Measuring empathic, person-centred communication in primary care nurses: validity and reliability of the Consultation and Relational Empathy (CARE) Measure

Patients consistently score empathy and the human aspects of care as top priorities
in their health care 1]–4]. Research has linked empathic care to higher levels of patient satisfaction 5]–7], enablement 8]–10] and improved health outcomes 8], 10]–14]. Its importance is emphasised in healthcare policies 15]–17] and professional codes of conduct 18], 19]. Healthcare practitioners are increasingly expected to demonstrate their interpersonal
skills in terms of empathic, patient-centred care in practice and training 20], 21]. Measurement is crucial to evaluate this aspect of quality of care and to obtain
feedback on individual practitioners.

The Consultation and Relational Empathy (CARE) Measure is a patient-assessed measure
of the quality of the encounter with healthcare professionals 3], 21]. Ten items ask patients’ perception of the practitioner’s ‘relational empathy’, defined
as the healthcare practitioner’s ability to:

a) understand the patient’s situation, perspective and feelings (and their attached
meanings);

b) communicate that understanding and check its accuracy, and

c) act on that understanding with the patient in a helpful (therapeutic) way 3], 21].

The development of the measure was based on a review of existing measures and qualitative
interviews with patients, and their feedback on the individual items in order to create
a measure that was meaningful regardless of the patients’ socioeconomic status 21]. We did this by assessing the views of patients living in areas of high or low socioeconomic
deprivation and, in an iterative process, developed, validated and tested the CARE
Measure in primary care consultations with general practitioners (GPs) 21], 22].

Since its development and validation with general practitioners (GPs) in the UK 21], the measure has been extensively validated with a range of physician groups in primary
and secondary care 22]–26]. It has been widely used nationally (including in GP appraisal and revalidation)
and internationally, and has been translated and validated in various languages 23], 24], 27]. However, to date nurses have not been included in this expanding body of work on
the CARE Measure. Given the increasing role of nurses in primary care in many countries,
it would seem timely to asses whether the CARE Measure is valid and reliable in this
professional group. It would be scientifically wrong to assume that a measure developed
primarily for use with GPs will also be valid and reliable with nurses. The role of
nurses in primary care is distinct from that of GPs; in the United Kingdom (UK), practice
nurses are employed by GPs to carry out routine annual reviews of a limited number
of single chronic disease, and some also do minor illness clinics. GPs, on the other
hand, deal with a wide range of clinical issues, including the management of most
mental health problems and patients with complex multimorbidity of chronic diseases.

In carrying out the current study we have a number of hypotheses to be tested based
on our previous work on empathy and the CARE Measure:

1. We would expect the CARE measure to be relevant to most consultations with practice
nurses, as we have found for primary care and secondary care doctors 22], 25], 26].

2. Since the CARE measure reflects patients’ views on generic interpersonal skills,
we would expect it to be valid and reliable in primary care nurses, similar to what
we have found for GPs and other doctor groups 22], 25], 26].

3. We would expect the CARE measure to load onto a single factor in factor analysis
as found in other studies 22], 24]–26].

4. As in this previous work 22], 24]–26], we would predict the CARE Measure would show convergent validity with patient satisfaction
but divergent validity with patient enablement, since the latter is a construct quite
distinct from satisfaction 28].

5. We would also predict that the CARE Measure would be related to factors such as
consultation length and continuity, as shown in our previous work with doctors 22], 25], 26].