011). There are six widely accepted types of behaviors believed to be associated with pain (listed under Pain Behaviors in Figure 1): (a) facial expressions (e.g., frowning, grimacing); (b) verbalization and vocalizations (e.g., moaning, grunting, noisy breathing); (c) body movements (e.g., rigid or tense body posture, guarding, fidgeting); (d) changes in interpersonal interactions (e.g., aggression, decreased socialization); (e) changes in activity patterns or routines (e.g., refusing food, changes in rest or sleep); and (f) changes in mental/emotional state (e.g., crying, irritability, increased confusion) (AGS Panel on Persistent Pain in Older Persons, 2002; Corbett, Achterberg, et al., 2014). Some authors assert that facial expressions of pain are the most powerful automatic or subconscious determinant of the empathic sense of another's pain (Botvinick et al., 2005; Goubert et al., 2005; Latimer et al., 2011; Lautenbacher et al., 2018). In general population studies, even children with higher levels of empathy perform better than lower empathy peers at identifying facial expressions of pain in others, contributing to associations between high empathy and higher evaluations of pain intensity (Yan et al., 2017).

Tools exist to help measure pain behaviors in nonverbal persons, including persons with dementia, but tools range in validity and reliability; moreover, no universal tool for nonverbal pain assessment exists, limiting usefulness (Corbett, Achterberg, et al., 2014; Ersek et al., 2010; Herr et al., 2011; Schnakers et al., 2010).

Clinician Empathy

Within the hatched lines that represent the clinician's response is a large circle that represents the clinician's empathy, which can be titrated in terms of dose, frequency, and duration of empathic encounter (Figure 1). Empathy is central to the model and influences all components of the patient–clinician encounter. This section of the article will define empathy, then describe the four sub-components of empathy—cognitive response, affective response, ethical response, and behavioral response—which are represented by the smaller interior circles (Gallese, 2003; Giummarra et al., 2015; Goubert et al., 2005; Stepien & Baernstein, 2006).

Decety and Fotopoulou (2015) described empathy as a subjective experience between the clinician and patient, in which the clinician uses the patient's verbal and nonverbal responses to experience and understand the patient's emotional state. Empathy involves the internal representation of another person's pain experience, possibly facilitating better recognition and understanding of pain (Green et al., 2009), and may result in optimal pain assessment and more effective treatment. In addition, empathy enhances a clinician's sense of shared humanity with patients and families, enabling clinicians to apply ethical principles in practice (Bramley & Matiti, 2014; Olsen, 1991; Perez-Bret et al., 2016).

Evidence suggests people experience the same brain activity when they experience pain themselves and when they observe others experiencing pain (Decety & Fotopoulou, 2015). The amygdala, insula, periaqueductal gray, and multiple parts of the cortex—brain regions involved in the experience of physical pain—are activated by the perception or imagination of another person in pain (Gleichgerrcht & Decety, 2014; Lamm et al., 2011), suggesting pain is a shared experience when observed by another. According to a meta-analysis of brain imaging studies across populations, brain regions responsible for empathy, pain-processing, perspective-taking, and emotional responses are also activated in observers exposed to the pain of others (Green et al., 2009; Jackson et al., 2005; Lamm et al., 2011). Brain activity associated with empathy is also associated with the greater frequency with which nurses document pain in their general population patients (Corradi-Dell'Acqua et al., 2019), further showing connections between empathy and pain appraisal. The activation of brain areas involved in pain experience and empathy provide evidence for empathy's involvement in pain assessment in general populations (Latimer et al., 2011), making it relevant to the assessment of pain in persons with dementia.

Cognitive Response of Empathy. The cognitive response of empathy is defined as the intellectual ability of a clinician to identify and understand a person's internal perspective and lived experience (Giummarra et al., 2015; Green et al., 2009; Stepien & Baernstein, 2006). Psychological and biological research identify three subcomponents of the cognitive response: (a) knowledge/training, specifically regarding pain assessment in nonverbal persons; (b) familiarity (i.e., a clinician's previous experience with a patient); and (c) past experiences (e.g., with assessing pain, personal experiences of pain) (Goubert et al., 2005; Preston & de Waal, 2002). Although education, knowledge, and experience are important components of the cognitive response in empathy, they alone are not sufficient to prompt empathy. Perspective-taking, which is enabled by these subcomponents, is required (Gleichgerrcht & Decety, 2014). Perspective-taking involves imaginatively seeing through the eyes of the patient as a way to better understand the patient's experience and emotions. Evidence suggests perspective-taking, when measured, can predict how sensitively physicians rate pain in others (Gleichgerrcht & Decety, 2014).

Research by Latimer et al. (2011) also supports the claim that knowledge, perspective-taking, and past experiences—all components of the cognitive response of empathy—influence pain assessment in nonverbal persons (Jackson et al., 2005; Preston & de Waal, 2002). Studying pain assessment in infants, the authors found that RNs detected pain in infants more often and with greater sensitivity, and scored their own pain in hypothetical situations higher, than non-nurse health professionals (Latimer et al., 2011). The authors concluded that nurses show greater situational empathy and perspective-taking, which may correlate with greater sensitivity to nonverbal behavioral pain cues (Latimer et al., 2011).

It is important to note that countertransference, the patient's influence on the clinician's feelings, attitudes, and desires for attachment (Bapat & Bojarski, 2019), differs from empathy (Zepf & Hartmann, 2008). When clinicians consciously recognize and use countertransference reactions to better understand their patient's experience through perspective-taking, empathic understanding can result (Zepf & Hartmann, 2008).

Affective Response of Empathy. The affective response of empathy is a form of emotional attunement (Halpern, 2003) that involves imagining and sometimes vicariously sharing in the lived emotional experience of another person (Goubert et al., 2005; Stepien & Baernstein, 2006). The affective response incorporates cue salience (i.e., interpreting the strength of a perceived pain signal); implicit biases related to similarities or differences between the patient and the observer (e.g., race, gender) (Giummarra et al., 2015; Luo et al., 2015; Preston & de Waal, 2002); and emotions that reflect orientation to self, other (the patient), or both (Goubert et al., 2005). When a clinician is self-oriented, observing pain may produce self-oriented emotions such as distress or fear, which may prompt self-oriented behaviors (e.g., denial of pain severity) to avoid unpleasant emotions associated with pain (Goubert et al., 2005). When a clinician is affectively oriented to the patient, observing pain may rouse emotional resonance (Decety & Fotopoulou, 2015), leading to a desire to relieve pain through treatment that links to the behavioral response of pain treatment (Lee, 2019; Lee & Park, 2016). A clinician may experience a mix of affective orientations, resulting in a mix of behavioral responses (e.g., distress while attempting to reduce pain). This orientation to self or patient may be influenced by biases. For example, Decety et al. (2010) reported that students from the University of Chicago rated pain higher and showed greater sensitivity to videos of persons in pain who were said to have contracted AIDS due to a blood transfusion compared to the same videos of persons in pain who were said to have contracted AIDS due to sharing needles involved in drug addiction (Decety et al., 2010). In a recent study investigating the effect an observer's positive or negative impression of a person had on pain estimation, Khatibi and Mazidi (2019) found similar biases. The authors found people rated pain higher in persons they perceived in positive ways than persons they perceived negatively and expressed greater tendency to help and higher levels of empathy toward persons they perceived positively (Khatibi & Mazidi, 2019). Furthermore, for persons with lower likeability, the authors found observers' justification of the person's pain predicted pain estimation and the observer's tendency to help. Among less likeable persons, the level of a test character's dislikeability was the best predictor of an observer's empathy and tendency to help. These findings may have implications for persons with advanced dementia who demonstrate behaviors that are difficult for clinicians to understand or manage. Such biases may influence the quality of care clinicians provide (Khatibi & Mazidi, 2019).

Evidence suggests a diminished affective response can negatively influence pain perception and assessment. Decety et al. (2010) found that suppressing emotions inhibits a physician's perception of pain in others and diminishes one's arousal to observing pain, which results in lower ratings of pain. Being mindful of one's emotional responses to observed pain is critical, as feelings can influence a clinician's perceptions and judgment (Ofri, 2013). One study found that a person's feelings may distort his/her capacity for empathy during decision-making, contributing to under- or overestimates of suffering depending on the observer's emotional state (Silani et al., 2013).

Ethical Response of Empathy. A clinician's sense of duty or motivation to reduce suffering is the ethical response of empathy (Gleichgerrcht & Decety, 2014; Jeffrey, 2016; Morse et al., 1992). Sometimes called empathic concern, this response interacts with the clinician's cognitive and affective responses, and together influences behavioral responses (Halpern, 2003; Jeffrey, 2016; Morse et al., 1992; Stepien & Baernstein, 2006). Gleichgerrcht and Decety (2014) found that empathic concern, the sensitivity toward another person's well-being that links ethical and affective responses, was predictive of how sensitively physicians rated pain. Compassion, the desire to actively alleviate suffering in another person (Sinclair et al., 2017; Soto-Rubio & Sinclair, 2018), proceeds from the ethical response of empathy (Soto-Rubio & Sinclair, 2018). Compassion can be diminished or fatigued in difficult clinical circumstances (e.g., understaffed care environments [Longhurst, 2015]). Diminished compassion can affect care by causing clinicians to act irritable with patients or reduce standards of care (Dasan et al., 2015).

Behavioral Response of Empathy. The interplay of cognitive, affective, and ethical responses results in behavioral responses by the clinician (Goubert et al., 2005). Having observed pain in a person with dementia, a clinician may actively respond with empathy, evidenced by behaviors such as kind or caring facial expressions, a warm communication style, gentle touch when appropriate, and action to alleviate pain (Decety & Fotopoulou, 2015). Furthermore, a clinician may respond with empathic behaviors over time through repeated effort to understand and alleviate pain and pain behaviors. In contrast, a clinician may respond with self-oriented behavior, which does not produce empathic care (Decety & Fotopoulou, 2015). A clinician with low empathy or sympathetic affect, a response to suffering that involves feeling sadness for a suffering person but does not result in action to relieve that suffering, may refrain from actively relieving suffering; or may respond with higher levels of personal distress or compassion fatigue, which may impair effective assessment of pain in the patient (Gleichgerrcht & Decety, 2014).

In the only published study to examine the association between clinician empathy and pain assessment and treatment in persons with dementia, Lee and Park (2016) found evidence that higher nurse empathy, specifically in the cognitive response domain of perspective-taking, is positively associated with use of evidence-based pain assessment and management. The authors also found that higher empathy scores are associated with more positive nurse attitudes toward pain in persons with dementia, which in turn, are associated with higher use of pain guidelines and evidence-based pain management (Lee & Park, 2016). Studies of clinician empathy and pain treatment outcomes are also limited in general populations, but two studies provide early evidence for associations. In one study, an intervention to increase clinical empathy was associated with reductions in racial disparities in pain treatment decisions, reflecting increases in pain treatment decisions for minority patients in particular (Drwecki et al., 2011). In another study of persons with chronic pain, physician empathy was found to be correlated with decreases in pain intensity and improvements in pain relief, suggesting more effective treatment by physicians with greater empathy (Cánovas et al., 2018). Cánovas et al. (2018) identified clinician empathy as a relevant and unexplored target for intervention in pain management.

Diagnostic Success

Diagnostic success, defined in the current model as sensitive interpretation of pain behaviors that ideally results in more accurate assessment, is difficult to measure in patients unable to self-report pain. Limited evidence in the general population suggests high empathy may be associated with greater accuracy in inferring facial expressions of pain when measured on some indices (Green et al., 2009), but more research is needed in general populations and among persons with dementia. Without the availability of self-report to confirm ratings, the current model uses diagnostic sensitivity as a proxy consistent with previous studies (Gleichgerrcht & Decety, 2014; Green et al., 2009; Latimer et al., 2011).

Pain-Related Outcomes and Correlates

A clinician's empathic behavioral response (e.g., treatment) will affect pain outcomes and other empirically supported correlates of pain in persons with dementia (Husebo, Ballard, Sandvik, et al., 2011; Lee & Park, 2016; Snow et al., 2004). Correlates of pain in persons with dementia include agitation (Feldt et al., 1998; Lin et al., 2011); mood disorders, such as depression and negative affect (Brummel-Smith et al., 2002; Cipher & Clifford, 2004; Corbett et al., 2012; Lawton et al., 1996); changes in functionality and activities of daily living (Deyo, 1988; Flo et al., 2014); and sleep disturbances (Flo et al., 2016). Although one systematic review found mixed evidence for pain treatment's effect on agitation in persons with dementia, possibly due to lack of rigorous studies and small sample sizes (Husebo, Ballard, & Aarsland, 2011), a cluster randomized clinical trial found a pain treatment intervention significantly reduced agitation, pain, and the overall severity of neuropsychiatric symptoms in nursing home residents with moderate to severe dementia (Husebo, Ballard, Sandvik, et al., 2011). More rigorous research is needed to test associations among pain treatment interventions, empathy, and pain-related adverse outcomes in persons with advanced dementia.

Contextual Factors

Cultural, situational, interpersonal, intrapersonal, and social factors (Hadjistavropoulos et al., 2011; Lorié et al., 2017), which may relate to clinical environment or other workforce conditions (Wilkinson et al., 2017), comprise the contextual factors that influence the regulation and interaction of empathy's responses, and affect how a clinician gathers, processes, and responds to observed pain behaviors. For example, declines in clinical empathy over time are well-documented (Mahoney et al., 2016; Neumann et al., 2011), making years of experience and physician age (Gleichgerrcht & Decety, 2014; Green et al., 2009; Latimer et al., 2011) factors to investigate and control.

Compassion fatigue, the reduced motivation to alleviate suffering (resulting in diminished empathic behavioral response), is associated with contextual work conditions such as understaffing, lack of resources, poor managerial support, or prolonged exposure to suffering among clinicians (Cocker & Joss, 2016; Coetzee & Laschinger, 2018), making contributors to compassion fatigue relevant in the current model. Clinician burnout, the experience of work-related strain that involves feelings of exhaustion and other symptoms, is similarly associated with lower empathy and less positive attitudes toward persons with dementia (Aström et al., 1991) and patients in general (Wilkinson et al., 2017). Based on available evidence, factors contributing to compassion fatigue, burnout, and clinician distress (McPherson et al., 2016) can be considered contextual factors in the current model.

Discussion

The purpose of the current review was to evaluate study findings regarding the role of empathy in the pain assessment of persons with advanced dementia and to propose a conceptual model of the role of clinician empathy in the diagnosis and treatment of pain and pain behaviors in persons with advanced dementia. The model incorporated evidence from clinical and neurocognitive studies and presents a framework for using clinical empathy interventions to improve the effectiveness of pain appraisal and treatment in persons with advanced dementia.

Given the benefits associated with clinician empathy (Derksen et al., 2013) and well-documented declines in empathy throughout medical training and as years of clinical experience increase (Gleichgerrcht & Decety, 2014; Green et al., 2009; Latimer et al., 2011; Neumann et al., 2011), it is important that researchers and health systems develop interventions that improve empathy in clinicians, particularly those involved in the assessment and treatment of pain in persons with dementia. Multiple systematic reviews show empathy is not a fixed trait; instead it is a modifiable skill and way of relating to patients that can be improved with effective interventions (Kelm et al., 2014; Kiosses et al., 2016; McConville et al., 2017). In one randomized controlled trial of physician residents and fellows from multiple specialties, clinicians who received three 60-minute empathy training modules in addition to standard medical education (control group) showed greater changes compared to controls in consultation and relationship empathy scores as rated by multiple patients (difference = 2.2, p = 0.04), greater changes in knowledge of the neurobiology of empathy (difference = 1.8, p < 0.001), and improved ability to decode facial expressions of emotion (difference = 1.9, p < 0.001) (Riess et al., 2012). In a mixed methods study testing the effectiveness of a different empathy intervention, researchers found baccalaureate nursing students who received two modules of training (105 minutes per session) demonstrated increased clinical empathy (difference = 2.1, p = 0.037) and positive qualitative empathic results (Nosek et al., 2014). Finally, in one systematic review of 13 randomized controlled studies with adequate data, health professionals who participated in an empathy intervention improved empathic behavior compared to controls (standardized mean difference = 0.8, p < 0.001) (Kiosses et al., 2016).

Limitations

Due to variations in empathy interventions and empathy measurement scales, it is unknown what types, doses, and duration of empathy interventions are most effective. Additional research on the types and titration of empathy interventions is needed. Furthermore, when developing and testing clinical empathy interventions on outcomes for persons with dementia and pain, all aspects of clinician empathy should be considered and not just cognitive components, which the field of medicine has historically focused on (Halpern, 2003; Sulzer et al., 2016). A systematic review of empathy development in medical contexts similarly recommended clinical empathy interventions should focus on relational elements and more standardized conceptualization of the multifaceted nature of empathy (Sulzer et al., 2016).

Research Implications

The current model reveals important opportunities for future research. Evidence concerning the accuracy of pain ratings as related to clinical empathy is limited in the general population and difficult to measure among persons with dementia due to the absence of self-report. Research is needed to better understand the relationship between clinicians' empathy and the accuracy of their pain ratings in persons with dementia. Research is also needed to understand associations among clinician biases, specifically racial/ethnic biases, and dementia pain assessment and treatment.

Despite disparities in the assessment and treatment of pain among African American individuals overall (Hoffman et al., 2016), and specifically among African American individuals with dementia (Ford et al., 2015), it is unknown if racial/ethnic biases among clinicians are associated with differences in pain management practices or pain-related behavioral outcomes among racial/ethnic minorities with dementia, as is evidenced in the general population (Drwecki et al., 2011). Understanding, for example, how a clinical empathy intervention is associated with pain management practices in racially diverse patient populations may help improve racial disparities (Ford et al., 2015).

In addition, the model can be used to test the effectiveness of dementia pain educational interventions among clinicians with different levels of empathy and explore relationships between clinician empathy, dementia pain assessment and treatment, and interventions that modify contextual factors, such as clinical work environment or nursing staffing ratios. Research exploring the mediating relationship between contextual factors, such as nursing staffing ratios and other factors associated with burnout or compassion fatigue (Kane et al., 2007), and empathy in the context of pain assessment and treatment in persons with dementia is also recommended. Finally, researchers wishing to test associations among pain interventions and pain or correlates of pain in persons with advanced dementia should consider clinician empathy an important factor to control. Rigorous, validated measures for empathy are available to test levels and dimensions of clinician empathy, but no tool is considered a universal measure for empathy (Yu & Kirk, 2009).

Conclusion

In representing the relationship between clinician empathy and pain assessment and treatment for persons with advanced dementia, the current article presents a model that may be used to guide empathy intervention research and the care of persons with advanced dementia. Empathy enhances awareness and interpretation of nonverbal communication and behavioral indicators of pain, making it relevant to assessing emotional and behavioral expressions of pain in persons with dementia unable to self-report pain. The model can help clinicians better understand empathy's relationship with pain assessment, treatment, and outcomes and how contextual factors may enhance or diminish a clinician's empathic response. Increased understanding o f clinician empathy may help promote patient-centered, ethical care for persons with dementia.

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Table of Evidence of Studies Supporting the Relationship Between Variables in the Model of Empathic Pain Assessment in Persons with Dementia

According to the literature, the pain experience in persons with advanced dementia is associated with behaviors that indicate pain; which relate to a clinician's assessment of pain, which is influenced by the clinician's level or dose of empathy, which influences how successfully the clinician diagnoses pain and treats pain, resulting in measurable changes in adverse outcomes related to pain. These variables andtheir interaction can be influenced by external, contextual factors. The model was created with three assumptions derived from available evidence: 1) The pain experience can be measured in persons with dementia who cannot self-report pain; 2) Empathy influences an observer's sensitivity to observing pain in others; and 3) Empathy augments cognition by providing additional data for clinical judgment.

Quality ratings are based on the Oxford Centre for Evidence-based Medicine grading guide (Medicine, 2009). Two authors independently rated each study.

Relationship within ModelAuthor, yearAim(s)MethodSample/SettingFindingsQuality Rating
Pain behaviors can be observed and interpretedSnow et al., 2004To present a conceptual model of the pain assessment process in persons with dementia and discuss validation methods.Conceptual method based on integrative review of literature and theory.Persons with dementiaA multidimensional model of pain assessment that emphasizes the role of the external rater and posits that a nociceptive stimulus leads to pain sensation, then pain perception, then exhibition of external signs of pain by the patient, then an external rater's observation and interpretation of those external signs. Authors conclude pain assessment in persons with dementia must be multidimensional and address challenges of using external ratings to assess pain in this population.5
Pain behaviors can be observed and interpreted Contextual factorsHadjistavropoulos et al., 2014To summarize evidence on the pain experience and assessment of pain in people with dementia and identify the utility of non-verbal cues (e.g., facial expression) as a way to access the subjective pain experience in the absence of self-report.Literature reviewPersons with dementiaPersons with dementia, especially those who cannot self-report, are at high risk of under-recognition, underestimation, and undertreatment of pain. Systematically assessing nonverbal expressions of pain is essential and possible given the information that is communicated through facial expressions. To enable more reliable and accurate judgments of painin nonverbal persons with dementia, trainingin the recognition of empirically described facial expressions of pain is critical. In the absence of clinically validated pain biomarkers, real-time, automated video assessments of facial pain expression should be developed.5
Pain behaviors can be observed and interpretedHerr, Coyne, McCaffery, Manworren, & Merkel, 2011To present clinical practice recommendations for appropriate pain assessment using a hierarchical framework for assessing pain in persons unable to self-report.Expert guidelinesNon-verbal older adults including persons with dementiaAn established and recommended framework for pain assessment that is relevant for patients who cannot self-report their pain.5
Pain behaviors can be observed and interpretedLautenbacher, Walz, & Kunz, 2018To relate the observed facial pain responses to the self-report of pain and to the responses to non- noxious vs. noxious stimuli to identify which facial descriptors are most indicative of pain.Participants watched 40 video-clips, showing facial expressions of older individuals with and without dementia during non-painful and painful pressure stimulation. After each clip, participants were asked to rate the videos using commonly used facial descriptors of pain and also to provide global pain estimate ratings of how much pain they observed.32 geriatric nurses with 10+ years of experience (54% of their patients had dementia) and 30 control participants (secretaries and administrative staff not caring for a person with chronic pain or dementia) that were matched for age, gender and education.Participants were better predicting the pain self-report of the observed individuals when using facial descriptors than when using global pain estimates. Especially, the anatomical descriptors (e.g. opened mouth, narrowing eyes) showed greatest predictive power. Results were not affected by pain-expertise of the observers (nurses vs. control subjects) or diagnostic status of the observed (patients with dementia vs. cognitively unimpaired subjects).2b
Empathy as phenomenonPreston & de Waal, 2002To show that consistencies exist because all empathic processes rely on a general perception-action design of the nervous system, is adaptive for myriad reasons, and exists across species.Theory; review of literatureSocial mammals including human adults, human children, human infants, monkeys, apes, and rats.Perception-action processes are the driving force in the evolution of empathy. With the more recent evolutionary expansion of prefrontal functioning, these basic processes have been augmented to support more cognitive forms of empathy. Focusing on the evolution of perception-action processes connects empathy with basic phenomena including imitation, social facilitation, group alarm, vicariousness of emotions, and mother-infant responsiveness.5
Empathy is associated with pain observation and assessment Diagnostic successGreen, Tripp, Sullivan, & Davidson, 2009To examine the role of empathy in rating intensity of facial expressions of pain and the accuracy of ratings relative to self-reported pain; and to examine the potential mediating role of available pain cues or the moderating role of gender.Video pain assessment study; participants were shown video clips of facial expressions of persons experiencing a cold presser pain task, and then asked to estimate that pain experience, which was then compared with the video pain recipient's actual pain ratings.130 undergraduate college studentsHigher empathy was associated with an overall increase in estimates of senders' pain, which was not mediated by video subject or participant gender or the duration of painful facial expressions. High empathy was associated with greater accuracy in inferring pain on one of three inferential accuracy indices, warranting a need for more research about the accuracy of pain ratings associated with high empathy.2b
Empathy is associated with pain observation and assessment Empathy prompts behavior/actionDecety & Fotopoulou, 2014To synthesize literature and examine why physician empathy has a positive impact on patients.Conceptual model based on integrative review of neuroscience and clinical studies.Current neuroscience evidence of neurobiological and cognitive mechanisms underlying the role of empathy in medicine.Model argues that clinicalempathy results from the integration of cognitive, emotional, and behavioral factors in both the recipient of empathy and in the person empathizing; and that empathy is embedded in an interaction between a physician and a patient. Argues higher empathy drives clinician to respond with patient-oriented behavior and empathic care. Presents two non-mutually exclusive explanations: social baseline theory and the free energy principle. Empathy is a powerful element facilitating treatment effectiveness.5
Empathy is associated with pain observation and assessmentGleichgerrcht & Decety, 2014To investigate how individual dispositions relate to behavioral measures of pain sensitivity, empathy, and professional quality of life.Web-based self-report measures of empathy (Interpersonal Reactivity Inventory) and behavioral task of watching a series of video clips of general population patients experiencing different levels of pain, demonstrating facial expressions indicative of pain, then providing ratings of pain intensity1,199 board-certified physicians who had previously completed measures for a study on empathy and burnout.Controlling for confounding variables, perceived pain intensity was positively and strongly correlated with induced personal distress from watching the pain videos (r= 0.62, p< 0.001), as well as with the perspective taking scale of the IRI (r = 0.11, p < 0.001). Linear regression of the IRI sub-domains on pain intensity (F3,1995 = 5.53, p= 0.001, R= 0.12, constant = 24.0) revealed significant positive predictive effects of perspective taking (B= 0.24, t= 3.65, p< 0.001, β= 0.11), and personal distress (B= 0.14, t= 2.06, p= 0.04, β= 0.07), but not empathic concern (B= −0.02, t= −0.31, p= 0.76, β= −0.01). A significant negative correlation was found between perceived pain intensity and both physician age (r= −0.14, p= 0.04) and years of experience (r= −0.15, p= 0.03).2b
Empathy is associated with pain observation and assessmentCorradi-Dell'Acqua et al., 2019To investigate whether individual pain management decisions in the emergency department could be explained by brain patterns related to empathy, risk-taking, and error monitoringFunctional magnetic resonance imaging (fMRI) studyof three well-established tasks probing relevant cognitive and affective dimensions; and pain management monitoring over 15- month period.70 Emergency Department nursesUsing multivariate patter analysis, brain activity associated with empathy wasfound to be positively associated with the frequencywith which nurses documented pain in their general population patients.4
Empathy is associated with pain observation and assessment Empathy prompts behavior/actionGoubert et al., 2005To synthesize evidence of empathy in the context of pain, emphasizing behavioral aspects to reduce distress, and present a conceptual model of empathy for pain evidence.Integrative review and conceptual framework of empathy and pain.General population literature from neuroscience, medicine, and psychology.Model of empathy focuses on neurological processes and behaviors that occur during an interpersonal empathic observation of pain. Model uses research to show cognitive, affective, and ethical responses of empathy result in behavioral responses by the clinician. Model accounts for contextual influences related to the relationship, attachment patterns, and other social factors between the sufferer and the observer. Incorporates the “bottom up” processes (i.e., features of the incoming pain cue stimulus) and “top down” processes (i.e., characteristics of the observer and features of the observer's knowledge, such as prior experiences) of empathy by organizing them into relevant cognitive and affective response subcategories; the orientation within response states; and contextual influences. Specifically focuses on behavioral actions resulting from observer empathy (e.g., assistance, care) and concludes empathy is a vehicle through which the outcome of an observer's behavior is achieved.5
Empathy is associated with pain observation and assessmentLamm, Decety, & Singer, 2011To assess the consistency of a growing body of literature's finding that empathy for pain is underpinned by neural structures that are also involved in the direct experience of pain.Image-based meta-analysis of 41 studies.Nine independent functional magnetic resonance imaging (fMRI) investigations and a coordinate-based meta-analysis of 32 studies that had investigated empathy for pain using fMRI.A core network of bilateral anterior insular cortex and medial/anterior cingulate cortex is associated with empathy for pain. Activation in these areas overlaps with activation during directly experienced pain, leading authors to link their involvement to global feeling states and the guidance of adaptive behavior for both self- and other-related experiences. This core network was co-activated with distinct brain regions depending on the environment: While viewing pictures of body parts in painful situations recruited areas underpinning action understanding to a stronger extent, eliciting empathy by means of abstract visual information about the other's affective state more strongly engaged areas associated with inferring and representing mental states of self and other. Social neuroscience paradigms provide reliable and accurate insights into complex social phenomena such as empathy.2a
Empathy is associated with pain observation and assessmentLatimer, Jackson, Johnston, & Vine, 2011To validate the Empathy for Infant Pain video program by determining whether nurse and non-nurse control groups' pain scores of 24 video clips showing infants undergoing real medical procedures were equal.Descriptive cross-sectional video judgement study of infant pain display indicators (facial expression, limb movement, and vocal expression).50 female participants (25 nurses and 25 allied health controls)Nurses scored facial cues for all categories higher than the control group. Nurses scored their own pain in hypothetical situations and that of the infants consistently higher than the control group.2b
Empathy is associated with pain observation and assessmentJackson, Meltzoff, & Decety, 2005To investigate the neural mechanisms and hemodynamic response during the perception of pain in others, to understand the process of empathy for painFunctional magnetic resonance imaging (fMRI) study in which participants were shown a series of photographs of hands and feet in situations likely to cause pain, and a matched set of control photographs without painful events. Participants were asked to assess on-line the level of pain experienced by the person in the photographs.General population: 15 healthy right-handed volunteers (7 females, 8 males) aged between 19 and 29 years (mean = 22, SD = 2.6).Results demonstrated that perceiving and assessing painful situations in others was associated with significant bilateral changes in activity in several regions notably, the anterior cingulate, the anterior insula, the cerebellum, and to a lesser extent the thalamus, which are regions that play a significant role in pain processing. Activity in the anterior cingulate was strongly correlated with participants' ratings of the others' pain, suggesting the activity of this region is modulated according to subjects' reactivity to the pain of others. Findings suggest there is a partial cerebral commonality between perceiving pain in another individual and experiencing it oneself.4
Empathy is associated with pain observation and assessmentLee, 2019To identify mediation effects of cognitive and affective empathy between attitudes toward dementia and pain assessment.Descriptive correlation study using mediation analysis and data from self-reported questionnaires.183 third- and fourth-year nursing students caring for patients with dementia.Cognitive empathy was positively correlated with attitudes to dementia and with pain assessment of persons with dementia; attitudes to dementia was positivelycorrelated with pain assessment in persons with dementia. Emotional empathy and cognitive empathy were positively correlated. Cognitive empathy had a significant mediating effect on pain assessment in persons with dementia.4
Empathy is associated with pain observation and assessmentYan, Pei, & Su, 2017To investigate the relationship between children's empathy and their behavioral and perceptual response to facial pain expression.Two-factor mixed experiment using Eye-tracking to test evaluation of pain intensity of facial expressions62 5-to-6-year-old typical-development children were recruited from a local kindergarten in ChinaChildren with high empathy performed better identifying facial expressions of pain and gave higher evaluation of pain intensity. Rating for pain in painful expressions was best predicted by a self-reported empathy score. Of facial clues, children fixated on eyes and mouth more quickly, more frequently and for longer times when detecting pain.2b
Empathy is associated with pain observation and assessment Empathy prompts behavior/action Contextual factorsDecety, 2010To critically examine current knowledge in developmental and affective neuroscience with an emphasis on the perception of pain in others.Integrative reviewGeneral population neuroscience studies.Empathy is critical for healthy psychological and social interaction. Empathyis a process involving motivation that results in behavior and is moderated by attitudes, dispositions, mood, and motivations within a contextual environment. Distinct yet interacting brain circuits underpin the different components of empathy, which each have their own course of development. To complement traditional behavioral methods for improving empathy, a neurodevelopmental approach to elucidate the mechanisms underlying affective reactivity, understanding emption, and emotion regulation is needed.5
Empathy is associated with pain observation and assessmentKhatibi & Mazidi, 2019To investigate the effect of an observer's impression of a person in pain and justification of his/her pain on the observer's pain estimation, tendency to help and perceived empathy.Participants read scenarios intended to manipulate the reader's impression of characters (four positive characters, four negative; half female) who ultimately were fired from their work. Participants then observed 1-s videos of four levels of pain expression (neutral, mild, moderate, strong) in those characters during an examination. Participants then rated pain estimation, tendency to help and perceived empathy. Afterwards, participants rated their likability of characters.General population: 30 healthy individuals (half females)Participants rated pain inpositive characters higher than pain in negative characters; expressed more tendency to help and a higher level of perceived empathy towards positive characters than negative characters. Perceived injustice towards a person was the best predictor of observer's pain estimation, tendency to help, and perceived empathy for the highest level of pain in positive characters. For negative characters, dislikeability was the best predictor of tendency to help and perceived empathy. Justification of pain was a predictor of pain estimation and tendency to help.4
Empathy is associated with the treatment of painLee & Park, 2016To identify nurses' empathy, attitudes, and pain management for persons with dementia and the factors associated with pain management by nurses.Cross-sectional survey utilizing the Interpersonal Reactivity Index (IRI), which measures four empathy factors.114 nurses who care for persons with dementia from 12 geriatric hospitals.Significant positive correlation was found between empathic concern and attitudes, perspective-taking of empathy, and self-reported administration of pain management. There was also a correlation between empathy and pain management. The significant factors affecting the performance of pain management includedperspective-taking of empathy, use of pain management in dementia guidelines, and attitudes toward pain in persons with dementia.4
Empathy is associated with the treatment of painCanovas et al., 2018To assess the impact of physician empathy, as perceived by patients with chronic pain, regarding pain relief and health-related quality of life.Prospective noninterventional study. The same physician visited each patient at baseline and after one and three months.2,898 patients with moderate to severe chronic pain who were referred to pain clinics (not dementia specific).Physicians' empathy and patients' dispositional optimism have a role in determining positive outcomes in patients with chronic pain. Scores for pain intensitydecreased significantly (P< 0.001) from baseline to month 3, with reductions of 33.7%, 42.5%, 40.0%, and 46.9%, respectively. Pain intensity decreased from 6.3 ± 1.5 at baseline to 4.7 ± 1.8 at one month and 3.8 ± 1.9 at three months (P < 0.050). Significant improvements in EuroQol-5Dpain scales were also reported. The Jefferson Scale of Patient Perceptions of Physician Empathy and the Life Orientation Test-Revised, but not the Pain Coping Questionnaire, were associated with pain relieve and health-related qualityof life in patients.4
Empathy is associated with the treatment of painDrwecki, Moore, Ward, & Prkachin, 2011To test three hypotheses: Experiment 1: That patient race and empathy are associated with undergraduate pain treatment decisions. Experiment 2: That a perspective-taking intervention would reduce racial disparities in undergraduate pain treatments. Experiment 3: That a perspective-taking intervention would reduce pain treatment disparities among registered nurses (RNs).Laboratory studies of pain treatment decisions using video in three populations. Participants in intervention experiments 2 and 3 were randomized. Analyses controlling for participant gender as a factor were conducted for each analysis.Experiment 1: 51 White undergraduate students (20 men, 31 women) ages 18–21 years old. Experiment 2: 60 White undergraduates students (18 men, 42women) ages 18–20 years old. Experiment 3: 40 registered nurses (RN) seeking advanced nursing degrees (8 men, 32 women) ages 22–69, with mean 8 years experience (31 White, 3 African American, 4 Asian, and 2 other races/ethnicities).Racial empathy bias influences treatment of pain (participants demonstrated significant pro-White pain treatment biases). However, participants engaged in an empathy-inducing, perspective-taking intervention that instructed participants to imagine how patients' pain affected patients' lives exhibited a 55% reduction in pain treatment bias in comparison to controls. Pro-White empathy biases were highly predictive of pro-White pain treatment biases. The magnitude of the empathy bias experienced predicted the magnitude of the treatment bias exhibited.2b
Contextual factorsNeumann et al., 2011To investigate changes in medical trainee empathy and reasons for those changes during medical school and residency.Systematic review18 studies (11 on medical students, 7 on residents) about medical trainee empathy published January 1990 to January 2010. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and students with sample size <30 were excluded.Studies generally showed a significant decrease in empathy during medical school and a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the “hidden,” “formal,” and “informal” curricula as main reasons for empathy decline. Empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality.2a
Contextual factorsMahoney, Sladek, & Neild, 2016To examine student and doctor empathy, and associations between empathy and clinical learning structures.Longitudinal study of three groupsMedical students (n= 281); private doctors in South Australia (n= 78); and doctors from public teaching hospitals (n= 72) in South Australia.First year medical students' empathy scores at the end of the year (102.8 ± 17.7) were significantly lower than at the start of the year (112.3 ± 9.6)p< .05). There were no other significant differences in students' empathy scores by year groups or across the two time points. Empathy scores were nearly equal for private and hospital clinicians and higher than average scores for students. Students described issues that adversely affected empathy includingsystemic issues, specific incidents, and course structure.2b
Contextual factorsHadjistavropoulos et al., 2011To present a detailed framework for understanding the interactions among social and psychological and determinants of pain by examining the process of pain communication.Synthesis of literature and conceptual frameworkHuman and animal studies of pain expression and interpretation.The communications modelof pain represents a synthesis of a very large body of empirical findings. The model poses the internal experience of pain is communicated as action, interaction, and transaction, with transaction (behavior) taking the form of action to relieve pain. The experience of pain communication occurs in the context of cultural, situational, intrapersonal, interpersonal, and social determinants;and can be mediated by observer attitudes, abilities, and characteristics.5
Contextual factorsLorie, Reinero, Phillips, Zhang, & Riess, 2017To investigate how culture mediates nonverbal expressions of empathy and communication in healthcare.Systematic review16 peer-reviewed, experimental or observational studies of nonverbal expressions of empathy and communication across cultures in clinical settings. Patients studied did not specifically have dementia.Implicit biases influence clinician-patient communication. Racially discordant patient-physician dyads were associated with impaired exchange of clinical information and lower patient ratings of physician trust and warmth. Some nonverbal behaviors appear to be desired universally, others suggest cultural meanings (e.g., eye gaze, hand gestures, touch). Implicit cultural bias can be revealed through nonverbal expressions, which can result in conflicting signals.3a
Contextual factorsCoetzee & Laschinger, 2018To appraise compassion fatigue literature and models and develop a comprehensive theoretical model of compassion fatigue.Integrative review11 studies of compassion fatigue in healthcare.The authors conclude that empathy itself does not put nurses at risk of developing compassion fatigue, but instead a lack of resources, inadequate positive feedback, and the nurse's response to personal distress—contextual factors that can alter the effectiveness of behavioral actions stemming from empathy.5
Contextual factorsWilkinson, Whittington, Perry, & Eames, 2017To complete a rigorous, systematic exploration of the literature about the relationship between burnout and empathy in healthcare staff.Systematic review10 quantitative studies published of nurses or medical professionals that used the Maslach Burnout Inventory to assess burnout and a standardized outcome measure for empathyEight of the studies provided empirical support for a negative relationship between empathy and burnout. One study demonstrated support for a positive relationship between burnout and empathy. One study reported contradictory evidence with positive and negative correlations between different subscales of empathy and burnout measures. Overall, there was consistent evidence for a negative association between burnout and empathy.2a
Contextual factorsAstrom, Nilsson, Norberg, Sandman, & Winblad, 1991To investigate relationships between nursing staff burnout and empathy and attitudes toward dementia patients; and to relate the ratings of burnout, empathy and attitudes to nurses' experience at work.Longitudinal study and semi-structured interview.60 nursing staff in geriatric and psychogeriatric care (RNs, LPNs and nurse's aides) caring for persons with dementia.Burnout correlated with lower empathy and less positive attitudes in the staff. RN's showed the most positive attitudes towards demented patients over time and differed compared to the nurse's aides and LPN's. Regression analysis showed that 'experience of feed-back at work' and 'time spent at present place of work' were the most important factors when explaining burnout among the staff. Staff with high empathy experienced “a close contact with the patient” as the most stimulating factor at work while staff with low empathy experienced “improvement of the patient's health” and “contact with colleagues” as the most stimulating factors. The importance of counteracting burnout in the care of demented patients is stressed.2b
Treatment of Pain Behaviors Reduces Adverse Outcomes in Persons with DementiaHusebo, Ballard, Sandvik, Nilsen, & Aarsland, 2011To determine whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes.Cluster randomized controlled trial; participants were randomized to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four weeks after the end of treatment or to usual treatment.352 residents with moderate to severe dementia and clinically significant behavioral disturbancesA systematic approach to managing pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia. Agitation was significantly reduced in the intervention group compared to the control group after eight weeks (repeated measures analysis of covariance adjusting for baseline score, P<0.001): with the average reduction in scores for agitation being 17%. Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms (−9.0, −5.5 to −12.6) and pain (−1.3, −0.8 to −1.7), but groups did not differ significantly for cognition or activities of daily living.2b
Treatment of Pain Behaviors Reduces Adverse Outcomes in Persons with DementiaHusebo, Ballard, & Aarsland, 2011To conduct a systematic review of studies about whether pain medication can improve agitation in persons with dementia.Systematic reviewThree prospective studies with controlled intervention trials involving persons with dementia and outcomes of agitation or other related behavioral disturbances, published 1992–2010.Findings were inconsistent. Although some correlations were reported, these did not support the hypothesis that pain management reduced agitation. Low sample size in two of the studies (<50) and a serious lack of rigorous studies on the effect of pain treatment and agitation in persons with dementia may have contributed to inconsistencies. More research is needed.1a-
Treatment of Pain Behaviors Reduces Adverse Outcomes in Persons with DementiaElliott & Horgas, 2009To assess the feasibility of conducting a repeated-measures study of pain in persons with dementia and investigate the effect of the scheduled dosing of acetaminophen in reducing observable pain behaviors in community-dwelling persons with dementia.Pilot study using a within-subjects ABAB withdrawal design, with data collected daily for 24 days. To examine the effects of scheduled extended-release acetaminophen (1.3 g every 8 hours) in reducing pain-related behaviors, two baseline (nontreatment) phases were alternated with two treatment phases.3 participants (2 women; mean age = 85 years; mean Mini-Mental State Examination score = 11.7) with osteoarthritis.Results show it is possible to conduct intensive, daily pain investigation in community-dwelling older adults with moderate to severe dementia. Behavioral indicators of pain varied daily and in response to treatment. During treatment phases, pain behaviors decreased in both frequency and duration relative to the control and baseline phases and increased when treatment was withdrawn. Acetaminophen use reduced pain behaviors associated with musculoskeletal pain in persons with dementia. Results provide preliminary evidence that acetaminophenis an effective pain reliever for persons with dementia.2b
Treatment of Pain Behaviors Reduces Adverse Outcomes in Persons with DementiaPieper et al., 2013To provide a comprehensive overview of the current state of evidence regarding the effectiveness of interventions targeting pain on the outcome behavior, and interventions targeting behavior on pain, in dementia.Systematic review16 intervention studies of adults with a main diagnosis of dementia: 9 studies focused on an intervention targeting pain and pain-related behaviors; 6 studies focused on a pain intervention targeting pain related behaviors, 1 study focused on a behavioral intervention targeting pain.Available evidence suggests pain interventions targeting behavior, and behavioral interventions targeting pain are effective in reducing pain and behavioral symptoms in dementia.1a-
Modifiable nature of empathyBuffel du Vaure et al., 2017To assess the effects of Balint groups on empathy.A two-site randomized controlled study; Participants in the intervention group received a training of 7 sessions of 1.5- hour Balint groups, over 3 months.N = 299 Fourth-year medical students; 155 intervention group, 144 control group.The intervention group showed higher self-rated Jefferson's School Empathy Scale for Medical Students score at follow-up than the control group [Mean (SD): 111.9 (10.6) vs. 107.7 (12.7), P=0.002]. The score increased from baseline to follow-up in the intervention group, whereas it decreased in the control group [1.5 (9.1) vs. −1.8 (10.8), P=0.006]. There was no significant difference in Consultation and Relational Empathy (CARE) scores at follow-up between the two groups (P=0.49).2b
Modifiable nature of empathyKelm, Womer, Walter, & Feudtner, 2014To synthesize the published literature about interventions that quantitatively evaluated changes in empathy among medical students, residents, fellows and physicians.Systematic review of 64 clinical empathy intervention studies.Medical students, residents, fellows and physicians.Eight of 10 studies with highly rigorous designs found targeted empathy interventions increased empathy.1a-
Modifiable nature of empathyKiosses, 2016To systematically assess the effectiveness of interventions aimed at increasing health professionals' empathic responses.Systematic review of 13 randomized controlled trials17 randomized controlled trials in health professionals (13 studies used experiential approaches, four used non-experiential learning approaches).Based on 13 trials with adequate data, health professionals in the intervention group improved empathic behavior when compared to control group (SMD 0.8, 95 % CI 0.4, 1.2; P value <0.001).1a-
Modifiable nature of empathyWundrich et al., 2017To examine whether specific training can improve empathy in medical students.Randomized controlled trial; the intervention group participated in an empathy skills training with simulated patients. The control group participated in a history course.158 medical studentsIntervention group participants demonstrated significantly higher levels of empathy when rated by simulated patients and experts compared to the control group. In contrast, no significant group differences were observed in self-rated empathy.2b
Modifiable nature of empathyMcConville, McAleer, & Hahne, 2017To assess the effectiveness of mindfulness training in medical and other health professional student groups and to compare the effectiveness of different mindfulness-based programs. Meta-analysis evaluated the effect of mindfulness training on empathy, mindfulness, depression, anxiety, stress, mood, and self-efficacy.Systematic review and meta-analysis19 studies (representing 1815 participants) focused on medical (n=10), nursing (n=4), social work (n=1), psychology(n=1), and medical plus other health (n=3) students. Intervent ions were based on mindfulness.Mindfulness-based interventions improve empathy, mindfulness, mood and self-efficacy and decrease stress, anxiety, and depression in health profession students. There is a range of presentation options, enabling mindfulness training to be relatively easily adapted and integrate into health professional training.1a-
Modifiable nature of empathyNosek, 2014To test the Nonviolent Communication intervention's effect on empathy. The intervention included two, one-hour and forty-five minute trainingsessions.Mixed methods single group pre/post-test design incorporating the Interpersonal Reactivity Index (IRI) to measure empathy.N= 55 baccalaureate student nursesQuantitative results revealed an increase in empathy post training. Qualitative analyses demonstrated positive impact of Nonviolent Communication in empathizing with self and others.2b-
Modifiable nature of empathyRiess, Kelley, Bailey, Dunn, & Phillips, 2012To test the effect of an empathy training protocol (three 60-minute empathy training modules) grounded in neuroscience on physician empathy as rated bypatients.Randomized controlled trialN=99 residents and fellows from surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedicsThe empathy training group showed greater changes in patient-rated Consultation and Relational Empathy (CARE) scores than the control (difference 2.2; P=0.04). Trained physicians also showed greater changes in knowledge of the neurobiology of empathy (difference 1.8; P<0.001) and in ability to decode facial expressions of emotion (difference 1.9; P<0.001).1b-
Authors

Dr. Starr is Research Fellow, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Center for Bioethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and Dr. Magan is Assistant Professor, University of Rhode Island, College of Nursing, Kingston, Rhode Island.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The authors acknowledge support from the Ruth L. Kirschstein National Research Service Award training program in Individualized Care for At Risk Older Adults at the University of Pennsylvania, funded by the National Institute of Nursing Research (T32NR009356). Dr. Starr also acknowledges support from the Rita and Alex Hillman Foundation's Hillman Scholars Program in Nursing Innovation and the Jonas Nurse Leaders Scholars Program.

The authors thank Mary Ersek, PhD, RN, FPCN, and Christine Bradway, PhD, RN, CRNP, FAAN, for their comments during manuscript development.

Address correspondence to Lauren T. Starr, PhD, MBE, BA, RN, Research Fellow, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 3615 Chestnut Street, Ralston-Penn Center, RM319, Philadelphia, PA 19104; email: ltstarr@nursing.upenn.edu.

Received: July 30, 2018
Accepted: February 04, 2020
Posted Online: April 14, 2020

10.3928/19404921-20200402-01

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