Abstract
Purpose Empathetic engagement is considered a vital component in forming respect-based relationships between patients and clinicians, leading to more optimal patient care. The purpose of this study was to explore whether there was a relationship between dental hygiene students’ levels of empathy and student demographics including age, gender, year in school, and the degree type of dental hygiene program attending.
Methods This was a cross-sectional observation study conducted among dental hygiene undergraduate students attending three dental hygiene programs in the Midwestern United States. Two programs offered associate degrees and one offered a baccalaureate degree. Participants completed the 20-item Jefferson Scale of Empathy©, student edition (JSE-S) along with demographic questions including age, gender, year in dental hygiene program, and degree type of dental hygiene program. Descriptive statistics and comparisons of the empathy scores were conducted using t-test and one-way analysis of variance (ANOVA). Regressions were conducted to determine whether the students’ year in dental hygiene program and the type of degree program were predictors of empathy.
Results Forty-one participants completed the questionnaire for a 65% response rate. The mean empathy score was 83.05 ± 10.04 among the participants. There were no statistically significant differences between levels of empathy of first- and second-year students or those attending a two-year institution versus a four-year university. Age, year in program, and type of degree were not shown to be predictors of empathy.
Conclusion Results from this study did not show relationships or predictors of empathy with dental hygiene students’ demographics or type of degree program. Future research should expand beyond a small homogenous convenience sample and include a longitudinal gauge to assess potential fluctuations in empathy as students progress throughout the curriculum and as practicing clinicians.
- empathy
- emotional intelligence
- dental hygienists
- dental hygiene students
- allied dental education
- cognition
INTRODUCTION
Empathy is significant in the relationship between a patient and their healthcare provider. The expression “empathy” is derived from the Greek “empatheia,” which translates as appreciation for another person’s feelings. It was not until 1918 that empathy was noted as being a significant factor in the relationship between a patient and their health care provider.1,2 Empathy can be considered universal in that it is recognized through basic emotional expressions that transcend language and culture.3 Before the introduction of emotional intelligence (EI) in medicine, health care providers were encouraged to maintain a degree of distance and take an analytical approach to patient care.4 A modern attitude includes breaking down barriers of communication in favor of an empathetic approach.3
Benefits to having high levels of empathy have been thoroughly researched in the medical professions including physician groups, nursing, and pharmacy. Research supports a strong correlation between empathy and health-care outcomes. Research has also shown EI, which includes empathy, to be associated with better adherence to providers’ recommendations, decreased malpractice cases, and increased patient satisfaction.3,5–7 A 2009 study by Rakel et al. noted that patients with influenza who perceived their physicians to be empathetic showed objective changes in their immune system and significantly reduced duration and severity of symptoms; therefore, the mere perception of empathy can be adventagous.8 Beyond the benefits to the patient, empathetic providers also see personal advantages. Studies show that nurses with higher empathy present with lower occurrence of errors, less emotional exhaustion, and greater job satisfaction. Conversely, poor empathy exposes providers to greater risk of fatigue, job dissatisfaction, and an increase in conflicts with patients.1,3,7,9
Studies including the broader topic of EI have emerged within the dental community; however, little attention has been given to dental hygienists. Partido and Stafford found EI was positively correlated with academic performance of dental hygiene students.10 Another study found that subcomponents of EI were a predictor of stress and burnout in dental hygiene students.11 Similarly, Smallidge et al. found that higher EI correlated with teaching effectiveness in dental hygiene clinical instructors.12 There has been little research on the more specific subset of EI, empathy, and how it is relevant to dental hygienists. Rogo et al. found that patients rated their dental hygienists as having high levels of empathy.13 Despite this gap in research, the American Dental Education Association has emphasized including empathy as part of the dental curriculum as it is known to play a role in provider/patient relationships.14
Empathy may be influenced by a student’s year in school. Research has shown that empathy ratings decline when medical students begin seeing patients in their assigned clinical settings.15,16 First and second year medical students have been shown to present with higher empathy than third year students and resident physicians.15 The results of several reviewed studies suggest that empathy declines throughout various allied health professions and continues to decline with passing time.6,15–17 Ferri noted a waning of empathy ratings when nursing students began to see patients on a clinical rotation. This is possibly related to a level of jadedness that comes with continual exposure to humanity.9 A small number of studies have examined the mechanisms for age-related differences in empathy, as an older age is often correlated with one’s year in school and have found reduced activity in key brain areas associated with cognitive empathetic expression.18 Inconsistently, other studies have shown little relationship between age and empathy.2
Hojat et al. studied demographic indicators for empathy among medical students and found that both gender (in favor of female students) and race (in favor of African-American and Hispanic students) are statistically significant.19 Given the differences in demographics between types of learning institutions where community colleges are notably more diverse,20 the exploration of possible differing levels of empathy between students seeking an associate degree verses a baccalaureate might be meaningful.
The actual act of measuring levels of empathy including its potential decline has proven to be more difficult than simply defining the term; however, methods have been developed. Empathy has been challenging to quantify as it is a complex, multifaceted, dynamic concept which has been described in literature in a variety of ways. The conceptualization of empathy has also evolved, relating inversely to various medical diciplines.21 Empathy can, however, and has been measured in a number of ways ranging from subjective measurements (self-rating questionnaires) to more objective methods (functional magnetic resonance imaging—fMRI).22
The relationship between a health care provider and patient is a synergetic alliance where each must mutually contribute to achieve the desired outcome. Empathetic engagement is thought by many medical and psychological researchers to be the key component in forming those relationships, ultimately leading to more optimal patient care.1,9,21
Considering the benefits to expressing high levels of empathy within varied health care professions identified in the literature, it is important to explore empathy in dental hygiene. A preliminary step to addressing this issue includes gauging the potential correlation between dental hygiene students’ demographic information and their levels of empathy. The Jefferson Scale of Empathy© and the student version (JSE-S) were developed by Hojat et al. to meet the need for an instrument to measure empathy in the context of health professional education and patient care.2 The JSE-S is the most common scale used to measure empathy in nursing, pharmacy, and medical education.19 Observing how empathy relates to demographics in dental hygiene student populations may help decision makers throughout the curriculum development process. Moreover, understanding that some studies have noted that students experience a decrease in empathy as they begin seeing patients in a clinical setting might assist educators with when to introduce empathy-boosting exercises.6,23–25 The purpose of this study was to explore whether there is a relationship between dental hygiene students’ levels of empathy as measured by the JSE-S and student demographics including age, gender, year in school, and the degree type of dental hygiene program.
METHODS
This preliminary feasibility study used a cross-sectional design and was considered exempt by the Institutional Review Board at The Ohio State University. A convenience sample of undergraduate junior and senior dental hygiene students enrolled in three Commission on Dental Accreditation accredited programs (A, B, C) were recruited via email to participate in the study during the Fall Semester 2020. Program A was a baccalaureate degree program in a dental school, Program B and C were associate degree programs in community colleges; all programs were in the Midwestern United States (US).
The Jefferson Scale of Empathy©, student version (JSE-S) was used with permission from Thomas Jefferson University Medical College as the instrument to measure empathy. The JSE-S consists of 20 questions using a 7-point Likert-scale and has been tested for validity and reliability among students worldwide. The Likert-type scale rates as 1 (strongly disagree) to 7 (strongly agree) with ten of the items phrased positively and scored directly while ten are phrased negatively and reverse-scored, i.e. 1 (strongly agree) and 7 (strongly disagree). Empathy scores can range from 20, very low empathy, to 140, very high empathy. The higher the score, the greater the participant’s empathetic orientation. Demographic characteristics including age, year in dental hygiene program, and the degree type of program attending were multiple-choice questions, gathered via questionnaire.
Program directors of programs A, B, and C received an email describing the study and were asked to contact their students via email invite them to participate. An incentive of winning one of five $25 gift cards in a drawing was offered. Participants were provided information about the purpose of the study, benefits and risks of participation, and the privacy and confidentiality of their information. Each participant received a link directing them to a coded electronic version of the JSE-S that also included four demographic questions—age, gender, year in dental hygiene program, and the type of program they attended. Participants had as much time as needed to complete the questionnaire and they were not required to answer all of the items; data was collected during November and December 2020.
The participants’ coded data was transferred into SPSS Version 26 (IBM; Armonk, NY, USA) for analysis. Descriptive statistics were completed, and independent sample t-tests were run to determine differences between levels of empathy and the degree type of program attending along with year in dental hygiene program. One-way ANOVA and Pearson correlation were conducted (p < 0.05) followed by linear regression statistics to analyse associations between levels of empathy and age. There were to few males in the sample to conduct meaningful statistics on gender effects, thus gender was omitted as a factor.
RESULTS
Of the 63 students invited to participate, 41 completed the questionnaire, for a response rate of 65.0%. Thirty-nine percent of participants (n=16) did not list the type of program they were attending. First-year dental hygiene students made up 31.7% (n=13) of the participant pool, where 68.3% of participants (n=28) were noted as second-year students. Of the 41 participants, there were a total of 37 female participants, two male participants, and two who preferred not to disclose their gender identity (Table I).
Descriptive statistics by number of total respondents*
An independent-samples t-test was conducted to compare levels of empathy between students seeking an associate degree versus a baccalaureate. There was not a significant difference in the scores for associate degree-seeking students (M=82.08, SD=15.78) and students attending a four-year university (M=80.69, SD=6.99); t(23)=−.289, p=0.775. A simple linear regression was calculated to see if the degree type of program attended was a predictor of empathy. The results of the regression indicated that the model explained 0.4% of the variance and that the model was not statistically significant, F(2,22)=0.42, p<0.959. It was found that the type of degree being sought did not significantly predicted empathy (β1=.343, p<.952).
An independent-samples t-test was conducted to compare levels of empathy between first-year dental hygiene students and second year students. There was not a significant difference in the scores for first-year students 1 (M=84.92, SD=6.60) and second-year students (M=82.17, SD=11.29); t(39)=−.811, p=0.422. While first-year dental hygiene students present with higher average levels of empathy versus second-year dental hygiene students, the difference was not statistically significant.
To determine association between empathy and age, a one-way ANOVA and Pearson correlation coefficients were calculated. A simple linear regression was carried out to test if age significantly predicted levels of empathy. The results of the regression indicated that the model explained 6.9% of the variance and that the model was not statistically significant, F(3,20)=0.495, p<0.69. It was found that age did not predicted empathy (β1=2.79, p<.238). Gender was not considered as only 0.7% of the participants identified as male.
Empathy levels can be scored between 20, low empathy, and 140, high empathy. Most of the participants scored between 83 and 89 for a total empathy score; however, the range was 35 to 96 with a mode of 83. Mean empathy scores for the participants in this study are not seen as high or low as proxy-norms for levels of empathy in dental hygienists per the JSE-S do not exist.
DISCUSSION
The results of this study revealed no statistically significant association between mean empathy scores and year in dental hygiene program, the type of learning institution attended, and age. Comparatively, regression statistics did not note these demographics as predictors of empathy. This is in contrast to a study of dental students by Javed which noted a decline in levels of empathy among dental students as they progressed throughout their program.26 A similar decline was found in a study by Aggarwal et al.23 A potential limitation with the results of this study lies within a small and relatively homogenous convenience sample of dental hygiene undergraduates. Additionally, levels of empathy may have been different if participants were assessed prior to entering their academic program. A study by Mirani et al. observed medical students over a five-year span whose findings aligned with Javed and Aggarwal.16 While results regarding empathetic engagement are mixed, extensive research does note a decline in levels of empathy over time. Future research may involve a longitudinal study that monitors a single group of dental hygiene students as they progress throughout their academic program, through the completion of clinical rotations, and even into clinical practice after licensure is achieved.
While there are few findings on levels of empathy between students attending a two-year versus a four-year institution in the literature, there is emerging research regarding empathy in relation to demographics. A study of medical students by Hojat et al. concluded that there were correlations between empathy and both gender and race.19 The type of learning institution attended was considered for the current study as community colleges proffer a more diverse student body including older non-traditional students.20 However, findings from this study yielded no difference in empathy between the participants and the degree type of program attending. Future research regarding empathy and demographics might include comparing levels of empathy between the same demographic groups—age group, gender, race—of those attending a community college versus a four-year university. Additionally, 39% (n=16) of the participants did not indicate which program they attended. This added a limitation to analyzing differences by program. It is possible that the participants may have felt this question would have allowed them to be easily identified. Gender was not analyzed in this study as an insufficient number of participants (n=2) identified as male.
This cross-sectional study only evaluated participants at one point in time which limits the ability to characterize how participants may change over time. A study performed by Hojat in 2015 reported on eleven years of data pertaining to the JSE-S and medical students with the goal of establishing norms and cutoff scores for program admissions. Hojat concluded there were higher levels of empathy in women versus men and recognized a positive correlation between scores on the JSE-S and performance on objective licensing examinations. Levels of empathy for female applicants were 116.2 ± 9.7, and levels of empathy for men were 112.3 ± 10.8. The tentative cutoff score to identify low scorers was ≤95. Comparatively, the study participants yielded a mean empathy score of 83.05 ± 10.04, which would be low per Hojat’s standards of medical school applicants. Norm data, however, was only defined within the boundaries of one specific learning institution and for students applying to medical school.27 While the Hojat study found strength in a relatively large sample size and eleven years of data, their findings may not necessarily apply to dental hygiene undergraduates. Other studies using various forms of the JSE report mixed results. Dental students and physicians have shown varying levels of empathy.1,17,26 Findings vary according to the study, location, and group of participants. A comparative list of levels of empathy across various study populations is shown in Table II.
In contrast to this study’s findings the results of several reviewed studies suggest that empathy declines throughout various allied health professions and continues to decrease over time.6,15–17 Given this noted decline, researchers have responded by assessing the possibility of increasing a person’s level of empathy via different interventions. A study by Ferri et al. evaluated the effects of expert-patient teaching on empathy development in nursing students.9 It was found that teaching the concepts of empathy, a basic intervention performed by nurse educators, was effective in improving empathetic engagement.9 Webster conducted a similar study of nursing students that cited the benefits of implementing a creative reflective teaching strategy to boost empathy levels among nursing students towards patients with mental illness.28
Role-playing exercises, narrative medicine education, and empathy skill training have all been alternative teaching methods implemented by various allied health disciplines that have shown to increase a provider’s empathetic abilities.6,29,30 Yang et al. argues that some nurses experience burnout and a decline in empathetic engagement as soon as one year post graduating which enforces the notion that empathy-boosting interventions should be provided for both students and practicing clinicians.6 As several methods have been used across disciplines to increase empathy, educators can consider implementing such interventions with dental hygiene students.
This study had limitations. Because of the COVID-19 pandemic restrictions, adjustments to the original study design were obligatory. Initially, site visits to each campus were scheduled to describe the JSE-S questionnaire. It is theorized that an in-person visit would have increased participation beyond the 41 participants and possibly yielded more answers to the demographic item regarding the type of learning institu tion being attended. It notable that 39% (n=16) of participants failed to indicate the type of program they attended, and it is not known why this item was left blank. The small sample size was also a limitation. The study population was from three dental hygiene programs in one state limiting the generalizability of the findings.
If one assumes that the scores on the JSE-S reflect the provider’s attitude toward empathy in patient care, and not necessarily their empathic behavior in a non-professional setting, empirical data are needed to establish a link between attitudes and behavior. Future research should expand beyond a small convenience sample and include a longitudinal gauge to assess potential fluctuations in empathy as students’ progress throughout their clinical rotations. Dental hygiene educators might use data about levels of empathy to determine when teaching empathetic engagement might be most effectively executed or when empathy-boosting exercises could be utilized. Longitudinal research would be required to investigate the outcome of empathy training in cultivating the known benefits of higher levels of empathy among dental hygiene students and practicing clinicians. Other areas of future research may be in the role of empathy in career burnout.
CONCLUSION
There were no relationships or predictors of empathy with dental hygiene students’ demographics in this feasibility study. Lack of predictors may indicate that empathy can be developed in dental hygiene students throughout the curriculum. Future research should expand beyond a small homogenous convenience sample and include a longitudinal gauge to assess potential fluctuations in empathy as dental hygiene students progress throughout the curriculum and later as practicing clinicians. Additionally, types of interventions should be studied to determine if they increase empathy in dental hygiene students.
Footnotes
NDHRA priority area Professional development: Education (evaluation).
DISCLOSURES
This study was funded through a graduate student grant from the International Federation of Dental Hygienists. The authors have no conflicts of interest to report.
- Received January 12, 2024.
- Accepted March 24, 2024.
- Copyright © 2024 The American Dental Hygienists’ Association
