Keywords

1 Introduction and Background References

The word “empathy” is derived from Greek word “empatheia” meaning “affection or passion with a quality of suffering” [1]. Empathy is a critical ingredient for patient satisfaction and improved patient wellbeing therefore must be a part of the entire hospital experience for patients [2,3,4]. It is an emotion much needed in nurses as they are in regular touch with patients and their families [3, 5,6,7].

Empathy is distinct from Sympathy which refers to the ability to take part in someone else’s [4], feelings, mostly by feeling sorrowful about their misfortune, which is not desirable in a healthcare context. Empathy is a powerful ability for healthcare-professionals because patients feel heard, supported, cared for, and validated when they feel someone is taking steps to understand their pain [3, 6].

Hojat concluded that empathy is primarily a cognitive attribute especially in the healthcare context. It involves the process of understanding of a patient’s condition and communication of this understanding with the intention to help reduce suffering [4]. Apart from cognitive, there are also affective, and behavioral expressions of empathy [4]. These are measured using self-reported and behavioral tools to understand the internal mechanisms that lead to empathy. The tools for empathy such as the Jefferson Scale of Empathy [JSE) [7] are also based on self-reporting and do not cover behavioral aspects. A comprehensive scale is needed to evaluate all aspects of empathy and its improvement over time. Measuring and consequently enhancing empathy among nurses through training would result in improvement of patient satisfaction and outcomes [8, 9].

Despite the importance of empathy in patient treatment and well being, there is limited published research and data related to empathy of nurses in India. However a study was conducted on empathy levels of Indian medical students using JSE scale and empathy levels were found to be lower in comparison with medical students globally [1].

India has 3.07 million nurses overall including midwives, nurses, women health visitors and auxilary nurse midwives. 1.7 nurses per 1000 people, which is 43% less than WHO norms (Rajya Sabha, March 2020). Nurses in India face several challenges in terms of lack of time and resources due to this fact. The current tools for measuring empathy in the healthcare context do not take into account the Indian context and Indian challenges in the components considered. Many researchers have modified the JSE as per the context of the study and to get better results for empathy measurement [1, 10,11,12].

2 Review of Literature

2.1 Tools to Measure Empathy

Cognitive, affective and behavioral facets of empathy co-exist [4, 13]. Empathy is measured by using both self-reporting and observational measures to understand the internal neurological and physiological processes that drive it [13, 14].

The Jefferson Scale of Empathy (JSE) is a globally used tool developed to measure empathy in healthcare professionals in the context of patient care [10, 11, 15]. The Questionnaire of Cognitive and Affective Empathy (QCAE) [14] addresses inconsistencies in other measurement tools such as the Interpersonal Reactivity Index (IRI). It is a reliable tool to measure the different aspects of empathy (cognitive and affective and their respective parts) based on the social cognitive neuroscience approach with respect to empathy and its related neural processes [10, 16, 17].

2.2 Factors Affecting Empathy Scores in Healthcare Professionals

Studies have found that nurses who are women tend to score higher than men on empathy scores [1]. Nurses working in different wards in a hospital in Iran underwent a cross-sectional research using the JSE measurement scale. This proved that while there is similarity in results of nurses from different wards, empathy scores increase with experience. Three factors of “Perspective Taking, Compassionate Care, and Walking in Patient’s Shoes” were found to be key factors that drive empathy [17].

Research also proves that there is a reduction in empathy scores in medical students as they progress from first year to final year. The maximum decrease in scores is observed between medical students as they progress from second to their third year as they start with clinical training, this being a time when empathic communication is really needed. However, this decline reflects that changes in empathy are found on some parameters that were important and not in others. In fact, some facets of empathy which are thought to be more critical to good physician–patient communication actually improved during this phase [8, 11].

2.3 Empathy in the Indian Context

William Chopik of Michigan State University had conducted a study on the country by country ranking on empathy based on data gathered from 104,365 adults spread across 63 countries. The highest scoring countries are Ecuador and Saudi Arabia, and nations such as the US also score very high compared to east Asian countries [18] The African continent mostly scores low and India is comparatively quite average on the empathy score. However, Chopik pointed out that it was only a snapshot and he noted that cultures are constantly evolving therefore there were possibilities for changes in empathy scores (see Fig. 1).

Fig. 1
figure 1

The world map evolved from William Chopik’s study on country ranking on empathy

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Upbringing, economic strata, culture, age and gender influence the level of empathy of individuals [19]. Indian parenting styles and the education system have a strong influence on the population. Empathy is a much talked about but ignored characteristic in India.

249 undergraduate medical students of a medical college of Kolkata underwent a cross-sectional study through interviews. The study looked into the sociodemographic profile of the students, their career satisfaction and future career aspirations. The JSE (medical students’ version) was adapted for this study. It was concluded that empathy levels of medical students of this study was quite low compared to other studies conducted outside India. Empathy reduced among the students with each semester, which is in line with other research in this regard [1, 20].

2.4 The Indian Nursing Scenario

The nurse-to-patient ratio in India is 3:1777, and as per WHO recommendations, nurses to current population ratio should have been 3:1000, implying a shortfall of 18,09,757 nurses approximately in the country. The attrition rate of nurses in India is 28 to 35% which is much higher than the average in the healthcare sector, which is around 10.1%. A lack of adequate number of institutions providing training in nursing, and migration of nurses to other countries from India are the two most prominent reasons for the shortage of trained nurses in India [21, 22, 25]. Shortage of staff is a strong contributor towards workplace stress for nurses in India which in turn impacts patient care [23, 24, 25].

3 Aim

To conduct a pilot study and design and develop a reliable tool or scale which assesses the cognitive, affective, and motivational aspects of empathy in nurses in India.

4 Methods

Interviews were conducted with five behavioral design experts, healthcare professionals and human factors specialists (having minimum 10 years of experience, Average Age: 37 years) to understand the requirements for empathy scale and to identify a set of keywords related to cognitive, affective, and motivational aspects of empathy. A set of keywords also picked from the existing JSE scale. Then, both sets of keywords have been considered for ratings (on a seven-point Likert scale).

18 Indian nurses from diverse backgrounds in terms of age, gender, marital status, state and type of hospital were administered the questionnaire. (Mage ± SD = 28.50 ± 7.84; male = 56%, female = 44%). The nurses were from 19 to 46 years old, belonged to Karnataka, Kerala, Andhra Pradesh, Rajasthan, Tamil Nadu, and Haryana and were associated with Private, Govt, Autonomous hospitals and Universities. Their qualifications included B.Sc, M. Sc and Ph.D.

The scale captured sociodemographic data and included 30 items that captured family support, educational support, and emotional factors for empathy. It measured factors such as individual motivation on the job, understanding of the importance of empathetic behavior in patient treatment. It also evaluated detrimental factors such as stress, lack of training, lack of time and resources, which lead to non-empathetic behavior and conflicts with patients. The items in the pilot empathy scale are listed below in the Table 1. A few questions were adapted from the JSE which have been highlighted in Table 1 as “Existing”, whereas new questions have been listed as “New”.

Table 1 New empathy tool for Indian nurses
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Factor analysis (principal component analysis, using 50 iterations and Varimax Rotation Matrix, minimum coefficient value = 0.50) was performed to come up with the new sets of items and the modified empathy scale which was then standardized after reliability check (by calculating Cronbach’s alpha).

5 Results and Discussions

The nurses responded to the questions on a 7 points Likert Scale. The results were analyzed with 50 iterations and a rating and correlations came out across 8 components.

Item numbers 1 to 3 in Table 2 represent the level of empathy in the individual environment in which the nurse was brought up and currently exists. These came out to be 0.879, 0.573 and 0.843 under factor 1, thus proving that there is a strong correlation between the empathetic environment (upbringing, family, teachers) with the nurses’ display of empathetic behavior towards patients. Item 4, 11, 13, 16, 19, 20 are at 0.890, 0.925, 0.733, 0.873, 0.730, 0.923) under Factor 1 represent the cognitive construct and positive mindset of the nurses towards practicing empathy with patients including the importance of listening, observation of patient body language and the understanding of the positive impact of empathy caring for patients. In the Indian context as seen through Item 18, which is at 0.662 under Factor 1 it appears there is a stronger need to understand the family background of patients, which may not be considered important internationally. Nurses are valuing the importance of empathy and many are motivated towards patient care; however, there are several stress factors due to lack of resources and time that have a detrimental effect on the nurse patient interaction in India which comes through in Item 8 at 0.855 under Factor 2. Certain factors such as Item 29, sense of humor during patient treatment which are there in JSR, may not considered a critical factor in the Indian context as it comes under Factor 3 at 0.683 (Table 2).

Table 2 Rotated component matrix
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Table 3 Total variance explained
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6 Reliability

The new empathy scale covers cognitive, affective, and motivational aspects of empathy, and the responses for each item was consistently rated by Indian nurses (Cronbach’s alpha > 0.70), which is considered reliable overall. The constructs listed in Table 1, related to the empathy in the individual’s environment including family and education (IEENV) were found to be at 0.78; Positive cognitive constructs such as the nurse’s understanding of the importance of listening, observing body language and the overall importance of empathetic behavior (COGP) came out to be at 0.94, The importance of the emotional aspects of empathetic behavior (EMO) came out to be at 0.72. The negative cognitive aspects such as shortage of resources, stress factors due to stress and home and work (COGN) came out to be 0.88. Pearson Correlation was carried out on the motivation for empathetic behavior (EMPMO) which came out to be > 50 which is considered reliable.

7 Conclusion

Factors such as upbringing, family support and educational background have a strong correlation with empathy displayed in the nurse-patient relationship in the Indian context. Stresses such as shortage of resources and time have a negative effect on nurse empathy. This new empathy scale is effective to measure the empathy of Indian nurses and might further be used by researchers to measure the impact of training on the empathetic responses of Indian nurses towards patients.

Some of the limitations of the tool is that the scale is a self-reported measure, as it is directly reported by the nurses on a Likert scale. Further development of this tool will need include a scale for observers such as doctors and patients to record affective and behavioral traits of nurses.

The next steps for this research will be to test this scale on a larger population, since it has been tested only on a population of 18 nurses. Additionally, the scale would need to be tested further with an Indian and International population of nurses to determine whether the Indian factors identified are accurate and relevant.