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Introduction: Empathy is the cornerstone of the relationship between the healthcare provider and the patient. In Lebanon, no studies have investigated the factors associated with empathy among community pharmacists. Hence, the importance of this research to better understand empathy and help community pharmacists with this vital aspect of their practice. Objective: This study aimed to evaluate empathy and possible factors associated with it among Lebanese community pharmacists. Methods: This cross-sectional study was carried out between March and July 2018. It enrolled a proportionate random sample of 435 community pharmacists from all Lebanese districts. The Epi info software calculated the minimum sample size, based on a total number of 3762 community pharmacists, with an expected frequency of 50% of pharmacists with low empathy, and a 95% confidence interval. The minimal sample size required was 350 community pharmacists; our sample size was 435 to account for missing values. Results: Our results revealed that 228 (53.4%) pharmacists had low empathy. Lower empathy was significantly associated with more physical (Beta=-0.331) and mental (Beta=-0.126) work fatigue, higher age (Beta=-0.125) and a practice experience between 3 years and less than 6 years compared to less than 6 months (Beta=-2.440). Conclusion: Low empathy levels were significantly associated with individual factors such as age, practice experience, mental and physical work fatigue among community pharmacists in Lebanon. Nonetheless, the accepted model of pharmacy practice requires that pharmacists establish effective communication and use interpersonal skills. Furthermore, increased work fatigue should not hinder community pharmacists’ access to self-care, whether for their mental or physical health.
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R E S E A R C H Open Access
Factors associated with empathy among
community pharmacists in Lebanon
Eva Hobeika
1*
, Souheil Hallit
2,3*
, Hala Sacre
2,4
, Sahar Obeid
1,2,5
, Aline Hajj
6,7
and Pascale Salameh
2,8,9
Abstract
Introduction: Empathy is the cornerstone of the relationship between the healthcare provider and the patient. In
Lebanon, no studies have investigated the factors associated with empathy among community pharmacists. Hence,
the importance of this research to better understand empathy and help community pharmacists with this vital
aspect of their practice.
Objective: This study aimed to evaluate empathy and possible factors associated with it among Lebanese
community pharmacists.
Methods: This cross-sectional study was carried out between March and July 2018. It enrolled a proportionate
random sample of 435 community pharmacists from all Lebanese districts. The Epi info software calculated the
minimum sample size, based on a total number of 3762 community pharmacists, with an expected frequency of
50% of pharmacists with low empathy, and a 95% confidence interval. The minimal sample size required was 350
community pharmacists; our sample size was 435 to account for missing values.
Results: Our results revealed that 228 (53.4%) pharmacists had low empathy. Lower empathy was significantly
associated with more physical (Beta = 0.331) and mental (Beta = 0.126) work fatigue, higher age (Beta = 0.125)
and a practice experience between 3 years and less than 6 years compared to less than 6 months (Beta = 2.440).
Conclusion: This study shed the light on some factors associated with empathy among Lebanese community
pharmacists. Low empathy levels were significantly associated with factors such as age, practice experience, and
mental and physical work fatigue, all of which impact the practice, as the accepted model of pharmacy practice
requires that pharmacists establish effective communication and use interpersonal skills. Therefore, developing
empathetic communication skills is considered essential. Furthermore, increased mental and physical work fatigue
should not hinder community pharmacistsaccess to self-care, whether for their mental or physical health.
Keywords: Empathy, Community pharmacists, Work fatigue, Lebanon
Introduction
Empathy is an ambiguous concept [1] that has been por-
trayed as a notion hard to define and measure [2]. Mul-
tiple definitions exist, but the one adapted for the patient
care context is: predominantly a cognitive attribute that
involves an understanding of patientsconcerns, the cap-
acity to communicate this understanding, and an intention
to help[1,3]. It is divided into three components:
affective or emotional, cognitive, and somatic. In this
paper, empathy will refer to emotional empathy.
Previous studies have established that empathy is the
cornerstone of the relationship between the healthcare
provider and the patient [1,4]. Indeed, greater empathy
was linked to better patient compliance [5,6], more
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* Correspondence: eva.hobeika@hotmail.com;souheilhallit@hotmail.com
Eva Hobeika and Souheil Hallit are first co authors and contributed equally
to this work.
1
Faculty of Arts and Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
2
INSPECT-LB: Institut National de Santé Publique, Épidémiologie Clinique et
Toxicologie, Beirut, Lebanon
Full list of author information is available at the end of the article
Hobeika et al. Journal of Pharmaceutical Policy and Practice (2020) 13:32
https://doi.org/10.1186/s40545-020-00237-z
accurate diagnosis [7] and prognosis [8], and increased
patient satisfaction [6]. Among the various categories of
healthcare professionals, community pharmacists are
considered to be the most accessible
5
. Previous findings
showed that pharmacists who can communicate em-
pathetically build a good rapport with patients, thus im-
proving patient outcomes [9].
Evidence showed a negative association between empathy
and burnout, higher empathy being associated with lower
levels of burnout [10,11], noting that burnout includes
mental exhaustion, negative attitudes, and physical deple-
tion. Moreover, the increased psychological distress among
healthcare providers is related to decreased empathy and,
consequently, alters the quality of care provided [12].
Furthermore, higher depressive symptoms have been corre-
lated with lower empathy, suggesting that efforts to reduce
depression may improve levels of empathy [13]. Also, good
quality of sleep and recreational activities and exercise were
also associated with higher empathy [14].
On the other hand, the relationship between empathy
and gender showed that women had higher empathy
levels compared to men, to a nearly significant degree [15,
16]. Although empathy is essential for patient care, it de-
clines as medical students progress through training [17].
However, evaluations of the relationship between age and
empathy among healthcare professionals, reveal that older
practitioners have a higher level of empathy, mainly attrib-
uted to the maturity acquired over the years [18].
In 1994, Mark H. Davis introduced a social psycho-
logical approach to empathy. It suggested that the indi-
viduals empathic abilities can plausibly influence their
management of conflict or other relationship-related be-
haviors. To inclusively define empathy, Davis proposed
an organizational model that would take into account
the different constructs falling under the broad heading
of empathy[19]. This organizational model breaks
down a typical empathy encounter into an exposure of
the observer to the target, followed by a cognitive,
affective, and/or behavioral response taking place from
the observers side [19]. Four related constructs make up
the skeletal structure of this model. Antecedents, pro-
cesses, intrapersonal, and interpersonal outcomes are de-
lineated by associations between them; especially with
constructs adjacent to each other. Davismodel (1994)
has been used extensively as the underlying theoretical
framework [20], in healthcare-related literature, aiming
at understanding the organizational approach to em-
pathy between healthcare providers and patients. It
opened the door towards a better understanding of em-
pathetic interactions in the workplace. Moreover, Gerace
et al. integrated themes into Davislinear model of em-
pathy, delineating nursesefforts for empathic communi-
cation with patients [20]. This study has also added a
double-headed arrow to indicate perspective-taking as a
means to regulate nursesemotions towards patients
(not present in the original model) [20]. Other scales
have been used extensively among health professionals,
such as the Jefferson Scale of Empathy. However, it does
not offer theoretical tools necessary to establish a text-
book basis for the works of empathy, as compared to
Davismodel that provides an organizational aspect to
the empathic interactions between healthcare providers
and patients.
Lebanon is a country with a political instability, espe-
cially after the displacement of over a million Syrian refu-
gees since 2012, which had a negative impact on the
country economically and socially [21,22] and created
higher xenophobic attitudes among Lebanese in general
[23]. Furthermore, community pharmacists are not satis-
fied financially especially after the drop in the medications
prices following the decisions taken by the Ministry of
Public Health [23], which added more stressors to their
daily life and a lower quality of life [24].
Based on Davis and Gerace models, Fig. 1presents an
adapted version of the organizational model shedding
the light on empathy among community pharmacists. In
this figure, the antecedents construct enumerates several
factors that community pharmacists have brought to the
situation. These factors have the potential to influence
both processes and outcomes towards empathy [19] and
will be assessed throughout our study.
To the best of our knowledge, no studies have investi-
gated the factors associated with empathy among commu-
nity pharmacists. Hence, the importance of this research
to better understand empathy and help community phar-
macists with this vital aspect of their practice.
Therefore, this study aimed to evaluate empathy and
possible factors associated with it among Lebanese com-
munity pharmacists.
Methods
General study design
This cross-sectional study was carried out between
March and July 2018. It enrolled a proportionate ran-
dom sample of 435 community pharmacists from all five
Lebanese Mohafazat. Geographically, Lebanon is divided
into five major districts, termed Mohafazat, Beirut,
North, Mount Lebanon, Beqaa, and South. This sample
is based on an exhaustive list provided by the Lebanese
Order of Pharmacists (OPL, the official association of
pharmacists in Lebanon). The methodology used is de-
scribed elsewhere [24,25].
Sample size calculation
According to the OPL list, a total of 3762 community
pharmacists (employers and employees) practice in 3157
community pharmacies distributed across all regions.
Hobeika et al. Journal of Pharmaceutical Policy and Practice (2020) 13:32 Page 2 of 9
The Epi info software calculated the minimum sample
size, based on a total number of 3762 community phar-
macists, with an expected frequency of 50% of pharma-
cists with low empathy (in the absence of since similar
studies in the country), and a 95% confidence interval.
The minimal sample size required was 350 community
pharmacists.
Out of the 500 randomly distributed questionnaires (in
500 pharmacies), 435 (87%) were completed and col-
lected back; the remaining 65 (13%) corresponded to
pharmacists who refused to participate in this study.
Thus, the total sample included 435 participants.
Questionnaire and variables
The questionnaire was self-administered, closed-ended,
and available in either French or English, the teaching
languages in Lebanese schools of pharmacy. Well-
trained field workers distributed it to the pharmacists
after explaining the study objectives and obtaining writ-
ten informed consent. To ensure optimal objectivity,
pharmacists filled out the questionnaire without getting
any guidance on any of the questions. The average com-
pletion time was between 15 and 20 min. Field workers
collected back the questionnaires and sent them in
closed boxes for data entry. This process allowed to pre-
serve pharmacistsanonymity.
The questionnaire consisted of two sections. The first
section included socio-demographic and practice charac-
teristics, i.e., age, gender, demographic area, level of edu-
cation, years of practice, location of the pharmacy, the
approximate number of patients per day, job position,
working hours per week. A house crowding index was
also assessed. It was calculated by dividing the total
number of individuals living in the house by the total
number of rooms, excluding bathrooms and kitchen.
The second section included the following scales:
Toronto empathy questionnaire
It consists of 16 items [26]. A five-point scale, ranging
between neverand often, is used to rate each item.
Positively worded items 1, 3, 5, 6, 8, 9, 13, and 16 were
scored as: 0 (Never); 1 (Rarely); 2 (Sometimes); 3
(Often); 4 (Always), whereas negatively worded items 2,
4, 7, 10, 11, 12, 14 and 15 were reversed. All the scores
were summed to derive the total empathy score. Higher
scores designated higher empathy. The Cronbachs alpha
in this study was 0.729.
The three-dimensional work fatigue inventory (3D-WFI)
This inventory consists of 18 questions divided into
three 6-question packs. Each pack measured one dimen-
sion of work fatigue: physical (e.g., feeling physical ex-
haustion at the end of the workday), mental (e.g., facing
Fig. 1 The Organization Model of Empathy in Community Pharmacists. Framework built using Daviss (1994) linear antecedents, processes, intrapersonal and
interpersonal outcomes framework [19]
Hobeika et al. Journal of Pharmaceutical Policy and Practice (2020) 13:32 Page 3 of 9
difficulty to think and concentrate at the end of the
workday), and emotional (e.g., facing difficulty to show
and deal with emotions at the end of the workday) [27].
The score ranged from 0 (never) to 4 (every day). Higher
scores indicated higher fatigue in all three dimensions.
The Cronbachs alpha values were 0.880 (physical work
fatigue), 0.710 (mental work fatigue), and 0.848 (emo-
tional work fatigue).
Hamilton depression rating scale (HDRS)
This 17-item scale is validated in Lebanon [28]. It mea-
sures the severity of depressive symptoms (e.g., feelings
of guilt, depressed mood, suicide, etc.) [29]. The total
score is computed by summing the answers to the 17
questions, with higher scores indicating higher levels of
depression. The Cronbachs alpha value was 0.870 for
this study.
Beirut distress scale (BDS-22 scale)
This 22-item scale, validated in Lebanon, is used to
screen for stress [30]. It assesses six factors in adults,
over the past week: demotivation, depressive symptoms,
psychosomatic symptoms, mood deterioration, intellec-
tual inhibition, and anxiety. The total score is calculated
on a 4-point Likert scale from 0 (not at all) to 3 (all of
the time), with higher scores indicating higher levels of
stress. In this study, the Cronbachs alpha was of 0.935.
Lebanese insomnia scale (LIS-18)
This scale, validated in Lebanon, is used to screen for in-
somnia [31]. It consists of 18 items scored on a 5-point
Likert scale from 1 (never) to 5 (always). Items 4, 18,
and 22 are reversed. Higher scores indicate higher in-
somnia. In this study, the Cronbachs alpha was 0.811.
Forward and back translation procedure
The translation from English into French was carried
out by a translator and validated by a healthcare profes-
sionalsexpert committee, and a language professional.
A backward translation was then performed by a native
English-speaking translator, fluent in French and un-
familiar with the notions of the scales. The expert com-
mittee compared the back-translated English version to
the original one and resolved discrepancies and incon-
sistencies by consensus. Both versions were piloted on a
sample of 20 pharmacists, before launching data collec-
tion. The results of the pilot sample were excluded from
the final datasheet.
Statistical analysis
A study-independent person, not involved in the data
collection process, performed the data entry. The statis-
tical analysis was done on SPSS version 23. Student t-
test was applied to check for associations between the
empathy score and dichotomous variables (i.e., gender).
The ANOVA test was used to compare means of 3 or
more groups (i.e., educational level). Finally, a stepwise
linear regression was performed, taking the self-reported
empathy score as the dependent variable, and all the var-
iables that showed a significant association in the bivari-
ate analysis as independent variables. A p-value was
significant when p< 0.05.
Results
Sociodemographic characteristics of the participants and
other parameters
Out of 500 distributed questionnaires, 435 (87%) were
completed and collected back. The mean age of the par-
ticipants was 38.97 ± 11.13 years, and 52% were males
(Table 1).
Since the Toronto empathy scale does not have a cut-
off point, the median (= 60) was used as the cut-off
point. The mean empathy score was 59.02 ± 7.32, with
228 (53.4%) of the pharmacists having low empathy.
Table 2summarizes the scores of the intended measured
parameters.
Bivariate analysis
The results of the bivariate analysis related to the factors
associated with the empathy score are summarized in
Tables 3and 4. The mean empathy score was slightly
higher in females compared to males (59.95 vs. 58.17;
p= 0.013). The mean empathy score was significantly
higher in those having a Pharm.D degree (59.94) versus
all other education levels, in those living in South
Lebanon (61.41) compared to all other districts, and in
those having a practice experience of fewer than 6
months. Lower empathy was significantly associated with
older age (r = 0.135), higher mental (r = 0.401) and
physical (r = 0.399) work fatigue, higher insomnia (r =
0.098), and higher stress (r = 0.233).
Multivariable analysis
The results of the stepwise linear regression, taking the
empathy score as the dependent variable, revealed that
lower empathy was significantly associated with more
physical work fatigue (Beta = 0.331), more mental work
fatigue (Beta = 0.126), a practice experience between 3
years and fewer than 6 years compared to fewer than 6
months (Beta = 2.440), and older age (Beta = 0.125)
(Table 5).
Discussion
A better understanding of empathy leads to a clearer
comprehension of the patient-pharmacist interaction
and, therefore, to a constructive relationship. The results
of the multivariable analysis demonstrated that lower
empathy was significantly associated with older age,
Hobeika et al. Journal of Pharmaceutical Policy and Practice (2020) 13:32 Page 4 of 9
more physical and mental work fatigue, and a practice
experience between 3 years to fewer than 6 years com-
pared to fewer than 6 months.
Our results showed that 53.4% of the Lebanese com-
munity pharmacists have low empathy, consistent with
those found among American community pharmacists
(58% low empathy) [9]. Professional interactions are usu-
ally based on objectivity and ethical standards. Hence,
the blurring of the line becomes understandable in pro-
fessions that involve a certain degree of care-giving.
Healthcare providers, such as pharmacists, get to a point
where they either get too carried out by patientscon-
cerns, or too little (low empathy). To reach an inter-
active balance, where empathy is not surpassed by either
sympathy or lack of care for patients, pharmacists must
learn to manage their empathetic behaviors [19].
In the present study, higher physical and mental work
fatigue were associated with lower empathy, in agree-
ment with results from previous research showing that
community pharmacists with emotional exhaustion,
depersonalization, and average job levels had mental dis-
engagement, and reduced their commitment to helping
patients [3234]. Lebanese community pharmacists, al-
though held in high esteem by the population [35] have
a low level of job satisfaction due to financial constraints
[36]. This dissatisfaction can explain the fact that phar-
macists feel less concerned about communicating with
patients and show less empathy towards them. Since the
literature establishes a connection between financial
constraints and lower empathy, it was used here to
hypothesize an explanation for physical and mental work
fatigue mediated by financial constraints.
Table 1 Sociodemographic and socioeconomic characteristics
of the participants (n= 435)
Factor N (%)
Gender
Male 223 (52.0%)
Female 206 (48.0%)
District
Beirut 77 (18.0%)
Mount Lebanon 150 (35.1%)
North 66 (15.5%)
South 48 (11.2%)
Bekaa 48 (11.2%)
Educational level
Bachelor of science 250 (58.4%)
Pharm.D 106 (24.8%)
Masters 60 (14.0%)
PhD 12 (2.8%)
Professional status
Employer 299 (68.7%)
Employee 128 (30.0%)
Experience
Less than 6 months 24 (5.6%)
6 months to 1 year 20 (4.6%)
1 year to less than 3 years 36 (8.4%)
3 years to less than 6 years 64 (14.8%)
6 years to less than 12 years 118 (27.4%)
More than 12 years 169 (39.2%)
Approximate number of patients seen per day in the pharmacy
< 10 3 (0.7%)
1050 131 (30.8%)
50100 188 (44.2%)
> 100 103 (24.2%)
Working hours per week
116 h per week 27 (6.3%)
1731 h per week 48 (11.2%)
3240 h per week 96 (22.3%)
More than 40 h per week 259 (60.2%)
Social status of the patients
Poor 26 (6.1%)
Middle 193 (45.6%)
High 16 (3.8%)
Do not know 185 (43.7%)
Family income per month
< 1000 USD 35 (8.9%)
10002000 USD 90 (20.7%)
20003000 USD 129 (32.7%)
Table 1 Sociodemographic and socioeconomic characteristics
of the participants (n= 435) (Continued)
Factor N (%)
> 3000 USD 140 (35.5%)
Mean ± SD
Age (in years) 38.97 ± 11.13
House crowding index 0.89 ± 0.44
Table 2 Description of the intended measured parameters in
our sample
Variables Mean ± SD
Empathy score 59.02 ± 7.32
Stress score 42.37 ± 13.49
Insomnia score 37.53 ± 8.44
Depression score 6.90 ± 7.01
Emotional work fatigue score 17.38 ± 10.42
Mental work fatigue score 8.36 ± 6.50
Physical work fatigue score 7.63 ± 8.29
Hobeika et al. Journal of Pharmaceutical Policy and Practice (2020) 13:32 Page 5 of 9
Our results showed that the third dimension of work
fatigue, called emotional work fatigue, was not signifi-
cantly associated with lower empathy. We speculate that
emotional work fatigue is affected by several factors, i.e.,
pharmacists state of mind, personality and other envir-
onmental cues that are not necessarily related to work
performance. Thus, it is not directly affected by one
source (the job at hand), like in the case of mental and
physical work fatigue.
Previous findings [37] evaluating the correlation be-
tween empathy and age among pharmacists from all sec-
tors (not just community pharmacists) have shown that
older health professionals had greater empathy and were
more assertive. Oppositely, our results revealed that older
age was significantly associated with lower empathy; this
difference can be explained by the job dissatisfaction expe-
rienced by the Lebanese community pharmacists [36].
Through continuous job dissatisfaction, pharmacists
become less concerned and caring, expressing lower em-
pathy levels towards their patients. As they get older, their
relationship with loyal patients is affected by the lack of
time taken to bond and empathize. So, this low level of
empathy might affect the pharmacist-patient relationship
and result in losing recurring customers over time, which
in turn ends in job frustration because of a dissatisfactory
income. Hence, the observed loop-cycle of older age lead-
ing to continuous job dissatisfaction, which leads to lower
empathy.
Our study showed that having a practice experience
between 3 years and less than 6 years was significantly
associated with lower empathy. Previous studies [9] sug-
gest that professional experience years play a role in the
empathetic development process of community pharma-
cists: those more experienced develop empathetic skills
socially, through a social learning model. Thus, pharma-
cists look up to fellow pharmacists or professional men-
tors during their formative professional years and use
these observed attitudes and behaviors later on in their
professional interactions [9]. Therefore, pharmacists hav-
ing 36 years of experience are in transition between
learning from experienced mentors and developing their
empathetic social skills. These pharmacists are in a mid-
dle zone, where they dont need mentors anymore but
lack enough experience to navigate empathetic
Table 3 Bivariate analysis of factors associated with the
empathy score
Variable Mean Empathy Score
Gender
Male 58.17 ± 6.93
Female 59.95 ± 7.61
p-value 0.013
Education level
Bachelor of Pharmacy 59.36 ± 6.83
Pharm.D. 59.94 ± 7.65
Masters degree 56.96 ± 7.78
PhD 56.50 ± 7.30
p-value 0.038
District
Beirut 56.85 ± 7.58
Mount Lebanon 59.87 ± 6.89
North 58.28 ± 7.93
South 61.41 ± 5.64
Bekaa 58.72 ± 7.45
p-value 0.005
Years of practice
Less than 6 months 63.16 ± 4.87
6 months to less than 1 year 62.15 ± 8.73
One year to less than 3 years 59.25 ± 8.84
3 years to less than 6 years 57.85± 7.32
6 years to less than 12 years 59.46 ± 7.69
12 years or more 58.18 ± 6.49
P-value 0.008
Post hoc analysis: Districts (Beirut vs Mount Lebanon p= 0.033; Beirut vs Bekaa
p= 0.007); Years of practice (less than 6 months vs 3 years to less than 6 years
p= 0.034; less than 6 months vs 12 years or m ore p= 0.025)
Table 4 Bivariate analysis of continuous variables associated
with the empathy score
Age
r0.135
p-value 0.007
Emotional work fatigue
r0.031
p-value 0.527
Mental work fatigue
r0.401
p-value < 0.001
Physical work fatigue
r0.399
p-value < 0.001
Stress score
r0.233
p-value < 0.001
Insomnia score
r0.098
p-value 0.043
Depression score
r0.077
p-value 0.114
Hobeika et al. Journal of Pharmaceutical Policy and Practice (2020) 13:32 Page 6 of 9
interactions on their own. Being in this intermediate
level can explain why they exhibit low empathy levels
when compared to the other groups, keeping in mind
that empathy is a social skill, mostly acquired through
social practice and interactions with as many patients as
possible through time. One way to improve empathy, in
this case, is to develop continuous and integrated strat-
egies to enhance empathic skills, and to progressively
evaluate the ability of pharmacists to respond empathic-
ally throughout their clinical progression [38].
Statistically, our results found no significant relation-
ship between depression score and empathy level. This
may seem counterintuitive, but several well-cited studies
explain the lack of association between different mea-
sures of empathy and depression. OConnor et al. [39]
suggest that the ability to know what people are think-
ing, termed Theory of Mind (ToM), is a prerequisite for
empathy and is common in depressed people. However,
healthy empathy also requires an understanding of caus-
ality, which is affectively distorted in depression. There-
fore, the presence of depression is not associated with
empathy levels since depressed people may have normal
cognitive empathy levels, but a different empathy experi-
ence (due to the misinterpretation of empathy).
Clinical implications
This study showed that lower levels of empathy were
significantly associated with older age, increased physical
and mental work fatigue, and practice experience be-
tween 3 years and less than 6 years. No future measures
or adopted solutions can affect the age-related factor.
However, it is possible to improve work fatigue condi-
tions. One way to decrease fatigue is for pharmacists: to
get proper rest, attend to the bodys physiological needs
by maintaining balanced lifestyles, ensure good physical
health, and receive the support needed for proper men-
tal health. Since empathy is an active dynamic process,
the community pharmacist becomes more receptive to
patientsneeds after decreasing work fatigue. This way,
the pharmacist is better equipped to reach out to pa-
tients and fulfill the accepted model of pharmacy prac-
tice, which requires effective communication and the
use of interpersonal skills.
Pharmacy schools took many initiatives to include cur-
riculum modifications, aiming at enhancing empathy in
pharmacists during their training. Indeed, by going to
the source as early as possible, pharmacy students get a
solid formation on empathy and its psychosocial attri-
butes [40]. Implementing different learning techniques
i.e., simulated learning with ethical scenarios, inter-
professional and problem-based learning, can lead to en-
hanced values, ethics, and decision-making [41]. Several
studies show that empathetic relationships with patients
are followed by rewards, with empathetic dialogue lead-
ing to patient satisfaction, adherence to treatment
(sometimes), comprehension, and enhanced clinical out-
comes [42].
Limitations
Our study has several limitations. First, information bias
may occur since the questionnaire used is based on self-
report of pharmaciststhoughts and interpretation of
symptoms. Social desirability bias may also be noted
since participants may want to seem conforming to so-
cial norms; this was taken into consideration by making
sure that they know that their answers remain anonym-
ous. Secondly, no causality inferences can be made since
this study is cross-sectional. Further longitudinal studies
are warranted to make causality inferences. However, for
this study, we were able to make associations (evaluation
of factors associated with empathy). Thirdly, some of the
scales used in the questionnaire, such as the Toronto
Empathy Questionnaire, are not validated in Lebanon.
Nevertheless, the results derived from these scales were
found to be noteworthy by the authors, since they pro-
vide consistency upon comparison to other studies.
Conclusion
This study shed the light on some factors associated
with empathy among Lebanese community pharmacists.
Low empathy levels were significantly associated with
factors such as age, practice experience, and mental and
physical work fatigue, all of which impact the practice,
as the accepted model of pharmacy practice requires
that pharmacists establish effective communication and
use interpersonal skills. Therefore, developing empath-
etic communication skills is considered essential.
Table 5 Multivariable analysis: Linear regression taking the empathy score as the dependent variable
Variable Unstandardized Beta Standardized Beta p95% Confidence Interval
Physical work fatigue 0.331 0.375 < 0.001 0.410 0.252
Age 0.125 0.187 < 0.001 0.185 0.065
Mental work fatigue 0.126 0.152 0.015 0.227 0.025
Years of practice 3 years to less than 6 years compared to less
than 6 months compared to less than 6 months
a
2.440 0.122 0.009 4.275 0.605
a
Reference group
Hobeika et al. Journal of Pharmaceutical Policy and Practice (2020) 13:32 Page 7 of 9
Furthermore, increased mental and physical work fatigue
should not hinder community pharmacistsaccess to
self-care, whether for their mental or physical health.
Acknowledgments
We would like to thank all pharmacists who participated in this study.
Authorscontributions
SH and PS designed the study; EH ad SH drafted the manuscript; SH and PS
carried out the analysis and interpreted the results; SO and AH assisted in
drafting and reviewing the manuscript; HS edited the paper for English
language. All authors reviewed the final manuscript and gave their consent.
The author(s) read and approved the final manuscript.
Funding
None.
Ethics approval
The study protocol was approved by the Psychiatric Hospital of the Crosss
Ethics committee (HPC-006-2019). From each pharmacist, their written
informed consent was acquired.
Competing interests
The authors have no conflicts of interest to disclose.
Author details
1
Faculty of Arts and Sciences, Holy Spirit University of Kaslik (USEK), Jounieh,
Lebanon.
2
INSPECT-LB: Institut National de Santé Publique, Épidémiologie Clinique et
Toxicologie, Beirut, Lebanon.
3
Faculty of Medicine and Medical Sciences, Holy Spirit
University of Kaslik (USEK), Jounieh, Lebanon.
4
Drug Information Center, Order of
Pharmacists of Lebanon, Beirut, Lebanon.
5
Departments of Psychology and Research,
Psychiatric Hospital of the Cross, Jal Eddib, Lebanon.
6
Laboratory of Pharmacology,
Clinical Pharmacy and Quality Control of Drugs, Faculty of Pharmacy, Pôle
Technologie-Santé (PTS), Faculty of Pharmacy, Saint-Joseph University, Beirut 1107
2180, Lebanon.
7
Faculty of Pharmacy, Saint-Joseph University, Beirut 1107 2180,
Lebanon.
8
Faculty of Pharmacy, Lebanese University, Hadat, Lebanon.
9
Faculty of
Medicine, Lebanese University, Hadat, Lebanon.
Received: 27 March 2020 Accepted: 1 June 2020
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... Empathy is considered to be the ability to sense others' emotions and understand what they may be feeling. By nature, empathy is considered a complex multidimensional and interpersonal state [1,19,20]. Empathy is influenced by many factors, including context, therefore making it challenging to measure consistently [1,19,20]. Nevertheless, the ability to understand a patient's emotional state from their point of view is foundational to humanistic healthcare [1,19,[21][22][23][24][25]. ...
... By nature, empathy is considered a complex multidimensional and interpersonal state [1,19,20]. Empathy is influenced by many factors, including context, therefore making it challenging to measure consistently [1,19,20]. Nevertheless, the ability to understand a patient's emotional state from their point of view is foundational to humanistic healthcare [1,19,[21][22][23][24][25]. However, evidence would suggest there are challenges in providing the best of empathic healthcare for patients. ...
... Empathy is influenced by many factors, including context, therefore making it challenging to measure consistently [1,19,20]. Nevertheless, the ability to understand a patient's emotional state from their point of view is foundational to humanistic healthcare [1,19,[21][22][23][24][25]. However, evidence would suggest there are challenges in providing the best of empathic healthcare for patients. ...
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... Moreover, the OPL has been supporting students' organisations and young researchers by delivering research-based conferences and promoting soft skills and student-based activities (Hallit, Tawil, et al., 2020a;Sacre, Tawil, Hallit, Hajj, et al., 2019;Tawil, Hallit, Sacre, Hajj, & Salameh, 2020). et al., 2020), in addition to continuing education , communication with patients (Hobeika, Hallit, et al., 2020), and knowledge, attitude, and practices regarding various chronic (Hallit, Zeidan, et al., 2020) and infectious diseases (Yaacoub et al., 2019). The results of these studies could feed into the quality assurance projects of pharmacy practice. ...
... Also, an assessment of the societal perspective showed that the general population is barely satisfied with pharmacists' services (Iskandar et al., 2017). Other studies reported lower empathy (Hobeika, Hallit, et al., 2020), burnout (Rahme et al., 2020), and low quality of life (Sacre, Obeid, et al., 2019) among pharmacists. ...
... [P]-Pharmacy practice in Lebanon faces economic and financial difficulties (despite small breakthroughs in this regard), reflecting the Lebanese context and leading to pharmacists' dissatisfaction (Hallit, Zeenny, Sili, & Salameh, 2017), burnout (Rahme et al., 2020), lower empathy towards patients (Hobeika, Hallit, et al., 2020), and reduced quality of life (Sacre, Obeid, et al., 2019), all expected to lower service quality and decrease professional sustainability on the long run. ...
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... Any problem immersed in empathy becomes soluble" (Baron-Cohen, 2011). A low level of empathy in the patient's relationship may be associated with the pharmacist's older age, physical, and mental fatigue (Hobeika et al., 2020). Pharmacists' empathy in pharmacy or virtual space is closely linked to improved treatment adherence, satisfaction, and patient treatment outcomes. ...
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... Work fatigue in medical professionals has received a great amount of attention in recent years after many studies showed that this population is particularly vulnerable for developing mental, emotional and physical exhaustion [3][4][5]. Studies among medical professionals reported moderate-to-high levels of emotional exhaustion and depersonalization, with low-to-moderate levels of personal achievements [6][7][8]. In addition, high work fatigue affects health and wellbeing of doctors [7]. ...
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... Empathy among community pharmacists in Lebanon (Hobeika et al., 2020) -Lebanese pharmacists' confidence and self-perceptions of computer literacy and online education Zeenny et al., 2021a) 4.4. Interprofessional collaboration -Implementation and evaluation of interprofessional education programs in Lebanon ( Zeeni et al., 2016;Farra et al., 2018;Hajj et al., 2019) ...
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... 63 As reported by Hobeika et al. 53.4% of pharmacists represented low empathy. 64 In addition, a survey showed that pharmacist empathic learning had great influence from other professionals in their lives, whereas another group demonstrated that their empathy was learned through self-reflective, attentive, and introspective ability. 65 Limitations of this scoping review Some primary studies may have been missed due to not being indexed in the databases searched. ...
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Background Emotional intelligence (EI) can help perceive, understand, and manage emotions, and positively impact performance in any profession, including pharmacists, and consequently may have positive influence on patient-related outcomes. Although there is strong body of evidence suggesting that developing EI in healthcare professionals (HCPs) can increase their capacity to successfully communicate and build relationships with patients, thus increasing patient satisfaction, little is known about it in pharmaceutical care (PhC). Objectives This review aimed to synthesize available data on the probable impact of EI on PhC. Methods PubMed, Web of Science, and Embase databases were searched for papers in English dated between January 2000 and June 2021. Quantitative, qualitative, or mixed method studies on EI and PhC that involved practicing pharmacists were included. Results The inclusion criteria were met by four papers only. One reported positive impact of EI in reducing the negative correlation between autistic like traits and empathy among hospital pharmacists. One study demonstrated that EI levels can be significantly enhanced through pharmacy leadership programs. Another study established a positive correlation between EI and entrepreneurial orientation in practicing community pharmacists. Higher EI scores were predictors of increased work innovation, proactivity, and risk-taking levels. One study reported comparative EI data between different HCPs and found pharmacists’ superiority in the EI sub-domains of self-awareness, self-motivation, and social skills. Conclusions Additional research is required to provide evidence on how EI and EI development programs can add value to the provision of PhC. Processes and resources ought to be developed and secured to support the implementation and follow-up of such programs to bring long-term benefits to practicing pharmacists and consequently positively impacting patient-reported health outcomes.
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Health professionals who have experienced ill-health appear to demonstrate greater empathy towards their patients. Simulation can afford learners opportunities to experience aspects of illness but to date there has been no overarching review of the extent of this practice or the impact on empathic skills. Our aim was to determine from the evidence – what is known about simulation-based learning methods of creating illness experiences for health professions and the impact on their empathic skills. Arksey and O’Malley’s methodological framework informed our scoping review of articles relevant to our research question. Three databases (Medline, Embase and Web of Science) were searched in November 2020 and a sample of 516 citations were exported to Covidence Systematic Review Software© for screening. Following review and application of our exclusion criteria, 79 articles were selected in February 2021 to be included in this review. Of the 79 articles, 52 [66%] originated from the USA, 37 (47%) were qualitative based and 17 (28%) used a mixed-methods model. 77 (97%) of the articles explored the impact on learners with the majority (85%) reporting positive impact and range of emotions evoked. For instance, loss of independence throughout paralysis or impairment simulations left the majority of participants feeling vulnerable – ‘somebody they did not want to be, something negative’. Often learners gained a greater sense of empathy towards their patients, generating a range of measures that they could translate into practice to demonstrate a more holistic approach (providing more time, conveying reduced amounts of information). However, some studies observed more negative effects and additional debriefing was required post-simulation. For example, auditory hallucination studies reported a decrease in intention to help or interact with individuals with a mental illness, they did not engender goodwill or a desire to have contact, but rather facilitated social distance and negative emotions, as well as an increased willingness to apply forced treatment. A sense of suspicion and less positive attitudes towards older adults was likewise observed in some simulations of old age. Learners were noted to internalize perceived experiences of illness and to critically reflect on their empathic role as healthcare providers. A diverse range of simulation methods and techniques, evoking an emotional and embodied experience, appear to have a positive impact on empathy and could be argued as offering a complementary approach in healthcare education; however, the long-term impact remains largely unknown.
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Article
Objectives: to assess work fatigue and its associated factors among community pharmacists in Lebanon. Methods: This cross-sectional study was conducted between March and July 2018. A proportionate sample of community pharmacies was selected from all regions of Lebanon. A standardized questionnaire was used to assess the studied variables. Results: The results showed that 50.12% of the pharmacists had emotional work fatigue [95% CI 0.454-0.549], 55.01% had mental work fatigue [95% CI 0.503-0.597], and 54.78% had physical work fatigue [95% CI 0.501-0.595]. Higher mental work fatigue was significantly associated with higher stress (Beta=0.185) and having a master’s degree compared to a bachelor’s degree (Beta=2.23). Higher emotional work fatigue was significantly associated with higher stress (Beta=0.219), working more than 40 hours compared to ≤ 16 hours (Beta=2.742), and having 6 months to less than 1 year of practice compared to less than 6 months (Beta=-5.238). Higher physical work fatigue was significantly associated with higher stress (Beta=0.169) and having better soft skills (Beta=-0.163). Conclusion: Work-related fatigue is high among community pharmacists and touches all aspects: physical, mental, and emotional. In our study, community pharmacists’ fatigue levels were associated with educational level, years of experience, working hours, stress, depression, and soft skills, while no relation was found with gender, age, position in the pharmacy, and economic status. Interventions are recommended to tackle this public health problem that affects pharmacists, and eventually, patients.
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Article
Objective: to describe the generation and validation of the Lebanese Insomnia Scale (LIS-18) to be used for the evaluation of insomnia in Lebanese adult patients. Methods: This cross-sectional study, conducted between August 2017 and April 2018, enrolled 789 community dwelling participants using a proportionate random sample from all Lebanese Mohafazat. Results: The LIS-18 scale items converged over a solution of five factors with an Eigenvalue over 1, explaining a total of 59.64% of the variance. A high Cronbach’s alpha was found for the full scale (0.821). The first ROC curve, comparing participants with diagnosed insomnia to healthy individuals, showed that the optimal score was seen at a cutoff of 58.00, with a good sensitivity and specificity at this cutoff (93.3% and 88.4%, respectively). A second ROC curve, comparing participants taking drug medication for insomnia vs. those not taking drug, showed that the optimal score was seen at a cutoff of 52.50, with a good sensitivity and specificity at this cutoff (89.5% and 80.0%, respectively). A third ROC curve, comparing participants diagnosed by a physician or taking drug medication for insomnia and healthy control without insomnia drug, showed that the optimal score was seen at 51.50, with good sensitivity and specificity at this cutoff as well (90.0% and 78.10%, respectively). The positive predicted value (PPV) of the LIS-18 score in sample 2 was 93.3%, whereas the negative predicted value (NPV) was 88.4%. Conclusion: The results demonstrate that the LIS-18 can be used in clinical practice and research to measure insomnia.
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Background: The Angioedema Quality of Life (AE-QoL) is the first patient reported outcome measure developed for the assessment of quality of life (QoL) impairment in patients with recurrent angioedema (RAE). This study aimed to evaluate the clinimetric properties of the AE-QoL in Thai patients and to establish categories of QoL impairment assessed by the AE-QoL. Methods: The validated Thai version of the Dermatology Life Quality Index (DLQI) and Patient Global Assessment of Quality of Life (PGA-QoL) were used to comparatively evaluate the Thai version of AE-QoL. Spearman correlations between the Thai AE-QoL and two other standard measurements (DLQI and PGA-QoL) were investigated to determine convergent validity. The Thai DLQI and PGA-QoL were used to categorize patients according to their QoL. Known-group validity of the Thai AE-QoL was later analyzed. The reliability of the Thai AE-QoL was investigated using Cronbach's alpha and intraclass correlation. Three different approaches including the distribution method, receiver operating characteristic curve analysis, and the anchor based-method were used for the interpretability. Results: A total of 86 patients with RAE with a median age of 38.0 ± 15.1 years (range 18-76) were enrolled. Of those, 76 patients (88%) had RAE with concomitant wheals, and 10 patients (11.6%) had RAE only. The AE-QoL assessed RAE-mediated QoL impairment with high convergent validity and known-groups validity, high internal consistency and test-retest reliability, and good sensitivity to change. Although the AE-QoL did not differentiate between patients with moderate and large effect as measured by PGA-QoL or DLQI in this study, AE-QoL total values of 0-23, 24 to 38, and ≥ 39 could define patients with "no effect", "small effect", and "moderate to large effect" of RAE on their QoL, respectively. Conclusions: This study supports the validity and reliability of the Thai version of the AE-QoL, which is a very different language from the original version. Categories allow to classify the effect of RAE on patients' QoL as "none", "small", and "moderate to large". Further studies are needed to confirm the applicability of AE-QoL in other Asian populations".
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Background: Recurrent angioedema (AE) is an important clinical problem in the context of chronic urticaria (mast cell mediator-induced), ACE-inhibitor intake and hereditary angioedema (both bradykinin-mediated). To help patients obtain control of their recurrent AE is a major treatment goal. However, a tool to assess control of recurrent AE is not yet available. This prompted us to develop such a tool, the Angioedema Control Test (AECT). Methods: After a conceptional framework was developed for the AECT, a list of potential AECT items was generated by a combined approach of patient interviews, literature review, and expert input. Subsequent item reduction was based on impact analysis, inter-item-correlation, additional predefined criteria for item performance, and a review of the item selection process for content validity. Finally, an instruction section was generated, and an US-American-English version was developed by a structured translation process. Results: A 4-item AECT with recall periods of 4 weeks and 3 months was developed based on 106 potential items tested in 97 patients with mast cell mediator-induced (n=49) or bradykinin-mediated recurrent AE (n=48). 84 items were excluded based on impact analysis. The remaining 22 items could be further reduced by a method-mix of inter-item-correlation, additional predefined criteria for item performance, and review for content validity. Conclusions: The AECT is the first tool to assess disease control in recurrent AE patients. Its retrospective approach, its brevitiy and its simple scoring make the AECT ideally suited for clinical practice and trials. Its validity and reliability need to be determined in future independent studies.
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Background: Chronic Spontaneous Urticaria (CSU) is common, chronic, and debilitating, and has serious effects on quality of life (QoL) and mental health. Three of four CSU patients are women. The impact of CSU on female sexual functioning remains largely unknown. Objective: To determine the prevalence of sexual dysfunction in female patients with CSU and to characterize their impairment of sexual functioning and its drivers. Patients and methods: Fifty-six female patients with CSU and 55 female aged-matched healthy control subjects were evaluated for sexual functioning with the Female Sexual Function Index (FSFI). Patients were also assessed for their duration, activity, and control of disease, as well as angioedema, anxiety, depression, fatigue, and QoL impairment. Results: Sexual functioning, i.e. total FSFI scores and all sub-scores, was markedly reduced in female CSU patients versus control subjects, and two of three patients (67.9%) had sexual dysfunction. Impaired sexual functioning was linked to high disease activity and poor disease control. Sexual dysfunction was more common in CSU patients with angioedema and vice versa. Angioedema was a significant predictor of sexual dysfunction in female patients with CSU (Odds ratio: 7.3). Reduced sexual functioning was associated with anxiety, depression, and fatigue and significantly linked to impaired QoL, more so in patients with angioedema as compared to those without. Conclusions: CSU has strong negative effects on female sexual function, especially in patients with angioedema. Additional studies on sexual health in patients with CSU are needed and should focus on the impact of effective treatment on sexual functioning.
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Purpose: To assess the relationship between xenophobia and the coping strategies and evaluate factors associated with xenophobia in Lebanon. Design/Methods: This cross-sectional study, conducted between March-July 2017, enrolled 433 participants. Results: Severe xenophobia (Beta=1.46) and female gender (Beta=1.45) were associated with higher problem-focused engagement scores. Participants with low income had lower problem-focused disengagement score compared to those without income. Moderate (Beta=0.80) and intense xenophobia (Beta=1.38) were significantly associated with higher emotion focused engagement, whereas female gender was significantly associated with lower emotion-focused engagement (Beta=-0.71) and disengagement (Beta=-0.83). Being divorced compared to single (Beta=2.32) and female gender (Beta=2.04) were associated with higher xenophobia. Practice implications: Our study supports the prevalence of xenophobia amongst Lebanese, but requires a broader assessment of that trend.