Greatly appreciate the comments and in particular the excellent resources from my last post. We are in a series of posts (here, here, and here for prior) called “Cares More” an initiative for physical therapists to regain or maintain their calling and meaning within the profession, provide a series of evidence based factors that are non “hands on” per se and differentiate us from other healthcare providers.
The last post was on empathy-likely the “secret sauce” of care. To summarize, The research does show that one can lose empathy, regain empathy, enhance empathy, be instructed in empathy, and have legitimate deficits in empathy. As it turns out empathy is more complex than our initial “blink” and this is where we need to encourage instruction in empathy. There are really 3 stages of empathy (Zaki & Ochsner, 2009)-unfortunately as healthcare providers, we only think of this construct in one way-putting ourselves in another’s shoes. The first stage is “experience sharing”, essentially the emotional component when we “feel” someone else’s emotion (pain, discomfort, predicament) as if they were our own. The second stage or “mentalising” is the cognitive consideration to those states, their sources, and trying to work through understanding them and finally, “prosocial concern” or having the motivation to act-reaching out, developing treatment plans, etc. Said differently, empathy takes a warm heart, detached mind, and motivation. In my experience, good providers are often very good at 2/3 but the best physical therapists 3/3!
However, Called to Care providers while seeing empathy as perhaps the secret sauce, should also recognize that it isn’t the only non “hands on” intervention ingredient in the significantly vast recipe. In this post, I will elaborate on two related concepts that have strong evidentiary support. My hope is that they become additional tools and resources for health care providers for all of the reasons brought up in the foundation post.
High Quality Connections
A critical component of the patient-therapist interaction is the connection or relationship that is established. An essential component of Called to Care is a thorough understanding of what high quality connections (HQCs) are and how they can be built and strengthened. Another component is insight into how people thrive at work (Dutton & Heaphy, 2008). It is also essential for physical therapists to collaborate with other staff and with their managers.
The energy and vitality of organizations depend on the quality of the connections between people in the organization. A focus on HQCs and their energy-generating capacities shows how small actions like respectful engagement can transform the energy between people (Dutton, 2003). The positive effect of HQCs is revealed by the feelings of both persons involved, what they do, and the beneficial outcomes they produce. HQCs can be viewed as dynamic, living tissue that exists between two people at work when there is some interaction involving mutual awareness (Berschied & Lopes, 1997).
Stephens and colleagues assert that HQCs deserve greater theoretical attention and base this assertion on four assumptions. First, they assume that humans are intrinsically social, have a need to belong, and make connections as an important aspect of their social experience. Second, they assume that connections are dynamic, changing as people’s feeling, thoughts, and behavior changes when they interact with one another. Third, work is performed through social processes, and connections are key elements for understanding how work is accomplished. And fourth, they assume that connections vary in quality (Stephens, Heaphy, & Dutton, n.d.).
Connection quality is marked by three subjective experiences. First, connection quality is sensed by feelings of vitality. People in a HQC are more likely to feel positive arousal and a heightened sense of positive energy (Quinn & Dutton, 2005). Second, the quality of a connection is felt through a sense of positive regard (Rogers, 1951). Being regarded in a positive context connotes feelings of being loved, respected and cared for in a connection (Stephens, Heaphy, & Dutton, n.d.). Finally, the subjective experience of a connection’s quality is marked by the degree of mutuality. Mutuality captures the shared vulnerability and responsiveness that both people feel when they are fully engaged in a connection (Miller & Stiver, 1997). These three subjective markers help explain why HQCs are experienced as attractive and pleasant and why they are life-giving (Stephens, Heaphy, & Dutton, n.d.).
Research has shown that HQCs improve individual functioning through cognitive, physiological, and behavioral processes. For example, it has been shown that even a few interactions with others can improve both persons’ cognitive performance (in speed of processing and working memory performance) (Ybarra et al., 2008). Furthermore, medical evidence shows that even brief interactions at work can have salutary effects on people’s cardiovascular, neuroendocrine, and immune systems (Heaphy & Dutton, 2008). Research also shows that HQCs facilitate an individual’s recovery and adaptation when suffering from loss or illness (Lilius, Worline, Maitlis, Kanov, Dutton, & Frost, 2008). Furthermore, HQCs are an important means by which individuals develop and grow (Ragins & Verbos, 2007).
HQCs are vital to the energy of any organization, and are marked by measurable positive feelings. The empirical evidence on the psychological, physiological, and behavioral benefits of HQCs, as taught to physical therapists and incorporated in clinical and work contexts, are core to the success of Called to Care.
Fredrickson’s (1998) broaden-and-build theory of positive emotions is part of Called to Care because of its potential benefits to patient, physical therapist, and workplace dynamics. The theory says that positive emotions broaden thought-action repertoires, enabling individuals to be flexible on higher-level connections and consider wider than usual ranges of percepts, ideas, and actions. The broaden-and-build theory of positive emotions says that broadened cognition enhances flexibility, that in turn and over time builds personal resources, including mindfulness, resilience, social closeness, and even physical health (Cohn, Fredrickson, Brown, Mikels, & Conway, 2009; Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008; Waugh & Fredrickson, 2006). The broaden-and-build theory combines hedonic well-being (the experience of pleasant emotions) with eudaemonic well-being (striving toward one’s potential and purpose in life). These are facilitated by accumulating psychosocial resources (Kashdan, Biswas-Diener, & King, 2008). The implication is that even though pleasant positive emotions are fleeting, they can have a longer-lasting effect on functional outcomes that in turn lead to enhanced well-being and connectedness. In this way, positive emotions expand people’s mindsets in ways that, little-by-little, reshape who they are (Garland et al., 2010, p. 850).
Broaden-and-build, if adopted by physical therapists and utilized in patient care interactions, may significantly impact the relationship and provide enhanced benefits outside of the physical therapy interventions. Induced positive emotions increase people’s ability to be “one” or close with others (Waugh & Fredrickson, 2006, p. 850) and their trust in acquaintances (Dunn & Schweitzer, 2005). Fredrickson and Losada (2005) suggest that a person’s affect and general well-being is represented by their “positivity ratio,” defined as the ration of their positive to negative emotions experienced over time. Normal functioning has been characterized by positivity ratio of about 2:1 (Schwartz et al., 2002). However, patients in physical therapy may have medical conditions that subject them to a negativity bias, where negative emotions, events, and problems command the attention and prevent individuals from assessing situations evenhandedly (Rozin & Royzman, 2001). This suggests that in order to overcome the potency of negative emotions, positive emotions need to outnumber them by more than the 2:1 (normal functioning). Losada and Heaphy (2004) have identified 3:1 as the tipping point ratio above which optimal functioning emerges. This was further tested by Fredrickson and Losada (2005), who found that when the ratio is above 3:1, people experience the broaden-and-build effects of positive emotions and demonstrate goodness, growth, and resilience. When the ratio dips below 3:1, positive emotions are insufficient to support optimal functioning and might languish (Keyes, 2002). While recent commentary (Brown, 2013) have questioned some of the math behind 3:1, there is ample supportive evidence for a ratio greatly exceeding positive to negative.
Two other significant effects of the “Losada ratio” are important to physical therapists as they influence physical health components. Fredrickson and Levenson (1998) have shown that positive emotions—both amusement and contentment—can speed cardiovascular recovery from anxiety and fear. Perhaps even more significant, positive emotions have been shown to help patients rebound from adversity and cardiovascular reactivity, ward off depressive symptoms, and continue to grow (Fredrickson, Tugade, Waugh, & Larkin, 2003; Ong, Begeman, Bisconti, & Wallace, 2006; Tugade & Fredrickson, 2004). The mounting evidence of the benefits of broaden-and-build theory make it a core component of Called to Care. Armed with shaping expectations, empathy, high quality connections, and broaden and build as a core foundation, physical therapists are in a unique position to influence care.