One of the key elements and main outcomes of high-quality, effective nursing education is therapeutic communication based on empathy. Improving the empathic attitude and therapeutic communication skills of nursing students has always been an important element of nursing education. Since the effective use of empathy consistently leads to more-positive patient outcomes, including greater patient satisfaction and compliance with treatment, regardless of the increasing technological demands of current health care organizations and the delivery of services, empathy remains at the center of all nurse-patient encounters [1, 2].

The authors have defined empathy as a predominantly cognitive attribute that involves the ability to understand (rather than feel) the experiences, concerns, and perspectives of others, combined with a capacity to communicate this understanding [1, 2]. However, other scholars have emphasized that an intention to help is another feature of empathy (called the empathic tendency) associated with the emotional dimension of empathy [3, 4, 5]. The term “empathic tendency” encompasses the empathic communication potential of a person [3]. Studies evaluating the development of empathy in health care professionals have shown a tendency to measure these two dimensions of empathy separately, and this studies have provided useful information about the development of an empathic attitude in nursing and medical students as well as important suggestions for how to teach it [3, 4, 5].

Nursing curricula, incorporating basic theoretical knowledge, usually devote a designated number of hours to teaching students how to understand patients' experiences and communicate their empathy to them [6, 7, 8]. However, evidence about the empathic skills of students and graduates is most often based on short-term measurements in relation to a particular course, seminar, or workshop. Studies conducted in recent years have shown that, in some groups, empathy was more likely to decrease over time. In these groups, although empathic skills seem to have been learned, the level of empathic tendency decreased by the end of their undergraduate education [1, 4, 5, 7, 8, 9, 10]. These results reveal that teaching empathy continues to be a challenge for educators and researchers.

Current developments in knowledge, technology, and regulations for patient safety have forced nursing curricula to change. However, effective communication remains one of the main outcomes of all nursing curricula, and empathy is a critical component of being an effective team member and health care provider [11, 12, 13].

In this context, nursing schools in Turkey, as in many countries worldwide, began to change their curricula in the early years of the new millennium. Before these changes began to be implemented, nursing schools were applying a traditional curricula in which lectures were structured according to the main nursing disciplines such as medical or surgical nursing, resembling the biomedical model. At the same time, educational methodology was basically traditional and teacher-centered; instructors played an active role in lecturing to students, and students were passive recipients of knowledge. After the early 2000s, many nursing schools began to restructure their curricula according to their own missions and visions, as well as those of the governing university. These new curricula were generally labeled “integrated curricula” to distinguish them from the traditional model. In these integrated curricula, basic concepts and topics related to nursing science and the nursing profession, in contrast to only medical topics, have been added to the curricula [14, 15].

The structures of integrated curricula are generally based on content related to human developmental stages, basic human needs, nursing concepts, body systems, and functional health patterns [14]. The titles of courses have also been changed according to their objectives, differentiating them from medical specialties. Along with course structures and titles, teaching methods have also changed. Instructors lecturing in integrated curricula have been encouraged to change their teaching methods from classic monologues to more-interactive instructional and assessment methods. In traditional curricula, communication as a course was usually relegated to one semester in the second academic year, and it was addressed in relation to cases in classes and/or in clinical practicums throughout the four academic years. By contrast, integrated nursing curricula are typically outcome-based, and effective and therapeutic communication skills are one of the main outcomes of these curricula. For this reason, unlike traditional curricula, communication-related content is integrated into various courses and lectures, as a certain subject and for a designated number of hours, from the beginning of the freshman year through graduation. In regard to evaluating these skills, in addition to other skills, empathic skills and empathic tendency are generally measured to demonstrate whether communication-related outcomes have been achieved. This is the strongest element of the new, integrated curricula [15].

To provide guidance to those who plan to develop new curricula, recognizing the development of empathy in students over the course of four years of nursing curricula is important. For this reason, the specific purpose of this study is to demonstrate whether there is a difference in empathic skills and empathic tendency levels of undergraduate nursing students between integrated and traditional curricula.

The ages of the students were between 21 and 25 (mean 22.74±1.16) and all were female. The students in both groups were not statistically different comparing with socio-demographic traits such as family type, locations they lived and age (p>.05).

The comparisons of the ECSS scores for both groups are displayed in Table 1. Comparing the initial scores with the final scores for the ECSS, a significant difference was found between the two scores in both groups. The ECSS scores of students in both curricula increased significantly (p<.05). The ECSS mean scores of students in the traditional curricula increased from 129.99±19.20 to 167.47±21.28 (p=.001). The scores of students in the integrated curricula increased from 131.09±16.85 to 177.92±19.10 (p=.001). Despite the similarity in the initial ECSS scores of the students in both groups (p>.05), there was a significant difference between the two groups in the second set of ECSS scores (p<.05) at the end of their four years of undergraduate education. The final ECSS scores of students in the integrated curricula (177.92±19.10) were statistically higher than the scores of those in the traditional curricula (167.47±21.28) (p=.002).

Table 1
Comparison of Initial and Final Scores of the Empathic Communication Skill Scale (ECSS)

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The comparisons for the ETS scores are displayed in Table 2. Comparing the initial scores with the final scores for the ETS, a significant difference was found between these two scores in both groups. The ETS scores of students in both curricula decreased significantly (p<.05). The ETS scores of students in the traditional curricula decreased from 75.39±8.57 to 71.77±8.80 (p=.001). In the integrated curricula group, scores for the ETS decreased from 77.95±9.75 to 73.04±7.78 (p=.003). There was no significant difference between the two groups compared to the final ETS scores (z=−.71, p=.477).

Table 2
Comparison of Initial and Final Scores of the Empathic Tendency Scale (ETS)

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Since similar changes were found in both groups, the change in the scores was also calculated and both groups were compared to those scores. Thus, the mean of the difference in the scores between the initial and final scores (in both scales, the ECSS and the ETS, and both groups) were calculated. The comparisons of the mean change in scores are displayed in Table 3. The change difference for the ECSS scores (initial and final) of the students following the integrated curricula was significantly higher than the change difference of students in the traditional curricula (t=−2.92, p=.004). There was no statistical difference between the students following the integrated curricula and those following the traditional curricula when compared with change of scores of the final and initial ETS scores (t=1.32, p=.186).

Table 3
Comparison of Mean of the Difference between Initial and Final Scores between Traditional Curricula and Integrated Curricula

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The findings of the study presented here have shown that empathic communication skills increased in both groups during their four years of undergraduate nursing education, regardless of the curricula structure. All the students had higher empathy scores at graduation compared to their initial scores. Despite both curricula having improved students' empathic skills, the empathic skills scores of students in the integrated curricula were significantly higher than those in the traditional curricula. Various studies have demonstrated that empathic communication skills can be developed and improved by training curricula and/or by short-term, well-structured courses [8, 10, 13, 16, 17]. Moreover, studies have suggested that not only curricula structure but also teaching methodology could be significant in developing empathic skills [12, 18, 19]. Cunico et al. [6] suggested that attending empathy-training courses in addition to the formal curricula content and practice increased students' empathic capacities. McKenna et al. [10] indicated that learning through practice in undergraduate curricula is more effective than lecture content alone for developing empathy. However, these additional courses were usually administered to small groups, and instructional strategies included role-playing, watching videos, and learning by doing were often used as teaching methods. Brunero et al. [9] emphasized that the most promising method for nursing students to increase their levels of empathy is through experiential learning. The results of this study indicated that more hours allotted to theoretical and practical studies designed to increase empathy and communication skills helped to improve empathy skills.

The results of this study reinforced the importance of allocating a greater number of hours to the study of communicative skills and providing opportunities to practice the skills repeatedly in different situations. Furthermore, as stressed in adult-learning literature, experiential learning activities contributed to internalizing skills by helping students to understand what they need to learn individually.

By contrast, this study also showed that the empathic tendency levels of students in both groups decreased significantly at the end of their four undergraduate years. Regardless of curricula structure and teaching methods, this result indicates that empathic tendency, as the emotional dimension of empathy, deserves greater attention. Empathic tendency is related to critical factors in nursing care such as the willingness to listen, positive regard for the other, and sensitivity toward others' lives and understanding the lives of others.

The authors investigating the development of empathy define the empathic tendency as the potential of an individual to understand the feelings and experiences of another. They suggest that learning empathy as a skill may not be enough for a nurse to achieve high-quality patient care. If there is no emotional intent to help others, in this case, patients, then empathic skills may not be used genuinely. Many previous studies have found similar results, suggesting increased empathic skills and decreased empathic tendency levels. For example, after training that comprised 14 empathy-training sessions, Dökmen [3] found an increase in empathic skills but no difference in empathic tendency. Pazar et al. [5] and Ward et al. [7] found similar decreases in the empathic tendencies of nursing students.

Studies conducted with medical students have suggested similar results [4, 8, 20, 21, 22]. Chen et al. [20] demonstrated that empathy levels of medical students decreased significantly following the clinical-practice period. The authors addressed the stressful aspects of medical education, such as extended work hours, insomnia, and working with people who are suffering [4]. These kinds of educational experiences can also be applied to nursing education. Similar experiences, challenges, and confrontations are experienced during the years of nursing education.

Before students are well equipped, encountering individuals who are suffering pain, loneliness, weakness, and dependence upon others and those facing death during clinical experiences may cause insensibility and avoidance of empathizing. In addition, frequent encounters of this kind can create a kind of desensitization resulting in normalization. Moreover, students can be at risk for compassion fatigue later on, which can result in a reduction in empathy [23, 24]. The most common symptom of compassion fatigue is emotional numbness [24]. Despite an assumption by some authors that nursing students are not faced with such dramatic experiences during their clinical practices, the findings of this study implied that they might avoid empathy in order to protect themselves against pain and anxiety caused by emotions such as fear, hopelessness, desperation, and other negative feelings. These kinds of feelings may emerge in relation to patients and their families, but they can also be related to the academic environment and educators' attitudes.

There are also many studies showing the sources of stress that nursing students experience during their education. For example, Gibbons [25] stated that nurse educators need to consider how course experiences contribute to potential distress. Also Gibbons et al. [26] addressed the use of avoidance as a coping strategy and the strongest predictor of burnout among nursing students. Arieli [27] addressed the emotional challenges of clinical placements and suggested that understanding the types of emotional work that students do in the process of their clinical experience is critical to educators.

While this study reinforces the concept that instructional methods have the potential to improve the empathic capacity of nursing students, as suggested by Ward [28], it also points to the need to study empathic tendency, a more personal and emotional element of empathy. As a result, to be able to achieve a desired empathic attitude in students and graduates, nursing educators should focus on the emotional, personal, and tacit aspects of learning experiences. The use of simulation in nursing education seems to be promising method for illuminating this dark side of the tendency to empathize [29, 30].

There are two major limitations of this study. The study sample is relatively small, and the data are somewhat outdated. However, since current curricula have had similar constructions and courses in nursing education, the results can still be considered timely. In addition, the measurement tools were based on self-report, and there were no observational tests to determine actual empathic behaviors.

The results of the study suggest that undergraduate nursing curricula, whether traditional or integrated, can improve empathy. However, it seemed that the integrated curricula were more effective than the traditional curricula for increasing empathic communication skills. The decrease in empathic tendency levels in both curricula requires further research. Conducting observational studies to determine the outcomes of empathic competency on patient care and job performance are recommended. Providing personalized support and consultation to students about how to express their emotions, how to cope with unfavorable emotions, and how to enhance their helping behaviors can be beneficial for improving an integrated empathic approach. Educators and nurse managers should also give more attention to the decrease in empathic tendency levels and attempt to discover the reasons for and the results of this phenomenon.