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Enhancing empathy in undergraduate nursing students: an experiential ostomate simulation.


AIM The aim of this study was to implement and evaluate an experiential learning simulation created to enhance nursing students' empathy during patient care encounters.

BACKGROUND The investigators proposed that an ostomy simulation experience would be an efficient method for providing this educational content.

METHOD Content analysis was conducted on essays using Krippendorff's technique to quantify the simulation. results Each unit of measure, or paper, contained between 1 to 14 empathic comments. Of the total sample, 22.8 percent had three or five empathic comments; 10 percent had four, and 9 percent had six or more comments per paper. Eighty-five percent of participants felt this simulation experience was beneficial for enhancing empathy in clinical practice.

CONCLUSION The assignment was an effective, objective method that utilized simulation to teach empathy to baccalaureate nursing students.


Empathy--Nursing Students--Simulation Caring --Clinical Simulation


Given the focus on learning the newest technologies, practicing technical skills, and staying abreast of scientific advances in health care, the complexity of empathy can be lost in undergraduate nursing education. It is therefore essential that nurse educators help students develop the skills that promote therapeutic nurse-patient relationships and promote caring attitudes through the intentional teaching of empathy.

Empathy is a complex and multidimensional concept defined in various ways in the context of nursing. Although it is often considered elusive and difficult to measure, empathy is central to the nursing role. Evidence continues to demonstrate the utility of teaching empathy in nursing education (Dal Santo, Pohl, Saiani, & Battistelli, 2014; Scudder, 2012).

The purpose of this study was to implement and evaluate an experiential learning simulation designed to enhance nursing students' empathy during patient care encounters. The simulation experience allowed students to experience what it is like to be a patient who needs to wear an ostomy bag. The aims of the study were twofold: to cultivate nursing students' empathy for patients with an illness and enhance their clinical practice through self-reflection as a means of nurturing empathy. For this study, empathy was defined as the ability of the nursing student to understand and appreciate a patient's perspective regarding an illness and to experience the emotional reactions to their situation as a core process in building a therapeutic nurse-patient relationship (Gerace, O'Kane, & Muir-Cochrane, 2013).


It is widely acknowledged in the nursing literature that the empathic ability of the nurse is essential to developing and fostering a therapeutic nurse-patient relationship (Peplau, 1952; Vanlaere, Timmermann, Stevens, & Gastmans, 2012; Williams & Stickley, 2010). Nursing is one of the most trusted professions in health care, and, as such, patients desire to have the nurses who care for them display the characteristics of empathy and caring. Empathy promotes the perception of and understanding of how others view their world (Halter, 2014, p. 143). It is more than "listening attentively" to the patient and exhibiting "attending" behaviors, both aspects of caring in nursing. The nurse-patient relationship is dynamic and interactive, and it is within this dynamic interplay that empathy exists. To foster and promote therapeutic nurse-patient relationships and thus promote the physical and emotional well-being of patients, the "nurse must be able to respond to clients empathically, competently, and intelligently" (Dearing & Steadman, 2009, p. 174).

It is important for nurse educators to implement strategies that facilitate the learning of empathy (Williams & Stickley, 2010). Research on simulation programs in academia continues to reveal that clinical skills are made better when these skills are reinforced through simulation (Cant & Cooper, 2010) and simulation programs are an important component in nursing education to help bridge the gap between theory and practice (Gonzalez et al., 2010). Empathy can be modeled and taught using simulation (Blum, Hickman, Parcells, & Locsin, 2010; Panosky & Diaz, 2009). Teaching empathy to nursing students through a simulation experience helps them gain insight into what the patient is experiencing, what the illness event means to the patient and how it affects the patient's life (Vanlaere et ah, 2012).

Panosky and Diaz (2009) asked students to role-play a patient with a newly acquired diagnosis or medical condition similar to the one used in the current study. Student comments indicated they achieved an in-depth understanding of what it is like to be a patient with this particular diagnosis.

Blum et al. (2010) explored the use of simulation in a health assessment course to teach caring behaviors to nursing students. The results of their quantitative study showed that self-identified caring behaviors increased with the use of simulation.

Vanlaere et al. (2012) conducted a qualitative descriptive study to gain insight into the use of empathy sessions and their impact on empathic abilities. Their study demonstrated that all participants experienced "at least one experience (session) that really affected them" (p. 73). Participants played the role of an elderly patient based on a patient profile. The physical discomfort from pain and cold experienced by participants as simulated patients led to self-reflection and, in turn, small changes to the students' practice.

Lockyer, Gondocz, and Thivierge (2004) support experiential learning as a teaching strategy that requires an introspective look at how the experience affects the person. Promoting attitudes and behaviors such as self-awareness, nonjudgmental positive regard for others, and self-reflection is important in the development of nursing students who will demonstrate empathic willingness. When self-awareness and self-reflection happen, a transformation takes place whereby nursing students gain insight into the actual experience a patient may have. Self-reflection, a skill that requires nursing students to recognize and remain cognizant of their own personal values and beliefs and how they influence their behaviors and interactions with patients, helps transform new experiences into knowledge and action. When students self-reflect on the learning process that takes place, they become more self-aware and the knowledge gained becomes part of the self.


This study was conducted in a state university as part of baccalaureate nursing students' undergraduate simulation program during the fall 2013 and spring 2014 semesters. Data were gathered after receiving approval from the university's institutional review board. The study used quantitative content analysis (QCA) as the research method, a technique that allows the researcher to objectively tally content of written communication for predefined terms (Boettger & Palmer, 2010; Rourke & Anderson, 2004). The assumptions are that text has meaning, the writer of the text intends to convey meaning as part of his or her purpose in writing, and the reader understands that the text has a message.

Krippendorff (2004) defined content analysis as "a research technique for making replicable and valid inferences from texts (or other meaningful matter) to the contexts of their use" (p. 18). In QCA, sampling units are the communication messages that are examined, and coding units are the content that will be categorized and analyzed. For this study, the sampling units are written papers submitted by participants about their simulation experience. The coding units are the comments and/or phrases that were identified a priori as empathy comments that would be counted or tallied in the analysis.

Simulation Experience

The pedagogical approach of experiential learning through the use of simulation was used in this study to develop and advance the skills of nursing students responding with empathic ability toward a patient with an ostomy (Vanlaere et ah, 2012). This simulation experience was part of the established curriculum plan and was required for all junior nursing students. Only those students who consented to participate in this study resubmitted their papers at the end of the educational activity and completed a satisfaction survey and a demographic sheet.

All students were fitted with an ostomy bag in the simulation lab and were instructed on how to measure a correct opening of the wafer and apply it. Clinical Resource Lab (CRL) faculty assisted in the correct placement based on the simulated injury, for example, placement of ileostomy versus colostomy. The ostomy wafer and ostomy appliance were provided as part of the students' supply and all students had the same appliance. The simulation included a prebriefing based on ostomy equipment and placement.

The instructions for the simulation were to wear the ostomy bag with fecal moulage for 48 hours continuously while performing normal daily activities. Students were given the freedom to be creative in the moulage of simulated fecal matter and used products such as brownie mix, canned soup, chocolate pudding, and mashed potatoes with food coloring added to make it look more realistic. The content had to resemble feces in the form of texture and consistency, but not scent. Students were asked to be self-aware of the mental, physical, and emotional changes during the simulation in preparation for writing the required paper.

CRL faculty removed the ostomy bag after 48 hours; students who applied the appliance on a Friday could remove it themselves the following Sunday, taking a photo with a time stamp as proof of wearing the bag for the required time. Students who experienced a rash or had other untoward effects from the ostomy bag were allowed to remove the bag, inform CRL faculty, and stop the simulation.


Caruso and Mayer (1998) developed the Multi-Dimensional Emotional Empathy Scale used in this research. This is a 30-item self-report measure used to rate perceived empathic ability on a five-point Likert scale; scores range from 1 (strongly agree) to 5 (strongly disagree). The scale provided seven categories used a priori to code for empathy statements self-reported by students in their papers written after the simulation experience. The seven categories are: empathic suffering, positive sharing, responsive crying, emotional attention, feeling for others, emotional contagion, and general empathy. (See Table 1.)

Virtual and Face-to-Face Debriefing

The simulation experience debriefing was completed virtually; students were given a PowerPoint to review and the article by Panosky and Diaz (2009) to read as the first part of the debriefing process. CRL faculty were also given the article to prepare for debriefing. The virtual debriefing gave students time to contemplate issues or concerns and reflect on the experience. It also accommodated students who ended their 48-hour experience at different time points.

For the second part of debriefing, the students had a group discussion with CRL faculty to assist with processing their reactions, feelings, and emotions. The students then wrote a paper about their experience with instructions to reflect on the last 48 hours and describe what it was like for them as persons who now had an ostomy bag. The paper was handed in at the next lab session. CRL faculty reviewed the papers, graded them, and returned them to the students. Recruitment

CRL faculty announced the study to all nursing students at the end of the simulation experience, explaining that participation was voluntary. The study commenced after all grades for the assignment were submitted to control for bias. Students were told that if they chose to participate they could withdraw from the study at any time without negative consequences or effect on their grade.

After consenting to be part of the study, student participants resubmitted their papers (without names and grades) for analysis. Papers were given a study number and the three investigators were blind to participant identification. Participants were also given a demographic sheet and satisfaction survey based on the characteristics of Jeffries' (2012) simulation framework. Students answered six questions that rated the degree to which they were satisfied with the learning experience. They used a scale where 1 indicated low satisfaction, 3 indicated medium satisfaction, and 5 indicated high satisfaction.

Scoring and Data Analysis

Descriptive statistics on sample characteristics and student feedback were done for informational purposes using the demographic sheet and student satisfaction survey. Data were collected and analyzed using SPSS version 7.

Data analysis on empathy included the following steps: a) establish coding protocol, b) identify phrases that represent the concept of empathy, c) perform interrater reliability, and d) count the frequency of the identified phrases indicative of empathy and tally scores.

The investigators established the coding protocol on a priori categories based on Caruso and Mayer's (1998) conceptualization of emotional empathy. One point was given for each example of coding content present in comments and/or phrases in the written papers (e.g., "I get it"; "I see now"; "I feel upset"; "So wouldn't I feel"); each point counted toward the overall score as an indication of the presence of empathy. Total comments and/or phrases were tallied to yield a final score; higher scores indicated a greater presence of empathy, the desired outcome of the study. (See Table 2.)

To establish interrater reliability, one sample paper was randomly selected for independent coding using the a priori categories. The three investigators independently performed a preliminary coding of the same sample paper and maintained individual logs of the tallied count of empathic statements. After they met to review their assessments, 85 percent agreement was achieved.

Another discussion took place to review the categories and review where there were differences in scoring. Some items of disagreement concerned comments and phrases that met the categories of empathy. After discussion, interrater reliability of 92 percent agreement was achieved. This step was essential to ensure reliability and establish trustworthiness of the description of the phenomenon from the text under study (Weber, 1990). The procedure led to each reviewer's having a more thorough understanding of the scoring procedure.

Participants' papers were randomly divided among the three reviewers for coding. Comments within the papers that focused on one of the identified recording units (e.g., "It moved me..." or "I feel deeply about...") were coded as empathy comments and were given one point; each occurrence was counted toward the final tally. The tallied points for each paper analyzed from each reviewer were entered into SPSS 14.0 statistical software for quantitative analysis. The desired outcome was for a high number of comments that would be indicative of assimilating the cognitive and emotional components of empathy, but no specific number of comments was targeted to avoid bias during the review.


A descriptive analysis was done that provided a demographic description of the sample (N = 69). Participant ages ranged from 18 to 40 years, with 80 percent (n = 53) between the ages of 18 and 20; 17 percent (n = 13) were ages 21 to 23, and 3 percent (n = 3) were 36 to 40 years of age. Women comprised 84 percent (n = 58) of the sample. Participants varied in ethnicity, with 80 percent white, non-Hispanic, 10 percent African American, 6 percent Asian American, and 4 percent Hispanic.

The satisfaction survey revealed that the majority of student participants (85 percent, n = 58) believed that this type of simulation experience was beneficial for strengthening therapeutic relationships and enhancing their empathy toward patients who experience life-changing events. Only two participants reported a negative response to the simulation, stating it was not a worthwhile educational activity; these students did not believe they needed to wear an ostomy appliance in order to improve their nursing care or clinical practice. Approximately 13 percent (n = 9) claimed to be indifferent to this type of experience as part of their undergraduate simulation program. Based on these results, there is strong support for using this type of simulation as an educational activity for promoting empathy.

Content analysis found a range from 1 (7.6 percent) to 14 (1.3 percent) empathic comments in a sampling unit (each paper). (See Table 3.) All papers had at least one empathic comment; 65 percent of the sample had between three to six empathic statements per paper, providing reasonable evidence that the simulation experience stimulated empathy in the nursing students. Given the small sample size, 65 percent of the total sample was a significant outcome.


The results of this study indicate that the learning simulation had a positive effect on promoting an emotional response and awareness of the skill of empathy. Although the students simulated only one type of medical condition, it is possible they will translate their experience to other medical and psychiatric conditions, empathizing, for example, with the stress experienced by caretakers when a family member has Alzheimer's disease or with individuals who experience problems associated with stigma, such as mental illness or substance abuse.

Research has shown that empathy tends to decline over time among undergraduate nursing students, particularly as they spend more time in clinical practice focusing on technical skills (Ward, Cody, Schaal, & Hojat, 2012). It is critical that nurse educators remain mindful of incorporating teaching strategies that reinforce empathic skills. This study has examined one type of educational activity as a pedagogical strategy that can be implemented in a simulation program as part of the curricular plan for enhancing the skill of empathy. This type of simulation can be adapted to include other medical conditions, address issues across the life span, and serve as a platform for interprofessional collaboration with nursing and medical students.


The limitations of this study include a small sample size, a single academic institution, and a singularly focused type of patient illness. Therefore, the results are not generalizable.


Nursing is both an art and science. With today's tremendous advances in technology and science, incorporating empathy training into nursing education is important and should be considered part of the entire clinical curriculum. The use of a simulation experience that allows students to experience an illness through the patient's eyes is only one educational activity that can be used to achieve this goal. There are other strategies that nurse educators can use, such as incorporating simulation in the classroom, role-modeling therapeutic communication, or incorporating an evolving case study throughout the semester, with students assigned to the role of the nurse. Interprofessional activities that bring together students from various health care professions to enact a clinical case study can also be used.

Using content analysis of student papers was one way to examine and quantify a subjective experience. Despite the limitations of this study, the results do show support for this type of teaching strategy to enhance empathy, at least in the baccalaureate nursing student population.

The investigators' previous research on this phenomenon used the qualitative Colaizzi phenomenological method to first understand the student's lived experience as an ostomate patient (Diaz, Maruca, Kuhnly, & Jeffries, 2015). This study expands on that research by using content analysis to determine if the simulated experience was beneficial in increasing empathy evidenced by a higher count of empathic comments. Future studies could expand the implementation and evaluation of this type of simulation in graduate programs and advanced nursing practice programs. By incorporating this type of simulation across all nursing program, from undergraduate to graduate, students will continue to demonstrate empathy in their nursing practice, ultimately elevating the art of nursing.

doi: 10.5480/15-1578

Annette T. Maruca, PhD, RN-BC, is assistant clinical professor, University of Connecticut School of Nursing, Storrs. Desiree A. Diaz, PhD, RN-BC, CHSE, CNE, is assistant professor, University of Central Florida. Joan E. Kuhnly, DNP, APRN, NNP-BC, IBCLC, CNE, is assistant clinical professor, University of Connecticut School of Nursing. Pamela R. Jeffries, PhD, RN, FAAN, ANEF, is dean and professor of nursing, George Washington University School of Nursing, Washington, DC. For more information, contact Dr. Maruca at


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Table 1: Seven Categories of Empathy Comments

Empathic Suffering      Positive Sharing        Responsive Crying

"I could not go even    This experience made    "I could understand
five minutes without    me appreciate what      why someone might cry
being overly            patients go through."   about their
conscious of it                                 situation."
[ostomy bag] on my

"I was honestly         "I learned that the     "I felt like crying
overwhelmed imagining   greatest help I can     when others looked at
going through surgery   offer a patient is to   me like I had a
for a colostomy.        be open and             disease."

Emotional Attention     Feeling for Others

"I now pay attention    The pain I felt
to the feelings and     removing the ostomy
emotions of other       bag I understood how
people."                sore their abdomens
                        must be."

"I pay closer           "I think some of
attention to someone    their concerns are
who is upset or         because of fear of
crying."                the unknown."

Emotional Contagion     General Empathy

"I will now be able     "This experience was
to anticipate my        an eye opener."
patient's needs."

"I began to think of    "I learned from this
ways I can make it      experience how to put
easier for my future    myself in my
patients."              patient's shoes."

Table 2: Data Categories and Coding

Data Categories       Empathic Comments             Scoring

Empathic Suffering    "It makes me feel ..."        Every empathic
Positive Sharing      "I feel good ..."             comment identified
Responsive Crying     "I felt choked up ..."        in a paper was
Emotional Attention   "I pay closer attention       counted as one
                        to ..."                     point; the points
Feeling for Others    "I get it now ..."            were tallied per
Emotional Contagion   "So do I feel the same ..."   paper for a total
General Empathy       "I see now ..."               count.

Table 3: Results

Number of                        Percent of
empathic statements    N (69)    sample

1                      5          7.6
2                      4          6.3
3                      16        22.8
4                      7         10.1
5                      16        22.8
6                      6          8.9
7                      4          6.3
8                      3          3.8
9                      5          7.6
10                     2          2.5
14                     1          1.3
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Author:Maruca, Annette T.; Diaz, Desiree A.; Kuhnly, Joan E.; Jeffries, Pamela R.
Publication:Nursing Education Perspectives
Date:Nov 1, 2015
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