Impact of a Training Programme on the Empathy Skills of Nursing Students During the COVID‐19 Pandemic: A Quasi‐Experimental Study

ABSTRACT

Aim

To explore the impact of an innovative empathy training programme on undergraduate nursing students' empathy skills in the course of developing the COVID‐19 pandemic.

Design

A quasi‐experimental study with one group and a pretest–posttest design.

Methods

The training programme was produced with inspiration from an earlier qualitative study. It was held as an online 2‐hour daily programme during 5 continuous weeks for 71 nursing students in the fourth, sixth and eighth semesters. Data collection was done before (T1), immediately (T2) and 2 months (T3) after the training programme using the Jefferson Scale of Empathy–Nursing Student version R. The data were analysed using the repeated measures analysis of variance (ANOVA).

Results

The mean scores of total empathy scale (T1:108.1 ± 0.06 to T3: 118.6 ± 0.4) and its three subscales (perspective taking; T1: 56.2 ± 0.9 to T3: 60.5 ± 2.5, compassionate care; T1: 43.1 ± 0.1 to T3: 46.5 ± 0.9, and standing in the patient's shoes; T1: 8.7 ± 0.5 to T3: 12.2 ± 0.6) increased over time. These results showed that our two hypotheses were accepted (p < 0.0001) and the training programme had a moderately positive effect on increasing students' empathy scores (effect size: 0.53–0.69), except for the compassionate care subscale, which only showed a small positive effect (effect size: 0.31). However, the mean score of empathy in female students was significantly higher than in males at T1 (p < 0.01), there was no difference between male and female students at T3 (p > 0.05).

Conclusions

This training programme can be incorporated into the undergraduate nursing curriculum planning to improve the quality of care and the relationship between patients and nursing students in clinical settings.

Implications for the Profession and/or Patient Care

Empathy is one of the essential nursing professional skills. Teaching this skill can be useful in increasing patients' quality of care.

1. Background

Empathy is a powerful communication skill and helps understand patients' feelings, ideas and values (Hardee 2003). It is a broad and multidimensional concept with different definitions in the literature (Levett‐Jones et al. 2019). Empathy is defined as the ability to understand and respond to individuals' thoughts and emotions (Nembhard et al. 2023). It is an important capability that harmonises the feelings and thoughts of a person, connects him to the social world, leads to assistance and prevents harm to others (Decety et al. 2016). It has a complex construct with cognitive, emotional, moral and behavioural dimensions. Empathy as a competency includes identification with the patient's suffering, an intrinsic motivation to empathise, understanding the patient's perspective and the ability to convey the perceptions arising from these feelings and perspectives to the patient (Ferri et al. 2019). It has an important place in nurses' therapeutic communication. It is a visible skill, and a core element of communication between nurses and patients, which can be taught (Bas‐Sarmiento et al. 2020). Using this skill, nurses can better understand their patients and establish supportive relationships with them (Hussein and Saad 2021). Thus, the main task of nurses is not only to care for and inform their patients about their disease and treatment but also to establish an effective therapeutic relationship with them by using empathy, assessing patients' concerns, understanding them and providing comfort and support (Karimi et al. 2015).

A review of nursing theories shows that theorists such as Travelbee, Peplau, Paterson and Zderad discussed the concept of empathy in their theories (DeLaune et al. 2019). Travelbee, in her theory of human‐to‐human relationships, showed that the establishment of therapeutic communication and empathy with the patient is a professional and effective way to communicate with him. In her theory, Travelbee stated that the empathic nurse can recognise a person's distress, identify its source and anticipate the behaviour that results from it (Parola et al. 2020). Peplau emphasised empathic relationships with patients at all stages of nurse–patient communication (Hagerty et al. 2017). Paterson and Zderad highlighted the nurse–patient relationship as an interactive and empathetic experience (Allande Cussó et al. 2021).

A review of the literature shows that in over 200 published studies, there are positive effects of empathetic and compassionate interactions on improved patient outcomes, lower costs in healthcare systems and reduced burnout in healthcare providers (Trzeciak et al. 2017). Although evidence shows the importance of maintaining a high level of empathy with patients, many healthcare providers have a limited ability to communicate empathetically with their patients (Kahriman et al. 2016; Ouzouni and Nakakis 2012). The findings of a study revealed that 70% of healthcare professionals lose opportunities to express their empathy with patients (Foster and Yaseen 2019). There are several reasons for this, including caring for a large number of patients, having insufficient time and concentrating on treatment. Also, different types of medical education and a lack of sufficient empathy education play an important role in this area (Hojat et al. 2013; Managheb and Bagheri 2013). Empathy is a skill that requires training, practice, experience, teaching and education to improve in target groups (Derksen et al. 2021). The American Medical Education College states that teaching students empathy skills is a necessity and that universities should train all healthcare students to increase their level of empathy during interactions with patients.

Current understanding of the existing gap suggests that despite the rise of various programmes to improve students' empathy levels (Li et al. 2019; Yang et al. 2020), there is a movement towards an erosion in empathy levels of healthcare providers (Hurissa et al. 2023). It is accompanied by mixed results concerning declining empathy during the academic education years among nursing and medical students (Håkansson Eklund et al. 2019). Moreover, evidence shows empathy is not taught adequately in a regular training programme during nursing curriculum (Castelino and Mendonca 2023). Also, there is a lack of effectiveness of training programmes to improve clinical empathy in healthcare providers (Hurissa et al. 2023). The results of a systematic review of 28 simulation‐based intervention studies showed an increase in the level of nursing students' empathy but with a small effect size (Cho and Kim 2024). The findings of another systematic review presented similar results. It showed that in 10 of 13 studies with a single group of undergraduate nursing students, there was a significant change in the level of students' empathy between the pretest and posttest, but the clinical effectiveness of programmes has often been low (Levett‐Jones et al. 2019). It is important to remember that nursing students are future nurses and must have sufficient empathy while caring for patients and their families (Cho and Kim 2024). Since empathy is a process of integrating individual experiences and perceptions over time (Cho and Kim 2024), it has been recommended to develop it in the early stages of the undergraduate programme with a structured, creative and innovative approach (Castelino and Mendonca 2023). These findings emphasise the need for designing and implementing empathy training programmes with high effectiveness to improve the level of empathy in nursing students.

Inasmuch as empathy is recognised as an ability or skill that can be learned and developed through education and practice (Cannity et al. 2021). We used an innovative empathy training programme in a single group of undergraduate nursing students during the COVID‐19 pandemic. At a time when there were limitations on holding in‐person training courses in classrooms, the needs of patients, nursing students and the healthcare system were greater than ever.

2. Congruence Framework of the Study

The framework of this study is based on the theme of ‘Congruence’. Congruence and its components were extracted from an earlier qualitative study to explore the nature of clinical empathy in the nurse–patient relationships in oncology settings. Congruence was found as an overarching theme with three subthemes of copresence, metacognition, perception and 21 categories (Sedaghati 2017). Historically, congruence is one of the key concepts in Carl Rogers' theory of personality. His theory focused on the importance of self‐concept and the way in which individuals perceive and interpret their experiences. Congruence involves the consistency between a person's self‐concept and actual behaviour (PHILO‐notes 2023). Rogers believed that congruence is one of the three characteristics or attributes of the therapist in his/her relationship with clients. It shows that the therapist is real and/or genuine, open, integrated and authentic during their communications with the client (Rogers 1977, 2007). Furthermore, the results of the qualitative study showed that clinical empathy has a composite construct with inherent and didactic nature; it can be seen as a two‐sided mirror and is accompanied by organisational and contextual challenges (Rohani et al. 2018; Sedaghati 2017). Clinical empathy has benefits for the patient and the nurse; however, it can bring emotional and physical vulnerability for the nurse in certain circumstances (Rohani et al. 2018).

The training programme of this study was prepared based on the above‐mentioned concepts. To the best of our knowledge, our training programme has not been used in previous studies for nursing students or other healthcare groups; therefore, we decided to conduct this study and use this innovative empathy training programme.

3. The Study

3.1. Aim

This study aimed to explore the impact of an innovative empathy training programme on undergraduate nursing students' empathy skills in the course of developing during the COVID‐19 pandemic.

3.2. Hypothesis

There are two hypotheses:

1. The innovative empathy training programme will have an impact on the total score of the empathy scale in undergraduate nursing students.

2. The innovative empathy training programme will have an impact on the subscale scores of the empathy scale in undergraduate nursing students (perspective taking, compassionate care and standing in the patient's shoes).

4. Methods

4.1. Design

This is a quasi‐experimental study with one group and a pretest‐posttest design. A quasi‐experimental study aims to establish a cause‐and‐effect relationship between dependent and independent variables. However, it does not have random assignment, and it also does not need to have a control or comparison group, although they commonly have it (Polit and Beck 2017). In this study, we have no randomisation, also due to small number of students at the university, we could not select a control or comparison group.

The training programme was delivered at one university of medical sciences in the city of Tonekabon in Iran. Tonekabon is a city in Mazandaran province, and it is located on the coast of the southern Caspian Sea, 160 miles north of the capital city.

4.2. Sampling and Data Collection

A total of 106 undergraduate nursing students in the fourth, sixth and eighth academic semesters were invited to participate in the study through an online invitation from 10th of January to 10th of February 2022, at the university website. Inclusion criteria for sampling in the study were as follows: undergraduate nursing students in the fourth semester and higher who experienced communication with patients in the clinical field, students without a history of mental health problems and no participation in the communication or empathy education courses or workshops in the past. Exclusion criteria included: incomplete responses to the questionnaires and one session absence in the training programme.

At the time of sampling, all theoretical courses were offered online at the university, and there was the sixth wave of the coronavirus in the province. Based on the colour‐coded COVID‐19 warning, the level of disease transmission in the city was orange (moderate alert). Of all the invited university students, 96 students accepted to join the study and signed the informed consent form. During the online course, 25 students could not join the online programme due to internet problems or other reasons, and only 71 students remained in the study (Figure 1). A power analysis by G* Power 3 version 3.1.5.1 showed that the remaining sample (n = 71) was enough to detect changes by an effect size of 0.2 and a power of 90% at a 0.05 significance level in the study.

FIGURE 1.

Diagram of sampling and data collection in undergraduate nursing students.

The sample filled out the instruments in three stages: before, immediately and 2 months after the empathy training programme.

4.3. The Innovative Empathy Training Programme

The programme was held in an online 2‐hour training, once a week, for 5 continuous weeks for 71 undergraduate nursing students. The educational programme was produced by the first (MS) and the last (CR) authors based on the results of an earlier qualitative study on clinical empathy (Rohani et al. 2018; Sedaghati 2017). Congruence as a main theme and its components were selected from that study to provide the material for the empathy training programme. The qualitative validity of the content of the training programme was evaluated by three faculty members with doctoral degrees in nursing and psychology at the university.

In the training sessions, a combination of different teaching methods, including feedback lectures, group discussions and peer‐assisted learning (PAL) by focusing on specific clinical scenarios and role playing in the virtual chat rooms as well as media, PowerPoint slides, educational videos and homework assignments, were used. These were inspired by previous studies (Jeong and Kim 2019; Levett‐Jones et al. 2019; Yang et al. 2020). For group discussions, students were sent to small virtual chatrooms; they discussed different empathy scenarios; and then returned to the main chatroom, reported and discussed their responses, and got feedback.

Educational objectives of the innovative empathy training programme were written based on Bloom's taxonomy (Adams 2015). This taxonomy consisted of six categories: knowledge, comprehension, application, analysis, synthesis and evaluation. In Bloom's taxonomy, after the category of knowledge, the rest of the categories are recognised as ‘skill or ability’. These categories are necessary preconditions for practice (Anderson and Krathwohl 2021). During the training programme, entertaining clips such as music and humour were used to prevent boredom and make the sessions attractive. A summary of the innovative empathy training programme is shown in Table 1.

TABLE 1.

A summary of innovative empathy training programme for undergraduate nursing students.

Session	Objectives	A summary of key content	Activities
First	Students take ability to: Explain the concept of empathy similar concepts and different types of empathy in their own words. Describe their lived experiences in the area of related concepts. Compare different types of empathy. Compare the concept of empathy in different theories.	The differences between the concepts of empathy, sympathy and compassion are explained. Different types of empathy are described (cognitive, emotional, behavioural, ethical and clinical). The concept of empathy in Carl Rogers' theory is discussed. The concept of empathy in different nursing theories is compared and discussed.	Students are asked to: Discuss the concepts of empathy, sympathy, compassion and different types of empathy. Share their lived experiences of empathy with patients. Compare similarities and differences of the concept of empathy in various nursing theories of Peplau, King, Martha Rogers, Peterson‐Zderad and Travelbee.
Second	Students take ability to: Discuss and deliver logical reasoning about the theme of ‘Congruence’ in different examples.	Congruence and its dimensions are introduced in the clinical setting. Co‐presence as a dimension of congruence and its components are discussed with clinical examples. Altruism in therapeutic communication is explained and demonstrated in clinical settings. Accessibility is explained. Relationship based on honesty is demonstrated. Good communication is defined. Spiritual attention to patients is demonstrated. Relationship with the patients based on trustworthiness is demonstrated. Elixir of love with patients is described. Compassionate attention, being open in communication with the patient and approachability in the clinical settings are discussed. Being open in communication is expressed.	Students are asked to: Cooperate with each other, and give three examples for congruence. Evaluate each of the examples to identify the causes of congruence.
Third	Students take ability to: Compare two concepts of ‘metacognition’ and ‘perception’ and their components together. Present their responses to the examples by logical reasoning.	Metacognition and perception as dimensions of congruence and their components are introduced in therapeutic communication with the patient by clinical examples. Self‐control, self‐awareness, recognition of the situation, flexibility, aesthetic feelings, emotional reflection and emotional connection are explained. Standing in the patient's shoes, standing in the family's shoes and emotional connection are discussed.	Students are asked to: Release their responses to the authors' examples about metacognition and perception in the online groups. Answer three clinical cases individually at home (home assignments).
Fourth	Students take ability to: Present a self‐reflection on the key points during a therapeutic relationship with the patient. Role play for the key points during a therapeutic relationship with the patient.	Key points during empathy with the patient are discussed: ‐Don't discuss the grief with the patient ‐Apply reflection ‐Encourage patient to talk about his feelings and needs ‐Apply empathy techniques, such as greeting, being kind and nice, using appropriate eye contact, listening to the patient with interest and respect for the patient and his family ‐Assess patient's needs in the area of empathy ‐Release nursing diagnoses and planning with a patient‐centred approach	Students are asked to: Discuss empathy techniques with each other and practice during role play in the online chat rooms.
Fifth	Students take ability to: Analyse, synthesise and evaluate important information in different clinical case scenarios of empathy	Discussion on five clinical empathy scenarios in online groups. Answer the questions of clinical empathy scenarios based on the phases of nursing process: assessment, identifying patients' needs, nursing diagnosis, planning and evaluation. A summary of training is presented at the end of the session.	Students are divided into three groups and each group receives five clinical empathy scenarios to answer questions and discuss. After group discussion in online chat rooms, all groups return to the main chat room, present their responses and discuss how they make decisions and plan to deal with these clinical situations. One person from each group is selected as a group leader to coordinate the virtual group and present a summary of all responses in the online main chat room. All groups are given feedback on the group responses and all their activities. The training programme is evaluated by the nursing students.

Abbreviation: PAL, peer assisted learning.

4.4. Instruments

4.4.1. Demographic Information Sheet

It was prepared by the research team and included the variables of age, sex, marital status, academic semester and school year.

4.4.2. Jefferson Scale of Empathy‐Nursing Student Version R (JSENS Version R)

It is a specific scale with 20 items and three subscales for measurement of empathy skills in nursing students. In this study, a Persian version of the scale was used (Sedaghati Kesbakhi et al. 2017). The respondents mention the level of their agreement or disagreement with each of the items on a 7‐point Likert‐type scale (from strongly disagree to strongly agree, with scoring 1–7). The rating response on the scale ranged between 20 and 140. To calculate the scores of the scale, at first, the scores of the 10 items should be inverted (Item Numbers 1, 3, 6, 7, 8, 11, 12, 14, 18 and 19) (Ward et al. 2009). Three subscales are: ‘perspective taking’ (Item Numbers 2, 4, 5, 9,10, 13,1 5,16, 17 and 20), ‘compassionate care’ (Item Numbers 1, 7, 8, 11, 12, 14, 18 and 19) and ‘standing in the patient's shoes’ (Item Numbers 3 and 6) (Hojat and LaNoue 2014).

The internal consistency of the scale was 0.90 by Cronbach's alpha coefficient in the psychometric evaluation of the study (Sedaghati Kesbakhi et al. 2017). In our study, the level of the Cronbach's alpha coefficient was 0.77.

4.5. Data Analysis

The data were entered into the SPSS version 20 (IBM Corporation, Armonk, NY, USA) and the repeated measures analysis of variance (ANOVA) was used to analyse. Normal distribution of the outcome variables was assessed using the Shapiro–Wilk test. Results were considered statistically significant if the p value was less than 0.05. Effect size was used for estimating the amount of training programme effect. It was interpreted by Cohen's threshold: small: 0.2; moderate: 0.5; large: 0.8; and very large: 1.3 (Serdar et al. 2021).

4.6. Ethical Consideration

This study adheres to the Declaration of Helsinki (Shrestha and Dunn 2020), and it was approved by the Ethics Committee of Islamic Azad University, Tonekabon Branch with the ethical code of IR.IAU.TON.REC.1399.056. All objectives and phases of the study were explained to the nursing students. The authors paid attention to the ethical principles of anonymity, the confidentiality of information and the right of voluntary participation of students and their withdrawal at any stage of the study. Written informed consent was obtained from all nursing students before their participation in the study. In the consent form, it was written that the student's participation in this training programme is voluntary, and their participation or non‐participation will not affect the evaluations of their official university courses.

5. Results

5.1. Descriptive Results

The mean age of the nursing students was 22.2 ± 1.4 years. Most of the students were female (69%) and single (97.2%). The level of empathy in students based on the demographic variables in three time‐point measurements is shown in Table 2. It was found that 2 months after training, the mean and standard deviation (SD) of empathy in female (118.9 ± 3.7) and married students (118.8 ± 7.07), students over 22 years old (118.9 ± 3.2) and students in the sixth semester (119.3 ± 3.3) were higher than the male students, singles, students less than 22 years old and students in the fourth and eighth semesters, respectively. The mean score of the female students was more than the male students in the preintervention phase, but after the training programme, there were no significant differences between male and female students (Table 2).

TABLE 2.

The level of empathy in undergraduate nursing students based on the demographic variables in three time‐point measurements from T1 to T3 (n = 71).

Demographic variables	Number (%)	Before training (T1), mean (±SD)	Immediately after training (T2), mean (±SD)	Two months after training (T3), mean (±SD)
Age
< 22	41 (57.7)	109.04 ± 12.7	125.2 ± 5.1	118.5 ± 3.5
> 22	30 (42.3)	106.8 ± 11.8	126.4 ± 4.2	118.9 ± 3.2
p value*	—	0.712	0.166	0.769
Sex
Female	49 (69)	110.5 ± 11.1	126.1 ± 5.1	118.9 ± 3.7
Male	22 (31)	102.6 ± 12.5	124.9 ± 3.8	118.1 ± 2.5
p value*	—	< 0.010	0.308	0.324
Academic semester
4th	24 (33.8)	109.3 ± 13.3	125.2 ± 5.2	118.7 ± 3.5
6th	23 (32.4)	110.08 ± 10.4	127.2 ± 4.5	119.3 ± 3.3
8th	24 (33.8)	105.04 ± 12.1	124.9 ± 4.2	118.6 ± 3.4
p value**	—	0.303	0.209	0.402
Marital status
Single	69 (97.2)	107.8 ± 12.1	125.7 ± 4.7	118.7 ± 3.3
Married	2 (2.8)	118.5 ± 3.5	127 ± 5.6	118.8 ± 7.07
p value*	—	0.163	0.985	0.095

Note: *Independent t‐test; ** ANOVA; scale range: 20–140.

5.2. Empathy Results Over Time

The results of Shapiro–Wilk tests showed that the distribution of total empathy and its subscales is normal (p > 0.05).

The results of repeated measures ANOVA showed that two hypotheses of the study were accepted. The innovative empathy training programme had a positive impact on the total empathy of undergraduate nursing students. Thus, students' empathy mean scores increased significantly from T1 (108.1 ± 0.06) to T3 (118.6 ± 0.4) (p < 0.0001). Moreover, the programme had a positive impact on the subscales of empathy in undergraduate nursing students. It means that students' empathy mean scores increased significantly in the subscales of perspective taking (T1: 56.2 ± 0.9 to T3: 60.5 ± 2.5), compassionate care (T1: 43.1 ± 0.1 to T3: 46.5 ± 0.9) and standing in the patient's shoes (T1: 8.7 ± 0.5 to T3: 12.2 ± 0.6) over time (p < 0.0001) (Table 3).

TABLE 3.

The results of one‐way repeated measures ANOVA for the Jefferson Scale of Empathy–Nursing Student version R (JSENS version R) and its subscales in undergraduate nursing students at three time‐point measurements from T1 to T3.

Variables	Scale range	Before training (T1), mean ± SD	Immediately after training (T2), mean ± SD	Two months after training (T3), mean ± SD	F	p	Effect size (ES)
Total empathy	20–140	108.1 ± 0.06	125.7 ± 0.7	118.6 ± 0.4	122.4	p < 0.0001	0.63
Perspective taking	10–70	56.2 ± 0.9	64.8 ± 0.6	60.5 ± 2.5	81.6	p < 0.0001	0.53
Compassionate care	8–56	43.1 ± 0.1	47.9 ± 0.09	46.5 ± 0.9	31.4	p < 0.0001	0.31
Standing in the patient's shoes	2–14	8.7 ± 0.5	12.9 ± 0.8	12.2 ± 0.6	161.06	p < 0.0001	0.69

Note: Interpretation of ES: small: 0.2; moderate: 0.5; large: 0.8; and very large: 1.3.

The results of effect size based on Cohen's thresholds showed that this programme had a moderate positive impact on increasing the level of mean scores of total empathy and its subscales (d = 0.53–0.69), except for compassionate care, which showed a small positive effect over time (d = 0.31) (Table 3).

6. Discussion

This quasi‐experimental study was conducted to explore the impact of an innovative training programme on the empathy skills of undergraduate nursing students during the spread of the COVID‐19 pandemic. The results of the study showed that our hypotheses were accepted. The empathy training programme had a moderate positive impact on the total score of empathy and its subscales, except for the subscale of compassionate care, which only showed a small influence. It can be argued that compassionate care is inherent, and it is one of the components of emotional empathy (Abramson et al. 2020). The subscales of perspective taking and standing in the patient's shoes are related to cognitive empathy, and thus they can be successfully taught and learned through training programmes (Yang et al. 2020). Here, one of the most important arguments pertains to the effectiveness of the training programme in improving nursing students' ability to empathise with their patients. The effectiveness of empathy intervention programmes in nursing education has always been essential and criticised (Levett‐Jones et al. 2019). Based on the literature, it can be discussed that the reason for the effectiveness of our innovative empathy training programme is due to two main educational streams: an experiential and/or a humanistic learning approach. Experiential learning is the process of learning through lived or shared experiences; however, humanistic learning focuses on the development of the student's self‐concept (Bas‐Sarmiento et al. 2020). It seems that educational methods which call for critical thinking and are dependent on the affective dimension of learning in Bloom's taxonomy levels for educational goals are more effective than easy didactic methods. Furthermore, a multifaceted approach that combines different pedagogical interventions can bring satisfactory results (Samarasekera et al. 2023). Our study showed that although we could not hold face‐to‐face classroom training courses due to the COVID‐19 pandemic, we used various teaching methods and focused on the concept of congruence within the clinical case scenarios to improve empathetic behaviours of students. Thus, we followed our engagement to nurture nursing students' empathy with both technical and affective skills to guarantee the quality of patient care during the pandemic.

The positive impact of our training programme on the level of empathy in nursing students is similar to earlier studies in Iran. One of these studies showed a significant positive effect on the mean scores of empathy and the attitudes of nursing students, immediately and 2 months after an empathy skill training programme for elderly people (Gholamzadeh et al. 2018). Another study about the effect of empathy skills and self‐awareness training on the empathetic behaviours of midwifery students showed that although a significant increase was reported in the postintervention empathy scores of the students in comparison to the preintervention scores (within‐group differences), after the intervention, no significant difference was found in the students' empathy scores in the intervention group in comparison to the controls (between‐group differences) (Tafazoli et al. 2018). Moreover, our findings are in line with earlier studies abroad. In a clinical trial after implementing a neuroscience‐informed curriculum intervention, the scores of empathy in areas of communication and counselling increased in resident physicians of the intervention group in comparison to the controls. The ability to decode emotional states and expressions was higher in the intervention group than in the controls (Romero‐Martínez et al. 2019). Also, the results of a longitudinal cohort study for empathy enhancement in Peruvian medical students showed that empathic behaviours of students increased in the intervention group after the training courses (Fernández‐Rodríguez et al. 2020). Furthermore, in an experimental study with Turkish paediatric nurses, an empathy training programme was applied through creative drama techniques. The findings showed that after the training programme, Turkish nurses in the intervention group had a higher mean score of empathy in comparison to the controls (Kahriman et al. 2016). In addition, the result of a study with Egyptian psychiatric nurses revealed that after an empathy‐based training programme, the majority of nurses in the intervention group reported a high level of empathic skills compared to low‐level skills in the controls (Osman et al. 2018).

Interpretation of our results based on the demographic characteristics of nursing students revealed interesting results. The findings indicated that before starting the innovative empathy training programme, the level of empathy in female students was significantly higher than in male students. But, after implementing the programme, there was no significant difference between male and female students in our study. This result is parallel with a descriptive study on changes in the level of nursing students' empathy during 4 years of education (Kesbakhi and Rohani 2020). However, the result of a cross‐sectional study with 437 Indian medical students showed that the empathy score of female students was higher than male students (Nair et al. 2018). Authors argued that higher empathy in women can be attributed to inherent empathy and their natural ability to manage life stressors and cope with them (Shashikumar et al. 2014). A higher level of empathy in women can originate from their maternal instinct (Duarte et al. 2016). Also, it has been discussed that sex differences in empathy are most likely the result of sexual bio‐developmental features, interpersonal care styles, socialisation, interpersonal communication styles and gender role expectations (Vallabh 2011). Literature shows a disagreement between the relationship of empathy and personal character. This finding underscores the need for more short‐ and long‐term research on the impact of personal characteristics on increasing empathy (Juniarta et al. 2024).

In summary, the results of our study showed that our innovative online empathy training programme had a positive effect on increasing total empathy and its subscale scores in undergraduate nursing students at different academic levels over time.

6.1. Strengths and Limitations of the Study

One of the strengths of our study refers to the type of empathy training programme. The content of our empathy training programme is innovative and context based since it was extracted from our earlier qualitative study and focused on the multistructural nature of empathy. Our training programme is based on the lived experiences of oncology nurses in the same society where our sample of nursing students was studying. But, on the other hand, the COVID‐19 pandemic had a significant impact on our study and forced us to adapt to different parts of the study. We had to present the training programme as an online programme to prevent the spread of the disease among the students. Although, due to the pandemic, we were unable to measure students' empathy skills with an observation checklist in clinical settings, the final evaluation of the training programme showed that 98% of the students were satisfied and about 93% of them wrote some of their positive experiences while empathising with their patients in clinical settings on the final evaluation form. Furthermore, the number of married students was low in our study, which might affect our results. Also, a real comparison or control group was not selected due to the small number of students at the university. Additionally, we did not select nursing students from other universities as a comparison or control group due to the different educational environments, which could influence the precision of the study results.

6.2. Implications for Nursing Education or Practice

Based on these results, integrating this innovative empathy training programme into the curriculum planning of undergraduate nursing students is suggested. It can be a useful empathy training programme to promote the quality of relationships between patients and nursing students in clinical settings and consequently, the quality of patient care in real‐life healthcare settings. Also, it can be a valid base for an empathy training programme in other nursing schools. Based on this programme, longitudinal studies are suggested to track changes in the level of empathy in nursing students.

7. Conclusions

The results of this study showed that our innovative empathy training programme had a positive effect on increasing the total empathy skill scores of nursing students, and their subscales scores, including the ‘perspective taking’, ‘standing in the patient's shoes’, and ‘compassionate care’. Since empathy is a clinical skill that can be learned, this innovative programme might be integrated into undergraduate nursing curriculum planning. It can assist in improving the quality of relationship between patients and nursing students and in increasing patients' quality of care in clinical settings.

Author Contributions

The conceptualisation of this study was done by M.S.K. and C.R. The innovative empathy training programme was developed by M.S.K. and C.R. The training programme was implemented by M.S.K. S.A. contributed several significant texts for developing the training programme. Data were collected and computerised by M.S.K. and S.A., and L.H.T. analysed the data. M.S.K. and C.R. did data curation and interpretation together. The first draft of the manuscript was written by M.S.K. All the authors contributed significant text and critical revisions in the manuscript. C.R. did supervision and main critical revisions of the manuscript. All authors read and approved the final manuscript.

Conflicts of Interest

All authors declare that they have no financial or nonfinancial competing interests that might create a conflicts of interest with the information that has been presented in this article. This study adhered to the Declaration of Helsinki, and it was approved by the Research Ethics Committee of Tonekabon University with the ethical code of IR.IAU.TON.REC > 1399.056.

Kesbakhi, M. S. , Arab S., Tabaghdehi L. H., and Rohani C.. 2025. “Impact of a Training Programme on the Empathy Skills of Nursing Students During the COVID‐19 Pandemic: A Quasi‐Experimental Study.” Nursing Open 12, no. 6: e70223. 10.1002/nop2.70223.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.