Assessment tools for evaluating empathy in health professions students: A systematic review

doi:10.21203/rs.3.rs-1623797/v1

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Assessment tools for evaluating empathy in health professions students: A systematic review

https://doi.org/10.21203/rs.3.rs-1623797/v1

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Introduction: Empathy is a complex construct that can be understood as the ability to appreciate and respond to an affective experience of another person. It is one of the main competencies in health professionals training due to its relevance in professional-patient relationship. There are several assessment tools for evaluating empathy, with currently no consensus on which would be more appropriate.

Objective: To identify, systematically evaluate and summarize information available in literature regarding assessment tools for evaluating empathy in health professions undergraduate students.

Method: Up to April 2020 PubMed, EMBASE, CINAHL, Web of Science, Lilacs, Scopus and ERIC and Cochrane Library were systematically searched to identify primary studies which aimed to assess empathy in undergraduate health professions students. Included studies were categorized according to the empathy assessment tool used.

Results: Were identified 776 studies and 55 were included. The assessed population included 21,820 students, 97.58% of whom were registered on medicine course. Jefferson Scale of Empathy (72.72%) and Interpersonal Reactivity Index (18.18%) were identified as the main questionnaires used to assess empathy.

Conclusion: There was an increase in the number of publications involving the assessment of empathy in the last decade. Most of the studies identified focus on undergraduate medical courses from developed countries, and the instrument most used to assess empathy was the Jefferson Scale of Empathy.

Empathy

Undergraduate

Medical education

Learning outcomes

Assessment

Empathy is considered a key competence in the training of health professionals (1), as it is one of the main components of the health professional-patient relationship and influences not only patient satisfaction and confidence in the proposed treatment, but also the creation of bonds them (2, 3). Empathy is a polysemic and multidimensional concept that can be understood as one’s ability to appreciate and respond to another person's affective experience (4, 5).

Multiple studies concerning physicians’ levels of empathy focus on medical education (6–8). Several factors are known to interfere in the development of empathy in students, such as the teaching environment, presence of mentors, relationship with preceptors and professional colleagues (9–11), social isolation (11–13), activity overload (9, 11, 12), elitist thoughts related to the medical profession (13), Technicality (11, 14) and the decline in professional enthusiasm itself (11).

Although there are several studies in this field, there is no consensus about what the best methods would be used to teach or improve empathy, nor about what would be the most adequate assessment tools. Therefore, it is worth emphasizing the relevance of studies that enable a deeper understanding of methods for assessing the health professions students’ levels of empathy. Several instruments have been developed over the years and are described in the literature, most of them aimed at assessing empathy in the general population but, in recent decades, others have also been developed specifically for health care (15). Thus, this review aimed to identify, systematically evaluate and summarize information regarding the assessment tools used worldwide to assess levels of empathy in health professions students.

This study performed a systematic review of literature and was carried out in accordance with Cochrane Collaboration Guidelines (16) and reported following PRISMA recommendations (17).

Study Eligibility Criteria

This systematic review considered primary studies that assessed the levels of empathy among health professions students using validated assessment tools. All studies published in the databases before April 2020 were included and there was no restriction regarding the date of publication.

Qualitative analysis studies were also eligible for inclusion as long as they met this review’s inclusion criteria, considering they can have high representation and quality for analyzing levels of empathy in undergraduate students.

Studies whose population did not consist of undergraduate health professions students, as well as review studies, editorials, letters, conference abstracts, books, dissertations, theses, case reports, opinion articles and conference proceedings were excluded.

Search strategy

An electronic search was performed in PubMed, EMBASE, Cumulative Index for Nursing and Allied Health (CINAHL), Web of Science, Lilacs, Scopus, Education Resource Information Center (ERIC) and Cochrane Library databases, using the following key-words combination: "empathy" AND ("education, medical, undergraduate" OR "clinical clerkship") AND (evaluation OR assessment OR measurement). Terms selection was based on the controlled vocabulary thesaurus Medical Subject Headings (MeSH). The search strategy was built aiming to contemplate the study’s primary goal and considering the main terms related to the context of interest. Searches were completed in April 2020.

Study selection

The selection process was carried out by two independent reviewers (LCG and RFCM). After duplicates removal, the selection process was performed in three steps. Thus, titles were analyzed, followed by the reading of the abstracts and, the reading of the full texts to final check for eligibility. In each of the stages, disagreements were solved through consensus among the reviewers, and in case of doubt, a third reviewer was consulted (PZT). The studies that met the inclusion criteria were analyzed and their reference lists were independently checked by the two reviewers in order to identify studies with potential relevance that were not retrieved in the electronic search.

Data Extraction and Data Synthesis

A standardized form was developed based on the model proposed by the Cochrane Collaboration to perform primary studies data collection. Information related to the study, the population assessed and the empathy assessment instrument used were collected, namely: authors, year of publication, country where the study was developed, type of study, sample characteristics (number of participants, participants’ course and school year), context where the study was developed (simulated environment, clinical context or classroom), instrument used to assess empathy, form of assessment (self-assessment, peer assessment, assessment by simulated patient or assessment by teachers) and means of instrument application (interview, behavior observation by evaluator or self-response) were registered.

Information regarding each included study is summarised in overview tables and the analysis was qualitatively performed.

The electronic search yielded 776 references. At the end of the selection process (Fig. 1) 55 studies were included, that assessed a total of 21,820 undergraduate health professions students, of these, 21,294 (97.58%) were studying medicine, 218 (0.99%) dentistry, 180 (0.82%) nursing and 21 (0.09%) pharmacy. Only one study did not specify the courses in which its participants were enrolled, and the 107 students assessed in this study were classified as “diverse courses”.

The main characteristics of the included studies are shown in Table 1 (Appendix A).

The analysis of the included primary studies allowed us to identify that the publications took place between 1978 and 2020 (Fig. 2). Between 1978 and 2000 only four studies assessing the levels of empathy among health professions students were identified (n = 4). Studies published after 2000 were grouped by periods of five years, which demonstrates the increase in the number of publications on the issue of interest. Three studies were published between 2001 and 2005, four studies published between 2006 and 2010, 17 studies were published between 2011 and 2015 and, 27 of the 55 studies included in this review were published between 2016 and 2020. These results demonstrate that the number of studies involving the assessment of empathy in health professions students has been growing over the years.

Regarding the geographic location where the studies were carried out (Fig. 3), it was possible to observe that 23 studies were carried out in North America, all of them in the United States, assessing 12,023 undergraduate students. In Asia, 16 studies were carried out assessing 5,663 students, followed by Europe, where 12 studies were performed, involving 2,169 students. In Oceania, two studies were carried out with 149 students. In South America, two studies were identified, both carried out in Brazil, assessing 1,816 undergraduate students.

The analysis of the environment in which the studies were performed indicated that 43 studies (78.18%) were carried out in a classroom environment, 11 studies (20.0%) took place in a simulated environment and only one study (1.82%) was carried out in a clinical context.

Regarding the school year in which students were enrolled, 23 studies assessed empathy in students enrolled between the 1st and 3rd year of graduation, 31 studies analyzed students from the 4th year of graduation and only one of the studies did not provided this information.

The analysis of study design showed that 31 studies developed a cross-sectional observational design, including students from all undergraduate years. Six studies had a longitudinal observational design: one study followed students from the first to the third year, three studies followed students from the first to the 4th year of graduation and the other two studies followed students from the first to the 6th year. Ten studies had a quasi-experimental cross-sectional design without a control group, involving students between the 1st and 6th year of graduation, and three other studies developed a quasi-experimental design without a control group, following students from the first to the 3rd year of training. Two randomized controlled trials and only one qualitative study were identified.

Empathy assessment tools

The analysis of the instruments used to assess empathy in the primary studies showed that the Jefferson Scale (JSE) was the instrument most frequently used, present in 72.72% of the included studies (n = 40), followed by the Interpersonal Reactivity Scale of Davis (IRI), applied in ten studies. The Consultation and Relational Empathy Questionnaire (CARE) and the Empathic Quotient (EQ) were used in two studies each, while the Objective Structured Clinical Examination (OSCE) was used in three studies. Only one study used the Empathy Scale in Patient Care (ESPC) and 13 studies used other types of quantitative instruments. Some studies used more than one instrument simultaneously or in a complementary way, which explains why the sum of the instruments (Fig. 4) is higher than the number of included studies.

Considering the type of assessment, 76.36% (n = 42) of the included studies used instruments based on self-assessment, 8.9% (n = 5) were instruments applied by an external observer, and 14.54% (n = 8) used both approaches.

This review aimed to identify, systematically evaluate and summarize information regarding the assessment tools used worldwide to provide a standardized assessment of the levels of empathy in health professions students. It was identified 55 studies that instruments designed to provide a standardized evaluation of empathy levels through self-assessment or by an external observer. Most of the included studies used were carried out in the United States and used the Jefferson Scale of Empathy. An important increase in the number of publications related to empathy during the years of academic formation was observed in the last ten years.

According to Hemmerdinger e cols (18), empathy may be measured from three different perspectives: self-rating, patient-rating, and observer rating. The self-rating empathy assessment tools are represented by the self-administered questionnaires (first-person assessment). Patient-rating relates to assessment performed by another individual also involved in the context (second person assessment). Finally, the observer rating considers the empathy measurement based on observation (third-person assessment). The choice of assessment tool to be employed depends on several factors related to the study context and one of them is the number of assessments to be carried out. It is worth noting that in cases of studies involving larger populations, such as multicentric studies, second and third-person based assessment instruments become more difficult to be performed (18).

Most of the included studies analyzed in this review (40/55) used the Jefferson Scale of Empathy (JSE) developed by Hojat and cols (19) to measure empathy in health care settings and further updated for use in wider populations of health profession students and practitioners (20). This questionnaire focuses on the health care field and understands empathy as a cognitive attribute. The JSE has been translated and validated into several languages and it is easy to apply, as it is a self-administered questionnaire consisting of 20 questions based on a Likert scale, enabling its application in a fast manner, with good acceptance among the individuals studied (18).

The preference for using the JSE for the empathy assessment in health professions students, according to some authors, lies on the possibility of assessing empathy within the health care context (21).

According to Williams and Beovich (22), the JSE demonstrates robust structural validity, internal consistency, and convergent validity. However, the quality of evidence for reliability, measurement error, and cross-cultural validity of its translated and transculturally adapted versions is considered poorer and only addressed by few studies. Thus, further research are necessary to strengthen evidence and caution should be considered when using the JSE to draw conclusions considering these properties (22).

The Jefferson Scale of Empathy also has a version for the assessment of empathy by a second person, the Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE). It consists of a five items questionnaire to be answered by the patients on a seven-point Likert scale, in order to assess their perception about the physician’s level of empathy. The JSPPE has good validity and reliability in the assessment of empathy (23–25).

The Davis Scale (IRI – Interpersonal Reactivity Index) was the second questionnaire most frequently used by the primary studies included in this review. It was used by ten studies. This scale is based on Davis' definition of empathy, understood as a group of mechanisms that are associated with a subject's reactions to the experiences of others with whom he/she relates, even if he/she does not experience them himself/herself (26). The IRI is a self-administered questionnaire consisting of a 28-item Likert scale, which considers the cognitive and affective dimensions of empathy from four subscales, each of them with seven items: 1) Perspective taking; 2) Empathic concern; 3) Personal distress; and 4) Fantasy (27).

As it is a self-administered questionnaire, Davis Scale can be quickly applied and has good acceptance. In addition, like the Jefferson Scale of Empathy, it has been translated and validated into several languages. Studies performed with both the IRI-Davis and the JSE found positive correlations between the degree of empathy presented in the IRI’s subscales Perspective Taking and Empathic Concern with the Jefferson Scale. However, it is not a questionnaire focused on the health care field and the health professionals’ relationship with their patients (18, 27).

It is also worth mentioning other questionnaires identified in this review. Although they had a lower number of occurrences, these instruments should be considered as possibilities for assessing empathy among undergraduate students.

One of them is the Consultation and Relational Empathy Questionnaire (CARE) developed by Neumann and cols (6). CARE was developed and validated for use in Primary Health Care, so that patients could assess the empathy of physicians from their own perspective. It is based on responses by a second person and composed of 10 items, graded on a five-point Likert scale. Two of the included studies used this questionnaire in the context of a simulated environment, in which teachers performed the students’ assessment (third person) and also trained simulated patient assessment were considered (second person) (28, 29).

Another questionnaire employed in two of the included studies was the Empathic Quotient (EQ). It is a tool based on self-response, which contains 60 items, 40 of them designed for empathy assessment and 20 for control, with the intention of distracting the respondent from the focus of empathy, therefor avoiding the socially expected responses. The EQ test seeks to assess the cognitive and affective aspects of empathy and has been used to assess empathy in patients with autism and Asperger's. It is considered a test with good validity for self-assessment of empathy (30, 31).

The Objective Structured Clinical Examination (OSCE) is an assessment carried out in a controlled environment, designed to verify the clinical skills and abilities that are necessary for the health professions student (32, 33). This instrument was used by three studies, all of them performed with undergraduate medical students (33–35).

It is worth emphasizing the importance of providing translated, validated and cross-culturally adapted versions of the questionnaires designed to assess empathy among heath profession students, so that the dialogue among studies performed in different countries can be expanded, contributing significantly to advances in scientific knowledge. Furthermore, the use of these instruments in the health education context provides valid information regarding the gaps on empathy levels which are valuable to guide future interventions planning. Empathy assessment in the context of health education is the basis to reality transformation due to its positive impact on communication between caregivers and patients, as well clinical and the quality of patient care (36).

Study limitations

Considering that the general goal of the present study was to identify questionnaire used for empathy assessment in the context of undergraduate courses in the health care, an assessment of the methodological quality of the primary studies included was not carried out. Likewise, the analysis of the psychometric properties of each instrument identified in the primary studies was not performed, namely: internal consistency, reliability, measurement error, content validity, construct validity, criterion validity and responsiveness, as it is prioritized by COSMIN (37).

Studies involving the assessment of empathy in health professions have shown an important evolution in the last ten years. Despite that, they are concentrated in medical programs from developed countries and empathy assessments has been performed by cross-sectional studies, without longitudinal monitoring and without conducting interventions to address the identified gaps on students’ empathy levels.

The different empathy assessment scales identified in this review allow us exploring this concept from different perspectives. The Jefferson Scale (JSE) was identified as the most frequently used empathy scale. This scale has been translated and validated for a greater variety of languages and countries when compared to the other available instruments.

Although the Davis Scale was not particularly developed for use in health-related professions, in this review it was the second most frequently used tool for empathy assessment in health professions students. This scale has been widely used in research for over 20 years, aiming to assess empathy not only considering its cognitive dimension, but understanding it as a multidimensional concept, related to the response of one individual to another individual’s situation.

The assessment of empathy in a more comprehensive way, through valid and reliable instruments and including the various stakeholders involved, could expand the possibility for educators to better understand this phenomenon and help students throughout their graduation training and should be considered by future studies

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

The raw data of the current study are not publicly available due to the use of specific software for systematic literature reviews but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

Not applicable

Authors' contributions

LCG and RFC reviewed, analyzed and interpreted the data and were the major contributors in writing the manuscript. AE reviewed studies to systematic review. PZT was the coordinator of the study and double check the studies to systematic review when necessary.

Acknowledgements

Not applicable

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No competing interests reported.

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Assessment tools for evaluating empathy in health professions students: A systematic review

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Abstract

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Introduction

Methods

Study Eligibility Criteria

Search strategy

Study selection

Data Extraction and Data Synthesis

Results

Discussion

Study limitations

Conclusion

Declarations

References

Additional Declarations

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