Empathy in dental care – the role of vicarious trauma

Abstract

Objectives: In health care, empathy is associated with compassion, thoughtfulness, attentiveness and caring. While empathy is perceived as desirable and positive, it can potentially be associated with negative aspects, such as secondary traumatic stress or vicarious trauma (VT). VT addresses the secondary vicarious influences of patients’ pain and discomfort on clinicians. Dentists are routinely exposed to patients’ anxiety, pain and discomfort. These may lead to VT, which in turn can affect empathy. The objectives of the present study were to examine the existence of VT among dentists and its association with their empathic approach. Materials and methods: Two-hundred and fifty dentists were approached personally and by mail, and asked to complete: (i) the Jefferson Scale of Physician Empathy – Health Professionals; (ii) the Vicarious Trauma Scale; and (iii) demographic, personal and professional data, including age, definition of professional speciality, number of working hours per week and number of sleeping hours per night. Results: A total of 200 dentists responded (80% response rate). No differences were found between genders regarding empathy or VT. Dentists who have been accredited as a specialist in one of the dental fields (dental specialists) presented higher empathy scores than general practitioners. VT correlated positively with number of working hours per week and negatively with empathy. The best predictor of empathy was number of sleeping hours per night, followed by VT and age. Conclusions: Empathy in the clinical setting is closely associated with secondary VT among dentists. Decreasing dentists’ VT may benefit dentists’ empathy and through this lead to better clinical outcomes.

INTRODUCTION

Empathy is a psychological phenomenon that refers to the ability of a person to understand the feelings expressed by others and respond compassionately to another person’s distress¹. In this complex form of psychological inference, observation, memory, knowledge and reasoning are combined to yield insights into the thoughts and feelings of others². Empathy implies at least three different processes: feeling what another person is feeling; knowing what another person is feeling; and having the intention to respond compassionately to another person’s distress¹.

In health care, the concept of empathy is diverse, but mostly likened to ideas of compassion, thoughtfulness, attentiveness and caring. All these lead toward a desirable type of ‘chairside manner’ that generates understanding and is usually perceived as associated with positive rapport with patients³.

Health professionals usually identify competence, respect and empathy among the most important skills for professionalism⁴. Empathy can significantly encourage and motivate patients to take part in their treatment, and positively affect patients’ adherence to medical regimens and satisfaction from treatment⁵. It is considered an important factor for successful treatment outcomes3., 6., reduction of recovery time⁷ and even pain decrease8., 9.. Concomitantly, empathy positively affects professional satisfaction among physicians, decreases physician burnout and improves physician–patient relationships5., 10..

It has previously been reported that clinical experience among medical students is followed by a decrease in empathy¹¹. Among first-year dental students, empathy levels were high and similar to those reported in medical specialities such as psychiatry; however, during the second year of study, dental students’ empathy levels dropped and remained low during the remainder of their studies¹².

Medical educators suggested that clinical training may negatively affect the empathy of medical residents and students, and that the beginning of clinical interaction with patients is responsible for the decline in empathy11., 12., 13.. Additionally, work-related challenges, including long work hours and sleep deprivation, were indicated as factors responsible for the decline in empathy¹¹.

One possible factor that may explain the decline in empathy over time is vicarious trauma (VT), a special form of therapist burnout connected to the therapist–patient interaction. VT was originally presented as a concept that marks the changes occurring in mental health professionals over time, and specifically represents the effects of work with trauma victims¹⁴. The term ‘vicarious traumatisation’ is attributed to McCann and Pearlman, who identified that working with trauma victims may cause severe and lasting psychological effects¹⁴.

According to Pearlman and Saakvitne¹⁵, VT involves changes such as disruptions in the therapist’s both self- and professional identity and in his/her cognitive beliefs, particularly in the areas of safety, trust, esteem, intimacy and control. If these experiences are not appropriately processed and assimilated, they can eventually lead to the development of post-traumatic stress disorder-like symptoms14., 16.. While there are similarities between the concepts of VT, compassion fatigue and burnout, there are also noticeable differences15., 17.. One major difference is that VT focuses on changes in cognitive schemas while still acknowledging symptomatic distress¹⁴.

One of the aspects of VT research addressed its influence on physicians and nurses¹⁸. In the context of patient–doctor interactions, VT was used to address the secondary vicarious influences of patients’ pain and discomfort on clinicians. It has been observed mostly among physicians who work in challenging contexts¹⁹.

Stress, fear and anxiety are quite common in dental care, with about 6%–15% of the world’s adult population suffering from high dental anxiety and phobia²⁰. Patients’ anxiety significantly increases before dental procedures21., 22. and is closely associated with the pain experienced²¹.

Therefore, during their professional activity, dentists are routinely exposed to patients’ anxiety, pain and discomfort. These challenging contexts may lead to secondary vicarious influences, namely VT, which can further affect dentists’ empathy. Indeed, recent studies confirm that dentists suffer from various stress-related physical and emotional problems, especially new dentists at the outset of their careers²³.

The aim of the present study was to examine the existence of VT among dentists and its association with dentists’ empathy toward their patients.

MATERIALS AND METHODS

An a priori power analysis determined that a minimal cohort of 200 is necessary for the study. Therefore, 250 dentists, licensed to practice dentistry in Israel, were approached personally and through a link to an online version of the questionnaires sent via email. Response rate was 80% and the final number of dentists that participated in the study was 200.

The following measures were used.

• 1Assessment of empathy.

There are numerous methods to assess empathy, out of which self-rating scales are the most commonly reported ones used by health care professionals. The Jefferson Scale of Physician Empathy – Health Professionals (JSPE-HP) is a scale designed to specifically measure empathy among physicians and was therefore chosen for this study13., 24..

The JSPE-HP is a 20-item psychometrically validated scale, used among physicians13., 24., 25., 26., dental students¹² and recently dentists²⁷. Participants rate their level of agreement on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). Results range from a minimum of 20 to a maximum of 140 (the higher the score, the higher the participant’s level of empathy)²⁴ (Appendix 1).

• 2Assessment of VT.

In earlier literature, the Trauma and Attachment Belief Scale (TABS) was frequently used to measure VT28., 29.. The TABS is an 84-item proprietary measure that length limits its usefulness as a screening measure. The Vicarious Trauma Scale (VTS) developed by Vrklevski and Franklin is a brief and publicly available screening measure of VT30., 31..

The VTS consists of eight items that are rated on a 7-point Likert type scale, ranging from 1 (strongly disagree) to 7 (strongly agree). Total scores range from 8 to 56, with higher scores indicating higher levels of distress. The measure has demonstrated adequate internal reliability (Cronbach’s alpha = 0.88–0.77) in previous studies30., 31.. A score in the range of 8–28 indicates low VT, a range of 29–42 indicates moderate VT, and a range of 43–56 indicates high VT³¹ (Appendix 2).

• 3Demographic, personal and professional data.

Earlier research reported the existence of positive correlations between empathy and physicians’ field of professional speciality13., 26., 32., 33., and between empathy and number of sleeping hours per night11., 34.. Additionally, a correlation was reported between burnout and number of working hours per week³⁵. Therefore, information regarding field of professional speciality, number of sleeping hours per night, number of working hours per week, gender and age was collected as well.

Questionnaires were translated into Hebrew and back-translated to English to ensure accuracy.

Each participant signed an informed consent form or approved his/her participation electronically via the web. The Committee for approving research on human subjects at Tel-Aviv University approved the study, which was conducted in full accordance with the World Medical Association Declaration of Helsinki.

Statistical analyses were conducted by the Department of Statistics at Tel-Aviv University. SPSS software (version 21.0) was used with a significance level of P < 0.05 for statistical analyses. The following statistical tests were performed: Cronbach’s alpha, t-test, the Pearson correlation test, and linear stepwise regression analyses.

RESULTS

Both the JSPE-HP and VTS questionnaires showed acceptable Cronbach’s coefficient alpha values (JSPE-HP = 0.78; VTS = 0.68).

Among the study population, 33% were female and 11% were specialists licensed in one of the dental fields of specialisation or residents within the process of acquiring their accreditation as dental specialists. No differences were found between males and females with regard to their JSPE-HP or VTS scores.

The mean and SD values of the study variables are presented in Table 1. Dental specialists (licensed specialists and residents) presented higher empathy scores than general practitioners (121.95 vs. 111.17, P < 0.01).

Table 1.

Study variables (mean and SD scores, N = 200)

	Female	Male	Mean
JSPE	113.32 ± 12.06	112.05 ± 14.22	112.36 ± 13.51
VTS	30.54 ± 7.68	30.50 ± 7.56	30.60 ± 7.62
Age	32.49 ± 9.24*	36.30 ± 10.70*	34.96 ± 10.38
Working hours per week	28.82 ± 15.84*	36.45 ± 14.24*	34.07 ± 15.17
Sleeping hours per night	6.8 ± 1.50	6.69 ± 1.30	6.73 ± 1.37
Years of professional experience	5.77 ± 9.07	8.51 ± 10.08	7.54 ± 9.8

^*P < 0.05.

JSPE, Jefferson Scale of Physician Empathy; VTS, Vicarious Trauma Scale.

An inverse correlation was found between empathy, VTS score and number of sleeping hours per night (r = −0.202, −0.191, respectively, P < 0.01). A positive correlation was found between empathy and age (r = 0.157, P < 0.05; Table 2).

Table 2.

Pearson correlation between the study variables (N = 200)

	JSPE-HP	VTS	Experience	Sleeping hours	Working hours	Age
JSPE-HP	1
VTS	−0.202†	1
Experience	0.137	−0.087	1
Sleeping hours	−0.191†	0.018	0.026	1
Working hours	0.060	0.263*	0.187†	0.200†	1
Age	0.157*	−0.089	0.927†	0.004	0.124	1

^*Correlation is significant at the 0.05 level (two-tailed).

^†Correlation is significant at the 0.01 level (two-tailed).

JSPE-HP, Jefferson Scale of Physician Empathy – Health Professionals; VTS, Vicarious Trauma Scale.

Vicarious Trauma Scale scores correlated positively with number of working hours per week (r = 0.263, P < 0.01) and negatively with empathy (r = −0.202, P < 0.01; Table 2).

Stepwise regression showed that the best predictor for VTS score was number of working hours per week (B = 0.13, β = 0.27, P < 0.001), followed by JSPE-HP (B = −0.10, β = −0.18, P < 0.01). For this model, R² = 0.099 and F = 10.35.

The best predictor of empathy was number of sleeping hours per night (B = −1.84, β = −0.189, P < 0.01), followed by VTS score (B = −0.29, β = −0.163, P < 0.05) and age (B = 0.18, β = 0.14, P < 0.05). For this model, R² = 0.086 and F = 6.00.

DISCUSSION

The importance of an empathic approach in the dentist–patient relationship is undisputable and well acknowledged³⁶. However, understanding the factors that affect empathy is far from complete. Among others, the empathic approach of dentists can be associated with a factor that is rarely discussed in dental care – VT.

Vicarious traumatisation is often studied among social workers who are especially prone to dealing with subjects who have been exposed to trauma. Several factors such as professional experience, social support, life stress, age, gender, education and socioeconomic status were shown to moderate the impact of VT among this population37., 38.. Moreover, the impact of VT exposure can be also buffered by a high sense of professional self-efficacy³⁹.

Studies among physicians showed that primary care physicians who suffer from VT would benefit from external support, such as Balint groups, workshops and practice-based research networks⁴⁰.

In the present study, the average VTS score of dentists (male and female alike) was about 30, which represents a medium level of traumatisation³¹. This is similar to the level found among social workers in the USA³¹. The dentist is exposed to the stress of his/her patients on a regular basis. The finding that dentists showed VTS levels similar to those of social workers indicates that VT affects dentists in ways that are similar to those of other health professionals.

The average empathy score of the study population was 112, which is quite similar to what was found in previous studies among dental students and physicians in the USA12., 13. and among physicians in Italy²⁵. Similar to Italy²⁵, no differences in empathy were found between males and females in the present study. This is different from American and Mexican physicians, where empathy was more prominent in women13., 24., 41.. This may be due to cultural peculiarities or differences in sampling measures⁴².

Dental specialists had higher empathy levels than general practitioners. Specialities in dentistry are mostly procedure-oriented (e.g. prosthodontics, periodontics, etc.). The finding confirms the results concerning American and Korean practitioners where ‘procedure-oriented’ (mostly surgical physicians) scored higher on empathy than ‘people-oriented’ physicians (mostly medical generalists)13., 26., 32., 33.. Apparently, the additional professional education leads to less vulnerability to the stress involved with treating anxious and stressed patients. Possibly, the higher sense of professional self-efficacy among specialists may buffer the impact of VT and through it further affect their empathy.

Dentists’ empathy correlated with the number of sleeping hours per night, indicating once again that empathy is closely associated with sleep11., 34.. Interestingly, empathy was found to increase with age, possibly due to better communication skills and possibly also due to an increase in the professional self-efficacy of the more experienced dentists.

An inverse correlation was found between the JSPE-HP and VTS scores, indicating that the higher the VT, the lower the dentists’ empathy levels. By definition, VT occurs via empathic engagement with clients’ traumatic experiences15., 16.. Figley⁴³ notes that empathy is a major resource for those trying to help traumatised clients but, in the process, the helper may be traumatised as well. Using avoidance strategies, such as not engaging in empathy, may be functional in enabling the practitioner to continue carrying out the work⁴⁴. The decline in empathy can also be explained by the prolonged responses to the chronic emotional and interpersonal stressors on the job, manifested by a higher VTS.

The strongest predictor of dentists’ VT was number of working hours per week. Working hours in dentistry are often associated with dentists’ burnout³⁵, possibly due to prolonged exposure to patients’ stress and pain, but also as a result of fatigue and less time devoted to burnout relief activities⁴⁵. In order to prevent burnout, interventions that involve spending time with family and friends and self-care including paying attention to nutrition and performing exercises can help in balancing personal and professional life45., 46.. Such activities can also affect VT and, through it, empathy. Moreover, communication skills both improve empathy and are one of the intervention methods used to prevent burnout. Thus, the interactions between working hours, burnout, communication skills, VT and empathy are important and worth further exploration.

The strongest predictors of dentists’ empathy were number of sleeping hours per night, VTS score and age, further supporting the notion that fatigue and exposure to patient distress affect empathy. As empathy is important both to the dentists and their patients, more attention should be given (especially among younger professionals) to address these issues.

Some limitations should be noted. Although the study had a relatively high response rate, it is possible that those professionals who were interested in this issue were more responsive and introduced a bias. The study refers to Israeli dentists and is not necessarily representative of other countries.

Further work is necessary to better understand these issues. Such projects should involve actual recording of dental encounters followed by behavioural scoring of the dentists’ interaction with their patients. Also, a longitudinal design, in which young dentists’ empathy and VT levels are followed over time, will enable the mapping of possible changes during the dentists’ professional career.

Understanding the importance of interpersonal skills and empathy in health professions has already changed the curricula of medical and dental schools. The American Dental Education Association (ADEA) indicates that applying appropriate interpersonal and communication skills is an important competency in dental education⁴⁷. Acknowledging the possible role of VT on empathy decline among dental professionals will lead to better dealing with these complex issues and to a more empathic dental care.

CONCLUSIONS

Empathy in the clinical setting is closely associated with VT among dentists. VT should be considered more comprehensively in future dental studies dealing with empathy and dentist–patient relationships.

Acknowledgements

No funding was received for the presented work. The authors would like to thank the dentists who participated in this study.

Conflicts of interest

The authors declare that there are no conflicts of interest.

Appendix 1.

The Jefferson Scale of Physician Empathy – Health Professionals (JSPE-HP)²⁴

1. I try to imagine myself in my patients’ shoes when providing care to them

2. My patients value my understanding of their feelings, which is therapeutic in its own right

3. An important component of the relationship with my patients is my understanding of their emotional status, as well as that of their families

4. I try to understand what is going on in my patients’ minds by paying attention to their non-verbal cues and body language

5. Dentists† should try to think like their patients in order to render better care

6. I believe empathy is an important therapeutic factor in dental† treatment

7. Empathy is a therapeutic skill without which success in treatment is limited

8. ‡ Dental† illness can be cured only by dental† treatment; therefore, emotional ties to my patients do not have a significant influence on medical or surgical outcomes

9. ‡I do not allow myself to be influenced by strong personal bonds between my patients and their families

10. ‡I believe emotion has no place in treatment of dental† illness

11. ‡Because people are different, it is difficult for me to see things from my patients’ perspectives

12. ‡Attentiveness to my patients’ personal experiences does not influence treatment outcome

13. My patients feel better when I understand their feelings

14. A dentist’s† sense of humour contributes to a better clinical outcome

15. I consider understanding my patients’ body language as important as verbal communication in caregiver–patient relationships

16. ‡I try not pay attention to my patients’ emotions in history taking or in asking about their physical health

17. ‡Asking patients about what is happening in their personal lives is not helpful in understanding their physical complaints

18. ‡It is difficult for me to view things from my patients’ perspective

19. ‡I do not enjoy reading non-dental† literature or the arts

20. ‡My understanding of how my patients and their families feel does not influence dental† treatment

Scale ranging from 1 (strongly disagree) to 7 (strongly agree).

^†The word ‘Dentist/s’ replaced the word ‘Physicians/s’ and the word ‘dental’ replaced the words ‘medical/surgical’, which were used in the original questionnaire.

^‡Items with reverse scoring (1 = strongly agree, 7 = strongly disagree).

Appendix 2.

Vicarious Trauma Scale (VTS)³⁰

1. My job involves exposure to distressing material and experiences

2. My job involves exposure to traumatised or distressed clients

3. I find myself distressed by listening to my clients’ stories and situations

4. I find it difficult to deal with the content of my work

5. I find myself thinking about distressing material at home

6. Sometimes I feel helpless to assist my clients in the way I would like

7. Sometimes I feel overwhelmed by the workload involved in my job

8. It is hard to stay positive and optimistic given some of the things I encounter in my work

Scoring: 1. Strongly disagree; 2. Disagree: 3. Slightly disagree; 4. Neither agree nor disagree; 5. Slightly agree; 6. Agree; 7. Strongly agree.