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J Clinic Care Skill 2024, 5(2): 93-101 |
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Ethics code: IR.SKUMS.REC.1400.251
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Received: 2024/02/25 | Accepted: 2024/06/8 | Published: 2024/06/27
Received: 2024/02/25 | Accepted: 2024/06/8 | Published: 2024/06/27
How to cite this article
Ganji F, Ghasemi S, Tavassoli E, Lotfizadeh M. Examining the Emotional Experiences of Individuals Who Have Lost Loved Ones to COVID-19 and Their Perception of the Empathy Displayed by Healthcare Staff. J Clinic Care Skill 2024; 5 (2) :93-101
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1- Social Determinants of Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
2- Student Research Committee, Shahrekord University of Medical Sciences, Shahrekord, Iran
2- Student Research Committee, Shahrekord University of Medical Sciences, Shahrekord, Iran
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Introduction
The COVID-19 pandemic has emerged as one of the most significant threats to physical, social, and mental health in the current century. To date, the advancement of this disease has inflicted substantial harm on the health and economic well-being of nations. The loss of loved ones is regarded as the most significant source of pressure and mental stress in every individual’s life, leading to various mental and physical effects on companions. Also, 10% of individuals experience severe problems requiring therapeutic intervention, while 30% encounter moderate issues [1]. Moreover, during the COVID-19 pandemic, families encounter challenges such as the illness and death of multiple family members within a short timeframe, economic hardships, the inability to afford treatment for the patient, restrictions on visiting the individual, maintaining social distance, and the impossibility of conducting a mourning ceremony for the deceased [2]. In cases of deaths transpiring in the intensive care unit (ICU), issues include the patient’s intubation, the inability to bid farewell to the individual, and poor communication between doctors and the patient’s family [3]. Coping with the death of relatives depends on the individual’s personality, relationship with the deceased person, and the circumstances surrounding their death. Risk factors that can exacerbate grief include a person’s mental health history, absence of social support, sudden death, lack of readiness for the loss of a loved one, and deaths transpiring in hospitals and ICUs [1].
In line with positive psychology, the presence of positive emotions can foster the development of enduring resilience, aiding individuals in coping more effectively with future stressful events [4]. Emotions constitute a crucial aspect of human behavior, significantly influencing human life. Individuals with a form of emotional equilibrium tend to exhibit high mental well-being. Mental well-being involves assessing life in relation to satisfaction and achieving a balance between positive and negative emotional states. Numerous studies have affirmed that positive emotions have significant implications for an individual’s mental well-being and overall flourishing when compared to negative emotions [5]. Conversely, negative affect is linked to low self-esteem, dissatisfaction, stress, and physical symptoms [6]. In a study, researchers concluded that a one-unit increase in negative emotion leads to a 13% reduction in people’s utilization of emotion regulation strategies [7]. In a separate study, it was mentioned that the perception of the threat posed by COVID-19 correlates positively with negative emotions and emotional symptoms like depression, anxiety, anger, and hostility [8]. Apart from legal responsibilities, healthcare professionals carry a moral and professional duty to provide treatment and empathy to these patients and their families [1].
Empathy is defined as the capacity to place oneself in the shoes of others to gain a better understanding of their feelings and experiences during interactions [9]. Within the medical realm, the act of empathizing with a patient involves comprehending their experiences, pains, and distressing memories, and communicating in a manner that reflects this understanding to aid the patient [10]. Therefore, empathy stands as a crucial element in patient communication, fostering the ability to establish understanding and exhibit clinical empathy. The trait of empathy relies on an individual’s innate capacity to grasp the patient’s emotions and can be demonstrated in diverse healthcare settings [11-13].
In Selman et al.'s study, Twitter users conveyed feelings of sadness, despair, and anger stemming from the loss of their acquaintances, relatives, or friends to COVID-19. Opinions were varied regarding bidding farewell through remote video conferences. As per these individuals, the presence of doctors during the final moments was consoling. The study underscored the necessity for end-of-life care providers to enhance and streamline communication between relatives and terminally ill patients. Furthermore, it emphasized the significance of providing support to individuals during the mourning process [14]. In Kentish et al.'s study, family members highlighted challenges in communicating with the ICU team and comprehending their loved one’s medical and treatment information. These challenges encompassed issues such as insufficient long-distance communication, leading to heightened feelings of isolation and discomfort for the patient. Additionally, constraints like the inability to visit patients in the ICU and the disruption of emotional connections during the final moments of life due to quarantine were noted. Other difficulties included the absence of genuine connections, the sense of helplessness in families, the inability to participate in a proper farewell ceremony, and the loss of meaningful moments with the deceased individual. These challenges contribute to complex grief among family members. Consequently, family members bore a significant burden following the loss of their loved one [15]. The referenced studies focused on the experiences of families who had lost a member due to COVID-19; however, no study akin to ours was identified.
The COVID-19 pandemic and the resulting loss of loved ones created a significant crisis for the families of these patients. Following the passing of a loved one, individuals may either blame themselves or others. Medical personnel are at the forefront of combatting this lethal epidemic and previous and future pandemics. Alongside their professional responsibilities, part of their caregiving duty involves expressing emotions and empathy towards companions, potentially influencing their mental and physical well-being and that of their families. Hence, recognizing the essential nature of employees’ empathy skills and the equilibrium between positive and negative emotions in companions, and the absence of a comprehensive study on this matter, this study sought to assess the positive and negative emotions and the empathy perception of medical staff operating in hospitals affiliated with the Shahrekord University of Medical Sciences towards the companions of patients who succumbed to COVID-19.
Instrument and Methods
Design
This descriptive-analytical cross-sectional study was conducted at the Shahrekord University of Medical Sciences in 2020-2022.
Participants and sampling
The study population was the companions of the deceased patients of COVID-19, whose death occurred from 2020 to September 2022. The sample size was estimated to be 402 people according to the following formula, considering the significance level of 01. 0 and accuracy of 9. 0.
N=(Z1-α/2)2×pq/d2
Initially, COVID-19 death statistics were acquired from the health center of Shahrekord province, followed by reaching out to the families of the patients. Samples were chosen through convenience sampling. Inclusion criteria comprised a willingness to engage in the study and having a first or second-degree family connection with patients who passed away due to COVID-19 during the pandemic. The maximum duration post-death was set at six months. Exclusion criteria encompassed patients with cognitive impairments like severe mental illnesses, memory disorders, substance abuse, and diminished awareness and alertness.
Tools and data collection
Data were collected using the Jefferson Scale of Empathy (JSE) and the Positive and Negative Affect Schedule (PANAS).
The JSE was utilized to evaluate the patient’s perception of healthcare personnel’s empathy. This tool assesses communication skills, the quality of human relationships, and medical expertise through five items. Participants were required to rate each item on a Likert scale ranging from one (strongly disagree) to seven (strongly agree). The total score was calculated by summing the points from each item, resulting in scores between 5 and 35. Higher scores indicated a more favorable perception of the doctor’s empathy by the patient. The reliability coefficient and content validity of this scale were confirmed by experts’ opinions [16].
The PANAS was employed to assess positive and negative affect. Responses were rated on a five-point scale (very much, a lot, moderate, a little, and not at all). Each subscale had an overall score range of 10 to 50. Participants answered based on their general state during hospitalization and the passing of their loved one. This questionnaire consists of 20 items, with ten items (1, 3, 5, 9, 10, 12, 14, 16, 17, and 19) measuring positive affect, where higher scores indicated more positive feelings towards the patient. Additionally, ten items (2, 4, 6, 7, 8, 11, 13, 15, 18, and 20) assessed negative emotions, with higher scores indicating more negative emotions towards the patient. The questionnaire evaluates two mood dimensions: positive affect and negative affect. The reliability coefficient for this scale was α = 0.771, and its content validity was confirmed by expert opinions [17].
The researcher obtained COVID-19 death statistics, as well as the addresses and contact numbers of the families of deceased patients, from the health center in Shahrekord city. A maximum of three companions per deceased individual were included in the study. Eligible participants completed questionnaires online. Initially, the phone number listed in the records was contacted, and an explanation was provided. Those who had interacted with the medical staff during the deceased patient’s treatment were requested to fill out the questionnaire. No specific familial relationship was required. Upon agreement to participate, a phone number was collected to send an electronic questionnaire accessible at https://form.avalform.com/view.php?id=43218385.
Data analysis
The collected data were coded and analyzed by SPSS version 26 software. In addition to descriptive statistics, appropriate statistical tests, such as independent t-test, analysis of variance (ANOVA), and Scheffe's test were used.
Findings
A total of 402 individuals took part in the study, with 64.9% being men, 35.1% being women, and 81.3% having first-degree relatives who had passed away. The surveyed individuals held various occupations such as teachers, professors, and employees (42.3%). Additionally, 80.3% of companions had no underlying health conditions, and 81.6% did not require medication. However, 78.4% of the deceased had been admitted to the ICU. The most common level of education among companions was a diploma or lower (53.5%; Table 1).
Table 1. Frequency of clinical and demographic characteristics of companions of deceased patients of COVID-19
According to the companions’ perspective, the level of empathy exhibited by doctors (ranging from a minimum score of 0.5 to a maximum score of 0.35) averaged 12.77±7.27, which was below the mean. On the other hand, the levels of positive and negative emotions (ranging from a minimum score of 10 to a maximum score of 50) were 30.61±8.6 and 29.52±9.53, respectively. With an average score of 30, the emotional responses of the deceased companions were deemed moderate.
The scores for the perception of empathy (p=0.061) and positive affect (p=0.925) and negative affect (p=0.149) among the companions did not exhibit any significant differences between the two genders (p<0.05). Similarly, the perception of empathy towards the healthcare staff (p=0.136) and positive affect (p=0.265), and negative affect (p=0.128) based on the marital status of the companions did not demonstrate statistically significant variances (p<0.05). The perception of empathy (p=0.077) and positive affect (p=0.474) and negative affect (p=0.263) in the companions concerning the year of the deceased’s passing did not reveal any statistically significant differences (p<0.05).
There were notable differences in the perception of empathy towards the healthcare staff based on the age of the companions (p=0.002), and significant variations were observed in the levels of positive (p=0.001) and negative (p<0.0001) affect among the companions according to their age (Table 2).
In pairwise comparisons, a significant distinction was noted in the empathy scores towards the treatment staff among companions aged 41-50 years compared to those over 60 years (p=0.050). The level of positive affect in individuals aged 20-30 years significantly differed from that of those aged 41-50 years (p=0.020). Furthermore, the negative affect in companions aged 20-30 years significantly contrasted with that of individuals aged 60 (p=0.000), and the negative affect in companions aged 20-30 years also significantly differed compared to those aged 40-30 years (p=0.002).
The rural companions exhibited a significantly higher level of understanding of the empathy displayed by the treatment staff compared to their urban counterparts. A notable difference was observed in the level of empathy based on the companions’ place of residence (p<0.05). However, there was no significant variance found in the scores of positive and negative affect concerning the place of residence in urban and rural areas (p>0.05). Regarding the companions’ medical history, there was a statistically significant difference in the positive affect scores, indicating a notably higher positive affect among companions without a history of illness (p<0.05). However, there were no statistically significant differences in empathy and negative affect based on the companions’ medical history (p>0.05). The negative affect experienced by companions with a history of drug use was significantly higher than that of individuals without such a history (p=0.05). However, there were no significant differences in positive affect and perception of empathy between companions with a history of drug use and those without (p<0.05). The negative emotions of companions whose deceased family members were hospitalized in the ICU were notably higher than those of companions whose deceased family members were not hospitalized in the ICU (p=0.051). Nevertheless, positive affect and perception of empathy among the companions did not exhibit any significant differences based on whether the deceased family member was hospitalized in the ICU or not (p>0.05; Table 2).
Table 2. Perception of healthcare staff empathy and positive and negative affect of companions of deceased COVID-19 patients based on their age, place of residence, medical history, using medication, and admitting the deceased to the ICU
Companions who shared a second-degree family relationship with the patient rated healthcare personnel empathy higher (p=0.000) and exhibited more positive affect (p=0.000), while individuals with a first-degree family relationship with the deceased experienced higher levels of negative affect (p=0.004). Those with diplomas and lower educational qualifications expressed significantly higher levels of perception of medical staff empathy compared to other educational groups (p=0.027). Conversely, companions with a bachelor’s degree showed significantly higher levels of positive affect than other educational groups (p=0.032) and lower levels of negative affect (p=0.027).
In paired comparisons, companions with diplomas and lower degrees expressed a significantly higher perception of treatment staff empathy compared to those with bachelor’s degrees (p=0.000). However, the level of positive affect among companions with bachelor’s degrees was notably higher than those with diplomas and lower degrees (p=0.032) and also higher than those with master’s degrees or higher (p=0.000). Additionally, individuals with bachelor’s degrees exhibited significantly lower levels of negative affect compared to those with diplomas and lower degrees (p=0.036; Table 3).
Table 3. Perception of healthcare personnel empathy and positive and negative affect of companions of deceased COVID-19 patients based on family relationships, level of education, and occupation
Companions who were employed in labor or held non-governmental positions expressed a significantly higher level of perception regarding treatment staff empathy compared to individuals in other occupations (p=0.010). Additionally, housewife companions exhibited significantly higher levels of positive affect than individuals in other occupations (p=0.013). However, the level of negative affect remained consistent across all job types, showing no significant differences in this aspect (p=0.192).
In paired comparisons, companions employed in labor or non-governmental positions had higher empathy perception scores regarding treatment staff than housewives (p=0.018), with no significant difference observed compared to other occupations (p=0.829). Furthermore, the level of positive affect among housewives was significantly higher than that of laborers or individuals in non-governmental positions (p=0.037) and other occupations (p=0.012).
Discussion
The current study aimed to assess the positive and negative affect as well as the perception of empathy among medical staff at hospitals affiliated with Shahrekord University of Medical Sciences towards companions of patients who succumbed to COVID-19, marking the first investigation in this area. Results indicated that, as per companions’ feedback, the perception of empathy from medical staff was below the average level. However, the positive and negative affect levels among companions were found to be at an average level. Essentially, the degree of joy, contentment, and satisfaction reported by companions was equivalent to their level of sadness, discomfort, and dissatisfaction. Numerous studies have demonstrated that the balance between positive emotions and negative affect when encountering challenges remains consistent among individuals [18-20], aligning with the outcomes of the current study. Essentially, considering the inherent nature of positive and negative affect, individuals across various life circumstances and challenges must harmonize and regulate their emotions to attain equilibrium. The ratio of positive emotions to negative feelings holds significant implications for mental well-being and its preservation [18, 19].
The potential reason behind the reduced level of empathy exhibited by personnel towards companions could be attributed to the nature of COVID-19. Sonis et al. noted that historically, medical staff spend more time by the patient’s bedside to express empathy. Actions, such as placing a hand on the patient’s shoulder were indicative of the staff’s empathy. However, amidst the ongoing pandemic and the necessity for physical distancing, these gestures are now infrequently observed [21]. Additionally, due to the constraints imposed by this disease, prolonged conversations and close proximity with patients’ relatives and companions are often unfeasible. Hall et al. highlighted that the numerous challenges faced by medical staff, such as inadequate personal protective equipment, the high mortality rate and complications associated with COVID-19, the fear of transmitting the virus to family members, and the loss of colleagues to the disease, have both short-term and long-term impacts on the mental well-being of companions [22]. Consequently, companions may experience a lack of empathy from personnel or receive diminished support as a result.
Observing the doctor’s face and engaging in communication with patients and their companions can enhance empathy. According to Kratzke et al., doctors wearing transparent masks can foster greater empathy in patients. However, during the COVID-19 pandemic, doctors were compelled to wear masks, shields, and specialized attire, both when interacting with patients and their companions, making it challenging to establish effective communication [23]. Despite these obstacles, patients and their companions consistently hold high expectations for doctors and medical staff during critical situations. Selman et al. investigated the perspectives and experiences of Twitter users who have lost a friend, relative, or loved one to COVID-19, emphasizing that doctors who offer comfort during the dying process play a crucial role. Care providers in the final moments of life should facilitate and enhance communication with loved ones. The study also underscored the significance of providing support to individuals during the mourning process [14].
In contrast to the findings of the current study, according to Cook et al., doctors attempt to bridge the gap left by absent loved ones for isolated patients, employing innovative methods to connect these individuals with their families. To maintain their humanity and empathy towards dying patients, doctors exhibit exemplary conduct and engage in tasks alongside patients and their families with profound empathy. The discrepancy between the outcomes of this study and ours may stem from variations in data collection methods [24]. Consistent with the results of the present study, according to Liu et al., there is a need to enhance and cultivate empathy in the treatment provided by frontline nurses combating COVID-19. They also highlighted that companions perceive the empathy of medical staff to be lacking [25].
Based on our findings, there were no discernible differences in the levels of empathy perception, positive affect, and negative affect concerning the year of the deceased’s passing, the gender, or the marital status of companions. However, companions residing in rural areas reported significantly higher levels of empathy perception from doctors compared to those living in urban areas. This could be attributed to the rural population’s perceptions of the healthcare services rendered by doctors. In other words, the elevated expectations of urban dwellers in contrast to those of rural residents may result in a lower rating for doctors’ empathy.
Moreover, the perception of empathy from physicians among individuals aged 40-50 was higher than in both older and younger age brackets. This trend could be attributed to the elevated expectations and increased education levels of newer generations. Additionally, the reduced interaction with healthcare providers and doctors in comparison to the older age group may contribute to the higher ratings given by this particular age group. Conversely, the heightened need for care and greater empathy among individuals over 60 years old, coupled with increased interactions with healthcare providers and doctors, could explain the lower perception of empathy within this age group.
The level of positive affect among companions without a medical history significantly surpassed that of companions with a medical background. This discrepancy may stem from the fact that individuals with a medical history, who have encountered various illnesses throughout their lives, likely endure more pain, suffering, and discomfort. Consequently, they might have had more negative encounters with doctors or healthcare providers.
Similarly, the negative affect experienced by companions with a history of drug use far exceeded that of those without such a history, aligning with the findings related to positive affect and its correlation with medical history. Companions with a history of drug use have likely endured illnesses necessitating drug usage to alleviate their suffering. Hence, it is evident that these individuals experience higher levels of negative affect compared to those who do not use drugs.
Furthermore, companions whose deceased loved ones were admitted to the ICU before passing exhibited heightened negative emotions, indicating a stressful situation for these individuals. The ICU is recognized as one of the most anxiety-inducing areas within a hospital, impacting not only patients but also their closest family members who may undergo emotional turmoil [26]. Given that severe illnesses and ICU admissions often occur suddenly and without warning [27, 28], families unprepared for such circumstances may endure psychological trauma and emotional distress [29]. Essentially, the diagnosis and subsequent ICU hospitalization of a pivotal family member can disrupt the entire family dynamic. During this period, family members may witness a shift in their roles, experience fear, and grapple with insecurity, leading to an upsurge in negative emotions towards the situation [30-33]. Consequently, the findings of this study align with prior research. Previous studies have highlighted that the fear of death, uncertainties regarding prognosis and treatment, emotional conflicts, concerns about financial stability, alterations in roles, and disruptions in daily routines can trigger reactions of shock, anger, despair, anxiety, and depression, particularly within the initial 72 hours of a family member’s hospitalization [27, 32, 33].
A notable aspect of the current study was the higher empathy score among second-degree companions toward the treatment staff. Additionally, the positive affect in second-degree companions who had lost someone was significantly greater than that in first-degree companions who had experienced a loss. However, the negative affect reported by first-degree companions was considerably higher than that of second-degree companions. Hence, the results regarding positive and negative affect can be viewed as complementary. Companions with diplomas or lower educational degrees, as well as companions engaged in non-governmental jobs and labor-intensive work, rated doctors’ empathy more highly. This observation may stem from varying expectation levels, limited knowledge among this group about doctors’ responsibilities, and their relatively modest demands.
According to Feder et al., hat the restrictions imposed during interactions between companions and patients, aimed at preventing infections and further spread of the virus, often lead to discomfort among companions and their subsequent protests directed at healthcare providers. They also emphasized that amidst the COVID-19 epidemic, when visitation restrictions are in place, the companionship and empathy exhibited by healthcare workers play a pivotal role in alleviating stress, aiding in grief management for those who have lost loved ones, and enhancing the quality of life for companions [34]. Discrepancies in the findings of various studies concerning doctors’ empathy levels and patient satisfaction with the care provided may be attributed to variations in guidelines across countries, healthcare systems, and hospitals.
Kentish et al. emphasized that family members carry a significant burden when faced with the loss of a loved one, and they suggested that family-centered crisis protocols should be revised to enhance the experiences of patients, families, and healthcare providers [15]. Liu et al. highlighted the importance for hospital departments to implement effective strategies aimed at enhancing the attitude and empathy of staff members to elevate the quality of hospital care for patients and their families [25].
With the rise of new diseases and infectious pandemics such as Influenza H1N1, SARS, and COVID-19 in recent years, concerns about disease transmission and mortality, coupled with limited knowledge during the initial phases of outbreaks, and the altered hospital conditions due to isolation measures, extreme distancing, and restricted visitation policies have led to reduced empathy among healthcare providers towards companions and patients. This, in turn, may elevate negative affect and diminish positive affect. In a similar vein, the current study revealed low levels of empathy among healthcare providers, correlating with heightened negative affect. Consequently, there is a pressing need to revise guidelines for managing these infectious diseases, particularly in anticipation of future pandemics. Addressing the existing scenario by enhancing employees’ empathy skills and adjusting the treatment approaches of healthcare workers can enhance service quality, promote social satisfaction among healthcare staff, and ultimately improve patient care. Recognizing the critical need for empathy among patients and companions of deceased individuals, there is a pressing demand to enhance empathy skills and address the current situation. Empathy skills training, a crucial aspect of medical staff’s caregiving abilities, along with revisions to relevant guidelines and their ongoing monitoring, should be prioritized by hospitals and healthcare organizations. Moreover, adjustments to family-centered crisis protocols are essential to ensure that families and companions of all diseases, both during pandemics and non-pandemic periods, receive support in coping with the loss of their loved ones through the empathy of medical staff, facilitating quicker adaptation. It is recommended that hospitals maintain comprehensive records of patient caregivers and their involvement in patient care to explore and assess the relationship between healthcare providers and patients, as well as their companions, in future studies.
One of the study’s limitations is the inability to reach all companions, including some who were illiterate and involved in the care of the deceased patient.
Conclusion
There is a low perception score among COVID-19 companions regarding the empathy of healthcare personnel and their positive and negative affect scores.
Acknowledgments: This research was conducted with the assistance of the Vice-Chancellor for Research at Shahrekord University of Medical Sciences. The authors express their gratitude to Shahrekord University of Medical Sciences.
Ethical Permissions: The research proposal for this article underwent review by the Research Ethics Committee of Shahrekord University of Medical Sciences and received approval under the code IR.SKUMS.REC.1400.251. Participants provided informed consent by signing a consent form and were thoroughly briefed on the study procedures. Strict confidentiality measures were upheld to safeguard information.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Ganji F (First Author), Discussion Writer/Assistant Researcher (40%); Ghasemi SM (Second Author), Introduction Writer/Main Researcher (20%); Tavassoli E (Third Author), Statistical Analyst (20%); Lotifizadeh M (Forth Author), Methodologist/Assistant Researcher (20%)
Funding/Support: This study was supported by the Shahrekord University of Medical Sciences (grant number: 5959).
The COVID-19 pandemic has emerged as one of the most significant threats to physical, social, and mental health in the current century. To date, the advancement of this disease has inflicted substantial harm on the health and economic well-being of nations. The loss of loved ones is regarded as the most significant source of pressure and mental stress in every individual’s life, leading to various mental and physical effects on companions. Also, 10% of individuals experience severe problems requiring therapeutic intervention, while 30% encounter moderate issues [1]. Moreover, during the COVID-19 pandemic, families encounter challenges such as the illness and death of multiple family members within a short timeframe, economic hardships, the inability to afford treatment for the patient, restrictions on visiting the individual, maintaining social distance, and the impossibility of conducting a mourning ceremony for the deceased [2]. In cases of deaths transpiring in the intensive care unit (ICU), issues include the patient’s intubation, the inability to bid farewell to the individual, and poor communication between doctors and the patient’s family [3]. Coping with the death of relatives depends on the individual’s personality, relationship with the deceased person, and the circumstances surrounding their death. Risk factors that can exacerbate grief include a person’s mental health history, absence of social support, sudden death, lack of readiness for the loss of a loved one, and deaths transpiring in hospitals and ICUs [1].
In line with positive psychology, the presence of positive emotions can foster the development of enduring resilience, aiding individuals in coping more effectively with future stressful events [4]. Emotions constitute a crucial aspect of human behavior, significantly influencing human life. Individuals with a form of emotional equilibrium tend to exhibit high mental well-being. Mental well-being involves assessing life in relation to satisfaction and achieving a balance between positive and negative emotional states. Numerous studies have affirmed that positive emotions have significant implications for an individual’s mental well-being and overall flourishing when compared to negative emotions [5]. Conversely, negative affect is linked to low self-esteem, dissatisfaction, stress, and physical symptoms [6]. In a study, researchers concluded that a one-unit increase in negative emotion leads to a 13% reduction in people’s utilization of emotion regulation strategies [7]. In a separate study, it was mentioned that the perception of the threat posed by COVID-19 correlates positively with negative emotions and emotional symptoms like depression, anxiety, anger, and hostility [8]. Apart from legal responsibilities, healthcare professionals carry a moral and professional duty to provide treatment and empathy to these patients and their families [1].
Empathy is defined as the capacity to place oneself in the shoes of others to gain a better understanding of their feelings and experiences during interactions [9]. Within the medical realm, the act of empathizing with a patient involves comprehending their experiences, pains, and distressing memories, and communicating in a manner that reflects this understanding to aid the patient [10]. Therefore, empathy stands as a crucial element in patient communication, fostering the ability to establish understanding and exhibit clinical empathy. The trait of empathy relies on an individual’s innate capacity to grasp the patient’s emotions and can be demonstrated in diverse healthcare settings [11-13].
In Selman et al.'s study, Twitter users conveyed feelings of sadness, despair, and anger stemming from the loss of their acquaintances, relatives, or friends to COVID-19. Opinions were varied regarding bidding farewell through remote video conferences. As per these individuals, the presence of doctors during the final moments was consoling. The study underscored the necessity for end-of-life care providers to enhance and streamline communication between relatives and terminally ill patients. Furthermore, it emphasized the significance of providing support to individuals during the mourning process [14]. In Kentish et al.'s study, family members highlighted challenges in communicating with the ICU team and comprehending their loved one’s medical and treatment information. These challenges encompassed issues such as insufficient long-distance communication, leading to heightened feelings of isolation and discomfort for the patient. Additionally, constraints like the inability to visit patients in the ICU and the disruption of emotional connections during the final moments of life due to quarantine were noted. Other difficulties included the absence of genuine connections, the sense of helplessness in families, the inability to participate in a proper farewell ceremony, and the loss of meaningful moments with the deceased individual. These challenges contribute to complex grief among family members. Consequently, family members bore a significant burden following the loss of their loved one [15]. The referenced studies focused on the experiences of families who had lost a member due to COVID-19; however, no study akin to ours was identified.
The COVID-19 pandemic and the resulting loss of loved ones created a significant crisis for the families of these patients. Following the passing of a loved one, individuals may either blame themselves or others. Medical personnel are at the forefront of combatting this lethal epidemic and previous and future pandemics. Alongside their professional responsibilities, part of their caregiving duty involves expressing emotions and empathy towards companions, potentially influencing their mental and physical well-being and that of their families. Hence, recognizing the essential nature of employees’ empathy skills and the equilibrium between positive and negative emotions in companions, and the absence of a comprehensive study on this matter, this study sought to assess the positive and negative emotions and the empathy perception of medical staff operating in hospitals affiliated with the Shahrekord University of Medical Sciences towards the companions of patients who succumbed to COVID-19.
Instrument and Methods
Design
This descriptive-analytical cross-sectional study was conducted at the Shahrekord University of Medical Sciences in 2020-2022.
Participants and sampling
The study population was the companions of the deceased patients of COVID-19, whose death occurred from 2020 to September 2022. The sample size was estimated to be 402 people according to the following formula, considering the significance level of 01. 0 and accuracy of 9. 0.
N=(Z1-α/2)2×pq/d2
Initially, COVID-19 death statistics were acquired from the health center of Shahrekord province, followed by reaching out to the families of the patients. Samples were chosen through convenience sampling. Inclusion criteria comprised a willingness to engage in the study and having a first or second-degree family connection with patients who passed away due to COVID-19 during the pandemic. The maximum duration post-death was set at six months. Exclusion criteria encompassed patients with cognitive impairments like severe mental illnesses, memory disorders, substance abuse, and diminished awareness and alertness.
Tools and data collection
Data were collected using the Jefferson Scale of Empathy (JSE) and the Positive and Negative Affect Schedule (PANAS).
The JSE was utilized to evaluate the patient’s perception of healthcare personnel’s empathy. This tool assesses communication skills, the quality of human relationships, and medical expertise through five items. Participants were required to rate each item on a Likert scale ranging from one (strongly disagree) to seven (strongly agree). The total score was calculated by summing the points from each item, resulting in scores between 5 and 35. Higher scores indicated a more favorable perception of the doctor’s empathy by the patient. The reliability coefficient and content validity of this scale were confirmed by experts’ opinions [16].
The PANAS was employed to assess positive and negative affect. Responses were rated on a five-point scale (very much, a lot, moderate, a little, and not at all). Each subscale had an overall score range of 10 to 50. Participants answered based on their general state during hospitalization and the passing of their loved one. This questionnaire consists of 20 items, with ten items (1, 3, 5, 9, 10, 12, 14, 16, 17, and 19) measuring positive affect, where higher scores indicated more positive feelings towards the patient. Additionally, ten items (2, 4, 6, 7, 8, 11, 13, 15, 18, and 20) assessed negative emotions, with higher scores indicating more negative emotions towards the patient. The questionnaire evaluates two mood dimensions: positive affect and negative affect. The reliability coefficient for this scale was α = 0.771, and its content validity was confirmed by expert opinions [17].
The researcher obtained COVID-19 death statistics, as well as the addresses and contact numbers of the families of deceased patients, from the health center in Shahrekord city. A maximum of three companions per deceased individual were included in the study. Eligible participants completed questionnaires online. Initially, the phone number listed in the records was contacted, and an explanation was provided. Those who had interacted with the medical staff during the deceased patient’s treatment were requested to fill out the questionnaire. No specific familial relationship was required. Upon agreement to participate, a phone number was collected to send an electronic questionnaire accessible at https://form.avalform.com/view.php?id=43218385.
Data analysis
The collected data were coded and analyzed by SPSS version 26 software. In addition to descriptive statistics, appropriate statistical tests, such as independent t-test, analysis of variance (ANOVA), and Scheffe's test were used.
Findings
A total of 402 individuals took part in the study, with 64.9% being men, 35.1% being women, and 81.3% having first-degree relatives who had passed away. The surveyed individuals held various occupations such as teachers, professors, and employees (42.3%). Additionally, 80.3% of companions had no underlying health conditions, and 81.6% did not require medication. However, 78.4% of the deceased had been admitted to the ICU. The most common level of education among companions was a diploma or lower (53.5%; Table 1).
Table 1. Frequency of clinical and demographic characteristics of companions of deceased patients of COVID-19
According to the companions’ perspective, the level of empathy exhibited by doctors (ranging from a minimum score of 0.5 to a maximum score of 0.35) averaged 12.77±7.27, which was below the mean. On the other hand, the levels of positive and negative emotions (ranging from a minimum score of 10 to a maximum score of 50) were 30.61±8.6 and 29.52±9.53, respectively. With an average score of 30, the emotional responses of the deceased companions were deemed moderate.
The scores for the perception of empathy (p=0.061) and positive affect (p=0.925) and negative affect (p=0.149) among the companions did not exhibit any significant differences between the two genders (p<0.05). Similarly, the perception of empathy towards the healthcare staff (p=0.136) and positive affect (p=0.265), and negative affect (p=0.128) based on the marital status of the companions did not demonstrate statistically significant variances (p<0.05). The perception of empathy (p=0.077) and positive affect (p=0.474) and negative affect (p=0.263) in the companions concerning the year of the deceased’s passing did not reveal any statistically significant differences (p<0.05).
There were notable differences in the perception of empathy towards the healthcare staff based on the age of the companions (p=0.002), and significant variations were observed in the levels of positive (p=0.001) and negative (p<0.0001) affect among the companions according to their age (Table 2).
In pairwise comparisons, a significant distinction was noted in the empathy scores towards the treatment staff among companions aged 41-50 years compared to those over 60 years (p=0.050). The level of positive affect in individuals aged 20-30 years significantly differed from that of those aged 41-50 years (p=0.020). Furthermore, the negative affect in companions aged 20-30 years significantly contrasted with that of individuals aged 60 (p=0.000), and the negative affect in companions aged 20-30 years also significantly differed compared to those aged 40-30 years (p=0.002).
The rural companions exhibited a significantly higher level of understanding of the empathy displayed by the treatment staff compared to their urban counterparts. A notable difference was observed in the level of empathy based on the companions’ place of residence (p<0.05). However, there was no significant variance found in the scores of positive and negative affect concerning the place of residence in urban and rural areas (p>0.05). Regarding the companions’ medical history, there was a statistically significant difference in the positive affect scores, indicating a notably higher positive affect among companions without a history of illness (p<0.05). However, there were no statistically significant differences in empathy and negative affect based on the companions’ medical history (p>0.05). The negative affect experienced by companions with a history of drug use was significantly higher than that of individuals without such a history (p=0.05). However, there were no significant differences in positive affect and perception of empathy between companions with a history of drug use and those without (p<0.05). The negative emotions of companions whose deceased family members were hospitalized in the ICU were notably higher than those of companions whose deceased family members were not hospitalized in the ICU (p=0.051). Nevertheless, positive affect and perception of empathy among the companions did not exhibit any significant differences based on whether the deceased family member was hospitalized in the ICU or not (p>0.05; Table 2).
Table 2. Perception of healthcare staff empathy and positive and negative affect of companions of deceased COVID-19 patients based on their age, place of residence, medical history, using medication, and admitting the deceased to the ICU
Companions who shared a second-degree family relationship with the patient rated healthcare personnel empathy higher (p=0.000) and exhibited more positive affect (p=0.000), while individuals with a first-degree family relationship with the deceased experienced higher levels of negative affect (p=0.004). Those with diplomas and lower educational qualifications expressed significantly higher levels of perception of medical staff empathy compared to other educational groups (p=0.027). Conversely, companions with a bachelor’s degree showed significantly higher levels of positive affect than other educational groups (p=0.032) and lower levels of negative affect (p=0.027).
In paired comparisons, companions with diplomas and lower degrees expressed a significantly higher perception of treatment staff empathy compared to those with bachelor’s degrees (p=0.000). However, the level of positive affect among companions with bachelor’s degrees was notably higher than those with diplomas and lower degrees (p=0.032) and also higher than those with master’s degrees or higher (p=0.000). Additionally, individuals with bachelor’s degrees exhibited significantly lower levels of negative affect compared to those with diplomas and lower degrees (p=0.036; Table 3).
Table 3. Perception of healthcare personnel empathy and positive and negative affect of companions of deceased COVID-19 patients based on family relationships, level of education, and occupation
Companions who were employed in labor or held non-governmental positions expressed a significantly higher level of perception regarding treatment staff empathy compared to individuals in other occupations (p=0.010). Additionally, housewife companions exhibited significantly higher levels of positive affect than individuals in other occupations (p=0.013). However, the level of negative affect remained consistent across all job types, showing no significant differences in this aspect (p=0.192).
In paired comparisons, companions employed in labor or non-governmental positions had higher empathy perception scores regarding treatment staff than housewives (p=0.018), with no significant difference observed compared to other occupations (p=0.829). Furthermore, the level of positive affect among housewives was significantly higher than that of laborers or individuals in non-governmental positions (p=0.037) and other occupations (p=0.012).
Discussion
The current study aimed to assess the positive and negative affect as well as the perception of empathy among medical staff at hospitals affiliated with Shahrekord University of Medical Sciences towards companions of patients who succumbed to COVID-19, marking the first investigation in this area. Results indicated that, as per companions’ feedback, the perception of empathy from medical staff was below the average level. However, the positive and negative affect levels among companions were found to be at an average level. Essentially, the degree of joy, contentment, and satisfaction reported by companions was equivalent to their level of sadness, discomfort, and dissatisfaction. Numerous studies have demonstrated that the balance between positive emotions and negative affect when encountering challenges remains consistent among individuals [18-20], aligning with the outcomes of the current study. Essentially, considering the inherent nature of positive and negative affect, individuals across various life circumstances and challenges must harmonize and regulate their emotions to attain equilibrium. The ratio of positive emotions to negative feelings holds significant implications for mental well-being and its preservation [18, 19].
The potential reason behind the reduced level of empathy exhibited by personnel towards companions could be attributed to the nature of COVID-19. Sonis et al. noted that historically, medical staff spend more time by the patient’s bedside to express empathy. Actions, such as placing a hand on the patient’s shoulder were indicative of the staff’s empathy. However, amidst the ongoing pandemic and the necessity for physical distancing, these gestures are now infrequently observed [21]. Additionally, due to the constraints imposed by this disease, prolonged conversations and close proximity with patients’ relatives and companions are often unfeasible. Hall et al. highlighted that the numerous challenges faced by medical staff, such as inadequate personal protective equipment, the high mortality rate and complications associated with COVID-19, the fear of transmitting the virus to family members, and the loss of colleagues to the disease, have both short-term and long-term impacts on the mental well-being of companions [22]. Consequently, companions may experience a lack of empathy from personnel or receive diminished support as a result.
Observing the doctor’s face and engaging in communication with patients and their companions can enhance empathy. According to Kratzke et al., doctors wearing transparent masks can foster greater empathy in patients. However, during the COVID-19 pandemic, doctors were compelled to wear masks, shields, and specialized attire, both when interacting with patients and their companions, making it challenging to establish effective communication [23]. Despite these obstacles, patients and their companions consistently hold high expectations for doctors and medical staff during critical situations. Selman et al. investigated the perspectives and experiences of Twitter users who have lost a friend, relative, or loved one to COVID-19, emphasizing that doctors who offer comfort during the dying process play a crucial role. Care providers in the final moments of life should facilitate and enhance communication with loved ones. The study also underscored the significance of providing support to individuals during the mourning process [14].
In contrast to the findings of the current study, according to Cook et al., doctors attempt to bridge the gap left by absent loved ones for isolated patients, employing innovative methods to connect these individuals with their families. To maintain their humanity and empathy towards dying patients, doctors exhibit exemplary conduct and engage in tasks alongside patients and their families with profound empathy. The discrepancy between the outcomes of this study and ours may stem from variations in data collection methods [24]. Consistent with the results of the present study, according to Liu et al., there is a need to enhance and cultivate empathy in the treatment provided by frontline nurses combating COVID-19. They also highlighted that companions perceive the empathy of medical staff to be lacking [25].
Based on our findings, there were no discernible differences in the levels of empathy perception, positive affect, and negative affect concerning the year of the deceased’s passing, the gender, or the marital status of companions. However, companions residing in rural areas reported significantly higher levels of empathy perception from doctors compared to those living in urban areas. This could be attributed to the rural population’s perceptions of the healthcare services rendered by doctors. In other words, the elevated expectations of urban dwellers in contrast to those of rural residents may result in a lower rating for doctors’ empathy.
Moreover, the perception of empathy from physicians among individuals aged 40-50 was higher than in both older and younger age brackets. This trend could be attributed to the elevated expectations and increased education levels of newer generations. Additionally, the reduced interaction with healthcare providers and doctors in comparison to the older age group may contribute to the higher ratings given by this particular age group. Conversely, the heightened need for care and greater empathy among individuals over 60 years old, coupled with increased interactions with healthcare providers and doctors, could explain the lower perception of empathy within this age group.
The level of positive affect among companions without a medical history significantly surpassed that of companions with a medical background. This discrepancy may stem from the fact that individuals with a medical history, who have encountered various illnesses throughout their lives, likely endure more pain, suffering, and discomfort. Consequently, they might have had more negative encounters with doctors or healthcare providers.
Similarly, the negative affect experienced by companions with a history of drug use far exceeded that of those without such a history, aligning with the findings related to positive affect and its correlation with medical history. Companions with a history of drug use have likely endured illnesses necessitating drug usage to alleviate their suffering. Hence, it is evident that these individuals experience higher levels of negative affect compared to those who do not use drugs.
Furthermore, companions whose deceased loved ones were admitted to the ICU before passing exhibited heightened negative emotions, indicating a stressful situation for these individuals. The ICU is recognized as one of the most anxiety-inducing areas within a hospital, impacting not only patients but also their closest family members who may undergo emotional turmoil [26]. Given that severe illnesses and ICU admissions often occur suddenly and without warning [27, 28], families unprepared for such circumstances may endure psychological trauma and emotional distress [29]. Essentially, the diagnosis and subsequent ICU hospitalization of a pivotal family member can disrupt the entire family dynamic. During this period, family members may witness a shift in their roles, experience fear, and grapple with insecurity, leading to an upsurge in negative emotions towards the situation [30-33]. Consequently, the findings of this study align with prior research. Previous studies have highlighted that the fear of death, uncertainties regarding prognosis and treatment, emotional conflicts, concerns about financial stability, alterations in roles, and disruptions in daily routines can trigger reactions of shock, anger, despair, anxiety, and depression, particularly within the initial 72 hours of a family member’s hospitalization [27, 32, 33].
A notable aspect of the current study was the higher empathy score among second-degree companions toward the treatment staff. Additionally, the positive affect in second-degree companions who had lost someone was significantly greater than that in first-degree companions who had experienced a loss. However, the negative affect reported by first-degree companions was considerably higher than that of second-degree companions. Hence, the results regarding positive and negative affect can be viewed as complementary. Companions with diplomas or lower educational degrees, as well as companions engaged in non-governmental jobs and labor-intensive work, rated doctors’ empathy more highly. This observation may stem from varying expectation levels, limited knowledge among this group about doctors’ responsibilities, and their relatively modest demands.
According to Feder et al., hat the restrictions imposed during interactions between companions and patients, aimed at preventing infections and further spread of the virus, often lead to discomfort among companions and their subsequent protests directed at healthcare providers. They also emphasized that amidst the COVID-19 epidemic, when visitation restrictions are in place, the companionship and empathy exhibited by healthcare workers play a pivotal role in alleviating stress, aiding in grief management for those who have lost loved ones, and enhancing the quality of life for companions [34]. Discrepancies in the findings of various studies concerning doctors’ empathy levels and patient satisfaction with the care provided may be attributed to variations in guidelines across countries, healthcare systems, and hospitals.
Kentish et al. emphasized that family members carry a significant burden when faced with the loss of a loved one, and they suggested that family-centered crisis protocols should be revised to enhance the experiences of patients, families, and healthcare providers [15]. Liu et al. highlighted the importance for hospital departments to implement effective strategies aimed at enhancing the attitude and empathy of staff members to elevate the quality of hospital care for patients and their families [25].
With the rise of new diseases and infectious pandemics such as Influenza H1N1, SARS, and COVID-19 in recent years, concerns about disease transmission and mortality, coupled with limited knowledge during the initial phases of outbreaks, and the altered hospital conditions due to isolation measures, extreme distancing, and restricted visitation policies have led to reduced empathy among healthcare providers towards companions and patients. This, in turn, may elevate negative affect and diminish positive affect. In a similar vein, the current study revealed low levels of empathy among healthcare providers, correlating with heightened negative affect. Consequently, there is a pressing need to revise guidelines for managing these infectious diseases, particularly in anticipation of future pandemics. Addressing the existing scenario by enhancing employees’ empathy skills and adjusting the treatment approaches of healthcare workers can enhance service quality, promote social satisfaction among healthcare staff, and ultimately improve patient care. Recognizing the critical need for empathy among patients and companions of deceased individuals, there is a pressing demand to enhance empathy skills and address the current situation. Empathy skills training, a crucial aspect of medical staff’s caregiving abilities, along with revisions to relevant guidelines and their ongoing monitoring, should be prioritized by hospitals and healthcare organizations. Moreover, adjustments to family-centered crisis protocols are essential to ensure that families and companions of all diseases, both during pandemics and non-pandemic periods, receive support in coping with the loss of their loved ones through the empathy of medical staff, facilitating quicker adaptation. It is recommended that hospitals maintain comprehensive records of patient caregivers and their involvement in patient care to explore and assess the relationship between healthcare providers and patients, as well as their companions, in future studies.
One of the study’s limitations is the inability to reach all companions, including some who were illiterate and involved in the care of the deceased patient.
Conclusion
There is a low perception score among COVID-19 companions regarding the empathy of healthcare personnel and their positive and negative affect scores.
Acknowledgments: This research was conducted with the assistance of the Vice-Chancellor for Research at Shahrekord University of Medical Sciences. The authors express their gratitude to Shahrekord University of Medical Sciences.
Ethical Permissions: The research proposal for this article underwent review by the Research Ethics Committee of Shahrekord University of Medical Sciences and received approval under the code IR.SKUMS.REC.1400.251. Participants provided informed consent by signing a consent form and were thoroughly briefed on the study procedures. Strict confidentiality measures were upheld to safeguard information.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Ganji F (First Author), Discussion Writer/Assistant Researcher (40%); Ghasemi SM (Second Author), Introduction Writer/Main Researcher (20%); Tavassoli E (Third Author), Statistical Analyst (20%); Lotifizadeh M (Forth Author), Methodologist/Assistant Researcher (20%)
Funding/Support: This study was supported by the Shahrekord University of Medical Sciences (grant number: 5959).
Keywords:
Empathy [MeSH], Positive affect [MeSH], Death [MeSH], Medical Staff [MeSH], Iran [MeSH], COVID-19 [MeSH], Coronavirus [MeSH]
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