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Empathic communication as a “Risky strength” for health during the COVID-19 pandemic: The case of frontline Italian healthcare workers

Objective. The healthcare professionals’ empathic attitude in taking care of their patients is supposed to be a key factor in fighting the COVID-19 pandemic in order to guarantee the healthcare systems survival during and after this unprecedented healthcare crisis. Notwithstanding, the high exposure and involvement in emotionally overwhelming situations and the close and continuous contact with patients and families' negative emotions, risks to drain healthcare providers’ resources with possible consequences on the long run. Methods. We had proof of this phenomenon in a cross-sectional study we conducted on 1150 health professionals during the early outbreak of the COVID-19 Italian pandemic. Here, we summarize details of the 376 healthcare workers who directly assisted COVID-19 patients. Results. Results revealed that clinicians' reporting higher empathy were the personnel that suffered the most from psychosomatic symptoms, r = .149, p = .008). Conclusion. This finding demonstrated the possible "side effects" of empathic communication as a "risky strength" of health professionals. Practical implications. This study suggests the need to supply healthcare workers with "psychological self-protective equipment" capable of mitigating the massive impact of this emergency on their present and future wellbeing.


Correspondence
Empathic communication as a "Risky strength" for health during the COVID-19 pandemic: The case of frontline Italian healthcare workers The COVID-19 outbreak has been extraordinarily demanding for healthcare systems worldwide. During the first months of 2020, Italy has faced one of the heaviest outbreak, with over 100179 confirmed cases and around 28884 deaths [1,2]. Furthermore the Italian healthcare system was on the verge of total collapseat least in the regions most affected by the virus spread, such as Lombardy -and more than 4,500 healthcare professionals were infected as of April 30.
While specialized intensive care units in Italy were overwhelmed by the increasing number of cases, healthcare providers who did not have expertise in infectious disease treatment stepped up to provide care for patients with COVID-19 [1]. As the epidemic curve increased, many healthcare providers voluntarily joined the epidemic control efforts, and 1500 healthcare providers (including 300 physicians and 500 nurses) from across Italy voluntarily came to the most affected Italian regions to offer their support. Unanimous -across healthcare specialties -was their sense of responsibility to relieve patients and families' suffering and the need to put coordinate efforts to safeguard the whole country from the virus spread.
In the face of this unpredictable disease and its related safety risks, healthcare providers feared infection and worried about their loved ones, but they still joined the institutional call to give their professional contribution to contain the epidemic and showed a limitless spirit of empathy. Finset and colleagues [3] suggested that this characteristic is expected to be a key factor in fighting the COVID-19 pandemic in order to guarantee the healthcare systems' survival during and after this unprecedented healthcare crisis. Nonetheless, although empathy is essential inpatient-doctor interactions, it might also be a challenging task for clinicians, often helped by mutual trust [3]. Indeed, the high exposure and involvement in emotionally distressing situations and the need to acknowledge patients and families' negative emotions risk to drain healthcare providers' psychological and physical resources with possible consequences on the long run [4,5].
The authors of this letter encourage to take into serious consideration the fact that, while some studies have shown that clinicians' empathy positively impacts on quality of care, it should not be forgotten that more empathic clinicians might be at higher risk of distress [6]. We had proof of this phenomenon in a crosssectional study that we recently conducted on 1150 Italian health professionals during the early outbreak of the COVID-19 Italian pandemic. Here, we summarize details of the 376 healthcare workers who directly assisted COVID-19 patients. They were invited to fill an online questionnaire includingin addition to information on demographic and professionals aspects -the following items: self-report items designed to assess healthcare professionals' empathic attitude in terms of their perspective taking ability (e.g. item: A health care professional who is able to view things from another person's perspective can provide patients' with better care) and a list of psychosomatic symptoms adapted from the Copenhagen Psychosocial Questionnaire [7]. Table 1 describes more in details the sample characteristics. Results revealed that clinicians' higher empathy exposed them to suffer from more psychosomatic symptoms as demonstrated by significant correlations between the average experience of symptoms and the Perspective Taking score (r = .149, p = .008). This finding might complement reflections by Finset and colleagues by adding knowledge about the implications of empathic communications for the clinicians' wellbeing and demonstrates its possible "side effects" as a "risky strength" of health professionals.
The crucial role of healthcare providers in this unprecedented crisis is not in doubt; still healthcare professionals face great challenges and are at high risk of distress due to their empathic response. While attitude to empathy is an key personal feature of healthcare professionals and buffers the effects of burnout, it also seems to expose personnel to more frequent psychosomatic symptoms. Our study provides early insight into the psychophysical consequences that Italian healthcare workers are experiencing. This shows the need to supply them with "psychological self-protective equipment" capable of mitigating the massive impact of this emergency on their actual and future wellbeing [8,9]. Post-pandemic research has suggested to provide healthcare workers with psychological supports based on models of psychological adjustment and resilience. The efficacy of debriefing and psychological first aid, help-lines and support groups for professionals has also been documented. Healthcare institutions have ethical duties to reflect on the work-related stressors when the Covid-19 emergency will be over [10,11].

Contributors
All authors had full access to all the data in this study and take responsibility for the integrity of the data and the accuracy of the data analysis. SB and LP contributed equally and share the corresponding authorship. SB conceived of and designed the study. LP run the analysis. SB and GG supervised data collection and analysis. All authors contributed to reviewing and editing the manuscript.

Ethics committee approval
The study we mentioned in this letter receive the approval by the Ethic Commission of the Department Psychology of the Catholic University of Milan -Italy (IRB n : 04_2020).

Declaration of Competing Interest
We declare no competing interests.