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A review of empathy education in nursing

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 Nursing Inquiry 2010; 17(1): 65–74

Feature

A review of empathy education in

nursing
Scott Brunero, Scott Lamont and Melissa Coates
Prince of Wales Hospital, Sydney, Australia

Accepted for publication 6 September 2009

BRUNERO S, LAMONT S and COATES M. Nursing Inquiry 2010; 17: 65–74

A review of empathy education in nursing
The ability for nurse educators to improve the empathy skill set of nurses has been the subject of several studies with varied out-
comes. The aim of this paper is to review the evidence for empathy education programmes in nursing and make recommenda-
tions for future nurse education. A review of CINAHL, Medline, Psych Info and Google Scholar was undertaken using the
keywords empathy, person centredness, patient centredness, client centredness, education and nursing. The studies included
were required to have measured the effectiveness of empathy training in postgraduate and or undergraduate nurses. The
included studies incorporated both qualitative and quantitative methods and were published in peer-reviewed journals. Studies
were ranked for level of evidence according to The Joanna Briggs Institute criteria. Seventeen studies from the literature review
were found that met the inclusion criteria. Of the 17 studies, 11 reported statistically significant improvements in empathy
scores versus six studies that did not. Several variables may affect empathy education that need to be accounted in future stud-
ies such as; gender, cultural values and clinical speciality experience. Models of education that show most promise are those
that use experiential styles of learning. The studies reviewed demonstrated that it is possible to increase nurses’ empathic
ability.

Key words: education, empathy, nursing, person centredness, training.

Engaging patients is seen as a critical part of the nurse–
patient relationship with empathy being reported as an inte-
gral component of the relationship (McCabe 2004; Stein-
Parbury 2005; Innes, Macpherson, and McCabe 2006).
Reynolds, Scott, and Jessiman (1999) argued that the pres-
ence of empathy is critical to the development of the thera-
peutic relationship, while Kalish (1971) suggests that
empathy was the most important component of such a rela-
tionship. The use of empathy has been well documented
across the health professions as a means of engaging
patients; by nurses (Reynolds and Scott 2000), medical staff
(Kim, Kaplowitz, and Johnston 2004), pharmacists (Lonie
et al. 2005) and dentists (Molen, Klaver, and Duyx 2004).
Correspondence: Scott Brunero, Mental Health Liaison Nursing, Prince of Wales
Hospital, EBB, NERU, rm 7, High St, Randwick, 2031 NSW, Australia.
E-mail: <scott.brunero@sesiahs.health.nsw.gov.au>; <scottbrunero@
hotmail.com>
Empathy has been proposed to be the ability to perceive
the meaning and feelings of another and to communicate
those feelings to the other person (Stein-Parbury 2005).
Empathy as a therapeutic tool has its origins in the work of
Carl Rogers (1959) who saw empathy as a core of his person-
centred approach to counselling. Rogers (1959) describes
empathy as: the state of perceiving the internal frame of ref-
erence of another person, with accuracy and with emotional
components and meanings that pertain to it, as if one were
with the other person, but without the loss of the as-if condi-
tion (Rogers 1959).
Barret-Lennard (1981) suggests that empathy is a cyclic
model involving the following stages; understanding and
recognising the other person (empathee’s) emotions,
communicating this understanding to the empathee and
recognising that this has been understood. Hojat et al.
(2002) views empathy in two parts: cognitive empathy and
affective empathy. The cognitive domain involves the abil-
ity to understand another person’s inner experience and

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S Brunero, S Lamont and M Coates
feelings, with an ability to view the outside world from the
other person’s perspective. The affective domain involves
the entering into or joining in the emotional experience
of the other, which may also define sympathy (Hojat et al.
2002). While it maybe difficult for health professionals to
function solely in one domain, the health professional
who acts in the affective domain could lose their objectivity
and become overwhelmed by the emotions of the patients
in their care. The affective domain of empathy has also
been described as a maladaptive human response (Hojat
et al. 2002).
Several previous studies have attempted to demonstrate
the effectiveness of the use of empathy within health-care.
Reynolds and Scott (2000) report a positive relationship
between empathy and patient responses such as; relief from
pain, improved pulse and respiratory rates, and clients self-
report of worry and distress. Williams (1979) showed that
nurses, who displayed high levels of empathy to institution-
alised elderly patients, found that these patients experienced
a statistically significant improvement of self-concept, as
understood by a reduction in dehumanisation and deper-
sonalisation. LaMonica et al. (1987) found less anxiety,
depression and hostility in cancer patients being cared for by
nurses who show high levels of empathy. Reynolds and Scott
(2000) report that the quality of client’s self-disclosure was
found to be associated with the level of empathy used by
nurses. Efforts to use empathy skills, understand their influ-
ence on patient care and the ability of nurse’s to apply these
skills would appear warranted.
METHOD
Given that the aim of the study was to review the outcomes
of empathy programmes in nursing and make recommenda-
tions for future nurse education, a review of CINAHL, Med-
line, Psych Info and Google Scholar was undertaken using
the keywords empathy, person centredness, patient centred-
ness, client centredness, training, education and nursing.
Included studies were required to measure the effectiveness
of empathy levels in postgraduate nurses and or undergradu-
ate nurses, be either qualitative or quantitative in their
research design and had been published in a peer-reviewed
journal. Excluded studies were that of other professional dis-
ciplines. The time period for the publication of the studies
was left open as the volume of papers is limited. The studies
included in the review were analysed using a method sug-
gested by The Joanna Briggs Institute (2007). Articles that
contained quantitative data were ranked in terms of levels of
evidence, with level 1 being evidence obtained from reviews
66
of all randomised control trials (RCTs), level 2 being
obtained from at least one properly designed RCT, level 3
(I) being obtained from a well designed control trial without
randomisation, level 3 (II) being obtained from a compara-
tive study without randomisation but with control and alloca-
tion, level 3 (III) being obtained from a comparative study
with the control being historical and level 4 being obtained
from case series, audits, questionnaires, surveys and litera-
ture reviews (The Joanna Briggs Institute 2007). In an
attempt to understand the educational methods used within
the studies, all the studies were analysed for the learning
style described within the training programmes as defined
by Laschinger and Boss (1984) and Burnard (1992).
RESULTS
Seventeen studies from the literature review were found that
met the inclusion criteria. Two populations of nurses have
been primarily studied, undergraduate nurses (table 1) and
postgraduate nurses (table 2). One study combined both
students and postgraduate nurses (Taylor et al. 2009). These
study results are included in with the postgraduate nurses
(table 2), as the authors identified difficulty in determining
how many were students and postgraduates. According to
The Joanna Briggs Institute’s (2007) evidence-level ratings of
studies, two studies met criteria for level 2, seven for level
3(II), seven for level 3(III) and one for level 4. The research-
ers overall felt a need to study empathy training quantita-
tively. A total of nine empathy measurement tools that have
had some level of validation were used in the studies.
A range of qualitative measures such as participant’s satisfac-
tion questionnaires and checklists were used to evaluate the
studies.
The majority of the papers (n = 10) were published
before 2000, with seven being published after this. While
empathy is not a new concept to nursing the more recent pub-
lications do support the currency of empathy education in the
modern nursing environment. Most of the studies were com-
pleted in the UK or North America, with the study completed
by Fatma (2001) in Turkey. Cultural variations on empathy
were not discussed within the studies, yet nurses work within a
wide range of diverse cultural and language groups.
Clinical specialties of the nurses within the studies
included; four generalist nursing studies, one palliative care
nursing study, two medical ⁄ surgical nursing studies, one
oncology study and one women’s health nursing study.
While a broad range of nursing specialties are described,
little is discussed in the literature on the varying levels of
empathic nursing skills needed for the nursing specialities
(Cutcliffe and Cassedy 1999).
 2010 Blackwell Publishing Ltd
 Table 1 Undergraduates studies

Sample and method

Author Evidence level Include speciality Measures Intervention Outcome
Cinar and 3(III) Undergraduates nurses Empathic skill scale 4-year undergraduate course Empathy significantly increased
Cevahir n = 139 Experiential between second and fourth year
(2007)
Cutcliffe and 3(III) Quasi experimental Ivey empathy rating scale 12-day short skills-based course Statistically significant improvement

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Cassedy n = 38 Experiential in empathy scores
(1999) Undergraduates
Hodges 2 Undergraduates nurses, Video tape of students’ post 13 hours over 3 weeks, for No significant difference between
(1991) general nurses education, rated by the empathy education and groups
n = 13 empathy education patient interview assessment psychological mindedness
versus n = 13 psychological schedule education
mindedness education Experiential
Nardi 3(III) Post test control group design Gazda empathy scale 3 hours of education, 2 hours Statistically significant improvement
(1990) n = 35 student nurses for testing for intervention group
Experiential
Rogers 3(III) Undergraduates nurses n = 135 Empathy construct rating Baccalaureate undergraduate Not significant
(1986) females scale nursing programme
Non-experiential
Evans et al. 3(III) Pre–post test undergraduate Layton empathy tests 3-year nursing degree Empathy skills learnt in
(1998) Bachelor of Nursing course Hogan scale Non-experiential undergraduate course not sustained
students
n = 10
Wikstrom 4 n = 428, first-year undergraduate Critical discussion group Visual art programme to 85% of students reported on themes
(2001) nurses increase empathy (small group of empathy
Sample selected randomly from work). Students studied Visual art programme stimulated
among eight university colleges Edward Munch’s The sick students to discuss and write about
child and interpreted with a empathy
focus on personal knowledge
of empathy
Experiential

67
Empathy
 Table 2 Postgraduate studies

68
Evidence Sample and method
Author level Include speciality Measures Intervention Outcome
Wallston 3(II) Controlled trial Nurse responses audio 450-word statement, Intervention group showed
et al. (1978) n = 24 controls taped transcribed and containing elements of a significant increase in person-
n = 20 intervention analysed for difference helpful response, with centredness
Postgraduates between groups illustrative examples of
empathy
S Brunero, S Lamont and M Coates

Non-experiential
Ancel (2006) 3(III) Pre–post test Empathic communication 5 days of education Statistically significant improvement
n = 263 nurses skill B, participants Experiential for intervention group
Postgraduates satisfaction form
Razavi 2 Pre–post, longitudinal and Reading of a role play with 105 hours of education follow Trend upwards in use of emotionally
et al. 2002 randomised an actor, rating of words up at 3 and 6 months laden words
n = 115 oncology nurses used Experiential
n = 57 intervention
n = 58 control
LaMonica 3(II) Evaluation of patients Multiple affect adjective 14- to 16-hour programme used, Clients cared for by nurse trained
et al. (1987) after nurse education on checklist topics helping model, empathic group showed significantly less
empathy skills La Monica ⁄ Oberst patient responses, communication hostility and anxiety than controls
n = 56 nurses intervention satisfaction scale theory, perception of verbal
n = 53 controls Empathy construct rating and non-verbal feelings,
n = 656 patients scale ineffective communication
Postgraduates styles, care of oneself
Experiential
LaMonica 3(II) Pre–post test controlled study Carkuff index of Human relations model, Education significantly raised staff
et al. (1976) 2n = 39 registered nurses communication didactic and experimental empathy levels
Carkhuff Empathy Scale learning, 11 hours in total,
spread over seven sessions
Experiential

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 Table 2 (continued)

Evidence Sample and method

Author level Include speciality Measures Intervention Outcome
Edwards, 3(II) Matched pair, pre–post test study Communications skills 90 minutes educational Statically significant improvement
Peterson, n = 22 (women health nurses) were assessed after case sessions over 12 weeks weekly in the quality of active listening,
and Davies Randomly selected nurses, case scenario read aloud using a or bi weekly case study initiating statements, and frequency
(2006) scenarios read aloud nurses communication skills problem-based approach, then of initiating skills

 2010 Blackwell Publishing Ltd

responded verbally and checklist self-directed reading
then were rated on active Multiple component
listening, assertiveness intervention best practice
skills, etc guideline
Experiential
Fatma (2001) 3(II) Quasi experimental design Dokmens scale of empathic skills 20 hours of empathy skills Empathic communication skills
n = 43 nurses intervention Empathic tendency scale education developed in the intervention group,
n = 70 controls Experiential education did not impact on
empathic tendency levels
Herbek and 3(II) Controlled trial Mehrabian and Epstein emotional 6 hours of intensive education Statistically significant difference
Yammarino Medical surgical nurses Empathic tendency scale over 7 weeks
1990 n = 16 intervention Experiential
n = 19 controls
Yates, 3(III) Postgraduate palliative Staff–patient interaction 14-week group session of 90 Statistically significant improvement
Clinton, care nurses response scale minutes each and peer in empathic ability
and Gary Pre and post test consultation
(1998) n = 181 Experiential
Taylor et al. 3(II) Pre and post Response empathy scale Self-directed learning package, Statistically significant improvement
(2009) n = 201 participants received a in empathic ability
There was difficulty in workbook and DVD, which
determine the difference contained the pre and post
between students and RNs, measures which were returned
which has been noted by mail. Ten hours was the
in the study suggested time to complete the
package
Non-experiential

69
Empathy
S Brunero, S Lamont and M Coates
The interventions described ranged significantly in
length. Two of the studies (Evans et al. 1998; Cinar and
Cevahir 2007) considered the whole undergraduate training
course as the intervention. Within the postgraduate educa-
tion programmes, most programmes ranged from 6 to
105 hours in length, with one education programme consist-
ing of a short reading task (Wallston et al. 1978). Statistically
significant results were evident from the shorter duration
studies 11 hours (LaMonica et al. 1976), with the longest
programme of 105 hours showing only trend improvement
(Razavi et al. 2002). Length of education is a significant vari-
able as there are high costs associated with delivering educa-
tion programmes to nurses. Of the 17 studies 11 described
using experiential learning styles within their training
programmes, with five using didactic styles of learning and
one study using a self-directed learning package (tables 1
and 2, intervention column for each study learning style)
(Laschinger and Boss 1984; Burnard 1992). Of the 11 studies
that used experiential style learning, eight are reported to
have statistically significant positive results on empathy skill
improvement (tables 1 and 2, intervention and outcome
column).
Of the 17 studies, 11 reported improvements in empathy
skill level of participants. In the higher level evidence studies
(level 2), one study showed trend improvement (Hodges
1991), with the other not showing any statistical significant
improvement (Razavi et al. 2002). The small sample size in
the Hodges’ (1991) study (n = 13, intervention group of
undergraduates) would limit the generalisability of the
results. Razavi et al. (2002) had a much larger sample
(n = 57 intervention and n = 58 control) but chose uncon-
ventional measurement methods. This study did not use pre-
viously published validated measurement tools of empathy,
instead asking their participants to rate empathic words after
reading of a role play. Although these two studies attempted
to use higher methodological approaches, they both are lim-
ited by their sample size and choice of measurement tool.
The levels 3(II) and 3(III) studies showed with all but one of
the studies, significant improvements on empathy scores.
Sample sizes in these studies ranged from n = 10 to n = 263,
with the non-significant study by Rogers (1986) having a
large sample of n = 134. Overall sample sizes varied greatly
across the all studies from n = 10 to n = 428.
One of the difficulties with the Rogers’ (1986) study was
the length of intervention they considered, the whole 3-year
undergraduate programme. The levels 3(II) and 3(III) stud-
ies mostly used validated measurement tools, thus enhancing
their chance of demonstrating positive outcomes. The use of
valid and reliable measurement tools are seen as critical part
70
of constructing effective research methodologies (Burns and
Grove 2002).
Overall agreement between researchers regarding the
studies, which showed significant improvement, were pri-
marily characterised by their shorter length of educational
programme and use of a validated measurement tool. The
vast majority of the study samples were dominated by
females, which is typical within nursing studies given the
reported gender bias in nursing research (Polit and Beck
2008).
DISCUSSION
The results yielded a range of measurement tools used which
highlight the need to develop standardised ways to evaluate
changes in empathy as a result of education (Reynolds and
Scott 2000; Ancel 2006; Yu and Kirk 2008). Yu and Kirk
(2008) reviewed measurement tools of empathy (n = 20)
and concluded that there is no consistent use of measure-
ment tools and a strong need to evaluate the rigour of instru-
ments used. Tools that have been developed may not take
into account patient views on empathy, or only measure par-
ticular components of empathy (Ancel 2006). The range of
measurement instruments in the studies reviewed show only
two instruments being used: the empathy construct rating
scale (LaMonica et al. 1987) and the empathic tendency
scale (Epstein 1972).
Understanding the time it takes to impart empathy
skills to nurses is critical as there is an obvious cost to
education. Several studies attempted to evaluate change
in empathy scores in undergraduate education over a 3- to
4-year period. Many variables during the undergraduate
nurse’s education could impact on their empathy skill
level. As an example, the level of clinical exposure and
number of clinical placements in areas of nursing where
the nurse–patient relationship plays a significant part in
care, such as mental health, could impact the level of
nurse’s skill (Rogers 1986; Evans et al. 1998; Cinar and
Cevahir 2007).
There were two studies that showed negative results,
Hodges (1991) and Rogers (1986). Hodges (1991) attri-
butes this to the type of intervention applied and the lack
of reliability and validity of the instrument chosen to
measure the change. Rogers (1986) reports the lack of
measured change in a baccalaureate programme, because
of the difficulty in separating out the empathy specific
parts of education compared to the overall education
programme. Studies completed over long durations have
been reported elsewhere to be limited as there are
 2010 Blackwell Publishing Ltd

variables that are out of control of the researcher (Burns
and Grove 2002).
Empathic responses can be influenced by a number of
variables; personality, gender, interpersonal style, culture,
social confidence, environment and the level of communi-
cation skills that have been learnt (Alligood and May 2000).
Empathy researchers will need to develop a greater under-
standing of these variables to further the ability of educa-
tion to improve empathic response. Chung and Bernak
(2002) discuss the importance of culture and empathy
within a counselling framework. Suggesting the key to being
culturally empathic is to accept the culture, values and
beliefs of others, while retaining your own culturally iden-
tity. There was limited attempt to control for these variables
within the studies reviewed. None of the studies tried to
determine any differences between genders. A probable rea-
son for this is simply the limited number of males within
the nursing profession making sample sizes of males within
the studies too small for analysis. Our ability to empathise
with others is argued to be gender influenced with reports
of males demonstrating less empathic ability than females
(Baron-Cohen 2002; Lawson, Baron-Cohen, and Wheel-
wright 2004).
The use of experiential learning styles was reported in
the majority of the studies’ training programmes. This clear
trend towards its use in empathy training is worthy of pursu-
ing in further studies. Several of the studies describe using
role play and case scenario-based experiential work
(Tables 1 and 2, noted in intervention column as ‘experien-
tial’). Case scenario-based learning is a subset of experien-
tial learning, including aspects of problem-based learning
and simulation, and involves using cases for teaching and
getting students to problem solve clinical scenarios (Delpier
2006). Of the studies reviewed, Edwards, Peterson, and
Davies (2006) used a case study-experiential learning
approach, reporting statistically significant improvements
in nurse’s empathic ability. Its benefits are said to allow
students to test out a variety of clinical styles or judgements
with the minimum of risk (Delpier 2006). Clinical cases can
use realistic content and events to create scenarios that accur-
ately reflect the clinical setting (Krautschield, Kaakinen,
and Rains-Warner 2008). The use of role play within clinical
scenarios allows participants to explore a variety of roles that
may be different to their own. When designing empathy
education, educators need to place the nurse in the role of
patient and the nurse, as to give the nurse the opportunity
to reflect and understand the patient’s emotional state in a
controlled situation (Colier 1999). Reflections on the role
play experience by the participants, is where new concept
formation and learning is achieved (Colier 1999). This may
 2010 Blackwell Publishing Ltd
Empathy
be more didactic, allowing teaching of the advanced com-
munication skills necessary to become empathic. This then
leads to the participant generating new ways of working,
incorporating new skills into their current practice and
reflecting on how it may be useful. Educators should link
the reflection to the new concepts of how empathic behav-
iour can reduce workloads, including more accurate patient
assessment and reduction in patient hostility (Reynolds and
Scott 2000).
Without the experiential aspect of learning, there is a
concern that skills are only taken on superficially, where
knowledge may increase but behaviour change does not.
Ramsden (1992) argues that experiential learning styles can
countenance this and generate the deep learning that is
required. Experiential learning needs to revolve around the
day-to-day work of the nurse and reflect the high demands
that are placed on nurses (Hamilton 2008).
FUTURE IMPLICATIONS FOR EMPATHY
EDUCATION FOR NURSES
Future empathy education needs to consider activities
to enhance self-awareness and assessment of the clinician’s
personal value systems (Halpern 2003). The suggestion here
is that one must increase the understanding of their own
values, before one can attempt to understand another’s
(Reynolds, Scott, and Jessiman 1999; Stein-Parbury 2005).
Stein-Parbury (2005) suggests that identifying accurately with
the patient moves the helping relationship to a more inti-
mate level. As such, being able to distinguish when and
where to use empathy is important as it may be perceived as
an invasion if poorly judged. James (1989) describes emo-
tional burden as being the work generated by dealing with
other people’s feelings. It is argued that being empathic in
an unskilled way can lead to over involvement and in some
cased increase depression (Hojat et al. 2002). The role of
managing ones own emotional response when being
empathic needs to be highlighted in education programmes.
Processes such as clinical supervision have demonstrated
effectiveness on reducing the stress and the emotional
labour of nursing (Brunero and Stein-Parbury 2007).
There was no reflection on the issue of state versus trait
empathy within the studies reviewed. Empathy researchers
could identify study participants empathy skills scores
by using, for example, the Empathy Construct Rating Scale
(LaMonica 1981), which can determine trait empathy. Indi-
viduals with low scores on trait empathy could be identified
for more in-depth training and development. Conversely,
exposing people with high-trait empathy to full training
71
S Brunero, S Lamont and M Coates
may be unnecessary and ultimately lead to a higher cost in
training. Kunyk and Olson (2001) concept analysis found
five conceptualisation of empathy in nursing; (i) as a
human trait, (ii) a professional state, (iii) a communication
process, (iv) a caring process and (v) as a special relation-
ship. In Kunyk and Olson’s (2001) professional state;
empathy can be learnt and uses cognitive and behavioural
components to express understanding of the patient’s real-
ity back to them. The tension in this conceptual model is
one of state versus trait empathy. Alligood and May (2000)
argue that empathy is based on inherent personal ability.
Morse and Pooler (2002) suggest that learned empathy is a
second-level empathic response, suggesting the learned
response keeps the caregiver somewhat detached, objective
and therapeutically at arms length. Hojat et al. (2002) also
support this view. Morse and Pooler (2002) argue that
state-level empathy is learnt and therefore open to change,
while Alligood and May (2000) argue that trait levels of
empathy are difficult to modify. Further studies that can
determine this difference will lead to more effective train-
ing programmes.
Our study was limited by the use of English language
publications and therefore our understanding of empathy in
a western nursing cultural context. Nursing across the world
is highly mobile and needs to survive in a multicultural con-
text; the use of empathy will need to be examined within this
context in future studies.
CONCLUSION
Efforts to determine the effectiveness of empathy-based
education have shown positive results, although in varied
populations of nurses using a range of measurement tools.
For empathy education to evolve, its effectiveness will need
to be seen in well-designed trials, which demonstrate not
only its effectiveness but also the pragmatic issues of deliver-
ing education in both the undergraduate and postgraduate
nurse populations. Generalisability of the results is difficult
due to the number of measurement tools and different styles
of education used.
Being empathic has a significant place in nursing within
the therapeutic relationship. The studies reviewed demon-
strated that it is possible to increase nurse’s empathic ability
from a range of clinical specialties and at both undergradu-
ate and postgraduate levels.
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