Family Responses to Different Types of Clinician Empathy Expression in Pediatric Care Conferences

Abstract

Background:

Clinician empathy positively impacts patient outcomes. Few studies have assessed the effects of different types of empathic expression.

Objective:

To describe how families respond when clinicians express empathy in different ways.

Design:

Prospective, mixed-methods cohort.

Setting/Subjects:

English and interpreted pediatric inpatient care conferences at a U.S. quaternary hospital between January 1, 2018 and January 1, 2021.

Measurements:

Directed content analysis of clinician empathic statements and family responses.

Results:

Of 29 patient-family dyads, 11 (39%) used language interpretation. In response to 80 clinician empathic statements, families expressed agreement or shared more 84% (67/80) of the time. Families shared more about their perspective in response to explore statements 71.4% (10/14) of the time, in response to validate statements 61% (17/28) of the time, and in response to respect/support statements 39% (11/28) of the time.

Conclusion:

Certain types of empathic statements may be more effective at prompting families to share more about their perspective, a key element of shared decision-making.

Introduction

Shared decision-making is critical for family-centered care, particularly for preference-laden decision-making such as that faced in critical illness or at the end of life.¹ Empathy expression may be an effective way for clinicians to gather information about family preferences, potentially improving shared decision-making.^2,3 When clinicians express empathy, patients rate their care higher, and clinicians have improved job satisfaction.^4–7 Despite these positive impacts, clinicians often miss opportunities to express empathy, and these missed opportunities negatively impact family experiences and outcomes.^5,8–14

Care conferences are meetings among patients, families, and multidisciplinary clinicians, typically involving information-sharing and decision-making.⁹ Few studies have looked at clinician empathic expression in pediatric care conferences. Existing studies compare empathy expression to lack thereof.^2,10 To our knowledge, this exploratory mixed-methods study of pediatric care conferences for seriously ill children is the first to look at how families respond when clinicians express empathy in different ways. We wondered if some types of empathic statements are more effective in allowing families to share more of their perspective.

Methods

This was a secondary analysis of the “Empathic Expression in Interpreted and Non-Interpreted Care Conferences of Seriously Ill Children” prospective, mixed-methods cohort study.¹⁰ We analyzed transcripts of care conferences at a single quaternary pediatric hospital. We conducted qualitative thematic analysis following Standards for Reporting Qualitative Research.¹¹ The hospital Institutional Review Board approved this study.

Participants

Study participants included hospitalized patients and family members with a planned care conference between January 2018 and January 2021, and clinicians participating in the conference. To focus on patients with serious illness, we included patients in the Pediatric intensive care unit (ICU), Cardiac ICU, Neonatal ICU, or inpatient units with palliative care consults. All conference participants provided informed consent.

Data collection

We collected patient clinical characteristics and caregiver demographics from electronic health records and surveys, respectively. Care conference audio recordings were transcribed verbatim. All interpretation was performed using professional interpreters, and only English portions were transcribed. Transcripts were not shared with study participants.

Data analysis

We summarized patient and family demographics, family empathic opportunities, clinician responses, and family responses, using counts and percentages. The codebook used for the directed content analysis in this study is discussed in detail elsewhere.¹⁰ We leveraged the Verona Coding Definitions of Emotional Sequences (VR-CoDES CC),^12–17 for family emotional expression, with a framework from October et al. to assess clinician and family responses.² Clinician responses were categorized using a mnemonic for empathic statements: NURSE(S) (name, understand, respect, support, explore, silence), which is used nationally to teach empathy expression.¹⁸ We grouped the statements into three categories:

• (1)validate (name, understand, align with positive emotion)
• (2)explore (explore, silence)
• (3)respect/support (respect, support)

Throughout the manuscript, codes are referred to in bold, and subcodes are referred to in italics. When clinicians responded to emotional expressions with empathic statements, they were coded as “unburied” (if followed by a pause of greater than five seconds to allow family to respond), or “buried” (if immediately followed by medical talk). Family responses to clinician statements were categorized as (1) alliance statements (deepen statements, including subcodes for emotional deepening or mourning, where families shared more about emotions, and agreement or gratitude statements); (2) cognitive statements (families did not acknowledge emotional content); and (3) no replies (families were interrupted, did not reply, or gave a brief reply such as “ok”).

Prior analyses of this dataset suggested that unburied empathy was far more effective in generating family alliance than buried empathy or missed opportunities.¹⁰ Therefore, for this secondary analysis focused on trends among the most effective empathic statements, we analyzed only unburied NURSE(S) statements and their responses.

The study team included pediatric physicians and a research assistant with experience in critical care, oncology, bioethics, palliative care, and health services and qualitative research, with an advisory panel of representatives from the hospital's patient family advisory council, patient navigation and interpretation services, and Center for Diversity and Health Equity.

Coding was done in groups of two or more. All challenging excerpts were reviewed with the advisory panel, using a vote in rare cases when consensus was not reached. Because we coded as a team, we did not test for inter-rater reliability. Dedoose software was used for data analysis.¹⁹

Results

Demographic data

We identified 69 eligible patients, 29 were included. Others were excluded because they could not be reached, the study team was unavailable, or the family declined (details described elsewhere.¹⁰). Median age was 8 months (Table 1). Eleven (39%) used language interpretation (8 Spanish, 2 Vietnamese, 1 Somali). Most patients (17/29, 59%) were in an ICU.

Table 1.

Patient and Parent Demographics

Demographics	N (%)
Patient age (median, range, N = 29)	8 Months (2 weeks to 17 years)
Patient gender
Male	11 (38)
Female	18 (62)
Other/nonbinary	None
Parent age (median, range) (N = 27)	33 (21–49)
Parent gender (N = 27)
Male	4 (15)
Female	22 (81)
Other/nonbinary	1 (4)
Parent race/ethnicity (N = 27)
American Indian or Alaska Native	2 (7)
Asian	4 (15)
Black or African American	2 (7)
Hispanic	8 (30)
Non-Hispanic White	10 (37)
Did not answer/prefer not to say	1 (4)
Parent Language for care (N = 29)
English	18 (62)
Spanish	8 (28.5)
Somali	1 (3.5)
Vietnamese	2 (7)
Patient Hospital location
PICU	7 (24)
NICU	4 (14)
CICU	6 (21)
Acute care	12 (41)
Primary diagnoses
Genetic	7 (24)
Cardiac	7 (24)
Pulmonary	6 (21)
Traumatic	1 (3.5)
Endocrine	1 (3.5)
Neurologic	3 (10)
Oncologic	1 (3.5)
Gastrointestinal	2 (7)
Immunologic	1 (3.5)

CICU, cardiac intensive care unit; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit

Clinician empathic expression

We identified 210 family emotional expressions. In response to these, clinicians expressed unburied empathy 80 times, with 80 family responses (Table 2). When expressing unburied empathy, clinicians were most likely to validate family emotions (name, understand, align with positive emotion, 35%, 28/80) or respect or support families (35%, 28/80), and least likely to explore family emotions (explore, silence, 17.5%, 14/80). Ten statements (12.5%) included more than one category of empathic statement (Table 3). There did not appear to be meaningful differences in empathic response types used in interpreted compared to English conferences (validate statements: 37% of English vs. 46% of interpreted empathic responses; respect/support statements: 43% of English vs. 33% of interpreted responses; explore statements: 20% of English vs. 21% of interpreted responses).

Table 2.

Types and Totals of Clinician Unburied Empathic Statements and Family Responses, With Examples

Statement		Total N	Example
Family empathic opportunities		210	Parent: Yeah, it breaks my heart to know that he is hungry.
Clinician unburied empathic statements		80a
Validate (N = 28)	Name	5	Palliative care attending: It is hard. Even if it is somewhat expected, it is still so hard.
	Understand	17	Genetics attending: None of us can imagine exactly what you're going through, but I think the tragedy of losing a child is something that touches all of us.
	Name and Understand	2
	Align with Positive Emotion	4	[Mom: I know here they love my family a lot.] Neuro-Oncology Attending: We do. You got that right.
Respect/support (N = 28)	Respect	18	Social worker: And [mom's name], I think it's important for you to know that you've done everything possible that you can do.
	Support	10	NICU attending: Well, we will get working as hard as we can on our end to make sure that we can get you as much support as possible, you and [child]
Explore (N = 14)	Explore	4	Palliative care attending: Can you say more about that?
	Silence	10
Combination responsesa		10	ICU fellow (respect and understand): I think we, as your team, have all watched you traverse this canyon of pain and hardship. And we're now asking you to look ahead and keep going into an even deeper canyon. And I realize, I can't imagine what that feels like because we know how much you love her. And I've watched you be here and advocate for her and have really put her first.
Family responses		80
Alliance	Agreement or Gratitude	22	Parent: Yeah you know I feel fully supported.
	Deepen or Mourn	45	Parent: My mom had a relative who had a tracheostomy, and he suffered very much. And I don't want that for my daughter. And I know that it's probably not the same situation, but I don't know how she will take it and especially as she gets older.
Cognitive or no response		13	Parent: So would this change? Would [child] still need medication to help with her secretions or not?

Throughout manuscript, as in the table, codes are referred to in bold text, and subcodes are referred to in italics.

^a Ten clinician unburied empathic statements included more than one category of emotional response (e.g., included both a validate statement and a respect/support statement).

Table 3.

Family Responses to Different Types of Clinician Unburied Empathic Statements

Clinician statements	Family responses
	Alliance response		Cognitive or no response, N (%)
	Agreement or gratitude, N (%)	Deepen or Mourn, N (%)
Validate (N = 28)	9 (32)	17 (61)	2 (7)
Respect/support (N = 28)	9 (32)	11 (39)	8 (29)
Explore (N = 14)	2 (14.3)	10 (71.4)	2 (14.3)
Combination statements (N = 10)
Validate and respect/support	2	3	1
Validate and explore	0	3	0
Respect/support and explore	0	1	0

Throughout manuscript, as in the table, codes are referred to in bold text, and subcodes are referred to in italics.

Percentages are given across rows.

Families expressed alliance (deepen/mourn, or agreement/gratitude) 84% (67/80) of the time (Table 3). Excluding the small number with more than one empathic statement type, validate and explore statements had the most family alliance responses (93%, 26/28; and 86%, 12/14, respectively), compared to respect/support statements (71%, 20/28). In eliciting families sharing more about their perspective (deepen/mourn subcodes within alliance), explore and validate statements appeared to be most effective, with families sharing more in response 71.4% (10/14) and 61% (17/28) of the time (respectively), compared to 39% (11/28) of the time for respect/support statements.

Discussion

This study suggests that some types of empathic statements appear to be more effective at prompting families to share more about their perspective, a critical aspect of shared decision-making and family-centered care. Specifically, families seem to share more when clinicians use statements that explore or validate emotions, compared to those that express respect or support for families. Explore statements (which included the use of silence) were most often associated with family sharing and deepening, yet they were used least frequently by clinicians. This is in line with existing literature about pediatric care conferences by October et al., who found that only 9% of all physician empathic statements were explore statements.² As previously described, we found that when clinicians expressed unburied empathy, regardless of which type of statement, families responded with alliance frequently.¹⁰

It is intuitive that statements exploring family emotions directly, or offering silence/space for families to expand on emotions, were associated with increased family sharing and emotional deepening.^20–22 Based on our results, statements that validate family emotions may also provide an open-ended communication strategy that encourages family sharing and deepening. In contrast, statements that express respect or support for families appeared less likely to lead to more family sharing and deepening. While such statements may have other benefits, they may not address the emotions as directly, or may be more likely to be interpreted as closed-ended or conclusive statements.

This study was conducted at a single institution which may limit generalizability. Furthermore, this exploratory analysis is not powered to draw statistical conclusions. For conference participants, knowledge about being recorded may have influenced behavior. We collected audio only, and analyzed written transcripts, thus missing nonverbal communication. This study is novel because it included families who spoke different languages. However, use of interpretation may have impacted the cadence of the conversations, including expression of empathy and response to it. We did not assess interpretation quality, although all conferences used professional interpreters. Further, our findings are limited in their ability to draw conclusions about differences across language or culture.

In pediatric and adult care conferences, studies show that increased family speak time and strategies that increased family participation are associated with increased family satisfaction.^20,21 Such statements may promote clinicians to learn more about family perspectives, potentially improving the recommendations they make and positively impacting shared decision-making. The American College of Critical Care Medicine's policy statement on shared decision-making includes a recommendation to explore family values when discussing preference-laden decisions.¹ Emotional processing is essential for rational decision-making²³; thus, statements that increase family emotional sharing may improve a family's ability to participate in shared decision-making.²

To this end, our results suggest that unburied empathic statements, in particular explore and validate statements, as well as silence, may be effective at increasing family participation, and possible sharing of their perspectives, goals, and values. Despite this, explore statements were used least often by clinicians. Future work should explore why clinicians are less likely to utilize explore statements or silence after emotional expression. To improve communication, family satisfaction, and shared decision-making, clinicians may consider increasing using empathic statements that promote family sharing, such as explore, silence, and validate.

Authors' Contributions

Dr. A.E.O. and Dr. A.T. conceptualized and designed the study, carried out analysis, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. J.B. carried out analysis and reviewed and revised the manuscript. Mx. A.M. collected data and reviewed and revised the manuscript. Ms. M.C.B. directed and carried out quantitative analysis, and reviewed and revised the manuscript. Ms. M.S., Ms. K.W., Dr. A.R.R., and Ms. B.F. provided feedback regarding study design and data analysis, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Funding Information

This project was supported by Seattle Children's Research Institute's Center for Clinical and Translational Research through the Academic Enrichment Fund, the Faculty Research Support Fund, and the Treuman Katz Center for Pediatric Bioethics. Dr. J.B. has received grants for unrelated work from the National Institutes of Health, the Cambia Health Foundation, the National Palliative Care Research Center, the Seattle Children's Research Institute, and the Lucile Packard Foundation for Children's Health. Dr. A.R.R. has received grants for unrelated work from the National Institutes of Health, the American Cancer Society, Arthur Vining Davis Foundations, the Cambia Health Foundation, Conquer Cancer Foundation of ASCO, CureSearch for Children's Cancer, the National Palliative Care Research Center, and the Seattle Children's Research Institute. Dr. A.T. is supported, in part, by the Cambia Health Foundation. The work described in this article reflects the opinions of the authors and not the funders.

Author Disclosure Statement

No competing financial interests exist.