EMPATHY AND EMPATHIC COMMUNICATION: NURSING STUDENT 
PERCEPTIONS OF PROGRAM EFFECTIVENESS, ACADEMIC  
EXPERIENCES, AND COMPETENCE 
 
 
 
Except where reference is made to the work of others, the work described in this 
dissertation is my own or was done in collaboration with my advisory committee.  
This dissertation does not contain any proprietary information. 
 
 
___________________________________________ 
Libba Reed McMillan 
 
 
 
Certificate of Approval: 
 
 
 
 
    
Kathy Jo Ellison  David M. Shannon, Chair 
Professor  Professor 
Nursing  Educational Foundations, Leadership 
  and Technology 
 
 
 
    
Sean Forbes  George T. Flowers 
Associate Professor  Interim Dean 
Educational Foundations, Leadership  Graduate School 
and Technology 
 
EMPATHY AND EMPATHIC COMMUNICATION: NURSING STUDENT 
PERCEPTIONS OF PROGRAM EFFECTIVENESS, ACADEMIC  
EXPERIENCES, AND COMPETENCE 
 
 
Libba Reed McMillan 
 
 
A Dissertation 
Submitted to  
the Graduate Faculty of 
Auburn University 
in partial fulfillment of the 
Requirements for the 
Degree of 
Doctor of Philosophy 
 
 
Auburn University 
May 10, 2007 
 
 
 iii
EMPATHY AND EMPATHIC COMMUNICATION: NURSING STUDENT 
PERCEPTIONS OF PROGRAM EFFECTIVENESS, ACADEMIC  
EXPERIENCES, AND COMPETENCE 
 
Libba Reed McMillan 
 
Permission is granted to Auburn University to make copies of this dissertation at its 
discretion, upon requests of individuals or institutions and at their expense.  
The author reserves all publication rights. 
 
 
 
             
      Signature of Author 
 
 
             
      Date of Graduation 
 
 
 iv
VITA 
 
 Rebecca Elizabeth (Libba) Reed McMillan, daughter of Willard (Skeet) and Mary 
Reed, was born in Talladega, Alabama on August 31, 1960. She married Kenneth Neil 
McMillan, Lt. Col USAF (retired) on June 18, 1983. She graduated from Auburn 
University with a Bachelor of Science degree in Nursing in June, 1983, and completed 
her Master of Science in Nursing from the University of Texas in Arlington (UTA) in 
December, 1986. The areas of specialization included Cardiovascular Clinical Specialist, 
Teaching, and Adult Health. It was through working with various types of patients?
those that were critically ill, emergency trauma, cardiac rehabilitation, school nursing 
students, families at a poverty clinic in South America and maternal-child/Special Care 
nursery patients?that she grew to appreciate and understand the importance of her 
dissertation topic on empathy. She entered Graduate School at Auburn University in 
January, 2005, and pursued her doctoral degree in Educational Psychology. She worked 
as a Graduate Teaching Assistant from August, 2006-present in the Department of 
Educational Foundations, Leadership, and Technology. She lives in Auburn with her 
wonderful family, which includes her husband, two daughters Meredith and Madeline, 
and four-legged family members, Maggie and Moses.  
 
 v
DISSERTATION ABSTRACT 
EMPATHY AND EMPATHIC COMMUNICATION: NURSING STUDENT 
PERCEPTIONS OF PROGRAM EFFECTIVENESS, ACADEMIC  
EXPERIENCES, AND COMPETENCE 
 
Libba Reed McMillan 
Ph.D., May 10, 2007 
(M.S.N., University of Texas, 1985) 
(B.S.N., Auburn University, 1983) 
 
156 Typed Pages 
Directed by David M. Shannon 
 
The purpose of this survey study was to examine the relationship between senior 
baccalaureate nursing student?s perceptions of their nursing program effectiveness in 
teaching them to empathically communicate with patients and family members and (a) 
attitudes toward empathy in patient care and (b) perceived competence as a result of 
instruction. Nursing program components, as measured by the researcher-designed 
Nursing Student Empathic Communication Questionnaire, were divided into the 
following five areas: academic exposure to patient care situations, curricular emphasis 
during the nursing program, perceived program effectiveness, perceived competence, and 
academic sources. Student attitudes toward empathy in patient care were measured by the 
JSPE Nursing Student Version R . This instrument contains 20 Likert-type questions that 
 vi
measure orientation or attitudes toward empathy in patient care. Another purpose of the 
study was to perform psychometric evaluation of the JSPE Nursing Student Version R to 
support the existence of empirical relationships among a set of variables determined in 
the literature to be associated with empathy. The examination of the underlying 
constructs of this measurement was important to this study because this data contributes 
to the construct validity of the instrument with nursing students.  
 The study was conducted using a survey design and data collection from 
September to November 2006. The population consisted of 14 baccalaureate programs 
with CCNE accreditation, with a sample population of 600 nursing seniors. Results of the 
study showed through backward regression technique that the sub-component of 
academic exposure was the highest predictor of student attitudes toward empathy in 
patient care. Academic exposure accounted for 11.6% of the variance for student attitudes 
toward empathy in patient care. The subcomponent of academic exposure was also the 
highest predictor of perceived competence as a result of nursing program instruction. 
Academic exposure accounted for 19.1% of the variance of perceived competence as a 
result of nursing program instruction. A hierarchical regression analysis was used to 
examine the extent to which attitudes toward empathy were related to perceived 
competence after controlling for the influence of the four program components. These 
results showed that the four program components contributed 22%, with the addition of 
attitudes toward empathy in patient care contributing only 1.1%. Implications to nursing 
education underscore the importance of increased exposure to clinical patient-care 
situations and highlight the role of faculty feedback and remediation from both attitudes 
toward empathy and perceived competence perspectives.
 vii
 
 
 
 
 
 
 
 
 
ACKNOWLEDGMENTS 
 
If there were but one word to describe this journey towards pursuit of this degree, 
it would be intense and heartfelt gratitude. I have become deeply reflective (downright 
emotional) over these past two years at the realization of the many people that have been 
truly instrumental to the process of my completing this degree. I?m humbled when I 
consider the blessings I have received and experienced as a result of others? sacrifices. 
Many of these individuals will never fully realize the profound role they played in 
supplying ?exactly what I needed? in word and deed. This includes such kindnesses as 
prayer, words of encouragement, reality checks, and opportunities afforded to me that 
exemplify sheer grace. Additionally, the foresight and insight of my parents to prepare 
the foundation from which to build my educational experience absolutely astounds me as 
to what they sacrificed financially to facilitate my own development. I praise God for the 
sacrifices my husband and children (Meredith and Madeline) have made willingly to 
support my finishing this degree and enormous encouragement they have bestowed. My 
committee?David Shannon, Kathy Jo Ellison, and Sean Forbes?has been instrumental 
to my success with each providing timely, wise council that was unique to their own 
personalities and talents. Dr. Shannon has blessed me with his tireless mentorship, 
guidance, encouragement, time, and patience over the past two years. Sean Forbes 
inspired me to constantly ?dig deeper? and to finish the journey strong through the 
 viii
doctoral birthing process. Kathy Jo Ellison provided emotional support through my 
transition from novice to greater academic maturity. Fellow graduate school buddy, 
Sophie Ryan has been a constant source of support as both mentor and friend. I?m 
grateful to have had this opportunity and cherish all the blessings I have experienced. 
 
 ix
 
 
 
 
 
 
 
 Style manual or journal used: Publication Manual of the American Psychological  
Association, Fifth Edition (2001)          
Computer software used:  Microsoft Word 2003; SPSS, Version 13.0  
             
 
 x
 
 
 
 
 
 
 
 
 
TABLE OF CONTENTS 
 
 
LIST OF TABLES..................................................................................................... xii 
 
I. INTRODUCTION ......................................................................................... 1 
 
 Purpose of the Study ...................................................................................... 5 
 Research Questions........................................................................................ 6 
 
II. LITERATURE REVIEW .............................................................................. 8 
 
 Empathy ......................................................................................................... 12 
 
  Definitions of Empathy...................................................................... 12 
  Empathy as a Human Trait ................................................................ 15 
  Empathy as a Professional State ........................................................ 16 
  Empathy as a Communication Process.............................................. 16 
  Related Concepts ............................................................................... 17 
  Role of Empathy and Empathic Communication in Patient Care...... 19 
 
 Didactic and Clinical Teaching-Learning Practices of  
  Empathic Communication ................................................................. 23 
 
  Modeling............................................................................................ 23 
  Technological Techniques ................................................................. 24 
  Combination Approach...................................................................... 25 
  Artwork and the Humanities.............................................................. 26 
  Poetry ................................................................................................. 27 
  Drama................................................................................................. 28 
  Focus on Therapeutic Communication Skills.................................... 29 
  Difficult Patient Situations................................................................. 30 
  Challenges to Educators..................................................................... 31 
 
 Outcome Measures of Achievement of Student Learning Outcomes............ 33 
   
  Measurement of Empathy.................................................................. 33 
 
 xi
 Student?s Attitudes toward Empathy in Patient  
  Care and Program Instruction ............................................................ 37 
 
  Moderate-No Change in Empathy ..................................................... 38 
  Declines in Empathy.......................................................................... 40 
  Increased Empathy............................................................................. 41 
 
 Perceived Competency................................................................................... 42 
 
  Role of Education .............................................................................. 43 
  Competence-Confidence Link ........................................................... 46 
  Self-Perception of Competency ......................................................... 47 
  Advanced Empathic Communication ................................................ 49 
 
 Summary........................................................................................................ 50 
 
III. METHODS .................................................................................................... 53 
 
 Overview........................................................................................................ 53 
 Population ...................................................................................................... 54 
 Instrumentation .............................................................................................. 55 
 
  JSPE Nursing Student Version-R ...................................................... 56 
  Nursing Student Empathic Communication Questionnaire............... 58 
  Program Effectiveness ....................................................................... 62 
  Academic Sources.............................................................................. 63 
  Academic Exposure ........................................................................... 63 
  Competence........................................................................................ 63 
  Curricular Emphasis........................................................................... 64 
  Section B............................................................................................ 66 
 
 Data Collection Procedures............................................................................ 66 
 
  Sample Size Considerations............................................................... 68 
 
 Data Analysis................................................................................................. 69 
 
  Nursing Student Empathic Communication Questionnaire............... 71 
 
 Summary........................................................................................................ 72 
 
IV. RESULTS ...................................................................................................... 73 
 
 Overview........................................................................................................ 73 
 Sample Demographics ................................................................................... 74 
 xii
  Research Question 1 .......................................................................... 76 
  Research Question 2 .......................................................................... 78 
  Research Question 3 .......................................................................... 84 
 
 Overview of Descriptive Statistics................................................................. 84 
 Overview of Full Model Results.................................................................... 84 
 Program Effectiveness and Student?s Attitudes toward 
  Empathy in Patient Care .................................................................... 87 
 Academic Sources and Student?s Attitudes toward 
  Empathy in Patient Care .................................................................... 88 
 Academic Exposure and Student?s Attitude toward  
  Empathy in Patient Care .................................................................... 89 
 
  Research Question 4a......................................................................... 91 
  Research Question 4b ........................................................................ 91 
 
 Overview of the Full Model Results.............................................................. 91 
 Academic Exposure and Perceived Competence........................................... 95 
 Curricular Emphasis and Perceived Competence.......................................... 96 
 Program Effectiveness and Perceived Competence....................................... 97 
 Summary........................................................................................................ 98 
 
V. DISCUSSION................................................................................................ 100 
 
 Limitations ..................................................................................................... 103 
 Implications.................................................................................................... 105 
 
  Student?s Attitudes toward Empathy in Patient Care ........................ 106 
  Student?s Perceived Competence to Empathically Communication . 110 
 
 Summary........................................................................................................ 112 
 Recommendations for Future Research......................................................... 113 
 
REFERENCES .......................................................................................................... 115 
 
APPENDICES ........................................................................................................... 127 
 
 Appendix A: Survey Questionnaire?JSPE Nursing Student Version R...... 128 
 Appendix B: Information Letter.................................................................. 130 
 Appendix C: Nursing Student Empathic Communication Questionnaire... 133 
 Appendix D: Auburn University Institutional  
  Review Board (IRB) Protocol................................................ 138 
 Appendix E: Flyer Template....................................................................... 141 
 xiii
LIST OF TABLES 
 
 
Table 1 Nursing Student Empathic Communication  
  Questionnaire Construct Overview.................................................... 59 
 
Table 2 Comparison of Sample Group with National Population .................. 76 
 
Table 3 Descriptive Statistics and Percentiles between the  
 JSPE S-Version (n = 685 medical students) and JSPE  
 Nursing Student Version R (n = 600 senior nursing students) .......... 78 
 
Table 4 Descriptive Statistics JSPE Nursing Student Version R.................... 79 
 
Table 5 Factor Analysis (Rotated). Extraction Method:  
 Principal Component Analysis, Rotation Method  
 Varimax with Kaiser Normalization.................................................. 81 
 
Table 6 Nursing Student Empathic Communication  
Questionnaire Components................................................................ 83 
 
Table 7 Dependent Variable: Student?s Orientation or  
 Attitudes toward Empathy in Patient Care  
 (JSPE Nursing Version-R Total Scores)............................................ 85 
 
Table 8 Sub-construct Questions for Independent Variables.......................... 87 
 
Table 9 Sub-variables for Program Effectiveness for Restricted Model ........ 88 
 
Table 10 Sub-variables for Academic Sources................................................. 89 
 
Table 11 Sub-variable Analysis for Academic Exposure on Restricted Model 90 
 
Table 12 Dependent Variable: Student Perceived Competence in  
 Present Ability as a Result of Nursing Program Instruction.............. 92 
 
Table 13 Sub-construct Questions for Independent Variables.......................... 94 
 
Table 14 Sub-variable Analysis for Academic Exposure ................................. 95 
 
 xiv
Table 15 Sub-variables for Curricular Emphasis.............................................. 97 
 
Table 16 Sub-variables for Program Effectiveness in Restricted Model.......... 98 
 
 
 1 
I. INTRODUCTION 
 
Baccalaureate nursing program educators are faced with intense expectations 
from many stakeholders, such as patients, students, academic accreditation communities, 
and healthcare administrators, to produce graduates that can enter their professional 
practice with a high degree of skills and competence. Core nursing competencies, such as 
critical thinking, communication, assessment, and technical skills, direct many aspects of 
the teaching/learning process in baccalaureate nursing education (AACN, 1998). Nursing 
educators are continually faced with making judicious decisions in the evolving process 
of revising, refining and enhancing curricular content to embody these core 
competencies. A central goal for nursing education programs is to identify and maximize 
student learning experiences of these competencies in both the clinical and theoretical 
setting to facilitate student achievement and thereby meet educational standards 
necessary for accreditation (Standards for Accreditation of Baccalaureate and Graduate 
Nursing Programs, 2003).  
In regard to addressing the attainment of core competency of communication, the 
role of the nurse extends beyond mere information gathering regarding disease and 
treatment. There is expansion of this role into the creation of a therapeutic relationship 
that assesses the patient?s concerns, promotes understanding, exhibits empathy and 
 2 
communicates empathically through providing comfort and support (Hardee, 2003; 
Kruijer, 2000; Platt & Platt, 1998; Price & Archbold, 1997). 
Therapeutic communication, which includes empathy, in patient care is accepted 
as a necessary component in the nursing profession and must thereby be an essential 
element to accredited nursing education programs (AACN, 1998; Standards for 
Accreditation for Baccalaureate and Graduate Nursing Programs, 2003). Empathic 
communication skills are critical to providing high-quality nursing care to patients in an 
attempt to holistically understand the patient?s perspective. These skills pertaining to 
therapeutic communication must include evidence that the student: (a) demonstrate 
communication skills during assessment, intervention, evaluation, and teaching, (b) adapt 
communication methods to patients with special needs, such as psychological or sensory 
disabilities, (c) use therapeutic communication within the nurse-patient relationship, and 
(d) elicit and clarify patient preference and values (AACN, 1998, p. 10). This 
clarification process of patient preferences and values involves the ability of the nurse to 
understand the patient?s perspective and communicate this understanding, which involves 
empathic ability. 
Correspondingly, empathy has been linked with improved patient outcome 
measures, and is regarded to be a key determinant of patient and family satisfaction, 
improved clinical outcomes in the form of recovery and healing, fewer malpractice suits 
and litigations and overall positive perspectives of care (Chant et al., 2002; Platt & Platt, 
1998). Although much has been learned about the role of empathy in patient care 
(Alligood & May, 2000; Baillie, 1996; Freshwater & Stickley, 2003; Gould, 1990; 
Irurita, 1999; Kunyk & Olson, 2001; Lauder et al., 2002; Morse et al., 1992; Smyth, 
 3 
1996; Thorne et al., 2005; Yegdich, 1999), and patient outcomes (Caris-Verhallen et al., 
1999; Chant et al., 2002; Forsyth, 1979; Platt & Platt, 1998; Reynolds & Scott, 2000), 
few studies have explored the potential relationship between student perception of 
effectiveness of the nursing program in teaching empathic communication as related to 
student attitudes toward empathy in patient care (Mozingo et al., 1995; Rogers, 1986). 
Even fewer studies have delved into student perception of program effectiveness and 
their perceived competency to empathically communicate as a result of this instruction 
(Farrand et al., 2006; Hale et al., 2006). Program effectiveness encapsulates the 
aforementioned components of academic sources, curricular emphasis, and academic 
exposure, which are tightly wedded to fulfilling the expectations of the stakeholders and 
the nursing profession. 
The decision-making process of curricular reform cited by both nursing and 
medical school faculty, center on common themes of program evaluation variables in the 
teaching-learning process of healthcare students. These include curricular emphasis of 
when content is taught or concentrated during the program (Benbassat & Baumal, 2004; 
Deloney & Graham, 2003; Farrand et al., 2006; Hale et al., 2006; Hojat et al., 2004; 
Layton, 1979; Mangione et al., 2002; Rogers, 1986; Spiro, 1992), academic exposure to 
patient care situations (Beckman & Frankel, 2003; Dolan, 2003; Edwards et al., 2004; 
Gerrish, 2000; Hodges, 1991; Lauder et al., 2002; Makoul, 2006; Nicol et al., 1996; 
Mozingo et al., 1995; Steginga et al., 2005; Woolley & Jarvis, 2007), and use of 
pedagogical methods utilized by faculty members in the clinical and academic setting 
(Becker & Sands, 1988; Bowles et al., 2001; Butler et al., 2005; deLucio et al., 2000; 
Hardee, 2003; Hodges, 1991; Holm & Aspegren, 1999; Kruijver et al., 2001; Layton, 
 4 
1979; Lonie et al., 2005; Reynolds et al., 1999; Roter et al., 2004; Shapiro et al., 2004; 
Wikstrom, 2001) .  
The predictive ability of program factors is manifested not only by the outcome of 
the student?s successful completion of the nursing program, but also by a student?s 
perception of their competence to deliver patient care as a result of nursing program 
instruction. At stake in a program effectiveness evaluation by students is far more than 
academic reputation of the nursing program. The ultimate goal for effective nursing 
education entails ensuring positive change in the student?s demonstrated ability to 
perform skills, perceived competence to perform skills, and enhanced positive attitudes 
toward patient care. In particular, the identification of didactic and clinical teaching-
learning practices that support the achievement of improved student learning outcomes 
regarding the competency of communication, including empathic communication, is 
fertile ground for nursing education from an accreditation standpoint (AACN, 1998; 
Standards for Accreditation for Baccalaureate and Graduate Nursing Programs, 2003). 
One pivotal way of identifying these practices is by the solicitation of feedback from the 
student, a major stakeholder of nurse education. The scarcity of studies that have 
evaluated nursing program effectiveness in teaching therapeutic communication 
(empathic communication), as well as the vital role of student attitudes toward empathy 
in patient care and perceived competency to empathically communicate with patients and 
families are the driving forces of this study. 
However, lack of agreement of a definition of empathy has hindered the ability to 
measure the construct. Researchers that have published studies on empathy have focused 
on varied aspects of measuring the construct (Carkuff & Truax, 1967; Davis, 1983; 
 5 
Hogan, 1969; Hojat, 2007; Hojat et al., 2002a, 2002b, 2003, 2004; LaMonica, 1981). 
Approaches to measurement of empathy in healthcare students necessitate an instrument 
to reflect student?s orientations or attitudes toward empathy in patient care (Hojat, 2007; 
Hojat et al., 2002a, 2002b, 2003, 2004). Researchers at the Center for Research in 
Medical Education and Health Care developed a research instrument that was designed to 
specifically measure empathy among students and practitioners of the health professions. 
Empathy in patient care is defined as ?a predominantly cognitive (rather than an 
emotional) attribute that involves an understanding (rather than a feeling) of experiences, 
concerns, and perspectives of the patient, combined with a capacity to communicate this 
understanding? (Hojat, 2007, p. 80). This research team cited the import of investigating 
the development of empathy among health professions students and practitioners and to 
examine correlates, antecedents, and outcomes of empathy at different stages of training 
as well as different types of practices (Hojat, 2007). Understanding what empathy is (and 
is not) leads to investigation of what value empathy contributes to patient care. 
 
Purpose of the Study 
The purpose of this survey study was to examine the relationship between senior 
baccalaureate nursing student?s perceptions of their nursing program effectiveness in 
teaching them to empathically communicate with patients and family members and (a) 
attitudes toward empathy in patient care, and (b) perceived competence in empathically 
communicating with patients and family members as a result of nursing instruction. 
Nursing program components and student?s perceived competence as measured by the 
Nursing Student Empathic Communication Questionnaire were divided into the 
 6 
following five areas: academic exposure to patient care situations, curricular emphasis 
during the nursing program, perceived program effectiveness, perceived competence, and 
academic sources. Student attitudes toward empathy in patient care were measured by the 
published JSPE Nursing Student Version R (Hojat, 2007). 
Another purpose of the study was to perform psychometric evaluation of the JSPE 
Nursing Student Version R to support the existence of empirical relationships amongst a 
set of variables determined in the literature to be associated with empathy. The 
examination of the underlying constructs of this measurement was important to this study 
because these data contribute to inferences made from scores regarding the construct 
validity of the instrument developed to measure nursing student?s attitudes toward 
empathy in patient care.  
 
Research Questions 
The following research questions were developed to examine relationships 
between selected variables represented in student perception of program effectiveness 
and student attitudes toward empathy in patient care. The first two questions regard 
contributions of data that contribute to researcher inferences regarding the validity of the 
instrument that is used in the study that measures student?s attitudes toward empathy in 
patient care. Program effectiveness, as related to the core competency of therapeutic 
communication, which includes empathic communication, is addressed in Questions 3 
and 4. The four research questions are: 
1. Is there a statistical difference between the JSPE Version S (developed for 
medical and other health professions students) and the JSPE Nursing Student Version R?  
 7 
2. What unique themes, dimensions and factors emerge from the JSPE 
Nursing Student Version R scores? 
3. To what extent do predictor scales of the Nursing Student Empathic 
Communication Questionnaire (a) academic exposure to patient care situations, (b) 
curricular emphasis during the nursing program, (c) perceived program effectiveness, and 
(d) academic sources predict nursing student?s orientation or attitudes toward empathy in 
patient care as measured by JSPE Nursing Student Version R total scores? 
4a. To what extent do nursing program components (program effectiveness, 
curricular emphasis, academic exposure, and academic sources) predict student?s 
perceived competence to empathically communicate with patients and families as a result 
of their nursing program instruction? 
4b. To what extent does orientation or attitudes toward empathy in patient 
care (JSPE Nursing Student Version R total scores) contribute to the prediction of 
perceived competence above and beyond program components? 
 
 
 8 
II. LITERATURE REVIEW 
 
 Baccalaureate nursing program educators are faced with intense expectations 
from many stakeholders, such as patients, students, academic accreditation communities, 
and healthcare administrators, to produce graduates that can enter their professional 
practice with a high degree of skills and competence (AACN, 1998; Standards for 
Accreditation of Baccalaureate and Graduate Nursing Programs, 2003). These demands 
have led to a need by nursing institutions to prepare students to (a) fulfill the role and 
critical competencies for professional nursing practice, and (b) establish ways by which 
the achievement of these goals can be evaluated and refined to promote the integrity of 
the institution and advance the nursing profession (AACN, 1998). 
 Broadly defined within the context of professional nursing education, the role of 
the nurse includes (a) providing care, (b) designing, managing and coordinating care, and 
(c) functioning as members of a profession (AACN, 1998). The role component 
encompassed in the purpose of this study involves the ability of the nurse to form 
partnerships with patients, communicate with the patient, and advocate and teach patients 
(AACN, 1998). This aspect of communication is contained within the core competency 
of communication (p. 9), and includes the use of therapeutic communication as a means 
to elicit and clarify patient preferences and values. Other core competencies include 
assessment, critical thinking, and the performance of technical skills (pp. 9-12). All skill 
 9 
bases can be expected of new nurses at the time of graduation from baccalaureate-degree 
nursing programs (p. 2).  
Empathic communication skills are critical to providing high-quality nursing care 
to patients in an attempt to holistically understand the patient?s perspective. These skills 
pertaining to therapeutic communication must include evidence that the student: (a) 
demonstrate communication skills during assessment, intervention, evaluation, and 
teaching, (b) adapt communication methods to patients with special needs, such as 
psychological or sensory disabilities, and (c) use therapeutic communication within the 
nurse-patient relationship, and elicit and clarify patient preference and values (AACN, 
1998, p. 10). This clarification process of patient preferences and values involves the 
ability of the nurse to understand the patient?s perspective and communicate this 
understanding, both of which involve empathic ability. 
One method by which nursing institutions ensure achievement of both 
institutional and professional standards is through the process of accreditation. 
Accrediting agencies consider the program?s mission, goals, and expected outcomes to 
determine the quality of the program and the educational preparation of members of the 
profession or occupation (Standards for Accreditation for Baccalaureate and Graduate 
Nursing Programs, 2003). The Commission on Collegiate Nursing Education (CCNE) is 
an accrediting agency that serves stakeholder?s interests by assessing and identifying 
programs that engage in effective educational practices. Institutions that seek CCNE 
accreditation of their baccalaureate programs seek ways in which to improve and enhance 
educational programs for professional students by assuring that nursing program 
 10 
outcomes adequately prepare students for professional practice (Standards for 
Accreditation of Baccalaureate and Graduate Nursing Programs, 2003). 
There are four standards utilized by CCNE to determine program outcomes. 
These standards of program quality, numbered I-III, include mission and governance, 
institutional commitment and resources, and curriculum and teaching-learning practices. 
Standard IV is program effectiveness: student performance and faculty accomplishments. 
The driving assumption of this study is based upon the premise that nursing program 
quality of the didactic and clinical teaching-learning practices and learning environment 
(CCNE accreditation Standard III-E) should support the achievement of positive student 
learning outcomes. Research studies, as discussed in this literature review, have posited 
that attitudes and perceived competence contribute to supportive evidence of attainment 
of positive learning outcomes. 
In order to examine the possibility of a relationship between student perception of 
program effectiveness in teaching them to empathically communicate (a) attitudes toward 
patient care, and (b) competence to empathically communicate as a result of nursing 
program instruction, there needs to be appropriate measures of attitudes and competence. 
Feedback from students, as stakeholders in nursing programs, provides valuable 
information regarding attitudes and competence through the use of instruments that 
measure student attitudes toward empathy in patient care and the use of instruments that 
measure perceived competence as a result of effective nursing program instruction. This 
information contributes to holding programs accountable and ensuring that outcomes are 
appropriate in preparing students to fulfill their nursing role upon graduation. This 
 11 
student feedback solicitation leads to the four research questions that define the purpose 
of this study. 
In this chapter, literature is related to the purpose of the study, integrating the 
broad themes of the independent variables. These include fulfilling the critical 
competencies for professional nursing practice in the interface between empathy and 
empathic communication as part of therapeutic communication, and the didactic and 
clinical teaching learning practices used by programs to support the achievement of 
student learning outcomes. The final sections of this chapter relate the independent 
variables to the dependent variables or outcome measures of: (a) attitudes toward 
empathy in patient care, and (b) perceived competence to empathically communicate with 
patients and families as evidence toward the achievement of these student learning 
outcomes. 
Health care researchers who have published studies on therapeutic 
communication within the nurse-patient relationship have included elements of empathy 
and empathic communication. To understand the different aspects of teaching empathic 
communication, three premises must be critically analyzed. These include: (a) the 
definition of empathy, (b) the role of empathy and empathic communication in patient 
care, and (c) how empathy is taught, which includes didactic and clinical teaching and 
learning practices. This section of the literature review is organized around these central 
tenants in terms of how empathy and empathic communication encompass elements of 
therapeutic communication and how the knowledge and skills obtained in nursing 
programs are used to fulfill the role and critical competencies for professional nursing 
practice.  
 12 
Empathy  
There is no specific agreement on the definition of the concept of empathy. 
Kunyk and Olson (2001) suggest that conceptualizations of empathy are incomplete and 
need further enrichment. Unfortunately, this lack of agreement of a definition and 
congruent conceptualization of empathy has hindered the advancement of the concept 
(Hojat, 2007; Kunyk & Olson, 2001; Morse et al., 1992; Yardley, 1999), and presented 
theoretical and methodological challenges (Alligood & May, 2000; Hodges, 1991; Kunyk 
& Olson, 2001; Yegdich, 1999).  
The origin of the word empathy dates back to the 1880s from a translation of a 
German word, einfuhlung, which is used to describe the emotional appreciation of 
another?s feelings (Hardee, 2003; Hojat, 2007). Most historical trajectories of the concept 
of empathy stem from the works of the founder of client-centered therapy, Carl Rogers. 
Rogers defined empathy as ?the ability to sense the client?s private world as if it were 
your own without ever losing the ?as if? quality? (Rogers, 1957, p. 95). Later, in 1975, 
Rogers replaced the ?as if? you were in the other person?s shoes to ?being in? the other 
person?s shoes. 
Definitions of Empathy 
Empathy is defined as the ability for another human to understand another?s 
perspective or ?put themselves into another?s shoes? so they can feel the way another 
person does in regard to a particular situation or problem (Olson, 1995; Price & 
Archbold, 1997). Empathy is also further broadened to include the ability to perceive and 
reason coupled with the ability to communicate understanding of another?s feelings and 
attached meanings. A research team at Jefferson Medical College proposed a definition 
 13 
of empathy in the context of patient care in promoting positive patient outcomes (Hojat, 
2007; Hojat et al., 2002, 2003, 2004). This definition underscores the significance of 
three key ingredients in the definition of empathy: (a) cognition, (b) understanding, and 
(c) communication. Hojat (2007) describes empathy as ?a predominantly cognitive 
(rather than emotional) attribute that involves an understanding (rather than a feeling) of 
experiences, concerns, and perspectives of the patient, combined with a capacity to 
communicate this understanding? (p. 80). Hojat (2007) further cites the need for a 
distinction to be made between ?cognition and emotion, understanding and feeling, and 
empathy and sympathy? in the conceptualization of empathy in patient care (p. 3). 
LaMonica (1981), a nurse educator and researcher, defines empathy as ?a central 
focus and feeling with and in the client?s world. It involves accurate perception of the 
client?s world by the helper, communication of this understanding to the client, and the 
client?s perception of the helper?s understanding? (p. 399). Benbassat and Baumal (2004) 
utilize a multiphase process to define empathy. This includes the beginning phase of 
gaining an insight to patient?s concerns, feelings and sources of distress, followed by 
engagement, which includes identification with those feelings. This in turn produces 
compassion, followed by a desire to alleviate the cause of distress in the patient. 
Stepien and Baernstein (2006) utilize a vernacular definition in the clinical 
context that work together to achieve patient benefit. The aspects of empathy in the 
clinical setting include: (a) emotional components, (b) cognitive, (c) behavioral, which 
include the ability to convey understanding and perspective back to the patient, as well as 
(d) moral components. The addition of moral components draws upon the physician?s 
internal motivation to empathize. Rudebeck (2000) echoes the view of empathy as 
 14 
possessing affective and cognitive elements as feelings always have the concrete aspect 
of referring to something that the patient is experiencing. When emphasizing the role of 
empathy in diagnosing and understanding the patient and their illness, Rudebeck posits 
that ?there is nothing more real, nor more important than that which the patient wants to 
tell? (p. 18). 
Kunyk and Olson (2001) provide exemplars of the discrepancies that prevent the 
concept of empathy from being fully mature and useful to the nursing profession. The 
quest to identify empathy-related variables in which to build theory to advance the 
concept and advance the scientific base for the nursing profession was identified and 
addressed earlier by Forsyth (1979). The existence of five conceptualizations, spanning 
the works of 22 theorists, highlights the vast variety of perspectives, patient outcomes, 
process, and measurement methodologies that embody the concept of empathy.  
Through extensive literature searches, Kunyk and Olson (2001) posit that there 
are five conceptualizations of empathy: (a) a human trait, (b) a professional state, (c) a 
communication process, (d) as caring, and (e) as a special relationship. The majority of 
authors and researchers on empathy embrace the first three conceptualizations. Empathy 
as caring and empathy as a special relationship are less prevalent in the literature. 
Authors embracing empathy as caring depart from the desired outcome of the patient 
being understood, and focus on nursing interventions that meet the patient?s needs. 
Empathy as a special relationship focuses on the mutuality of an emerged friendship 
between the nurse and patient to meet patient goals. This friendship provides a critical 
element in nursing roles with hospice patients, where there is a reconciliation of needs 
and vast coping requirements associated with the terminal nature of conditions. 
 15 
Empathy as a Human Trait 
In conceptualizing empathy as a human trait, empathy is seen as an innate natural 
ability. Researchers that ascribe to this conceptualization acknowledge that empathy 
cannot be taught, but rather once identified, empathy can be reinforced or refined. 
Authors in this category focus on the accurate perception of other?s feelings and 
situations, and understanding what this means for the other person. An author that 
ascribes to these beliefs is Alligood (1992), who posits that there are two types of 
empathy, labeled ?basic? and ?trained.? ?Basic? empathy is seen as a human attribute, 
and is likened to natural or ordinary feelings for others. This empathy is involuntary and 
cannot be taught, but can be reinforced to develop empathic expertise. Alligood and May 
(2000) describe the second type of empathy as ?trained?, which is a clinical skills state 
utilizing the interpersonal process. 
Another author who shares the view of empathy as a human trait is Morse et al 
(1992). These authors discuss the level of the nurses? engagement as being determined by 
two broad characteristics, which include whether the nurse is focused on the patient?s 
response or focused on protecting him/her self from experiencing the patient?s suffering. 
The second characteristic includes whether an empathic response is at the first level, 
which is spontaneous or reflexive, or at the second level, which is learned.  
These authors describe the human responses of the nurse at the first level 
requiring emotional insight to the feelings of the suffrage of the patient. Of critical import 
is emotional involvement, where the caregiver is willing to identify and experience the 
other?s pain and suffering, which requires enormous emotional energy. 
 16 
Empathy as a Professional State 
Empathy as a professional state varies from the view of empathy as a human trait 
in that it comprises both cognitive and behavioral components, and is envisioned as a 
learned communication skill. In essence, the nurse deliberately chooses the best response 
to convey understanding to the patient, while maintaining objectivity to emotional 
involvement with the patient. Alligood and May (2000) address the prevalence of 
empathy studies on the trained type, which utilizes the interpersonal process with the 
patient. In essence, understanding empathy expands beyond mere use of appropriate 
words, rote trained responses, or behavioral skills acquisition. Alligood and May (2000) 
state the need for a new approach that focuses on basic empathy and the use of the 
intrapersonal process to connect with the patient?s feelings and consequently provide 
understanding of self and others. 
Price and Archbold (1997) describe the process of individuals viewing the world 
according to their own beliefs, experiences, value systems, and cultural backgrounds. In 
light of this conceptualization, the authors posit that there should be a communication 
process that develops when individuals mature cognitively and emotionally as one 
becomes more self-aware. Therefore, the development of empathy is a life-long process 
that can be enhanced by teaching of self-awareness skills, in combination with one?s 
natural ability. 
Empathy as a Communication Process  
Empathy as a communication process is outcome-based, where the patient feels 
understood as a result of the nurse perceiving the patient?s situation and subsequently 
expressing this understanding. Thus, the patient feels understood and thereby perceives 
 17 
the nurse as empathic. This conceptualization of empathy holistically includes aspects of 
the aforementioned types of trait and professional state. Empathy as a communication 
process combines innate abilities of the nurse, awareness of patient?s feelings, and 
learned ways to respond that benefit the patient.  
Baillie (1996) emphasizes this closeness-empathy link as aligned with ?getting to 
know? the patient, which is also a stressful component to the empathic relationship. The 
nurse?s ability to empathize with patients is related to such aspects as previous 
experience, knowledge about people, and personal and professional experience. This 
process of the patient being understood has also been described in the context of ?being 
known? (Thorne et al., 2005), as presented through predominant themes utilizing 
patient?s perspective of the dynamics of the human connection between medical 
physicians and cancer patients. ?Being known? involved communication and 
acknowledgement by the healthcare provider of the patient?s personal and situational 
uniqueness. Subtle and overt cues from healthcare professionals consisted of eye contact, 
sitting instead of standing, feelings of unrushed demeanor by the professional, and 
remembering one?s personal name. A common element was the ability of the healthcare 
provider to understand the patient?s perspective of the difficulties associated with their 
cancerous condition. Verbal communication was important in this study, through 
producing variance in the benefit of non-clinical conversation and physical touch. 
Related Concepts 
In understanding the concept of empathy, the process of differentiation from 
related concepts functions to clarify components that are similar. Among the concepts 
collectively termed as empathy are sympathy, pity and compassion. Related concepts, 
 18 
although containing subtle differences, are often confused or erroneously conceptualized 
as interrelated with empathy. This differentiation between concepts varies in the way the 
nurse or healthcare provider communicates with the patient or family and in the way the 
patient responds. 
Sympathy is emotional identification with the patient?s plight, which evokes 
responses of the nurse such as feeling sad, teary eyed, emotionally fatigued, and feelings 
of loss in response to another?s loss (Morse et al., 2006; Stepien & Baernstein, 2006; 
Yegdich, 1999). By contrast, empathy does not depend on having these congruent 
feelings. Differentiations between empathy and sympathy include the element of 
sympathy involving compassion and shared emotions with patients, and empathy 
involving passion and shared understanding (Hojat et al., 2002; Spiro, 1992). Spiro 
(1992) further addresses the distinction between the concept of sympathy that means ?I 
want to help you?, and empathy that means ?I could be you? (p. 843).  
The role of sympathy as requiring a reasonable distance to maintain emotional 
balance is contrasted in the literature. Stepien and Baernstein (2006) note physicians who 
share their patient?s feelings can experience adverse affects, such as lack of objectivity 
and emotional fatigue. Hojat (2007) describes the joining of patient emotions as in 
sympathy as potentially impeding clinical outcomes. In contrast, empathy ?disentangles? 
the individual and enhances clinician?s performance in a linear manner and needs no 
restraining boundaries (Hojat et al., 2003). 
However, Morse et al. (1992) discusses how sympathy (along with pity, 
consolation, and compassion) serves a useful function as a first-level response that 
naturally comforts the patient. These authors posit that the loss through nursing programs 
 19 
of this first-level response has negatively impacted the efficacy of nursing care. 
Appropriate amounts of expression of sympathy, that are perceived as genuine and 
approximate the patient?s true feelings, can enhance care and demonstrate acceptance of 
the patient?s state. Additionally, sympathy serves a role in moving the sufferer from the 
state of misery and into a position of ?taking it? (p. 814). 
Sympathy should be further distinguished from the related concepts of pity and 
compassion. Pity is an expression of regret or sorrow for one who is suffering, distressed, 
or unhappy. Pity confirms the sufferer?s state, which hastens the adjustment period and 
allows the patient to attain comfort sooner (Hardee 2003; Morse et al., 2006). 
Compassion is a strong emotion or sentiment that is stimulated by the presence of 
suffering and that evokes a recognition and mutual sharing of the pain and despair of the 
sufferer (Morse et al., 2006). 
Role of Empathy and Empathic Communication in Patient Care 
The role of empathy and empathic communication in patient care embody the 
perspectives of both the nurse and the patient. Studies related to the expression of 
empathy from the nurse, such as establishing a relationship through contact with the 
patient, are described. The outcomes, predominately shown through expressions of 
patient satisfaction, are illustrated through studies involving patients with complex needs. 
There are many researchers that posit that empathy is an important ingredient in 
the helping relationship, is the foundation of understanding patient?s needs, concerns and 
emotions, and is fundamental to the nursing practice (Freshwater & Stickley, 2003; 
Kunyk & Olson, 2001; Lauder et al., 2002; Reynolds & Scott, 2000; Thorne et al., 2005). 
Baillie (1996) conducted phenomenological research on the nature of empathy from the 
 20 
nurses? perspective in order to gain an understanding of the experience of empathy. Using 
interviews with surgical nurses, the nurses described the nature of empathy as 
multifaceted and influenced by complex relationships between the nurse, the patient and 
the environment. The results of the study found responses of the nurses clustered around 
seven main themes, which detailed the relationship of closeness and involvement in 
empathy, empathy as active and therapeutic, empathy as an individual and personal 
experience, developing the ability to empathize, discussing when empathy is difficult, 
and developing empathy with the individual patient (p. 1302-1304). Empathy as a 
therapeutic response was inferred to the patient ?through touch, eye contact, tone of 
voice, giving time, and sitting at the patient?s level? (Baillie, 1996, p. 1303). Other 
researchers (Charon, 1993; Benbassat & Baumal, 2004; Bowles et al., 2001; Reynolds & 
Scott, 2000; Spiro, 1992) have echoed this response in patients. Additionally, experience 
was identified as a key factor in developing empathy, as derived from the nurses? own 
personal experiences, previous nursing experiences, and insight through significant 
other?s similar experiences. The role of effective communication and formulating a good 
relationship with the patient was instrumental in the ability of the nurse to empathize.  
Non-verbal behavior, as studied by Caris-Verhallen et al. (1999), resulted in the 
occurrence of non-verbal communication between nurse-elderly patient interactions. 
Through the use of video-taped nurse-patient communication, there were six non-verbal 
behaviors observed, which included patient-directed eye gaze, affirmative head-nodding, 
smiling, leaning forward, affective touch and instrumental touch. Except for instrumental 
touch, non-verbal behaviors were found to be important in establishing a good 
 21 
relationship with the patient. The predominant behaviors the nurse exhibited were eye 
gazing, head nodding and smiling to establish a good relationship with the patient. 
In terms of patient outcome measures, effective empathic communication is 
widely regarded to be a key determinant of patient and family satisfaction, by showing 
and providing understanding, comfort and support (Haidet & Paterniti, 2003; Hardee, 
2003; Kruijer, 2000; Platt & Platt, 1998; Thorne et al., 2004). From a patient?s 
perspective, there were several factors that contributed to patient perception of nursing 
care delivery that inhibits or enhances care delivery. Irurita (1999) describes levels of 
care, as described by patients participating in a qualitative study, containing elements of 
?soft-hand? and ?firm-hand.? ?Soft-hand? includes the highest level of care to preserving 
integrity. ?Firm hand? refers to technically competent clinical care (not demonstrating 
feeling or compassion). Factors that were found to enhance perceived quality of care 
were those elements attributed to ?soft-hand? care, which also included establishment of 
an effective nurse-patient relationship. Study results emphasized the positive results of 
spending sufficient time with the patient to establish and nurture the relationship, 
continuity of contact between the nurse and the patient, and the nurse possessing personal 
attributes of compassion and empathy. 
Reynolds and Scott (2000) posit that empathy is crucial to the fundamental aim 
and achievement of nursing goals. Through an extensive literature search the authors 
establish the following aspects of empathy to nursing. These findings indicated that 
empathy (a) enabled nurses to create a climate of trust and to establish their client?s 
perceptions of need, (b) enabled nurses to judge the client?s state and readiness to talk, (c) 
is needed in order that nurses can understand the origins and purposes of client?s 
 22 
responses to health problems, (d) facilitated positive health outcomes for clients, among 
which are reduction of anxiety, depression, and physiological distress. The achievement 
of outcomes is dependent upon the ability of the nurse to offer high levels of empathy to 
clients (p. 231).  
Improved clinical outcomes have been linked with empathic care, such as better 
recovery, improved healing, fewer malpractice suits and litigations (Fields et al., 2004), 
and an overall positive perspective of patient care (Butler et al., 2005; Chant et al., 2002; 
Platt & Platt, 1998; Reynolds & Scott, 2000). Thorne et al. (2005) describes the impact of 
poor or ineffective communication on cancer care patients, and extends beyond ?bad 
manners? and encompasses a number of untoward effects related to the effectiveness of 
clinical encounters. The authors describe the ?informational context? consisting of 
significant misunderstandings by patients regarding their disease, or the seriousness of 
their clinical situation. The ?clinical context? related to communication is increased fear 
and anxiety, and decreased patient satisfaction with care and unnecessary psychosocial 
distress. 
Platt and Platt (1998) described the influence of the healthcare provider?s 
understanding of the patient?s concerns and values, though the patient might not make 
these concerns obvious nor express them clearly. The authors further address obstacles 
encountered by medical students in expressing and possessing empathy, such as there 
being people with whom you cannot empathize, fear or perplexity of what to say after an 
empathic reflection with a patient, fear of opening the floodgates after a display of 
understanding, and trouble working with angry patients. 
 23 
Didactic and Clinical Teaching-Learning Practices of Empathic Communication 
Nursing educators utilize many pedagogical methods to didactically teach 
empathy and empathic communication. Among these methods explicated through the 
works of nursing and medical educators are theoretical lectures from faculty members, 
role playing, patient-actors, journal reflections, discussions, modeling, and the recent 
insurgence of technological advancements through computer-assisted programs. These 
methods are used independently or in combination to produce various outcomes in 
student learning. Efficacies of methods are discussed and suggest various levels of 
success in yielding empirical evidence of producing more empathic behavior in nurses.  
Modeling 
Just as there are individual uses of components used in training, there are also 
variations and combinations of multiple components, such as demonstrated in the 
research performed by deLucio (2000). Means for training in this study were instruction, 
combined with modeling and modeling with feedback to create an environment where the 
participants would perceive their own feelings as well as each other?s. The outcome 
variables were communication skills measured under simulated conditions using a variety 
of instruments. This study showed that the training program in communication and 
techniques of emotional self-control as a whole improved when the nurse was presented 
with communication with families of seriously ill patients. In particular, there were 
improvements by the nurse in listening skills, empathizing, and coping with emotions. 
Various combinations of modeling, labeling, and rehearsal were used to teach 
empathy to four experimental groups of baccalaureate junior- and senior-level nursing 
students (Layton, 1979). Rehearsal was the only effective condition in the study. 
 24 
Directions for future research posed whether or not the use of negative examples to 
enhance learning would be advantageous. Based on the findings of this technique, the 
study suggested the need to introduce the learning of interpersonal skills early in the 
student?s education, such as the junior year of nursing school.  
Technological Techniques 
Congruent with Hodges (1991), the authenticity component of clinical 
experiences can be enhanced through the use of technological means that afford the 
student the ability to practice and develop skills in a safe and controlled environment 
under direct supervision. Woolley and Jarvis (2007) purport the use of DVD, CCTV, and 
digital recording technologies to support these skills, when applied within a framework, 
such as a cognitive apprenticeship model. Woolley and Jarvis proffer utilizing a 
combination of four elements: didactic training, role-playing, experiential training, and a 
role model of empathy. Hodges (1991) aimed to examine the development of empathy in 
student nurses. In this study, there were two groups of students participating in two 
training experiences (empathy and psychological-mindedness), but in different order. The 
psychological-mindedness group received lectures and discussions containing elements 
of patient perceptions, stereotypes, expectations and communication. Video-tapes of 
nurse-patient communications were played and stopped periodically, and students were 
asked to respond in writing and verbally. Students competed with each other to give the 
most empathic response, as they were immediately given feedback as to what the ideal 
response would entail by the researcher. Student?s specific ability with patients was 
video-taped and their performance rated by the patients using an assessment instrument. 
The results of the study posited that empathy was neither increased nor decreased. 
 25 
Kruijver et al. (2001) described results of research regarding communication 
skills of nurses during interactions with simulated cancer patients. Admission interviews 
between 53 ward nurses and simulated cancer patients were video-taped and analyzed 
using the Roter Interaction Analysis system. The results showed that the nurses 
predominately used instrumental communication with patients, which centered on 
providing information about medical topics. Structuring behavior and behavior that 
involved the patient during the conversation were rarely used. Predominate use of closed 
questions did not contribute to affective behavior that would indicate empathy, concern 
and optimism. The authors cite the use of simulated patients as instrumental in providing 
feedback commonly associated with patients in actual settings.  
Combination Approach 
In a study with medical residents, Laidlaw et al. (2006) found that residents who 
underwent prior communication skills training significantly outperformed those who did 
not. The use of multiple interventions, mix of teaching methods and clinical placements, 
self report and patient assessments demonstrated improvements in reinforcing positive 
attitudes and beliefs needed to effectively prepare the nurse for psychosocial and 
emotional patient-care situations (Gysels, Richardson, & Higginson , 2004; Steginga et 
al., 2005; Thorne et al., 2004). Laidlaw et al. (2006) found stronger evidence for the 
value of prior communications skills training, new evidence of a strong relationship 
between communications skills proficiency and clinical knowledge application. Prior 
communication skills training supported the interpretations by the authors that patient-
doctor communication can be taught, learned and retained with appropriate training 
(p.23). The combination approach used video-taping and a structured clinical 
 26 
examination with four patient scenarios. These scenarios were focused on delivering bad 
news, handling anger, determining reasoning for non-compliance, and handling sensitive 
information compassionately. 
Steginga et al. (2005) reported improvements in the outcome variables consisting 
of attitudes toward and perceived skills in the psychosocial care of patients with cancer 
and their families, knowledge about cancer and cancer nursing, preparedness for cancer 
nursing, and participant?s perceptions of course effectiveness through use of a 
combination of teaching methods. This study utilized small group learning, didactic and 
interactive approaches, and clinical placements to note improvement in nurse?s scores. 
The nurses? self-report of course effectiveness showed mean scores of 4.43 on a 5-point 
scale (high effectiveness) in the nurse feeling more confident in caring for people with 
cancer, and a mean score of 4.73 in meeting educational and learning needs. Gysels et al. 
(2005) found best results from training methods that were (a) carried out over a longer 
period of time, and (b) that were learner-centered using several methods combining a 
didactic approach focusing on theoretical knowledge with rehearsal and feedback from 
peers to be effective, particularly with training nurses to care for cancer patients. 
Artwork and the Humanities 
Pedagogical approaches have been researched by which nursing students were 
encouraged to use their imagination and personal knowledge of empathy with the use of 
visual artwork and the humanities. One study by Wikstrom (2001) consisted of the 
interpretations and observations of a reproduction of Edward Munch?s ?The Sick Child?, 
which included problem solving (written reports) and reflection (small-group dialogues) 
in terms of empathy. The pedagogical approach that served as the framework for 
 27 
Wikstrom?s study was VanManen?s model, which stresses (a) the learner?s possession of 
a great volume of experience prior to entering an educational experience, and (b) that 
student learning is obtained more from discovery than information delivery. The visual 
arts of the reproduction of ?The Sick Child? served to actively elicit from the student 
prior experiential knowledge, which can lead to reflection and problem solving. This 
approach resulted in lively discussions from the students as to both artwork interpretation 
of empathy expressed by the child and the mother in the painting (atmosphere, tone, 
emotion of the mother, emotion of the child, sympathy versus empathy), and similar 
ambiguous clinical practice situations they had experienced. 
Smyth (1996) posed the question, ?In what ways may the experience of art 
contribute to the understanding and development of empathy in the nurse-patient 
relationship?? (p. 936). The author describes the role aesthetic experience has having 
several implications to nursing practice, which include (a) allowing the nurse to gain 
specific insight to another?s perspective, (b) inviting the nurse to step outside of the 
normal frame of reference, (c) helping to better understand the needs and contexts of 
clients from diverse cultures, (d) promoting freshness, spontaneity, and optimism, (e) 
helping deal with uncertainty and indeterminacy, (f) invoking a sense of unity, and (g) 
enhancing empathic capacity. Empathic capacity is obtained by the nurse incorporating 
aesthetic experience and the arts from a personal perspective, and then using that self-
awareness to create a larger view of the nurse-patient relationship. 
Poetry 
Also drawing upon literature-based humanities, Shapiro et al. (2004) conducted a 
study using first-year medical students to assess whether reading and discussing poetry 
 28 
and prose related to patient and doctors could significantly increase medical student 
empathy and appreciation of the relevance of the humanities for their own professional 
development. The format of the class consisted of on-site readings of poetry, skits and 
short stories that emphasized understanding of the perspectives of the patient, family 
members, physician, and personal beliefs when pertaining to topics of doctor-patient 
relationship, physical examination, listening to patients, pain, sexuality, cross-cultural 
issues, lifestyle modification/noncompliance and geriatrics. This study found significant 
improvements in empathy, particularly in a more detailed and complex understanding of 
the patient?s perspective, as well as an increase in student acknowledgement of ways to 
incorporate reading literature to help with training-related stress. Through qualitative 
analysis, students in this study expressed ways in which literature and the focus on the 
humanities had served to change their perspective. These aspects included understanding 
patient?s feelings about their daily lives in coping with illness, and contributed to their 
heightened need for personal expression of feelings, as well as listening to those of their 
patients. 
Drama 
The use of drama was found to be successful in teaching first-year medical 
students about empathy and compassion, especially regarding an end-of-life patient 
scenario (Deloney & Graham, 2003). The true-story drama, entitled ?Wit? was regarding 
a 50-year old women suffering from Stage 4 ovarian cancer, and who was undergoing 
experimental treatment at a major teaching hospital. This drama was shown following a 
pre-play lecture on end-of-life care, and followed by a post-play discussion with the cast. 
Students were asked to complete a survey containing items regarding pedagogical utility 
 29 
of teaching understanding patient perspectives with end-of-life issues, as well as the 
degree in which they felt ?emotionally moved? and their present skill with dying patients.  
The authors found this technique effective for students that had some clinical 
experience, though early in the curriculum, because it created a thoughtful, safe 
environment where the students could allow themselves to feel the full range of emotions, 
such as anger, tears, or silence. Student response to questions regarding ?Preferred the 
play to didactic lectures on end-of-life care?, and ?Preferred play to reading journal 
articles? were 78% and 74% respectively. 
Focus on Therapeutic Communication Skills 
Other methods have included the observation of students with real patients, and 
have utilized self-assessments, psychometric tests, and rating scales of observed behavior 
during patient encounters and simulation training (Benbassat & Baumal, 2004; Butler et 
al., 2005; de Haes et al., 2001; Kreuijver et al., 2000; Makoul, 2006; Stepien & 
Baernstein, 2006). Short-training courses in solution-focused brief therapy skills have 
also been utilized to examine the extent to which these short training courses affected 
nurses? communication skills and improved feelings of competence and willingness to 
engage in patient interactions (Bowles et al., 2001; Butow, 2005). 
Holm and Aspergren (1999) performed comparative analysis on medical students 
regarding teaching that was organized traditionally with lectures and clinical classes and 
those where other pedagogical methods were used, such as problem-based learning, small 
group seminars, and integrated communication skills. The role of the student?s own 
active search for knowledge in addition to pedagogical techniques was emphasized in this 
study. These researchers concluded that a pedagogical mode of teaching that centers on 
 30 
the role of the student?s own active search for knowledge and self expression of clinical 
experiences counteracts development of rigid responses to clinical encounters with 
patients that is harmful to both the student and the clinical situation in empathic ability.  
Pedagogical techniques that focus more specifically on training students in the 
detection of the patient?s concerns has been shown be an effective and teachable skill, 
resulting in long-term changes in communication behaviors of physicians, and retained 
effectively with appropriate training (Benbassat & Baumal, 2004; deLucio et al., 2000; 
Haidet & Paterniti, 2003; Haq, 2004; Laidlaw et al., 2006; Makoul & Schofield, 1999). 
Most notably, Makoul (2003) utilized video footage of verbiage from patients, called 
Patient Narrative Videos, as a trigger film for discussion with medical students of 
difficult patient situations, such as chronic pain, diabetes, and manic-depression. These 
trigger films were designed to lend perspective directly from the patient as to 
confirmation of the large and small details and challenges of their everyday lives with the 
illness.  
Difficult Patient Situations 
The use of role play and subsequent student reaction has been used as a method to 
teach difficult patient perspectives such as end-of-life skills, breaking bad news, 
managing pain, and discussing advanced directives (Butler et al., 2005; Torke et al., 
2004). Torke et al. (2004) utilized reader?s theater, which involves the use of a script that 
depicts a patient?s experience to engage learners in meaningful dialogue regarding the 
illness. The discussions by the students were led by faculty members and focused on the 
reactions of the student to the character?s behavior. This technique was also used with 
pain management scenario role plays, breaking bad news, such as cancer diagnosis with 
 31 
patients, and advanced directives role plays. The majority of student responses indicated 
that these techniques enhanced their understanding of how to address these topics with 
patients, as well as improved their perception of preparation for the clinical skill. 
 Beckman and Frankel (2003) further delineate unique empathic communication 
skills related to cancer care that differ in varied communities and includes delivering of 
bad news, effectively working with families, encouraging truly informed choices, 
facilitating the transition to palliative care, honoring end-of-life requests, grief work, and 
personal awareness. Differentiation between role playing, which involves the learner 
drawing upon their own experiences with difficult situations (Back et al., 2003), has been 
effectively used and possesses many advantages to the simulated patient technique 
(Kruijver et al., 2001). 
Challenges to Educators 
Increased demands from patients underscores nursing school educators? need to 
determine which patient care situations necessitate advanced empathic communication 
skills. Common content areas requiring empathic communication proficiency include 
psychosocial issues, breaking bad news, patients from diverse cultural backgrounds, 
bereavement, problem situations, sexual issues, pain, anxiety and injury (Butler et al., 
2005; Haq et al., 2004). Communication with patients and family members described as 
?rude, hostile or difficult? represent difficulties and challenges inherent in empathic 
communication, as well as nurse-patient encounters that include a sincere dislike for a 
patient, lack of point of reference to the particular experience (such as a male nurse 
empathizing with a pregnant patient), blaming of the patient for his or her condition, and 
the nurse thinking that the patient is responsible for the clinical condition, such as a 
 32 
smoker with lung disease (Platt & Platt, 1998; Rudebeck, 2000), and disabled patients 
(Chant et al., 2002).  
Chant et al. (2002) identified eight problems in communication skills teaching 
that hampered nurse educators. Among these are shortages of nursing training and the 
variations of course content, timing, duration and assessment. Additionally there were 
shortages of communication skills training with certain groups of patients in the clinical 
areas coupled with poor evaluation of the course outcomes. There were also challenges 
built into curriculum and policy that threaten the effectiveness of programs that teach 
empathic communication. Haq et al. (2004) posits that among these challenges to 
educators are (a) communication skills may be devalued and not considered teachable; 
(b) teachers and students may assume skill will automatically improve with experience; 
(c) expectations of teaching and evaluation methods may be vague or inconsistent among 
different faculty and throughout courses; (d) skills introduced in pre-clerkship years are 
not applied or evaluated in clerkships; (e) resources and time are insufficient to teach and 
evaluate skills; (f) improving communication skills requires faculty and students to 
possess self-awareness, interpersonal sensitivity, and the willingness to be self-reflective 
and accommodating; (g) few faculty have received formal training in communication 
skill teaching and evaluation; and (h) the presence of inconsistent feedback from faculty 
resulting in confusion among learners. 
Haq et al. (2004) describes the uniqueness of communication skill teaching which 
contains challenges to both student and teacher. Students must possess self-awareness, 
sensitivity to the needs of other, the capacity for critical self-reflection, the ability to 
detect their own biases, and openness to make changes based on patient concerns and 
 33 
cues. However, ignoring hints of patient?s and families? concerns can involve mediating 
variables, such as embarrassment of the student to express themselves emotionally, or 
failure to detect verbal and nonverbal cues from the patient of anxiety or depression 
(Benbassat & Baumal, 2004). 
The consequences of failure of nurse educators to train nursing students to 
effectively empathically communicate extend beyond negative patient care, poor patient 
outcomes, and negative health care experiences by the patient (Butler et al., 2005; 
Reynolds et al., 1999), and impact student development. Consequences of inadequately 
prepared students in communicating effectively with patients include student 
development of feelings of frustration, helplessness, anxiety, uselessness, and guilt, 
which can place an emotional toll on the student (Rowe, 2003). 
 
Outcome Measures of Achievement of Student Learning Outcomes 
Measurement of Empathy  
An important step towards the advancement of empathy as a concept is through 
empirical contributions that measure empathy. Student orientations or attitudes toward 
empathy with typical patient situations encountered during nursing school also 
necessitate development and validation of empathy measurements. Measurement of 
empathy is important to nursing because it is difficult to perform research that is useful to 
practice, research and education if the concept is inadequately defined (Alligood & May, 
2000; Hojat, 2007; Hojat et al., 2003; Kunyk & Olson, 2001; Reynolds & Scott, 2000). It 
is also difficult to advance the concept of empathy past the current state if further 
enhancement on the conceptual work is not performed (Kunyk & Olson, 2001). 
 34 
Instruments designed to measure empathy fall into three groups (Fitzpatrick et al., 
2004; Reynolds & Presley, 1988). The types of approaches include self-rating scales, 
ratings by expert judges or colleagues, and client/patient ratings. Reynolds et al. (1999) 
describe the importance of the use of patient views, described as the client, in 
determining which elements of empathy are the most relevant to therapeutic helping, and 
which components contribute the most to therapeutic outcomes. These authors assert that 
in order to assess the nurse?s empathic ability, there must be a measurement reflecting the 
patient?s views of what they feel the nurse ought to be doing. 
Measurement of empathy has reflected the need for research of both practical and 
theoretical value in defining empathy and empathic behavior (Hogan, 1969; Hojat, 2007; 
Hojat et al., 2002a, 2002b, 2003, 2004; Reynolds et al., 1999). Examples of four empathy 
scales commonly used with healthcare professionals include the Empathy Construct 
Rating Scale (LaMonica, 1981), the Interpersonal Reactivity Index, (Davis, 1983; 1994), 
the Layton Empathy Test (1979), and the Jefferson Scale of Physician Empathy, Versions 
S, R, HP (Hojat et al., 2001, 2002a, 2002b).  
The Empathy Construct Rating Scale was developed by LaMonica (1981), a 
nurse, for specific situations encountered in nursing. This scale has been used frequently 
as a self-rating scale to quantify empathic behavior. Performance of factor analysis 
concluded that it measured empathy as a single trait (Gould, 1990). This scale consists of 
84 Likert-type items about the respondent?s actions toward another person or the 
respondent?s feelings. Questions range from ?well-developed empathy? to ?lack of 
empathy.? The results on construct validity of the ECRS suggested that the theoretic 
construct of empathy was not generalizable, and empathy cannot be divided into 
 35 
subscales because it exists as a whole and all elements need to be present in helpers for 
empathy to exist. 
The Interpersonal Reactivity Index (IRI) was developed to measure individual 
differences in empathy (Davis, 1983). This instrument contains 28 items, from four 
components of empathy containing both cognitive and emotional domains. There are four 
sub-scales with 7-items which include perspective taking, empathic concern, fantasy and 
personal distress. Perspective taking refers to the cognitive tendency to see things from 
another?s point of view; empathic concern is the respondent?s tendency to experience 
feelings of warmth, compassion and concern for others. Fantasy scales refer to the 
cognitive tendency to transpose one?s self imaginatively into feelings and actions of 
fictitious characters. Personal distress is an affective measure of self-oriented feelings of 
unease in tense, interpersonal settings (Becker & Sands, 1988). As reported by Davis 
(1983), the IRI subscale scores correlate positively with Hogan?s Empathy Scale in the 
Perspective Taking subscale (r = 0.40), and the highest negative correlation was found on 
the Personal Distress subscale (r = -0.33).  
The Layton Empathy Test (1979) is a cognitive test of principles of empathy that 
was used to study the use of modeling to teach empathy to nursing students. Consisting of 
two forms, each form consisted of 12 True/False and two multiple choice items. Learning 
of empathy was measure by the written test, and the students were additionally evaluated 
by use of the Carkhuff Empathy Scale and the Barrett-Lennard Relationship Inventory. 
As reported by Layton (1979), reliability coefficients were low, ranging from .24 to .26. 
The implications from Layton?s study suggested the need to introduce the learning of 
interpersonal skills early in nursing education, as senior nursing students did not benefit 
 36 
from this study. Congruent with Layton?s study from a student-teaching perspective, 
Mangione et al. (2002) described the need for an operational measurement of physician 
empathy as being useful to medical educators to determine whether empathy could 
change at various levels of medical education. This study found that an empathy measure 
could serve educators by providing utility to assessment procedures that require vast 
resources, such as time, expense and are largely subjective in nature.  
Recognizing the need for an empathy measurement instrument that was designed 
for empirical investigations on the development of empathy among students and 
practitioners, the Jefferson Scale of Physician Empathy (JSPE) was originally designed 
for use in medical students, then modified to be used in practicing physicians and other 
health care professionals (Hojat et al., 2002a, 2002b, 2003, 2004). Hojat (2007) describes 
the development of the framework for the instrument development as comprising initial 
comprehensive review of the literature on the concept of empathy to identify theoretical 
views, and perusal of existing empirical research on the topic. The second step utilized by 
the research team in development of the JSPE, was to examine face and content validity. 
Factor analysis was used as a statistical method to screen the best items of the instrument 
and ultimately yielded the final generic version of the JSPE, which contained 20 items 
(Hojat, 2007; Hojat et al., 2001).  
As described by Hojat et al. (2005) and Hojat (2007), the generic version of the 
JSPE contained scales from the IRI (empathic concern, fantasy, and perspective taking), 
personality facets from the NEO PI-R (warmth, dutifulness, faith-in-people), items from 
self-report (compassion and sympathy), self-reported personal attributes (empathy, 
compassion, trust, sympathy, tolerance, personal growth, communication, self protection, 
 37 
humor, and clinical neutrality). Scales from the IRI, such as ?perspective taking? ability, 
should be associated with better social functioning, due to the ability for an individual to 
anticipate the behavior and reactions of others (Davis, 1983). Persons that score high on 
the ?fantasy? component will most likely exhibit a relationship with measures of 
emotionality. ?No consistent pattern of relationships is expected between empathic 
concern scores and measures of social functioning? (Davis, 1983, p. 115). 
The Student (S) and the Health Professional (HP) versions of the JSPE were 
revised to produce versions appropriate for students and health professionals. Further 
modifications were made in the wording of the S-Version to create the R-Version, which 
substituted the word ?nurses? or ?nursing care? instead of ?physician? or ?medical care? 
(Hojat, 2007). The JSPE Nursing Student Version R does not have any known published 
data at this time. 
 
Student?s Attitudes toward Empathy in Patient Care and Program Instruction 
Literature suggests that empirical evidence of educational outcomes should infer 
curricular effectiveness. Robert Gagne? (1985) describes attitudes as possessing three 
aspects as a condition of learning. These include: (a) a cognitive aspect, or an idea, (b) an 
affective aspect, which includes feelings that accompany the idea, and (c) a behavioral 
aspect. The behavioral aspect pertains to the readiness or predisposition for action 
(Gagne, 1985, p. 222). The role of studies of attitude changes or behavioral changes is 
often associated with desired expected outcomes of program instruction. Beckman and 
Frankel (2003) caution (in the context of communication skills training) that ?skills, 
attitudes, and knowledge can be discussed, lectured about and practiced in the classroom, 
 38 
but in the final analysis communication occurs at the bedside one conversation at a time? 
(p. 85). Student?s attitudes toward empathy in patient care were elucidated through 
studies that reported declines, improvements and lack of change in attitudes. These 
studies represented the gamut of program instruction from academic years encompassing 
the junior- and senior-years of instruction. 
Moderate-No Change in Empathy 
Other medical researchers have structured studies around the same question of 
effect of training on empathy and attitude changes. Assessment of empathy in different 
years of internal medicine training was found to result in mean empathy scores that 
neither changed significantly over one year, nor across multiple years in internal medical 
students.  This led to conclusions that empathy remained relatively stable during 
residency training programs (Mangione et al., 2002). Rogers (1986) identified self-
reported and client-rated empathy levels of baccalaureate nursing students during the last 
three years of their nursing education as a means to determine the effectiveness of 
nursing instruction. As well as taking the LaMonica?s ECRS empathy instrument, the 
students were also asked to respond to items related to their perception of faculty clinical 
priorities, reason for majoring in nursing and stress-producing life-change events, based 
on previous works of Rahe (1972). Cross-referencing was also obtained through patient 
ratings the students who had previously performed care. The results of this study 
indicated a moderately well-developed concern for other as measured by the ECRS. 
However, educational progression was not associated with significant increases between 
the academic classification from sophomore to seniors on the ECRS, self-report, and 
patient rating. 
 39 
Becker and Sands (1988) investigated the relationship of self-reported empathy 
with clinical experience among junior-level baccalaureate students using a 
multidimensional measure of empathy. One goal of the study was determining outcomes 
of short-term interventions aimed at developing empathy levels. Thirty-five nursing 
students completed Davis? IRI at four times during their junior year. The study cited high 
levels of stability among first-year nursing students in their self-reported empathy scores, 
which has implications for short-term intervention aimed at increasing empathy levels. 
 Regarding curricular timing and attitudes, a nursing study of cohorts in the first 
year reported being highly committed to working therapeutically with people who have 
mental health problems and this high level of commitment, which was maintained 
throughout the course. One inference of the study results was that a positive 
predisposition to work with specific client groups provided educators with the advantage 
of a foundation from which to develop and refine effective responses (Lauder et al., 
2002). Mangione et al. (2002) found that empathy was found to be a relatively stable trait 
that is not easily amenable to change in residency training programs, though it is unclear 
whether targeted activities designed to improve empathy actually increased scores. 
An experiment conducted by Hodges (1991) in the development of empathy in 
student nurses showed that empathy was not increased nor decreased after experiencing 
an empathic training and psychological-mindedness experience. In this study, student 
nurses were assessed for their specific interview behaviors. The empathy training 
consisted of elements of didactic training, role-playing, role modeling, and some 
experiential training. Data obtained from the Patient Interview Assessment schedule 
 40 
indicated that empathy training had no statistical differences, though there were several 
limitations cited when evaluating the results of this study. 
Declines in Empathy 
Empirical studies of medical school students have yielded trends toward declines 
in empathy, with students becoming more cynical as they progressed through their 
programs, despite receiving training and instruction on empathy (Benbassat & Baumal, 
2004; Deloney & Graham, 2003; Hojat et al., 2004; Rosenfield & Jones, 2004). Reported 
causes for this decline of empathy were attributed to a lack of role models, educational 
experiences that encouraged emotional detachment, such as valuing seeing over listening 
to the patient (Rosenfield & Jones, 2004); affective distance, such as depersonalization of 
the patient?s disease; clinical neutrality (Benbassat & Baumal, 2004; Hojat et al., 2004); 
and negative academic experiences, such as isolation, chronic lack of sleep, sadness, 
prolonged exposure to human tragedies and depression (Spiro, 1992).  
Rosenfield and Jones (2004) address central dilemmas in student?s attitudes 
during their medical school clerkships aimed at elucidating educational challenges in 
teaching and learning how to provide empathic care. These broad categories (p. 928-933) 
included a focus on pathology versus health, not knowing versus too much knowing, 
vulnerability versus denial, and reaction versus inaction. The process through their 
programs consists of the shift of perspective of the student from the initial stage of 
disease being the norm in the hospital to concerns about lack of competence in 
communicating with the patient for fear of ?saying the wrong thing? or appearing to lack 
the necessary knowledge. Also problematic are students that are overly aggressive to 
confuse their understanding of the patient (pseudo-empathy) and understanding what the 
 41 
patient is conveying (true empathy). During the vulnerability and denial phase, students 
often become overwhelmed with the intensity of patient suffering and are forced to face 
their own vulnerability to illness. The fourth phase is the student learning how to tolerate 
a patient?s affect and anxiety, rather than avoiding it, and learning when and how to 
understand the patient rather than reacting.  
In his research involving Yale University School of Medicine students, Spiro 
(1992) describes the educational curriculum?s effect on medical students. Training foci 
served as a barrier to human understanding and hampered the growth of empathy. A 
combination of masking feelings, learning detachment and equanimity, exclusion of the 
humanities in the curriculum, and focus on the disease process resulted in leeching of 
empathy away from the typical student that previously possessed a great amount. 
Research on timing of empathy and empathic communication content in 
curriculums has been studied as a possible reason for negative attitudinal change. Spiro 
(1992) studied first- and second-year medical students and found that they are much more 
receptive to anecdotal stories by faculty regarding roles of the patient and the physician. 
By the third and fourth year, the students have little time and enthusiasm for these 
anecdotes because their medical values have been set by the educational system.  
Increased Empathy 
Lonie et al. (2005) had similar findings regarding curricular timing of empathy 
training and changes in pharmacy students? self-reported empathic attitudes and 
behaviors. From this study many practical curricular revisions were rendered that allowed 
for more focused and extensive education on empathy as well as on other communication 
skills, timing considerations throughout the semester, and reorganization of topic delivery 
 42 
to facilitate reflection and integration of one concept before presenting another. This 
study measured empathy using the La Monica Empathy profile (LEP), which measured 
empathy along five modes: (a) non-verbal behavior, (b) perceived feelings and listening, 
(c) responding verbally, (d) respect for self and others, and (e) openness, honesty, and 
flexibility. Along these 5 dimensions, the results showed significant improvement in the 
dimensions of perceiving feelings and listening, and respect for self and others. The 
authors attributed these results to communication skills education the students 
experienced recently in the program. The active listening component had been stressed as 
an important empathic intervention in the communication skills course, thereby causing 
the authors to attribute the shift in attitudes (as reflected by the LEP) to student 
understanding of the concepts.  
 
Perceived Competency 
Competence has been cited as one outcome objective of nurse education programs 
and possesses a behavioral objective or skill component (Hale et al., 2006; Milligan, 
1998; Stewart et al., 2000; Watson, 2002; While, 1994). Holistic conceptualizations of 
competence include knowledge, skills, attitudes, performances and levels of sufficiency 
(Benner 1984; Milligan, 1998; Short, 1984). Nursing student competence has been 
linked, but is not synonymous, with feelings of confidence, correlated with previous 
experience of performance and evaluation of the task, and linked with student satisfaction 
with clinical experiences (Butler et al., 2005; Dolan, 2003; Edwards et al., 2004; Hale et 
al., 2006; Stewart et al., 2000). Faculty must make decisions regarding optimal use of 
clinical experiences. These decisions include patient-student placement, post-clinical 
 43 
discussions, length of time in clinical setting, and selection of clinical sites. Faculty are 
constrained by the practical reality of a limited amount of clinical and academic time in 
which to use these resources, and lack of substantial empirical evidence of what 
combination of teaching methods and experiential learning are most effective (Reynolds, 
1992). 
Role of Education 
Despite seemingly common goals of nursing education and similar curriculum 
frameworks, there exists significant variability as to identification of reasons for student 
perception of their own competency levels, particularly when their educational 
experience is completed. Lauder et al. (2002) described the need for faculty to examine 
the prevailing perceptions of student nurses themselves regarding their ability to develop 
and practice skills necessary for effective therapeutic nurse-patient relationships. Most 
notably, this study examined the variables of role competency, role support and empathy 
to predict variability in levels of therapeutic commitment reported by student nurses. 
Results of this study found that third-year students had higher role competency than first-
year students, although this was not significant. One pivotal finding this research 
highlighted was the impact of the clinical experience on student expectations about 
learning and the way in which educators contribute to student perceptions of what and 
from whom they need to learn. Departing from a self-perception of competence, was a 
study by researchers that determined that operational measures of empathy were linearly 
associated with ratings of clinical competence given by faculty members in the third-year 
of medical school students (Hojat et al., 2002). In this study, associations between 
empathy scores and ratings of clinical competence of medical school students correlated, 
 44 
though student?s grades in objective examinations did not significantly correlate with 
empathy scores (p.525-526). 
Should greater emphasis be placed upon performance or competence for a proper 
education? While (1994) posits that the question is pivotal to nurse education because the 
more relevant focus of nurse education should be the performance of students in the real-
life situation rather than competence. Watson (2002) asserts that the insistence of 
competence should not be at the expense of a proper education. Examples contained in 
higher education and exposure to other disciplines that relate content to understanding the 
deeper discipline are necessary to produce highly educated nurses. 
Hall (2006) posits that the challenge of clinical placement development presents 
an opportunity to reconsider previously held views of clinical experiences design and to 
modify nursing education goal attainment. Due to the scarcity of clinical experiences, 
there are disparities and paradoxes between health promotion and prevention, while co-
existing, with the emphasis on cure and palliation. The use of a social participation 
model, such as developing clinical placements as communities of learning, would be 
useful to students as an offer of support and collaborations with levels of expertise. 
Positing that experience alone was not the key, Nicol et al. (1996) developed a 
framework which captured the student?s trajectory to develop and integrate both 
cognitive and affective skills acquisition domains. Among these are: (a) Level A, which 
refers to initial exposure to the skill, (b) Level B, where the skills are practiced in a skills 
center prior to clinical placement, (c) Level C, where the student can perform safe and 
accurate performance under direct supervision in the care setting, (d) Level D, where the 
student?s performance is ?competent? with indirect supervision in the patient care setting, 
 45 
and (e) Level E, where there is skill mastery, and the student is confident and efficient to 
situational cues. 
Preparedness for practice post-graduation was related to competency and was 
found to influence student?s ability to transition from the role of student to qualified nurse 
(Edwards et al., 2004; Gerrish, 2000). Edwards et al. (2004) studied the relationship 
between nursing student?s perceived competence and preparedness for practice and the 
location of clinical placements. Drawing from the research establishing the import of 
clinical experiences to competency, this study added the dimension of competency and 
student satisfaction with their clinical experience. Utilizing a quasi-experimental design, 
BSN students were given a pre- and post-test regarding the impact of clinical placement 
location (rural versus metropolitan) as to generating positive clinical experiences. 
Findings supported the value of diverse patient care settings, such as exhibited in the 
rural setting, to increased student perceptions of competence and preparation for practice. 
Whether educational reforms have equipped nursing students with the ability to 
have the necessary knowledge, skills, and confidence to transition from student to 
qualified nurse remains undetermined. Gerrish (2000) described the process of nurses 
learning to perform their role as haphazard and resulting in the perceived lack of support 
and inadequate preparation. Some poignant factors that emerged from this study of 
cohorts indicated the increased need for clinical experiences in order for the students to 
develop confidence, and repetitive practice to achieve a sense of continuity of patient 
care. 
 46 
Competence-Confidence Link 
Understanding the role of confidence as differentiated from competence is 
important for nurse educators because self-evaluation of confidence contributes to a 
student?s willingness to undertake an activity, and consequently perceived performance 
of a skill. Stewart et al. (2000) highlighted the difficulty and complexity between the 
selection of suitable anchored statements for use in a self-evaluation instrument between 
the terms ?competence? and ?confidence.? In house officers (medical students), the study 
concluded that positive expressions of confidence did appear to relate to the house 
officer?s expression of competence. Conversely, a negative expression of confidence 
could more likely be attributed to anxiety or perceived incompetence. The study 
highlighted the value of self-evaluation instruments to promote or facilitate reflection, but 
these instruments might not be used to accurately judge the individual?s evaluation.  
Bowles et al. (2001) studied nurse?s communications skills training with a pre- 
and post-training instrument designed to examine the extent to which a short training 
course affected nurses? communication skills. Quantitative data instrument questions 
examined six areas on a Likert-type scale. Two of these areas centered on (a) competence 
in talking with people who are troubled, and (b) confidence in talking with people who 
are troubled. There were positive trends for competency and confidence, though not at a 
statistical level of significance. 
Reasons cited as contributing to a lack of confidence and knowledge in clinical 
skills include lack of time in clinical placements, lack of exposure to both urban and rural 
settings, lack of community development, over-emphasis on theoretical premises, and a 
lack of outcome competencies and hands-on practice (Dolan, 2003; Edwards et al., 2004; 
 47 
Farrand et al., 2006; Hall, 2006; Neary, 2001). Farrand et al. (2006) conducted a study of 
senior-level nursing students that examined student ratings of perceived confidence in 
their areas of nursing practice in core competencies for entry into practice. This study 
was performed following a competency-based approach to curriculum development. 
Competency-based curriculum students were compared with a previous curricular model 
(Project 2000). Results of this study indicated that increased confidence was achieved as 
a result of the increased curricular modifications that emphasized longer clinical 
placements, greater emphasis on skills, and a 3-month supervised clinical practice period. 
However, in keeping with the relationship between competence and confidence that was 
exhibited by Stewart et al. (2000), this study also supported the lack of congruency 
between student nurses? confidence and competence. 
Sharp et al. (2003) described the perception of competency to perform procedures 
with family practice residents. This study suggested that residents were not being taught 
procedures in a manner that resulted in residents feeling competent to perform the 
procedures. The researchers found that 79% reported receiving some training in the 
procedures, but less than half (43%) felt competent to perform the procedures. This study 
brought to question whether the students had received adequate exposure to the patient 
care encounter, and highlighted the wide variance in training experiences and perceived 
competence after graduation.  
Self-Perception of Competency 
Lauder et al. (2002) described competency as it relates to one?s role, described as 
a self-perception that working with one?s task is a ?legitimate part of one?s role and that 
one has the skills and knowledge to discharge this responsibility well? (p. 484). Their 
 48 
findings cited several factors that hinder role competency of the nurse in therapeutic 
relationships. These included failure to develop empathy, not viewing aspects of the role 
as a legitimate part of one?s responsibility, and time constraints that hinder relationship 
with patients. In their study of three cohorts of nursing students, role competency was the 
greatest predictor of therapeutic commitment. The implications to nurse educators from 
this study highlighted the need for students to be given opportunities to continue to 
develop skills which allow them to foster therapeutic relationships, especially with the 
subject group in this study, which included patients with mental health problems. 
Competency in the clinical setting was found to be influenced by student 
perception of being provided with sufficient experiences, time, and safe experiences 
during clinical rotations to gain confidence (Dolan, 2003; Edwards et al., 2004; Gerrish, 
2000; Sharp et al., 2003; Woolley & Jarvis, 2007). Dolan (2003) conducted eight focus 
groups centered on four themes: Components of competency, assessment process issues, 
evidence to support competency, and the preceptorship experience. The results of this 
study indicated the students did not perceive they had a holistic experience of care, but 
rather were focused on getting competencies ?signed off.? Students were also concerned 
with the lack of experience with specific common skills and inconsistencies between 
preceptors? interpretation of competencies. 
A comprehensive study (Mozingo et al., 1995) examined factors affecting 
perceived competency levels in graduating Baccalaureate nursing seniors. Drawing from 
literature citing several factors that potentially affect competency levels of students, such 
as self-esteem, stress, anxiety, and academic experiences, this study examined three 
classes from a large baccalaureate nursing program. This study found that perceived 
 49 
competency was related to the performance of clinical/technical skills, level of anxiety, 
and social support. A pervasive theme throughout the students was the desire for more 
faculty feedback in increasing confidence of students and technical skill practice 
opportunities. 
Advanced Empathic Communication 
 Patient care situations that require advanced competency in empathic 
communication (such as end-of-life issues, cancer care, difficult patients, and chronic 
care patients) must be disease- or situation-specific to produce changes (Back et al., 
2003; Butow, 2005; Hale et al., 2006; Mukohara et al., 2004; Thorne et al., 2005). 
Additionally, students need to be given the opportunity to continue to develop skills 
which allow them to effectively interface with patients experiencing a gamut of 
challenges such as in the mental health population (Lauder et al., 2002), seriously-ill 
patients (Kruijver et al., 2001; Lucio et al., 2000) rural or remote patients (Edwards et al., 
2004), and the palliative care of children and adolescents (Hale et al., 2006). An 
evaluation of educational preparation for cancer and palliative care nursing for children 
and adolescents revealed several deficiencies that were contrary to the national standard 
of competence; among these were the lack of emphasis on the assessment of clinical 
skills, the problem of student selected content of assessment, the different starting points 
of students, and the lack of reliability and validity of the assessment process (Hale et al., 
2006).  
 
 50 
Summary 
Nursing faculty are continually challenged to prepare students to fulfill the role 
and critical competencies for professional nursing practice, and establish ways by which 
the achievement of these goals can be evaluated and refined to promote the integrity of 
the institution and advance the nursing profession (AACN, 1998). Broadly defined within 
the context of professional nursing education, the role of the nurse includes (a) providing 
care, (b) designing, managing and coordinating care, and (c) functioning as members of a 
profession (AACN, 1998). The role component encompassed in the purpose of this study 
involved the ability of the nurse to form partnerships with patients, communicate with the 
patient, and advocate and teach patients (AACN, 1998). This aspect of communication is 
contained within the core competency of communication, and includes the use of 
therapeutic communication as a means to elicit and clarify patient preferences and values.  
The driving assumption of this study was based upon the premise that nursing 
program quality of the didactic and clinical teaching-learning practices and learning 
environment (CCNE accreditation Standard III-E) should support the achievement of 
positive student learning outcomes. Research studies, as discussed in this chapter, have 
posited that attitudes and perceived competence contribute to supportive evidence of 
attainment of positive learning outcomes. 
In order to examine the possibility of a relationship between student perception of 
program effectiveness in teaching them to empathically communicate and (a) attitudes 
toward patient care and (b) competence to empathically communicate as a result of 
nursing program instruction, there needs to be appropriate measures of attitudes and 
competence. Literature from nursing and other healthcare professions provided valuable 
 51 
information regarding attitudes and the use of instruments that measure student attitudes 
toward empathy in patient care. Among these were the IRI, Layton?s Empathy Scale, 
ECRS, the NEO-PI scale and versions of the JSPE instrument. 
In this chapter, literature was related to the purpose of the study, integrating the 
broad themes of the independent variables. These included fulfilling the critical 
competencies for professional nursing practice in the interface between empathy and 
empathic communication as part of therapeutic communication, and the didactic and 
clinical teaching learning practices used by programs to support the achievement of 
student learning outcomes. Broad themes of empathy conceptualizations, definitions, and 
the role of empathy in patient care, established the import of the concept as instrumental 
in understanding the patient?s perspective and providing nursing care. Empathy as a 
concept was discussed as related to the conceptualizations of (a) a human trait, (b) a 
professional state, (c) a communication process, (d) as caring, and (e) as a special 
relationship. The didactic and clinical teaching practices to teach empathic 
communication expanded the gamut of use of the humanities and artwork, combinations 
of approaches, use of technology, and reflective exercises with students. 
The final sections of this chapter related the independent variables to the 
dependent variables or outcome measures of: (a) attitudes toward empathy in patient care, 
and (b) perceived competence to empathically communicate with patients and families as 
evidence toward the achievement of these student learning outcomes. Literature 
regarding attitudes toward empathy in patient care was structured upon three tenants, 
such as declines, improvements, and moderate to no-change upon measurement. Student 
perception of competence encompassed a competence-confidence link, self-perceptions 
 52 
of competence, and patient care situations requiring advanced competency, such as 
cancer care and communicating with terminal illness. 
 53 
III. METHODS 
 
Overview 
 The use of survey design was used to answer the research questions discussed in 
this study. This research study presents factor analysis of the JSPE Nursing Student 
Version R and multiple regression analysis of data collected from September, 2006? 
November, 2006. The study population included nursing student seniors from 14 
participating nursing programs who were scheduled to graduate in December 2006 or 
May 2007. The survey, described in detail in this chapter, included the administration of 
two questionnaires (see Appendix A). The Jefferson Scale of Physician Empathy (JSPE) 
Nursing Student Version R is a modification of the JSPE S-Version and is a self-
administered, 20-item test that was developed by researchers at the Center for Research 
in Medical Education and Health Care at Jefferson Medical College. The JSPE S-Version 
was designed to reflect students? orientation or attitudes toward empathy in patient care. 
The JSPE Nursing Student Version R, though containing items closely worded to the 
JSPE S-Version, has no previous published data regarding its unique psychometric 
properties.  
The Nursing Student Empathic Communication Questionnaire is a researcher-
developed questionnaire containing questions to examine senior nursing student?s 
perspectives regarding the teaching of therapeutic communication (including empathy) in 
 54 
their nursing programs. This questionnaire contained sections regarding clinical exposure 
of students to patient-care situations, meeting of needs of students with timing and 
curricular emphasis, perceived program effectiveness and influence to use empathic 
communication from various teaching sources.  
The survey instruments were administered via on-site classroom collection from 
the researcher. In general, the responding samples were determined to be representative 
of their respective populations through power analysis. Data was entered and analyzed by 
use of SPSS Graduate Student Edition Version 13. 
 
Population 
The population in the study consisted of baccalaureate nursing school seniors 
attending Commission on Collegiate Nursing Education (CCNE) accredited programs. 
CCNE accredited programs were selected because the programs had demonstrated 
successful completion of similar formative and summative evaluation through CCNE, the 
autonomous arm of the American Association of Colleges of Nursing. Representation 
comprised of 14 programs from 13 institutions in the Southeast region included programs 
from Tennessee (2), Alabama (7), Florida (1), and Georgia (3). Two programs from one 
institution consisted of students from the accelerated nursing program and the traditional 
program. Students were identified for the study by their classification as seniors-level 
students with anticipated graduation in December 2006 or May 2007. A single-stage 
sampling procedure was used where the sample group was sampled directly (Creswell, 
2003). 
 55 
The selection process utilized a geographically restricted sample chosen due to 
availability of the sample group for data collection. The sample was stratified to ensure 
representation of characteristics present in the entire population to improve 
generalizability. Among these considerations were program size, geographical regions, 
demographics of regions (rural versus urban), institution classification (private and 
public), diversity of applicants (age and race) and religious affiliation of institution. 
Within each program stratum, the sample did not contain individuals with the same 
characteristics in the same proportion as the characteristic appears in the entire 
population. However, the population as a whole was representative of national statistics 
with a few exceptions, as discussed in Chapter 4. 
 
Instrumentation 
 There were two survey instruments used to collect data in the research study. 
These consisted of (a) Jefferson Scale of Physician Empathy (JSPE) Nursing Student 
Version R and (b) Nursing Student Empathic Communication Questionnaire (NSECQ). 
These questionnaires were combined for ease of student distribution in the form of a 
single stapled packet on white paper with grayscale headings using Arial 11 font for 
optimal readability (Dillman, 2000). The JSPE comprised questions 1-20 on the first page 
of the packet, and the NSECQ questionnaire comprised pages 2-4. The JSPE Nursing 
Student Version R was used following express permission from the author.  
The students were given instructions prior to delivery of the questionnaire packet 
detailing the placement of one single answer per question as well as use of pencil, marker 
or ink pen to indicate answer selections. Students were instructed to not place any 
 56 
identifying information on the packet, such as school name or personal name. Students 
were also given the Information Letter (see Appendix B) prior to questionnaire 
administration describing IRB considerations and inviting the students to participate in 
the study. Instructions as to definitions of Likert-scale items and an empathy definition 
were indicated above the questions on both scales. Questionnaire packets were collected 
upon completion by student placement of completed packets face-down into a box 
located in the rear of the classroom provided by the researcher. To prevent the potential 
appearance of coercion to participate in the study by both the researcher and the faculty 
member, the students completed the questionnaire with the researcher and faculty 
member outside the classroom door. 
JSPE Nursing Student Version-R 
 The JSPE Nursing Student Version-R is derived from a generic version of the 
Jefferson Scale of Physician Empathy, acronym JSPE. This instrument was chosen by the 
researcher due to its relevancy to health profession students in the clinical context of 
patient care situations. There are other commonly used measures of empathy that have 
been used for the general public, such as the Interpersonal Reactivity Index (IRI), the 
Emotional Empathy Scale, and the Hogan Empathy Scale. Hojat et al. (2001) describes 
the generic version of the test as self-administered, containing 20 items, developed by 
researchers at the Center for Research in Medical Education and Health Care at Jefferson 
Medical College. The purpose of the original test is to measure orientation or attitudes of 
medical students toward empathic relationships in health care situations. Following the 
preliminary data on the generic version of the JSPE, the research team slightly modified 
the scale by replacing the wording referring to ?physician? with the appropriate title of 
 57 
the students from other health professions (nurse, therapist). Respondents indicate the 
extent of their agreement or disagreement for each of the 20 items using a 7-point Likert 
scale ranging from Strongly Agree = 7 to Strongly Disagree = 1. The possible range of 
resulting scores was 20-140 (Hojat, 2001).  
 Creswell (2003) describes the importance of reporting past use of the instrument 
in demonstrating reliability. Hojat (2007) reports descriptive statistics of the student 
version as the mean-item scores ranging from a low of 4.57 to a high of 6.63 on the 7-
point scale, and the standard deviations ranging from 0.78 to 1.45. Psychometric review 
reports that all item-total score correlates were positive and statistically significant (p < 
0.01), ranging from a low of 0.30 to a high of 0.66. The median item-total score 
correlation was 0.50. The JSPE Nursing Student Version- R has no previously published 
statistical analysis, which highlights the importance of establishing validity and reliability 
of this version. 
Researcher selection of the JSPE Nursing Student Version-R was largely based on 
the enhanced validity due to pre-established psychometrics. Hojat (2007) speaks to the 
psychometric analysis of the JSPE and suggests that the instrument can serve as an 
operational measure of students? orientation or attitudes toward empathy in patient care 
(S-Version). The instrument was subjected to factor analysis to retain the best items. 
Gorsuch (1974) describes factor analysis as a statistical method used to examine the 
empirical relationships among a set of variables, as well as exploring the underlying 
constructs associated with a set of items into important and meaningful factors.  
 58 
Nursing Student Empathic Communication Questionnaire 
A researcher-developed, two-sectioned questionnaire was used to gather data for 
this study (see Appendix C). This questionnaire had not been previously administered to 
a sample group. The Likert-type questions were all phrased with a positive frame to 
ensure consistency of response (Dillman, 2000). Section A of the questionnaire consisted 
of 10 primary items with subscales that, through extensive and comprehensive literature 
review, were considered to be factors associated with BSN student?s nursing program 
components to establish perceptions regarding the teaching of therapeutic communication 
(including empathy) clinical and academic experiences. Conceptual frameworks, 
empirical research and theoretical views from a multidisciplinary perspective were used 
to understand the concept of empathy and empathic communication and to extrapolate the 
necessary elements regarding teaching techniques in nursing programs. Literature was 
selected through medical, psychology, and nursing databases over the past 10 years. 
Keywords included empathy, empathic communication, competency, patient 
perspectives, and clinical experiences. 
The questionnaire was piloted by experts and non-experts from various 
geographical regions prior to student administration to students to ensure readability, 
establish content validity, provide a projected completion timeframe, and elicit feedback 
and recommendations for improvement. Participants in the pilot feedback included a 
Master?s prepared nurse educator that has published research on the concept of empathy, 
a nurse manager working in a hospital clinical setting, a nurse training and development 
specialist and a pre-nursing student. Additionally, a published author and researcher in 
the field of psychometric development of empathy tools who specialized in working with 
 59 
healthcare professionals and students were utilized in the pilot study of the instrument 
packet. Feedback was instrumental in slight modifications in questionnaire wording to 
enhance clarity, organization of constructs, and the addition of questions pertinent in the 
clinical arena. 
The questionnaire asked participants to rate the degree that they disagreed or 
agreed with statements regarding their nursing programs. The questionnaire was designed 
with similar component parts grouped together (Dillman, 2000). Table 1 displays the 
variable, Likert-type scale options, and questions contained within the variable 
(construct). 
 
Table 1 
Nursing Student Empathic Communication Questionnaire Construct Overview  
VARIABLE/CONSTRUCT Question 
Numbers 
Questions Likert Scale
Options 
Program Effectiveness 
(Questions 5 and 6 were not 
included in the sub 
component nor used in 
regression analysis, due to 
demographical nature of the 
questions) 
1-4 1. Overall, my nursing program has been 
effective in preparing me to be 
competent in empathically communica-
ting with patients and families. 
2. My ability to empathically communicate 
with patients and families has improved 
since the start of my program. 
3. I receive consistent feedback among all 
my faculty members regarding core 
competency behaviors to communicate 
therapeutically with patients and 
families. 
4. Empathic communication skills are 
valued by my faculty. 
5. Empathy assessment should be a part of 
the selection criteria for nursing school. 
 
Strongly Disagree, 
Disagree, Neutral, 
Agree, Strongly 
Agree 
(table continues)
 60 
Table 1 (continued) 
VARIABLE/CONSTRUCT Question 
Numbers 
Questions Likert Scale
Options 
 
 
 
Academic Sources 
 
 
 
7a-7h 
6. I would attend more classes on the topic 
of learning how to empathically 
communicate with patients and family if 
they were offered in my nursing 
program. 
Please rate the degree to which you learned 
or were influenced to use empathic 
communication from each of the following 
sources: 
a. Classroom teachers 
b.  Clinical teachers 
c. Practicing nurses 
d. Lecture content 
e. Journal entry and personal 
reflection 
f. Role-playing 
g. Simulation with computers 
h. Post clinical discussions with 
peers and faculty 
 
 
 
 
 
 
(1) Not at all to (5) 
a great extent  
Academic Exposure 
(frequency of experience to 
patient care situations) 
8a-8f a. The number of times I (or my clinical 
group peers) discussed empathic 
communication in a post-conference 
with my clinical instructors. 
b. I have provided nursing care to patients 
that have experienced uncontrolled 
pain in my clinical rotation. 
c. I have provided nursing care to patients 
that have been given a recent chronic 
disease diagnosis (such as diabetes, 
congestive heart failure). 
d. I have provided nursing care to a 
patient?s family member(s) 
immediately following post-news of 
the patient?s terminal condition. 
e. Patients/families have made positive 
comments specifically about my 
communication ability in 
?understanding their perspective?. 
N= never 
S= seldom 
O= Often 
AEC= Almost 
every clinical 
EC= Every clinical 
 61 
Table 1 (continued) 
VARIABLE/CONSTRUCT Question 
Numbers 
Questions Likert Scale
Options 
  7.  I have received negative performance 
feedback or remediation on my clinical 
performance for ?less than acceptable? 
therapeutic communication with a 
patient or family member. 
 
Perceived Competency 9a-9h Please indicate the extent to which you 
perceive you are competent in your present 
ability as a result of your nursing program 
instruction: 
a. Empathically communicating with 
patient and family members regarding 
end-of-life decisions. 
b. Empathically communicating with the 
patient with uncontrolled pain. 
c. Empathically communicating with 
patients that have been given a recent 
chronic disease diagnosis (such as 
diabetes, congestive heart failure). 
d. Empathically communicating with a 
patient?s family member(s) 
immediately following post-news of 
the patient?s terminal condition. 
(1) Not competent 
to (5) highly 
competent 
  e. Empathically communicating with 
patients that are mentally ill/psychiatric 
care situations. 
f. Empathically communicating with the 
elderly. 
g. Empathically communicating with 
patients/family from a different culture. 
h. Empathically communicating with 
patients who are identified by other 
members of the health care team as 
?difficult? (such as angry, demanding, 
rude, hostile, etc.) 
 
(table continues)
 62 
Table 1 (continued) 
VARIABLE/CONSTRUCT Question 
Numbers 
Questions Likert Scale
Options 
Curricular Emphasis 10a-10e Please indicate the time and emphasis of 
curriculum on empathic communication in 
your nursing program: 
a. pre-nursing 
b. Junior year academics 
c. Senior year academics 
d. Clinical experiences in Junior 
year 
e. Clinical experiences in Senior 
year 
FFS= Fell far short 
of my needs 
FS= Fell short of 
my needs 
NA= Was 
necessary amount 
SE= Somewhat 
exceeded that 
which was needed 
FE= Far exceeded 
that which was 
needed 
 
 
Program Effectiveness 
Questions 1-4 referred to overall perception of program effectiveness in teaching 
empathic communication. Responses were based on a five-point Likert-type scale with 
the following choices ranging from Strongly Disagree (SD), to Strongly Agree (SA). 
Examples of questions in this section included sought to elicit student perception of the 
program in utilizing resources, such as faculty and clinical instruction to enhance 
empathic ability in communicating with patients and families. Questions 1-2 sought to 
determine an overall perception of program effectiveness and improvement of student 
ability as a result of instruction in the program. Questions 3-4 refer to the resource of 
faculty in teaching empathic communication. Questions 5-6 acknowledge the student?s 
personal role in determining perception of program effectiveness, such as import of 
empathy as part of selection criteria for nursing school and personal desire and 
professional development to broaden own learning skills in improving empathic 
 63 
communication ability of offered in the program. However, these two questions were not 
used in the regression analysis due to the demographical nature of the questions as 
representing a different construct than questions 1-4. 
Academic Sources 
Questions 7a-7h, Academic Sources, were used to rate the degree to which the 
student learned or were influenced to use empathic communication from sources 
commonly cited in the literature that are used with program instruction. These are 
classroom and clinical teachers, practicing nurses, lecture content, role-playing, post 
clinical discussions with peers and faculty, and journal entry personal reflections. A 
newer method, that includes use of computer simulations was included, though more 
pervasive in medical literature. The five-point Likert scale ranged with responses from 1= 
?not at all? to 5 = ?to a great extent?.  
Academic Exposure 
 Questions 8a-8f, Academic Exposure, asked participants to indicate the frequency 
they experienced patient care situations in their clinical experiences. Response choices 
included Never, Seldom, Often, Almost Every Clinical, and Every Clinical. Question 8e 
and 8f were included to reflect the performance component of the student in empathically 
communicating with patients and families, such as positive comments from patients and 
family members and remediation for less than acceptable empathic communication from 
clinical performance.  
Competence 
 Questions 9a-9h was based on establishing the extent of student perception of 
competence in their present ability as a result of their nursing program instruction. Likert-
 64 
scale selections ranged from 1-5, with 1= ?not competent? to 5 = ?highly competent?. 
Examples of questions included frequent patient and family care scenarios that are 
common in the professional literature as requiring high empathic communication skills 
and that potentially could require perspectives and communication skills beyond what the 
student had experienced through everyday experiences. These areas included end-of-life 
decisions, uncontrolled pain, recent chronic disease diagnosis, immediately following 
post-news of the patient?s terminal condition, mentally ill/psychiatric situations, elderly, 
patients form a different culture, and patients identified as ?difficult?. 
Curricular Emphasis 
 Questions 10a-10e consisted of questions regarding the construct of curricular 
emphasis on empathic communication in their nursing program. Five-point Likert items 
ranged from ?fell far short of my needs? to ?far exceed that which was needed?. The 
major time periods ranged from the initial entry into nursing school program with the pre-
nursing curriculum through the senior year. Clinical experiences were separated from 
academic experiences in this question grouping to reflect theory-practice components and 
program emphasis. 
In examining face validity of items included in the Nursing Student Empathic 
Communication Questionnaire, there were items included that potentially could appear as 
irrelevant. However, these items were included based on theoretical support. For 
example, questions regarding the ?frequency that patient care situations were 
experienced? was based on a linkage of ?learned or were influenced to use empathic 
communication? by sources, such as by the influence of faculty members and/or clinical 
 65 
instructors. Since patient care assignments are directed by clinical instructors and faculty, 
these items were included in multiple sections for cross-validation.  
Potentially problematic due to theoretical diversification and lack of consensus, is 
the section of the questionnaire related to perceived competency. The conundrum of 
trained versus inherent empathy made construction of these items particularly difficult. 
Students were asked to indicate the ?extent to which you perceive you are competent in 
your present ability as a result of your nursing program instruction?. Students that 
attributed their competency in empathically communicating with various clinical 
scenarios to other sources than their nursing program instruction, such as life experiences 
or their spirituality would experience difficulty in answering this section. Some students 
expressed their dissonance with this section in the form of anecdotal comments 
reinforcing this belief. However, this section was included because it was theoretically 
linked with AACN Standards, which state that ?nursing educators must design programs 
that allow students to acquire the described knowledge, skills, competencies and values, 
and must evaluate graduates to ensure the achievement of desired outcomes at 
graduation? (p. 2). Competency in clinical ability is one indicator of effectiveness of 
nursing instruction from the student perspective. 
Questions related to time and curricular emphasis in the nursing program was 
framed from the perspective of capturing the student?s needs (ranging from ?fell far 
short? to ?far exceeded that which was necessary?) on the theoretical premise of program 
effectiveness in providing exposure to patients and families in which to provide empathic 
communication and receive necessary remediation or reinforcement through clinical 
discussions and in the academic arena through skill enhancement. 
 66 
Section B 
 Section B of the questionnaire contained demographic questions consisting of 
gender, age, ethnicity and clinical area of interest post-graduation. These demographic 
questions were supported in the literature as being predictors of empathy and empathic 
communication (Hojat, 2007). Clinical areas of specialization representative of 
coursework encountered in nursing programs consisted of both broad categories of 
employment such as maternal-child health, adult health, community health and 
specialized categories such as emergency-trauma, critical-care, renal, and labor-delivery.  
 
Data Collection Procedures 
 A survey design was selected for this study to provide a quantitative description 
of nursing student perceptions of program effectiveness in teaching empathic 
communication. The purpose of this design was to provide a means to generalize from 
the sample to a population so that inferences could be made regarding characteristics, 
attitudes, and behaviors of this population (Creswell, 2003). Survey design was the 
preferred type of data collection procedure for the study because it afforded the 
researcher many advantages. Among these advantages were economy of design, student 
availability, convenience to researcher and students, relatively low printing costs and the 
rapid turnaround in data collection. Survey collection was also chosen because of the lack 
of burden on the time demands of the respondents, privacy concerns of program 
effectiveness input, and logistical obstacles to limited student availability of the senior 
level students that are potential challenges with other data collection methods, such as 
interviews, structured observations or record reviews. There were many advantages that 
 67 
survey design afforded in identification of attributes of a large population from a 
relatively small group of individuals. This consideration was particularly important with 
the use of factor analysis in seeking construct validity of the JSPE Version R Scale.  
 The survey was administered to senior nursing students with one-time data 
collection occurring during the months encompassing Fall Semester 2006. This time 
period lasted from late September to late November 2006, with survey administration 
conducted by the researcher at specified times in accordance with student attendance in 
their classrooms. 
Data was collected by use of self-administered questionnaires. A hard-copy 
version of the survey instrument versus electronic format was chosen for improved 
response rate and timely response by the students. Additionally, use of the self-
administered questionnaire in hard-copy format was utilized rather than an Internet or 
online survey due to the large number of institutions in the sample group. The advantages 
of this collection method such as ensured data availability and convenience offset the 
potential weaknesses incurred by cost of travel by the researcher and questionnaire 
printing costs. 
Procedures for recruitment of the sample group were initiated by obtaining 
potential CCNE accredited schools from the AACN web-site. Telephone contact was 
made by the researcher to the nursing school Dean or Assistant Dean to request 
permission to recruit students from the programs. Electronic information letters were sent 
following verbal permission describing the study?s purpose, use of results, contact 
information, flyer, questionnaire, IRB status, and requesting for permission to begin 
arranging data collection. Tentative dates and times for data collection were requested 
 68 
and provided by the Dean or by a designated nursing program contact person with 
consideration given to optimize and prevent interruption of existing classroom 
instruction. Only mandatory courses containing an entire senior student class were 
scheduled for data collection, which usually consisted of leadership or senior seminar 
courses. Consideration by the researcher and coordination with the contact faculty was 
given to select optimal data collection times, dates, and classroom agendas inherent with 
each institution. Individual IRB approval was sought for each participating institution 
according to protocols (see Appendix D). 
Each institution was given access to a flyer template (see Appendix E) for 
distribution in student mailboxes or posting in classrooms or central student locations 
describing the study, purpose, data collection, date and time, and voluntary status. No 
institutions chose to distribute the flyer, but rather verbally announced through the faculty 
member the voluntary research participation opportunity to students prior to data 
collection. The sample was selected by offering students the opportunity to participate 
after reading a script that explained the voluntary nature of the study, how results would 
be utilized, ensuring anonymity, and questionnaire completion instructions. There was no 
compensation by the researcher or classroom faculty for participation in the study. There 
were no provisions for questionnaire completion for students that were not in classroom 
attendance during the data collection period.  
Sample-Size Considerations 
 Pedhauzur (1997) and Meyers et al. (2006) recommended the use of a target ratio 
of 10-15 participants for every variable. The use of a sample size of 600 students in this 
 69 
study exceeded this criterion which was analyzing the two instruments, combined 53-
item questionnaire inventories. 
Data was coded by nursing program affiliation and respondent and responses 
were entered into SPSS Graduate Student Version 13 by the researcher.  Variables were 
numbered in the order they appeared on the questionnaires. The use of the five-point 
Likert-scale for the Nursing Student Empathic Communication Questionnaire provided a 
neutral category with the number 3. The JSPE Nursing Student Version R utilized a 7-
point Likert scale, ranging from lower numbers representing strongly disagrees, to the 
higher numbers representing strongly agree responses. Section B was recoded to 
represent the categories of post-graduation clinical interest, gender, age, and ethnicity.  
 
Data Analysis 
 The JSPE Nursing Student Version R was initially analyzed in Research Question 
1 with descriptive analysis and a one-sample t-test.  Research Question 2 utilized factor 
analysis and Research Question 3 utilized the JSPE Nursing Student Version R as the 
dependent variable and the Nursing Student Empathic Communication Questionnaire 
sub-constructs consisting of academic exposure, curricular emphasis, perceived program 
effectiveness and academic sources as independent variables.  Question 4a and 4b 
consisted of multiple regressions with the dependent variable of perceived competence 
and the Nursing Student Empathic Communication Questionnaire sub-constructs 
consisting of academic exposure, curricular emphasis, perceived program effectiveness 
and academic sources as independent variables.  JSPE Nursing Student Version R total 
scores were added in Research Question 4b as an independent variable along with the 
 70 
sub-constructs with the dependent variable of perceived competence. Meyers et al. (2006) 
emphasizes the importance of further analysis, such as multiple regressions, after factor 
analysis to predict the value of a quantitative variable in multiple regressions using the 
factors as the independent variables. 
In the factor analysis, the data was initially analyzed through univariate extraction 
rotation, with Eigen-values plotted. Meyers et al (2006) describe factor analysis as a 
process that allows the identification of a few components, factors, or dimensions that 
underlie a larger set of variables. Varimax rotation followed, with correlations analyzed. 
Reliability values, statistical correlations of the total scores, and descriptive data 
(including means and standard deviations) were analyzed for questions 1-20. Frequency 
analysis and percentile (25
th
, 50
th
, and 75
th
) were analyzed to be used in comparison data 
with the JSPE Version S. Descriptive statistics served to describe and summarize 
observations (Ary et al., 2006).  
 The scoring algorithm for the JSPE Nursing Student Version R was performed by 
the researcher as per protocol established by Hojat (2007), which consisted of (a) 
ensuring that 80% of the 20 items were answered in order to be included in the data 
analysis, (b) ensuring that respondents with 4 or fewer unanswered items, missing values 
were replaced with the mean score calculated from items completed by the respondent, 
and (c) reverse scoring of question items 1, 3, 6, 7, 8, 11, 12, 14, 18, and 19. Total JSPE 
Nursing Student Version R scores were calculated and this independent variable was 
renamed ?JSPE Version R total? for analysis by multiple regression technique. Higher 
total JSPE Nursing Student Version R scores indicate greater empathic behavioral 
orientation of the student. 
 71 
Nursing Student Empathic Communication Questionnaire 
 The Nursing Student Empathic Communication Questionnaire variables were 
selected for inclusion in the analysis for the research study. There were five constructs 
used in the construction of the questionnaire. Chapter 4 presents the concepts, question 
numbers, mean, standard deviations, and Cronbach?s alpha of these components that 
constituted the Nursing Student Empathic Communication Questionnaire.  
 Correlation, reliability and descriptive analyses were performed on the variables 
of JSPE Version R Total, Program Effectiveness, Academic Sources, Academic 
Exposure, Perceived Competence, and Curricular Emphasis. Regression analysis with 
criteria of significance at .05 was performed with three full models, with (a)the dependent 
variable perceived competency and Program Effectiveness, Academic Sources, Academic 
Exposure, JSPE Nursing Student Version R total scores, and Curricular Emphasis as 
independent variables, (b) the dependent variable perceived competency and Program 
Effectiveness, Academic Sources, Academic Exposure, and Curricular Emphasis as 
independent variables, and (c) the dependent variable of JSPE total scores and academic 
exposure, curricular emphasis, program effectiveness, and academic sources as 
independent variables. The goal of this selection of these variables was to determine how 
and to what extent, variability of the dependent variable depends on manipulations of the 
independent variables (Pedhazur, 1997). Additionally, backward regression was 
performed with the full model between Competence as the dependent variable and 
student attitudes toward empathy in patient care (JSPE Nursing version R total scores) 
and individual questions within the constructs of Academic Exposure, Program 
Effectiveness and Curricular Emphasis and Academic Sources as independent variables. 
 72 
Backward regression was used to explain each of the four independent variables offering 
the most parsimonious solution. 
 Chapter 4 provides detailed analysis of both descriptive statistics and results of 
the factor analysis of the JSPE Nursing Student Version R. The full model and restricted 
models of the multiple regression analysis are analyzed and depicted in tabular form. 
 
Summary 
 The use of the JSPE Nursing Student Version R combined with the Nursing 
Student Empathic Communication Questionnaire addressed the research questions by 
combining constructs represented in the literature into scales designed to measure 
empathy and student perception of program effectiveness in teaching empathic 
communication. The sample group of senior nursing students from 14 nursing programs 
was selected from BSN programs that are currently CCNE accredited. Methodology that 
consisted of researcher data collection through survey design, via site visits to each 
program, was selected to optimize sample size of the student population.  
 73 
IV. RESULTS 
 
Overview 
 Chapter 4 described the first statistical analysis employed to the data as 
descriptive statistical procedures. By analyzing the results from this sample group of 
nursing seniors, the goal of this research study is to make general statements about the 
population as a whole (Gravetter & Wallnau, 2004). The results are presented as a 
descriptive overview of the responses from the questionnaire, providing percentages, 
means and standard deviations of each response to each variable.  
 Exploratory factor analysis provided psychometric properties to the JSPE Nursing 
Student Version R tool. Comparisons between the score distributions, percentiles, and 
descriptive statistics of the S Version of the JSPE (Hojat, 2007, p. 105) and the R Version 
are presented, which are crucial to providing empirical confirmation to assist with 
supporting validity of the JSPE Nursing Version R in the nursing student population. 
Correlational analysis of JSPE Nursing Student Version R total scores are presented as 
compared to the five constructs represented in the Nursing Student Empathic 
Communication Questionnaire. Finally, regression analysis was used to examine 
predictors of perceived competency in present ability to empathically communicate as a 
result of nursing program instruction and student attitudes toward empathy in patient care 
(JSPE Nursing Student Version R total scores) . 
 74 
Sample Demographics 
 As described in detail in Chapter 3, nursing school seniors from 14 nursing 
programs completed and returned 600 surveys representing an overall mean response rate 
of 83%. Reponses from the individual programs ranged from 55% to 94% response rates, 
with a median of 86%. The sample population for the research study analysis included 
demographic information regarding age, ethnicity, gender and clinical areas of interest 
post-graduation.  
The greatest percentage of students from the sample group was from age 20-22 
years (46.6%), followed by 23-25 year olds. The greatest percentage of the sample was 
females (88%). Caucasian ethnicity constituted the largest percentage (83%). The largest 
percentage of post graduation clinical interest was Critical Care (27%). 
The senior nursing student participant pool consisted of 276 (46.6%) age 20-22 
year olds, 154 (26%) 23-25 year olds, 45 (7.6%) 26-28 year olds, 59 (10%) 29-36 year 
olds, and 58 (9.8%) reporting their age as greater than 36. The participant pool consisted 
of a population of 523 females (88%) and 72 males (12%). There were 5 participants that 
declined to indicate this information.  
The sample group reported their ethnicity as: African American, 53 (9%), Asian, 
17 (3%), Caucasian, 494 (83%), Hispanic, 14 (2%), Native American, 4 (.7%), and Other, 
10 (1.7%). There were 8 participants that constituted missing data in indicating their 
ethnicity. The final demographic question, asking participants to indicate their primary 
area of clinical interest post-graduation was: Adult Health, 51 (9%), Labor and Delivery, 
61 (10%), Cardiac Step-down unit, 21 (3.5%), Maternal-Child, 55 (9%), Community 
Health, 9 (1.5%), Pediatrics, 80 (13%), Critical Care (ICU/CCU), 164 (27%), Psychiatry, 
 75 
10 (1.7%), Emergency/Trauma, 92 (15.5%), Renal/Hemo-dialysis, 6 (1%), Geriatrics, 16 
(2.7%), and Other, 30 (5%). 
Generalizing to other populations is important to establishing external validity 
(Cronbach, 1990). Researchers desire to furnish results of a study that furnish information 
about a larger realm of subjects, conditions, and operations than were actually 
investigated (Ary et al., 2006). In this study, demographic findings (see Table 2) were 
compared to statistics provided by the American Association of Colleges of Nursing 
(2006), which stated that 90% of participating schools reported female gender, and males 
accounted for 10%. In terms of ethnicity, Asian students accounted for 5.8%, African 
American, 12%, Hispanic. 5.2%, Native American, .8% and Caucasian (White), 76% 
(Fang, Wilsey-Wisniewski, & Bednash, 2006). 
In terms of the sample group represented in this study, gender was slightly over 
represented by the male sample in this study (chi-square = 3.92) of the population 
reflected in AACN figures. In terms of ethnicity, there were a larger percentage of 
Caucasian students (particularly female students) participating in this study than reported 
in the AACN national figures, as well as smaller diversification of minority groups, 
particularly among Asian and Hispanic students surveyed in this study (chi-square = 
27.4). 
 
 76 
Table 2 
Comparison of Sample Group with National Population 
 AACN Sample 
Gender   
Female 90.3% 88% 
Male 9.7% 12% 
Ethnicity   
African American 12.1% 9% 
Asian 5.8% 3% 
Caucasian 76.1% 83% 
Hispanic 5.2% 2% 
Native American 0.8% 0.7% 
Other ?? 1.7% 
AACN demographic figures regarding Gender (n = 161,787 students) and Ethnicity (n = 
148,944 students) enrolled Fall 2005 (Fang, Wilsey-Wisniewski, & Bednash, 2006). 
 
Research Question 1 
The first research question was, ?Is there a statistical difference between the JSPE 
Version S and the JSPE Nursing Student Version R was answered by utilizing 
 77 
comparative analysis in psychometric properties of the JSPE S-Version and the JSPE 
Nursing Student Version R?? Researchers at Jefferson Medical College collected data for 
685 first year students. Data was combined from student groups due to the similarities of 
all three classes (matriculates of 2002, 2003, and 2004). According to Hojat, the mean 
item scores ranged from a low of 4.57 to a high of 6.63 on the 7-point scale and standard 
deviations ranged from 0.78 to 1.45. The item-total score correlations were all positive 
and statistically significant (p < 0.01), ranging from a low of 0.30 to a high of 0.66. The 
median item-total score correlation was 0.50. Descriptive statistics and reliability 
coefficients for the S-Version of the JSPE are reported in Table 3. 
 The results of data collected in this study of 600 senior nursing students from 14 
CCNE accredited nursing programs in the Southeast were analyzed. Descriptive statistics 
and reliability coefficients for the JSPE Nursing Student Version R are reported in Table 
3. The mean item scores ranged from a low of 3.89 to a high of 6.56 on the 7-point scale, 
and standard deviations ranged from 0.97 to 1.65. The item-total score correlations were 
all positive and statistically significant (p < 0.01), ranging from a low of 0.17 to a high of 
0.53. The median item-total score correlation was 0.37. 
Comparisons of the JSPE Versions S and R yielded similar means and standard 
deviations with 115 and 114.57 respectively, and standard deviations of 10 and 10.94 
respectively. The results of a one-sample t-test failed to render statistical significance (t = 
-1.22, p=.224). The greatest variability was in the range, which was 75-140 for the JSPE 
Version S and 56-140 for the JSPE Nursing Student Version R.  
 
 
 78 
Table 3 
Descriptive Statistics and Percentiles between the JSPE S-Version (n = 685 medical 
students) and JSPE Nursing Student Version R (n = 600 senior nursing students)  
JSPE S-VERSION JSPE R-VERSION 
Mean 115 Mean 114.57 
Standard Deviation 10 Standard Deviation 10.94 
25
th
 Percentile 108 25
th
 Percentile 108 
50
th
 Percentile 115 50
th
 Percentile 116 
75
th
 Percentile 122 75
th
 Percentile 122 
Possible Range 20-140 Possible Range 20-140 
Actual Range 75-140 Actual Range 56-140 
Alpha Reliability estimate 0.80 Alpha Reliability estimate 0.77 
 
Research Question 2 
Research question 2 was, ?What unique themes, dimensions, and factors emerge 
from the JSPE Nursing Student Version R scores?? An exploratory factor analysis using 
a principal component extraction method and a varimax rotation of 20 self-report JSPE 
Nursing Student Version R empathy items was conducted on the sample of nursing 
school seniors (n = 598) of the 14 nursing school programs. Prior to running the analysis 
with SPSS Graduate Student Version 13, the data were screened by examining the 
descriptive statistics on each item, with results displayed in Table 4. Means for each item 
 79 
variable ranged from 6.56 to 3.88, and standard deviations ranged from .97 to 1.6, 
indicating a heterogeneous sample group. Inter-item correlations were a mean of .182 
with minimum of -.112 to a maximum of .507. Because of the large sample size, the 
variables-to-cases ratio was deemed adequate. 
 
Table 4 
Descriptive Statistics JSPE Nursing Student Version R (n = 598) 
Variable Mean S.D. 
 I believe that emotion has no place in the treatment of medical illness (reversed) 6.56 .97 
Patients feel better when their nurses understand their feelings 6.41 1.00 
Understanding body language is as important as verbal communication in nurse-patient 
relationships 6.36 1.05 
Attention to patients? emotions is not important in history taking (reversed) 6.34 1.15 
Nurses? understanding of the emotional status of their patients, as well as that of their families 
is one important component of the nurse-patient relationship. 6.31 .97 
I believe that empathy is an important therapeutic factor in medical treatment 6.31 .99 
Patients? illnesses can be cured only by medical or surgical treatment; therefore, nurses? 
emotional ties with their patients do not have a significant influence in medical or 
surgical treatment (reversed) 6.28 1.15 
Nurses should try to understand what is going on in their patients? minds by paying attention 
to their non-verbal cues and body language. 6.14 1.15 
Asking patients about what is happening in their personal lives is not helpful in understanding 
their physical complaints (reversed) 6.14 1.24 
Attentiveness to patients? personal experiences does not influence treatment outcomes 
(reversed) 6.04 1.15 
Nurses? understanding of their patients? feelings and the feelings of their patients? families 
does not influence medical or surgical treatment. 6.01 1.47 
(table continues) 
 80 
Table 4 (continued) 
Variable Mean S.D. 
Patients value a nurse?s understanding of their feelings which is therapeutic in its own right. 5.99 1.11 
I do not enjoy reading non-medical literature or the arts (reversed) 5.88 1.64 
Nurses should try to stand in their patients? shoes when providing care to them. 5.59 1.33 
Empathy is a therapeutic skill without which the nurse?s success is limited. 5.49 1.59 
A nurse?s sense of humor contributes to a better clinical outcome 5.22 1.41 
It is difficult for a nurse to view things from patients? perspectives (reversed) 4.57 1.34 
Nurses should try to think like their patients in order to render better care 4.47 1.44 
Because people are different, it is difficult to see things from patients? perspectives (reversed) 4.42 1.51 
Nurses should not allow themselves to be influenced by strong personal bonds between their 
patients and their family members (reversed) 3.89 1.47 
 
Using the Kaiser-Guttman retention criterion of eigenvalues greater than 1.0, a 
five factor solution provided the clearest extraction. These five factors accounted for 
50.62% of the total variance. Table 5 presents the 20 items and their factor correlation 
loadings. Communalities were fairly high for each of the 20 items, with a wide range of 
.30 to .74. Factors are discussed and re-named by the researcher to reflect the overall 
predominant theme displayed by the cell group. Meyer et al. suggests this method based 
on the works cited by most statisticians. Coefficients less than .40 were eliminated from 
consideration, as they were not strongly related to the factor (Meyer et al., 2007). 
 81 
Table 5 
Factor Analysis (Rotated). Extraction Method: Principal Component Analysis, Rotation 
Method Varimax with Kaiser Normalization 
Variable Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 
Attention to patients? emotions is not important 
in history taking (reversed) 
.703     
Attentiveness to patients? personal experiences 
does not influence treatment outcomes 
(reversed) 
.690     
I believe that emotion has no place in the 
treatment of medical illness (reversed) 
.623     
Patients? illnesses can be cured only by medical 
or surgical treatment; therefore, nurses? 
emotional ties with their patients do not have a 
significant influence in medical or surgical 
treatment (reversed) 
.622     
Nurses? understanding of the emotional status of 
their patients, as well as that of their families is 
one important component of the nurse-patient 
relationship. 
.561     
Nurses should try to understand what is going 
on in their patients? minds by paying attention to 
their non-verbal cues and body language. 
.547 
    
Nurses? understanding of their patients' feelings 
and the feelings of their patients' families does 
not influence medical or surgical treatment. 
.541 
    
Asking patients about what is happening in their 
personal lives is not helpful in understanding 
their physical complaints (reversed). 
.524 
    
I believe that empathy is an important 
therapeutic factor in medical treatment 
.443 
    
Understanding body language is as important as 
verbal communication in nurse-patient 
relationships 
 
.740 
   
Patients feel better when their nurses understand 
their feelings 
 
.683 
   
(table continued)
 82 
Table 5 (continued) 
Variable Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 
A nurse?s sense of humor contributes to a better 
clinical outcome 
 .511    
Patients value a nurse?s understanding of their 
feelings which is therapeutic in its own right. 
 .437    
Nurses should try to think like their patients in 
order to render better care. 
  .777   
Nurses should try to stand in their patients' 
shoes when providing care to them. 
  .650   
Because people are different, it is difficult to see 
things from patients? perspectives (reversed). 
   .850  
It is difficult for a nurse to view things from 
patients? perspectives (reversed). 
   .823  
I do not enjoy reading non-medical literature or 
the arts (reversed). 
    .617 
Empathy is a therapeutic skill without which the 
nurse?s success is limited. 
    .598 
Nurses should not allow themselves to be 
influenced by strong personal bonds between 
their patients and their family members 
reversed) (
 
    .585 
 
Factor 1: ?Emotional Engagement? (eigenvalues = 4.83) accounted for 24.15 % 
of the variance and contained nine items; Factor 2: ?Nurse Relationship? (eigenvalues = 
1.84) accounted for 9.19% of the variance and contained four items; Factor 3: ?Patient 
Identification? (eigenvalues = 1.34) accounted for 6.71 % of the variance and contained 
two items; Factor 4: ?Patient?s Perspective? (eigenvalues = 1.08) accounted for 5.42% of 
the variance and contained two items; and Factor 5: ?Nursing as an art? (eigenvalues = 
1.03) accounted for 5.14% of the variance and contained three items. Corrected item-total 
 83 
correlations ranged from .190 to .559, and Cronbach?s coefficient alpha ranged from .77 
to .79 among the five factors, indicating fairly good subscale reliability. 
The Nursing Student Empathic Communication Questionnaire reliability 
estimates were computed using Cronbach?s alpha coefficient for the five item constructs 
included in the questionnaire. The results are displayed in Table 6. These are program 
effectiveness, academic sources, exposure to patient care situations, perceived 
competency as a result of the nursing program instruction, and curricular emphasis. 
Cronbach?s alpha coefficients ranged from the highest (.83) of the time and emphasis of 
curriculum on empathic communication to the lowest (.63) of the exposure to patient care 
situations, resulting in a median of .77.  
 
Table 6 
Nursing Student Empathic Communication Questionnaire Components  
Questionnaire Concept/Variable # of 
Items 
Mean S.D. Cronbach?s 
Alpha 
Curricular Emphasis 5 14.96 3.49 .83 
Perceived competency  8 27.03 5.86 .80 
Program effectiveness 4 15.40 2.84 .77 
Academic Sources  8 25.75 5.15 .70 
Academic Exposure  6 14.61 3.22 .63 
 
 84 
Research Question 3 
To what extent do predictor scales of the Nursing Student Empathic 
Communication Questionnaire (a) academic exposure to patient care situations, (b) 
curricular emphasis during the nursing program, (c) perceived program effectiveness, and 
(d) academic sources predict nursing student?s orientation or attitudes toward empathy in 
patient care as measured by JSPE Nursing Student Version R total scores? 
 
Overview of Descriptive Statistics 
Correlational analysis between the JSPE Nursing Student Version R totals with 
the four Nursing Student Empathic Communication Questionnaire constructs/variables 
yielded correlations ranging from the highest correlation of Program effectiveness (.168) 
to the lowest correlation of -0.46 for the construct variable of Academic Exposure. Other 
correlations between the JSPE Nursing Student Version R were Academic Sources 
(.143), and Curricular Emphasis (.063).  
 
Overview of the Full Model Results 
For the dependent variable, student?s orientation or attitudes toward empathy in 
patient care (JSPE Nursing Version-R total scores), a multiple regression procedure was 
performed with four independent variables. As described in the methods section, a 
backward elimination procedure was performed to first examine a full model with all four 
predictors and then restrict the final model to those variables that contributed beyond 
what would be expected by chance (Pedhauzur, 1997). The most important criterion is 
that of meaningfulness of the predictor to the equation (Pedhauzur, 1997). Summaries of 
 85 
the full and restricted model results of the multiple regression analyses for the student?s 
orientation or attitudes toward empathy in patient care (JSPE Nursing Version- R total 
scores) as the dependent variable is represented in Table 7.  
 
Table 7 
Dependent Variable: Student?s Orientation or Attitudes toward Empathy in Patient Care 
(JSPE Nursing Version-R total Scores) 
INDEPENDENT VARIABLE r 
Semi-partial 
correlation 
Beta 
(Full) 
Beta 
(Restricted)
Program effectiveness .168*** .111 .142 .133 
Academic Sources .143** .088 .113 .107 
Academic exposure -.046* -.100 -.108 -.112 
Curricular emphasis .063 -.022 -.027 removed 
Full Model: F = 6.679, df (4, 592), p < .001 
*p <.05, **p < .01, ***p < .001 
Restricted model: F = 8.811, df (3,593), p < .001 
 
 Three of the four independent variables, program effectiveness, academic 
exposure, and academic sources were statistically significant (p < .05). The independent 
variable, curricular emphasis, was removed from the full model due to lack of 
significance (p =.576). Table 7 displays the independent variables and their respective 
 86 
zero-order and semi-partial correlations. Program effectiveness and academic sources 
accounted for the highest proportion of variance. 
The restricted model comparisons are presented in Table 7. R-squared values and 
standard error of the estimate are statistically unchanged (.001) from the full model R
2
 
yielding .043 and the restricted model .043 with the removal of curricular emphasis. 
Standard error of the estimate in both the full model and the restricted was 11.28. 
The full model explained 4.3% of the variance, with an F = 6.679 and the 
restricted model, explained 4.3% of the variance, with F = 8.81. The difference between 
these two models was not statistically significant (p > .05), so the more parsimonious 
model was accepted. To further examine which aspects of program effectiveness, 
academic exposure, and academic sources related to student?s orientation or attitudes 
toward empathy in patient care (JSPE Nursing Version- R total scores), follow-up 
regression analysis was performed using specific items from these subscales. As with the 
overall regression, a backward elimination approach was taken to obtain the most 
parsimonious model. 
Table 8 describes each sub-construct (individual questions contained in the 
variable) of the predictors that were utilized in the backward regressions. Included in 
these are academic exposure, program effectiveness, and academic sources. Curricular 
emphasis was not further examined after being removed from the overall regression 
analysis. These follow-up regressions resulted in effect sizes greater than that of the 
overall regression with R
2
 values ranging from 5.4% to 11.6%, compared to just 4.3%.  
 
 87 
Table 8 
Sub-construct Questions for Independent Variables 
No. of Items R
2
S.E. 
Variable 
Full Restrict Full Restrict Full Restrict
Program Effectiveness 4 3 .059 .056 11.20 11.20 
Academic Sources 8 4 .054 .046 11.27 11.27 
Academic Exposure 6 4 .116 .113 10.88 10.88 
 
 
Program Effectiveness and Student Attitudes toward Empathy in Patient Care 
Backward elimination regression was performed on the four questions regarding 
program effectiveness as the independent variable and student?s attitudes toward empathy 
in patient care (JSPE Nursing Student Version R total scores) as the dependent variable. 
In the full model, program effectiveness had the largest Beta value. Results are displayed 
in Table 9. The overall full model resulted in an R 
2 
of .059 (F = 9.32, p < .001, standard 
error of the estimate 11.20). Question 2, ?My ability to empathically communicate with 
patients and families has improved since the start of my program?, was eliminated. The 
remaining three questions retained in the restricted model were Question 1 (Beta .098): 
?Overall, my nursing program has been effective in preparing me to be competent in 
empathically communicating with patients and families?, Question 3, (Beta -.125): ?I 
receive consistent feedback among all my faculty members regarding core competency 
 88 
behaviors to communicate therapeutically with patients and families?, and Question 4, 
?Empathic communication skills are valued by my faculty?, Beta .225. 
 
Table 9 
Sub-variables for Program Effectiveness for Restricted Model 
Sub-variables Beta sig 
Q4. Empathic communication skills are valued by my faculty  .225 .001 
Q3. I receive consistent feedback among faculty members. -.125 .011 
Q1. Overall, my nursing program has been effective in 
preparing me to be competent in empathically communicating 
with patients and families. 
.098 .043 
 
 
Academic Sources and Student Attitudes toward Empathy in Patient Care 
Backward elimination regression was performed on the eight questions regarding 
the construct of the independent variable Academic Sources and student?s attitudes 
toward empathy in patient care (JSPE Nursing Student Version R total scores) as the 
dependent variable. This process resulted in the removal of role playing, post-clinical 
discussions with peers and family, classroom teachers, and practicing nurses. The more 
parsimonious model was accepted. Sub-variables are depicted in Table 10. Full model 
values yielded R-squared value of .054, Standard Error of the Estimate 11.27, df (8,587), 
F = 4.15, R-squared value for the restricted model yielded .046, with a standard error of 
 89 
the estimate 11.27, df (4,591), F = 7.11, p < .001, which differed from the full model, R
2
 
change < -.004, and F-change of 2.30 (p>.05). 
 
Table 10 
Sub-variables for Academic Sources 
Sub-variables Beta sig 
Clinical teachers .154 p < .001 
Lecture Content .115 .008 
Simulation with Computers  .109 .014 
Journal Entry personal reflections  .071 p >.05 
 
  
Academic Exposure and Student?s Attitudes toward Empathy in Patient Care 
Backward elimination regression was performed using the questions contained in 
the construct of academic exposure as predictors with the dependent variable of student?s 
attitudes toward empathy in patient care (JSPE Nursing Student Version R total scores). 
The R
2
 values for academic exposure were .116, with the standard error of estimate 
10.88. The R
2
 value indicates that 11.6% of the variance can be explained with the six 
questions included in the academic exposure construct. The F value was significant at 
12.94, df (6,589). The results of this regression analysis are displayed in Table 11.  
 90 
Table 11 
Sub-variable Analysis for Academic Exposure on Restricted Model  
Sub-variables Beta sig 
8f. I have received negative feedback/remediation on my 
clinical performance for ?less than acceptable? therapeutic 
communication with a patient or family member. 
-.294 .001 
8a. The number of times I (or my clinical group peers) discussed 
empathic communication in a post-conference with my 
clinical instructors. 
.100 .012 
8e. Patients/families have made positive comments specifically 
about my communication ability in ?understanding their 
perspective? 
.089 .030 
8d. I have provided nursing care to a patient?s family member(s) 
immediately following post-news of the patient?s terminal 
condition.  
-.077 .069 
  
 During the backward regression, four questions were retained in the final 
restricted model. Question 8b, ?I have provided nursing care to patients that have 
experienced uncontrolled pain in my clinical rotation?, and Question 8c, ?I have provided 
nursing care to a patients that have been given a recent chronic disease diagnosis (such as 
diabetes, congestive heart failure). Question 8d, ?I have provided nursing care to a 
patient?s family member (s) immediately following post-news of a patient?s terminal 
condition? was retained in the third model, but was significant at p = .069.  
 91 
Beta values and the standard error of estimate are indicated. The highest positive 
Beta value was from question 8a, which are discussions between clinical instructors and 
clinical group students. Question 8f, ?I have received negative performance feedback or 
remediation on my clinical performance for ?less than acceptable? therapeutic 
communication with a patient or family member?, was significant at the p < .001, 
represents the highest Beta value, though negative (-.294), which is discussed further in 
Chapter 5.  
Research Question 4a 
To what extent do nursing program components (program effectiveness, 
curricular emphasis, academic exposure, and academic sources) predict student?s 
perceived competence to empathically communicate with patients and families as a result 
of their nursing program instruction? 
Research Question 4b 
To what extent does orientation or attitudes toward empathy in patient care (JSPE 
Nursing Student Version R Total scores) contribute to the prediction of perceived 
competence above and beyond program components in Research Question 4a? 
 
Overview of the Full Model Results 
For the dependent variable, perceived competence, a multiple regression 
procedure was performed with four independent variables. As described in the methods 
section, a backward eliminative procedure was performed to first examine a full model 
with all four predictors and then restrict the final model to those variables that contributed 
beyond what would be expected by chance (Pedhauzur, 1997). The most important 
 92 
criterion is that of meaningfulness of the predictor to the equation (Pedhauzur, 1997). 
Summaries of the full and restricted model results of the multiple regression analyses for 
the perceived competency category dependent variable is represented in Table 12.  
 
Table 12 
Dependent Variable: Student Perceived Competence in Present Ability as a Result of 
Nursing Program Instruction 
INDEPENDENT VARIABLE r Semi-partial correlation 
Beta 
(Full) 
Academic exposure 
a
.387*** .282 .306 
Curricular emphasis
 a
.329*** .127 .152 
Program effectiveness 
a
.313*** .101 .130 
Academic Sources
 a
.300*** .031 .039 
Attitudes toward empathy  
(JSPE Nursing Version-R totals)
b
 .129*** .104 .106 
*p < .05, **p < .01, ***p < .001 
Full Model: F = 42.71, df(4, 592), p < .001 
Restricted model: F = 56.52, df(3,593), p < .001 
a ? R
2 
= .224, F (4,592) = 42.715, p < .001  
 
b ? R
2 
Change = .011, F (1, 591) = 8.311, p = .004 
 
 93 
 Three of the four independent variables, program effectiveness, academic 
exposure, and curriculum emphasis were statistically significant (p < .05). The 
independent variable, academic sources, was removed from the full model due to lack of 
significance (.269). Table 12 displays the independent variables and their respective r-
values and semi-partial correlations. Academic exposure accounted for the highest 
proportion of variance after controlling for the other independent variables, followed by 
program effectiveness and curricular emphasis. The independent variable, academic 
sources was removed in the following backward regression analysis. 
The full model explained 22.4% of the variance, with an F = 42.71 and the 
restricted model explained 22.2% of the variance, with F = 56.52. The difference between 
these two models was not statistically significant (p > .05), so the more parsimonious 
model was accepted. 
The restricted model comparisons are presented in Table 12. R-squared values 
and standard error of the estimate are statistically changed (.001) from the full model R
2
 
yielding .224 and the restricted model .222 with the removal of academic sources. 
Standard error of the estimate in both the full model and the restricted was 5.18. 
Research Question 4b 
To what extent does orientation or attitudes toward empathy in patient care (JSPE 
Nursing Student Version R Total scores) contribute to the prediction of perceived 
competence above and beyond program components? A hierarchical regression was used 
to examine the extent to which attitudes toward empathy were related to perceived 
competence after controlling for the influence of four program components. Table 12 
summarizes the results for the hierarchical regression analysis. Overall, the four program 
 94 
components resulted in statistically significant (F (4,592) = 42.715, p < .001). The 
addition of attitudes toward empathy resulted was also statistically significant F (1, 591) 
= 8.311, p = (.004). The corresponding effect sizes are noteworthy. Whereas the four 
program components contributed 22.4%, the addition of attitudes toward empathy only 
contributed 1.1%.  
To further examine which aspects of program effectiveness, academic exposure, 
and curricular emphasis, follow-up regression analysis was performed using specific 
items from these subscales addressed in Research Question 4a. As with the overall 
regression, a backward elimination approach was taken to obtain the most parsimonious 
model. 
Table 13 describes each sub-construct (individual questions contained in the 
variable) of the predictors that were utilized in the backward regressions. Included in 
these are academic exposure, curricular emphasis, and program effectiveness. Academic 
sources were removed after the restricted model. 
 
Table 13 
Sub-construct Questions for Independent Variables 
No. of Items R
2
S.E. 
Variable 
Full Restrict Full Restrict Full Restrict
Academic Exposure 6 5 .191 .187 5.29 .530 
Program Effectiveness 4 2 .115 .113 5.53 5.55 
Curricular Emphasis 5 3 .112 .112 5.55 5.54 
 95 
Academic Exposure and Perceived Competence 
Backward elimination regression was performed using the questions contained in 
the construct of academic exposure as predictors with the dependent variable of perceived 
competence. Academic exposure was utilized for further regression analysis because it 
had the largest Beta value from the previous full model analysis. The R
2
 values for 
academic exposure were .191, with the standard error of estimate 5.29. The R
2
 value 
indicates that 19% of the variance can be explained with the six questions included in the 
academic exposure construct. The F value was significant at 23.135, df (6,589). The 
results of this regression analysis are displayed in Table 14.  
 
Table 14 
Sub-variable Analysis for Academic Exposure  
Sub-variables Beta sig 
8e. Patients/families have made positive comments specifically 
about my communication ability in ?understanding their 
perspective? 
.242 .001 
8a. The number of times I (or my clinical group peers) discussed 
empathic communication in a post-conference with my 
clinical instructors. 
.171 .001 
8c. I have provided nursing care to patients that have been given 
a recent chronic disease diagnosis (such as diabetes, 
congestive heart failure). 
.115 .007 
(table continues) 
 96 
Table 14 (continued)   
Sub-variables Beta sig 
8f. I have received negative feedback/remediation on my 
clinical performance for ?less than acceptable? therapeutic 
communication with a patient or family member. 
-.100 .011 
8b. I have provided nursing care to patients that have 
experienced uncontrolled pain in my clinical rotation. 
.098 .020 
  
 During the backward regression, five questions were retained in the analysis. The 
question that was not statistically significant, and was removed was Question 8d, ?I have 
provided nursing care to a patient?s family member(s) immediately following post-news 
of the patient?s terminal condition?. The final restricted model consisted of five items and 
yielded an R
2
 of .187, and a standard error of the estimate of 5.3. 
Beta values and the standard error of estimate are indicated. The highest Beta 
value was from question 8e, which is performance based on the perceptions of patients 
and families of the student?s ability. Discussions between clinical instructors and clinical 
group students (Question 8a) followed. Question 8f was not significant at the p < .005, 
but was included with .011 because it represents a negative Beta value, which could mean 
that negative performance feedback or remediation, while still significant, does not occur 
in the clinical setting.  
 
Curricular Emphasis and Perceived Competence 
Full model values yielded R-squared value of .112, Standard Error of the Estimate 
5.55, df (5,594), F = 14.91, Pre-nursing (Beta = .109), senior year academics (Beta = 
 97 
.106), and clinical experiences in the junior year (Beta =.154) were significant at p > 
.005. R-squared value for the restricted model yielded .112, with a standard error of the 
estimate 5.54, df(3,594), F = 24.78, which did not significantly differ from the full model, 
R
2
 change < .001. 
Backward elimination regression was performed on the five questions regarding 
the construct of curricular emphasis on empathic communication in the nursing program 
(independent variable) and perceived competency as the dependent variable. A backward 
regression removed clinical experiences in the senior year, and removed junior year 
academics. Results are displayed in Table 15. 
 
Table 15 
Sub-variables for Curricular Emphasis 
Sub-variables Beta sig 
Clinical experiences in Junior year .175 .001 
Senior year academics .136 .007 
Pre-nursing .113 .006 
 
Program Effectiveness and Perceived Competence 
Backward elimination regression was performed on the four questions regarding 
overall program effectiveness as the independent variable and perceived competency as 
the dependent variable. Results are displayed in Table 16. Backward regression was 
performed with all questions in the full model (F = 19.35, R
2
 = .115, standard error of the 
 98 
estimate= 5.53). As a result of the backward elimination process, Question 4 (Empathic 
skills are valued by my faculty) and removed Question 2,? My ability to empathically 
communicate with patients and families has improved since the start of my program?. 
The remaining two questions were retained in the final restricted model. These were 
Question 1 (Beta .112): ?Overall, my nursing program has been effective in preparing me 
to be competent in empathically communicating with patients and families?, and 
Question 3 (Beta .268): ?I receive consistent feedback among all my faculty members 
regarding core competency behaviors to communicate therapeutically with patients and 
families?. 
 
Table 16 
Sub-variables for Program Effectiveness in Restricted Model 
Sub-variables Beta sig 
I receive consistent feedback among faculty members. .268 .001 
Overall, my nursing program has been effective in preparing me 
to be competent in empathically communicating with patients 
and families 
.112 .012 
 
 
Summary 
 The four research questions were answered through use of various data analysis 
techniques. The JSPE Nursing Student Version R was initially analyzed by comparative 
analysis with the JSPE S-Version and through factor analysis. Factor analysis yielded 
 99 
five main factors, which were renamed. Additionally, total JSPE Version R totals were 
selected for inclusion as an independent variable along with the Nursing Student 
Empathic Communication Questionnaire sub-constructs, and the correlations between the 
two instruments were analyzed. These sub-constructs (predictors) consisted of academic 
exposure (to clinical situations), curricular expectations, program effectiveness and 
academic sources.  
The use of student attitudes toward empathy in patient care (JSPE Nursing 
Student Version R total scores) was used as the independent variable in hierarchical 
regression analysis to examine the extent to which attitudes toward empathy were related 
to perceived competence after controlling for the influence of the four program 
components of the Nursing Student Empathic Communication Questionnaire. Program 
components did not relate strongly with attitudes toward empathy in patient care (R 
2 
= 
4.3%), but did relate with student perceived competency to empathically communicate 
with patients and families as a result of nursing instruction (R 
2 
= 22%). The primary 
predictor of student attitudes toward empathy in patient care and perceived competency 
was in the follow-up regressions on the questions within the component ?academic 
exposure?. These results are discussed in Chapter 5 as it has implications for nursing 
education in terms of establishing utility considerations of the measurement of attitudes 
toward empathy in nursing programs and predictors of perceived competence. 
 
 100 
V. DISCUSSION 
 
Empathy and empathic communication are critical to the practice of nursing. The 
purpose of this study was to examine baccalaureate nursing student seniors? perceptions 
of program effectiveness, academic experiences, curricular emphasis, and academic 
sources in predicting perceived competence as a result of the instruction in preparation 
and teaching of empathic communication with patients and families, as well as measure 
student attitudes toward empathy in patient care. The need for improved understanding 
by nursing educators of teaching methods, effectiveness of clinical and academic 
experiences with perceived nursing student competence are necessary to improve nursing 
instruction.  
An additional purpose of this study is to perform psychometric evaluation of the 
JSPE Nursing Student Version R to confirm empirical relationships among a set of 
variables determined in the literature to be associated with empathy and explore the 
underlying constructs and hence contribute to the construct validity associated with 
measuring empathic attitudes of nursing students.  
The research was based on two hypotheses which include (a) the extent that 
students who perceived that they were effectively taught empathic communication in 
their nursing programs would rate their perceived competency in empathically 
communicating with patients and families as higher than those students who perceived 
 101 
their nursing program as less effective, and (b) the extent that students who perceived that 
they were more effectively taught empathic communication in their nursing programs 
would have higher scores on the JSPE Nursing Student Version R, thus indicating more 
positive attitudes toward empathy in patient care. 
If a relationship exists in the areas supported in the literature as indicators of 
program effectiveness, which include (a) student exposure to patient care scenarios in the 
clinical setting; (b) curricular time and emphasis on empathic communication; (c) the role 
of student attitudes toward empathy in patient care; (d) perceived higher effectiveness of 
nursing programs in preparation of empathically communicating with patients and 
families; and (e) opportunities to learn or influenced to use empathic communication 
from academic and clinical sources, then applying the knowledge about its existence 
might contribute to understanding teaching techniques of empathic communication that 
enhance faculty?s efforts to teach students effectively. 
The research was organized using four research questions. The four research 
questions were (a) determining if a statistical difference existed between the JSPE 
Version-S and the JSPE Nursing Student Version-R; (b) determining what unique 
themes, dimensions, and factors emerge from the JSPE- Nursing Student Version-R 
scores; (c) determining to what extent exposure to patient care situations, curricular 
emphasis, perceived program effectiveness and academic sources predict student attitudes 
toward empathy in patient care; and (d) determining to what extent exposure to patient 
care situations, curricular expectations, perceived program effectiveness and academic 
sources predict perceived competence of nursing student?s ability to empathically 
communicate with patients and their families. 
 102 
The first research question compared scores between the two versions of the tools 
using a one-sample t-test. The second research question was addressed through use of 
exploratory factor analysis of the JSPE Version-R questionnaire through survey research. 
The third and fourth research questions were addressed through multiple regression 
analysis of the sub-components of the Nursing Student Empathic Communication 
Questionnaire, with student attitudes toward empathy in patient care (JSPE Nursing 
Student Version-R total scores) as the dependent variable and sub-components of the 
Nursing Student Empathic Communication Questionnaire, with student perceived 
competency to empathically communicate with patients and families as the dependent 
variable.  
Finally, hierarchical regression was used to examine the extent to which attitudes 
toward empathy were related to perceived competence after controlling for the influence 
of the four program sub-components of the Nursing Student Empathic Communication 
Questionnaire. The design of the study was explanatory in nature, using a non-
experimental method. Baccalaureate nursing student seniors from 14 programs in the 
Southeast were selected as the survey population. 
Data were initially analyzed using descriptive statistics. This included means, 
standard deviations, frequencies, and percentages. Additionally, Cronbach?s alpha 
coefficients were conducted for reliability analysis. Chi-square analyses determined that 
the sample population (n = 600) was representative of the total baccalaureate nursing 
school seniors in the southeast from the programs. The multiple regression analysis was 
initially conducted through the use of backward elimination regressions to estimate a full 
 103 
model and create a more parsimonious model. The dependent variable was perceived 
competency to empathically communicate with patients and families. 
 
Limitations 
Prior to discussing the results in detail, limitations of the study need to be 
acknowledged, as this affects the interpretation of the results. First, there are some 
considerations regarding validity that must be addressed. Internal invalidity can arise 
from various sources as discussed by Campbell and Stanley (1968).  
The historical occurrence of events that potentially coincided with the collection 
of data is of concern. There is a potential for participant perspectives to be altered, either 
heightened or diminished, due to curricular content discussed in the academic setting 
across the various fourteen nursing programs prior to data collection. Additionally, the 
presence of particular clinical situations or dialog with family members or faculty could 
affect student response as empathic content could be potentially reinforced prior to 
administration of the questionnaire. With each program being collected at varied times 
throughout the semester coinciding with curricular content, there is a potential for a 
stimulated interested in the topic beyond the control of the researcher. Related to 
questionnaire administration timing concerns in the form of order effects that could 
potentially result from student fatigue, variance in classroom teaching introductions and 
instructions prior to researcher explanation, classroom stress, and student interest and 
availability depending on whether the questionnaire was administered prior to class or at 
the conclusion of the classroom instruction. This also applies to the wide variance in 
questionnaire administration throughout the semester, ranging from late-September to 
 104 
late-November that could potentially impact student participation. Senior level students 
could potentially have increased pressures and stress related to upcoming deadlines as 
well as fatigue and burnout with data collection that occurred at institutions at the end of 
the semester with anticipated graduation. 
Campbell and Stanley (1968) discuss the need for study findings to be generalized 
to different subjects, settings and experimenters, thus possessing external validity. There 
were some limitations of this study consisting of experimenter effect, and measurement 
of the dependent variable through instrumentation. Experimenter effect by the researcher 
and potential for participating faculty sensitization may influence certain responses by the 
students. The use of standardized scripts by the researcher prior to each data collection 
was devised to limit unintentional influence. However, verbal comments made by nursing 
program representatives/faculty and student perception of faculty support of research 
study prior to data collection could result in bias in responses to questions on the 
questionnaires as well as influence student participation in the study. 
Measurement of the dependent variable (perceived competence in communicating 
empathically with patients and families and student?s attitudes toward empathy in patient 
care as measured by JSPE Nursing Student Version R total scores) could influence 
validity of the study. The use of a researcher-designed tool that has not been previously 
tested, nor subjected to prior factor analysis variable modifications could affect the 
generalizability of results. The use of expert and non-expert pilot testing as described in 
Chapter 3 was utilized to increase content and face validity of the Nursing Student 
Empathic Communication Questionnaire. Consideration was made to incorporate 
variables consistent with the examination of program effectiveness as cited in the 
 105 
literature. For instance, parity of number of questions related to clinical, academic and 
curricular/program entities was attempted. 
The use of senior-level nursing students without prior use of randomized 
experimental and control groups (exposed versus not-exposed) to neither the program 
components, nor a pre test-post test evaluation to examine the magnitude of changes is 
problematic. This is due to a lack of baseline to determine the extent of program 
effectiveness in impacting student attitudes, especially given the supportive literature 
addressing decrease of empathic ability occurring in seniors. 
The use of two scales that are measuring student perception and attitudes, which 
are subjective, are less desirable than using criteria that is more objective, such as 
standardized test scores, behavioral skills, or performance standards. In the case of 
measuring empathic communication, it would be helpful to know what scores or the 
nature of their clinical performance in communicating empathically with patients. 
However, if this information is the standard pass/fail criteria, then this information is not 
as usable due to lack of variability. Actual behavioral skills in empathically 
communicating were not assessed, nor triangulated with other means, such as peer and 
patient evaluations.  
 
Implications 
There was not a statistical difference between the JSPE Version-S (developed for 
medical and other health professions students) and the JSPE Nursing Student Version-R. 
There was a larger variability in range of scores in the nursing population, which might 
be attributable to the greater diversification in the fourteen nursing programs throughout 
 106 
the Southeast than was represented in the medical student sample size from one 
institution (Jefferson Medical College). The implications for nursing education lend 
support for contribution of nursing student data that can be utilized in performing 
psychometrics on measuring student attitudes toward empathy in patient care. The non-
significant findings will contribute to further studies that can compare the S-Version and 
the R-Version to improve reliability and validity of the R-Version.  
It is noteworthy that there was no statistical difference in student orientations 
toward empathy in patient care between medical and nursing students. From a practical 
standpoint, there are potential opportunities for collaborative efforts between nursing and 
medical school programs to share resources of clinical experiences, scenario 
development, research, and faculty expertise. 
There were five unique themes, dimensions, and factors that emerged from the 
JSPE Nursing Student Version-R scores. These results can be supportive through 
additional studies to screen for the best items for inclusion and modification in the 
Nursing Student Version-R for use in nursing student populations. This study provided 
preliminary data that can be used for meta-analytic and comparative studies that could be 
used to improve and validate this scale to construct and modify items particularly for 
nursing students. 
Student?s Attitudes toward Empathy in Patient Care 
The best component of the Nursing Student Empathic Communication 
Questionnaire, which included (a) academic exposure to patient care situations, (b) 
curricular emphasis during the nursing program, (c) perceived program effectiveness, and 
(d) academic sources to predict nursing student?s orientation or attitudes toward empathy 
 107 
in patient care as measured by JSPE Nursing Student Version-R total scores were 
questions included in academic exposure. The least predictive of student attitudes 
regarding empathy in patient care was time and emphasis of curriculum on empathic 
communication in the nursing program, including pre-nursing through the senior year. 
The implications to nurse education is to formatively evaluate program instruction to 
ensure that empathic attitude development and enhancement is not being diminished or 
negatively impacted, perhaps due to student fatigue, lack of reinforcement, or ineffectual 
remediation. 
The most statistically significant question in academic exposure regarded the 
student receiving negative feedback or remediation. The relatively high negative Beta, as 
compared to other questions in this category, could be attributed to student?s having 
negative attitudes regarding empathy in patient care, confusion as to what constitutes 
?remediation?, or lack of any feedback regarding performance of empathic 
communication in the clinical setting. The role of faculty feedback is particularly 
emphasized in the research findings of Mozingo et al. (1995) as related to student?s desire 
for more positive feedback from faculty members. 
Comprehensive tools to adequately assess and document clinical proficiency of 
empathic communication need to be established and maintained for consistency between 
faculty and clinical instructors as described by Schirmer et al. (2005). This finding is also 
described in literature cited by Kruijver et al. (2000) and Winefield and Chur-Hansen 
(2000) in the evaluating the outcomes of communication skill teaching and changes of 
attitudes in empathy. 
 108 
Though less statistically significant, the question regarding the number of times 
that empathic communication was discussed in post-conference with clinical instructors 
reinforces the pivotal role of the clinical instructor and the import of the clinical 
experience. There needs to be strong infrastructure, accountability and communication in 
place between the faculty delivering academic concepts and faculty, instructors, or staff 
that are interfacing with the student in the clinical arena. It is imperative for clinical 
faculty/instructors to reinforce theoretical content and have practical and meaningful 
discussions to instruct, remediate and prevent student fear and burnout from potentially 
emotional patient care situations.  
Several researchers (Deloney & Graham, 2003; de Lucio et al., 2000; Hall, 2006; 
Laidlaw et al., 2006; Mozingo, 1995), reinforced the importance of student?s being able 
to feel supported and have their feelings affirmed after reflecting on caring for difficult 
patient care situations, as was evoked with the use of a dramatic patient coping with end-
of-life issues. The complexity of issues facing students in the clinical setting dictates the 
need for increased trust and sensitivity by the clinical instructor to handle debriefings of 
patient care issues in a professional manner. Issues that are discussed in the clinical site, 
while recently poignant can serve as important reflective training tools, if discussed 
immediately following clinical exposure.  
Program effectiveness followed academic exposure as predicting student attitudes 
regarding empathy in patient care. The role of faculty is magnified in this program 
component, as the two most significant questions pertained to faculty influence. The 
highest Beta value was given to ?empathic communication skills being valued by 
faculty?, followed by student perception of ?consistent feedback among faculty 
 109 
members?. The negative Beta value regarding feedback could be attributed to disparities 
in feedback among faculty or lack of any feedback from faculty. This component of 
feedback is emphasized in the works by Woolley and Jarvis (2007) to provide supportive 
feedback, but additionally have means available, such as video recordings, that can 
enhance learning. 
Faculty and clinical instructor modeling and positive attitudes communication is 
critical for the training of positive attitudes and solid empathic communication techniques 
to be imparted to the student. The effective use of role modeling, as discussed by Price 
and Archbold (1997) was reinforced in this study. Their study explained the faculty?s role 
increased the student?s self-efficacy that resulted in improved ability to empathize.  
Whether a particular model of feedback is followed or an eclectic approach to 
discussing empathic communication subject matter, there needs to be increased 
awareness and proficiency with those faculty or instructors that are guiding the post-
conference clinical discussions. Failure to have trained faculty or clinical instructors that 
value empathic communication is tantamount to having instructors that are not 
technically proficient or are poor critical thinkers. The effectiveness of trained faculty in 
enhancing and providing empathic communication was discussed by Haq et al. (2004) 
and Butler et al. (2005). Positive interactions between healthcare professionals and 
through training can lower anxiety of students and improved clinical environments 
between professionals. Rosenfield and Jones (2004) reinforced the role of faculty 
assisting students in managing their stresses associated with confronting illness and 
suffering. 
 110 
Academic sources illuminated the role of clinical teachers as being the most 
statistically significant in predicting student?s attitudes regarding empathy in patient care. 
Lecture content followed as most significant. The use of role play, lecture, computer 
simulation and journal reflections were supported in this study and throughout literature 
as effective means to teach empathic communication. However, more innovative 
techniques are needed to fully capture patient-care scenarios and family dynamics while 
in the clinical setting. For example, effective student?s attitudes toward empathy in 
patient care might be improved if empathic communication lecture exercises were 
replaced with student interactions one-on-one with patient volunteers relating their 
perspectives coupled with journal entry personal reflections, as evidenced in literature 
cited by Reynolds et al. (1999).  
Student?s Perceived Competence to Empathically Communicate 
Academic exposure, followed by program effectiveness and curricular emphasis 
were the most predictive of student?s perceived competence to empathically 
communicate with patients and families as a result of their nursing program instruction. 
Academic sources were removed due to low statistical significance. The implication for 
nurse education highlights the need for significant attention to exposure of various types 
of patients from a communication standpoint, rather than strictly based on patient illness 
or pathology, and meaningful discussions of these patient situations during the post-
conference time.  
The implications to nurse educators also connects the constructs of perception of 
competency and the need for students to have been exposed to the opportunity to perform 
the task as illuminated by Sharp et al. (2003). As highlighted by Edwards et al. (2004) 
 111 
there was a significant role of the clinical experience in promoting and contributing to 
greater student perception of competence and satisfaction. This finding is important to 
supporting the results from this study of academic exposure.  
Curricular emphasis showed statistical significance in the need for ensuring 
communication proficiency in the junior year, to prevent the reinforcement of poor 
technique during the senior practicum, which could lead to decreased empathy and a loss 
in empathic communication ability. This finding was congruent with research performed 
by Layton (1979), which echoed the need for learning to occur early in the student?s 
education to prevent established styles that are potentially ineffective. With senior level 
students performing in autonomous roles with practicum rotations, there is the potential 
for lack of faculty input, diverse selection of various types of patients, or remediation 
prior to graduation. Thus, as shown in this study, the junior year is pivotal to exposure to 
clinical situations involving empathic communication in developing student perceptions 
of competency. 
Also statistically significant in this study were patients and family positive 
comments about empathic ability. This input from the patient is a critical element in 
evaluating student performance of empathic communication ability, as indicated by 
studies by Reynolds (1999), highlighting the role of measuring by patient?s terms and 
While (1994) concludes that emphasis should be placed by nursing educators on 
performance in the clinical setting. As reinforced in Mozingo?s (1995) study, the more 
students are exposed to patient situations and feel competent in their ability to 
empathically communicate; they seek out more opportunities and gain confidence in their 
ability. 
 112 
In this study, nursing student?s orientation and attitudes toward empathy in patient 
care (JSPE Nursing Student Version-R Total scores) did not contribute to the prediction 
of perceived competence to empathically communicate with patients and family members 
above and beyond program components, particularly questions regarding academic 
exposure. The implications for nurse educators is that the utility of the JSPE Nursing 
Student Version-R to predict senior nursing student?s perceptions of competency to 
empathically communicate with patients and family members as a result of nursing 
program instruction is better accomplished by the use of program evaluation questions on 
the Nursing Student Empathic Communication Questionnaire. The interplay between 
knowledge, confidence, attitudes, and perceived skills in this study was highlighted as 
well in the study by Steginga et al. (2005), which evaluated a cancer nursing education 
course. The link with confidence and competence to relate to difficult patient situations 
reinforces the need for educational programs that explore these variables.  
However, as cited earlier in the limitations discussion, the use of this tool is of 
potential benefit to nurse educators in establishing baseline measures of student attitudes 
longitudinally. Additionally this instrument has potential benefit with other predictors 
than perceived competency, such as clinical performance ratings and testing.  
 
Summary 
Empathy and empathic communication are complex entities, yet crucial to the 
practice of nursing. The role of nurse educators in teaching empathy effectively is 
necessary in addressing the recommendations from AACN in preparing professional 
nurses to enter practice. Nurses are presented daily with the opportunity to address patient 
 113 
and family needs in a patient-sensitive manner, inclusive of empathy and empathic 
communication.  
Data from this study reinforce the need for greater attention to be focused in the 
realm of clinical instruction, to maximize faculty input and feedback, and reinforce 
theoretical tenants that are taught in the academic setting. With the role that exposure to 
clinical patient-care situations has in influencing student perceptions of competence, 
there are several practical steps that nurse educators can take to maximize patient 
outcomes and prepare students for entry into professional practice. 
Teaching methods need to be examined and revised to determine effectiveness 
between time expenditure and maximum results. Research related to linking empathic 
communication with improved patient-care outcomes could advance the import of 
empathy. Improved patient care could exist in the form of greater care in obtaining 
patient and family input as to clinical performance of the nursing student. The use of 
patient and family input would provide greater insights as to clinical performance, than 
current practices utilizing clinical instructors or student self-reflection. Of the four 
empathic communication and empathy predictor variables, academic exposure to patient 
care situations in the clinical experience was most significant in two of the research 
questions.  
 
Recommendations for Future Research 
Based on the results of this study, recommendations for future research are: 
? Continued evidence in support of the psychometrics of the JSPE Nursing 
Student Version R at various stages in the student?s program (pre-nursing, 
 114 
junior level, senior level) to determine program?s effectiveness in 
producing positive or negative changes in attitudes toward empathy in 
patient care and perceived competence. 
? Development of methods to ?track? exposure of students to various patient 
situations requiring difficult empathic communication skills (such as angry 
or hostile patients, patients experiencing uncontrolled pain, patients and 
families that have been given recent post-news of terminal condition). 
? Development of clinical performance system that provides variability in 
scoring. This tool should incorporate inputs from patients, peers, nurses, as 
well as documentation of specific remediation by faculty member or 
clinical instructor.  
? Further use of the Nursing Student Empathic Communication 
Questionnaire to provide data as to usefulness of instrument in evaluating 
student perception of program effectiveness. This information could assist 
with both formative and summative evaluations of nursing programs. This 
questionnaire?s sub-components might be useful in some aspects of 
professional development of the faculty and clinical staff members, such 
as providing training for deficient areas.  
 
 
 
 115 
 
 
 
 
 
 
 
 
 
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APPENDICES 
 
 
 128 
APPPENDIX A 
SURVEY QUESTIONNAIRE ? JSPE NURSING STUDENT VERSION R 
 
 
 
 129 
 130 
APPENDIX B 
INFORMATION LETTER 
 
 131 
5 September 2006 
 
Dr. __________ 
Assistant Dean, School of Nursing 
_________ University 
_____________ 
 
Dear Dr. __________: 
 
I am writing to ask your help with a study I am performing for my Doctoral 
dissertation at Auburn University in Educational Foundations, Leadership and 
Technology. This study explores student empathy and perceptions of effectiveness of 
their nursing programs in teaching empathic communication skills. The study will 
contribute to the body of literature that addresses the significant concerns facing nursing 
faculty in regard to how students learn about communicating empathically, effectiveness 
of teaching methods, evaluation of student performance, and identifying perceived 
competencies of students in using effective therapeutic communication. The subject of 
empathic communication is of particular importance to me as a fellow nursing 
professional with over 23 years experience. I greatly acknowledge the vital role nursing 
faculty has in educating BSN students in providing tremendous patient care through their 
communicative ability as well as performance of technical skills after graduation. 
 
Your nursing program was selected through a convenience sampling of 
accredited, CCNE affiliated programs in the Southeast. The choice of utilizing accredited 
schools was important as it indicates tremendous professionalism and incredible 
commitment of your leadership as well as your staff. Upon your approval, I would like to 
request to conduct a research study using your senior-level nursing students at _________ 
University. Items are based upon constructs identified in the literature such as the role of 
curriculum, clinical experiences, and practical concerns toward teaching empathic 
communication. By understanding the student?s perceptions, necessary information can 
be analyzed to improve the understanding of teaching concerns and barriers in nursing 
and thus ultimately lead to educating nurses that can improve health care through both 
their technical and communicative expertise. 
 
Results from the survey will be published in my dissertation, as well as submitted 
to professional journals upon completion. Your school?s answers from the students are 
completely anonymous and will be released only in summary form in which no school 
can be identified. The questionnaires will be administered by myself during approved 
times, such as immediately following scheduled classes. The estimated time for 
instructions and completion of the two questionnaires will be approximately 15 minutes. 
Participation from the students is voluntary. 
 
If you would be interested in participating in this study, please contact me. I will 
then request a time to set up the meetings with the students. Presently, I have submitted 
this study for Auburn University IRB approval. I would like to begin data collection as 
 132 
soon as I have received approval, which could be as early as mid- September. I will be 
glad to send you a copy of the two questionnaires upon your request. 
 
If you have any questions, comments, or concerns regarding this study, I will be 
happy to talk with you further. My telephone number is (334) 826-9566. My e- mail 
address is Reedreb@auburn.edu. My committee chairman and advisor for this study is 
Dr. David Shannon at (334) 844-3071.  
 
Thank you very much for your consideration. 
 
Sincerely yours, 
 
 
Libba Reed McMillan, RN MSN 
Doctoral Candidate/ Auburn University 
1903 North Ashe Court 
Auburn, Alabama 36830 
(334) 826-9566 
reedreb@auburn.edu  
 
  
 
 133 
APPENDIX C 
 NURSING STUDENT EMPATHIC COMMUNICATION QUESTIONNAIRE 
 
 
 
 
 134 
 
 135 
 
 
 
 136 
  
 
 
 
 137 
 138 
APPENDIX D 
AUBURN UNIVERSITY INSTITUTIONAL REVIEW BOARD (IRB) PROTOCOL 
 
 
 
 139 
 140 
 141 
 
 
 
 
 
 
 
 
 
APPENDIX E 
FLYER TEMPLATE 
 
 142 
CALLING ALL SENIOR NURSING 
STUDENT VOLUNTEERS! 
 
Would you be willing to participate in a 
research study? 
 
TOPIC: Empathy and Empathic Communication: 
Student Perceptions of Program Effectiveness, 
Academic Experiences, and Competence 
 
: Immediately following/before your 
____________class or actual TIME 
: To better understand ways to improve 
student learning and faculty teaching of empathic 
communication with patients and families 
: 15 minutes 
: Fill out two short questionnaires?40 questions 
total 
 
Your answers are completely anonymous 
 
Libba McMillan, RN MSN 
Doctoral Candidate 
Auburn University