- Email: [email protected]
The effect of an elective psychiatry course on pharmacy student empathy
Available online at www.sciencedirect.com
Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
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The effect of an elective psychiatry course on pharmacy student empathy Jerry Michael McGuire, PharmD, BCPPa,*, Leigh Ann Bynum, PhDa, Emily Wright, PharmDb a
Belmont University College of Pharmacy, Nashville, TN b Hospital Corporation of America, Nashville, TN
Abstract Introduction: While a number of published studies have evaluated the impact of pedagogical methods on pharmacy student stigma and attitudes toward patients with mental illness, the current study is the first to compare a psychiatry elective course to traditional lecture on pharmacy student empathy toward patients with mental illness. Materials and methods: All third-year pharmacy students at one pharmacy school enrolled in the Pathophysiology/ Therapeutics III course and prior to enrollment in an Advanced Psychiatry elective course, were invited to complete a survey containing the Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS). Demographic variables including age, gender, family history of mental illness, and previous experience in mental health hospitals were also collected. The same survey instrument (JSE-HPS with demography) was administered after traditional lecture/prior to psychiatry elective and at the conclusion of the Advanced Psychiatry elective. Results: The survey was completed by 60% (N ¼ 41) of students prior to traditional lecture, 45% (N ¼ 31) after traditional lecture and 88% (N ¼ 14) after the psychiatry elective. Mean empathy scores increased from 109.32 pre-lecture to 112.86 postlecture (p ¼ 0.162 vs. pre-lecture) and 120.00 post-elective (p ¼ 0.001 vs. pre-lecture). Conclusion: The teaching methods employed in the psychiatry elective course, including media, contact-based education and an auditory hallucination simulator, lead to an increase in pharmacy student empathy toward patients with mental illness. Pharmacy educators should continue to explore novel ways to increase pharmacy student empathy toward patients with mental illness. r 2016 Elsevier Inc. All rights reserved.
Keywords: Students; Pharmacy; Empathy; Psychiatry
Introduction Empathy can be seen as a vague and uncertain human quality; however, there is some consensus on the cognitive nature of this construct. Empathy has been defined in “patient-care situations, as a cognitive attribute that involves *Corresponding author: J. Michael McGuire, PharmD, BCPP, Belmont University College of Pharmacy, Nashville, TN 37212. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2016.03.005 1877-1297/r 2016 Elsevier Inc. All rights reserved.
an ability to understand the patientʼs inner experiences and perspectives and a capability to communicate this understanding.”1 Researchers have demonstrated that empathy can positively impact patient satisfaction, reduce medical errors, and positively influence patient adherence to clinical recommendations.2–4 Some researchers have asserted that empathy is such an important factor in the patient/provider relationship that it should characterize all health care relationships including the patientʼs relationship with his/her pharmacist.5 Fortunately, health care providers
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typically report higher levels of empathy than non-health care providers. For example, Wilson et al.5 utilized the Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS), a validated scale, to evaluate empathy in pharmacy, nursing, and law students and discovered higher empathy ratings in pharmacy and nursing students as compared with law students. Because empathy is, by definition, a cognitive process, it is intuitively appealing that this is a skill that can be taught. In fact, the Accreditation Council for Pharmacy Education (ACPE), the American Association of Colleges of Pharmacy (AACP), and the Center for the Advancement of Pharmaceutical Education (CAPE) Educational Outcomes emphasize the importance of empathy as a component in pharmacy education.6 There have been a number of investigations into pharmacy student empathy and the effect of different pedagogical techniques. Lor et al.7 utilized the JSE-HPS in a randomized study to evaluate the effect of a simulation of disability (loss of dominant hand use, loss of vision, and loss of speech) on pharmacy student empathy. The authors found a significant increase in empathy seven days after the simulation but not 90 days after the intervention.7 Van Winkle et al.8 evaluated the effect of a theatrical performance on the challenges of aging on pharmacy and medical student empathy utilizing the JSEHPS. They found higher empathy ratings immediately after the workshop but the effects were not sustained after participation in the workshop.8 Chen et al.9 evaluated the impact of a patient empathy modeling assignment for 10 days in which advanced pharmacy practice experience students “became the patient.” The authors found an increase in student empathy as measured by the Jefferson Scale of Physician Empathy.9 Lastly, Manolakis et al.6 found an increase in pharmacy student empathy as a result of a module on death and dying that incorporated media as measured by the Balanced Emotional Empathy Scale (BEES). Based on these data, it appears that empathy can increase as a result of a variety of pedagogical techniques. Perhaps there is no patient population in greater need of an empathetic health care provider than those with mental illness. According to National Survey on Drug Use and Health (NSDUH), in 2013, there were an estimated 10 million adults aged 18 years or older in the United States. with Serious Mental Illness (SMI) in the past year, which represented 4.2% of all U.S. adults.10 Since pharmacists are consistently rated as some of the most accessible and trusted health care professionals, they would inevitably encounter patients with SMI, and it is critical that they feel comfortable providing care to those patients.11 A 2012 survey of patients taking mental health medications conducted by the College of Psychiatric and Neurologic Pharmacists (CPNP) along with the National Alliance on Mental Illness (NAMI) found 91% of patients felt very comfortable going to community pharmacies and 83% reported feeling respected by their pharmacist.12 However, 43% reported that they did not have a strong professional relationship with
their pharmacist and 75% reported that they did not receive effectiveness or safety monitoring assistance from their pharmacist.12 Rickles et al.13 surveyed community pharmacists regarding their attitudes toward patients with depression and schizophrenia and found generally more negative attitudes toward patients with schizophrenia than depression. Alternatively, Cates et al.14 found generally positive attitudes among pharmacists toward patients with mental illness and providing care to those patients. Because of the prevalence of SMI and the accessibility of pharmacists, it is important that pharmacy students be taught not only about mental illnesses and their treatment but also how to empathize with this patient population. There have also been several investigations into pedagogical techniques and their impact specifically on stigma and attitudes toward patients with mental illness. Bell et al.15 compared the Social Distance Scale (SDS) and items regarding stigmatization for third-year pharmacy students prior to any lectures on mental illness with pharmacy graduates who were attending a seminar in Sydney, Australia. They found no difference in the scores on the SDS and the items related to mental health stigma. Contactbased education that incorporates patients with mental illness has been found to decrease social distance and stigma.16–19 Likewise, elective courses in psychiatry have been found to have a favorable impact on social distance, stigma, and attitudes related to psychiatry.20–22 The purpose of the current study was to evaluate and measure the impact of traditional large classroom lecture on pharmacy student empathy compared to a smaller elective course which utilized contact-based education, media, and an auditory hallucination simulator. The stated hypothesis is that the elective with its pedagogical techniques would increase pharmacy student empathy toward patients with mental illness more than traditional lecture on mental illness. Methods This study utilized the Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS). The JSEHPS is a 20-item survey utilizing a seven point Likert scale from 1 (“strongly disagree”) to 7 (“strongly agree”). The original Jefferson scale was developed to be used in the physician population but was modified to be applicable to other health care professionals as well as health care professional students.1,23 The scaleʼs psychometric properties remained at acceptable levels with the modifications with a reported coefficient alpha of 0.81 and a test–retest reliability of 0.65.1 The JSE-HPS was demonstrated to be both valid and reliable for measuring empathy in pharmacy students, with results similar to those found previously in physicians and medical students.24 Participation in the present study was both voluntary and anonymous. The survey was offered to third-year pharmacy students at Belmont University College of Pharmacy, a private, faith-based university in the southeastern
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United States. The Universityʼs Institutional Review Board approved the study prior to implementation. Students were asked to think about patients with mental illness when completing the survey. The class was invited to participate in the survey at the beginning of their third year and at the end of the fall semester of the same year. A subset of the class was invited to participate in the survey a third time if they completed an Advanced Psychiatry elective in the spring semester of their third year. An electronic version of the survey was utilized for all three administrations of the survey. As part of the third-year curriculum, all students complete approximately 21 hours of neuropsychiatry topics in the Pathophysiology/Therapeutics III course that utilizes didactic lecture as well as case-based learning in a corequisite course (Case Studies I). The first administration of the JSE-HPS was offered to all students (N ¼ 68) in the didactic lecture class prior to the presentation of these topics by the college faculty primarily responsible for those disease areas. Topics included epilepsy, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, attention-deficit hyperactivity disorder, and substance use disorders. In addition, students were asked if they had enrolled in the Advanced Psychiatry elective course. The elective course, Advanced Psychiatry, was offered to students in the spring semester of their third year. The elective course utilized a variety of techniques including traditional lecture, contact-based education with patients, media such as movies and patient videos, a hallucination simulator, and reflective writing. The contact-based education included a traditional lecture on the topic and a patient suffering from that mental illness. The patient discussed his/her personal experience with the symptoms, treatment, as well as stigma they may have experienced. One patient had experienced eating disorders and the other had experienced depression. Media was employed at multiple points in the course. Students viewed and critiqued A Beautiful Mind, which tells the story of John Nash, a Nobel Prize winning mathematician, who suffered from schizophrenia.25 The class viewed and critiqued the movie and the accuracy of the portrayal of a patient with schizophrenia. Additional media included patient testimonials or videos that displayed symptoms of Touretteʼs syndrome, conversion disorder, autism spectrum disorder, and depression. The course also incorporated an auditory hallucination simulator.26 The hallucination simulator was utilized to simulate what patients who have auditory hallucinations experience. While listening to the hallucinations, the students completed multiple activities including a word find, number find, job application, and a modified mental status examination which was conducted by one of the course faculty. The students utilized personal headphones and adjusted the volume to a comfortable level. Course topics and assessments are summarized in Table 1. Statistical analyses were conducted using IBMs SPSSs Statistics, version 21. Independent samples t-tests were
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used to compare the mean empathy scores between the groups. Comparisons were made between before and after the traditional lecture and before and after the elective. Comparisons were also made between groups before traditional lecture and after the elective. In all analyses, the type I error rate was maintained at 0.05. Results The survey was completed by 41/68 students prior to traditional lecture for an initial response rate of 60%. At the conclusion of the traditional lecture the response rate decreased to 43% or 29/68. At the end of the advanced psychiatry course, 14 of the 16 (88%) enrolled students completed the survey. Empathy scores were calculated as recommended in the Jefferson Scale of Empathy scoring algorithm. Ten items in the JSE-HPS are negative statements and responses to these items were reversed for scoring. Scores ranged from 20 to 140, with higher scores being indicative of greater empathy. Demographic variables were also collected including age, gender, family history of mental illness, and experience working in a mental health institution. Baseline demographics, family history, and experience working in a mental health institution are included in Table 2. Independent samples t-tests were performed to determine if there were differences between those who completed the survey before and after the traditional lecture. While there was a positive trend in empathy scores, the difference in mean JSE-HPS scores pre- (109.32) vs. post-lecture (112.86) was not significant (p ¼ 0.162). However, when comparing post-lecture (112.86) with post-elective (120.00), there was a statistically significant increase in mean JSEHPS scores (p ¼ 0.025). Additionally, when comparing prelecture (109.32) with post-elective scores (120.00), there was also a statistically significant increase in mean JSE-HPS scores (p ¼ 0.001). There was no statistically significant difference when comparing the pre-elective cohort (n ¼ 12) with the post-elective (n ¼ 14) cohort on mean JSE-HPS scores (113.00 vs. 120.00, respectively; p ¼ 0.115). There was no significant difference in mean JSE-HPS score change for those with a close relative with mental illness and those without (p ¼ 0.08) or in those who had worked in mental health institution (p ¼ 0.61). Empathy scores for those students who had completed an IPPE at a mental health institution (n ¼ 2) decreased at the conclusion of the psychiatry elective (107.50, Cohenʼs d ¼ 2.81) (Table 3). Discussion The students who participated in this study displayed a greater increase in empathy scores in the psychiatry elective course than with traditional lecture. This is the first study to specifically evaluate the possible impact of a psychiatry elective course on pharmacy student empathy toward
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Table 1 Course description and assessments for Advanced Psychiatry elective Topic
Class description
Assessment(s)
Course introduction and history of psychiatry
In-class lecture which reviewed the history of psychiatric treatment including the asylum era and deinstitutionalization as well as the mental status examination with video clips In-class viewing and discussion of “A beautiful mind”25
Multiple choice questions on midterm/ final exams
Schizophrenia in film
Auditory hallucination simulator Personality disorders
Bipolar disorder
Eating disorders
Midterm exam Autism spectrum Disorders “The quiet room” Pediatric bipolar disorder
Students individually participated in auditory hallucination simulator exercise for approximately 45 minutes; exercise included activities that were completed while listening to the “hallucinations” “Flipped classroom” approach in which students reviewed a recorded lecture which discussed the diagnosis of personality disorders and treatment options; during class a variety of movie depictions of personality disorders was shown and students had to identify the personality disorder Student groups presented the case of a famous person they researched who was purportedly diagnosed with Bipolar Disorder
Guided reflection article Multiple choice questions on midterm/ final exams Brief guided reflection article
In-class assessment identifying personality disorders depicted in movie clips Multiple choice questions on midterm/ final exams Group presentation Multiple choice questions on midterm/ final exams In-class lecture which reviewed diagnosis and treatment; “patient” with Patient Case eating disorder shared personal story Multiple choice questions on midterm/ final exams
“Flipped classroom” approach in which Students reviewed recorded lecture which discussed diagnosis and treatment; in-class discussion of autism Students individually read “The quiet room” by Lori Schiller and wrote a reflective article27 In-class lecture which reviewed diagnosis and treatment
Patient case Multiple choice questions on final exam Guided reflection article
Multiple choice questions on exam Impulse control disorders In-class lecture which reviewed diagnosis and treatment Multiple choice questions on exam Miscellaneous psychiatric In-class lecture which reviewed Touretteʼs Syndrome, malingering, Multiple choice questions on disorders factitious disorders, somatic symptom disorders; lecture incorporated a exam variety of patient videos Major depressive disorder In-class lecture which reviewed alternatives to medication for the Brief guided reflection based and alternative treatment of major depressive disorder including electroconvulsive “patient” testimonial treatments therapy (ECT), transcranial magnetic stimulation (TMS), bright light Multiple choice questions on therapy, ketamine and others; TMS and ECT videos were shown; exam “patient” shared personal experience with depression in herself and in family member who committed suicide Field trip Toured a psychiatric hospital, discussed patient flow into/out of mental None health hospital and barriers to treatment Final exam
patients with mental illness. Additionally, this is the first study to directly evaluate the impact on empathy of a psychiatry elective vs. traditional lecture and case-based learning led by the same instructor. While a causal relationship cannot be established between the increase in empathy scores and the pedagogical teaching methods employed in the psychiatry elective, there is reason to believe that this is the case. The current research is consistent with previous investigations which have found that psychiatry elective courses and contact-based education positively impact pharmacy
final final final
on Final
student attitudes, social distance, and stigma regarding patients with mental illness and are also more effective than traditional lecture.15–18,20–22 These findings enhance the literature through the incorporation of a validated empathy rating scale as well as the comparison of a psychiatry elective directly with traditional lecture in the same cohort of students. Prior research in this area has predominantly included scales that evaluate pharmacy student stigma or social distance. Stigma can be defined as “an attribute that is deeply discrediting and that reduces the bearer from a whole and usual person to a tainted,
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Table 2 Demographics Pre-lecture n ¼ 41 (60%)
Post-lecture n ¼ 31 (46%)
Age 19–21 22–24 25–27 28–30 31–33 433
1 19 10 7 3 1
1 12 8 5 3 2
Gender Male Female
21 (51%) 20 (49%)
(2%) (46%) (24%) (17%) (7%) (2%)
Family member with mental illness Yes 16 (39%) Father 1 (6%) Mother 5 (31%) Sibling 4 (25%) Grandparent 7 (44%) Aunt/uncle 6 (38%) Cousin 2 (13%) No 25 (61%)
Pre-elective n ¼ 13 (81%)
Post-elective n ¼ 14 (88%)
(3%) (39%) (26%) (16%) (10%) (6%)
1 (8%) 7 (54%) 2 (15%) 2 (15%) 1 (8%) 0
1 (7%) 5 (36%) 4 (29%) 3 (21%) 1 (7%) 0
12 (39%) 19 (61%)
4 (31%) 9 (69%)
4 (29%) 10 (71%)
17 3 8 7 3 4 7 16
8 2 5 4 2 3 4 5
10 2 6 6 3 4 2 4
(55%) (18%) (47%) (41%) (18%) (24%) (41%) (52%)
(62%) (25%) (63%) (50%) (25%) (38%) (50%) (38%)
(71%) (14%) (43%) (43%) (21%) (29%) (14%) (29%)
Completed an introductory practice experience (IPPE) in a mental health institution Yes 3 (7%) 1 (3%) No 38 (93%) 30 (97%)
1 (8%) 12 (92%)
2 (14%) 12 (86%)
Worked at a mental health institution Yes 2 (5%) No 39 (95%)
2 (15%) 11 (85%)
0 14 (100%)
2 (6%) 29 (94%)
discounted one,” while social distance is an assessment of an individualʼs willingness to participate in personal relationships with a stigmatized group.16,17 Empathy is a different cognitive and emotional concept than social distance or stigma, and thus was assessed with a specific empathy rating scale.24 It has been proposed that feelings of empathy toward a stigmatized group can improve attitudes toward that group, thus, empathy may affect both stigma and social distance.28 Limitations of the current study include the small sample size. Overall, 68 students were invited to complete the survey before and after traditional lecture. A total of 60% and 43% completed the survey before and after
traditional lecture, respectively. Overall, 16 students enrolled in the psychiatry elective course and 88% of the students completed the survey at the conclusion of the course. While positive change was observed pre- and post-elective, it failed to be statistically significant. This could be due to the small number of students enrolled in the elective thus not providing adequate statistical power. In addition, it is possible that self-selection bias impacted the results of the study in that the students who chose to enroll in the Advanced Psychiatry elective may have been inherently more empathic toward patients with mental illness to begin with. This is evidenced by the fact that 71% of those who enrolled in the course had a
Table 3 Mean Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS) scores and group comparisons
Mean JSE-HPS scores and group comparisons a
Significant at p o 0.05.
Pre-lecture n ¼ 41
Post-lecture n ¼ 29
Pre-elective n ¼ 12
Post-elective n ¼ 14
109.32
112.86 (p ¼ 0.162 vs. pre-lecture)
113.00
120.00 (p ¼ 0.001a vs. pre-lecture; p ¼ 0.025a vs. post-lecture; p ¼ 0.115 vs. pre-elective)
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close family member with mental illness. However, mean empathy scores for those who were enrolled in the elective course at baseline (113.00) were not significantly different from those who did not enroll in the course (112.86). A surprising finding, which warrants further study, was that empathy scores decreased (i.e., less empathy) for those students who completed an introductory practice experience (IPPE) at a mental health institution. There were, however, only two students in this group, so this finding may be due to chance. Students on IPPEs spend an extended period of time over a semester being exposed to pharmacy practice in various settings that may include a mental health institution. It was expected that students who had an IPPE at a mental health institution would have higher empathy ratings since direct patient contact has been associated with improvements in attitudes regarding patients with mental illness.16–19 However, Cates29 recently reported that an advanced pharmacy practice experience in psychiatry did not improve social distance, stigmatizing attitudes, or attitudes toward mental illness. Our finding in a very small subset of students warrants further research to determine the impact of early and advanced pharmacy practice experience on pharmacy student empathy toward patients with mental illness. Additional areas for research include a comparison of pharmacy students with other graduate students. As has been discussed previously, general empathy ratings have been found to be higher in health vs. non-health profession students.5 It would, therefore, be of interest to explore differences in empathy among health professional students in fields such as pharmacy, nursing, medicine, and clinical social work. Ideally, the assessment of the pedagogical techniques should be assessed over the course of multiple years to determine if the pedagogical techniques are truly responsible for the increase in student empathy. This may be difficult to assess, however, as the student population changes and there are subtle differences in courses from semester to semester that are difficult to control. An assessment of the long-term impact of the Advanced Psychiatry elective should also be conducted. Data has largely shown that educational interventions may increase empathy immediately but the effect has not been sustained.7,8 In conclusion, the teaching methods employed in the psychiatry elective course which included media, contact-based education, and an auditory hallucination simulator lead to an increase in pharmacy student empathy toward patients with mental illness. Conflict of interest McGuire is the speakers bureau for Sunovion Pharmaceuticals and Forest Pharmaceuticals. Consultant for Otsuka America Pharmaceuticals Inc. Stock holder in Bristol Myers Squibb; Bynum and Wright has no financial disclosure ti disclose.
References 1. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry. 2002;159(9):1563–1569. 2. Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004;27(3):237–251. 3. Stepien KA, Baernstein A. Educating for empathy. A review. J Gen Intern Med. 2006;21(5):524–530. 4. Roter DL, Hall JA, Merisca R, Nordstrom B, Cretin D, Svarstad B. Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care. 1998;36(8): 1138–1161. 5. Wilson SE, Prescott J, Becket G. Empathy levels in first- and third-year students in health and non-health disciplines. Am J Pharm Educ. 2012;76(2): Article 24. 6. Manolakis ML, Olin JL, Thornton PL, Dolder CR, Hanrahan C. A module on death and dying to develop empathy in student pharmacists. Am J Pharm Educ. 2011;75(4): Article 71. 7. Lor KB, Truong JT, Ip EJ, Barnett MJ. A randomized prospective study on outcomes of an empathy intervention among second-year student pharmacists. Am J Pharm Educ. 2015;79(2): Article 18. 8. Van Winkle LJ, Fjortoft N, Hojat M. Impact of a workshop about aging on the empathy scores of pharmacy and medical students. Am J Pharm Educ. 2012;76(1): Article 9. 9. Chen JT, LaLopa J, Dang DK. Impact of patient empathy modeling on pharmacy students caring for the underserved. Am J Pharm Educ. 2008;72(2): Article 40. 10. Substance Abuse and Mental Health Services Administration. Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings 2014. Available at: 〈http://store.samhsa.gov/shin/con tent//NSDUH14-0904/NSDUH14-0904.pdf〉. Accessed May 1, 2016. 11. Lonie JM. From counting and pouring to caring: the empathic developmental process of community pharmacists. Res Social Adm Pharm. 2006;2(4):439–457. 12. Caley CF, Stimmel GL. Characterizing the Relationship Between Individuals with Mental Health Conditions and Community Pharmacists: Results from a 2012 Survey. Available at: 〈https://cpnpf.org/top-initiatives〉. Accessed May 1, 2016. 13. Rickles NM, Dube GL, McCarter A, Olshan JS. Relationship between attitudes toward mental illness and provision of pharmacy services. J Am Pharm Assoc. 2010;50(6):704–713. 14. Cates ME, Burton AR, Woolley TW. Attitudes of pharmacists toward mental illness and providing pharmaceutical care to the mentally ill. Ann Pharmacother. 2005;39(9):1450–1455. 15. Bell JS, Johns R, Chen TF. Pharmacy studentsʼ and graduatesʼ attitudes towards people with schizophrenia and severe depression. Am J Pharm Educ. 2006;70(4): Article 77. 16. Patten SB, Remillard A, Phillips L, et al. Effectiveness of contact-based education for reducing mental illness-related stigma in pharmacy students. BMC Med Educ. 2012;12:120. 17. Buhler AV, Karimi RM. Peer-level patient presenters decrease pharmacy studentsʼ social distance from patients with schizophrenia and clinical depression. Am J Pharm Educ. 2008;72(5): Article 106.
J.M. McGuire et al. / Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]] 18. OʼReilly CL, Bell JS, Chen TF. Consumer-led mental health education for pharmacy students. Am J Pharm Educ. 2010;74 (9): Article 167. 19. Bell JS, Johns R, Rose G, Chen TF. A comparative study of consumer participation in mental health pharmacy education. Ann Pharmacother. 2006;40(10):1759–1765. 20. Dipaula BA, Qian J, Mehdizadegan N, Simoni-Wastila L. An elective psychiatric course to reduce pharmacy studentsʼ social distance toward people with severe mental illness. Am J Pharm Educ. 2011;75(4): Article 72. 21. Gable KN, Muhlstadt KL, Celio MA. A mental health elective to improve pharmacy studentsʼ perspectives on mental illness. Am J Pharm Educ.. 2011;75(2): Article 34. 22. Einat H, George A. Positive attitude change toward psychiatry in pharmacy students following an active learning psychopharmacology course. Acad Psychiatry. 2008;32(6):515–517. 23. Hojat M, Mangione S, Nasca TJ, et al. The jefferson scale of physician empathy: development and preliminary psychometric data. Educ Psychol Meas. 2001;61(2):349–365.
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24. Fjortoft N, Van Winkle LJ, Hojat M. Measuring empathy in pharmacy students. Am J Pharm Educ. 2011;75(6): Article 109. 25. Grazer B, Howard R. (Producers), Howard R (Director). A Beautiful Mind; 2001. 26. Deegan P. Hearing Distressing Voices Toolkit. Available at: 〈https://www.patdeegan.com/pat-deegan/training/hearing-voi ces-training〉. Accessed May 1, 2016. 27. Schiller L, Bennett A. The Quiet Room. New York, NY: Grand Central Publishing; 2011. 28. Batson CD, Polycarpou MP, Harmon-Jones E, et al. Empathy and attitudes: can feeling for a member of a stigmatized group improve feelings toward the group? J Pers Soc Psychol. 1997;72(1):105–118. 29. Cates ME. Pharmacy Studentsʼ Attitudes Toward Mental Illness are Unaffected by Participation in a Psychiatric Pharmacy Advanced Pharmacy Practice Experience. Poster presented at: College of Psychiatric and Neurologic Pharmacists Annual Meeting, Tampa, FL; April 2015.
Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
Short communication
http://www.pharmacyteaching.com
The effect of an elective psychiatry course on pharmacy student empathy Jerry Michael McGuire, PharmD, BCPPa,*, Leigh Ann Bynum, PhDa, Emily Wright, PharmDb a
Belmont University College of Pharmacy, Nashville, TN b Hospital Corporation of America, Nashville, TN
Abstract Introduction: While a number of published studies have evaluated the impact of pedagogical methods on pharmacy student stigma and attitudes toward patients with mental illness, the current study is the first to compare a psychiatry elective course to traditional lecture on pharmacy student empathy toward patients with mental illness. Materials and methods: All third-year pharmacy students at one pharmacy school enrolled in the Pathophysiology/ Therapeutics III course and prior to enrollment in an Advanced Psychiatry elective course, were invited to complete a survey containing the Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS). Demographic variables including age, gender, family history of mental illness, and previous experience in mental health hospitals were also collected. The same survey instrument (JSE-HPS with demography) was administered after traditional lecture/prior to psychiatry elective and at the conclusion of the Advanced Psychiatry elective. Results: The survey was completed by 60% (N ¼ 41) of students prior to traditional lecture, 45% (N ¼ 31) after traditional lecture and 88% (N ¼ 14) after the psychiatry elective. Mean empathy scores increased from 109.32 pre-lecture to 112.86 postlecture (p ¼ 0.162 vs. pre-lecture) and 120.00 post-elective (p ¼ 0.001 vs. pre-lecture). Conclusion: The teaching methods employed in the psychiatry elective course, including media, contact-based education and an auditory hallucination simulator, lead to an increase in pharmacy student empathy toward patients with mental illness. Pharmacy educators should continue to explore novel ways to increase pharmacy student empathy toward patients with mental illness. r 2016 Elsevier Inc. All rights reserved.
Keywords: Students; Pharmacy; Empathy; Psychiatry
Introduction Empathy can be seen as a vague and uncertain human quality; however, there is some consensus on the cognitive nature of this construct. Empathy has been defined in “patient-care situations, as a cognitive attribute that involves *Corresponding author: J. Michael McGuire, PharmD, BCPP, Belmont University College of Pharmacy, Nashville, TN 37212. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2016.03.005 1877-1297/r 2016 Elsevier Inc. All rights reserved.
an ability to understand the patientʼs inner experiences and perspectives and a capability to communicate this understanding.”1 Researchers have demonstrated that empathy can positively impact patient satisfaction, reduce medical errors, and positively influence patient adherence to clinical recommendations.2–4 Some researchers have asserted that empathy is such an important factor in the patient/provider relationship that it should characterize all health care relationships including the patientʼs relationship with his/her pharmacist.5 Fortunately, health care providers
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typically report higher levels of empathy than non-health care providers. For example, Wilson et al.5 utilized the Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS), a validated scale, to evaluate empathy in pharmacy, nursing, and law students and discovered higher empathy ratings in pharmacy and nursing students as compared with law students. Because empathy is, by definition, a cognitive process, it is intuitively appealing that this is a skill that can be taught. In fact, the Accreditation Council for Pharmacy Education (ACPE), the American Association of Colleges of Pharmacy (AACP), and the Center for the Advancement of Pharmaceutical Education (CAPE) Educational Outcomes emphasize the importance of empathy as a component in pharmacy education.6 There have been a number of investigations into pharmacy student empathy and the effect of different pedagogical techniques. Lor et al.7 utilized the JSE-HPS in a randomized study to evaluate the effect of a simulation of disability (loss of dominant hand use, loss of vision, and loss of speech) on pharmacy student empathy. The authors found a significant increase in empathy seven days after the simulation but not 90 days after the intervention.7 Van Winkle et al.8 evaluated the effect of a theatrical performance on the challenges of aging on pharmacy and medical student empathy utilizing the JSEHPS. They found higher empathy ratings immediately after the workshop but the effects were not sustained after participation in the workshop.8 Chen et al.9 evaluated the impact of a patient empathy modeling assignment for 10 days in which advanced pharmacy practice experience students “became the patient.” The authors found an increase in student empathy as measured by the Jefferson Scale of Physician Empathy.9 Lastly, Manolakis et al.6 found an increase in pharmacy student empathy as a result of a module on death and dying that incorporated media as measured by the Balanced Emotional Empathy Scale (BEES). Based on these data, it appears that empathy can increase as a result of a variety of pedagogical techniques. Perhaps there is no patient population in greater need of an empathetic health care provider than those with mental illness. According to National Survey on Drug Use and Health (NSDUH), in 2013, there were an estimated 10 million adults aged 18 years or older in the United States. with Serious Mental Illness (SMI) in the past year, which represented 4.2% of all U.S. adults.10 Since pharmacists are consistently rated as some of the most accessible and trusted health care professionals, they would inevitably encounter patients with SMI, and it is critical that they feel comfortable providing care to those patients.11 A 2012 survey of patients taking mental health medications conducted by the College of Psychiatric and Neurologic Pharmacists (CPNP) along with the National Alliance on Mental Illness (NAMI) found 91% of patients felt very comfortable going to community pharmacies and 83% reported feeling respected by their pharmacist.12 However, 43% reported that they did not have a strong professional relationship with
their pharmacist and 75% reported that they did not receive effectiveness or safety monitoring assistance from their pharmacist.12 Rickles et al.13 surveyed community pharmacists regarding their attitudes toward patients with depression and schizophrenia and found generally more negative attitudes toward patients with schizophrenia than depression. Alternatively, Cates et al.14 found generally positive attitudes among pharmacists toward patients with mental illness and providing care to those patients. Because of the prevalence of SMI and the accessibility of pharmacists, it is important that pharmacy students be taught not only about mental illnesses and their treatment but also how to empathize with this patient population. There have also been several investigations into pedagogical techniques and their impact specifically on stigma and attitudes toward patients with mental illness. Bell et al.15 compared the Social Distance Scale (SDS) and items regarding stigmatization for third-year pharmacy students prior to any lectures on mental illness with pharmacy graduates who were attending a seminar in Sydney, Australia. They found no difference in the scores on the SDS and the items related to mental health stigma. Contactbased education that incorporates patients with mental illness has been found to decrease social distance and stigma.16–19 Likewise, elective courses in psychiatry have been found to have a favorable impact on social distance, stigma, and attitudes related to psychiatry.20–22 The purpose of the current study was to evaluate and measure the impact of traditional large classroom lecture on pharmacy student empathy compared to a smaller elective course which utilized contact-based education, media, and an auditory hallucination simulator. The stated hypothesis is that the elective with its pedagogical techniques would increase pharmacy student empathy toward patients with mental illness more than traditional lecture on mental illness. Methods This study utilized the Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS). The JSEHPS is a 20-item survey utilizing a seven point Likert scale from 1 (“strongly disagree”) to 7 (“strongly agree”). The original Jefferson scale was developed to be used in the physician population but was modified to be applicable to other health care professionals as well as health care professional students.1,23 The scaleʼs psychometric properties remained at acceptable levels with the modifications with a reported coefficient alpha of 0.81 and a test–retest reliability of 0.65.1 The JSE-HPS was demonstrated to be both valid and reliable for measuring empathy in pharmacy students, with results similar to those found previously in physicians and medical students.24 Participation in the present study was both voluntary and anonymous. The survey was offered to third-year pharmacy students at Belmont University College of Pharmacy, a private, faith-based university in the southeastern
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United States. The Universityʼs Institutional Review Board approved the study prior to implementation. Students were asked to think about patients with mental illness when completing the survey. The class was invited to participate in the survey at the beginning of their third year and at the end of the fall semester of the same year. A subset of the class was invited to participate in the survey a third time if they completed an Advanced Psychiatry elective in the spring semester of their third year. An electronic version of the survey was utilized for all three administrations of the survey. As part of the third-year curriculum, all students complete approximately 21 hours of neuropsychiatry topics in the Pathophysiology/Therapeutics III course that utilizes didactic lecture as well as case-based learning in a corequisite course (Case Studies I). The first administration of the JSE-HPS was offered to all students (N ¼ 68) in the didactic lecture class prior to the presentation of these topics by the college faculty primarily responsible for those disease areas. Topics included epilepsy, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, attention-deficit hyperactivity disorder, and substance use disorders. In addition, students were asked if they had enrolled in the Advanced Psychiatry elective course. The elective course, Advanced Psychiatry, was offered to students in the spring semester of their third year. The elective course utilized a variety of techniques including traditional lecture, contact-based education with patients, media such as movies and patient videos, a hallucination simulator, and reflective writing. The contact-based education included a traditional lecture on the topic and a patient suffering from that mental illness. The patient discussed his/her personal experience with the symptoms, treatment, as well as stigma they may have experienced. One patient had experienced eating disorders and the other had experienced depression. Media was employed at multiple points in the course. Students viewed and critiqued A Beautiful Mind, which tells the story of John Nash, a Nobel Prize winning mathematician, who suffered from schizophrenia.25 The class viewed and critiqued the movie and the accuracy of the portrayal of a patient with schizophrenia. Additional media included patient testimonials or videos that displayed symptoms of Touretteʼs syndrome, conversion disorder, autism spectrum disorder, and depression. The course also incorporated an auditory hallucination simulator.26 The hallucination simulator was utilized to simulate what patients who have auditory hallucinations experience. While listening to the hallucinations, the students completed multiple activities including a word find, number find, job application, and a modified mental status examination which was conducted by one of the course faculty. The students utilized personal headphones and adjusted the volume to a comfortable level. Course topics and assessments are summarized in Table 1. Statistical analyses were conducted using IBMs SPSSs Statistics, version 21. Independent samples t-tests were
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used to compare the mean empathy scores between the groups. Comparisons were made between before and after the traditional lecture and before and after the elective. Comparisons were also made between groups before traditional lecture and after the elective. In all analyses, the type I error rate was maintained at 0.05. Results The survey was completed by 41/68 students prior to traditional lecture for an initial response rate of 60%. At the conclusion of the traditional lecture the response rate decreased to 43% or 29/68. At the end of the advanced psychiatry course, 14 of the 16 (88%) enrolled students completed the survey. Empathy scores were calculated as recommended in the Jefferson Scale of Empathy scoring algorithm. Ten items in the JSE-HPS are negative statements and responses to these items were reversed for scoring. Scores ranged from 20 to 140, with higher scores being indicative of greater empathy. Demographic variables were also collected including age, gender, family history of mental illness, and experience working in a mental health institution. Baseline demographics, family history, and experience working in a mental health institution are included in Table 2. Independent samples t-tests were performed to determine if there were differences between those who completed the survey before and after the traditional lecture. While there was a positive trend in empathy scores, the difference in mean JSE-HPS scores pre- (109.32) vs. post-lecture (112.86) was not significant (p ¼ 0.162). However, when comparing post-lecture (112.86) with post-elective (120.00), there was a statistically significant increase in mean JSEHPS scores (p ¼ 0.025). Additionally, when comparing prelecture (109.32) with post-elective scores (120.00), there was also a statistically significant increase in mean JSE-HPS scores (p ¼ 0.001). There was no statistically significant difference when comparing the pre-elective cohort (n ¼ 12) with the post-elective (n ¼ 14) cohort on mean JSE-HPS scores (113.00 vs. 120.00, respectively; p ¼ 0.115). There was no significant difference in mean JSE-HPS score change for those with a close relative with mental illness and those without (p ¼ 0.08) or in those who had worked in mental health institution (p ¼ 0.61). Empathy scores for those students who had completed an IPPE at a mental health institution (n ¼ 2) decreased at the conclusion of the psychiatry elective (107.50, Cohenʼs d ¼ 2.81) (Table 3). Discussion The students who participated in this study displayed a greater increase in empathy scores in the psychiatry elective course than with traditional lecture. This is the first study to specifically evaluate the possible impact of a psychiatry elective course on pharmacy student empathy toward
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Table 1 Course description and assessments for Advanced Psychiatry elective Topic
Class description
Assessment(s)
Course introduction and history of psychiatry
In-class lecture which reviewed the history of psychiatric treatment including the asylum era and deinstitutionalization as well as the mental status examination with video clips In-class viewing and discussion of “A beautiful mind”25
Multiple choice questions on midterm/ final exams
Schizophrenia in film
Auditory hallucination simulator Personality disorders
Bipolar disorder
Eating disorders
Midterm exam Autism spectrum Disorders “The quiet room” Pediatric bipolar disorder
Students individually participated in auditory hallucination simulator exercise for approximately 45 minutes; exercise included activities that were completed while listening to the “hallucinations” “Flipped classroom” approach in which students reviewed a recorded lecture which discussed the diagnosis of personality disorders and treatment options; during class a variety of movie depictions of personality disorders was shown and students had to identify the personality disorder Student groups presented the case of a famous person they researched who was purportedly diagnosed with Bipolar Disorder
Guided reflection article Multiple choice questions on midterm/ final exams Brief guided reflection article
In-class assessment identifying personality disorders depicted in movie clips Multiple choice questions on midterm/ final exams Group presentation Multiple choice questions on midterm/ final exams In-class lecture which reviewed diagnosis and treatment; “patient” with Patient Case eating disorder shared personal story Multiple choice questions on midterm/ final exams
“Flipped classroom” approach in which Students reviewed recorded lecture which discussed diagnosis and treatment; in-class discussion of autism Students individually read “The quiet room” by Lori Schiller and wrote a reflective article27 In-class lecture which reviewed diagnosis and treatment
Patient case Multiple choice questions on final exam Guided reflection article
Multiple choice questions on exam Impulse control disorders In-class lecture which reviewed diagnosis and treatment Multiple choice questions on exam Miscellaneous psychiatric In-class lecture which reviewed Touretteʼs Syndrome, malingering, Multiple choice questions on disorders factitious disorders, somatic symptom disorders; lecture incorporated a exam variety of patient videos Major depressive disorder In-class lecture which reviewed alternatives to medication for the Brief guided reflection based and alternative treatment of major depressive disorder including electroconvulsive “patient” testimonial treatments therapy (ECT), transcranial magnetic stimulation (TMS), bright light Multiple choice questions on therapy, ketamine and others; TMS and ECT videos were shown; exam “patient” shared personal experience with depression in herself and in family member who committed suicide Field trip Toured a psychiatric hospital, discussed patient flow into/out of mental None health hospital and barriers to treatment Final exam
patients with mental illness. Additionally, this is the first study to directly evaluate the impact on empathy of a psychiatry elective vs. traditional lecture and case-based learning led by the same instructor. While a causal relationship cannot be established between the increase in empathy scores and the pedagogical teaching methods employed in the psychiatry elective, there is reason to believe that this is the case. The current research is consistent with previous investigations which have found that psychiatry elective courses and contact-based education positively impact pharmacy
final final final
on Final
student attitudes, social distance, and stigma regarding patients with mental illness and are also more effective than traditional lecture.15–18,20–22 These findings enhance the literature through the incorporation of a validated empathy rating scale as well as the comparison of a psychiatry elective directly with traditional lecture in the same cohort of students. Prior research in this area has predominantly included scales that evaluate pharmacy student stigma or social distance. Stigma can be defined as “an attribute that is deeply discrediting and that reduces the bearer from a whole and usual person to a tainted,
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Table 2 Demographics Pre-lecture n ¼ 41 (60%)
Post-lecture n ¼ 31 (46%)
Age 19–21 22–24 25–27 28–30 31–33 433
1 19 10 7 3 1
1 12 8 5 3 2
Gender Male Female
21 (51%) 20 (49%)
(2%) (46%) (24%) (17%) (7%) (2%)
Family member with mental illness Yes 16 (39%) Father 1 (6%) Mother 5 (31%) Sibling 4 (25%) Grandparent 7 (44%) Aunt/uncle 6 (38%) Cousin 2 (13%) No 25 (61%)
Pre-elective n ¼ 13 (81%)
Post-elective n ¼ 14 (88%)
(3%) (39%) (26%) (16%) (10%) (6%)
1 (8%) 7 (54%) 2 (15%) 2 (15%) 1 (8%) 0
1 (7%) 5 (36%) 4 (29%) 3 (21%) 1 (7%) 0
12 (39%) 19 (61%)
4 (31%) 9 (69%)
4 (29%) 10 (71%)
17 3 8 7 3 4 7 16
8 2 5 4 2 3 4 5
10 2 6 6 3 4 2 4
(55%) (18%) (47%) (41%) (18%) (24%) (41%) (52%)
(62%) (25%) (63%) (50%) (25%) (38%) (50%) (38%)
(71%) (14%) (43%) (43%) (21%) (29%) (14%) (29%)
Completed an introductory practice experience (IPPE) in a mental health institution Yes 3 (7%) 1 (3%) No 38 (93%) 30 (97%)
1 (8%) 12 (92%)
2 (14%) 12 (86%)
Worked at a mental health institution Yes 2 (5%) No 39 (95%)
2 (15%) 11 (85%)
0 14 (100%)
2 (6%) 29 (94%)
discounted one,” while social distance is an assessment of an individualʼs willingness to participate in personal relationships with a stigmatized group.16,17 Empathy is a different cognitive and emotional concept than social distance or stigma, and thus was assessed with a specific empathy rating scale.24 It has been proposed that feelings of empathy toward a stigmatized group can improve attitudes toward that group, thus, empathy may affect both stigma and social distance.28 Limitations of the current study include the small sample size. Overall, 68 students were invited to complete the survey before and after traditional lecture. A total of 60% and 43% completed the survey before and after
traditional lecture, respectively. Overall, 16 students enrolled in the psychiatry elective course and 88% of the students completed the survey at the conclusion of the course. While positive change was observed pre- and post-elective, it failed to be statistically significant. This could be due to the small number of students enrolled in the elective thus not providing adequate statistical power. In addition, it is possible that self-selection bias impacted the results of the study in that the students who chose to enroll in the Advanced Psychiatry elective may have been inherently more empathic toward patients with mental illness to begin with. This is evidenced by the fact that 71% of those who enrolled in the course had a
Table 3 Mean Jefferson Scale of Empathy Health Professions Student Version (JSE-HPS) scores and group comparisons
Mean JSE-HPS scores and group comparisons a
Significant at p o 0.05.
Pre-lecture n ¼ 41
Post-lecture n ¼ 29
Pre-elective n ¼ 12
Post-elective n ¼ 14
109.32
112.86 (p ¼ 0.162 vs. pre-lecture)
113.00
120.00 (p ¼ 0.001a vs. pre-lecture; p ¼ 0.025a vs. post-lecture; p ¼ 0.115 vs. pre-elective)
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close family member with mental illness. However, mean empathy scores for those who were enrolled in the elective course at baseline (113.00) were not significantly different from those who did not enroll in the course (112.86). A surprising finding, which warrants further study, was that empathy scores decreased (i.e., less empathy) for those students who completed an introductory practice experience (IPPE) at a mental health institution. There were, however, only two students in this group, so this finding may be due to chance. Students on IPPEs spend an extended period of time over a semester being exposed to pharmacy practice in various settings that may include a mental health institution. It was expected that students who had an IPPE at a mental health institution would have higher empathy ratings since direct patient contact has been associated with improvements in attitudes regarding patients with mental illness.16–19 However, Cates29 recently reported that an advanced pharmacy practice experience in psychiatry did not improve social distance, stigmatizing attitudes, or attitudes toward mental illness. Our finding in a very small subset of students warrants further research to determine the impact of early and advanced pharmacy practice experience on pharmacy student empathy toward patients with mental illness. Additional areas for research include a comparison of pharmacy students with other graduate students. As has been discussed previously, general empathy ratings have been found to be higher in health vs. non-health profession students.5 It would, therefore, be of interest to explore differences in empathy among health professional students in fields such as pharmacy, nursing, medicine, and clinical social work. Ideally, the assessment of the pedagogical techniques should be assessed over the course of multiple years to determine if the pedagogical techniques are truly responsible for the increase in student empathy. This may be difficult to assess, however, as the student population changes and there are subtle differences in courses from semester to semester that are difficult to control. An assessment of the long-term impact of the Advanced Psychiatry elective should also be conducted. Data has largely shown that educational interventions may increase empathy immediately but the effect has not been sustained.7,8 In conclusion, the teaching methods employed in the psychiatry elective course which included media, contact-based education, and an auditory hallucination simulator lead to an increase in pharmacy student empathy toward patients with mental illness. Conflict of interest McGuire is the speakers bureau for Sunovion Pharmaceuticals and Forest Pharmaceuticals. Consultant for Otsuka America Pharmaceuticals Inc. Stock holder in Bristol Myers Squibb; Bynum and Wright has no financial disclosure ti disclose.
References 1. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry. 2002;159(9):1563–1569. 2. Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004;27(3):237–251. 3. Stepien KA, Baernstein A. Educating for empathy. A review. J Gen Intern Med. 2006;21(5):524–530. 4. Roter DL, Hall JA, Merisca R, Nordstrom B, Cretin D, Svarstad B. Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care. 1998;36(8): 1138–1161. 5. Wilson SE, Prescott J, Becket G. Empathy levels in first- and third-year students in health and non-health disciplines. Am J Pharm Educ. 2012;76(2): Article 24. 6. Manolakis ML, Olin JL, Thornton PL, Dolder CR, Hanrahan C. A module on death and dying to develop empathy in student pharmacists. Am J Pharm Educ. 2011;75(4): Article 71. 7. Lor KB, Truong JT, Ip EJ, Barnett MJ. A randomized prospective study on outcomes of an empathy intervention among second-year student pharmacists. Am J Pharm Educ. 2015;79(2): Article 18. 8. Van Winkle LJ, Fjortoft N, Hojat M. Impact of a workshop about aging on the empathy scores of pharmacy and medical students. Am J Pharm Educ. 2012;76(1): Article 9. 9. Chen JT, LaLopa J, Dang DK. Impact of patient empathy modeling on pharmacy students caring for the underserved. Am J Pharm Educ. 2008;72(2): Article 40. 10. Substance Abuse and Mental Health Services Administration. Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings 2014. Available at: 〈http://store.samhsa.gov/shin/con tent//NSDUH14-0904/NSDUH14-0904.pdf〉. Accessed May 1, 2016. 11. Lonie JM. From counting and pouring to caring: the empathic developmental process of community pharmacists. Res Social Adm Pharm. 2006;2(4):439–457. 12. Caley CF, Stimmel GL. Characterizing the Relationship Between Individuals with Mental Health Conditions and Community Pharmacists: Results from a 2012 Survey. Available at: 〈https://cpnpf.org/top-initiatives〉. Accessed May 1, 2016. 13. Rickles NM, Dube GL, McCarter A, Olshan JS. Relationship between attitudes toward mental illness and provision of pharmacy services. J Am Pharm Assoc. 2010;50(6):704–713. 14. Cates ME, Burton AR, Woolley TW. Attitudes of pharmacists toward mental illness and providing pharmaceutical care to the mentally ill. Ann Pharmacother. 2005;39(9):1450–1455. 15. Bell JS, Johns R, Chen TF. Pharmacy studentsʼ and graduatesʼ attitudes towards people with schizophrenia and severe depression. Am J Pharm Educ. 2006;70(4): Article 77. 16. Patten SB, Remillard A, Phillips L, et al. Effectiveness of contact-based education for reducing mental illness-related stigma in pharmacy students. BMC Med Educ. 2012;12:120. 17. Buhler AV, Karimi RM. Peer-level patient presenters decrease pharmacy studentsʼ social distance from patients with schizophrenia and clinical depression. Am J Pharm Educ. 2008;72(5): Article 106.
J.M. McGuire et al. / Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]] 18. OʼReilly CL, Bell JS, Chen TF. Consumer-led mental health education for pharmacy students. Am J Pharm Educ. 2010;74 (9): Article 167. 19. Bell JS, Johns R, Rose G, Chen TF. A comparative study of consumer participation in mental health pharmacy education. Ann Pharmacother. 2006;40(10):1759–1765. 20. Dipaula BA, Qian J, Mehdizadegan N, Simoni-Wastila L. An elective psychiatric course to reduce pharmacy studentsʼ social distance toward people with severe mental illness. Am J Pharm Educ. 2011;75(4): Article 72. 21. Gable KN, Muhlstadt KL, Celio MA. A mental health elective to improve pharmacy studentsʼ perspectives on mental illness. Am J Pharm Educ.. 2011;75(2): Article 34. 22. Einat H, George A. Positive attitude change toward psychiatry in pharmacy students following an active learning psychopharmacology course. Acad Psychiatry. 2008;32(6):515–517. 23. Hojat M, Mangione S, Nasca TJ, et al. The jefferson scale of physician empathy: development and preliminary psychometric data. Educ Psychol Meas. 2001;61(2):349–365.
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24. Fjortoft N, Van Winkle LJ, Hojat M. Measuring empathy in pharmacy students. Am J Pharm Educ. 2011;75(6): Article 109. 25. Grazer B, Howard R. (Producers), Howard R (Director). A Beautiful Mind; 2001. 26. Deegan P. Hearing Distressing Voices Toolkit. Available at: 〈https://www.patdeegan.com/pat-deegan/training/hearing-voi ces-training〉. Accessed May 1, 2016. 27. Schiller L, Bennett A. The Quiet Room. New York, NY: Grand Central Publishing; 2011. 28. Batson CD, Polycarpou MP, Harmon-Jones E, et al. Empathy and attitudes: can feeling for a member of a stigmatized group improve feelings toward the group? J Pers Soc Psychol. 1997;72(1):105–118. 29. Cates ME. Pharmacy Studentsʼ Attitudes Toward Mental Illness are Unaffected by Participation in a Psychiatric Pharmacy Advanced Pharmacy Practice Experience. Poster presented at: College of Psychiatric and Neurologic Pharmacists Annual Meeting, Tampa, FL; April 2015.