Empathy is the capacity to recognize and identify with feelings experienced by another (Taylor, Lillis, LeMone, & Lynn, 2008). The ability to empathize is considered vital to the delivery of quality nursing care (Brunero, Lamont, & Coates, 2010; Ward et al., 2009). Indeed, higher levels of empathy have been associated with better patient care (Zachariae et al., 2003), lower rates of malpractice (Ward et al., 2009), and lower risk of compassion fatigue (Abendroth & Flannery, 2006).
Measuring empathy in individuals is challenging. Although various tools have been used to measure empathy in nursing professionals and students, the findings of studies using these tools are inconsistent (Yu & Kirk, 2009). In addition, to the best of our knowledge, no research study has explored empathy as an early predictor of entry into a nursing career (Baron-Cohen, 2007; Billington, Baron-Cohen, & Wheelwright, 2007).
The current study differs from previous nursing research regarding empathy because we used the empathizing quotient (EQ) questionnaire and systemizing quotient (SQ) questionnaire developed and validated by Baron-Cohen and Wheelwright (2004). The empathizing–systemizing (E-S) theory argues that individual differences can be partially explained by people’s relative scores on the empathizing and systemizing dimensions. Empathizing is defined as the drive to identify and respond to another individual’s thoughts, emotions, and feelings, whereas systemizing is understood to be the drive to analyze, explore, and construct systems (Baron-Cohen & Wheelwright, 2004). Studies involving the E-S theory have found that women, in general, tend to score higher on measures of empathizing than of systemizing, whereas men, in general, tend to score higher on measures of systemizing than of empathizing (Baron-Cohen, 2007). As a result, an individual who scores high on the systemizing quotient and low on the empathizing quotient is sometimes said to have a “male brain,” whereas a person with the reverse pattern is said to have a “female brain” (Baron-Cohen, 2003). Although the EQ-SQ tools have been widely used in psychology and other disciplines, they have not yet been applied to help understand and characterize empathizing and systemizing qualities in nursing.
The purpose of our research was to explore whether empathizing and systemizing characteristics were important factors underlying students’ self-selection into nursing programs and their continuing success in nursing programs, and whether the importance of these characteristics differed for men and women who choose nursing as a career. We compared male and female nursing students and other college majors in terms of their empathizing and systemizing characteristics. Quantifying these characteristics may help nurse educators to devise better strategies for attracting a more diverse body of students—especially men—into nursing and to determine which entering students are more likely to remain in a nursing program. We also analyzed how empathizing and systemizing characteristics differed among students at different stages of a nursing program. The findings from this study may help to construct an index of students’ development as they progress through a nursing program, which ultimately may serve as a potentially useful measure of program efficacy and may provide further insights in attracting and retaining more students in nursing.
The following three research questions were addressed in our study:
- Do nursing students differ from other students in their E-S characteristics?
- Do male and female nursing students differ in their E-S characteristics? Do male nursing students have higher empathizing characteristics than the general population of male students enrolling in other majors?
- Do E-S characteristics differ among nursing students at different stages of a nursing program?
In addition to answering the research questions, our study presented a valid and reliable tool for measuring empathy—the Empathizing Quotient—which may provide worthwhile insights in relation to the nursing profession.
Previous research defines empathy in a variety of ways. However, all definitions stress the ability to perceive and identify the feelings of another and to respond to those feelings (Baron-Cohen, 2003; Batson, 2009; Decety, 2011a, 2011b; Decety & Ickes, 2009; Shamay-Tsoory, 2010; Stein-Parbury, 2005). Empathy is an essential precondition for forming caring relationships and is vital to quality nursing care (Reynolds, Scott, & Jessiman, 1999). In fact, Brunero et al. (2010) and Ward et al. (2009) suggested that empathy is one of the most important characteristics nursing practitioners bring to the caring environment. (See Halpern  and Oakley, Knafo, Madhavan, and Wilson  for nuanced discussions of the problems related to empathy in caregivers.) For this reason, education in empathy is woven throughout all nursing curricula.
Nursing research has addressed the questions of how empathy can be sustained, improved, and measured in practicing nurses and nursing students. Many research studies have attempted to evaluate how undergraduate nursing education helps to mold empathetic characteristics in nursing students through curriculum design, clinical education, and role modeling (Brunero et al., 2010). For example, Alligood (2005) explored levels of empathy in nurses and nursing students and discussed that empathy can be taught and learned through the educational process. Yet, little is understood about the relationship between empathy and its potential genetic and environmental underpinnings. In other words, are people attracted to fields such as nursing because they are naturally high empathizers? Do people become more empathetic as they progress through a nursing program? Do nurses who differ from the norm in their E-S characteristics show differing satisfaction with their career choice?
The question regarding whether capacity for empathy is natural or is developed through education during a nursing program is important for several reasons. Among other things, it may shed light on the alarmingly high attrition rate in the nursing profession—an estimated 30% to 60% of new graduates leave nursing practice within the first year (Beecroft, Kunzman, & Krozek, 2001; Kovner et al., 2007). If individuals are attracted to nursing because they are naturally highly empathetic, this trait may be a useful tool for assessing whether a particular individual is likely to succeed in a nursing program and, more importantly, to stay in the profession after graduation. Traditionally, students have been admitted into nursing programs primarily on the basis of their grade point average (GPA) and scores on preadmission tests (Newton, Smith, & Moore, 2007), and little or no importance has been placed on empathy characteristics relating to student admissions. Alternatively, if a capacity for empathy can be nurtured and developed through education, this knowledge may also be useful in reducing attrition by spurring educators to sharpen the focus on nuanced attention to empathy in nursing education.
One problem with the study of empathy in nursing is that researchers have been unable to identify a valid and reliable measurement tool that accurately reflects a nurse’s ability to practice empathetically (Yu & Kirk, 2008, 2009). Yu and Kirk (2009) found little uniformity in either the choice of tools or the reliability of studies, with none of the tools used to measure empathy in nursing research proving to be strong either psychometrically or conceptually. Research on cognitive attributes related to empathy in nursing students is found sparingly in the literature, and empathy is often not studied specifically but rather measured in terms of more general psychological traits, such as caring and compassion (Eley, Eley, Young, & Rogers-Clark, 2010). Therefore, the need for more research and better tools to understand empathy is of critical concern to the field of nursing.
According to E-S theory, individuals can be categorized into a number of personality profiles based on the relative dominance of empathizing versus systemizing characteristics (Baron-Cohen, 2002). Researchers of the E-S theory believe these characteristics result from a complex mixture of environmental and biological factors, with the most crucial influences occurring as the brain takes shape during fetal development (Buxbaum & Baron-Cohen, 2010; Chakrabarti & Baron-Cohen, 2011; Chura et al., 2010; Lombardo et al., 2010). This interaction between biological and environmental factors helps to explain why women dominate in the role of caregivers in virtually every society (Oakley, 2011; Zahn-Waxler, Shirtcliff, & Marceau, 2008). Baron-Cohen (2003) theorized that women’s brains are, in general, predisposed toward empathizing, whereas men’s brains are generally predisposed toward systemizing. These differing developmental tendencies, along with cultural influences, may help to explain why only 6% to 9% of nurses in the United States are men (American Association of Colleges of Nursing, 2010, 2012; Fairbanks, 2010; Minority Nurse, 2011).
A descriptive correlative design was used for this study of undergraduate students enrolled in a variety of majors, including nursing, at a large midwestern U.S. research university. The study used two measures: the EQ, a 40-item questionnaire, and the SQ-R (the SQ-R is a revised version of the original SQ questionnaire), a 75-item questionnaire, to evaluate empathizing and systemizing characteristics. Scores on the EQ range from 0 to 80 and from 0 to 150 on the SQ-R. Both questionnaires are similar in format; participants are asked to respond to each question by selecting definitely agree, slightly agree, slightly disagree, or definitely disagree (Baron-Cohen & Wheelwright, 2004; Wheelwright et al., 2006). An example of a SQ-R (systemizing) question is: “When I read something, I always notice whether it is grammatically correct” (Wheelwright et al., 2006). A sample EQ question is: “I can easily tell if someone else wants to enter a conversation” (Lawrence, Shaw, Baker, Baron-Cohen, & David, 2004).
After gaining institutional review board approval, researchers used e-mail to contact faculty teaching a variety of college courses and asked for their help in recruiting students to participate in the study. Faculty members who agreed to participate in the study sent one of the two links to students in the selected courses on two consecutive days (the survey links were sent separately to avoid student burnout by answering too many survey questions at once). Extra credit was offered to students who agreed to participate in the study. To prevent any concerns related to student coercion, all students, including nursing students, were offered extra-credit projects, one of which was participation in this study, to earn extra-credit points. Ultimately, 1,872 undergraduate students completed both surveys.
A total of 1,482 non-nursing students and 390 nursing students participated in this research. Gender, class standing, and major academic area were of the most importance for the analysis in this research and is described in the Discussion section.
Besides nursing, students declared majors in the following fields: Integrated Studies, Humanities, Business Administration, Science and Math, Engineering/Computer Science, Education/Human Services, and Social Science. The majority of students were Caucasian (75.1% non-nursing versus 81.7% nursing). The gender proportion of this study mirrors that of the university population, with few male students declaring nursing as a major. There were 13.8% male nursing students who participated in this study. This number was slightly higher than the national percentage of male nursing students, which was estimated at 6% (Minority Nurse, 2011). Regarding the general student population, 41.7% of the participants were male, which is close to the national average of 43% (Williams, 2010). Finally, class standing was noted as important. Class standing among non-nursing and nursing participants did not vary considerably, except for freshman participants. The university in this study admitted only a small number of nursing students during their freshman year, with most students declaring the nursing major during their sophomore year. Therefore, only a small percentage (4.6%) of the overall nursing student population had a class standing as a freshman.
Research Question 1
Nursing students showed substantially higher empathy scores relative to the general student population. Table 1 displays the t test results, demonstrating that nursing students have statistically significantly higher EQ scores than non-nursing students (p < 0.001). The difference between the two groups is approximately 6 points on the EQ scale, which translates to just over one half of a standard deviation (i.e., SD = 0.5). Nursing students in the university’s second-degree nursing program were excluded from this analysis because they were viewed as postbaccalaureate students and therefore did not compare directly to students from other disciplines that do not have second-degree students.
Table 1: Comparison of Nursing Students’ and Non-Nursing Students’ Empathizing Quotient Scores
Research Question 2
Mean EQ and SQ scores for both genders are shown in Table 2. Female nursing students scored higher on the EQ than their male counterparts, whereas the reverse was true for the SQ. Both of these differences were statistically significant (p < 0.01). All analyses for research question 2 included both first-degree and second-degree nursing students because we were analyzing data within the nursing student population as a whole.
Table 2: Comparison of Mean Scores of the Empathizing Quotient (EQ) Questionnaire and Systemizing Quotient-Revised (SQ-R) Questionnaire
With regard to the second part of research question 2, both male and female nursing students scored higher in empathy compared with men and women, respectively, in other disciplines. Table 2 shows that men attracted to nursing not only scored higher in empathy than men in other disciplines, but they scored higher in systemizing traits than all female students (both nursing and non-nursing).
Male nursing students showed significantly higher EQ scores when compared with the general population of male students (p < 0.01). On average, this difference was approximately 5 points on the EQ scale, or roughly one half of one standard deviation.
Research Question 3
Our data findings suggest that both EQ and SQ-R scores may increase over time while students are in a nursing program. Although we did not track students longitudinally, we can examine differences in EQ and SQ-R scores among sophomore, junior, and senior nursing students. As noted previously, freshmen were not included in this analysis because nursing students at this university generally could not formally declare their major until at least their sophomore year. Second-degree nursing students were also excluded from this analysis, as they were post-bachelor degree.
EQ and SQ-R scores did not appear to differ between sophomore and junior nursing students. However, senior students showed noticeably higher scores on both the SQ-R and the EQ. For senior versus non-senior students (i.e., sophomores and juniors together), t tests showed that the difference between the SQ-R scores of the two groups was statistically significant (p < 0.05), whereas the difference in EQ scores approached statistical significance (p = 0.056).
Not surprisingly, our findings support previous research demonstrating that nursing students are highly empathetic. However, the current research is the first to compare nursing students’ levels of empathy with those of other college students and to measure empathy differences between genders. In the latter regard, only 8% of the male students who participated in this study (54 of 667 male participants) chose nursing as a major. Numerous studies have confirmed anecdotal observations that only a small population of men are attracted to nursing (American Association of Colleges of Nursing, 2010, 2012; Fairbanks, 2010; Minority Nurse, 2011). However, no previous research, particularly regarding the role of empathy, has examined why men are attracted to nursing. This research is also the first study to use Baron-Cohen’s EQ-SQ questionnaires in understanding empathy among nursing students.
Our results show that students admitted to the baccalaureate nursing program at a large midwestern U.S. research university demonstrated significantly higher levels of empathy than students majoring in other disciplines. In addition, both male and female nursing students separately scored significantly higher in empathizing characteristics compared with those of their gender in the non-nursing student population. This result is despite the fact that the male nursing students in our sample scored lower in empathy and higher in systemizing characteristics than the female nursing students, which is consistent with similar findings in the general population. These data support previous findings by Baron-Cohen (2003; 2007) and Baron-Cohen and Wheelwright (2004) that women tend to score higher in empathizing characteristics and men score higher in systemizing characteristics; our study shows that nursing students demonstrate the same general patterns. Although gender influences students’ college majors and career choices in many ways, including through cultural constructs, this finding supports the conclusion that a high capacity for empathy plays a significant role in attracting students, including men, to a nursing career. Further, the finding suggests that nursing programs should consider the possibility of assessing empathy skill sets during the admission processes, as well as over the duration of the program and after graduation.
Another important finding is that baccalaureate nursing students in the last stage of the nursing curriculum scored somewhat higher than their younger academic cohorts in empathizing characteristics and significantly higher in systemizing characteristics. We can interpret this to mean that as students’ progress through a nursing program, they not only increase their empathizing skills but they also, and especially, increase their systemizing skills. These stronger systemizing skills, in turn, may reflect both a greater breadth of knowledge and strengthened critical thinking skills, which are important for organization and prioritization in the delivery of patient care. It also must be considered that students with lower systemizing traits may leave the nursing program before completing it.
A final contribution of this study is the application of the EQ and the revised SQ-R to better understand the important E-S characteristics as related to nurses. The use of these tools, particularly the EQ, may enable high school guidance counselors or professional career counselors to help to direct students with high empathizing characteristics toward a career in nursing. Understanding this information may better equip future nurses to manage the long-term stress that is inherent in nurses’ lives. In addition, the study findings suggest that these tools, especially the SQ-R, may become a useful measure of program efficacy, thus opening new doors for further research aimed at establishing an index of students’ development as they progress through a nursing program.
As mentioned previously, many nursing schools use GPA to determine who will be accepted into their nursing program. However, GPA is not necessarily reflective of those students who will become caring, empathetic nurses. The survey tools used in our study could become one of several new parameters used to identify strong student candidates for the field of nursing. Results of these surveys may be especially important to share confidentially with students who may show highly empathizing characteristics but might be struggling academically in prenursing and nursing courses. Knowledge of these positive characteristics may assist in redirecting the students’ previous beliefs, thus providing a positive narrative to help them to succeed in nursing (Wilson, 2011).
The use of these tools can advance the understanding of nursing practice specifically to the relationship of caring and empathy. In nursing, there is always the risk of developing compassion fatigue and withdrawing from interactions with patients to protect oneself. This can lead to dehumanizing patients and their needs. With the aid of these tools, students can become more aware of their own empathetic actions and relationships with their patients. The acquisition of practice skills is critical to the development of professional expertise (Benner, Tanner, & Chesla, 2009) and could be reinforced through reflective practice in classroom education and clinical experiences with regard to maintaining high empathizing traits that continue into nursing practice.
Several limitations of this study should be considered when interpreting the results. First, the findings are based on a sample of undergraduate students attending one large midwestern university and may not be generalizable to other geographical areas or to a non-nursing student population. For this reason, and because this study is the first to use the EQ and SQ questionnaires in a nursing context, future studies might use this tool to test for similar findings in other nursing programs, as well as among practicing nurses. However, it should be noted that one previous study found no significant difference in empathy characteristics between nursing student and non-nursing student populations (Baron-Cohen, Richler, Bisarya, Gurunathan, & Wheelwright, 2003).
Second, the findings of this study relied on self-reported data. Future studies should aim to replicate these results using objective measures of empathizing and systemizing characteristics.
Finally, the study compared the EQ and SQ scores of nursing students at different stages of a nursing program and found the SQ (and to a lesser extent, the EQ) scores of seniors (i.e., late-stage nursing students) to be higher than those of students at earlier stages. However, the study did not measure changes in individual students longitudinally. In addition, the study did not compare these results with similar data from non-nursing students. It may be that all students, including those in non-nursing disciplines, tend to improve their empathizing and systemizing skills over time. Future studies should take this possibility into consideration.
This study compared the empathizing and systemizing characteristics of undergraduate students enrolled in a nursing program with the same characteristics of undergraduate students in other disciplines. The results showed that nursing students’ demographic profiles are similar those of the general population. Specifically, female nursing students are generally more empathetic than their male peers, whereas male nursing students generally have stronger systemizing characteristics than their female peers. However, the results also show that students who are attracted to nursing as a career are more empathetic than the general population of students and that this is true for both women and men.
The findings, based on class standing, indicate that as nursing students advance in their education from the first to the final semester, their systemizing characteristics increase with a concomitant slight increase in empathizing characteristics. This is an important finding, as it confirms that as nurses grow in their ability to prioritize and think critically, they continue to maintain the high capacity for empathy that is essential for nursing practice.
The findings of this research are especially significant in light of the fact that nursing student and patient interactions reflect a patient-centered care approach that emphasizes an empathetic relationship as foundational. As health care reform continues to challenge nursing practice to reach better outcomes with lower costs, patient-centered care is becoming the foundation for reaching these goals. Evidence demonstrates that patient-centered care improves outcomes in several ways, including patient satisfaction, length of stay, and lower overall costs (Cliff, 2012). The foundation of patient-centered care relies on empathetic caregivers, but, just as important, nursing students understand the link between empathy and better patient outcomes. Patients are the center of nursing care, and patients look to nurses to receive empathetic and humanistic nursing care. This research links how empathy is a fundamental trait that attracts individuals to nursing.
Quantification of the empathizing characteristics of nurses is important, as many nurses find themselves in stressful situations that lead to high empathetic distress once they begin professional practice. Greater knowledge and understanding of what helps to sustain and build empathy in nurses may aid us to better address the alarming high attrition rate in nursing (Beecroft et al., 2001; Kovner et al., 2007). Our study suggests ways that nurse educators may use measures of students’ empathizing characteristics as sources of insight in relation to the evaluation of students who are most likely to succeed and find satisfaction in their professional nursing roles.
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Comparisona of Nursing Students’ and Non-Nursing Students’ Empathizing Quotient Scores
|Group||Empathizing Quotient Score||n||t Value||95% CI|
|Nursing students||51.0||247||9.5 (p < 0.001)||[4.7, 7.1]|
Comparison of Mean Scores of the Empathizing Quotient (EQ) Questionnaire and Systemizing Quotient-Revised (SQ-R) Questionnaire
|Group||EQ Mean Score||SQ-R Mean Score||n|
|Female nursing students||51.9||57.2||336|
|Male nursing students||45.2||65.1||54|
|Female non-nursing students||48.3||56.9||869|
|Male non-nursing students||40.5||67.4||613|