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Article history: When facing a person in need, professional nurses will tend to adopt an objective perspective compared to
Accepted 15 January 2013 nursing students who, instead, will tend to adopt an imagine-other perspective. Consequently, professional
nurses will show lower vicarious emotional reaction such as empathy and distress. Using samples from
Keywords:
Spain (Studies 1 and 2) and United states (Study 3), we compared perspective taking strategies and the emo-
Empathy
tional responses of nurses and nursing students when perceiving a sick child (Study 1) and a sick adult (Stud-
Distress
Perspective taking
ies 2 and 3). Taken together, the results supported our hypotheses. We discuss the applied value of
Nursing considering the relationship between perspective-taking and its emotional consequences for the nursing
profession.
© 2013 Elsevier Ltd. All rights reserved.
0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.01.010
B. López-Pérez et al. / Nurse Education Today 33 (2013) 334–338 335
findings. First, extensive research shows that objective-perspective higher tendency to adopt an imagine-other (M = 5.50, SD = .97) than
leads to feel a lower vicarious emotional reaction (i.e., empathy an objective perspective (M = 3.20, SD = 1.54), t(29) = 2.53, p b .02.
and distress) than does imagine-other perspective (Davis, 1996; In contrast, the professional nurses reported an equal tendency to
Hoffman, 2002; Batson, 2011). Second, Cameron and Payne (2011) adopt objective (M = 4.77, SD = 1.10) and imagine-other (Ms =
recently showed that when people anticipate that they are going to 4.30, SD = 1.60) perspectives. Age did not significantly interact
face with the suffering of many they tend to collapse their vicarious with perspective-taking strategy, F(2, 56) b 1.
emotional reaction (i.e., compassion, pain or distress). Therefore, as
professional nurses are used to daily face with different victims, we Emotional Consequences
reasoned that they will try to adopt an objective perspective as an Emotional responses of nursing professionals and student nurses
emotion regulation strategy to prevent a very intense vicarious emo- were assessed with a number of emotion adjectives through the emo-
tional reaction. tional response questionnaire. These adjectives were averaged to form
an empathy index (i.e., warmth, softhearted, tenderness, moved, com-
Method passionate, and sympathetic; Cronbach's α = .70) and a distress index
(upset, grief, sorrow, distressed, worried, and anxious; Cronbach's
Participants α = .88). We conducted the same mixed-factor ANOVA with emotional
Sixty people, between 18 and 55 years of age (M = 28.76, SD= reaction (empathy vs. distress) as a within-subject factor. The analysis
10.14), from different universities (nursing students, n = 30) and hospi- did not yield a significant within-subject effect for the emotional
tals (professional nurses, n = 30) agreed to participate (see Table 1). reaction factor, F(1, 57) = 2.94, p >.09. The interaction of this factor
with either age or role was also not significant, Fs(1, 57) b 1.68, p > .20.
Procedure However, the analysis did yield a significant between-subject effect
Participants from different areas of Madrid were asked to partici- for role, F(1, 57)= 5.79, p b .02. The professional nurses reported
pate. They were told that their opinion was needed on a photograph. feeling less empathy (Ms = 4.40, SD= .99) than did nursing students
After signing the informed consent, which contained the IRB number (M = 5.07, SD= .68), t(58)= 3.04, p b .005. The same pattern was true
approval from the university or hospital, the participants completed a for distress (Ms = 3.92 vs. 5.20, SDs = 1.54 vs. .85), t(58)= 3.99,
packet that consisted of an introduction to the study, followed by the p b .001 (see Table 2).
presentation of a picture (see Appendix 1). The participants then com-
pleted two questionnaires. The first included two separate items in Relationships Between Perspective-Taking Strategies and Emotional
which participants indicated the extent to which they remained objec- Reactions
tive (i.e., “I tend to remain objective and not emotionally involved”) and We conducted two regression analyses, each including as criteria
imagined the other's thoughts and feelings (“I tend to put myself in the either empathy or distress, and as predictors the measures of objec-
other shoes to understand how he/she is feeling about it”). Each item tive and other-imagine perspectives. The two regression equations
had a 7-point Likert Like Scale response format (1= Never, 7 = Totally). were significant [R 2c = .14 and .14, Fs (2, 57) = 4.61 and 4.57,
The second questionnaire was a version of the emotional response ps b .01] and revealed that empathy and distress were negatively
questionnaire developed by Batson et al. (1987), adapted into Spanish associated with adopting an objective perspective (βs = − 0.29 and
by Oceja and Jiménez (2007). The version used 12 emotional terms, − 0.38, respectively, ps b .03). The unreported predictors were not sig-
with a 7-point Likert Like Scale response format (from 1 = Not at all nificant (see Table 3).
to 7 =Extremely). This questionnaire was used to assess empathy and The results suggest that nursing students tend to adopt an
distress and showed good internal psychometric properties in the imagine-other perspective to a greater extent than the objective per-
American (see Batson, 1991) and Spanish contexts (see Oceja and spective, and that they felt higher empathy and distress when observ-
Jiménez, 2007). ing a sick child. These results also suggest that the tendency to adopt
the objective-perspective is negatively associated with feeling such
Results and Discussion vicarious emotions.
Table 1
Samples description for Studies 1, 2 & 3.
1 80 20 30 25 25 84 M = 10.50 SD = 7.03
2 72 25 35 15 25 82 M = 15.30 SD = 9.42
3 85 30 20 15 35 90 M = 19.26 SD = 10.15
336 B. López-Pérez et al. / Nurse Education Today 33 (2013) 334–338
Results and Discussion The goal of Study 3 is to assess the generalizability of the results from
Studies 1 and 2. We conducted a conceptual replication with a North
Perspective-Taking Strategies American sample. The relationship between perspective-taking strate-
The mixed-factor ANOVA with perspective-taking strategy as gies and emotional consequences is discussed.
within-subject factor, role as a between-subject factor, and age as
continuous covariate showed a significant interaction between Method
perspective strategy and role, F(2, 56)= 5.27, p b .01. Specifically, the
students reported a higher tendency to adopt the imagine-other (M = Participants
5.60, SD= 1.30) than the objective (M = 3.43, SD= 1.10) perspectives, The sample consisted of 60 participants: 30 professional nurses
from a large hospital in Texas, and 30 nursing students from the Uni-
versity of Texas at Tyler. Professional nurses were randomly selected
from hospital staff and invited to participate in the study. Access was
granted to the employee break room, which was used to conduct the
Table 3 procedure. The sample was mostly comprised of American females
Regression analyses. ages 24 to 66 (M = 41.07, SD = 12.61).
Study Empathy Distress Nursing students were recruited from the College of Nursing at the
University of Texas at Tyler. Students were informed about the survey
β t p β t p
and asked if they wished to volunteer. The sample was mostly com-
Study1 Objective perspective −.29 −2.26 .02 −.37 −2.92 .01
prised of American females ages 21 to 31 (M = 23.23, SD = 2.42).
Imagine-other perspective .16 1.24 .22 −.02 −.17 .86
Study 2 Objective perspective −.25 −2.28 .03 −.29 −2.70 .01
Imagine-other perspective .52 4.76 .001 .51 4.68 .01 Procedure
Study 3 Objective perspective −.25 −2.28 .03 −.34 −2.76 .01 The materials and the procedure in Study 3 were translated ver-
Imagine-other perspective .53 4.76 .01 .22 1.78 .10
sions of those used in Study 2.
B. López-Pérez et al. / Nurse Education Today 33 (2013) 334–338 337
Results and Discussion students) report less distress compared to undergraduate nursing
students.
Perspective-Taking Strategies The present research has important implications. Compared to
The mixed-factor ANOVA with perspective-taking strategy as nursing students, professional nurses tend to adopt an objective per-
within-subject factor, role as a between-subject factor, and age as spective which, in turn, reduces the intensity of the vicarious emo-
continuous covariate did not yield any significant effect, F(2, 56)b 1.44, tional responses, such as empathy and distress that they experience.
ps>.20. This is coherent with the results obtained by Cameron and Payne
(2011) which showed that the emotional response is different when
Emotional Consequences facing mass suffering, because people tend to keep detached not to
Again, the empathy and distress indexes (Cronbach's α = .86 for suffer the others' pain. This emotional regulation strategy of reducing
each) were the two measures of the emotional reaction. The distress and empathy involves both benefits and liabilities. Regarding
mixed-factor analysis of variance with emotional reaction as the benefits, lower distress may improve job performance and patient
within-subject factor, role as between-subject factor, and age as care because it is associated with less conflict among colleagues
continuous covariate did yield a significant between-subject effect (Leiter et al., 2010). Regarding the liabilities, lower empathy among
for role, F(1, 57) = 4.01, p = .05. The professional nurses reported nurses may consequently decrease the prosocial behavior towards
feeling less empathy and distress (Ms = 4.79 and 2.91, SDs = 1.44 their patients (Batson, 2011; Davis, 1996).
and 1.33, respectively) than did nursing students (Ms = 5.08 and Another limitation of our work is that professional nurses worked
3.65, SDs = 1.16 and 1.61, respectively). The difference for empathy in different nursing areas (Oncology, ICU, Traumatology & Gynecolo-
was not significant, t(58) = .79, but was for distress, t(58) = 2.05, gy) but mainly in Oncology, which may contribute to lack of distress.
p b .05. The unreported effects were not significant, Fs b 2.73, ps > .10 For future studies, it would be necessary to compare the emotional
(see Table 1). response depending on the different nursing areas.
Finally, a longitudinal study with nursing students and profession-
al nurses is needed to test if the changes in the emotional outcome
Relationships Between Perspective-Taking Strategies and Emotional (lower distress and objective perspective) are learned along the ex-
Reactions perience or depend on other factors.
We conducted two regression analyses to test whether the measures Summing up, the perspective adopted by current and future
of the perspective-taking strategies predict emotional reactions. The two nurses may have important consequences. More attention should be
regression equations were significant [R2c =.16 and .16, F (2, 57)=5.69 then paid to those training programs that assist these professionals
and 5.69, psb .01] and revealed that empathy and distress were predicted in controlling and managing the perspective to adopt in each situa-
by imagine-other perspective (βs=0.53 and 0.22, respectively, psb .01) tion. Langewitz et al. (2010) showed that training professional oncol-
and that empathy was negatively associated with objective perspective ogy nurses in communication skills increased their empathic accuracy
(β=−0.25, pb .02). The unreported predictors were not significant to patients' emotional cues. Introducing instruments to assess the
(see Table 3). perspective-taking and its emotional consequences should be an im-
The results in the American sample differ slightly from the portant piece of these training programs that benefit the situation of
other two studies. There were no significant differences between both those who suffer and those who take care.
professional and students in the reported tendency to adopt an
objective and imagine-other perspective. Regarding the emotional
reaction provoked by observing an adult in need, both groups felt Acknowledgements
similar levels of empathy, but students did report significantly
more distress, which is consistent with the results from Studies This research is supported by the project PSI2011-28720 from
1 and 2. the Spanish Ministry of Science and Innovation and the grant
AP2008-00065 from the Spanish Ministry of Education.
General Discussion
In the present research, perspective-taking strategies and emo- Appendix 1. Picture used in the Study 1
tional reaction among nursing students and professional students
were compared. Regarding perspective-taking, the results of the
three studies suggest that, in comparison with the other group, pro-
fessional nurses report a higher tendency to adopt an objective per-
spective, whereas nursing students report a higher tendency to
adopt an imagine-other perspective.
Regarding the emotional reaction, the results of the three studies
showed that students reported more empathy and distress than did
professional nurses. Furthermore, taken together, the results suggest
that these two vicarious emotions are negatively associated with
adopting an objective perspective (i.e., trying to remain not emotion-
ally involved) and positively with adopting an imagine-other per-
spective (i.e., trying to understand the other's situation). These
results are consistent with the research by Batson et al. (1997) and
Hoffman (2002) in that adopting different perspective-taking strate-
gies affects emotional consequences in predictable ways.
It is important to acknowledge that the nursing students who
volunteered in these studies were from different grades. An area of
interest for future research is to follow perspective-taking strategies
over time. For example, Kunst-Wilson et al. (1981) found that stu-
dents who are further along in their education (graduate nursing
338 B. López-Pérez et al. / Nurse Education Today 33 (2013) 334–338