Empathy assessment in healthcare students is highly heterogeneous: A systematic review and meta-analysis (2012-2016)

Table 1 Scales and studies in the meta-analysis

Study	Country	n	mean Age	Male %	Field	Reliability	Items	Aims	Main results
Balanced emotional empathy scale
Dehning et al[82]	Ethiopia	237	21.4	87.3	Medical Students	0.72	30	To examine the differences in empathy between first year and final year medical students in Jimma University, Ethiopia	Male students had statistically significant lower empathy scores
Caring ability inventory
Ma et al[91]	China	598	20.9	6.4	Nursing Students	0.77	37	To investigate baccalaureate nursing students’ caring ability in the context of China and to explore the role of clinical practice learning in the development of students’ caring skills	Students in the clinical stage of training scored lower than students in the pre-clinical stage.
Caring behaviour inventory tool
Labrague et al[111]	Greece, Philippines, India, Nigeria	586	22.3	10.1	Nursing Students	0.92	42	To identify the correlation between instructors’ and students’ caring behaviours and to explore the impact of instructors’ caring on students' perceptions of their own caring behaviours	The highest self-reported subscale in the Caring Behaviour Inventory was assurance (mean = 4.796), and the lowest self-rated subscale was connectedness (mean = 4.541)
Loke et al[92]	Singapore	657	20.3	13.2	Nursing Students	0.922	42	To evaluate the impact of Singapore’s pre-registration nursing programmes on students' concept of caring	Results indicated a statistically significant reduction in the overall level of caring behaviour in first to final year students
Davis’ interpersonal reactivity index
Neumann et al[112] (1)	Germany	44	22.8	54.5	Medical Students	0.721	28	To investigate the psychometric properties of two empathy scales	Reliability was satisfactory and comparable to international adaptations
van Ryn et al[113] (1)	USA	4732		50.1	Medical Students	0.825	14	To examine individual predictors of first semester medical students' attitudes toward the value of physician empathy in clinical encounters	In univariate and multivariate analyses, Discomfort with uncertainty, close-mindedness, dispositional empathy, elitism, medical authoritarianism, egalitarianism, self-concept and well-being predicted students' empathy
Costa et al[95] (1)	Portugal, Brazil, UK, New Zealand, Ireland	3069		38.5	Medical Students	0.776	24	To examine psychometric properties (reliability, factor structure) of two empathy scales and compare them	The Interpersonal Reactivity Index and Jefferson Scale of Physician Empathy are only weakly related, suggesting that they may measure different constructs (maximum correlation 0.313)
Emotional intelligence assessment scale - empathy
Senyuva et al[97]	Turkey	471	20.65	16.6	Nursing Students	0.87	6	To analyse the correlation of self-compassion and emotional intelligence of nursing students	There was a correlation between self-compassion and emotional intelligence (r = 0.400, P < 0.05) and that emotional intelligence has positive contributions to the features of nurses with developed self-compassion
Jefferson scale of physician empathy
Kimmelman et al[114]	USA	415	26	54	Osteopathic medical students	0.83	20	To determine differences according to year of schooling in mean levels of empathy among osteopathic medical students	There were no statistically significant differences by year of schooling in respondents' gender, ethnicity, or specialty orientation and no statistically significant differences by year of schooling in the mean empathy scores
Mandel and Schweinle[115]	USA	328	24	17.4	Physician Assistant Students	0.8	20	To investigate empathy trends among physician assistant students through their education and included gender differences and specialty job interest	62% had lower median empathy scores toward the end of their didactic training than at the time of matriculation (P = 0.0001). Female students were significantly more empathetic at the time of matriculation than men (P = 0.0003), while both genders appeared to lose empathy in a parallel fashion during didactic training (P = 0.76). There was no association between empathy scores and prospective job category interest
Neumann et al[112] (2)	Germany	44	22.8	54.5	Medical Students	0.803	20	To investigate the psychometric properties of two empathy scales	Reliability was satisfactory and comparable to international adaptations
Paro et al[90]	Brazil	299		61.7	Medical Students	0.84	20	To adapt the Jefferson Scale of Empathy to the Brazilian culture and to test its reliability and validity among Brazilian medical students	Principal component analysis confirmed the construct validity of the scale for three main factors: Compassionate Care (first factor), Ability to Stand in the Patient’s Shoes (second factor), and Perspective Taking (third factor). Gender differences with respect to empathy were not significant
Calabrese et al[116]	USA	373	26.1	52.8	Osteopathic medical students	0.84	20	To investigate correlations between empathy and interprofessional collaboration in osteopathic medical students and to examine differences in empathy and interprofessional collaboration scores by sex, class year, and specialty interest	Significant correlation was found between scores on the empathy and attitudes scales (r = 0.42, P < 0.01). Women scored higher than men on the empathy scale (117.1 vs 111.9). No statistically significant difference on the scores of the 2 scales was observed among students who planned to pursue "people-oriented" specialties compared with those interested in “technology/procedure-oriented” specialties as well as in different years if education
Costa et al[89]	Portugal	77		31.2	Medical Students	0.77	20	To model empathy longitudinally during medical school at three time points: at the entrance, final of pre-clinical phase and at the beginning of clinical training	Empathy scores at all times were higher for females than for males, but only significantly at the end of the preclinical phase. The model had satisfactory fit student's empathy did not decline over time. Empathy scores were significantly and positively related with Openness to Experience and Agreeableness at admission
Gonçalves-Pereira et al[117]	Portugal	202		32.7	Medical Students	0.75	20	To examine the relationship of empathy with professionalism	There was a weak association between empathy and person-orientation
Hsiao et al[118]	Taiwan	613	23.3	89.1	Nursing Students	0.93	20	To examine the psychometric properties of a Chinese version of the Jefferson Scale of Empathy-Health Profession Students among Taiwanese undergraduate nursing students	The content validity index of 0.89. Factor analysis yielded three components of perspective taking, compassionate care and standing in the patient’s shoes, explaining 57.14% of total variance. Women scored higher on empathy than men
Kiersma et al[96] (1)	USA	216	20.5	24.1	Pharmacy and nursing students	0.855	20	To validate an empathy scale to measure empathy in pharmacy and nursing students.	The Kiersma-Chen Empathy Scale scores on the empathy scale were positively associated with Jefferson scale scores (P < 0.001). Factor analysis showed a poor fit for the Kiersma-Chen Empathy Scale
Preusche and Wagner-Menghin[81]	Austria	516		47.8	Medical Students	0.823	20	To adapt the Jefferson Scale of Physician Empathy into a German version, examine its psychometric properties, to compare the level of attitude towards empathy with other adaptations	Item-total score correlations were all positive. Reliability was high; a 6-7 wk test-retest correlation for a subsample was 0.45. Factor analysis revealed a four-factor solution
Shariat and Habibi[119]	Iran	1187	22.6	36.1	Medical Students	0.79	20	To examine empathy in Iranian medical students and the psychometric properties of Jefferson Scale of empathy	Female students had higher scores of empathy and empathy decreased with higher years of education. The scale had acceptable internal consistency and test re-test reliability with a three-structure solution emerging from factor analysis
Wen et al[33]	China	753		36.8	Medical Students	0.83	20	To examine empathy among medical students in China	The three factors solution accounted for 48% of the variance. The mean empathy score was 109.60. The empathy score of medical students had significant differences between male and females (P < 0.05) and academic year (P < 0.05)
Williams et al[88]	Australia	330		34.8	Paramedics	0.75	20	To investigate psychometric properties of Jefferson Scale of Physician Empathy in paramedic students	The 2-factor solution, “compassionate care” and “perspective taking”, accounted for 44.2% of the total variance. The 17-item two-factor model produced good model fit and good reliability estimates. Three of the original items did not fit the model.
Khademalhosseini et al[120]	Iran	260	20.9	46.2	Medical Students	0.76	20	To measure the empathy score among medical students	Empathy scores decreased with increase in the students’ age (P = 0.001) year of study (P = 0.030). Mean empathy score in basic science level (65.5) was higher than clinical level empathy (55.5). Female students had higher mean empathy score (65.53) than male students (59.02)
Leombruni et al[121]	Italy	257	20.6	44.4	Medical Students	0.76	20	To examine psychometrics and confirm factor structure of the Italian version of the Jefferson Empathy Scale in Italian medical students	The empathy scale showed an acceptable internal consistency (r = 0.76) and test-retest reliability (r = 0.72). Confirmatory factor analysis found that the 3-factor structure has acceptable data fit. Female medical students showed a higher mean empathy score than did males
Mostafa et al[28]	Bangladesh	348		29.9	Medical Students	0.88	20	To measure and examine empathy among a sample of undergraduate medical students of Bangladesh	Mean empathy score was 110.41. There were significant associations between gender and empathy scores. The level of empathy in medical students gradually increases after clinical training in medical college. Non-significant difference were noted between empathy scores and specialty preferences.
van Ryn et al[113] (2)	USA	4732		50.1	Medical Students	0.88	20	(see details above)	(see details above)
Williams et al[122]	Australia	1111		18.4	Healthcare students (medicine, nursing, physiotherapy, occupational therapy, paramedics, midwifery, nutrition and dietetics)	0.78	20	To examine self-reported empathy levels of students enrolled in different health disciplines from two large Australian universities.	The mean female empathy score was significantly higher than the mean male score. Paramedic students had significantly lower empathy scores than all other participants except nursing students (P < 0.0001)
Youssef et al[84] (1)	Trinidad and Tobago	667	22.2	35	Medical Students	0.77	20	To explore the empathy profile of students across five years of medical training and to examine whether the Jefferson Scale for Physician Empathy correlated with a measure of cognitive empathy, the Reading the Mind in the Eyes Test and a measure of affective empathy, the Toronto Empathy Questionnaire	There was a significant correlation between the Jefferson Scale of Physician Empathy and the Toronto Empathy Questionnaire (rho = 0.48). There was a decline in medical student empathy scores over time. There was weak little correlation between scores from the Reading the Mind in the Eyes Test and the Jefferson Scale of Physician Empathy. Female students demonstrated significantly higher scores on all three measures.
Hojat and Gonnella[123]	USA	2637	23.4	49	Medical Students	0.8	20	To provide typical descriptive statistics, score distributions and percentile ranks of the Jefferson Scale of Empathy-Medical Student version	The score distributions of the Jefferson Scale of Empathy tended to be moderately skewed and platykurtic. Women obtained a significantly higher mean score (116.2 ± 9.7) than men (112.3 ± 10.8) on the Jefferson Scale of Empathy (P < 0.01). The tentative cut-off score to identify low scorers was ≤ 95 for men and ≤ 100 for women.
Jeon and Cho[103]	South Korea	447		18.1	Pharmacy students	0.713	20	To validate an empathy sale and to investigate the empathy levels of pharmacy students in South Korea	The 3-factor model of the empathy scale was confirmed by confirmatory factor analysis and the convergent validity was also supported by its correlations with the interpersonal reactivity index subscales.
Montanari et al[104]	Italy	797	22.63	26	Nursing Students	0.78	20	To test the psychometric properties of the Jefferson Scale of Empathy-Health Professional Student’s version and to describe their empathic engagement	Fit for a three-factor solution for 14 items: compassionate care/emotional engagement, perspective-taking, and standing in the patient's shoes. Confirmatory factor analysis on the second half of the sample showed good fit indexes for the 14-item solution and the 20 item solution of the scale, with the exception of one item
Park et al[87]	South Korea	5343	26.4	61.5	Medical Students	0.83	20	To evaluate empathy in Korean medical students throughout the country and to make suggestions to improve empathy	Females and post-baccalaureate students had higher scores. Students from higher grade levels had lower scores than those from the lower grade levels
Park et al[99]	South Korea	2692	24.7	62	Medical Students	0.715	20	To examine the relationship between stress, social support, and empathy among medical students	Empathy and social support were positively correlated, and empathy and stress negatively correlated. In the regression model, stress and social support predicted empathy
Petek Ster and Selic[102]	Slovenia	845	22.5	31.4	Medical Students	0.781	20	To re-validate the Jefferson Scale of Empathy (Student version) and its factor structure prior further research on empathy in medical students.	Females achieved higher empathy scores. The three-factor structure of empathy was confirmed. A higher proportion of explained variation was observed with Perspective Taking and Standing in the Patient's Shoes, and better internal consistency was noted in a reduced-item scale (16-18 items).
Williams et al[94]	Malaysia	204	20	44.3	Medical Students	0.7	20	To examine empathy scores in undergraduate medical students	The mean empathy score for first year students was significantly higher than second year students (P < 0.05). No significant difference relating to gender
Aggarwal et al[86]	India	978	21.6	31.6	Dentistry Students	0.677	20	To measure the self-reported empathy levels among dental undergraduate and postgraduate students and to review factors that could affect empathy	There were significant differences in empathy scores by gender and age (P < 0.01)
Costa et al[95] (2)	Portugal, Brazil, UK, New Zealand, Ireland	3069	38.5		Medical Students	0.69	20	(see details above)	(see details above)
Ferreira-Valente et al[101]	Spain	1104	20.7	32	Medical Students	0.78	20	To examine the psychometric properties of a Spanish empathy scale	The Spanish scale had acceptable to good sensitivity, convergent validity and reliability. The confirmatory factor analysis supported the three-factor solution and the second order latent factor model
Jordan and Foster[98]	USA	163			Medical Students	0.8	20	Examination of the interpersonal theory of clinical, personality, and social psychology to examine the construct of empathy and theorize about likely interpersonal correlates	All factors of empathy were related to interpersonal warmth. Perspective taking and compassionate care were associated with submissiveness. Walking in the patient’s shoes was correlated with social support and less loneliness
Mahoney et al[124]	Australia	281	26	42	Medical Students	0.815	20	To examine student and doctor empathy, and possible associations between empathy and the structure of clinical learning	Empathy decreased during the course of each year, but no differences between years of clinical education.
Sng et al[93]	Singapore	881		46.3	Medical Students	0.83	20	To investigate psychometric properties of Jefferson Scale of Physician Empathy	Empathy declined between preclinical and clinical years. Female and medical specialty interest respondents had higher scores but factor analysis suggested that the three factor model did not fit adequately
Spasenoska et al[100]	Malaysia	193	19.3	43	Medical Students	0.68	20	To investigate psychometric properties of Jefferson Scale of Physician Empathy	The scale was best interpreted as a two factor solution of perspective taking and compassionate care
Stansfield et al[125]	USA	4797	23.7	50.5	Medical Students	0.86	20	Analysis of factor structure of empathy and relations to other factors	Components of empathy change over time during undergraduate medical education (towards the end of education, it is a four factor structure of feelings, importance, ease, and metacognitive effort
Kiersma-Chen empathy scale
Kiersma et al[96] (2)	USA	216	20.5	24.1	Pharmacy and nursing students	0.86	15	(see details above)	(see details above)
Narcissism, aloofness, confidence, empathy (NACE) scale - empathy
Pitt et al[85]	Australia	133	27	14	Nursing Students	0.79	24	To describe the personal qualities of newly enrolled Bachelor of Nursing students; to determine if these a change according to age, gender, and time	Females were significantly more conscientious, community orientated and involved while males had significantly higher narcissism and aloofness scores and lower empathy
Patient-Practitioner orientation scale
Dockens et al[126]	USA	93	22.6	6.5	Speech and hearing sciences students	0.78	18	To determine preferences to patient-centeredness in pre-service speech and hearing students in the field of speech and hearing sciences	Across exposure levels, students exhibited high preference to patient centeredness with a mean empathy score of 4.13. A paired sample t-test revealed a significant difference (P < 0.0001) between the caring and sharing subscales of the empathy scale. No significant differences across levels of exposure for sharing subscale and caring subscale
Professionalism assessment scale - empathy
Klemenc-Ketis and Vrecko[127]	Slovenia	122	22.1	22.1	Medical Students	0.84	10	To develop and validate a scale for the assessment of professionalism in medical students based on students' perceptions of and attitudes towards professionalism in medicine	The scale was developed with 22 items. The Cronbach’s alpha of the scale was 0.88. Factor analysis revealed three factors: empathy and humanism, professional relationships and development and responsibility
Pro-Social personality battery (Other-Oriented empathy)
Eley et al[128]	USA	145	24	40.7	Medical Students	0.77	18	To examine personality trait profiles of rural longitudinal integrated clerkships students	Rural longitudinal integrated clerkships students who intended and matched to family medicine showed the highest levels of Reward Dependence (warm sociability) and Other-Oriented Empathy compared to any other specialty
Toronto composite empathy scale
Tsiantou et al[83]	Greece	460	20.7	34.8	Dentistry Students	0.75	52	To examine empathy among dentistry students in Greece and validate the Toronto Composite Empathy Scale	The scale has good discriminant and convergent validities. Test-retest reliabilities ranged from 0.478 to 0.779. Rotated factor analysis indicated that items loaded on two cognitive and three emotional factors. Females had significantly higher empathy scores
Toronto Empathy Questionnaire
Youssef et al[84] (2)	Trinidad and Tobago	662	22.2	35	Medical Students	0.85	16	(see details above)	(see details above)

Table 2 Meta-analytic means of Cronbach’s alpha per empathy scale

Scale	N	k	Alpha	95%CI		I2	P-value
Balanced Emotional Empathy Scale	237	1	0.72	0.666	0.769	--	--
Toronto Composite Empathy Scale	460	1	0.75	0.716	0.781	--	--
Caring Ability Inventory	598	1	0.77	0.743	0.795	--	--
Pro-Social Personality Battery (Other-Oriented Empathy)	145	1	0.77	0.71	0.821	--	--
Patient-Practitioner Orientation Scale	93	1	0.78	0.707	0.839	--	--
Narcissism, Aloofness, Confidence, Empathy (NACE) scale - Empathy	133	1	0.79	0.734	0.838	--	--
Davis’ Interpersonal Reactivity Index	7845	3	0.791	0.742	0.835	96.40%	< 0.001
Jefferson Scale of Physician Empathy	37159	34	0.798	0.774	0.821	98.30%	< 0.001
Professionalism assessment scale - Empathy	122	1	0.84	0.794	0.879	--	--
Toronto Empathy Questionnaire	662	1	0.85	0.833	0.867	--	--
Kiersma-Chen Empathy Scale	216	1	0.86	0.831	0.886	--	--
Emotional Intelligence Assessment Scale - Empathy	471	1	0.87	0.85	0.887	--	--
Caring Behaviour Inventory Tool	1243	2	0.921	0.915	0.927	0%	0.731
Overall	49384	49	0.805	0.786	0.823	98%	< 0.001

N: Number of participants, k: Number of studies.

Table 3 Meta-regression results

Variable	Coefficient (95%CI)	Standard error	t	P
mean age	-0.00528 (-0.01813, 0.007571)	0.006301	-0.84	0.409
Male %	0.000527 (-0.00077, 0.00182)	0.000634	0.83	0.413
Constant	0.677161 (0.394914, 0.959408)	0.138389	4.89	< 0.001