European Journal of Dental Education ISSN 1396-5883

Psychometric properties of the Greek version of the Toronto

Composite Empathy Scale in Greek dental students
D. Tsiantou1, D. Lazaridou1, T. Coolidge2, K. N. Arapostathis1 and N. Kotsanos1
1
Department of Paediatric Dentistry, Faculty of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece,
2
Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, Washington, USA

Keywords Abstract
empathy; dental students; education research;
psychometrics. Introduction: Empathy levels of health practitioners are related to patient satisfaction
and treatment outcomes. The Toronto Composite Empathy Scale (TCES) was recently
Correspondence developed to assess cognitive and emotional empathy levels in both professional and
Dimitra Tsiantou personal spheres, and tested in an English-speaking sample of dental students. The aim
Department of Paediatric Dentistry of this study was to examine the psychometrics of the Greek version of the TCES.
Faculty of Dentistry, Aristotle University of
Thessaloniki
Materials and Methods: The TCES was translated into Greek and administered to
Thessaloniki 54124 , Greece
all of the dental students at Aristotle University of Thessaloniki. A random subset of
Tel: +306973052955
Fax: +302310999582
students completed the questionnaire twice for test–retest analysis.
e-mail: tsiantoudim@yahoo.gr
Results: Nearly all (96.5%) of the students completed the questionnaire. The internal
Accepted: 29 January 2013 consistencies of each of the four subscales were generally acceptable (Cronbach’s
alphas: 0.676–0.805), and the scale showed good discriminant and convergent validities
doi: 10.1111/eje.12037
(r’s for discriminant validity: 0.217 and 0.103; r’s for convergent validity: 0.595 and
0.700). Test–retest reliabilities ranged from 0.478 to 0.779. After eliminating items that
fell on both cognitive and emotional factors, a rotated factor analysis indicated that
the items loaded on two cognitive and three emotional factors.

Discussion: Our results indicate that the Greek version of the TCES has good psycho-
metric properties. The factor analysis indicates that the emotional and cognitive aspects
of empathy are distinct, supporting the need to address both aspects in studies of
empathy.

Conclusions: The Greek version of the TCES is a reliable and valid tool for the mea-
surement of cognitive and emotional empathy, in both professional and personal life,
in Greek dental students.

communication abilities are considered to be central to the suc-

Introduction
Empathy has been defined as the ability to ‘perceive the internal
frame of reference of another with accuracy as if one were the
other person but without ever losing the ‘as if’ condition’ (1; p.
210). This ability allows humans to recognise and understand
the internal thoughts and feelings of others, facilitating social
relationships in general (2–4). Whilst scientific advances con-
tinue to improve our understanding of disease (including
detection, prevention and treatment), empathy and associated
cess of healthcare providers as they operate within a particular
type of social relationship, namely the doctor–patient relation-
ship (5). In this relationship, healthcare providers must be able
to focus on patients, listen carefully to their medical history
and understand exactly how they possibly feel (6). The impor-
tance of these skills in dentistry is highlighted by their inclusion
in the set of competencies required for dentists practising in
the European Union (7) and other areas, such as the United
States (8).

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Eur J Dent Educ 17 (2013) 208–217
Tsiantou et al.
Greater levels of empathy in physicians result in more
favourable treatment outcomes (9, 10), better adherence to
treatment (11) and closer monitoring of the patient (12). In
dentistry, empathy has been correlated with greater satisfaction
and decreased dental fear (13), greater levels of cooperation in
children (14), more satisfied patients in aesthetic dentistry (15)
and prosthodontics (16), better compliance in orthodontics
(17) and better treatment outcomes in myofascial pain (18).
Whilst a number of definitions or descriptions of empathy
have been suggested, Davis points out that some have argued
that empathy is primarily cognitive (involving accuracy in
understanding someone else’s mental state through perspective-
taking) and others have argued that it is primarily emotional
or affective (involving physiological responses in the observer,
such as experiencing the same emotion that the other is feeling)
(19). Still others consider empathy to include both cognitive
and emotional aspects, arguing that the ability to understand
another’s perspective requires an emotional response to observ-
ing the other, whilst merely experiencing the same emotion as
the other can result in emotional contagion, rather than empa-
thy. Evidence supporting the view that there are cognitive and
emotional aspects of empathy comes from a variety of fields.
For example, some forms of psychopathology are associated
with deficits in cognitive empathy (e.g. autism and bipolar dis-
order), whilst others are associated with deficits in emotional
empathy (e.g. alcoholism and schizophrenia) (20, 21). In addi-
tion, individuals without psychiatric problems but who have
greater emotional empathy are more successful on experimental
tasks that require emotional understanding, whilst those with
greater cognitive empathy are more successful on tasks requir-
ing cognitive understanding (22). Third, developmental evi-
dence indicates that emotional empathy begins to develop in
the child earlier than cognitive empathy (23). Finally, a growing
body of literature indicates that individual differences in emo-
tional and cognitive empathies are associated with differences
in brain structures; furthermore, in addition to brain regions
that appear to be involved in all types of tasks requiring empa-
thy, different specific regions are associated with tasks involving
emotional vs. cognitive empathies (20, 24, 25).
Researchers have assessed psychometrically strong measure-
ment tools for empathy, including those appropriate for medi-
cal students (26–35), pharmacy students (36), nursing students
(35, 37, 38) and physicians (27, 29, 35, 39–41). Most of the
studies in health profession students (27, 29, 34–37, 42–44)
measure empathy using the same self-report scale: the Jefferson
Scale of Physician Empathy Health Professionals [JSPE-HP
(45)]. This scale has been shown to have good psychometric
properties in dental students (42); however, it does not clearly
identify emotional and cognitive aspects of empathy. To pro-
vide the emotional context of empathy, some studies with
health professionals (33, 46–48) have measured empathy in
professional life with emotional intelligence tools. Furthermore,
the JSPE-HP measures students’ empathy in professional set-
tings only and thus does not refer to students’ empathy in their
personal lives. The latter may be important in contributing to
understanding whether students’ empathies are trait-like, or
differ in professional and personal situations.
Yarascavitch et al. (49) designed a new questionnaire, the
Toronto Composite Empathy Scale (TCES). The purpose of the
ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 17 (2013) 208–217
Greek Version of TCES
questionnaire was to incorporate the cognitive and emotional
dimensions of empathy, in both personal and professional life.
This scale combined questions from four scales related to
empathy: JSPE-HP (45), Interpersonal Reactivity Index (19),
E-Scale (50) and the short form of the Empathy Quotient (51).
The TCES consists of 52 questions, 26 for the professional set-
ting and another 26 for personal life, equally divided into cog-
nitive and emotional empathy in each case. This results in four
subscales consisting of 13 items each: the Personal Cognitive
subscale, the Personal Emotional subscale, the Professional
Cognitive subscale and the Professional Emotional subscale.
The personal and professional subscales ask the respondent to
rate how often he/she responds in certain ways in situations
involving friends or people in general (personal subscales), or
patients (professional subscales). For example, an item in the
Personal Emotional subscale reads: ‘I tend to get emotionally
involved with a friend’s problems’, whilst the corresponding
item in the Professional Emotional subscale reads: ‘I tend to
get emotionally involved with my patient’s problems’. Similarly,
an item in the Personal Cognitive subscale reads: ‘I try to think
like my friends in order to help them more’, whilst the corre-
sponding item in the Professional Cognitive subscale reads: ‘I
try to think like my patients in order to help them more’. Each
item is answered on a 6-point scale, where 1 = ‘At no time’
and 6 = ‘All the time’. Possible scores for each subscale range
from 13 to 78, where higher scores refer to greater levels of
empathy. Yarascavitch et al. found that the TCES showed
acceptable internal consistency, with Cronbach’s alpha values of
0.759 for the Personal Cognitive subscale, 0.765 for Personal
Emotional, 0.814 for Professional Cognitive and 0.768 for Pro-
fessional Emotional. The authors did not report whether the
alphas would be affected by deleting any item. The team also
found evidence for convergent validity, measured by higher
correlations between the two cognitive subscales (r = 0.646)
and the two emotional subscales (r = 0.691), and discriminant
validity, measured by lower correlations between the two per-
sonal subscales (r = 0.190) and the two professional scales
(r = 0.066). However, the authors did not report the scale’s
test–retest reliability, nor did they conduct a factor analysis of
the items to examine whether they performed as expected (49).
Finally, although other authors have typically found that
females score higher on empathy than males (30, 42), Yarascav-
itch et al. (49) did not report whether gender was related to
scores on the TCES.
Whilst Greek dental patients who were interviewed about
their expectations and perceptions towards dental care stated
that dentists’ empathy was foremost in their expectations (52),
to date studies in Greece have not assessed the empathy levels
of dentists. Whilst other Greek studies have used scales for
describing the empathic style and caring behaviour of some
health professionals [nurses and physicians; (52–55)], these
have not strictly measured the levels of healthcare practitioners’
empathy.
It seems therefore that, although there are valid self-report
scales in English, there is no empathy scale with established
psychometric properties for Greek dental students or dentists.
Thus, developing and testing the Greek version of the TCES in
dental students would be useful. The aim of this study is to
report on the development and psychometric properties of the
209
Greek Version of TCES
Greek version of TCES in dental students, including its internal
consistency, test–retest reliability and construct validity. In
addition, we report on gender differences found on the mea-
sure.
Materials and methods
The study took place in the Faculty of Dentistry, Aristotle Uni-
versity of Thessaloniki (AUTH), and was approved by the Insti-
tutional Review Board at Aristotle University, Greece (Code No
215/29-9-2010). Faculty of Dentistry, AUTH, is one of the two
dental schools in Greece, enrolling about 500 dental students,
almost equally divided over the five training years. All under-
graduate dental students were judged capable to participate in
the study (whole sample population). Nineteen additional stu-
dents, selected randomly from a pool that had completed the
fifth year assignments after the deadline for the regular gradua-
tion date and were waiting for the next graduation date, partic-
ipated in the pilot study.
The English version of the TCES was translated into the Greek
language. The modified guidelines of the American Association
of Orthopedic Surgeons (AAOS) to health and quality of life
(56) were followed in order to translate the TCES. The AAOS
guidelines involve the translation and cultural adaptation of the
questionnaire and include six stages. According to these steps,
two bilingual researchers independently translated the scale from
English to Greek (forward translation). Second, both transla-
tions were synthesised to create a uniform version. The new
translation was independently translated back into English by
two new translators who were unaware of the original version
(back translation). In the fourth stage, all translators together
came to a consensus about the pre-final version of the question-
naire that would be used in the pilot study. Item 15 [‘When I
see a hurt stranger/patient, I tend to remain calm’ (reversed)] is
ambiguous with regard to whether the situation refers to is an
emotional or physical one. The back translation revealed that
the original Greek translation was construed to be ‘wounded’,
which is more likely to refer to a physical experience. Therefore,
the Greek wording was changed to ‘When I see a stranger/
patient in pain…’. The pre-final version was then piloted with
the 19 dental students who had completed training but not yet
graduated. The piloting revealed that items 25 [‘I find myself
unaffected by other people’s/my patients’ misfortunes’
(reversed)] and 26 [‘I find it hard to feel sorry for other people/
my patients when they are having problems’ (reversed)] were
somewhat confusing. On the other hand, slightly simplified revi-
sions (‘I am not affected by…’ and ‘It is hard for me to feel
sorry…’) were more acceptable, and therefore, these revised
items were used in the final questionnaire. (The Greek version
of the TCES is available from the first author on request.)
The final form of the questionnaire consisted of two sections.
The first one was a cover letter aimed to inform students of
their voluntary participation in the study; they were asked to
provide their names (to allow comparison of the TCES scores
for test–retest purposes), gender and similar personal data,
highlighting that their personal data were confidential and
accessible only by the research team. The second section was
the Greek version of the TCES and other questionnaires not
reported on here.
210
Tsiantou et al.
The questionnaires were distributed to all students of the
Dental School, AUTH, over a 2-month period between October
and November 2010. The questionnaires were administered at a
predetermined time and in the classrooms in the Dental
School. Students had been given 30 min at the beginning of
tutorial courses to answer the questionnaires without any time
pressure or postponement of their training. The questionnaires
were collected at the same time. To check the test–retest
reliability, the questionnaire was given again for a second time
(2–4 weeks interval) to a random sample of the 25% of all par-
ticipants in each training year. After the initial and the retest
questionnaires were matched, all personal data were erased.
Questionnaires were coded and data were entered into an
Excel file and checked for accuracy. Analyses were carried out
with SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL,
USA). Participants who omitted 5% or more of the TCES items
were excluded. Amongst those who were retained for the analy-
ses, chi-square test was used to compare students who had
completed the TCES and those who had not on gender and
year of study, whilst Mann–Whitney test was used to compare
the age of these two subgroups. In addition to descriptive sta-
tistics, t-tests were used to examine gender differences on the
empathy scores, whilst Pearson’s r was used to determine how
similar the personal and professional dimensions were in both
the cognitive and emotional subscales. Cronbach’s alpha was
used to measure internal consistency, and Pearson’s r was used
for examining the test–retest reliability and convergent and dis-
criminant validities, as the distributions of the TCES scores
were normal. Factor analysis using varimax rotation was used
to examine the factor structure of the TCES.
Results
The questionnaire was distributed to all of the 490 students of
all training years who were present during the tutorial courses
in October/November 2010, and 469 students agreed to partici-
pate in the study (response rate 96.5%). Nearly all of the stu-
dents completed the entire set of questionnaires (including the
TCES) in 10–12 min, and all students finished in less than
20 min. Nine of the 469 students omitted 5% or more of the
TCES items and were therefore excluded. Amongst the 460
retained, the distribution in training years was almost equally
divided (from the first to the fifth year, there were 82, 82, 99,
93 and 104 participants, respectively). The mean age of the par-
ticipants was 20.70 years (SD = 2.56, median = 20.00,
range = 18–45), and 65.2% were female. Of the 460 who were
retained, 405 completed the TCES and 55 omitted up to 5% of
the items. Neither gender nor training year was related to TCES
completion. However, those who completed the TCES were
older than those who did not (median ages 20.50 vs. 20.00;
Mann–Whitney U-test = 9156.000, P = 0.036).
Overall, the mean score on the Personal Cognitive subscale
was 56.13 (SD = 6.85), the mean score on the Personal Emo-
tional subscale was 47.60 (SD = 8.67), whilst the means and
SDs on the Professional Cognitive and Emotional subscales
were 57.31 (7.71) and 40.13 (9.56), respectively. The means and
standard deviations of the four subscales by gender are shown
in Table 1. Females had significantly higher empathy scores on
the Personal Cognitive, Personal Emotional and Professional
ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 17 (2013) 208–217
Tsiantou et al. Greek Version of TCES

Emotional subscales. For males, the correlation for the Personal to the alphas obtained in our sample revealed that eliminating
and Professional Cognitive subscales was 0.681 (P < 0.001), any item in the Personal Emotional subscale would decrease this
and the correlation for the Personal and Professional Emotional value. The alpha of the Professional Emotional subscale would
subscales was 0.739 (P < 0.001). For females, the corresponding increase from 0.805 to 0.811 if one item was removed [Profes-
correlation coefficients were 0.542 and 0.675 (both P’s <0.001). sional item 25: ‘I am not affected by my patient’s misfortunes’
To check the test–retest reliability, the questionnaire was ran- (reversed)]. The alpha of the Personal Cognitive subscale would
domly administered to 115 students (25%) 3 weeks (1 week) increase from 0.676 to 0.683 if one item was removed (Personal
after the first administration. Of the 115, 110 agreed to com- item 23: ‘It is hard for me to see why some things upset people
plete the questionnaire a second time (response rate 95.65%). so much’); removing the corresponding item from the Profes-
One student omitted more than 5% of the TCES items in the sional Cognitive subscale (Professional item 23: ‘It is hard for
second administration and was excluded, leaving 109 who com- me to see why some things upset patients so much’) would
pleted the questionnaire both times. As seen in Table 2, all four increase the subscale’s alpha from 0.759 to 0.761. Significant
empathy subscale scores in the test (time 1) and retest distribu- positive correlations were found between the two cognitive
tion (time 2) were significantly correlated. (r = 0.595, P < 0.001) and the two emotional (r = 0.700,
The internal consistencies of each of the four subscales were P < 0.001) subscales, as well as between the two personal
generally acceptable, with Cronbach’s alphas ranging from 0.676 (r = 0.127, P < 0.001) and the two professional (r = 0.103,
to 0.805. Examination of the importance of the individual items P = 0.028) subscales (Table 3).
Initial inspections of the data indicated that they were appro-
priate for factor analysis [i.e. there were correlations >0.3 in
TABLE 1. Means and standard deviations of the Greek version of Toronto the correlation matrix, the Kaiser-Meyer-Olkin (KMO) measure
Composite Empathy Scale (TCES) by gender of sampling adequacy was 0.823, and the value for the Bartlett’s
test of sphericity was significant (approximate chi-square
Males mean Females mean test = 7747.061, df = 1326, P < 0.001)]. The unrotated factor
Subscale (SD) (SD) t analysis indicated that there were 15 components with eigen-
Personal cognitive 54.90 (7.35) 56.79 (6.48) 2.842**
values >1.0. The scree plot was examined in order to reduce
Personal emotional 43.85 (8.60) 49.60 (8.04) 7.126*** the number of potential factors. As a result, five components,
Professional cognitive 56.73 (7.77) 57.62 (7.67) 1.182 which together accounted for 40.00% of the variance, were
Professional emotional 38.16 (9.04) 41.18 (9.67) 3.255** selected for the rotated analysis. Table 4 contains the factor
loadings for each item on the five factors; loadings >0.3 are
SD, standard deviation. shown in boldface. The table also indicates whether the item
df = 458. was taken from the cognitive or emotional subscales. A visual
*P < 0.05; ** P < 0.01; *** P < 0.001. comparison of the personal and professional sections indicates
that almost all pairs of items loaded on the same scale(s) in
both sections of the questionnaire. (For example, item #1
TABLE 2. Test–retest reliability of the Greek version of Toronto Composite
Empathy Scale (TCES)
loaded on Factor 2 in both sections.) Across the TCES, all but
one of the emotional items loaded on Factors 1 and/or 5 (four
Time 1 mean Time 2 mean items loaded on both factors), whilst all of the cognitive items
Subscale (SD) (SD) r loaded on Factors 2, 3 and/or 4 (two items loaded on two of
the factors). The single emotional item that did not load at 0.3
Personal cognitive 56.13 (6.85) 56.39 (7.39) 0.669***
or higher on any factor loaded 0.298 on both Factor 1 and Fac-
Personal emotional 47.60 (8.67) 45.79 (9.27) 0.779***
tor 5. Six of the emotional items (Personal items 18, 25 and
Professional cognitive 57.31 (7.71) 56.70 (7.45) 0.478***
26; Professional items 16, 18 and 26) also loaded positively on
Professional emotional 40.13 (9.56) 40.03 (9.84) 0.657***
Factors 2, 3 or 4, and two of the cognitive items (Personal and
SD, standard deviation. Professional items 19) also loaded positively on Factor 1. One
*P < 0.05; **P < 0.01; ***P < 0.001. cognitive item also had a high negative (> 0.3) loading on an

TABLE 3. Internal reliability and construct validity of the Greek version of Toronto Composite Empathy Scale (TCES)

Subscale Personal cognitive Personal emotional Professional cognitive Professional emotional

1
Personal cognitive 0.676
Personal emotional 0.2172*** 0.7601
Professional cognitive 0.5953*** 0.7591
Professional emotional 0.700 ***
3
0.1032* 0.8051
1
Cronbach’s alpha.
2
Discriminant validity.
3
Convergent validity.
*P < 0.05; **P < 0.01; ***P < 0.001.

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Eur J Dent Educ 17 (2013) 208–217
Greek Version of TCES Tsiantou et al.

TABLE 4. First rotated factor analysis of the Greek version of the Toronto Composite Empathy Scale (TCES)

Factors

Items I II III IV V Scale assignment

Personal items
1 0.020 0.515 0.074 0.039 0.240 Cognitive
2 0.068 0.199 0.458 0.221 0.292 Cognitive
3 0.061 0.079 0.071 0.477 0.198 Cognitive
4 0.245 0.389 0.273 0.073 0.327 Cognitive
5 0.464 0.218 0.112 0.050 0.139 Emotional
6 0.067 0.021 0.639 0.020 0.185 Cognitive
7 0.206 0.161 0.223 0.230 0.576 Emotional
8 0.154 0.028 0.019 0.350 0.152 Cognitive
9 0.162 0.023 0.181 0.630 0.079 Cognitive
10 0.516 0.078 0.035 0.116 0.129 Emotional
11 0.158 0.512 0.021 0.101 0.087 Cognitive
12 0.440 0.196 0.077 0.003 0.207 Emotional
13 0.141 0.159 0.034 0.186 0.656 Emotional
14 0.282 0.465 0.098 0.144 0.118 Cognitive
15 0.497 0.136 0.078 0.258 0.024 Emotional
16 0.305 0.269 0.047 0.062 0.282 Emotional
17 0.046 0.020 0.717 0.143 0.098 Cognitive
18 0.362 0.211 0.379 0.132 0.073 Emotional
19 0.399 0.453 0.140 0.171 0.022 Cognitive
20 0.654 0.172 0.108 0.082 0.260 Emotional
21 0.329 0.087 0.025 0.093 0.544 Emotional
22 0.133 0.137 0.550 0.036 0.016 Cognitive
23 0.015 0.031 0.080 0.512 0.196 Cognitive
24 0.298 0.055 0.182 0.267 0.298 Emotional
25 0.379 0.013 0.002 0.477 0.128 Emotional
26 0.341 0.082 0.105 0.454 0.077 Emotional
Professional items
1 0.050 0.630 0.215 0.014 0.052 Cognitive
2 0.068 0.322 0.515 0.031 0.072 Cognitive
3 0.168 0.083 0.116 0.577 0.012 Cognitive
4 0.038 0.643 0.254 0.174 0.123 Cognitive
5 0.517 0.241 0.110 0.131 0.172 Emotional
6 0.069 0.097 0.697 0.066 0.087 Cognitive
7 0.322 0.213 0.381 0.201 0.439 Emotional
8 0.111 0.095 0.029 0.521 0.009 Cognitive
9 0.073 0.087 0.323 0.550 0.114 Cognitive
10 0.648 0.027 0.054 0.120 0.188 Emotional
11 0.099 0.667 0.066 0.081 0.079 Cognitive
12 0.555 0.221 0.043 0.029 0.144 Emotional
13 0.368 0.070 0.116 0.346 0.497 Emotional
14 0.026 0.738 0.179 0.186 0.183 Cognitive
15 0.487 0.172 0.251 0.118 0.026 Emotional
16 0.470 0.327 0.082 0.169 0.082 Emotional
17 0.137 0.099 0.691 0.103 0.027 Cognitive
18 0.426 0.324 0.245 0.006 0.120 Emotional
19 0.427 0.528 0.041 0.056 0.038 Cognitive
20 0.724 0.112 0.063 0.045 0.236 Emotional
21 0.505 0.029 0.060 0.176 0.474 Emotional
22 0.012 0.152 0.567 0.104 0.001 Cognitive
23 0.223 0.111 0.009 0.599 0.096 Cognitive
24 0.404 0.054 0.107 0.392 0.027 Emotional
25 0.359 0.108 0.050 0.297 0.037 Emotional
26 0.351 0.152 0.047 0.455 0.052 Emotional
Variance accounted for 11.32% 8.09% 7.72% 7.58% 5.29%

Values in bold face are greater than ± 0.3.

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Tsiantou et al.
emotional factor, whilst 3 emotional items had high negative
(> 0.3) loadings on a cognitive factor.
A second factor analysis was carried out after omitting the
eight items that had loaded positively on both emotional and
cognitive factors. These data also showed suitability for factor
analysis [i.e. correlations above 0.3 in the correlation matrix, a
KMO value of 0.809 and a significant value for Bartlett’s test of
sphericity (approximate chi-square test = 6119.890, df = 946,
P < 0.001)]. Twelve components with eigenvalues >1.0 were
identified in the unrotated analysis, whilst the scree plot indi-
cated that five of these were optimal for inclusion. Together,
these five factors accounted for 41.63% of the variance. The
results of the rotated analysis are presented in Table 5. All of
the emotional items loaded on Factors 1 and/or 5 (four items
loaded on both), and all of the cognitive items loaded on Fac-
tors 2, 3 and/or 4 (2 items loaded on two of these). There were
no emotional items that loaded positively on Factors 2, 3 and/
or 4, nor were there any cognitive items that loaded positively
on Factors 1 and/or 5. There were 3 emotional items that also
loaded negatively on Factors 2, 3 or 4, whilst 4 cognitive items
also loaded negatively on Factor 5. Factors 2 and 3 were
reversed in the second factor analysis (i.e. items that had
loaded on Factor 2 in the initial analysis now comprised Factor
3, and vice versa). According to the item loadings of the second
analysis, Factor 1 appears to focus on emotional involvement
in general (sample items: ‘I tend to get emotionally involved
with a friend’s/my patient’s problems’), whilst Factor 5 focuses
on helplessness and emergencies [sample item: ‘In emergency
situations I feel calm and composed (reversed)’]. Factor 2
focuses on using visual cues to determine the thoughts and
feelings of others (sample items: ‘I notice if someone/a patient
appears interested or bored with what I’m saying’), Factor 3
centres around taking the cognitive perspective of others (sam-
ple items: ‘I try to think like my friends/patients in order to
help them more’), whilst Factor 4 taps judging and understand-
ing the thoughts and feelings of others [sample items: ‘When
someone/a patient is offended by a remark, I find it hard to
understand why’ (reversed)].
Discussion
Our results indicate that the Greek version of the TCES has
good psychometric properties. All subscales demonstrated
acceptable or good internal consistency, with alphas very simi-
lar to those reported by Yarascavitch et al. (49). The high cor-
relations found for the pairs of two cognitive and two
emotional subscales suggest good convergent validity. In addi-
tion, the lower correlations found for the two personal and the
two professional subscales suggest good discriminant validity.
We also found good test–retest reliability for the scale; to
our knowledge, this is the first time that test–retest reliability
has been measured with the TCES. Whilst still highly significant
(P < 0.001), the test–retest coefficient for professional cognitive
empathy was somewhat lower compared with the other three
subscales. Future studies might elucidate whether this is related
to the scale, or an aspect of our particular sample (e.g. the
redistribution of the questionnaires coincided with the timing
of semester examinations, which might have influenced the rat-
ings of professional empathy).
ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 17 (2013) 208–217
Greek Version of TCES
Whilst the internal consistency analyses yielded values that
were very similar to those reported by Yarascavitch et al. (49),
the highest value was 0.805. The cognitive subscales could be
improved somewhat by eliminating item 23, but our results do
not indicate that a single item would improve both of the emo-
tional subscales if it was removed. To date, ours is the only
sample that explored item deletion as a method to improve the
alpha values, and it would be useful to administer the scale to
other samples to look for general patterns of item performance.
Especially as the TCES has only been tested in two samples to
date, it would also be desirable to include other measures
designed to assess convergent and/or divergent validity more
fully. Further, it might be fruitful to compare the measure with
judges’ ratings of the participants’ empathic behaviours and
communications, as a way of assessing criterion validity.
Whilst we found that every item selected by Yarascavitch
et al. (49) to be an emotional item fell on at least one of the
two emotional factors (with the exception of item 24, which
loaded at 0.298), and each item selected by that team to be a
cognitive item fell on at least one of the three cognitive factors,
several items loaded on both cognitive and emotional factors in
our original analysis. These items differed from those identified
in the internal consistency analyses as possible contenders to be
omitted to increase the alpha values. It is also of interest that
we found two emotional and three cognitive factors, rather
than one of each type. This may be related to the fact that the
scale’s items were drawn from a variety of sources. Additional
factor analyses (including confirmatory factor analysis) would
need to be conducted in other samples to determine whether
our findings that some items loaded on both emotional and
cognitive factors and that there are several emotional and cog-
nitive factors within the scale are related to our sample in some
way, or are related to the scale itself. In general, the second fac-
tor analysis indicates that the emotional and cognitive aspects
of empathy are distinct, supporting the need to address both
aspects in studies of empathy.
As is typical in research on empathy (30, 42), we found
that females scored higher than males did on three of the
four subscales. This is likely to be reflecting the fact that the
TCES items were based on those found in other empathy
scales (i.e. JSPE-HP (45), Interpersonal Reactivity Index (19),
E-Scale (50) and the short form of the Empathy Quotient
(51), and therefore, they would be answered in similar ways
as participants rate the items or similar items on other empa-
thy scales.
Looking at the various subscales in more detail, we found
that the mean levels of personal and professional cognitive
empathy were the same for males and females. However, for
both genders, the levels of emotional empathy were higher on
the personal subscales, compared with the professional sub-
scales. This may be due to the relatively short period of time
that dental students have been interacting professionally with
patients, compared with peers in their personal lives.
The males rated both their cognitive and emotional empa-
thies similarly in both the personal and professional domains
(r’s = 0.681 and 0.739). On the other hand, the females’ ratings
of their cognitive empathies in the two domains are somewhat
lower than the corresponding ratings of their emotional empa-
thies (r’s = 0.542 vs. 0.675). Because their mean scores are
213
Greek Version of TCES Tsiantou et al.

TABLE 5. Second rotated factor analysis of the Greek version of the Toronto Composite Empathy Scale (TCES)

Factors

Items I II III IV V Scale assignment

Personal items
1 0.001 0.033 0.495 0.037 0.395 Cognitive
2 0.024 0.411 0.185 0.191 0.430 Cognitive
3 0.056 0.088 0.036 0.530 0.161 Cognitive
4 0.192 0.233 0.359 0.078 0.525 Cognitive
5 0.427 0.111 0.168 0.056 0.266 Emotional
6 0.032 0.644 0.045 0.006 0.248 Cognitive
7 0.383 0.201 0.106 0.207 0.491 Emotional
8 0.145 0.012 0.031 0.407 0.183 Cognitive
9 0.132 0.198 0.006 0.623 0.152 Cognitive
10 0.566 0.070 0.087 0.125 0.065 Emotional
11 0.154 0.029 0.490 0.145 0.015 Cognitive
12 0.458 0.059 0.242 0.054 0.089 Emotional
13 0.281 0.029 0.240 0.273 0.553 Emotional
14 0.284 0.059 0.440 0.121 0.313 Cognitive
15 0.489 0.100 0.128 0.271 0.060 Emotional
16 0.376 0.047 0.286 0.071 0.138 Emotional
17 0.004 0.721 0.050 0.129 0.038 Cognitive
20 0.699 0.080 0.207 0.029 0.042 Emotional
21 0.454 0.019 0.137 0.151 0.405 Emotional
22 0.111 0.561 0.137 0.021 0.043 Cognitive
23 0.045 0.057 0.005 0.545 0.109 Cognitive
24 0.366 0.192 0.062 0.285 0.162 Emotional
Professional items
1 0.098 0.189 0.639 0.016 0.096 Cognitive
2 0.057 0.478 0.346 0.034 0.161 Cognitive
3 0.137 0.153 0.082 0.588 0.091 Cognitive
4 0.018 0.221 0.689 0.165 0.013 Cognitive
5 0.556 0.077 0.194 0.127 0.046 Emotional
6 0.073 0.715 0.094 0.074 0.125 Cognitive
7 0.466 0.361 0.182 0.200 0.346 Emotional
8 0.115 0.021 0.107 0.548 0.015 Cognitive
9 0.030 0.355 0.063 0.541 0.167 Cognitive
10 0.693 0.050 0.014 0.132 0.001 Emotional
11 0.119 0.074 0.653 0.079 0.017 Cognitive
12 0.555 0.048 0.224 0.003 0.030 Emotional
13 0.479 0.088 0.092 0.377 0.351 Emotional
14 0.100 0.175 0.752 0.177 0.067 Cognitive
15 0.532 0.237 0.219 0.166 0.079 Emotional
17 0.134 0.706 0.118 0.092 0.019 Cognitive
20 0.767 0.088 0.080 0.066 0.037 Emotional
21 0.619 0.038 0.045 0.199 0.291 Emotional
22 0.016 0.567 0.163 0.122 0.039 Cognitive
23 0.204 0.010 0.118 0.624 0.005 Cognitive
24 0.391 0.060 0.035 0.355 0.103 Emotional
25 0.313 0.023 0.121 0.245 0.067 Emotional
Variance accounted for 12.58% 8.40% 7.90% 7.83% 4.92%

Values in bold face are greater than ± 0.3.

similar (56.79 vs. 57.62), this suggests that the females draw on
different aspects of cognitive empathy when dealing with
patients vs. people in their personal life. On the other hand,
the males are more likely to use the same empathy tools in
both professional and personal domains.
Our results indicate that the Professional Emotional subscale
had the lowest mean score, the two cognitive subscales had the
highest scores and the Personal Emotional subscale fell in
between. By contrast, Yarascavitch et al. (49) found highest
scores for the two emotional subscales and lowest scores for
the two cognitive subscales in their study of Canadian dental
students (whilst the authors did not provide overall mean
scores, based on information presented in Figure 1 of their
paper, we estimate that the mean emotional sum scores ranged

214 ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 17 (2013) 208–217
Tsiantou et al.
from 40.95 to 49.40 across the years of dental training and the
mean cognitive sum scores ranged from 27.30 to 33.80). It is
possible that these differences are related to sampling differ-
ences.
Although we report on a single sample of dental students,
our results are strengthened by our very high response rate
(96.5%) compared with the rates of other studies (42). In
particular, the response rate was higher than the 36.5%
reported for the English version of the TCES (49). In the
present study, the questionnaires were distributed during tuto-
rials, whilst distribution of questionnaires in other surveys
was via email, and this difference may explain the different
response rates (42, 49).
Given the importance of empathy to the dentist–patient
relationship, one may ask whether empathy can be increased
through training. Whilst some authors have found that den-
tal and other health professional students can be taught
methods to increase empathy (e.g., ref. 57), others have
found that increases may be short-lived (e.g., ref. 58). Still
others have argued that empathy cannot be taught (59). It is
possible that the variety of definitions of empathy and/or
measures of empathy used in the various studies contribute
to this mixed literature. For example, Nash (4) asserts that
cognitive empathy can be increased, but emotional empathy
is developed in childhood and therefore unlikely to change
in adulthood.
As noted previously, healthcare professionals draw upon
scientific knowledge of diagnosis and disease prevention and
treatment, as well as empathy and other communication
skills, in their professional lives. A recent study of medical
students found that factors such as college grades and test
scores were more important predictors of success earlier in
the didactic portion of their training, whilst factors such as
empathy and personality were more important predictors of
success once the students began clinical interactions with
patients, suggesting that the two kinds of skills were differen-
tially important in gaining knowledge of disease and subse-
quently putting into practice that knowledge via the
healthcare professional–patient relationship (60). Drawing
upon the results of this study, dental school admissions crite-
ria might include indications that the applicant has high lev-
els of both kinds of skills (4).
In an intriguing study of practising physicians, Hojat and
colleagues found significant differences in empathy level by
specialty (45). For example, psychiatrists, paediatricians and
physicians whose specialty was internal medicine had the
highest levels of empathy, whilst neurosurgeons, orthopaedic
surgeons and anaesthesiologists had the lowest levels. These
cross-sectional data might be explained by the relatively
greater amount of ‘empathy training’ that psychiatrists and
others with the higher levels would have received, compared
with anaesthesiologists and others with the lower levels. On
the other hand, perhaps medical students with different levels
of empathy were differentially drawn to different specialties. It
would be informative to see whether dental students’ empathy
levels were related to their selection of specialties. Perhaps
empathy level might be a useful way of helping students
determine which area(s) of dentistry they might be best suited
for.
ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 17 (2013) 208–217
Greek Version of TCES
Our data indicate that the Greek version of the TCES is a
reliable and valid tool to measure the levels of emotional and
cognitive empathies in both the clinical and personal contexts.
Although the TCES consists of 52 questions, the measure can
easily be answered in a relatively short period of time. Given
that the JSPE-HP has been used with a variety of health profes-
sionals, we believe that the TCES could similarly have wide
usage across health professions.
Conclusions
The present study is the first to assess the psychometric proper-
ties of the Greek version of the Toronto Composite Empathy
Scale in dental students, as well as the first to report on this
scale’s test–retest reliability, factor analytic structure and gen-
der-related results. The Greek version of TCES displayed good
test–retest reliability and acceptable internal consistency, good
convergent and divergent validity and factor analytic results
consistent with the claim that the scale measures both emo-
tional and cognitive aspects of empathy. Taken together, our
results indicate that the Greek version of the TCES is a reliable
and valid tool for the measurement of cognitive and emotional
empathy, in both professional and personal life, in Greek dental
students.
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