empathy research essay

Cultivating empathy

Psychologists’ research offers insight into why it’s so important to practice the “right” kind of empathy, and how to grow these skills

Vol. 52 No. 8 Print version: page 44

• Personality

In a society marked by increasing division, we could all be a bit more kind, cooperative, and tolerant toward others. Beneficial as those traits are, psychological research suggests empathy may be the umbrella trait required to develop all these virtues. As empathy researcher and Stanford University psychologist Jamil Zaki, PhD, describes it, empathy is the “psychological ‘superglue’ that connects people and undergirds co-operation and kindness” ( The Economist , June 7, 2019). And even if empathy doesn’t come naturally, research suggests people can cultivate it—and hopefully improve society as a result.

“In general, empathy is a powerful predictor of things we consider to be positive behaviors that benefit society, individuals, and relationships,” said Karina Schumann , PhD, a professor of social psychology at the University of Pittsburgh. “Scholars have shown across domains that empathy motivates many types of prosocial behaviors, such as forgiveness, volunteering, and helping, and that it’s negatively associated with things like aggression and bullying.”

For example, research by C. Daniel Batson , PhD, a professor emeritus of social psychology at the University of Kansas, suggests empathy can motivate people to help someone else in need ( Altruism in Humans , Oxford University Press, 2011), and a 2019 study suggests empathy levels predict charitable donation behavior (Smith, K. E., et al., The Journal of Positive Psychology , Vol. 15, No. 6, 2020).

Ann Rumble , PhD, a psychology lecturer at Northern Arizona University, found empathy can override noncooperation, causing people to be more generous and forgiving and less retaliative ( European Journal of Social Psychology , Vol. 40, No. 5, 2010). “Empathic people ask themselves, ‘Maybe I need to find out more before I jump to a harsh judgment,’” she said.

Empathy can also promote better relationships with strangers. For example, Batson’s past research highlights that empathy can help people adopt more positive attitudes and helping behavior toward stigmatized groups, particularly disabled and homeless individuals and those with AIDS ( Journal of Personality and Social Psychology , Vol. 72, No. 1, 1997).

Empathy may also be a crucial ingredient in mitigating bias and systemic racism. Jason Okonofua , PhD, an assistant professor of psychology at the University of California, Berkeley, has found that teachers are more likely to employ severe discipline with Black students—and that they’re more likely to label Black students as “troublemakers” ( Psychological Science , Vol. 26, No. 5, 2015).

These labels, Okonofua said, can shape how teachers interpret behavior, forging a path toward students’ school failure and incarceration. When Okonofua and his colleagues created an intervention to help teachers build positive relationships with students and value their perspectives, their increased empathy reduced punitive discipline ( PNAS , Vol. 113, No. 19, 2016).

Similarly, Okonofua and colleagues found empathy from parole officers can prevent adults on probation from reoffending ( PNAS , Vol. 118, No. 14, 2021).

In spite of its potential benefits, empathy itself isn’t an automatic path toward social good. To develop empathy that actually helps people requires strategy. “If you’re trying to develop empathy in yourself or in others, you have to make sure you’re developing the right kind,” said Sara Konrath , PhD, an associate professor of social psychology at Indiana University who studies empathy and altruism.

The right kind of empathy

Empathy is often crucial for psychologists working with patients in practice, especially when patients are seeking validation of their feelings. However, empathy can be a draining skill if not practiced correctly. Overidentifying with someone else’s emotions can be stressful, leading to a cardiovascular stress response similar to what you’d experience in the same painful or threatening situation, said Michael J. Poulin , PhD, an associate professor of psychology at the University at Buffalo who studies how people respond to others’ adversity.

Outside of clinical practice, some scholars argue empathy is unhelpful and even damaging. For example, Paul Bloom, PhD , a professor of psychology at Yale University, argues that because empathy directs helping behavior toward specific individuals—most often, those in one’s own group—it may prevent more beneficial help to others ( Against Empathy: The Case for Rational Compassion , Ecco , 2016).

In some cases, empathy may also promote antagonism and aggression (Buffone, A. E. K., & Poulin, M. J., Personality and Social Psychology Bulletin , Vol. 40, No. 11, 2014). For example, Daryl Cameron , PhD, an associate professor of psychology and senior research associate in the Rock Ethics Institute and director of the Empathy and Moral Psychology Lab at Penn State University, has found that apparent biases in empathy like parochialism and the numbness to mass suffering may sometimes be due to motivated choices. He also notes that empathy can still have risks in some cases. “There are times when what looks like empathy promotes favoritism at the expense of the outgroup,” said Cameron.

Many of these negative outcomes are associated with a type of empathy called self-oriented perspective taking—imagining yourself in someone else’s shoes. “How you take the perspective can make a difference,” said John Dovidio , PhD, the Carl I. Hovland Professor Emeritus of Psychology and a professor emeritus in the Institute for Social and Policy Studies and of Epidemiology at Yale University. “When you ask me to imagine myself in another person’s position,” Dovidio said, “I may experience a lot of personal distress, which can interfere with prosocial behaviors.” Taking on that emotional burden, Schumann added, could also increase your own risk for distressing emotions, such as anxiety.

According to Konrath, the form of empathy shown most beneficial for both the giver and the receiver is an other-oriented response. “It’s a cognitive style of perspective taking where someone imagines another person’s perspective, reads their emotions, and can understand them in general,” she said.

Other-oriented perspective taking may result in empathic concern, also known as compassion, which could be seen as an emotional response to a cognitive process. It’s that emotion that may trigger helping behavior. “If I simply understand you’re in trouble, I may not act, but emotion energizes me,” said Dovidio.

While many practitioners may find empathy to come naturally, psychologists’ research can help clinicians guide patients toward other-oriented empathy and can also help practitioners struggling with compassion fatigue to re-up their empathy. According to Poulin, people are more likely to opt out of empathy if it feels cognitively or emotionally taxing, which could impact psychologists’ ability to effectively support their patients.

To avoid compassion fatigue with patients—and maintain the empathy required for helping them—Poulin said it’s important to reflect on the patient’s feeling or experience without necessarily trying to feel it yourself. “It’s about putting yourself in the right role,” he said. “Your goal isn’t to be the sufferer, but to be the caregiver.”

Be willing to grow

Cameron’s research found that the cognitive costs of empathy could cause people to avoid it but that it may be possible to increase empathy by teaching people to do it effectively ( Journal of Experimental Psychology: General , Vol. 148, No. 6, 2019).

Further, research by Schumann and Zaki shows that the desire to grow in empathy can be a driver in cultivating it. They found people can extend empathic effort—asking questions and listening longer to responses—in situations where they feel different than someone, primarily if they believe empathy could be developed with effort ( Journal of Personality and Social Psychology , Vol. 107, No. 3, 2014).

Similarly, Erika Weisz , PhD, a postdoctoral fellow in psychology at Harvard University, said that the first step to increasing your empathy is to adopt a growth mindset—to believe you’re capable of growing in empathy.

“People who believe that empathy can grow try harder to empathize when it doesn’t come naturally to them, for instance, by empathizing with people who are unfamiliar to them or different than they are, compared to people who believe empathy is a stable trait,” she said.

For example, Weisz found addressing college students’ empathy mindsets increases the accuracy with which they perceive others’ emotions; it also tracks with the number of friends college freshmen make during their first year on campus ( Emotion , online first publication, 2020).

Expose yourself to differences

To imagine another’s perspective, the more context, the better. Shereen Naser , PhD, a professor of psychology at Cleveland State University, said consuming diverse media—for example, a White person reading books or watching movies with a ­non-White protagonist—and even directly participating in someone else’s culture can provide a backdrop against which to adopt someone else’s perspective.

When you’re in these situations, be fully present. “Paying attention to other people allows you to be moved by their experiences,” said Sara Hodges , PhD, a professor of psychology at the University of Oregon. “Whether you are actively ­perspective-taking or not, if you just pay more attention to other people, you’re likely to feel more concerned for them and become more involved in their experiences.”

For example, in a course focused on diversity, Naser encourages her graduate students to visit a community they’ve never spent time in. “One student came back saying they felt like an outsider when they attended a Hindu celebration and that they realized that’s what marginalized people feel like every day,” she said. Along with decreasing your bias, such realizations could also spark a deeper understanding of another’s culture—and why they might think or feel the way they do.

Read fiction

Raymond Mar , PhD, a professor of psychology at York University in Toronto, studies how reading fiction and other kinds of character-driven stories can help people better understand others and the world. “To understand stories, we have to understand characters, their motivations, interactions, reactions, and goals,” he said. “It’s possible that while understanding stories, we can improve our ability to understand real people in the real world at the same time.”

When you engage with a story, you’re also engaging the same cognitive abilities you’d use during social cognition ( Current Directions in Psychological Science , Vol. 27, No. 4, 2018). You can get the same effect with any medium—live theater, a show on Netflix, or a novel—as long as it has core elements of a narrative, story, and characters.

The more one practices empathy (e.g., by relating to fictional characters), the more perspectives one can absorb while not feeling that one’s own is threatened. “The foundation of empathy has to be a willingness to listen to other peoples’ experiences and to believe they’re valid,” Mar said. “You don’t have to deny your own experience to accept someone else’s.”

Harness the power of oxytocin

The social hormone oxytocin also plays a role in facilitating empathy. Bianca Jones Marlin , PhD, a neuroscientist and assistant professor of psychology at Columbia University, found that mice that had given birth are more likely to pick up crying pups than virgin animals and that the oxytocin released during the birth and parenting process actually changes the hearing centers of the brain to motivate prosocial and survival behaviors ( Nature , Vol. 520, No. 7548, 2015).

Oxytocin can also breed helping responses in those who don’t have a blood relationship; when Marlin added oxytocin to virgin mice’s hearing centers, they took care of pups that weren’t theirs. “It’s as if biology has prepared us to take care of those who can’t take care of themselves,” she said. “But that’s just a baseline; it’s up to us as a society to build this in our relationships.”

Through oxytocin-releasing behaviors like eye contact and soft physical touch, Marlin said humans can harness the power of oxytocin to promote empathy and helping behaviors in certain contexts. Oxytocin is also known to mediate ingroup and outgroup feelings.

The key, Marlin said, is for both parties to feel connected and unthreatened. To overcome that hurdle, she suggests a calm but direct approach: Try saying, “I don’t agree with your views, but I want to learn more about what led you to that perspective.”

Identify common ground

Feeling a sense of social connection is an important part of triggering prosocial behaviors. “You perceive the person as a member of your own group, or because the situation is so compelling that your common humanity is aroused,” Dovidio said. “When you experience this empathy, it motivates you to help the other person, even at a personal cost to you.”

One way to boost this motivation is to manipulate who you see as your ingroup. Jay Van Bavel , PhD, an associate professor of psychology and neural science at New York University, found that in the absence of an existing social connection, finding a shared identity can promote empathy ( Journal of Experimental Social Psychology , Vol. 55, 2014). “We find over and over again when people have a common identity, even if it’s created in the moment, they are more motivated to get inside the mind of another person,” Van Bavel said.

For example, Van Bavel has conducted fMRI research that suggests being placed on the same team for a work activity can increase cooperation and trigger positive feelings for individuals once perceived as outgroup, even among different races ( Psychological Science , Vol. 19, No. 11, 2008).

To motivate empathy in your own interactions, find similarities instead of focusing on differences. For instance, maybe you and a neighbor have polar opposite political ideologies, but your kids are the same age and go to the same school. Build on that similarity to create more empathy. “We contain multiple identities, and part of being socially intelligent is finding the identity you share,” Van Bavel said.

Ask questions

Existing research often measures a person’s empathy by accuracy—how well people can label someone’s face as angry, sad, or happy, for example. Alexandra Main , PhD, an assistant professor of psychology at the University of California, Merced, said curiosity and interest can also be an important component of empathy. “Mind reading isn’t always the way empathy works in everyday life. It’s more about actively trying to appreciate someone’s point of view,” she said. If you’re in a situation and struggling with empathy, it’s not necessarily that you don’t care—your difficulty may be because you don’t understand that person’s perspective. Asking questions and engaging in curiosity is one way to change that.

While Main’s research focuses on parent-child relationships, she says the approach also applies to other relationship dynamics; for example, curiosity about why your spouse doesn’t do the dishes might help you understand influencing factors and, as a result, prevent conflict and promote empathy.

Main suggests asking open-ended questions to the person you want to show empathy to, and providing nonverbal cues like nodding when someone’s talking can encourage that person to share more. Certain questions, like ones you should already know the answer to, can have the opposite effect, as can asking personal questions when your social partner doesn’t wish to share.

The important thing is to express interest. “These kinds of behaviors are really facilitative of disclosure and open discussion,” Main said. “And in the long term, expressing interest in another person can facilitate empathy in the relationship” ( Social Development , Vol. 28, No. 3, 2019).

Understand your blocks

Research suggests everyone has empathy blocks, or areas where it is difficult to exhibit empathy. To combat these barriers to prosocial behavior, Schumann suggests noticing your patterns and focusing on areas where you feel it’s hard to connect to people and relate to their experiences.

If you find it hard to be around negative people, for example, confront this difficulty and spend time with them. Try to reflect on a time when you had a negative outlook on something and observe how they relate. And as you listen, don’t interrupt or formulate rebuttals or responses.

“The person will feel so much more validated and heard when they’ve really had an opportunity to voice their opinion, and most of the time people will reciprocate,” Schumann said. “You might still disagree strongly, but you will have a stronger sense of why they have the perspective they do.”

Second-guess yourself

Much of empathy boils down to willingness to learn—and all learning involves questioning your assumptions and automatic reactions in both big-picture issues, such as racism, and everyday interactions. According to Rumble, it’s important to be mindful of “what-ifs” in frustrating situations before jumping to snap judgments. For example, if a patient is continually late to appointments, don’t assume they don’t take therapy seriously––something else, like stress or unreliable transportation, might be getting in the way of their timeliness.

And if you do find yourself making a negative assumption, slow down and admit you could be wrong. “As scientists, we ­second-guess our assumptions all the time, looking for alternative explanations,” said Hodges. “We need to do that as people, too.”

Further reading

What’s the matter with empathy? Konrath, S. H., Greater Good Magazine , Jan. 24, 2017

Addressing the empathy deficit: Beliefs about the malleability of empathy predict effortful responses when empathy is challenging Schumann, K., et al., Journal of Personality and Social Psychology , 2014

It is hard to read minds without words: Cues to use to achieve empathic accuracy Hodges, S. D., & Kezer, M., Journal of Intelligence , 2021

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Open Access

Peer-reviewed

Research Article

Measures of empathy and compassion: A scoping review

Contributed equally to this work with: Cassandra Vieten, Caryn Kseniya Rubanovich, Lora Khatib, Meredith Sprengel, Chloé Tanega

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Centers for Integrative Health, Department of Family Medicine, University of California, San Diego, San Diego, California, United States of America, Clarke Center for Human Imagination, School of Physical Sciences, University of California, San Diego, San Diego, California, United States of America

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, San Diego, California, United States of America, T. Denny Sanford Institute for Empathy and Compassion, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Center for Empathy and Technology, University of California, San Diego, San Diego, California, United States of America

Roles Conceptualization, Data curation, Formal analysis, Investigation, Visualization, Writing – review & editing

Affiliation Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America

Roles Data curation, Investigation, Methodology, Project administration, Software, Writing – review & editing

Affiliation Human Factors, Netherlands Organisation for Applied Scientific Research (TNO), Soesterberg, The Netherlands

Roles Data curation, Formal analysis, Investigation, Project administration, Validation, Visualization, Writing – review & editing

Affiliation Clarke Center for Human Imagination, School of Physical Sciences, University of California, San Diego, San Diego, California, United States of America

Roles Data curation, Investigation, Validation, Writing – review & editing

¶ ‡ CP, PV, AM, GC, AJL, MTS, LE and CB also contributed equally to this work.

Affiliations U.S. Department of Veteran Affairs, VA Boston Healthcare System, Boston, Massachusetts, United States of America, Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America

Affiliation Compassion Clinic, San Diego, California, United States of America

Roles Writing – review & editing

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, VA San Diego Center of Excellence for Stress and Mental Health, San Diego, California, United States of America

Affiliation VA San Diego Center of Excellence for Stress and Mental Health, San Diego, California, United States of America

Roles Conceptualization, Writing – review & editing

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, VA San Diego Center of Excellence for Stress and Mental Health, San Diego, California, United States of America, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, California, United States of America

Affiliation Departments of Family Medicine and Medicine (Bioinformatics), School of Medicine, University of California, San Diego, San Diego, California, United States of America

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Institute for Empathy and Compassion, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Center for Empathy and Compassion Training in Medical Education, University of California, San Diego, San Diego, California, United States of America

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Institute for Empathy and Compassion, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Center for Empathy and Technology, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Center for Empathy and Compassion Training in Medical Education, University of California, San Diego, San Diego, California, United States of America

• Cassandra Vieten, 
• Caryn Kseniya Rubanovich, 
• Lora Khatib, 
• Meredith Sprengel, 
• Chloé Tanega, 
• Craig Polizzi, 
• Pantea Vahidi, 
• Anne Malaktaris, 
• Gage Chu, 

• Published: January 19, 2024
• https://doi.org/10.1371/journal.pone.0297099
• Reader Comments

Evidence to date indicates that compassion and empathy are health-enhancing qualities. Research points to interventions and practices involving compassion and empathy being beneficial, as well as being salient outcomes of contemplative practices such as mindfulness. Advancing the science of compassion and empathy requires that we select measures best suited to evaluating effectiveness of training and answering research questions. The objective of this scoping review was to 1) determine what instruments are currently available for measuring empathy and compassion, 2) assess how and to what extent they have been validated, and 3) provide an online tool to assist researchers and program evaluators in selecting appropriate measures for their settings and populations. A scoping review and broad evidence map were employed to systematically search and present an overview of the large and diverse body of literature pertaining to measuring compassion and empathy. A search string yielded 19,446 articles, and screening resulted in 559 measure development or validation articles reporting on 503 measures focusing on or containing subscales designed to measure empathy and/or compassion. For each measure, we identified the type of measure, construct being measured, in what context or population it was validated, response set, sample items, and how many different types of psychometrics had been assessed for that measure. We provide tables summarizing these data, as well as an open-source online interactive data visualization allowing viewers to search for measures of empathy and compassion, review their basic qualities, and access original citations containing more detail. Finally, we provide a rubric to help readers determine which measure(s) might best fit their context.

Citation: Vieten C, Rubanovich CK, Khatib L, Sprengel M, Tanega C, Polizzi C, et al. (2024) Measures of empathy and compassion: A scoping review. PLoS ONE 19(1): e0297099. https://doi.org/10.1371/journal.pone.0297099

Editor: Ipek Gonullu, Ankara University Faculty of Medicine: Ankara Universitesi Tip Fakultesi, TURKEY

Received: July 5, 2023; Accepted: December 21, 2023; Published: January 19, 2024

Copyright: © 2024 Vieten et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: CV received a grant from the T. Denny Sanford Institute for Empathy and Compassion at https://empathyandcompassion.ucsd.edu/ . Co-authors included faculty members affiliated with the T. Denny Sanford Institute who were involved in study design and reviewing/editing the manuscript. Other than that, the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Historically, psychological assessment has overwhelmingly focused on measuring human struggles, difficulties, and pathologies. However, converging evidence indicates that positive emotions and prosocial qualities are just as important for improving overall well-being as stress, depression, and anxiety are to detracting from health and well-being [ 1 ]. Across fields—from medicine, mental health care, and education to economics, business and organizational development—there is a growing emphasis on investigating prosocial constructs such as compassion and empathy [ 2 ].

Compassion, or the heartfelt wish to reduce the suffering of self and others, promotes social connection and is an important predictor of overall quality of life [ 2 ] and well-being [ 3 ]. Empathy, or understanding and vicariously sharing other people’s positive emotions, is related to prosocial behaviors (e.g., helping, giving, emotional support), positive affect, quality of life, closeness, trust, and relationship satisfaction [ 4 ]. Compassion and empathy improve parenting [ 5 ], classroom environments [ 6 ], and teacher well-being [ 7 ]. Compassionate love toward self and others is associated with disease outcomes as well, such as increased long-term survival rates in patients with HIV [ 8 ]. Self-compassion refers to being gentle, supportive, and understanding toward ourselves in instances of perceived failure, inadequacy, or personal suffering [ 9 ]. Research indicates that self-compassion appears to reduce anxiety, depression, and rumination [ 10 ], and increase psychological well-being and connections with others [ 11 , 12 ]. Both compassion and self-compassion appear to protect against stress [ 13 ] and anxiety [ 10 ].

In healthcare professionals, empathy is associated with patient satisfaction, diagnostic accuracy, adherence to treatment recommendations, clinical outcomes, clinical competence, and physician retention [ 14 – 16 ]. Importantly, it is also linked to reduced burnout, medical errors, and malpractice claims [ 17 ]. However, evidence indicates that empathy declines during medical training and residency [ 18 – 20 ]. This may present an opportunity to improve many aspects of healthcare by identifying ways to maintain or enhance empathy during medical training. It is also important to note that while empathy is beneficial for patients, the effects on healthcare professionals are more complicated. A distinction can be drawn between positive empathy and/or compassion versus over-empathizing , which can lead to what has been termed “compassion fatigue” and/or burnout.

Disentangling these relationships through scientific investigation requires selecting measures and instruments capable of capturing these nuances. In addition, growing evidence that empathy and compassion can be improved through training [ 21 , 22 ] relies on selection or development of measures that can assess the effectiveness of such training. While empathy and compassion training for healthcare professionals has shown positive outcomes, it still requires improvement. For example, in a recent systematic review, only 9 of 23 empathy education studies in undergraduate nursing samples demonstrated practical improvements in empathy [ 23 ]. Another systematic review of 103 compassion interventions in the healthcare context [ 24 ] identified a number of limitations such as focusing on only a single domain of compassion; inadequately defining compassion; assessing the constructs exclusively by self-report; and not evaluating retention, sustainability, and translation to clinical practice over time: all related to how compassion and empathy are conceptualized and measured. The researchers recommend that such interventions should “be grounded in an empirically-based definition of compassion; use a competency-based approach; employ multimodal teaching methods that address the requisite attitudes, skills, behaviors, and knowledge within the multiple domains of compassion; evaluate learning over time; and incorporate patient, preceptor, and peer evaluations” (p. 1057). Improving conceptualization and measurement of compassion and empathy are crucial to advancing effective training.

Conceptualizing compassion and empathy

Compassion and empathy are complex constructs, and therefore challenging to operationalize and measure. Definitions of compassion and empathy vary, and while they are often used interchangeably, they are distinct constructs [ 25 ]. Like many other constructs, both compassion and empathy can be conceptualized at state and/or trait levels: people can have context-dependent experiences of empathy or compassion (i.e., state), or can have a general tendency to be empathic or compassionate (i.e., trait). The constructs of empathy and compassion each have multiple dimensions: affective, cognitive, behavioral, intentional, motivational, spiritual, moral and others. In addition to their multidimensionality, compassion and empathy are crowded by multiple adjacent constructs with which they overlap to varying degrees, such as kindness, caring, concern, sensitivity, respect, and a host of behaviors such as listening, accurately responding, patience, and so on.

Strauss et al. [ 26 ] conducted a systematic review of measures of compassion, and by combining the definitions of compassion among the few existing instruments at the time, proposed five elements of compassion: recognizing suffering, understanding the universality of human suffering, feeling for the person suffering, tolerating uncomfortable feelings, and motivation to act/acting to alleviate suffering. Gilbert [ 27 ] proposed that compassion consists of six attributes: sensitivity, sympathy, empathy, motivation/caring, distress tolerance, and non-judgement.

Likewise, empathy has been conceptualized as having at least four elements (as measured by the Interpersonal Reactivity Index [ 28 ] for example): perspective-taking (i.e., taking the point of view of others), fantasy (i.e., imagining or transposing oneself into the feelings and actions of others), empathic concern (i.e., accessing other-oriented feelings of sympathy or concern) and personal distress (i.e., or unease in intense interpersonal interactions). Early work by Wiseman [ 29 ] used a concept analysis approach identifying four key domains of empathy: seeing the world the way others see it, understanding their feelings, being non-judgmental, and communicating or expressing that understanding. Other conceptualizations of empathy [ 30 ] include subdomains of affective reactivity (i.e., being emotionally affected by others), affective ability (i.e., others tell me I’m good at understanding them), affective drive (i.e., I try to consider the other person’s feelings), cognitive drive (i.e., trying to understand or imagine how someone else feels), cognitive ability (i.e., I’m good at putting myself in another person’s shoes), and social perspective taking. De Waal and Preston [ 31 ] propose a “Russian doll” model of empathy, in which evolutionary advances in empathy layer one on top of the next, resulting in their definition of empathy as “emotional and mental sensitivity to another’s state, from being affected by and sharing in this state to assessing the reasons for it and adopting the other’s point of view” (p. 499).

Compassion is conceptualized as generally positive, and “more is better” in terms of health and well-being. Empathy on the other hand can lead to positive outcomes such as empathic concern, compassion, and prosocial motivations and behaviors, whereas unregulated empathic distress can be aversive, decrease helping behaviors, and lead to burnout [ 32 ]. Compassion and empathy also appear to differ in underlying brain structure [ 33 ] as well as brain function [ 34 ]. Terms such as “compassion fatigue” are more accurately characterized as empathy fatigue, and some evidence indicates that compassion can actually counteract negative aspects of empathy [ 35 ].

When assessing compassion and empathy, it is often important to measure their opposites, or constructs that present barriers to experiencing and expressing compassion or empathy. Personal distress, for example, can be confused for empathy but in fact is a “self-focused, aversive affective reaction” to encountering another person’s suffering, accompanied by the desire to “alleviate one’s own, but not the other’s distress” [ 36 , p.72]. Personal distress is viewed as a barrier to true compassion, and experienced chronically, is associated with burnout (i.e. exhaustion, cynicism, and inefficacy due to feeling frenetic/overloaded, underchallenged/indifferent, or worn-out/neglected [ 37 ]).

Other constructs that have been measured as barriers to compassion include lack of empathy or empathy impairment, apathy, coldness, judgmental attitudes toward specific populations or conditions, and fear of compassion. In sum, compassion and empathy are not so much singular constructs as multi-faceted collections of cognitions, affects, motivations and behaviors. When researchers or program evaluators consider the best ways to assess empathy and compassion, they must often attend to measuring these constructs as well.

Past systematic reviews focused on measurement of empathy and compassion sought to (1) review definitions [ 26 , 38 ]; (2) evaluate measurement methods [ 39 ]; (3) assess psychometric properties [ 40 ]; (4) provide quality ratings [ 26 , 41 , 42 ]; and/or (5) recommend gold standard measures [ 26 , 43 ]. To our knowledge, this review is the first scoping review focused on capturing the wide array of instruments measuring empathy, compassion, and adjacent constructs.

We conducted a scoping review and broad evidence map (as opposed to a systematic review or meta-analysis) for several reasons. Whereas systematic reviews attempt to collate empirical evidence from a relatively smaller number of studies pertaining to a focused research question, scoping reviews are designed to employ a systematic search and article identification method to answer broader questions about a field of study. As such, this scoping review provides a large and diverse map of the available measures across this family of constructs and measurement methodology, with the primary goal of aiding researchers and program evaluators in selecting measures appropriate for their setting.

Another unique feature of this scoping review is a data visualization that we have developed to help readers navigate the findings. This interactive tool is called the Compassion and Empathy Measures Interactive Data Visualization (CEM-IDV) ( https://imagination.ucsd.edu/compassionmeasures/ ).

The aims of this scoping review were achieved, including 1) identifying existing measures of empathy and compassion, 2) providing an overview of the evidence for validity of these measures, and 3) providing an online tool to assist researchers and program evaluators in searching for and selecting the most appropriate instruments to evaluate empathy, compassion, and/or adjacent constructs, based on their specific context, setting, or population.

The objective of this project was to capture all peer-reviewed published research articles that were focused on developing, or assessing the psychometric properties of, instruments measuring compassion and empathy and overlapping constructs, such as self-compassion, theory of mind, perspective taking, vicarious pain, caring, the doctor-patient relationship, emotional cues, sympathy, tenderness and emotional intelligence. We included only articles that were specifically focused on measure development or validation, and therefore did not include articles that may have developed idiosyncratic ways of assessing compassion or empathy in service to conducting experiments. We included self-report assessments, observational ratings or behavioral coding schemes, and tasks. This review was conducted according to the PRISMA statement for scoping reviews [ 44 ]. The population, concept, and context (PCC) for this scoping review were 1) population: adults and children, 2) concepts: compassion and empathy, and 3) context: measures/questionnaires for English-speaking populations (behavioral measures and tasks in all languages).

Eligibility criteria

Articles were included if they focused on development or psychometric validation/evaluation of whole or partial scales, tasks, or activities designed to measure empathy, compassion, or synonymous or adjacent constructs. Conference proceedings and abstracts as well as grey-literature were excluded from this review, as were articles in languages other than English or reporting on self-report scales that were in languages other than English. Behavioral tasks or observational measures that were conducted in languages other than English, but were reported in English and could be utilized in an English-speaking context, were included. Papers were excluded if they were in a language other than English, did not include human participants, or did not focus on reporting on development or psychometric validation of measures of compassion, empathy, or adjacent constructs.

Information sources

To identify the peer-reviewed literature reporting on the psychometric properties of measures of empathy and compassion, the following databases were searched: PubMed, Embase, PsychInfo, CINAHL, and Sociological Abstracts. See Table 1 to review the search terms and strategy applied for each database. All databases were searched in October 2020 and again in May 2023 by a reference librarian trained in systematic and scoping reviews at the University of California, San Diego library.

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https://doi.org/10.1371/journal.pone.0297099.t001

Abstracts of the articles identified through the search were uploaded to Covidence [ 45 , 46 ]. Covidence is a web-based collaboration software platform that streamlines the production of systematic and other literature reviews. Each article was screened by two reviewers and any conflicts reviewed in team meetings until the team reached 90% agreement. Thereafter, one screener included or excluded each abstract.

Full text screening

After articles were screened in, full text for all articles tagged as “Measure Development/Validation” were uploaded to the system. The project coordinator (MS) reviewed all articles that were included to ensure that they were tagged appropriately and that all articles reporting on development or validation of measures or assessments of psychometric properties were included in this review.

Each article was reviewed for its general characteristics and psychometric evaluation/validation data reported. General data extracted from each article included: the article title, full citation, abstract, type of study, the name of the scale/assessment/measure, the author’s definition of the construct(s) being measured (if stated), the specific purpose of the scale (context and population, such as “a scale for measuring nurses’ compassion in patient interactions”), whether the measure was conceptualized as assessing state or trait (or neither or both); whether the scale was self-report, peer-report, or expert observer/coder; the validation population, number, gender proportion, and location; and any reviewer notes.

See Table 2 for the psychometric data extracted from each article. In this scoping review we did not evaluate or record/analyze the results of the psychometric evaluations or validations. We only recorded whether or not they had been completed. Because some members of the team did not have enough experience/training to properly identify psychometric evaluations or assessments, data extraction was completed using two data extraction forms (i.e., one for general data and one for psychometric data) constructed in Survey Planet [ 47 ]. A group of four experienced coders completed both the general and psychometric data extraction forms, and a group of six less experienced coders completed only the general data extraction form with an experienced coder completing the psychometric data extraction form.

https://doi.org/10.1371/journal.pone.0297099.t002

Once the data were extracted, they were reviewed by the research coordinator or principal investigator and combined into a spreadsheet. After combining, the answers were reviewed by a team of four additional reviewers to ensure that the information extracted was correct. These four reviewers received additional training on how to confirm that the appropriate information was extracted from the article as well as how to clean the information in a systematic way.

Systematic literature search

A total of 29,119 articles were identified and 9,673 duplicates were removed, resulting in 19,446 titles/abstracts screened for eligibility ( Fig 1 ). A total of 10,553 full-text articles were assessed for inclusion based on the criteria previously described. A total of 6,023 articles were included in the final sample. Of these articles, 559 reported on the development or validation of a measure of empathy and/or compassion, 1,059 identified biomarkers of empathy and/or compassion, and 3,936 used a measure or qualitative interview of empathy or compassion in the respective study. This scoping review reports on the 559 measure development/validation articles.

https://doi.org/10.1371/journal.pone.0297099.g001

Measure development and validation studies

An overview of the 503 measures of empathy or compassion that were developed, validated, or psychometrically evaluated in the 559 articles can be found in the S1 Table . The majority of the studies ( n = 181) used a student population for development and/or validation. Student populations included undergraduate students, nursing students, and medical students. A total of 136 studies used samples of general, healthy adults (18 and older). Eighty-three (83) studies developed and/or validated a measure using health care workers, mostly comprising physicians and nursing staff. A total of 66 studies reported on a combined sample of populations such as clinicians and patients. There were 63 studies that used a patient population (e.g., cancer patients, surgical patients). A total of 34 studies used samples of individuals in other specific professions (e.g., military personnel), 32 used youth and adolescent samples (5–18 years old), 18 included older adults/aging populations, while 28 used samples in mental health care related professions (e.g., therapists). Nine studies used samples in other specific populations (e.g., spouses of depressed patients).

The number of possible psychometric assessments was 13 (see list below), and the total types of psychometric assessments reported for each measure ranged from 0 to 12. On average, each measure reported four types of psychometric assessments being completed. The measures with the highest number of psychometric assessments reported included the Interpersonal Reactivity Index (IRI) and the Self-Compassion Scale (SCS) with 12 psychometric assessments each. All scales with eight or more psychometric assessments reported in the articles we located can be found in S2 Table .

In regards to the type of psychometric assessments reported, a total of 409 studies assessed internal consistency, 342 used construct validity, 316 used factor analysis or principal component analysis, 299 assessed convergent validity, 218 used confirmatory factor analysis, 187 evaluated content validity, 165 tested for discriminant/divergent validity, 108 assessed test re-test reliability, 71 measured interrater reliability, 69 tested for predictive validity, 68 used structural equation modeling, 38 controlled for or examined correlations with social desirability, and 6 used a biased responding assessment or “lie” scale. Eighty studies performed other advanced statistics.

Measures of empathy and compassion

A total of 503 measures of compassion and empathy were identified in the literature. S3 Table is sorted alphabetically by the name of the measure, and includes a description of each measure, year developed, type of measure, subscales (if applicable), administration time (if provided), number of items, sample items, and response set. The majority of the scales were developed in the past decade (since 2013). Most of the measures identified were self-report scales (412 scales). Fifty-three (53) were peer/corollary report measures (descriptions of target individuals’ thoughts, feelings, motives, or behaviors), and 38 were behavioral/expert coder measures (someone who has been trained to assess target’s thoughts, feelings motives or behaviors). There were 370 measures with subscales and 133 measures without subscales. The number of items of each scale varied widely from 1 item to 567 items. The average number of items was 32 (SD = 45.2) and the median was 21 items. Most authors did not report on the estimated time it would take to complete the measure.

Interactive data visualization

Data visualizations are graphical representations of data designed to communicate key aspects of complex datasets [ 48 ]. Interactive data visualizations allow users to search, filter, and otherwise manipulate views of the data, and are increasingly being used for healthcare decision making [ 49 ]. We used Google Data Studio to create an online open-access interactive data visualization ( Fig 2 ) displaying the results of this scoping review. Access it at: https://imagination.ucsd.edu/compassionmeasures/

https://doi.org/10.1371/journal.pone.0297099.g002

The purpose of this Compassion and Empathy Measures Interactive Data Visualization (CEM-IDV) is to assist health researchers and program evaluators in selecting appropriate measures of empathy and compassion based on a number of parameters, as well as learning more about how these constructs are currently being conceptualized. Visualization parameters include: number of types of psychometric assessments completed (1–12) on the y-axis, number of items on the x-axis (with measures with over 70 items appearing on a separate display, not shown in Fig 2 ), and the bubble size indicating the number of participants in the validation studies. Search filters include Population in which the measure has been validated (e.g. students, healthcare workers, general adults), Construct (e.g. empathy, compassion, caring, self-compassion), and Type of Measure (e.g. self-report, behavioral/expert coder). Users can also search measures by name of the parent measure. For example, there are multiple versions of the Jefferson Scale of Empathy (JSE) (e.g., for physicians, for nurses, for medical students). To retrieve all articles reporting on any version of the JSE, one would search for the parent measure (i.e., “Jefferson Scale of Empathy”). If a measure does not have multiple versions (for example, the Griffith Empathy Measure), this search would yield all articles on that single version.

A robust science of compassion and empathy relies on effective measures. This scoping review examined the broad literature of peer-reviewed published research articles that either developed, or assessed the psychometric properties of, instruments measuring compassion and empathy. The review also includes overlapping and related constructs such as self-compassion, theory of mind, perspective-taking, vicarious pain, caring, the doctor-patient relationship, emotional cues, sympathy, tenderness, and emotional intelligence.

Our review indicates that the field of measuring compassion and empathy is maturing. Strides have been made in recent years in conceptualization, definition, and assessment of compassion and empathy. Since the time of earlier critical reviews of measurement of compassion and empathy, several measures have gained more psychometric support: S2 Table shows that 34 measures have been subjected to 9 or more types of psychometric validation. Multiple measures in this review demonstrate consistent reliability and validity along with many other strengths.

Newer measures align more closely with experimental, theoretical and methodological advances in understanding the various components of compassion and empathy. For example, the newer Empathic Expressions Scale [ 50 ] recognizes that actual empathy behaviors are different from cognitive and affective aspects of empathy. In another example, increasing understanding of the role of warmth and affection as an important component of empathy has led to the development of the Warmth/Affection Coding System (WACS) [ 51 ]. That measure also includes both micro- and macro-social observations, recognizing that implicit and explicit behaviors are important for assessment.

As measurement becomes more precise, assessments have also reflected increasing understanding of the differences between compassion and empathy, and the interaction between the two. For example, the Compassion Scale [ 52 ] subscales include kindness, common humanity, mindfulness and indifference (reverse-scored), whereas the family of the Jefferson Scale(s) of Empathy include compassion as well as “standing in the patient’s shoes” and “understanding the client’s perspective.” Recognizing recent research on how compassion could temper consequences of empathic distress such as burnout, it becomes important for researchers and program evaluators to not only avoid conflating the two, but also measure both separately.

Empathy and compassion in specific circumstances for specific populations have also been developed, such as the Body Compassion Questionnaire [ 53 ] with clear relevance for adolescents and young adults, as well as those with eating and body-dysmorphic disorders, or the modified 5-Item Compassion Measure [ 54 ] created specifically for patients to assess provider compassion during emergency room visits.

In our review, we included self-report assessments, peer/corollary observational measures, and behavioral tasks/expert coder measures, for adults and children in English-speaking populations. A discussion of the utility of each of these types of measures follows, along with a rubric for measure selection that researchers and program evaluators can use with the assistance of the tables and/or CEM-IDV online tool.

Self-report measures

The vast majority of measures of empathy and compassion are self-report measures (surveys, questionnaires, or items asking people to report on their own compassion and empathy). While perhaps the most efficient way to assess large numbers of participants, historically self-assessments of compassion and empathy have been riddled with challenges. Over a decade ago, Gerdes et al. [ 38 ] in their review of the literature noted that:

In addition to a multitude of definitions, different researchers have employed a host of disparate ways to measure empathy (Pederson, 2009). A review of the literature pertaining to empathy reveals that as a result of these inconsistencies, conceptualisations and measurement techniques for empathy vary so widely that it is difficult to engage in meaningful comparisons or make significant conclusions about how we define and measure this key component of human behaviour. (pp. 2327).

While a 2007 systematic review of 36 measures of empathy identified eight instruments demonstrating evidence of reliability, internal consistency, and validity [ 40 ], a systematic review of 12 measures of empathy used in nursing contexts [ 41 ] revealed low-quality scores (scoring 2–8 on a scale of 14), concluding that none of the measures were both psychometrically and conceptually satisfactory.

Our scoping review did not assess psychometric robustness other than the number of psychometric assessments completed, but a 2022 systematic review of measures of compassion [ 26 ] continued to reveal low-quality ratings (ranging from 2 to 7 out of 14) due to poor internal consistency for subscales, insufficient evidence for factor structure and/or failure to examine floor/ceiling effects, test-retest reliability, or discriminant validity. They concluded that “currently no psychometrically robust self- or observer-rated measure of compassion exists, despite widespread interest in measuring and enhancing compassion towards self and others” (pp. 26).

Several issues have been identified as potentially explaining shortcomings of compassion and empathy measures. For example, definitions of compassion and empathy vary widely in scholarly and popular vernacular, which can lead to variability in respondents’ perceptions. In addition to issues of semantics, the vast majority of compassion and empathy measures are face valid, relying on questions such as “I feel for others when they are suffering,” or “When I see someone who is struggling, I want to help.” These questions can increase the risk for social desirability bias (i.e., the tendency to give overly positive self-descriptions either to others or within themselves) and other response biases. Indeed, feeling uncompassionate can be quite difficult to admit, requiring not only a large degree of self-reflection and insight, but also an ability to manage the cognitive dissonance, shame, or embarrassment that could accompany such an admission. This difficulty may be particularly true among healthcare professionals.

Using self-report measures to assess the impact of compassion-focused interventions can also be confounded by mere exposure and demand characteristics, particularly when compared to standard-of-care or wait-list controls. In other words, after spending eight-weeks learning about and practicing compassion, it is not surprising that one might more frequently endorse items with respect to compassion due to increased familiarity with the concept, or implicit desire to satisfy experimenters, as opposed to increased compassionate states or behaviors. On the other hand, interventions could paradoxically result in people more accurately rating themselves lower on these outcomes once they investigate more thoroughly their own levels of, and barriers to, compassion and empathy, potentially masking improvements.

Peer/corollary and behavioral/expert coder measures

With increasing technological, statistical, and conceptual sophistication, we can innovate new measures that can increase validity by triangulating more objective measures with self-perceptions. In fact, multiple measures using observation and ratings by peers, patients, or trained/expert behavioral coders have been developed to do just that. We identified 61 measures utilizing observational measures or peer/corollary reports, some involving a spouse, friend, supervisor, client or patient completing a questionnaire, rating form or checklist regarding their observations of that person. These measures may also include ratings of a live or recorded interaction by someone who has been trained to assess, or is an expert in assessing, compassion or empathy behaviors. Compassion or empathy behaviors include verbalizations and signals such as eye contact, tone of voice, or body language. Similarly, qualitative coding of transcribed narratives, interactions, or responses to interview questions or vignettes can be conducted with human qualitative coders, which is increasingly supported by artificial intelligence.

These methods have the clear benefit of avoiding self-report biases and providing richer data for each individual (for use in admissions or competency exams for instance). However, they can be labor intensive, can introduce potential changes in behavior due to knowing one is being observed, and can introduce another layer of subjectivity on the part of the observer/rater (which can be overcome in part by measures of agreement between two or more raters). They also tend to have fewer psychometric assessments testing their validity or reliability than other measures.

Behavioral tasks

Laboratory-based behavioral tasks have been useful for assessing empathy and compassion under controlled conditions while reducing self-report biases and taking less time than qualitative/observational measures. These lab protocols involve exposure to stimuli designed to induce empathy and compassion or related constructs. For example, respondents might view a video-recorded vignette that reliably results in responses to seeing another person who is suffering [ 55 ] or write a letter to a prison inmate who has committed a violent crime [ 56 ]. Game theory has been used to create tasks focused on giving people options to share with, withhold from, or penalize others with cash, points, or goods. These are used to assess prosocial behaviors and constructs adjacent to empathy and compassion such as altruism and generosity [ 57 ].

The association of these implicit measures of compassion and empathy with real-world settings or with subjective perceptions of empathy and compassion is unknown. A meta-analysis of 85 studies ( N = 14,327) indicates that self-report cognitive empathy scores account for only approximately 1% of the variance in behavioral cognitive empathy assessments [ 58 ]. This finding could demonstrate the superiority of implicit measures and a rather damning verdict for the accuracy of self-perceptions, or could imply that these different types of measures are capturing very different constructs (a problem that exists across many psychosocial versus behavioral measures, see [ 59 ]).

Selecting measures

Our review revealed that there is not one or even a few measures of empathy and compassion that are best across all situations. Rather than providing overarching recommendations, therefore, we emphasize that measurement is context-dependent. As such, we recommend a series of questions researchers and program evaluators might ask themselves when selecting a measure.

We encourage readers to use the online CEM-IDV as a decision-aid tool to identify the best measure for their specific needs. To select the most appropriate instrument(s), we offer the following questions (in a suggested order) to provide guidance:

• Which precise domains of empathy, compassion, or adjacent constructs do you want to measure? For example, is it the participant’s experience of empathy, or a skill or behavior? See the “General Construct” dropdown menu. Because definitions of empathy, compassion and related constructs are often imprecise, investigate whether the sample items, factors, and authors’ definition of the construct matches the outcome or variable you actually want to measure.
• What measurement type is best suited to answering your research/evaluation question, or what is feasible for your setting and sample size? For example, if you have limited time or a large sample size, you may prefer a self-report survey, whereas if you are concerned about self-report bias, you might consider a direct observation or behavioral task/expert coder measure. Use S1 Table to examine measures by type of measure, or use the “Type of Measure” filter in the CEM-IDV.
• What measure length, number of items, or time it takes to complete the assessment is feasible for the study? Refer to the X-axis of the CEM-IDV tool.
• What population (s) are you working with? Use the population filter to explore whether the measures you are considering have been validated in those populations.
• Do you want to differentiate the domain you are measuring from other adjacent constructs , such as sympathy or altruism, or distinguish between empathy and compassion? Select and include measures of each construct in order to make this distinction. Finally, now that you have selected several candidate measures, ask:
• How valid and reliable is the measure? Use S1 Table or the Y-axis of CEM-IDV tool to determine which psychometric assessments have been completed, and click on the measure in the table below to review the full text of the papers to discover the strength of those assessments, as well as familiarizing oneself with the recent literature on the measure. Evidence for the validity, factor structure, or length of measures is often hotly debated, and it can be that a measure has been improved or its interpretation cautioned by recent literature.

For example, imagine you are conducting a study of emergency room outcomes, including number of admissions, time from registration to discharge, and patient satisfaction. You would like to include emergency-room healthcare-provider empathy and/or compassion as a potential predictor or mediator of outcomes. After reviewing the literature on the topic and the definitions, you decide that compassion is the specific domain you are most interested in (Question 1). Because you are aware of the limitations of self-report measures, you decide not to use a self-report measure. You recognize that peer-reports, behavioral tasks, or expert coders are not appropriate for the fast-paced environment and number of interactions, but decide that patient reports of provider compassion would be ideal (Question 2). You recognize that the questionnaire must be brief, given the existing measurement burden and limited time participants have (Question 3). The population is emergency room clinicians and patients (Question 4). In this case, you are not interested in differentiating compassion from other similar constructs because that is not relevant to the question you are trying to answer: whether emergency room physician compassion predicts or mediates patient outcomes (Question 5).

In this case, you might use the CEM-IDV tool to select the population “Patients” and the construct “Compassion.” Your search yields eight potential measures, and upon reviewing each, you find that the 5-item Compassion Scale [ 54 ] has sample items that reflect what you are hoping to measure and was validated with emergency room patients and their clinicians. It demonstrates good reliability and validity and is an excellent choice for your project.

Strengths and limitations

This scoping review has several strengths. First, it covers a wide breadth of literature on ways to assess empathy, compassion, and adjacent constructs using different types of measures (i.e., self-report, peer/corollary report, and behavioral/expert coder). Second, the findings were integrated into an accessible interactive data visualization tool designed to help researchers/program evaluators identify the most suitable measure(s) for their context. Third, the review team included individuals with expertise in conducting reviews, with the project manager having received formal training in best practices for systematic reviews, and an experienced data librarian helping to develop the search string and conduct the literature search. Fourth, the literature search was conducted without a start date limitation, thus capturing all measures published prior to October 2020. Fifth, the review team employed a comprehensive consensus process to establish study inclusion/exclusion criteria and utilized state-of-the-art review software, Covidence, to support the process of screening and data extraction.

There are also several limitations to consider. First, our literature search was limited to five databases (i.e., PubMed, Embase, PsychInfo, CINAHL, and Sociological Abstracts), and excluded grey literature, conference proceedings/abstracts, and measures not written in English. We also included only articles specifically focused on development and/or psychometric validation of measures. Thus, it is possible we missed relevant measures. Second, although we captured how frequently a measure was validated and the types of available psychometric evidence for each measure, we did not review the quality of the evidence. Measures with greater numbers of psychometric assessments may not necessarily be the most appropriate in all contexts or for particular settings, and psychometric studies can lead to conflicting results/interpretations. Importantly, the number of psychometric assessments might be skewed in favor of older measures that have existed in the scientific literature longer, and allegiance biases are possible. Thus, we reiterate that readers would benefit most from using the questions recommended above when selecting measures. Third, this scoping review provides a static snapshot of available measures through October 2020 and does not include measures that may have been published after that time.

Finally, the scoping review does not identify gold-standard measures to use. While systematic reviews typically include quality assessments, scoping reviews do not. Rather, scoping reviews seek to present an overview of a potentially large and diverse body of literature pertaining to a topic. As such, this review did not evaluate the quality of design, appraise the strength of the evidence, or synthesize reliability or validity results for each study. It may therefore include multiple studies that may have weak designs, low power, or evidence inadequate to the conclusions drawn.

Given the multitude of problems facing society (e.g., violence and war, social injustices and inequities, mental health crises), learning how to cultivate compassion and empathy towards self and others is one of the most pressing topics for science to address. Furthermore, studies of compassion, empathy, and adjacent constructs rely on the use of appropriate measures, which are often difficult to select due to inconsistent definitions and susceptibility to biases. Our scoping review identified and reviewed numerous measures of compassion, empathy, and adjacent constructs, extracting the qualities of each measure to create an interactive data visualization tool. This tool is intended to assist researchers and program evaluators in searching for and selecting the most appropriate instruments to evaluate empathy, compassion, and adjacent constructs based on their specific context, setting, or population. It does not replace reviewers’ own critical evaluation of the instruments.

How a construct is measured reflects how it is being defined and conceptualized. Reviewing the subscales/factors and individual items that make up each measure sheds light on how each of these measures conceptualizes empathy and compassion. Ongoing research by our team is using these subscales, factors and items across measures to construct a conceptual map of compassion and empathy, which will be reported in a future paper. In the meantime, a useful feature of the CEM-IDV is that the list of articles yielded by searches includes subscales and sample items from each measure/article. These allow for a snapshot of how each measure or its authors have defined the constructs being assessed.

Future directions for measurement of empathy and compassion should consider incorporating advances in measurement and technology, and strive to bring together two or more assessment methods such as self-report, peer or patient reports, expert observation, implicit tasks, and biomarkers/physiological data to provide a more well-rounded picture of compassion and empathy. Innovations such as voice analysis and automated facial expression recognition may hold promise. Brief measures dispersed across multiple time points such as ecological momentary assessment and daily experience sampling may be useful. In conjunction with mobile technology and wearables, artificial intelligence and machine-learning data processing, could facilitate these formerly labor and time-intensive assessment methods.

Supporting information

S1 table. measure populations and psychometric assessments..

https://doi.org/10.1371/journal.pone.0297099.s001

S2 Table. Measures with 8+ psychometric assessments.

https://doi.org/10.1371/journal.pone.0297099.s002

S3 Table. Measures of compassion and empathy.

https://doi.org/10.1371/journal.pone.0297099.s003

Acknowledgments

Thank you to Omar Shaker for his work to create the online interactive data visualization.

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From Digital Media to Empathic Spaces: A Systematic Review of Empathy Research in Extended Reality Environments

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Information & Contributors

Bibliometrics & citations, view options, 1 introduction, 1.1 empathy, 1.2 empathy in extended reality.

1.3 Humans in Spaces: Spatiality

1.4 previous surveys, 1.5 scope of the present survey, 2 review methodology, 2.1 search strategy, 2.1.1 keywords..

2.1.2 Databases.

2.2 data extraction.

2.3 Survey Results

2.4 Description of the Included Articles

3 Data Synthesis: XR Spaces for Empathy

3.1 Technologies

3.2 Elicited Empathy

3.3 Spatial Context

4 Discussion

4.1 facilitating empathy in xr and metaverse, 4.2 spatio-temporal considerations for fostering empathy, 4.3 empathy at large: limitations, criticism, and ethics.

5 Research Roadmap: Three Opportunities for Empathy Across Physical and Virtual Spaces

5.1 designing and researching empathy with xr, 5.2 re-imagining experienced spaces: temporal and spatial empathy, 5.3 from virtual environments to the metaverse, 6 conclusion, a search strings and results.

B Included Publications

• Hadjipanayi C Christofi M Banakou D Michael-Grigoriou D (2024) Cultivating empathy through narratives in virtual reality: a review Personal and Ubiquitous Computing 10.1007/s00779-024-01812-w Online publication date: 27-May-2024 https://doi.org/10.1007/s00779-024-01812-w
• Pratama M Susanto A Septianita H Tedjabuwana R (2023) Building Social Justice Character Through X-Reality Technology: A Systematic Literature Review Proceedings of the 3rd International Conference on Business Law and Local Wisdom in Tourism (ICBLT 2022) 10.2991/978-2-494069-93-0_11 (79-89) Online publication date: 25-Jan-2023 https://doi.org/10.2991/978-2-494069-93-0_11
• Guarese R Pretty E Fayek H Zambetta F van Schyndel R (2023) Evoking empathy with visually impaired people through an augmented reality embodiment experience 2023 IEEE Conference Virtual Reality and 3D User Interfaces (VR) 10.1109/VR55154.2023.00034 (184-193) Online publication date: Mar-2023 https://doi.org/10.1109/VR55154.2023.00034
• Show More Cited By

Index Terms

Human-centered computing

Human computer interaction (HCI)

Interaction paradigms

Graphical user interfaces

Mixed / augmented reality

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University of Sydney, Australia

Association for Computing Machinery

New York, NY, United States

Publication History

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• Extended reality (XR)
• human-computer interaction (HCI)

Funding Sources

• Academy of Finland
• Biocenter Oulu, the Strategic Research Council (SRC), established within the Academy of Finland
• Academy Research Fellow funding by Academy of Finland
• Starting Grant of the Hong Kong Polytechnic University

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• Guarese R Polson D Zambetta F (2023) Immersive tele-guidance towards evoking empathy with people who are vision impaired 2023 IEEE International Symposium on Mixed and Augmented Reality Adjunct (ISMAR-Adjunct) 10.1109/ISMAR-Adjunct60411.2023.00179 (809-814) Online publication date: 16-Oct-2023 https://doi.org/10.1109/ISMAR-Adjunct60411.2023.00179

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The psychology of emotional and cognitive empathy.

The study of empathy is an ongoing area of major interest for psychologists and neuroscientists in many fields, with new research appearing regularly.

Empathy is a broad concept that refers to the cognitive and emotional reactions of an individual to the observed experiences of another. Having empathy increases the likelihood of helping others and showing compassion. “Empathy is a building block of morality—for people to follow the Golden Rule, it helps if they can put themselves in someone else’s shoes,” according to  the Greater Good Science Center , a research institute that studies the psychology, sociology, and neuroscience of well-being. “It is also a key ingredient of successful relationships because it helps us understand the perspectives, needs, and intentions of others.”

Though they may seem similar, there is a clear distinction between empathy and sympathy. According to Hodges and Myers in the  Encyclopedia of Social Psychology , “Empathy is often defined as understanding another person’s experience by imagining oneself in that other person’s situation: One understands the other person’s experience as if it were being experienced by the self, but without the self actually experiencing it. A distinction is maintained between self and other. Sympathy, in contrast, involves the experience of being moved by, or responding in tune with, another person.”

Emotional and Cognitive Empathy

Researchers distinguish between two types of empathy. Especially in social psychology, empathy can be categorized as an emotional or cognitive response. Emotional empathy consists of three separate components, Hodges and Myers say. “The first is feeling the same emotion as another person … The second component, personal distress, refers to one’s own feelings of distress in response to perceiving another’s plight … The third emotional component, feeling compassion for another person, is the one most frequently associated with the study of empathy in psychology,” they explain.

It is important to note that feelings of distress associated with emotional empathy don’t necessarily mirror the emotions of the other person. Hodges and Myers note that, while empathetic people feel distress when someone falls, they aren’t in the same physical pain. This type of empathy is especially relevant when it comes to discussions of compassionate human behavior. There is a positive correlation between feeling empathic concern and being willing to help others. “Many of the most noble examples of human behavior, including aiding strangers and stigmatized people, are thought to have empathic roots,” according to Hodges and Myers. Debate remains concerning whether the impulse to help is based in altruism or self-interest.

The second type of empathy is cognitive empathy. This refers to how well an individual can perceive and understand the emotions of another. Cognitive empathy, also known as empathic accuracy, involves “having more complete and accurate knowledge about the contents of another person’s mind, including how the person feels,” Hodges and Myers say. Cognitive empathy is more like a skill: Humans learn to recognize and understand others’ emotional state as a way to process emotions and behavior. While it’s not clear exactly how humans experience empathy, there is a growing body of research on the topic.

How Do We Empathize?

Experts in the field of social neuroscience have developed  two theories  in an attempt to gain a better understanding of empathy. The first, Simulation Theory, “proposes that empathy is possible because when we see another person experiencing an emotion, we ‘simulate’ or represent that same emotion in ourselves so we can know firsthand what it feels like,” according to  Psychology Today .

There is a biological component to this theory as well. Scientists have discovered preliminary evidence of “mirror neurons” that fire when humans observe and experience emotion. There are also “parts of the brain in the medial prefrontal cortex (responsible for higher-level kinds of thought) that show overlap of activation for both self-focused and other-focused thoughts and judgments,” the same article explains.

Some experts believe the other scientific explanation of empathy is in complete opposition to Simulation Theory. It’s Theory of Mind, the ability to “understand what another person is thinking and feeling based on rules for how one should think or feel,”  Psychology Today says. This theory suggests that humans can use cognitive thought processes to explain the mental state of others. By developing theories about human behavior, individuals can predict or explain others’ actions, according to this theory.

While there is no clear consensus, it’s likely that empathy involves multiple processes that incorporate both automatic, emotional responses and learned conceptual reasoning. Depending on context and situation, one or both empathetic responses may be triggered.

Cultivating Empathy

Empathy seems to arise over time as part of human development, and it also has roots in evolution. In fact, “Elementary forms of empathy have been observed in our primate relatives, in dogs, and even in rats,” the Greater Good Science Center says. From a developmental perspective, humans begin exhibiting signs of empathy in social interactions during the second and third years of life. According to  Jean Decety’s article “The Neurodevelopment of Empathy in Humans ,” “There is compelling evidence that prosocial behaviors such as altruistic helping emerge early in childhood. Infants as young as 12 months of age begin to comfort victims of distress, and 14- to 18-month-old children display spontaneous, unrewarded helping behaviors.”

While both environmental and genetic influences shape a person’s ability to empathize, we tend to have the same level of empathy throughout our lives, with no age-related decline. According to “Empathy Across the Adult Lifespan: Longitudinal and Experience-Sampling Findings,” “Independent of age, empathy was associated with a  positive well-being and interaction profile .”

And it’s true that we likely feel empathy due to  evolutionary advantage : “Empathy probably evolved in the context of the parental care that characterizes all mammals. Signaling their state through smiling and crying, human infants urge their caregiver to take action … females who responded to their offspring’s needs out-reproduced those who were cold and distant,” according to the Greater Good Science Center. This may explain gender differences in human empathy.

This suggests we have a natural predisposition to developing empathy. However, social and cultural factors strongly influence where, how, and to whom it is expressed. Empathy is something we develop over time and in relationship to our social environment, finally becoming “such a complex response that it is hard to recognize its origin in simpler responses, such as body mimicry and emotional contagion,” the same source says.

Psychology and Empathy

In the field of psychology, empathy is a central concept. From a mental health perspective, those who have high levels of empathy are more likely to function well in society, reporting “larger social circles and more satisfying relationships,” according to  Good Therapy , an online association of mental health professionals. Empathy is vital in building successful interpersonal relationships of all types, in the family unit, workplace, and beyond. Lack of empathy, therefore, is one indication of conditions like antisocial personality disorder and narcissistic personality disorder. In addition, for mental health professionals such as therapists, having empathy for clients is an important part of successful treatment. “Therapists who are highly empathetic can help people in treatment face past experiences and obtain a greater understanding of both the experience and feelings surrounding it,” Good Therapy explains.

Exploring Empathy

Empathy plays a crucial role in human, social, and psychological interaction during all stages of life. Consequently, the study of empathy is an ongoing area of major interest for psychologists and neuroscientists in many fields, with new research appearing regularly. Lesley University’s  online bachelor’s degree in Psychology  gives students the opportunity to study the field of human interaction within the broader spectrum of psychology.

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• Published: 09 September 2024

Unfolding the empathic insights and tendencies among medical students of two gulf institutions using interpersonal reactivity index

• Haniya Habib 1 ,
• Sara Anjum Niinuma 1 ,
• Khadeja Alrefaie 1 ,
• Heba Awad Al Khalaf 2 ,
• Mohammad Jasem Hani 2 ,
• Zeinab Yaareb Mosleh Al-Rawi 2 ,
• Zarish Hussain 1 ,
• Prianna Menezes 1 ,
• Sornali Rani Roy 3 ,
• Bincy Mathew 1 ,
• Salman Yousuf Guraya 2 ,
• Alfred Nicholson 1 &
• Shaista Salman Guraya 4  

BMC Medical Education volume  24 , Article number:  976 ( 2024 ) Cite this article

Metrics details

Empathy is an essential core competency for future doctors. Unfortunately, the medical curriculum is infamously known to burn out aspiring doctors, which may potentially lead to a decline in empathy among medical students. This research was planned to understand the evolution of empathic approaches among students across the curriculum using the Interpersonal reactivity index (IRI) as a benchmark at the Royal College of Surgeons in Ireland - Medical University of Bahrain (RCSI-MUB) and University of Sharjah (UoS).

We adopted a cross-sectional design and administered an online survey to the medical students of RCSI-MUB and UoS using a modified version of the IRI along with its three subscales of empathic concern (EC), perspective taking (PT), and personal distress (PD). To identify intra- and inter-institutional variations in empathy scores, the Analysis of Variance (ANOVA) was performed separately for each institution and with both institutions combined. A two-way ANOVA was conducted for the comparison between years and institutions. For the subscale analysis of EC, PT, and PD, we used one-way ANOVA for significant differences between years at both institutions. For the gender-effect analysis, t-test was performed to examine the differences in total IRI scores at both institutions combined and at each institution separately. Additionally, an Analysis of Covariance (ANCOVA) was done to identify the influence of gender on empathy scores.

A total of 140 students from both institutions participated in this study. We found a fluctuating pattern of empathy scores without a clear trend across the years. The sub-scales of EC, PD, and PT across academic years at both institutions showed significant differences within the EC at RCSI-MUB ( p  = 0.003). No significant differences were identified across other years from both institutions. There were significant differences between empathy scores from RCSI-MUB and UoS for EC ( p  = 0.011). Additionally, a pronounced interaction effect between year and institution was observed for PT ( p  = 0.032). The gender-wise analysis showed that female students had higher empathy scores than males ( p  = 0.004). The ANCOVA for IRI score results revealed a p -value of 0.023, indicating that gender plays a crucial role in empathy levels among medical students. The ANCOVA results revealed a p -value of 0.022 in the EC subscale.

Our study unveiled intricate patterns in empathy development among medical students across years and genders at RCSI-MUB and UoS. These congruences and dissimilarities in empathy scores signal a subjective understanding of empathy by medical students. The disparities in understanding may encourage medical educators to embed empathy in standard medical curricula for better healthcare outcomes.

Peer Review reports

In modern healthcare systems, empathy is considered as a fundamental pillar that plays a pivotal role in fostering patient trust, improving patient outcomes, and enhancing patient satisfaction [ 1 ]. Additionally, empathy allows physicians to communicate effectively with their patients and to express their humanistic and compassionate attitude [ 2 ]. Empathy pertains to the ability to perceive, recognize, and share another person’s feelings [ 3 ]. An empathic approach by physicians enhances physician-patient relationships, patient safety, and healthcare outcomes due to improved patient compliance and understanding of management plans [ 4 ]. Despite its outright benefits in the medical field, empathy needs to be better nurtured and understood in medical schools. A multitude of factors may contribute to this poor understanding of empathy, including a lack of a standard definition of empathy and consistency in the delivery and assessment of its cognitive, affective, and behavioral parts [ 5 ]. Furthermore, research has found that social commitment to medicine, including empathy, declines as students’ progress through their studies [ 6 ]. The medical curriculum is infamously known to burn out aspiring doctors, and consequently, their ethical values rapidly decrease, particularly during clinical years [ 7 ]. This is perhaps an aftermath of less emotional involvement of medical students with patients. [ 8 ].

In the context of patient care, a clear distinction between cognitive empathy, defined from a knowledge perspective (involving understanding processes), and empathy, defined from an emotional perspective (involving feelings and affect), is very crucial. These two forms of engagement yield different outcomes [ 9 ]. This emotional attunement of physicians fulfills the cognitive purpose of apprehending and sharing patients’ feelings and sufferings. Having a surplus of cognitive empathy (also known as clinical empathy) in patient care is consistently advantageous and can lead to the development of trust-based relationships, more precise diagnoses, enhanced patient compliance, and consequently, more favorable patient outcomes [ 10 , 11 ]. However, an excess of emotional involvement, also known as sympathy, can be detrimental to patient care, resulting in emotional exhaustion and professional burnout among healthcare providers and unchecked emotional reliance on the part of the patient [ 12 , 13 ]. Uncontrolled emotions can readily interfere with the objective process of making clinical decisions [ 14 ].

Empathy is contextually contingent and primarily shaped by situational factors and one’s inherent empathic tendencies [ 15 ]. These inherent tendencies can impact both cognitive and affective empathy. Individuals with high inherent empathic tendencies may better understand and appreciate others’ perspectives and emotions, complementing their cognitive empathy [ 16 ]. In medical education, understanding the inherent empathic tendencies of undergraduate medical students can provide valuable information to provide implications for their future patient care practices and interactions. In unison, such natural inclination towards emotional resonance can foster affective empathy, enabling one to genuinely share in the emotional experiences of others and respond compassionately [ 17 ]. Therefore, inherent empathic tendencies are integral to an individual’s overall empathic disposition, influencing how they connect with and understand the feelings and perspectives of those around them.

To date, numerous studies have explored the progression of empathy among medical students using various measurement scales, including the Interpersonal Reactivity Index (IRI) [ 18 , 19 , 20 , 21 , 22 ]. However, most of these studies have primarily focused on institutions in North America and Asia, with limited research conducted in the Middle Eastern region. It’s crucial to acknowledge that cultural nuances influence empathy, and therefore, findings from studies conducted in one cultural context may not necessarily generalize to medical institutions in other settings. This underscores the importance of conducting research in diverse cultural contexts to better understand the complexities of empathy development among medical students globally.

By investigating the empathic tendencies of medical students using the Interpersonal Reactivity Index (IRI) from two Middle Eastern institutions, we aim to shed light on the interplay of the complex relationship between innate empathy and external factors (educational environment), ultimately contributing to a more comprehensive understanding of empathy in medical education. By administering the IRI questionnaire, we aim to investigate the variations in empathic tendencies between these two groups of medical students, including perspective-taking (PT), empathic concern (EC), and personal distress (PD). PT measures the ability to shift to another person’s perspective, EC measures other-oriented feelings of sympathy and concern for others, and PD measures self-oriented feelings of personal anxiety and uneasiness in tense interpersonal settings. Additionally, this research seeks to identify potential factors or associations that may influence empathy scores within the context of medical education and institutional differences at the Royal College of Surgeons in Ireland, Medical University of Bahrain (RCSI-MUB) and the University of Sharjah (UoS) in the United Arab Emirates (UAE).

Our research delved into the evolution of the empathic approaches among medical students of two distinct academic institutions in the Middle Eastern region. The primary research question of our study was to determine the pattern of empathic insights of medical students across certain time points of their medical curriculum. A secondary end-point outcome was to compare yearly, gender-wise, and institutional variations in the understanding of medical students’ empathy between both institutions.

Materials and methods

The Bachelor of Medicine and Bachelor of Surgery (MBBS) programs of RCSI-MUB and UoS contain a foundation year and a 5-year program with three phases of basic medical sciences, pre-clinical, and clinical sciences. Empathy is not delivered as a stand-alone subject in both institutions; however, it is arbitrarily covered during the clinical training of medical students. Between March and June 2023, an email invitation was sent to the undergraduate medical students of RCSI-MUB and UoS studying in foundation year till year 5. The invitation included details of the research study, a participant information leaflet (PIL), and a consent form. The registered students received another email with PIL and a SurveyMonkey questionnaire. Participants were requested to abide by the regulations for data privacy and their institutional codes of professional conduct throughout the study.

The study’s target population was undergraduate medical students who were currently studying foundation year till year 5 of study. A purposive sampling method was used to recruit medical students, and a convenience sample was obtained by approaching the participants who were available at the time of data collection. We invited student representatives from each year and institution to provide their perceptions of the IRI questionnaire. In total, we invited 144 student representatives from foundation to year 5 of both institutions, around 24 students from each year. Of those, 140 participated in our study with a response rate of 97%.

Empathy measuring tools

An online survey was conducted using a modified version of the IRI, a widely recognized instrument for gauging empathy with a subset of scales and relevant tools [ 23 ]. This index was used for this study since it is the most widely used self-report measure for empathic tendencies due to its multidimensional approach and comprehensive assessment of empathic dispositions [ 24 , 25 ]. Its validity and ease of administration are why we selected it for our study to assess empathic tendencies. The questionnaire also collected demographic data of student initials, gender, and year of study. We utilized the modified version of IRI, where we evaluated three of its four subscales: PT, EC, and PD, which contribute to cognitive and affective empathy [ 26 ] (Appendix I ). PT, encompassing the cognitive aspect of empathy, delineates one’s capacity to understand and adopt another person’s viewpoint, thoughts, and feelings. On the other hand, EC is associated with affective empathy, encompassing the emotional resonance and compassionate response one feels in response to another person’s emotional distress or suffering. PD within the IRI pertains to an individual’s own discomfort and unease when confronted with the suffering of others, which can hinder empathic responses. Therefore, the IRI’s dimensions help dissect the intricate interplay between cognitive and affective empathy, shedding light on the multifaceted nature of empathic experiences. For the context of our study, we excluded the fantasy subscale, considering it less relevant to the medical milieu. The participants were instructed to answer on a 5-point scale of A-E ranging from ‘does not describe me well,’ ‘neutral’ to ‘does describe me well.’ Each subscale enquired about the participants’ insights on different empathic dispositions. A high score on PT indicates a tendency to adopt another’s psychological perspective, while a high score on EC shows a tendency to experience feelings of warmth, sympathy, and concern toward others. Finally, a high score on PD demonstrates a tendency towards feelings of discomfort when witnessing others’ negative experiences.

Statistical analysis

Total iri score analysis.

Initially, we conducted an analysis of the total IRI scores across all participants from both institutions, stratified by academic year (foundation to year 5). This comprehensive approach provided an overarching insight into the empathic tendencies of students at different stages in their academic journey. Descriptive statistics, including mean and standard deviation, were calculated for each year group, offering a preliminary understanding of each cohort’s data distribution and central tendency. A One-way Analysis of Variance (ANOVA) was performed separately for each institution and with both institutions combined to discern whether significant differences in empathy levels existed between various years’ groups. This step was crucial for identifying intra- and inter-institution variations in empathy scores. Furthermore, a Two-Way ANOVA was conducted with ‘year’ and ‘institution’ as factors to elucidate any interaction effects between the academic year and the institution to determine whether institutions had differential impacts on students’ empathy levels across the years.

Sub-scale analysis

Subsequently, we delved deeper into the individual sub-scales of the IRI (PT, PD, and EC) to dissect the components of empathy exhibited by students. Descriptive statistics for each sub-scale were computed for every year group at each institution, laying the groundwork for understanding the specific empathic tendencies prevalent in each cohort. One-Way ANOVA tests were employed for each sub-scale to probe for significant differences between years at both institutions. This granular analysis was important for unmasking the nuances of empathic development among students. Notably, since a significant variance was detected in the EC sub-scale at RCSI-MUB, post-hoc tests were executed exclusively for this group to identify any differences in insights about empathy. Additionally, Two-Way ANOVA tests were conducted for each sub-scale with ‘year’ and ‘institution’ as factors, facilitating a comparative analysis between the two institutions while considering the interaction effects.

Gender effect analysis

To investigate the influence of gender on empathy, we calculated the mean and standard deviation of total IRI scores for each gender at both institutions. T-tests were performed to examine the differences in total IRI scores between genders at both institutions combined and the total scores of each sub-scale at each institution separately. The rationale for selecting the t-test was its suitability for comparing the means of two groups (male and female students). This step was essential for validating the gender effect on empathy levels, offering a lens through which the data could be interpreted from a gender perspective. Lastly, we included an Analysis of Covariance (ANCOVA). This was conducted to control the potential confounding effect of gender on empathy scores. ANCOVA was applied to the combined data from both institutions, integrating gender as a covariate. This step was crucial to discern if the observed variations in empathy scores, both in total IRI and its subscales (PT, PD, and EC), could be attributed to gender differences among student cohorts.

Ethics approval

The study was approved by the relevant Institutional Research Ethical Committees of RCSI-MUB (REC/2023/147/18-Jan-2023) and UoS (REC-23-03-12-01-F). All participants gave fully informed written consent to participate at the start of the study.

Influence of year and institution

A total of 140 medical students from RCSI-MUB and UoS responded to the online questionnaire in our study. There were 89 female and 51 male students. The yearly distribution of IRI and three sub-scales scores for all participating students from both institutions is presented in Table  1 . This table illustrates the mean, median, standard deviation, and standard error of the total IRI scores and does not apply statistical tests to these values. Observationally, the data show a fluctuating but consistent pattern in empathy scores across the years without marked differences.

Figure  1 a and b, and 1 c display the bar plots of mean scores for the EC, PD, and PT sub-scales, respectively, for students at RCSI-MUB and UoS across different academic years. The results of the One-Way ANOVA for all three IRI sub-scales across the academic years at both institutions showed significant differences within the EC sub-scale at RCSI-MUB ( p  = 0.003), as detailed in Table  2 . Subsequently, the Tukey post-hoc test results, demonstrated in Table  3 , show a significant pairwise difference in EC between Year 1 and Year 4 students at RCSI-MUB ( p  = 0.035). No significant differences were identified in comparison to other years from both institutions.

Bar plot based on descriptive data with mean scores for empathic concern ( a ), personal distress ( b ), and perspective taking ( c )

Table  4 outlines the results of Two-Way ANOVA tests with significant differences between the insights of medical students from RCSI-MUB and UoS for EC ( p  = 0.011, Table  4 ). This implies that the educational environment or the mode of curricular delivery might exert a tangible influence on students’ empathic concerns. Additionally, a pronounced interaction effect between year and institution was observed for PT ( p  = 0.032, Table  4 ). An interesting analysis of the responses by medical students from RCSI-MUB and UoS for the subscale PT illustrates a unique pattern of the development of an empathic approach across different year groups (Fig.  2 ). Briefly, Fig.  2 displays the PT scores for foundation year students of RCSI-MUB students who exhibited higher scores than UoS. The PT scores of year 1 students at both institutions increased; however, a divergence was observed in year 2, with RCSI-MUB scores declining while UoS scores continued to increase. In year 3, the scores converged, with both institutions showing similar levels. Year 4 had a reversal, with RCSI-MUB scores increasing and UoS scores declining. Finally, in year 5, RCSI-MUB scores decreased while UoS scores escalated.

A plot diagram with the interaction effect between years and institution for perspective taking ( N  = 140)

Gender-specific findings

Table  5 shows the percentages of male and female students across different years at RCSI-MUB and UoS and the overall gender distribution by institution. Table  6 compares the mean IRI scores for female and male medical students from RCSI-MUB and UoS using a t-test. The results showed that female students had higher overall empathy scores than males ( p  = 0.004). The gender-wise comparison of scores among medical students for EC, PD, and PT showed a significantly higher empathic concern by female students of RCSI-MUB than their male counterparts ( p  = 0.014), as shown in Table  7 . This finding might have been influenced by the fact that all year 1 students at RCSI-MUB were females, potentially affecting the observed gender disparities. Table  8 outlines the ANCOVA for IRI results, which revealed a significant p -value of 0.023, which is below the conventional alpha level of 0.05, and ANCOVA for EC subscale shows a p -value of 0.022, affirming the impact of gender on empathy development.

The findings of our study offer a nuanced perspective on the trajectory of empathy development among medical students, reflecting a deeper understanding of empathy. Though there were insignificant differences for three subscales of IRI for each institution, there was a recognizable variation in EC scores and a fluctuating pattern of responses to PT between RCSI-MUB and UoS medical students. These results underscore the evolving nature of understanding empathy, that may be partly due to an absence of a standardized and accredited empathy-based curriculum. Lastly, female students had a significantly better understanding of EC, which signals a gender-based preference toward empathic care of patients.

These findings are consistent with the notion that empathy is not a static trait but rather a dynamic quality that evolves over time and can be influenced by various factors. In their cross-sectional and longitudinal mixed-methods study on undergraduate and graduate medical students, Michael et al., have deduced that targeted educational programmes should be introduced to develop empathic and patient-centered skills and competence of physicians [ 27 ]. Similar to other studies, our research also showed variations in responses and understanding of medical students in the absence of standard teaching of empathy in the curricula of both RCSI-MUB and UoS [ 28 , 29 , 30 ]. At the same time, we found yearly, gender, and institutional variations in understanding of empathy. The trends in PT scores suggested several points of consideration. The higher initial PT scores of foundation year students at RCSI-MUB compared to UoS may reflect differences in admission criteria, foundational training, or student characteristics between the two institutions. The shared increase in year 1 might indicate a common emphasis on developing perspective-taking skills early in medical education. The divergence in year 2, convergence in year 3, and subsequent variations may be indicative of differences in curricular focus, educational experiences, or other institutional factors that influence the development of perspective-taking skills at RCSI-MUB and UoS. The reversal in year 4 and the final intersection in year 5 may highlight variations in the later stages of medical training at each institution, potentially influenced by different clinical exposures or preparation for professional practice. These observed trends warrant further investigations to understand fully the factors contributing to the development of PT skills at medical academic institutions [ 31 ].

The identified significant variations within the EC sub-scale, particularly at RCSI-MUB between year 1 and 4 students, are particularly noteworthy. While the exact reasons for these variations require further exploration, these findings may indicate the uniqueness of the empathic development trajectory between years 1 and 4. Studies on empathy concerns among medical students report inconsistent data as they may decline, remain stable, or enhance [ 32 , 33 ]. Piumatti et al. witnessed that empathy remains stable in most medical students and declines in fewer [ 34 ]. Furthermore, the authors observed that freedom to talk and patient-centric motives for studying medicine were associated with a higher and consistent empathic approach. The differences in EC scores among students of both institutions might indicate variations in educational environment or curriculum or both. Further research is essential to interpret the implications of these findings fully and understand the factors contributing to the observed differences in EC scores among medical students at RCSI-MUB and UoS.

The significant interaction effect between year and institution for PT suggests that the journey of empathy development is not linear and is influenced by a myriad of factors, including the educational environment. The gender differences observed, especially within RCSI-MUB, further complicate the narrative. The exclusive female composition of year 1 students at RCSI-MUB could have introduced a potential bias, potentially skewing the results. However, gender distribution was more consistent in some years, particularly at UoS. The ANCOVA results revealed a p -value of 0.023, which falls below the conventional alpha level of 0.05, and p -value of 0.022 for EC subscale. This finding indicates that gender influences empathy levels among medical students. Female students exhibited higher empathy scores than their male counterparts, suggesting that gender differences might be an important factor to be considered in medical education and training. This insight into the gender disparities in empathic tendencies can be pivotal for medical educators and curriculum designers, as it highlights the need for tailored approaches to develop and nurture empathy among future healthcare professionals. However, we acknowledge the limitations in our demographic analysis due to the unavailability of additional sociodemographic details such as age, nationality, and socioeconomic status.

Most published studies have reported that female medical students are more empathic than their male counterparts [ 32 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. However, despite the overwhelming evidence supporting this correlation, there have been inconsistencies in the findings of some studies. Electroencephalography measures have not found significant gender differences in empathic abilities [ 44 ]. A cross-sectional study in Pakistan yielded results that align with the general trend, showing that females had significantly higher scores on specific items of the IRI and EC scales [ 45 ]. Nevertheless, when considering total empathy scores, both male and female students demonstrated similar levels of empathy overall. This emphasizes the importance of diverse participation in research to ensure comprehensive insights. Developing PT skills and strategies to mitigate PD are fundamental core competencies of medical graduates. Empirical research has argued that medical students’ distress may potentially lead to cynicism and subsequently affect their care of patients and their relationship with peers and faculty [ 46 ]. The manifestations and causes of PD, alongside its potential adverse personal and professional outcomes, are detrimental to enhancing EC among medical students [ 47 ]. These adverse consequences can be arrested by targeting medical education and paying more attention to fortifying the EC of medical students.

In our exploration of empathic development among medical students, the year-based analysis did not show significant differences across academic years, indicating consistency in empathy levels as students’ progress through their medical education. This finding adds an intriguing dimension to our understanding of empathy, suggesting that despite varying challenges and experiences encountered in different stages of medical education, the overall capacity for empathy among students remains relatively stable. However, this finding may be due to the cross-sectional nature of the study.

Despite significant similarities in the core curricula at RCSI-MUB and UoS, we posit that other factors unique to each institution, such as cultural contexts, teaching methodologies, student demographics, and extracurricular activities, might influence the development of empathic behaviors. Our study, therefore, recommends that researchers extend beyond the curriculum to include these broader institutional factors, offering a more nuanced perspective on how empathy is shaped within medical education settings.

Despite the significant role of empathy in enhancing healthcare outcomes, this important trait in medical students and residents has paradoxically been reported to decline during their clinical training [ 13 , 48 ]. Several factors can contribute, such as emotional exhaustion, suboptimal social support, burnout due to workload, and an inadequate curriculum [ 49 ]. For the professional enhancement of empathic skills of medical students, educators can consider well-structured faculty development programs [ 50 ], interprofessional education [ 51 ], simulation-based scenarios [ 52 ], and patient-centered medical education for effective communication [ 27 ]. Particular attention must be paid to interprofessional education, which carries great potential to enhance the empathic concerns of medical students [ 53 ].

Medical institutions might contemplate implementing structured empathy training modules, ensuring that future doctors are equipped with this indispensable soft skill. The observed differences between institutions underscore the need for a tailored approach, considering the unique characteristics of each institution. As the medical community continues to recognize the importance of empathy in patient care, research like ours calls for the need for continuous evaluation and refinement of medical curricula to foster this critical trait.

Strengths and limitations

This study was conducted on medical students of two premier medical institutions of the Middle Eastern region. This unique opportunity allowed us to analyze the cross-cultural and curricular influence of empathic approaches of medical students across the entire continuum of medical education. Additionally, this research yields significant findings that medical educators can use to modify the medical curriculum.

Our study has several limitations. First, based on the nature of the study, the number of participants may be considered small, limiting the generalizability of the findings. Second, this study identified differences in empathic approaches at defined time points rather than in a prospective manner. Due to the cross-sectional design, the research measured different participants at distinct stages rather than following the same individuals over time. Consequently, the findings reflect differences in empathy scores between separate groups rather than changes within the same individuals. This design limitation means that the study captures variations in empathy approaches at specific time points rather than longitudinally tracking how individual empathy develops or changes throughout progression in a medical program. Third, the results may not be used to cover other cultures or contexts. Finally, the self-reported insights of students to IRI may reflect subject bias. Individuals are likely to overestimate their empathy due to factors like social desirability.

Future directions

Our study used a self-administered IRI questionnaire and did not explore the empathy that takes place between patients and medical students. Future investigators should employ studies that could focus on patient perceptions of empathic student and physician behavior. Furthermore, expanding the sample size and incorporating longitudinal examination of participants to observe changes over time will certainly advance the understanding of medical students’ empathy. In addition, future research could benefit from incorporating gender balance and sociodemographic variables to present a more comprehensive demographic profile and to understand their potential influences on empathy development among medical students.

In summary, our study substantially contributes to the evolving nature of empathy development among medical students and the potential impact of curriculum and gender on this critical attribute. Though there are certain variations in insights about empathy, this study observed a unique fluctuating trend between RCSI-MUB and UoS across years and gender. Such disparities highlight the potential ramifications of curricular elements, teaching methodologies, clinical experiences, or even institutional ethos on students’ empathy development. This research urges medical educators to modify existing medical curricula by inculcating empathy into standard teaching and learning pedagogies.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Interpersonal Reactivity Index

Royal College of Surgeons in Ireland – Medical University of Bahrain

University of Sharjah

Bachelor of Medicine and Bachelor of Surgery

Empathic concern

Perspective taking

Personal distress

Analysis of Variance

Analysis of Covariance

Participant Information Leaflet

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Haniya Habib, Sara Anjum Niinuma, Khadeja Alrefaie, Zarish Hussain, Prianna Menezes, Bincy Mathew & Alfred Nicholson

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SSG conceptualized the idea. HH, SAN, and SSG developed the protocol. HH, SAN, HAK, MJH, and ZYMA obtained ethical approval at the respective institutions. Data collection was performed by HH, SAN, KA, HAK, MJH, ZYMA, ZH, PM, SRR, and BM. Data analysis was conducted by KA, HAK, MJH, HH, SAN and SYG. Initial draft prepared by SYG, SSG, KA, HH, and SAN. Later on, BM, AN, and SSG improved the intellectual content of the initial draft. All authors contributed and proofread the final draft. SYG, SSG, and AN supervised the whole project and ensured the accuracy of the devised protocol and research integrity. All authors have read and agreed to the published version of the manuscript.

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Habib, H., Niinuma, S.A., Alrefaie, K. et al. Unfolding the empathic insights and tendencies among medical students of two gulf institutions using interpersonal reactivity index. BMC Med Educ 24 , 976 (2024). https://doi.org/10.1186/s12909-024-05921-1

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Out-of-Body Experiences Can Profoundly Increase Empathy

September 9, 2024 by [email protected]

Marina Weiler, PhD

Out-of-body experiences, such as near-death experiences, can have a “transformative” effect on people’s ability to experience empathy and connect with others, a scientific paper from University of Virginia School of Medicine researchers explains.

The fascinating work from UVA’s Marina Weiler, PhD, and colleagues not only explores the complex relationship between altered states of consciousness and empathy but could lead to new ways to foster empathy during a particularly fractured time for American society – and the world.

“Empathy is a fundamental aspect of human interaction that allows individuals to connect deeply with others, fostering trust and understanding,” said Weiler, a neuroscientist with UVA’s Division of Perceptual Studies. “The exploration, refinement and application of methods to enhance empathy in individuals – whether through OBE [out-of-body experience]-related ego dissolution or other approaches – is an exciting avenue with potentially profound implications for individuals and society at large.”

How Out-of-Body Experiences Affect Empathy

Weiler’s paper examines the possibility that the dramatic increases in empathy seen in people who undergo out-of-body experiences may result from what is known as “ego dissolution” – the loss of the sense of self. In these instances, people feel they have been severed from their physical form and have connected with the universe at a deeper level. Sometimes known as “ego death” or “ego loss,” this state can be brought on by near-death experiences, hallucinogenic drugs and other causes. But people who undergo it often report that their viewpoint on the world, and their place in it, is radically changed.

“The detachment from the physical body often leads to a sense of interconnectedness with all life and a deepened emotional connection with others,” the researchers write. “These sensations of interconnectedness can persist beyond the experience itself, reshaping the individual’s perception and fostering increased empathy, thereby influencing personal relationships and societal harmony.”

Out-of-body experiences can seem more real than reality itself, the researchers note, and this sense of transcendental connectedness can translate into “prosocial” behaviors afterward. Experiencers often become more compassionate, more patient, more understanding. More than half in one study described their relationships with others as more peaceful and harmonious. Many become more spiritual and more convinced of the possibility of life after death.

In their paper, Weiler and her co-authors explore potential explanations for what is happening within the brain to cause these changes. But while that remains unclear, the lasting effects of OBEs are not. And by understanding how these life-changing experiences can enhance empathy, researchers may be able to develop ways to help foster it for society’s benefit during a conflicted age.

“Interest in cultivating empathy and other prosocial emotions and behaviors is widespread worldwide,” the researchers conclude. “Understanding how virtues related to consideration for others can be nurtured is a goal with personal, societal and potentially global implications.”

Findings Published

  Weiler and her colleagues have published their article in the scientific journal Neuroscience and Biobehavioral Reviews . The research team consisted of Weiler, David J. Acunzo, Philip J. Cozzolino and Bruce Greyson, all part of the Division of Perceptual Studies and UVA’s Department of Psychiatry and Neurobehavioral Sciences. The authors have no financial interest in the work.

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How Empathetic Are You? New Study Shows Trait Is Rising Among Young Americans

• A follow-up study found that empathy among American youth has been increasing in recent years, approaching levels seen in the 1970s.
• Experts attribute the rise to factors such as increased awareness of global challenges and the growing emphasis on mental health education and support.
• Actively listening to others and imagining yourself in someone else’s shoes are among some expert-backed tips for building empathy.

A recent study found that empathy among young Americans has been increasing since 2008, approaching levels seen in the 1970s. 

For the study, published in Social Psychological and Personality Science , researchers examined perspective-taking and empathic concern among American high school seniors and college students from 1979 to 2018.

Empathy is the ability to understand and accept how someone else feels regardless of your own feelings. Perspective-taking, on the other hand, means having the ability to experience the situation and feelings through another person’s point of view.

The researchers tracked these trends using three different sets of data over these four decades, including two that were representative of the entire country.  

They found that empathy levels have risen sharply among youth—something experts attribute to factors such as growing acceptance of mental health issues and a greater awareness of global challenges, like the recent pandemic. 

The results mark a notable shift from a 2011 study conducted by the same team, which found that U.S. college students scored 40% lower in empathy than their counterparts from the late 1970s.  

“This is great news, and goes against stereotypes that many people have about youth,” Sara Konrath, PhD , first author of the study and director of the Interdisciplinary Program on Empathy and Altruism Research at the Indiana University Lilly Family School of Philanthropy, told Health in an email. 

“Young Americans today are pretty empathetic, and this matters because empathy helps to promote kind behaviors like giving, sharing, helping, and volunteering,” she said.

Given these benefits, you might be curious as to how you stack up on the empathy scale, as well as what you can do to build this trait—which isn’t fixed. Here’s what psychologists had to say.

Frazao Studio Latino / Getty Images

Testing Your Empathy

There are many self-assessment tools available to help you evaluate your level of empathy, Alisha Simpson-Watt, LCSW, BCBA, LBA , executive clinical director and founder of Collaborative ABA Services, told Health in an email.

While a professional may guide you toward a particular test, you can also find the assessments online and take them without expert guidance. The test used in the recently published study is the Interpersonal Reactivity Index , which consists of 28 questions.

Others you might consider include: 

• The Empathy Quotient (EQ) : This test measures empathy levels in adults and comes in two versions, short and long.
• The Empathy Quiz : Three scientifically validated scales measure empathy in this assessment.

In addition to self-assessments, reflecting on your initial reactions when someone shares their struggles or emotions with you can give you a sense of how empathetic you are, Vinay Saranga, MD , a psychiatrist and founder of The North Carolina Institute of Advanced NeuroHealth, told Health in an email. 

For instance, if your first thought is, “I wish they would be quiet and go away,” it may indicate lower empathy, said Saranga. On the other hand, if you find yourself thinking, “I’m sorry you are feeling this way,” and “What can I do to help?” then you are likely more empathetic.

According to Simpson-Watt, some empathetic behaviors include:

• The ability to consider and understand someone else’s perspective outside your own.
• Recognizing and sharing another person’s thoughts and feelings.
• Having a genuine concern for the well-being of others.
• The ability to attend and actively listen to what others have to say
• Feeling overwhelmed or affected by traumatic events experienced by others.

How to Become More Empathetic

According to Saranga, it’s certainly possible to become more empathetic. To develop more empathy, try taking a few minutes to help someone struggling, imagine how they are feeling, and think about how you would want someone to support you if you were in the same situation.

“Sometimes that simply means just being there and giving them a shoulder to lean on, and sometimes it could mean helping them find a viable solution to overcome the current situation,” Saranga said.

While you’re interacting with that person, keep these tips from Saranga and Simpson-Watt in mind: 

• Practice active listening: Pay close attention to what they are saying without interrupting or judging them. 
• Show physical support: Offer a hug, hold their hand, or sit with them if needed to provide comfort. 
• Be present: Spend time with them until they feel better and let them vent if needed. 
• Affirm feelings: Reinforce their positive attributes and remind them of their strengths. 
• Understand your own biases: Recognize how your biases, thoughts, experiences, and views might affect your ability to empathize.
• See their perspective: Try to understand the other person’s point of view, even if you disagree. 
• Imagine their experience: Put yourself in their shoes to understand better what they're going through. 
• Observe verbal and nonverbal cues: Pay attention to the person’s verbal and nonverbal cues, such as tone of voice and body language, to understand their emotions.

Finally, remember to check in regularly to see how they’re doing and offer ongoing support, experts said.

Konrath S, Martingano AJ, Davis M, Breithaupt F. Empathy trends in American youth between 1979 and 2018: an update . Soc Psychol Personal Sci . Published online December 28, 2023. doi:10.1177/19485506231218360

Konrath SH, O'Brien EH, Hsing C. Changes in dispositional empathy in American college students over time: a meta-analysis . Pers Soc Psychol Rev . 2011;15(2):180-198. doi:10.1177/1088868310377395

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Green Energy Research: Collaboration and Tools for a Sustainable Future

Science Article | Green Energy | 6 Sep 2024

The Urgency of Green Energy Innovation

The recent Climate Change 2023 synthesis report emphasizes the consequences of delayed emission reductions: fewer effective adaptation options for a warming planet 2 . Geopolitical factors like the Russia-Ukraine conflict further underscore the need for a green energy transition, with Europe’s energy security concerns highlighting the reliance on imported fossil fuels.

The Green Energy Research Landscape

Against this backdrop, green energy development has become a critical area of research, reflected in a more than 10-fold increase in related publications from 2010 (1,105) to 2023 (11,346), according to Digital Science’s Dimensions database. Researchers around the world are striving to improve green energy technology and society’s ability to harness renewable energy sources more efficiently.

According to data analysed by Nature Navigator , which uses artificial intelligence to generate comprehensive summaries of research topics, ‘renewable energy systems and technologies’ is the field’s most frequently mentioned subtopic (Fig.1). At a research concept level, wind power generation, grid optimization and resource management all feature as common underlying themes.

Figure 1: Topic anatomy of green energy research First-level nodes denote the research subtopic (highest prevalence themes emerging from green energy research). Second-level nodes denote the research concepts associated with these research subtopics. Note: only the research concepts mentioned in the highest count of outputs within each subtopic are presented here. Credit: Nature Research Intelligence

Of the primary green energy research subtopics presented by Nature Navigator , it is telling that ‘materials for energy storage and conversion’ is the fastest-growing, with a compound annual growth rate (CAGR) of 30.2% over the last five years. This may reflect a growing consensus among researchers and industry that a lack of options to efficiently store electricity generated by intermittent renewable sources for later use is a key bottleneck preventing the greater penetration of these sources into the grid.

Real-World Example: Accelerating Heat Pump Innovation

Changmo Sung, a prominent green energy researcher at Korea University, leveraged Nature Navigator to identify trends, key areas, and potential breakthroughs in heat pump technology. This facilitated a collaborative project with LG Electronics, accelerating their research efforts.

“It also enabled the rapid discovery of researchers and institutions outside Korea working on similar or complementary projects related to heat pumps” Sung says.

• International Energy Agency, Global Energy Review 2021 (2021).
• Intergovernmental Panel on Climate Change, Climate Change 2023 (2023).

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The Role of Empathy in Health and Social Care Professionals

Maria moudatsou.

1 Department of Social Work, Hellenic Mediterranean University, 71410 Heraklion, Greece; rg.oohay@muostaduom

2 Laboratory of Interdisciplinary Approaches for the Enhancement of Quality of Life (Quality of Life Lab), Hellenic Mediterranean University, 71410 Heraklion, Greece; moc.liamg@uoluoporvatsitera

3 Centre of Mental Health, 71201 Heraklion, Greece

Areti Stavropoulou

4 Nursing Department, University of West Attica, 12243 Athens, Greece

Anastas Philalithis

5 Department of Social Medicine, Medical School, University of Crete, 70013 Heraklion, Greece; rg.cou@lalihp

Sofia Koukouli

The current article is an integrative and analytical literature review on the concept and meaning of empathy in health and social care professionals. Empathy, i.e., the ability to understand the personal experience of the patient without bonding with them, constitutes an important communication skill for a health professional, one that includes three dimensions: the emotional, cognitive, and behavioral. It has been proven that health professionals with high levels of empathy operate more efficiently as to the fulfillment of their role in eliciting therapeutic change. The empathetic professional comprehends the needs of the health care users, as the latter feel safe to express the thoughts and problems that concern them. Although the importance of empathy is undeniable, a significantly high percentage of health professionals seem to find it difficult to adopt a model of empathetic communication in their everyday practice. Some of the factors that negatively influence the development of empathy are the high number of patients that professionals have to manage, the lack of adequate time, the focus on therapy within the existing academic culture, but also the lack of education in empathy. Developing empathetic skills should not only be the underlying objective in the teaching process of health and social care undergraduate students, but also the subject of the lifelong and continuous education of professionals.

1. Introduction

Communication skills have been described as the most important ability for a health professional. Efficient communication depends upon the therapist feeling certain that they have really heard and recorded the health care user’s needs so as to provide personalized care [ 1 ]. It is important for health professionals to understand people’s feelings, opinions and experiences in order to assess their real needs and act accordingly, offering tailor-made services. Reaching that goal makes the development of empathetic skills necessary [ 2 ].

The concept of empathy is a common denominator for many health professionals such as nurses, doctors, psychologists, and social workers [ 3 , 4 , 5 , 6 ]. The person-centered approach for the unconditional acceptance of the health care user and empathy have for years been the fundamental values in the education and implementation of clinical social practice [ 3 , 7 , 8 , 9 ].

2. Material and Methods

The aim of the present paper was to analyze the concept of empathy and emphasize its importance to the health professions. The research questions under consideration have been the following: 1. What does empathy mean and which are its dimensions; 2. What are the role and meaning of empathy in health and social care professions for the therapeutic journey of the health care user; 3. How can we assess the levels of empathy in professionals (assessment tools); 4. Which factors influence empathy?

A literature search was conducted by searching PubMed and Scopus databases, to identify studies of the last fifteen years published in English and Greek language. The key-words used were ‘empathy’ and ‘health professionals’. Out of the search, 78 studies were identified that better answer the aim and purposes of the present paper. These studies were discussed and evaluated by the authoring team in order to reach consensus on the eligibility of each one with the proposed research questions. After agreement was reached, re-examination and analysis of the studies’ findings lead to the formulation of four thematic categories, namely, a) Concept definition and dimensions, b) The role of empathy in health and social care professionals, c) Assessing empathy, and d) Factors that influence empathy.

3.1. Concept Definition and Dimensions

Empathy is the ability to understand and share other people’s feelings [ 10 ]. It is a core concept as, according to the psychodynamic, behavioral and person-centered approaches, it facilitates the development of a therapeutic relationship with the health care user, providing the basis for therapeutic change [ 11 ].

Empathy was first mentioned in a psychotherapeutic context in the 1950s [ 7 ]. The person-centered approach defined it as the temporary condition that a health professional experiences in his/her effort to understand a health care user’s life without bonding with them [ 3 , 12 ].

The contemporary concept of empathy is multidimensional and consists of affective, cognitive, and behavioral aspects [ 6 , 11 , 13 ]. Throughout history, the development and integration of this concept evolved along three different time periods. Until the end of the 1950s, the cognitive dimension was mostly prevalent. From 1960 onwards, emphasis was given to the affective dimension, whereas since 1970, empathy has been defined in all its multi-dimensionality; that is, the behavioral aspect has been added to the everyday practice of the health care professionals [ 14 ].

The affective dimension consists of the concepts of caring and that of the sincere, unconditional acceptance of the health care user (congruence) [ 8 , 15 , 16 ]. Caring refers to the assistance and support as byproducts of an emotional interaction. The concept of the full and sincere unconditional acceptance refers to the approval of the ‘other’ and a consensus between people, without preconceptions or stereotypes.

The cognitive dimension pertains to the interpersonal sensitivity and the ability to understand the position the other person is in (perspective taking) [ 17 , 18 ]. Interpersonal sensitivity means objectively understanding the other person’s situation. It is a deep process of getting to know someone, based in both verbal and non-verbal cues. The ability to understand the other person’s situation refers to the flexibility and the objective understanding of the point of view of the other person (walk in their shoes, comprehending the way they perform cognitively, emotionally, and mentally) [ 17 , 18 ].

Altruism and the therapeutic relationship both belong to the behavioral dimension which develops empathy into practice [ 19 , 20 ]. Altruism is a socially directed behavior aimed at relieving difficulties, problems, and the pain associated with them [ 11 ].

Sympathy, empathy, and compassion are closely related terms that are often used interchangeably. Sympathy has been defined as an emotional reaction of pity toward the misfortune of another, especially those who are perceived as suffering unfairly [ 21 ]. Empathy is understood as a more complex interpersonal construct that involves awareness and intuition, while compassion is a ‘complementary social emotion, elicited by witnessing the suffering of others’ and is related with the feelings of concern, warmth associated to motivating of support [ 22 ]. Empathetic listening might result in compassion fatigue because of prolonged exposure to stress and all it evokes [ 23 ]. Self-care practice, well-being, and self-awareness are fundamental in enhancing empathy and reducing compassion fatigue [ 23 , 24 ].

3.2. The Role of Empathy in Health and Social Care Professionals

In a qualitative research study, nurse students, who were asked their opinion on empathy, emphasized the three dimensions of the concept [ 3 ]. Participants described it as the nurse’s ability to understand and experience other people’s feelings, thoughts, and wishes, as well as the nurse’s capacity to comprehend the emotional and cognitive state of the person they work with. To sum up, empathy is perceived as a combination of the emotional, cognitive and practical skills involved when caring for a patient [ 3 ].

Empathy is one of the fundamental tools of the therapeutic relationship between the carers and their patients and it has been proven that its contribution is vital to better health outcomes [ 8 , 25 , 26 ]. As it allows the health care providers to detect and recognize the users’ experiences, worries, and perspectives [ 27 ], it strengthens the development and improvement of the therapeutic relationship between the two parts [ 28 ]. It is widely acknowledged that the health professional’s empathetic ability leads to better therapeutic results [ 29 ].

The empathetic relationship of the health professionals with their health care users reinforces their cooperation towards designing a therapeutic plan and a tailor-made intervention, increasing thus the patient’s satisfaction from the therapeutic process. This way, quality of care is enhanced, errors are eliminated, and an increased percentage of health care recipients positively experience therapy [ 30 , 31 , 32 , 33 , 34 ]. Furthermore, it has been noted that the empathetic relationship developed during the process of care reinforces the therapeutic results, as the users better comply with the therapeutic course of action [ 34 ].

Studies performed in various groups of patients with different health problems generated positive results regarding the progress of their health. Specifically, studies of patients with diabetes showed that there is an association between empathy and the positive therapeutic course of disease [ 31 , 35 ]. Moreover, patients with cancer demonstrate less stress, depression, and aggressiveness when receiving empathetic nursing care [ 36 ]. The empathetic relationship between a midwife and a future mother increases the latter’s satisfaction and lessens the stress, the agony, and the pain of the forthcoming labor as the mother feels security, trust, and encouragement [ 37 ].

Understanding based on empathy is critical to the relationship between the health professional and the recipient of care. When that happens, health care users feel secure and trust the professional’s abilities. Therefore, the distance between the expert and the patient shortens and both of them come closer, enjoying mutual benefits [ 12 ]. Moreover, a relationship based on empathy helps the therapists lessen their stress and burnout in the workplace and adds to their quality of life [ 37 , 38 ]. It has been shown that physicians who have higher levels of empathy experience less burnout or depression [ 39 , 40 ].

Empathy is especially important to the social care professions. It has been noted that the ability of the social worker for empathy and understanding of the users’ experiences and feelings plays a crucial role in social care as empathy is one of the most important skills that these professionals may employ to develop a therapeutic relationship [ 5 , 41 ].

Health care users who experience empathy during their treatment exhibit better results and a higher possibility for a potential improvement [ 42 ]. Moreover, social workers with higher levels of empathy work more efficiently and productively as to the fulfillment of their role in creating social change [ 13 ]. This happens because empathy helps the social worker understand and feel compassion towards their health care users so as the latter can feel secure to express their thoughts and problems. This way, a basis for trust is created, one that leads to therapeutic change and the improvement of the care recipient’s overall social functionality [ 13 ]. Social functionality levels are assessed by the social worker and refer to the ability of a person to accomplish their everyday activities (preparing and keeping meals, seeking accommodation, taking care of their selves, commuting) as well as their ability to fulfill social roles (parent, employee, member of a community) according to the requirements of their cultural environment [ 43 ].

Empathy contributes to the precise assessment of the situation the health care user is in. It offers the therapists the chance to make good use of non-verbal cues (behavior modeling, body movements, tone of voice, etc.) and helps them manage the user’s emotions. What is more, empathy enhances the user’s ability to comprehend reality and improve the quality of their life [ 13 ].

3.3. Assessing Empathy

Although both health care users and health professionals consider empathy as very important for the development of the therapeutic relationship and a necessary skill for a therapist, studies show a reduction of empathy in professional relationships. Often, health care users believe that health professionals do not understand the situation that health care users are in, whereas research findings showed that health professionals and health care users have different views on the communication abilities of the former, as if they come from different worlds [ 44 , 45 ]. It is especially important that—according to research findings deriving from medical student samples—empathy seems to increase in the first year of studies, but starts decreasing around the third year and remains low up to graduation [ 46 , 47 ].

As mentioned before, there are different dimensions, but also levels of empathy. Accordingly, there are different assessment scales for professionals and patient-users [ 48 ].

One of the most important tools for the quantitative assessment of empathy is the Jefferson Scale of Empathy (JSE) which was originally used to evaluate empathy in medical students [ 27 , 49 ]. Subsequently, its use was extended to other professional groups also, for example physicians, health professionals in general and students of other health professions [ 27 , 49 , 50 , 51 ]. The Jefferson scale has been used in many countries, such as the USA, Poland, Korea, Italy, Japan and has been standardized for its validity and reliability [ 12 , 49 , 50 , 52 , 53 ]. It is self-administered and completed by physicians and other health professionals who provide care to patients in clinical settings. Moreover, students of medical, nursing, and other health care sciences may also complete it. The scale includes 20 questions and the overall score ranges from twenty to one hundred and forty; higher scores indicate a better empathic relationship in the medical and therapeutic care [ 26 , 49 , 53 , 54 ].

More specifically, for social work, the Empathy Scale for Social Workers (ESSW) is a questionnaire designed for the quantitative assessment of empathy in social care professionals and students. It can be very useful in practice settings to support decision making processes, assist career choice decisions, continuing education, and supervision needs in the field of social care. Its usefulness is also underscored for potential social work supervisors, as it helps identifying the types of empathy needed while supervising clinicians and staff. The scale is a screening and self-evaluation tool completed by social work students and practitioners [ 13 ]. It consists of 41 questions and every question is marked on a five point scale and higher scores indicate higher levels of empathy [ 13 ].

3.4. Factors that Influence Empathy

As mentioned before, although research has showed the value of empathy, there are still many difficulties in regards to its implementation in the clinical practice [ 32 ]. A relatively high percentage of health professionals, about 70%, find it difficult to develop empathy with their health care users [ 32 ].

Age, self-reflection, appraisal, and emotions’ expressions were associated with women’s social workers empathy. Social workers had a higher score of empathy whenever they had previous work experience [ 55 ]. Additionally, there are studies that support that being female is associated with higher levels of empathy [ 56 , 57 ].

Research outcomes suggest that protective factors of social workers’ empathy are prosocial behavior toward work and positive personal and environmental resources [ 58 ]. Self-esteem, work engagement, and emotional regulation are also positively associated with empathy [ 58 , 59 ]. On the other hand, empathy is limited due to daily stress, that is a risk factor for burnout and compassion fatigue [ 59 , 60 ].

Empathy is positively correlated with reflective ability and emotional intelligence both in professional social workers and social work students [ 55 , 61 ]. According to a study in social work students in India, empathy and emotional intelligence were extracted as predictors of resilience through regression analysis. The authors underlined the need to enhance these attributes in social work students through the provision of appropriate curricular experiences [ 62 ].

The lack of empathy—or the low empathy levels—depends on several reasons. The most important are the large number of health care users that professionals have to deal with, the lack of adequate time, the focus on therapy, the predominant culture in medical schools, and the lack of training in empathy [ 30 ].

Further reasons include presumptions, a sense of superiority from the health professionals, and a fear of boundary violation. Time pressure, anxiety, a lack of self-awareness, and a lack of appropriate training, as well as the different socio-economic status, all the above do not favor empathy either [ 13 ].

According to scientific views from the Medicine field, empathy can be learned and Medical schools should educate their students in this respect [ 63 , 64 ]. Many studies have pointed out the necessity for future professionals to receive training in order to enhance their empathetic skills [ 64 , 65 ].

Although empathy is a core, quality principle for the health care professions, there are studies that show that health professionals cannot adequately express it and implement it [ 66 , 67 ]. According to studies in undergraduate nursing students, empirical education through learning processes can positively influence empathy [ 4 , 68 ]. Education is considered, both by students and professionals, as especially important for the reinforcement of empathetic skills [ 4 , 69 , 70 ].

Nevertheless, research data on the effectiveness of education in empathy are limited [ 71 , 72 , 73 ]. In a research study, conducted in the USA regarding the effect that empathy education has on health professionals, it was found that education contributes a great deal to the improvement of the therapeutic relationship [ 32 ]. In the same study, trained professionals are more likely to detect the emotion and progress of their health care users and therefore further explore and meet their needs. Education can be offered through hands-on work, multimedia use, role play, and experiential learning [ 32 ].

In a qualitative study, health professionals made suggestions regarding the enhancement of empathy. These suggestions included more holistic, educational interventions in behaviors that are central to the patient’s needs, with an emphasis on personal development, professional training, and supervision programs, rather than education in behavioral and communication skills [ 74 ].

‘Diversity Dolls’ is a hands-on educational method for the reinforcement of empathy that is used among social care students in a Greek university, so that students can instill empathetic skills in socially vulnerable populations [ 75 ]. It is believed that the use of such based-on-art methods helps social care students to feel safe, to explore, and give meaning to the real circumstances people live in, through pleasant, participatory, interactive activities [ 76 ].

Globally, creative educational methods such as journaling, art, role-play, and simulation games globally are becoming more popular in the health and social care fields helping students to increase their knowledge and skills in relation to empathy [ 75 , 76 ].

Teaching techniques and classroom methodologies familiarize social workers to empathetic skills [ 55 ]. In a study, among social work students, the results suggest that empathetic modeling from professors and field supervisors enhance social work students’ empathy. Social work educators should not focus on traditional teaching but they ought to concentrate on interactive and creative education that enhances the empathetic modeling and relationship between educators and students [ 77 ]. Apart from teaching social work students with mental flexibility, regulation of emotional and perspective taking, social workers should be taught empathy throughout the phenomenological psychological approach (seminars that utilize transcribed audio recordings of interactions) [ 78 , 79 ]. Additionally, regular supervision has a key role in enabling social workers to process their own feelings and to deal with empathy [ 80 ].

4. Conclusions

Empathy among health care users and professionals significantly contributes to how both groups behave as well as to their therapy and overall well-being. The development of empathetic skills constitutes an important priority in the education of health and social care students and should be encouraged. Educational programs should primarily be performed in a hands-on way that will strengthen the students’ personal and social skills and allow them to effectively communicate with their patients.

Moreover, health care professionals should be supported through continuous and personal development education programs as well as through supervision sessions that will allow them to develop empathetic skills. Political will is a prerequisite for the financing and encouragement of further actions.

Author Contributions

All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

Study finds AI-generated research papers on Google Scholar - why it matters

By this point, most chatbot users have accepted the possibility that artificial intelligence  (AI) tools will hallucinate in almost every scenario. Despite the efforts of AI content detectors , fact-checkers, and increasingly sophisticated large language models (LLMs), no developers have found a solution for this yet. 

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Meanwhile, the consequences of misinformation are only getting higher: People are using  generative AI (gen AI) tools like ChatGPT to create fake research.

A recent study  published in the Harvard Kennedy School's Misinformation Review found 139 papers on Google Scholar , a search engine for scholarly literature, that appear to be AI-generated. The researchers found most of the "questionable" papers in non-indexed (unverified) journals, though 19 of them were found in indexed journals and established publications. Another 19 appeared in university databases, apparently written by students. 

Even more concerning is the content of the papers. 57% of the fake studies covered topics like health, computational tech, and the environment -- areas the researchers note are relevant to and could influence policy development . 

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After analyzing the papers, the researchers identified them as likely AI-generated due to their inclusion of "at least one of two common phrases returned by conversational agents that use large language models (LLM) like OpenAI's ChatGPT ." The team then used Google Search to find where the papers could be accessed, locating multiple copies of them across databases, archives, and repositories and on social media. 

"The public release of ChatGPT in 2022, together with the way Google Scholar works, has increased the likelihood of lay people (e.g., media, politicians, patients, students) coming across questionable (or even entirely GPT-fabricated) papers and other problematic research findings," the study explains. 

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The researchers behind the study noted that theirs is not the first list of academic papers suspected to be AI-generated and that papers are "constantly being added" to these. 

So what risks do these fake studies pose being on the internet? 

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While propaganda and slapdash or falsified studies aren't new, gen AI makes this content exponentially easier to create. "The abundance of fabricated 'studies' seeping into all areas of the research infrastructure threatens to overwhelm the scholarly communication system and jeopardize the integrity of the scientific record," the researchers explain in their findings. They went on to note that it's worrisome that someone could "deceitfully" create "convincingly scientific-looking content" using AI and optimize it to rank on popular search engines like Google Scholar. 

Back in April, 404 Media found similar evidence of entirely AI-fabricated books and other material on Google Books and Google Scholar by searching for the phrase "As of my last knowledge update," which is commonly found in ChatGPT responses due to its previously limited dataset. Now that the free version of ChatGPT has web browsing  and can access live information, markers like this may be less frequent or disappear altogether, making AI-generated texts harder to spot. 

While Google Scholar does have a majority of quality literature, it "lacks the transparency and adherence to standards that usually characterize citation databases," the study explains. The researchers note that, like Google Search, Scholar uses automated crawlers, meaning "the inclusion criteria are based on primarily technical standards, allowing any individual author -- with or without scientific affiliation -- to upload papers." Users also can't filter results for parameters like material type, publication status, or whether they've been peer-reviewed. 

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Google Scholar is easily accessible -- and very popular. According to SimilarWeb , the search engine had over 111 million visits last month, putting it just over academic databases like ResearchGate.net. With so many users flocking to Scholar, likely based on brand trust from all the other Google products they use daily, the odds of them citing false studies are only getting higher. 

The most potent difference between AI chatbot hallucinations and entirely falsified studies is context. If users querying ChatGPT know to expect some untrue information, they can take ChatGPT's responses with a grain of salt and double-check its claims. But if AI-generated text is presented as vetted academic research conducted by humans and platformed by a popular source database, users have little reason or means to verify what they're reading is real. 

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