The Loss of Empathy in Nursing Education

Laurie Scudder, DNP, NP


March 12, 2012

The Empathy Enigma: An Empirical Study of Decline in Empathy Among Undergraduate Nursing Students

Ward J, Cody J, Schaal M, Hojat M
J Prof Nurs. 2012;28:34-40.

Study Summary

Background: Empathy is central to the nursing role and has been found to be associated with improved patient outcomes and greater satisfaction with care. Empathy is defined here as a cognitive, rather than emotional, skill that includes the ability to understand a patient's experience and communicate in a manner that conveys a recognition of patient concerns and perspectives. The skill of empathy must be integrated into the process of absorbing the social role of the profession that student nurses learn throughout their education. In an increasingly complex and technology-laden healthcare environment, nursing students are so focused on the science of nursing that they might neglect the art, which includes the empathetic communication that is the heart of the nurse-patient relationship. The purpose of this study was to examine changes in empathy during the student experience.

Methodology: This longitudinal cohort study was conducted with 214 undergraduate nursing students drawn from 3 programs at a single institution: an associate degree program, a bachelor's degree program, and a facilitated post-degree program open to students who had earned a previous degree in another discipline. At the beginning of the academic year, students completed a survey containing questions about demographics, academic background, and future career plans. They also completed the Jefferson Scale of Empathy, which was adapted for nursing students from the Jefferson Scale of Physician Empathy. The empathy scale was readministered at the end of the school year.

Results: Participants were predominantly women (84%) and white (74%). Of the one third of the group with a previous undergraduate degree (n = 83), more than half (59%) held a degree in the sciences, with smaller numbers holding degrees in the humanities (29%) or business-related fields (12%). A statistically significant decline in empathy occurred in the total sample from the start to the end of the academic year, a decline that was small and, on the basis of an effect size of -0.16, determined to be of no practical importance. However, the magnitude of the decline was important in some subgroups, including Asian students (effect size of -0.62) and those with previous degrees in business (effect size -1.37) and the sciences (effect size -0.46). Of greater importance, a clinically relevant decline was found in students with more clinical exposure. In other words, as students gained more clinical exposure, they demonstrated a much greater decline in empathy scores over the year than did those with limited clinical experience during that year. This finding extended to students with previous work experiences in the clinical setting, who also evidenced declines in empathy of practical importance, with an effect size of 0.57.


This study, which captures the experiences of a group of students at a single institution over a single academic year, has important limitations. However, the results echo those of previous studies that found that younger nurses and those with less clinical experience were more empathetic. Research has documented similar reductions in empathy in medical students as they progress through the years of school. Why is this? Although no single factor can likely explain this phenomenon, Ward and colleagues speculate that several factors contribute to this decline, including lack of time (which limits opportunities for empathetic patient communication), anxiety, lack of support from colleagues, an intimidating educational environment, and expanded roles for nurses, which require increased technical skills. It is likely that all are contributing factors. However, the role of education must be examined with its increasing use of technology-driven models such as distance education, which limits opportunities for students to interact with faculty, thus minimizing opportunities for role-modeling. The researchers (all faculty members) suggest a number of commonsense strategies for incorporating empathy training into nursing education, including:

  • improved attention to selection of preceptors who will serve as positive role models;

  • provision of pseudohospitalization experiences to allow students to see the hospital experience through a patient's eyes;

  • use of standardized patients for role-playing;

  • recordings of student-patient interactions for later examination and identification of positive and negative behaviors; and

  • recognition and reward for empathetic behavior.

Clearly, students must learn the science of nursing. However, until the art of nursing is recognized as a necessary criterion for successful completion of coursework and as important as passing an exam, students will likely continue to demonstrate behaviors that make them good technicians but not necessarily very good nurses.



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