Impact of empathy interventions on cognitive, affective, and behavioral empathy in nursing students: a systematic literature review

Empathy is the most important soft skill that professional nurses must possess because it is the ability to understand and feel the emotions of others.^1–3 Empathy is defined as the ability to understand a patient’s situation, feelings, and perspectives without passing judgment, as well as the ability to communicate that understanding.⁴ William and Stickley⁵ defined empathy in a professional health setting as understanding a patient’s situation, feelings, and perspective without judgment, as well as the ability to express the understanding. According to Peplau,⁶ empathy is a vital component that a nurse must have. According to the Indonesian Ministry of Health,⁷ particularly in Indonesia, empathy is a core competency for nurses in the national healthcare system.

As a result, when nurses establish empathy, they are able to understand feelings, recognize emotional situations, and effectively respond to patients’ needs.⁸ According to William and Stickley,⁵ empathy is a fundamental quality of a helping relationship since it facilitates the development of mutual trust and understanding. Nurses with empathy can better understand their patients, as empathy has been shown to improve patient safety, well-being, satisfaction, and compliance with the treatment process.^9–11 According to Mercer,¹² empathy is related to higher treatment adherence, higher patient satisfaction, and lower psychological distress. Furthermore, lower levels of depression, anxiety, and pressure have been shown to increase emotional well-being, satisfaction, more positive team interactions, and a tendency to be more diligent at work in nurses.^13–15

A lack of empathy, on the other hand, can lead to a tendency to ignore patients’ psychological needs and an inability to appropriately identify the patient’s response, affecting the nurse-patient relationship and resulting in poor service.¹⁶ This lack of empathy predicts poor patient care because it fosters apathy, indifference, and dehumanization in nurses, increasing the risk of patient harm.^17,18 As a result, empathy is essential for nurses and is central to professional health practice.¹⁹

Many studies, however, claim that there is evidence of decreased empathy in nursing students during their study period.^20–22 Heavy workload, long working hours, time constraints, and a demanding and unfriendly educational environment can contribute to the empathy deficit.^23,24 Furthermore, students’ exposure to clinical matters, such as the number of meetings with patients during the study, might be more strenuous and impact their ability to empathize.²⁵ Kunyk and Olson²⁶ stated that, while empathy is frequently mentioned in nursing literature, patient perceptions reveal that empathy is not always demonstrated by nurses in their interactions with patients. Therefore, numerous studies have been conducted to develop various educational intervention methods to increase nursing students’ empathy skills.^27–29 Several methods are known to be effective in increasing empathy, including communication skills-based programs and mindfulness-based stress reduction.^30–34

In practice, empathy training typically focuses on three domains: cognitive, affective, and behavioral.³⁵ These three empathy components must be present in an individual and balanced with one another. When cognitive empathy is dominant without affective empathy, individuals may understand others’ perspectives, but this understanding can also be used to manipulate or exploit others by anticipating the consequences of their actions.^36,37 As only affective empathy is predominant, a person does not have enough self-control in capturing and sharing emotions with others.³⁸ However, these two domains will be incomplete unless they are followed by appropriate behavior, such as the ability to communicate and determine appropriate behavior based on one’s understanding of other people’s circumstances.³⁹ As a result, in any intervention method designed to increase empathy, the balance between the three domains must be considered.

The purpose of this study is to assess the method of empathy interventions in nursing students in relation to the three domains of empathy: cognitive, affective, and behavioral. The research question is, “Does the empathy intervention method for nursing students deliberate its impact on three domains (cognitive, affective, and behavior)?”

This study applied a systematic literature review to describe, evaluate, and synthesize empirical research on empathy interventions in nursing students. To ensure this literature review is systematic, the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA)⁴⁴ guideline was used, involving the following steps: (1) defining relevant studies and establishing inclusion/exclusion criteria; (2) creating search strategies; (3) identifying potential studies through the use of search and screening; (4) describing and assessing the study; and (5) analyzing and synthesizing findings.

2.3.

Study selection

A total of 99 journal articles were obtained through a search of two databases. Following that, the researcher conducted a title screening and issued a total of 53 articles, with 46 considered eligible for abstract screening. The researcher then conducted an abstract screening process, issuing 26 abstracts, with the remaining 20 articles proceeding to the full text review stage. When conducting a full-text review, one article was inaccessible in full text, so the researcher continued to review the remaining 19 articles. As a result of the review, as many as nine articles failed to meet the inclusion criteria, yielding ten articles, which will be discussed further in this study (Figure 1).

Figure 1.

PRISMA flow diagram of study selection for the systematic review.

The systematic search yielded 99 articles from both databases. Following the selection process, a total of ten studies met the inclusion and exclusion criteria and were then reviewed collectively (Figure 1). Nearly half of the studies were conducted in China (n = 4), and the majority involved undergraduate nursing students (n = 8). Most studies employed a quasi-experimental design (n = 9), with outcomes primarily assessed using the Jefferson Scale of Empathy–Health Profession Student version (JSE-HPS) (n = 4) (Table 1).

The present study discovered that four out of nine interventions were able to demonstrate a positive effect on empathy, and these studies discussed the impact of their intervention on the dimensions of empathy (cognitive, affective, and behavioral), while the other five only discussed the impact of the intervention on empathy in general. The intervention with the Situated Teaching Program and the EEM shows the results of measuring the dimensions of empathy. This shows that researchers evaluated the impact of the intervention on the dimensions of empathy.

Evaluation is important because there needs to be a balance between dimensions of empathy. A balance between the dimensions of empathy is required because it may have a negative impact on the individual if only one dimension most dominant, i.e., cognitive empathy. Individuals will more likely to manipulate the behavior of others if it is only dominated by cognitive processes, and this may raise potential issues if it occurs in individuals who serve in the health sector.^31,32

Research has consistently found that cognitive empathy is associated with higher levels of aggressiveness, whereas affective empathy serves as a protective factor against such behavior. However, when both cognitive and affective empathy are present, they jointly contribute to reducing aggressive tendencies.^50,51 When affective empathy dominates, a person lacks sufficient self-control in capturing and sharing emotions with others.³⁸ This cognitive domain distinguishes empathy from other similar concepts, such as sympathy and compassion, which can help individuals understand the experiences of others without evoking personal emotional responses, allowing them to be less emotionally affected by their suffering.^52,53 However, these two domains will be more complementary or augmented when they are followed by appropriate behavior; that is, the ability to communicate and determine appropriate behavior based on one’s understanding of other people’s circumstances.³⁹

The importance of balance between the empathy domains ensures a careful examination of how interventions may affect each of these domains. This is due to the fact that each domain necessitates a different training approach, so nursing educators must recognize the various obstacles they might face and provide targeted training in order to increase nurses’ ability to express empathy both during the study period and directly in healthcare practice.⁴⁸ According to research on the impact on specific empathy domains, interventions can improve the cognitive domain more than other domains, particularly for interventions that used experiential learning and simulation.^47,49

None of the studies that looked further into the empathy domains found that the interventions were effective in increasing affective empathy. The intervention using the Simulation-Based Empathic Communication Training method only focuses on cognitive empathy. Then, the intervention using HFS training showed the lowest increase in affective-related dimensions compared to other dimensions. In contrast, Japanese researchers discovered a decrease in affective empathy in health students when compared to cognitive empathy.⁵⁴ However, the behavior domain is also important, particularly for final-year students who have been directly involved in active service through internship programs. In this case (when dealing directly with patients), students must be able to translate their understanding of others into appropriate actions such as empathic communication or decision-making that takes the patient’s condition into account.^48,55

Further intervention research can consider the year of study for nursing students in determining whether that year requires a more specific domain of empathy or not, so that the intervention method chosen is in accordance with what the students require. Research can also be used to develop intervention methods that specifically increase nursing students’ affective empathy and behavior. In general, the reviewed studies indicated that there is a need for additional follow-up on the impact of these interventions over time. However, if the exact empathy domain and year of study are identified, it can be compiled into an independent curriculum or included in the learning.

This review examined ten empathy intervention studies targeting nursing students, with nine demonstrating effectiveness and one showing no significant impact. Four studies examined the impact of the nine intervention types on the cognitive, affective, and behavioral domains of empathy, while the other study did not. The Simulation-Based Empathic Communication Training intervention was found to be effective in increasing cognitive empathy, while The Situated Teaching Program (based on experiential learning) and HFS training interventions were found to be effective in increasing cognitive empathy compared to other domains. The Structured EEM intervention based on the Delphi Technique was found to be effective in increasing all three domains of empathy. The findings of this study suggest that future research on empathy interventions for nursing students should focus on developing methods that specifically enhance affective empathy and empathic behavior. Furthermore, the year of study that requires enrichment for a specific empathy domain can be taken into account in order to choose the suitable and effective intervention method.