Empathy in Dentistry: How Attitudes and Interaction with Older Adults Make a Difference by Dr. Jude Fabiano, DDS

This article was downloaded by: [Jude Fabiano] On: 02 March 2015, At: 12:48 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

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Empathy in Dentistry: How Attitudes and Interaction With Older Adults Make a Difference a

Deborah Waldrop , Thomas Nochajski , Elaine L. Davis , Jude c

Fabiano & Louis Goldberg

School of Social Work, University at Buffalo, Buffalo, New York, USA b

School of Dental Medicine, University at Buffalo, Buffalo, New York, USA c

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Ivoclar Vivodent, Amherst, New York, USA Accepted author version posted online: 13 Dec 2014.Published online: 13 Dec 2014.

To cite this article: Deborah Waldrop, Thomas Nochajski, Elaine L. Davis, Jude Fabiano & Louis Goldberg (2014): Empathy in Dentistry: How Attitudes and Interaction With Older Adults Make a Difference, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2014.993065 To link to this article: http://dx.doi.org/10.1080/02701960.2014.993065

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Gerontology & Geriatrics Education, 00:1â&#x20AC;&#x201C;22, 2015 Copyright ÂŠ Taylor & Francis Group, LLC ISSN: 0270-1960 print/1545-3847 online DOI: 10.1080/02701960.2014.993065

Empathy in Dentistry: How Attitudes and Interaction With Older Adults Make a Difference DEBORAH WALDROP and THOMAS NOCHAJSKI School of Social Work, University at Buffalo, Buffalo, New York, USA

ELAINE L. DAVIS Downloaded by [Jude Fabiano] at 12:48 02 March 2015

School of Dental Medicine, University at Buffalo, Buffalo, New York, USA

JUDE FABIANO Ivoclar Vivodent, Amherst, New York, USA

LOUIS GOLDBERG School of Dental Medicine, University at Buffalo, Buffalo, New York, USA

The development of empathy and positive attitudes are essential elements of professional education. This study explored the nature of empathy and its association with attitudes about, and exposure to older patients in a sample of dental students. Students completed an adapted version of the Jefferson Scale of Physician Empathy (JSPE), the Aging Semantic Differential (ASD) and answered questions about their exposure to older people. Factor analysis was used to identify four factors: (1) Empathy is Valuable, (2) Empathy is Demonstrated, (3) Empathy is not Influential, and (4) Empathy is Difficult to Accomplish. Higher empathy scores were related to the ASD subscale attitude of acceptability of aging and to greater exposure to older adults outside of clinical practice. There were no demographic predictors of higher empathy scores. KEYWORDS dental education, geriatric dentistry, empathy, attitudes, older adults

Address correspondence to Deborah Waldrop, LMSW, PhD, School of Social Work, University at Buffalo, 685 Baldy Hall, Buffalo, NY 14260, USA. E-mail: dwaldrop@buffalo.edu

D. Waldrop et al.

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INTRODUCTION Oral health is a key element of geriatric care. The American Society for Geriatric Dentistry, the Education Research Group of the International Association for Dental Research, and the American Association for Dental Research have been committed to improving oral health in older adults through education and skill development (American Society for Geriatric Dentistry, 2010; Dolan, Atchison, & Huynh, 2005). The development of a workforce of dentists with knowledge about and skills for working with older adults would be enhanced by interdisciplinary and interprofessional education (Best, 2010). For purposes of this article, the term older adults refers to individuals age 65 or older. Older adults experience greater numbers of coexistent chronic conditions and higher levels of health care utilization, including dentistry, than people younger than age 65 (Chalmers & Ettinger, 2008; Ettinger, 2007; Ferguson, Steinberg, & Schwien, 2010). In most general dental practices, older adults account for the largest number of visits and procedures (Ferguson et al., 2010). Many authors have asserted that geriatric dentistry requires special knowledge and clinical skills to treat dental conditions that occur in older adults, recognize the important connection between oral and systemic health to maintain optimal oral health and quality of life (Chapple, 2009; Frisbee, Chambers, Frisbee, Goodwill, & Crout, 2010; Sheets, Paquette, & Wu, 2009). Good care is enhanced by a humanistic approach, a warm relationship and sensitivity toward the patientâ&#x20AC;&#x2122;s systemic health and psychosocial concerns (Scully & Ettinger, 2007). The core values that define professionalism in dentistry have been identified as competence, fairness, integrity, responsibility, respect, and service mindedness (American Dental Education Association [ADEA], 2013). Service mindedness is defined as compassionate care for the benefit of individual patients and the public at large. Service mindedness encompasses the obligation to benefit others, compassion, and empathy. Empathic care requires the ability to understand and appreciate another personâ&#x20AC;&#x2122;s perspectives without losing sight of oneâ&#x20AC;&#x2122;s professional responsibilities (ADEA, 2013). Empathy is particularly germane to quality care for older people and has been linked to positive clinical outcomes (Hojat et al., 2011). However, the specific features or defining characteristics of empathy may vary across professional disciplines within health care. Although the impact of empathy has been linked to positive outcomes, the defining characteristics of empathy in dentists are largely unknown (Satterfield & Hughes, 2007; Sutherland, 1993). Preparing student dentists with knowledge of, positive attitudes about, and empathy for the growing population of older dental patients is an important element of education for an aging-prepared health care workforce. The twofold purpose of this study was to describe the nature of empathy in

Nature of Empathy

dental students and to investigate how attitudes about and exposure to older adults influence students’ empathy for older patients.

LITERATURE REVIEW

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Health-Related Quality of Life in Older Adults There is evidence that current older patients are better educated, more politically aware, and have more remaining teeth than in previous generations of older patients (Federal Interagency Forum on Aging-Related Statistics, 2012). However, the older population is not homogenous. Older people who have lower incomes have poorer oral health and more limited access to services (Tsakos, 2011). Frail and functionally dependent older adults also experience barriers to receiving oral health care (Ettinger, 2010). Systemic diseases that have an impact on oral health are more common in later life and should be an important factor in dental care for all older adults (Scully & Ettinger, 2007; Sheets et al., 2009). There are over 100 systemic diseases that have oral manifestations, including cardiovascular disease, stroke, respiratory infections, pancreatic cancer, diabetes, and nutritional problems (Haumschild & Haumschild, 2009). This interaction of oral and systemic diseases can have a cascade effect on well-being in later life. It is important for dental professionals to understand the special needs of older people and their ability to undergo and respond to care, establish communication with primary care physicians and be able to manage emergencies (Vieira & Caramelli, 2009). Communication and understanding between health care providers and their patients has received increasing attention in dentistry and dental education (Sherman & Cramer, 2005). Dentists’ caring attributes, such as gentleness and friendliness, have been found to be valued by patients as much as their professional competence (Gerbert, Bleecker, & Saub, 1994; Nash, 2010; Small, 2005). The relatively poor oral health status of older people who have coexisting chronic conditions underscores the urgency for dentists to be able to care for these underserved subgroups (Baumeister et al., 2007). Yet geriatric dentistry in the United States is still widely conceived of as simply involving dentures for patients in nursing homes (Ettinger, 2010). The lack of Medicare and other insurance coverage for older adults’ dental services limits access to care and contributes to complicating comorbid physical and psychosocial conditions in people who are frail, functionally dependent, cognitively impaired, or terminally ill (Griffin, Barker, Griffin, Cleveland, & Kohn, 2009; Kiyak & Reichmuth, 2005; Scully & Ettinger, 2007). Moreover, provider reimbursement for dental services is directly related to one’s state of residence and is often poor or nonexistent (Ettinger, 2010; Ferguson et al., 2010). Financial barriers to good oral health care can have a negative impact on health-related quality of life.

D. Waldrop et al.

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Empathy Understanding another person’s discomfort is essential to providing quality care (Winland, 2006). Empathy is necessary for effective communication between patients and providers to achieve optimal clinical outcomes. Empathy has been defined as a “predominantly cognitive attribute that involves an understanding of patients’ experiences, concerns and perspectives combined with a capacity to communicate this understanding and an intention to help” (Hojat, 2007, 2009; Hojat et al., 2009, p. 1183). Hojat et al. (2002) developed a measure of empathy that provides the opportunity to explore educational and clinical correlates as well as whether the level or type of empathy differs across the stages of medical education. Higher empathy scores have been positively associated with clinical competence and better patient outcomes in physicians (Hojat et al., 2011). The Jefferson Scale of Physician Empathy (JSPE; Health Professionals [HP] version) was developed to assess the development of empathy in other health care professionals (Hojat, 2007). The questions on the JSPE and JSPE-HP are the same with minor wording changes to make the JSPE-HP more generic (Hojat, 2007). The nature of empathy has been studied extensively in medical students but less so in dental students (Hojat et al., 2001). Sherman and Cramer (2005), using the JSPE-HP, found that the psychometric properties of empathy in a sample of dental students were comparable to those found in medical students (Sherman & Cramer, 2005). Four factors emerged: (1) perspective taking, (2) compassionate care, (3) standing in the patients’ shoes, and (4) efforts to ignore emotions in patient care. The questions associated with each factor can be found in Sherman & Cramer, 2005. This article presents the results of an analysis of the nature of empathy in dental students and its association with attitudes about and exposure to older adults.

METHOD Project Overview and Study Design The overall project is a large-scale longitudinal interdisciplinary effort that aimed to provide dental students with aging-enhanced education that will prepare them for effective practice with growing numbers of older people. Initially, we explored dental students’ knowledge about aging and found that though information is readily consumed by dental students, positive attitudes are not as easily taught (Fabiano, Waldrop, Nochajski, Davis & Goldberg, 2005; Waldrop, Fabiano, Nochajski, Zittel-Palamara, Davis & Goldberg, 2006). Subsequently, we explored the association between attitudes about and exposure to older adults and learned that attitudes are significantly influenced by the amount of exposure to older people (Nochajski, Waldrop, Davis, Fabiano & Goldberg, 2011). However, attitudes and knowledge may only partially contribute to the development of a caring professional.

Nature of Empathy

The study aimed to answer three research questions: (1) What are the characteristics of empathy in dental students? (2) Do levels of empathy vary by gender and age? and (3) What is the association between studentsâ&#x20AC;&#x2122; attitudes about, exposure to, and empathy for older patients. We hypothesized that empathy would vary by gender and be positively associated with age. We also hypothesized that studentsâ&#x20AC;&#x2122; attitudes about and exposure to older adults positively influence their empathy for their older patients. The results presented in this article are cross-sectional.

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Setting The University at Buffalo, School of Dental Medicine (SDM) admits approximately 90 new dental students into its 4-year program each year. The SDM Clinic is a major source of outpatient care for people who are disabled or have medically complex conditions. Of the approximately 46,600 visits per year, 72% are made by people age 50 years e or older (62% of the clinic population). Dental students begin to see patients in the campus-based clinic during the 2nd year, and their exposure intensifies in the 3rd and 4th year.

Sample Recruitment The sampling strategy was purposeful; each student in all 4 years of dental school was invited to participate. Participation was voluntary. The study was described during required classes for students in each year of the program, and class time was given for completion of the instrument. For the academic year of this study, there were a total of 344 students who had started the program: N = 81 in the 4th year, 71 completed the survey (87.7%); N = 87 in the 3rd year of the program, 61 completed the survey (70.1%); N = 88 in the 2nd year of the program, 81 completed the survey (92.1%); and N = 86 in the 1st year of the program and 100% completed the survey. A total of 299 (86.9%) completed the survey. The study was approved by the University at Buffalo Social and Behavioral Sciences Institutional Review Board. Study participation was completely voluntary. A written informed consent was nut used. Completion of the survey document was assumed to imply consent.

Sample Demographics The sample included 292 students. The Mean age was M = 26.3 (SD = 4.2 years) with an age range from 19 to 42 and 55.5% were younger than age 26. The sample included n = 169 men (56.5%). Nine percent said their parents were age 65 or older, 63.5% indicated that their grandparents were age 65 or older, and 30.8% said they had other relatives who were in this age group.

D. Waldrop et al.

Instrumentation The survey instrument had four sections: (1) Questions About You (demographics), (2) The Aging Semantic Differential (attitudes), (3) The Jefferson Scale of Physician Empathy (empathy), and (4) Frequency of Interactions with Older Adults.

QUESTIONS ABOUT YOU Students were asked for their age, year in dental school, gender, and marital status.

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AGING SEMANTIC DIFFERENTIAL The Aging Semantic Differential (ASD) involves 32 pairs of items (Rosencranz & McNevin, 1969). Items consist of bipolar adjective pairs that are opposite in meaning, and participants respond on a scale of 1 to 7 between the adjectives. The summary scale score ranges from 32 to 224, with lower scores reflecting more positive attitudes. There are four subscales: Personal Autonomy-Dependence, Instrumental-Ineffective, Personal AcceptabilityUnacceptability, and Integrity. Positive scores reflect attitudes that older adults are independent, effective, acceptable, and have integrity. Subsequent confirmatory factor analysis has been conducted by Intriere, von Eye, and Kelly (1995). The instrument has been used with a number of different groups and, when submitted to factor analysis, demonstrates different factor structures with different groups (e.g., medical students, undergraduate students). The ASD has been shown to demonstrate high internal reliability (Cronbach’s alpha .89) (Intrieri et al., 1995; Varkey, Chutka, & Lesnick, 2006).

THE JEFFERSON SCALE

PHYSICIAN EMPATHY

The Jefferson Scale of Physician Empathy (JSPE) is a 20-item instrument that uses a 7-point Likert-type scale and was developed to measure health care providers’ level of empathy for their patients (Hojat et al., 2001). Scores ranged from 20 to 140, with higher scores reflecting a more empathic behavioral orientation. The JSPE has been shown to demonstrate a high level of internal reliability (Cronbach’s alpha = .90). For our purposes, the JSPE was amended to use dental instead of medical and dentist instead of doctor.

INTERACTIONS WITH OLDER ADULTS This section involved five multiple choice questions about students’ frequency, context, and type of interactions with older adults, outside of the

Nature of Empathy

dental clinic as well as their interactions with older adults in the clinical setting. The “frequency” questions asked students to estimate how often outside of the clinic they interact with people who are older than age 65 (more than once a day, daily, a few times a week, a few times a month, rarely, never). The “context” question asked students to indicate with whom they interact who is older than age 65 (parents, grandparents, other relatives, neighbors, friends, others) by choosing all that apply. The “type” question asked students to check all types of interactions they have with older adults outside of the clinic (assist with chores, transportation, live with, caregiving, assist with personal care, attend religious services, at holidays only, and other).

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Analysis Survey results were entered into SPSS (version 22) for data management and analysis, which took place in stages. First, descriptive statistics were compiled. Next, to answer the first research question, maximum likelihood extraction was used to assess the factor structure of empathy in student dentists. Maximum likelihood extraction was also used to answer the second research question and to explore the association between empathy and demographic characteristics. A series of multiple regression analyses were used to answer the third research question and to explore the relationship between empathy and students’ attitudes toward older adults and the context and type of older adults with whom the students had contact outside the clinic. Bivariate analyses were used to compare the relationship between class and scores for the total empathy scale. ANOVA with Bonferroni adjustments was used to compare the responses of each class on the factors. Age was recoded into two categories, younger than 26 and 26 or older. Bivariate analyses for the age categories and gender were conducted using independent sample t tests. Correlations shown in Table 3 were standard Pearson correlations, as the measures were all continuous in nature. Multiple regression analyses were conducted using the JSPE total score and the four factors as dependent measures in separate analyses to determine if the influence of outside contacts with older people was more strongly associated with empathy than it was for attitudes. . In all multiple regression analyses, listwise deletion was used, resulting in a sample of 292 of the original 299 individuals in the sample. The losses in the sample were evenly distributed across the four classes. Entry was simultaneous, as we were interested in looking at unique contributions to the prediction of the dependent measure. Collinearity was assessed using tolerance and variance inflation factors (VIF). There were no collinearity issues in any of the analyses as all tolerance (<.2) and VIF (>5) indicators were not within the caution areas.

D. Waldrop et al.

RESULTS The Factor Structure of Empathy in Dental Students Initially, all 20 JSPE items were used, and four factors were identified using the scree plot and Eigen values of greater than one as a means for factor identification. However, four items did not load above .40 and were dropped from further analysis. A four-factor structure of empathy in dental students emerged which accounted for 63.7% of the total variance. The factors were (1) Empathy Is Valuable, (2) Empathy Is Demonstrated, (3) Empathy Is not Influential, and (4) Empathy Is Difficult to Accomplish. Table 1 presents the factor loadings.

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●

Empathy Is Valuable (Factor 1) had an initial Eigen value of 5.98, and five items accounted for 37% of the overall variance in the scale. Empathy is considered a therapeutic element of the helping relationship. Empathy Is Demonstrated (Factor 2) had an initial Eigen value of 1.93, and three items accounted for approximately 12% of additional variance in the overall scale. Empathy encompasses behavioral elements to show caring for a patient. Empathy Is not Influential (Factor 3) had an initial Eigen value of 1.27, and six items accounted for approximately 8% of the variance in the overall scale. Understanding of or attentiveness to patients’ concerns has no bearing on treatment outcomes. Empathy Is Difficult to Accomplish (Factor 4) had an Eigen value of 1.02, and two items accounted for an additional 6% of the overall scale variance. Understanding a patient’s experience is challenging.

There were no differences between classes in gender or age. There were no significant differences in empathy scores by age. Females were significantly higher on the overall empathy scale, F(1, 296) = 4.72, p = .030, η2 = .0158. Additionally, when considering the factors, females were significantly higher than males on Empathy Is Demonstrated (Factor 2), F(1, 294) = 5.57, p = .019, η2 = .0186; and significantly lower on Empathy Is not Influential (Factor 3), F(1, 296) = 7.09, p = .008, η2 = .0234; and Empathy Is Difficult to Accomplish (Factor 4) F(1, 294) = 6.80, p = .010, η2 = .0226 (see Table 2). THE RELATIONSHIP BETWEEN ATTITUDES, EXPOSURE OLDER ADULT PATIENTS

AND

EMPATHY

FOR

Results for the correlations shown in Table 3 suggest that empathy (JSPE total score) was related to the attitudes (ASD subscale). There also were significant associations between empathy and the number of different types of older people (e.g., older relatives, neighbors) the student had contact

Nature of Empathy

TABLE 1 The Factor Structure of Empathy in Dental Students Maximum Likelihood Extraction Factor

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1 emp6 My patients feel better when I understand their feelings emp5 I believe empathy is an important therapeutic factor in medical or surgical treatment emp8 An important component of the relationship with my patients is my understanding of their emotional status, as well as that of their families emp4 Empathy is a therapeutic skill without which success in treatment is limited emp3 My patients value my understanding of their feelings, which is therapeutic in its own right emp13 I try to understand what is going on in my patients’ minds by paying attention to their non-verbal cues and body language emp12 I consider understanding my patients’ body language as important as verbal communication in caregiver-patient relationships. emp14 I try to imagine myself in my patients’ shoes when providing care to them. emp9 I do not allow myself to be influenced by strong personal bonds between my patients and their families emp10 Attentiveness to my patients’ personal experiences does not influence treatment outcome emp1 My understanding of how my patients and their families feel does not influence medical or surgical treatment. emp7 Patient’s illness can be cured only by medical or surgical treatment; therefore, emotional ties to my patients do not have a significant influence on medical or surgical outcomes emp2 I believe emotion has no place in treatment of medical illness emp15 I try not pay attention to my patients’ emotions in history taking or in asking about their physical health. emp18 Because people are different, it is difficult for me to see things from my patients’ perspectives. emp16 It is difficult for me to view things from my patients’ perspectives

.784

.265

−.118

−.152

.751

.190

−.198

−.035

.669

.325

−.238

−.152

.634

.177

−.178

−.033

.608

.237

−.163

−.161

.344

.881

−.056

−.118

.408

.778

−.146

−.084

.390

.565

−.041

−.214

−.080

.027

.670

.104

−.206

−.152

.569

.009

−.038

−.066

.514

.102

−.333

−.268

.424

.259

−.266

−.109

.418

.153

−.151

.065

.415

.278

−.196

−.047

.210

.729

−.025

−.276

.189

.595

JSPE = Jefferson Scale of Physician Empathy. Extraction method: maximum likelihood, rotation method: Varimax with Kaiser Normalization, Factor 1: Empathy is valued, Factor 2: Empathy is demonstrated, Factor 3: Empathy is not influential, Factor 4: Empathy is difficult to accomplish. Rotation converged in six iterations. JSPE items are listed by number (e.g., emp 1 and grouped by factor). JSPE factor items are bolded and outlined.

98.70 (16.43) 5.02 (1.35) 5.15 (1.11) 3.11 (0.93) 3.18 (1.11)

5.40 (0.94) 5.40 (1.06) 3.06 (1.02) 3.18 (1.15)

3rd Year

102.04 (14.31)

4th Year

3.14 (1.01) 3.36 (1.31)

5.34 (1.05) 5.44 (1.18)

100.36 (19.66)

2nd Year

3.01 (0.87) 3.19 (1.12)

5.49 (1.02) 5.58 (1.04)

103.41 (17.16)

1st Year

3.21 (0.86) 3.39 (1.14)

5.27 (1.07) 5.28 (1.16)

99.42 (16.33)

Male

Female

2.91 (1.04) 3.03 (1.19)

5.39 (1.12) 5.58 (1.00)

103.75 (17.87)

Gender

Results are reported as Mean (Standard Deviation). 4th year class: N = 71, 3rd year class; N = 60, 2nd year class: N = 81, 1st year class: N = 86, Male students: N = 16, Female students: N = 130.

Total Jefferson Scale of Physician Empathy Empathy is valuable (Factor 1) Empathy is demonstrated (Factor 2) Empathy is not influential (Factor 3) Empathy is difficult to achieve (Factor 4)

Variable

Year in Dental School Program

TABLE 2 Empathy Scores by Gender and Year in Dental School

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1 .493∗∗∗ .597∗∗∗ .178∗∗ .215∗∗∗ .192∗∗ .087

.232∗∗∗ .185∗∗ .102 −.209∗∗∗ −.149∗

1 .672∗∗∗ .579∗∗∗ .624∗∗∗ .071 .166∗∗ .160∗∗

.079

.182∗∗ .191∗∗ .117∗ −.172∗∗ −.087

.244∗∗∗ .233∗∗∗ .234∗∗∗ −.198∗∗ −.116∗

.003

1 .666∗∗∗ .089 .108 .109

.143∗ .173∗∗ .081 −.102 −.079

.031

1 .033 .086 .073

.265∗∗∗ .197∗∗ .140∗ −.219∗∗∗ −.168∗∗

.010

1 .455∗∗∗ .250∗∗∗

.279∗∗∗ .190∗∗ .120∗ −.257∗∗∗ −.177∗∗

.007

1 .344∗∗∗

.093 .079 .035 −.068 −.090

.108

−.032 −.034 −.064 .007 −.052

1 .837∗∗∗ .758∗∗∗ −.749∗∗∗ −.562∗∗∗

1 .660∗∗∗ −.455∗∗∗ −.315∗∗∗

1 −.335∗∗∗ −.365∗∗∗

1 .400∗∗∗

JSPE = Jefferson Scale of Physician Empathy. Listwise N = 292. Items: 1–4 Aging Semantic Differential Subscales, 5–6: Number of social contexts and types of interactions with older adults, 7—8: Frequency of interaction; Number of older adults treated, 9: JSPE: total empathy score, 10: Factor 1: Empathy is valued, 11: Factor 2: Empathy is demonstrated, 12: Factor 3: Empathy is not influential, 13: Factor 4: Empathy is difficult to accomplish ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001.

Autonomy Instrumental Acceptability Integrity # Contexts # Types Frequency of Interaction 8 # Older Patients Treated 9 Total JSPE 10 Factor 1 JSPE 11 Factor 2 JSPE 12 Factor 3 JSPE 13 Factor 4 JSPE

1 2 3 4 5 6 7

TABLE 3 Correlation Matrix for Attitudes Toward and Interactions With Older Adults and Empathy

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D. Waldrop et al.

with and the number of contexts of interaction (e.g., caregiving, attending religious services) in which the contact occurred outside of the clinic, but not with frequency of such interactions or the number of older adults treated in the clinic. Results for the multiple regressions for JSPE total scale scores are presented in Table 4. The overall equation was significant, F(11, 258) = 5.746, p < .0001, R2 = .197, and demonstrates that the acceptability of older adults (ASD subscale) was positively associated with empathy scores (see Table 4). Greater numbers of different types of older adults with whom the student had contact and higher numbers of different contexts for these interactions were positively associated with the empathy. However, neither contact within the clinic nor the actual frequency of contact with older adults outside of the clinic was positively associated with empathy. Results for Empathy Is Valuable (Factor 1) were significant, F(11, 258) = 3.176, p < .005, R 2 = .119, adjusted R 2 = .082, and are presented in Table 5. The Acceptability subscale of the ASD showed a positive marginal trend, suggesting that students who had positive Acceptability scores also had high scores on Empathy Is Valuable (Factor 1). The only significant association was for the number of contexts of interactions that the student had with older adults. The relationship suggests that the more contexts the student was exposed to with older adults, the higher the score on Factor 1, Empathy Is Valuable. The results for Empathy Is Demonstrated (Factor 2) were significant, F(11, 258) = 3.651, p < .0001, R2 = .148, adjusted R2 = .112, and are presented in Table 6. Empathy was positively associated with the Acceptability subscale of the ASD. There was a positive association for gender, and females had higher levels of acceptability. There was also a marginal effect for the number of different types of older adults the student had contact with outside the SDM clinic (Table 6). The results for Empathy Is not Valued (Factor 3) were significant, F(11, 258) = 4.075, p < .0001, R2 = .148, adjusted R2 = .112. The only other factor that was significant was the number of different types of older adults contacted outside the SDM clinic, indicating that the more types of older adults they had contact with, the less likely they were to view the use of empathy as negative (Table 7). The results for Empathy Is Difficult to Accomplish (Factor 4) were significant, F(11, 256) = 2.553, p = .004, R2 = .099, adjusted R 2 = .60. However, the only significant factor was sex, with females showing lower scores than males. The number of different types of older adults contacted outside the clinic was marginal, reflecting that as this increased the perception of empathy being difficult decreased. No other factors were significant.

101.24 6 −.361 −.696 4.031 .141 3.844 3.496 −.789 −.172 1.794 2.012 1.653 1.619 1.467 1.275 .911 .806

7.177

Std. Error

.016 −.030 .191 .007 .167 .180 −.053 −.012

β 14.10 6 −.201 −.346 2.438 .087 2.620 2.743 −.866 −.213

Standardized Coefficients

.841 .730 .015 .931 .009 .006 .387 .831

.000

Sig.

−3.893 −4.656 .777 −3.045 .956 .987 −2.581 −1.760

87.119

Lower Bound

3.172 3.264 7.286 3.327 6.731 6.004 1.004 1.415

115.374

Upper Bound

95.0% Confidence Interval for b

Listwise N = 292. Aging Semantic Differential subscales: Instrumental, Autonomy, Acceptability, Integrity. Interactions with older adults: Context, type of older adult, type of interaction and number treated.

(Constant) Instrumental Autonomy Acceptability Integrity Numcont Numtype Newinteract Numtreated

Unstandardized Coefficients

TABLE 4 The Relationship Between Attitudes About and Interactions With Older Adults and Overall Empathy

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.118 .107 .199 .123 .247 .251 .063 −.019

Zero Order

−.012 −.021 .143 .005 .154 .161 −.051 −.013

Partial

Correlations

−.011 −.019 .136 .005 .146 .153 −.048 −.012

Part

5.931 −.008 .079 .209 .034 .207 .129 −.015 −.031

.463 .116 .130 .107 .105 .095 .082 .059 .052

Std. Error −.006 .053 .156 .028 .140 .104 −.016 −.035

β t 12.790 −.072 .610 1.957 .327 2.181 1.564 −.253 −.604

Coefficients

.000 .943 .542 .051 .744 .030 .119 .801 .547

Sig. 5.019 −.236 −.176 −.001 −.172 .020 −.033 −.131 −.134

Lower Bound 6.843 .220 .335 .419 .240 .393 .291 .101 .071

Upper Bound

95.0% Confidence Interval for b

(Constant) Instrumental Autonomy Acceptability Integrity Numcont Numtype Interact NumTreated

Unstandardized Coefficients

.163 .178 .223 .171 .200 .189 .078 −.031

Zero Order

−.004 .036 .116 .019 .129 .093 −.015 −.036

Partial

Correlations

−.004 .034 .111 .018 .123 .088 −.014 −.034

Part

TABLE 5 The Relationship Between Attitudes About and Interactions With Older Adults and Empathy Is Valuable (Factor 1): Multiple Regression Analysis

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6.110 .006 .029 .408 −.173 .141 .078 −.054

.483 .121 .132 .109 .108 .096 .083 .053

Std. Error .004 .019 .301 −.139 .096 .063 −.059

β 12.643 .048 .223 3.757 −1.600 1.468 .939 −1.023

Standardized Coefficients

.000 .962 .823 .000 .111 .143 .348 .307

Sig. 5.159 −.233 −.230 .194 −.385 −.048 −.086 −.158

Lower Bound 7.061 .244 .289 .623 .040 .331 .243 .050

Upper Bound

95.0% Confidence Interval for b

(Constant) Instrumental Autonomy Acceptability Integrity Numcont Numtype NumTreated

Unstandardized Coefficients

.102 .117 .234 .081 .140 .120 −.064

Zero Order

.003 .013 .219 −.095 .087 .030 −.061

Partial

Correlations

.003 .013 .214 −.091 .084 −.029 −.058

Part

TABLE 6 The Relationship Between Attitudes About and Interactions With Older Adults and Empathy Is Demonstrated (Factor 2): Multiple Regression Analysis

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2.583 −.136 −.046 −.205 .126 −.150 −.201 .053 .007

.396 .099 .111 .091 .089 .081 .070 .050 .045

Std. Error 6.515 −.111 −.035 −.176 .117 −.117 −.187 .064 .009 −1.370 −.416 −2.248 1.404 −1.848 −2.855 1.062 .155

.000 172 .678 .025 .161 .066 .005 .289 .877

1.803 −.331 −.265 −.385 −.050 −.309 −.340 −.046 −.081

3.363 .059 .173 −.026 .302 .010 −.062 .152 .095

Upper Bound

Lower Bound

Sig.

β t

95.0% Confidence Interval for b

Standardized Coefficients

(Constant) Instrumental Autonomy Acceptability Integrity Numcont Numtype Interact NumTreated

Unstandardized Coefficients

TABLE 7 The Relationship Between Attitudes About and Interactions With Older Adults and Overall Empathy

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−.201 −.169 −.198 −.102 −.218 −.257 −.067 .007

Zero Order

−.081 −.025 −.132 .083 −.109 −.167 .063 .009

Partial

Correlations

−.076 −.023 −.125 .078 −.103 −.159 .059 .009

Part

Nature of Empathy

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DISCUSSION We explored the nature of empathy and its association with attitudes about and exposure to older patients in a sample of 292 dental students at the University at [BLINDED FOR REVIEW] School of Dental Medicine. Maximum likelihood extraction of the JSPE yielded four factors: (1) Empathy Is Valuable, (2) Empathy Is Demonstrated, (3) Empathy Is not Influential, and (4) Empathy Is Difficult to Accomplish. Higher overall empathy scores were positively related to the attitude of acceptability and to exposure to older people outside of the clinic setting. Exposure to older adults in the clinic was not related to higher empathy scores. However, higher frequency of contact with different types of older adults and greater numbers of different contexts were related to higher empathy scores. The Acceptability subscale of the ASD was positively related to higher empathy scores. Females were significantly higher on the overall empathy scale and on Empathy is Demonstrated (Factor 2) scores and significantly lower on Empathy is not influential (Factor 3), and Empathy is Difficult to Accomplish (Factor 4). The findings that females demonstrated higher empathy is consistent with previous literature (Beauchamp & McKelvie, 2006; Gabard, Lowe, Deusinger, Stelzner, & Crandall, 2013; Nash, 2010). These study findings build on previous studies and contribute to the growing literature about empathy development in professional education in health care. Sherman and Cramer (2005) identified four factors that included a number of crossover loadings by using a principal components analysis: perspective taking, compassionate care, standing in the patientâ&#x20AC;&#x2122;s shoes, and efforts to ignore emotions. Our findings suggest that there may be some parity in the nature of empathy in dental students. The elements of Compassionate Care (S-C) and Empathy Is Valuable suggest the belief that empathy is therapeutic. The elements of Perspective Taking (S-C). Standing in a Patientâ&#x20AC;&#x2122;s Shoes (S-C) and Empathy Is Demonstrated suggest that there is a behavioral element of empathy. Finally, the elements of Empathy Is not Influential, Efforts to Ignore Emotions (S-C), and Empathy Is Difficult to Accomplish perhaps suggest that empathy may be detrimental to patient outcomes in dentistry. Sherman and Cramer (2005) did not investigate the association of identified components with other characteristics. We determined the number of underlying dimensions of the Empathy scale for dental students and used maximum likelihood, focusing more on the underlying dimensions. The results from Sherman and Cramer for the factor analysis were different than ours. Sherman and Cramer found gender differences, as we do, with females scoring higher than males. Sherman and Cramer also indicated that the scores dropped as a function of class. We see some of that, with an important

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D. Waldrop et al.

rebound in the 4th year. However, the results are not significantâ&#x20AC;&#x201D;but they do present an interesting discussion point. In a previous study of attitudes, we found that the 4th-year dental students showed the most gain in positive attitudes. We attributed this gain to exposure to older adults in the clinic and to mentorship. Although the expectations were that attitudes would be influenced by clinical exposure and to be associated with higher empathy scores, this did not occur. Increased clinical contact did not directly influence attitudes or empathy. The 4th-year students show levels of empathy that are similar to those in the 1st-year students, with the 2nd- and 3rd-year students showing lower levels. Given the previous findings with dental students (Sherman & Cramer, 2005) that demonstrate a similar pattern for empathy scores, with decreases from year 1 to year 2, and year 2 to year 3, then an increase in year 4, contributing factors may include that the increase in empathy for the 4th-year students may be a result of clinical mentorship and role modeling. Changes in empathy may also be related to experience whereas students see greater numbers of patients they begin to experience the value of empathy. During the 2nd and 3rd years of dental school, students have less patient contact, and more emphasis on technical aspects of treatment. It is also important to note that the Acceptability subscale from the ASD was the only one to show any association with empathy. The implication is that acceptance of older adult behavior is key to positive empathy development. Thus, facilitating the development of acceptance in dental students may lead to greater empathy for older dental patients. Another important finding relates to the relationship of empathy and the different contexts that the students had exposure to older individuals. Greater exposure was associated with more positive empathy scores. One consideration for dental education is the potential influence of increased exposure to older adults in a variety of contexts. This may help build more acceptance and influence empathy towards older patients.

Limitations The study had several limitations that are important to address. First, the data was cross-sectional. Longitudinal data would provide a deeper perspective on the nature of empathy in dental students and whether it changes with professional development. Second, the data is a convenience sample, collected from only one university clinic setting. Comparative data from more than one dental school would validate the structure of empathy and its relationship to attitudes and exposure. Third, our questions on exposure to types of older adults and different social contexts were categorical. Open-ended questions about studentsâ&#x20AC;&#x2122; interactions with older adults would allow us to discover the richness of their experience with older adults (e.g., how they interact, the

Nature of Empathy

nature of their relationship with older people). Future research is needed to confirm whether clinical training impacts empathy negatively and, if so, whether interventions can be designed to mitigate this impact (Chen, Lew, Hershman, & Orlander, 2007).

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Implications for Education Research has indicated that dentists have misinformation about older people and can be reluctant to treat frail and functionally dependent older adults thus raising the question of whether inadequate education about older people deters dentists from caring for older patients (Antoun, Adsett, Goldsmith, & Thomson, 2008; Holm-Pedersen, Vigild, Nitschke, & Berkey, 2005). Clearly, technical expertise is important for the provision of effective oral health care. However, dentists are also important members of the interdisciplinary healthcare team who can contribute to enhanced well-being in their older adult patients by understanding the interrelationship between systemic and oral health concerns and quality of life (Best, 2010).

CONCLUSIONS The nature of empathy has been studied extensively in medical students but less so in dental students. The factor structure presented here differs from that found among medical students and suggests that the nature of empathy may vary by profession. In a study of physicians, the empathy items aligned with factors described as “perspective taking,” “compassionate care,” and “standing in the patient’s shoes” (Hojat et al., 2002). The findings reported here suggest that among this sample of dental students the factor “empathy is not influential” may suggest that empathic behavior is perceived to hinder accomplishment of competent care, and “empathy is difficult to achieve” may suggest perceptions that demonstrating empathy is challenging. Understanding the components of empathy by discipline is fundamentally important to improving education of an aging-prepared workforce. Moreover, levels of empathy have been found to erode over the course of medical school (Colliver, Conlee, Verhulst, & Dorsey, 2010). Understanding whether empathy changes over the course of dental school and, if so, how and when are important considerations in the continuing development of dental education. The incorporation of intensifying clinical exposure over time in dental school may also be related to the development of a greater understanding of patients’ experience with coexistent health and psychosocial problems.

D. Waldrop et al.

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