The Effect of Empathy Training on the Empathic Skills of Nurses.

BACKGROUND: The profound impact of empathy training on quality nursing care has been recognized. Studies have shown that there has been little improvement in nurses' communication skills, and that they should work to enhance this area. Relevant training will lead to an improvement in nurses' empathic skills, which in turn, will enable them to understand their patients better, establish positive interpersonal relationships with them, and boost their professional satisfaction.
OBJECTIVES: To reveal the effect of empathy training on the empathic skills of nurses. PATIENTS AND METHODS: This study was conducted as an experimental design. The research sample consisted of 48 nurses working at the pediatric clinics of Farabi hospital of Karadeniz Technical University in Turkey (N = 83). Two groups, an experimental group (group 1) and a control group (group 2) were determined after questionnaires were supplied to all nurses in the study sample. At first, it was intended to select these groups using a random method. However, since this may have meant that the experimental and control groups were formed from nurses working in the same service, the two groups were selected from different services to avoid possible interaction between them. The nurses in the Group 1 were provided with empathy training through group and creative drama techniques. Pre-tests and post-tests were conducted on both groups. Data was collected via a questionnaire designed around the topic "empathic skill scale-ESS", developed by Dokmen. The Kolmogorov Smirnov test was employed to assess whether the measurable data was suitable for normal distribution. Data was presented as numbers and percentage distributions, as mean ± standard deviation and Chi-square, and as student t tests and paired t tests. The level of significance was accepted as P < 0.05.
RESULTS: The nurses in the experimental group had a mean score of 146.7 ± 38.8 and 169.5 ± 22.1 in the ESS pre-test and post-test, respectively. Although the nurses in the control group had a pre-test mean score of 133.7 ± 37.1, which increased to 135.1 ± 51.7 after the training, no statistically significant difference was found (P = 0.886). A comparison of the groups indicated that they scored similarly in the pre-test. However, the experimental group scored significantly higher than the control group in the post-test (P = 0.270 and P = 0.015, respectively).
CONCLUSIONS: In the light of these findings, it is recommended that communication skills should be widely included in in-service training programs; similar studies should be conducted on broader control groups formed through randomization; and a comparison should be made between the findings.

RCT Entities:   Population Interventions Outcomes

1. Background

Empathy is defined as the ability to understand how others feel and what they mean, and to convey these emotions to others (1). It is currently believed that empathy is multi-dimensional and involves emotional, cognitive, communicative, behavioral, moral, and relational dimensions (1-4). The objective of nurse-patient communication is to ensure that patient needs are identified and necessary care is provided. In order to identify these needs, nurses should be able to fully understand patients’ feelings, opinions, and conditions; this requires empathic knowledge and skills (5). Therefore, empathy is more than simply understanding and handling patients’ verbal expressions (6). Gaining, or training somebody to gain, empathic skills is not an easy process, but it may be facilitated by rich life experiences. Empathic skills are essential for the provision of effective nursing care (7); they are teachable, and important for cooperation-based relationships. It has been reported that the nature of the nursing profession requires nurses to have these skills (8-10). In their study, Reynolds & Scott (9) emphasized that nurses who are able to approach their patients empathetically can better understand their reactions to health problems, as well as the purpose and source of these reactions.

It is well documented in the literature that because some nurses consider themselves as lacking in communication skills, they most worry about being unable to cope with patients; for the same reason, they exhibit behaviors that hinder their communication with patients (11, 12) . In addition, nurses fear that they cannot deal with certain feelings and opinions of patients, due to their insufficient knowledge and educational background (13); they therefore employ communication-blocking behaviors in order to avoid talking about patients’ psychological problems. This also acts as protection against further psychological issues that may arise, not only in themselves, but also in patients (11). Despite the fact that empathy is hugely important in nursing, there have been a number of studies suggesting that nurses have low or intermediate empathic skills (2, 9, 14-18). Wilkinson (16) reported that there had been little improvement in nurses’ communication skills in the twenty years leading up to 1999. Studies have indicated that more efforts should be made for nurses to provide effective care and enhance their empathic and communication skills (9, 14-16, 18).

It has been observed that nursing practices in Turkey are focused on medical care and carried out in the form of routine duties or practices, instead of individualized care that is based on a problem-solving approach in accordance with patient needs (19). Nurses keep their patients at a distance, communication between the two is mechanical, there is a lack of meaningful interaction, and nurses serve the institution rather than their patients. In addition, this approach restricts nursing initiatives and leads nurses to carry out their practices automatically, without thinking or basing their actions on knowledge. Therefore, nurses should be provided with opportunities to gain or improve empathic skills so that they can understand the non-superficial feelings of patients and provide helpful care.

2. Objectives

The purpose of this research, which is based on the experimental design, was to assess the empathic skills of nurses working at the pediatric clinics of the Farabi hospital of Karadeniz Technical University in their interaction with patients, and to test the efficiency of the training provided.

3. Patients and Methods

3.1. The Method and Place of the Research

This research was carried out experimentally, between March and June 2011, at a university hospital with a capacity of 749 patients in the province of Trabzon, located in the north-east of Turkey. The clinics providing services to children at the Farabi hospital are: adolescent, nursing, infection, pediatric emergency, pediatric surgery, pediatric oncology, newborn, pediatric polyclinics, and pediatric intensive care services. A total of 83 nurses were working in these clinics at the time of the study.

3.2. The Research Universe

83 nurses working at children’s polyclinics at Farabi hospital of Karadeniz Technical University constituted the universe of the research.

3.3. The Research Sample

48 nurses constituted the sample. It was thought that all 83 nurses would benefit from applying empathy in their practice, but such application was not possible for those working in intensive care units, while those working at clinics may have had specialized interactions with patients. Therefore, they were excluded from the sample. As explained above, the experimental and control groups were selected from different services to avoid possible interaction between services. When determining the experimental group, we chose children’s services which could allow time for training and which were equal in their number of nurses, with the help of the head nurse. All the nurses working in these services were included in the study, without using a sampling method. Therefore, there were more nurses in the control group than in the experimental group: 31 and 17, respectively.

Before the study, we obtained a decision, dated and numbered B.30.2.K.T.Ü. 0.1H.00.00/1013 and 08.09 2009, and the necessary official permission from the hospital management, for the implementation phase of the research. Additionally, we obtained the oral consent of nurses who had volunteered to participate and those who worked at the pediatric clinics.

3.4. Research Design

The nurses were divided into two groups to evaluate the efficiency of the training. The nurses in the group 1 (experimental) were provided with empathy training through group and creative drama techniques, whereas group 2 (control) was not group 1 consisted of nurses from the Adolescent, Nursing, and Infection services while group 2 was drawn from the Pediatric Emergency, Pediatric Surgery, and Pediatric Oncology services. Pre-tests and post-tests were conducted on the nurses in both groups.

3.5. Research Instruments

Data was collected via a questionnaire designed around the focus topic and the “empathic skill scale” developed by Dokmen (20). The questionnaire consisted of questions about the demographics of the nurses, their professional characteristics, their experiences in empathy, and their empathic skills.

3.6. The Empathic Skill Scale (ESS)

This scale consists of two forms, “A” and “B”. The ESS-B form is based on six different problems encountered in daily life. Each problem is followed by 12 empathic responses that can be addressed to a person suffering from it. Therefore, the respondent is provided with a total of 72 empathic responses (12 for each problem) in written form. One of the 12 responses is irrelevant to the problem, and intentionally included to identify those who are not paying attention. Should a respondent choose even one of these irrelevant responses, which are valued at zero in the scoring, his/her form is excluded from the evaluation. Respondents are asked to choose four of the responses that follow each problem. After they have chosen a total of 24 responses, their performance is graded in accordance with the criteria included in the ESS-A form. The lowest score one can get from the ESS is 62, while the highest is 219. The scale was tested by Dokmen (20) for validity and reliability purposes. It was conducted on a group of 80 individuals twice, the second test being three weeks after the first. The re-test’s reliability was found to be 0.91, based on the evaluation of the scores obtained by 64 respondents.

3.7. The Application of the Empathy Training Program for Nurses

The program started in March 2011 and ended in June 2011. During the process, participants were informed of what was happening and creative drama techniques were employed. Games were used as a kind of warm-up, and sample situations were enacted through roleplay and improvisations, two key drama techniques. Nurses were encouraged to share their feelings and opinions in evaluations at the end of each session and during intervals. The creative drama method was implemented by a researcher who specialized in this field. The program lasted a total of 20 hours (four hours a day) over five sessions. Prior to the program, nurses were informed about the time and place of the sessions, as well as the application of the program and the general rules. It was ensured that all nurses participated voluntarily. Nurses in group 1 were divided into two groups, and provided with successive sessions that took place in the hospital’s training room. The room had been prepared by the researcher so that it would be suitable for group work. The program drew on the models and principles of adult education, and was based on the assumption that the participants would take on their own learning responsibilities. The nurses played an active part in all phases of the training, from planning to evaluation.

The first session included warm-up games based on communication and interaction, as well as name games. The purpose was to ensure that each participant got to know the other members of the group. In addition, observations were carried out on their ability to follow instructions, use their body, develop empathy, and describe themselves. The evaluation that followed the session emphasized basic communication concepts, verbal and non-verbal communication, empathy, and its importance.

The second session started with warm-up games based on communication. Afterwards, the nurses were provided with a worksheet entitled “Who am I?”, which had been designed to identify the extent to which they knew and could express their positive and negative sides. They were asked to draw their own faces inside an oval figure on the worksheet, and were obliged to write about their positive and negative sides inside and outside a rectangle, respectively. The worksheets were then hung on the wall, and the participants reflected on the activity. It was very important to enable them to gain awareness about how much they knew themselves, and how effectively they could express their different sides.

The third session also began with warm-up games. The participants performed a mirroring activity in pairs. They were then provided with instructions on pair improvisations, and asked to play certain roles; they were obliged to determine the roles and conflicts independently. The individuals in each pairs were referred to as either A or B. They were reminded that the instructions they would be provided with would form the introductory part of the improvisations. Pair improvisations began in accordance with the instructions. After a while, they were asked to stop. Finally, each pair presented their parts as instructed by the leader, for example:

A: I want to go out.

B: No, I won’t let you.

Through the evaluations made at the end of the activity, the feelings and opinions of the nurses regarding empathic thinking and improvisations were assessed. The participants were asked the following questions: “Was it difficult to say no?” “Who got permission?” “Did you have any difficulty in persuading?” “Did you experience any problems? If yes, how did you overcome them?” “Speaking of your roles, was any kind of empathy involved? Did you get any ideas about empathic thinking from the improvisations?”

Next, the nurses were asked to divide into groups of four or five to reflect on the question “How should a good nurse behave?”, Write down their ideas on the sheets provided, and present them. A discussion then took place regarding the similarities and differences.

The fourth session started with warm-up games in which the nurses were asked to walk while reflecting certain emotions, including anger, sadness, happiness, fright, embarrassment, surprise, and boredom, through their body language, gestures, and facial expressions, in response to particular situations. The prompts included: “You are very excited,” “you have just got a present,” “you are angry,” “your friend is late for an appointment,” “you are very angry,” “you have received bad news,” “you witnessed an accident while walking on the street,” “you have received news of your mother’s illness on the phone,” “you think you are being followed on the street,” “you have split tea over your guest,” “you have just seen the person you like chatting with someone else at a cafe, they have organized a surprise birthday party for you,” and so on. Afterwards, the nurses were provided with written instructions for pair improvisations and asked to perform them in turns. The following is an example.

3.8. Pair 1

Patient (receiving chemotherapy treatment): I’ve got a sprinkle of hair on the side of my head. No matter what I do, I can’t straighten it. I feel off color whenever I look at myself in the mirror.

Nurse: This is not a big deal. Don’t worry!

Patient: Nobody will like me when I go to school.

3.9. Pair 2

Nurse: This happens when one receives this kind of treatment. You’ll have hair in time (nurse).

Patient: The young girl with renal failure is secretly eating prohibited food.

Nurse: Having realized this, the nurse.

3.10. Pair 3

A: A diabetic child who does not know the severity of their condition

B: Nurse

Following this scenario, the instructor asked the nurses the following questions:

- How did you feel?

- What would you like to say about the communication methods in the roleplays?

- What were the positive and negative factors that prompted you to display empathy?

The indifferent, ineffective, offensive, or superficial responses or reflections that resulted from a lack of empathic listening were analyzed. The importance of listening was emphasized.

In the fifth session, the nurses were asked to form groups of three or four individuals and to present improvisations that would represent the patients and problems in their units. This was followed by an evaluation which sought answers to the questions: “How empathetically can we behave?” and “what kind of conflicts do you experience while working?”

At the end of the program, a discussion was held over the conventional definitions of empathy and communication techniques, the importance of empathy in nursing was stressed, and the participants were asked to evaluate the program.

3.11. Scope and Limitations of the Study

The study’s results were generalizable only to the nurses who provided care to the pediatric patients at Farabi medical faculty hospital of Karadeniz Technical University.

3.12. Data Analyses

The Kolmogorov Smirnov test was used to assess whether the measurable data was suitable for normal distribution. Student t tests were used to make comparisons between the two groups, while paired t tests were used to make comparisons between the scores of each group before and after the training. The qualitative data was analyzed using the Chi-square test. Measurable data was presented in ± standard deviations, while qualitative data was presented in numerals (%). The level of significance was accepted as P < 0.05.

4. Results

Table 1 shows that most of the nurses in Groups 1 and 2 were ≤ 30 years old, did not have a child, had a graduate or postgraduate degree, had three or more siblings, and belonged to a nuclear family. There was no statistical difference between the two groups in the variables.

Table 1.

The Distribution of Nurses According to Socio-Demographic Characteristics

Variables	Group I (n = 17)[a]	Group II (n = 31)[a]	P Value
Age
≤ 30	11 (64.7)	22 (71.9)	0.654
> 30	6 (35.3)	9 (29.0)
Marital status
Married	7 (41.2)	10 (32.3)	0.537
Single	10 (58.8)	21 (67.7)
Have a child
Yes	6 (35.3)	6 (19.4)	0.300
No	11 (64.7)	25 (80.6)
Educational status			-
Graduate or lower	3 (17.6)	7 (22.6)
Graduate or higher	14 (82.4)	24 (77.4)
Number of siblings
< 3	5 (29.4)	13 (42.0)	0.391
≥ 3	12 (70.6)	18 (58.0)
Family type
Nuclear	14 (82.4)	29 (93.5)	0.331
Extended	3 (17.6)	2 (6.5)

aValues are presented as No. (%).

Table 2 presents the nurses’ professional characteristics. Most of the participants in group 1 stated that they had been a nurse and serving their units for six years or less, they were serving at least 11 patients, they were quite satisfied with their relationships with their managers, they had chosen the nursing profession voluntarily, they were happy to work as a nurse, and that they had not chosen their units voluntarily. Most of the participants in group 2 stated that they had been a nurse and serving their units for ≤ six years, they were serving > 11 patients, they were partially satisfied with their working environment, they were satisfied with their relationships with their managers, they had not chosen the nursing profession voluntarily, and that they were quite happy to work as a nurse. A significant difference was determined between the two groups in terms of the number of nurses who reported that they had not chosen their units voluntarily (P = 0.031).

Table 2.

The Distribution of Nurses by Their Professional Characteristics

Characteristics	Group I (n = 17)[a]	Group II (n = 31)[a]	P Value
Number of years worked at their current unit
≤ 6 years	13 (76.5)	27 (87.1)
≥ 7 years	4 (23.5)	4 (12.9)	0.428
Number of years worked in the profession
≤ 6 years	10 (58.8)	20 (64.5)
≥ 7 years	7 (41.2)	11 (35.5)	0.697
Working hours
Constantly 08 - 16	-	-
Constantly 16 - 08	-	-	-
Mixed	17 (100.0)	31 (100.0)
Number of patients served
1 – 10	-	14 (45.2)
> 11	17 (100)	17 (54.8)
Level of satisfaction with the working environment
Satisfied	8 (47.1)	9 (29.0)
Dissatisfied	9 (52.9)	22 (71.0)	0.212
Level of satisfaction with managers
Satisfied	11 (64.7)	15 (48.4)
Dissatisfied	6 (35.3)	16 (51.6)	0.278
Choosing the nursing profession voluntarily
Yes	11 (64.7)	14 (45.2)
No	6 (35.3)	17 (54.8)	0.195
Level of satisfaction with working as a nurse
Satisfied	15 (88.2)	23 (74.2)
Dissatisfied	2 (11.8)	8 (25.8)	0.459
Choosing the unit
Voluntarily	2 (11.8)	13 (41.9)
Involuntarily	15 (88.2)	18 (58.1)	0.031

aValues are presented as No. (%).

Most of the nurses in both groups stated that they did not have difficulty in communicating with pediatric patients, they could not allocate sufficient time to the patients they were supposed to serve, they often regarded themselves as competent in understanding patients, and that they approached patients empathetically; this is shown in Table 3. No significant difference between the groups’ variables was found (P > 0.005).

Table 3.

The Experience and Evaluations of Nurses in Terms of Empathy

Variables	Group I (n = 17)[a]	Group II (n = 31)[a]	P Value
Having difficulty in communicating with pediatric patients
Yes	4 (23.5)	3 (9.7)	0.226
No	13 (76.5)	28 (90.3)
Being able to allocate enough time to patients needing attention
Able	6 (35.3)	9 (29.0)	0.654
Unable	11 (64.7)	22 (71.0)
Considering oneself competent in understanding patients
Feeling competent	11 (64.7)	27 (87.1)	0.134
Feeling incompetent	6 (35.3)	4 (12.9)
Approaching patients empathetically
Yes	12 (70.6)	25 (80.6)	0.460
No	5 (29.4)	6 (19.3)

aValues are presented as No. (%).

Most nurses in both groups stated that empathy was satisfactorily covered in their pre-graduation education, they did not receive any training in empathy after graduation, they believed in the necessity of intermittent but continuing training, and that they were not a member of any association. However, most of those in group 1 reported that their post-graduation empathy training was insufficient in terms of communication skills, they did not consider that they needed knowledge about empathy, they did not receive in-service training on empathy, they did not follow any publications on this topic, and they did not participate in any activities to do with empathy (P > 0.005). These results are given in Table 4.

Table 4.

The Distribution of Nurses by Their Background in Empathic Skills

Variables	Group I (n = 17)[a]	Group II (n = 31)[a]	P Value
Inclusion of empathy in pre-graduation education
Included	9 (52.9)	21 (67.7)	0.311
Not included	8 (47.1)	10 (32.3)
Receiving empathy training after graduation
Received	3 (17.6)	9 (29.0)	0.497
Not received	14 (82.4)	22 (71.0)
The sufficiency of the empathy training received after graduation in terms of communication skills
Sufficient	5 (29.4)	16 (51.6)	0.138
Insufficient	12 (70.6)	15 (48.4)
Thinking that knowledge about empathy is needed
Yes	7 (41.2)	19 (61.3)	0.181
No	10 (58.8)	12 (38.7)
Believing in the necessity of intermittent but continuous training			-
Yes	13 (76.5)	23 (74.2)
No	4 (23.5)	8 (25.8)
Receiving in-service training
Yes	6 (35.3)	19 (61.3)	0.085
No	11 (64.7)	12 (38.7)
Following publications
Yes	8 (47.1)	16 (51.6)	0.763
No	9 (52.9)	15 (48.4)
Being a member of an association
Yes	1 (5.9)	0	0.354
No	16 (94.1)	31 (100.0)
Participating in activities
Yes	6 (35.3)	18 (58.1)	0.131
No	11 (64.7)	13 (41.9)
Participating in training related to empathy
Yes	-
No	17 (100.5)	31(100.0)

aValues are presented as No. (%).

The nurses in group 1 had a mean score of 146.7 ± 38.8 and 169.5 ± 22.1 in the ESS pre-test and post-test, respectively. Although the nurses in group 2 had an ESS pre-test mean score of 133.7 ± 37.1 and a post-test mean score of 135.1 ± 51.7, no statistically significant difference was found (P = 0.886). A comparison of the two groups indicated that they had similar scores in the pre-test. However, group 1 scored significantly higher than group 2 in the post-test (P = 0.270 and P = 0.015, respectively) (Table 5).

Table 5.

The Empathic Skill Scale Scores of the Two Groups Before and After Training

	Before	After	Paired t (t Value)	P Value
Group 1	146.7 ± 38.8	169.5 ± 22.1	2.242	0.041
Group 2	133.7 ± 37.1	135.1 ± 51.7	0.135	0.886
Student t (t value)	1.117	2.535
P value	0.270	0.015

5. Discussion

Empathy is a teachable communicative skill; however, there are many problems related to communication training, not only at school but after (21-25). These problems are linked to educational programs, the gap between theory and practice, and the amount of importance attached to communication in the healthcare system. In addition, there is a lack of consensus on the concept of empathy, how to measure empathy in training, and how to highlight its importance in a well-structured training program.

Didactic, role-play, and drama techniques were used in the study. The effect of the empathy training was measured via the “empathic skill scale” developed by Dokmen (20). In parallel with the literature (6, 18, 26-29), the present study suggests that the empathy training program is effective in enhancing the empathy levels of nurses. Our research has found no significant difference between the empathy skill levels of nurses in group 1 and group 2, which were evaluated in terms of socio-demographic characteristics, experience and evaluation of empathy, and accumulation of empathic skills. According to the professional features of nurses, on the other hand, a significant difference was found between “empathy skill levels” of the nurses in group 1 and group 2 and “voluntarily choosing the unit worked at” (Table 2). When the groups were compared in terms of their empathic skill scores, they were found to be close to each other in the last test, whereas Group 1’s score was found to be statistically significantly higher than group 2’s in the second test. This result indicates that the quality of empathy training affects nurses’ development of empathic skills (Table 5). Several studies have found that such training programs prove to be effective when carried out in small groups and accompanied by various methods with student-centered and didactic elements (24, 25, 30). Similarly, this study suggests that it is more effective to collectively use a number of methods such as exercises, experience stories, discussions, roleplays, homework, question-answer sessions, and explanations, when improving nurses’ empathy skills. The training was based on the models and principles of adult education, and lasted for 16 hours over five sessions. The participants were provided with homework, and actively participated in small groups. It is without doubt that longer training would be more useful. In the literature, communication training varies between two and 10 weeks and lasts for six to 100 hours, while samples range between 8 and 218 (8, 16, 22, 24, 25).

In some of the studies conducted in Turkey, most of the data obtained especially through verbal, written, or other qualitative instruments indicates that empathic behaviors are heavily experienced. This can also be seen in the reflections of postgraduate students of creative drama (during or after the sessions) and of individuals participating in creative drama leadership/instructor programs in various institutions. These findings suggest that creative drama processes enable one to gain and improve empathic behaviors. Nevertheless, it seems that it is necessary to design and put into practice long-term creative drama sessions that are based on empathic skills. It should be noted that empathic skills cannot be developed overnight. They can only be improved in line with increased life experiences and first-hand interactions (31).

In conclusion, it was found that the ESS mean scores of the nurses increased after the training, which suggests that empathic training is effective in enabling nurses to gain empathic skills. More studies are required to reveal whether these acquired skills are used in communication with patients and whether they are permanently incorporated into behaviors.

In the light of these findings, it is recommended that in-service training programs should be implemented at hospitals to develop empathic communication skills, they should be maintained regularly, their efficiency and usability should be monitored, and that comparative studies should be conducted to reveal how pediatric patients and nurses are influenced by the improved communicative skills.