It has been more than 10 years since we wrote an article entitled “Understanding the patient’s perspective of emotional support.” The article conveyed the reasons why providing emotional support during a patient’s healthcare encounter were critical to patient outcomes and, therefore, should be a health system priority.

Emotional support has historically been defined as an underpinning principle of work that is conducted by healthcare professionals – it is the caring part. Numerous definitions of emotional support exist, incorporating a range of elements. Other words that are used to speak to emotional support may be compassionate care, empathy and understanding – words that convey the softer skills required in delivering health services. Emotional support is about awareness of other people's emotions and understanding their feelings.

At the time of our publication, hospital scores on providing emotional support to patients during the delivery of their care showed we had room for improvement. We published a methodology by which hospitals could respond to the low scores to improve them. Fast forward to today, and not much has changed with respect to patient experience scores. And this, despite emotional support still being recognized as an important predictor of good patient outcomes.

Since our article was published in 2012, the health system has catapulted forward in an accelerated fashion in many regards and more recently, out of the necessity to respond to the COVID-19 pandemic. Hospital stays are shorter. The care model for patients continues to rapidly change, moving care closer to home through virtual means and remote monitoring. However, measurement of patient experience scores was disrupted during the pandemic. These changes are altering the equation of what lends to a great patient experience.

More recently, empathy and compassion have come under fire within Ontario Hospitals, as there have been reports of patient voices being silenced and pleas for change by patients with respect to how they were treated in their patient experiences have gone ignored. Where measures are available, one could argue that overall patient experience scores are poor and vary across socioeconomic and racial divides.

Why is the healthcare system not paying attention and why does it continue to underrate this important link to a great patient experience? In our current system, anything outside the technical aspects of care is seen as superfluous or “fluff”. It is our opinion that, as the health system attempts to adapt and reconfigure itself to transform, it will be critical to not just focus on scientific advancements, technical aptitudes and operational efficiency but also on affective qualities or virtues, especially regarding emotional support. Patients report that empathy and compassion are just as important as training and experience when it comes to choosing a physician. We need to work at the system level to alter the system’s culture in favour of the patient experience. Change can only happen within the healthcare system if it happens at multiple levels.

A recurring complaint for patients in their care journey is how they were treated. Patient complaints are less frequent about the actual care. Complaints may address the way clinicians/staff communicated or the lack of it, or the amount a patient is involved in shared decision making. The gap in a great patient experience is typically the affective part of the care journey.

Published reports suggest that indicators of empathic engagement or emotional support in patient care, such as physician–patient communication, verbal interaction (e.g., positive talk), nonverbal cues (e.g., appropriate touch, eye contact, bodily posture, gestures), as well as the length of the encounter can lead to increased patient engagement and better adherence to treatment recommendations. Furthermore, relationships have also been reported between some measures of empathy and the patients' feelings of being important, the physicians' accuracy of diagnosis and the accuracy of prognosis. So, the evidence suggests that emotional support has a role to play within healthcare interactions.

Creating a therapeutic bond with patients is essential. A therapeutic bond ensues whereby treatment decisions are communicated and conveyed in a manner where the patient feels heard and cared for and there is a shared agreement about how to get the patient “back on their feet”. Our article suggested that patients require and respond to informative communication, setting up a healing ambiance, proximity and predictability of their care providers and a deep understanding/ personalization of their care. What happens when this is not present? Patients tell us anxiety and fear persist if these are not met or addressed. Patients require and benefit from, at minimum, a basic level of emotional support in their care journey.

The system can no longer continue to ignore that patients are expecting to be “cared for,” not just cured.

Team Perspective: Why is emotional support important at the team level?

Healthcare organizations have overwhelmingly focused on provider-patient interactions for too long, at the cost of ignoring peer interactions. We are learning that teams have an emotional life, but very little attention is given to nurturing or supporting that element of team life. Teams in healthcare spend an enormous amount of time talking about what they do, but very little time is spent talking about how they do it, or how they behave with each other while they do it. When patients see team interactions, they feel and know when teams are not working well together. The potential of incivility to jeopardize optimal patient care and, in turn, patient safety, represents one of the major factors that led to its identification as a latent issue in healthcare.

Many studies on healthcare teams have found that team members wanted work relationships characterized by warmth, authenticity and an inherent respect for each other; they wanted to be spoken with as opposed to spoken to, generally, outside of emergency situations; they wanted team members who would grow to understand, appreciate and eventually accept various differences among team members; and they wanted team members who recognized and benefitted from participation in the teams’ collective goals. Most importantly, team members wanted to feel psychologically safe with each other. In psychologically safe environments people believe that if they make a mistake or ask for help, others will not react badly. Psychological safety exists when people feel their workplace is an environment where they can speak up, offer ideas and ask questions without fear of being punished or embarrassed. According to the literature on psychological safety, the free exchange of ideas, concerns or questions within the healthcare context is far more hindered by interpersonal fear than most leaders recognize, and these, in turn, have an impact on provider experience and patient safety.

Organizational Perspective: Why is emotional support important at the organizational level?

In today’s healthcare environments, we are hearing that clinical resources are strained, clinicians feel burnt out and yet are expected to provide a level of service that requires outcomes where patients feel like their care was exemplary. We must acknowledge that individual providers are doing their best – and they should be applauded for it. However, every system is perfectly designed to get the result that it does (Deming). Similarly, in the same spirit, Wendy Austin – a nurse scholar – has suggested that healthcare environments are currently places where value resides in the scientific, the efficient, the economical, the impartial and the procedural. Protocols and routines provide the parameters of practice, not generosity of spirit. The question for all healthcare organizations should be: “How do we build empathy or emotional support into the structure of healthcare? How do we build a future that is no longer dependent on patients being lucky enough to stumble upon emotionally supportive care providers but instead dependent on attention to the institutional processes that shape and nurture empathy and an emotionally supportive work force?” Organizations need to make explicit efforts to work on the emotional intelligence and emotional support dimensions within their organizations as these have been identified as essential elements to improve patient experience overall.

Recommendations

The literature is increasingly abundant in questions around how to build emotional support or empathy into the foundation of healthcare delivery. We agree with and extend the ideas of Ted A. James from Harvard Medical School that empathy must be incorporated into the very fabric of the care delivery process, through focus on three key areas.

Empathetic leaders create empathetic cultures.

• Governments and healthcare organizations must invest in a people strategy. Healthcare leaders and organizations need to recognize that though there are pressures to invest in healthcare human resources in terms of staffing, there is the equal pressure to invest in the actual people who are providing care as well. Healthcare human resource strategies must go beyond the concept of hiring more staff, and into developing people and training of healthcare teams, as well as training of leaders. It is important to note that emotionally supportive cultures start at the top – with leaders. Some questions that leaders need to be encouraged to think about are: (1) Do my staff feel safe and cared for during times of crises?(2) Do I engage in listening sessions with staff to make sure that my staff feel heard and that I respond to their expressed needs? (3) Do I value my employees’ wellbeing?

Nurturing empathy development on care teams is essential for collaborative care.

• More extensively, organizations must set time aside for professionals to slow down and process their experiences. It is well known in the literature that there are art-based interventions with nurses like narrative interventions in healthcare using writing exercise, journaling, oral storytelling and reflective discussion of a story or poem as a defined approach for strengthening nursing teams and nurse-patient interactions. There are also team-based interventions like the Schwartz Rounds. Schwartz Rounds are grand rounds–style events that focus on a case or a theme related to the emotional impact of patient care that care team members experience. The teams share their experiences, and then the discussion opens to comments about the emotional life of the team. These rounds have been proven to lower healthcare worker stress, increase team functioning, increase empathy with patients and reduce burnout. Organizations need to set time aside in healthcare settings for professionals to process their healthcare context and experiences. We need to rethink healthcare cultures that value the healthcare clinician as a human doing and embrace the idea that clinicians are human beings.

Redesign with Empathy in Mind: It is good patient care.

• The overall vision for all of us should be to make emotionally supportive environments a universal experience for patients of the health system. The system is not working quite like it should – it continues to be focused on the transactional but not the relational. We need to transform care so that emotionally supportive imperatives are part of the foundation of care delivery. One goal should be to operationalize empathy by directly incorporating the patient’s voice into how care systems are designed. This approach of building it together or co-production requires a thorough understanding of the patient journey including pain points, challenges and obstacles patients face. Yes, patients are being included in conversations about quality and safety improvement at many healthcare organizations. To be more intensive and proactive, patients must also be included in real time/during care provision so we do not miss opportunities for emotional support provision. Patients have an opportunity to direct and guide clinicians on how to improve their experience during care. We are proposing to leverage the patient voice proactively – do not wait for a survey after the episode of care to fix things. Make the patient part of the healthcare team’s effort to provide for a good experience. It is good business.

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