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ORIGINAL ARTICLE
Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 57-61

Assessment of level of empathy among nursing students during internship


National Institute of Nursing Education, PGIMER, Chandigarh, India

Date of Web Publication29-Mar-2018

Correspondence Address:
Dr. Sukhpal Kaur
National Institute of Nursing Education, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_5_17

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  Abstract 


Background and Objective: Empathy is one of the therapeutic communication techniques for providing comfort to the client. It is an important component of meaningful interpersonal relationship. Internship is the period of tremendous changes, both personally and professionally. The current study was undertaken to assess the level of empathy among the nursing students during their internship. Methodology: The study was descriptive in nature. It was carried out at a nursing college of a North Indian city. Forty-six nursing interns participated in the study. Jefferson Scale of Empathy was administered three times to the students during the internship, i.e., at the beginning, at 6 months, and at the completion of internship. Results: Mean age ± standard deviation of the participants was 21.43 ± 0.91 with the range of 20–23 years. There was an increase in the number of participants with high level of empathy from the 23.9% at the beginning to 29.6% at the midway and 28.3% at the end of internship, but the increase was not statistically significant (P > 0.01). The mean empathy score, in the beginning, was 50.76 ± 4.2 with the range of 43–60. At the midway of the internship, the score was 52.13 ± 4.62 with the range of 40–60. However, at the end of internship the score was 52.41 ± 4.48 with the range of 40–60. There was no significant change in the empathy score throughout the internship (F = 1.816, P = 0.167). It may be because of the saturation level of empathy among the students of senior most class. Hence, future research may study empathy level among all the 4 years of training separately rather than only interns.

Keywords: Empathy, Jefferson scale of empathy, nursing students


How to cite this article:
Kaur S, Saini S, Waia I. Assessment of level of empathy among nursing students during internship. Indian J Soc Psychiatry 2018;34:57-61

How to cite this URL:
Kaur S, Saini S, Waia I. Assessment of level of empathy among nursing students during internship. Indian J Soc Psychiatry [serial online] 2018 [cited 2021 Jan 18];34:57-61. Available from: https://www.indjsp.org/text.asp?2018/34/1/57/228796




  Introduction Top


One of the qualities of a good nurse is that she/he should be empathetic in caring for the patients. Empathy is one of the therapeutic communication techniques for providing comfort to the clients. It is the ability to understand and accept another person's reality to accurately perceive feelings and to communicate this understanding to others.[1] Empathy is an expression of understanding of “how it is for the client” who is distressed, suffered, or sad.[2] Empathy as has been described by Davis [3] involves both cognitive as well as affective or emotional domains. The cognitive domain as per Hozat et al. is the ability to understand another person's inner experiences and feelings. It is also the capability to view the outside world from the other person's perspective.[4] However, the affective domain entails the capacity to enter into or join the experience of feelings of another person.[4] Sympathy and empathy are actually two distinct concepts. These are often mistakenly drawn into one terminological basket. Empathy is sharing the patients' understanding while sympathy is sharing one's own emotions with the patients.[5]

Various types of scales like balanced emotional empathy scale, Hogan empathy scale and Jefferson scale of empathy, etc., are being used to assess the level of empathy in health-care professionals. Jefferson Scale of empathy (Polish version) is proved to be very useful instrument in evaluating empathy in students.[6],[7] This scale was originally developed as a 90-item preliminary version. After pilot testing with groups of practising physicians, residents and medical students, a revised and shortened version of the instrument was developed. It was initially used to evaluate the attitudes of medical students toward physician empathy in patient care situations (the “S” version). It included 20 Likert-type items which were to be answered on a 7-point scale.[8] Then, the revised version of the Jefferson Scale of Physician Empathy for physician and health professionals (the “HP” version) was developed by Hojat et al.[4] Slight modification in the wording of “S” versions were made to make it more relevant to the caregivers' empathetic behavior rather than to empathetic perceptions. Total number of items remained the same.

The empathetic behavior of the health professionals has been linked to a number of attributes. The caring and concerned health-care professionals who communicate properly with their patients are likely to provide the best quality of care.[9] The nurses with higher empathetic level had a better attitude toward elderly patients.[10] The more empathetic physicians were more competent in history taking and performance of physical examination,[11] they were more satisfied,[12] and had better therapeutic relationship with the patients.[13]

Despite the fact that empathy can play an important role in improving outcome, there is dearth of studies in literature especially in nursing. George and Jayalakshmi [14] did a study on B. Sc. Nursing students and concluded that the level of empathy among the students was below average (30% score). Another study [15] has reported that there was no change in empathy during a 9-month training period among the 3rd year nursing students.

Internship is the last year of nursing training. The students, who successfully complete their formal education up to 3rd year, are admitted in internship. It is the period of transition. The students gain more of clinical skill during this period as there is very less of classroom teaching and more of clinical experience. The students are posted in clinical settings round the clock in various specialties such as psychiatry ward, emergency units (pediatrics and adults), operation theatre, community health nursing, and labor room. It is expected that these students pay attention to the needs and wants of the people; they should be listening to the patients and building therapeutic relationship with them to satisfy their expectations in a better way. Thus, internship is the period of tremendous change, both personally and professionally. These changes include long working hours, scarcity of sleep, more demands of patient care, and less time for the family. It has been reported that many interns have feelings of anxiety and depression at some point during the year.[16] Bellin [15] has documented that though there is enthusiasm at the beginning of internship, soon it gives way to depression, anger, and fatigue which can affect the empathetic attitude of the students. To know the fluctuations in the empathy level of B. Sc. Nursing interns at different stages of internship, the current study was undertaken with the objective to assess the level of empathy among the nursing students during internship.


  Methodology Top


The study was carried out at a nursing institute of a North Indian city. The institute is one of the premier institutions of India running three nursing programs: B. Sc. Nursing (4 years), B. Sc. Nursing (Post Basic), and M. Sc. Nursing. B. Sc. Nursing (4 years) is a 4 years program which constitutes 3 years of formal teaching and the 4th year as an internship (at the time of conducting the study). These students join nursing after 10 + 2 education in medical. Both the B. Sc. Nursing (Post Basic) and M. Sc. Nursing are of 2-year duration. The students of both these programs had already completed their diploma in nursing and degree course in nursing respectively and are registered nurses.

The study sample constituted 46 B. Sc. Nursing interns. They were posted in the hospital in various general wards, critical areas, operation theatre, and community health with four to 6 weeks of duration. They were posted round the clock in the hospital and were required to do 6 h of day duty and night duty for 12 h. In the 4 weeks posting, the students were required to do six-night duties, however in the areas with 6 weeks posting they had to do nine-night duties (three nights in continuation). In the operation theater and in the community areas, the students were posted only during day time for 7–8 h.

The Jefferson Scale of Empathy by Hojat was used in the study. It is twenty items and seven point Likert scale. It was further modified to make it more suitable for the current study. Minor modifications in the text of few items were made. For example, “I consider understanding my patient's body language is as important as verbal communication in physician-patient relationships” was revised to “I consider understanding my patient's body language is as important as verbal communication in nurse-patient relationships.” In other items also, the word “physician” was replaced by the word “nurse.” The seven-point scale was also converted into three point scale, i.e., disagree = 1, undecided = 2, agree = 3). The total number of item remained the same. Permission to use the scale and to do minor modifications in the tool was taken from the author.

The reliability of the modified tool was measured using split-half test method (r = 0.87). Item-total score correlation was also calculated. It indicated that all items were positive and 15 of them were significant, i.e., having value more than 0.2 and four had value between 0.1 and 0.2 and only one had value <0.1. However, in these five items also the scale mean decreased when deleted one by one. Hence, all the items were contributing to total score. Thus, the tool was reliable to be used in the present study.

Jefferson Scale of Empathy was administered three times to the students during the internship, i.e., at the beginning, at the midway, and at the completion of internship. The collected data were analyzed using descriptive and inferential statistics.

Approval was obtained from the Institution Ethics Committee. An informed verbal consent was sought from each individual. They were assured that the collected data would be used only for the research purposes, and that their decision to withdraw or refuse to participate will not have any impact on their practices.


  Results Top


Sociodemographic profile of the participants

The age of participants ranged from 20 to 23 years with Mean age ± standard deviation of 21.43 ± 0.91. More than one-third (39.1%) were of 21 years of age. About 47.8% each belonged to Hindu and Sikh religion. The majority (95.7%) were from an urban background. Two-third of them (67.4%) was in the first birth order among their siblings. Their family income Ranged from Rs. 1666/- to Rs. 12500/- with mean income Rs. 6078 ± 2756.50 [Table 1].
Table 1: Sociodemographic profile of the participants (n=46)

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Level of empathy at different stages of internship

There was increase in the number of participants with high level of empathy from the 23.9% at the beginning to 29.6% at the midway and 28.3% in the end of internship, but the increase was not statistically significant (P > 0.01). The mean empathy score, in the beginning, was 50.76 ± 4.2 with the range of 43–60. At the midway of the internship, the score was 52.13 ± 4.62 with the range of 40–60. However, in the end of internship, the score was 52.41 ± 4.48 with the range of 40–60. There was no significant change in the empathy score throughout the internship (F = 1.816, P = 0.167) [Table 2].
Table 2: Empathy level at different stages of internship among the subjects

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[Table 3] depicts the item wise responses of the participants as per Jefferson Scale of Empathy at different stages of internship. There was significant increase in the percentage of students in their responses like “An important component of the relationship with my patient is my understanding of the emotional status of the patients and their families;” “My understanding of my patients' feelings gives them a sense of validation that is therapeutic in its own right;” “My patients feel better when I understand their feelings;” “I try to imagine myself in my patient's shoes when providing care to them;” and “Patients” illness can be cured only by medical treatment; therefore, affectional ties to my patients cannot have a significant place in this endeavor.” There were certain aspects where the decrease on percentage of interns with high empathy was observed as they progressed in their internship. These were “I try to understand what is going on in my patient's mind by paying attention to their nonverbal cues and body language;” “I try to think like my patients in order to render better care.”
Table 3: Item wise favorable responses of as per Jefferson Scale of Empathy among the participants at different stages of internship

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  Discussion Top


Nursing is a profession based on human relations. Empathy is an important component of meaningful interpersonal relationship. It is the most important quality a nurse should possess in order to understand the individuals and their problems to provide them quality care. It is one of the most essential components of helping relationship. Empathy influences the ability of a nurse to become more sensitive human being. The current study assesses the level of empathy among nursing students during different stages of internship of 1-year duration.

It was seen that overall there was increase in the number of participants with a high level of empathy from the beginning to the end of internship, though the increase was not statistically significant. The reason of nonsignificant change may be because internship is the senior most class and the last year of the training, and to reach that level, students may get saturated level of empathy. Thus to do the discrimination in the level of empathy, the future researchers need to study level of empathy among all the 4 years of students separately so that difference in level of empathy can be observed each year. However, in item wise responses of the participants as per Jefferson Scale of empathy there was significant increase in the percentage of students in their responses like “An important component of the relationship with my patient is my understanding of the emotional status of the patients and their families;” “My understanding of my patients' feelings gives them a sense of validation that is therapeutic in its own right;” “My patients feel better when I understand their feelings;” “I try to imagine myself in my patient's shoes when providing care to them,” etc.

It is well said that “Practice makes a man perfect.” The interns are posted round the clock in the hospital and are required to perform their duties just like the practising nurses. Hence, in the due course of time, it is likely that there is an enhancement in their skill of handling the patients, communicating with the patients and their caregivers as well, understanding their feelings and problems, etc. All these may contribute to the development of empathetic behavior of the nursing students. Evidence suggest that empathy and communication skills can be improved with training. A statistically significant relationship between the empathetic skills and grades of education has also been shown by Cinar et al.[17] Similar results have also been reported in another Australian study carried out in undergraduate midwifery students.[18]

Contrary to these findings, the 1st-year dental students had shown to be having significantly higher empathy scores than students in any subsequent year. The decline in empathy levels has been reported to be the more exposure to patients.[19] Hojat et al.[20]et al. also observed a statistically significant fall in empathy levels in medical students from the beginning to the end of their 3rd year of medical school.


  Conclusion Top


It is concluded from the results of the present study that the level of empathy of the nursing students increases with their increase in nursing practice. The significant change in overall score is not observed as the saturation of empathy level may have occurred by the time students reach at the internship level. Thereafter, a considerable change may not be possible. But if the empathy level is assessed among all the students from 1st year to 4th year of training each year, then a significant change may happen as the students grow every year and the empathy level is also raised each year. Thus, it is recommended to have such type of research in future.

Our study had several limitations. First, it relies exclusively on self-reported measurement of empathy among the nursing interns. Second, the study was carried out only on the students pursuing their internship. Finally, the study was limited to one nursing college, and the sample size was small.

Hence, based on the results of the present study and the imitations cited above, the future research may focus on the recommendations such as behavioral observations of the activities of practising nurses along with the self-reported empathy, assessment of empathy on different levels of nursing training, and multicentric studies on large sample size.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Potter PA, Perry AG. Fundamentals of Nursing. 2nd ed. St. Louis: CV Mosby; 1989.  Back to cited text no. 1
    
2.
Kozier B, Erb G, Berman A, Synder SJ. Fundamentals of Nursing. 7th ed. Delhi, India: Saurabh Printers Private Ltd.; 2004. p. 421.  Back to cited text no. 2
    
3.
Davis MH. Empathy: A social psychological approach, Madison, Wisconsin: Brown Benchmark 1994. In: Hozat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: Definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry 2002;159:1563-69.  Back to cited text no. 3
    
4.
Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: Definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry 2002;159:1563-9.  Back to cited text no. 4
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George S, Jayalakshmi LS. A study to assess the level of empathy among nursing students. Nightingale Nurs Time 2005;1:4-8.  Back to cited text no. 14
    
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Bellini LM, Baime M, Shea JA. Variation of mood and empathy during internship. JAMA 2002;287:3143-6.  Back to cited text no. 15
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Clark DC, Salazar-Grueso E, Grabler P, Fawcett J. Predictors of depression during the first 6 months of internship. Am J Psychiatry 1984;141:1095-8.  Back to cited text no. 16
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Cinar N, Cevahir R, Sahin S, Sozeri C, Kuguoglu S. Evaluation of empathetic skills of nursing students with respect to the classes they are attending. Rev Electron Enferm 2007;9:588-95.  Back to cited text no. 17
    
18.
McKenna L, Boyle M, Brown T, Williams B, Molloy A, Lewis B, et al. Levels of empathy in undergraduate midwifery students: An Australian cross-sectional study. Women Birth 2011;24:80-4.  Back to cited text no. 18
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19.
Sherman JJ, Cramer A. Measurement of changes in empathy during dental school. J Dent Educ 2005;69:338-45.  Back to cited text no. 19
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Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, et al. An empirical study of decline in empathy in medical school. Med Educ 2004;38:934-41.  Back to cited text no. 20
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