Content uploaded by Mirella Castelhano
Author content
All content in this area was uploaded by Mirella Castelhano on Oct 28, 2020
Content may be subject to copyright.
Original Manuscript
Empathic profile of nursing
freshmen
Isabel Ame
´lia Costa Mendes , Maria Auxiliadora Trevizan ,
Mirella Castelhano Souza , Valtuir Duarte Souza-Junior ,
Simone de Godoy , Carla Aparecida Arena Ventura
and Sara Soares dos Santos
University of Sa
˜o Paulo, Brazil
Abstract
Objective: To analyze the empathic profile and the empathy scores of freshmen of the nursing course.
Design and participants: Descriptive study involving 399 freshmen students of two modalities of
nursing courses: Bachelor and Bachelor and Teaching Diploma, in the period from 2012 to 2015.
A sociodemographic questionnaire and the Empathy Inventory were applied.
Ethical considerations: The research received approval from the Research Ethics Committee of the
University of Sa
˜o Paulo at Ribeira
˜o Preto College of Nursing. The students registered their acceptance to
participate in the research by signing the Free and Informed Consent Form and anonymity was guaranteed.
Findings: The mean age of the participants was 19 years, being 85.5% female. The students were grouped
by course modality and all groups presented high empathy scores. A significant difference (p < 0.001) was
found, which indicates that students of the Bachelor and Teaching Diploma program presented a higher
degree of empathy for the General Score, Domain 2 (Interpersonal Flexibility), and Domain 3 (Altruism) in
relation to students in the Bachelor program.
Conclusion: Results show that nursing undergraduate freshmen are emphatic, with minimum differences
between the two courses. This profile is relevant for the development of future professionals capable to
demonstrate a balance between instrumental and expressive competences.
Keywords
Empathy, nursing, bachelor program, diploma program
Introduction
Even before its concept was defined in the nineteenth century, it was acknowledged that empathy pervades
human relationships. The origin of the word “einfu
¨hlung” dates back to 1873, when the German philosopher
Robert Vischer defined it as a projection of an observer’s internal predisposition in response to the percep-
tion of an object.
1
Translated into English in 1909, the word was called empathy, meaning a set of internal
characteristics that stimulate the search for knowledge of the other.
2
Corresponding author: Isabel Ame
´lia Costa Mendes, Ribeira
˜o Preto College of Nursing, University of Sa
˜o Paulo, Avenida dos
Bandeirantes, 3900, Campus Universita
´rio—Bairro Monte Alegre, Ribeira
˜o Preto 14040-902, Brazil.
Email: iamendes @usp.br
Nursing Ethics
2019, Vol. 26(7-8) 2298–2305
ªThe Author(s) 2018
Article reuse guidelines:
sagepub.com/journals-permissions
10.1177/0969733018780532
journals.sagepub.com/home/nej
Nursing is characterized as a profession whose mission is to promote the human being through care,
considering and respecting it in its freedom, oneness, and dignity. It is a profession that is sensitive to the
internalization of values that, in conjunction with specific knowledge, guide and sustain professional
practice. Caring presupposes the need for a set of attitudes that promote the full application of acquired
knowledge, taking into account that knowledge is always necessary, but not enough: the attitudes in tune
with the knowledge are crucial for a good practice of this profession.
3
Care favors and strengthens the professional experience that takes place in the extensive possibility
of meeting and relationship between nurses and the human beings they take care of. In this context, the
constant presence of nurses at the side of those whoarecaredfordeterminesthe significance of the
social role of nursing.
4
In the performance of their role, nurses need to harmonize two sets of skills: expressive and instru-
mental. The simultaneous use of rationality and sensitivity requires technical–scientific competence,
dexterity, politeness, kindness, delicacy, affectivity, and courtesy, that is, having the competence to
develop evidence-based care adjusted to the rhythm of scientific and technological developments and,
at the same time, benefiting from their sensitivity, showing their presence as sensitive professionals.
5
Thus, nurse–patient interaction and empathy are fundamental, being a condition for nurses to understand
patients’ feelings and to jointly build a care plan that seeks to promote their well-being.
6
This is only
possible for individuals who have the will, dedication, commitment, responsibility, and are able to harmo-
nize the instrumental and expressive skills.
7
The communication with the patient has therapeutic effects and
supports the healing process, demonstrated by the achievement of positive results in psycho-social aspects,
such as quality of life, anxiety, and depression, as well as in the improvement of objective parameters, such
as the reduction of blood pressure and blood glucose levels.
8
Empathy is the basis for the understanding between the patient and thehealth professional and is considered
a basic element in caring, also being associated with patient satisfaction.
9
It makes the relationship between the
professionals and the patients more intense, allowing the latter to express their needs.
10
It is a prerequisite for
nursing care and provides for improvements in the patients’ clinical and psychological conditions.
11
Considering the importance of empathy for nurses in their relationship with patients, the aim of this study
was to analyze the empathic profile and empathy scores of nursing freshmen students, aiming at learning
their level of empathy at the beginning of the program and addressing changes in the curriculum according
to these data, with the purpose to maximize their learning on ethical aspects of care. The sample was formed
by students from the two modalities of Nursing programs offered by the institution, as they have a different
curriculum and structure. The results of this study may contribute to leverage learning and action based on
the ethical principles of future nurses. These results will also offer a means to support pre-course assess-
ments of nursing freshmen students. Although it is a study focused on Brazil and Brazilian Nursing students,
these findings may be of interest to other nursing courses from different parts of the globe, showing the
relevance of the empathic profile and empathy scores and of working with them in Nursing curricula in the
process of forming nurses who will be able to provide an ethical care in their future career.
Design and participants
This is a descriptive, cross-sectional study with a quantitative approach. It was developed with freshmen
enrolled in two nursing undergraduate courses at a Public Higher Education Institution in the interior of the
state of Sa
˜o Paulo, which offers two modalities of nursing course: a Bachelor (lasting 4 years) and a
Bachelor and Teaching Diploma (with duration of 5 years, which provides training for comprehensive
professional practice, in addition to the pedagogical training legally required for professionals who will
work in secondary nursing education, preparing nursing technicians). The research received approval from
Mendes et al. 2299
the Research Ethics Committee of the University of Sa
˜o Paulo at Ribeira
˜o Preto College of Nursing
(protocol 1348/2011).
Data were collected between 2012 and 2015, from first-year undergraduates from both courses, who were
present in the classroom on the dates scheduled for the collection. The dates were scheduled in advance with
the teachers responsible for the disciplines. The questionnaires were applied after the students registered their
acceptance to participate in the research by signing the Free and Informed Consent Form. All the graduates
present at the collection dates were invited to participate in the study, and the average time for completing the
questionnaire was 20 min. Of the 520 (100%) graduating students in the years from 2012 to 2015, 399
(76.73%) participated in the research and answered two questionnaires, one regarding the sociodemographic
data to characterize the participants and the Empathy Inventory (EI).
12
Research using the EI has been used to
evaluate the levels of empathy, whether in adult volunteers
13,14
or in nursing professionals.
15
The EI consists of 40 questions that measure cognitive, affective, and behavioral behaviors. The answers
are indicated on a 5-point Likert scale, in which 1 (one) corresponds to “never” and 5 (five) to “always.” The
EI score can vary from 40 to 200 points, and the higher the score, the higher the individual’s empathic
degree. The inventory has four domains, namely, Domain 1—Perspective Taking (PT), with 12 questions
about a person’s ability to understand the perspective and feelings of the other; Domain 2—Interpersonal
Flexibility (IF), consisting of 10 questions about the person’s ability to tolerate other people’s behaviors,
attitudes, and thoughts, which are very different or frustrating. A low score in this factor indicates that the
person has difficulty to accept different points of view and tends to be easily annoyed in situations of
conflict of interest or interpersonal frustration; Domain 3—Altruism (AL), with 9 questions that reflect
individuals’ ability to sacrifice their own interests for the purpose of benefiting or helping someone: a low
score on this factor shows that the person is selfish; Domain 4—Affective Sensitivity (AS), which contains
9 questions that reflect feelings of compassion and interest in the emotional state of the other: a low score
indicates that the person has little attention or care in relation to other people’s needs.
12
For data analysis, Student’s t-test was used, comparing two means from non-paired samples. For the use
of this test, it is necessary to test if the variances of the two groups are statistically equal and if the data
follow a normal distribution. This procedure was performed using the PROC TTEST, as well as the PROC
generalized linear model (GLM) for analysis of variance (ANOVA), both in SAS
®
9.0 software. For the
comparisons, orthogonal contrasts were performed based on the t distribution. For the analysis of the EI’s
general and domain reliability, Cronbach’s alpha coefficient was calculated.
Results
The sample comprised 399 nursing students, 341 (85.5%) of whom were female, with a mean age of 19
years, minimum variation of 18 years and maximum of 48 years. Eight groups of undergraduate freshmen
students were analyzed: Group B1 consisting of freshmen from the Bachelor program of 2012 (15.8%);
Group B2 Bachelor of 2013 (15.8%); Group B3 Bachelor of 2014 (13%); Group B4 Bachelor of 2015
(15.5%); Group L1 Bachelor and Teaching Diploma of 2012 (11.3%); Group L2 Bachelor and Teaching
Diploma of 2013 (10.3%); Group L3 Bachelor and Teaching Diploma of 2014 (8.3%); and Group L4
Bachelor and Teaching Diploma of 2015 (10%).
The psychometric tests presented a Cronbach’s alpha of 0.87 for the General Score and 0.84 for Domain
1—PT; 0.83 for Domain 2—IF; 0.71 for Domain 3—AL; and 0.73 for Domain 4—AS.
Table 1 presents the general average of the students’ scores in each domain of the EI according to the
course. The empathy score for the General Score between the total group of Bachelor students (group B) and
the total group of Bachelor and Teaching Diploma students (group L) does not present considerable
variation between the groups.
2300 Nursing Ethics 26(7-8)
Table 1. Mean, standard deviation, and minima and maxima of the students’ general and domain (n ¼399) on the
Empathy Inventory according to the course (Ribeira
˜o Preto, SP, Brazil, 2017).
Group Variables N Mean Standard deviation Minimum Median Maximum
Bachelor: Group B General 240 144.06 15.82 52.00 144.50 180.00
D1 240 43.86 6.92 13.00 44.00 60.00
D2 240 29.69 7.08 10.00 31.00 46.00
D3 240 33.01 5.44 10.00 33.00 43.00
D4 240 37.50 4.78 19.00 38.00 45.00
Teaching Diploma: Group L General 159 145.03 18.30 93.00 144.00 187.00
D1 159 43.60 7.10 24.00 43.00 59.00
D2 159 30.73 7.70 12.00 32.00 47.00
D3 159 33.87 5.58 19.00 34.00 45.00
D4 159 36.82 4.83 24.00 37.00 45.00
D: domain.
Table 2. Comparisons between general and domain scores of the Empathy Inventory for the groups of freshmen from
the Nursing Bachelor (B) Bachelor and Teaching Diploma (L) programs between 2012 and 2015 (Ribeira
˜o Preto, SP,
Brazil, 2017).
Comparisons between Groups B and L per year p* 95% CI
General Score
B1—L1 2012 0.51 8.58 4.31
B2—L2 2013 0.21 –2.42 10.84
B3—L3 2014 0.04 –14.89 –0.17
B4—L4 2015 0.84 –6.04 7.36
Domain 1
B1—L1 2012 0.60 –3.40 1.97
B2—L2 2013 0.15 –0.78 4.74
B3—L3 2014 0.65 –3.74 2.37
B4—L4 2015 0.78 –2.40 3.17
Domain 2
B1—L1 2012 0.47 –3.84 1.79
B2—L2 2013 0.92 3.03 2.76
B3—L3 2014 0.02 –6.88 –0.45
B4—L4 2015 0.88 –2.71 3.14
Domain 3
B1—L1 2012 0.38 –3.04 1.17
B2—L2 2013 0.63 –1.64 2.69
B3—L3 2014 0.01 –5.45 –0.64
B4—L4 2015 0.75 –2.54 1.84
Domain 4
B1—L1 2012 0.56 –1.30 2.38
B2—L2 2013 0.05 –0.05 3.73
B3—L3 2014 0.90 –2.22 1.97
B4—L4 2015 0.67 –1.51 2.31
CI: confidence interval.
*p is the coefficient related to analysis of variance (ANOVA) test.
Mendes et al. 2301
Table 2 shows the comparisons between the general and domain scores of the EI between the groups of
the two course modalities. It was observed between groups A3 (Bachelor 2014) and L3 (Bachelor and
Teaching Diploma 2014) that the Bachelor group presented a higher degree of empathy for the General
Score (p ¼0.04), in Domain 2 (p ¼0.02), and in Domain 3 (p ¼0.01). In the individual analysis by groups
and by domains, a significant statistical difference was observed between B3 (Bachelor 2014) and L3
(Bachelor and Teaching Diploma 2014), where the teaching diploma group had a higher degree of empathy
for the General Score (p ¼0.04), in Domain 2 (p ¼0.02), and in Domain 3 (p ¼0.01).
Finally, Table 3 summarizes the overall score of all subjects in each course modality: Bachelor (B) and
Bachelor and Teaching Diploma (L), in each of the four domains of the EI.
Discussion
All the groups analyzed presented high empathy scores, which shows that, from the start, the individuals who
choose the nursing course for vocational training already present levels of empathy compatible with the needs
of this course. Researchers state that there is a statistically significant decline in empathy among nursing and
medical freshmen compared to senior students, and this prevails after the clinical internships.
11,16–18
A study involving nursing undergraduates revealed that junior students have a higher degree of
empathy compared to freshmen, and some researchers attribute this to maturity and because they have
more opportunities for training, besides empathic skills.
19
However, comparing the levels of empathy
among the nursing students in each course year at an Australian university showed that the sophomores
and junior students showed higher levels of empathy than the freshmen.
20
Freshmen in health courses in general were also submitted to this evaluation, which concluded that
nursing students have higher levels of empathy
8
than other students in the health area. Comparative analyses
of freshmen, sophomores, and junior students’ perceptions, however, did not demonstrate significant
differences in the levels of empathy between these groups.
17,21
There is a gap in the literature regarding studies analyzing the empathic profile of Nursing undergraduate
freshmen students. However, a study about the profile of Nursing undergraduate students from the same
institution showed that the majority of freshmen students from the Nursing and Teaching Diploma program
are from public high schools and the majority of students from the Nursing Bachelor’s Program are from
private high schools.Other characteristic found is that the majority offreshmen students work orhave worked
before enrolling the university. Thus, they are more mature due to their previous life experiences and are able
to better understand the context of the course and the importance of valuing interpersonal relationships.
22
This difference shows how empathy develops in the individuals inserted in society in different ways.
This factor may depend on several aspects, such as the social, cultural, academic, and family environment,
Table 3. Comparisons between groups for general and domain scores on the Empathy Inventory for freshmen in
Nursing Bachelor (B) and Bachelor and Teaching Diploma (L) program between 2012 and 2015 (Ribeira
˜o Preto, SP,
Brazil, 2017).
Comparisons between Groups B and L between 2012 and 2015 p* 95% CI
General Score 0.57 –4.35 2.42
Domain 1 0.72 –1.15 1.66
Domain 2 0.16 –2.51 0.43
Domain 3 0.12 –1.96 0.24
Domain 4 0.16 –0.27 1.65
CI: confidence interval.
*p is the coefficient related to analysis of variance (ANOVA) test.
2302 Nursing Ethics 26(7-8)
being the most characteristic and influential in people’s character. As known, the family environment
fosters emotional stability, later expressed in society through attitudes and behaviors; when the individual
goes to college to take a course, however, especially in the health area, he can only develop empathy
depending on his academic performance, course, and family life.
23
But fundamentally, if human values
are at the heart of the set of values professed to support the mission in the nursing education institution, its
teachers will be alert and dedicated to developing relational skills in students and to emphasize the
exercise of empathy during the course, understanding that this should be an investment goal in working
life. All teachers should engage in this undertaking throughout the course. Our results showed satisfactory
levels; but sufficient levels of empathy may be reached if further investments are made in this regard. To
the extent that further investments are made, better and therefore sufficient levels can be achieved in
terms of clinical empathy.
If we want to offer patient-centered care, we need to be attentive to our professionals’ degree of clinical
empathy.
24,25
There is evidence that skills required to deliver patient-centered care, and specifically to
develop empathy as learned behavior, can be taught and learned, although there is no clarity about the
sustainability of the outcomes.
24,26–29
Therefore, a training program is useful to maintain levels of
empathy that are compatible with the progress of the professional and the student, in tune with the
development of critical thinking.
25,30,31
Our experience dedicated to the study and analysis of undergraduate nursing students’ empathic profile
as from their entry into the course converges to the understanding that cognitive empathy is a learnable skill
whose seed needs to be planted in the undergraduate student’s fertile soil and continuously nurtured both
during the course and throughout the professional activity.
32
Empathy is, therefore, an essential asset of the health professional, which adds qualification to care and
improves patient outcomes. The recognition of this asset is based on evidence,
32
which maintains positions
favorable to the change of focus in the health professional’s curriculum: instead of being only focused on
knowledge acquisition, teaching needs to be refocused to prioritize cognitive empathy, to the same extent,
in order to be able to rely on empathic professionals.
This study has some limitations. Although the research is anonymous and voluntary, students may not
have answered the questionnaire honestly. In addition, we should also consider that our study was con-
ducted in Brazil only, involving undergraduate students from one of the 104 public nursing schools and 601
private nursing schools in this country, limiting the generalization of the results. Replicating the study in a
more representative number of nursing schools in the country would be indicated. In addition, there are
other scales to assess levels of empathy, which can be used and compared to the scale adopted in this study.
There is, however, a need to check whether this degree of empathy is maintained throughout and at the end
of the course.
Conclusion
Results showed that the students are empathic with minimum differences between the two courses. The
students from the Nursing and Teaching Diploma Program presented better results in “Interpersonal
Flexibility” and “Altruism” domains, when compared to students from the Bachelor’s Nursing Program.
This profile means that they are capable to tolerate behaviors, attitudes and thoughts of others, and can
deny their own interests with the aim to benefit or help other person. This result is important, as an
empathic profile among freshmen in undergraduate nursing programs is fundamental to develop future
professionals who are able to demonstrate a balance between their instrumental and expressive compe-
tences in their practice.
Mendes et al. 2303
Acknowledgements
M.A.T. and I.A.C.M. developed study idea. M.C.S., S.S.d.S., and I.A.C.M. performed data collection.
V.D.S., S.d.G., M.C.S. performed statistical analysis. M.C.S., V.D.S., M.A.T., and I.A.C.M. drafted manu-
script with contribution from S.d.G., C.A.A.V., and S.S.d.S. All authors read and approved the final
manuscript.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: This study was supported by the Ministry of Science, Technology, Innovation
and Communications, Brazil, by its National Council for Scientific and Technological Development—
CNPq, and by the Ministry of Education, CAPES, Brazil.
ORCID iD
Isabel Ame´lia Costa Mendes https://orcid.org/0000-0002-0704-4319
Maria Auxiliadora Trevizan https://orcid.org/0000-0002-7306-9805
Mirella Castelhano Souza https://orcid.org/0000-0001-9036-3304
Valtuir Duarte Souza Jr https://orcid.org/0000-0002-8660-9743
Simone de Godoy https://orcid.org/0000-0003-0020-7645
Sara Soares dos Santos https://orcid.org/0000-0003-0712-0200
References
1. Hunsdahl JB. Concerning Einfu
¨hlung (empathy): a concept analysis of its origin and early development. J Hist
Behav Sci 1967; 3: 180–191.
2. Burns DD and Auerbach A. Therapeutic empathy in cognitive-behavioral therapy: does it really make a difference?
In: Salkovskis PM (ed.) Frontiers of cognitive therapy. New York: Guilford Press, 1996, pp. 135–164.
3. Mendes IAC. O resgate do cuidar na enfermagem [The rescue of caring in nursing]. Rev Lat-Am Enferm 2000; 8:
1–5.
4. Carvalho V. Sobre a identidade profissional na Enfermagem: reconsiderac¸o
˜es pontuais em visa
˜o filoso´ fica [About
the professional identity in Nursing: punctual reconsiderations in philosophical vision]. Rev Bras Enferm 2013; 66:
24–32.
5. Figueiredo NMA. A mais belas das artes: pensar e o fazer da enfermagem: bases teo´ricas e pra´ticas para uma teoria
do cuidado/conforto [The most beautiful of the arts. ... nursing thinking and doing: theorethical and practical bases
for a theory of care/comfort]. Rev Bras Enferm 1997; 50(4): 620.
6. Arielli D. Emotional work and diversity in clinical placements of nursing students. J Nurs Scholarsh 2013; 45:
192–201.
7. Mendes IAC, Trevizan MA, Ferraz CA, et al. The re-humanization of the executive nurse’s job: a focus on the
spiritual dimension. Rev Lat-Am Enferm 2002; 10: 401–407.
8. Neumann M, Edelha¨user F, 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.
9. Duarte J, Gouveia JP and Cruz B. Relationships between nurses’ empathy, self-compassion and dimensions of
professional quality of life: a cross-sectional study. Int J Nurs Stud 2016; 60: 1–11.
2304 Nursing Ethics 26(7-8)
10. Willians B, Sifris A and Lynch M. A psychometric appraisal of the Jefferson Scale of Empathy using law students.
Psychol Res Behav Manag 2016; 6: 171–178.
11. Petrucci C, La Cerra C, Aloisio F, et al. Empathy in health professional students: a comparative cross-sectional
study. Nurse Educ Today 2016; 41: 1–5.
12. Falcone EMO, Ferreira MC, Luz RCML, et al. Inventa´rio de Empatia (I.E.): desenvolvimento e validac¸a
˜o de uma
medida brasileira [Construction of a brazilian measure to evaluate empathy: the Empathy Inventory (EI)]. Aval
Psicol 2008; 7: 321–334.
13. Pinho VD, Fernandes CS and Falcone EMO. A influeˆncia da idade e da escolaridade sobre a experieˆncia empa´tica de
adultos [Influence of age and schooling degree on adults’ empathic experience]. Estud Pesq Psicol 2011; 11: 456–471.
14. Pinho VD and Falcone EMO. O papel preditivo da habilidade empa´tica sobre o perda
˜o interpessoal [The predictive
role of empathic skill on interpersonal forgiveness]. Temas Psicol 2016; 24: 1507–1518.
15. Trevizan MA, Almeida RGS, Souza MC, et al. Empathy in Brazilian nursing professionals: a descriptive study.
Nurs Ethics 2014; 22: 367–376.
16. Ward J. The empathy enigma: an empirical study of decline in empathy among undergraduate nursing students.
J Prof Nurs 2012; 28(1): 34–40.
17. Lauder W, Reynolds W, Smith A, et al. A comparison of therapeutic commitment, role support, role competency
and empathy in three cohorts of nursing students. J Psychiatr Ment Health Nurs 2002; 9: 483–491.
18. Chen D, Lew R, Hershman M, et al. A cross-sectional measurement of medical student empathy. J Gen Intern Med
2007; 22: 1434–1438.
19. Ouzovnic C and Nakakis K. An exploratory student nurses’ empathy. Health Sci J 2012; 6(3): 534–552.
20. Williams B, Brown T, Boyle M, et al. Levels of empathy in undergraduate emergency health, nursing, and
midwifery students: a longitudinal study. Adv Med Educ Pract 2014; 5: 299–306.
21. Lovan SR and Wilson M. Comparing empathy levels in students at the beginning and end of a nursing program. Int
J Hum Caring 2012; 16: 28–33.
22. Correa AK, Souza MC, Santos RA, et al. Profile of students entering the nursing diploma program: University of
Sa
˜o Paulo at Ribeira
˜o Preto College of Nursing. Rev Esc Enferm 2011; 45: 933–938.
23. Anayaa MM, Amador LI and Martı´nez FG. Factores relacionados con la empatı´a en estudiantes de Enfermerı´a de la
Universidad de Cartagena [Empathy-related factors in Nursing students of the Cartagena University]. Enferm Clı
´
n
2016; 26: 282–289.
24. Rosenthal S, Howard B, Schlussel YR, et al. Humanism at heart: preserving empathy in third-year medical
students. Acad Med 2011; 86: 350–358.
25. Williams B, Boyle M and Howard S. Empathy levels in undergraduate paramedic students: a three-year long-
itudinal study. Nurse Educ Pract 2016; 16: 86–90.
26. Bosse HM, Nickel M, Huwendiek S, et al. Peer role-play and standardised patients in communication training: a compara-
tive study on the student perspective on acceptability, realism, and perceived effect. BMC Med Educ 2010; 10: 27.
27. Fields SK, Mahan P, Tillman P, et al. Measuring empathy in healthcare profession students using the Jefferson
Scale of Physician Empathy: health provider-student version. J Interprof Care 2011; 25: 287–293.
28. Guastello S and Frampton S. Patient-centered care retreats as a method for enhancing and sustaining compassion in
action in healthcare settings. J Compassion Health Care 2014; 1: 2.
29. Jeffrey D. Empathy, sympathy and compassion in healthcare: is there a problem? Is there a difference? Does it
matter? J R Soc Med 2016; 109: 446–452.
30. Ghazivakili Z, Nia RN, Panahi F, et al. The role of critical thinking skills and learning styles of university students
in their academic performance. J Adv Med Educ Prof 2014; 2: 95–102.
31. Taj J, Molloy E, Haines T, et al. Same-level peer-assisted learning in medical clinical placements: a narrative
systematic review. Med Educ 2016; 50: 469–484.
32. Cundell DR. Culturing the empathic health professional: challenges and opportunities. Healthc Transform 2017; 2:
71–83.
Mendes et al. 2305
