Given the importance of teaching attitude to medical students, questions have been raised regarding the possibilities of finding a standardized, valid reliable and feasible instrument that can measure it . Attitude is a complex construct. The decision should be made whether the instrument would test cognitive, psychomotor or affective aspects . Empathy is one of the component of attitude that enables health professionals to understand the experience of patient, concerns and perspectives . Health professionals should have certain degree of empathy and should put their knowledge, skills and attitude in their clinical practice to eliminate the pain and suffering of their patients .
Previous studies have addressed the need to measure empathy either at admission to medical school or during clinical training [7, 8, and 10]. The Jefferson Scale of Empathy (JSE) has been used in several countries such as the USA, Poland, Korea, Italy, Japan to evaluate empathy among health professionals and students of health professions. It has been standardized for its validity and reliability .
In Syria, there is a need to emphasize the role of Syrian health professionals during the crisis to respond to health, psychological and social needs of patients who suffer from different economic, social, psychological, and health problems. Researchers have indicated that empathy is not well addressed in medical curricula [17–20]. There is a need to design a tool that can measure the empathy in the context of Syrian health professionals during the crisis. Therefore, the Syrian Empathy Scale SES was developed to support decision-making processes and help identifying areas that require further attention and training. The designed scale includes 20 questions and the overall score ranges from twenty to one hundred and forty in which higher scores indicate a better empathic relationship in the medical and therapeutic care.
The SES was designed to be simple, practical, can be very useful in practice settings to assist continuing education in the field of health care. Writing statement, which is a crucial part in designing the empathy scale to anonymous group[17, 24], has not been an easy task as it has to be simple, short, direct debatable, clear-cut, meaningful and interesting. Attempt was made to make statements simple, clear and belonged to the same attitude variable as well as to make them relevant to the community during Syrian crisis . To increase the reliability of measurement, decrease error and save time, attempts was made to make each statement has one interpretation, contains one complete thought and one specific attitude related to one issue . Likert scales was also adopted in order to identify the extent to which the respondent would agree or disagree with the object . Negatively wording of half of the attitude statements was applied to provide a true measurement of an attitude, avoid the acquiescence bias and minimize extreme response that might be caused because of some respondents who might tend to agree with most statements . Moreover, careful statistical methods and analysis such as Cronbach’s alpha reliability coefficient were applied in order to verify the internal consistency of the applied scales . The value of Cronbach’s alpha which were considered as good (0.85) provided evidence about the reliability of the applied scale . The alpha coefficient obtained was similar to other values obtained in some studies [31, 32] and was higher than the values obtained in other studies [2, 33, 34]. Accordingly, this questionnaire can be considered as reliable for measuring empathy among Syrian health professionals. Anonymous questionnaires to a sufficient sample size was considered in order to further validate and improve the designed scale .
The findings of the present study showed that the SES empathy score of undergraduates was significantly higher than postgraduates and practitioners. Similar findings were reported about the decline in empathy with increasing age or year of education [35, 36, 37]. Studies have attributed many factors to this consistent finding. The stress of academic performance, long work hours , lack of quality sleep, and increased responsibilities with age  are some factors that contribute to declining empathy among older individuals .
The present study reported a significant difference between males and females in the SES mean score and higher empathy scores among females. The findings were consistent with previous findings reported [40–42] who attributed this to qualitative variance in integrating emotional information between males and females genders that can affect the decision-making process . Similarly, Hojat et al. attributed this to social learning, genetic predisposition, and evolutionary underpinnings .
After the factorial analysis, it was possible to identify five different components of empathy (Care and Understanding, Feeling, Health Care, Negative Empathy Impact and Clinical Decision Making). The findings support the goodness of the factorial analysis. Duarte et al. identified 6 components of empathy through the factorial analysis (compassionate care, perspective taking, cognitive dimension, standing in patient shoes clinical outcomes, no influence by others ) and could also supported the goodness of the analysis.
In fact, the designed scale can be a great tool for measuring the empathy among health professionals who live in similar fragile contexts. It has been simple, cheap, easy to design, to read by participant and relevant to community. The SES can be suggested for application in similar contexts. However, several procedures can be utilized to increase its validity and reliability before applying it in in linguistically and culturally diverse settings. For instance, multiple tests and items such as questionnaires, papers cases and observation of behavior could be developed . In addition, observation of medical students, during management of patients, can also be used together with empathy scale in order to improve the validity and reliability of the scale. An objective approach in which students are required to take OSCEs by standardized patients could also be suggested to explore the association between empathy scores and ratings of clinical competence in OSCE stations [7, 44–46].