American Journal of Pharmaceutical Education 2017; 81 (4) Article 74.

RESEARCH Emotional Intelligence and its Effect on Pharmacists and Pharmacy Students with Autistic-like Traits Yuji Higuchi, MD, PhD,a Masatoshi Inagaki, MD, PhD,b Toshihiro Koyama, PhD,a Yoshihisa Kitamura, PhD,a Toshiaki Sendo, PhD,a Maiko Fujimori, PhD,c Hitomi Kataoka, MD, PhD,a Chinatsu Hayashibara, MS,a Yosuke Uchitomi, MD, PhD,d Norihito Yamada, MD, PhDa a

Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan Okayama University Hospital, Okayama, Japan c Center for Suicide Prevention, National Institute of Mental Health, National Center for Neurology and Psychiatry, Tokyo, Japan d Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center, Tokyo, Japan b

Submitted January 13, 2016; accepted February 18, 2016; published May 2017.

Objective. To measure whether Emotional intelligence (EI) would minimize the negative association between autistic-like traits (ALT) and empathic behavior and enhance the positive association between ALT and psychological distress. Methods. Our sample population included 823 hospital pharmacists belonging to a district society, and 378 pharmacy students. Analyses were performed to examine relationships between scores on the Emotional Intelligence Scale (EQS), Autism-Spectrum Quotient (AQ), Jefferson Scale of Empathy (JSE), and General Health Questionnaire-12 (GHQ). Results. Complete answers were obtained from 373 pharmacists, and 341 students. EQS partially intervened the associations between AQ and JSE and between AQ and GHQ. Conclusion. EI partially intervened the relationships between ALT and empathy, and between ALT and mental health, both of which are necessary for optimal pharmaceutical practice. Keywords: autistic-like traits, emotional intelligence, empathy, pharmacy education, psychological distress

facilitate empathic connections with patients and coworkers, as well as intrapersonal self-regulatory and stress-coping strategies that may help prevent psychological distress during their practice.5 We hypothesized that emotional intelligence (EI) theories would be useful components of pharmacy education for both students and licensed pharmacists. Daniel Goleman originally developed the concept of EI in the context of business,6 and Salovey and Mayer expounded a definition: “the ability to perceive accurately, appraise, and express emotion; the ability to access and/or generate feelings when they facilitate thought; the ability to understand emotion and emotional knowledge; and the ability to regulate emotions to promote emotional and intellectual growth.”7 Goleman also pointed out the importance of EI in clinical medical settings.8 Unlike stable personality traits, EI can be viewed as a set of skills that can be taught, learned and developed.9,10 Hence, EI has been included in medical education for various health professionals such as physicians, nurses, and dentists.11-16 Additionally, students in a pharmacy communications course expressed positive perceptions of the importance

INTRODUCTION Despite advancements in medical technology, the therapeutic relationship between medical staff and patients remains essential to quality care.1 Patients consider empathy to be a basic component of all therapeutic relationships.2 Interpersonal communication skills that demonstrate empathy are important for pharmacists because they use these skills daily when counseling patients or communicating with physicians and other pharmacists.3 Pharmacists also need these skills to manage interpersonal incidents, such as interactions with upset patients.4 Negative interpersonal incidents may cause psychological distress among pharmacists. This stress may be alleviated via intrapersonal self-regulatory stress coping strategies. Pharmacy educators should teach students how to develop interpersonal behavioral skills that Corresponding Author: Masatoshi Inagaki, Department of Neuropsychiatry, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama 700-8558, Japan. Tel: 181-86-235-7242; Fax: 181-86-235-7246. E-mail: [email protected]

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American Journal of Pharmaceutical Education 2017; 81 (4) Article 74. of EI.17 One study reported that EI levels among graduates of a pharmacy leadership academy, which teaches specific skills related to communication and leadership, were significantly higher than those of a control group (p,.05) of students currently enrolled but had yet to graduate.18 Autism spectrum disorders (ASDs) are characterized by problems with social interaction, communication, and repetitive behaviors. ASDs are also associated with atypical empathic processing, and individuals with ASDs have difficulties comprehending and predicting the intentions and behaviors of others, as well as experiencing vicarious emotions.19,20 The autism scale ranges from typical development at one end to classic autism at the other, with ASD somewhere in between.21 Given this continuous view, there is growing evidence that individuals with sub-threshold autistic-like traits (ALT) may not just comprise certain relatives of those diagnosed with ASD, but may also include members of the general population.22 ASD is generally regarded as an inborn and lifelong condition, with treatment aimed at minimizing associated characteristics. In contrast, EI may be changeable. Thus, it is possible that individuals with ASD might be able to compensate for some of their functional impairments by increasing their level of EI. EI comprises some elements of social-emotional functioning that are often impaired in individuals with ALT, such as understanding and regulating emotion.23 In addition, comparing individuals with ASD to typically developing adults has revealed a negative association between ALT and EI in individuals with ASD.21,23 We previously reported that hospital pharmacists demonstrating high levels of ALTs are less likely to have the empathic attitudes necessary for building therapeutic relationships. Such individuals tend to experience high levels of psychological distress.24 Therefore, we hypothesized that EI would minimize the negative association between ALT and empathic behavior and enhance the positive association between ALT and psychological distress.

self-administered questionnaires to the participants along with a written description of the aim, methods, risks, and benefits of the study, and emailed reminders eight weeks after sending the questionnaires. Participants were asked to complete the questionnaires anonymously. With the approval of the Ethics Committee, we assumed that the return of questionnaires constituted informed consent. The second group of participants comprised of pharmacy students from three of the four universities in some districts that offer pharmacy programs; the fourth university declined to participate. Participants were fifth- and sixth-year students attending national public university A; sixth-year students from private university B; and fifth-year students from private university C. All students had either completed or were attending the interpersonal practice component of their pharmacy course at their universities. Data collection from students took place in the first semester of 2013 (university A on April 8, university B on May 21, and university C on July 28). All students who were recruited participated as a group on a scheduled day at their university. Before completing the questionnaires, a researcher briefly informed all student participants about the purpose of the study. They were assured that their participation was entirely voluntary and anonymous, and that their answers would be kept private and used for research purposes only. The EQS is a 65-item questionnaire designed to assess emotionally intelligent behavior, which provides an estimate of one’s underlying emotional and social intelligence.25-27 Each item presents a statement, and respondents are asked to state how much the statement applies to them using a 5-point Likert scale that ranges from 0 (not at all) to 4 (extremely). Total EI score ranges from 0 to 252. The EQS comprises three subscales (each with a score ranging from 0 to 84): intrapersonal factors for emotion regulation, interpersonal factors for properly maintaining social communication, and situational factors for controlling ability to properly and selectively use interpersonal or intrapersonal factors in response to changes in conditions.27 Intrapersonal items include statements such as, “I can suppress my feelings, depending on the situation.” Interpersonal items include statements like, “I do not want to say something that would hurt an opponent.” Situational items are statements like, “I can adjust well to changing situations” and “I am careful not to ruin a pleasant atmosphere.” The development of the psychometric properties of this instrument and instructions for using it are described in detail in the EQS manual.27 The scale was developed in Japanese and standardized for use with Japanese subjects.27 The Cronbach’s coefficient a of the three subscales are 0.894, 0.915, and 0.915, respectively, and the Pearson’s r correlation coefficients of test-retest

METHODS This study was approved by the Ethics Committee of the Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences. Participants consisted of two groups: licensed pharmacists and pharmacy students in Japan. The first group was comprised of licensed pharmacists of a society of hospital pharmacists in a specific district in Japan (n5823) who were working at a hospital for patient care. We contacted the pharmacy representatives at all of the hospitals in the district to invite all pharmacists belonging to the district society to participate in the study. We posted 2

American Journal of Pharmaceutical Education 2017; 81 (4) Article 74. reliability for the three subscales are 0.747, 0.612, 0.797, respectively, among the adult general population in Japan.27 The EQS scale has two quality control items to identify respondents who fail to read the questions thoroughly or misunderstand them. Typically, about 1% of respondents answer these two questions incorrectly. We excluded such respondents from our analyses. The AQ is a 50-item questionnaire that, like the EQS, requires respondents to state how well each item statement describes them. The AQ employs a 4-point Likert response scale ranging from 1 (not at all) to 4 (very well), and uses a dichotomous scoring method (0–0–1–1), which was designed to measure ASD traits in adults with normal intellectual ability.28 The AQ comprises five dimensions: social skills, attention-switching, attention to detail, communication, and imagination. The total score ranges from 0 to 50, with higher scores reflecting more severe symptomatology. The AQ can distinguish between groups of individuals with ASD and age-matched controls.28 The Japanese version of the AQ shows remarkably similar results compared with the original instrument in both the general population and in clinical groups. The cut-off point for ASD is a score of 32.29 The JSE is a 20-item questionnaire with a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). It was developed to measure empathy in the context of medical education and patient care,30,31 and its construct validity, internal consistency, and test–retest reliability have been confirmed.30,32 The total score ranges from 20 to 140, with higher scores signifying more desirable empathic behavior. Significant associations between JSE scores and health indicators, such as patient levels of hemoglobin A1c and low-density lipoprotein, support the hypothesis that more empathetic physicians produce better patient outcomes.33,34 As this version was the only option that had been validated for a Japanese sample, we used the Japanese S-Version (JSE), which was originally designed for medical students, and changed “Physicians” to “Pharmacists.”35 The GHQ-12 (GHQ) is a 12-item questionnaire that asks participants to use a 4-point Likert scale to express the degree to which each item describes oneself, from 0 (not at all) to 3 (very well). The GHQ assesses psychological distress of patients in general health care settings.36 In the present study, we used the full Likert response scale for scoring (0-1-2-3), rather than the more common dichotomous scoring (0–0–1–1) for statistical analyses, because this method produces a wider and smoother score distribution and has adequate validity.36 Thus, the total score ranged from 0 to 36, with higher scores representing higher levels of psychological

distress. This scale has been well-validated for the general Japanese adult population. 37 This study was a secondary analysis that had been previously planned. Significant associations between AQ and JSE/GHQ have already been reported as a primary result.24 All analyses were performed using IBM SPSS, version 22 (IBM Japan, Tokyo, Japan). An a priori statistical significance level was set at p,.01. Demographic information (age, sex, years in practice or years in school) was analyzed using descriptive statistics. To evaluate the possibility that EI may intervene the relationships between AQ and JSE/GHQ, we investigated the effect of total EQS score on these relationships (Figures 1 and 2). This analysis was performed with stratification by professional level (pharmacist or student), because the sampling method for each was different. The sizes of the indirect effects of AQ on JSE/GHQ through the EQS were estimated using a bias-corrected bootstrapping method38 with 1000 replications, and bootstrapped 99% confidence intervals (CIs) were obtained. The outcome variable was the JSE or GHQ score, and the independent variable was the AQ score. The intermediator was the total EQS score (Figures 1 and 2). We further controlled for sex and age. To explore how each subscale of the EQS intervened the relationships between AQ and JSE/GHQ, we conducted post-hoc analyses in which we substituted each subscale score of the EQS for the total score. According to the manual, subscales should be correlated very strongly with one other,27 and multicollinearity was expected when the three subscales ware simultaneously used as independent variables. Thus, we did not include all of the subscales in a model at once. These post-hoc analyses were performed without stratification, to increase statistical power.

RESULTS After the exclusion of questionnaires with answers that failed to meet the quality control standard of the EQS (eight pharmacists and six students), usable data were obtained from 373 pharmacists from 92 hospitals and 341 students from three universities. The sample population of pharmacists numbered 823; therefore, the response rate was 45.3% (5373/823) for this group. Compared with the officially reported data for the general population of pharmacists (a median of 11 years of work experience after qualification as a pharmacist, and a median of 318 hospital beds), there were no clear differences in the demographic variables of our participants. The response rate of the students was 90.2% (5341/378): 31 students whom we were unable to contact did not participate. 3

American Journal of Pharmaceutical Education 2017; 81 (4) Article 74.

Figure 1. Regression Coefficients in the Model (Pharmacists)

Demographic summaries of the respondents are shown in Table 1. Figures 1 and 2 show the results of the analyses. In the models without EI intervention, the AQ scores of both students and pharmacists showed significant inverse path coefficients for JSE scores (c1: p,.001, c2: p,.001) and significant positive path coefficients for GHQ scores (C1: p,.001, C2: p,.001). In the models with indirect effect of EI intervention, the bootstrapped 99% confidence intervals of a1 3 b1, a2 3 b2, A1 3 B1 and A2 3 B2 did not include zero, which indicated that all the intervention of EQS for the relationships between variables in the models were significant. We observed remaining significant direct effects of AQ scores of students and pharmacists on the GHQ (C91: p,.01, C29: p,.001) but not the JSE (c91: p5.754, c92: p5.111). For confirmation, we performed the same analyses adjusting for age (excluding 13 pharmacists who were missing age data), sex, and certification status (certified or not). We obtained similar results. As the results of the analyses produced similar data for the students and pharmacists, we combined these two groups for subsequent post-hoc analyses. The results of these analyses for each subscale of the EQS are shown in

Table 2. In the model without EI intervention, AQ had a significantly negative impact on JSE, and a significantly positive impact on GHQ, as was found when the two samples were analyzed separately. In the model with indirect effect of EI intervention, the indirect path of AQ through the interpersonal factor of EQS (A43B4) was not significant for JSE, although the other indirect paths (a33b3, a43b4, a53b5, A33B3, and A53B5) were significant (p,.01). In contrast, the direct paths (c’4 and c’5) of AQ on JSE in the models with mediation by interpersonal or situational factors of EQS were not significant, although the other direct paths (c’3, C’3, C’4, and C’5) in the mediation model were significant (p,.01).

DISCUSSION Our data verified the hypothesis that the negative associations between AQ and JSE and the positive relationship between AQ and GHQ would be partially intervened by EQS in a sample of pharmacists and pharmacy students. Furthermore, the direct path between AQ and JSE in the EQS mediation models (5c91, c92) was not significant, indicating that the substantial empathic attitude required for pharmacists could be improved 4

American Journal of Pharmaceutical Education 2017; 81 (4) Article 74.

Figure 2. Regression Coefficients in the Model (Students)

regardless of ALT. However, given that the direct path between AQ and GHQ in the EQS mediation model (5C91, C92) remained significant, even improved EI may not be sufficient to exclude all of the adverse effects of ALT on mental health. It has been argued that empathy may vary according to the career characteristics of the pharmacist, such that hospital pharmacists who have daily opportunities for direct patient contact may need to show greater empathy compared with those who mainly engage in dispensing.39 However, in clinical settings, pharmacists are identified as essential members of a collaborative care team and are needed to communicate with patients and other professionals, as dictated by the palliative care team system that was enacted in response to Japan’s 2007 Cancer Control Act. Thus, we urgently hope for an educational intervention designed to teach the interpersonal emotion comprehension skills necessary to ensure strong therapeutic relationships, and intrapersonal emotion regulation for emotion management and stress reduction in pharmacists. Based on our results, future studies could examine whether interventions to improve EI in intrapersonal, interpersonal, and situational domains could partly address the challenges produced by ALT, even if ALT itself is resistant to change as individuals age.

Intrapersonal, interpersonal, and situational domains evaluated by the subscales of the EQS mediated the relationship between AQ and JSE. A communication skills training (CST) program based on patient preferences,40 though not founded on EI, has been shown to meaningfully improve empathic behavior of health professionals, and as a result reduced depression of patients.41 Providing reassurance and addressing patient emotions with empathic responses, which are skills included in the CST, may overlap with the interpersonal factor of the EQS. Thus, a CST that incorporates a component specifically devoted to improvement in the interpersonal domain of EQS may facilitate improvement in the empathic attitude of individuals with high ALT. In contrast, the intrapersonal and situational domains of the EQS mediated the relationship between AQ and GHQ. Mindfulness-based stress reduction (MBSR), which is closely related to emotion regulation42 and thus relevant to the intrapersonal domain of EQS, is a technique for teaching individuals to attend to the present moment in a nonjudgmental, accepting manner. The goal of MBSR is to reduce psychological distress,43 and this therapy has been found to be effective in individuals with ASD.44 Thus, an educational intervention that targets improvement in the intrapersonal domain of 5

American Journal of Pharmaceutical Education 2017; 81 (4) Article 74. Table 1. Demographic Characteristics of Participants Gender

pharmacists (n5373) students (n5341) all (n5714)

Age *n513, missing

pharmacists (n5360) * students (n5341) all (n5701) * pharmacists(n5373) pharmacists(n5373)

Years After Qualification Hospital Beds EQS Total

EQS Intrapersonal

EQS Interpersonal

EQS Situation Management

AQ

JSE

GHQ-12

pharmacists (n5373) students (n5341) all (n5714) pharmacists (n5373) students (n5341) all (n5714) pharmacists (n5373) students (n5341) all (n5714) pharmacists (n5373) students (n5341) all (n5714) pharmacists (n5373) students (n5341) all (n5714) pharmacists (n5373) students (n5341) all (n5714) pharmacists (n5373) students (n5341) all (n5714)

Male 145 100 245 Mean 37.4 24.4 31.0 13.6 467.0 Mean 119.1 129.0 123.8 42.38 45.34 43.8 40.2 45.23 42.6 36.55 38.45 37.45 19.8 19.2 19.5 108.7 112.5 110.5 14.9 15.3 15.1

% 38.9 29.3 34.3 Median 34 24 26 11 366 Median 126 120 124 43 45 44 40 45 42 37 38 37 19 19 19 109 113 111 14 15 15

Female 228 241 469 SD 10.8 2.4 10.3 11.4 333.3 SD 32.9 33.5 33.6 11.8 11.9 11.9 11.834 12.7 12.5 13.241 13.4 13.3 7.3 6.7 7.0 12.4 11.4 12.1 4.7 4.7 4.7

% 61.1 70.7 65.7 Range [24–66] [22–43] [22–66] [0-44] [19-1182] Range [15–223] [49–223] [15–223] [6–79] [17–75] [6–79] [6–80] [11–78] [6–80] [3–82] [6–79] [3–82] [5–41] [6–40] [5–41] [58–140] [76–139] [58–140] [4–32] [3–32] [3–32]

Full Range [0–252]

[0–84]

[0–84]

[0–84]

[0–50]

[20–140]

[0–36]

Abbreviations: EQS: Emotional Intelligence Scale; AQ: Autism-Spectrum Quotient; JSE: Jefferson Scale of Empathy; GHQ-12: General Health Questionnaire-12; SD: standard deviation

EQS may be effective for reducing psychological distress among those with high ALT. Indeed, enhancing existing CSTs to include a greater focus on the interpersonal domain of the EQS as well as incorporating MBSR, which may strengthen the intrapersonal domain of the EQS, may improve empathic attitudes without impairing mental health among individuals with high ALT. The development and verification of new interventions incorporating EI improvement are eagerly anticipated. Our study has several limitations. As this study was cross-sectional, the causality between variables cannot be defined from our data. Questionnaires were selfcompleted by the pharmacists and pharmacy students; therefore, the possibility of self-selection and self-report biases must be considered. Our data were only from pharmacists in a rural association and students from three

universities; the convenience sample of students did not include a representative range of Japanese pharmacy students according to sex, year of study, or school characteristics. The response rate of the pharmacists was less than 50%. Because we indirectly requested their participation through the representatives of the pharmacy, there may have been selection bias. Although results from the pharmacist and student samples were similar, bias caused by the sampling process cannot be ruled out. These limitations may affect the generalizability of our study to other populations.

CONCLUSION We showed that among pharmacists and pharmacy students, EI partially mediated both the negative effect of ALT on empathic attitude and the positive effect of ALT on psychological distress. From our results, we suggest 6

American Journal of Pharmaceutical Education 2017; 81 (4) Article 74. Table 2. Regression Coefficients Between Variables in the Mediation Models Without Stratification Association between AQ and JSE Mediated by Subscales of EQS Without Stratification AQ on JSE mediated by a3: 0.56a b3: 0.31a a3 3 b3: 0.17b [ 0.27 to 0.11, Bootstrap 99% CI] a intrapersonal factor of EQS c3: 0.35 c93(5 c a3 3 b3): 0.18 b a a AQ on JSE mediated by a4: 0.70 b4: 0.37 a4 3 b4: 0.2598b [ 0.36 to 0.17, Bootstrap 99% CI] a interpersonal factor of EQS c4: 0.35 c94(5 c a4 3 b4): 0.09 AQ on JSE mediated by a5: 1.02a b5: 0.16a A5 3 b5: 0.16b [ 0.26 to 0.053, Bootstrap 99% CI] a situational factor of EQS c5: 0.35 C95(5 c a5 3 b5): 0.19 Association between AQ and GHQ-12 mediated by subscales of EQS without stratification AQ on GHQ-12 mediated by A3: 0.56a B3:-0.09a A3 3 B3: 0.05b [ 0.03 to 0.08, Bootstrap 99% CI] a intrapersonal factor of EQS C3: 0.30 C93(5 C A3 3 B3): 0.24a a AQ on GHQ-12 mediated by A4: 0.70 B4:-0.03 A4 3 B4: 0.02 [ 0.01 to 0.05, Bootstrap 99% CI] interpersonal factor of EQS C4: 0.30a C94(5 C A4 3 B4): 0.28a a a AQ on GHQ-12 mediated by A5: 1.02 B5:-0.11 A5 3 B5: 0.11b [ 0.07 to 0.16, Bootstrap 99% CI] a situational factor of EQS C5: 0.30 C95(5 C A5 3 B5): 0.19a Indirect effects of AQ on JSE and GHQ-12 through EQS (a,b; A, B) were estimated Bootstrap 99% Confidence Intervals (CI) evaluated these indirect effects Partialling out control variables of qualification status and sex Regression coefficients (a, b, c, c9, A, B, C, C9) are illustrated in Figure 1 and Figure 2 Abbreviations: AQ: Autism-Spectrum Quotient; JSE: Jefferson Scale of Empathy; GHQ-12: General Health Questionnaire-12; EQS: Emotional Intelligence Scale a p,.001 b p,.01

that EI is a promising clue in the search for a remedy for the adverse effects of ALT on empathetic attitudes, which foster both good practice and mental health in health care practitioners. Future studies may focus on the development of new interventions that address all three domains of the EQS.

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ACKNOWLEDGMENTS This work was supported in part by Research for Promotion of Cancer Control Programmes (H26-politicalgeneral-002) from the Ministry of Health, Labour, and Welfare, Japan. The authors thank the Okayama Society of Hospital Pharmacists and all the participants for their involvement.

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Emotional Intelligence and its Effect on Pharmacists and Pharmacy Students with Autistic-like Traits.

Objective. To measure whether Emotional intelligence (EI) would minimize the negative association between autistic-like traits (ALT) and empathic beha...
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