Establishing Validity Evidence for Parallel Patient-Provider Empathy Scales to Drive Self-reflection

DISCUSSION

Empathy is crucial for the development of a successful and effective pharmacist-patient relationship, as it helps to build rapport with patients, increase trust, and improve medication adherence as well as patient health-related outcomes.¹ This requires self-reflection of one’s knowledge, skills, and ability to be empathetic.¹ Empathy can be developed through experience, reflection, and feedback that is reinforced across multiple settings.¹ This study provides validity evidence for use of the KCES-R in student pharmacists and introduces the KCES-PV for patient or simulated patient use. Taken together, these two measures provide two methods of assessing students’ skills in expressing empathy with patients (self-assessment and patient/standardized patient rating).

Student pharmacists in the current project rated the importance of empathy very highly (global beliefs domain sum scores).¹¹ Students’ ratings regarding the importance of empathy may be attributed to an emphasis on empathy in their pharmacy school curricula.^12,13 Specifically, the literature suggests that programs often use communication encounters, communication courses, OSCEs, and practice laboratories to address empathy.¹

In the current project, students appeared to rate their empathy ability at a higher level than it was rated by simulated patients. There are several potential causes for this. First, students may overestimate their personal abilities.⁴ Second, a social desirability bias may exist (overreporting of positive or more desirable attributes, such as growth in empathy, and minimizing negative or undesirable attributes) in student responses as well. Thus, it is highly likely that some students may rate their ability higher than is deserved after using a survey instrument or a simulated patient experience (often known as the Dunning-Kruger effect).¹⁴ Lastly, it is interesting that global empathy beliefs and perceptions of students’ own skills were moderately correlated; thus, perhaps the higher a student perceived the importance of empathy, the greater they rated their own ability, possibly again reflecting the social desirability bias.

Student pharmacists’ post-OSCE reflections revealed a conceptual understanding of empathy but also a realization that practice was needed for further development, as plans were made for subsequent encounters. This is an interesting finding, since it may indicate that post-communication reflections for a specific interaction coupled with completion of a self-assessment of empathy may allow student pharmacists to assess their empathy skills and abilities more accurately. Deeper reflection may promote better self-awareness. For example, Smith, Norman, and Decety found that multiple measures of students’ empathy can allow for a more complete assessment.¹⁵ In our case, students’ reflections of the specific interaction with the patient may have produced a more vivid form of recall than mere completion of a self-assessment questionnaire of empathy. The specificity of the reflection questions may also have allowed the student pharmacists to better recollect their use of empathy for a specific health care interaction. Thus, use of patient ratings, watching the encounter, and then reflecting on the encounter may be a useful approach for students to grow and build self-awareness. Regular assessment and feedback are key to developing empathy in students.¹ Using validated assessments that allow for self-evaluation and rater/evaluator/simulated patient feedback can further contribute to the self-reflection process. Experiential learning and patient interactions, often in clinical settings, can also contribute to the development of empathy.¹ Future work could evaluate whether having student pharmacists reassess themselves after watching a video of the encounter results in greater convergence of their responses with the patients’ perceptions as well as how this develops during further patient interactions in experiential learning.

The KCES-R and KCES-PV are promising measures of empathy for use by health professional educators and researchers alike. The KCES has been used in thousands of student and health professional assessments of empathy internationally, including numerous articles in pharmacy education. Recently revised to reflect the validity evidence from those administrations, the KCES-R provides students with an opportunity to self-assess and report their perceived empathy skills. Self-assessment is an important skill for student pharmacists to develop, as it aligns with CAPE domain 4.1.³ The KCES-PV affords the patient the opportunity to provide their perspective of the student pharmacists’ ability to show empathy. Obtaining the patient’s perspective is essential for more comprehensive insight into the student’s demonstration of empathy. This external feedback provides a more complete and personally unbiased perspective of the student pharmacist’s true ability to empathize with patients, and can be useful for identifying specific aspects of student empathy in need of further development.^16,17 This study focused on the KCES-PV for rating student empathy ability, but future studies in other settings (ie, health care provider empathy in primary care) could expand the use of this scale to aid clinician professional development by providing a method of obtaining patient feedback.

The limitations of this study include that two institutions were used for implementation. Therefore, results may not be generalizable to other institutions. Further, the student population that participated in this project may not be a representative sample of other student pharmacists. National statistics indicate that 37% of PharmD graduates are men; our sample was a little lower at 30%. Fall 2020 student enrollments indicated that approximately 48% of students were White; our sample was higher at 70%.¹⁸ Moreover, this study used simulated patient care experiences and, therefore, may not be illustrative of patient care that is provided to patients in actual practices. Due to the nature of this study, student and simulated patient responses could not be linked, which limited the ability to compare responses, and demonstration of validity evidence for the KCES-PV was limited. Only one patient case scenario was used for this study; thus, case specificity effect could have occurred. This case presented a homeless patient at a community pharmacy picking up a new prescription (levetiracetam) following an emergency room visit for a seizure. Due to the somewhat complex nature of the patient scenario, student pharmacists may have either missed or not recognized opportunities to show empathy. The complexity of the patient scenario also may be a strength of this study, as from this single patient encounter alone, student ratings of empathy beliefs and skills increased. Lastly, as mentioned above, the responses of study participants could be subject to social desirability bias.