The Development of an Empathy Curriculum (Empathy in Health) for Healthcare Students Using VR Technology

*Alexia Papageorgiou, Julia Leinweber, Kerstin Böhm, Constantina Constantinou, Ourania Kolokotroni, Eleni Kapreli, Konstantina Savvoulidou, Nikos Strimpakos, Christiana Knais, Melissa Horlait, Nikos Papastamatiou and Chrystalleni Papadopoullou*

### **Abstract**

Empathy in Health is an Erasmus + funded project, which aims to design a curriculum for empathetic skill development in healthcare practitioners and home carers based on up-to-date evidence and cutting-edge technology tools. A literature review was carried out that focused on empathy in health care using VR technology. The results of the literature review helped develop a focus group guide for the purposes of the qualitative part of the need assessment exercise. The data from the focus groups were transcribed and analysed using the methodology of content analysis. The themes that emerged from the analysis of the focus groups' data lent themselves to three major working areas. These informed the development of the qualification framework, which in turn informed the development of the detailed curriculum. The Empathy in Health curriculum involves 21-hour classroom teaching, 3-hour Asynchronous Electronic Learning and 6-hour Directed Self Learning for graduate students or final year undergraduate students or Health Care Professionals. The curriculum covers understanding empathy and competencies necessary for empathy, understanding empathy in relationships and information exchanges in different health care contexts/environments, showing empathy in diverse environments and overcoming barriers/challenges to empathy.

**Keywords:** empathy, virtual reality, medical students, midwifery students, physiotherapy students, patient-centeredness, burnout, cultural diversity, communication skills, educational videos, role-plays, focus groups

### **1. Introduction**

The empathetic abilities of healthcare professionals are central to achieving the best patient outcomes in all fields of medicine, in physiotherapy, and midwifery. Next to being closely linked to treatment success and outcomes, the quality of provider interaction strongly affects how patients experience their treatment and their overall hospital stay. Patients highlight that empathetic communication is essential to their experience of respectful care, but they frequently experience dissatisfying or even disrespectful communication with their healthcare/home-care providers [1, 2]. Empathetic communication between health care provider and patient is key to facilitating shared decision making and negotiation around medical options and alternatives [3], which is an important factor for reducing healthcare costs as shared decision making can reduce unnecessary procedures or re-admission to hospital [4].

Whilst the relationship between healthcare providers and patients ideally is characterized by a partnership that facilitates patients' informed decision making and also by reciprocity in the interactions. It is important to emphasize that ultimately it is the healthcare providers who are responsible and accountable for the quality of their communication with their patients.

Research suggests that student empathy can decline during their educational years [5, 6]. Scarcity of practice placements is a challenge in many healthcare educational settings and may leave students with limited experience with communicating with patients in a particular setting, contributing to difficulty in empathizing with their patients. Targeted activities have been found to enhance and sustain healthcare students' empathy [7]. It is thus of high importance to offer training and practice to healthcare students that assists them in identifying opportunities to express and communicate empathy when providing care.

### **2. The aim of the empathy in health project**

Empathy in health is an Erasmus + funded project which aims to design a curriculum for empathetic skills development in healthcare practitioners and home-carers based on up-to-date evidence and cutting-edge technology tools. To carry out the project, a consortium was established that included the following partners: Mediterranean Management Learning (MMC), University of Nicosia Medical School, Charite University Medicine Berlin (previously Protestant University of Applied Science Berlin), University of Thessaly Physiotherapy Department, Department of Health Sciences Research Group Organization, Policy and Social Inequalities in Healthcare (OPIH), Vrije Universiteit Brussel, Omega Technology, and Cyprus Certification Company.

The objective of this research project has been to develop a certified three-day curriculum that will use a skills-based approach, educational videos, role-plays, and virtual reality scenarios to teach and empower healthcare students and home-carers to develop their empathetic skills during their encounters with patients and their carers and also their colleagues while avoiding burnout.

The aim of this curriculum is, therefore, to inform and train undergraduate and graduate healthcare students who will be future healthcare professionals with the necessary knowledge, skills, and competencies in developing and maintaining empathetic interactions. The project's task was to develop two different qualification

frameworks: one for higher education students (EQF7) and one for home-carers (EQF5). In this chapter, we will focus only on the training for higher education (EQF7).

### **3. Methodology**

#### **3.1 Literature review**

Each partner carried out a literature review that focused on empathy in healthcare using VR technology in their respective fields of education.

The search engines that were used include Embase, Medline (PubMed), PsychInfo, CINAHL, Scopus, and Web of Science.

The results of the literature review were used to develop the theoretical framework of the project. The selected studies were divided into five subcategories:


#### **3.2 Focus group guide**

A focus group guide was developed for the purposes of the qualitative part of the needs.

*Assessment exercise:* It provided specific information to the focus group facilitators on how to run.

*The focus groups*: It also included information on the logistics (duration, number of participants, documentation) of the focus groups, and more importantly on the flow of questions and the probes to be used in order to get the necessary qualitative information (**Table 1**).

#### **3.3 Focus groups**

The objective of the focus groups' was to investigate and describe the needs for achieving an effective empathetic consultation and interaction between the healthcare professionals and the patients. In addition, it aimed to inform the development of the necessary learning outcomes for the qualification framework and the different VR scenarios.

The methodological aspects of conducting focus groups were discussed by all partners and agreed upon by the core academic group of the participating academic institutions.

Each partner carried out focus groups with healthcare professionals and patients related to their area of expertise and practice.


#### **Table 1.**

*Focus groups' questions.*

### **3.4 Qualitative analysis of focus groups**

The data from the focus groups were transcribed and analyzed by at least two researchers per academic institution. The consortium applied the methodology of content analysis by Erlingsson & Brysiewicz [8]. More specifically, two researchers from each academic institution performed the following steps independently:


Following the above steps, researchers had two options for checking categories and themes for appropriateness and consistency of coding and the naming of categories:

1.The same two researchers checked each-other's categories and themes.

2.A third researcher checked the categories and themes of the two researchers.

Disagreements in coding were discussed until all coders agreed and a final list of themes was produced.

#### **3.5 Results**

The table below outlines the number of focus groups each partner carried out and the mode of delivery of focus groups. The original intention was to carry out the focus groups face-to-face, but due to the Covid-19 pandemic, some partners had to resort to online mode. Overall, four focus groups with healthcare professionals and four focus groups with patients took place in order to develop the training for higher education (EQF7) (**Table 2**).

#### **3.6 Themes that emerged from focus groups**

The themes that emerged from the analysis of the focus groups' data lent themselves to three major working areas and are summarized below. These informed


**Table 2.** *Number of focus groups, participants, and mode of focus group delivery.*


**Table 3.**

*Themes that emerged from focus groups.*

the development of the *qualification framework***,** which is presented in detail in Appendix 1, which in turn informed the development of the detailed curriculum (**Table 3**).

### **4. Development of the empathy in health curriculum**

#### **4.1 A curriculum at EQF Level 7**

This curriculum is based on the European Qualification Framework (EQF). The EQF is an 8-level framework based on learning outcomes. It is designed for all types of qualifications and serves as a translation tool between different national qualification frameworks. The main purpose of the EQF is to make qualifications more readable and understandable across countries and systems. This is important to support crossborder mobility of learners and workers and lifelong learning across Europe (see Description of the eight EQF levels).

More specifically, the curriculum is designed for Level 7 of the EQF. This means that the learning outcomes focus on students in the second cycle of higher education. This cycle typically finishes with a qualification labeled "Master" and is obtained after the successful completion of a study program with 60–120 ECTS credits. https://www. ehea.info/page-three-cycle-system.

**Table 4** provides information regarding the curriculum at a glance.

#### **4.2 The aim of the training program**

Empathy is the key to effective communication between patients and health carers [9] and has been shown to positively affect health outcomes and patient satisfaction but also improve patient safety [10]. Communicating with patients is the most frequently used procedure by healthcare providers, however, communication skills training in undergraduate healthcare programs is variable and assessment of interpersonal competencies often neither reliable nor consistent [11].

The training program "Empathy in Health" aims to fill this gap in healthcare education. The focus of the program is to enable students to communicate empathetically with patients, families, and colleagues in different situations and to identify challenges and barriers to their empathetic capacities, including burnout and stress. The program is aiming to enable students to:


#### **Table 4.**

*The curriculum at a glance.*


#### **4.3 Target groups**

The program addresses students of midwifery, physiotherapy, and medicine. Ideally, undergraduate students in their last year and already practicing professionals enrolled in master's studies should be encouraged to participate in the training program.

It is suggested that the students participating in this training program should already have *some* exposure to/experience in patient-care in their healthcare profession. Having profession-specific knowledge and technical skills are considered to be an important prerequisite to be able to work on empathetic competence and understand concepts to improve healthcare structures to be supportive of empathetic-care provision.

However, it is also considered important to strengthen empathy in the target group *before* they finish their studies, so they enter the workforce with this important set of knowledge, skills, and competencies related to empathetic care. This should increase their ability to relate with empathy to their patients, colleagues, and themselves, increasing patient satisfaction, the quality of their care as well as their own work satisfaction. The influx of young professionals who have received special training for maintaining and expanding their empathetic skills will increase awareness of the

importance of empathy in healthcare provision and is expected to have a positive effect beyond the individual interactions on the culture in the relevant healthcare settings.

#### **4.4 Working areas**

The first part of the curriculum focuses on enabling students to understand the theory and research behind empathy, as well as the competencies necessary for building and maintaining empathetic communication through the use of interactive learning activities and constructive feedback.

In the second part of the curriculum, empathy in relationships and information exchanges in different healthcare contexts/environments are being elaborated. The curriculum focuses on the skills necessary to develop a relationship that fosters and nurtures empathy and trust and to enhance patient-centred information exchanges.

A subsequent part of the current curriculum deals with the importance of cultural competence in patients and working with colleagues from various cultural and social backgrounds. Cultural competence is a critical core component of health professionals and should be considered as a part of "best practice" in providing empathetic patientcare. Achieving cultural competence is a process that is cultivated within the individual through the acquisition of knowledge, attitudes, skills and behaviors specific to culture, language, and communication.

The last part of the curriculum focuses on enabling students to understand the complex relationship between empathy and burnout in healthcare. In response to high levels of burnout in the healthcare professions which can affect professionals' empathetic abilities, as well as affect their mental and emotional health and retention, the curriculum aims to enable students to apply methods that prevent or alleviate symptoms of burnout.

#### **4.5 Training methodology**

The course is taught in a modular structure using work areas that have been derived from initial research conducted in the project.

Each working area focuses on *one important aspect of empathy in health care*. Starting with a general introduction to empathy the students then deepen their competencies by focussing on empathetic communication and dealing with intercultural situations and threats to empathetic behavior.

With an emphasis on practical exercises that are facilitated using virtual reality techniques or role-plays, the participants experience their competence in empathy directly and receive feedback from their peers – this enables them to work on improving their empathetic abilities individually or in groups.

Knowledge is transmitted in classroom teaching via lecture and by instructing students to perform interactive exercises in pairs or triads to foster learning and practice the aimed skills. The classroom structure has been chosen because of the social aspect of empathy and the importance of nonverbal and verbal communication which is difficult to realize in a digital environment.

Congruent with the concept of a flipped classroom where theoretical aspects are first taught via asynchronous electronic learning and then discussed and practiced in the classroom. Asynchronous electronic learning in this course is used to underline the importance of empathy and motivate the students before the course starts. It is also used to assess the competencies acquired during the course by assessing exchange between peers, self-reflection, and a knowledge quiz.

Directed self learning enables the students to deepen their knowledge and conduct their own learning path. A selection of articles and books is provided, but the student is also free to do her/his own research and connect to the learning community.

Using a workload corresponding to 1 ECTS allows the integration of the program in different study programs of health professions more easily and makes it available to a broader audience. It can also be integrated as a training course in the context of lifelong learning activities.

#### **4.6 Classroom teaching**

In this course, classroom teaching has been chosen to enable students to practice their empathetic and communicative competencies with peers and the teacher via role-plays and virtual reality exercises right after a theoretical input. The classroom teaching focuses on the theory-practice transfer right away.

Theoretical content is presented using PowerPoint presentations. Following this using self-reflection exercises, group work, and experiential exercises (role-play and VR) the tutor assures that students are able to translate theory and knowledge into skills that are directly transferable to their professions. In other words, the students achieve the desired learning outcome, which is to act empathetically in their profession.

#### **4.7 Asynchronous electronic learning**

Asynchronous electronic learning describes the possibility of initiating targeted learning processes in virtual learning spaces by means of digital media, alone or in groups, synchronously or asynchronously. Access takes place online and is linked to the possibility of communicating with teachers and other learners [12].

In this course, an online learning platform provides learning content, precise exercises to prepare for classroom teaching, and the possibility to communicate with peers and teachers.

#### **4.8 Directed self-learning**

In directed self-learning students direct their own learning process to achieve the competencies of their learning project. However, it does not mean they need to realize it alone, directed self-learning can also include consultation of peers and the creation of learning networks, for example, a community of practice. This course encourages directed self-learning by providing learning content and the possibility of exchange. Altogether, 6 hours of directed self-learning are suggested.

As part of their directed self-learning students will need to engage with the literature that is provided on the online platform.

### **5. Training techniques**

#### **5.1 Lecture**

The lecturers use a PowerPoint presentation to build a knowledge base in the three working areas (WAs).

### **5.2 Role-play**

A role-play is used in each working area (WA) to encourage students to practice learned skills in a group, and to give and receive feedback on their empathetic behavior. The role-plays are focussing on the following:


### **5.3 VR videos**

Three VR videos are used to enable students to practice empathy-related skills in the following areas:


### **5.4 Educational videos**

In addition, educational videos are used in each working area (WA) to encourage students to practice learned skills in a group and to give and receive feedback on their empathetic behavior. The educational videos are focussing on the following:


3.Medical consultation: An obese middle-aged patient with high cardiovascular risk (several risk factors). Communicating risk and practicing motivational interviewing techniques.

#### **5.5 Tutor guides**

For each work area, there are detailed tutor guides that will be freely available to the scientific community through our dedicated project website:

https://empathy.projectsgallery.eu/?fbclid=IwAR0ml6iunM8GB34HyyA9- FLyUOOuy\_DnKG4b0gU7kKmZAepKjn9C0ctR8yH4.

All tutor guides will be available in addition to the English language in Greek, German, and Dutch.

#### **5.6 Curriculum certification**

The curriculum is in the process of ISO certification by the Cyprus Certification Company.

https://www.cycert.org.cy/.

#### **5.7 Curriculum evaluation**

During the piloting of the curriculum materials, national trainers, students, national tutors, and the certification agency gave their feedback on what worked well and which areas needed improvement. The curriculum went through different phases of revision in order to reach its finalization.

In order to assess any differences in our student's practice, the Jefferson Scale of Physician Empathy (Student Versions) [13].


### **A. Appendix 1: Qualification framework**






## **Author details**

Alexia Papageorgiou<sup>1</sup> \*, Julia Leinweber<sup>2</sup> , Kerstin Böhm<sup>3</sup> , Constantina Constantinou<sup>1</sup> , Ourania Kolokotroni<sup>4</sup> , Eleni Kapreli<sup>5</sup> , Konstantina Savvoulidou<sup>5</sup> , Nikos Strimpakos<sup>5</sup> , Christiana Knais<sup>6</sup> , Melissa Horlait<sup>7</sup> , Nikos Papastamatiou<sup>8</sup> and Chrystalleni Papadopoullou<sup>9</sup>

1 University of Nicosia Medical School, Engomi, Cyprus

2 Institute Midwifery Science, Charité – Universitätsmedizin, Berlin, Germany

3 Protestant University of Applied Science Berlin, Berlin, Germany

4 Faculty of Nursing, University of Nicosia Medical School, Limassol, Cyprus

5 Faculty of Health Sciences, Physiotherapy Department, Clinical Exercise Physiology and Rehabilitation Research Laboratory, University of Thessaly, Lamia, Greece

6 M.M.C Management Center Ltd., Cyprus

7 Department of Health Sciences Research Group Organization, Policy and Social Inequalities in Healthcare (OPIH), Vrije Universiteit Brussel, Brussel, Belgium

8 Omega Technology, Athens, Greece

9 Cyprus Certification Company, Nicosia, Cyprus

\*Address all correspondence to: papageorgiou.a@unic.ac.cy

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## *Edited by Sara Ventura*

*Empathy - Advanced Research and Applications* is a compilation of recent experimental studies and theoretical models on the concept of empathy and its implication in various aspects of social life. The book describes the multifaceted construct of empathy and presents arduous concepts in a fluent and understandable way to reach readers who may not be familiar with the subject. Through this book, readers will understand the importance of empathetic skills and the neurological and psychological mechanisms of empathy. There is even the possibility to learn and improve one's empathetic ability. Empathy is vital for society's wellness and we hope that this book serves as a springboard for future research in the field.

Published in London, UK © 2023 IntechOpen © Tunatura / iStock

Empathy - Advanced Research and Applications

Empathy

Advanced Research and Applications

*Edited by Sara Ventura*