Research ArticleRESEARCH

Measuring Empathy in Iranian Pharmacy Students Using the Jefferson Scale of Empathy-Health Profession Student Version

Fatemeh Mirzayeh Fashami, Mona Nili, Mina Mottaghi and Ali Vasheghani Farahani
American Journal of Pharmaceutical Education March 2023, 87 (2) ajpe8687; DOI: https://doi.org/10.5688/ajpe8687

Abstract

Objective. To assess validity of the Farsi-translated version of the Jefferson Scale of Empathy-Health Profession Student version (JSE-HPS) and measure empathy scores of Iranian pharmacy students.

Methods. The JSE-HPS questionnaire was administered to 504 Iranian pharmacy students in 2019. Confirmatory factor analysis and exploratory factor analysis were used to explore the underlying components and construct validity. Group comparisons of the empathy scores and the underlying components were conducted using statistical tests.

Results. Based on 496 useable survey questionnaires, three domains of empathy among Iranian pharmacy students were confirmed by confirmatory factor analysis: compassionate care, perspective taking, and standing in a patient’s shoes. Two items in the JSE-HPS were removed, as their factor loadings were under the permissible limits in exploratory factor analysis. Empathy scores were significantly higher among female pharmacy students.

Conclusion. These findings support the validity and reliability of the Farsi version of the JSE-HPS among Iranian pharmacy students.

Keywords

INTRODUCTION

Over the past few decades, the pharmacist’s role has evolved from a dispensing nature to that of a caregiver.1 In community and hospital pharmacies, pharmacists counsel patients on adverse effects and drug interactions, share their knowledge with other health care providers, and help to improve prescribing by mitigating the risk of medication errors and adverse effects.1-4 Therefore, improving the pharmacist-patient relationship through improving empathy has become increasingly important.5 Empathy is an essential component of the health care provider–patient relationship.6,7 It is a multidimensional concept that includes affective, cognitive, and behavioral aspects.8 Empathy improves communication between pharmacists and patients, builds trust in patients, and helps patients feel safe and understood.9 This effective communication results in patients’ satisfaction and better clinical outcomes.9,10 In addition, fostering a sense of social support can also decrease patients’ complaints.11

In 2006, the Iranian National Pharmacy Education Committee recognized the importance of empathy for pharmacy practice and recommended improving empathy through formal pharmacy education.12 Despite this, no study has been conducted to measure empathy among pharmacy students in Iran. The Jefferson Scale of Empathy-Health Profession Student version (JSE-HPS) is a validated English tool that can be administrated to students in health professions other than medicine, and the Farsi-translated version of JSE-HPS was used previously among nursing and midwifery students in Iran.13,14 The JSE-HPS has been used to measure empathy among pharmacy students in other countries such as the United States,11 the United Kingdom,15 and Korea.16 The main objective of this study was to validate the Farsi-translated of JSE-HPS among pharmacy students in Iran. Additionally, the empathy score of pharmacy students in Iran was measured and compared with other studies among pharmacy students.

METHOD

This cross-sectional study was conducted among 504 pharmacy students in five pharmacy schools, including three private schools (Islamic Azad University Tehran Medical Sciences, International Campus of Tehran University of Medical Sciences, and the International School of Shahid Beheshti University of Medical Sciences) and two public schools (Tehran University of Medical Sciences and Shahid Beheshti University of Medical Sciences) located in Tehran, Iran. All participants were in their fourth, fifth, and sixth year of Doctor of Pharmacy (PharmD) programs. The study was approved by the institutional review board of Shahid Beheshti University of Medical Sciences in March 2019.

The Farsi-translated version of the JSE-HPS was received from the Center for Research in Medical Education and Health Care, the Jefferson Medical College, Thomas Jefferson University. The participants answered each empathy item on a seven-point Likert scale (1=strongly disagree, 7=strongly agree). Negative items were reverse scored, consequently (1=strongly agree, 7=strongly disagree). In the second part of the questionnaire, demographic data including age (18 to 25/26 and above), gender (male/female), marital status (single/married), type of school (public/private), pharmacy year (fourth/fifth/sixth) and annual family income (below poverty line/above poverty line) was included.

The survey was conducted from April to May 2019 by distributing the paper-based questionnaires in the classrooms, and students filled them out individually. Professors’ permission was obtained in advance to distribute the questionnaires in classrooms. When the questionnaires were distributed, it was explained that there were no right or wrong answers for the items, and participants were assured that their answers would be kept anonymous and confidential to decrease socially desirable responses. Furthermore, participants were asked to select the first answer that came to their mind and not spend much time on each item. All the questionnaires were numbered and collected according to the JSE requirements.

In the present study, psychometrics and other measurement properties of the instrument were examined by a set of analysis methods. First, descriptive statistics were used to describe demographic information, and t tests and one-way analysis of variance (ANOVA) were used for group comparisons of the empathy scores related to background factors. Second, the internal consistency aspect of the reliability for the scale and underlying constructs was evaluated by calculating the Cronbach alpha coefficient. A Cronbach alpha value above 0.6 was considered as an acceptable range for the reliability test.17

The factor structure of the scale was evaluated in two steps. In the first step, exploratory factor analysis was used to explore the underlying components associated with the items of the scale. Exploratory factor analysis was also used to minimize the length of the JSE-HPS instrument by retaining the best items with factor structure coefficients greater than 0.40, as the minimum salient rotated factor loading. Retained factors that were highly relative to each other were loaded on underlying constructs. For this purpose, principal component analysis followed by orthogonal varimax rotation was used to obtain independent factors (construct validity). Before exploratory factor analysis, the Kaiser-Mayer-Olkin measure was conducted to evaluate the sampling adequacy. Moreover, the Bartlett test for sphericity was measured to indicate whether the intercorrelation matrix is factorable.

In the second step, the latent variable structure was evaluated by confirmatory factor analysis to confirm or reject the structure and the model fit of the scale. Structural equation modeling was used for confirmatory factor analysis; it was included the incremental and absolute fit indexes to determine the goodness of the model fit. Absolute indexes including χ2, goodness of fit (GFI), and root mean square error of approximation (RMSEA) were used to indicate how well the model fit the data. A value above 0.9 was considered acceptable for GFI. A value of RMSEA less than 0.08 was required for a good fit.18 The degrees of freedom (df), sample size, and p value were also calculated based on the recommendation indicated to accompany these three measures along with χ2.19 Because χ2 is sensitive to sample size, the ratio of the χ2 to its degrees of freedom was also calculated, which was recommended to have a value less than 4.0 for good fit.20

All data were analyzed using SPSS Statistics version 23 for Windows (IBM Corp) and Analysis of Moment Structures statistical software (IBM Corp). The significance level was considered as 0.05.

RESULTS

The survey was administered to 504 student pharmacists with a 98% response rate. The majority of students were women, 18-25 years old (Table 1). As demonstrated in Table 2, the overall empathy score for women was significantly greater than that for men (p<.01). Women also showed a significantly higher empathy score for compassionate care (p<.01) and perspective taking (p<.05). Regarding different age groups, as demonstrated in Table 2, the 18-25 group showed significantly higher empathy for both the overall score (p<.05) and perspective taking compared with the group 26 years old and above (p<.05). No significant differences were observed between empathy scores and its dimensions with marital status, year in pharmacy program, type of school, and family income.

View this table:
Table 1.

Demographic Characteristics of the Study Population

View this table:
Table 2.

Mean and Standard Deviation of Scores for Empathy and the Three-Factor Components and Their Association With Characteristics of the Study Population (N=496)

The Kaiser-Mayer-Olkin measure was conducted, and the result showed an overall index of 0.88, confirming the sample adequacy for factor extraction. In addition, the Bartlett test for sphericity showed that the intercorrelation matrix was factorable (p<.01). The result of exploratory factor analysis, as demonstrated in Table 3, showed that 18 items with factor loading greater than 0.40 were retained in the three-factor-model structure. Ten items all with factor coefficients greater than 0.40 were loaded on compassionate care (Table 3). The item “Attentiveness to patients’ personal experiences does not influence treatment outcome” is one example item with the highest factor coefficient.

View this table:
Table 3.

Rotated Factor Loading of JSE-HPS in Iranian Student Pharmacists (N=496)a

Perspective taking included six items, all with factor coefficients greater 0.5. An example item is “Health care providers should try to think like their patients to render better care,” which had the highest factor coefficient. The third factor, namely standing in a patient’s shoes, included two items with factor coefficients greater than 0.7. A sample factor was “Because people are different, it is difficult to see things from a patient’s perspective.” Item 5 and item 18 had factor coefficients less than 0.40 (0.34 and 0.35, respectively) and, consequently, were excluded from the factor structure.

The Cronbach alpha for the overall internal reliability of the 18-item, Farsi-translated JSE-HPS was 0.85. The reliability coefficients for perspective taking, compassionate care, and standing in the patient’s shoes were between 0.68 and 0.81 (Table 4).

View this table:
Table 4.

The Mean, Standard Deviation, Median, Range and Reliability of Overall JSE-HPS in Iranian Student Pharmacists and Its Three Constructs (N=496)

To identify the model structure, the 18 items were tested by confirmatory factor analysis. The results of fit indices and the three-factor model (latent variable structure) were illustrated in Figure 1. According to the findings, the three-factor-model structure provided a good fit to the data; the ratio of the χ2 to its degrees of freedom was 3.16 and GFI=0.92.

Figure 1.
Figure 1.

Final measurement model for the Farsi-Translated Version of the Jefferson Scale of Empathy-Health Professions Students

The oval items refer to latent variables. The rectangular items are representative of observed variables. The circles are measurement error.a Factor correlationb Standardized factor loadingc Proportion of variance explained in the observed variableChi square=416.607, Degree of Freedom (df)=132, p-value<0.000Goodness of Fit Index (GFI)=0.917, Normed Fit Index (NFI): 0.847Tucker Lewis Index (TLI): 0.871, Akaike’s Information Criterion (AIC)=497.607,Comparative Fit Index (CFI): 0.889, Root Mean Square Error of Approximation (RMSEA)=0.066

DISCUSSION

This study was conducted to validate the Farsi-translated JSE-HPS. The study findings support the three-latent-construct model, including the constructs compassionate care, perspective taking, and standing in a patient’s shoes. The model structure is consistent with that reported in pharmacy students in Korea,16 Malaysia,21 China,22 and nursing students in Iran.13 On the other hand, a two-latent-construct model structure for empathy has been suggested by studies conducted among pharmacy students, medical students, and physicians in Western countries.7,11,23 This difference may be due to some cultural differences (eg, collectivism vs individualism) between Eastern and Western societies.24 In other words, pharmacy students in Eastern societies, including Iran, may tend to feel empathy in a more collectivist way and consider “standing in a patient’s shoes” as part of empathy.24

This study found compassionate care as the main component of empathy in Iranian pharmacy students, while in many studies, perspective taking was the main factor.6,13,16,21,22,25,26 The same results were obtained in Iranian medical students,27 which might be explained by the influence of the culture and/or religious beliefs on health care professions students and their vision about empathy.

Two items with a factor coefficient less than 0.40 were dropped from the Farsi-translated JSE-HPS in Iranian pharmacy students because they did not fit into the model. These two items are “A health care provider’s sense of humor contributes to a better clinical outcome” and “Health care providers should not allow themselves to be influenced by strong personal bonds between their patients and their family members.” These items did not fit into the model probably because of value differences in Eastern and Western societies. Generally, in Western societies, sense of humor is considered a way to improve any relationship, including the provider-patient relationship.28 However, people from Eastern societies are generally very cautious in using humor in any relationship.29 Therefore, it is not surprising that the item “A health care provider’s sense of humor contributes to a better clinical outcome” was dropped in JSE-HPS among pharmacy students in Iran. Moreover, for the item “Health care providers should not allow themselves to be influenced by strong personal bonds between their patients and their family members,” which also did not fit into the model, one possible explanation is that creating personal bonds with patients and their family members is not always considered a cultural value in Iran as an Islamic country. For example, talking to of the opposite sex (ie, a man to a woman and vice versa) is forbidden in many situations based on Islamic values.30 Hence, this item was also dropped in the JSE-HPS among pharmacy students in Iran.

This study also examined the empathy score of pharmacy students in Iran and compared mean differences in empathy levels with those published by the other countries in terms of psychometric properties. The overall empathy score in our study (mean item score=5.4) was in the same range of that measured in pharmacy students in the United States (mean=5.5),11 Korea (mean=5.4),16 and China (mean=5.6).22 It is comparable to the mean empathy score in medical students in Iran (mean=5.3).27 In contrast, the mean empathy score among Iranian pharmacy students is higher than the reported empathy score among Malaysian pharmacy students (mean=4.2).21 Cultural differences and religious beliefs may contribute to differences in empathy score across the countries.27

Women had significantly higher empathy scores compared to men. This is not surprising, as similar results were reported in pharmacy students in the United States,11 nursing students in Italy31 and China,32 and medical students in Iran,27 Brazil,33 and Portugal.34 In our study, women had higher scores in the two constructs of compassionate care and perspective taking. Female medical students in Iran also reported to have higher scores in the two mentioned constructs.25 One possible reason could be that women are better at responding to emotional signals, which plays a dominant role in empathy.23 Moreover, according to investment theory, women have a more caregiving approach toward their children.23,35 This can also be true in a patient care context.36

Empathy scores were significantly higher in students who were between 18 and 25 years old. These results agree with findings of studies among Iranian medical and dentistry students,37 medical students in Pakistan,38 and nurses and nursing students in Italy.39 Although O’Brien and colleagues40 proposed that perspective taking increases over time and reaches a maximum in middle-aged adults, the results of our study indicate greater compassionate care in younger students than older ones. In our study, compassionate care was higher in the younger students than in the students who were above 26 years old and above. Several reasons may account for the decline in empathy score in older students, such as an increase in stress level and more responsibilities.38 Additionally, according to some studies, older adults have shown lower levels of empathy in comparison to younger people,41,42 which is consistent with the result of our study.

This study had some limitations. First, we cannot generalize the findings of this study to all pharmacy students in Iran. Based on our available resources, we decided to collect data from five pharmacy schools, which recruit about 500 students each year, almost of one-third of all recruited pharmacy students in Iran. Although the five pharmacy schools included in this study were representative of the types of pharmacy schools in Iran, this study did not have a representative sample of all pharmacy schools in Iran. Second, self-reported empathy may introduce social desirability bias and overestimation of empathy scores. To reduce the social desirability bias, respondents were reassured that the collected data would be kept completely confidential and would be analyzed with aggregated data. Finally, this study used the Likert scale, which may create response bias.

CONCLUSION

The result of the study confirmed the validity of the Farsi-translated JSE-HPS and the three-factor-model structure including compassionate care, perspective taking, and standing in a patient’s shoes. The empathy score of the current pharmacy students, who are Iran’s future pharmacists, was in the middle range of empathy scores compared to other countries. One possible strategy to improve empathy levels among pharmacy students is to use paid actors, called standardized patients, for simulation of real pharmacy environments. This simulated environment can provide opportunities for students to start learning how to use empathy to create effective connections with their patients. In addition, the actors can give students detailed feedback emphasizing how the interaction made them feel. By using the Farsi-translated JSE-HPS, pharmacy schools in Iran will be able to track changes in empathy levels among their students. It can also be used as a tool to assess the effectiveness of the interventions for improving empathy levels among pharmacy students in Iran. Since pharmacists are in direct communication with patients and their family members, improving empathy levels among pharmacy students can eventually lead to increasing patient satisfaction and better clinical outcomes in Iran’s health care system.

ACKNOWLEDGMENT

The authors wish to acknowledge Donya Karimpour Khameneh and Homa Hemati, who assisted us in distributing and collecting the survey questionnaires. We also would like to thank the Center for Research in Medical Education and Health Care at Thomas Jefferson University for giving us permission to use the Jefferson Scale of Empathy.

  • Received April 12, 2021.
  • Accepted April 7, 2022.

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Measuring Empathy in Iranian Pharmacy Students Using the Jefferson Scale of Empathy-Health Profession Student Version
Fatemeh Mirzayeh Fashami, Mona Nili, Mina Mottaghi, Ali Vasheghani Farahani
American Journal of Pharmaceutical Education Mar 2023, 87 (2) ajpe8687; DOI: 10.5688/ajpe8687
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