Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
This article was downloaded by: [Jude Fabiano]On: 02 March 2015, At: 12:48Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Click for updates
Gerontology & Geriatrics EducationPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wgge20
Empathy in Dentistry: How Attitudes andInteraction With Older Adults Make aDifferenceDeborah Waldropa, Thomas Nochajskia, Elaine L. Davisb, JudeFabianoc & Louis Goldbergb
a School of Social Work, University at Buffalo, Buffalo, New York,USAb School of Dental Medicine, University at Buffalo, Buffalo, NewYork, USAc Ivoclar Vivodent, Amherst, New York, USAAccepted author version posted online: 13 Dec 2014.Publishedonline: 13 Dec 2014.
To cite this article: Deborah Waldrop, Thomas Nochajski, Elaine L. Davis, Jude Fabiano & LouisGoldberg (2014): Empathy in Dentistry: How Attitudes and Interaction With Older Adults Make aDifference, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2014.993065
To link to this article: http://dx.doi.org/10.1080/02701960.2014.993065
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.
This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
Gerontology & Geriatrics Education, 00:1–22, 2015Copyright © Taylor & Francis Group, LLCISSN: 0270-1960 print/1545-3847 onlineDOI: 10.1080/02701960.2014.993065
Empathy in Dentistry: How Attitudesand Interaction With Older Adults Make
a Difference
DEBORAH WALDROP and THOMAS NOCHAJSKISchool of Social Work, University at Buffalo, Buffalo, New York, USA
ELAINE L. DAVISSchool of Dental Medicine, University at Buffalo, Buffalo, New York, USA
JUDE FABIANOIvoclar Vivodent, Amherst, New York, USA
LOUIS GOLDBERGSchool of Dental Medicine, University at Buffalo, Buffalo, New York, USA
The development of empathy and positive attitudes are essential ele-ments of professional education. This study explored the nature ofempathy and its association with attitudes about, and exposure toolder patients in a sample of dental students. Students completedan adapted version of the Jefferson Scale of Physician Empathy(JSPE), the Aging Semantic Differential (ASD) and answered ques-tions about their exposure to older people. Factor analysis was usedto identify four factors: (1) Empathy is Valuable, (2) Empathy isDemonstrated, (3) Empathy is not Influential, and (4) Empathyis Difficult to Accomplish. Higher empathy scores were related tothe ASD subscale attitude of acceptability of aging and to greaterexposure to older adults outside of clinical practice. There were nodemographic predictors of higher empathy scores.
KEYWORDS dental education, geriatric dentistry, empathy,attitudes, older adults
Address correspondence to Deborah Waldrop, LMSW, PhD, School of Social Work,University at Buffalo, 685 Baldy Hall, Buffalo, NY 14260, USA. E-mail: [email protected]
1
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
2 D. Waldrop et al.
INTRODUCTION
Oral health is a key element of geriatric care. The American Society forGeriatric Dentistry, the Education Research Group of the InternationalAssociation for Dental Research, and the American Association for DentalResearch have been committed to improving oral health in older adultsthrough education and skill development (American Society for GeriatricDentistry, 2010; Dolan, Atchison, & Huynh, 2005). The development of aworkforce of dentists with knowledge about and skills for working witholder adults would be enhanced by interdisciplinary and interprofessionaleducation (Best, 2010).
For purposes of this article, the term older adults refers to individu-als age 65 or older. Older adults experience greater numbers of coexistentchronic conditions and higher levels of health care utilization, including den-tistry, than people younger than age 65 (Chalmers & Ettinger, 2008; Ettinger,2007; Ferguson, Steinberg, & Schwien, 2010). In most general dental prac-tices, older adults account for the largest number of visits and procedures(Ferguson et al., 2010). Many authors have asserted that geriatric dentistryrequires special knowledge and clinical skills to treat dental conditions thatoccur in older adults, recognize the important connection between oral andsystemic health to maintain optimal oral health and quality of life (Chapple,2009; Frisbee, Chambers, Frisbee, Goodwill, & Crout, 2010; Sheets, Paquette,& Wu, 2009). Good care is enhanced by a humanistic approach, a warm rela-tionship and sensitivity toward the patient’s systemic health and psychosocialconcerns (Scully & Ettinger, 2007). The core values that define profession-alism in dentistry have been identified as competence, fairness, integrity,responsibility, respect, and service mindedness (American Dental EducationAssociation [ADEA], 2013). Service mindedness is defined as compassionatecare for the benefit of individual patients and the public at large. Servicemindedness encompasses the obligation to benefit others, compassion, andempathy. Empathic care requires the ability to understand and appreci-ate another person’s perspectives without losing sight of one’s professionalresponsibilities (ADEA, 2013).
Empathy is particularly germane to quality care for older people and hasbeen linked to positive clinical outcomes (Hojat et al., 2011). However, thespecific features or defining characteristics of empathy may vary across pro-fessional disciplines within health care. Although the impact of empathy hasbeen linked to positive outcomes, the defining characteristics of empathy indentists are largely unknown (Satterfield & Hughes, 2007; Sutherland, 1993).Preparing student dentists with knowledge of, positive attitudes about, andempathy for the growing population of older dental patients is an impor-tant element of education for an aging-prepared health care workforce. Thetwofold purpose of this study was to describe the nature of empathy in
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
Nature of Empathy 3
dental students and to investigate how attitudes about and exposure to olderadults influence students’ empathy for older patients.
LITERATURE REVIEW
Health-Related Quality of Life in Older Adults
There is evidence that current older patients are better educated, more polit-ically aware, and have more remaining teeth than in previous generationsof older patients (Federal Interagency Forum on Aging-Related Statistics,2012). However, the older population is not homogenous. Older peoplewho have lower incomes have poorer oral health and more limited accessto services (Tsakos, 2011). Frail and functionally dependent older adults alsoexperience barriers to receiving oral health care (Ettinger, 2010). Systemicdiseases that have an impact on oral health are more common in later lifeand should be an important factor in dental care for all older adults (Scully &Ettinger, 2007; Sheets et al., 2009). There are over 100 systemic diseases thathave oral manifestations, including cardiovascular disease, stroke, respiratoryinfections, pancreatic cancer, diabetes, and nutritional problems (Haumschild& Haumschild, 2009). This interaction of oral and systemic diseases can havea cascade effect on well-being in later life.
It is important for dental professionals to understand the special needsof older people and their ability to undergo and respond to care, estab-lish communication with primary care physicians and be able to manageemergencies (Vieira & Caramelli, 2009). Communication and understandingbetween health care providers and their patients has received increasingattention in dentistry and dental education (Sherman & Cramer, 2005).Dentists’ caring attributes, such as gentleness and friendliness, have beenfound to be valued by patients as much as their professional competence(Gerbert, Bleecker, & Saub, 1994; Nash, 2010; Small, 2005).
The relatively poor oral health status of older people who have coex-isting chronic conditions underscores the urgency for dentists to be able tocare for these underserved subgroups (Baumeister et al., 2007). Yet geriatricdentistry in the United States is still widely conceived of as simply involvingdentures for patients in nursing homes (Ettinger, 2010). The lack of Medicareand other insurance coverage for older adults’ dental services limits accessto care and contributes to complicating comorbid physical and psychoso-cial conditions in people who are frail, functionally dependent, cognitivelyimpaired, or terminally ill (Griffin, Barker, Griffin, Cleveland, & Kohn, 2009;Kiyak & Reichmuth, 2005; Scully & Ettinger, 2007). Moreover, provider reim-bursement for dental services is directly related to one’s state of residenceand is often poor or nonexistent (Ettinger, 2010; Ferguson et al., 2010).Financial barriers to good oral health care can have a negative impact onhealth-related quality of life.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
4 D. Waldrop et al.
Empathy
Understanding another person’s discomfort is essential to providing qual-ity care (Winland, 2006). Empathy is necessary for effective communicationbetween patients and providers to achieve optimal clinical outcomes.Empathy has been defined as a “predominantly cognitive attribute thatinvolves an understanding of patients’ experiences, concerns and perspec-tives combined with a capacity to communicate this understanding and anintention to help” (Hojat, 2007, 2009; Hojat et al., 2009, p. 1183). Hojat et al.(2002) developed a measure of empathy that provides the opportunity toexplore educational and clinical correlates as well as whether the level ortype of empathy differs across the stages of medical education. Higher empa-thy scores have been positively associated with clinical competence and bet-ter patient outcomes in physicians (Hojat et al., 2011). The Jefferson Scale ofPhysician Empathy (JSPE; Health Professionals [HP] version) was developedto assess the development of empathy in other health care professionals(Hojat, 2007). The questions on the JSPE and JSPE-HP are the same withminor wording changes to make the JSPE-HP more generic (Hojat, 2007).
The nature of empathy has been studied extensively in medical stu-dents but less so in dental students (Hojat et al., 2001). Sherman and Cramer(2005), using the JSPE-HP, found that the psychometric properties of empathyin a sample of dental students were comparable to those found in medicalstudents (Sherman & Cramer, 2005). Four factors emerged: (1) perspec-tive taking, (2) compassionate care, (3) standing in the patients’ shoes, and(4) efforts to ignore emotions in patient care. The questions associated witheach factor can be found in Sherman & Cramer, 2005. This article presentsthe results of an analysis of the nature of empathy in dental students and itsassociation with attitudes about and exposure to older adults.
METHOD
Project Overview and Study Design
The overall project is a large-scale longitudinal interdisciplinary effort thataimed to provide dental students with aging-enhanced education that willprepare them for effective practice with growing numbers of older people.Initially, we explored dental students’ knowledge about aging and found thatthough information is readily consumed by dental students, positive attitudesare not as easily taught (Fabiano, Waldrop, Nochajski, Davis & Goldberg,2005; Waldrop, Fabiano, Nochajski, Zittel-Palamara, Davis & Goldberg, 2006).Subsequently, we explored the association between attitudes about andexposure to older adults and learned that attitudes are significantly influ-enced by the amount of exposure to older people (Nochajski, Waldrop,Davis, Fabiano & Goldberg, 2011). However, attitudes and knowledge mayonly partially contribute to the development of a caring professional.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
Nature of Empathy 5
The study aimed to answer three research questions: (1) What are thecharacteristics of empathy in dental students? (2) Do levels of empathy varyby gender and age? and (3) What is the association between students’ atti-tudes about, exposure to, and empathy for older patients. We hypothesizedthat empathy would vary by gender and be positively associated with age.We also hypothesized that students’ attitudes about and exposure to olderadults positively influence their empathy for their older patients. The resultspresented in this article are cross-sectional.
Setting
The University at Buffalo, School of Dental Medicine (SDM) admits approx-imately 90 new dental students into its 4-year program each year. The SDMClinic is a major source of outpatient care for people who are disabled orhave medically complex conditions. Of the approximately 46,600 visits peryear, 72% are made by people age 50 years e or older (62% of the clinicpopulation). Dental students begin to see patients in the campus-based clinicduring the 2nd year, and their exposure intensifies in the 3rd and 4th year.
Sample Recruitment
The sampling strategy was purposeful; each student in all 4 years of dentalschool was invited to participate. Participation was voluntary. The study wasdescribed during required classes for students in each year of the program,and class time was given for completion of the instrument. For the academicyear of this study, there were a total of 344 students who had started theprogram: N = 81 in the 4th year, 71 completed the survey (87.7%); N = 87 inthe 3rd year of the program, 61 completed the survey (70.1%); N = 88 in the2nd year of the program, 81 completed the survey (92.1%); and N = 86 inthe 1st year of the program and 100% completed the survey. A total of 299(86.9%) completed the survey. The study was approved by the Universityat Buffalo Social and Behavioral Sciences Institutional Review Board. Studyparticipation was completely voluntary. A written informed consent was nutused. Completion of the survey document was assumed to imply consent.
Sample Demographics
The sample included 292 students. The Mean age was M = 26.3 (SD =4.2 years) with an age range from 19 to 42 and 55.5% were younger thanage 26. The sample included n = 169 men (56.5%). Nine percent said theirparents were age 65 or older, 63.5% indicated that their grandparents wereage 65 or older, and 30.8% said they had other relatives who were in thisage group.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
6 D. Waldrop et al.
Instrumentation
The survey instrument had four sections: (1) Questions About You (demo-graphics), (2) The Aging Semantic Differential (attitudes), (3) The JeffersonScale of Physician Empathy (empathy), and (4) Frequency of Interactionswith Older Adults.
QUESTIONS ABOUT YOU
Students were asked for their age, year in dental school, gender, and maritalstatus.
AGING SEMANTIC DIFFERENTIAL
The Aging Semantic Differential (ASD) involves 32 pairs of items (Rosencranz& McNevin, 1969). Items consist of bipolar adjective pairs that are oppo-site in meaning, and participants respond on a scale of 1 to 7 betweenthe adjectives. The summary scale score ranges from 32 to 224, with lowerscores reflecting more positive attitudes. There are four subscales: PersonalAutonomy-Dependence, Instrumental-Ineffective, Personal Acceptability-Unacceptability, and Integrity. Positive scores reflect attitudes that olderadults are independent, effective, acceptable, and have integrity. Subsequentconfirmatory factor analysis has been conducted by Intriere, von Eye, andKelly (1995). The instrument has been used with a number of differentgroups and, when submitted to factor analysis, demonstrates different fac-tor structures with different groups (e.g., medical students, undergraduatestudents). The ASD has been shown to demonstrate high internal reliability(Cronbach’s alpha .89) (Intrieri et al., 1995; Varkey, Chutka, & Lesnick, 2006).
THE JEFFERSON SCALE OF PHYSICIAN EMPATHY
The Jefferson Scale of Physician Empathy (JSPE) is a 20-item instrument thatuses a 7-point Likert-type scale and was developed to measure health careproviders’ level of empathy for their patients (Hojat et al., 2001). Scoresranged from 20 to 140, with higher scores reflecting a more empathic behav-ioral orientation. The JSPE has been shown to demonstrate a high level ofinternal reliability (Cronbach’s alpha = .90). For our purposes, the JSPE wasamended to use dental instead of medical and dentist instead of doctor.
INTERACTIONS WITH OLDER ADULTS
This section involved five multiple choice questions about students’ fre-quency, context, and type of interactions with older adults, outside of the
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
Nature of Empathy 7
dental clinic as well as their interactions with older adults in the clinical set-ting. The “frequency” questions asked students to estimate how often outsideof the clinic they interact with people who are older than age 65 (more thanonce a day, daily, a few times a week, a few times a month, rarely, never).The “context” question asked students to indicate with whom they interactwho is older than age 65 (parents, grandparents, other relatives, neighbors,friends, others) by choosing all that apply. The “type” question asked stu-dents to check all types of interactions they have with older adults outside ofthe clinic (assist with chores, transportation, live with, caregiving, assist withpersonal care, attend religious services, at holidays only, and other).
Analysis
Survey results were entered into SPSS (version 22) for data managementand analysis, which took place in stages. First, descriptive statistics werecompiled. Next, to answer the first research question, maximum likelihoodextraction was used to assess the factor structure of empathy in studentdentists. Maximum likelihood extraction was also used to answer the sec-ond research question and to explore the association between empathy anddemographic characteristics. A series of multiple regression analyses wereused to answer the third research question and to explore the relationshipbetween empathy and students’ attitudes toward older adults and the con-text and type of older adults with whom the students had contact outsidethe clinic.
Bivariate analyses were used to compare the relationship between classand scores for the total empathy scale. ANOVA with Bonferroni adjustmentswas used to compare the responses of each class on the factors. Age wasrecoded into two categories, younger than 26 and 26 or older. Bivariateanalyses for the age categories and gender were conducted using indepen-dent sample t tests. Correlations shown in Table 3 were standard Pearsoncorrelations, as the measures were all continuous in nature.
Multiple regression analyses were conducted using the JSPE total scoreand the four factors as dependent measures in separate analyses to determineif the influence of outside contacts with older people was more stronglyassociated with empathy than it was for attitudes. . In all multiple regres-sion analyses, listwise deletion was used, resulting in a sample of 292 ofthe original 299 individuals in the sample. The losses in the sample wereevenly distributed across the four classes. Entry was simultaneous, as wewere interested in looking at unique contributions to the prediction of thedependent measure. Collinearity was assessed using tolerance and varianceinflation factors (VIF). There were no collinearity issues in any of the analy-ses as all tolerance (<.2) and VIF (>5) indicators were not within the cautionareas.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
8 D. Waldrop et al.
RESULTS
The Factor Structure of Empathy in Dental Students
Initially, all 20 JSPE items were used, and four factors were identified usingthe scree plot and Eigen values of greater than one as a means for factoridentification. However, four items did not load above .40 and were droppedfrom further analysis. A four-factor structure of empathy in dental studentsemerged which accounted for 63.7% of the total variance. The factors were(1) Empathy Is Valuable, (2) Empathy Is Demonstrated, (3) Empathy Is notInfluential, and (4) Empathy Is Difficult to Accomplish. Table 1 presents thefactor loadings.
● Empathy Is Valuable (Factor 1) had an initial Eigen value of 5.98, and fiveitems accounted for 37% of the overall variance in the scale. Empathy isconsidered a therapeutic element of the helping relationship.
● Empathy Is Demonstrated (Factor 2) had an initial Eigen value of 1.93, andthree items accounted for approximately 12% of additional variance in theoverall scale. Empathy encompasses behavioral elements to show caringfor a patient.
● Empathy Is not Influential (Factor 3) had an initial Eigen value of 1.27,and six items accounted for approximately 8% of the variance in the over-all scale. Understanding of or attentiveness to patients’ concerns has nobearing on treatment outcomes.
● Empathy Is Difficult to Accomplish (Factor 4) had an Eigen value of 1.02,and two items accounted for an additional 6% of the overall scale variance.Understanding a patient’s experience is challenging.
There were no differences between classes in gender or age. Therewere no significant differences in empathy scores by age. Females weresignificantly higher on the overall empathy scale, F(1, 296) = 4.72, p =.030, η2 = .0158. Additionally, when considering the factors, females weresignificantly higher than males on Empathy Is Demonstrated (Factor 2), F(1,294) = 5.57, p = .019, η2 = .0186; and significantly lower on Empathy Is notInfluential (Factor 3), F(1, 296) = 7.09, p = .008, η2 = .0234; and EmpathyIs Difficult to Accomplish (Factor 4) F(1, 294) = 6.80, p = .010, η2 = .0226(see Table 2).
THE RELATIONSHIP BETWEEN ATTITUDES, EXPOSURE AND EMPATHY FOR
OLDER ADULT PATIENTS
Results for the correlations shown in Table 3 suggest that empathy (JSPEtotal score) was related to the attitudes (ASD subscale). There also weresignificant associations between empathy and the number of different typesof older people (e.g., older relatives, neighbors) the student had contact
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
Nature of Empathy 9
TABLE 1 The Factor Structure of Empathy in Dental Students Maximum Likelihood Extraction
Factor
1 2 3 4
emp6 My patients feel better when I understandtheir feelings
.784 .265 −.118 −.152
emp5 I believe empathy is an importanttherapeutic factor in medical or surgicaltreatment
.751 .190 −.198 −.035
emp8 An important component of the relationshipwith my patients is my understanding of theiremotional status, as well as that of their families
.669 .325 −.238 −.152
emp4 Empathy is a therapeutic skill without whichsuccess in treatment is limited
.634 .177 −.178 −.033
emp3 My patients value my understanding of theirfeelings, which is therapeutic in its own right
.608 .237 −.163 −.161
emp13 I try to understand what is going on in mypatients’ minds by paying attention to theirnon-verbal cues and body language
.344 .881 −.056 −.118
emp12 I consider understanding my patients’ bodylanguage as important as verbal communicationin caregiver-patient relationships.
.408 .778 −.146 −.084
emp14 I try to imagine myself in my patients’shoes when providing care to them.
.390 .565 −.041 −.214
emp9 I do not allow myself to be influenced bystrong personal bonds between my patients andtheir families
−.080 .027 .670 .104
emp10 Attentiveness to my patients’ personalexperiences does not influence treatmentoutcome
−.206 −.152 .569 .009
emp1 My understanding of how my patients andtheir families feel does not influence medical orsurgical treatment.
−.038 −.066 .514 .102
emp7 Patient’s illness can be cured only by medicalor surgical treatment; therefore, emotional ties tomy patients do not have a significant influenceon medical or surgical outcomes
−.333 −.268 .424 .259
emp2 I believe emotion has no place in treatmentof medical illness
−.266 −.109 .418 .153
emp15 I try not pay attention to my patients’emotions in history taking or in asking abouttheir physical health.
−.151 .065 .415 .278
emp18 Because people are different, it is difficultfor me to see things from my patients’perspectives.
−.196 −.047 .210 .729
emp16 It is difficult for me to view things from mypatients’ perspectives
−.025 −.276 .189 .595
JSPE = Jefferson Scale of Physician Empathy.Extraction method: maximum likelihood, rotation method: Varimax with Kaiser Normalization, Factor 1:Empathy is valued, Factor 2: Empathy is demonstrated, Factor 3: Empathy is not influential, Factor 4:Empathy is difficult to accomplish.Rotation converged in six iterations.JSPE items are listed by number (e.g., emp 1 and grouped by factor).JSPE factor items are bolded and outlined.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
TAB
LE2
Em
pat
hy
Score
sby
Gen
der
and
Yea
rin
Den
talSc
hool
Yea
rin
Den
talSc
hoolPro
gram
Gen
der
Var
iable
4th
Yea
r3r
dYea
r2n
dYea
r1s
tYea
rM
ale
Fem
ale
Tota
lJe
ffer
son
Scal
eof
Phys
icia
nEm
pat
hy
102.
04(1
4.31
)98
.70
(16.
43)
100.
36(1
9.66
)10
3.41
(17.
16)
99.4
2(1
6.33
)10
3.75
(17.
87)
Em
pat
hy
isva
luab
le(F
acto
r1)
5.40
(0.9
4)5.
02(1
.35)
5.34
(1.0
5)5.
49(1
.02)
5.27
(1.0
7)5.
39(1
.12)
Em
pat
hy
isdem
onst
rate
d(F
acto
r2)
5.40
(1.0
6)5.
15(1
.11)
5.44
(1.1
8)5.
58(1
.04)
5.28
(1.1
6)5.
58(1
.00)
Em
pat
hy
isnotin
fluen
tial
(Fac
tor
3)3.
06(1
.02)
3.11
(0.9
3)3.
14(1
.01)
3.01
(0.8
7)3.
21(0
.86)
2.91
(1.0
4)Em
pat
hy
isdifficu
ltto
achie
ve(F
acto
r4)
3.18
(1.1
5)3.
18(1
.11)
3.36
(1.3
1)3.
19(1
.12)
3.39
(1.1
4)3.
03(1
.19)
Res
ults
are
reported
asM
ean
(Sta
ndar
dD
evia
tion).
4th
year
clas
s:N
=71
,3r
dye
arcl
ass;
N=
60,2n
dye
arcl
ass:
N=
81,1s
tye
arcl
ass:
N=
86,M
ale
studen
ts:
N=
16,Fe
mal
est
uden
ts:
N=
130.
10
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
TAB
LE3
Corr
elat
ion
Mat
rix
for
Attitu
des
Tow
ard
and
Inte
ract
ions
With
Old
erA
dults
and
Em
pat
hy
12
34
56
78
910
1112
13
1A
uto
nom
y1
2In
stru
men
tal
.672
∗∗∗
13
Acc
epta
bili
ty.5
79∗∗
∗.4
93∗∗
∗1
4In
tegr
ity.6
24∗∗
∗.5
97∗∗
∗.6
66∗∗
∗1
5#
Conte
xts
.071
.178
∗∗.0
89.0
331
6#
Typ
es.1
66∗∗
.215
∗∗∗
.108
.086
.455
∗∗∗
17
Freq
uen
cyof
Inte
ract
ion
.160
∗∗.1
92∗∗
.109
.073
.250
∗∗∗
.344
∗∗∗
1
8#
Old
erPat
ients
Tre
ated
.079
.087
.003
.031
.010
.007
.108
1
9To
talJS
PE
.182
∗∗.2
32∗∗
∗.2
44∗∗
∗.1
43∗
.265
∗∗∗
.279
∗∗∗
.093
−.03
21
10Fa
ctor
1JS
PE
.191
∗∗.1
85∗∗
.233
∗∗∗
.173
∗∗.1
97∗∗
.190
∗∗.0
79−.
034
.837
∗∗∗
111
Fact
or
2JS
PE
.117
∗.1
02.2
34∗∗
∗.0
81.1
40∗
.120
∗.0
35−.
064
.758
∗∗∗
.660
∗∗∗
112
Fact
or
3JS
PE
−.17
2∗∗−.
209∗∗
∗−.
198∗∗
−.10
2−.
219∗∗
∗−.
257∗∗
∗−.
068
.007
−.74
9∗∗∗
−.45
5∗∗∗
−.33
5∗∗∗
113
Fact
or
4JS
PE
−.08
7−.
149∗
−.11
6∗−.
079
−.16
8∗∗−.
177∗∗
−.09
0−.
052
−.56
2∗∗∗
−.31
5∗∗∗
−.36
5∗∗∗
.400
∗∗∗
1
JSPE
=Je
ffer
son
Scal
eofPhys
icia
nEm
pat
hy.
List
wis
eN
=29
2.Item
s:1–
4A
ging
Sem
antic
Diffe
rentia
lSu
bsc
ales
,5–
6:N
um
ber
ofso
cial
conte
xts
and
types
ofin
tera
ctio
ns
with
old
erad
ults
,7—
8:Fr
equen
cyofin
tera
ctio
n;N
um
ber
ofold
erad
ults
trea
ted,9:
JSPE:to
talem
pat
hy
score
,10
:Fa
ctor
1:Em
pat
hy
isva
lued
,11
:Fa
ctor
2:Em
pat
hy
isdem
onst
rate
d,12
:Fa
ctor
3:Em
pat
hy
isnotin
fluen
tial,
13:Fa
ctor
4:Em
pat
hy
isdifficu
ltto
acco
mplis
h∗ p
<.0
5,∗∗
p<
.01,
∗∗∗ p
<.0
01.
11
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
12 D. Waldrop et al.
with and the number of contexts of interaction (e.g., caregiving, attendingreligious services) in which the contact occurred outside of the clinic, butnot with frequency of such interactions or the number of older adults treatedin the clinic.
Results for the multiple regressions for JSPE total scale scores are pre-sented in Table 4. The overall equation was significant, F(11, 258) = 5.746,p < .0001, R2 = .197, and demonstrates that the acceptability of older adults(ASD subscale) was positively associated with empathy scores (see Table 4).Greater numbers of different types of older adults with whom the student hadcontact and higher numbers of different contexts for these interactions werepositively associated with the empathy. However, neither contact withinthe clinic nor the actual frequency of contact with older adults outside ofthe clinic was positively associated with empathy. Results for Empathy IsValuable (Factor 1) were significant, F(11, 258) = 3.176, p < .005, R2 = .119,adjusted R2 = .082, and are presented in Table 5. The Acceptability sub-scale of the ASD showed a positive marginal trend, suggesting that studentswho had positive Acceptability scores also had high scores on Empathy IsValuable (Factor 1). The only significant association was for the number ofcontexts of interactions that the student had with older adults. The relation-ship suggests that the more contexts the student was exposed to with olderadults, the higher the score on Factor 1, Empathy Is Valuable.
The results for Empathy Is Demonstrated (Factor 2) were significant,F(11, 258) = 3.651, p < .0001, R2 = .148, adjusted R2 = .112, and are pre-sented in Table 6. Empathy was positively associated with the Acceptabilitysubscale of the ASD. There was a positive association for gender, and femaleshad higher levels of acceptability. There was also a marginal effect for thenumber of different types of older adults the student had contact with outsidethe SDM clinic (Table 6).
The results for Empathy Is not Valued (Factor 3) were significant, F(11,258) = 4.075, p < .0001, R2 = .148, adjusted R2 = .112. The only otherfactor that was significant was the number of different types of older adultscontacted outside the SDM clinic, indicating that the more types of olderadults they had contact with, the less likely they were to view the use ofempathy as negative (Table 7).
The results for Empathy Is Difficult to Accomplish (Factor 4) weresignificant, F(11, 256) = 2.553, p = .004, R2 = .099, adjusted R2 = .60.However, the only significant factor was sex, with females showing lowerscores than males. The number of different types of older adults con-tacted outside the clinic was marginal, reflecting that as this increased theperception of empathy being difficult decreased. No other factors weresignificant.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
TAB
LE4
The
Rel
atio
nsh
ipB
etw
een
Attitu
des
Aboutan
dIn
tera
ctio
ns
With
Old
erA
dults
and
Ove
rall
Em
pat
hy
Unst
andar
diz
edCoef
fici
ents
Stan
dar
diz
edCoef
fici
ents
95.0
%Confiden
ceIn
terv
alfo
rb
Corr
elat
ions
bSt
d.
Err
or
βt
Sig.
Low
erB
ound
Upper
Bound
Zer
oO
rder
Par
tial
Par
t
101.
247.
177
14.1
0.0
0087
.119
115.
374
(Const
ant)
66
Inst
rum
enta
l−.
361
1.79
4.0
16−.
201
.841
−3.8
933.
172
.118
−.01
2−.
011
Auto
nom
y−.
696
2.01
2−.
030
−.34
6.7
30−4
.656
3.26
4.1
07−.
021
−.01
9Acc
epta
bili
ty4.
031
1.65
3.1
912.
438
.015
.777
7.28
6.1
99.1
43.1
36In
tegr
ity.1
411.
619
.007
.087
.931
−3.0
453.
327
.123
.005
.005
Num
cont
3.84
41.
467
.167
2.62
0.0
09.9
566.
731
.247
.154
.146
Num
type
3.49
61.
275
.180
2.74
3.0
06.9
876.
004
.251
.161
.153
New
inte
ract
−.78
9.9
11−.
053
−.86
6.3
87−2
.581
1.00
4.0
63−.
051
−.04
8N
um
trea
ted
−.17
2.8
06−.
012
−.21
3.8
31−1
.760
1.41
5−.
019
−.01
3−.
012
List
wis
eN
=29
2.Agi
ng
Sem
antic
Diffe
rentia
lsu
bsc
ales
:In
stru
men
tal,
Auto
nom
y,Acc
epta
bili
ty,In
tegr
ity.
Inte
ract
ions
with
old
erad
ults
:Conte
xt,ty
pe
ofold
erad
ult,
type
ofin
tera
ctio
nan
dnum
ber
trea
ted.
13
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
TAB
LE5
The
Rel
atio
nsh
ipB
etw
een
Attitu
des
Aboutan
dIn
tera
ctio
ns
With
Old
erA
dults
and
Em
pat
hy
IsVal
uab
le(F
acto
r1)
:M
ulti
ple
Reg
ress
ion
Anal
ysis
Unst
andar
diz
edCoef
fici
ents
Coef
fici
ents
95.0
%Confiden
ceIn
terv
alfo
rb
Corr
elat
ions
bSt
d.
Err
or
βt
Sig.
Low
erB
ound
Upper
Bound
Zer
oO
rder
Par
tial
Par
t
(Const
ant)
5.93
1.4
6312
.790
.000
5.01
96.
843
Inst
rum
enta
l−.
008
.116
−.00
6−.
072
.943
−.23
6.2
20.1
63−.
004
−.00
4A
uto
nom
y.0
79.1
30.0
53.6
10.5
42−.
176
.335
.178
.036
.034
Acc
epta
bili
ty.2
09.1
07.1
561.
957
.051
−.00
1.4
19.2
23.1
16.1
11In
tegr
ity.0
34.1
05.0
28.3
27.7
44−.
172
.240
.171
.019
.018
Num
cont
.207
.095
.140
2.18
1.0
30.0
20.3
93.2
00.1
29.1
23N
um
type
.129
.082
.104
1.56
4.1
19−.
033
.291
.189
.093
.088
Inte
ract
−.01
5.0
59−.
016
−.25
3.8
01−.
131
.101
.078
−.01
5−.
014
Num
Tre
ated
−.03
1.0
52−.
035
−.60
4.5
47−.
134
.071
−.03
1−.
036
−.03
4
List
wis
eN
=29
2.Agi
ng
Sem
antic
Diffe
rentia
lsu
bsc
ales
:In
stru
men
tal,
Auto
nom
y,Acc
epta
bili
ty,In
tegr
ity.
Inte
ract
ions
with
old
erad
ults
:Conte
xt,ty
pe
ofold
erad
ult,
type
ofin
tera
ctio
nan
dnum
ber
trea
ted.
14
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
TAB
LE6
The
Rel
atio
nsh
ipB
etw
een
Attitu
des
About
and
Inte
ract
ions
With
Old
erA
dults
and
Em
pat
hy
IsD
emonst
rate
d(F
acto
r2)
:M
ulti
ple
Reg
ress
ion
Anal
ysis
Unst
andar
diz
edCoef
fici
ents
Stan
dar
diz
edCoef
fici
ents
95.0
%Confiden
ceIn
terv
alfo
rb
Corr
elat
ions
bSt
d.
Err
or
βt
Sig.
Low
erB
ound
Upper
Bound
Zer
oO
rder
Par
tial
Par
t
(Const
ant)
6.11
0.4
8312
.643
.000
5.15
97.
061
Inst
rum
enta
l.0
06.1
21.0
04.0
48.9
62−.
233
.244
.102
.003
.003
Auto
nom
y.0
29.1
32.0
19.2
23.8
23−.
230
.289
.117
.013
.013
Acc
epta
bili
ty.4
08.1
09.3
013.
757
.000
.194
.623
.234
.219
.214
Inte
grity
−.17
3.1
08−.
139
−1.6
00.1
11−.
385
.040
.081
−.09
5−.
091
Num
cont
.141
.096
.096
1.46
8.1
43−.
048
.331
.140
.087
.084
Num
type
.078
.083
.063
.939
.348
−.08
6.2
43.1
20.0
30−.
029
Num
Tre
ated
−.05
4.0
53−.
059
−1.0
23.3
07−.
158
.050
−.06
4−.
061
−.05
8
List
wis
eN
=29
2.Agi
ng
Sem
antic
Diffe
rentia
lsu
bsc
ales
:In
stru
men
tal,
Auto
nom
y,Acc
epta
bili
ty,In
tegr
ity.
Inte
ract
ions
with
old
erad
ults
:Conte
xt,ty
pe
ofold
erad
ult,
type
ofin
tera
ctio
nan
dnum
ber
trea
ted.
15
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
TAB
LE7
The
Rel
atio
nsh
ipB
etw
een
Attitu
des
Aboutan
dIn
tera
ctio
ns
With
Old
erA
dults
and
Ove
rall
Em
pat
hy
Unst
andar
diz
edCoef
fici
ents
Stan
dar
diz
edCoef
fici
ents
95.0
%Confiden
ceIn
terv
alfo
rb
Corr
elat
ions
bSt
d.Err
or
βt
Sig.
Low
erB
ound
Upper
Bound
Zer
oO
rder
Par
tial
Par
t
(Const
ant)
2.58
3.3
966.
515
.000
1.80
33.
363
Inst
rum
enta
l−.
136
.099
−.11
1−1
.370
172
−.33
1.0
59−.
201
−.08
1−.
076
Auto
nom
y−.
046
.111
−.03
5−.
416
.678
−.26
5.1
73−.
169
−.02
5−.
023
Acc
epta
bili
ty−.
205
.091
−.17
6−2
.248
.025
−.38
5−.
026
−.19
8−.
132
−.12
5In
tegr
ity.1
26.0
89.1
171.
404
.161
−.05
0.3
02−.
102
.083
.078
Num
cont
−.15
0.0
81−.
117
−1.8
48.0
66−.
309
.010
−.21
8−.
109
−.10
3N
um
type
−.20
1.0
70−.
187
−2.8
55.0
05−.
340
−.06
2−.
257
−.16
7−.
159
Inte
ract
.053
.050
.064
1.06
2.2
89−.
046
.152
−.06
7.0
63.0
59N
um
Tre
ated
.007
.045
.009
.155
.877
−.08
1.0
95.0
07.0
09.0
09
List
wis
eN
=29
2.Agi
ng
Sem
antic
Diffe
rentia
lsu
bsc
ales
:In
stru
men
tal,
Auto
nom
y,Acc
epta
bili
ty,In
tegr
ity.
Inte
ract
ions
with
old
erad
ults
:Conte
xt,ty
pe
ofold
erad
ult,
type
ofin
tera
ctio
nan
dnum
ber
trea
ted.
16
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
Nature of Empathy 17
DISCUSSION
We explored the nature of empathy and its association with attitudesabout and exposure to older patients in a sample of 292 dental studentsat the University at [BLINDED FOR REVIEW] School of Dental Medicine.Maximum likelihood extraction of the JSPE yielded four factors: (1) EmpathyIs Valuable, (2) Empathy Is Demonstrated, (3) Empathy Is not Influential, and(4) Empathy Is Difficult to Accomplish. Higher overall empathy scores werepositively related to the attitude of acceptability and to exposure to olderpeople outside of the clinic setting.
Exposure to older adults in the clinic was not related to higher empa-thy scores. However, higher frequency of contact with different types ofolder adults and greater numbers of different contexts were related to higherempathy scores. The Acceptability subscale of the ASD was positively relatedto higher empathy scores.
Females were significantly higher on the overall empathy scale andon Empathy is Demonstrated (Factor 2) scores and significantly lower onEmpathy is not influential (Factor 3), and Empathy is Difficult to Accomplish(Factor 4). The findings that females demonstrated higher empathy is consis-tent with previous literature (Beauchamp & McKelvie, 2006; Gabard, Lowe,Deusinger, Stelzner, & Crandall, 2013; Nash, 2010).
These study findings build on previous studies and contribute to thegrowing literature about empathy development in professional education inhealth care. Sherman and Cramer (2005) identified four factors that includeda number of crossover loadings by using a principal components analy-sis: perspective taking, compassionate care, standing in the patient’s shoes,and efforts to ignore emotions. Our findings suggest that there may besome parity in the nature of empathy in dental students. The elements ofCompassionate Care (S-C) and Empathy Is Valuable suggest the belief thatempathy is therapeutic. The elements of Perspective Taking (S-C). Standingin a Patient’s Shoes (S-C) and Empathy Is Demonstrated suggest that thereis a behavioral element of empathy. Finally, the elements of Empathy Isnot Influential, Efforts to Ignore Emotions (S-C), and Empathy Is Difficultto Accomplish perhaps suggest that empathy may be detrimental to patientoutcomes in dentistry.
Sherman and Cramer (2005) did not investigate the association of iden-tified components with other characteristics. We determined the number ofunderlying dimensions of the Empathy scale for dental students and usedmaximum likelihood, focusing more on the underlying dimensions. Theresults from Sherman and Cramer for the factor analysis were different thanours. Sherman and Cramer found gender differences, as we do, with femalesscoring higher than males. Sherman and Cramer also indicated that the scoresdropped as a function of class. We see some of that, with an important
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
18 D. Waldrop et al.
rebound in the 4th year. However, the results are not significant—but theydo present an interesting discussion point.
In a previous study of attitudes, we found that the 4th-year dental stu-dents showed the most gain in positive attitudes. We attributed this gain toexposure to older adults in the clinic and to mentorship. Although the expec-tations were that attitudes would be influenced by clinical exposure and to beassociated with higher empathy scores, this did not occur. Increased clinicalcontact did not directly influence attitudes or empathy. The 4th-year studentsshow levels of empathy that are similar to those in the 1st-year students, withthe 2nd- and 3rd-year students showing lower levels. Given the previousfindings with dental students (Sherman & Cramer, 2005) that demonstrate asimilar pattern for empathy scores, with decreases from year 1 to year 2, andyear 2 to year 3, then an increase in year 4, contributing factors may includethat the increase in empathy for the 4th-year students may be a result of clin-ical mentorship and role modeling. Changes in empathy may also be relatedto experience whereas students see greater numbers of patients they beginto experience the value of empathy. During the 2nd and 3rd years of dentalschool, students have less patient contact, and more emphasis on technicalaspects of treatment.
It is also important to note that the Acceptability subscale from the ASDwas the only one to show any association with empathy. The implicationis that acceptance of older adult behavior is key to positive empathy devel-opment. Thus, facilitating the development of acceptance in dental studentsmay lead to greater empathy for older dental patients.
Another important finding relates to the relationship of empathy andthe different contexts that the students had exposure to older individuals.Greater exposure was associated with more positive empathy scores. Oneconsideration for dental education is the potential influence of increasedexposure to older adults in a variety of contexts. This may help build moreacceptance and influence empathy towards older patients.
Limitations
The study had several limitations that are important to address. First, the datawas cross-sectional. Longitudinal data would provide a deeper perspectiveon the nature of empathy in dental students and whether it changes with pro-fessional development. Second, the data is a convenience sample, collectedfrom only one university clinic setting. Comparative data from more than onedental school would validate the structure of empathy and its relationship toattitudes and exposure. Third, our questions on exposure to types of olderadults and different social contexts were categorical. Open-ended questionsabout students’ interactions with older adults would allow us to discover therichness of their experience with older adults (e.g., how they interact, the
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
Nature of Empathy 19
nature of their relationship with older people). Future research is neededto confirm whether clinical training impacts empathy negatively and, if so,whether interventions can be designed to mitigate this impact (Chen, Lew,Hershman, & Orlander, 2007).
Implications for Education
Research has indicated that dentists have misinformation about older peopleand can be reluctant to treat frail and functionally dependent older adultsthus raising the question of whether inadequate education about older peo-ple deters dentists from caring for older patients (Antoun, Adsett, Goldsmith,& Thomson, 2008; Holm-Pedersen, Vigild, Nitschke, & Berkey, 2005). Clearly,technical expertise is important for the provision of effective oral health care.However, dentists are also important members of the interdisciplinary health-care team who can contribute to enhanced well-being in their older adultpatients by understanding the interrelationship between systemic and oralhealth concerns and quality of life (Best, 2010).
CONCLUSIONS
The nature of empathy has been studied extensively in medical studentsbut less so in dental students. The factor structure presented here differsfrom that found among medical students and suggests that the nature ofempathy may vary by profession. In a study of physicians, the empathyitems aligned with factors described as “perspective taking,” “compassion-ate care,” and “standing in the patient’s shoes” (Hojat et al., 2002). Thefindings reported here suggest that among this sample of dental studentsthe factor “empathy is not influential” may suggest that empathic behavioris perceived to hinder accomplishment of competent care, and “empathyis difficult to achieve” may suggest perceptions that demonstrating empa-thy is challenging. Understanding the components of empathy by disciplineis fundamentally important to improving education of an aging-preparedworkforce. Moreover, levels of empathy have been found to erode overthe course of medical school (Colliver, Conlee, Verhulst, & Dorsey, 2010).Understanding whether empathy changes over the course of dental schooland, if so, how and when are important considerations in the continuingdevelopment of dental education. The incorporation of intensifying clinicalexposure over time in dental school may also be related to the developmentof a greater understanding of patients’ experience with coexistent health andpsychosocial problems.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
20 D. Waldrop et al.
REFERENCES
American Society for Geriatric Dentistry. (2010). Retrieved from http://www.scdonline.org/
Antoun, J. S., Adsett, L. A., Goldsmith, S. M., & Thomson, W. M. (2008). Theoral health of older people: General dental practitioners’ beliefs and treatmentexperience. Special Care in Dentistry, 28(1), 2–7.
American Dental Education Association. (2013). ADEA statement of profes-sionalism in dental education. Retrieved from http://www.adea.org/Pages/Professionalism.aspx
Baumeister, S. E., Davidson, P. L., Carreon, D. C., Nakazono, T. T., Gutierrez, J. J.,& Andersen, R. M. (2007). What influences dental students to serve special carepatients? Special Care in Dentistry, 27(1), 15–22.
Beauchamp, K., & McKelvie, S. J. (2006). Personality traits and university program.Psychological Reports, 99(1), 277–291.
Best, H. (2010). Educational systems and the continuum of care for the older adult.Journal of Dental Education, 74(1), 7–12.
Chalmers, J. M., & Ettinger, R. L. (2008). Public health issues in geriatric dentistry inthe United States. Dental Clinics of North America, 52(2), 423–446.
Chapple, I. L. C. (2009). The impact of oral disease upon systemic health-Symposiumoverview. Journal of Dentistry, 37(8), S568–571.
Chen, D., Lew, R., Hershman, W., & Orlander, J. (2007). A cross-sectional measure-ment of medical student empathy. Journal of General Internal Medicine, 22(10),1434–1438.
Colliver, J. A., Conlee, M. J., Verhulst, S. J., & Dorsey, J. K. (2010). Reports onthe declines of empathy during medical education are greatly exaggeratee: Areexamination of the research. Academic Medicine, 85, 588–593.
Dolan, T. A., Atchison, K., & Huynh, T. N. (2005). Access to dental care among olderadults in the United States. Journal of Dental Education, 69(9), 961–974.
Ettinger, R. L. (2007). Oral health and the aging population. Journal of the AmericanDental Association, 138(Suppl), 5S–6S.
Ettinger, R. L. (2010). Meeting oral health needs to promote the well-being of thegeriatric population: Educational research issues. Journal of Dental Education,74(1), 29–35.
Fabiano, J. A., Waldrop, D. P., Nochajski, T. H., Davis, E. L., & Goldberg, L. J. (2005).Understanding dental students’ knowledge and perceptions of older people:Toward a new model of geriatric dental education. Journal of Dental Education,69(4), 419–433.
Federal Interagency Forum on Aging-Related Statistics (2012). Older Americans2012: Key Indicators of well-being. Retrieved from: http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2012_Documents/Docs/EntireChartbook.pdf
Ferguson, D. A., Steinberg, B. J., & Schwien, T. (2010). Dental economics and theaging population. Compendium of Continuing Education in Dentistry, 31(6),418–420.
Frisbee, S. J., Chambers, C. B., Frisbee, J. C., Goodwill, A. G., & Crout, R. J.(2010). Association between dental hygiene, cardiovascular disease risk factors
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
Nature of Empathy 21
and systemic inflammation in rural adults. Journal of Dental Hygiene, 84(4),177–184.
Gabard, D. L., Lowe, D. L., Deusinger, S. S., Stelzner, D. M., & Crandall, S. J. (2013).Analysis of empathy in doctor of physical therapy students: A multi-site study.Journal of Allied Health, 42(1), 10–16.
Gerbert, B., Bleecker, T., & Saub, E. (1994). Dentists and the patients who love them:Professional and patient views of dentistry. Journal of the American DentalAssociation, 125(3), 264–272.
Griffin, S. O., Barker, L. K., Griffin, P. M., Cleveland, J. L., & Kohn, W. (2009). Oralhealth needs among adults in the United States with chronic diseases. Journalof the American Dental Association, 140(10), 1266–1274.
Haumschild, M. S., & Haumschild, R. J. (2009). The importance of oral health inlong-term care. Journal of the American Medical Directors Association, 10(9),667–671.
Hojat, M. (Ed.). (2007). Empathy in patient care: Antecedents, development, mea-surement and outcomes. New York, NY: Springer.
Hojat, M. (2009). Ten approaches for enhancing empathy in health and humanservices cultures. Journal of Health & Human Services Administration, 31(4),412–450.
Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Vergare, M., & Magee, M. (2002).Physician empathy: Definition, components, measurement, and relationship togender and specialty. American Journal of Psychiatry, 159(9), 1563–1569.
Hojat, M., Louis, D. Z., Markham, F. W., Wender, R., Rabinowitz, C., & Gonnella,J. S. (2011). Physicians’ empathy and clinical outcomes for diabetic patients.Academic Medicine, 86(3), 359–364.
Hojat, M., Mangione, S., Gonnella, J. S., Nasca, T., Veloski, J. J., & Kane, G. (2001).Empathy in medical education and patient care. Academic Medicine, 76(7), 669.
Hojat, M., Vergare, M. J., Maxwell, K., Brainard, G., Herrine, S. K., Isenberg, G. A.,& Gonnella, J. S. (2009). The devil is in the third year: A longitudinal study oferosion of empathy in medical school. Academic Medicine, 84(9), 1182–1191.
Holm-Pedersen, P., Vigild, M., Nitschke, I., & Berkey, D. B. (2005). Dental carefor aging populations in Denmark, Sweden, Norway, United Kingdom, andGermany. Journal of Dental Education, 69(9), 987–997.
Intrieri, R. C., von Eye, A., & Kelly, J. A. (1995). The aging semantic differential: Aconfirmatory factor analysis. Gerontologist, 35(5), 616–621.
Kiyak, H. A., & Reichmuth, M. (2005). Barriers to and enablers of older adults’ useof dental services. Journal of Dental Education, 69(9), 975–986.
Nash, D. A. (2010). Ethics, empathy, and the education of dentists. Journal of DentalEducation, 74(6), 567–578.
Nochajski, T. H., Waldrop, D. P., Davis, E. L., & Goldberg, L. J. (2011). Factorsthat influence dental students’ attitudes about older adults. Journal of DentalEducation, 73(1), 95–104.
Rosencranz, H. A., & McNevin, T. E. (1969). A factor analysis of attitudes toward theaged. Gerontologist, 9(1), 55–59.
Satterfield, J. M., & Hughes, E. (2007). Emotion skills training for medical students:A systematic review. Medical Education, 41, 935–941.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5
22 D. Waldrop et al.
Scully, C., & Ettinger, R. L. (2007). The influence of systemic diseases on oral healthcare in older adults. Journal of the American Dental Association, 138(Suppl),7S–14S.
Sheets, C., Paquette, J., & Wu, J. C. (2009). Better oral health for better systemichealth. Dentistry Today, 28(5), 90–93.
Sherman, J. J., & Cramer, A. (2005). Measurement of changes in empathy duringdental school. Journal of Dental Education, 69(3), 338–345.
Small, B. W. (2005). The soft side. General Dentistry, 53(1), 12–13.Sutherland, J. A. (1993). The nature and evolution of phenomenological empathy in
nursing: An historical treatment. Archives of Psychiatric Nursing, 8(6), 369–376.Tsakos, G. (2011). Inequalities in oral health of the elderly: Rising to the public
health challenge? Journal of Dental Research, 90(6), 689–690.Varkey, P., Chutka, D. S., & Lesnick, T. G. (2006). The aging game: Improving med-
ical students’ attitudes toward caring for the elderly. Journal of the AmericanMedical Directors Association, 7(4), 224–229.
Vieira, C. L. Z., & Caramelli, B. (2009). The history of dentistry and medicine rela-tionship: could the mouth finally return to the body? Oral Diseases, 15(8),538–546.
Waldrop, D. P., Fabiano, J. A., Nochajski, T. H., Zittel-Palamara, K., Davis, E. L.,& Goldberg, L.J. (2006). More than a set of teeth: Assessing and enhancingdental students’ perceptions of older adults. Gerontology & Geriatrics Education,27(1),37–56.
Winland, R. D. (2006). Professional development: Empathy. General Dentistry, 54(5),300.
Dow
nloa
ded
by [
Jude
Fab
iano
] at
12:
48 0
2 M
arch
201
5