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NIHR School for Primary Care Research. Training of primary care practitioners in empathy and optimistic communication: consulting the wider community.

Communicating with empathy and optimism

When medical practitioners communicate with empathy and optimism, patients can have better health outcomes and are more satisfied with their consultations. Brief, evidence-based training can help practitioners to do this better. We developed very brief online training in empathy and positive communication for GPs, nurses and physiotherapists called EMPathicO, funded by NIHR-School for Primary Care Research. The training was based on published evidence, behavioural analysis, and involved practitioners and patients at all stages of its development.

The COVID-19 pandemic has shone a spotlight on inequalities in healthcare and it is well known that there is a lack of diversity of participants taking part in research. Ignoring diversity is a missed opportunity for meeting the health needs of the wider population. It was extremely important, therefore, that we sought the views from a range of communities about the appropriateness and relevance of empathic and optimistic behaviours to ensure that the training is culturally sensitive to a wider range of patients.

Reaching out to communities

NIHR are committed to improving diversity in research and have established the Equality, Diversity and Inclusion (EDI) Programme Board and People in Research, to make research more inclusive and representative of the people who need it. However, individual projects still face challenges in determining how best to reach wider community groups and under-served populations. For this project we started with an online search and sought organisations or individuals with experience of public involvement and working with communities in healthcare or healthcare research. Our searches revealed very few such organisations but we came across a health forum which brings together community organisations and healthcare organisations to improve health and wellbeing for people from deprived communities, whilst empowering communities to engage in and influence local health care services. This was our turning point.

Getting started

David Truswell, who works closely with the health forum we identified, is an independent consultant who has extensive experience of service improvements within NHS health and social care, specifically tailored to serve diverse communities. An initial meeting with David formulated a plan of how best to engage different communities in reviewing our training materials.

To get started, David himself provided an independent critical review of our training materials, which provided a starting point for the focus groups. He then approached two community groups in the London area: a Caribbean social group and a South Asian disability support group to get involved with our project, through the health forum. As a result of rapid adaptations made in response to the COVID-19 pandemic, community groups were meeting online and were therefore happy to take part in a focus group over MS Teams. Focus groups were rapidly organised, with the help of the community group leaders.

Seeking views and perspectives

Research has shown that the African-Caribbean community in the UK experience health inequity in relation to a number of health issues1 and it has been proposed that communication issues in primary care can play a significant role in the healthcare experience and access to services for diverse communities2.

The focus groups were conducted on MS Teams, although in hindsight Zoom would have been a more accessible platform as it is used more frequently by community groups. 6 female and 2 male members of the Caribbean community group took part in the first group. 6 females and 1 male took part in the second focus group. All spoke English. The focus groups lasted approximately 2 hours including a comfort break and were recorded for the purposes of report-writing by agreement with all participants and then permanently deleted. The focus groups were led by David, and I (a researcher from the University of Southampton) provided the technical support, gave a brief introduction to the project but was otherwise an observer to the meeting.

We separated the meeting into 2 parts. Firstly, participants were asked to view a selection of our EMPathicO training slides (that had been pre-selected from the training materials to focus the discussions and shortened to include key points). Participants were asked about their views of empathic and optimistic behaviours in the training slides including how they would feel to be treated in such a way by their primary care practitioner.

The second part of the meeting involved participants viewing a training video which is part of the EMPathicO intervention, and brings together the communication skills suggested in the training within a simulated patient consultation. This stimulated conversations around the overall intervention.

Following each focus group, David compiled a detailed report of the meeting, summarising participant views and perspectives of primary care consultations, specifically around empathic and optimistic communication.

How it has helped

Focus group participants identified many areas where our training materials aligned with their views of empathic and optimistic communication in healthcare consultations. There was general agreement about our definition of empathy and concurrence that empathic communication was an important component of healthcare consultations. However, many reported that through personal experience, empathy was not always conveyed in such a way as was being described. A number of areas were identified where are our training materials misaligned with participant views. It was identified that some verbal and nonverbal behaviours may not be perceived or interpreted in the way that was intended in certain cultures or communities. For example, body language and non-verbal behaviours can have significant cultural variability. The groups told us that demonstrating empathy through mirroring of behaviours with someone from an unfamiliar culture should be avoided by healthcare professionals as it would be unclear what message is being conveyed. Verbal utterances, such as ‘um’, ‘ah’, ‘go on’ can come across as simply performing expected listening ‘behaviours’ rather than actually listening. Referring to ‘other patients like you’ as a way of delivering positive messages based on others’ experiences was seen as a poor choice of words as it is unclear if this is referring to factors such as age, gender or ethnicity. With further input from public contributors, we used this important feedback to undertake further optimisation of our training intervention prior to our main trial. This will help ensure our intervention is culturally sensitive to the wider community.

Motivations for taking part in the focus group

We asked participants about their reasons for taking part in the focus group. It is important to dispel the mystification and stereotyping that can surround the factors that encourage and motivate people from diverse communities to participate in research studies. This is particularly pertinent as researchers increasingly recognise the need to improve levels of research participation from under-represented communities. The participants in our focus groups reported a wish to help improve the way in which doctors communicate with patients from under-represented communities; wanting to improve communication for patients where English is not their first language; and wanting to take part and learn more about research.

Reflections on the focus group process.

Both focus groups were successful in engaging participants and encouraging discussion. Participants appeared to speak freely, openly and confidently about their experiences and express views and preferences about the training materials in empathy and optimism. Interactions between participants were positive and encouraging, and everyone had time to contribute their own views. This may be helped by the familiar setting of a community group, led by a consultant who was independent from the research team and known to the community.

We asked David about his thoughts about this relatively novel process of engaging communities in research, and he had the following reflections:

In summary

We are very grateful to David and the two community groups who agreed to take part in this work and showed genuine interest and engagement in improving healthcare communication, especially for under-served groups. The work has given really valuable insight into how empathic communication may be perceived within different communities, and this has been used to optimise the training intervention prior to our main trial.

The increased familiarity with online meetings during the pandemic allowed us to reach out to communities which may have been quite difficult to arrange face-to-face. Meeting as a community group, facilitated by an independent consultant, allowed participants to speak freely amongst their friends, and allowed open and frank discussions about empathy, optimism and primary care consultations in general.


Jane Vennik, Research Fellow, University of Southampton

David Truswell, Independent consultant, SomeFreshThinking