You are here

Article Text

Article menu

Download PDFPDF

Medical education and training
Original research
Empathy in occupational therapy students: a cross-sectional study at a Spanish university
  1. Sergio Serrada-Tejeda,
  2. Rosa Mª Martínez-Piedrola,
  3. Elisabet Huertas-Hoyas,
  4. Nuria Máximo-Bocanegra,
  5. Nuria Trugeda-Pedrajo,
  6. Mª Pilar Rodríguez-Pérez,
  7. Patricia Sánchez-Herrera Baeza,
  8. Marta Pérez-de-Heredia-Torres
  1. Faculty of Health Sciences, Universidad Rey Juan Carlos, Alcorcon, Madrid, Spain
  1. Correspondence to Dr Elisabet Huertas-Hoyas; elisabet.huertas{at}urjc.es

Abstract

Introduction Empathy is an important interpersonal skill and a fundamental component in the professional–patient relationship, being the basis for implementing person-centred practice. In several studies, a decrease in empathy levels throughout training in medicine, nursing or dentistry, among others, has been shown. There are few studies on the occupational therapy branch of healthcare. The aim was to determine the degree of empathy perceived by students of occupational therapy at a Spanish university, as well as to analyse the differences between empathy levels according to the different degree courses and gender.

Methods A descriptive cross-sectional study was designed with a sample of 221 occupational therapy students from a Spanish university. The Davis Interpersonal Reactivity Index (IRI) and the Jefferson Scale of Empathy-Health Profession Student’s Spanish version (JSPE-HPS-S) were used as outcome measures.

Results According to the results found, high level of empathy was found on all dimension of the IRI (69.84 (9.80)) and the JSPE-HPS-S (122 (94–140)). Although high levels of empathy among occupational therapy students are observed in all degree courses, no significant differences were found between them. Statistically significant differences and a moderate effect size (r) were found between the variables according to the gender of the participants, with females showing greater empathy in the overall scores of the IRI as well as in the JSPE-HPS-S (p=0.002, r=0.212; p=0.001, r=0.327, respectively).

Conclusions Empathy is an essential competence for the development of quality occupational therapy practice. According to the results and although occupational therapy students showed high levels of empathy, it is important to pay attention to the evolution of empathy and to provide students with learning experiences that prevent its possible decline.

  • education & training (see medical education & training)
  • medical education & training
  • medical ethics

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2021-058821

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Strengths and limitations of this study

    • This is the first cross-sectional study conducted in Spain to assess empathic skills in occupational therapy students.

    • The culturally adapted and validated Spanish version of the Jefferson Medical Empathy Scale for health professionals was used.

    • The results are specific to a single university and do not represent the totality of occupational therapy university students in the Spanish context.

    Introduction

    Empathy covers a broad spectrum of cognitive and emotional factors that enables putting ourselves in the place of others by appreciating their perspectives and emotional state, generating a shared affection or vicarious feeling.1 2 Being empathic in the context of patient-centred care lies in having an open predisposition to the complaint and the demand made by the patient, whoever the patient is and whatever the demand is, and trying to understand it from the patient, not only from the healthcare provider.3 For this reason, empathic behaviour is considered an important interpersonal skill and a fundamental component of the professional–patient relationship that allows laying and implementing the foundations for the development of a person-centred practice.4 In this context, multiple investigations have determined that a high level of empathy in healthcare professionals improves clinical competence and care4 5 and patient satisfaction,6 among others. However, this skill is not completely innate and can be learnt in both its cognitive and affective dimensions.7 According to Blanco et al,8 there are cultural, environmental, experiential and educational factors that influence and condition its development.

    Because in patient-oriented healthcare, recognising and seeking occasions to display empathetic behaviour is a central element of the healthcare professional–patient relationship, in recent years the study of empathy among students in different healthcare settings has gained increased interest, as current published studies showed a decline in empathy scores among medical professionals.9–13 In addition, a decline has been similarly observed throughout the first year of training in other health professions, such as nursing or dentistry,14 as a result of the need to cope with new responsibilities and excessive workload.

    In occupational therapy, empathy is a key element to consider during the intervention process in order to provide the support and understanding that are necessary to face the difficulties that may arise as a consequence of difficulties in occupational performance. In addition, the development of empathic attitudes has been shown to improve patient health outcomes.15 However, although the literature on health professions students’ empathy has increased, little research has been done to assess the level of empathy in occupational therapy students. Historically, the first study, developed by Christiansen,16 assessed empathic skills in occupational therapy students, using the Hogan Empathy Scale17 and indicated that healthcare professionals show innate skills that facilitate and aid therapeutic relationships. Similarly, Wise and Page,18 who were more focused in assessing the emotional dimension of empathy and used the Affective Sensitivity Scale19 with first-year occupational therapy students, suggested that the implementation of a formative process on empathic skills could have positively affected students’ empathy levels.

    Currently, the few existing studies that are available in the field of occupational therapy have preferably used the Jefferson Medical Empathy Scale, version for health professionals (JSPE-HPS)20 and have been carried out in Australia21 and the USA.22 The research conducted by Brown et al,21 with a sample of 92 occupational therapy undergraduate students, indicated that although students showed high levels of empathy, these values were lower than those observed in other health professionals and no significant changes occurred throughout the university programme. On the other hand, Metz and Christoff,22 using a convenience sample of three rehabilitation science professional programmes, in which students enrolled in the clinical Occupational Therapy Doctorate programme were included, suggested that higher levels of empathy may be associated with greater capacity and better abilities to respect and consider people with a stigmatising medical condition or disease.

    Similarly, gender differences in empathic skills have also been a subject of research, and although there has been controversy regarding gender differences in empathy among healthcare and medical student, some authors suggest that the gender differences observed in psychological research may be due to cultural expectations and stereotypical beliefs, which determine and facilitate the tendency to imitate certain socially expected models of behaviour.23 In this regard, Abe et al24 indicated that personality type is a factor with a stronger strength of association with empathy than gender. In contrast, several studies12 21 24–27 have found significant differences in empathy according to gender, identifying gender differences related to cognitive and affective factors that determine empathy.25

    Due to the scarce existing literature and considering the importance of empathy throughout occupational therapy training, the purpose of this study was to determine the level of empathy of students in the 4 years of the occupational therapy degree at a Spanish university, as well as to analyse the differences between empathy levels according to gender and degree course.

    Material and methods

    Study design and participants

    A cross-sectional descriptive observational study was carried out. For its realisation, students of the bachelor’s degree in occupational therapy at the Faculty of Health Sciences of the Universidad Rey Juan Carlos in Alcorcón (Madrid, Spain) volunteered to participate in the project. The occupational therapy degree has a total duration of 4 years and has recently been reapproved by the World Federation of Occupational Therapists (WFOT), ensuring that the WFOT Minimum Standards for Occupational Therapist Training have been met. The study was carried out at the beginning of the second semester, so that none of the students could be conditioned by external factors, such as the exam period. In addition, the third-year and fourth-year students had already completed their first practicum in different healthcare settings.

    The sampling was consecutive non-probabilistic. Recruitment of undergraduate students was carried out by means of information on internal campus media. The data collection process was organised in such a way that occupational therapy degree professors will oversee delivering the Interpersonal Reactivity Index (IRI) and the JSPE-HPS questionnaires in the university classroom corresponding to each degree course at the Faculty of Health Sciences of the Universidad Rey Juan Carlos. For each level of the occupational therapy degree programme, a faculty member who did not teach in that degree course was assigned to avoid students being conditioned to fill out the questionnaire for academic reasons. Before completing the questionnaire, students received an explanatory statement and information about their participation, which would be voluntary and anonymous. All questionnaires were anonymised in such a way that the privacy of the participants was preserved. Once the students completed their questionnaires, the professor responsible for each occupational therapy degree level gave all the questionnaires to a professor who did not participate in the previous phases. This professor considered each questionnaire as completed when the information on age, degree course, gender, questionnaire’s items were filled in and informed consent document was signed.

    All students who participated in the study met the following inclusion criteria: being between 18 and 65 years of age, being a student of the Universidad Rey Juan Carlos (URJC) occupational therapy degree, having signed the informed consent form and having completed both questionnaires. As exclusion criteria, it was considered that the student did not complete both questionnaires, or did not sign the informed consent form.

    Participants and public involvement

    Patients and the public were not involved in the design and planning of this study.

    Assessment instruments used

    1. Davis Interpersonal Reactivity Index (IRI): this scale is especially useful in research on the multidimensionality of the empathic process in the general population.28 It is adapted to Spanish29 and consists of 28 items accompanied by a Likert-type scale with 5 response alternatives according to the degree to which the statement describes the person (0: does not describe me well to 4: describes me very well). In accordance with the model proposed by Davis, the items are grouped into four subscales of seven items each called: perspective taking, fantasy, empathic concern and distress or personal discomfort, with seven items each. The perspective taking (dimension 1) and fantasy (dimension 3) subscales assess the more cognitive processes, while the empathic concern (dimension 2) and personal distress (dimension 4) subscales measure people’s emotional reactions to the experiences of others of discomfort and anxiety in the face of discomfort and anxiety in the face of negative experiences of others. The four subscale ranges from 0 to 28, so the higher the score, the greater the empathy level. The confirmatory factor analysis of Spanish adapted version of the IRI showed an acceptable fit (χ2/df=9291; GFI=0.899; (Root Mean Square Error of Approximation) RMSEA=0.06) as well as good internal consistency for all the dimensions with Cronbach’s alpha values between 0.69 and 0.80.

    2. Jefferson Scale of Empathy-Health Profession Student’s version (JSPE-HPS)20: it assesses empathy in the context of the clinical relationship from a cognitive approach and from the perspective of emotions and is composed of 20 items within 3 dimensions: dimension 1 perspective taking, dimension 2 compassionate care and dimension 3 putting oneself in the patient’s place. They are scored according to a Likert scale from 1 (strongly disagree) to 7 (strongly agree). Scores range from a minimum of 20 to a maximum of 140 and the higher the score, the higher the participant’s level of empathy. The reliability and validity of the JSPE-HPS has previously been demonstrated.18 21 30–32 Its Spanish validation, JSPE-HPS-S,33 show adequate psychometric properties: Cronbach’s alpha=0.786; ICC=0.90 (95% CI=0.86 to 0.93; p<0.0001) and the resulting model showed an acceptable fit (χ2=269 095, df=167, p<0.001; CFI=0.87; RMSEA=0.04).

    Statistical analysis

    The estimated effect size for the main outcome measures established in the present work was 0.60. Considering a power of the statistical test of 0.90 and an alpha error of 0.05 for the comparison of means for independent samples, a minimum of 44 subjects in each group is required, according to the G*Power software (V.3.1.9).

    Normality analysis of the sample was performed using the Kolmogorov-Smirnov test. Subsequently, descriptive statistics were calculated for the study variables. Given the non-parametric distribution of the variables, the mean difference of the scores between groups was analysed: Kruskal-Wallis tests were used to compare the differences between the four different degree courses and the Mann-Whitney U test was performed for comparing gender differences. To estimate the difference between the four different degree courses, the epsilon-squared estimate (ε2) of effect size was proposed.34 To estimate the differences between two groups, Rosenthal’s r (r) was calculated and Cohen’s guidelines for r were considered (a large effect is 0.5, a medium effect is 0.3 and a small effect is 0.135).

    The analysis of the variables was performed with the statistical programme IBM SPSS Statistics for Windows, V.27.0 (Copyright 2013 IBM SPSS Corp).

    Results

    Out of a total of 290 students enrolled in the occupational therapy programme, a sample of 221 students (76.2%) finally participated in the study. The majority were female (88.2%) with a mean age of 20.62 years. Table 1 describes the sociodemographic results of the sample and the descriptive statistics of the empathy scales. In general, the students reported high level of empathy according to the data found in the IRItotal score: 69.84 (9.80) as well as in the JSPE-HPS-Stotal score: 122 (94–140). When the analysis was carried out according to the degree course to which they belonged, the results indicated that no differences were found between groups (table 2), so as no significant correlations were found, ε2 of effect size were not calculated. However, statistically significant differences were evident between the groups of participants, in relation to the gender variable. Table 3 shows the differences and effect size according to the level of empathy between males and females. A moderate effect size was observed, and the group of women showed higher scores in the global scores of both the IRI (p=0.002, r=0.212) and JSPE-HPS-S Scale (p=0.001, r=0.327). In the IRI, statistically significant differences were found in dimensions 2 (empathic concern) and 3 (fantasy), while in the JSPE-HPS-S, such differences were observed in all three test dimensions.

    View this table:
    Table 1

    Descriptive data according to subsamples

    View this table:
    Table 2

    Descriptive and comparative analysis of scale scores between groups according to university years

    View this table:
    Table 3

    Descriptive and comparative analysis of scale scores between groups according to gender

    Discussion

    The aim of the present study was to determine the degree of empathy self-perceived by students of the occupational therapy degree programme at a Spanish university as well as analysing empathy levels in four independent samples of students from all 4 years of the degree programme and across genders.

    According to the results found in our study, occupational therapy students showed a high level of empathy. Previous studies with occupational therapy students18 21 22 not only showed high levels of empathy, but also indicated a correlation between empathy and the ability to empathise.18 However, different international studies,36–39 where empathy was analysed in other health professions (medicine, nursing, dentistry), showed lower mean scores, such as 113.52 (nursing), 106.37 (paramedic), 116.54 (osteopathic medicine), 110.92 (medicine), 113.65 (physiotherapy) compared with 123.12 (occupational therapy, according to our findings). It is possible that these scores may depend on other factors such as cultural, social, curriculum or academic load. According to a study by Williams et al,39 a low level of empathy was correlated with deficiencies in self-awareness of emotional states. This circumstance can lead health professionals to behave in a cold and disinterested manner to protect themselves emotionally in the face of painful and shocking scenes, as noted in a study by Williams et al,40 in which they found lower scores in paramedical students compared with other professions. However, empathetic professionals are more successful in healthcare and are more reflective and able to think about issues such as the impact of a technological product on its users.41 42 In this line, another of the main aspects investigated and analysed, according to which a decrease in empathy levels of students may occur, is the excessive use of technology compared with the holistic perspective of patient care during the establishment of the therapeutic relationship.20 This fact would favour affective distancing and depersonalisation of the patient.43 In this sense, the occupational therapy profession is patient oriented, while other health professions are more procedure oriented, may require less interaction, or require more training in technology management.

    Clinical practice, as part of the training of health science professionals, is a determining moment in the acquisition and maintenance of empathy, because it is the time when they are in contact with the patient. However, there are discrepancies in the level of empathy throughout the degree courses. Some studies have shown an increase,44 while others observed a decrease during the educational trajectory,45 without being able to establish a consensus as to whether clinical practices increase or decrease empathy. The present study is in line with that conducted by Brown et al21 with occupational therapists, in which they observed no statistically significant differences in empathy scores, regardless of the degree course the student was in. In this sense, such as future studies, it would be appropriate to analyse the multiple factors that may be contributing to the results of our study, such as the duration and type of clinical practice, learning of communication skills, personality, application of teaching methodologies, experiential learning, among others, throughout the 4 years. For occupational therapists, empathy facilitates patient-centred understanding and the achievement of significant therapeutic results for each person.46 Therefore, it is especially indicated as an emotional competence in the training curriculum and is one of the objectives of education in this profession. This is reflected in the 2016 WFOT Minimum Standards for the Education of Occupational Therapists,47 which recommends a broader training that not only focuses on technical, clinical and professional skills, but also emphasises emotional competencies. Within these competencies, as a requirement for acquiring the clinical competence of communicating with the patient and picking up their concerns, training in communication skills, interpersonal relationships and affective sensitivity is contemplated as an essential part of the programmes.47 48 The training programme of the occupational therapy degree of the URJC in Madrid has the approval of the WFOT and includes among its training the development of competencies that allow students to develop specific skills for the establishment of relationships with people during their practical training and future professional experience, SE competencies are directly assessed during the practical training that takes place during the last two university years in different health and/or social-health contexts. This practical training requires a specific evaluation by the professionals who supervise their practical stay, so that during and at the end of their training, the student receives direct feedback on the development of their professional competences, as well as on the personal skills and attitudes shown towards the users. This continuous training, which supports the development in emotional competencies, may be a factor that favours empathy among students of this degree, regardless of the course evaluated. There is not any indication if individuals who select occupational therapy as a profession are already more empathetic than average. In fact, a recent study49 conducted with a sample of 1160 health sciences students (nursing, pharmacy, occupational therapy, physiotherapy, etc) indicates that these students show high scores in aspects related to self-confidence in themselves. This could imply that they choose what they like, confident in themselves. Although empathy is not mentioned, it is a profile for all health professions, so that ‘all’ would start from the same emotional conditions/skills.

    However, in studies with other health professions,11 20 such as medicine, empathy levels decrease according to the degree course. Therefore, the Spanish educational context as well as the training programme of each institution is of utmost importance. Delgado-Bolton et al50 not only highlight the training programme, but also the cultural reasons or access to health resources. A study by Blanco Canseco et al51 justified a decline in empathy according to the progress of the degree courses with the possible progress of responsibility assumed by the final year residents and the anxiety due to job uncertainty. Other authors15 found a correlation between age and this decline, the older the patient, the less empathy. There are many possible reasons that can lead to this decline. However, as university professors, we must attend to those variables that are in our hands, such as those related to training and clinical practice, and not only focus on students obtaining optimal levels of empathy, but also have strategies for the prevention of burn out, as one of the causes of empathy loss.52 Furthermore, as suggested by Polonio-López et al,53 in occupational therapy other aspects such as emotional intelligence can be improved through a structured practical programme, in order to reduce stress as well as improve the relationship with their patients.

    The participants in our study were mostly female, which is similar to the actual proportion of students enrolled in the occupational therapy degree programme at the URJC. Gender differences have been found in most of the research conducted on empathy with health science students, where females obtained significantly higher scores than males.23 24 54 In contrast to a study conducted by Brown et al20 with occupational therapy students, in our work we found statistically significant differences, with a moderate effect size, between females and males, both in the empathy outcome measure and in the fantasy and empathic concern dimensions of the interpersonal reaction outcome measure. It is likely that this difference may be due, in part, to cultural expectations about gender roles as noted by some authors,51 where females are expected to perceive others’ emotions better and are more likely to provide emotional support. In addition, it may be that the caregiver role assigned to females in current Spanish society is still based on a paternalistic model that is influencing the development of more empathic skills in females than males.23 According to the data found in our study, the greatest differences between females and males were observed in cognitive and affective aspects of empathy, considered essential factors in professional relationships with patients. This is even though, according to our data, both females and males show a similar cognitive capacity to understand the other’s situation and to put themselves in the other’s place. On the other hand, higher scores were found in the emotional components in females, which may indicate that females react more affectively, presenting more empathic behaviours than males.55 Specifically, females scored higher than males in all dimensions of the interpersonal reaction outcome measure, although there were no significant differences in the ability to understand the other person’s point of view or in personal distress. However, according to the data found, females presented greater imaginative ability to put themselves in the other person’s place, with significantly more feelings of compassion, concern and caring for others. In this sense, some studies indicate that females have a greater capacity to identify with the patient’s experiences and feelings.37 However, a recent study,24 conducted with Japanese medical students, indicated that personality type is a factor with a stronger strength of association with empathy than gender. Furthermore, the teaching of empathy as part of the competencies to be acquired by the student seems to indicate that it is effective, as pointed out by a review with current meta-analysis.56

    One of the main limitations of the study is that the results do not correspond to a longitudinal follow-up of the sample, but rather the results report in a particular way on the event in a specific degree course. However, this methodology has been used in similar studies.9 39 44 On the other hand, although the sample size is adequate, it is not representative of the reality of occupational therapy students, since these data correspond to a single university and there is no equity between women and men in the sample analysed. However, studies conducted on occupational therapy students reflect this same variability.21 On the other hand, one of the strengths of our study is that to avoid response and social desirability bias, the professors who administered the test did not teach students in that degree course, as well as all the questionnaires were anonymised and administered in non-penalising situations, such as exams periods, as described by Hojat.36 However, our study has interesting implications for the healthcare teaching context, since we found high levels of empathy regardless of the students’ course which may suggest, despite the lack of longitudinal follow-up, that empathic skills remain stable throughout the 4 years of the degree. Moreover, it is also observed that final year students show high levels of empathy that may help in dealing with situations in the healthcare relationship with patients where empathic skills are necessary. However, we have not identified what other factors may impact or limit these skills, nor have we followed up senior students during their first year in the work setting, which could yield interesting results as the context and situation of the students varies.

    Therefore, due to the importance of cognitive and emotional aspects, necessary to establish an adequate healthcare relationship, it would be advisable to evaluate and carry out longitudinal follow-ups of the students’s empathic skills to identify how empathic competencies evolve throughout the different degree courses, as well as designing studies to identify the effectiveness of the university degree programmes in improving emotional skills and competencies.

    Data availability statement

    Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by Rey Juan Carlos University Research Ethics Committee, No of the approval: 0504201907319. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We thank all the participants of the study for their collaboration, time and dedication.

    References

    1. ↵
      1. Decety J
      . Empathy in medicine: what it is, and how much we really need it. Am J Med 2020;133:561–6.doi:10.1016/j.amjmed.2019.12.012pmid:http://www.ncbi.nlm.nih.gov/pubmed/31954114
      OpenUrlPubMed
    2. ↵
      1. Hojat M
      . Empathy in patient care: antecedents, development, measurement, and outcomes. New York: Springer, 2007.
    3. ↵
      1. Carrió FB
      . [Empathy, core value in clinical practice]. Med Clin 2011;136:390–7.doi:10.1016/j.medcli.2009.06.032pmid:http://www.ncbi.nlm.nih.gov/pubmed/19732917
      OpenUrlPubMed
    4. ↵
      1. Ogle J,
      2. Bushnell JA,
      3. Caputi P
      . Empathy is related to clinical competence in medical care. Med Educ 2013;47:824–31.doi:10.1111/medu.12232pmid:http://www.ncbi.nlm.nih.gov/pubmed/23837429
      OpenUrlPubMed
    5. ↵
      1. Cánovas L,
      2. Carrascosa A-J,
      3. García M, et al
      . Impact of empathy in the patient-doctor relationship on chronic pain relief and quality of life: a prospective study in Spanish pain clinics. Pain Medicine 2018;19:1304–14.doi:10.1093/pm/pnx160
      OpenUrl
    6. ↵
      1. Menendez ME,
      2. Chen NC,
      3. Mudgal CS, et al
      . Physician empathy as a driver of hand surgery patient satisfaction. J Hand Surg Am 2015;40:1860–5.doi:10.1016/j.jhsa.2015.06.105pmid:http://www.ncbi.nlm.nih.gov/pubmed/26231482
      OpenUrlCrossRefPubMed
    7. ↵
      1. Heyes C
      . Empathy is not in our genes. Neurosci Biobehav Rev 2018;95:499–507.doi:10.1016/j.neubiorev.2018.11.001pmid:http://www.ncbi.nlm.nih.gov/pubmed/30399356
      OpenUrlPubMed
    8. ↵
      1. Blanco JM,
      2. Caballero F,
      3. García FJ, et al
      . Validation of the Jefferson scale of physician empathy in Spanish medical students who participated in an early clerkship immersion programme. BMC Med Educ 2018;18:209.doi:10.1186/s12909-018-1309-9pmid:http://www.ncbi.nlm.nih.gov/pubmed/30208887
      OpenUrlPubMed
    9. ↵
      1. Chen D,
      2. Lew R,
      3. Hershman W, et al
      . A cross-sectional measurement of medical student empathy. J Gen Intern Med 2007;22:1434–8.doi:10.1007/s11606-007-0298-xpmid:http://www.ncbi.nlm.nih.gov/pubmed/17653807
      OpenUrlCrossRefPubMed
    10. ↵
      1. Hojat M,
      2. Vergare MJ,
      3. Maxwell K, et al
      . The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med 2009;84:1182–91.doi:10.1097/ACM.0b013e3181b17e55pmid:http://www.ncbi.nlm.nih.gov/pubmed/19707055
      OpenUrlCrossRefPubMedWeb of Science
    11. ↵
      1. Khademalhosseini M,
      2. Khademalhosseini Z,
      3. Mahmoodian F
      . Comparison of empathy score among medical students in both basic and clinical levels. J Adv Med Educ Prof 2014;2:88–91.pmid:http://www.ncbi.nlm.nih.gov/pubmed/25512926
      OpenUrlPubMed
    12. ↵
      1. Hojat M,
      2. Mangione S,
      3. Nasca TJ, et al
      . An empirical study of decline in empathy in medical school. Med Educ 2004;38:934–41.doi:10.1111/j.1365-2929.2004.01911.xpmid:http://www.ncbi.nlm.nih.gov/pubmed/15327674
      OpenUrlCrossRefPubMedWeb of Science
    13. ↵
      1. Neumann M,
      2. Edelhäuser F,
      3. Tauschel D, et al
      . Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med 2011;86:996–1009.doi:10.1097/ACM.0b013e318221e615pmid:http://www.ncbi.nlm.nih.gov/pubmed/21670661
      OpenUrlCrossRefPubMedWeb of Science
    14. ↵
      1. Nunes P,
      2. Williams S,
      3. Sa B, et al
      . A study of empathy decline in students from five health disciplines during their first year of training. Int. J. Medical Education 2011;2:12–17.doi:10.5116/ijme.4d47.ddb0
      OpenUrl
    15. ↵
      1. Sanchez G,
      2. Ward Peterson M,
      3. Musser ED
      . Measuring empathy in health care. In: Foster A, Yaseen Z, eds. Teaching empathy in healthcare. Cham: Springer, 2019.
    16. ↵
      1. Christiansen CH
      . Measuring empathy in occupational therapy students. Am J Occup Ther 1977;31:19–22.pmid:http://www.ncbi.nlm.nih.gov/pubmed/835675
      OpenUrlPubMed
    17. ↵
      1. Hogan R
      . Development of an empathy scale. J Consult Clin Psychol 1969;33:307–16.doi:10.1037/h0027580pmid:http://www.ncbi.nlm.nih.gov/pubmed/4389335
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Wise BL,
      2. Page MS
      . Empathy levels of occupational therapy students. Am J Occup Ther 1980;34:676–9.doi:10.5014/ajot.34.10.676pmid:http://www.ncbi.nlm.nih.gov/pubmed/7425073
      OpenUrlCrossRefPubMed
    19. ↵
      1. Campbell RJ,
      2. Kagan N,
      3. Krathwohl DR
      . The development and validation of a scale to measure affective sensitivity (empathy). J Couns Psychol 1971;18:407–12.doi:10.1037/h0031492
      OpenUrlCrossRefWeb of Science
    20. ↵
      1. Hojat M,
      2. Mangione S,
      3. Nasca TJ
      . The Jefferson scale of physician empathy: development and preliminary psychometric data. Educ Psychol Meas 2001;61:349–65.
      OpenUrlCrossRefWeb of Science
    21. ↵
      1. Brown T,
      2. Williams B,
      3. Boyle M, et al
      . Levels of empathy in undergraduate occupational therapy students. Occup Ther Int 2010;17:135–41.doi:10.1002/oti.297pmid:http://www.ncbi.nlm.nih.gov/pubmed/20623554
      OpenUrlCrossRefPubMed
    22. ↵
      1. Metz AE,
      2. Christoff A
      . Empathy and regard: perspectives held by graduate students of rehabilitation sciences. J Allied Health Sci Pract 2020;18:110.
      OpenUrl
    23. ↵
      1. Löffler CS,
      2. Greitemeyer T
      . Are women the more empathetic gender? the effects of gender role expectations. Curr Psychol 2021;34.doi:10.1007/s12144-020-01260-8
    24. ↵
      1. Abe K,
      2. Niwa M,
      3. Fujisaki K, et al
      . Associations between emotional intelligence, empathy and personality in Japanese medical students. BMC Med Educ 2018;18:47.doi:10.1186/s12909-018-1165-7pmid:http://www.ncbi.nlm.nih.gov/pubmed/29587725
      OpenUrlPubMed
    25. ↵
      1. Shin HS,
      2. Park H,
      3. Lee Y-M
      . The relationship between medical students' empathy and burnout levels by gender and study years. Patient Educ Couns 2022;105:432–9.doi:10.1016/j.pec.2021.05.036pmid:http://www.ncbi.nlm.nih.gov/pubmed/34127334
      OpenUrlPubMed
    26. ↵
      1. Duarte MI,
      2. Branco MC,
      3. Raposo ML, et al
      . Empathy in medical students as related to gender, year of medical school and specialty interest. SE Asian Jnl Med Educ 2015;9:50.doi:10.4038/seajme.v9i1.97
      OpenUrl
    27. ↵
      1. Hojat M,
      2. Gonnella JS,
      3. Mangione S, et al
      . Empathy in medical students as related to academic performance, clinical competence and gender. Med Educ 2002;36:522–7.doi:10.1046/j.1365-2923.2002.01234.xpmid:http://www.ncbi.nlm.nih.gov/pubmed/12047665
      OpenUrlCrossRefPubMedWeb of Science
    28. ↵
      1. Davis MH
      . A multidimensional approach to individual differences in empathy. Catalog of Selected Documents in Psychology 1980;10:1–17.
      OpenUrl
    29. ↵
      1. Carrasco-Ortiz MA,
      2. Delgado-Egido B,
      3. Barbero-García MI
      . Propiedades psicométricas del interpersonal reactivity index (IRI) en población infantil Y adolescente española. Psicothema 2011;23:824–31.
      OpenUrlPubMed
    30. ↵
      1. Hojat M,
      2. Gonnella JS,
      3. Nasca TJ, et al
      . Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry 2002;159:1563–9.doi:10.1176/appi.ajp.159.9.1563pmid:http://www.ncbi.nlm.nih.gov/pubmed/12202278
      OpenUrlCrossRefPubMedWeb of Science
    31. ↵
      1. Hojat M,
      2. Gonnella JS,
      3. Mangione S, et al
      . Physician empathy in medical education and practice: experience with the Jefferson scale of physician empathy. Seminars in Integrative Medicine 2003;1:25–41.doi:10.1016/S1543-1150(03)00002-4
      OpenUrlCrossRef
    32. ↵
      1. Hojat M,
      2. Spandorfer J,
      3. Isenberg GA, et al
      . Psychometrics of the scale of attitudes toward physician-pharmacist collaboration: a study with medical students. Med Teach 2012;34:e833–7.doi:10.3109/0142159X.2012.714877pmid:http://www.ncbi.nlm.nih.gov/pubmed/22934590
      OpenUrlPubMed
    33. ↵
      1. Serrada-Tejeda S,
      2. Sánchez-Herrera-Baeza P,
      3. Rodríguez-Pérez Mª Pilar, et al
      . Cultural adaptation and psychometric properties of the Jefferson empathy scale health professions students' version in SpanishOccupational therapy students. BMC Med Educ 2021;21:472.doi:10.1186/s12909-021-02845-ypmid:http://www.ncbi.nlm.nih.gov/pubmed/34488731
      OpenUrlPubMed
    34. ↵
      1. Tomczak A,
      2. Tomczak E
      . The need to report effect size estimates revisited. An overview of some recommended measures of effect size. Trends Sport Sci 2014;1:19–25.
      OpenUrl
    35. ↵
      1. Fritz CO,
      2. Morris PE,
      3. Richler JJ
      . Effect size estimates: current use, calculations, and interpretation. J Exp Psychol Gen 2012;141:2–18.doi:10.1037/a0024338pmid:http://www.ncbi.nlm.nih.gov/pubmed/21823805
      OpenUrlCrossRefPubMed
    36. ↵
      1. Hojat M
      . Empathy in health professions education and patient care. 124. New York: Springer International, 2016: 275–331.
      OpenUrl
    37. ↵
      1. Hojat M,
      2. DeSantis J,
      3. Shannon SC, et al
      . The Jefferson scale of empathy: a nationwide study of measurement properties, underlying components, latent variable structure, and national norms in medical students. Adv Health Sci Educ Theory Pract 2018;23:899–920.doi:10.1007/s10459-018-9839-9pmid:http://www.ncbi.nlm.nih.gov/pubmed/29968006
      OpenUrlCrossRefPubMed
    38. ↵
      1. Williams B,
      2. Brown T,
      3. McKenna L, et al
      . Empathy levels among health professional students: a cross-sectional study at two universities in Australia. Adv Med Educ Pract 2014;5:107–13.doi:10.2147/AMEP.S57569pmid:http://www.ncbi.nlm.nih.gov/pubmed/24833947
      OpenUrlPubMed
    39. ↵
      1. Williams JHG,
      2. Cameron IM,
      3. Ross E, et al
      . Perceiving and expressing feelings through actions in relation to individual differences in empathic traits: the action and feelings questionnaire (AFQ). Cogn Affect Behav Neurosci 2016;16:248–60.doi:10.3758/s13415-015-0386-zpmid:http://www.ncbi.nlm.nih.gov/pubmed/26486794
      OpenUrlPubMed
    40. ↵
      1. Williams B,
      2. Boyle M,
      3. Howard S
      . Empathy levels in undergraduate paramedic students: a three-year longitudinal study. Nurse Educ Pract 2016;16:86–90.doi:10.1016/j.nepr.2015.09.002pmid:http://www.ncbi.nlm.nih.gov/pubmed/26440934
      OpenUrlPubMed
    41. ↵
      1. Schweitzer F,
      2. Rau C,
      3. Gassmann O, et al
      . Technologically reflective individuals as enablers of social innovation. J Prod Innov Manage 2015;32:847–60.doi:10.1111/jpim.12269pmid:http://www.ncbi.nlm.nih.gov/pubmed/27134342
      OpenUrlPubMed
    42. ↵
      1. Ratka A
      . Empathy and the development of affective skills. Am J Pharm Educ 2018;82:7192.doi:10.5688/ajpe7192pmid:http://www.ncbi.nlm.nih.gov/pubmed/30643318
      OpenUrlAbstract/FREE Full Text
    43. ↵
      1. Yerxa EJ
      . Infinite distance between the I and the it. Am J Occup Ther 2009;63:490–7.doi:10.5014/ajot.63.4.490pmid:http://www.ncbi.nlm.nih.gov/pubmed/19708478
      OpenUrlCrossRefPubMed
    44. ↵
      1. Roh M-S,
      2. Hahm B-J,
      3. Lee DH, et al
      . Evaluation of empathy among Korean medical students: a cross-sectional study using the Korean version of the Jefferson scale of physician empathy. Teach Learn Med 2010;22:167–71.doi:10.1080/10401334.2010.488191pmid:http://www.ncbi.nlm.nih.gov/pubmed/20563934
      OpenUrlPubMed
    45. ↵
      1. Shariat SV,
      2. Habibi M
      . Empathy in Iranian medical students: measurement model of the Jefferson scale of empathy. Med Teach 2013;35:e913–8.doi:10.3109/0142159X.2012.714881pmid:http://www.ncbi.nlm.nih.gov/pubmed/22938682
      OpenUrlPubMed
    46. ↵
      1. Jamieson M,
      2. Krupa T,
      3. O'Riordan A, et al
      . Developing empathy as a Foundation of client-centred practice: evaluation of a university curriculum initiative. Can J Occup Ther 2006;73:76–85.doi:10.2182/cjot.05.0008pmid:http://www.ncbi.nlm.nih.gov/pubmed/16680911
      OpenUrlCrossRefPubMed
    47. ↵
      1. World Federation of Occupational Therapists
      . Minimum standards for the education of occupational therapists revised in 2016. Available: https://www.wfot.org/resources/new-minimum-standards-for-the-education-of-occupational-therapists-2016-e-copy
    48. ↵
      1. Yu M-L,
      2. Brown T,
      3. Thyer L
      . The association between undergraduate occupational therapy students' listening and interpersonal skills and performance on practice education placements. Scand J Occup Ther 2019;26:273–82.doi:10.1080/11038128.2018.1496272pmid:http://www.ncbi.nlm.nih.gov/pubmed/30124096
      OpenUrlPubMed
    49. ↵
      1. Arslantürk K,
      2. Öz F
      . Health sciences undergraduate students' perceived meaning of life and their coping styles. Perspect Psychiatr Care 2020;56:439–47.doi:10.1111/ppc.12453pmid:http://www.ncbi.nlm.nih.gov/pubmed/31729043
      OpenUrlPubMed
    50. ↵
      1. Delgado-Bolton R,
      2. San-Martín M,
      3. Alcorta-Garza A, et al
      . [Medical empathy of physicians-in-training who are enrolled in professional training programs. A comparative intercultural study in Spain]. Aten Primaria 2016;48:565–71.doi:10.1016/j.aprim.2015.10.005pmid:http://www.ncbi.nlm.nih.gov/pubmed/26723489
      OpenUrlPubMed
    51. ↵
      1. Blanco Canseco JM,
      2. Valcárcel Sierra C,
      3. Guerra Jiménez MDC, et al
      . [Clinical empathy among family and community medicine residents and tutors. The view of physicians and patients]. Aten Primaria 2020;52:185–92.doi:10.1016/j.aprim.2018.04.009pmid:http://www.ncbi.nlm.nih.gov/pubmed/30522783
      OpenUrlPubMed
    52. ↵
      1. Tlili MA,
      2. Aouicha W,
      3. Sahli J, et al
      . Prevalence of burnout among health sciences students and determination of its associated factors. Psychol Health Med 2021;26:212–20.doi:10.1080/13548506.2020.1802050pmid:http://www.ncbi.nlm.nih.gov/pubmed/32835517
      OpenUrlPubMed
    53. ↵
      1. Polonio-López B,
      2. Triviño-Juárez JM,
      3. Corregidor-Sánchez AI, et al
      . Improving self-perceived emotional intelligence in occupational therapy students through practical training. Front Psychol 2019;10:920.doi:10.3389/fpsyg.2019.00920pmid:http://www.ncbi.nlm.nih.gov/pubmed/31114523
      OpenUrlPubMed
    54. ↵
      1. Christov-Moore L,
      2. Simpson EA,
      3. Coudé G, et al
      . Empathy: gender effects in brain and behavior. Neurosci Biobehav Rev 2014;46 Pt 4:604–27.doi:10.1016/j.neubiorev.2014.09.001pmid:http://www.ncbi.nlm.nih.gov/pubmed/25236781
      OpenUrlPubMed
    55. ↵
      1. Berg K,
      2. Blatt B,
      3. Lopreiato J, et al
      . Standardized patient assessment of medical student empathy: ethnicity and gender effects in a multi-institutional study. Acad Med 2015;90:105–11.doi:10.1097/ACM.0000000000000529pmid:http://www.ncbi.nlm.nih.gov/pubmed/25558813
      OpenUrlCrossRefPubMed
    56. ↵
      1. Fragkos KC,
      2. Crampton PES
      . The effectiveness of teaching clinical empathy to medical students: a systematic review and meta-analysis of randomized controlled trials. Acad Med 2020;95:947–57.doi:10.1097/ACM.0000000000003058pmid:http://www.ncbi.nlm.nih.gov/pubmed/31688037
      OpenUrlPubMed

    Footnotes

    • Contributors Conception and design, SS-T and MP-d-H-T. Analysis and interpretation of the data, SS-T and EH-H. Investigation, NM-B, NT-P, PRF and PS-HB. Drafting of the paper, RM-P. Revising it critically for intellectual content, SS-T, RM-P and EH-H. The final approval of the version to be published, MP-d-H. All authors agree to be accountable for all aspects of the work. The guarantor MP-d-H-T accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.