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Table 2 Factors influencing empathy in healthcare settings

From: The development of empathy in the healthcare setting: a qualitative approach

Impact level Factors Components Quotes
High stability Born characteristics Personalities “[…] everybody is born with a certain personality type. And whatever nurture you get beyond that is still working on the baseline that you’re already inborn with, and nurture might not be able to overcome what nature has already given you”. 20-FGD4
Early life experience Childhood experience “I have a cousin who’s… he’s a child but he’s like quite- quite sick, always in and out of hospital, and he has a lot of medical problems, so I’ve seen how it affects like their family and then I always hear how like his mum, who’s my aunt, talk about a lot of things, you know, a lot of things they’re worried about, and things like that. So I guess sometimes when I speak to patients then I will be reminded of how sometimes all they want is to be reassured, or to know some things they’re really just worried about and they don’t know”. 22-FGD4
  Parental guidance “So, little things, little experiences I still can remember, like people on the street asking for money and my mum will just put some in, and she said things like, ‘although this might not be much for us but to them it’s still a lot of money,’ and yeah just helping those in need, just doing little things through little experiences.” 16-FGD3
Medium stability Non-work-related life experience   “I think actually another point really broadened my perspective was actually when we went for National Service. I think it really gave me a great deal of people from really diverse backgrounds that because previously the 12 formal years of education, it’s quite a small bubble, because we always hang around with people from very, very similar backgrounds. […] It helps you understand more like where people are coming from, or why people will approach certain problems in certain ways.” 12-FGD2
  Personal value and belief system Sense of right and wrong “I have certain personal biasness towards certain group of people. I know that’s my inherent biasness and it’s and professionally I shouldn’t have that kind of biasness, but I know I do. So these are the ones that I try a lot harder to work with. So one specific example is those with eating disorders, those anorexic. So to me, they do have an underlining issue. It may be psychiatric, it could be whatever. But it’s very difficult for me to empathize with them. Like, what makes you starve yourself?” 53-FGD11
   Professional identities “If your top priority as a nurse, if let’s say, your own principle, your value as a nurse is number one to care for the patient, I think it will always be at the back of your mind. Even though you’re busy, you just find like ten seconds to just pop your head and tell the patient ‘are you okay, do you need my help?’ ‘No’ that’s all. Just merely ten seconds will do.” 48-FGD10
   Religion “I mean some religions they teach about showing love and showing kindness to the people you meet, so definitely for some their religion would also teach them these values which would help them develop empathy.” 09-FGD2
   Culture & social norms “Sometimes because of the culture that which you are from, maybe you're not aware that some of your behaviour hurt others. But- you don't have that, how to say, that- didn't (wasn’t) aware that some of your behaviour hurt others. But if someone tell you that your behaviour is not properly (proper) that's why (you) will hurt others, you better behaviour in the other way, if someone alert you, then you just realise then you will consciously (try) to change your behaviour.” 01-FGD1
  Personal skills Communication skills “[…] even though you get the translator, sometimes it might not be words to words translating you see, so you couldn't really get the meaning out of it, then you just guess a bit and all that.” 29-FGD6
   Emotion regulation & coping abilities “Some people, like what I used to be along in my career, when it got too painful, I avoided. That was my strategy to deal with the feelings related to empathy that I couldn’t handle, at the earlier point of my life as a social worker.” 54-FGD11
  Work related experience Work culture “I think if you create an empathetic environment, I think generally anyone who works in that environment can actually pick up on it and they themselves be able to develop that soft skill as well, I feel, in a way. If your colleagues or people you’re working with do not display such attitude, then even if you yourself display such attitude, it may last you for a while. But perhaps after a long time, that might just die off as well.” 37-FGD7
   Work experience “[…] after serving people through my career and things like that, the empathy kind of evolved into walking with you but not carrying you while I walk with you. The boundary making is a part of the thing now, I realized. Last time it used to be ‘woah I’m totally one with you’, like watching Korean drama, cry my eyes out and things like that. But now there’s a little bit of boundary, I know that I’m a watcher of the whole situation, I’m not in it and losing myself.” 54-FGD11
   Work guidelines & standard “I would think also because structurally we have a lot of paper works that are legal documents. So we are very on task to fill up the documents more than talking to patient. Which is what happens the moment you graduate. Which is why staff who work long enough start to just become task oriented.” 60-FGD12
   Work set up “[…] or even in terms of like the layout of the clinic room, for example, if like the doctor’s computer is facing the wall then end up like sometimes they may not even look at the patient, which makes the patient feel very neglected or like the doctor doesn’t care…” 13-FGD3
   Monitoring & reward system “The kind of recognition that people get, I think, it’s very easy for organizations to recognize people who are very successful in terms of academic, very objective markers of success like academic or how many research papers you produce, how many patients you treat, what medal you won, but we don’t very often, we are doing it more now, but we don’t very often reward people for empathy obviously because it’s harder to see someone displaying empathy, because it’s a very one-to-one thing but I think recognizing it also tilts the focus towards that and makes people realize that it’s actually a more important aspect of the care that you give.” 17-FGD3
   Supervisor influence “[…] different senior doctors have different preferences when it comes to presentations, so, in the same way, if they don’t consider showing empathy a very important…, or they think it’s just a waste of time, then definitely juniors who are still learning how to become doctors, they would adjust and they would learn accordingly.” 21-FGD4
   Role model “[…] it’s also perhaps significant people along the way that affects us, that bolds us, that changes our way of thinking, our reaction or coach or mental guide. So I think that is also significant in shaping me as a healthcare professional.” 53-FGD11
  Training & education   “What’s being taught nowadays in school is not so much how to care, but how to show- or how to pretend that you’re caring. At the start you know we’re just pretending, you know, but after going through our clinical years you sort of understand what it means to care and how- what kind of impact it can have and I think that in itself is sort of teaching you like empathy in a sense that why you need to care. And the how to show you’re caring, it sort of makes sense once you see why you need to care.” 07-FGD2
Low stability factors Physiological states   “[…] sometimes really you just didn’t have enough sleep, you didn’t each much, you just get really tired, you just don’t want to care.” 60-FGD12
Mental states Mood “If I'm actually in a terrible mood in the morning and usually the first patient of the day usually gets it. (Laughter) I mean we'll try not to, cause we remind ourselves
‘you shouldn't vent’, but sometimes I mean you're all human right.” 31-FGD6
  Burnout “Anyone who’s worn out definitely will try to protect themselves more. Like look at survival situations. Nobody’s going to care about other people, they only care about themselves.” 59-FGD12
Situational stressors & priorities   “Usually in the most emergency situations also, empathy takes the backseat. I would say that the priority is to stabilise the patient. But of course at the same time you try to maintain dignity and all, you try to not let patient suffer”. 33-FGD6
Interpersonal interactions Patient-healthcare professional relationship “I mean some of the family members are just rude and harsh and they expect us in a way like robots, emotionless. So it’s like whatever they can do, like they are hurt by the doctors diagnosis, results, wrong results, like results everything, so they will push the blame on the nurse. And, it kind of triggered us to the point where we will suddenly just burst and treat harshly to the patient, to the family members. And that will effect over (affect) empathy.” 47-FGD9