Nurse Education Today 41 (2016) 1–5

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Nurse Education Today

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Empathy in health professional students: A comparative

cross-sectional study
Cristina Petrucci, Carmen La Cerra, Federica Aloisio, Paola Montanari, Loreto Lancia ⁎
Department of Health, Life and Environmental Sciences — University of L'Aquila, Edificio Delta 6-Via San Salvatore, 67100 Coppito (L'Aquila), Italy

a r t i c l e i n f o a b s t r a c t

Article history: Background: It has been shown that empathy strengthens the relationship between patients and health profes-
Received 28 July 2015 sionals and also improves patient and health professional satisfaction, which helps promote the best clinical out-
Received in revised form 9 March 2016 comes. Empathy is considered an essential prerequisite for a nurse to effectively care for a patient and for a
Accepted 23 March 2016 holistic understanding of a patient's perspective in a student population.
Objectives: The main aim was to compare empathy levels between health professional students attending differ-
Keywords:
ent university courses.
Empathy
Jefferson Scale of Empathy
Design: A comparative study with a cross-sectional approach was conducted in two successive academic year co-
Nursing students horts of 1st year health professional students at a public Italian university.
Undergraduate nursing course Participants and Methods: A sample of 1st year health professional students at a public Italian university was in-
Health professional students vestigated using the Jefferson Scale of Empathy Health Professional Students version (JSE-HPS).
Results: Overall, 502 health professional students were included in the study. The students in nursing showed sig-
nificantly higher empathy levels than the students in other health professions. Furthermore, the female students
were found to exhibit significantly more overall empathy than the male students were.
Conclusions: The undergraduate nursing students showed a significantly higher mean score of empathy mea-
sured by the Jefferson Scale of Empathy Health Professional Students version (JSE-HPS) than the students attend-
ing other health undergraduate courses. This could mean that a particular aptitude in establishing a help-
relationship with other people exists among the students that choose to become a nurse.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction communicate this understanding and an intention to help” (Hojat,

The term “empathy” refers to a personality trait that plays an impor-
tant role in interpersonal relationships and communication skills
(Hemmerdinger et al., 2007). Introduced in nursing science around
1973, the concept of empathy has become widely seen over the time
as an essential condition of effective nursing care (Herdman, 2004;
Kunyk and Olson, 2001; Määttä, 2006).
Feeling empathy means understanding the experience of others.
This includes cognitive, affective and behavioral components (Goubert
et al., 2005). In the Client-Centered Theory of Carl Rogers, empathy is
defined as the ability “to perceive the internal references frame of
another person with accuracy and with emotional and meaning compo-
nents [...] as if one were the other person, but without losing the condi-
tion of ‘as if’”. In this definition empathy is referred to as an act of will,
thus his intentional component (Määttä, 2006). Hojat defined empathy
as “a cognitive attribute mainly that includes the understanding of ex-
periences, problems and perspectives of the patient, and the ability to
⁎ Corresponding author at: University of L'Aquila, Department of Health, Life and
Environmental Sciences, Edificio Delta 6-Via San Salvatore, 67100 Coppito (L'Aquila), Italy.
E-mail address: loreto.lancia@cc.univaq.it (L. Lancia).
2009).
The clinical meeting between a patient and a health care profession-
al is the central activity of medical and nursing care. Empathy is consid-
ered a basic component of caring for someone (Yu and Kirk, 2009). In
fact, the basic tasks of nursing care consist of understanding the needs,
feelings and situation of a patient. Empathy is the basis of this under-
standing (Zeighami et al., 2012).
The policies of different health systems and educational objectives of
various study courses of health professions highlight the importance of
having an empathetic approach in a field of patient care (Määttä, 2006).
Empathy strengthens a relationship between a patient and health
professional and improves the satisfaction of both (McMillan and
Shannon, 2011; Walker and Alligood, 2001; Reynolds, 2000). It helps
create a non-defensive climate and allows patients to express their
own health needs (Mercer and Reynolds, 2002; Neumann et al., 2009).
Moreover, empathy is considered an essential prerequisite for effec-
tive nursing care and a holistic understanding of a patient's perspective
(Reynolds, 2000).
High levels of empathy in nursing and medical practice favor posi-
tive health and clinical outcomes for patients, such as reducing psycho-
logical stress, improving self-concept, reducing anxiety and depression,

http://dx.doi.org/10.1016/j.nedt.2016.03.022
0260-6917/© 2016 Elsevier Ltd. All rights reserved.
2 C. Petrucci et al. / Nurse Education Today 41 (2016) 1–5

and lower complication rates (Del Canale et al., 2012; Hojat et al., 2011; Table 1
Reynolds, 2000). Descriptive characteristics of the sample.

Trainers and teachers in the nursing field must foster the empathetic Sample
component in nursing students and maintain it at a high level, starting Total 502
with basic education (Reynolds and Scott, 1999). Females 333 (68.4%)
Mean age 21.27 (SD 3.32)
In the literature, several studies evaluated the presence of empathy
Median age 20.00 (IQR 1.00)
among health professional (HP) students and analyzed its levels. Specif- Min — max of age 18–48
ically, they compared empathy levels of subgroups in the same study
course to detect any differences by year of course attended, age, and Degree courses
Nursing 298 (59.4%)
gender. In 2002, Lauder analyzed the perceptions of empathy by nursing
Physiotherapy 55 (11.0%)
students of first, second and third year and found no significant differ- Neuro-psychomotor therapy in developmental age 33 (6.6%)
ences in empathy levels between these groups (Lauder et al., 2002). Obstetrics 20 (4.0%)
Subsequently, in 2010, Brown analyzed students attending the Occupa- Psychiatric rehabilitation techniques 20 (4.0%)
tional Therapy Course in an Australian University and showed an overall Orthotics and ophthalmology assistance 16 (3.2%)
Prevention techniques for the environment and the workplace 16 (3.2%)
a high level of empathy with no significant differences in the year of the
Dental hygiene 15 (3.0%)
study course was attended (p = 0.470) (Brown et al., 2010). Biomedical laboratory techniques 11 (2.2%)
Similarly, no significant differences were found by Lovan and Wilson Occupational therapy 12 (2.4%)
in 2012 in a sample of American nursing students assessed at the end of Nutrition and diet 6 (1.2%)
the degree course compared with nursing students at the beginning of
Upper-secondary schools attended
the course (Lovan and Wilson, 2012). In the same year a study conduct- Classical studies and science education 317 (63.1%)
ed in Australia reported that nursing students showed satisfactory Technical and professional education 86 (17.1%)
levels of empathy and no significant differences between the age, gen- Other upper-secondary schools 92 (18.3%)
der and year of study (McKenna et al., 2012).
In 2014 Williams compared empathy levels of first, second and third
year students at an Australian University. Unlike previous studies, the (Leombruni et al., 2014; Paro et al., 2012): it offers the advantage of
author noted that students in the second and third years showed higher being translated in various languages, and, moreover, being adapted
levels of empathy than the first year (Williams et al., 2014). to different targets: 1) medical students (JSE-S), 2) health professionals
Since all retrieved studies were focused only on specific target and physicians (JSE-HP), and 3) health professional students, including
groups, and since the empathy is essential in order to ensure positive nursing students (JSE-HPS).
outcomes in nursing care, a comparative study among health profes- According to the authors, this version of the scale showed satis-
sional students was considered useful in order to increase knowledge factory reliability (Cronbach's Alpha of 0.78) and a valid construct
in this field. that confirmed the three factors highlighted in the original version:
“Emotional Engagement”, “Compassionate Care Perspective Taking”,
2. Aims and “Standing in patient's shoes” (Montanari et al., 2015).
Like the original version, this 7-point Likert scale contained 20 items
Because studies comparing empathy levels between health profes- and ranged from 20 (minimum level of empathy) to 140 (maximum of
sional students attending different university courses were not found level of empathy) without any established cut-off (Hojat et al., 2001).
in the literature, this cross-sectional study aimed to assess HP students A socio-demographic questionnaire was also administered to per-
in different courses. Secondly, we sought to detect any significant differ- form a comparative analysis of several factors that can be predictive of
ences in relevant subgroups of the overall sample. empathy.

3. Methods
3.1. Design and Sample
A comparative cross-sectional study was conducted on a population
of 1st year health professional students (Table 1) attending a public
Italian university at the beginning of the academic year.
3.2. Tools
An Italian-validated version of the Jefferson Scale of Empathy was
used (Montanari et al., 2015). This tool has been chosen for different
reasons: in the literature there are several tools to measure empathy,
but the majority of them has not been developed in health care settings
and is not intended for health care professionals. Among the few re-
trieved tools for health care professionals, one resulted too long (500
items) and developed only for nurses, another one had low levels of
construct validity and reliability, and the last one has been developed
to assess teacher's perceptions of nursing students' empathic ability
(Yu and Kirk, 2009). Then, the only one which met the needs of this
research was Jefferson Scale of Empathy Health Professional Students
version (JSE-HPS), which, because of its wide use, also makes the data
comparable with other researches.
The Jefferson Scale of Empathy is a widely used psychometric tool in
order to measure empathy levels among health professional students
3.3. Data Collection
After an informed consent was obtained, questionnaires were
administered to two consecutive academic cohorts (2013/2014 and
2014/2015) of 1st year health professional students. Questionnaires
were administered in May 2014 and April 2015. Particular attention
was paid to create a positive environment during the questionnaire
administration. In order to avoid that students would feel forced to par-
ticipate in the study, questionnaires were anonymous and collected in a
sealed envelope.
3.4. Data Analysis
Descriptive analyses were performed for all investigated variables.
Because a normal distribution of data was assumed, a T-test and analysis
of variance (ANOVA) with a Bonferroni post hoc-test were used to com-
pare continuous variables. A Chi Square-test was used to perform com-
parisons of categorical variables. For correlation analyses, a Pearson
coefficient was used.
As suggested by the authors of the scale (Hojat et al., 2001), missing
data were replaced with the mean. If a respondent failed to answer
more than 4 items, the form was considered incomplete and excluded
from analyses. Data were collected using Microsoft Access 2010 and an-
alyzed by IBM SPSS software version 19.0.
 C. Petrucci et al. / Nurse Education Today 41 (2016) 1–5 3

Overall, the female students were significantly more empathic than

their male colleagues, as well as the students that read books (other
than text-books) compared to those who did not.
A small insignificant difference in empathy was found between the
students who stated to be involved in the volunteer programs and
those not involved in any type of volunteer programs.
Although not significant, a difference in empathy level was found
between the students from upper-secondary schools specializing in
classical studies and science compared to their colleagues coming
from upper-secondary schools specializing in technical and professional
education.
Finally, the correlation analysis showed no relationship between
empathy and age. Only a moderate, positive correlation was found be-
tween empathy and the evaluation marks obtained at the end of sec-
ondary school (Table 3).

5. Discussion

This is the first study conducted on a sufficiently large sample that

Fig. 1. Comparison of the empathy mean score between the nursing students and other HP
students. (Bars represent 95% Confidence Interval for the mean).
3.5. Ethical Considerations
The study was approved by the ethics committee on July 16, 2013.
Permission to use the JSE-HPS was obtained by the Center for Re-
search in Medical Education and Health Care of the Jefferson Medical
College of Thomas Jefferson University.
Students participated on a voluntary basis and data were processed
anonymously.
4. Results
Overall, 502 health professional students attending the 1st academic
year were included in the study: 301 in 2014 and 201 in 2015.
The median age of the investigated sample was 20 (IQR = 1.00) with
a predominance of females and nursing students (Table 1).
Data analyses highlighted that the students in nursing showed sig-
nificantly higher levels of empathy than the students in other health
professions (113.52 vs. 108.99) (Fig. 1), despite both the groups had a
homogeneous distribution for age (t test = − 0.310; p = 0.756) and
gender (Chi square = 0.42; p = 0.837).
An overall subgroup comparison of empathy level was conducted on
the main variables. The entire sample is provided in Table 2.
aimed to compare the empathy levels of health professional students
attending different university courses and to detect any significant dif-
ferences into the relevant subgroups of the overall sample.
Empathy is a fundamental component of the personality of health
professionals because it allows them to establish an effective therapeutic
and helping relationship with patients (Alligood, 1992; Herdman, 2004;
Kalisch, 1973; Kunyk and Olson, 2001; Määttä, 2006; Peplau, 1952;
Brunero et al., 2010). Similarly, nursing students are required to establish
helping relationships with patients by promoting positive attitudes and
behaviors that can affect nursing care (Williams and Stickley, 2010).
The main result of this study is that, at the beginning of the first year
of study, the undergraduate nursing students showed a significantly
higher mean score of empathy measured by the JSPE-HPS than the stu-
dents attending other health undergraduate courses. This might be ex-
plained by the fact that students who choose to attend the graduate
program in nursing may have a particular aptitude in establishing a
helping relationship with other people, which is a key point of the nurs-
ing profession.
However, which personality traits are distinctive for a nurse remain
unclear. Understanding why nurses choose their profession has long
been of interest (Eley et al., 2012). Various studies identified that an em-
pathetic disposition can influence the choice of attending the graduate
program in nursing. According to Eley and colleagues, reasons for enter-
ing nursing are related to levels of innate and developmental personal-
ity traits. They found that dominant personality traits, such as “to be
altruistic”, were associated with the choice to become a nurse (Eley
et al., 2012).

Table 2
Group comparisons for the empathy level values.

Variable Subgroup Year 2014 Year 2015 All years

N Score p-Value N Score p-Value N Score p-Value

Mean (SD) Mean (SD) Mean (SD)

Courses Nursing 212 113.79 (10.99) 0.001⁎ 86 112.86 (12.89) 0.075 298 113.52 (11.56) 0.000⁎
Others 89 108.25 (16.35) 115 109.56 (12.95) 204 108.99 (14.51)
Gender Males 94 106.83 (12.21) 0.000⁎ 60 107.06 (12.05) 0.006⁎ 154 106.92 (12.11) 0.000⁎
Females 193 114.78 (12.41) 140 112.51 (13.03) 333 113.82 (12.71)
Volunteer programs Yes 69 113.35 (12.61) 0.385 50 112.25 (13.06) 0.424 119 112.89 (12.75) 0.247
No 232 111.79 (13.16) 151 110.55 (12.99) 383 111.30 (13.09)
Books read (other than text-books) None 60 109.86 (13.47) 0.056 38 106.94 (14.45) 0.169 98 108.73 (13.86) 0.024⁎
1 93 110.66 (14.37) 56 110.66 (12.96) 149 110.66 (13.81)
2 65 112.33 (11.47) 47 112.50 (13.08) 112 112.40 (12.12)
N2 81 115.22 (11.91) 59 112.38 (11.66) 140 114.02 (11.84)
Upper-secondary schools Classical studies and science education 203 112.10 (14.05) 0.870 114 111.96 (12.85) 0.498 317 112.05 (13.61) 0.553
Technical and professional education 44 111.55 (10.60) 42 109.29 (14.83) 86 110.45 (12.81)
Other upper-secondary schools 50 112.95 (11.16) 42 110.47 (11.55) 92 111.82 (11.35)
⁎ Significant p-values.
4 C. Petrucci et al. / Nurse Education Today 41 (2016) 1–5
Table 3
Correlation coefficients.a
Empathy score
Age −0.064
Upper-secondary diploma grade 0.196
a tween empathy and academic success in order to consider the empathy
Correlation coefficient ranges between −1 and 1.
Studying levels of empathy of health professional students allows us
to understand if it can be considered a predictor of a university course
choice and if it is a stable trait or changes during the course program.
Empathic responses can be influenced by variables such as gender,
culture, environment and communication learned skills (Alligood and
May, 2000). Similar to other studies (Hojat et al., 2002; Williams et al.,
2014; Fields et al., 2011; Magalhães et al., 2011; Hasan et al., 2013;
Kataoka et al., 2009; Chen et al., 2007), the results of this study highlight
that the female students had significantly higher average scores of em-
pathy than the male students.
According to Leppel, student gender is an important independent
factor in choosing a degree course: women usually choose academic
courses traditionally dominated by women, such as nursing (Leppel,
2001).
Our data analysis also showed that the emphatic profiles of the
health professional students we studied were also related to reading
books (others than textbooks) and to the kind of upper secondary
school that was attended. Concerning reading books, the results showed
that the level of empathy increased as reading increased. Similar find-
ings were highlighted in a study by Hojat (Hojat, 2007) and reinforced
results from other studies in which reading and working on narratives
and poetry is considered an effective strategy to foster empathy during
nursing education (Stepien and Baernstein, 2006; Hojat, 2009).
Although the difference was not significant, the results of this study
showed that empathy was higher in the students that came from a clas-
sical and scientific education program than in students from technical
and professional schools. The type of secondary school deserves of
further study in view of Lancia's studies. According to those studies,
compared to colleagues from upper secondary schools specializing in
classical studies and science, nursing students from technical and pro-
fessional schools had worse final grades, average of the examination
scores, and number of graduates within a legal program duration
(Lancia et al., 2013).
Some studies showed that empathy is not a stable personality trait
and can be changed using educational interventions to develop innate
empathic capacity (Hojat et al., 2013; Hojat, 2007).
Students with low empathy scores could be identified for more in-
depth training and development. Conversely, exposing people with
high-trait empathy to full training may be unnecessary and ultimately
lead to higher training costs (Brunero et al., 2010).
The local dimension is a limitation of this study. In Italy there are
more types of health professional degree courses compared to other
countries. To effectively use empathy measurements to select the best
nursing students, wider investigations involving other countries are
needed to confirm the results of this research and demonstrate if the
empathy is really a predictor of academic success in nursing students
and if it affects nursing-sensitive outcomes in patients.
6. Conclusion
This study has investigated empathy in a wide sample of health pro-
fessional students. At the beginning of the first year of study, it was
found that the undergraduate nursing students showed a significantly
higher mean score for empathy measured using the Jefferson Scale of
Empathy Health Professional Students version (JSE-HPS) than the stu-
dents attending other health undergraduate courses. This could mean
that a particular aptitude in establishing a help-relationship with
other people exists among the students that choose to become a
nurse. Furthermore, the female students were significantly more em-
pathic overall than their male colleagues were.
p-Value Further research is needed to explain whether empathy as personal-
0.154
ity trait changes during a study program, and, if so, which factors impact
b0.000 this change. In addition, results lead to better study the relationship be-
as an important attribute to measure in “pre-nursing” as an admission
criterion.
Acknowledgments
The authors would like to thank the health professional students
who willingly gave of their time to participate in our research.
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