Nurse Education Today 85 (2020) 104296

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Nurse Education Today

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The effect of structured empathy education on empathy competency of T

undergraduate nursing interns: A quasi-experimental study
Chao Yanga, Ya-Li Zhub, Bi-Ying Xiaa, Ya-Wei Lia, Jun Zhanga,
⁎

a
Faculty of Nursing, Wuhan University School of Health Sciences, Wuhan 430071, PR China
b
Minda Hospital, Hubei Minzu University, Enshi 445000, PR China

ARTICLE INFO ABSTRACT

Keywords: Background: Empathy is a crucial element in fostering a positive relationship between nurses and patients.
Empathy Recent research indicates that the degree of empathy in nursing students declines as they gain education or
Nursing education experience. A number of teaching strategies have been used to improve nursing students' empathy competence
Empathy education levels. However, little is currently known about how empathy is best taught or enhanced in senior nursing
Nursing students
students in China.
Undergraduate nursing interns
Objectives: To implement a structured empathy educational program as developed from the Delphi technique, as
well as to evaluate its effects on empathy competence among undergraduate nursing interns.
Design: This study is quasi-experimental, with two-group comparison.
Participants: Undergraduate nursing students in their fourth year (n = 118) were recruited from an affiliated
teaching hospital in Wuhan, Central Part of China, between January 2018 and March 2018.
Methods: A convenience sample of 118 undergraduate nursing interns were recruited from a teaching hospital in
Wuhan and assigned to either the intervention or the control group according to their preference. Participants in
the intervention group had received a 2-week, 12-hour structured empathy-related educational program (two
sessions per week, 3 h per session), whereas the control group received no intervention. The Jefferson Scale of
Empathy-Health Providers (JSE-HPs) was used to assess students' empathy levels before and after the inter-
vention.
Results: An independent samples t-test revealed that scores of empathy competence levels in the intervention
group were significantly higher than those in the control group following the intervention. Three domains of
empathy competence level were also significantly higher in the intervention group after the two weeks' training
relative to the control group, namely: perspective taking, compassionate care, and standing in the patient's shoes.
Conclusions: This modified empathy educational program may prove beneficial in improving the empathy
competence level of undergraduate nursing interns.

1. Introduction professional-patient relationship, empathy is characterized as the

Empathy consists of the ability to understand and appreciate other
people's perspectives and experiences, as well as to react with an ap-
propriate compassionate response (Batt-Rawden et al., 2013; Sheehan
et al., 2013). As a multi-dimensional concept, empathy can be cate-
gorized into two types: cognitive empathy and affective empathy
(Mohammadreza et al., 2002). Cognitive empathy refers to the ability
to identify and understand the inner experiences and feelings of others.
Affective empathy refers to the automatic, subconscious entering into
the emotional experience of another person, the innate ability to ex-
perience the same emotion as others—this can also be defined as
sympathy (Mohammadreza et al., 2002). In the context of the health
health professional's ability to understand the patient's world and to feel
and think from the patient's perspective without judgement, combined
with the capacity to communicate this understanding (Saltzman, 2007;
Williams and Stickley, 2010).
Empathy can increase the patient's therapeutic adherence and
overall patient satisfaction (Batt-Rawden et al., 2013; Ozcan et al.,
2018), and can enhance the health status of the patients (Batt-Rawden
et al., 2013; Cunico et al., 2012). Evidence has increasingly converged
on empathy as crucial in building a positive relationship between
health professionals and patients (Canale et al., 2012; Derksen et al.,
2013; Maruca et al., 2015). In clinical practice, communication be-
tween nurses and patients is the key to ensure the patients' needs are

⁎
Correspondence author.
E-mail address: junz@whu.edu.cn (J. Zhang).

https://doi.org/10.1016/j.nedt.2019.104296
Received 5 June 2019; Received in revised form 31 August 2019; Accepted 18 November 2019
0260-6917/ © 2019 Elsevier Ltd. All rights reserved.
C. Yang, et al. Nurse Education Today 85 (2020) 104296

Table 1
Empathy educational program.
Education session (duration) Objectives Content Teaching strategies

Session 1: Bring learner to the empathic
world (2 h);
Review the basic knowledge of empathy
(1 h)
Session 2: Transmission of emotion and
language skills (3 h)
Session 3: Nonlinguistic skills (3 h)
Session 4: Practicing empathy (3 h)
Identify empathy. 1. Appreciation of medical films; Video demonstration;
2. Describe and discuss the empathy Didactics.
phenomenon around its value;
3. Concepts and development
related to empathy;
4. Factors influencing the empathy ability
of medical students.
Assess the importance of language skills in the care 1. Transmission of emotion; Didactics;
relationship; 2. Language skills in general/special Problem-based learning
Identify emotion. situations; (PBL);
3. Sound skills; Task-based learning (TBL).
4. Voice training.
Assess the importance of nonlinguistic skills in the 1. Nonlinguistic skills; Didactics;
care relationship. 2. Expression and expression performance Problem-based learning
game; (PBL);
3. Listening and listening training; Task-based learning (TBL).
4. Respect in empathy;
5. Identification and management of
emotion;
6. Emotional response;
7. Self-introduction and image.
Experience patients' inner feelings and emotions; 1. Experience the illness conditions; Situational teaching;
Reduce perceptual bias and get rid of self-centered 2. Debate in roles of nurses and Role-playing.
thinking and dealing with problems. patients;
3. Melodrama and psychological drama
through role play.

met (Kahriman et al., 2016). Nurses who care for their patients em-
pathetically can better understand their patients' reactions to health
problems, as well as the source and purpose of the reactions (Reynolds
and Scott, 2010). For nursing interns, clinical practice is a key period
for cultivating students' ability to empathize (Zhang et al., 2015). Lack
of empathy will lead to ignorance of patients' psychological needs in the
communicative process and inability to identify patients' feedback ex-
peditiously, which will ultimately affect the nurse-patient relationship
and the outcomes of nursing care (Zhou, 2014).
Current studies have indicated that empathy competence levels of
medical and nursing students declines significantly as students progress
through the academic curriculum (Kyung Hye et al., 2015; Shariat and
Habibi, 2013). This may be due to a high workload, long hours, time
constraints, or a demanding and hostile educational environment in the
clinical stages of senior nursing students' programs (Hojat and Vergare,
2009; Kyung Hye et al., 2015). Due to the lack of research on senior
nursing students, it is imperative to identify and enact appropriate in-
terventions to maintain or improve the empathy competency levels of
these students.
Prior to this experimental study, we developed an empathy educa-
tional model (EEM) for medical university students using the Delphi
Technique, which has reached consensus among experts. Based on the
EEM, we created the structured empathy educational program. The aim
of this study was to improve undergraduate nursing interns' empathy
competence levels via a structured empathy educational program in
order to gain insights into nursing students' empathy education in
China.
2. Methods
2.1. Study design
This study was a two-group quasi-experiment with pre- and post-
test.
2.2. Sample
A convenience sampling was used to recruit undergraduate nursing
interns from the affiliated tertiary hospital in Central China. The in-
clusion criteria were: (1) full-time undergraduate nursing students and
currently enrolled in the final year of the program; (2) has never takes
any prior empathy courses; and (3) is willing to participate in the study.
We computed the sample size by G*Power 3.1.9.2. A sample size of
82 was determined to provide a statistical power of 80%, assuming a
type Ι error of 0.05, an effect size of 0.7, and a 20% attrition rate (Faul
et al., 2007). Ultimately, a total of 118 nursing interns were recruited
for the study and then assigned to either the control group (n = 52) or
the intervention group (n = 66) according to their own preference.
2.3. Interventions
This was the second part of our funded research program
(Structured Empathy Educational Model for Undergraduate Nursing
Interns: Delphi Technique-Based Developmental Process and Efficacy
Testing). In the first part, we developed an EEM using the Delphi
Technique (in another submitted report titled ‘Developing an Empathy
Educational Model (EEM) for Undergraduate Nursing Students: A
Delphi Technique’). The EEM was comprised of nine dimensions: (1)
bring the learner to the empathic world; (2) introduce the basic
knowledge of empathy; (3) master empathic skills; (4) practice em-
pathy; (5) evaluate empathic ability; (6) follow-up support; (7) the
distribution of hours dedicated to empathy education; (8) forms of
empathy training; and (9) the student's impressions of empathy edu-
cation.
The structured instructive material in the study was designed based
on the EEM, and was delivered in the classrooms of the university. The
program consisted of a 2-week, 12-hour structured empathy education
program (two 3-hour sessions per week). The educational strategies
included didactics, video demonstrations, situational teaching, pro-
blem-based learning (PBL), and task-based learning (TBL). Table 1
presents the interventional content in detail.
2.4. Measurement tools
We developed a demographic questionnaire to collect relevant in-
formation, including student characteristics (i.e., age, gender, ethnicity,

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C. Yang, et al.
single-child status, the location of the family, family members, and
family income), and familiarity of empathy content.
The Jefferson Scale of Empathy-Health Providers (JSE-HPs) is used
to assess empathy competence levels among health care professionals,
including nursing students. The JSE-HPs is psychometrically sound with
satisfactory validity, consistency, and test-retest reliability scores (Lor
et al., 2015), and has been translated into 56 languages worldwide
(Thomas Jefferson University, 2018). It contains 20 items with three
domains: (1) perspective taking; (2) compassionate care; and (3)
standing in the patient's shoes. This scale uses a 7-point Likert scale
(1 = strongly disagree; 7 = strongly agree). The maximum obtainable
score of JSE-HPs is 140; a higher score indicates a higher tendency
towards empathic engagement in patient care (Hsiao et al., 2013; Lee
et al., 2018).
Chinese researchers translated and modified this questionnaire into
Chinese to render it suitable for nursing students in China (Li and Sun,
2011). The Chinese version of JSE-HPs had been previously tested in
229 practising nursing students and showed good internal consistency.
The Cronbach's α coefficients were 0.836 for the total scale, and 0.830
for the split-half reliability (Li and Sun, 2011).
2.5. Procedures
A total of 118 participants completed both the demographic ques-
tionnaire and the Chinese version of JSE-HPs at the beginning of the
training (T0). The intervention group participated in the empathy
educational program for two weeks. The control group received no
empathy education. All subjects were evaluated by JSE-HPs at the end
of the 2-week program (T1).
2.6. Statistical analysis
Data were analyzed using descriptive statistics and inferential sta-
tistics (IBM SPSS Statistics, version 21.0). Chi-squared test was used to
compare equivalence on demographic data between both groups.
Independent samples t-test was used to explore the differences of em-
pathy competence level between both groups. A two-sided p < 0.05
was considered statistically significant.
2.7. Ethical considerations
Permission to conduct the study was obtained from the Research
Ethics Committees of the University Medical School and the hospital.
The first author obtained informed consent from each participant prior
to inclusion in the study. All questionnaires were collected anon-
ymously and researchers kept all data strictly confidential.
3. Results
A total of 102 participants completed the 2-week study, with 57 in
the intervention group and 45 in the control group. The ages of the
students ranged from 20 to 24 years, with a mean of 21.58 (SD = 0.91).
Of the 118 students who participated in the study, most were female
(82.2%). Fig. 1 displays the flow of the study participants.
No significant differences were found between the intervention and
control groups with regard to student demographics (i.e., gender, eth-
nicity, single-child status, the location of the family, family members,
and family income), and familiarity of empathy (Table 2).
3.1. Comparing differences of empathy competence level between both
groups
Independent samples t-test was used to examine the differences of
the JSE-HPs between both groups (Table 3). Results showed that the
mean score on the JSE-HPs scale was significantly increased in the in-
tervention group, from 116.65 at T0 to 127.65 at T1. In the control
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Nurse Education Today 85 (2020) 104296
group, the increment was from 113.58 to 114.62, which was non-sig-
nificant. The total average score on the JSE-HPs scale in the interven-
tion group was significantly higher than that of the control group at T1
(p < 0.001).
3.2. Comparing the three empathy domains between both groups
Independent samples t-test was used to examine the differences of
three empathy domains between the two groups (Table 4). Results
showed that the mean scores of the three domains in the intervention
group were significantly higher than those in the control group: per-
spective taking (12.81 ± 1.83 vs. 11.31 ± 2.04, p < 0.001); com-
passionate care (45.21 ± 5.11 vs. 41.53 ± 5.26, p = 0.001); and
standing in the patient's shoes (50.60 ± 6.12 vs. 44.38 ± 7.17,
p < 0.001).
4. Discussion
Previous studies have clearly demonstrated the benefits of empathy
in clinical practice, which could result in improved care for patients and
their families (Mennenga et al., 2015). Empathy is regarded as a vital
quality in a professional nurse (Wilkes et al., 2014). For nursing stu-
dents, a clinical internship is an important period for their role transi-
tion from students into practitioners. However, we found very little
information in the current literature concerning how to best teach or
foster empathy in undergraduate nursing interns.
Previous studies have reported that various interventions had been
used effectively to increase empathy among nursing students, such as
traditional learning (Ward et al., 2012), simulation (Everson et al.,
2015; Levett-Jones et al., 2017; Ward, 2016), experiential learning
activities (Cunico et al., 2012), perspective taking exercises (Lobchuk
et al., 2016), workshop (Fleming et al., 2015; Gholamzadeh et al.,
2018), game-based learning (Lu et al., 2018), expressive art/psycho-
drama (Ozcan et al., 2011), and film interventions (Reilly et al., 2012).
However, to our knowledge, and despite a variety of attempted inter-
ventions, there remains a lack of a systematic and structured education
program for nursing interns in China. Hence, we developed an educa-
tion program, named EEM, using the Delphi Technique, and we ex-
amined the efficacy of this structured empathy education on under-
graduate nursing interns.
Our results revealed a significant increase in both the overall JSE-
HPs scores and the three domains' scores in the intervention group,
including perspective taking, compassionate care, and standing in the
patient's shoes; these results are consistent with those of previous stu-
dies (Ozcan et al., 2018; Sheehan et al., 2013).
Our educational program has four unique features. First, the focus of
the training program is ameliorating not only behavioral empathy
skills, but also the understanding and attitude of empathy towards
students. During the training procedure, we emphasized the compre-
hension of empathy and the understanding of others through teaching
empathy strategies and simulating different patients. Second,
throughout the four sessions, we applied many different training forms,
including didactics, video demonstrations, problem-based learning
(PBL), task-based learning (TBL), situational teaching and role-playing
to improve the students' learning and interest (Lee et al., 2018; Levett-
Jones et al., 2019). Third, the designation of the empathy educational
program was based on the EEM, which provides a comprehensive re-
ference for empathy education whose content is broad in scope and
structured in its delivery. Fourth, the reasonable selection of an ap-
propriate empathy-measuring instrument. We used the JSE-HPs ques-
tionnaire to measure the empathy competency level, which is a sub-
jective, self-rated instrument. Students could evaluate their empathy
competency level in relation to their own unique situation.
Various empathy measurement instruments exist, all of which had
prior evidence of satisfactory validity and reliability (Levett-Jones
et al., 2019). The instruments can be broadly divided into subjective
C. Yang, et al. Nurse Education Today 85 (2020) 104296

Fig. 1. Flow chart of participants for this quasi-experiment.

Table 2 Table 3
Sociodemographic characteristics of the students (n = 118). Comparison of empathy competence by independent samples t-test.
Intervention Control group t p Intervention group Control group t p
group (n = 66) (n = 52) (n = 57) (n = 45)

Mean ± SD Mean ± SD Mean SD Mean SD

Age 21.83 ± 0.74 21.27 ± 1.01 3.35 0.001 JSE-HPs

N (%) N (%) Χ2 p Baseline (T0) 116.65 21.38 113.58 14.83 0.883 0.359
Gender Male 12(18.00) 9(17.31) 0.06 0.903 2 weeks (T1) 127.65 13.81 114.62 13.81 4.634 < 0.001
Female 54(82.00) 43(82.69)
Ethnicity Han 63(95.45) 48(92.31) 2.054 0.490 JSE-HPs: The Jefferson Scale of Empathy- Health Providers version.
Tujia 3(4.55) 4(7.69)
Whether or Yes 28(42.42) 17(32.69) 4.545 0.281
not No 38(57.58) 35(67.31)
Table 4
single- Comparison of three domains in JSE-HPs between two groups.
child
Intervention group Control group t p
The location City level 15(22.73) 11(21.15) 0.016 0.816
(n = 57) (n = 45)
of the County 18(27.27) 14(26.92)
family level
Mean SD Mean SD
Town 33(50.00) 27(51.92)
Family With 47(71.21) 38(73.08) 0.16 0.825 Perspective taking
member parents Baseline (T0) 11.65 2.83 11.21 2.24 0.919 0.347
Single 4(6.06) 3(5.77) 2 weeks (T1) 12.81 1.83 11.31 2.04 3.809 < 0.001
parent Compassionate care
family Baseline (T0) 42.21 7.61 41.38 5.58 0.657 0.497
Three 15(22.73) 11(21.15) 2 weeks (T1) 45.21 5.11 41.53 5.26 3.487 0.001
generations Standing in the patient's shoes
Family Poverty 22(33.33) 13(25.00) 0.169 0.072 Baseline (T0) 45.53 9.05 43.75 8.07 1.112 0.262
income Medium 44(66.67) 34(65.38) 2 weeks (T1) 50.60 6.12 44.38 7.17 4.609 < 0.001
Rich 0(0.00) 5(9.62)
Familiarity of Familiar 1(1.52) 6(11.54) 7.321 0.996
T0: at the baseline.
empathy General 50(75.76) 29(55.77)
T1: after the intervention.
Don't know 15(22.73) 17(32.69)

have been used simultaneously to assess empathy competency levels,

self-assessment tools and objective independent measurement tools. the results from the individual instruments differed. Compared to the
Most prominent among these are the JSE-HPs and the Objective measurement results of JSE-HPs, empathy scores were significantly
Structured Clinical Examination (OSCE). Although both instruments higher when rated by Standard Patients (SPs) (Lee et al., 2018;
Wündrich et al., 2017). Another tool, the OSCE, was objectively

4
C. Yang, et al.
evaluated by the second and the third person, and was performance-
oriented, which could increase the authenticity of the results (Lee et al.,
2018). The students could give a high self-rated empathy score on JSE-
HPs, which could result in ceiling effects (Wündrich et al., 2017). More
studies are needed to address the impact of bias within these self-report
questionnaires (Levett-Jones et al., 2019; Polit and Beck, 2012).
In western countries, clinical practice is synchronized with theore-
tical teaching, which means that students are exposed to clinical
practice from the onset of the program (Guan and Wang, 2012). In
contrast, for most nursing students in China, clinical practice is not
typically introduced until the final year of the nursing program, which
comprises the first contact students have with real patients. Considering
that previous studies have observed that the most severe decline in
empathy occurs among those student nurses with the highest number of
clinical encounters (Hojat and Vergare, 2009; Sheehan et al., 2013;
Ward et al., 2012). It is especially important to maintain or improve
empathy competency in undergraduate nursing students by enriching
their nursing experiences.
4.1. Implications
This study has several implications. First, there is a need for edu-
cators to add empathy education to routine educational content, and to
continue searching for appropriate teaching strategies to develop em-
pathy competency in nursing students. Second, integrating and com-
bining different strategies in the teaching process will enhance the
understanding of nursing students about their patients, thereby
achieving higher empathy to promote positive patient outcomes. Third,
health professionals should place the emphasis of these empathy edu-
cational programs on becoming role models for other to-be nurses.
Fourth, educators must focus on the inner thoughts of each student.
4.2. Limitations
This study has several limitations. First, the participants comprised
a convenience sample of undergraduate nursing interns in one tertiary
hospital; therefore, the results may not be generalizable to all nursing
students. Second, a non-randomized method was used to assign parti-
cipants into the intervention and control groups. We assigned partici-
pants based on their own preference, which may bias the final results.
Third, the subjective measurement tool was not paired with an objec-
tive measurement tool of empathy, which may introduce bias. In ad-
dition, there was no blinding for either the data analysis or who con-
ducted the intervention; this may affect the accuracy of the results.
Fourth, the long-term efficacy with follow-up or the transference to
clinical achievement was not examined in this study.
5. Conclusions
To our knowledge, this is the first experimental study conducted in
China to explore the effectiveness of a structured empathy educational
program for undergraduate nursing interns. The results indicate that
the program could significantly improve empathy competence for un-
dergraduate nursing interns, which may provide a validated paradigm
for empathy education in other nursing schools. Follow-up studies on
longitudinal changes in empathy performance and transference to
clinical performance are also suggested.
Funding statements
This work was supported by the Teaching Reform Fund of Wuhan
University School of Medicine (No. 2016020).
Contributions
ZY, YC and ZJ designed the study and wrote the research protocol.
5
Nurse Education Today 85 (2020) 104296
ZY and YC did the literature review, conducted the experiment, quality
control, statistical analysis and prepared the manuscript draft. ZJ con-
tributed to the revisions in depth for the manuscript. XB and LY checked
the data and revised the manuscript. All authors contributed to and
approved the final manuscript.
Declaration of competing interest
None.
Acknowledgments
Appreciations extend to all participants in the study.
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