The Gratitude Mediates the Relationship Between Self-Esteem and Empathy Among Medical Students

DOI: https://doi.org/10.21203/rs.3.rs-1072627/v1

Abstract

Background: One of the important parts of medical students' competence is empathy, which is believed to significantly influence patient satisfaction, clinical outcomes, and the sense of professional fulfillment.

Objective: This study explored the potential mediating effect of gratitude on the relationship between self-esteem, cognitive empathy, and affective empathy, which may provide fundamental data for educational programs aiming to promote cognitive empathy and affective empathy.

Design: The paper surveyed a total of 344 medical students with the Self-Esteem Scale, Gratitude Questionnaire-6, and the Chinese version of the Interpersonal Reactivity Index Scale. It uses descriptive analysis to determine the levels of self-esteem, gratitude, and empathy, and Pearson’s correlation to analyze correlations between them. It also conducts the pathway analysis with the equipment of structured equation modeling to test the mediating effect of gratitude on the association between self-esteem and empathy.

Results: A total of 306 (88.95%) medical students completed the survey. It finds that, first, the levels of self-esteem, gratitude, cognitive empathy, and affective empathy are significantly correlated. Second, self-esteem has a direct, positive effect on cognitive empathy and affective empathy. Third, gratitude has a mediating role between self-esteem, cognitive empathy [b self-esteem - gratitude - cognitive empathy = 0.072, 95% CI = (0.013 to 0.131), p< 0.05], and affective empathy [bself-esteem - gratitude - affective empathy = 0.241, 95% CI = (0.018 to 0.134), p< 0.001].

Conclusion: Based on the role of self-esteem and gratitude in predicting cognitive empathy and affective empathy, this model can be used in the practice of clinical education to promote cognitive empathy and affective empathy in medical students.

Introduction

As the future medical workers, clinical interns will play a key role in the medical system. Thus, the medical education becomes a global concern that is worthy of attention [1]. More importantly, how to train medical students into qualified workers has become one of the key challenge’s educators face [2]. According to previous studies, positive emotions have been regarded as a critical factor of cultivation, among which empathy [3] has the possibility to serve as a catalyst for medical students' synthetic development [4], and help educate qualified, and even able medical practitioners [5]. Empathy refers to the process of understanding and responding to unique affective experiences expressed by others [6]. Empathic capability is an important skill of medical staff [7]. It has been closely associated with the improvement of patient satisfaction as well as clinical outcomes, and the settlement of physician-patient conflicts [8–10]. Physicians who are more empathetic will also enjoy greater job satisfaction, and make better clinical decisions [8, 11, 12]. All of that makes empathy an important aspect of the clinical competence of medical students. Therefore, this study aims to explore the factors affecting medical students’ ability of empathy, and to come up with possible devices to influence it, thus providing a pathway for the medical education in the future.

Empathy And Self-esteem

Empathy is a multidimensional construction that implies affective and cognitive responses to another person [13, 14]. Cognitive empathy refers to understanding the other person’s state of mind [15.16], while affective empathy includes the right emotional response [17]. Self-esteem is an important predictor of empathy, and individuals with higher self-esteem are more likely to express empathy [18]. Self-esteem is a psychological strength essentially showing one’s overall evaluation of his- or herself [19], which is an internal psychological resource and an important part of the self-system. Research showed that individuals with higher self-esteem scores higher during dynamic self-evaluation [20], which makes individuals maintain a positive psychological state, and thus continuously express empathy in the interpersonal communication. It also found that the level of college students' self-esteem effectively predicts their achievement motivation and self-efficacy [21]. To be stimulated and maintained, the empathic behavior pattern of doctor-patient communication usually needs to be equipped by achievement motivation and self-efficacy control [22]. Self-esteem and empathy are related to personality and one’s value system. Therefore, self-esteem may affect empathy through related attributes [23].

Efficient social interactions are dependent with self-esteem and empathy [24, 25]. Moreover, self-esteem spurs enthusiasm and initiative to communicate interpersonally [26]. According to Alvaro’s conservation of resources theory, happiness attracts more personal resources, and self-esteem is a personal resource to offset burnout [27]. Lewandowska and Weziak-Bialowolska [28] found in their research that self-esteem is closely related to empathy. Previous studies also showed that self-esteem was negatively correlated with negative emotions [29]. Individuals with low self-esteem levels may have emotional problems such as anxiety and social phobia [30]. Negative emotions such as stress and anxiety may lead to occupational burnout, leaving the empathy of medical students plunging. However, Individuals with high self-esteem may be more positive and optimistic, which also helps manage stress, and reduce negative emotions and dissatisfaction with life [31, 32]. Indeed, persons with lower self-esteem are controlled only by the motive to protect themselves [33], and they have an unclear sense of self. Furthermore, a clearly coherent sense of self is predictive of empathy of personal distress and concern [34]. Therefore, self-esteem may positively predict empathy.

The Role Of Gratitude

Gratitude is another important predictor of empathy [35], for it is an empathic emotional experience that has a positive correlation with cognitive empathy and affective empathy [35, 36]. It has been conceptualized as a psychological tendency that tends to appreciate others’ helpful actions [37]. It has also played a unique role in shaping interpersonal relations and work attitudes [38]. For instance, clinical staff with higher levels of gratitude show more care and patience when communicating with patients with difficulties. Such a positive attitude of communication can buffer negative feelings in clinical interactions. And the trait of gratitude is generally manifested in a wide and stable psychological tendency of being sensitive, caring for others, and recognizing the beneficial behaviors of others in the process of interpersonal interactions [39]. According to the broaden-and-build theory [40], positive emotions build enduring personal resources, and broaden people’s momentary repertoires of cognition and behaviors. Thus, the positive emotion of gratitude could possibly enhance empathy.

In addition, another study also found that gratitude is affected by self-esteem. To be more specific, individuals with a higher level of self-esteem are more grateful [41]. Self-esteem has been closely correlated with personality traits, affectivity [29]. Gratitude is the emotional experience that comes from perceiving the prosocial behavior of others [36], that is, the experience of gratitude involves the perception of the relationship between oneself and others. Individuals with higher self-esteem have stronger social adaptability and more positive emotional experience [30.42]. This in turn promotes positive perceptions of society, stimulating gratitude to society and others [40]. Therefore, self-esteem may positively predict gratitude.

The Current Study

Socio-demographic factors may affect medical student empathy. There are studies that indicate differences in levels of empathy by gender variable. Several studies have shown that women are more empathetic than men [43–45]. More specifically, women had higher levels of emotional affective component, but no gender differences in cognitive component. In addition, the literature suggests that current undergraduates in the healthcare field display less empathy than earlier generations did [46], and even fail to recognize the significance of empathy. However, some studies found an increase [43] in empathy levels during undergraduate education, while others found no change [4, 44]. Therefore, this study will explore the gender differences in empathy level.

In addition, although past studies have explored the relationship between self-esteem, empathy, and gratitude. However, to our knowledge, the correlation among self-esteem, empathy, and gratitude in medical students has not been fully interpreted. Thus, the paper investigated medical students’ empathy levels and their relationship with gratitude and self-esteem, and intends to provide fundamental data for educational programs aiming at promoting empathy. Based on results of previous studies, the paper hypothesized that self-esteem directly affects empathy, and gratitude plays a mediating role between self-esteem and empathy.

Methods

Participants and procedure

A total of 330 medical students participated in the cross-sectional survey, and 306 (92.73%) of them answered all the questions. Out of the 306 participants, 115 (37.6%) were male and 191 (62.4%) were female, and their mean age was 23.24 years (SD = 1.35, range 18-27). In terms of professional distribution, 103 (33.7%) were practitioners of traditional Chinese medicine, 65 (21.2%) of clinical Chinese and Western medicine, 74 (24.2%) of rehabilitation therapy, and 64 (20.9%) of acupuncture and massage.

This study was conducted in affiliated hospitals of a provincial medical university. It deployed a pen-and-paper questionnaire to investigate the socio-demographic characteristics, empathy, self-esteem, and gratitude of medical interns. After signing the informed consent, participants were asked to complete a questionnaire in the classroom.  The researcher and the trained graduate student of psychology were chosen as the experimenter, explaining the intention of the research to the students and emphasizing the principles of voluntariness, anonymity, and pragmatic answers. All questionnaires were recovered on the spot after completing the test. The Institutional Ethics Committee approved all the procedures.

Measures

Self-Esteem

Self-Esteem was measured according to the Self-Esteem Scale, or SES (Rosenberg, 1965). Out of ten items of the Scale, five adopt the reverse scoring method, each of them scored on a four-point scale ranging from 1 (very inconsistent) to 4 (very consistent). It includes items such as “I am satisfied with my life” and “In most ways my life is close to my ideal”. Scores may be anywhere from 10 to 40 points. The higher the scores are, the higher the level of self-esteem is. Scores below 25 points are grouped as low self-esteem, 26-32 moderate-level self-esteem, and over 33 high self-esteem [47]. The Chinese version of the Scale proves reliable and is widely used [48]. Cronbach’s alpha was tested 0.86 in the study.

Gratitude

Gratitude was measured according to the Gratitude Questionnaire-6, or GQ-6 [36]. Each of the six items included in the Questionnaire is scored on a seven-point scale ranging from 0 (completely disagree) to 6 (completely agree). It includes items such as “I feel thankful for what I have received in life” and “I sometimes feel grateful for the smallest things”. Scores may be anywhere from 6 to 42 points. The higher the scores are, the higher the level of gratitude is. The Chinese version of the Scale proves reliable [49]. Cronbach’s alpha was tested 0.76 in the paper.

Empathy

Empathy was measured according to the Chinese version of the Interpersonal Reactivity Index, or IRI-C, whose usage in the Chinese context has been proved reliable with adequate concurrent and construct validity by Zhang et al. [50]. The IRI-C is a 22-item self-report scale assessing individual empathy from four dimensions, namely, perspective-taking, fantasy, empathy concern, personal distress. The study used perspective-taking and empathy concern subscales, which contained 11 items. Each item is rated on a five-point scale ranging from 1 (very inconsistent) to 5 (very consistent). Five items adopt the reverse scoring method. The Index is compiled by Davis (1980) based on the multidimensional theory of empathy, a tool to measure the ability of empathy. The factor of perspective-taking is to measure the cognitive components, find out the tendency of individuals to understand, and see things from others' point of view in real life. The factor of empathy concern measures the emotional components and the degree of concern for others, warmth, and compassion. Therefore, the study adopts the perspective-taking subscale with the five items to measure cognitive empathy (e.g., “I sometimes try to understand my friends better by imagining how things look from their perspective.”). Scores range from 5 to 25, with higher scores indicating greater cognitive empathy. Affective empathy was measured by the empathy concern subscale with six items (e.g., “I often have tender, concerned feelings for people less fortunate than me.”). Scores of empathy concern subscales range from 6 to 30, with higher scores indicating greater affective empathy. Cronbach’s alpha of the perspective-taking subscale and the empathy concern subscale were 0.70 and 0.71 respectively, and the total Cronbach’s alpha was 0.74 in the study.

Data Analyses

Data analyses were conducted via SPSS 23.0 and Mplus 7.0. First, SPSS was used for data analyses, descriptive analyses, reliability tests, t-test, and correlation analyses for the whole sample. This study only used the self-report method to collect data, and there may be a common method bias (CMB) problem. In order to further improve the rigor of research, statistical analyses were carried out by Harman’s single factor test and the confirmatory factor analysis of the single-factor model.

Next, the Structural Equation Model (SEM) was deployed to examine the mediating role of gratitude in the relationship between self-esteem and empathy of medical college students during the pandemic of COVID-19. We used chi-square values to evaluate model fit, the Akaike information criterion (AIC), the Bayesian information criterion (BIC), the root-mean-square error of approximation (RMSEA), the Tucker Lewis index (TLI), the comparative fit index (CFI), the standardized root-mean-square residual (SRMR). A non-significant chi-square indicates a good model-data fit. General cutoffs for accepting a model are equal to, or greater than 0.90 for the CFI and TLI, and less than 0.08 for the SRMR and RMSEA.

Finally, we applied the SEM approach to assessing the following models: (a) a direct effect model with structural paths from self-esteem to cognitive empathy and affective empathy, and (b) an indirect effect model, with the gratitude inserted in between. The final model is presented in Figure 1.

Results

Common Method Bias Test

Harman's univariate test was used to analyze 27 items of the three scales. A total of 6 factors with characteristic roots greater than 1 were extracted, and the explanatory power of the first factor was 26.20%, less than the standard value of 40%. At the same time, the confirmatory factor analysis of single-factor model was used to test, and the fitting indexes were poor（c2/df = 4.40，CFI = 0.61，TLI = 0.57，SRMR = 0.09，RMSEA = 0.11. The statistic test results showed that there was no significant common method bias in the measurement.

Descriptive Statistics and Correlations

As shown in Table 1, descriptive analyses of the level of College Students' self-esteem, gratitude, cognitive empathy, and emotional empathy demonstrated that medical students’ overall ability of empathy was above average during the pandemic of COVID-19, their cognitive empathy (M = 3.33, SD = 0.65, t = 8.82, p < 0.001) and affective empathy levels (M = 3.23, SD = 0.68, t = 5.93, p < 0.001) were significantly higher than the theoretical median value (Md = 3). However, there were still 30.7% medical students whose affective empathy level was lower than the theoretical median value (Md = 3), and 22.9% of students whose cognitive empathy was lower than the theoretical median value (Md = 3). In addition, the self-esteem (M = 2.76, SD = 1.25, t = 15.70, p < 0.001) of medical students in this sample were significantly higher than the theoretical median value (Md = 2.5), and the gratitude level (M = 3.13, SD = 0.60, t = 7.52, p < 0.001) in this sample were significantly higher than the theoretical median value (Md = 3). The study revealed that there were 35 (11.4%) students with high self-esteem, 125 (40.8%) with moderate-level self-esteem, and 146 (47.7%) with low self-esteem. A further data analysis showed that males' empathy is significantly lower than females (t = -2.24, p< 0.05), while other factors have no significant difference.

Correlation analyses showed that there are significant correlations among variables (see Table 1). Self-esteem is significantly and positively associated with gratitude, cognitive empathy, and affective empathy; gratitude is significantly and positively associated with the other two factors.

Structural Equation Model Analyses

Prior to testing the mediating effect, the paper examined the direct effect of self-esteem on cognitive empathy and affective empathy regardless of gender and other socio-demographic characteristics. The direct effects model demonstrated a good fit: [ c2 = 15.47，df = 9，CFI = 0.987，TLI = 0.973，RMSEA = 0.052，SRMR = 0.037]. The results of the path analysis indicated that the path coefficient of self-esteem exerts direct effect on cognitive empathy b = 0.351 (p < 0.001), and affective empathy b = 0.450 (p < 0.001).

In order to further probe the predictive mechanism of self-esteem on cognitive empathy and affective empathy, gratitude served in this study as a mediating variable based on a direct model. The model   demonstrated a good fit:[ c2 = 433.529, df =121, CFI = 0.961, TLI = 0.924, RMSEA = 0.074, SRMR = 0.071]. The results are shown in Figure 1. Analyses on the various paths of the model found that self-esteem was a positive predictor of cognitive empathy [b self-esteem - gratitude - cognitive empathy = 0.072, 95% CI = (0.013 to 0.131), p < 0.05] and affective empathy [b self-esteem - gratitude - affective empathy = 0.241, 95% CI = (0.018 to 0.134), p < 0.001] through the mediating variable of gratitude.

Discussion

It is believed that empathy is the royal road to the optimal physician-patient relationship, while serving as an important indicator of the overall ability of physicians in China [51]. Results of the study showed that the levels of medical students' self-esteem, gratitude, cognitive empathy, and affective empathy are not only significantly higher than the theoretical median value, but also higher than previous studies [52], maybe partly because participants were from different grades. In Zhang’s study, participants were freshmen and sophomores in medical schools; but participants in this study are clinical interns, who may have a higher average empathy score. Besides, female medical students have consistently scored significantly higher on affective empathy levels than male students [53]. This is a consistent result about the empathy’s gender difference among medical students [43–45]. It has been observed that women have higher empathy scores to date [54, 55], maybe because their maternal instincts make them more sensitive to emotions than men [56].

This study took “self-esteem” as an important predictor of empathy, just as previous studies did [57, 58]. Consistent with past research outcomes, results of the study indicated that self-esteem help increases empathy [18]. However, the results of this study are inconsistent with the findings of Liu’s study on Chinese medical students [59], which showed a negative correlation between self-esteem and empathy. Individuals with high self-esteem cannot accept others’ opinions and take care of others’ feelings and tend to make judgments according to their values. Therefore, the relationship between self-esteem and empathy needs further verification. Different levels of self-esteem (e.g., low, medium, high) may affect their relationship with empathy. Future research should further explore the relationship between the two from different levels of self-esteem.

Previous studies also showed that self-esteem was negatively correlated with negative emotions [29]. Individuals with low self-esteem levels may have emotional problems such as anxiety and social phobia [30]. Negative emotions such as stress and anxiety may lead to occupational burnout, leaving the empathy of medical students plunging. However, Individuals with high self-esteem may be more positive and optimistic, which also helps manage stress, and reduce negative emotions and dissatisfaction with life [31, 32]. According to Alvaro’s conservation of resources theory, happiness attracts more personal resources, and self-esteem is a personal resource to offset burnout [27]. The empathy of a medical worker in the first place may be rewarded with positive feedback from patients, and his or her job satisfaction may thus increase. This may create a positive reinforcement cycle, and a better doctor-patient relationship. Medical students with high self-esteem are likely to be more empathetic with clinical patients, and thus can better meet the needs of, and be more active during, the empathetic communication between doctors and patients. After all, this is more in line with the current and future demands for qualified medical workers.

What’s more, this study explored the relationship between self-esteem and empathy, as well as the mediating role of gratitude in between from the perspective of empathy competence of medical students. The study found that self-esteem and gratitude are significantly correlated with cognitive empathy and affective empathy, which is consistent with previous research results [18]. Moreover, structural equation analysis results showed that self-esteem not only directly impact cognitive empathy and affective empathy, but also indirectly affects empathy through gratitude. Based on the broaden-and-build theory of positive emotions, gratitude can broaden the horizon of people’s thoughts and actions, and serve as a lifelong resource [60]. Gratitude is closely related to empathy [36], and able to strengthen it. Individuals with high level of gratitude tend to have more positive cognitive and emotional input, pay more attention to prosocial behaviors and social responsibility in interpersonal interactions [61]. Previous studies have shown that gratitude can promote individual prosocial behavior. Now, clinical medical students are facing new demands and pressure in workplace due to the prevention and control of COVID-19. Effective, evidence-based provider communication resources must be offered in such a context [62].

Previous studies have shown that gratitude stimulates social behaviors, and individuals with high level of gratitude are more likely to help, support, forgive and sympathize with others [36, 63]. The study introduced gratitude and researched its mediating effect between self-esteem and empathy. Results showed that self-esteem affects not only cognitive empathy and emotional empathy directly, but also empathy indirectly through the mediating variable of gratitude. The level of self-esteem is dependent with the level of gratitude, while the latter promotes cognitive empathy and affective empathy. Higher self-esteem helps individuals to better adapt to the environment, improve evaluation of self-worth and self-ability, get more positive experience, and thus induce the positive emotion of gratitude [64]. This offers inspiration for educators to train medical students to be empathetic [65].

Implications For The Educational Practice

There is an increasing focus on empathy in clinical circumstances. Most empathy-building ways require to empathize others’ ability or motivation [66]. However, empathy is more than an ability or motivation; it also reflects personality traits that drive people to generate positive emotions and behaviors. The study further verified how the personal trait of self-esteem affects empathy, and provided evidence and related theories to support it. Meanwhile, the results showed that self-esteem affects the empathy of medical students by influencing another trait of gratitude. Empathy is the product of learning, which can be improved through training [67]. The cultivation of medical students’ self-esteem and gratitude is of great significance to improve their ability to communicate empathetically. Clinical teachers can carry out humanistic training with real clinical cases or standardized patients. Medical students can gain a sense of accomplishment and worth during the training, thus enhancing their positive emotional experience. Educators should teach medical students' to be grateful to others and the society, and increase their empathy accordingly. That will be a supplement to the blind spots of the clinical education at present.

Limitations

However, the study still has some limitations. Firstly, cross-sectional data used in this study made it difficult to explain the causal relationship between variables. Secondly, the subjects of this study were senior medical students, who might be inspired by these traits. It should be cautious when relating the results with other sample groups and those with problems. Finally, this study lacks subjects of pre-clinical postgraduates or those at an early medical stage. Future research could probe into this group of students.

Conclusion

The findings of this study indicated that self-esteem, as a positive experience, can improve empathy by promoting gratitude of medical students. Self-esteem can also directly foster cognitive empathy and affective empathy, and facilitate medical students' prosocial behaviors. This has provided a pathway for clinical education.

Abbreviations

Nil

Declarations

Acknowledgments

Nil.

Authors’ contributions

ZY developed the study design, performed the statistical analysis, and drafted the manuscript. OY participated in and supervised data collection. RY verify data and critically modify important knowledge content in the manuscript. All the authors finally agreed with the current version of the manuscript.

Funding

This work was supported by Philosophy and Social Science Project in Guizhou, China (Project No. 19GZYB60).

Availability of data and materials

Data and materials are available from corresponding author.

Declarations

Ethics approval and consent to participate

This study were approved by the Ethics Committee of Guizhou University of traditional Chinese medicine. The process was carried out in accordance with relevant guidelines and regulations. All participants provided written, informed consent. 

Consent for publication

Not Applicable.

Competing interests

All the authors declare no competing interests.

Author details

1College of Humanities and Management, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, 550000, China. 2The Second Affiliated Hospital, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, 550000, China. 

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Tables

Table 1 Descriptive statistics and correlations for key variables (N = 306)

 

M

SD

Self-esteem

Gratitude

Cognitive empathy

Affective empathy

Self-esteem

2.76

0.60

1

 

 

 

Gratitude

5.13

1.25

.349***

1

 

 

Cognitive empathy

3.26

0.61

.164**

.225***

1

 

Affective empathy

3.22

0.69

.571***

.333***

.280***

1